HANDBOUND
AT THE
UNIVERSITY OF
TORONTO PRESS
MEDICAL RECORD
A Weekly yoicrnal of Medicine and Surgery
EDITED BY
GEORGE F. SHRADY, A.M., M.D.
SURGEON TO ST. FRANCIS HOSPITAL, NEW YORK; CONSULTING SURGEON TO THE GENERAL MEMORIAL HOSPITAL, TO THE COLUMBUS
HOSiri AL, NEW YORK, TO THE NEW YORK RED CROSS HOSPITAL, AND CONSULTING PHYSICIAN-INXHIEF
TO THE HOSPITALS OF THE HEALTH DEPARTMENT OF THE CITY OF NEW YORK
Volume 57
JANUARY 6, 1900— JUNE 30, 1900
NEW YORK
WILLIAM WOOD AND COMPANY
1900
'<
The Publishers' Printing Company,
J2 ami S4 Lafayette Place,
New York.
LIST OF CONTRIBUTORS TO VOL. LVII.
Abbe, Dr. Robert, New York.
Abrams, Dr. Albert, San P"ran-
cisco, Cal.
Adler, Dr. I., New York.
Alexander, Dr. L. S., St. Augus-
tine, Fla.
Allen, Dr. Charles Warrenne,
New York.
Alter, Dr. Francis W., Toledo,
Ohio.
Ashmead, Dr. Albert S., New-
York.
liAiLEY, Dr. Pearce, New York.
JSaldwin, Dr. J. F., Columbus, O.
Kalleray, Dr. G. H., New York.
Barry, Dr. William F., Woon-
socket, R. I.
Baruch, Dr. Simon, New York.
Bassler, Dr. Anthony, New York.
Beck, Dr. Carl, New York.
Bell, Dr. George Huston, New
York.
Benedict, Dr. A. L., Buffalo, N. Y.
Bennett, Dr. Tho.mas L., New
York.
Berg, Dr. Albert A., New York.
Bierhoff, Dr. Frederic, Berlin,
Germany.
BoGARDUS, Dr. H. J., (ersey City,
N.J.
Bogert, Dr. S. S., New York.
Bolton, Dr. Percival R., Ithaca,
N. Y.
BowEN, Dr. F. J., Mt. Morris, N. Y.
Brothers, Dr. Abram, New York.
Brown, Dr. Thomas R., Balti-
more, Md.
Brown, Mr. Goodwin, New York.
Bullard, Dr. W. Duff, New
York.
Bullard, Dr. William K., Nassau,
N. P.
Bull, Dr.' Charles Stedman,
New York.
Bullitt, Dr. James B., Louis-
ville, Ky.
Burgess, Dr. O. O., San Fran-
cisco, Cal.
Burt, Dr. Stephen Smith, New
York.
Buxton, Dr. B. H., New York.
Byrne, Dr. John, New York.
Cantwell, Dr. F. W., El Paso,
Tex.
Carpenter, Dr. Charles Ray-
mond, Leavenworth, Kansas.
Carter, Dr. H. VV., New York.
Cassidy, Dr. Patrick, Norwich,
Conn.
Chapin, Dr. Henry Dwight,
New York.
Clouting, Dr. Charle.s A., New
York.
Cotton, Dr. W. G., East Bethle-
hem, Pa.
Cox, Dr. Edwin Marion, New
York.
Creighton, Dr. Sarah Robin-
son, Boston, Mass.
Davis, Dr. Charles E., New
York.
Davis, Dr. Edward P., Philadel-
phia, Pa.
Dayton, Dr. Hughes, New York.
Delatour, Dr. H. Beeckman,
Brooklyn, N. Y.
Dessau, Dr. S. Henry, New York.
Douglas, Dr. Charles J., Boston,
Mass.
Dunckel, Dr. Walter A., New
York.
EiNHORN, Dr. Max, New York.
Elsberg, Dr. Charles A., New
York.
English, Dr. D. E., Millburn, N. J.
Fanoni, Dr. Antonio, New York.
Fest, Dr. Francis T. B., Hon-
duras.
Fielder, Dr. Frank S., New
York.
Fluhrer, Dr. William F., New
York.
Forestier, Dr. H., Aix-les-Bains,
France.
Fowler, Dr. George R., New
York.
Fraenkel, Dr. Joseph, New York.
Fridenberg, Dr. Percy, New
York.
Fruh, Dr. Carl O. S., Philadel-
phia, Pa.
Gallant, Dr. A. Ernest, New
York.
Galloway, Dr. C. M., Xenia,
Ohio.
Gau, Dr. H. F., Cincinnati, Ohio.
GiBNEY, Dr. Homer, New York.
Gibson, Dr. C. C, New York.
GoLDAN, Dr. S. Ormond, New
York.
Goodhue, Dr. E. S., Balbec, Ind.
Gordon, Mr. Frederick T.,
League Island Navy Yard, Pa.
Gottheil, Dr. William S., New
York.
Graves, Dr. Schuyler Colfax,
Grand Rapids, Mich.
Greanelle, Dr. W. J., New York.
Green, Dr. W. O., Louisville,
Ky.
GuiTERAS, Dr. Ramon, New
York.
Hamilton, Dr. Allan McLane,
New York.
Hanan, Dr. James Taylor, Brook-
lyn, N. Y.
Hays, Dr. Benjamin K., Oxford,
N. C.
Hedges, Dr. E. W., Plainfield,
N.J.
Herman, Dr. J. Edward, Brook-
lyn, N. Y.
Hillis, Dr. Thomas J., New York.
HiRSCH, Dr. William, New York.
Holmquist, Dr. A. J., Como, Colo.
Horner, Dr. J. S., West Pawlet,
Vt.
Jackson, Dr. George Thomas,
New York.
Janeway, Dr. E. G., New York.
Johnson, Dr. F. W., Boston,
Mass.
Johnson, Dr. William Crawford,
Frederick, Md.
Josephson, Dr. J. C, Baltimore,
Md.
Kemp, Dr. Robert Coleman,
New York.
Kendall, Dr. H. E., Sydney,
Nova Scotia.
Kessel, Dr. George, Cresco, Iowa.
Kitchener, Dr. J. M. W., East
Orange, N. J.
Knopf, Dr. S. A., New York.
Kohn, Dr. Samuel, New York.
Kraus, Dr. Frederic, Carlsbad,
Austria.
Lamb, Dr. D. S., U. S. Army.
Leake, Dr. Henry K., Dallas,
Texas.
Leszynsky, Dr. William M., New
York.
Levene, Dr. p. A., New York.
Levin, Dr. I., New York.
Libman, Dr. E., New York.
Lloyd, Dr. Samuel, New York.
Lockwood, Dr. George Roe,
New York.
Loveland, Dr. B. C, Syracuse,
N. Y.
Loveland, Dr. E. K., Watertown
Conn.
Lustgarten, Dr. S., New York.
Lyon, Dr. Irving Phillips, Buf-
falo, N. Y.
Manges, Dr. Morris, New York.
Mason, Dr. Charles F., Iloilo,
Panay, P. I.
IV
CONTRIBUTORS TO VOL. LVII.
Massey, Dr. G. Betton, Phila-
delphia, Pa.
May, Dr. Charles H., New York.
Mayer, Dr. Abraham, New York.
Mayo, Dr. W. J., Rochester, Minn.
Meltzer, Dr. S. J., New York.
Meyer, Dr. Willy, New York.
Miller, Dr. H. T., Springfield,
Ohio.
Mock, Dr. E. V., Cambridge, 111.
Morris, Dr. Robert T., New
York.
Morton, Dr. William J., New York.
Nagle, Dr. John T., New York.
Newton, Dr. Richard Cole,
Montclair, N. J.
NicoLL, Dr. Henry D., New York.
NuTT, Dr. John Joseph, San
Diego, Cal.
O'Neill, Dr. Joseph Alan, New
York.
Overton. Dr. Frank, Patchogue,
N. Y.
Partsch, Dr. Herman, Brooklyn,
N. Y.
Payne, Dr. William Anderson,
Brooklyn, N. Y.
Peters, Dr. W. H., Providence,
R. I.
Proben, Dr. Charles J., New
York.
Prudden, Dr. T. Mitchell, New
York.
Ransom, Dr. J. D., Dannemora,
N. Y.
Robinson, Dr. A. R., New York.
Rockwell, Dr. A. D., New York.
Rogers, Dr. Philip F., Milwau-
kee, Wis.
Rose, Dr. A., New York.
RuGGLES, Dr. E. Wood, Roches-
ter, N. Y.
Sachs, Dr. B., New York.
Satterthwaite, Dr. Tho.mas E.,
New York.
Schott, Dr. Th., Bad Nauheim,
Germany.
Schultz, Dr. R. C, Los Angeles,
Cal.
Shaw, Dr. Henry L. K., Albany,
N. V.
Sheuwell, Dr. S., Brooklyn, N. Y.
Shrady, Dr. George F., New
York.
Smith, Dr. Andrew H., New York.
Smith, Dr. Stephen, New York.
Snow, Dr. WILLIA^t Benha.m,
New York.
Somberger, Dr. S. J., Cortland,
N. Y.
Squire, Dr. C. L., Elmira, N. Y.
Stedman, Dr. Thomas L., New
York.
Stimson, Dr. Lewis A., New
York.
Talmey, Dr. B. S., New York.
Teubner, Dr. Charles, San
Francisco, Cal.
Thomas, Dr. T. Gaillard, New
York.
Thomson, Dr. W. H., New York,
Trudeau, Dr. E. L.. Saranac Lake,
N. Y.
Truneqek, Dr. C, Prague, Aus-
tria.
Turner, Dr. S. S., Chicago, 111.
Valk, Dr. Francis, New York.
Van Santvoord, Dr. R., New York.
Vineberg, Dr. Hiram N., New
York.
Vinton, Dr. C. C, New York.
Ware, Dr. Martin W., New
York.
Washburn, Dr. Wickes, New
York.
Weir, Dr. Robert F., New York.
Wells, Dr. Clarence A., Quincy,
111.
Wells, Dr. J. Hunter, Pyeng-
yang, Korea.
Wells, Dr. Walter A., Wash-
ington, D. C.
Wiener, Dr. Joseph, New York.
Wendell, Dr. A. V., Newark, N. J.
Wetmore, Dr. Josephine M.,
Grinnell, Iowa.
Whitbeck, Dr. John F. W.,
Rochester. N. Y.
Wood, Dr. E. L., Dansville, N. Y.
Worthington, Dr. S. M., Ver-
sailles, Ky.
Wyeth, Dr. John A., New York.
Societies irf which Reports have been
Published.
American Association of Genito-
urinary Surgeons.
A.merican Climatological Asso-
ciation.
American Dermatological Asso-
ciation.
American Gynecological Asso-
ciation.
American Laryngological Asso-
ciation.
American Medical Association.
American Neurological Associa-
tion.
American Orthopedic Associa-
tion.
American Pediatric Society.
American Surgical Association.
As-sociation of American Physi-
cians.
Congress of American Physi-
cians and Surgeons.
Medical Association of the
Greater City of New York.
Medical Society of the County
of New York.
Medical Society of the State
of New York.
New York Academy of Medi-
cine.
New Y'ork County Medical As-
sociation.
New York Medical Union.
New Yopk Medico-Surgical So-
ciety.
New York Neurological So-
ciety.
New York Pathological So-
ciety.
Practitioners' Society of New
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Medical Record
A Weekly yoitmal of Medicine and Surgery
Vol. 57, No. I.
Whole No. 1522.
New York, January 6, 1900.
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©rigittaT ^irticlcs.
THE DIET IN TYPHOID FEVER.
By morris manges, M.D.
NERAL MEDK
IC ; VISITING
1 HOSI'ITAL, NE
In view of the unanimity which prevails among medi-
cal writers on the subject of the diet of typhoid fever,
it may seem surprising that this subject requires any
discussion at all. That this unanimity is so marked
among authors in all countries may be attested by a
perusal of even the latest editions of the text-books
and systems of medicine. Indeed, so accomplished a
clinician as Chantemesse, in the celebrated " Traite de
Medecine" of Charcot and Bouchard, dismisses the
whole subject of the diet in typhoid fever in five lines.
Nearly all writers are agreed in maintaining that the
diet during the febrile stage shall consist either of
milk alone or some preparation of it, beef-juice, or
tea, or bouillon, gelatins, meat peptones, soniatose and
similar preparations, eggs, various gruels and broths,
and alcohol; also a few vegetable- and fruit-juices.
But on one point they are one and all unanimous, that
under no conditions shall solids in any form be al-
lowed to the febrile typhoid patient, and that even
in the administration of liquid foods especial care
shall be taken that these be chosen with reference to
their blandness and to the amount of residue which is
left after they have been digested in the stomach. One
writer has even gone to the extreme of stating that
even milk itself ought not to be allowed, since this is
a good culture medium for the typhoid bacilli, and
hence he has recommended preparations of malt, since
it has been sliown that the typhoid bacilli do not thrive
in this medium.
As to the diet after defervescence, writers are again
quite unanimous in stating that no solids of any kind
should be administered until at least seven to ten days
have elapsed after the establishment of a normal tem-
perature; and when the fluid diet is departed from at
this stage, the utmost care should again be exercised in
the selection of bland articles of nourishment. It is
true that a few writers, among whom we may mention
Peabody of this city, have recommended that meat be
administered as soon as the temperature reaches the
normal line, yet such has been the fear of the febris
carnis that these teachings have for a long time stood
alone. The fact remains, therefore, that the general
consensus of opinion is that the patient in typhoid
fever shall be kept upon a liquid diet as long as there
is the slightest possibility of the existence of ulcerated
areas in the intestinal tract.
But there is another side to this question. The
observations which have been reported, it is true, do
not include a very large number of cases; yet they have
been conducted on such careful lines that they are
well worthy of attention. Of these recent publications
I may mention that of A. J. Barr,- of Leeds, England,
' Read before the Metropolitan Medical Society, November
28, iSgg.
'British Med. Jour., iSgy, vol. i.. p. 125.
who reports his observations upon cases of typhoid
fever in which the patients were fed with bread and
butter, minced meat, and ordinary mixed diet, even
though they had a temperature of 104" F. So far
from doing the patients any harm, he even claims that
they were benefited thereby. His observations were
based on thirty-one cases, of which only three ended
fatally; and to these three patients he had never been
able to give solid food. He lost no case in which
early full feeding was adopted, and his own mortality
was not so great as the average mortality of the hospi-
tal (that is, of the Leeds General Infirmary). Re-
lapses occurred in two of the thirty-one cases (six per
cent).
Much more striking is an elaborate report that
comes from Russia. Bushuyev, being fully convinced
of the desirability of feeding patients with typhoid
fever as fully as possible, concluded to have a com-
parative test made of this metnod, and arranged with
his colleague, Sartsievich, that all the cases of typhoid
fever which were admitted to the hospital in the year
1896-97 should be compared from this standpoint.
Accordingly on the one division only milk (two quarts
every twenty-four hours), one or two eggs soft boiled
or in Stokes' mixture, were allowed to the patient,
while on the other the full diet, the details of which
will be stated below, was given. The results were as
follows :
Dushuye\ Sartsievich,
Whole number of patients 80 74
Recovered 72 (90 p. c.) 65 (87. S p. c.)
.Vverage day of illness on entrance
in the hospital 7.5 5.8
.\verage day of entrance to divi-
sion 8.4 8.3
Day on which recovery was com
plete 49.5 55
Number of days spent in hospital. 42 49.2
Days of fever in hospital 1S.9 22.3
Dismissed incapable of duty 6 (8.3 p.c.) lo (i5.4p.c )
Died 8(iop.c) g(i2.ip.c.)
Average day entrance to hospital. 8.5 5.8
Average day of entrance to divi-
sion 9.1 S.4
Day of death (average) . . . 2S.6 26.7
Number of days between entry
and death 20 i 19.4
Bushuyev argued that those who objected to feeding
based their objections not so much on the insuffi-
ciency of the digestive juices as the danger of hemor-
rhages. He argued that the changes which result in
perforation rarely come on suddenly, but occur gradu-
ally; furthermore, that the lesions are so far re-
moved from the stomach that by the time the foods,
even those hard to digest, reach these areas, they are
so far changed that one can hardly imagine that they
could injure the intestines. Wholly indigestible sub-
stances such as fruit seeds or skins, which might in-
jure the gut, are as a rule so rolled up in mucus or
intestinal contents as to be harmless. Autopsies on
cases of typhoid fever on the thirtieth day or later, in
patients who had been liberally fed, showed that the
intestines were in the same condition as under ordinary
typhoid diet. That the cause of perforation is not the
character of the food, but the nature of the ulcer, is
MEDICAL RECORD.
[January 6, 1900
asserted by Bushuyev, since one never hears of perfora-
tion of the tuberculous ulcer due to food. He also
absolutely states that he knows of nothing to support
the view held by some, that injury to the intestinal
walls by solid food might provoke a re-entrance of the
bacilli, and increase the frequency of relapses.
From the table of supplies open to him, Bushuyev
devised the following plan for feeding typhoid pa-
tients, which he carried out for two years :
7 A.M. Tea with roll.
8 A.M. 400 CO. of soft (liquid) oatmeal, barley, or
wheat porridge witli butter.
9 A.M. One or two boiled eggs, soft or hard, as the
patient desires.
lo-ii A.M. A glass (200 to 220 c.c.) of milk with
roll, one-half a cutlet, and a bit of boiled meat (160
to 168 gm.).
12-12:30 P.M. A plate (220 c.c.) of chicken soup
or a bowl of ordinary soup, sometimes with a bit of
chicken from the soup, and a small cup of kisel (a
sort of sour jelly) ; rarely a little preserved fruit.
3 P.M. Tea with a roll.
6 P.M. A cup of chicken or beef soup; semolina
pudding or milk; a bit of chicken.
8 P.M. Milk with a roll.
During the night: Coffee or tea ivith milk two to
four times; coffee with cognac.
For dinner or supper the white bread may be re
placed with black (with the crust), and the soup by a
thick wheat gruel. Many patients prefer boiled meat
to cutlets, and the ordinary soldier's soup to hospital
soup and gruel. The milk is generally boiled; occa-
sionally it is given in the form of junket. As to
beverages, the patients were allowed cold water,
boiled or unboiled, cranberry juice, milk of almonds,
small amounts of beer, and kvass. The cranberry
juice was particularly grateful to the patients. In
addition the patients received from one to three
ounces of wine in the morning, and every two hours
half an ounce of Stokes' mi.xture.
Bushuyev naively states that had he had a greater
variety of articles of food he could have excited the
appetites of the patients, so that in some instances
they might have eaten more. As it was, some com-
plained of insufficiency of bread. He was also un-
able to give the patients as much milk as he wished.
During the year 1897 under this diet he lost twenty-
si.x out of three hundred and eighteen patients, or 8.2
percent. During the years 1888 to 1897, the deaths
from typhoid fever at the military hospital at Kiev
varied between 10 and 19.3 per cent. The mean
average in ten years was 12.4 per cent., three hundred
and fifty-eight deaths in twenty-eight hundred and
eighty-seven patients. Thus in 1897 with a mixed
diet the death rate was materially less than for the ten
years previous.
He declares enthusiastically that under this treat-
ment the general condition of the patients was far bet-
ter than that of those kept on exclusively fluid diet.
The common complaints were scarcely ever heard. At
meals the patients were uncommonly wide awake, and
even tliose that were ill sat up in bed, begged for food,
and ate with much satisfaction Only a few had to be
fed by nurses. If one observed the patients at meal-
time, he wholly forgot that they were seriously ill,
with temperatures above 39° C. (102.5° F-)- The
visitors in the ward at meal-times were amazed "by
seeing almost no typhoid fever cases."
He states further that during the first hours in the
ward the patient lies in a motionless condition, fail-
ing to answer questions and refusing food, but if one
succeeds in some way or other in persuading him to
eat a bit of meat or cutlet, or an egg, he begins imme-
diately to show some interest in the surroundings.
In a few days, often within a day, no trace of the
typhoid c nditioii remains. Unfortunately, it is im
possible 10 persuade all typhoid-fever patients to eat.
Attempts at forced fi,eding cause vomiting. Every
care sliould be directed toward stimulating the pa-
tient's appetite, and to avoid disgusting him by what
is brought before him.
When the patient enters in an unconscious condi-
tion he should be given as much of a liquid diet as he-
can take without vomiting, and if it be impossible to
feed him by the mouth, he should be fed through the
nose with a tube.
The tongue and lips remain in relatively good con-
dition; there are no unpleasant gastric or intestinal
symptoms. The bowels are often constipated, and
pea-soup stools occur only in cases fed with milk and
bouillon.
As regards complications, it i:; to be noted that
intestinal hemorrhage is not more frequent during a
solid diet than under exclusive liquids. Thus Bush-
uyev did not lose a single case from intestinal hem-
orrhage.
In 1897, among three hundred and eighteen cases
there were only four instances of hemorrhage, i.e., 1.7
per cent., whereas in the statistics of others it varies
from two to ten per cent. Of the four patients with
hemorrhage, two died, and it is to be noted that of
these four patients only one received solid diet, two
entering the hospital in so serious a condition that
they had to have forced liquid feeding, and the other
was that of a physician who preferred to be fed upon
liquids. Perforation occurred in the last two years
only once in five hundred and nine patients, that is,
.19 per cent. The other authors estimate it from 1.25
to 3.04 per cent. General peritonitis occurred only
twice.
The loss of weight in these patients was less than
that which occurred in those on a more restricted diet
The general condition was so good that they preferred
as a rule to walk to their tubs and to the closet.
Long before the end of the fever they got out of bed,
and there was much difficulty in making them lie
down. In summer they went out into the garden
almost on the first day of the febrile condition.
Dr. Thayer, whose abstract of this paper in " Pro-
gressive Medicine," 1899, vol. i., p. 328 et seq., I
have quoted so liberally, in commenting on it states
that both reasoning and the figures are such as to
make us reflect. He adds that if a more liberal diet
than that afforded by the purely liquid regimen could
be assimilated, the patient's strength would hold out
materially better, and in diphtheria and pneumonia or
febrile tuberculosis we endeavor to feed the patient as
fully as possible on a simple, easily absorbable, and
nourishing diet; but in typhoid fever we are re-
strained by a vague fear that any departure from the
customary regimen is for some reason or other dan-
gerous.
Tha3'er believes that indiscretions of diet may pro-
duce sudden rise of temperature with alarming symp-
toms, but he has never seen anything to show that this
is more common in typhoid fever than in any other
similar condition.
The only other elaborate reports which have recent-
ly been published on the use of solid foods in typhoid
fever are those of Dr. F. C. Shattuck, of Boston,
which were published in 1897, and the recent address
of Dr. R. H. Fitz, of Boston. Shattuck's line of
argument is very similar to that of Bushuyev, and his
results are equally striking. He was led to take up
this line of treatment as a result of having accident-
ally fully fed a number of typhoid-fever patients, the
true diagnosis of which was not made until some time
afterward. These results were so strikingly favorable
that he was led to adopt a fuller regimen in the treat-
' Jour. .\mer. Med. Assoc, July lo, l8g7, p 51.
January 6, 1900]
MEDICAL RECORD.
ment of his cases at the Massachusetts General Hos-
pital. The statistics which he reports are most satis-
factory.
Shattuck, after arguing against the fallacy of the old
doctrines of depletion in acute febrile disorders, urged
that although typhoid fever was a self-limited disease,
yet its long duration rendered it necessary that, inas-
much as we could not directly attack the cause of the
disease, our duty was to support the patient's strength
to the utmost by maintaining nutrition at the highest
level. We have no fear of feeding febrile patients in
other diseases, and he calls attention to the forced
feeding in the suppurative fevers, whether tuberculous
or not. Furthermore, he says that no matter how we feed
a patient there will be intestinal peristalsis, and the
waste products must pass over the ulcerated areas.
Furthermore, he does not accept the old idea that re-
lapses are due to dietetic errors alone, but that ner-
vous excitement, undue fatigue, etc., also cause rises of
temperature; nor does he believe that tiiese factors
can cause fresh infection by bacilli. Thus for twelve
years, from 1886 to 1897 inclusive, three hundred and
eighty cases were under his treatment. From 1886 to
1893, two hundred and thirty-three were upon exclu-
sively milk diet, with a mortality of ten ]3er cent. ; from
1892 to 1897, one hundred and forty-seven were upon
a more liberal diet, with a mortality of 8.1 per cent.
Shattuck admits that the number of his observations
is small, and that other factors in the treatment, such
as the introduction of hydrotherapy, may have had
sometiiing to do with his better results ; but one factor
remains, namely, that the more liberal diet at all
events did no harm. Shattuck does not advise eating
everything, but he insists that we should treat the pa-
tient and not the disease, that we should feed him with
reference to his digestive powers and not with refer-
ence to the fever, and furtliermore, that there is no
increased danger of irritation from food which leaves
no irritating residue, and which cautious trial shows
is digested without disturbances. His diet includes;
1. Milk, hot or cold, with or without salt, diluted
with lime water, soda water, Apollinaris, or Vichy
water; peptogenic and peptonized milk; cream and
water (i.e., less albumin); milk with white of egg,
buttermilk, koumyss, matzoon, whey; milk with tea,
cotTee, or cacao.
2. Soups — beef, veal, chicken, tomato, potato,
oyster, mutton, pea, bean, squash; carefully strained
and thickened with rice (powdered), arrowroot, flour,
milk or cream, egg, barley.
3. Mellin's food, malted milk, carnipeptone, bovi-
nine, somatose.
4. Beef juice.
5. Gruels — strained corn meal, crackers, flour, bar-
ley water, toast water, albumen water with lemon juice.
6. Ice cream.
7. Eggs, soft boiled, raw, egg-nog.
8. Finally, minced lean meat, scraped beef ; the soft
part of raw oysters; soft crackers with milk or broth;
soft puddings without raisins ; soft toast without crust ;
blanc mange, wine jelly, apple sauce, and macaroni.
In the admirable address' at the recent general dis-
cussion on typhoid fever at the last meeting of the
New York State Medical Association, Dr. R. H. Fitz,
of Boston, presented the statistics on typhoid fever at
the Massachusetts General Hospital, extending from
182 I to 1899. In the course of this address, among
other things, he directed especial attention to the in-
fluence of diet upon the course of typhoid fever, upon
the general mortality, the occurrence of hemorrhage
and of perforation :
"For the thirty years from 1839 ^'^ ^^69 the diet of
'Boston Med. and Surg. Jour.. Nov. 23, iSgg. I am in-
debted to Dr. Fitz for his courtesy in sending rae advance slieets
of liis paper.
the patients was liquid, the fluids often containing
some farinaceous ingredients. From 1869 to 1879
beef tea and beef juice were largely used in addition
to the milk, and from 1879 to 1899 the liquid portion
of the diet has been chiefly milk. Between 1893 and
1898 the patients under the care of Dr. Shattuck
[namely, the cases which have been referred to above]
have received, in addition to the milk, minced meat,
raw and soft-boiled eggs, macaroni, soft crackers,
toast, and puddings. Patients under the care of Dr.
E. G. Cutter, during a like period, have been fed on
skimmed milk, buttermilk, eggs and milk, albumen
water, chicken broth, and beef juice with barley water.
The mixed foods were so strained as to be freed from
solid particles. During the thirty years of liquid
farinaceous diet, the average mortality was 14.: per
cent. In the milk and beef-tea decade it was 16.6
per cent., although in the immediately preceding
liquid farinaceous decade it was 15.9 per cent. From
1S79 to 1899, among those patients using milk as the
principal article of food, the mortality was 14.6 per
cent., which was about the same as during the period
of liquid farinaceous diet. The mortality was only
1 1.3 per cent., however, among the patients between
1893 and 1898, who were fed upon the liquid and soft
solid diet prescribed by Dr. Shattuck. This mortality
compares very favorably with that of 15.1 per cent,
noted among the patients using a largely milk diet,
and with a 16.6 per cent, mortality occurring among
patients taking strained, starchy, and proteid fluids.
As regards the occurrence of hemorrhages, it was
noted among patients living on a milk diet in 10.6
per cent. ; among those fed on proteid and amylaceous
fluids it was sixteen per cent., while it was only nine
per cent, among the patients living upon fluids and
soft solids. The inference from this comparison is
that a diet of soft solids not only does not provoke an
intestinal hemorrhage, but also rather lessens the ten-
dency to this complication. On the other hand, the
strained mixed diet may increase somewhat the fre-
quency of the hemorrhages.
"The frequency of perforation could be noted with
sufficient accuracy to permit comparison, only in the
cases reported within the past thirty years. From
1869 to 1879 the average frequency of this occurrence
was I.I per cent.; from 1879 to 1889 0.3 per cent.,
and from 1889 to iSgg 1.6 per cent. These differ-
ences are so slight as to make it doubtful if dietetic
treatments have had any eft'ect in modifying the fre-
quency to these grave complications of typhoid-fevei
patients. Of ten patients with perforation, between
1893 and 1897, five, or 2.8 per cent., were using a
largely milk diet; two, or 1.8 per cent., the strained
liquid diet; and three, or 3.4 per cent., were fed upon
liquid and soft solid diet.
" As to frequency of relapses, careful thermometric
records having only been made at the hospitals since
1869, it is possible to make comparisons only since
then. It is to be noted that the frequency of relapses
has increased from 8.7 per cent, of the decade from
1869 to 1879 to '3-6 P^"" cent, in the next decade, and
1 1.3 per cent, in the last decade, namely, 1889 to
1899. This frequency may possibly, as has frequent
ly been maintained, be due to hydriatric treatment of
the disease.
" It is to be noted that relapses were rather more
frequent among patients living upon a largely milk
diet, since among them the ratio of relapses was 13. i
percent.; it was ii.i per cent, among patients liv-
ing upon strained proteid and amylaceous diet, and
10.2 per cent, among the patients fed upon fluids and
soft solids." Fitz, therefore, in his conclusions main-
tains that a considerable variety in the diet may be
permitted not only without detriment, but also with
possible benefit to the patient.
MEDICAL RECORD.
[January 6, 1900
uU Number.
Number on Liquid
Diet, 82.
Per Cent.
Per Cent.
12.2
13-4
15-5
14.5 (12 cases.)
4-4
4.SS
3-3
3 5
My own experience in this field is, I regret to say,
more limited than I would like. There are many rea-
sons for this small number, one being that the number
of typhoid-fever cases is usually small during the
greater part of my service at the Mount Sinai Hospi-
tal {i.e., February ist to August ist), and, furthermore,
I did not begin this plan of treatment till the middle
of May. This year's epidemic, also, was peculiar
both in the comparatively small number of cases and
its severity. Never have I seen such a series of bad
cases; the tendency to complications was unusually
great, among which pneumonia was the most preva-
lent. This is shown in the hospital statistics of the
cases of typhoid fever treated this year up to November
24, 1S99 :
Total Number 90.
Total deaths 11
Total relapse 14
Total perforation .... 4
Total hemorrhage ... 3
Mortality of hospital for 1S96, 7.6 per cent.; for
1897, 9.57 per cent.; average mortality, 1893-1897,
11.09 per cent.; average percent, of relapse, 1893-
1897, 8.42.
The percentages for the series of eight cases on
fluids and soft solids are not given, as it is scarcely
justifiable to present any results based on such a
small number. It is to be noted, however, that there
were no deaths, hemorrhages, or perforations. The
two relapses will be discussed later on.
This series, as stated, included only eight cases,
four males and four females, the ages of whom ranged
from sixteen to twenty-five years. The plan of treat-
ment was that ordinarily pursued at the hospital, i.e.,
a minimum amount of medication, usually including
only dilute hydrochloric acid and stimulants, unless
some special indications should arise. Plunges at
90° to 80° F. or cold packs were the routines for high
temperatures. The majority of the cases were of the
severe type, as their subsequent course proved.
The diet allowed was the soft diet of the hospital.
This includes soft boiled eggs, milk, milk toast, cus-
tard, strained jellies, chicken, rice, farina, strained
oatmeal and other cereals, softened soda crackers,
baked potatoes. One and all the patients relished
their food, although I must confess it at first seemed
somewhat uncanny to see these patients sitting up in
bed, trays in front of them, and with contents rapidly
disappearing. That they digested the food was proven
by the constant supervision of the stools; it is also to
be noted that diarrhoea was not present in any larger
proportion than is usual in this disease. In several
of the cases there was constipation; two of the pa-
tients had two or three soft stools daily. The tongues
were always moist, whether they were coated or not.
In other words the food was tolerated in every way,
and that it was absorbed was manifest from the fact
that, as a rule, these patients emaciated less rapidly
than the others who were under liquid food treatment
at the same time. The better nutrition of these pa-
tients was also demonstrated by blood counts which
were made for other purposes on two of them, both of
which ran severe courses; one of them was compli-
cated by pharyngeal diphtheria. On the twelfth day
there were 4,280,000 erythrocytes, and 12,000 leuco-
cytes. In the other case, in the fifth week, the exami-
nation showed 5,087,000 erythrocytes, although the
temperature was still elevated.
There were no deaths, although according to the high
average mortality of the hospital for this year we should
have expected at least one death. This is remarkable
in view of the severity of the cases, diphtheria, pye-
litis, mastitis, and a marked psychosis being among
the complications. There were no hemorrhages, since
we can eliminate the few drachms of blood which
were once reported in one case. Perforation and in-
deed all peritoneal symptoms were absent. Likewise
there were no thromboses.
Relapses were reported in two cases. Of these one
occurred three weeks after the patient's discharge from
the hospital, and can therefore hardly be attributed to
the increased diet. The other relapse was that of a
robust domestic, who had a mild primary attack,
but who subsequently had two severe relapses. It is
to be observed that in her first relapse she was fed on
milk alone. This apparently did not prevent her hav-
ing the second relapse.
Whether this high percentage of relapses (twenty-
five per cent.) — which, it is to be observed, is higher
than the average of the other hospital cases for this
year — is a coincidence or not, I will not discuss, since
it would be rash to draw conclusions from eight cases.
The larger statistics of Fitz and Shattuck demonstrate
that relapses are less under full diet than they are on a
liquid regime. On the other hand, if we eliminate the
one case in which the relapse occurred three weeks
after discharge from the hospital, as we are justly al-
lowed, then the percentage would be twelve, which
would be close to the hospital average.'
Having thus presented the leading facts which have
thus far been presented on this side of the dietetic
question, let us review the grounds on which the
necessity of a liquid or soft diet in typhoid fever has
been so generally emphasized, so that we may see
the practical reasons pro and con. In no other wav
can any definite conclusions be reached. The subject
is deserving of discussion, even though all the text-
book writers are unanimously opposed to any change.
For a long time many were opposed to the bath treat-
ment; to-day it maintains its popularity even though
statistics show that hemorrhages and relapses are
probably more frequent under this treatment than
they ordinarily are. The benefits from the treatment
far outweigh the disadvantages of the method. In
medicine nothing is fixed, and progress is alone pos-
sible by constant revision, even of that which at the
time is universally accepted.
The fundamental principle is that typhoid fever is
a general infectious disease, the chief and most im-
portant feature of which is the lesions in the intes-
tines; and since these lesions are accompanied by an
ulceration more or less deep of the intestinal walls,
every effort should be made to secure the utmost pos-
sible rest for the gut, both in the nature of the food
residue which passes through the involved intestine,
and the amount of distention to which its w-alls may
be subjected by undue fermentations.
The extent to which these views now prevail in the
minds cf some of the very best authorities may be in-
ferred from the statements made by some of them that
constipation is the ideal state, and that the bowels
should be moved as little as possible. But it is to be
answered that typhoid fever is something more than
' In the discussion a number of cases of typhoid fever were
reported in which tlie patients were, for some reason or another,
fed upon solids throughout the whole course of the disease.
Among these was one narrated by l^r. Leszynsky . the patient,
being the wife of a doctor, thought she knew all about feeding,
and insisted upon a diet of tongue and ham sandwiches, etc.
.She could not be dissuaded, her chosen diet was regularly given
to her ; the course of the disease was uneventful. IJr. Kubin
stated that while he was house physician of the C.ei man Hospital
scraped ham was often allowed without any bad effects. Dr.
Koplik said that at Bellevue Hospital Dr. .Monzo Clark and Dr.
Delafield not infrequently permitted scraped meat. I may add
that during a recent conversation with Dr. Janeway on this topic
he told me of a patient at liellevue Hospital who insisted on
being fed on corned beef and cabbage ; no harm resulted, since
his case pursued the ordinary course.
January 6, 1900]
MEDICAL RECORD.
an intestinal lesion. The bacilli can be found in the
blood as early as the fifth day, and are in the spleen
and other organs at aa even earlier period. Later on
they may be found in almost any part of the body.
This has been well shown by Keen, in his elaborate
synopsis on the various parts of the body in which
Eberth's bacillus has been found. ' This list includes
the blood, the endocardium and endocardial vegeta-
tions, the walls of the arteries and veins, thrombi,
muscles, the connective tissues, the skin, the synovial
sheaths of tendons, joints, the bones, the brain and
spinal cord, thyroid gland, parotid gland, orbit, middle
ear, lungs, pleura, peritoneum, liver, the gall bladder
and bile, the spleen, the mesenteric glands, the kidney,
the urine, ovaries, testicles and epididymis, and even
in the placenta and fcetus.
In his most recent paper on the diagnosis of typhoid
fever, Osier* lays special stress upon the necessity of
recognizing the general infection in typhoid fever,
since it is the failure to recognize this that so often
leads to errors in the early diagnosis of this disease.
Thus the to.xffimia from which the patient suffers is
not alone due to the poisons which are produced by
the bacilli in the intestine, but is due to those which
are elaborated in the other organs.
Furthermore, typhoid fever is not alone due to the
typhoid bacilli, but it is a mixed infection in which
the colon bacilli, staphylococci, streptococci, and
other micro-organisms play a most important part;
hence the fever in the early stages of typhoid fever is
entirely due to the typhoid infection, but in the later
stages there is the added factor of the mixed infec-
tions which occur in the ulcerated areas in the intes-
tines and elsewhere. Moreover, not a few cases have
been reported in which the most careful examination
at autopsies has failed to find the slightest involvement
of the intestines.'
Another important fact which must not be over-
looked is this: that the severity of the intestinal
lesion cannot be inferred from the amount of diar-
rhoea. The deepest ulceration may be accompanied
by constipation, and furthermore a marked catarrhal
condition of the mucous membrane with only moderate
ulcerations of Peyer's patches may be accompanied by
an unusual number of intestinal evacuations. The
difficulties attending this question may be inferred by
the following quotation from Hare: '
"The consensus of opinion seems to be that diar-
rhoea is usually more active in serious cases.
Whether this is an instance of purging js an effort of
elimination, a favorite theory of those who are fond
of using purgatives and so-called intestinal antisep-
tics, with the idea that by so doing they eliminate
poisons and prevent their formation, or whether it is
a manifestation of severe ulceration of the bowel witli
an associated catarrh, is difficult to determine. Ord
agrees with the view that diarrhoea is usually asso-
ciated with ulceration, and his opinion has been con-
firmed by the autopsies he has seen. Peabody states
the case exactly opposite to this view. That Ord's
view is not correct seems proved by the fact that ad-
vanced ulceration is often found in cases which have
not had diarrhcea, and cases of marked diarrhoea are
seen in which the autopsy does not reveal much in-
testinal ulceration. In Bryant's case diarrhoea was
active, yet no intestinal lesions were found. In all
probability diarrhrea is neither indicative of a severe
nor a slight attack in many cases, although if it is
violent the exhaustion produced by the discharges
'"Surgical Complications and Sequels of Typhoid Fever,"
i?qS, p. 23.
'' New York Med. Journal. November ii, i8gg.
'Biggs (Med. News, November ii, iSgg) lias well shown the
fallacy of calling this disease enteric fever.
'' " Medical Complications and Sequelce of Typhoid," Febru-
ary, i8gg, p. 121.
may seriously imperil the patient's chance of re-
covery."
Finally it is urged, but by no means proven, that
administration of solids necessarily increases diar-
rhoea or tympanites. The contrary is often true.
Bushuyev and Shattuck especially note that many of
their patients were constipated; in my own cases on
solids the same was frequently reported.
The opponents of the administration of solid food
forget that, no matter how carefully the diet is regu-
lated, the intestinal contents must pass over the ulcer-
ated areas; that peristalsis must take place. Its ad-
vocates argue tliat the former lose sight of the fact
that fortunately the favorite site of the lesions in the
intestines is the ileum, especially its lower part, less
frequently the jejunum and the colon, hence food even
of a solid nature must have been fairly well digested
before it reaches this part. The other arguments ad-
vanced have been sufficiently referred to in the state-
ment from Bushuyev given above. If any further
details are needed upon this question as to whether
peristalsis is especially injurious, one may recall the
various procedures of the so-called eliminative treat-
ment of the disease.
The point upon which special stress must be laid is
that typhoid fever is a general toxemia, and it is to
this rather than to any particular lesion that we must
direct our attention and regulate our diet. Barr has
urged that ulcerations in the intestine are like ulcers
elsewhere, and that they will heal much more rapidly
when the blood and the tissues are well nourished.
The disease being one of long duration, the patient is
enabled to combat it far better if his general nutrition
has been kept at the highest point possible under the
circumstances. That this plan is feasible is shown
by the results narrated by Barr, SKattuck, Fitz, and
Bushuyev. My own limited experience confirms it.
The general mortality is decidedly less under liberal
diet that on liquid or restricted soft foods, as the sta-
tistics already given sufficiently prove, so far as statis-
tics in so variable a disease as typhoid fever will en-
able one to judge.
The second ground of contention is the presence of
the fever. Those in favor of liquid diet maintain that
the digestive secretions are lessened, and hence the
quantity of saliva, gastric juice, pancreatic juice, and
bile is entirely insufificient to digest anything but the
simplest foods. Furthermore, the lack of appetite
prevents the administration of anything except liquids;
even the patient's appetite is not a safe guide, for he
may simulate hunger under the false impression that
his recovery will be facilitated if he takes a large
quantity of nourishment. Thus the fact is empha-
sized that it is one thing to introduce food into the
body, but that it is quite another to digest and assimi-
late it. But, say the opponents of these views, we
feed other fevers no matter what their nature may be,
whether they be the prolonged fevers of tuberculosis,
of suppuration, or other conditions; indeed, we make
it a point to do everything which we can to get the
patient to take the maximum quantity of nourishment.
Be these views as they may, all are agreed that there
is such an enormous waste of the body albuminoids
and fats that we must strive as far as possible to re-
place these lost tissues in the diet, and at the same
time we must seek to protect the remaining tissues
from too rapid destruction. The general consensus of
opinion is, that this can be amply provided for by
increasing the quantities of liquid food, our guides
being the amount of residue which is found in the
stools, the general condition of the nutrition of the
patient, and the state of his mouth, etc. That this
is not fully accomplished is shown by the marked
emaciation which always accompanies typhoid fever.
Voit has shown that the caloric value of three or four
MEDICAL RECORD.
[January r, 1900
pints of milk daily is not sufficient to feed and replace
the waste in this disease. Furthermore, no food pro-
duces more virulent toxins than does milk. Every
podiatrist is emphatic in directing attention to this
important point in the treatment of gastro-enteric dis-
orders in children. The imperative need for more
nourishment is only too frequently attested by the piti-
able cries for food so often uttered by these patients,
even before defervescence. Although the diet allowed
by Bushuyev is that of an enthusiast who has gone to
the other extreme, yet the fact tliat his patients thrived
on it proves that an increased diet may not alone be
eaten by this class of patients, but may also be fully di-
gested and assimilated.
The third point of contention is the danger of hem-
orrhage. So far as the limited number of cases
quoted above will permit any judgment, it must be con-
fessed that it would seem that the administration of
solids has not increased the frequency of hemorrhage.
Indeed its frequency is distinctly less in the series of
Bushuyev, Shattuck, and Fitz. Thus Bushuyev had
only four cases in his series of three hundred and
eighteen, i.e., 1.7 per cent, but of these one only had
solid food, thus reducing the percentage to 0.3 per
cent. Fitz reports nine per cent, of hemorrhage of
those upon fluids and soft solids, as opposed to six-
teen per cent, among those on liquids. There were
no hemorrhages in my own cases. On the other hand,
so eminent an authority as Curschmann' reckons die-
tetic errors among the exciting causes of intestinal
hemorrhages.
Fourth, the danger of perforation does not seem to
bear any relation to the character of the food adminis-
tered, at least so far as the statistics which are avail-
able will permit any judgm.ent. Nor indeed is this
surprising, for perforation is due to the nature of the
lesion, to the progressive ulceration rather than to
anything else. It has repeatedly been shown that
perforation bears no relation to the severity of the
general symptoms. It is true that a gut which is un-
duly active in its peristalsis, and is unduly distended
by gas, will be much more apt to rupture under these
conditions than when they are more favorable. As
this subject has already been sufficiently gone into, it
need not be discussed at any greater length here.
Fifth, the subject which is apparently much less
difficult of determination from statistics is the occur-
rence of recrudescences of fever and relapses from the
administration of food. Yet in a disease which is as
protean in its manifestations as typhoid fever, in
which the collected statistics even of enormous num-
bers of cases show such great variations in the fre-
quency of relapses, in which the epidemics from year
to year present the most varied phenomena, one
must be reserved in passing judgment. We do not
yet know why one case relapses and the other does
not. 'Y\i^ post hoc and propter //(;<: must be carefully
kept asunder; for undue mental excitement or even
fatigue, the administration of drugs (Hare mentions
the occurrence of recrudescences after full doses of
strychnine), the change from one liquid to another,
as has been claimed by West, and many other occur-
rences may cause relapses. Hence in a given case
one can never be certain that the relapse which occurs
has been due to the administration of food. Still the
general consensus of opinion is that, in a large num-
ber of cases, relapses or recrudescences or fever have
resulted directly from dietetic errors. Every physi-
cian who has had an extensive experience with
tyishoid fever has encountered numerous such exam-
ples. I am sure that every year I have seen cases of
relapses which have apparently resulted from errors of
diet. The most striking case of this kind which I
' " Der Unterleibstyphus." Notlinagel's "Spec. Pathologic
unci Therapie." 1S98. Bd. iii., Theil i., 206.
can recall is that of a boy whose fever most persis-
tently remained elevated. Search as we would, we
never could find any cause for its protracted course.
The death of the patient in the neighboring bed soon
brought his fever to an end. It was then that we
learned that this patient was surreptitiously supplied
with fruit, cakes, etc., on visiting days, and taking pity
on his neighbor he passed it over to him. Many of
the relapses of this kind are due to another factor;
i.e., the patients are so famished that they ravenously
devour what they can lay hands on, often doing so
surreptitiously. Bread, fruit, and sponge-cake are the
especial offenders in the case of hospital patients.
But is there any evidence to show that indiscretions
of diet produce rises of temperature with unpleasant
symptoms more frequently in typhoid fever than in
other conditions? I can fully indorse Thayer's state-
ment ' already quoted, that " an indiscretion of diet
may produce such symptoms in any condition of se-
vere physical exhaustion," and that he " has never seen
anything to suggest that it is more common in typhoid
fever than in any other similar condition." Neither
does Shattuck believe that relapses are due solely to
dietetic errors. It must be distinctly remembered that
relapses occur even on a strict milk diet. It is possi-
ble that relapses may take place more frequently un-
der full feeding, just as they are reported more fre-
quently in the Brand treatment. The question is one
which is very difficult of solution, and time and a
larger experience can alone sohe it. The only avail-
able statistics are those of Fitz already quoted, i.e.,
that relapses occurred in 13.1 per cent, on a milk diet,
in I I.I per cent, on a strained, proteid, and amylace-
ous diet, and in 10.2 percent, on fluids and soft solids.
As to the question of the diet in convalescence, it
follows that those who believe in full feeding have
■ already solved it before defervescence has occurred.
If the patient has been kept on liquids, my own ex-
perience inclines me to allow solids gradually at the
earliest possible moment, the guides being the pa-
tient's general condition, the presence of hunger,
clean tongue, and the absence of sloughs or much
mucus from the stools.
The question of radical increase of diet may also
come up at other times. Among these I may mention
the unduly prolonged persistence of fever. Not a few
of these cases are cases of inanition or starvation,
the bodily and mental phenomena of which are not
recognized as such, but are reckoned among the
typhoid phenomena. A careful consideration of all
the features of the case, and more especially an ex-
amination of the blood, will often reveal the true con-
dition.
The most marked example of starvation which I
have thus far encountered occurred in a case in pri-
vate i^ractice this spring. After having been for some
time under the care of another physician, the bad con-
dition of the patient led to a change of her medical
adviser. I found the patient, a wildly maniacal wo-
man, aged thirty years, with fever of 104.5° F- > pulse,
140; respiration, 38. Feeding was utterly impossible
on account of her mania. There was no other re-
course except to feed her by means of the stomach
tube. This was easily effected with the aid of a gag.
Within twenty-four hours the effect was almost magi-
cal : all the symptoms, especially the mental changes,
were decidedly improved. Investigation of the diet
on which tiie patient had been fed before I assumed
charge showed that the nourishment which si had re-
ceived was absolutely liquid, and of the most meagre
character. I may add that the subsequent course of
the case was most prolonged and complicated, ano yet
she recovered in spite of eighteen profuse hemorrhages,
a lobar pneumonia, and saphenous thrombosis.
' Loc. (it. , p. 332.
January 6, 1900]
MEDICAL RECORD.
In this connection I may be pardoned if I refer to
the use of the stomach tube in typhoid fever. While
there have not been many occasions on which its use
has seemed necessary to me, yet I have never had oc-
casion to regret its use. The indication has been
uncontrollable vomiting. Careful lavage of the stom-
ach, and the introduction of small quantities of predi-
gested food while the tube was in situ, have given sat-
isfactory results. \\'e do not hesitate to use the tube
in cases of strangulated intestines, after laparotomies,
etc. Why should we hesitate to use it in typhoid
fever, if the indication should arise? It need scarcely
be added that such a procedure should be entrusted
only to those who by constant practice are able to pass
the soft stomach tube with the least amount of dis-
comfort to the patient. At such a time and place
the bungler ought to recognize his proper sphere.
There is still another point of which experience
has taught me to recognize the value, i.e., the impor-
tance of allowing intervals in which nothing at all is
permitted to enter the stomach in patients whose feed-
ing has been rendered difficult from fermentations,
vomiting, etc. This is especially frequent when the
diet has been entirely liquid; the stomach is cease-
lessly deluged with liquids; its motility and secretion
being diminislied, its burden cannot be effectually
disposed of; stagnation results with its coincident
fermentation, and the familiar vicious circle is estab-
lished. Rest to the organ is the simplest and best way
to remedy this distressing combination.
In conclusion I would state that I have not touched
on many other points in the dietetic treatment of this
disease. This was done advisedly, since I believe I
have presented enough to show the paramount need of
physicians paying more attention to the diet in these
cases. At present it is entirely too stereotyped, or it
is not regulated at all, the simple direction being
given to feed the patient on milk! If only a fraction
of the energy which is now wasted in prescribing
needless drugs were devoted to intelligent personal
supervision of the diet, the patient would gain much;
if another fraction of this same energy were given to
securing proper disinfection of the stools, urine, bed-
clothing, etc., the patient's family and the community
at large would be greatly benefited; and if still
another fraction of this energy were devoted to a-
study of the diagnosis of typhoid fever, the profession
at large would be spared the humiliation of being so
frequently and so justly scourged for its ignorance on
this most important topic. And, as a corollary, the
patient's stomach would be spared many a task, and
it would be left in condition to digest something
more than the emasculated slops which are now ten-
dered under the guise of many of the so-called foods!
Finally, I must add, lest I may perchance be mis-
understood, that I do not advise that each and every
patient be placed upon these less restricted diets, nor
that every article of diet may be allo\Ved. The ques-
tion has not yet been sufficiently studied to justify
one in giving any sweeping directions. Enough
material has, however, been gathered by such trust-
worthy clinicians as Fitz and Shattuck to justify
physicians, especially those who have the advantages
of hospital services, in giving an extended trial to the
more liberal feeding of typhoid-fever patients.
Rectal Adenomas According to Beach {Phila-
delphia Medical Journal, December 16, iSgg, p. 1195),
rectal adenomas may be hard or soft. They contain
the constituent elements of the mucosa and submucosa.
They may be benign or malignant. Benign in origin,
they may become malignant. Early recognition, made
possible by the newer methods of inspection, is of first
importance.
TWO CASES OF TUMOR PRESSING UPON
THE CAUDA EQUINA; REMOVAL; RE-
COVERY.'
By B. SACHS, M.D.,
In the cases to be reported herewith, the symptoms
pointing to intra-vertebral tumor were slight, yet defi-
nite enough to warrant prompt surgical interference.
In both cases the neoplasm was found and success-
fully removed. The patients have been relieved of
the distressing symptoms. In both the chances of life
are far better than if the malignant tumor had been
allowed to go on growing indefinitely.
Case I. — The first patient was seen by me Septem-
ber 23, 1899, in consultation with Dr. J. A. Wyeth,
who will publish the full surgical details in his series
of spinal cases.
Colonel J — — , fifty-six years of age, married, a man
of robust constitution, has been suffering for the past
eighteen months from severe pains in the right thigh
and leg, associated latterly with sudden and severe
spasmodic contractions of the thigh muscles. He had
been shot in the Civil War, the bullet passing obliquely
through the upper portion of both thighs and out. His
pains were suspected to be connected, possibly, with
this old bullet wound, or to be of the ordinary neural-
gic type (sciatic and crural). Anti-neuralgic measures
had been employed by various physicians in the South
without benefit to the patient, who was finc.lly referred
to Dr. Wyeth for further treatment. At the time of
my first and the only examination prior to the opera-
tion, I was struck by the cachectic condition of the
patient, by the violence of the pains, and by the fre-
quent severe spasms of the muscles of the right thigh;
these spasms being preceded, as a rule, by excruci-
ating pain. The entire right thigh and leg W'ere some-
what wasted, but the muscular power was in keeping
with the amount of muscular tissue preserved. The
patient could not state whether this condition had
been developed during the past two years, or whether
the limb had been wasted in consequence of the bul-
let wound, thirt)'-five years ago. As there was little if
any paralysis, I was inclined to accept the latter the-
ory, and did not allow the general atrophy of the mus-
cles to interfere with the localization of the lesion.
The pain, as described by the patient, was neuralgic
in character, not markedly affected by the position of
the limb, but was much more persistent than in ordi-
nary neuralgias, and radiated from the lumbar region
of the spine into the posterior portion of the entire
extremity as far as the toes, and occasionally would
go into the anterior aspect of the thigh. In walking,
the lower portion of the spine was rigid and appeared
to be a functional rigidity due to pain. The spinal
column was not very sensitive at any part. Deep
pressure upon the spinous processes of the second and
third lumbar vertebras produced some pain. On press-
ing even lightly at a point about one inch to the left
and between these vertebrae, pain was excited, and this
pain radiated down the leg in the same fashion and
was exactly like the pain which the patient experi-
enced at other times. This statement was made so
positively that it had great weight, in view of the very
moderate development of all other symptoms. The
suspicion of a neoplasm involving the cauda equina
was strengthened by the objective disturbances, how-
ever slight, of sensation. There was a distinct dimi-
nution, not a loss, of tactile pain and temperature
sense in the posterior and upper inner portion of both
thighs; pulling of the hair, slight pricks of a pin,
blowing of breath upon the skin could not be readily
' Read before the New York Neurological Society, December
MEDICAL RECORD.
[January 6, 1900
distinguished; but more intense stimuli could be per-
ceived. The right knee jerk was absent, the left nor-
mal and lively; both Achilles-tendon reflexes could
not be elicited; there was no ankle clonus; the scrotal
reflex of the left side was greatly increased; all other
deep and superficial reflexes were about normal. The
vesical and rectal reflexes were not impaired. The
heart and kidneys were normal.
The persistent neuralgic pains and the slight objec-
tive disturbances of sensation, though they had lasted
nearly two years, formed a scanty basis upon which to
rest a diagnosis of tumor; but the presence of a new
growth was rendered more probable by the severe spas-
modic contractions of the thigh muscles and by the
production of pain exactly like those of which the
patient complained, from pressure near the second
lumbar vertebra. Moreover, the site of this painful
area tallied perfectly with the portion of the spinal
axis to which the objective sensory symptoms had to
be referred. The absence of the right knee jerk and
the atrophic condition of the muscles of the thigh and
leg would have pointed to a lesion nearer the second
lumbar segment; but these symptoms were accounted
for by the old bullet wound. In the absence of vesi-
cal and rectal disturbances, and because of the strictly
unilateral character of the symptoms, although the
disease had lasted nearly two years, preference was
given to the cauda equina, rather than to the lumbar
segments, as the site of this lesion. That the neoplasm
was extradural was also probable, for an intradural
growth would surely have produced symmetrical symp-
toms referable to the cauda equina, and if intradural,
the symptoms would be more symmetrical ; the sen-
sory and motor symptoms in the case w^ere taken to be
irritation symptoms of the anterior and posterior roots.
At the conclusion of my first examination I urged Dr.
Wyeth to operate at once for the removal of the growth
which he was to find under the second or third lumbar
vertebra. The operation was undertaken on October
ist. A large incision was made from the third lum-
bar vertebra upward. Upon dissecting away the mus-
cles from the median line, a small bulging mass was
observed on the left side between the second and third
lumbar vertebra;. The mass appeared so vascular that
Dr. Wyeth exercised the greatest precaution not to in-
jure it while removing the laminaa of the exposed ver-
tebrrE. Upon exposure of the spinal canal, a tumor,
of the size of a small walnut, adherent to the dura and
to the inner surface of the, bones, was in evidence.
This was removed in blunt fashion, without injuring
the soft parts; the lamina had, however, been invaded
by the disease. A microscopical examination of the
mass proved this to be an alveolar sarcoma. The
surgeon removed as much as was practicable of the
diseased bony tissues, but whether or not the line of
demarcation between healthy and diseased tissue had
been reached could not be stated with certainty.
On the filth day after the operation I had an oppor-
tunity of examining him. He was out of bed, and, for
the first time in many months, was free from pain and
able to walk about with comfort. The spasmodic
movements of the limbs had ceased, and the most
careful testing failed to reveal any objective sensory
disturbances. It was evident, therefore, that these
symptoms were due entirely to pressure of the tumor
upon the strands of the cauda equina. The knee jerk
has not returned, but this I hold to be due to the in-
jury of years ago. The patient made an excellent
recovery, returning to his home in the South a month
after the date of the operation. He was free of pain,
had full use of his limbs, and was evidently none the
worse for the removal of two laminre. It is, of course,
possible that the patient may some day suffer a relapse
— possibly from a deposit in some other organ -but he
has been cured, apparently, of the spinal disease, and.
if Bruns is right, a recurrence of the spinal affection
need not be feared.
Case II. — In the second patient the difficulties of
diagnosis were far greater and the disease was more
advanced.
A. A , thirty-two years of age, was admitted Oc-
tober 9, 1899, into Mt. Sinai Hospital, in the service
of Dr. Alfred Meyer, who was kind enough to place
the patient under my care. His father died of pneu-
monia.; his mother is living and healthy. There was
no history of any previous infection, and, according
to his own statement, the patient has been moderate
in all his habits. Ten years ago he was supposed to
have pulmonary tuberculosis, and Dr. Looniis advised
his going to Colorado. The patient spent two years
in California, and evidently recovered from the dis-
ease which threatened his life.
Tlie patient remained well until one year ago, when
he began to feel shooting pains in the back and legs.
They were most marked every second or third night.
During the past six months the attacks of pain became
more frequent, occurring during the day-time as well
as at night. About six or seven months ago he noted
a girdle sensation about the level of the umbilicus,
which he experiences no longer. He has also noticed
paraesthesise of the plantar surfaces of the feet, but
only when walking barefooted. Three or four months
ago, he thinks, there was ansesthesia on the outer side
of the left leg. He states that a few months ago there
was distinct double vision. Hearing, taste, and smell
have always been normal. About six months ago his
legs became unsteady, and the unsteadiness increased
after an enforced rest in bed of six weeks. He expe-
rienced distinct pain while walking, and states that
this was more marked in the left leg. During the last
two months walking had become increasingly difficult.
The patient thinks that the difficulty was due to the
fact that he was unable to bear the weight of the body,
not to a tendency to swaying. He never noticed any
symptoms about the arms, but during the past six
months has had a feeling of stifTness in the lower por-
tion of the back, but did not know that there was any
change in the configuration of the spine. There was
tardy micturition, and occasionally the act was accom-
panied by pain. The patient is of the emotional
order; many of his statements have had to be taken
with a grain of salt; they were colored by the fact
that he had been seen by a number of physicians, who
had evidently questioned him closely in their endeavor
to elicit the symptoms of tabes dorsalis, the diagnosis
with which the patient had been sent to the hospital.
His condition at the time of my first examination,
October 14, 1899, may be summed up as follows:
Slight weakness of the external rectus, evidenced by
slight lateral nystagmus-like movements on following
the finger to the extreme left. The pupils reacted
normally to light and during accommodation. Every
passive movemerit of the eyelids was promptly per-
ceived. There were no tremor of the tongue and no
facial tremor. In the upper extremities not a single
symptom was to be elicited. On the chest, back, and
abdomen sensation was normal, and all the reflexes
could be elicited. There was a distinct kyphos in-
volving the twelfth dorsal and the upper three lumbar
vertebrae. There was no pain on pressure over this
area, except at one point about one inch to the left of
the median line between the third and fourth lumbar
vertebrjE. Muscular power was evidently diminished
in both lower extremities, the left leg being weaker
than the right. But, in spite of his pain, the patient
could be got out of bed and made to stand and to take
a few steps, but his locomotion was ditflcult, and made
doubly so by the fear of the pain accompanying it.
Both knee jerks were absent. On the right side the
plantar reflex was wanting; on the left side it was
January 6, 1900]
MEDICAL RECORD.
sliglitly present. Both Achilles-tendon reflexes were
wanting. In the lower extremities the sensation was
normal, except on the dorsal aspect of the left thigh,
of the left half of the perineum, scrotum, and of the
penis. In this area there was no absolute loss of any
form of sensation, but there was distinct diminution
of all. Heat and cold could be felt, but could not
well be distinguished from one another. There was
no marked interference at this time with the vesical
and rectal reflexes, and no other symptoms of any ac-
count were noted, except that the lungs seemed suspi-
cious. Both apices were dull, and there was distinct
broncho-vesicular breathing at the left apex, witii
crepitant and subcrepitant rales. These rales were
also heard over the entire left chest anteriorly.
In view of the normal condition of the pupils, the
absence of strictly ataxic symptoms, and the presence
of a kyphos and of a considerable amount of paresis
in the lower extremities, the diagnosis of tabes was
rejected. The gradual onset of the disease, the rapid
development of the lumbar deformity, the weakness of
the lower extremities, the loss of the deep reflexes, and
the strictly unilateral character of the sensory changes
pointed to a lesion involving the lowest portion of the
spinal axis. The diagnosis of a malignant neoplasm
was made after the first examination. In deference,
however, to the views of several colleagues, to the sus-
picion of tuberculosis years ago, and to the signs pre-
sented by the patient at the time of the examination
at the hospital, and also in consideration of the marked
kyphos present, the possibility of a lumbar Pott's dis-
ease was borne in mind. At the suggestion of the
attending physician, the patient was suspended, and it
was concluded to put him upon the iodides, nutritious
diet, etc., and other appropriate treatment for a period
of two weeks. While the patient was suspended, it was
noted that the kyphos was not corrected and that the pa-
tient could hardly move his legs and thighs. During
the period allowed the symptoms showed no improve-
ment, and on November 3d I urged the patient's remov-
al to the surgical ward for operation by Dr. Gerster.
The symptoms had not been altered, except that the
weakness of the legs had slightly increased, but the
areas of disturbed sensation remained practically
the same. It was at this time a little doubtful whether
the trouble was entirely restricted to the Cauda equina,
or whether the lumbar enlargement had been partially
involved. The conclusions reached were that the neo-
plasm within the vertebral canal pressed upon the
lowest spinal strands, those connected with the first,
second, and third sacral segments. It was probable
that the neoplasm arose from the inner surface of the
bone pressing upon the left half of the cauda, but that
it had gradually extended across the median line to
the right. It was evident that the disease was steadily
progressing, and the appearance of the kyphos denoted
involvement of the body of the vertebra. The mer-
curial and iodide treatment to which the patient had
been subjected in the medical wards had been of no
avail; the possibility of a gummatous affection was
dismissed, so that the diagnosis was narrowed down to
a tuberculous or other malignant neoplasm. If tuber-
culous, there was every reason to suppose that the proc-
ess was strictly localized, and I did not, therefore,
allow this possibility to deter me from urging opera-
tive interference.
At my suggestion, Dr. Gerster, on November 10,
1899, midertook to do a laminectomy of the second
and third lumbar vertebras. I quote from the sur-
geon's record of the operation :
"Longitudinal incision from 12 D to 4 L. As soon
as lamina of the third lumbar was removed, nodular,
elastic, pale, somewhat gelatinous masses were seen to
occupy the space between the laminse of the second
lumbar and fourth lumbar vertebra. Puncture gave
no result, proving the masses were solid. The spine
of the third lumbar vertebra was movable and detached
from the lamina. As soon as this was removed it be-
came evident that the entire posterior portion of the
third lumbar vertebra had been invpded by a new
growth, which had disrupted the cohesion between the
spine and the laminaj. The loose portion of the lam-
ina of the third lumbar vertebra was removed by for-
ceps and scissors, when the semi-globular tumor mass
was exposed in'its full extent. To ascertain whether
the neoplasm extended up the canal, the spinous proc-
ess and the lamina of the second lumbar vertebra were
also removed, and it was shown that the tumor ex-
tended only to the lower margin of this vertebra. The
tumor was removed, and above the normal and glisten-
ing dura was clearly seen. The cauda equina under
the tumor had evidently been much compressed and
appeared attenuated. The wound was drained with
gauze, and most of it closed with button sutures. The
patient made a good recovery from the operation."
Sections of the tumor, prepared for me by Dr. A.
Wiener, show it to be a small-celled fibro-sarcoma.
The first sensory tests were made two hours after
the operation, and at that time seemed to be about the
same as before the operation, except that on the right
buttock the area of anesthesia was more extensive.
• Three days after the operation, on the 13th, sensation
in the legs seemed improved. The patient could feel
stimuli, but had some difficulty in locating the point
at which he was touched. Since the day of operation
the patient has been improving steadily, but he is still
confined to his bed. The wound has been allowed to
granulate slowly, for the purpose of thwarting the re-
currence of the new growth.
The history of the case has been rather uneventful,
the patient slowly regaining power in both lower ex-
tremities, having full control over the vesical and rec-
tal reflexes, but exhibiting more marked disturbance of
sensation.' The extension of the areas of anaesthesia
directly after operation must be attributed to hemor-
rhage or some other slight accident during the opera-
tion. At the present time there is only a slight ana'S-
thesia to touch and to pain on the soles and dorsal
margins of each foot, and on the posterior aspect of
each thigh and leg, the disturbance being greater on
the left side than on the right. Both knee jerks are
absent, and an electrical examination proved that the
responses were diminished, but not distinctly altered
in any of the thigh and leg muscles or nerves.
Although this patient has not yet fully recovered his
health, the improvement is so marked as to lead to the
hope of a temporary recovery. The resemblance to
the first case was so striking that I felt justified in
reporting it; for we can claim in this, as in the case
of the first patient, that life has been prolonged by the
operation. Surgical interference w as surely warranted,
and if any error in judgment has been made it was in
the length of time the operation was delayed. If we
had not deferred to the fear that the disease was, after
all, tuberculous, I doubt whether the invasion of the
bone would have been as complete, and we could have
been more certain of radical enucleation of the tumor.
While Dr. Gerster removed as much as could be seen
of the malignant mass, it is possible that some of the
new growth remained behind, and the danger of relapse
is, therefore, so much the greater.
The writings of Gowers and Horsley,^ of Thorburn,^
Starr,' Putnam and Warren,^ and the excellent mono-
^ I .nm indebted to Dr. Beer of the house staff for repeated and
careful sensory tests.
= Med.-Chir. Trans.. 188S, p. 407.
^ Brain, vol. xi., p. 2Sg ; also monograph, " A Contribution to
the Surgery of the Spinal Cord," London, iSSg.
^ Amer. Jour, of the Med. Sci.. July, 1892; Brain, October,
1S94; Amer. Jour, of the Med. Sci., June, 1895.
' Amer. Jour, of the Med. Sci , October, 1S99.
MEDICAL RECORD.
[January 6, 1900
graphs of Schlesinger' and of Bruns' have left little
to be said on the subject of spinal tumors, but it may
not be amiss to refer briefly to the lessons taught by
the experience here recorded. Bruns' opinion, that
the diagnosis of an intravertebral tumor can be made
only by a fortunate combination of circumstances,
may hold good in many instances; more often the ex-
amination has not been searching enough. In my
first case a chronic neuralgia was diagnosticated, in
the second a tabes dorsal is. In the first case the
error was pardonable, for the sensory changes were so
slight that I would not have ventured to attach much
importance to them, if the disturbances in sensation
had not tallied very accurately with the area which
was painful on pressure, and pressure exerted over the
area produced pain corresponding in every particular
to that felt spontaneously by the patient. In the sec-
ond case the areas of anaesthesia were also distinct
and peculiarly limited to the sacral distribution. The
unilateral disturbance of sensation in one-half of the
perineum, scrotum, and penis is surprising, in view of
the large size of the tumor; but evidently it must, for
mechanical reasons, have exerted far greater pressure
upon the left than upon the right half of the Cauda
equina. In both cases the question arose whether the
symptoms were due solely to pressure upon the cauda
equina, or whether the lumbar enlargement was the
site of the trouble independently of, or in association
with, the Cauda equina. The restriction of objective
sensory disturbances to the region supplied by the
sacral plexus, the bilateral distribution of tlie pain,
the absence of marked vesical and rectal symptoms,
the relatively slight paralysis, pointed to the cauda
equina and not to the lumbar enlargement. The ques-
tion was practically settled by the discovery in each
case of an area painful on percussion below the level
of the second lumbar vertebra. However secure we
may feel in our present knowledge of segmental func-
tion, it will surely be wiser to urge operation at or
near the site of a kyphos, or over the painful area on
the spine and from there upward or downward, than to
disregard such palpable evidence of trouble and
to trust in refinements of diagnosis. In both cases the
method was adopted with entirely satisfactory results.
Segmental diagnosis" has been carried to such a de-
gree of perfection that the more difficult question is
not, Where is the lesion ? but What is the nature of the
lesion? Do the symptoms warrant a diagnosis of
tumor in a given case? Pain and other sensory or
motor symptoms, strictly localized, unilateral or bilat-
eral, but progressive, and bearing for a long time the
characteristic marks of root symptoms, followed pos-
sibly by symptoms of an advancing invasion of the
cord substance, should suggest the probability of in-
travertebral neoplasm. If extra-spinal, the sensory
symptoms will predominate for a long period of time;
but whether extra- or intradural, it is not easy to decide;
except that if the neoplasm is intradural, cord symp-
toms will be added earlier to those pointing to root
involvement. In both my cases I predicted extradural
growths, because unilateral symptonis persisted for a
great while, and in the second case because of the
rapid invasion of the spinal column while the sensory
symptonis remained unilateral.
Upon the nature of the growth in either case I did
not care to speculate, for an experience* reported thir-
' " Beitrage zur Klinik der Ruckenmarks- und Wirbeltumoren,
1S9S.
" " Die Geschwtilste des Nervensystems," Berlin, 1S97.
^ C/. writings of Starr (/cc cit.) ; Head, Brain, 1893 ; Schultze,
Deutsche Zeitschr. f. Nerv-enheilk. , vol. v., p. 247 ; Sherrington,
Journal of Physiology, 1892, vol. xiii., No. 6 ; and of Wichmann,
" Die Ruckenmarksnerven und ihre Segmentsbezuge," Berlin,
1900.
■■Sachs: Journal of Nervous and Mental Disease, vol. .\iii.,
18S6.
teen years ago taught me that solitary tubercles may
occur in the spinal cord of persons who are apparently
in excellent health, and who had not presented tuber-
culous signs in any other organ. In the first patient
sarcoma was probable; in the second, the history of
tuberculous disease suggested the possibility of spinal
caries or of solitary tubercle; the new growth was,
however, distinctly sarcomatous. If one bears the
entire progress of the disease in mind, there are, after
all, few chronic spinal processes that take the slow yet
steadily progressive course so typical of intravertebral
neoplasm.
Whenever there is a strong suspicion of extra-spinal
neoplasm, and a possibility of reaching the site of a
supposed tumor, an exploratory operation should be
attempted, and at as early a stage as possible. I am
tlioroughly opposed to unwarranted operations, as
when there is evidence of complete destruction and
involvement of the cord; but in this matter I would
prefer to take sides with Horsley and Starr than to
adopt the ultra-conservative views from which even
Bruns could not wholly escape. An exploratory lam-
inectomy, if properly done, is comparatively harmless,
particularly in the dorsal and lumbar regions; and,
fortunately, a large number of spinal neoplasms occur
in these regions. The removal of several lumbar
lamina does not interfere with the stability of the
vertebral column. In my first case, even if the tumor
had not been found, the patient would not have been
made worse by the operation; and this, I doubt not,
would be true of many other cases. The second pa-
tient would have had better chances of rapid recovery
if the operation had been done a fortnight earlier,
when the idea was first mooted. In the presence of
malignant disease prompt action is the most conserva-
tive. The report submitted herewith should give some
support to that view.
PUERPERAL INSANITY.'
By WILLIAM HIRSCH, M.D.,
Since the earliest times in the history of medicine
the relation of child-bearing to insanity has interested
physicians. The literature which exists on this sub-
ject has become so voluminous that it hardly can be
overlooked to-day. If in spite of this I take the
liberty of bringing this subject before you, it is not
because I think that I can add anything to the facts
collected, but rather on account of the great differ-
ences of opinion which exist among physicians on the
subject. I feel the more justified in doing so, as
these differences do not consist entirely of academical
and theoretical questions, but have an important bear-
ing on the treatment and general management of in-
dividual cases.
Since the doctrine as enunciated by Hippocrates,
it has been a generally accepted theory that all the
different stages belonging to the process of gestation
are apt to produce certain forms of mental disease,
which, according to this theor)', were classified as
psychoses of pregnancy, psychoses of puerperium, and
psychoses of lactation. When I speak of puerperal
psychoses, I wish to be understood as comprising all
these three categories under the general term. A
great many theories have been advanced as to the
pathological relation between the uterus during this
period and the psychoses. Hippocrates laid great
stress on the manner in which the milk entered the
breasts, and held this process responsible for the pro-
duction of the mental disease. According to him the
• Read before the Metropolitan Medical Society, January 24,
1899.
January 6, 1900]
MEDICAL RECORD.
retention of the lochia post partum produced a mani-
acal condition. Since the times of Hippocrates this
view, though under various modifications, has pre-
vailed, that the entire process of gestation in all its
different phases produced certain chemical changes in
the female body, which under favorable circumstances
may affect the brain and produce a mental disorder.
It is not my intention to give you a history of the
various theories and views regarding this subject. I
wish to discuss only certain questions, and especially
those which are of practical importance, which must
necessarily influence us in the treatment and manage-
ment of the patient.
The principal question of course, in which all our
investigations must culminate, is the role which the
process of gestation plays in the production of psy-
choses. This point is of vital importance in the
treatment of our patients. Take, for instance, a
woman who develops a severe psychosis, say during
the third month of pregnancy. Shall we allow her to
go to term or not? I think it is evident that if we
are convinced that pregnancy as such has produced
the mental disease, we could not expect to cure the
latter while the cause not only persists, but increases
for the next six months with the further progress of
pregnancy. According to the fundamental principle
of the practice of medicine, it would be our duty to
remove the cause of the disease^to empty the uterus.
In order to throw some light on this important ques-
tion it is necessary to discuss several points. The
first would be: Does there exist a certain form of
mental disease which is clinically so characteristic
that we could make the diagnosis of a puerperal psy-
chosis merely from the psychopathic symptoms, as for
instance we can diagnosticate an alcohol psychosis or
epileptic insanity merely from the clinical aspects?
This has been claimed by only a few psychiatrists, as
for instance Fiirstner, who in the year 1875 published
a few cases under the name of " puerperal insanity,"
of which he claimed that they formed a special dis-
ease which was clinically well defined and different
from any other form of insanity. Whether Fiirstner
has kept up this view until to-day I do not know.
His new disease, however, seems not to have been ac-
cepted by other psychiatrists, and I think that nobody
believes to-day in the existence of a specific puerperal
ps)'chosis.
If, therefore, the process of gestation plays any role
at all in the production of insanity, it can be only that
of an etiological factor like other etiological moments.
The place which it occupies in etiology could be de-
termined solely by experience and observation, and in
order to determine this important question we have
to refer to a valuable but equally dangerous medium
of science — i.e., statistics.
I do not intend to fatigue you with figures either
from my own experience or from the observation of
others. I only want to ask you to let me consider
with you for a moment the manner in which statistics
have been employed in this question, and what con-
clusions have been drawn from them. Most authors
who have written on this subject have taken the entire
number of all mental diseases among women vi'hich
came under their observation, and then calculated the
percentage of those cases which would go under one
of the three categories of puerperal psychoses. In
other words, any -woman who was either pregnant or
was in the puerperal stage, or who nursed a baby at
the onset of the disease, counted as a puerperal psy-
chosis. The higher the percentage of these cases was
the more apparent was, according to the conclusion of
these authors, the connection between the process of
gestation and insanity. Some writers, as for instance
Ripping, report that nearly twenty-two per cent, of all
their female cases of insanity were puerperal psycho-
ses. Now, are we justified in drawing such conclu-
sions from these figures? I think that it would be a
great mistake to do so. In my mind these figures do
not prove more or less than the simple fact that of so
and so many insane women such and such percentage
happened to be in one of the stages of gestation. In
order to decide the point in question it would be
necessary to supplement these figures by others, as,
for instance, what is, under normal conditions, the
percentage of women who are in one of these stages?
If we consider that one entire process of gestation,
including the stages of pregnancy and lactation, takes
nearly two years, and that in some countries the aver-
age woman has five or six children, it is evident that
if these women should get a mental disease at all be-
tween the ages of twenty and forty years, they have
more than fifty per cent, of chances to be classified as
puerperal psychoses. It always remains to be proven
that such a woman would not have acquired the dis-
ease just as well without her pregnancy.
While it is very difficult to obtain from statistics
sufficient data to draw any reasonable conclusion re-
garding this subject, I think the figures themselves
which have been reported by different authors may
lead to quite an opposite verdict if they are looked at
in a certain light. There are, for instance, very
marked discrepancies between their various reports.
As I said. Ripping reports 21.6 per cent, of puerperal
psychoses, while others have totally different figures.
A recent publication from one of the largest private
institutions in Germany has only 12.5 per cent. Now
what is the reason for this discrepancy ? This latter
institution receives mostly patients of the higher
classes, especially of the German and Russian aristoc-
racy, while Ripping's report is from a public institu-
tion in which the patients belong to the lowest class
of social life. Now what follows from this? That
in the aristocracy the process of gestation is less apt
to produce mental diseases than in the lower classes?
If this were so, then the total percentage of insanity
ought to be less also in the higher classes. But is
this true? No, quite the contrary; there is much
more insanity among the aristocracy than among
the laboring classes. The only conclusion, therefore,
which could reasonabl)' be drawn from these figures
is, that the women of the higher classes bear fewer
children than those of the lower classes, which as-
sumption corresponds, as you all know, to facts.
Most women of the laboring classes between twenty
and forty years of age are either pregnant or nursing
a baby, while in the aristocracy women are much
more careful in preventing conception, and nursing
their own babies is quite a rarity. In an analogous
way the reports of French authors show considerably
lower figures in the percentage of puerperal psychoses
for the simple reason that French women have fewer
children. But is insanity a rarer occurrence among
French than among German women ? By no means.
The percentage is, on the contrary, higher in France
than in any other country. What do these figures
prove, then? "• If anything, they show that the process
of gestation plays quite a subordinate role in the etiol-
ogy of mental disease.
Furthermore, if the different phases of child-bearing
would really play such an important role in the pro-
duction of psychoses, it would be reasonable to ex-
pect that in all these cases of so-called puerperal
psychoses the other etiological factors should be less
than in ordinary cases of insanity. The principal
element in the etiology of mental disease is, as you
all know, heredity. Now is there less heredity in
these puerperal cases than in others? No; accord-
ing to the reports which I have referred to, there is
even a higher percentage of heredity in these cases.
The recent report from the German institution men-
MEDICAL RECORD.
[January 6, igoo
tioned gives heredity in sixty-six per cent, of these
puerperal cases, which is even higher than one usu-
ally finds in insanity. In my own cases of mental
diseases of all kinds I have found heredity as an etio-
logical factor in only fifty-eight per cent.
If, furthermore, these twenty per cent, of all cases
of female insanity should really be due to the influ-
ence of gestation, insanity should be much more fre-
quent among women than among men. But this is
not the case. All statistics show that there is very
little difference in this respect between the two sexes;
that if anything men are in the majority. It is true
that there are certain etiological factors in men which
play an inferior role in women, as for instance alcohol
and syphilis, general paresis being comparatively rare
among women. This, however, is balanced by other
factors in women besides child-bearing, as for instance
the menopause, etc., but it could never reach the enor-
mous difference of twenty per cent.
While all these facts strongly indicate that there is
nothing peculiar in the so-called puerperal insanity, I
will not deny, on the other hand, that the process of
gestation may in some cases play a more or less im-
portant role in etiology, and that for the sake of
proper treatment we have to make the relation between
this factor and the mental disease a subject of special
consideration in each individual case.
Now let us consider under what circumstances and
in what diseases any of the phases of gestation might
be apt to influence our judgment of the cases regard-
ing the prognosis, or to affect our method of treatment
and the management of the patient. Any pregnant
woman, of course, might as easily acquire a mental
disease as any other woman. The prognosis of such
disease is exactly the same as it would be under ordi-
nary circumstances. It depends on the history of the
case, heredity, general health, and the general classi-
fication. Still the question will always be asked by
the laity as well as by physicians, whether such a
woman should be allowed to go to term or whether
her pregnancy should be terminated. After what I
have said before, it is needless to assert again that it
would be obviously absurd to perform an abortion
in every case of pregnancy complicated by a mental
disorder. On the other hand, however, this question
must always be borne in mind, as under certain cir-
cumstances the uterus should be emptied. The most
frequent of mental diseases is a simple melancholia.
As long as such a patient is physically in a good con-
dition, as long as her general nutrition is good, there
is no reason why we should interfere with the process
of nature. Such a patient should be treated like any
other woman with melancholia — which treatment, of
course, cannot be discussed here — and the further
course of the disease might prove to be entirely in-
dependent of pregnancy. I have seen quite a number
of patients who developed a melancholia during the
earlier part of pregnancy, and who under proper treat-
ment made a prompt recovery before the birth of the
child. There is, however, a certain class of melancholic
cases, especially in weak, ansmic womeli, in which w'e
have to deal with a rapid loss of strength and flesh,
and in which, even under ordinary circumstances, it is
sometimes extremely difficult to keep up the general
nutrition. If such a woman is rapidly losing weight,
I should surely not allow her to go on with her preg-
nancy, but would have an abortion performed, of
course under the greatest precautions as to shock and
loss of blood. The same holds good for cases in
which the patient has to be fed forcibly with the
stomach tube. Melancholic patients sometimes have
the delusion that they are too bad to eat, or they may
want to starve themselves to death, or a hallucinatory
voice may tell them : " You must not eat." In such
cases it might be necessary to perform artificial feed-
ing for some time, and as naturally under such cir-
cumstances the general nutrition can be kept up only
with great difficulty, I would also terminate pregnancy
in such a case. Another indication for surgical in-
terventitDn would be extreme restlessness on the part
of the patient, as we see it in cases of melancholia
agitata or acute mania. Patients in this condition
sometimes have to be forcibly restrained, and it is
hardly necessary to point out the danger in which
pregnancy might involve a woman under such circum-
stances.
There are some cases of hysteria in which the fear
of having children is apt to produce a severe mental
disorder. We sometimes see such women just at the
border-line of insanity, and may be able by a surgical
intervention to prevent the development of a severe
psychosis. I must admit that just in these cases the
question whether we shall interfere or not belongs to
the most difficult problems in practice. On the one
hand, we are averse to performing an abortion on any
hysterical woman who does not want a child. On
the other hand, we do not want a mental disease to
develop, if we possess the means to prevent it. How
we have to act in individual cases of this kind cannot
possibly be described theoreticall)'. Our decision
must be based on personal experience, on psychological
and psychiatrical knowledge. No rules can be laid
down; every case has to be judged by itself. I have
seen several cases of this kind during the last few
years, in which I feel satisfied that the development of
a severe mental disease has been prevented by an
operation.
A question which we are frequently asked is, whether
insanity during pregnancy has any direct bearing on
the offspring. As in all questions, authorities differ.
My personal opinion is, that the development of the
child will not be influenced at all by such a disease
during pregnancy, but that the development underlies
the general law of heredity as under ordinary circum-
stances.
The puerperal state plays a more important etio-
logical role than pregnancy in the production of in-
sanity. There are certain mental diseases which come
on during or within a limited period after delivery
which are indeed intimately connected with this proc-
ess. It is this class of cases which gave rise to the
term "puerperal mania." This name has been re-
tained all over the world, although it is generally ad-
mitted to-day that most of these cases do not show
true mania at all. In order to reach a clear under-
standing of this class of disease, and to realize the true
connection between it and the process of parturition,
it is necessary to consider several types respectively.
We sometimes meet cases of transitory disturbances
of consciousness during the process of parturition.
They are most frequently produced by mental shock,
excitement, fear, etc. They occur mostly in unmarried
women, in whom the natural excitement is increased by
shame and sorrow. The clinical aspect of these cases
is that of psychical epilepsy. The patient becomes
suddenly very excited and agitated. The face is
flushed, the eyes are staring. Her actions are impul-
sive and inco-ordinated. She might in this condition
commit any act of violence, attack her friends or kill
her child. After this condition has lasted for one hour
or several hours, the patient passes into a deep sleep as
after genuine epilepsy, from whiclw she awakens with
total amnesia for the period of her excitement. In
some cases of this kind the history of epileptic con-
vulsions in previous life may reveal their true epi-
leptic nature. These cases have, of course, a great
medico-legal significance, many cases of infanticide
being due to this disturbance of consciousness.
Another group of mental disturbances during or
after parturition may be classified as toxic psychoses.
January 6, 1900]
MEDICAL RECORD.
13
The clinical features of these cases consist of an acute
delirium. Of course, I don't mean the ordinary fever
delirium, but a certain psychopathic state, which is
apt to occur during the course of various mental dis-
eases. This delirium as a rule sets in quite abruptly,
without any prodromic symptoms or after a very short
period of mental depression. It is not dependent on
temperature. The patient may have fever or the tem-
perature might be perfectly normal. The atypical
form and the rapid change of the symptoms are char-
acteristic of this form of disease. From a dull and
apathetic condition the patient suddenly passes into a
state of restlessness and agitation. Hallucinations of
one or more senses are always present. There is in-
coherence of thought and action. The entire pro-
gramme of psychosensory and psychomotor symptoms
is apt to occur without order or system. The prog-
nosis depends largely on the physical condition of the
patient. Cases in which the constitution is run down
and the general nutrition bad may terminate fatally
within a short time. Otherwise complete recovery
will take place. The duration of this class of cases
varies from a few days to several weeks. When they do
not end in recovery by this time a secondary psychosis
develops which may assume the clinical character of
an ordinary melancholia or mania, or frequently the
atypical form of mental disorder may develop which
has been described by Kahlbaum as dysphrenia. The
secondary psychosis may last for a number of months
and tlien end in recovery or pass into a state of ter-
minal dementia.
As far as the etiology of these cases is concerned it
would be erroneous to assume that we must neces-
sarily have a septic infection. Any inflammatory
process in the body is apt to produce a toxic psychosis.
Cases of acute delirium, such as I have described,
have been observed after any infectious disease as
well as after any local inflammatory process even as
slight as an ordinary angina. Therefore cases of
vaginitis, endometritis, salpingitis, or oophoritis occur-
ring post partum are just as apt to produce the psy-
chosis as severe septicaemia.
Some authors maintain that ura;mia, with or without
eclampsia, produces a special kind of insanity. I
myself, however, do not agree with this view. We see
in these instances the same toxic delirium which is
produced by other toxic agents; besides, we must bear
in mind that albuminuria is a comparatively frequent
symptom in cases of psychoses and does by no means
necessarily indicate a nephritis. Albuminuria is in
a good many instances the consequence of the psycho-
sis rather than its cause.
Those cases of mental disturbance which are pro-
duced by excessive loss of blood, such as may occur
in placenta prajvia, have a very similar clini'.al aspect.
Here also the psychosis begins with an acute delirium,
which, however, has more the character of ii^anition
psychoses. We have the typical asthenic de'irium
which we frequently see after a collapse; this cvndi-
tion, loo, may end fatally or lead to recovery after a
short time. The development of a secondary psycho-
sis is not so frequent as it is after a toxic delirium.
If it does set in, however, the prognosis is less favor-
able than in the toxic cases.
Finally we see, after cases of very difficult labor,
mental disturbances which might be classified as trau-
matic psychoses. They do not differ, however, from
cases which may occur after any other trauma or sur-
gical operation. Mostly they are of the hysterical
type, but may assume a more severe character, as acute
dementia, etc.
In all these different varieties of psychoses during
or after parturition, the etiological factors which I
have mentioned — shock, intoxication, inanition, and
trauma — must of course be looked at only as the ex-
citing causes. As a rule we find, as in most mental
diseases, certain predisposing causes, as heredity,
degeneration, malnutrition, ana;mia, etc. Although
parturition plays an important etiological role in these
cases in one sense, it is evident that all cases might
also result from other causes connected with shock, loss
of blood, intoxication, etc., so that we are not justified
here either in speaking of a specific puerperal insanity.
So far as the treatment of these cases is concerned
we must, of course, give our first attention to the un-
derlying cause — for instance, any local inflammation
of the sexual apparatus. In those cases which are the
outcome of exhaustion, an energetical stimulation of
the bodily strength is of the greatest importance. A
sufficient amount of nourisliment is absolutely neces-
sary. If the patient refuses to eat and cannot be fed
otherwise, we must employ the stomach tube at once
and not wait until the loss of strength has advanced
too far. Nutritive enemata are very valuable as a
help in nutrition, if the patient takes some nourish-
ment through the mouth, but they cannot be relied on
exclusively. In cases of delirium after excessive loss
of blood, an intravenous or intracellular infusion of
a saline solution is indicated. In the endeavor to
preserve the general strength it is of the utmost im-
portance to combat the motor restlessness. The pa-
tient, of course, has to be kept in bed. Wet packs and
warm baths have often, at least temporarily, a sooth-
ing effect. If fever is present, ice applications and
cold sponge-baths are useful. If the starting-point of
the restlessness lies in the psychomotor area, hypo-
dermic injections of hyoscine or hyoscyamine are effica-
cious, while in psychosensory irritation opium should
be given. In some cases which seem to be dependent
upon congestive conditions hypodermic injections of
ergotin are often beneficial. It is of the greatest, im-
portance in these cases to produce sleep. In fact
sleep is just as important as nourishment; a long
period of insomnia may very quickly exhaust the
patient and lead to a fatal issue. If sleeplessness
sets in, as it nearly always does, it is therefore indi-
cated to administer hypnotic remedies in liberal doses.
Trional and sulphonal may be given in doses of 2 gm.
Another valuable hypnotic in cases of this kind is
paraldehyde, which may be given in doses up to 8
gm., even 10 gm. As long as the delirium persists,
mental impressions of all kinds must be forbidden.
Ornaments and pictures should be removed from the
room, which must be kept dark. It should be abso-
lutely quiet. The nurse must be instructed not to
speak to the patient unnecessarily. If other psycho-
ses, as melancholia or mania, develop secondarily, they
must of course be treated as under ordinary circum-
stances.
Finally we have to consider the relation which the
process of lactation bears to mental diseases occurring
during this period. Although the various statistics
show that insanity occurs more frequently during this
period than during pregnancy, I do not believe that
the process as such has anything to do with the pro-
duction of the psychosis. It is evident that all the
weakening influences which child-bearing has on the
nervous system are apt to show themselves during the
first few months after delivery. If we consider the many
cases of anamia due to post-partum hemorrhage, the
cases of exhaustion through difficult labor, the mental
excitement of the young mother, which is frequently
increased, especially in the lower classes, by anxiety
about the future, etc., we surely cannot be surprised
to find the average nervous system of women during
the first few months after delivery of the child more
disposed to mental and nervous diseases than under
ordinary circumstances. The psychoses which are
observed during this period have absolutely nothing
specific in their clinical features. They are the same
14
MEDICAL RECORD.
[January 6, 1900
as might occur in any other woman at any other time.
Their prognosis depends on the same factors and the
treatment must be the same as under ordinary circum-
stances.
In concluding I may be allowed to summarize with
a few words the important points of the relation of
child-bearing to mental diseases:
1. A specific form of mental disease, which might
be called puerperal insanity, does not exist. The
different psychoses w'hich are observed during one of
the stages of gestation are the same as those we see in
other patients.
2. Pregnancy may, under certain circumstances, be
one of the etiological factors of insanity. Its etio-
logical importance, however, is proven by neither
statistics nor clinical observation. It is, therefore,
not permissible to terminate pregnancy on account of
a psychosis, unless there are special indications for
such intervention.
3. During parturition we sometimes meet a transi-
tory disturbance of consciousness, the clinical features
of which resemble psychical epilepsy.
4. Psychoses which occur in connection with the
act of parturition are produced ((/) by trauma in cases
of difficult labor; (/') by anaemia and exhaustion after
severe hemorrhage; (<) by intoxication in septic cases
or cases with local inflammations, or urasmia. The
clinical symptoms of this group of psychoses consist
of an acute delirium which either leads to recovery
after a short time or passes into a secondary ps3xho-
sis. All these cases may be produced by the same
causes in the non-pregnant state. The clinical fea-
tures have nothing specific in any way.
5. Lactation, as such, plays no role at all in the
production of insanity. It is due to other circum-
stances that during the first few months after delivery
women on the average are more predisposed to nervous
and mental diseases than under ordinary conditions.
^hzTCUptxitic pints.
ConjunctiYitis. — In white staphylococcus forms irri-
gation may be practised with decinormal salt solution,
or with the following:
1} Borate of sodium 3 iij
Chloride of sodium 3 ss.
Cryst. carbolic acid gr. xv.
Water gal. i .
The frequency of the irrigation should be regulated
by the accumulation of matter on the surface of the
conjunctiva. The upper lid being everted and the
irrigating bag being hung twelve inches above the
plane of the patient's eye, the nozzle of the irrigator
is held over the bridge of the patient's nose and the
fluid allowed to run over the everted lid and the
inferior retrotarsal surface into a mass of absorbent
cotton held on the temple. This should be repeated
every half an hour. — Dudley S. Reynolds, Medical
JSlews, October 28th.
Diabetes Mellitus — J. M. Allen (Jownal of the
American Medical Association, October 28th) says:
The combination which I have used with apparent
benefit is as follows:
^ Creosote gftt. %
Tinct. nux vomica g't. x.
Saw palmetto 3 i .
M.
In saw palmetto we have something of a tonic as
well as a stimulant to the mucous membrane, thereby
lessening retrograde metamorphosis of this tissue.
Basing my treatment on the philosophy of etiology
and pathology as given, it is as follows: (i) Allow
the patient to eat only such foods as can be digested
by the stomach, giving the duodenum rest, and thereby
preventing physiological hyperemia. This continued
for a time will reduce the hypersemia to a point so
small and feeble as not to be a source of irritation to
the inflamed, etc., structures. (2) Use intestinal
germicides, the value of which, in my experience, is
in the order given : creosote, sulphocarbolate of zinc,
hyposulphite of soda, eucalyptol, menthol, oil of cin-
namon, sulphide of calcium, salol, betanaphthol, car-
bonate of guaiacol. I have found the pulvis hydrastis
canadensis, combined with salol, efficient and more or
less alterative to the mucous membrane. To control
reflex reaction I use gr. rpV to yV of morphine three
times daily, or aqua chloroformi, a dessertspoonful
three times daily. All of these patients suffer more
or less from anaemia of the nerve centres; to prevents
this I give gr. -^^ to -^^ of strychnine nitrate three
times a day, or the equivalent amount of nux vomica.
As a tonic I use either the bitter tonics or the phos-
phate of lime, or wine of the phospho-glycerate of lime
(Chapteau) ; the ferruginous preparations and the cod-
liver oils should be excluded.
For Cystitis, especially in its chronic form:
If Balsami canadens 20
Magn. calcin 27
Pulv. sapon.,
Pulv. benzoes aa q. s.
Ut f. pil. No. c. S. Four to six pills daily.
— Mesnard.
Toothache. —
1} Cocaine o. 25
Chloroform q. s.
Essence \'iolet 5.0
Camphorated oil,
Essence peppermint,
Creosote aa 2.0
If Creosote.
Chloroform,
Laudanum aa 10
Tinct. benzoin 30
Goitre. — It has been my opinion for some 3'ears
past that iodine alone was the essential medical
remedy for the removal of such goitres as could be
influenced by medicine, and with this idea in mind I
have, during the last four years, treated three-fifths of
my cases with iodine and two-fifths with the thyroid
preparation, and have found in thirty thus treated that
the patients who received the iodine improved more
rapidly than the others, and during the last three
months my patients have been taking iodine, only ac-
companied by tonics as required. Few of them can
take iodine steadily for many weeks, without showing
evidence of weakness; slight an.Tmia is likely to fol-
low, with increased rapidity of the heart's action;
often slight dyspnoea and headache with diminution
of bodily weight. The prescription is as follows:
If lodi (crystals) gr. ij.
Pot. iodid gr. iv.
Spir. vini rect 3 i.
Syr. simplicis J i.
Aquce destill J ij.
M. S. A teaspoonfnl in a wineglassful of water, one hour
after each mealtime.
After about two weeks, sometimes from the beginning,
an iron tonic is given; and if the patients are weak- i
ening rapidly, strychnine combined with calisaya and
iron, the iodine being discontinued for a week or two
at a time. After three weeks there is usually a per-
ceptible difference in the size of the goitre. In six
months many of the goitres disappear, others are re-
duced to from one-half to one-eighth their original
size. — Frederick G. Schaefer (Journal oj the Ameri^
can Medical Association, November 25th).
January 6, 1900]
MEDICAL RECORD.
15
Medical Record:
A Week/y Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 51 Fifth Avenue.
New York, January 6, 1900.
NEEDED REFORMS IN OUR AMBULANCE
SYSTEM.
Owing to the fact that of late the oft-time and much
discussed question relative to New York's ambulance
service and the seeming inhumanity of some of our
hospitals in subjecting patients to apparently unneces-
sary transfers from one institution to another has re-
ceived considerable attention at the hands of the daily
press, it is time to look at the question in its practical
bearings as to possible reform.
Of the various charges brought against the ambu-
lance surgeon by the laity, impugning his capability as
a physician and criticising his general conduct, we
would suggest that the many complaints harbored by
the public are the result not so much of wilful short-
comings of the young surgeon as the outcome of a sys-
tem which is palpably inefficient. To expect that a
man but recently graduated from a medical college, and
having had at the best but six months' experience in
practical medicine, should be capable at all times of
rendering a diagnosis absolutely correct and permit-
ting of no doubt, would savor of the miraculous. That
he might, however, without injury to himself cultivate
a little more of the " savoir faire," and likewise be ap-
preciative of the fact that an ambulance surgeon does
not of necessity constitute the pivotal point around
which the rest of mankind ought to rotate in silent
admiration, is a bit of advice which, if followed,
might tend to make the relations between himself and
the general public of a more genial nature.
Mistaken diagnoses have been, and probably will
continue to be, made, and we much doubt if there be a
single practitioner who during some time of his career
has not been guilty of an error ; " errare humanum est"
When any doubt exists, however, be it ever so slight,
it should be accorded the patient, for it were far better
that one hundred cases not demanding treatment were
taken to the hospital than that one case diagnosed
" drunk " should be for hours locked in a cell, and that
later examination should disclose a serious injury or
illness.
By making this a rule the opportunity would be
denied the daily press of presenting, as was recently
che case, a table of cases in each of which " intoxica-
tion " had been the verdict, while subsequent exami-
nation revealed serious injury; though in so large a
metropolis as New York, in which hundreds of ambu-
lance calls are daily answered, the fact that seven er-
rors have been committed during a period extending
over eighteen months, should not be accounted suffi-
cient to prejudice the public at large.
If those of our hospitals equipped with an ambu-
lance service would descend from their throne and re-
vise some of the existing rules and regulations, it
would benefit both their reputation and the public's
safety, and tend to obviate future criticism. As we
have before remarked, it is absurd to exact from a
novice that which can be the result only of experience.
The ambulance surgeon of the present day, when sum-
moned to a case, has no opportunity for calling a con-
sultation, but has to rely solely upon his own knowl-
edge. Would it not be better, as a furtherance toward
preventing mistakes, to constitute his duties the clos-
ing ones of his hospital career instead of the opaiing
ones? During a space of one and a half years much
valuable experience should be gleaned.
Transferring of patients from one hospital to an-
other, save where it can be accomplished without the
shadow of a risk to the life and health of the patient,
is an unjustifiable act, and, if done to further an ulterior
purpose, becomes criminal. A low mortality rate is a
result to be desired, but fair means should be employed
to obtain it. Only a few days ago a coroner's jury
had occasion to denounce this practice and censure
the hospital authorities for permitting repeated trans-
fers, which ultimately resulted in the death of the pa-
tient concerned. Citizens of Greater New York are as
a whole but little interested in hospital statistics, and
the fact that one institution can, at the end of the
fiscal year, boast of a lower mortality rate than some
other, is a matter of but little import to them. What
the individual desires, who when ill has to seek hos-
pital treatment, is the feeling of assurance that he will
be accorded all the care and attention necessary to his
health and comfort, irrespective of the hospital receiv-
ing him. The fact that a mortally injured or sick
person dies after admission to a hospital is not going
to diminish the standard or injure the reputation of
the institution concerned one whit. Every person of
even mediocre intelligence realizes that wonders can-
not be performed at the present day.
Poverty has from time immemorial been deemed a
crime, and frequently treated as such; but surely in
so noble a profession as that of medicine, one calling
perhaps for more arduous work and unrewarded self-
sacrifice than any other, the lowliest and most humble
of our brethren should not be subjected to indignities
which would never fall to the lot of his brother more
blessed with worldly goods.
The needed reforms in the present system are ob-
vious enough. There should be no such thing as ques-
tioning the fact whether or not a given patient is a
suitable one for any particular hospital. Every insti-
tution having an ambulance should take any and every
case presenting itself. In case of accident every
victim is a suitable one for every hospital professing
to care for emergency cases. If there is doubt as to
the seriousness of the injury, the patient should be
taken to the hospital for necessary diagnosis and
treated there until he recovers or dies.
i6
MEDICAL RECORD.
[January 6, 1906
THE TREATMENT OF PNEUMONIA.
To die or not to die? that is too often the question
that the physician is asking himself under the pro-
fessional mask of encouragement that he assumes at
the bedside of pneumonia or any critical disease.
The more he doubts the certain efficacy of any par-
ticular drug, the more sincere he believes himself to
be. To have unlimited, exuberant faith in any line
of treatment, and emphatically and hopefully to prog-
nosticate a successful issue, is, he feels, akin to quack-
ery. An honest skepticism is the only attitude that
his own heart will allow him. If the toxic effects are
greater than the body can combat the patient must die.
If not so great, the body will wage its own war and
the methods of treatment are but turns in the scale
one way or the other.
Such is the solid, unenthusiastic, almost resigned
tone of the honest discussions that follow the presen-
tation of any line of treatment for serious diseases.
We are sometimes almost tempted to think that the
physician can be little more than an umpire to decide
how the fight is waging, and that his prescriptions
have as little effect on life and death as ^is bulletins;
but this is a hypersensitive, over-conscientious, faint-
hearted attitude to take. It might be pardoned in the
laboratory student whose chemical symbols work out
in exact equations, but it should never be the attitude
of the hopeful practitioner. The experience that ac-
companies good theory and sound judgment is some-
thing too individual and intangible to be set down in
print as a rule for other men, but the fact remains that
the spirit of fight and the energy of action are as essen-
tial in combating disease as the application of statis-
tical studies. Every inch counts. Every step must be
fought with the spirit to win, not with the cold calcu-
lation of chances. It is the old, level-headed player
in this game of life and death who knows how to play
up to his man and score a point with a worn-out trick.
And, after all, knowledge unfolds but slowly. What
we claim for science one day we relegate to empiricism
the next, when we find that we had hit a half-truth at
random. Therefore there is Salvation in the faith
th^t begets action.
From this point of view the optimistic attitude
taken by Dr. A. H. Smith, of New York, in a recent
paper on "The Treatment of Pneumonia in the Light
of its Newer Pathology " {Medical News, December
16, 1899) is worthy of further comment. It is of
little moment from the present standpoint whether the
pathology as outlined by Dr. Smith will stand the
tests of further histological and chemical investigation,
for he makes the assertion that pneumonia is not
an inflammation at all, but simply a process which
permits of the development of bacteria, i.e., a culture
medium. Apart from this he says that by reason of
the fact that the lungs possess a double circulation,
the study of therapeutic agents intended to affect them
has special points for consideration. Reasoning from
these hypotheses he claims that rational therapeutic
indications would be met most directly by the ap-
plication of local and general anti-bacterial agents.
Thus if local contact with germicides could be ef-
fected, some progress could be made in the treat-
ment of the disease; and since the blood exudate
found in the alveoli supplies the pabulum for the
growth of bacteria, any agent that can modify that
medium and render it unsuitable for the growth of
micro-organisms would be the means of solving the
problem of pneumonia therapy.
If given at the outset of the disease. Dr. Smith says
that the evidence at hand in favor of the beneficial
results of the use of calomel is sufficient to merit its
continued use. Its action, he believes, is to prevent
the growth of further bacteria and not to counteract
the effects of bacterial toxins already formed. Calo-
mel should be given early in the disease. Small con-
tinued doses are probably as efficient as large amounts.
The opinions of Flint and Hare with reference to the
beneficial action of large doses of quinine are quoted
with approval. Inhalations of chloroform are believed
to be of some benefit, inasmuch as they exercise, in
laboratory experiments at least, a depressing effect on
the growth of the pneumococcus. The gratifying ex-
periences of a number of observers who have admin-
istered creosote by inhalation and by the stomach are
quoted, and in the form of carbonate of creosote its
use is warmly recommended. The salicylates, notably
the salicylate of ammonium, is highly thought of, not
only acting on the pneumonia but exercising a stimu-
lating effect on the heart.
Dr. Smith's preferences may be summed up in his
own words : " I have been searching for the best weapon
against the pneumococcus. I have used all the drugs
mentioned with the exception of large doses of quinine,
which have seemed to me too slow in action and too
disturbing to the stomach. At one time the salicy-
lates were my preference, but I think that late in the
disease they may be depressing to the heart, and they
may often cause gastric irritation. I now prefer creo-
sote. In my hands it has done good service and the
testimony of many authorities is strongly in its favor.
... As to accessory treatment the indications are,
first, stimulation of the emunctories to carry off the
poison as it forms; second, sustaining the vital powers
and particularly the heart; third, relieving the pul-
monary c irculation by vaso-dilators and venesection;
fourth, compensation for loss of respiratory surface,
by inhalation of oxygen; fifth, reduction of excessive
temperature by cold; and, sixth, relief of incidental
symptoms."
BULLETS IN MODERN WARFARE.
The war in South Africa is affording unfortunately
an ample and accurate test of the effects of bullets
fired from a modern small-bore rifle, and the conclu-
sions so far arrived at coincide in most respects with
the opinions formed of the destructive nature of these
weapons and of the character of the wounds produced
by them, by our surgeons during the Cuban and
Philippine wars. Naturally, however, knowledge on
the matter will be very considerably amplified owing
to the number of men engaged, to the accuracy of the
Boers' shooting, and to the fact that their principal
weapon is the rifle. The firearm used by the British
January 6, 1900]
MEDICAL RECORD.
17
is the Lee-Metford, and the bullet is termed Mark II.
The Boers use the Mauser. The Lee-Metford bullet
is rather longer than the Mauser, but its velocity is
somewhat less, consequently the momentum of each is
practically the same. It should be said that both
these bullets are wholly mantled, and are consequently
non-expansive.
Drs. Keith and Rigby contributed to Tlie Lancet of
December 2d a very complete and exhaustive article
on the nature of the injuries inflicted by the Mauser
bullet, by the Mark II., by the Mark IV., and by the
Dum-duni bullets. Although the experiments were
carried out on the cadaver the results detract little from
their value viewed comparatively. After pointing out
that there were three different types of bullet wounds
met with, viz., flesh wounds, wounds in which bone is
involved, and wounds in which the bullet has passed
through a cavity with fluid contents, Drs. Keith and
Rigby went on to compare the destructive qualities of
the four bullets in the following manner: If the de-
structive power of the Mauser be taken as a unit, that
of the British service Mark II. bullet is nearly twice
and that of Mark IV. more than twice as great, and
the Dum-dum probably four or five times that of the
unit. They sum up thus: " We find that the destruc-
tive effect of the Mark II. bullet, the Mark IV. bullet,
and the Dum-dum bullet stand to the Mauser in the
ratio of 1.7, 2, and 5.4 to 1. But this result applies
mostly to flesh wounds, the bone-destroying and ex-
plosive tendencies of all, and especially of the open-
nosed bullet Mark IV., being unnecessarily great.
One point of exceptional interest in regard to all
these injuries is that neither the wound of entrance nor
exit is any index to the amount of destruction wrought.
The conclusions, therefore, to be drawn would seem to
be these; that the covered bullet expelled from a
modern small-bore, provided no vital part or bone is
reached, is not nearly so deadly as one fired from the
older type of rifle; that when a bone is struck there
is always fearful shattering, the bone being invariably
irretrievably injured; that the unmantled and open-
nosed bullets are the most effective, so far as disabling
is concerned, of any yet brought out, their effect both
on bone and soft tissue being of a terribly destructive
nature."
JXcius of tTxe "SSJceli.
Northwestern Medical and Surgical Society. —
At the thirtieth annual meeting of the Northwestern
Medical and Surgical Society the following officers
were elected for the ensuing year: President, Dr. R.
A. Murray; Vke-Presiitcnt, Dr. Frank Grauer; Treas-
urer, Dr. Robert H. Greene; Secretary, Dr. S. Henry
Dessau.
New York State Sanatoria for Consumptives. —
The committee appointed by the New York State
board of health to study the question of State sanato-
ria is preparing a report in which it will rec9mmend
that a system of local institutions be established with
one or more State institutions, which shall be main-
tained by a per capita tax on the locality from which
each patient comes. The plan is said to be at vari-
ance with that outlined in the bill introduced in the
legislature last winter at the request of the State
Medical Association.
Obscure Disease. — The physicians of Madison
Township, Pa., are puzzled over an obscure malady
which has become prevalent in the community and
has proved fatal after a brief illness. By some the
disease is thought to be cerebro-spinal meningitis.
Measles is reported to be epidemic among the chil-
dren at Newburg, N. Y. More than one hundred cases
have been reported to the health officer, twenty-three
new ones in one day. No deaths have been reported,
and few adults are attacked.
The Medico-Legal Society. — At the annual dinner
and election of officers of the Medico-Legal Society
at the Hotel St. Andrew on December 20th, the fol-
lowing were elected: President, Mr. Clark Bell, of
this city; Pirst Vice-President, Dr. George L. Porter,
of Connecticut; Second Vice-President, Dr. T. D.
Crothers, of Connecticut.
Osteopaths in Georgia. -^Governor Candler of
Georgia has vetoed a bill passed recently by both
houses of the general assembly, providing for the
practice in that State of osteopathy. At the public
hearing given by the governor before taking action on
the bill, it was contended that osteopaths knew noth-
ing of materia medica, while they would be given the
right to prescribe medicine the same as any regular
licensed physician should the bill become operative.
Hospital Ships in Japan. — It is stated in The
Hospital that Japan possesses several - specially
equipped hospital ships for use in warfare. These
have been provided under the supervision of the
Japanese Red Cross Society, which joined the Geneva
Convention many years ago. The ships were built in
England, and in time of peace are used as passenger
boats. The Kosai-Maru, equipped only last year, has
a fine saloon, easily convertible into a ward. Arrange-
ments have been made for special wards for the isola-
tion of infectious cases, and a distinct sanitary service
will be organized in case of war.
A Red Cross Swindler. — A man, calling himself a
clergyman, has been convicted at Fairfield, 111., of
fraudulently receiving money orders, and sentenced to
imprisonment for eighteen months. He operated by
soliciting contributions from persons in Ohio, Indiana,
and Illinois in the name of the American Red Cross.
In the presence of the contributors, he would seem-
ingly insert a money order for the amount contributed
in a stamped envelope and mail it to Miss Clara Bar-
ton. What he really inserted, however, was simply a
blank piece of paper, the money order being slipped
into his pocket and subsequently cashed on a forged
order.
The Composition of Cigarettes. — An analysis of
various brands of cigarettes, both English and Ameri-
can, has just been concluded in the laboratory of The
Lancet. Tests for opium, arsenic, and other alleged
ingredients were madt, but they were negative in their
MEDICAL RECORD.
[January 6, 1900
results in every instance. The only injurious substance
found was tobacco. We wish The Lancet commission
had enlarged the scope of its inquiry a little, in order
to determine what it is that causes the peculiarly nau-
seating odor of these nasty cylinders.
Japanese Physicians for China. — The Chinese
authorities have engaged a staff of Japanese medical
men for service at Newchwang, where the plague pre-
vails. The mission numbers fifteen physicians who
are said to have had special training. At its head is
Dr. Murata Shosei, a pupil of Kitasato.
Trying a Tuberculosis Cure. — It is reported that
a trial of Crotte's alleged cure for pulmonary tuber-
culosis, an attempt to exploit which was made at the
Columbus meeting of the American Medical Associa-
tion, is being conducted at St. Luke's Hospital in this
city. The principle of the treatment, so far as M.
Crotte has announced it, is the saturating of the dis-
eased portions of the lungs with formic aldehyde by
means of cataphoresis.
An Anti-Tobacco Congress. — The second interna-
tional congress against the abuse (which is here syn-
onymous with "use") of tobacco will be held in Paris
during the summer of 1900. The work of the congress
will be divided into seven sections, dealing severally
with (i) history, statistics, various methods of the em-
ployment of tobacco; (2) chemical and physiological
researches on tobacco ; (3) diseases caused by tobacco ;
(4) hygiene and sociological questions; (5) education
as a means of restricting the use of tobacco; (6) the
morality and criminality of tobacco users; (7) miscel-
laneous. Papers may be read in English, French,
German, Spanish, Italian, or Russian. Those desiring
to become members of the congress are requested to
signify their intention to the president of the commit-
tee of organization, M. E. Decroix, 20 his, rue Saint-Be-
noit, Paris. The subscription to the congress, which
has been fixed at five francs, or one dollar, should be
sent at the same time.
Conscience-Stricken Contributors to Hospitals. —
A writer in Tit-Bits says that in many of the London
hospitals there is a list kept, headed " Hospital Con-
science Gifts." Anonymous donors will often contrib-
ute a sum stating that they do so as a kind of expia-
tion of some error or misdoing on their part, and the
money so contributed is entered on this list. One gen-
tleman contributed £20 to the accident ward of a cer-
tain hospital, stating that he offered the money as he
had an accident, for which he regarded himself re-
sponsible, upon hib conscience. He had seen a brick
one night in the middle of the road in which he lived,
and had failed to remove it. In consequetice of this
a cyclist met with an accident by which he was se-
verely injured. A fashionable nobleman, who some
time ago accidentally caused the death of a game-
keeper while out shooting, not only provided for the
man's wife and family, but yearly contributes £,200 to
the hospital to which the unfortunate man was con-
ve)'ed. Thoughtless throwers-down of orange peel
contributed in one year to one hospital alone over
;^S00 — their consciences burdened by the memory of
that thoughtless act which often results in misery 'to
others.
Danger from Samples of Medicine. — The coroner
of Philadelphia, after having investigated the death
of a child from ingestion of sample pills, has called
the attention of the director of public safety to the
danger attending the indiscriminate and careless dis-
tribution of patent medicines and nostrums, particu-
larly headache powders.
Smallpox and Chickenpox. — No end of trouble
has been caused in various parts of the country during
the past year or two by confusion in the minds of va-
rious physicians between variola and varicella. The
latest case of the sort was at Dixon, 111., where numer-
ous cases of smallpox occurred in the course of six
weeks, but were all diagnosed as chickenpox, the mis-
take not being discovered until there had been nearly
one hundred cases. Recently a mistake the other way
was made by a physician on a train between Chicago
and New York. He notified the conductor that there
were two cases of smallpox aboard, and the conductor
telegraphed the nev.'S ahead to Pittsburg. When the
train arrived there it was held, and policemen would
not permit any of the passengers to alight. The city
physician examined the patients, two children, found
they were ill with nothing more serious than chicken-
pox, and the train was released. The passenger who
had caused the commotion by declaring the cases to
be smallpox was a physician from Kansas, and fearing
that the passengers would carry out their promise to
make it pleasant for him the rest of the journey, he
waited over for another train.
Philadelphia Pediatric Society — At a stated meet-
ing held December 12th, Dr. C. F. Judson exhibited
a case of Erb's palsy in a girl aged about ten years,
due to pressure by forceps during delivery; also a
case of rotatory spasm in a colored child aged about
two years, with evidences of rickets; and a case of
left hemiplegia with aphasia in a child about three
years old, in whom there had been a convubion at
the age of ten months with left hemiplegia, and an-
other convulsion at the age of eighteen months with
paralysis of the left side of the face. Dr. Judson
also reported a case of cerebral diplegia in a child
that presented tremor. Drs. F. T. Stewart and Alfred
Hand, Jr., detailed the account of a case of dilatation
of the colon in a child three years old, terminating fa-
tally. Dr. J. Madison Taylor reported a fatal case of
hemorrhagic purpura, occurring in a girl thirteen years
old; also a case of scurvy resembling syphilitic hemi-
plegia; also a case of Hodgkin's disease in a boy aged
seven years, and a case of arthritis deformans in a boy
aged nine years. Dr. Alfred Hand, Jr., reported a
case of multiple auto-vaccination.
College of Physicians of Philadelphia : Section
on General Medicine. — At a stated meeting held
December nth. Dr. Alfred Stengel exhibited a case
of ancemia with splenic enlargement, occurring in a
child three years old, in which following or in con-
junction with enterocolitis there developed profound
January 6, 1900]
MEDICAL RECORD.
19
ansemia with enlargement of the spleen. The hemo-
globin was diminished in greater degree than the red
cells, and there was no leucocytosis. Dr. Stengel pro-
posed the following classification of the ansemias in
childhood with enlargement of the spleen: A, with-
out leucocytosis: i, primary (splenomegaly) ; 2, sec-
ondary (syphilis, rickets, tuberculosis, gastro-intesti-
nal disorders). B, with leucocytosis: i, primary
(leukaemia); 2, secondary. Dr. J. A. Scott read a
communication on "A Case of Mitral Stenosis," with
exhibition of the specimen, in which he discussed at
length etiology, pathology, and diagnosis. Dr. M.
Howard Fussell read a paper on " The Position and
Color of the Ring in Heller's Test for Albumin in the
Urine," in which he pointed out that the color-ring
due to biliary pigment, potassium iodide, and the like
is at the junction of the nitric acid and the overlying
urine, the white band of albumin a little above this
line of junction, and the ring of urates some distance
above the latter. Dr. Joseph Sailer read a paper en-
titled " Withdrawal of Liquids from the Diet of Dia-
betes Mellitus," in which he related that such with-
drawal in a case under observation failed to afford
any relief, but rather aggravated existing conditions,
primarily of course the thirst, and especially also the
secretion of urine and the elimination of sugar. Dr.
H. D. Beyea read a paper entitled "An Ovarian Cyst
Associated with Diabetes ; Operation, followed by Dis-
appearance." He referred also to a few other cases
of like nature recorded in the literature, and expressed
the opinion that some undetermined etiological rela-
tion must exist between the character of the tumor and
the morbid symptoms.
Pathological Society of Philadelphia. — At a stated
meeting held December 14th, Drs. G. E. de Schweinitz
and J. D. Steele reported a case of melanotic sarcoma
of the choroid and orbit, in which primary operation
was followed by recurrence. The secondary operation
was radical and quite extensive, but there has been no
recurrence. Dr. J. A. Scott exhibited a specimen of
syphilis of the liver, the organ being enlarged, multi-
lobulated, and covered by a dense capsule, with much
cicatricial contraction and deformity. The spleen
also was much enlarged, and mould-like deposits were
present upon several portions of the intestine. Sec-
tions disclosed marked interstitial hepatitis. Dr. L.
N. Boston also exhibited a specimen of syphilis of
the liver, the organ being rather diminished in size
and the seat of numerous nodules, some large, some
small. Sections in this instance also exhibited the
histological appearances of interstitial hepatitis. Dr.
A. A. Eshner exhibited a specimen of carcinoma of
the oesophagus, from an elderly man who presented
during life symptoms, and after death lesions, of tu-
berculosis. The lesion in the oesophagus was situated
about three inches above the cardia, and its histologi-
cal character was disclosed on microscopical examina-
tion. Drs. J. H. Jopson and A. A. Ghriskey reported
a case of anthrax, and exhibited cultures of anthrax
bacilli in various media, as well as cover-slip prepara-
tions. The patient had been a morocco finisher, who
presented a lesion upon the forearm acquired by in-
oculation of a scratch-wound, and in which bacilli
were found that on microscopical examination and on
culture exhibited the characters of anthr^.x bacilli.
Death occurred suddenly and unexpectedly, but an
autopsy could not be secured. No other case of the
disease was observed among those employed in the
same factory.
Diphtheria in Philadelphia is so prevalent that a
number of schools have been closed for purposes of
disinfection. It is now proposed to disinfect with
formaldehyde all of the schools during the Christmas
holidays, in order to begin the new year with a clean
bill of health; and it is hoped that with aid of the
volunteer staff of medical inspectors infection in the
schools will be kept at a minimum.
Aa International Congress on Malaria is to be
organized by the Liverpool School of Tropical Dis-
eases. It was this school that sent out the commis-
sion under Dr. Roland Ross to Sierra Leone last
summer, the labors of which have added so materially
to our knowledge of the malarial mosquito.
Post-Graduate Instruction in Moscow. — The medi-
cal faculty of the University of Moscow has decided
to open a school for post-graduate instruction, in
which clinical instruction in twelve subjects will be
given. The material will come chiefly from the
Catharine Hospital, but other public hospitals and
clinics w'ill also be drawn upon as occasion offers.
Orleans Parish (La.) Medical Society. — At the
annual meeting of the Orleans Parish (La.) Medical
Society, December loth, the following officers were
elected to serve during 1900: President, Dr. T. S.
Dabney; Vice-Presidents, Drs. H. S. Magruder, H. B.
Gessner, and E. J. Graner; Secretary, Dr. E. H.
Walet; Librarian, Jix. S. P. Delaup; Treasurer, Dr.
Maguire.
The Eastern Medical Society of the City of New-
York At the annual meeting of this society, held
December 8th, the following officers were elected for
the ensuing year: President, Dr. Abram Brothers;
First Vice-President, Dr. J. Guttman; Second Vice-
President, Dr. A. Hymanson ; Secretary, Dr. R. Abra-
hams; Treasurer, Dr. J. Barsky.
The Japanese Navy Medical Services. — There are
one hundred and seventy-one medical officers of the
Japanese navy, whose rank is as follows: Inspectors-
general, two; deputy inspectors-general, thirteen;
deputy assistant inspectors-general, twenty-one; fleet
surgeons, thirty-one ; staff surgeons, sixty-three; sur-
geons, thirteen; assistant surgeons, twenty-six; deputy
assistant surgeons, two. The pharmacists number fif-
teen.
The British Medical Association will hold its
sixty-eighth annual meeting at Ipswich, from July 3T
to August 3, 1900. The president will be Dr. W. A.
Elliston, and the local secretary Dr. E. A. Barnes of
Eye. The address in surgery will be delivered by
Mr. Frederick Treves, that in medicine by Dr. Pye-
Smith, and that in obstetrics by Dr. W. J. Smyly.
so
MEDICAL RECORD.
[January 6, 1900
The address in surgery will doubtless deal with mili-
tary practice if the Boer war is ended in time to
permit Mr. Treves to return from South Africa to
deliver it.
Professor Koch, it is announced, is now studying
malaria in Batavia, but will soon go to New Guinea.
Dr. Alfred E. Thayer of this city has been elected
professor of pathology and bacteriology in the West
Virginia University at Morgantown.
Berks County (Pa.) Medical Society.— At a stated
meeting held at Reading on December 12th, Dr. John
M. Bertolet read a paper on " Witch Doctors and Their
Deceptions."
Bequests to Hospitals. — By the will of Mrs. Eliza-
beth C. Judd, widow of Colonel Henry B. Judd, of
Wilmington, Del., $5,000 is bequeathed to St. Luke's
Hospital, New York, and $500 to the Delaware Hos-
pital of Wilmington.
Transactions of the Twelfth International Medi-
cal Congress. — The Russian government has made
an appropriation of 9,200 rubles to cover the expense
of publication and distribution of the volumes of
Transactions of the Moscow Congress, which are now
in press.
Help for Struggling Young Physicians. — A physi-
cian of St. Petersburg, Dr. G. I. Arkhangelsky, who
died last summer, left nearly his entire fortune (about
$12,000) to the Society for the Protection of Public
Health, in order to establish a fund for the assistance
of young physicians in the first years of their practice.
A Contribution to the Appendicitis Question — In
a letter to T/a Aledical Press and Circuhir of recent
date, Dr. Keen, of Philadelphia, mentions several of
the most insistent advocates of instant operation in
every case of appendicitis, and makes the surprising
statement concerning them that, while they advocate
this plan in theory, they do not practise it in fact.
An International Congress on Tuberculosis ^At
a recent meeting of the Council of the British Associ-
ation for the prevention of consumption, it was re-
solved to call a preliminary meeting of prominent in-
dividuals and representatives of institutions for the
purpose of making arrangements for the Internal
Congress on Tuberculosis, which is to be held in
London in the spring of 1901, under the presidency
of the Prince of Wales.
An International Health Conference. — The Italian
Foreign Office has sent a note to the various powers
which were represented at the International Hygienic
Conference held in 1897 at Venice, inviting them to
give their opinion as to the advisability of convening
another meeting of the same kind to take measures,
on an international scale, for the defence of Europe
against the plague.
The Osiris Prize. — A triennial prize of the value
of about $20,000 has been established by W. Osiris, of
Paris, through the French Institute, for the most not-
able work published or discovery announced during
the preceding three years, which shall be of benefit to
humanity. Special reference is made to medical dis-
coveries.
Doctors Mulcted — A jury at York, Pa., on De-
cember i2th, awarded the plaintiff $1,000 damages
against Drs. Vaillic and John A. Hawkins in an action
to recover for alleged negligent treatment of a broken
leg. It was charged that the leg was so tightly ban-
daged as to become gangrenous, and require amputa-
tion.
Camden (N. J.) District Medical Society.— At a
stated meeting held on December 12th, reports were
made as follows: Practice of medicine, Drs. E. L. B.
Godfrey, J. R. Stevenson, W. R. Powell; health-con-
ditions of Camden in respect to malaria and typhoid
fever, Dr. E. L. B. Godfrey; contagious disease in
Camden, Dr. J. F. Leavitt; gynaecology, Drs. H. H.
Sherk, H. F. Palm, J. F. Leavitt; Surgery, Drs.
Alexander McAllister, E. A. Y. Schellinger, Paul M.
Mecray.
Philadelphia Neurological Society At a stated
meeting held December 18th Dr. Wharton Sinkler ex-
hibited a case of acute anterior poliomyelitis in a
young man aged eighteen years, in whom the symp-
toms appeared after bathing for a long time in the
open air. There was at first myalgic pain with loss of
power in both lower extremities, followed by improve-
ment almost to normal on one side, with persistent
flaccid paralysis, loss of reflexes, and degenerative re-
actions in the other side, and without sensory derange-
ment. The expulsive function of the bladder was at
first impaired. Dr. James Hendrie Lloyd exhibited
a case of hysterical choreiform movement in a girl
aged about nineteen years, who presented rhythmic
beating of the left hand against the thigh, and in the
sitting posture also a distinct and asynchronous rhyth-
mic lateral movement of the corresponding thigh.
Other hysterical stigmata had not been detected.
Restraint of the movement in the affected arm was
attended with appearance of a similar movement in
the opposite member. Dr. Charles K. Mills reported
a case of unilateral progressively ascending paralysis,
probably representing a new form of degenerative dis-
ease. Dr. Mills was inclined to consider the case
one of unilateral amyotrophic lateral sclerosis, while
Dr. Sinkler, who also had seen it, thought it might be
due to disease of the posterior roots in their passage
through the intervertebral orifices. Drs. C. W. Burr
and D. J. McCarthy reported a case of serous menin-
gitis in a man who presented symptoms suggestive of
typhoid fever, but without Widal reaction, diazo-re-
action, and other distinctive phenomena. Cerebro-
spinal fever also was thought of, as this disease was
prevalent at the time. Improvement and exacerbation
followed alternately on several occasions, but death
eventually took place in coma. Toward the close
deafness set in suddenly. Post-mortem examination
disclosed in addition to excess of cerebro-spinal fluid
thickening of the ependyma of the ventricles and
round-cell infiltration of the subjacent brain tissue.
January 6, 1900]
MEDICAL RECORD.
Similar lesions were induced experimentally in cats
by introduction into the cerebro-spinal cavity of dilute
hydrochloric acid, urine, bacterial toxins, etc. Dr.
Joseph Sailer reported a case of motor and sensory
disturbance of obscure nature occurring in a man
about thirty-one years old, who presented loss of pain-
ful and thermal sensibility and of motor power, and
increased reflexes on one side of the body, with early
recovery, leaving only loss of sexual power. The
urine was free from albumin. The lesion was thought
tentatively to consist in some disturbance at the level
of the restiform bodies.
Dr. Bernard Sachs has been appointed on the vis-
iting staff of the Manhattan State Hospital to fill the
vacancy caused by the death of Dr. Charles Inslee
Pardee.
Bequests to Hospitals. — By the will of the late Mr.
Daniel S. Ford, of Boston, proprietor of I'lie Youth's
Companion, the Massachusetts General Hospital re-
ceives $7,000, the Boston City Hospital $6,000, and
the Children's Aid Society and the Children's Hospi-
tal of Boston each $5,000.
An Ambulance Refused by the Boers.— A dispatch
from Durban to the London Times says that the Trans-
vaal government has refused to receive the ambulance
organized by Mr. Sivewright, an ex-minister of Natal,
and that it will now be offered to Natal. It is not
likely, however, in view of the circumstances that the
authorities will accept it. The medical corps attached
to this ambulance was composed of Afrikander physi-
cians studying at the University of Edinburgh, who
sailed only recently for South Africa.
The Course of the Plague. — A case of what was
undoubtedly the plague was discovered on December
12th in the person of the bookkeeper in a Chinese
establishment in Honolulu. The council of state was
immediately called in extraordinary session, and ap-
propriated $25,000 for the use of the board of health
in combating the disease. The Oriental quarter was
at once quarantined, and no one was allowed to enter
or leave this section without a permit from the board
of health. Within twenty-four hours after the book-
keeper's case had been diagnosed as the bubonic
plague five deaths had occurred, all from the plague-
Fumigation plants and crematories were established at
the four corners of the Oriental section, and the bod-
ies of the dead were cremated. The transports War-
ren, Centennial, and Newport were in the harbor, but
left in the course of the week, the first-named for Ma-
nila. The others reached San Francisco on Decem-
ber 27th, and were detained at quarantine. — In India
a recrudescence of the epidemic is threatened. Ah-
mednuggur has suffered very badly from the plague,
and is not yet free from it. Sholapur now has a severe
epidemic. Bombay is thought to be in the beginning
of another plague experience. Parts of the Satara
district have been badly attacked. News from relia-
ble sources in the Orient is to the effect that the dis-
ease is prevalent in China and also in Japan, and the
officers at Manila have taken precautions to prevent
the plague from getting a foothold there. — In Mauri-
tius during December there were twenty new cases of
plague in the island, and twelve deaths from the disease
occurred during the same period. — A despatch from
Manila, dated January 3d, states that the health officers
have found a native having all the symptoms of bu-
bonic plague in a house in the walled city, where two
deaths which may have been due to plague have oc-
curred. The patient has been isolated and every pre-
caution has been taken to prevent a spread of the dis-
ease. The quarantine system in the Philippines has
been placed under the direction of the Marine-Hospi-
tal service. There are already two quarantine plants
in the islands, and some of the surgeons of the Marine-
Hospital service are already on their way to Manila
and are expected to arrive there within a short time.
Smallpox has broken out among the Indians in the
Colville Reservation, Washington.
Beriberi has been epidemic among the Chinese
population in Hong Kong during the past summer and
autumn.
Suit against a Chicago Hospital. — A woman resid-
ing in Racine, Wis., has entered suit in the Cook
County circuit court against the Presbyterian Hospi-
tal of Chicago for $100,000 damages. She alleges
that she has been made an invalid for life by the mis-
take of a nurse in the institution, who gave her a dose
of medicine intended for another patient. The hospi-
tal authorities admit that an error was made by one of
the nurses, but declare that the medicine given by
mistake was harmless.
A Hospital Offered to the City. — Negotiations are
said to be in progress looking to the transfer of the
Brooklyn Homoeopathic Hospital, Dispensary, and
Training-School for Nurses, in Cumberland Street, to
the New York City authorities. The plan suggested is
that the control should vest in the city along with the
actual property and obligations of the institution, and
that in return the city should agree to maintain it
under the homceopathic system. The property is worth
about $150,000 and there are obligations amounting to
$60,000. The hospital was organized in 1852.
The Alleged Grave Robbery in New Haven. — A
hearing in the case of Dr. Oliver T. Osborne, professor
of materia medica and therapeutics in the Yale Medi-
cal School, on the charge of unlawfully disinterring a
body, was held at New Haven on December 26th. The
charge was of removing from its grave, without permit
for an autopsy, the body of a negro girl, within a few
hours after burial. The prosecution was instituted on
complaint of some members of the family of the dead
girl, who watched the grave and claimed to have wit-
nessed the removal of the body. Dr. Osborne denied
that there was any attempt at secresy in the steps that
were taken to secure an autopsy. The evidence
brought forward by the prosecution was of a contradic-
tory nature, and at its conclusion Dr. Osborne was
acquitted of the charge.
An Attempt to Check Suicides It is said that a
bill will be introduced at the coming session of the
legislature at the instance of the New York State
MEDICAL RECORD.
[January 6, i goo-
Medical Society to prohibit the sale of carbolic acid
except upon a physician's prescription. It is esti-
mated that in 60 per cent, of the suicides in this State
during 1899 carbolic acid was the means employed.
Professor Ogston, of Aberdeen, has gone to South
Africa. He was not sent by the British authorities,
but went as a private individual to take advantage of
the opportunities there offered for the study of military
surgery.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
December 30, 1899. December 23d. — Surgeon H.
E. Ames, order of December 20th modified, ordered to
duty in connection with fitting out the Kearsarge, New-
port News, Va. Assistant Surgeon E. J. Grow de-
tached from the Massachusetts and ordered to the Dixie.
December 27th. — Medical Inspector M. H. Simons or-
dered to Cleveland, Ohio, for recruiting duty.
A Hospital Interne Suspended. — A member of the
medical house staff of Bellevue Hospital was recently
suspended for three months by the commissioners of
charities. The action was taken because, it was
charged, the physician received money with which to
buy delicacies for a patient. The commissioner has
posted in all the city hospitals an order forbidding all
employees of the department of public charities, includ-
ing the members of the medical staff, to accept from
a patient, or other inmate, any sum of money for any
purposes whatever, except with the knowledge and
cSnsent of the superintendent of the institution in
which the patient or inmate may be. Any infraction
of this rule will, it is announced, be punishable by
instant dismissal.
Famine in India.— A recent report from Calcutta
states that nearly three million persons are receiving
aid from the famine relief fund. The government is
spending almost 200,000 rupees daily. It is estimated
that the cost of the relief to the end of March will
be 30,000,000 rupees. Reports from American mis-
sionaries are to the effect that the present famine in
Western India promises to be far more distressing
than even the famine of two years ago. The entire
community in some places will be in distress. A se-
vere drought has already begun in the Ahmednuggur
district. In many places it is hard to get sufficient
water to drink, and no rain can be expected until the
middle of June. The early crops in the Ahmednug-
gur district were only from one-eighth to one-sixth of
full ones, and the later crops are almost a total fail-
ure. In other districts the crops are small. Hus-
bands are leaving their wives, and parents their chil-
dren. Relief corps are being organized; some charity
also is administered, but official relief, Mr. Hume says,
never can meet the multitude of necessities.
Obituary Notes. — Dr. Gustavus S. Winston died
at his home in this city on December 29th of apoplexy.
He was born in New York in 1833, and was a graduate
of the College of Physicians and Surgeons ip the class
of 1863. In the Civil War he was surgeon of the
Eighth Regiment, and was captured and confined in
Libby Prison, from which he escaped with the assist-
ance of a friend of the family, living in Richmond.
Dr. Winston was medical director of the Mutual Life
Insurance Company for about twenty-five years, and a
great part of the time was the chief director.
Dr. Elliott Coues, of Washington, died at the
Johns Hopkins Hospital in Baltimore on Christmas
day, from the eft'ects of an operation performed some
time ago. He was born in Portsmouth, N. H., in
1842, and was graduated from the medical department
of the Columbian University in Washington in 1863.
In 1862 he entered the United States army as a medi-
cal cadet, and two years later was promoted to assist-
ant surgeon, which rank he held until his resignation
in 188 1. His special interest was in natural history,
more particularly ornithology, and wherever his army
duties called him he made exhaustive studies of the
fauna and flora of the region. He held the cliair of
anatomy in the National Medical College, Washing-
ton, from 1877 to 1883, when he was appointed pro-
fessor of biology in the Virginia Agricultural and
Mechanical College. The range of Dr. Coues' literary
life was very great. He was the author of thirty-seven
volumes, and contributed over one thousand articles
to various magazines and periodicals. He served six
different scientific journals in editorial capacities, and
his name was on the rolls of more than fifty foreign
and American scientific societies. One of his most
important labors in recent years was done on the Cen-
tury Dictionary, to which, in seven years, he contrib-
uted forty thousand words and definitions in general
biology, comparative anatomy, and all branches of
zoology.
Dr. Thomas O'Callaghan, of Jersey City, died
suddenly on December 27th while making a profes-
sional call on a patient. He was sixty-five years old,
and was a graduate of the New York University Medi-
cal School in 1862. He had practised in Jersey City
continuously ever since his graduation.
Dr. Frank Gruber, of Newark, N. J., died sud-
denly on December 30th while attending a patient.
He was stricken with apoplexy as he sat down at the
bedside of his patient, and he died within a few min-
utes. He was fifty-seven years old, and was born in
Germany.
Dr. Lewis Armstrong died at Middletown, N. Y.,
on December 3 1 St, aged eighty-one years. He had been
prominent in medical and business circles in Orange
County for many years.
Dr. Henry F. Gehring, of Chateaugay Lake, died
at Malone, N. Y., December 30th. A few days before
he performed a surgical operation, and in some way
slightly scratched his finger. Symptoms of septic
poisoning setin, quickly resulting in death. He was
a graduate of Starling Medical College, Columbus,
Ohio, in 1884.
Dr. Francis G. Bonynge, of Chicago, died at his
home in that city on December 26th. He was a grad-
uate of the University College in London in 1878, of
the Royal College of Surgeons in Ireland in 1879, and
of Kings and Queens College, Ireland, in 1880.
Dr. Wickliffe Smith, of Delphi, Ind., surgeon of
the i6ist Indiana regiment, was killed on December
January 6, 1900]
MEDICAL RECORD.
23
zgth, together with his Cuban boy, Francisco Sousa,
three miles from Delphi, by a Wabash train. On ac-
count of the cold weather they were bundled up so they
did not hear the train. Both were instantly killed.
Dr. Smith was a graduate of the Medical College of
Ohio in the class of 1874.
Dr. Irwin Fisher, of Harlingen, N. J., was found
dead in his bed on the morning of December 31st,
He was a graduate of the Medico-Chirurgical College
of Philadelphia in the class of 1896. He was a mem-
ber of the Somerset County Medical Society and of
the New Jersey State Medical Society, and was the
coroner of Somerset County.
Dr. Almira L. Fowler Breakspear died on Sun-
day at her home in West Orange, N. J. She was sev-«
enty-three years old, and was born at Cohocton, N. Y.
She was graduated from the Jackson Academy, Jack-
son, Mich., and from the Woman's Medical College of
Boston. She first practised medicine in this city, and
moved to Orange in 1858.
SIR JAMES
PAGET, BART.,
D.C.L., LL.D.
F.R.S., F.R.C.S.,
The death is announced in London of Sir James Pa-
get, in his eighty-sixth year. He was born at Great
Yarmouth, January 11, 18 14. He was educated at St.
Bartholomew's, became a member of the Royal Col-
lege of Surgeons in 1836, and was elected a fellow of
the same nistitution in 1843. In 1875 he was presi-
dent of the Royal College of Surgeons, and from 1884
to 1895 was vice-chancellor of London University.
He was created a baronet in August, 187 i, in recog-
nition of his many discoveries in surgery. In 1881 he
was appointed a member of the royal commission to
inquire into the condition of the London hospitals for
smallpox and fever cases. At the jubilee, in 1882, in
commemoration of the three hundredth anniversary of
the founding of the University of Wurzburg, he was
one of the foreign scientific celebrities who received
honors.
He was also a corresponding member of the Insti-
tute of France and an honorary fellow of many univer-
sities and other institutions. For many years he had
been consulting surgeon of St. Bartholomew's Hospi-
tal.
Sir James Paget was one of the most famous English
surgeons of the century, and made many contributions
to surgical knowledge. Among his best known liter-
ary works are the " Pathological Catalogue of the
Museum of the College of Surgeons," " Report on the
Results of the Use of the Microscope," published in
1842, and " Lectures on Surgical Pathology," published
in 1853, 1863, and 1868. He°was also an extensive
contributor to the "Transactions" of the Royal Soci-
ety, of which he was a fellow, and other learned insti-
tutions. Since 1863 he had been surgeon to the
Prince of Wales, and since 1878 sergeant surgeon to
Queen Victoria.
The Cuban Orphan Society of New York City-
has made an application to the State board of chari-
ties to approve of its incorporation. The objects of the
society are to care and educate the orphan and desti-
tute children of Cuba through the establishment of an
institution in Cuba for that purpose.
New York Aledical Journal, December ^o, i8gg.
Some Practical Notes upon Diseases of the Rec-
tum.— L. H. Adler, Jr., alludes to the natural reluc-
tanc'e of patients to undergo rectal examination, and
then passes to consider some of the maladies of this
region most commonly met with. Congenital malfor-
mation occurs once in eleven thousand births. He
believes that in fistula the internal opening is to be
found in most cases between the two sphincters, and
not, as is commonly believed, higher in the rectum.
As to operation in phthisical cases, his rule is, " If
the lung trouble is active, no operation; otherwise,
operate." For cases of fissure, opium should be
avoided and iodoform used instead. He believes that
constipation is greatly on the increase, the latter being
due to modern ways of living, adulterated food-stuffs,
and rapid eating with little exercise.
Diphtheria : Remarks on Clinical Diagnosis and
Treatment. — H. B. Sheffield emphasizes the essential
early clinical signs of the disease, contrasting the ap-
pearance of the pharynx in diphtheria with that pre-
sented in the varieties of amygdalitis, follicular, paren-
chymatous, herpetic, and necrotic. Not much definite
information caii be obtained from the condition of the
submaxillary glands, except that diphtheria presents
generally a greater enlargement, hardness, and tender-
ness of them. Albuminuria strongly suggests true
diphtheria. A table of diagnostic signs between
laryngeal diphtheria and non-diphtheritic membranous
laryngitis is given. He uses antitoxin only in com-
bination with other remedies, and gives formulas of
drugs which have served him well.
Tubercle Germs and Giant Cells in Human Tis-
sue.— P. G. Bourland refers to the literature of the
subject of tubercle bacilli in giant cells, and narrates
his own findings. Several thousand specimens were
examined, including material from lung, kidney, liver,
spleen, lymph nodes, and granulations from a tubercu-
lous knee joint. In only four instances (three in lung
and one in liver) did he find the bacilli within the
cells. The full microscopic findings in the four cases
are given. Bourland believes that the relation between
bacillus and cell is a variable one. It is not fixed by
anything apparent in the light of our present knowl-
edge. He describes his method of examination and
gives a bibliography.
Diet in Typhoid Fever. — E. Speidel advocates a
daily rectal irrigation with two quarts of decinormal salt
solution, and its interstitial injection in cases in which
for any reason the rectum is unavailable. Water
should also be given internally with great freedom.
For nutrition, buttermilk, sweet milk (prepared in va-
rious ways), milk with malt extract, unfermented grape
juice, strained oyster or clam broth in commencing
convalescence, and broiled steak are all commended.
The patient should be allowed chewing-gum for a
short period each day. Then follow various solids.
The article contains several practical recipes for the
palatable preparation of the various food-stuffs named.
Mastoiditis: The Importance of Early Surgical
Treatment. — B. J. F. McCaw concludes a practical
article as follows: (i ) In threatened mastoid involve-
ment and in the mild acute cases the conservative
plan of treatment should be tried for at most a week
or ten days unless dangerous symptoms arise. (2)
Operative interference should be instituted {a) in
acute cases where there is sagging of the postero-supe-
24
MEDICAL RECORD.
[January 6, 1900
rior canal wall, [b) when the infection is of a virulent
nature, and (c) in all cases complicating chronic otor-
rhcea.
The Surgical Treatment of Phthisis.— VV. C. Wood
states that tiiere are four plans of surgical treatment
to be considered: First, aspiration of cavities and
direct medication; second, pneumonotomy or incision
and drainage of cavities; third, pneumonectomy or
excision of a tuberculous focus; fourth, obliteration of
a cavity by causing collapse of the lung. He gives
the technics of each of the methods enumerated.
Examination of the Urine in Epileptics. — E. G.
Klein examined the urine in twenty-three cases as
soon as possible after an epileptic seizure. Specific
gravity ranged from 1.007 to 1.026; traces of albumin
were present in fifteen of the cases; glucose was not
found in any. Results are als'o given of analyses of
the urine of the same patients some time after the at-
tack had passed over.
An Arrangement of Gastric Instruments Devised
to Facilitate the Physical Examination of the
Stomach and Its Treatment C. S. Fischer describes
and figures various tubes, siphons, and electric-light
devices which he has found of service for the exami-
nation and treatment of patients with gastric troubles.
Nothing essentially new as regards treatment is given.
Heroin in Affections of Respiratory Organs. — H.
D. Fulton commends the use of heroin in acute and
chronic bronchitis as well as in tuberculous cases. A
solution for hypodermatic use may be made by the ad-
dition of a little acetic acid. Maximum doses cause
gastric derangements similar to those of morphine.
The remedy is often curative as well as alleviative.
The Medical News, December jo, i8gg.
Splenectomy. — J. Wesley Bove'e, in a review of this
subject,- says that the operation was probably first per-
formed by Zanarelli, in 1549. The spleen is thought
to be the source of origin of leucocytes and the grave-
yard of the red blood cells, though in its absence the
lymphatic glands and bone-marrow assume its func-
tion. No characteristic symptoms follow splenectomy
in children, while in the adult they are increased pulse
rate, syncope, pallor, temperature above normal, weak-
ness, loss of weight, anaimia, headache, drowsiness,
voracity, thirst, diminished or increased urinary secre-
tion, griping ])ain in the abdomen, and pain and ten-
derness of the long bones. Among the indications
for splenectomy are enlargement of the organ, malig-
nant disease, axial rotation, wandering spleen, cysts,
chronic congestion, amyloid disease, and rupture. But
the operation should never be done except under the
most favorable circumstances, unless immediate death
threatens. Variations from the normal blood con-
ditions, and leucocythasmia, are most important com-
plications. The diagnosis is generally simple. The
mortality of tliis operation between i885'and 1895 is
reported as 20.68 per cent.
The Pathology and Treatment of White Swelling
of the Knee. — A. B. Judson asserts tiiat white swell-
ing of the knee goes from bad to worse so long as the
patient continues to subject the joint to the weigiit of
the body when standing, and the severe traumatism
attending walking and running. He arrests motion by
means of a posterior uprigiit which is worn day and
night. The weight-bearing function is held in abey-
ance bv the use of the ischiatic crutch, worn only
when the patient is up. In undue flexion of the knee
the fixative brace may be used.
A Brief Report of an Epidemic of Typhoid Fever
in Worthville, N. C, during 1898 Charles Hub-
bard reports the recent epidemic of this village to be
in accordance with Osier's observation, " Outbreaks
of typhoid fever are more likely to occur in extremely
hot and dry seasons when the water-supply is very
low." In tlie whole town there were sixty-three pure
cases with a death rate of about ten per cent., besides
several suspicious ones. Eighteen of the sixty-three
were under twelve years of age.
/oil ma/ aj the Amer. Mccl. Assoc, Dec. jo, iSgg.
Splenic Anaemia, or *< Banti's Disease," Compli-
cated by Diabetes Mellitus.— In 7he Medical A'ctvs
of March 27, 1897, H. A. Hare reported a case of
splenic anajmia with grave blood changes in a man
aged twenty-four years. An examination revealed a
great excess of lymphocytes, although the total number
of leucocytes was about normal. The red cells varied
from time to time from 1,000,000 to 2,800,000. The
spleen was enormously enlarged. While under obser-
vation from 1895 to 1S98 nothing abnormal was re-
vealed by examination of the urine. Hare now further
reports that the patient came to him in November, 1898,
and was found to be passing thirty grains of sugar to the
ounce. It was not possible to make a blood count, as
the patient failed to return the next day. The author
is unable to say whether there was any connection be-
tween the two diseases.
Some Phases of Intranasal Surgery. — G. V.
Woolen, of Indianapolis, summarizes the reasons
which should underlie the chief operative measures in
the nares, as follows: (i) To restore nasal respira-
tion and relieve disease of the respiratory tract; (2)
to aid the drainage of the nose and its accessory cavi-
ties; (3) to remove pressure irritation; (4) to remove
local hyperajsthetic tissues; (5) to render local medi-
cation possible and successful ; (6) to remedy auditory
disease, (7) to remedy voice difficulties; (8) to re-
move malignant disease. Woolen urges that much
confusion could be avoided by a proper consideration
of what should be regarded as a normal nose in each
individual case, and of the distinction between a tem-
porary and a permanent obstruction or lesion.
Procedure of Election in Certain Cases of Enlarged
Prostate. — In tiiis article James H. Dunn advocates
suprapubic enucleation in certain selected cases of
prostatic disease, namely, that class of cases- — rela-
tively not very large — with large obstruction but few
complications and comparatively young and sound
physique. He claims that in a relatively sound man,
even of advanced years, especially if the urine be un-
infected, a skilfully executed suprapubic cystotomy is
not a procedure of much danger. He believes that in
these selected cases a skilled technique will reduce the
mortality of suprapubic prostatectomy very materially
below ten per cent.
Do We Obey the Code of Ethics ?— R. G. Eccles,
of Brooklyn, holds that the code of ethics of the Amer-
ican Medical Association is perfect in every respect,
except where it forbids the prescribing of patent med-
icines. In the changed condition of things patented
medicines, such as chloroform, are ethical, while the
secret remedies are no longer patented. These prepa-
rations, whether advertised exclusively among physi-
cians or not, which the author would have placed
under the ban.
The Work of the American Pharmaceutical As-
sociation in Relation to the Materia Medica of the
Future. — In this address F. F. Stewart, of New York,
calls the attention of the profession to the work of the
January 6, 1900]
MEDICAL RECORD.
25
American Pharmaceutical Association, and as cliair-
man of tiiat committee asks that aid may be given to
make the pharmacy of the future what it should be,
viz., a branch of medical science.
Diagnosis of Intestinal Perforation by Means of
Ether Inflation per Rectum. — E. M. Sutton, of Peo-
ria, reports a practical application of this means of
diagnosis in the case of a gunshot wound of the abdo-
men.
Boston Medical and Surgical /ournal, Dec. 28, i8gg.
Surgery of the Bile Passages, Especially of the
Common Bile Duct W. S. Halsted reports a number
of cases in which operations for the removal of gall
stones in the common duct were followed by truly
splendid results, in view of the desperately emaciated
and enfeebled condition of the patients. Briefly sum-
marized, the cases were the following: Dilatation of
the first part of the duodenum caused by constricting
adhesions, with an ulcer on the confines of the pylorus ;
primary carcinoma of the duodenal papilla and diver-
ticulum Vateri; dynamic dilatation of the first portion
of the duodenum and of the pyloric portion of the
stomach, gall stones in gall bladder, hydrops vesicae;
common and cystic ducts reduced to fibrous cords,
dilated hepatic duct and gall bladder; choledochotomy
performed twice, gall bladder shrivelled at first opera-
tion with two stones in duct, large and distended at
second operation when only one stone occupied com-
mon duct; dense adhesions containing a small abscess;
renal pains resembling intestinal colic — adhesions
were absorbed with great rapidity after perforation and
extrusion of stone; stone in ampulla ulcerated through
walls of common duct and through its duodenal cover-
ings.
Unlooked-for Dystocia in Certain Multiparas.—
E. S. Poland says in resume of his article that certain
multipara;, after one or more easy deliveries, lose the
power of natural parturition ; this is due to failure of
the expelling forces in the uterus and abdominal walls.
Artificial delivery is imperative in such cases as
promptly as a diagnosis is established. Infant mor-
tality is high in artificial delivery by the natural pas-
sages. The human female is very tolerant of aseptic
mechanical genital injuries. The author ends with
the query, Is suprapubic delivery justifiable in these
cases when a positive diagnosis is established?
Extraperitoneal Nephro-Ureterectomy for Tuber-
culous Disease — ^A case is described by Edgar Gar-
ceau, in which nephrectomy was performed for pyelo-
nephritis on October 25, 1897. The ureter was not
removed, but the tuberculous ureteral stump caused
abscess formation, which on November 24th was
drained and the ureter removed. In October, 1899,
the patient was in excellent health and strong enough
to do an exhausting day's work. There are slight
bladder lesions, and a few pus cells have been found
in the urine, but the immense improvement in the
patient's condition fully justified the operation.
The Closure of Rents Implicating the Anal
Sphincter A. T. Cabot describes his method of
operation upon a ruptured perineum, calling attention
to the importance of dissecting out and suturing the
sphincter-ani muscle with buried stitches of catgut.
X-Ray Examinations for Life Insurance- Com-
panies.— Francis H. Williams considers that an exam-
ination with the fluorescent screen gives the most
trustworthy and complete evidence of the normal or
abnormal condition of the chest organs.
2'he Philadelphia Medical Journal, December jo, i8gg.
A Case of Successful Suture of the Vas Deferens
Divided in a Hernia Operation. — John B. Roberts
accidentally divided the vas deferens, which had been
thinned by the pressure of a large hernial mass. He
united the divided ends by making a slit in the lower,
inserting the upper into the lower, and then closing
the slit and holding the parts together by sutures.
The operation seemed to be successful, to judge from
the fact that there was no atrophy of the testicle six
months or more later.
Further Thoughts on the Silver-Nitrate Injections
in the Treatment of Pulmonary Phthisis. — Thomas
J. May injects Tr[ v. of a five-per-cent. solution of sil-
ver nitrate over the course of the vagi in the neck in
the treatment of pulmonary tuberculosis. The results
in some cases have been encouraging.
A Case of Tetanus Successfully Treated with
Antitetanic Serum — ^E. B. Adams adds one more
case to the list of those in which orrhotherapy has
been employed with success in tetanus.
Grave Secondary Anaemia Simulating Progressive
Pernicious Anaemia. — J. M. Da Costa describes a
case of secondary anaemia supposed to be due to
achylia gastrica.
On the Significance of Bovine Tuberculosis and
Its Eradication and Prevention, in Canada — By J.
George Adami. See Medical Record, vol. Ivi., p.
423.
General and Local Infection by the Bacterium Coli,
with Report of Cases. — By J. N. Hall. See Medi-
cal Record, vol. Ivi., p. 244.
An Obstetric Tricyclic Calendar. — William L.
Kantor presents a device by means of which the prob-
able date of labor may be calculated.
A New Pile Clamp. — Arthur E. Hertzler shows an
illustration of a new instrument.
The Lancet, December 2J, l8gg.
The Treatment of Surgical Tuberculous Affections.
— In the second of the Harveian lectures, W. Watson
Cheyne discusses the question of tuberculous peri-
tonitis which he finds in about five per cent, of tuber-
culous cases examined post mortem. It may be due to
various tuberculous foci elsewhere, but the most fre-
quent source is infection from intestinal ulceration.
The majority of his operative cases were in women,
while the majority of cases as found on the autopsy
table were in men. Reference is made to pathology,
symptomatology, and complications. About fifty per
cent, are cured by operation. The rationale of cure may
be that the removal of a large amount of fluid may
lead to an outpouring of serum, possibly bactericidal.
Even in dry peritonitis the irritation of abdominal
section and the breaking up of adhesions lead to a
similar outpouring.
Observations Bearing on the Question tf Influ-
ence which is Exerted by the Agglutins in the
Infected Organism. — A. E. Wright and G. Lamb call
attention to ths fact that the agglutins are now re-
garded as bacteriotrophic and anti-bacterial. Diver-
gent views obtain, however, on the question as to how
far they exert an influence in warding off a bacterial
invasion and restraining the growth of bacteria already
active. As the result of a series of experimeirts made
at the Army Medical School at Netley, the authors
26
MEDICAL RECORD.
Qanuar)' 6, 1900
conclude that the agglutins are inoperative in vivo be-
cause their experiments establish the fact (or go far
toward so doing) that the micro-organisms which cul-
tivate themselves in the organism are as a matter of
fact cultivating themselves in the presence of agglu-
tins. This question is capable of being resolved by
a quantitative determination of the amount of agglu-
tins in the organs in which the micro-organisms are
cultivating themselves. The experiments are along
this line.
Gangrene Complicated by Glycosuria. — C. S. ^^'al-
lace anal3-zes twenty-five cases and concludes that true
gangrene occurs in diabetic patients unaccompanied
by such arterial disease as would itself produce the
gangrene. Glycosuria may precede the gangrene, and
may be not a contraindication, but an actual indica-
tion for operation. The latter should be done before
sepsis has set in, and the limb should be removed as
near the trunk as possible. Sepsis may produce a
glycosuria, while a pre-existing glycosuria may be ag-
gravated by gangrene. There is no positive evidence
that neuritis produces a glycosuria comparable to that
of gangrene. The condition of the arteries may be
similar to that associated with chronic renal affections.
Involuntary Reduction of Dislocation of the
Shoulder. — E. I. Day records the histor)' of a case of
dislocated shoulder in a woman in whom reduction
was attempted without an anaesthetic. Severe pain
compelled a postponement, and for the succeeding
night she slept sitting up in a chair. During the
night she gave a sudden start and felt something move
at the joint with intense pain, but immediately after she
felt all right. Examination the following morning
showed that the bone was in its right position.
Infantile Hemiplegia Associated with Aphasia. —
Ernest Hutchinson gives the history of a boy aged two
years who as the result of a fall experienced paralysis
of the right arm, leg, and lower part of face and tongue,
with inability to speak. He did well under a treat-
ment similar to that given adults in similar circum-
stances, but the aphasia had persisted when the
patient was last seen.
Lactation in a Male Infant. — G. M. Blair reports
the case of a boy with highly developed mammae as
large as a walnut. Pressure caused milk to exude.
The external genitals were normal except that only one
testicle appeared in the scrotum. The child's general
condition was bad, and he suffered from vomiting and
emaciation.
Removal of a Hat-Pin from the Stomach J.
Halliwell reports the case of a woman aged sixty
years who accidentally swallowed a hat-pin about four
and a half inches long. It was removed by abdominal
section four days after. Operative details and recov-
ery-were without unusual features.
A Review of Surgery during the Past Hun-
dred Years. — The Bradshaw lecture by H. G. Howes.
The British Medical Journal, December 2J, i8gg.
A Case of Scurvy-Rickets in a Boy of Twelve
Years. — Edmund Owen looks upon rachitis as the
prescorbutic stage of scur\'y, and says that when he is
told an infant or a child is the sulDJect of scurvy he
does not need to be told that the patient is also
rachitic. The term scurvy-rickets was applied to the
disease by Cheadle, but the author thinks the second
part riiuy well be dropped, the afifection being called
simply scurvy. When hemorrhages have occurred be-
neath the periosteum or into the planes of other con-
nective tissues, the disease is no longer rickets, but
frankly scurvy. Scorbutus is very rare in children
over three years old, for by that time a child develops
a taste for fresh fruit which he usually finds some
means to gratify. Scurvy-rickets is more common
among the children of the rich than of the poor, for
it is the well-to-do mother who feeds her child on the
prepared foods, the poor woman finding such fatal
luxuries beyond her means- Mr. Owen has seen one
case, however, in which the disease occurred in an
infant who had been fed upon fresh cow's milk diluted
with large quantities of barley-water. Even scalding
the nursery milk with the view of freeing it of patho-
genic germs materially detracts from its value as a
food for infants. When infants are hand-fed the diet
should be changed from time to time, no one kind of
artificial food being relied upon exclusively. Another
reason why the children of the poor are less likely to
become scorbutic is that they get a taste occasionally
of the food of their elders, and this, while possibly
physiologically wrong, is not altogether without its
recommendation.
On Primary Resection of Gangrenous Intestine.
• — Arthur E. Barker discusses the line of action to be
adopted in cases of gangrenous strangulated hernia:
(i) To incise the gangrenous loop and establish a
permanent artificial anus; (2) to perform the same
operation but subsequently to resect tlie intestine, re-
establish its continuity, and close the fecal fistula; (3)
to perform primary enterectomy and obviate the neces-
sity of an artificial anus. The author's experience
leads him to regard the last-named as the best course
to pursue when the patient is not too exhausted.
When there has been stercoraceous vomiting the
stomach should be thoroughly washed out, before
operation, with warm brandy and water. The patient
should be wrapped in flannel or wool and. be kept
warm during and after the operation. In the after-
treatment Barker advises the hypodermic transfusion
of a pint of saline solution twice a day. Nutritive
enemata are to be given every io'ur hours, alternating
with hot-water enemata at equal inter\-als.
Case of Syphilitic Disease of the Heart and Liver :
Sudden Death. — Percival M. May reports the case of
a man thirt}' years old who died suddenly after having
suffered from intense precordial pain and vomiting.
At autopsy s)-philitic lesions were found in the liver
and in the septum ventriculorum and other parts of
the heart. Primary infection had occurred ten years
before.
A Case of Snake-Bite Treated by Dr. Calmette's
Antivenene. — Arthur Beveridge reports the case of a
man, twenty-six years old, who was bitten on the ankle
by a cobra. When seen an hour later lie was in col-
lapse. The wound was incised and pure nitric acid
was applied, and an injection of 10 c.c. of antivenene
was given. Stimulants were also given. The man
recovered.
A Case of Rupture of the Heart. — Allan Kalen-
burg reports the case of a woman, forty-five years old,
who was going up a steep hill with a load of thirty
pounds on her head. She struck her foot against a
stone and, failing to recover her balance, fell to the
ground and died almost immediately. At the autopsy
the heart, which was fatty, was found to be ruptured.
Fracture of the Spine in the Lower Dorsal Region.
— Noble Smith reports the case of a man twenty-two
years old who was crushed under his horse and suffered
a fracture of the spine. An operation was performed
four years and a half later, the patient being then par-
alyzed in the lower limbs. The result of the opera-
tion was a partial restoration of the power to walk.
lanuan- 6, 1900]
MEDICAL RECORD.
27
A Case of Compound Depressed Fracture of the
Skull. — John D. Gimlette reports the case of a Chi-
nese coolie who suffered a fracture of the skull by a
falling piece of quartz. He was trephined ten days
after the accident. At this time he had hemiplegia
of the left side. Eleven days after the operation power
began to return in the paralyzed limbs, and the man
eventually recovered entirely.
A Case of Poisoning with Liquor Morphinje
HydrocMoridi ; Recovery — Horace C. Colman re-
ports the case of a patient with pulmonary tuberculosis
who took a little over a grain of morphine hydrochlo-
ride in rather less than twenty-four hours, and pre-
sented quite marked symptoms of poisoning. Much
benefit was derived from inhalation of ammonia.
An Unusual Case of Blood-Poisoning.— J. M. Pear-
son repons a case of septic poisoning in a woman
eight days after childbirth. There were no symptoms
indicative of a uterine origin of the trouble, but the
uterus was nevertheless curetted and some small shreds
of placental tissue were removed.
An Adult Infested by Oxyurides for Over Twelve
Years. — E. Hav.kins reports a case of this nature, in
which, after many remedies had been vainly tried, a
cure was obtained by the administration of four grains
of cascara sagrada every seventh night for several
months.
The Pharmacopceia in Its Relation to Medical
Men. — The second of a series of lectiues on " Phar-
macy and the British Pharmacopceia," delivered be-
fore the Society of Apothecaries of London by Nestor
Tirard.
The Surgical Treatment of Tuberculous Diseases.
— By W. Watson Cheyne. See Medical Record, voL
ivii., p. 25.
Medual Press and Circular, December 20, jSgg.
Suppurative Mastitis in the Newly Bom. — Fran-
cis A. Winder relates a series of four cases of suppu-
ration in the breasts of children shortly after birth.
Three were girls and one was a boy. Discussing
the subject of lactation in children, he says that it
may be seen in male as well as in female children,
and that it generally occurs very soon after birth.
The quantity secreted is very small and tends to dis-
appear spontaneously ; it never oozes from the nipple,
and it takes some amount of squeezing to cause it to
exude, but if it is " drawn '" more is secreted to take its
place. It is this "drawing" which causes the breasts
to inflame. There is always a history of interference,
squeezing, rubbing, pressing the breast, etc. And
finally, it is frequently a unilateral phenomenon. It
is more frequently seen in the first-bom of families.
As to treatment the writer says, " Foment and leave
alone."
Recto-Vaginal Haematoma Arthur Giles reports
a rare instance of recto-vaginal hsematoma following
normal labor. There was pain beginning in the ab-
domen and later on referred to the recnim as well.
On the morning after delivery the perineum was bulg-
ing and hjematoma was diagnosticated, the tumor being
of the size of a fcetal head, the skin being almost
gangrenous. After careful cleaning an incision two
and a half inches long was made over the most promi-
nent point, and fresh blood and clots were washed out.
No bleeding points could be detected. The cavity
was syringed out with warm iodine lotion (3 i. to O i.)
and packed with strips of cyanide gauze. There
seemed to be no adequate cause for the haematoma,
which in this situation is rare. The indication here
seems to be to incise and pack early, and not to tem-
porize as in hsmatomas of some other situations.
Cases of Amenorrhcea Treated with a New Salt
of Manganese. — Dr. Murrell relates the case of a
nursemaid, unusually ansemic, presenting a condition
of uncomplicated oligochromamia. Five grains of
citrate of manganese were given three times a day.
The following month the patient menstruated for the
first time in nine months. A second instance of
amenorrhaea treated with prompt results is given.
The citrate is soluble and has advantages over binox-
ide and permanganate.
The Surgical Treatment of Tuberculous Diseases.
— By W. Watson Cherae. See Medical Record, vol.
Ivii.', p. 1:5.
Some Notes upon the Tuberculin Test. — By
Edward O. Otis. See Medical Record, vol. Iv., p.
690.
Berliner klinische WocJunschrift, December 11, i&gg.
The Scientific Establishment of Organotherapy.
— A. Loewy and P. F. Richter make an earnest plea
for the rescue of organotherapy from the semi-char-
latanry into which it has in certain respects fallen,
and for its establishment upon a firm, scientific basis.
They recall the over-confident promises of Brown-
Sequard and his suggestion of the phrase " internal
secretion," and note the scepticism with which the
profession has corae to regard many forms of organo-
therapy, but from a review of some of the more impor-
tant contributions to medical literature and from their
own experiments they show that it has a true scientific
basis which, while it needs to be more carefully deter-
mined in many directions, yet offers the certaint)' of
jMDsitive therapeutic results. The greater part of the
article is occupied with a description of the effects of
the administration of ovarian extract (oophorin) upon
the female organism, showing that while extirpation
of the ovaries is regularly followed by atrophy of the
uterus and various nervous and psychical disturbances,
the use of oophorin after operation will prevent the
occurrence of most of these untoward manifestations.
They also commend the use of the preparation in chlo-
rosis, claiming that it improves the blood state and
leads to a regulation of the menstrual function.
Acute Lead Poisoning. — W. Zinn reports the case
of a woman of thirtj- -three years who took in the dark
by mistake a spoonful of a mixture called " silver-
polish," which was afterward shown to be mainly oxide
of lead. Sis hours later she began to have the symp-
toms of mild abdominal irritation, which continued
with varying severity for nearly three weeks, when she
was seen by the author. He found the usual signs
and symptoms of acute lead poisoning. The patient
was placed on the customar}" treatment, but it was some
ten weeks before her SMnptoms had entirely subsided.
A reference is made to similar cases previously re-
ported.
Certain Further Aspects of the Treatment of
Tuberculosis. — E. Klebs calls attention to the gastric
disrarbances of tuberculosis, stating that in cases of
pure achylia gastrica thyroid atrophy is often present.
He inclines to the belief that this atrophy is due to
the influence of the toxin of the tubercle bacillus. He
has employed in these cases the fresh thyroid juice
with most excellent results. A second point mentioned
is that of mixed infection and the possibility of utiliz-
ing this principle in therapeusis. The author relates
the histories of two cases of tuberculosis created with
injection ot a substance isolated from typhoid cases.
Marked benefit was noted in both.
28
MEDICAL RECORD.
[January 6, 1900
Treatment of Whooping-Cough with Antitussin.
— Max Heim commends the use of this remedy, claim-
ing that it lessens the number and severity of the par-
oxysms, loosens secretion, may confine the malady to
the catarrhal stadium, and is free from injurious effects.
The remedy is a salve to be applied externally.
The Influence of Ob'phorin on Albuminous Metab-
olism.— From experiments on a castrated dog, A.
Loewy concludes that the internal administration of
oophorin leads to an increase of metabolism, and that
at the expense of the non-nitrogenous substances in
the body.
Milnchener tried. Wochenschrift, December J2, i8gg.
Contribution to the Pathology of Syphilis of the
Brain and Spinal Cord. — Theodor Struppler says
that although earlier authorities thought that syphilitic
affections of the brain developed only during the later
stages of the disease, it is now acknowledged that they
may occur at any time during its course, from a few
weeks to years after the primary infection, occasion-
ally even before the eruption. In such cases the sug-
gestion might sometimes be made that these manifes-
tations are due to reinfection, the first infection having
been unnoticed. The following conditions are pos-
sible for the formation of a cyst : circumscribed gum-
mata, induration of brain tissue, encephalitis, syphi-
litic arteritis with thrombosis, and encephalomalacia.
Circumscribed gummata in the central nervous system
are found chiefly in the meninges or in the cerebral
cortex; in the cranial nerves, central ganglia, and ven-
tricles. Heubner believed that simple encephalitis
and softening of the brain, not dependent on diseased
blood-vessels or new growths, frequently accompany
syphilis. Oftentimes an exact differential dia'gnosis
between specific encephalitis and encephalomalacia
cannot be made intra vitam. The youth of the patient
and the lesions found at autopsy in other organs are
most important factors in forming a diagnosis. Ac-
cording to the investigations of Lamy, all syphilitic
affections of the spinal cord are divided into spinal
meningitis, meningomyelitis, and syphilitic myelitis,
all of them being of vascular origin.
Involvement of the Anterior Abdominal Wall in
Carcinoma of the Stomach Rudolf Seggel reviews
this subject, and says that often gastric carcinoma is
without symptoms — at least those referable to the
stomach itself. As in the case of gastric ulcer, so in
cancer, direct extension to the anterior abdominal wall
is unusual. According to Striimpell, the extension of
carcinoma to neighboring organs is just as rare.
Murchison, in a series of three Iiundred cases, found
only twenty-five of gastric fistula through the ai)dom-
inal wall, and of these only six were carcinomatous.
Lange, in two hundred and ten cases of cancer of the
stomach, reports only one perforation of the abdominal
wall. Cases of perigastritic abscess, originating from
gastric carcinoma resulting from ulcus ventriculi and
opening through the abdominal wall, have been re-
ported. Still another mode of infection of the abdom-
inal wall is by means of metastases through the lymph
channels.
Syphilis of the Aorta as the Cause of Aneurism.
— The teaching that aortic aneurism has been the re-
sult of endarteritis or arteriosclerosis has largely ob-
tained, but Arnold Heller brings forward many argu-
ments in favor of syphilis as the most usual cause of
this affection. Clinical statistics support this view,
and the results of antiluetic treatment in cases of
aneurism also favor it. The syphilitic origin seems
especially clear in cases occurring in youth and early
adult life. According to statistics, the proportion of
cases of syphilitic origin to all cases of aneurism is
as follows: Heller, eighty-five percent.; Malmsten,
eighty per cent. ; Rasch, eighty-two per cent. ; A.
Friinkel, thirty-six per cent.; Welch, sixty-six per
cent. ; Etienne, sixty-nine per cent. ; and Gerhardt,
fifty-three per cent.
Indications for the Transplantation of Skin-Flaps
Without Pedicle. — Renter, in a discussion of the rel-
ative merits of the Krause and Thiersch methods of
skin transplantation, shows that although Thiersch's
method will undoubtedly hold the chief place in the
future, that of Krause is most valuable when there is
a special necessity for preserving the elasticity of the
part. Its value depends more on the recognition of
the indications for its application than on the tech-
nique. It is especially useful in cases in which there
is little danger of infection or of insufficient nourish-
mnt of the parts and in cases of contracture of joints
from scars. Renter cites one case in a child in which
the skin-flap applied to the knee grew proportionally
with the part on which it was planted.
The Munich Law Concerning the Hygiene of
Dwellings. — Biberfeld discusses the possible working
of a statute which provides that, if an apartment or
living-room is found to be in an unsanitary condition,
the tenant can leave at any time without giving legal
notice.
A New Fermentation Saccharometer. — Theodor
Lohnstein describes and pictures an apparatus for de-
termining the percentage of sugar, which can be used
with undiluted urine. The saccharometer is patented
in Germany.
A Bicycle Satchel for Physicians. — Arthur Muel-
ler describes an obstetrical bag which can be readily
attached to a bicycle.
Deutsche mcdicinische Wochenschrift, Dec. 14, i8gg.
Cholecystotomy with Waterproof Drainage of the
Gall Bladder. — Poppert describes a new procedure
which he has adopted with excellent results in the
operative treatment of gall stones. The danger of the
methods hitherto in use in the treatment of the gall
bladder, especially when the latter is small, has been
that of leakage into the abdominal cavity with result-
ant peritonitis. The author, after the gall bladder has
been emptied, inserts a catheter and sutures the walls
of the viscus firmly around it. Experience has shown
that these sutures will hold absolutely for from ten to
fourteen days, by which time adhesions will have
formed, removing all danger of leakage. The gall
bladder is not sutured to the external wound, but is left
in its normal position, while the abdominal wound is
carefully tamponed around the catheter. When the
latter is removed there will be a fistulous tract leading
down to the gall bladder, but walled off from the peri-
toneal cavity. This soon closes by granulation.
Room Disinfection by Means of Formaldehyde.
— M. Friedemann presents a series of tables showing
the results of disinfection experiments with formalde-
hyde, two different forms of apparatus being employed.
The results obtained were encouraging, though very
resistant bacteria and spores were not employed in the
experiments. The main objection was the villanous
odor, which rendered the rooms uninhabitable for two
or three days after the disinfection had been effected.
The Formation of Sugar from Albumin. — Ferdi-
nand lUumenthal presents an elaborate review of the
literature bearing upon this question, and comes to
January 6, 1900]
MEDICAL RECORD.
29
the conclusion that we have as yet no entirely satis-
factory and unexceptionable theory of glycogen forma-
tion in the economy.
Vratch, Dccc7nl'ir 4, iSgg.
The Plague Epidemic at Kolobovka in 1899. —
A. M. Levin gives the history of this epidemic occur-
ring during the past summer at Kolobovka, a village of
thirty-five hundred inhabitants in the Astrakhan pro-
vince, Russia. The disease was of a malignant char-
acter, twenty-three out of the twenty-four cases termi-
nating fatally. Of these twenty-three deaths eighteen
occurred within the first three days of the disease.
I'rompt measures of inspection, isolation, and disin-
fection were instituted, and the epidemic lasted only
about four weeks, the first patient falling ill on July
1 6th and the last one on August 9th. On August
nth and the following days all the inhabitants of the
village, except forty, were inoculated with Haffkine's
serum in doses of 3 c.c. for men, 2 c.c. for women,
I c.c. for children of school age, and from -j-L to J- c.c.
for children under ten years of age. No ill effects fol-
lowed the injections, and this first experiment of inocu-
lation of an entire community was counted a success.
Rupture of the Perineum in Coitus K. K.
Skrobanski reports the case of a healthy peasant wo-
man, twenty-two years of age, who suffered a rupture
of the perineum during the first attempt at coitus on
her wedding night. The tear was about 2 cm. in
depth and did not involve the anus. The wound was
washed out and tamponed with iodoform gauze. Four
days later the wound was nearly healed and the patient
was allowed to return home, but was cautioned not to
permit coitus for some time. She did not return, and
when hunted up a week later was found to have disre-
garded the injunction of abstinence, but with no evil
results. The author reviews the literature of this ac-
cident, and finds records of twenty-two cases collected
by Neugebauer.
The Penetration of Formaldehyde into Objects
in the Disinfecting-Chamber. — M. G. Verbalovski
gives in detail the results of several experiments made
to determine the efficacy of the Kareeff disinfecting-
chamber. He found that the formaldehyde would
thoroughly disinfect the interior of mattresses, pil-
lows, upholstered furniture, eta, without injury to the
fabric.
Bulletm de P Acadcmie de MSdecine, December £^ i8gg.
Upon the Existence of Arsenic Normally in
Animals and Its Localization in Certain Organs.
— Armand Gautier, as the result of experimentation
upon animals and man, has found arsenic to be nor-
mally present in appreciable amount in the cell nuclei
of the thyroid and thymus glands, in the skin, and
probably in the pituitary gland, but absent from all
other tissues. This discovery may have an important
bearing on the treatment of diseases due to troubles
of the thyroid gland, and should also be taken into
account by toxicologists. Arsenic found in organs
other than those mentioned would indicate poisoning.
Prophylactic Treatment of Syphilis. — M. Fernet
takes exception to the way in which the out-patient
clinics for venereal diseases attached to certain hospi-
tals in Paris are conducted, especially to the publicity
and to the overcrowding. He also complains that many
persons of means apply for gratuitous treatment,
whereas the clinics should be reserved for the really
poor. He, however, disapproves of Fournier's sugges-
tion that the venereal service in hospitals be under
the charge of physicians selected by competitive ex-
amination, thus creating a new specialty in nospital
service, which he considers to be against the interests
ot science and of physicians.
The Treatment of Functional Epilepsy by the
Bromide of Strontium — J. V. Laborde has found
that 10 to 12 gm. of this drug daily, in divided doses,
is efficacious in epilepsy.
Mediisinskoc Obozrenie, December, i8gg.
Osteomalacia in Women and Its Treatment V.
V. Uspenski advises total castration in the treatment
of osteomalacia. In cases of pregnancy the removal
of uterus and ovaries may be effected through the
vagina in the early months, but Porro's operation is
to be resorted to in the later months. In the early
period of pregnancy, when a radical operation is not
consented to, the best treatment is to induce abortion
and follow that with a course of phosphorus. All the
other modes of treatment — by salt baths, mud baths,
sulphur baths, the internal use of mineral waters,
nourishing food, a change of residence, weaning of
the child (if the woman is nursing), the use of cod-
liver oil, quinine, iron, lime salts, etc. — are uncertain
and find'application only as succedanea to the treat-
ment by phosphorus or operation.
The Sense of Hearing in the Insane. — V. E.
Larionoff tested the hearing in twenty cases of mental
disease, in twelve of which there were or had been at
some time auditory hallucinations. Two patients had
fairly good hearing, but the others were either entirely
deaf in one ear or could hear the watch only on con-
tact or at a distance of from one to six vershki. In
nearly every case bone conduction was absent both for
the watch and the tuning-fork; yet nearly all could
distinguish tones fairly well. The author concludes
from this that there is a special musical centre in the
brain, and this conclusion, he says, is confirmed by
the results of his physiological and anatomical in-
vestigations.
Normal Pregnancy and Childbirth after Opera-
tion for Ectopic Gestation. — The course of normal
pregnancy following the operative treatment of a pre-
vious extra-uterine gestation is, according to A. N.
Solovieff, unquestionably more favorable than after
an expectant plan of treatment. He contends there-
fore that, immediately upon a diagnosis of ectopic
pregnancy being made, we should remove the foetal
sac in order to avoid those dangers which arise from
the existence at the same time of the products of an
intra-uterine and an extra-uterine pregnancy. The
author reports a case of his own and cites many from
the literature in support of this view.
Syphilitic Cirrhosis of the Liver and Chyliform
Ascites. — V. Poliakoff reports a case of syphilitic cir-
rhosis of the liver, occurring in a woman forty-eight
years of age, which was accompanied by a transudation
into the peritoneal cavity of a milky-white fluid. This
fluid was not chylous, as analysis failed to show the
presence of fat. The author has found three cases of
a similar peritoneal effusion in the literature, each of
which was associated with a cancerous affection of the
peritoneum. In none of these cases could the cause
of the peculiar color of the effused fluid be determined.
The Nails of the Human Hand.— P. A. Minakoff
has made an exhaustive study of the nails of the hand,
some of the results of which he regards as of medico-
legal importance. Among other things he asserts that
the nails of the right hand in a right-handed person
are w.ider by from one-half to two millimetres than the
corresponding nails on the left hand, while in left-
handed persons the reverse obtains, and in the ambi-
dextrous the nails are of equal size on the two hands.
so
MEDICAL RECORD.
[January 6, 1900
The thickness of the nails diminishes progressively
from the thumb to the little finger.
A Case of Ovariotomy in the Fifth Month of
Pregnancy.— I. S. Batasheff reports this case, in which
the operation was successfully performed without in-
terruption to the pregnancy.
A New Culture Medium for Tubercle Bacilli. —
O. I. Bronstein has obtained very satisfactory results
with Hesse's culture medium, as described in the
Zeitsc/trijt Jur Hygiene, xxxi., 3.
A Review of Insane Asylum Reports in Russia
for 1897 — V. C. Serbski analyzes the reports of
seventeen institutions in different parts of Russia.
Revue de Thcrapeiitique, December j, i8gg.
Treatment of Affections of the Prostate and
Seminal Vesicles in Acute and Chronic Blennor-
rhagia. — Jules Janet gives an expose of the signs
which permit a diagnosis of prostatic and seminal-
vesicle implications in acute and chronic gonorrhoea:
First, we must distinguish purely congestive from in-
fectious prostatitis. The former is apt to come on after
abundant washings with permanganate of potassium,
giving difficulty in urination, a sensation of weight in
the rectum, which persists between the washings. It
is distinguished from the infectious form by the sec-
ond test glass of urine remaining clear or clearing up
rapidly under the influence of washings, and secondly
in that this condition of the prostate does not interfere
with treatment and does not prevent the permanganate
washings from having their usual rapid effect. In
case of infectious prostatitis we find ( i ) that the second
test glass remains turbid despite the washings, and
that we find quite lively gonococci, when perhaps
there are few or none at all in the drop taken from the
meatus; (2) that the treatment by permanganate does
not succeed, and that recurrences are noted at the least
suspension of washings; (3) that massage of the pros-
tate followed by a washing is all that is necessary to
clear up the urine of the second glass. The author
then describes the symptoms of affections of the pros-
tate and vesicles in chronic gonorrhoea. The article
is to be continued.
Beer Yeast in the Treatment of Gastro-Enteritis,
Particularly of Infancy.— E. Thiercelin and A. Che-
vrey report the result of experiences during the epidem-
ic of last summer in Paris. It is thought that the pres-
ence of yeast in the stomach and intestines interferes
with the development of germs and diminishes gastro-
intestinal fermentation, or that its association with the
gastro-intestinal germs determines a diminution of the
virulence of the latter by a phenomenon of symbiosis
analogous to but opposite to that which is produced
in microbic associations when the virulence of the
germs is great. In all the observations there was a
rapid effect produced upon the diarrhoea. Levurin,
which is looked upon as the active principle of yeast,
gave equally good results, and would point to the
action being due to the antiseptic properties of the
yeast.
French Journals.
Treatment of Tinnitus.— After giving an anatom-
ical description of the ear with illustration, and going
over the various affections of the organ itself and of
other organs capable of causing the symptom of buz-
zing, the various remedies employed are passed in re-
view. Cimicifuga racemosa has been recommended
by Robin and Mendel as a drug governing vascularity
and a moderator of reflex irritation. It is used as a
tincture (gtt. xv.-lx.), fluid extract (gtt. x.-xxx.), or
cimicifugin (product of precipitation of the tincture
by water (5-20 cgm.). These authors have found,
with the exception of cases lasting over two years, that
cimicifuga gives prompt and complete results. — Bul-
letin Glneral de Therapeutique, Decemlier 8, i8gg.
Autopsy of the Stomach.— Maurice Letulle, in a
beautifully illustrated article, discusses examination of
the stomach in situ, ablation, line of incision in open-
ing, examination of the open stomach, cutting, coloring,
preserving, etc. — La Presse- Midicale, December zj,
J8gg.
Pertussis and Its Treatment E. Covin advocates
aerotherapy, and his remarks upon local treatment can
be summed up in the two words asepsis and antisepsis.
— Journal de Medecine, Dece?nber 10, i8gg.
Anaesthesia by Nitrous Oxide and Oxygen R.
Nogue presents a new inhalation apparatus which is
illustrated by three drawings, and he cites instances in
which it has been employed. — La Prance Medicale,
Decetnber 8, i8gg.
Expression and Digital Compression of the Pros-
tate.— A. Guepin treats of massage in various forms
as applied through the rectum. — La Tribune Medicale,
December jj, i8gg.
Localized Suppurations in Women After Deliv-
ery— Grandmaison has recently studied three cases
of localized suppuration after childbirth bacteriolog-
ically as well as clinically, and concludes that somatic
causes have played the chief role. — La Medecine
Moderne, December ij, i8gg.
LI PoUclinico, December i, i8gg.
Relative Toxicity of the Urine in Children and
in Adults. — Ettore Santagelo states that in healthy
adults the urotoxic coefficient, or the amount of uro-
toxins emitted during the twenty-four hours for each
kilogram of body weight, is between 0.2 and 0.3. In
healthy children the coefficient is between 0.3 and
0.4. The urine of children is less toxic than that of
adults, but only absolutely so, for children in the
twenty-four hours manufacture per kilogram of their
body weight a larger amount of toxic principles than
do adults in the same period of time and for the same
weight. The physiological effects produced upon
animals by the urine o^ healthy children are the same
as those caused by the urine of adults. The toxicity
of either adult or infantile urine is in inverse ratio to
the total amount excreted in twenty-four hours, and in
direct relation to the specific gravity, the depth of
color, and the per cent, of urea of the urine. This
points to the evident toxicity of urea. The toxicity
of the urine in children suffering from ankylostomiasis
differs but slightly from that of healthy children.
Polyclonia and Chorea. — Augusto Murri says that
so far no essential distinctions have been established
between polyclonia, tic, and chorea. This is probably
due to the fact that these motor disorders all arise from
one area in the brain. While many forms of choreic
movements are now classified as symptoms merely,
Sydenham's chorea must still be considered as a dis-
ease, because we do not as yet know with what morbid
process it should be connected, but it is probable that
it signifies some as yet unknown lesion in the " zone
of Rolando."
La Riforma Medica, Dec. 4-y, z8gg.
Experimental Researches upon the Action of
Morphine on the Development and Course of Tu-
berculous Infection. — G. Tedeschi, desiring to ascer-
tain the action of morphine in tuberculosis, inoculated
a number of guinea-pigs with tuberculous sputum and
i
January 6, 1900]
MEDICAL RECORD.
31
then carefully noted the effect of certain given closes
of morphine. The animals used are extremely re-
sistant to morphine poisoning, but not immune. The
lethal dose is about 0.06 to each 100 gm. of body
weight, or 0.60 to each kilogram. The morphine was
found to accelerate the disease instead of retarding it,
but was less injurious in its effects the further ad-
vanced the disease. In practice, therefore, morphine
should be resorted to in advanced tuberculosis only.
Further studies upon this subject are desirable.
Toxic Psychoses due to Thyroidin. — Corrado
Ferrarini reports the case of a young woman who de-
veloped symptoms of violent mental disturbance after
the administration of thyroidin for the reduction of
obesity.
Annals of Surgery, December, l8g8.
Properitoneal and Interstitial Inguinal Herniae. —
Van Buren Knott has found only sixty-six cases of
this nature on record. He relates a personal case
occurring in a farmer aged sixty-four years in which
operation was followed by an uneventful recovery. He
was able to operate in five hours after the first symptom
of obstruction had been experienced, but even here the
vitality of the gut was so lowered by the extra press-
ure following its incomplete reduction, that the pro-
priety of returning it into the abdomen was for some
time in question. In all cases of inguinal hernia pre-
senting an unusual location, or shape, of the sac,
great care should be exercised that a reduction of a
portion of the contents of the sac into another com-
partment of the same be not mistaken for a complete
reduction into the abdomen. He believes that all
cases of properitoneal or interstitial inguinal herniae,
whether strangulated or not, should be immediately
subjected to an operation, as thereby the unusual dan-
gers of this condition are minimized.
Operative Relief of Ectopia Vesicae. — D. E. Mun-
dell suggests the following method which he has suc-
cessfully demonstrated on the lower animals: Trans-
plant a portion of bladder wall of, say, a sheep to the
lower lateral abdominal fascia of the patient. After
a period of seven or 'eight days, the union of the tw'O
tissues is sufficiently strong to allow a plastic opera-
tion, whereby a skin flap with the bladder attached
may be swung over upon the extruded bladder, and
the edges of the attached piece of bladder sutured to
the defective bladder. The skin flap will afford suffi-
cient nourishment to the exsected bladder until union
has occurred between the bladder edges, then the
superimposed skin may be separated from the now
perfect bladder. By employing a transplanted piece
which has been removed from the lower portion of the
bladder of the animal, the aggregation of the circular
muscular fibres will approach very nearly to an ideal
sphincter.
Nitrous Oxide and Ether by the Open Method.
— A. H. Miller advocates the commencement of anjES-
thesia with nitrous oxide, and, as soon as antesthesia is
complete, the removal of the inhaler and the substitu-
tion of the ether cone. He has notes of one hundred
and sixty cases in which no one has been conscious
when the change was made or has experienced any-
thing disagreeable from the anfesthetic. The average
time required in his cases for anaesthesia has been 3.05
minutes.
Differentiation of the Urines F. Tilden Brown
makes a plea for a more general employment of ure-
teral catheterization, claiming that it enables us to de-
termine whether there is a urinary lesion present, and
if so whether this lesion is in the superior urinary
tract or the inferior. When a renal lesion exists we
can determine which kidney is affected, what is the
nature of the lesion, and what is the condition of the
other kidney.
Persistent Thyro-Glossal Duct.— G. E. Armstrong
has seen one instance of this in a boy aged six years.
A small lump the size of a pea was situated in the
median line of the front of the neck about three centi-
metres below the hyoid bone. It gradually became the
size of a filbert, and the skin over it was red and in-
flamed. An incision discharged a colloidal material.
The sac was scraped but refilled. Later the sac was
again opened and the cyst wall and duct were dissected
out. There was no recurrence.
Proper Wire for Introduction into an Aneurismal
Sac. — J. C. Reeve, Jr., from experiments in passing
wires of different kinds into a hardened bladder finds
that a silver or gold wire, about .0085 inch in
diameter, and of sufficient temper to retain its coil,
would seem to be all that is required to fill, when
carrying the positive galvanic current, an aneurism
with clots, and is not so thin as to be in danger of
breaking.
Mechanism of Fracture of the Neck of the
Radius — E. R. Corson has examined by the .v-ray'
apparatus a case of this comparatively rare fracture.
Its rarity is due to the fact that it enters only indirectly
into the formation of the elbow joint. In the present
case he was led to believe that the head was torn off
from the neck, and he believes that this is the usual
way in which the accident occurs.
Actinomycosis in Man with Special Reference to
the Cases which have been Observed in America.
— J. Ruhrah finishes in this article his elaborate study
of this disease. There seem to be some sixty-five
cases on record, all of which have been carefully an-
alyzed. A voluminous bibliography is appended.
The Medical Exammer, December, j8gg.
The Manner in which the Effect of Muscular
Exercise upon the Heart and Blood-Vessels Alters
the Expectancy of Life. — T. Sidney Short, after a
brief description of the anatomy and physiology of the
circulation and the effects of muscular e.xercise upon
the human body, divides the takers of exercise into
three classes: First, those whose muscles want exer-
cise because they do not get enough. In these the
heart muscle is not diseased but flabby, pale, and easily
fatigued. Here exercise is a benefit and increases the
insurance value of the risk. Too great exercise dis-
tends the heart because its walls have but little tone.
E.xercise must be moderate, frequently repeated, and
regular. The second class consists of those who keep
their muscles in good condition. Regular exercise is
essential to keep them up to their normal state of health.
Tlie special danger to this class is a long continuation
of slight over-degrees of strain. Long-continued stress
of overwork of any kind gradually produces an effect
which shortens their lives. The third class is made
up of those who have some defect in the vessels. Ex-
ercise is not here to be wholly tabooed. Suitably
arranged exercises can be taught one of this class
until he has built up his heart to allow of his taking
moderate exercise quite comfortably. When actual
disease is present, exercise must be taken most cau-
tiously, and all sudden strains absolutely forbidden.
A Study of the Head and Face of Interest to
Medical Examiners. — William C. Krauss calls atten-
tion to the abnormalities of face, skull, eyes, and ears
noted in a study of various types of degeneracy, and
gives measurements of one illustrative case. The
article is in essence a study of the practical applica-
32
MEDICAL RECORD.
[January 6, 1900
tion of the principles of modern anthropolog)' to the
work of the insurance examiner. Attention is called to
the present incompleteness of the science, and the ad-
mission is made that no special type or types of cranial
deformities or irregularities have as yet been found
pathognomonic of any class or classes of degenerates.
Study of Four Hundred Cases of Tuberculosis.
— The cases were all examined by C. A. McCoUom
for admission to one of the fraternal orders. He
states that it takes five factors to make a "gilt-edge"
risk: a full family age, clean family history, standard
weight, clean personal record, and normal physiological
condition. A minus combination of any three of these
would constitute a questionable risk which might
eventually develop tuberculosis.
The Use of Alcoholic Beverages as It Applies to
Life Insurance. — P. J. Strathy makes three classes of
drinkers — the tippler, the spree-devotee, and the man
who is almost always temperate but has an occasional
"festivity." If a man drinks frequently between
meals, drinks early in the day (perhaps a cocktail be-
fore breakfast), he is not a fit subject for life insurance.
Ethics of Examining. — S. T. McDermith says that
examiners should never compliment applicants upon
their good physical condition, should never abuse the
medical director at the home office if his recom-
mendations are vetoed, and should give a full and free
report of the pros and cons in a doubtful case.
Medicine, December, i8gp.
Milk as a Carrier of Infection.— C. O. Probst
describes the measures necessary for protection against
milk infection. Since milk contains all the essential
elements of food, its use is almost universal. It is an
admirable vehicle for conveying to man many patho-
genic micro-organisms. It may be contaminated by
an infected atmosphere. Diphtheria, scarlatina, and
typhoid fever are chiefly to be dreaded as agents of its
infection after it has left the cow. Tuberculosis is
perhaps a more important disease, and generally in-
fects milk before it leaves the cow. There should be
systematic, rigid inspection of the dairy itself, includ-
ing the cows, their food and water supply, the stables,
milk-house, and persons handling the milk. The per-
mit system, depending on the results of inspection in
each case, should be strictly enforced. There must be
a revolution in the construction of cow stables. They
must be light, clean, well ventilated, and spacious.
Finally, the hearty co-operation of the dairymen is an
important element of success in obtaining pure milk.
Malignant Tumors of the Eye. — William H.
Wilder asserts that the malignant tumors affecting the
conjunctiva are usually epithelial, although sarcoma
sometimes appears at the sclero-corneal junction.
Primary tumors of the cornea are extremely rare.
New growths of the iris are not common. Of all tu-
mors affecting the eyeball, those most to be dreaded
occur in the choroid, ciliary body, and retina. There
are four stages in the clinical history of these cases:
(i) a period of early growth before there is any irrita-
tion; (2) a period of inflammation; (3) perforation of
the eyeball and extension of the tumor outside the
eye; (4) metastasis.
General Surgical Anaesthesia and Anaesthetics. —
Ernest J. Mellish states that chloroform almost invari-
ably kills by its effect primarily upon the circulatory
system, and ether by its effect primarily upon the re-
spiratory system. Anaesthetics act directly or indi-
rectly upon all the tissues, interfering profoundly with
metabolism. The anaesthetic should be selected ac-
cording to the conditions present in the individual
case. No person who has not a wholesome fear of
anaesthetics can be trusted to administer them. The
pupillary reflexes constitute the best guide in anees-
thesia. Anaesthetic mixtures are generally less safe
than the " straight goods."
The Treatment of Syphilitic Stenosis of the
Larynx by Intubation. — Thomas C. Evans advocates
intubation in syphilitic stenosis of the larynx for the
relief of dyspnoea, adding that there is no shock nor
hemorrhage nor danger of infection.
Dublin Journal of Medical Science, December, J&gC).
Venereal Diseases and Their Therapeutics.— T.
L. Swan says that the classification of venereal dis-
eases into gonorrhoea, chancroid, and Hunterian
chancre is unalterable, but that the three have nothing
in common except locality. He describes the genesis
and development of the soft sore, and notes the com-
parative absence at the present time of phageda-na.
This he ascribes to the fact that as persons in civilized
communities become immunized to a degree by a re-
mote or recent inoculation by the microbes of the dis-
eases of civilization, so persons showing no powers of
resistance have either escaped the immunizing taint or
it has become attenuated and lost. As to the treat-
ment of syphilis he notes that the great difficulty is
the length of time required to combat the periodic
manifestations of the toxins. He prefers the intra-
muscular injections of the mercurial cream of Lambkin,
the formula not being given. He adds a few words
concerning two types of the disease occurring in in-
dividuals completely unprotected by influences which
confer partial immunity, one malignant syphilis and
the other syphilis tertiare precox. In the latter case,
mercurials, iodides, etc., were without effect, but
thyroid tablets given internally rapidly healed the
rupial sores which covered the entire body.
Observations on the Treatment of the Third
Stage of Labor, Especially as Regards the De-
livery of the Placenta.— G. Cole-Baker has never
seen in any text-book a description of what he regards
as a perfectly satisfactory method of delivering the
placenta and membranes. He applies a third ligature
to the cord in addition to the conventional two, the
third being two inches from the first and on its ma-
ternal side. The special points to which he calls at-
tention are as follows: i. The importance of the care-
ful treatment of the third stage of labor, and unceasing
control of the uterus during this stage; 2. The binder
in many cases is superfluous; 3. The advantages of
three ligatures on the umbilical cord; 4. Crede's
method of expression relates only to the first step of
the third stage; 5. Traction (vis a fronte) is equally
good, if not preferable, treatment to " detrusion " in
the second step of the third stage; 6. An ideal and
perfectly satisfactory treatment for the third and last
step of the third stage has yet to be described.
Innominate Aneurism. — J. Craig gives the notes
of a case occurring in a man of sixty-five years. He
was treated with morphine, saline laxatives, milk diet
flavored with coffee, and a roast apple four times
daily, and a daily dosage of gr. xv.-xxx. of sodium
iodide in milk. All walking was strictly forbidden.
At the end of eighteen months, except for a slight
prominence and diminished resonance over the former
site of the sac, all physical signs had disappeared
and the patient was in excellent condition.
The Medical Chronicle, December, i8gg.
The Dietetic Treatment of Disease. — J. Dresch-
feld holds that in acute fevers it is well to give thp
patient an abundant amount of food, but not too much
liquid food. In chronic, febrile diseases dietetic
January 6, 1900]
MEDICAL RECORD.
33
treatment is all-important, phthisical patients requir-
ing thirty to thirty-five calories per kilo weight, so that
quality should also be considered and much fat given.
In gout, the nitrogenous diet is usually best suited to
those cases in which the patient is stout, has dyspeptic
symptoms, and passes urine not rich in urea. Some
appear to do best on a vegetable diet. A diet rich in
proteids and carbohydrates often gives rise to dyspep-
tic troubles. In diabetes the usual diet may often
cause total disappearance of the urine, but fat and al-
cohol should be added to it. I:i chronic Bright's, the
diet should contain a small qu. ntity of proteids, and
fat and carbohydrates give th ; necessary heat. In
"dyspepsite" light and finely divided albuminous
food is well borne by patienti suffering from hyper-
acidity, and even when the hydrochloric acid is absent,
if the motor power of the stomach is still intact. If
not intact, small quantities of food in a concentrated
form must be given. In order to obtain the proper
nutritive value we should try to give f.it in the various
stomach affections. Butter, cream, and bacon are usu-
ally well digested, but cod-liver oil and pancreatic
emulsion are sometimes better borne. Some functional
derangements of the stomach are only types of neuras-
thenia and require forced feeding. These are cases
in which there is pain after food, or persistent vomit-
ing, with perhaps enteroptosis, displacement of the
kidney, etc., and in which emaciatation takes place
rapidly. Electrical treatment and massage are im-
portant aids, but often bodily rest, and the partaking
of large quantities of milk, first alone and then in com-
bination with carbohydrates and albuminous food, will
obtain a cure.
Fractures of the Hyoid Bone and of the Laryn-
geal Cartilages. — J. E. Piatt reports a case. The
chief danger of such injuries, he says, lies in the in-
terference with respiration, and resort to early trache-
otomy would greatly diminish the mortality. If the
fragments of a fractured hyoid bone be displaced in-
ward, an attempt may be made to reduce them by a
finge«- in the throat. The parts should be kept at rest,
and, if the patient cannot swallow, nutrient enemata
should be given. Accidents to the hyoid bone have
originated in alnios tall cases from some form of direct
violence.
The Edinbu}-gh Medical Journal, December, iSgg.
Appendicitis. — Gilbert Barling reports one hundred
and seventeen cases operated upon. In forty-two the
operation was performed in a quiet interval, and only
one death occurred. The remaining seventy-five cases
he divides into four groups: i. The " safe " abscess,
with the pus so localized by adhesions that the surgeon
opens into it without danger of infecting the general
belly cavity. 2. "Non-adherent abscess" in which
the pus is shut off from the general cavity, but the
operator has to open the general cavity to seek it. 3.
" Subacute," widespread suppurative peritonitis. 4.
Acute fulminating peritonitis. Group i copiprised
nineteen cases with one death; group 2, twenty-oge
cases, no deaths; group 3, nine cases with three
deaths ; group 4, twenty-six cases with eleven deaths.
The total mortality is twenty per cent., which the
author considers to be in most instances the mor-
tality of delay. The diagnosis of appendicitis being
often difficult, the physician should see his patient at
short intervals in the first three or four days of the at-
tack. The great thing in recognizing a case suitable
for operation is not to take any one point as essential
to diagnosis, and to dwell not so much upon the ab-
sence of any one particular feature as upon the in-
tensity of such symptoms as are present.
The Effect of Extreme Cold on Injury. — Henry
A. Duffett reports two cases in which extreme cold
had a beneficial effect on injuries by producing a form
of dry gangrene. One was that of a sailor whose
finger was injured by being caught in the cogs of a
winch. It was wrapped in a not over-clean piece of
lint, washed with ice-water. The cold was intense
and the man was pn deck constantly. A fortnight later,
the author saw the patient, and found the joint black
and shrivelled, insensitive and smelling foully. He
amputated the finger; primary union occurred, and the
man was at work in ten days.
Bacteriology of Typhus Fever — Andrew Balfour
believes that thediplococcus is derived from the blood,
because it occurs so persistently in typhus and typhoid
cases, and because of the post-mortem occurrence of an
organism almost identical with that derived from the
living blood.
Aconite Poisoning. — W. A. Potts reports the case
of a man who swallowed half an ounce of liniment of
aconite, and recovered under treatment with strychnine
and whiskey.
Acromegaly. — G. A. Gibson reports a case which
he describes at length. Treatment of this disease, he
says, has been attempted in two directions — one the
removal of the pituitary body, and the other the ad-
ministration of extract of that body. Neither has
given the slightest good result. The use of thyroid
extract has frequently produced improvement, but, on
the other hand, injurious results have been described.
Remissions take place in most cases of acromegaly.
The patient's strength must be supported, and any
disturbing symptom treated. In Gibson's cas_e the
use of thyroid tabloids caused considerable improve-
ment, accompanied by a steady loss of weight.
Atheroma of the Aorta. — John R. Ambler com-
ments on the frequency of cases of this affection met
with in post-mortem examinations. In one hundred
patients in an asylum, the author found the condition
in sixty-nine per cent. The average age of all cases
in which atheroma was noted was: males 53.14 years;
females 52.37 years. In general paralysis in which it
was noted, the average age was; males 45.37 years;
females 40.5 years. In phthisis pulmonalis, the aver-
age age was: males 41.18; females 36.46, Is this
condition the result of impact of the blood, or of
disease; and if so, what disease?
The Simulation of the Symptoms of Other
Maladies by those of Chronic Renal Disease — H.
W. Syers thinks that unless the urine be systemati-
cally examined in all cases, renal disease may often be
overlooked, as it simulates so many other affections.
Its influence in the causation of cardiac lesions seems
to be as important as that of acute rheumatism, and
the effects even more disastrous. The arteries are
also often affected, and inflammation of the pericardium
may occur, although rarely. In middle-aged patients
suffering from distention and pain after food, loss of
appetite, and irregularity of bowels, it is never safe to
omit an examination with cold nitric acid. Trouble-
some headache always calls for such an examination.
Constipation alternating with diarrhoea is alv/ay« sug-
gestive of renal disease, as is uncontrollable or fecal
vomiting. Tingling and numbness in one of the ex-
tremities with some headache and nausea may be the
only early signs of cirrhotic kidneys, or there may be
merely giddiness and swimming in the head. Various
diseases of the chest may be simulated by kidney
affections shown by modifications in the act of breath-
ing. Anaemia is a well-recognized symptom of renal
disease, and is sometimes practically the one feature
in the case.^ — Treatf/ient, December 14,
34
MEDICAL RECORD.
[January 6, 1900
Society ^leports.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, December 21, i8gg.
William H. Thomson, M.D., President.
State Care of Consumptives. — On motion of Dr. C.
E. Nammack, the following resolution, emanating from
the Section on Medicine after its recent discussion of
this topic, was adopted by the Academy :
" Whereas, The prevalence of pulmonary tubercu-
losis, especially among the poor, has been, and con-
tinues to be, the cause of more deaths among the
citizens of this State than any other disease; and
" Whereas, The great value of treating this disease
in special institutions, under proper conditions, has
been demonstrated, both abroad and at home; and
" Whereas, The inadequacy of private endeavor,
however well directed, in dealing with this enormous
problem is admitted by all who have made a study of
this question ; therefore be it
" Resolved, That the New York Academy of Medi-
cine recommends the establishment of State and
municipal sanatoria for the treatment of pulmonary
tuberculosis."
The Clinical Uses of the Sphygmograph — Dr. R.
Van Santvoord read a paper on this subject. He
said that in the case of two vessels, one having twice
the internal diameter of the other, it would take twice
as much pressure over the latter to obliterate the pul-
sation in the vessel. One of the chief clinical uses of
the sphygmograph was to enable one to detect high
arterial tension in the early stage of its existence.
Its presence was usually manifested by the flat top
curve, and it was indicative of arterial sclerosis chiefly,
although this was sometimes combined with contracted
arterioles. A large number of sphygmograms were
exhibited, and their meaning was interpreted. Sev-
eral were pointed out in which the quality of the pulse,
as determined by the finger on the radial artery, had
been very far from the truth. They showed how very
misleading the pulse might be, even to the touch of
the experienced physician. His tracings also showed
that excessively low tension might be of significance
in chronic as well as in acute diseases. He had been
puzzled repeatedly with complaints of faintness from
patients shortly after taking a dose of nitroglycerin.
This might be explained by an unusually rapid absorp-
tion of a dose which ordinarily caused no inconven-
ience. The chief objection made to the sphygmograph
had been the different results obtained by different
observers. It was true that the faulty application of
the instrument would give unreliable results. The
spring pressure must be carefully graduated, not only
to the arterial tension, but to the calibre of the vessel.
A series of tracings should be taken with a gradually
increasing pressure on the spring and on the band
holding the instrument against the wrist. For the
latter purpose he had found it convenient to have a
small tourniquet attached, one on either side of the
instrument. It was well to remember that almost
always when the first part of the curve was "nicked
out " it indicated that the spring pressure was inappro-
priate. Failure to apply the middle of the pad directly
over the artery sometimes resulted in giving a distor-
tion to the tracing, resembling that given by too great
tension of the spring. Occasionally arteries would be
found which were too small to give a good tracing,
and the same was true of cases in which the action of
the ventricle was very weak. After an experience of
fifteen years he had come to look upon the sphygmo-
graph as very useful, and as presenting no more fal-
lacies than other methods of investigation which no
physician would think of discarding.
Dr. Louis Faugeres Bishop said that the paper
made it clear that the author had succeeded in obtain-
ing more information from the sphygmograph than had
many other physicians who used it, though perhaps
less frequently. As the author had pointed out, one
must be guided more by the shape of the tracing than
by the actual amount of spring pressure in determin-
ing the arterial tension. He had personally always
regarded .as most nearly correct that tracing which
gave the best picture. When there was a tracing with-
out a dicrotic notch one could feel very sure that this
defect was due to imperfect technique. Mention had
not been made of the fact that the same tracings could
be obtained by attaching a manometer to the cut ves-
sel of an animal, an observation which was interesting
as proving that the sphygmograph really did give a
true picture.
Dr. S. J. Meltzer said that he had had some expe-
rience with the graphic method in connection with
experimental research, although not so much with the
sphygmograph. He would not trust himself to form
any opinion from the form of a pulse tracing as to the
character of the arterial tension. Statements had
been lately made to the effect that the heart increased
in size under exertion, and it would, therefore, be in-
teresting to know whether, in the case in which the
tracing had been taken from a person after exercise,
an effort had been made to determine any coincident
change in the size of the heart. No tracings had been
exhibited in illustration of cardiac irregularity. For
this kind of investigation the record should include a
time-marking tracing.
Dr. H. W. Berg said that he had tried to make use
of the sphygmograph, but had been unable to obtain
tracings to which any diagnostic importance could be
attached. The great difficulty seemed to be that in
any given case tracings taken only a few minutes
apart, with the same spring pressure, showed marked
variations. Although twenty-six years had elapsed
since Marey had first brought forward his instrument,
and many competent observers had given their best
energy and much time to the study of the sphygmo-
graph, the instrument was still far from being prac-
tical and reliable. There was one exception to this
statement, and that was tlie sphygmograph ic tracing
of an irregular pulse, but even this did not add much
to the value of the instrument in view of the ease with
which such information could be secured from the
finger on the radial pulse.
Significance of the Dicrotic Notch. — Dr. Andrew H.
Smith said that he had used the sphygmograph a good
deal some years ago, and had met with just the diffi-
culties that had been emphasized by the last speaker.
In some patients the artery was placed very deeply,
and more or less overlaid by the tendons of the wrist,
and, under these circumstances, it was very difficult so
to adjust the instrument as to secure reliable sphyg-
mograms. We had been taught to believe that the
(^erotic notch was the result of a secondary wave
taking place on the closure of the aortic valves, and
yet sometimes a most marked dicrotic wave was ob-
tained in cases of aortic regurgitation. It was not
uncommon to be able to see, in the pulsation of the
vessels of the neck, this dicrotic impulse, when the aor-
tic valves were so much destroyed that one would not
have supposed they could have produced such a result.
He was inclined to think that, in some instances at
least, the dicrotic notch was the result of a reflux of
the blood in the opposite direction. If the conditions
in the circulation beyond were altered, a change would
result in the dicrotism, and in the general characters
of the sphygmogram. For example, if the arm was
ligated above the elbow, as for a venesection, the
January 6, 1900]
MEDICAL RECORD.
35
dicrotisin would disappear, and all of ihe qualities of
the high-tension pulse would be produced. In the
same way, if the patient held his breath for some time,
the tracing would show a very much smaller excursion.
Again, it was not always easy to determine whether
there was a sufficient degree of tension to give a slight
excursion from tension, or whether this condition arose
from the feebleness of the ventricular contraction.
Peculiar Tracings. — He recalled a case in which
the sphygmogram had indicated forty beats to the
minute, with fairly marked dicrotism and an enormous
excursion. In this case, the rhythm had changed fre-
quently, and, in the course of a single tracing, it had
been possible to see distinctly where the dicrotic notch
had increased in amplitude from one beat to another
until it liad finally equalled the amplitude of the reg-
ular stroke. The pulse had then changed from forty
to eighty beats per minute, and it had been no longer
possible to distinguish, either by the sphygmograph
or by the finger, between the exaggerated dicrotism
and the alternate beats.
Effect of Working in Compressed Air. — Some
time ago he had employed the sphygmograph in obser-
vations on the men subjected to high air pressure
while working in the caissons of the Brooklyn Bridge.
This study had been exceedingly interesting, and had
shown an increased amplitude, with more pronounced
dicrotism and a greater frequency of the pulse. He
failed to attach, however, much importance to the in-
strument, either as a means of securing a record or as
an aid to diagnosis.
A Useful instrument. — Dr. C. L. Dana said that
he had succeeded in obtaining fairly uniform tracings
and records with the sphygmograph which had been,
at times, useful both for diagnosis and prognosis.
He had confined his use of the sphygmograph almost
entirely to persons who had reached the degenerative
period of life, and in whom there were a certain stead-
iness and rigidity of the blood-vessels. Moreover, he
had not been studying cardiac disease by this means,
but rather the rigidity of the blood-vessels, the e.xtent
to which they were filled, and the strength with which
the heart pumped the blood into them. Again and
again he had found, in cases of apoplexy, a type of
pulse giving an almost pathognomonic tracing. In
these cases the vessels were dilated, but not well filled.
These tracings seemed to him to show a need for
strengthening the action of the heart, or at least for
carefully watching the circulation. In certain classes
of neuroses rather striking sphygmograms could be
secured. Basedow's disease yielded a very character-
istic tracing. The sphygmograph was also of some
value in determining the quality of some of our drugs.
Application of the Instrument Personally, he
never thought of keeping any record of spring pressure,
nor did he strap the instrument on the wrist. The
patient laid the hand on the table, and the examiner
held the instrument on the wrist and endeavored to
secuie the best possible record. Three or four tracings
should be taken under varying pressure. He was con-
vinced that the instrument should be held by the phy-
sician, and not strapped to the patient.
Dr. Van Santvoord, in closing, said that, in some
instances, the disappearance of the dicrotic notch was
legitimate, and did not indicate faulty technique. He
had not studied any of the tracings with reference to
the effect on the rhythm of the heart of defects in the
auricle or ventricle. In going over his records, in
the preparation of this communication, he had been
impressed with their very great uniformity under sim-
ilar circumstances. Variations in the conditions
would, of course, produce marked, but very readily
interpreted, variations in the sphygmograms. He had
not observed ordinarily marked variations in the
tracings taken from the same patient under the same
conditions at an interval of only a few minutes. He
did not feel that he could take trustworthy sphygmo-
grams without strapping the instrument to the patient's
wrist.
Election of Officers. — The annual election resulted
as follows: Vice-Fresident, T)x. G. L. Peabody; Trics-
iee, Dr. A. Jacobi ; Treasurer Jor ihe I'rustees, Dr.
R. H. Sayre; Treasurer, Dr. H. L. Collyer; Commit-
tee on Admissions, Drs. C. E. Nammack and J. B.
White; Committee on Library, Dr. Alfred Meyer.
NEW YORK COUNTY MEDICAL ASSOCIA-
TION.
Stated Meeting, December 18, i8gg.
Frederick Holme Wiggin, M.D., President.
Hysterectomy Without Preventive Haemostasis
Dr. A. Brothers presented a uterus containing a
number of fibroids, in order to call attention to the
method of hysterectomy without preventive haemosta-
sis— a method in vogue in Europe at the present time.
This was the first case in which he had operated in
this manner. The uterus had been seized per vagi-
nam in the usual way, and the usual circular incision
made, together with the upward dissection both ante-
riorly and posteriorly so as to open into the space in
front as well as into Douglas' cul-de-sac. The uterus
had then been seized higher and higher by traction
forceps, and in that way the fundus was drawn down.
Up to that time there had been no hcemostasis. In
the present instance he had used clamps to the broad
ligament, applied from above downward until three or
four had been used on each side. In that case the
indication had not been the presence of fibroids so
much as the fact that the patient had been a sufferer
from pelvic inflammation for thirty years. He had
removed the uterus on one side completely and the
uterine horn on the other side, leaving the diseased
tube and ovary because of extensive and firm adhe-
sions there.
Report of a Case of Alcoholic Cirrhosis of the
Liver in a Baby — Dr. R. Abrahams reported this
case, that of a girl aged sixteen months, who up to
the age of fourteen months had been in good health.
Since that time there had been loss of appetite, in-
creasing pallor of the face, constipation, and increase
in the size of the abdomen. He had first seen the
child on November 4th. The skin had then been dry
and scaly, and the appetite capricious. There had
been no hemorrhages from the stomach or bowel, and
no jaundice. The abdominal distention had been
extreme, the circumference at the umbilicus being
twenty-six inches. Owing to the ascites the liver and
spleen could not be defined. There was no effusion
except that in the abdominal cavity. The diagnosis
of cirrhosis of the liver had been made by exclusion.
Syphilis had been excluded by careful inquiry and
examination. An ascites from tuberculosis would
develop more slowly than in this case. In the ab-
sence of cedema of the lower extremities and marked
urinary signs and symptoms, interstitial nephritis had
been excluded. It had been finally ascertained that
since very early infancy the baby had been allowed to
imbibe beer quite freely. For two weeks the child
had been given two-grain doses of iodide of sodium,
but without result. The ingestion of water had been
restricted, the bowels kept relaxed, and the beer
stopped. After a time paracentesis had been per-
formed, and then it had been found that the liver was
smooth and hard and extended down almost to the
iliac spine. Since the tapping, early in November,
there had been no return of the ascites. The liver
36
MEDICAL RECORD.
[January 6, 1900
had diminished slightly. The patient and photo-
graphs were exhibited.
Dr. H. Illoway said that numerous cases of alco-
holic cirrhosis had been reported in children. Some
physicians maintained that alcoholism was rarely a
factor in the production of cirrhosis of the liver in
children, yet personally he was firmly convinced that
it was almost always the cause of this affection in
young subjects. Dr. J. H. Musser, of Philadelphi?
had recently expressed the same opinion. Cirrhosii,
might develop almost any time after birth, but it vas
most common between the sixth and twelfth years.
Mention was made by the speaker of a case of a child
of two years, still at the breast, in which the mother
had been accustomed to drink alcoholic liquors freely.
Cirrhosis had also been ascribed to measles and scar-
latina, yet in quite an extensive experience with these
diseases he had never met with cirrhosis in children.
It had seemed to him that beer had a more potent
effect on the liver of young children than some of the
stronger alcoholics.
Etiology, Diagnosis, and Treatment of Cystitis.
— Dr. Ramon Guiteras read this paper. He said
that cases of irritable bladder were often called cysti-
tis, although really they were nothing more than the
result of congestion of the neck of the bladder from a
foreign body or from the irritating character of the
urine. Acute cystitis was generally due to the exten-
sion of a gonorrhoea from the urethra during the third
or fourth week, or to instrumentation in a case of
posterior urethritis. Congestion or distention of the
bladder wall, undue exercise, particularly bicycle or
horseback riding, and exposure to wet and cold were
important predisposing causes of cystitis. Frequent
and painful urination, associated with the presence of
pus or blood in the urine, were the chief symptoms of
cystitis. Recto-abdominal palpation would reveal
tenderness in the region of the trigone. Acute cystitis
might be confounded with posterior urethritis, pros-
tatitis, seminal vesiculitis, and vesical irritability.
Posterior urethritis was usually an accompaniment of
acute cystitis, and occurred before, and also after, the
latter. In acute posterior urethritis the pus flowed
back into the bladder, so that the urine would contain
pus just as in a case of cystitis. When the urine was
passed into three glasses, the last glass would be
found to contain more pus than in a case of posterior
urethritis. In a case of posterior urethritis the first
glass would contain more pus tlian the other two, and
would also show the presence of shreds. In cases of
acute prostatitis there was pain in the rectum and on
sitting, and rectal examination would reveal tender-
ness and enlargement of the prostate. In seminal
vesiculitis rectal examination would show the vesicles
to be enlarged and tender, and after the inflammation
had subsided a cjuantity of detritus could be expressed
into the bladder by massage. In chronic cystitis the
patient would probably urinate ten or twelve times in
the twenty-four hours, and the urine would be light
in color and alkaline, and would contain some al-
bumin or blood. When evacuated into three glasses
the first and third would contain the most pus. In
making the diagnosis of chronic cystitis, one must
consider chronic posterior urethritis, chronic prosta-
titis, kidney lesions, and bladder irritability, as well
as certain nervous affections. In cases of chronic
posterior urethritis there were usually only shreds
washed out, and these would be found chiefly in the
first glass. In kidney lesions there was usually pain
in the loin in addition to the physical signs of en-
largement of the kidney. The pain of cystitis was
more often referred to a point back of the pubes. In
cystitis the pus was usually found associated with
alkaline urine, while in pyelitis the urine was usually
acid. In cystitis the pus was constant; in kidney dis-
ease it might be intermittent, and it was usually less
abundant than in cystitis. Bladder irritability was
distinguished from chronic cystitis by the absence of
pus in the urine. Percussion and palpation would
determine whether or not the bladder was enlarged,
and palpation would reveal tenderness, enlargement,
or the presence of calculi. The cystoscope would
show a reddened and thickened appearance of th:
bladder in cases of ulceration. This instrument
would also enable the opei^ator to determine the pres-
ence or absence of calculi and tumors.
Treatment: In the treatment of acute cystitis, hot
sitz-baths would be found of the greatest service.
They should be given twice daily, as hot as can be
conveniently borne. Hot rectal douches of saline
solution were also beneficial. By the mouth the pa-
tient should be given alkaline diluents and antispas-
modics. When the spasms and pain were severe
suppositories of belladonna and morphine should be
used. If the urethra was not too sensitive, bladder
irrigations through the meatus were desirable. The
best solution was the permanganate of potassium,
beginning with the strength of i : 4,000 and gradually
increasing until at the end of a week the maximum
was reached — 1 : 1,000. Subsequently nitrate of silver
solution should be substituted, using at first i : 16,000
and slowly increasing it to i : 4,000. Sometimes it
was better to make use of deep urethral instillations
of five or ten minims of a solution of nitrate of silver,
using a strength varying from one grain to the ounce
to four grains to the ounce. Although in cases of
acute cystitis it was not advisable to pass an instru-
ment through the urethra into the bladder, such in-
strumentation was not usually contra-indicated in
chronic cases. When the urine was ammoniacal
nothing in the way of intestinal medication was equal
to urotropin, given in doses of 3 ss. three or four
times a day. In cystitis due to stricture, it was well
to dilate the stricture if possible, but if the stricture
w-as very small and resistant it should be divided
with a urethrotome, a Maissonneuve knife, or, if deep-
ly situated, by external perineal section. When the
prostate was very greatly enlarged enucleation should
be done, but in the case of very moderate and hard
hypertrophy of this gland he preferred the Bottini
operation. Bottini's galvano-cautery knife not only
reduced the size of the gland directly, but by destroy-
ing some of the blood-vessels diminished the blood
supply, and so favored atrophy of the gland. When
the cystitis was the result of tumor of the bladder, the
tumor should be removed, if possible, by suprapubic
cystotomy, cauterizing the base. In cases of malig-
nant tumor of the bladder drainage would give relief.
Causes of Cystitis in Women — Dr. Alexander J.
C. Skene spoke of the etiology and treatment of cysti-
tis in women. He said that the treatment did not
differ from that of cystitis in the male, unless due to
some other cause. What he would call the preventive
treatment in women was by far the more important.
The etiology was also quite distinct from that in the
other sex. For anatomical and physiological reasons
the bladder was far more exposed to injuries, and if
he were to judge by his own experience he would say
that the most frequent cause was trauma, either dam-
age during parturition or surgical operations on the
pelvic organs, or the use of instruments, such as the
catheter. Cystitis in women was far more frequently
caused by injury than by sepsis. The sepsis might
be either from without or from within. Before the
days of aseptic surgery the etiology of cystitis had
been but vaguely known; subsequently it had been
believed that cystitis was the result of the infection
of the bladder by septic or specific germs, but this, he
thought, was not the case. If this view was correct,
then there should have been a disappearance of cysti-
January 6, 1900]
MEDICAL RECORD.
tis under aseptic precautions, but such had not oc-
curred. Just as soon as it had dawned upon him that
many cases of cystitis arose from the traumatism in-
flicted by the metallic catheter, he had substituted the
rubber catheter. The result had been a very marked
diminution in the number of cases of cystitis, although
the same aseptic precautions had been taken in the
use of both the metallic and the soft-rubber catheters.
It was now very rare for him to see a case of cystitis
after prolonged catheterization. -He believed that
cystitis could be produced by the decomposition of
urine and the development of pathogenic germs, but
this result was rare unless the mucous membrane had
been injured by the catheter or by some surgical oper-
ation. Another class of cases coming under the same
categorj' were those in which the cystitis was the re-
sult of prolonged standing. This was far worse than
long walking, because the latter stimulated the circu-
lation, whereas prolonged standing gave rise to con-
gestion and stagnation. These patients often com-
plained of a feeling of weight and tenesmus, and were
then seized with pain in the bladder and frequent
urination. On examining the bladder in some of
these cases he had found a small ecchymosis. With
rest and simple treatment these patients would re-
cover, but if they persisted in standing they would
develop a well-marked cystitis. The most persistent
and obstinate cases of cystitis that he had seen in
women had resulted from a suprapubic cystotomy
with the idea of draining the bladder. In many
cases in which the vagina was rigid, drainage would
be very imperfect, and unless the treatment was kept
up the original inflammation would not be entirely
cured. The patient being temporarily relieved by the
drainage of the bladder, the fistula was usually closed,
and then it would be found that the patient was worse
than before. A piece of scar tissue in the bladder
was almost sure, sooner or later, to break down and
light up another attack of cystitis. Another cause of
cystitis in women was physical exploration of the
bladder, though done by the most scrupulously clean
operators. He referred particularly to the dilatation
of the urethra and catheterization of the ureters, and
the use of the endoscope.
Methods of Diagnosis — Very little damage to the
mucous membrane would be sufficient to allow of the
development of a cystitis. He contended that in
nearly all cases a diagnosis could be made not only
of cystitis but of the kind and degree of inllammation
of the bladder, without making use of any of the in-
struments for internal exploration. For such informa-
tion as he needed he relied upon a skilful analysis of
the urine. It was very easy to exclude urethritis.
The bladder having been allowed to become fairly
well distended, the patient should pass a little urine
to wash out the urethra, and then the urine should be
collected and examined. If the bladder was washed
out tiioroughly, and then the next few drachms of
urine secreted were found to contain the products of
inflammation, it was almost positive evidence that the
inflammation was in the ureters or kidneys.
Treatment. — For thoroughly cleansing the bladder
he had found borax decidedly better than boric acid.
It was important to remember that the fluid should be
instilled — not injected — because the bladder should
be allowed to fill very slowly. Care should also be
taken not to allow the bladder to contract down upon
the end of the catheter. The injection of an infusion
of hydrastis, or of a very mild solution of nitrate of
silver, was to be recommended in many instances.
The stronger solutions of silver would certainly give
temporary relief, but the ultimate result was not so
good as when the solution was not stronger than one
or two grains to the ounce. When a more decided
effect was desired it could be more safely secured by
the repeated injection of a mild solution. In addi-
tion to these measures h6 would make use of the con-
stitutional treatment advised in the paper. However,
when there were ulcerations such mild injections
would not be sufficient. The ulcerated surface
should be brought into view, and that particular area
destroyed by a rather strong caustic application.
Such an application to be effective must be circum-
scribed. In cases of cystitis caused by the presence
of neoplasms in the bladder, he would recommend a
method of treatment that had recently given him
much satisfaction. This consisted in doing a supra-
pubic cystotomy, and then seizing the base of the
growth, compressing it, and cutting it off with the
cautery, or with the electro-hamostatic forceps. This
method, if properly carried out, was entirely bloodless,
and left a most desirable stump, and one which healed
in two or three weeks at the most.
Dr. Eugene Fuller said that all of Dr. Skene's
cases of traumatism were examples of cystitis arising
from infection. In the male much more difficulty
was experienced in securing good drainage. Atony,
traumatism, deficient drainage, calculi, and neoplasms
might all act as causes to make the bladder receptive
of germs. The most common mode of infection in
the male was by an ascending infection from the ure-
thra. In some severe cases of cystitis not only was
the muscular coat involved, but the surrounding tis-
sues were invaded. Here the bladder might become
invested in dense adhesions and greatly reduced in
size.
Washing the Bladder. — Dr. W. K. Otis empha-
sized the danger of mistaking disease of the kidney
for disease of the bladder. Particularly in tubercu-
lous disease the entire trouble might be located in the
kidney, and yet the symptoms point directly to the
bladder. In cases of chronic cystitis one must rely
almost wholly on local treatment. In irrigating the
bladder the effort should be made, not only to cleanse
it thoroughly with an aseptic solution, but also to act
directly upon the mucous membrane. When there
was an associated posterior urethritis, the catheter
should be introduced only just within the external
sphincter. This would be known by the fact that on
removing the syringe the fluid would not return out of
the catheter, although fluid cguld be introduced into
the bladder. Having moderately distended the blad-
der, the catheter should be removed, and tiie patient
allowed to evacuate the fluid, thereby cleansing both
urethra and bladder at the same time. When the dis-
ease was wholly within the bladder, a soft-rubber or a
silk catheter should be employed. A total emptying
of the bladder was secured by having the patient in
the erect posture, and this should always be the posi-
tion except when the person was too feeble. The
double-current catheter was not to be recommended,
as the fluid passed from one eye to the other without
cleansing the bladder. Nor was it well to employ the
irrigator. When the bladder was atonic, care should
be taken not to distend the organ, and pressure should
be made over the pubes so as to secure a thorough
emptying of the viscus after the washing. Litho-
lapaxy he considered the ideal operation in all cases
of vesical calculus in which it was possible to intro-
duce the necessary instruments. This operation was
safer, and the convalescence was more rapid than
after suprapubic cystotomy.
Dr. Guiteras closed the discussion. He said that
tra ima or anything else which caused congestion of
the bladder should be looked upon as a predisposing
cause of cystitis, the direct and active cause being
infection. It was possible at the present time to
sterilize even woven catheters by a short exposure to
formaldehyde vapor.
Syphilis of the N3rvous System, and the Use
38
MEDICAL RECORD.
[January 6, 1900
and Abuse of Mercury and Iodine in Its Treat-
ment.—Dr. VViLLiAM M. bESZYNSKY presented a
paper with this title. He considered more particular-
ly intracranial syphilis. Thorough treatment of syph-
ilis in the early period after infection, he said, was
generally considered to be the most effective way of
preventing the disastrous phenomena of tertiary syph-
ilis. One was forced to acknowledge, however, from
clinical experience that even when such early and
thorough treatment was carried out, the patient was
not insured against the later manifestations, although
usually when they did occur they were decidedly
milder than in cases neglected in the early stages.
All neurologists were familiar with the history of an
initial lesion but an absence of recognized secondary
manifestations. There was no known method by
which the virus of syphilis could be eradicated so
that the physician could assert positively that there
would be no further manifestations. Recent exuda-
tive inflammations, gummatous growths, pachymenin-
gitis, obi iterative endarteritis, and periarteritis were
the conditions which were most amenable to antisyph-
ilitic treatment. In general, the results were ob-
served within two or three weeks. The rapidity
varied with the virulence of the disease, its duration,
and the susceptibility of the patient to mercury and
iodine. The preferable method of administering mer-
cury was by daily inunction until the specific effect of
the remedy was observed. Iodine, in the form of
iodide of potassium, was given in saturated olution,
beginning with ten minims three times daily, well
diluted. Some patients could take readily as much
as two or three drachms of the saturated solution three
times a day. It had seemed to him that the action of
iodide was more rapid than that of mercury, though
he iisually began with the mercurial inunctions. The
use of the iodide should generally be continued until
all active symptoms had subsided, though two or three
months was about the average time. Much harm
might be done to the general health by excessively
prolonged and injudicious use of iodide and mercury.
Thus, primary optic atrophy progresses more rapidly
to complete blindness under such medication. Tonic
measures of all kinds should be considered an essen-
tial part of the treatment. As a prophylactic measure
small doses of the iodide should be administered for a
short time about three or four times each year. When
the diagnosis of syphilitic disease was doubtful too
much dependence should not be placed upon the so-
called therapeutic test. While it possessed at times
a certain value, it was more often unreliable. It was
well known that iodine promoted the absorption of
non-syphilitic processes. It should also be remem-
bered that syphilis could not be positively excluded,
even when a case proved obstinate under antisyphi-
litic treatment. Patients with tabes who had never
received antisyphilitic treatment since the onset of
the tabetic symptoms should certainly receive a short
course of such medication, but if this had already
been done it was not only useless but positively
harmful to repeat it. It was greatly to be deplored
that many practitioners had accepted the opinion ad-
vocated so zealously by some, that without syphilis
there would be no tabes. At the present time the pre-
vention of syphilis was practically impossible.
Dr. Edward D. Fisher said that in all syphilitic
disease of the nervous system the more acute the
process the better was the response to antisyphilitic
medication. For instance, in pseudo-general paresis
under the use of one or two hundred grains of the
iodide daily, in conjunction with mercurial inunc-
tions, one frequently observed excellent results.
Again, in all cases of ocular muscle paralysis coming
on suddenly without any history of traumatism or
rheumatism, it was fair to assume that the disorder
was of syphilitic origin, and the treatment should be
shaped accordingly. Tonics should always be admin-
istered in conjunction with antisyphilitic treatment.
Spinal syphilis was frequently mistaken for tabes, the
gummatous infiltration being in the same region, and
giving rise to the same class of symptoms, except that
tabes was never rapid in its course, whereas spinal
syphilis frequently developed "in the course of a very
few weeks. In such a case he knew of no other treat-
ment equal to th6» use of mercury and iodide. In
cases of tabes exhibiting sudden exacerbations he
would also make use of this treatment. Such symp-
toms were supposed to indicate the occurrence of a
new gummatous infiltration.
Dr. Edward G. Janeway said that in suspected
cases of cerebral syphilis the physician's first duty
should be to try to determine the location and nature
of the lesion. There might be, for example, a hyper-
ostosis of the bones of the skull sufficient to give rise
to marked symptoms. He recalled having seen an
autopsy on a case in which a most distinguished neu-
rologist had diagnosticated a tumor of the brain, and
an unsuccessful attempt had been made to remove it
by operation. No tumor had been found, but at the
autopsy a syphilitic hyperostosis was found in the re-
gion in which it had been thought the new growth was
situated. A gummous pachymeningitis was occasion-
ally associated with hemorrhages, thus materially
modifying the symptoms. Marked irritative phenom-
ena might result from a very localized lesion on the
surface of the brain, resulting in adhesion of the pia
and dura. In two cases he had seen syphilitic hemi-
plegia from arterial obstruction at the end of five or
six months; it was sometimes a precocious event.
Sometimes very remarkable results were obtained
from very moderate doses ; in other cases, the mercu-
rial and the iodide must be pushed vigorously. At
times the iodide was not well borne by the m.outh,
and in such cases, or when the patient was in convul-
sions or was unconscious, the drug should be admin-
istered per rectum. When there was an individual
intolerance to iodide of potassium, the iodide of
sodium or the iodide of strontium should be tried,
though he prefered the iodide of potassium whenever
it could be taken.
Late Syphilitic Fever. — Incidentally the speaker
mentioned the fact that there was sometimes a con-
tinued fever in tertiary syphilis, which was most apt
to be mistaken for tuberculosis. In cases of this
kind he had seen exceedingly good results from very
moderate dosage; indeed, he had knovi'n such doses
to succeed in some of the less urgent cases of cerebral
syphilis.
Tabes and General Paresis. — He very firmly be-
lieved that the vast majority of the cases of tabes
owed their origin to syphilis, and he held the same
opinion regarding most cases of general paresis. In
case of doubt he was in favor of giving the patient
the benefit of the doubt by employing the therapeutic
method of diagnosis.
Dr. Charles I. Proben said that it had been es-
timated that about two-thirds of all cases of syphilis
failed to present tertiary manifestations. In cases of
the degenerative type one could hardly expect to ac-
complish anything by antisyphilitic treatment. The
latter acted on the granuloma tissue by producing
fatty degeneration, and possibly also by acting on the
germs in the blood. The lymphatic vessels were very
early affected in syphilis, and in the clearing out of
the lymphatics and of the blood-vessels, iodide was
especially useful. When the patient was observed to
be losing weight rapidly, the iodide should be reduced
or withheld. This emaciation was most striking when
iodide was given to a tuberculous individual.
Administration of Mercury. — Dr. Boleslaw La-
January 6, ] 900]
MEDICAL RECORD.
39
POWSK.1 said regarding the administration of mercury
that in all severe forms of syphilis the quickest and
safest method of giving the mercury was by inunction.
Before beginning such a course of medication, the
physician should first inquire whether the kidneys
were able to eliminate the mercury. If these organs
were found to be impaired, one must be very careful
about administering mercury. Some cases of nervous
syphilis did not improve until after prolonged treat-
ment— perhaps not for three months. If there was
reason to believe that scar tissue v/as present the
specific medication should be persisted in for a long
time, because it was well known that such tissue
proved amenable to tiiis remedy. His own opinion,
iDased on a large experience, was that metallic mer-
cury was the best form in which to administer this
remedy, as it imposed less work on the system. The
only exception he would make to this rule was when
there was great urgency. In cases in which there
was doubt, he would even be willing to make use of
the rather dangerous intravenous injection of subli-
mate before saying to the patient that nothing further
could be done.
Dr. Leszynsky, in closing the discussion, took ex-
ception to the statement of Dr. Fisher, that iodide
did no harm. It did harm in two ways, viz., ( i ) by
interfering with general nutrition; (2) when given
for a long time the patient became so accustomed to
its use that, if urgent symptoms should develop the
physician would be powerless to give relief. This
was not theory, but fact. Cases of tabes with sudden
accessions of symptoms were usually examples of
pseudo-tabes. Most of the cases of cerebral syphilis
in which he had used large doses of iodide of potas-
sium had shown an increase in body weight. He
had sometimes felt that he had hastened connective-
tissue formation and destruction of nerve tissue by
the administration of iodide. He had never made
use of calomel injections, and would be loath to do
so. Intravenous injection he did not think had been
practised much on human beings; it was exceedingly
dangerous.
NEW YORK NEUROLOGICAL SOCIETY.
Stated Meeting, December 5, i8gg.
Fredei^ick Peterson, M.D., President.
Multiple Sclerosis with Symptoms of Progressive
Muscular Atrophy. — Dr. Graeme M. Hammond
presented a case of multiple sclerosis occurring in the
person of a man, tbirty-eight years of age, exhibiting
symptoms resembling those of progressive muscular
atrophy. This combination, he said, was quite rare.
The patient was a locomotive fireman by occupation,
and had a good personal and family history. About one
msnth after an attack of the grippe ten years ago his
present trouble began. The first symptom had been a
paralysis of the internal rectus of the left eye, and this
had been followed by weakness of the left superior
and the right internal rectus. At the present time, in
addition to these symptoms, there was left hemianop-
sia. About one year ago there had been a sudden loss
of smell on both sides. About six years ago he had
begun to show symptoms of locomotor ataxia. The
knee jerks were absent. Last January he had noticed
weakness in the little and ring fingers of the right
hand. This weakness had extended to the other fin-
gers, and had been accompanied by atrophy. The
atrophy was now well marked in both upper extremi-
ties, and fibrillar twitchings could be noticed in the
affected muscles. These muscles responded slightly
to the galvanic current, but not at all to the faradic.
This history was very characteristic of multiple scle-
rosis. In 1897 a similar case had been reported in
one of the German journals. In the case presented,
true intention tremor and scanning speech were not
present. It had occurred to him that the patient
might be suffering from a progressive muscular atro-
pby engrafted upon a multiple sclerosis, but it was
also possible that the scleiotic changes had taken
place in an unusual position in the anterior horns.
The optic nerves had remained normal.
Dr. B. Sachs said that his impression was that the
case might be almost anything else tlian multiple
sclerosis. This diagnosis did not seem to him justi-
fied in the absence of neatly all of the cardinal symp-
toms. The case was certainly puzzling, but he was
reminded of a case of tabes with progressive muscular
atrophy, and he believed the president of this society
had reported such a case some time ago.
Dr. Joseph Collins said that he hesitated to make
this diagnosis after a hasty and superficial examina-
tion; nevertheless he could not but feel that this was
a case of locomotor ataxia plus progressive muscular
atrophy. It was possible that it was an example of
syringomyelia and tabes, for he had had such a case
under observation for a long time.
Dr. George W. Jacoby agreed with the last two
speakers, for certainly, he said, the symptoms in the
upper extremities and the optical symptoms resembled
those of a nuclear aft'ection, while the symptoms pre-
sented by the lower extremities were like those of
tabes. It was, of course, rather presumptive to make
a diagnosis after Dr. Hammond had studied the case
so carefully.
Dr. Frederick Peterson thought this patient pre-
sented all the symptoms of locomotor ataxia. Atro-
phies of this kind were not very uncommon in loco-
motor ataxia. Several years ago he had exhibited to
this society. a case of typical locomotor ataxia with
tiiree symmetrical quadrants of vision lost, so that the
person saw out of only one-quarter of each eye. He
therefore looked upon the case as a locomotor ataxia
presenting the unusual symptoms already cited.
Dr. Hammond replied tliat at first he had also
looked upon his case as one of locomotor ataxia with
ocular symptoms, but on studying it more carefully he
could not find the slightest indication of syphilitic
infection, the man having indeed been singularly free
from previous illness of any kind. He was temperate
in his habits, was not neurotic, and presented an un-
usually good personal history. Again, his tabetic
symptoms had not been at all prominent; the Rom-
berg symptom was hardly noticeable, and there was
none of the bladder or sexual symptoms of tabes.
The fact that there had been lesions of the optic, the
third, and the olfactory nerves, coming on respectively
at intervals of several years, he looked upon as proof
that this was a sclerosis affecting these different
nerves. An affection of the posterior columns in dis-
seminated sclerosis was not at all unique. The atrophy
in the hands was, however, decidedly unique.
Intracranial Growth. — Dr. Philip Meirowitz
presented a man aged thirty-eight years, who had come
to him on December i, 1899, complaining of ambly-
opi.i of the left eye. He was entirely blind in the
right eye from an injury inllicted with a piece of steel.
The disturbance of vision had first appeared in the
summer of 1898, and had reappeared four months ago.
'i'hese " blind spells ' had come on several times a day,
and had lasted about eight minutes each time. They
had continued altogether for about six weeks, and had
been unaccompanied by pains. A tremor in the right
upper extremity had also developed about the same
time as the trouble with the eyes. Jerking of the
right arm had been quite marked at night. Vertical
headache had been present and quite troublesome
some months ago, but it no longer occurred. About
4°
MEDICAL RECORD.
[January 6, 1900
the middle of last July he had been seized with attacks
of vomiting after taking food, and had improved under
milk diet and the administration of iodide of potas-
sium. About this time he had had a sudden loss of
consciousness, and again two or three months ago.
There was no distinct history of syphilis. Examina-
tion showed dilatation of the left pupil and good reac-
tion to light, with absence of nystagmus. Tremor of
the right arm was quite marked, and was aggravated
by movement. His gait was good; the knee jerks
were exaggerated ; there was no ankle clonus. There
were no sensory disturbances. Dr. Valk had examined
the eyes with the ophthalmoscope, and had found a
papillitis. There were no mental dulness and no im-
pairment of the memory. The speaker expressed the
opinion that there was an intracranial growth, and
believed that its location in the cerebellum would ac-
count for most of the symptoms. He was inclined to
believe that it was a syphiloma, because of the effect
of treatment with the iodide, and the lack of definite-
ness regarding a possible syphilitic infection.
Dr. S. B. Onuf said that the patient had been under
his care at the time that he had received the iodide.
There had then been a staggering gait, a marked
intention tremor, increased knee jerks, and ankle
clonus on the right side. His eye showed marked
choked disc and a number of retinal hemorrhages.
He had at first hesitated between a diagnosis of tumor
and multiple sclerosis. Dr. Coffin had expressed the
opinion that the shape of the hemorrhages — small and
wedge-shaped — pointed rather toward syphilis. The
man had then been put upon rapidly increasing doses
of the iodide, and had improved promptly. The dila-
tation of the pupil and the intention tremor were
notably controlled by this treatment. He did not
doubt that the trouble was syphilitic, but could not
accept the theory that all of the symptoms could be
explained by one syphiloma.
Dr. Meirowitz replied that Dr. Francis Valk, in
his recent ophthalmoscopic examination, had found
tlie retina entirely normal. The absence of disturb-
ance of speech and of nystagmus, and the presence of
papillitis, seemed to him sufficient to exclude multiple
sclerosis. It was, of course, quite possible that there
were a number of lesions, but when the symptoms
could be explained by one lesion, this course seemed
the more rational.
Two Cases of Tumor Compressing the Cauda
Equina ; Removal ; Recovery. — Dr. B. Sachs re-
ported these cases (see jiage 7).
Dr. Joseth Collins said that the cases presented
should be a cause for much congratulation of the
reader of the paper, as well as of the surgeon who
operated. The history of the first case seemed to
him to have pointed unequivocally to the presence and
location of a intraspinal tumor, and he was glad that
Dr. Sachs had had the courage to urge operation. He
was reminded of a case seen by him in which he had
endeavored to have a glioma operated upon, but the
surgeons had arrived too late to be of assistance. He
felt sure that the mortality in these cases was not so
great that neurologists should not be on the alert to
diagnose them and urge operative intervention.
Dr. Peterson added his congratulations to those of
the last speaker. It seemed to him that tumors in
this particular locality were more difficult of diagnosis
than in other portions of the cord. One important fea-
ture of the paper was the aid that tlie sensitive area or
the deformity had given in establishing the diagnosis.
Dr. Sachs, in cl sing, emphasized the point that
even if the sensory changes were very slight, they
should be reckoned with in making the diagnosis.
This had been well exemplified in the first case.
Another point insisted upon was, that he had managed
by pressure upon a definite point to elicit the same
pain as that of which the patient had complained.
This had been extremely well marked in the first case.
Dysphrenia. — Dr. VVillia.m Hirsch read a paper
with this title. f-Ie said that the term "dysphrenia"
liad been applied to the secondary or sympathetic psy-
choses in contradistinction to the idiopathic or mental
diseases, such as mania and melancholia. The sec-
ondary psychoses which were produced by bodily dis-
eases were not characterized by the same uniformity
of symptoms that marked the idiopathic variety. In
the secondary psychoses there were frequent remis-
sions with ])erfect lucidity duiing the course of the
disease. Outbreaks of violence might be quickly fol-
lowed by stupor. The speaker said that a further
characteristic which he would call attention to was the
occurrence of somatic symptoms, as loss of pupillary
or patellar reflexes, rise of temperature, irregularity of
the heart action, and certain vasomotor phenomena,
such as cedema. In the secondary psychoses, the in-
terstitial tissues, and particularly the blood-vessels,
were the ones first and mainly affected. This was in
accordance with the accepted pathology of the systemic
spinal diseases. The changes in the interstitial tis-
sues were produced by the diseases starting outside of
the brain, such as the acute febrile diseases. There
were a few cases in which, purely from the mental
symptoms, one was justified in making a diagnosis of
dysphrenia, even though ignorant of the exact nature
of the underlying bodily disease. A case of this kind
was then reported by Dr. Hirsch. The patient was a
young and neurotic girl, seen by him first on Septem-
ber 5, 1896. She had then presented the condition of
hallucinatory confusion. After an interval of quiet,
on February 17, 1897, she became violent, and devel-
oped hallucinations of hearing and sight. At this
time the temperature was normal. After about ten
days she became stupid; her pupils were contracted,
and the pulse was 60. After about one week, auto-
matic movements of the hands and head appeared.
On March i4lh menstruation came on, and she quickly
became normal, and remained well for ten days. In
April, 1897, she was given thyroid extract, and quickly
recovered. She remained well for nearly two years.
On February 2, i8gg, she unexpectedly developed the
same violent symptoms as before. She showed some
transitory improvement again under the administration
of thyroid extract, but soon passed into a condition of
dementia. After about three months she became
quieter; the pupils and patellar reflexes returned; the
temperature became normal, and her breasts, which
had been much enlarged, returned to their natural size.
Since that time her mental state had been goof'. The
clinical features of this case evidently did not corre-
spond to any primary psychosis. A loss of reflexes
was generally considered as indicative of permanent
change, but it was not impossible that this symptom
might exist in functional disturbance. In the case
just reported he believed that the menstrual disturb-
ances were not the cause, but a symptom of the dis-
ease, as in the fourth, or worst, attack menstruation
had had little or no effect on the mental state. The
speaker suggested that the term " originary dysphre-
nia " should be applied to those cases which, in their
clinical aspects, resembled those known to be pro-
duced by toxic or infectious agents, but in which no
cause for such infection could be found.
Dr. Brown said that he had been deeply interested
in the paper, and had seen a number of somewhat
similar cases presenting apparently a ]ihysical basis
for the mental disorder. In some cases of even very
severe mental disease the mental symptoms would
clear up during the later stages, for example, of a
tuberculosis.
Dr. Mary Putnam-Jacobi asked Dr. Hirsch if he
looked upon general paresis as a secondary psychosis.
January 6, 1900]
MEDICAL RECORD.
41
and also in what way the case of dysphrenia reported
by him differed from recurrent attacks of hysterical
insanity; also how far the failure to distinguish per-
sonality was really a mental symptom and how much
the result of personal caprice.
Dr. B. Sachs said that probably all present had
seen cases similar to the one described. He had him-
self had under observation a number of women be-
tween the ages of fifteen and twenty years who had
passed through very remarkable periodical mental
changes. He had been much impressed with the
suddenness with which tiiese changes had occurred.
All of these patients had been members of strongly
neuropathic families. They had passed quickly from
a condition of mania to one of depression. A patient
now under his care had regularly had periods of six
months or more in which she had been in a condition
of maniacal excitement, and had then very suddenly
passed into a condition apparently normal, but really
only a stepping-stone to a period of excitement. It
was questionable, in his mind, whether the class of
cases spoken of in the paper represented a distinct
entity in mental diseases. Such marked physical
changes as had been described in the paper had not
come under his observation.
Dr. Peterson expressed his belief that dysphrenia
would be a convenient term for those cases which it
would be difficult to describe under other names. The
trouble was that these terms in psychopathy were usu-
ally founded upon clinical symptoms, with but little
reference to the pathology, so that after a time the
word came almost to include all insanity. Last sum-
mer, at Heidelberg, he had found about four varieties
of insanity recognized, viz., paresis, senile dementia,
katatonia, and dementia precox. About fifty per cent.
of the cases in Germany at the present time were
called katatonia, and the remainder were included
under the term dementia precox.
Dr. Hirsch closed the discussion. He said that it
was certainly remarkable how many insane patients
would pass through a disease like typhoid fever with-
out developing any mental symptoms — indeed, the
patient whose history had been given had just passed
through a typhoid fever in this way. He, too, recog-
nized the great evil that had resulted from introducing
names into' psychiatry ; but dysphrenia was not a new
name, and certainly was useful in connection with a
case like the one reported, which could not be well
placed in any other classification. Dr. Sachs had re-
ferred particularly to circular insanity — to cases essen-
tially chronic in their nature — but he had been dis-
cussing cases that were really acute. The mental
disease consisted of a series of psychopathic condi-
tions. The diagnosis of dysphrenia could be made
only from a detailed history and long study. By a
primary psychosis he meant a mental disease origi-
nating in the parenchyma of the organ ; by a secondary
psychosis one originating in the interstitial tissue;
hence general paresis would be a secondary psychosis.
©orvespotTxTcMcc.
Bliadness in Finland. — The different degrees to
which blindness prevails among various populations is
always a matter worthy of study. J. Widmark has in-
vestigated the subject as regards Denmark, Sweden,
Norway, and Finland (Nordiskt Ahdicinskt Arkh\
August; Neia Jor/'/f^^;?/;//, October 25th). He finds
that for every ten thousand inhabitants there are 5.3
blind persons in Denmark, 8.3 in Sweden, 12.8 in
Norway, and 15.1; in Finland. The preponderance \n
Finland, which is not observed among children under
ten years of age, is attributed to the great prevalence
of trachoma. Curiously enough the " endemic " affects
only the natives. — Sanitarian.
OUR LONDON LETTER.
(From our Special Correspondent.)
THE WAR — THE TWO ADJOURNED DEBATES I TUBER-
CULOSIS AND TABES — guy's HOSPITAL GROUNDS
THE LATE DRS. STARK, HAMILTON, HICKS, AND
PRENDERGAST.
London, December 15, i8gg.
The war is absorbing all our conversation. Even
when we meet to discuss medical and other peace top-
ics, as soon as the debate is over groups are asking
one another their views of the latest telegrams. It
seems therefore an unfortunate time for the two set dis-
cussions of our two leading societies to have extended
over three evenings each. Still this wealth of mate-
rial must be utilized, and news from the war has not
at this date reached, nor can it for some time reach, a
point when its surgery can be fitly considered.
To our debates, then. That on tuberculosis was
concluded on Tuesday, having been resumed by Dr.
Sidney Martin, who said that although tuberculosis
was so prevalent mankind must be considered immune,
as healing was common. In the lungs reinfection
from without was frequent. The primary attack might
be recovered from. In an interval of a few months to
many years a second attack, varying in seat, would
occur; so again a third attack. Of course either
might be fatal. The result would be determined by
the extent of the damage and the virulence of the in-
fection. Such points were important in discussing
treatment; so too was that of secondary infections, as
streptococcus, in regard to wiiich hygienic surroundings
and pure air were the best preventives. Drugs could
not be discarded. Antiseptics by moutli or subcutane-
ously were futile. To increase the patient's resistance
was the chief aim. Open air did this; so did rest
during febrile states, and judicious, not over-feeding.
Destruction of sputum and boiling of milk prevented
re-infection.
Dr. J. E. Pollock remarked on the decline of con-
sumption in this country, and said open air was no new
treatment. He had recommended it in a paper in
1865. Fresh air was best in the open if the tempera-
ture suited the patient and sunshine was to be had.
Sanatoria were good for the poor, but had disadvan-
tages for those who could afford more care and com-
forts or change of climate.
Dr. Drewitt insisted on the difference between fresh
air and draught. Ventilation should have more atten-
tion. Diet was not sufficiently considered. Carniv-
orous birds were not so liable to tubercle as the seed-
eaters — a fact to consider. Scotch-oatmeal feeders, he
said, were scourged by tuberculosis.
Dr. Washbourn said at first phtiiisis was a purely
tuberculous process when the natural defences could
limit it. Impure air brought secondary invasions — the
great risk, e.g., pneumococcus and streptococcus.
Dr. Walters said catarrhal patients needed a higher
temperature than others and were more affected by
draughts.
Dr. P. Weber dwelt on tlie importance of a flesh
diet, Dr. S. Watson on Qlimatic influences, and Mr. P.
Gould on surgical tuberculosis, in which, he said, the
social position of the patient was most important in
prognosis.
The president (Mr. Bryant) added his conviction of
the extreme importance of fresh pure air in operative
cases and no doubt in others also.
Dr. Fowler replied at length, maintaining his views
and expressing liimself most hopefully if only the
treatment was carried out for the benefit of the patients
and not exploited commercially. He held that there
was no pathological basis for the belief in the impor-
42
MEDICAL RECORD.
[January 6, 1900
tance of septic organisms. Their action would pro-
duce septicemia, and in the vast majority of cases
there was no evidence of this. The rectal temperature
he had known to explain non-progress and so be a
guide to a puzzling case. The open air produced a
veritable air-hunger, and so rendered patients apt to
neglect the direction to avoid draughts. He preferred
carbohydrate and fatty food to nitrogenous. The treat-
ment should be continuous night and day and extend
over long periods. The difficulty usually was to get
doctors and patients to realize how long it must be.
The Pathological Society's debate on the relation of
tabes to general paralysis of the insane was resumed
by Sir William Gowers, who found little to criticise in
Dr. Mott's paper. The preponderant relation of tabes
to syphilis he considered was now admitted as fact.
In his last one hundred private cases syphilis was un-
questionable in sixty-eight and probable in twelve.
In the remaining twenty cases it was possible, as there
had been exposure to the ordinary risk and in some
cases gonorrhoea had been taken. In six cases of
juvenile tabes he had met with, the evidence of inher-
ited syphilis was clear. His experience confirmed Dr.
Buzzard's, that when the two diseases were associated
tabes preceded paralysis. The theory that the changes
in the posterior columns depend on the meningitis
was strenuously advocated twenty-five years ago, though
perhaps not precisely in the form suggested by Dr.
Bruce, but it had been abandoned for good reasons,
e.g:, the inconstancy of the extra-neural changes or the
failure to account for some of the most remarkable
facts of tabes. The question of the identity of tabes
and paralysis he regarded as very much one of words,
but he asked whether common causation could create
identity in diseases differing widely in symptoms.''
Does not the common use of the word disease refer to
a definite aggregation of symptoms rather than to caus-
ation? As to the question asked by Dr. Mott, whether
the toxic agent lowers the durability of the nerve ele-
ments so that some other factors induce a premature
decay. Sir William Gowers had long taught that that
is the secret of the incidence of degenerative diseases.
An average normal man he thought inherited equal
vitality in all his structures, and went to pieces at last
like the " one-hoss shay " in mature, equable, and senile
decay. At the other extreme were patients whose
structural elements were deficient in some part of the
muscular or nervous system, so deficient in some cases
that they decayed as soon as they were completely de-
veloped.
Dr. Savage admitted that in both general paralysis
and tabes the evidences of destructive changes were
similar, but thought that it did not prove that exactly
the same causes had been at work. The debris in a
wrecked house was the same, however the fire origi-
nated. On the clinical side the toxic element affected
the least stable and most developed tissues. All the
symptoms of general paralysis might be seen in the
various stages of alcoholic intoxication, and similar
symptoms occurred in plumbism and in influenza.
The same parts were affected by the poison. Only in
the more stable poisons or in those which had a spe-
cially pernicious effect on the tissues did decay ensue.
He was convinced that syphilis played a most impor-
tant part in both diseases. He observed that tabetic
symptoms often preceded general paralysis by years,
but he had also seen many patients who had had tabes
and insanity for many years without becoming general
paralytics. Many tabetics improved in their ataxy
with the development of mental symptoms. In an
asylum patients are met with suffering from general
paralysis, having every degree of ataxy. The ataxic
symptoms were very rare in females. Though not
quite convinced that the two diseases were one, he
admitted they had similar causes and left similar path-
ological debris. He thought a toxic cause was the
chief one and syphilis the most common toxin. In
some cases he believed there might be an autotoxin
from rapid brain changes as in acute delirious mania.
Dr. Ferrier favored the view that the two diseases
were the same, probably due to the same cause — syph-
ilis either hereditary or acquired. All other assumed
causes had been found wanting. The pathological
process was sclerosis, whether inflammatory or not,
and the question remained why in one case the cortex
was affected and in another the posterior columns.
Dr. Payne said that the specimens now shown by
Drs. Mott and Batten supplied the anatomical proof of
Fournier's clinical conclusion, that the two diseases
were closely related and probably identical. A com-
mon syphilitic origin went far to prove identity. Once
diffuse cirrhosis of the liver due to syphilis was not
admitted; other instances of diffuse inflammation pro-
duced by syphilis had been admitted in recent years
only. He had seen primary lateral sclerosis improve
under antisyphilitic treatment.
Dr. Hale White said that while there were two
groups in which syphilis affected the cortex and the
cord, so there were cases in which the first effect was
seen in the peripheral nerves. That the same cause
might damage sometimes one part, sometimes another,
was seen in lead poisoning.
Dr. Batten gave an account of his investigations,
illustrating it with specimens and lantern slides, and
promised to bring before the society some further re-
searches on the subject. He dealt on this occasion
with the condition of the peripheral nerves and the
origin of the degeneration of the posterior columns.
As to the latter he held there was considerable evi-
dence in favor of Dr. Bruce's suggestion. He said
degeneration of the posterior columns occurred in cases
of cerebral tumor, and in some cases was limited to
those columns, the roots being unchanged.
The debate was at this point again adjourned.
While excavating in the grounds of Guy's Hospital
lately the workmen came on an accumulation of human
bones and a number of tobacco pipes. Some years
ago a large number of skeletons were removed from
the grounds when digging the foundations for additional
buildings. It is conjectured that the hospital was
built on the site of a burial ground for victims of the
great plague.
Dr. Stark, who was killed by a shell at Ladysmith,
was a well-known naturalist who was engaged in
classifying the plants and fauna of South Africa, and.
on the outbreak of war offered his services to the army.
Probably you have read that the only words he spoke
after being hit by the shell were, " Take care of my
cat." It has been conjectured that the last word was
not completed, and should be catalogue.
Mr. Edward Hamilton, of Dublin, died on the 7th
instant, aged seventy-five years. He had been three
times president of the College of Surgeons there, \ iz.,
in 1875, 1892, and 1893. As a teacher and a surgeon
he long held a most important position, and all through
his career received the respect of all who knew him.
Few men could be more esteemed by his brethren and
by his fellow-citizens.
Dr. Henry Hicks, F.R.S., whose death occurred on
the iSth ult., was well known as a geologist. He was
president of the Geological Society, 1896-98, and re-
ceived the diamond jubilee medal in 1897.
The death is also announced of Inspector-General
Prendergast, in his ninetieth year. He had a distin-
guished career, and was present at the chief battles in
the Crimea.
It is one thing to write and another thing to have
readers. The test of what a man can do is the num-
ber he can interest in his work.
Januar)- 6, 1900J
MEDICAL RECORD.
43
THE PATHOGENESIS OF GENERAL H^EM-
ACHROMATOSIS (DIABETE BRONZE).
To THE Editor
Medical Recok
Sir: Apropos of the article of Dr. H. W. Berg, in
a recent issue of the Medical Record, permit me
to make a few remarks regarding the pathogenesis of
diabete bronze, or, as it is now properly termed, gen-
eral hasmachromatosis. The characteristic features of
this disease consist; (i ) in the deposition of an enor-
mous amount of an iron-containing pigment in the
liver, pancreas, gastro-intestinal canal, skin, lymphat-
ic glands, etc. ; (2) in hypertrophic cirrhosis of the
liver and the pancreas; and (3) in the onset of dia-
betes mellitus, which appears either periodically or
only as a terminal event. Regarding the source of
the iron-bearing pigment, all writers seem to agree at
present that it is derived from the hemoglobin which
was separated within the blood-vessels from the red
corpuscles by some pathological process. As to the
nature of this factor the diverging opinions can be
classified under two heads. Some, perhaps the ma-
jority, of the older writers consider the diabetes as the
primary cause of the group of symptoms, and assume
that the excess of sugar in the blood is, in some way
or another, responsible for the destruction of the red
cells. Another group of authors, consisting mostly of
recent writers on the subject, believe that the destruc-
tion of the red blood corpuscles is caused by some un-
known agent, and that the degenerated haemoglobin is
deposited in the cells of the liver, pancreas, etc., caus-
ing an interstitial inllammation of these organs, which
subsequently leads to a "pancreatic diabetes."
The purpose of these lines is to put forward a new
suggestion; but, before doing so, I wish also to offer
some discussion of the hypothesis set forth by Dr.
Berg in his interesting paper on diabete bronze.
The hypothesis belongs to the first category; it sim-
ply assumes that the excess of sugar in the blood
causes the separation of haemoglobin from the stro-
mata of the red cells within the circulation. It
seems to me, in the first place, that this hypothesis
does not fit Dr. Berg's own case, inasmuch as pig-
mentation of the skin of iiis patient appeared eigh-
teen months before tlie diabetes set in. Then if it be
true that the excess of sugar in the blood always
causes a solution of the red cells, why should there
be among the great number of cases of diabetes only
so very few — twenty-four — cases of the bronzed type?
Again, of the great number of investigators on the
character of the blood in diabetes, nobody has ever
observed the presence of any unusual number of
"shadows," red cells without haemoglobin. The
weakest point, however, of this assumption I believe
is its reasons. I shall discuss only one point. Be-
cause Brasol has shown that when sugar is injected
into the circulation it causes a passage of fluids from
the tissues into the blood-vessels, and because the
addition of water to blood dissolves out the haemoglo-
bin from the red-blood globules. Dr. Berg comes to
the conclusion that red cells must become dissolved
in diabetic blood. Was the dilution of the blood in
Brasol's experiments caused by the entrance of water
into the blood-vessels.' Dr. Berg himself uses the
expression " fluids from the tissue," which is an iso-
tonic fluid, and does not dissolve red cells. The
physiological process in the experiments of Brasol is
simply as follows: The introduction of a very concen-
trated solution of sugar, forty to fifty per cent., into
the circulation increases considerably the osmotic
pressure within the blood, and causes a stream of the
tissue-lymph into the blood-vessels till the hypertonic
blood serum becomes isotonic. At no time during
this process are the blood cells bathed by hypotonic
fluid, and it is a hypotonic fluid alone which can
separate the haemoglobin from the stromata of the red
cells.
The suggestion which I wish to offer is as follows:
In general hasmachromatosis there is an enormous
amount of iron-bearing pigment deposited in nearly
all the organs of the body. This iron comes from
the red cells. But examination of the blood has not
revealed any noteworthy diminution in the number of
the red cells nor a reduction of htemoglobin. Nor is
the presence of haimoglobinuria noted in any of the
described cases. In short, there is no indication of a
pathological condition of the blood. On the other
hand, blood diseases, even pernicious anaemia, do not
produce hasmachromatosis. Neither did the experi-
ments with the blood destroying poisons lead to real
hffimachromatosis. All this seems to speak against
the assumption that a pathological condition of the
red cells is at the bottom of this disease. From
where, then, is the enormous storing up of iron in the
organs of the body coming? I answer, that the seat
of the trouble is perhaps located in that part of the
mechanism of the iron metabolism which is entrusted
with the removal of the iron from the body. Only
very small amounts of iron are absorbed, and about
the same quantity is excreted again, mostly by the
mucous membranes of the intestines. Perhaps, then,
by some fault in this mechanism the organs and cells
of the body retain all or most of the iron which reaches
them on its normal round through the body. This
hypothesis has the merit that it is accessible to an
experimental test. If the assumption is correct, an
analysis of the iseces would reveal any deviation from
the normal. S. J. Meltzer, M.D.
166 West. One Hundred and Twentv-sixth Street,
"IS STATIC ELECTRIFICATION A SPECIFIC
FOR ORGANIC AND STRUCTURAL NER-
VOUS DISORDERS?"
To the Editor of the Medical Record.
Sir: Dr. Rockwell asks this question in your last
issue, after reading my article in your issue of Decem-
ber 9th.
The question, as put, utterly misrepresents the spirit,
meaning, intent, and facts of my article. Electrifica-
tion is the production of an electric charge; electriza-
tion is to subject the human body to the action of
electric currents. The former would not disturb a
timid child; the latter may force a giant into fixed
contortions or kill him. My entire article, as its title
states, was devoted to the use of currents (and inci-
dentally sparks) and therefore to electrization. Will
any one deny that electrization will affect organic and
structural diseases? The " specific " and " panacea "
ideas we leave to our critic.
However, as to one point, Dr. Rockwell may be
taken seriously. He denies my originality as to the
static induced current. He has in his possession "an
old, old book by one named Mauduyt," etc., which
gives " in descriptive and illustrative detail what is
now called the static induced current."
I have also in my possession a dozen or more "old,
old booVs," among them this same author, Mauduyt,
and plenty of new ones., all of which give exactly what
Dr. Rockwell refers to as given in his Mauduyt. I
have searched these books long and carefully to find
any allusion to the form of current which I named the
static induced current. So have many others. No-
where is there any reference to a current which will
produce a continuous muscular contraction, namely,
physiological tetanus, similar to that produced by the
faradic current. These authorities deal with the spray,
sparks, and mainly with shocks from Leyden jars. To
44
MEDICAL RECORD.
^January 6, 1900
graduate the length of the spark from a Leyden jar
and thus to define the limit of the shock, the Lane
electrometer, which is simply a Leyden jar with modi-
fied metallic connections and other contrivances, were
used. The result was a single spark from the jar and
a single muscular contraction. It is to this Lane
electrometer form of Leyden jar that my critic un-
doubtedly refers. Let us see what Mauduyt, his own
authority, actually says of it. I translate: "Its ad-
vantages are (i) to furnish a sure and fixed measure
of the force of the shocks; (2) to give them at a
strength w'hich is agreeable; (3) to preserve this
strength as long as is thought suitable, and to be able
to augment or diminish it at will; (4) to determine
and regulate their course." Not a word is said of a
tetanizing or, so to speak, faradic current, such as the
static induced current is, in these conclusions from
Mauduyt (nor elsewhere in his writings).
If Dr. Rockwell will produce any record or instance,
prior to my publication in 1881, of a current derived
from electrostatic apparatus, which has in any one's
experience produced physiological tetanus, namely,
continuous muscular contractions, as does a faradic
current, then I will withdraw any claim to originality
for the discovery of the static induced current I have
ever made. If, on the other hand, he cannot sustain
his statement, let him frankly say so.
VViLLiAM J. Morton, M.D.
A REVIEW OF THE HISTORY AND LITERA-
TURE OF APPENDICITIS.
To THE Editor of the Medical Record
Sir: In a review of the " History and Literature of
Appendicitis," by Dr. George M. Edebohls, in your
issue of November 25, 1899, referring to the various
operative measures he says: "The expedient adopted
by Wyeth of operating at two sittings represents an
unnecessary compromise." This " compromise " is in
my opinion so essential to the safety of the patient in
a large proportion of certain forms of appendicitis
that I desire to state my position clearly, and with
emphasis. I hold that in many instances unnecessary
dangers are incurred by the boldness of certain opera-
tors in the efforts to remove septic accumulations from
tiie peritoneal cavity. To advise in all cases a free
dissection for the removal of the remains of a dis-
eased appendix and the plastic exudate, which with
the mesentery and contiguous intestinal loops form
the wall of an abscess resulting from infectious ap-
pendicitis, is to encourage a dangerous practice.
In the earlier hours of infection, when the amount of
septic matter is small, and the adhesions and area of
infection are limited, a complete operation which will
require no more than the "gridiron" incision of Mc-
Burney can often be done with perfect propriety and
with safety by a skilful operator. In my experience,
these cases are, however, very rare. When there has
been a considerable exudate measuring with the ag-
glutinated mass three or four inches in the various
diameters, these complete operations cannot without
grave risk be safely accomplished unless the incision
through the abdominal wall is enlarged in order to
give the surgeon complete control of the septic area,
and thus prevent spreading the infection to uninvaded
portions of the peritoneal cavity. Enlarging the in-
cision by division of the muscular fibres is very ob-
jectionable, for the reason that it weakens the ab-
dominal wall, and not infrequently results in ventral
hernia. When an abscess has formed, and this ab-
scess can be opened directly through any part of the
abdominal wall in which adhesions exist which enable
the operator to drain the septic contents off without
entering the general peritoneal cavity, I hold it is
better practice to do this than to attempt removal of
the infectious mass. The vast majority of these pa-
tients recover, and only a very small proportion of them
have a second attack. Should a second attack occur
I should carry out the same line of practice, and in-
sist upon a removal of the diseased appendix after the
acute infection had passed, and in what we call the
quiescent period.
In the larger abscesses, in which no adhesions have
occurred between the mass and any part of the ab-
dominal wall, I make it a rule, after making the grid-
iron incision and discovering this condition, to insert
gauze in such a way as to keep the wound open, and
to secure adhesions between the mass and the perito-
neum at tlie margins of the incision, waiting twenty-
four to forty-eight hours to institute drainage For
this second operation cocaine anaesthesia is sufficient.
One other point I would like to bring up. Dr.
Edebohls says: "Ligation of the stump, though still
very generally practised, cannot be considered a per-
fectly safe procedure." There does not seem to nie to
be much force in this criticism. It may be asked if
any method of closing the opening in the appendix or
caecum can be considered a perfectly safe procedure.
With one or two exceptions I have practised simple
ligation of the stump with a silk thread in all of my
cases. In the other instances in which the gangrene
had extended so far as to involve the cascum, I have
been compelled to resort to the Lembert silk suture as
practised in ordinary intestinal wounds. Dr. Ede-
bohls mentions two cases, one by Dock and one un-
published case, in which leakage and fatal peritonitis
followed slipping of the ligature. If we consider the
thousands of cases in which the ligature has been used
with only, so far as known, two such fatal cases, it
does not seem to me to be a very bad record for this
method. I believe that the intestines, and- in fact all
of the organs within the abdomen, should be submitted
to the least possible manipulation and traumatism in
all surgical procedures. The insertion of sutures or
of Dr. Dawbarn's purse-string suture after inversion of
the appendix, all require more manipulation than the
simple ligature, and in my opinion offer no greater
guarantee of safety to the patient- I have never had
an accident after the ligature, nor do I know of any
accidents which occurred in the work of my colleagues
in my long connection with the hospital service in this
city. After tying the appendix close to the crecum
where the tissues are sound and removing the diseased
organ, I curette the little funnel-shaped portion of the
divided appendix which is beyond the ligature, and
then thoroughly cauterize it with a mercuric chloride
tablet. I again curette the funnel-shaped stump in
order to remove any excess of the mercury. The re-
sults so far have been such in all cases as to justify
my own continuance of this method.
JoHx A. Wyeth, M.D.
New York.
l^ccUcat Items.
No Indian Lunatics. — Commissioner William A.
Jones, after careful study of the subject, has come to
the conclusion that "a full-blooded Indian lunatic
never lived." He holds that insanity was not known
to the red man until he began mixing with the whites.
— Catholic Ne7os.
Hungarian Punishment for Bigamy. — Bigamists
in Hungary are compelled to submit to a queer pun-
ishment. The man who has been foolish enough to
marry two wives is obliged by law to live with both of
them in the same house.
Medical Record
A IVeekly yoiirnal of Medicine and Surgery
Vol. 57, No. 2.
Whole No. 1523.
New York, January 13, 1900.
$5.00 Per Annum,
Single Copies, loc.
®riguial J^rticXcs.
THE RELATIVE INTENSITY OF THE SEC-
OND SOUNDS AT THE BASE OF THE
HEART: A STUDY OF ONE THOUSAND
CASES.
Dv SARAH ROBINSON CREIGHTON, M.D.,
Most modern text-books on physical diagnosis state
or imply that in the normal heart the aortic second
sound is louder than the second sound heard in
the pulmonary area. The following quotations ex-
emplify the prevailing view: "On account of the
more powerful recoil in the aorta, the aortic is the
predominating sound." ' In F. C. Shattuck's book,'
the matter is stated in this way: "The sound is,
in health, somewhat louder and sharper here {i.e.,
in the second right interspace near the sternum)
than it is over the corresponding point in the left
side." In Da Costa's " Physical Diagnosis," ' we
read: "The second sound of the latter" (the aortic
valve) " when compared with that of the former " (the
pulmonary valve) " is found to be sharper and more
accentuated." Musser states thaf" "In health, the
pulmonic second sound is not so loud as the corre-
sponding sound of the aorta." Guttman* says: "In
normal conditions of the heart, the aortic second
sound has the same intensity as the pulmonic, or even
a somewhat greater intensity." Gerhardt ° makes a
somewhat different statement from any of the above.
"Normally," he says, "the second sounds (in the aor-
tic and pulmonic areas respectively) are equal."
In the works on diseases of the heart, I find very
meagre statements about the condition of the second
sounds at the base of the normal heart, except the fol-
lowing from Bramwell : ' " The aortic second is louder
and more accentuated than the pulmonary" ; and from
Sansom," who says: "The sound audible in this di-
rection" {i.e., over the pulmonary area) "is normally
less intense than that heard on the aortic side."
Nearly all the other writers convey the impression
that they believe the aortic second sound to be the
louder in health; for example, Broadbent" writes:
"In the pulmonic and aortic areas, accentuation of the
second sound is the point especially to be observed as
denoting increased pressure in the pulmonic or sys-
temic circulations respectively." Whittaker'" writes:
" A strong accentuation of the second pulmonary sound,
in the absence of other cause, may suffice to establish
the diagnosis" (of mitral stenosis). Osier makes no
' Tyson: " Physical Diagnosis," p. 120.
' " Auscultation and Percussion," p. 61.
' " Physical Diagnosis."
* " Medical Diagnosis," p. 35S.
^ Eulenburg's " Encyclopedia," p. 89.
'"Auscultation and Percussion," fourth edition, Tubingen,
1884.
■" " Diseases of the Heart," p. 138.
* " Diagnosis of Diseases of the Heart and Thoracic Aorta,"
p. 189.
° " Diseases of the Heart." p. 24.
'" Article on " Diseases of the Heart," in " Twentieth Century
Practice of Medicine," vol. iv., p. 242.
explicit statement on the subject, so far as I can see.
Cutler' says, " The second sound is loudest over the
second left interspace or third rib and over the second
right intercostal space, both close to the sternum " ; and
later on in the article, "The pulmonic second sound"
(in cases in which the heart has been uncovered by re-
traction of the lungs) " is often louder than the aortic
second." Andre Petit " says : " The reinforcement of
the second sound at the pulmonary vahe reveals an
excess of pressure in the pulmonary circulation, and
should put one on the track of some obstacle to the
emptying of the left heart, particularly of the auricle
in mitral stenosis."
Among books on children's diseases, Rotch and
Starr say nothing in particular on this subject. Holt '
makes a definite statement, namely: " Normally, the
loudest of the heart sounds is the first sound at the
apex ; the weakest sound is the second sound at
the aortic orifice." Hochsinger,' also, asserts that
" in infants and young children the second sound is
weaker in the aortic area than in the pulmonary area.
It is loudest in tire second left intercostal space."
It will be seen that Holt and Hochsinger are the
only ones of all these writers who definitely state that
the pulmonic second sound is louder than the aortic
second sound, in health. All the others record pre-
cisely opposite observations, with the exception of
Gerhardt, who found both second sounds equal in
intensity. The statements of the majority of the
writers just quoted are all the more amazing when one
observes that, as long ago as 1885, so careful a stu-
dent as Vierordt proved experimentally that, contrary
to the idea of all the writers just quoted, the pulmonic
second sound is frequently louder than the aortic sec-
ond sound in the healthy heart.
Vierordt measured the relative intensity of the dif-
ferent heart sounds in the following manner: Over a
given valve area (for example, the second right chon-
dro-sternal articulation) he placed, one after another,
layers of gutta-percha of uniform thickness, and noted
how many were needed to prevent the transmission of
the heart sounds to the ear. Then, by repeating the
process over another valve area, he was able to record in
quantitative form any difference in the relative inten-
sity of the sounds in the two areas, as measured by the
number of layers necessary to obliterate them. These
experiments showed that in only fi\e out of thirty-six
cases was the aortic sound louder than the pulmonic.
Once they were equal. The average results of his
estimation were as follows: Between the ages of four
and ten years the intensity of the pulmonic second
was to that of the aortic second as 7.78 is to 6.26;
eleven and twenty years, as 6.60 is to 4.92 ; twenty-one
and forty years, as 5.68 is to 4.81 ; forty-one and fifty
years, as 5.39 is to 5.46.
Moller,' using similar methods, found that in twelve
cases the aortic second was, on the average, stronger
than the pulmonic, the ratio being 2.32 to 2.24. Five
' " The American System of Medicine," vol. ii., p. 344.
' " Traite de Medecine," vol. v.
' " Diseases of Infancy and Childhood," p. 561.
•■"Die Auscultation des kindlichen Herzens " (Wien, 1890),
p. 16.
° Moller : Dissertation, " Ueber die Intensitat der HerztOne,"
Konigsberg, 1S79, p. 26.
46
MEDICAL RECORD.
[January 13, 1900
of his twelve cases showed an aortic second stronger
than the pulmonic second; four cases showed a pul-
monic second stronger than the aortic second; in
three cases, the aortic and pulmonic second sounds
were equal. On the other hand, Schreiber,' who
DECADES.
100%-
90%
80%-
70%-
80%-
20%-
10%.
i 0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
—100^
\
\
--80^
— -70;/
--60»/
--50"/
40»/
\
V
\
\
\
--soy
\
— -20}(1
--.oi
V
^
V
^_
worked with Moller and investigated the same num-
ber of cases, found that, on the average, the pulmonic
second was the stronger (2.25 to 2.07). In nine of
the twelve, the pulmonic second was the louder.
Personal Experience. — In view of the discrepancy
between the measurements of Vierordt, Schreiber, and
Moller, and the statements handed on from one mod-
ern text-book to another, it seemed to me worth while
to investigate the matter in a considerable number of
cases. Accordingly, during the summer of 1899, in
Dr. Richard C. Cabot's clinic at the Massachusetts
General Hospital, one thousand cases were examined.
The cases were distributed in the various decades as
follows:
Under lo years 123
From 10 to 19 years 130
20
29
30 '
39
40 '
49
so '
.S9
bo '
69
IS2
109
50
Total 1 .000
Among these were 24 cases of general debility, 51
cases of malaria, 63 of gastro-intestinal disorders, etc.
The remainder were divided among such affections as
the ancemias, neurasthenia, sciatica, etc.
In the 1,000 cases examined, the pulmonic second
sound was the louder in 291 cases; the aortic second
sound was the louder in 486 cases; while the two
sounds were of equal intensity in 223 cases. When
w-e come to examine these figures more in detail, we
find that the younger the patient the more apt is the
pulmonic second sound to be accented. Thus an ac-
cented pulmonic second sound was shown:
Out of 123 cases under 10 years, by 1 1 1 or 90-}- per cent.
130
from
10 to 19 years,
by
S7 '
66.9
207
20 " 29 "
"
III '
53-1
181
30" 39 "
"
51 '
' 27.6
182
40 " 49 "
24 ■
' 131
109
50" 59 "
"
lb '
• 14. b
50
( »t
60 " 69 "
"
2 '
' 4
18
I ti
70" 79 "
"
0
' 0
On the other hand, accentuation of the aortic sec-
ond became more common with each decade. An
accented aortic second sound was shown :
Out of 123 cases* under 10 years, by only 4 or 8 2 per cent.
207 "
" 20 '
u ly ycir=
29
72 " 35-
181 "
" 30
39
" 100 " 54.
182 "
" 40 '
' 49 "
" 136 " 74-
109 "
" 50 '
' 59 "
" 82 " 75.
50 "
" 60
69 "
" 46 " 92
18 "
" 70 '
' 79 "
" 17 " 94
* In eight the second sounds were equal.
Exhibited in tabular form, these figures give the
curves shown in Charts i and 2.
In each of these cases the heart was normal, so far
as could be determined, and we eliminated all patients
having diseases which are ordinarily supposed to alter
the heart sounds in any way, except pulmonary
phthisis. Nine-tenths of these patients had walked a
considerable distance to the out-patient department
and were by no means seriously sick, while many of
them were healthy individuals, assistants in the clinic,
interpreters, or relatives accompanying patients.
Effects of Exercise and Position. — Many were ex-
perimented with to ascertain the effects of exercise
and position on the second sounds. Exercise does
not seem to alter the relative intensity of the aortic
and pulmonic second. In a few instances, the aortic
was louder in the upright position, while the pulmonic
came out with greater force when the patient was lying
down.
Accentuation in Youth.- — In children under four years,
the accentuation at the pulmonary orifice is very strik-
ing; between the ages of ten and twenty, it is less so,
and from twenty years on, there is seldom any marked
difference between the sounds until after the fortieth
year, when the aortic second begins to come out
sharply.
Tentative Explanations. — Such are the facts. It
is, of course, well known that in the foetus at term the
100;;^-
90/^—-
80/„.-
70°/-
0-9
10-19
20-29
DECADES.
30-39 1 40-49
50-59
60-69
70-79
100^
--90%
— 80°/
r^
^
y
/
r
J
-—70°/
/
1
^%
--50°/,
40»/
0
/
/
/
soV
J
-—80%
- — 20%
--.0%
20/.--
10% -
/
/
^
/
ulmonic Second Sound
wall of the right ventricle is nearly if not quite equal
in thickness to that of the left. From this time on,
the thickness of the right ventricle diminishes, until
at two years it is often actually thinner than at six
months intra-uterine, despite the great increase in the
size of the heart as a whole.' This fact, viz., the
' Gibson : " Diseases of the Heart and Aorta, " p. 8.
January 13, 1900]
MEDICAL RECORD.
47
relatively great thickness of the right ventricular wall,
must be taken into consideration in very young chil-
dren, and probably assists in accounting for the great
accentuation in the pulmonic second sound at that
age. It may be further suggested that, in children up
to nine years, the accentuation of the pulmonic sec-
ond, which I have shown to be normal, is to be ac-
counted for partly by the fact that the lungs are not
fully expanded before that age. Rotch says:' "At
what age the lungs reach their full expansion forward
has not been determined. It would appear that it is
not before five or si.x years, and it is probably still
later." We know that in any disease causing a rise
in blood pressure in the pulmonary circulation, such
as phthisis, pneumonia, emphysema, etc., we have an
accentuation of the sound produced at the pulmonary
valves. It seems that the lack of expansion of an
otherwise normal lung may well produce the same
effect as consolidated tissue. The reason for the pul-
monic accentuation from ten years on is not so easy to
understand, but whatever the explanation may be, the
results of these one thousand cases would seem to
show that, up to the time of full physical maturity
(twenty-fifth to thirtieth year), the recoil of tlie blood
upon the pulmonary valves is more forcible than that
which closes the aortic valves. This difference dimin-
ishes progressively with growth until full maturity,
when the normal condition would seem to be equality
in the recoil of the blood against both sets of valves.
We may suppose that this situation holds until degen-
eration of arteries, and all the many changes which
follow the gradual wearing out of various parts of the
body, increase the resistance in the systemic circula-
tion. The latter has many more pitfalls to encounter
than the pulmonary circulation, especially in the tis-
sues of the kidney and liver, which offer splendid
ground for degenerative changes. Autopsies certainly
prove that it is rare to find perfect kidneys after forty
years of age.
Conclusions. — i. Accentuation of the pulmonic sec-
ond sound is almost invariable in young children and
frequent in youth.
2. After the fortieth year of life, the reverse is the
case, and it is then rare to find a pulmonic second
sound as loud as the corresponding aortic sound.
3. Between the ages of twenty and thirty years,
there is no marked accentuation of either sound.
^4. In view of the above facts, it is obvious that
en one speaks of an accented pulmonic second
as corroborative of a diagnosis of heart disease,
accentuation must mean an increase in the loud-'
the sound over that normally to be expected at
Jge of the patient in question. A comparison with
the aortic second is not sufficient to settle the ques-
tion.
5. Further, when we speak of an aortic second sound
as accented, we must mean (in case of patients over
forty years) more accented than it normally is. Once
more, the simple comparison with the pulmonic sec-
ond sound will not settle the question. The compari-
son must be with an ideal standard carried in the mind.
6. In interpreting the meaning of an accentuation
of the pulmonic second in suspected mitral stenosis,
one. must bear in mind the age of the patient. The
presence of a pathological accentuation of the sound
can be determined only in relation to the degree of
accentuation which is to be expected at the age of the
patient in question.
Erysipelas. — Moist applications of a two-per-cent.
solution of creolin frequently cause very rapid sub-
sidence of the inflammation and fever. — M. Wolf,
Wiener med. Fresse, October 8, 1899.
' Kotch ; " Pediatrics," p. 75.
ACQUIRED NON-MALIGNANT STRICTURE
OF THE RECTUM: CAUSES, SYMPTOMS,
AND TREATMENT.
By W. duff BULLARD, M.D.,
By the great majority of observers, syphilis has been
regarded as the most common etiological factor in
stricture of the rectum. No convincing argument,
however, has yet been brought forward which proves
beyond conjecture that syphilis finds in the rectum
structures more readily yielding to its ravages than
tissues in other portions of the alimentary canal.
Before proceeding to the discussion of the subject
proper of this article, I shall endeavor to give a brief
re'sume of what has been said by various authors upon
diseases of the rectum with especial reference to
syphilis as a causative factor.*
White,' of Bath, the first English surgeon, I be-
lieve, who wrote a work on stricture of the rectum,
makes no mention of the venereal poison as a cause
of stricture. This is also the case with Mayo" and
Frederick Talman,' and even Mr. Syme, in a paper on
diseases of the rectum, does not allude to it. Indeed,
it would appear that the earlier English writers have
passed over in silence any venereal disease as a cause
of stricture. Thus, as early as 181 5, Richerand '
speaks of "condyloms internes" of the rectum.
Others have spoken of tubercles in this organ causing
stricture, but Bushe' says that "neither Morgagni,
Desault, Tanson, White, Copeland, nor Calvert say
that these tubercles depend on any specific cause."
Both Richerand and Delpech, however, assert most
distinctly that they depend upon the venereal poison.
Bushe, in a short chapter on venereal ulceration of
the rectum, says: "This ulceration may arise from
the direct application of the venereal poison, or it may
coexist with other secondary symptoms." He does
not, however, speak of this disease as causing strict-
ure. South," among the numerous causes enumerated
as giving rise to stricture, includes that of syphilis,
and says: "The immediate cause of stricture of the
rectum is always a more or less extensive inflamma-
tion or continual irritation of the rectum, in con-
sequence of which there is a secretion of plastic
matter, thickening and elongation of tissue."
According to Copeland,' Desault saw stricture so
frequently in combination with other symptoms de-
cidedly venereal, that he did not hesitate at once to
put his patients under a course of mercury, and, he
says, with a success that fully warranted him in con-
sidering it as very frequently a symptom of the vene-
real disease. It must be stated here, however, that
at the same time Desault resorted to local treatment
by means of the bougie. Copeland further remarks
that stricture is much more frequent than physicians
imagine, and it is not so frequently of a capcerous
origin as authors would lead us to believe. Curling,"
in speaking of chronic ulceration of the rectum, says:
" Mr. Avery exhibited a specimen of ulceration of the
rectum in a female, the history of which clearly showed
the connection of the lesion with syphilis and its
probable occurrence as one of the secondary phe-
nomena of the disease. When the patient died she
had numerous indelible marks of syphilitic eruption
on the limbs and trunk, and was suffering from sore
throat." It appears that Mr. Curling is not a believer
in the so-called " syphilitic stricture," for when speak-
ing of stricture he remarks " that Desault supposed
they were of syphilitic origin, but his observations in
reference to that point are not satisfactory." Mr.
Quain,' while speaking of ulceration and stricture as
a result, does not allude to venereal disease as a cause.
* For many of tlie references giA-en in the text, acknowledg-
ment is due to Erskine Mason.
48
MEDICAL RECORD.
[January 13, 1900
In looking over some of the standard authors on
general surgery, I find Chelius'" includes syphilis as
one of the causes of stricture. Erichsen makes no
mention of any venereal stricture, but speaks of hav-
ing met " that form which occurs low down several
times in young women otherwise perfectly healthy.''
The same is true of the works of Fergusson, Pirrie,
and Druitt. Gross" says: "A syphilitic stricture is
occasionally met with in the lower bowel, caused not
by any constitutional taint, but by direct inoculation
with chancrous matter." Mr. Henry Smith " regards
this disease as due to constitutional syphilis, and ad-
vocates " the exhibition of small doses of mercury
and the iodide of potassium " in the treatment of the
same. Lancereaux'^ confirms the ideas expressed by
Gosselin ; and Bumstead ''' is an advocate of the dis-
ease being chancroidal and not syphilitic. Berkeley
Hill,"' on the other hand, while giving an accurate
description of this stricture, says: "Many observers,
among whom is Gosselin, do not regard this as a pro-
duct of the syphilitic diathesis," but he does not give
his own opinion. I infer, however, that he enter-
tains the more modern view in reference to this sub-
ject when he says: "In the treatment of syphilitic
stricture of the rectum specifics are of little value."
Among the more recent authors I find that Dr.
Van Buren" regards the chancroid, especially when it
takes on a phagedenic character, as the only mode in
which any form of the venereal disease is certainly
known to give rise to strictures of the rectum. On the
other hand, I find Mr. AUingham," in referring to
ulceration of the rectum, uses the following language:
" I have no doubt that a good many are of syphilitic
origin. They may be the result either of secondary
or tertiary syphilis, and other syphilitic lesions will
be observed; but sometimes the ulceration of the
bowel with a syphilitic history is the only sjTnptom
present." With reference to stricture of the rectum
he says: "lam of the opinion that some strictures
are syphilitic in their origin, and when they are, the
patients generally do well." For these cases he ad-
vocates anti-syphilitic treatment.
Again, Hamilton'" remarks: "The most common
cause of stricture of the rectum in public practice is
syphilis and chancroid. At Charity Hospital these
cases are constantly under observation, and they are
observed to be particularly frequent among women.
Gosselin" concluded from his observations on twelve
patients, all women, that the affection known as
"syphilitic stricture" was due to the local sore, "the
chancroid," rather than to constitutional syphilis.
Mason"" states that the deductions he would make
are: "The disease appears peculiar to females; it
occurs chiefly between the ages of eighteen and thirty-
five years. The locality of the stricture, as a rule, is
between one and two inches from the anus. Anti-
syphilitic remedies possess no beneficial influence
over the disease. This disease is more frequent than
is generally supposed." Though unwilling to deny
that a stricture of the rectum might occur as the result
of a syphilitic ulcer, he believes that such an occur-
rence must be exceedingly rare; and, therefore, the
term "syphilitic stricture" is an improper name.
Hence the disease, being due to the chancroid, should
be known as the "venereal," or rather "chancroidal"
stricture. He reports thirty-one cases, all in women.
Baumler^' states that: " A number of authors look
upon 'chancres' as the sole cause of the stricture.
Others, among whom are A. Guerin and Verneuil,
urge the syphilitic nature of the process upon which
the disease depends. Virchow leaves it undecided,
since he has had no opportunity to examine the early
stages of the process. It must, however, be admitted
that secondary ulceration of the rectum may extend
upward from affections about the anus, and also that
gummata may occur in the rectum. Moreover, if
stricture of the rectum is found in young women, it is
probably due to ' chancre ' cicatrices: if it is met with
in old women and men, the inference should be that
it is either caused by cancer or by a syphilitic infiltra-
tion with its consequences. Only in those cases in
which no cicatricial tissue has been formed, i.e., where
the contraction is due to the infiltration alone, will
the results of anti-syphilitic treatment contribute any-
thing toward rendering the diagnosis more certain."
The " chancres " referred to in the above quotation
are evidently intended to mean only the local sore —
chancroid.
Cooper and Edwards"' state that "syphilitic ulcera-
tion is most often due to the disintegration of gum-
matous growths and is therefore connected with the
tertiary stage of the disorder." They also state that
"a history of syphilis is obtainable in from twenty to
thirty per cent, of all cases of stricture of the rectum."
In a rapid examination of their book, it was noted
that no mention was made as to whether they found
stricture occurring more frequently in women or not.
The Allinghams"" say: "In our experience, certainly
half of the cases of stricture with ulceration have
been syphilitic of a late secondary or tertiary type."
No mention of stricture of the rectum occurring more
frequently in women is here made, and they do not
deign to mention how it is possible to distinguish
between a stricture of the tertiary type and one of the
secondary.
Matthews"' says : " I have already stated that I do
not hold to the theory of chancroidal ulceration and
consequent stricture, as advocated by Ziegler, Mason,
Kelsey, Van Buren, Gosselin, and others. Nor do I
subscribe to the belief that the stricture is caused by
the contraction of the cicatrix of the healed ulcer.
... I believe that strictures in a syphilitic subject
are the result of a syphilitic neoplasm which becomes
organized into firm tissue. . . . Indeed, so firm am I
in this belief, that if it is a question between cancer
and no cancer, and it is decided that it is not malig-
nant, ninety-nine out of every hundred cases will, in
my opinion, prove to be syphilitic."
Allingham, in tabulating his cases of stricture,
says: "Thus out of the total number of ninety-nine
cases of stricture, fifty-two or more were syphilitic."
Matthews, although he mentions many cases of
stricture seen in his own practice among women, also
attaches no importance to the fact, for he does not
anywhere state that women are more commonly
affected, as least so far as the writer could see. All
the authorities in the same way either ignore this
peculiarity in the etiology, or state that it is simply a
disease of women, and rest their argument there.
It seems curious to the writer that so many observers
should pass over this peculiar feature with so little ■
reference, and continue along the lines laid down,
when the facts in the case do not warrant such a course.
Kelsey says: "Of the existence of syphilitic
ulceration of the rectal pouch occurring in the late
secondary or tertiary stage of the disease, there can
be no more doubt than of the existence of the same con-
dition in the fauces or trachea. ... I believe it to be a
rare condition . . . and one that in no way accounts for
the condition of hypertrophy of the surrounding tissues j
and stenosis so commonly described as ' syphilitic
stricture ' of the rectum." Again, quoting Fournier's
description of the so-called ano-rectal syphiloma, he
says: "The disease commences as an infiltration of
the rectal wall by the neoplasm; the deposit is entirely
submucous and occurs by preference in the rectal
pouch, and always encircles the whale calibre. . . .
There is no contraction and no ulceration until later.
As the deposit increases in amount, the mucous mem-
brane over it loses its vitality and becomes ulcerated,
January 13, 1900]
MEDICAL RECORD.
49
and the deposit itself finally degenerates into fibrous
tissue, retracts, and causes stricture."
Such a process as Fournier describes is unknown in
any other part of the body, and equally unknown as
any process characteristic of syphilis. Nor is it in
any way amenable to anti-syphilitic treatment, the
condition being simply a chronic hypertrophic proctitis
independent of syphilis. The weight of evidence is
decidedly in favor of the possibility of the causation
of stricture by phagedenic chancroids; but that any
large proportion of strictures are in any way due
either to chancroids or syphilis has never been proved,
while recent clinical and microscopical study is all
against this time-honored theory. The views of Dr.
Kelsey are, in the opinion of the writer, not sufficiently
radical. The author would go still further and say
that not one in a thousand cases of stricture is caused
either by chancroid or syphilis, and that what Dr.
Kelsey designates "chronic hypertrophic proctitis"
can be explained frequently, not as the effect of in-
flammation starting in the rectal wall, but as the
direct result of some mechanical cause external to the
rectum and encroaching upon its calibre.
After reviewing the writings of the many authors
above referred to, it would seem that no two of them
agree as to the frequency with which syphilis and
chancroids act in the production of stricture of the
rectum. All are, however, of the opinion that the dis-
ease is more frequent in women.
In the writer's opinion, the primary syphilitic lesion
occurs in the rectum only in victims of passive ped-
erasty or by means of direct contagion. There is very
little destruction of tissue produced by a chancre, and
the tendency is for it to run its course to spontaneous
healing in from four to six weeks. Mucous patches
may also occur in the rectum as a secondary manifes-
tation of syphilis. As is well known, the fauces and
pharynx are the parts most frequently affected by this
type of the disease. The symptoms here are more
aggravated by irritants, such as tobacco, alcohol, etc.
Men are more subject to these irritations. Why
should the female rectum be the structure in which
the mucous patch proceeds to stricture, while the male
organ escapes.'' Mucous patches in the fauces pro-
duce decided symptoms. Let the syphilographer tell
us how many patients suffer from symptoms of ulcer-
ated mucous patches in the rectum at this stage of
syphilis. The writer believes their answer will be
that no case showed symptoms of rectal disease which
were not present before the syphilis was contracted.
But if we admit that mucous patches occasionally do
occur in the rectum, will they cause stricture of the
rectum without first presenting well-marked symptoms
of acute ulceration with its muco-purulent discharge
and tenesmus? No. The mucous patch is distinctly
an ulcerative lesion, and rarely extends deeper than
the mucous membrane, and always responds to clean-
liness and anti-syphilitic treatment. These rectal
strictures, however, do not respond to anti-syphilitic
treatment at any stage of their development.
Most authorities look upon tertiary lesions and the
ano-rectal syphiloma of Fournier as tiie cause of most
non-malignant strictures of the rectum. The ano-
rectal syphiloma is supposed to be a diffuse infiltra-
tion of all the lower part of the rectal wall, causing
an hypertrophy which narrows the canal. Such a
process occurs, but it is, in the writer's opinion, neither
caused by, nor characteristic of, syphilis. In his
opinion, it is due to prolonged irritation acting in the
rectum, or more frequently to external causes, such as
will be subsequently described under the head of
stricture from cellular deposit.
Several authorities claim to have seen gummata
as circumscribed swellings in the wall of the rectum;
but, if such is the case, the writer can see no reason
why such deposits in this locality should not as readily
respond to anti-syphilitic treatment as they do in other
parts of the body. However, authorities state that
they do not respond to specific treatment. Therefore
the author believes it is safe to say that no lesion in
the body is syphilitic that does not respond to specific
treatment. Furthermore, he is convinced that syphilis
per se is not a causative factor in stricture of the rectum.
The more frequent occurrence of stricture in the female
rectum can be accounted for by reason of the greater
liability to traumatism to which the latter is exposed.
Every coitus and every pregnancy affect the rectal
wall, and every inflammatory process in uterus, tubes,
or ovaries may exert a pernicious influence.
The author is of the opinion that the great majority
of observers have been led to consider syphilis the
causative factor in the production of rectal stricture
by the fact that this condition has been most frequent-
ly observed in syphilitic subjects. To the author's
mind it appears much more rational to assume that
syphilis is not immediately responsible for such lesions
for the following reasons:
Endarteritis is a well-recognized state in syphilis.
This change in the vascular system, combined with
the resultant low state of nutrition, renders the mucosa
of the rectum less resistant to irritants and trauma.
Under these circumstances, small losses of the epithe-
lial covering, which would readily be restored in
healthy individuals, remain unhealed and constitute
the beginning of simple inflammatory or ulcerative
conditions. Examples of this are offered in the in-
dolent healing of wounds and in the delayed union of
fractures in syphilitic subjects.
The production of a stricture of the rectum is char-
acterized by a progressive narrowing of the lumen of
this viscus. The varieties of lesions that tend to pro-
duce such a condition may be divided into two large
classes:
I. Lesions external to the bowel, producing me-
chanical obstructions and circulatory disturbances
resulting in involvement of the rectal wall.
II. Lesions originating in the wall of the bowel
itself.
Lesions external to the bowel operating to produce
rectal stricture are of more frequent occurrence in the
female than in the male subject.
This is undoubtedly due to the fact that in the former
the rectum lies in closer proximity to the organs of
generation, which are more subject to radical changes
than in the latter. Disease of the vulva or vagina, as
manifested in the cicatricial contraction following old
non-syphilitic ulceration, chancroidal disease, exten-
sive gonorrhoeal inflammation, and, most common of
all, traumatisms, as illustrated by the ruptured peri-
neum, directly affect the rectal wall. Enlargement of
the uterus in pregnancy or any disease of the adnexa,
if allowed to progress, interferes with proper perform-
ance of the rectal functions. Pressure is exerted upon
the elastic rectal wall, thereby producing a rounded
spur which projects into the lumen of the bowel. If
there be added to this a constipated habit and the
straining necessary to force the hardened faces be-
yond this spur, the continuity and integrity of the
rectal wall are menaced. This condition, if unrelieved,
obstructs the circulatory efforts of nature which are
essential to the sustenance of the mucosa. The
mucosa gradually loses its elasticity and vitality,
until, by constant irritation, the stools erode the epi-
thelium covering the spur. Ulceration now takes
place, and the steps between this stage and stricture
of the rectum are short.
This sequel can, perhaps, most frequently be ob-
served in patients suffering from adherent retrofiexed
uterus; but it may also result from the action of any
mass encroaching upon the normal calibre of the
50
MEDICAL RECORD.
[January 13, 1900
rectum. Nature, apparently realizing the dangers to
which the rectum is exposed, endeavors to overcome
them by dilating the canal into what is called the
"rectal pouch." If, however, this "rectal pouch" is
surrounded by a plastic exudate from a contiguous
pelvic peritonitis, cellulitis, peri-prostatic or pelvic
abscess, the power of adapting itself to the mass of
faeces is lost. Under these circumstances the pressure
necessary to push a stool beyond the obstruction may
be likened to an attempt to force semi-fluid material
through an old stiffened section of rubber hose having
a partial kink in its calibre. Dilatation occurs above
the kink until sufficient pressure is exerted to force a
passage or to burst the tube. The inflammatory de-
posit may so interrupt peristaltic action as to give rise
to obstruction.
Stricture resulting from such a condition is likely
to consist of an hypertrophy of all the walls of the
bowel for three or four inches above the point where
the lumen of the gut is encroached upon by the in-
flammatory deposit. This results from Nature's efforts
to force the contents of the rectum through the adher-
ent and obstructed portion of the bowel. Later, when
dilatation results from constant pressure above, ulcera-
tion and pocketing occur. This, however, is observed
only in those well-advanced cases in which treatment
had not been applied or in which the real trouble had
not been recognized.
Chancroids frequently occur at the anal margin and
cause fissures and ulcers about the anus. The author,
however, does not believe that they are the cause of
stricture except in those cases in which the action of the
sphincter is impaired or in which they are allowed to
progress to the phagedenic type, and the induration
that follows such an extensive process causes a migra-
tion of leucocytes into all the neighboring tissues that
later become organized into firm tissue. The function
of the rectum is to expel all irritating substances and
not to draw them in. If chancroidal poison was carried
directly into the rectum we surely would find that
nearly every prostitute had a stricture of the rectum.
II. Lesions occurring in the rectal wall.
Tuberculosis is sometimes the cause of stricture of
the rectum. The rectum is rarely the primary focus
of the disease, but when the system is lowered by
tuberculosis of the lungs or the like, the bacilli find a
locus resistenti® minoris in the peri-rectal tissue or
in the folds of the mucous membrane itself. If they
lodge in the peri-rectal tissue, a tuberculous abscess
is formed with subsequent ulceration and stricture. If
the mucous membrane is first involved, then ulcera-
tion at once begins and spreads rapidly, leaving areas
of hard indurated and granulating tissue. This ulcer-
ation is most intractable to all forms of treatment,
and the infiltration of the rectal wall results in a wide,
dense stricture composed of fibrous bands, and large
areas the seat of ulceration. The diseases of the
colon, such as dysentery, typhoid, amoebic colitis, etc.,
produce ulceration in the rectal wall as elsewhere in
the alimentary tract. These ulcerations may not heal
readily, and a fibrous stricture results.
He also believes that gonorrhoea exerts no influence
in the formation of stricture of the rectum except from
direct contagion.
Hemorrhoids is a lesion that exerts the most potent
influence. These varicosities, when they become en-
gorged, inflamed, and strangulated, obstruct the pas-
sage of stools. They may slough oft the surrounding
tissue. The ulcer thus left is generally at first super-
ficial and of little consequence; but if left neglected
it gradually extends through the whole mucous mem-
brane to the submucous layer of the rectal wall. A
partial stricture is likely to result from subsequent
cicatrization.
Abscess and fistula in ano are the most common
diseases of the rectum. Abscesses usually press upon
the rectal wall, as is shown by the excruciating pains
suffered by the patient at stool. If the abscess rup-
tures externally, then small damage is done to the
rectal wall. If the abscess discharges internally, a
marked ulceration occurs about this opening from the
irritation of the infective material carried over its sur-
face by the fjeces. Granulation of the abscess cavity
takes place and frequently results in the formation of
a large, soft mass of exuberant granulations protruding
into the rectal calibre. This mass causes a necrosis
of tissue in that part of the rectal wall contiguous
thereto. These strictures are soft, prone to hemor-
rhage, and easily dilated under appropriate and judi-
cious treatment.
Prolapse of the rectum, especially when it origi-
nates in childhood, tends to narrow the rectal canal
as the result of the thickening of all its walls incident
to its repeated fall and reduction, and thus causes
stricture.
Surgical operations within the rectum and in the
neighboring tissues are quite a common cause of
stricture of the rectum. Many such cases are reported
from all types of operations; perhaps the most common
are those following surgical interference in hemor-
rhoids and fistula in ano.
During the past winter the writer saw two such
cases. One, a woman operated upon for hemorrhoids
six years before at a large New York hospital (prob-
ably Whitehead's operation was done) showed abso-
lutely no sphincter, the anal orifice being a square
opening with no contractile power whatever. Two
inches up in the rectum a fibrous stricture was felt
and then seen through a speculum. Dilatation was
not attempted, as the patient, when first seen, was suf-
fering from an acute attack of obstruction. At the
subsequent operation, the stricture was found to extend
upward into the bowel for five inches. The whole
stricture was divided posteriorly and the wound packed
after irrigation and cleansing of the bowel. The re-
covery vi'as uninterrupted. Several details of interest
in this case will be reported in a later article. The
second case occurred in a -man who consulted a well-
known (so-called) rectal specialist of New York City.
This gentleman injected some fluid into the rectal
wall for the cure of hemorrhoids. A slough and
ulceration followed, and the patient, becoming dis-
satisfied with the way he was progressing, forswore all
physicians after six months of treatment. Eighteen
months later, he was frightened at his condition and
called at my office. He presented an easily dilatable
stricture, giving to the touch the feeling of a number
of hard polypoid masses surrounded by soft, friable
tissue. This condition improved greatly under dilata-
tion and local applications.
Pessaries, glass enema tubes, a fall upon the but-
tocks, bones, pins, and foreign bodies of various kinds ■
that have become impacted in the rectum, are all likely ■
to cause ulceration and subsequent stricture. "
The symptoms occasioned by stricture of the rectum
can be discussed in two classes: I. Before ulceration
occurs. II. After ulceration occurs.
I. Stricture of the rectum presents very few symp-
toms before ulceration takes place. Alternating con-
stipation and diarrhoea, a sensation of fulness in the
abdomen and of weight in the pelvis, may be all that
is present. Every physician sliould feel that such a
condition, not responding to the usual treatment in
such affections, is sufficient to call for a careful and
thorough rectal examination. Occasionally a patient
will not present even so many symptoms as above
mentioned. The only trouble that would attract at-
tention to the rectum as the cause of difficulty may be
a slight throbbing pain at the anus and a feeling of
nausea after a stool.
January 13, 1900]
MEDICAL RECORD.
51
The stools of a patient suffering from stricture of
the rectum are necessarily different in character from
those occurring in the healthy subject. They usually
consist of small, hard, rounded lumps of fecal scybala
not unlike a number of grapes separated from the
common stalk. The so-called "ribbon-shaped" stools
are rarely seen, and then only in those cases in wliich
the stricture is at the anus or is forced down to it by
the act of straining. They are of little diagnostic
value, as they may be caused by a spasmodic contrac-
tion of the sphincter when no stricture is present. As
the stricture becomes dense, and the tissue organized
into fibrous bands, the symptoms become more severe.
There are now distention of the abdomen, impairment
of digestion, eructation of gases, and distress after
eating. Fecal masses can be felt in the transverse
and descending colon. The patient now begins to
suffer from tenesmus, and is obliged to go to stool
time after time to pass but a few lumps of fecal matter
and an excessive amount of muco-purulent material
from the irritated mucous membrane of the bowel.
The fecal masses begin to act as foreign bodies and
cause a catarrhal inflammation of the whole intestinal
canal with its attendant mucous discharge and septic
absorption.
Relief is temporarily obtained from the use of
cathartics, but the process repeats itself again and
again, exhausting alike the patient and the intestinal
functions. If the patient becomes constipated, acute
obstruction may occur and a fatal issue result, unless
operative interference is at once instituted. This
is more likely to occur If the stricture is in the sig-
moid or high up in the rectum, where the intestine
may twist upon itself in its peristaltic efforts to push
the obstruction onward, than if it is low down in the
rectum where all the force is concentrated upon a
mass held steadily in position by the surrounding
organs and a tight meso-rectum.
II. After ulceration begins.
As a rule, the writer believes that ulceration is the
first step in tlie production of a stricture of the rectum,
and consequently cases with as obscure symptoms as
detailed above are the exception and not the rule.
The symptoms of ulceration of the rectum should at
once attract the attention of the physician. Pain,
muco-purulent discharge, and tenesmus are character-
istic. The patient is called to stool any number of
times in twenty-four hours, to pass only a few scybala
surrounded by a quantity of slime and muco-purulent
material streaked with blood. If the patient consults
a physician when these symptoms are first noticed
and proper treatment is instituted, most patients should
be cured, and the sufferer escape from the formation
of stricture of the rectum. Only too frequently, I
fear, the general practitioner prefers to temporize
with a serious condition that needs the care of a
specialist as much as does a new growth of the larynx.
An ulcer of the rectum will rarely respond to internal
treatment, even if it be supplemented by the use of an
occasional suppository. Treatment locally to the dis-
eased area, and that alone, is essential. A few addi-
tions to the physician's regular armamentarium and
some training should suffice to render local treatment
of an ulcer of the rectum possible in every physician's
office. The result should be nearly as satisfactory as is
the treatment of an ulcer anywhere upon the limbs or'
body, instead of being a "bete noire" as now. The
writer believes that, could the general profession realize
the importance of local treatment and apply it in ulcer
of the rectum, non-malignant stricture of the rectum
would become a rare condition, instead of a compara-
tively common one as it is to-day. If the ulceration
is neglected, it gradually extends, the symptoms grow
more severe, and the patient becomes exhausted from
the constant drain on the system and the tenesmus.
Nature endeavors to remedy the evil, and cicatricial
bands and inflammatory deposit narrow the rectal
calibre. Then appear the symptoms of deranged in-
testinal functions, the abdominal soreness and pain,
distention, eructation of gases, nausea, occasional at-
tacks of vomiting, localized areas of peritonitis sur-
rounding the diseased mass, chronic obstipation and
septic absorption, until the patient succumbs to acute
obstruction or exhaustion.
The presence of stricture of the rectum can easily
be discovered if the physician understands the use of
the numerous instruments at his disposal. The Kelly
tube and Kelsey's modification of the same can be
used to explore for stricture as high as the niiddle of
the descending colon. Great care should be taken
not to attempt to force any instrument by an obstruc-
tion. The instrument should be removed and an at-
tempt made to pass a soft-rubber bougie. It is better
at first to use a large size, a No. 8 or 10. This large
size will distend the folds of mucous membrane. If
this soft instrument seems to catch, some soap-suds or
olive oil should be injected through the opening in the
centre of the bougie, and another attempt made very
gently to pass the bougie onward. If resistance is
still met with, there is very good reason to believe
some obstruction exists. The bougie should be removed
and notice taken how many inches of it w ere introduced
before the obstruction was reached. A Kelly tube may
then be introduced about the same distance as the bou-
gie, its obturator removed, and with the assistance of an
electric head-light the distal end of the stricture can
easily be observed, and its calibre accurately measured.
A hard-rubber olive-headed bougie on a small flexible
metal stem can then be introduced through the tube
directly into the lumen of the stricture. It is not de-
sirable for diagnostic purposes to force a large size
through the stricture. It is safer to pass one that is
nicely adjusted to the lumen of the .stricture. By this
means the depth of the stricture and any excessive
narrowing of its calibre higher up can readily be de-
termined. The resistance to the return of the bougie
after it has passed the upper limit of the stricture de-
termines its proximal end as readily as in the case of
a urethral stricture. With some experience, the
operator can detect the exact nature of the stricture,
whether of a dense fibrous type or of partially organ-
ized tissue with an excessive amount of ulceration.
The metal stem on the bougie employed by the writer
is very small. As soon as the olive head has been
introduced into the stricture, the walls of the stricture
can be perfectly viewed through the tube as they are
gradually distended by the onward passage of the bul-
bous head.
The treatment of these strictures should be governed
by the peculiar conditions present in each individual
case. When the stricture is found to be quite wide
and thick and of large calibre, with considerable
ulceration, the treatment should be directed toward
curing the ulceration.
Stimulating, cauterizing, and protective applications
should be made directly to the ulcerating areas. Heal-
ing will usually attend the conscientious and skilful
use of such applications. The inflammatory deposit
about the stricture, which is constantly increased by
the irritation of infective materials upon the ulcers,
will begin to be absorbed, and the bowel wall will be-
come less rigid and more amenable to gradual dilata-
tion. As soon as the irritation is overcome, nature
will cause the disappearance of a surprisingly large
amount of this partially organized material. Just in
proportion to the physician's success in overcoming
this irritation and infiltration of tissue is the prognosis
good or bad. The longer the duration of the disease
the more fully organized the tissue will be, and the less
will it respond to the efforts of nature to absorb it. The
52
MEDICAL RECORD.
[January 13, 1900
prognosis, then, in an old case should be guarded as to
complete or rapid recovery. The author believes that
the vast majority of cases in which the patient is not
already suffering from chronic obstruction, when first
seen can be made more comfortable by the above briefly
outlined treatment than by any operation at present
at our disposal. Uhen the disease has progressed to
such an extent that the stricture is of a very narrow
calibre, the patient greatly reduced and suffering
from chronic obstruction, radical treatment is at once
demanded. Here, operation is the lesser of two evils.
There are several classical methods to relieve these
advanced cases.
The operation known as posterior proctotomy is the
most generally useful. This operation consists in an
incision made in the posterior wall of the rectum from
the upper limit of the stricture backward and outward,
dividing all the tissues involved in the stricture, in-
cluding the sphincter and all the cellular tissue be-
tween the rectum, tlie coccyx, and the external gluteal
fold. Such an incision is best made in the median line
behind. The bowel should then be thoroughly irri-
gated with some mild solution until the greater part of
the fecal masses in the rectum and colon has been
entirely removed. The wound is then tightly packed
with sterile gauze. The extensive oozing may be
controlled by using very hot irrigating fluids, and
careful packing of the entire wound cavity. The care
of these cases after operation is by far the most im-
portant part of the treatment. Any surgeon can make
an incision through the rectal wall, but how to treat
the incision afterward so as to get the best possible
result does not seem to be thoroughly understood.
Much of the benefit to be derived from the operation
is lost by permitting rapid healing, as, unless that
part of the incision that is expected to form a portion
of the bowel passage' is not covered with mucous
membrane, the contraction of the cicatrix will over-
come the best efforts to preserve the calibre of the
bowel as large as was intended. In other words, every
means at our disposal must be employed toward ex-
tensive production of mucous membrane.
Granulation from the bottom and sides gf the in-
cision should be prevented as much as possible while
the slow-growing epithelium-covered mucous membrane
extends down over the sides of this incision to meet
that of the opposite side. If the mucous membrane will
grow on this cellular tissue which constitutes the bottoni
and sides of the incision, much will be gained, as there
is practically no contraction after this form of healing.
So it is desirable to have this wound heal not by pri-
mary or secondary union, but by third or last union.
The after-treatment of a typical case will be briefly
described. Twenty-four hours after the operation the
gauze packing is all removed, great care and gentle-
ness being observed in order to avoid hemorrhage, and
the bowel thoroughly irrigated with solution of bichlo-
ride of mercury i : 10,000, at about the temperature
1 10° F. This should run into the bowel from a douche
bag at the height of about four feet above the patient.
The irrigation should be kept up until the return flow
is clear. One-half the amount of gauze taken out is
then replaced with fresh gauze covered witli sterile
vaseline and placed in the incision. This is allowed
to remain in situ for twenty-four hours, and is then
removed and a smaller amount replaced. The bowels
are not moved for three days; then a half ounce of
licorice powder is given to soften thoroughly the fecal
mass. When the bowels are inclined to move a large
soapsuds enema is given, so that no irritation will be
felt by the patient when the mass passes through that
part of the bowel presenting only a raw surface. After
the bowels have moved satisfactorily the patient is
allowed to get out of bed and to return to his home
when his general condition warrants the exertion.
The stools are kept soft by any laxative, and a daily
movement is induced. Directly after the movement,
the bowel should be carefully irrigated with the anti-
septic solution as already mentioned.
The real work on the case now- commences. The
patient should be seen in the morning after the irriga-
tion, and the condition of the wound carefully in-
spected by speculas and artificial light. Granulation
will probably have already commenced. The en-
croachment of this process on the calibre of the bowel
opening must be stopped. It can be controlled by
light cauterization with the electric cautery, preceded
by an ethyl-chloride spray or by a two-per-cent. solu-
tion of eucaine " B," applied on a camel's-hair brush.
If the granulating areas are not extensive, covering
the wound cavity with bismuth subnitrate or any other
inert dusting-powder will accomplish the same result.
Along the edges of the mucous membrane, great care
must be observed in no way to arrest its growth by
too free cauterization. This process should be supple-
mented by stimulating applications to the edges of the
mucous membrane if there is any delay in its growth.
The anterior wall of the bowel, if it has been the
seat of ulceration and cicatrization, must also be
treated, and any further spread of ulceration or con-
traction prevented by the use of applications and
bougies. As a rule, from six weeks to three months
are needed to heal this wound properly. At the end of
that length of time, the patient should be nearly cured,
but about once a month before retiring the patient
should introduce a soft-rubber bougie that has been
fitted to the rectum and allow it to remain in place all
night. This bougie must not be passed oftener than
once a month, or it may cause some inflammatory
action which will start the ulceration afresh.
Another method is forcible divulsion of the strictured
tract by any of the powerful specula and dilators at
our command. This method is mentioned only to be
condemned as dangerous and unsurgical. It is im-
possible to tell how far the effects of such a divulsion
may go. It may tear through the wall of the rectum
into the cellular tissue and a septic peri-proctitis re-
sult, or the tear may extend into the peritoneum and
a septic cellulitis or peritonitis result in the premature
death of the patient.
If the local disease is so far advanced as to contra-
indicate an attempt to bring about a cure of the local
trouble, the descending- colon can be opened either in
the left inguinal or lumbar region, constituting the
operations known as left inguinal or lumbar colostomy.
Either of these operations will give immediate relief
to the sufferer. It is not my purpose here to give a
description of these operations, as they have been
fully described in numerous works on general surgery,
as well as in several works devoted entirely to rectal
diseases. It will be suflicient to state that a very
good technique for the inguinal operation (the pref-
erable) can be found in the '"Twentieth Century
Practice of Medicine" or in Dr. Kelsey's book,
"Surgery of the Rectum^and Pelvis.'"
Briefly summarized, the conclusions the author
would draw are :
1. The majority of rectal strictures are of non-
syphilitic origin.
2. Syphilis may be a predisposing, b':t it 's not an
•immediate, cause of stricture of the rectum.
3. Trauma is the chief immediate wt-V-sative factor
in the production of rectal stricture.
4. The proper and intelligent local treatment of
non-syphilitic ulceration of the rectum will minimize
the occurrence of rectal stricture.
302 Mauison .-Vveme.
BIBLIOGRAPHY.
1. Observation on .'Stricture of the Rectum, Bath, 1820.
2. Diseases of the Rectum, London, 1S33.
January 13, 1900]
MEDICAL RECORD.
53
8.
1S51
P- 47.
Stricture of the Rectum, London, 1S33,
Nosographie chirurgicale, Paris, 1815, tome 3, p. 43S_
Diseases and Malformations of the Rectum, New York,
, p. 26S.
Chelius : Surgery, American edition, p. 47.
Copeland ■ Diseases of the Rectum.
Curling : Observations on Diseases of tlie Rectum, London,
, p. 79-
Quain : Diseases of the Rectum, London.
Chelius : Surgery, edited by South, American edition,
Gross : Surgery.
Holmes : Surgery of Diseases of the Rectum.
Pract. and Hist. Treatment of Syphilis.
Bumstead : Venereal Diseases.
Syphilis and Local Contagious Disorders.
f)iseases of the Rectum, p. 109.
Allingham : Diseases of the Rectum, 1873, pp. 158-187.
Principles and Practice of Surgery, 1872, p. 775.
Arch. gen. de Med., December, 1854.
Mason : Li>i\ cit.
Ziemssen's Encyclopaedia.
Diseases of the Rectum, second edition, London, 1892, p.
Loc. cit., edition of i8g6, p. 330>
Diseases of the Rectum, iSg6, p. 344.
Quoted by Matthews, loc. cit.
Diseases of the Rectum and Pelvis, 1S97, p. 247.
POST-PARTUM HEMORRHAGE, ITS PREVEN-
TION AND TREATMENT, WITH THE RE-
PORT OF AN UNUSUAL CASE.
By EDWARD P. D.4VIS, A.M., M.D.,
Ix spite of recent advances in modern obstetric sci-
ence, post-partum hemorrhage remains one of the great
dangers to the parturient woman. Asepsis protects
her from the invasion of disease, but in post-partum
hemorrhage we have a source of morbidity and mor-
tality that often brings the patient into great danger
with but little warning.
We must recognize as the most frequent cause
of post-partum hemorrhage the patient's exhaustion.
This is of two sorts, local and general. The local
exhaustion which threatens her with bleeding is seen
in the relaxed condition of the uterus. The general
exhaustion which underlies the local condition is ob-
served in those cases of protracted labor in which the
mother fails to expel her child spontaneously. Less
frequent causes of post-partum hemorrhage are the re-
tention of a partially detached placenta or of a por-
tion of the placenta and membranes within the uterus,
lacerations of the t;enital tract which open blood-ves-
sels, and a profoundly altered condition of the pa-
tient's blood.
The prevention of post-partum hemorrhage calls for
the careful avoidance of exhaustion. This can be ef-
fected only by a thorough examination of each patient
before labor or in the earliest stages of labor, to as-
certain the presence or absence of an insurmountable
obstacle to delivery, and to recognize if possible any
complicating condition which may render the labor
unusually long and difficult. Much has been said re-
garding the value of palpation and auscultation in
diagnosis, making vaginal examinations infrequent,
and thus avoiding septic infection. In the same way
very much may be done to avoid exhaustion and hem-
orrhage if an accurate examination is made before la-
bor, ascertaining the relative size of mother and child,
the position of the child and its presentation, the posi-
tion of the placenta, the muscular vigor and develop-
mant of the mother's uterus and general muscular
system, and the presence or absence of abnormal dis-
tention of the uterus through multiple pregnancy or
polyhydramnios. We cannot too strongly insist upon
the fact that to be forewarned is literally to be fore-
armed in the prevention and treatment of post-partum
hemorrhage.
The complications recognized as predisposing to
hemorrhage must each be met in its appropriate way.
In the case of marked disproportion between the pel-
vis and tiie probable development of the child, induced
labor furnishes the practitioner with a safe method of
delivery. If the womb be over-distended by multiple
pregnancy or by excessive fluid, the physician will
leave instructions with his patient that he be sum-
moned early, and will take care to avoid the rapid
"emptying of the uterus. If the mother's general mus-
cular system and uterus are deficient in tone, she may
take appropriate tonics during pregnancy, and during
labor the physician will be on his guard to prevent
exhaustion.
In dealing with the more unusual causes of post-
partum hemorrhage, considerable difficulty is at times
experienced. In syphilitic patients we expect a par-
tially adherent placenta, which, becoming but par-
tially detached, gives rise to hemorrhage at labor. In
a patient who has had gonorrhcea during pregnancy,
adhesion of the membranes may csfuse slow dilatation
and interfere with the prompt and complete emptying
of the uterus. If a patient be seen early in her preg-
nancy, and if we find her the victim of malarial poison,
of profound toxsemia, or of specific disease, we may, by
the liberal use of iron and arsenic, so improve the
condition of the blood as entirely to avoid post-partum
hemorrhage. Each case of pregnancy and labor de-
mands its individual study, and no case can be suc-
cessfully treated without considering the prevention
of this important complication.
In the conduct of labor, much can be done to Jivoid
hemorrhage. It is well, if possible, to locate the pla-
centa. This may be accomplished by palpation and
auscultation, and should a suspicious oozing of blood
occur, a thorough vaginal examination should be made
immediately, the hand being introduced as far as pos-
sible toward the brim of the pelvis.
Remembering that exhaustion is the great cause of
bleeding, the patient's strength must be carefully pre-
served. During the first stage of labor, she should re-
ceive liquid food in small quantities, as frequently as
she can take it, and, if necessary, stimulus as well.
Loss of sleep during the first stage of labor must be
reduced to a minimum by the use of appropriate seda-
tives. Or. X. of hydrate of chloral given in syiup and
water, either by the mouth or by the rectum, may be
repeated three times at hourly intervals to advantage
in many cases. In other patients, gr. xx. of bromide
of ammonium gives good results. In other patients,
gr. X. of trional taken with broth, soup, or with a table-
spoonful of whiskey in hot water, causes several hours
of refreshing sleep. Care should be taken that the
bladder and rectum be frequently emptied, that unnec-
essary irritation of the bladder and delay in labor may
thus be avoided. A warm bath at the beginning of
labor often lessens the irritation and pain which the
patient suffers. An experienced nurse will carry her
patient through the first stage of labor in good condi-
tion by those arts of nursing which conduce so much
to her comfort. Obstetric nurses should be trained to
utilize the best postures for patients during this stage
of labor, and thus suffering may be reduced to a mini-
mum.
A prolonged first stage of labor must occasion anx-
iety to the physician. He must assure himself that
no insurmountable obstacle to the birth of the child
is present. If dilatation of the cervix seems practi-
cally impossible without assistance, he will find the
use of an elastic rubber bag filled with antiseptic fluid
of the greatest advantage. I employ most frequently
McLean's double bag, because it affords us the great-
54
MEDICAL RECORD.
[January 13, 1900
est amount of dilatation witli but one insertion of tlie
bag. ]Jy filling one half of the bag at first and then
the other from one to two hours later, we obtain, in
from two to three hours, a practical dilatation of
the OS.
During the second stage of labor, especial attention
inust be given to maintaining the general strength of
the patient. She should be placed in such a posture
as to favor the mechanism of labor. While the head
is passing through the pelvic brim, in cases in which
the back of the child is directed to the left side of the
mother's pelvis, she should lie upon her left side. In
second positions, when the back is toward the right
side of the mother's abdomen, the patient should lie
upon her right side. When the head has reached the
pelvic cavity and is coming down upon the pelvic
floor, patients sometimes do better in the semi-sitting
posture, resting the body upon the tuberosities of the
ischia and bending the trunk forward, while the hands
grasp firmly the back of a chair placed in front of the
patient. In some cases of difficult labor, we have suc-
ceeded by placing the patient upon a padded slop jar,
the trunk of the body bending forward.
The decision to interfere during the second stage of
labor requires careful observation and good judgment.
Thanks to aseptic precautions, it is undoubtedly at the
present time safer for the patient to interfere during
the second stage of labor as soon as her expulsive
powers show signs of exhaustion. I call attention
to the phrase " signs of exhaustion " as distinct from
an exhausted condition itself. It is the duty of the
practitioner not to allow the patient to become ex-
hausted. We have formerly been taught that the head
of the child must remain two hours upon the pelvic
floor before the use of forceps is justifiable. It is,
however, impossible to make a hard and fast rule
for these cases, and I have no doubt that many pa-
tients have suffered from exhaustion and hemorrhage
because of too long delay through some, arbitrary
standard. When the head has reached the pelvic
cavity, the membranes having ruptured, the cervix
being fully dilated, and the presentation and position
favorable for the use of forceps, delay must not occur.
The instrumental termination of labor must usually
be conducted under anaesthesia, and here a choice and
method of administration of the anesthetic have an
important bearing on post-partum hemorrhage. For
the use of forceps, I distinctly prefer ether. Deep
anaesthesia is never necessary in the use of forceps,
and while the patient should be sufficiently under the
anaesthetic to be insensible to pain and to relax her
limbs, she should never be in the semi-asphyxiated
condition often observed in prolonged operations un-
der ether. The administration of ether for the use of
forceps demands as much skill and care as does the
administration of ether for the removal of an ovarian
cyst. It is a tribute to the faithfulness and care of
practitioners that so few accidents from anaesthetics
occur in obstetric practice. But the burden of respon-
sibility thus often assumed by the practitioner alone
is excessive and unjust alike to him and to his patient.
Whenever possible, the anaesthetic for the termination
of labor should be given by a thoroughly competent
person, and one who will follow down the uterus with
the hand during delivery, and who understands the
manipulation of the womb necessary to prevent relax-
ation and hemorrhage.
When the physician has determined to end labor
instrumentally, he must consider the possible trau-
matic lesions which may expose his patient to the
dangers of post-partum hemorrhage. He may natu-
rally raise the questions, " Shall I allow the patient
to recover from the anresthetic and to expel the pla-
centa spontaneously, or shall I immediately remove
the placenta before the patient fully rouses? If lacer-
ations occur, shall I not be in a better position to re-
pair them if I empty the womb completely and repair
lacerations before the anaesthesia is entirely removed? "
In this regard, I believe that the safest course is,
after the delivery of the child, to continue the anaes-
thesia in a partial degree, allowing the patient to
rouse and become partially conscious and to assist in
the expulsion of the placenta. This may be done
without loss of time, and the result is usually satis-
factory. So soon as the child is delivered, the anaes-
thetist remains with the patient ready to administer
the ether again. Having cleansed his hands, the physi-
cian in charge, compressing the uterus gently as the
patient wakes and rouses, may urge her to bear clown,
and in from ten to twenty minutes after the birth of
the child, the placenta may readily be expressed by
Crede's method. When this has been done, the physi-
cian should determine whether or no laceration of the
cervix accompanied by hemorrhage is present. In
suspected cases, it is well to introduce a speculum
with tenaculum forceps and to examine the cervix.
In some cases, digital examination of the cervix will
detect the presence of a laceration sufliciently great to
demand suture. If there be ho such laceration, the
pelvic floor and perineum must next be subjected to
scrutiny. If it is necessary to take stitches, enough
ether may be administered to the patient to make her
controllable, and the suture be immediately performed.
Before the insertion of the suture in the pelvic floor
and perineum, if relaxation of the womb is threatened,
it will usually become apparent. The womb will fail
promptly and vigorously to contract, the patient will
have a greater flow than is natural after childbirth,
and the physician may be in doubt as to whether or
not hemorrhage will occur. I believe that the in-
terests of the patient are best served by taking all pos-
sible precautions against hemorrhage when a doubt
arises. In such cases, therefore, I am accustomed,
upon the appearance of relaxation of the womb, imme-
diately to douche the uterus thoroughly with hot salt
solution or with boiled water only, and to tampon it
with iodoform gauze. I Jiave yet to observe a case
of infection which could be traced to this manoeuvre,
and I have yet to be disappointed in it as a means
of assisting in the prevention of hemorrhage. So soon
as this is done, the patient should receive a hypoder-
matic injection of gr. -Jj of sulphate of strychnine.
After this, lacerations in the pelvic floor and perineum
may be repaired under anaesthesia, giving as )ittle
ether as ppssible, but holding the womb to prevent its
relaxation.
As soon as the patient has recovered from the anes-
thesia sufficiently to swallow, 3 ii- of fluid extract of
ergot should be taken by the mouth, or, if the patient
is nauseated, an injection of ergot should be made be-
neath the skin. It is possible to obtain for this pur-
pose aseptic ergot which can be readily injected and
directly absorbed. To control the womb, the physi-
cian must remain beside his patient, holding the uterus
firmly, but not fatiguing the uterine muscle with un-
necessary and useless manipulation. In grasping the
womb, care should be taken that pressure is exerted
upon the anterior and posterior walls, and that the
tube and ovary are not included in such compression.
Pressure should always be avoided upon the fundus of
the womb, for inversion of the uterus with its dangers
has followed the " dimpling " of the fundus. Under
the treatment described, the patient usually reacts
from labor in a satisfactory condition, the uterus re-
maining well contracted, and shock and relaxation of
the womb being avoided. Should these measures,
however, not be entirely efficient, gr. ,,i^ sulphate of
strychnine with gr. ,, J^^ of atropine may be injected.
The injection of ergot may also be repeated, or ergot
may be administered by the mouth. The patient's
January 13, 1900]
MEDICAL RECORD.
55
head should be kept low, and if the pulse is lacking
in volume, a rectal injection of freshly made coffee,
well diluted, will be found of advantage. As soon as
the danger of relaxation is past, if the physician fears
its recurrence, the nurse may apply cuii^pression to the
uterus, using three towels made into firm rolls eight
inches long and three inches in diameter. The womb
should be brought by the hand downward and forward,
one of these rolls being placed above the fundus and
one on either side, and the usual obstetric binder ap-
plied from above downward.
It is, however, exceedingly important that a patient
threatened with hemorrhage should not be left by her
physician while the danger exists. It is the duty of
her attendant to be sure that she has fully reacted
from delivery, that the pulse is slow, its volume good,
its tension good, the womb contracted, and the general
condition of the patient satisfactory, before she can be
left to the care of the nurse alone.
As regards the further treatment of such a case, tlie
external parts are kept scrupulously clean and disin-
fected with bichloride of mercury 1 : 4,000 after each
emptying of the bladder or rectum. The patient is
catheterized if needed, and if stitches have been taken,
the stitches are cleansed by irrigation with bichloride
1 : 8,000 or with lysol one per cent., and are then
pov/dered with boracic acid. Sterile napkins or nap-
kins soaked in bichloride i : 2,000, and dried, are con-
stantly worn. In from twenty-four to thirty-six hours
after delivery, the gauze is removed from the uterus
and the womb thoroughly douched with decinormal
salt solution at a temperature of 105° to 110° F. To
secure involution, the patient is given by the mouth
gr. Jjf strychnine sulphate, and gtt. xx. fluid ex-
tract of ergot every six hours for the first forty-eight
hours after delivery, beginning at such a time as the
judgment of the physician may dictate. The fre-
quency of the administration of these medicines is
lessened as the condition of the patient suggests. The
use of the catheter is avoided if possible, but the blad-
der is not allowed to become distended.
I have devoted considerable space to the preven-
tion of post-partum hemorrhage, believing that, like
septic infection, its prevention is more satisfactory
than the actual treatment of the condition. In the
presence, however, of post-partum hemorrhage occur-
ring immediately after labor, the physician must
quickly differentiate between a relaxed condition of
the uterus and hemorrhage from a tear in the cervix,
pelvic floor, or vaginal tissues. If the womb is well
contracted, and the blood is bright in color, coming
constantly in a small stream, its source w^ill be found
in a torn vessel in the cervix, pelvic floor, or vaginal
walls. An examination should be made immediately
to determine the cause of the hemorrhage, and stitches
should be taken to control it. In this connection, I
must call attention to lacerations in the anterior vagi-
nal wall near the urethra as a source of hemorrhage
after labor. I have seen this condition several times,
and recall one instructive case as follows:
A primipara had just been delivered, by her physi-
cian, of a child by a comparatively easy application of
the forceps. The placenta was removed by expression
and the patient was apparently in good condition.
Trickling hemorrhage, however, persisted, the cause
of which was not evident to the medical attendant.
The womb was well contracted, and, fearing some tear
of the cervix, the vagina was immediately tamponed
with gauze. The hemorrhage, however, increased, and,
upon seeing the patient, I found its source to be a
laceration in the anterior vaginal wall, which had
opened small vessels around the urethra, extending
downward from the base of the clitoris. The pressure
of the vaginal tampon increased the stasis of blood
and maintained the hemorrhage. The lacerations were
very slight, but the vessels had been much enlarged
during pregnancy, hence the bleeding. When the
vaginal tampon was removed, and the parts were thor-
oughly irrigated with hot sterile water, the bleeding
at once ceased. The patient made a good recovery.
If, however, no tear of the cervix, pelvic floor, or
vaginal tissues can be found, and the womb relaxes, it
shovld be grasped by the hand and a vaginal douche
of hot sterile water, two quarts at 110° F., should be
administered. Gr. -j'^ sulphate of strychnine with gr.
■jJ-u of atropine should be given hypodermatically,
when, in the majority of cases, the bleeding promptly
stops. Should further relaxation occur, we should
immediately tampon the uterus with aseptic or iodo-
form gauze.
Many cases of post-partum hemorrhage following
relaxation of the womb occur after the physician
has left his patient and when she is Tn charge of the
nurse. Physicians should leave with obstetric nurses
written orders, stating what may be done in the event
of hemorrhage before the physician arrives. It is my
habit to allow a competent obstetric nurse, should
hemorrhage occur before I can reach the patient, to
act as follows: First, she should remove the obstetric
binder, massage the uterus until it contracts, and grasp
it in the manner described; second, still holding the
uterus, with any aid available, she should give the pa-
tient a hot vaginal douche of two quarts of sterile water
or bichloride solution i : 8,000 at a temperature of
110° F. ; third, she should cause the patient to swal-
low two teaspoonfuls of fluid extract of ergot. Upon
the appearance of hemorrhage, the nurse should send
for the physician, but should remain grasping the uterus
until the hemorrhage has entirely ceased, or until the
physician arrives. Nurses should be cautioned not to
fatigue the uterine muscle by useless manipulation,
but, having brought it to contract by massage, to hold
the womb steadily but gently in a contracted state.
Post-partum hemorrhage is not very frequent when
care is taken to avoid it, in my experience, and in most
cases my nurses succeed in stopping the bleeding be-
fore my arrival.
Failure of th^womb to remain properly contracted,
persistent oozing hemorrhage in the absence of a lacer-
ation which accounts for the bleeding, must suggest to
the physician that a portion of the placenta or mem-
branes or a large clot remains within the uterus. Much
stress was formerly laid upon turning out the clot to
cause post-partum hemorrhage to cease. If precautions
are taken to avoid hemorrhage, a large clot seldom
forms. In the presence of the symptoms described, it
is, however, the physician's duty to explore the interior
of the womb and to be sure that it is empty and clean.
This may be done with the finger, with the hot douche,
or with the hot douche given through the blunt curette.
Difficulty is often found in attempting to use the finger
from the fact that it is hard to explore every portion of
the uterine cavity in the recently emptied womb with
the finger. The finger is unfortunately in many cases
too short. Very often a thorough intra-uterine douche
will bring away whatever is retained. In the giving
of this douche, if the cervix is shut down tightly, it
should be dilated gently with the finger. I prefer
a glass douche tube, containing a groove along its
posterior aspect, and made of especially chosen glass,
which enables me to boil the tube thoroughly before
using. Boiled water, decinormal salt solution, or lysol
one per cent, is chosen for this purpose. I do not
employ mercurial solutions within the uterine cavity
unless the case is complicated by some septic condi-
tion. When the uterus is large, the functions of the
finger and tube may be combined by the use of the
blunt curette. The surface of the interior of the womb
should be thoroughly but gently gone over while the
hot fluid runs freely through the curette. If oozing
56
MEDICAL RECORD.
[January 13, 1900
continues at the conclusion of the douche, it is well
to pack with gauze as described. I am quite aware
that to interfere with the uterine cavity during and
immediately after labor is an important procedure, but
by boiling the instrument employed, by thoroughly
cleansing the hands, by the plentiful use of hot dilute
antiseptic fluid, and by selecting the gauze employed
for the tampon carefully, I have seen none but good
results follow this procedure.
If the patient is kept externally clean by antiseptic
solutions, and if sterile napkins are worn, the gauze
packing may safely remain without disturbance from
twenty-four to thirty-six hours. It should then be re-
moved, and the uterus thoroughly but very gently
douched with decinormal salt solution at a tempera-
ture of from 105° to 110° F. This procedure requires
no anaesthetic, occasions but little manipulation, and
is usually well borne by the patient. For such pur-
poses, I employ the simple glass douche tube already
described, and have found it satisfactory.
In the case of highly ancemic and neurotic women,
the nervous system plays an important part in causing
hemorrhage. The following case of unusual hemor-
rhage illustrates the preceding statement:
Mrs. C , aged forty, a married woman, was de-
livered of a healthy child in normal labor at the Jeffer-
son Maternity, some two years before her recent labor.
Her recovery was without complications, and she left
the institution in good condition. ■ She was recently
admitted to the Maternity in labor, and in a highly
exhausted condition. A macerated foetus and its ap-
pendages were delivered; the placenta was removed
by the hand, the uterus thoroughly emptied and packed
with antiseptic gauze. The fcetus had been dead for
some time and was considerably decomposed. The
patient was given appropriate stimuli and reacted well
from delivery. In view of the highly decomposed con-
dition of the child, it was thought best to remove the
gauze at the end of twenty-four hours and thoroughly
irrigate the uterus. This was done, and upon removal
the gauze was found to have a slightly offensive odor.
Some hours afterward, the patient had a sudden and
severe hemorrhage. It was controlled by removing a
clot from the uterus, thoroughly irrigating it, and again
tamponing with gauze. She rallied promptly from
this, and apparently did well. After the removal of
this packing, a further hemorrhage occurred, which
was promptly controlled by the use of the blunt curette
with hot antiseptic fluid. It was feared that some
portion of membranes or placenta was remaining
within the uterus, but none could be found. After
this bleeding, the patient did well for ten days, when
it was thought justifiable to take her to the obstetric
clinic in the same building upon a stretcher. She did
not seem especially agitated during the clinic, as she
was subjected to no manipulation, and attention was
simply called to her anemic condition and the histoiy
of her bleeding. Shortly after returning to the ward,
another hemorrhage occurred, much less in quantity
but still distinct in character. This yielded promptly
to a hot vaginal douche, and the administration of
strychnine and ergot. Involution had proceeded nor-
mally; the womb was small and movable, and the
source of the hemorrhage could not readily be ascer-
tained. A fourth bleeding, slight in character, also
occurred. Two blood counts were made from this pa-
tient, and are as follows : November 6th : Hamoglobin
thirty-seven per cent.; red cells, 3,450,000; white
cells, 6,000. November 15th: Haemoglobin, forty-five
per cent.; red cells, 3,500,000; white cells, 2,800.
An examination of the pelvic organs at the time of
writing gives the following results: The pelvic floor
is in good condition. It has been slightly lacerated
in previous labors, but the lacerations have been
closed and have healed. The womb is slightly retro-
verted, movable, slightly larger than normal, but invo-
lution has proceeded quite as well as in the majority
of multiparae. There is a whitish secretion of mucus
in the vagina. Upon examining the cervix with a
speculum, the muous membrane is healthy in color.
There is no extensive laceration, and no sign of ulcer-
ation is present. The external genital organs show no
positive evidence of specific infection.
The patient's general condition is greatly improved.
Obstinate hemicrania, from which she suffered at first,
has largely disappeared, and she is convalescent at
present. Her treatment in addition to the local treat-
ment described has been as follows: She has taken
three times daily, before eating, a mixture of Fowler's
solution, gentian, and simple elixir, the dose of Fow-
ler's solution varying from one and a half to three
drops at each administration. After eating, tincture
of chloride of iron has been administered in increas-
ing doses until she has taken thirty drops three times
daily. Attention has been paid to the condition of
the intestinal tract, and purgatives of various sorts
with saline laxatives have been given as needed.
The question of syphilitic infection enters naturally
into consideration in this case. The statement was
made by some one knowing the patient's circum-
stances before admission, that her husband had be-
come recently syphilitic and had infected her. At
the time of the patient's labor, no lesion was discov-
ered in the genital canal indicating specific disease.
The presence of a macerated foetus points strongly to
syphilitic infection of the ovum, with the resulting
changes in the endometrium and decidua commonly
seen in these cases. There can be no reasonable doubt
that this condition of the maternal tissues had some-
thing to do with the patient's repeated hemorrhages.
That she herself is syphilitic in the usual sense of the
word and in the acute stage cannot be proven.
I may summarize this case as follows: A multi-
para became, during her pregnancy, anasmic and re-
duced in strength through hard work and the presence
of a macerated foetus within the womb. U'e must sup-
pose that the endometrium and decidua became exten-
sively altered, very probably through syphilis of the
ovum, and that its blood-vessels were in an unusually
friable condition. The expulsion of the macerated
fcetus was followed by relaxation of the womb and
hemorrhage at varying intervals in spite of the persist-
ent administration of tonics and stimulants, strychnine
and ergot being given in large doses during the first
ten days of the patient's puerperal period. During
this time, she had four hemorrhages without apparent
cause. Each was immediately controlled by methods
described. Her convalescence has covered a period
of between two and three months, her gain in hemo-
globin being practically one per cent, daily during the
time of her most rapid recovery. She had a rise of
temperature after delivery, indicating saprsmic ab-
sorption, but this rapidly declined to normal.
Medicine in Whiskey Bottles — It will be remem-
bered, says the Britisit l^harjitacentical Journal, with
wha* liidignation the parish beadle in " Oliver Twist "
related the rejection of some stufl^ in a blacking bottle
intended for a sick pauper woman. " Nous avons
changd tout cela," but there still remain a few fea-
tures of the ancient system which have lately been
responsible for a poisoning fatality. An old lady in
Ireland had been for some time attended by the dis-
pensary medical officer for an affection of the knee-
joint. Some time ago she got a lotion which con-
tained poison, and took the lotion by mistake for whis-
key. She exhibited all the symptoms of belladonna
poisoning.
January 13, 1900]
MEDICAL RECORD.
57
THE QUESTION OF LEGAL CONTROL OF
PROSTITUTION IN AMERICA.'
By S. LUSTGARTEN, M.D.,
In discussing tiie question of legal control of prosti-
tution in America (the United States) we approach a
subject that is almost entirely new. In but one
instance, and but for a short time, have there been
laws enacted by a State for the regulation of pros-
titution, with a view to prevent disease. This soli-
tary experiment occurred in St. Louis, in 1872. A
law, drafted upon the lines of that in operation in
Paris, was enacted by the Missouri legislature, the
object of which was to regulate and bring under con-
trol prostitution in the city of St. Louis. The provi-
sions of this law — I quote freely from the appendix
of the new edition of Sanger's book on prostitution —
were substantially as follows: All prostitutes plying
their avocation were registered. These were divided
in three classes — the inmates of houses, the occupants
of rooms outside of such liouses, and those known as
"kept women," or mistresses. Tliere was no distinc-
tion whatever between these classes. In the eyes of the
law, the '' kept woman " was quite as much a prostitute,
and subject to the provisions of the law, as her less
fortunate sister in the common disorderly house. No
registered woman was permitted to change her abode
without first giving notice to the authorities, so that
her whereabouts was constantly known. Many of the
more vicious and corrupt practices of the business
were absolutely prohibited, and practically suppressed.
Soliciting, either on the street or from windows or
doors of houses of prostitution, was severely punished,
a second offence generally resulting in a deportation
of the offender from the city as a vagrant. No car-
riage or public conveyance was permitted to stop or
stand in front of a house. No red lamp of sin was
tolerated; in short, no light of a color calculated to
attract attention was allowed in hallway or parlor. The
front doors of all houses were kept unlocked, thus ad-
mitting, at all hours, not only the patrons but the police
as well. In fact, every barrier between the authorities
and the vicious class was, as far as possible, removed.
The city was divided into three districts, both in
respect to sanitary and police regulations. A physi-
cian of recognized standing, called "social-evil exam-
iner," was placed in charge of each of these districts,
whose duty it was to compel weekly medical inspec-
tion of each and all the registered unfortunates. A
nominal fee was collected weekly from the inmates of
houses and rooms, and a larger fee from the proprie-
tors of houses. The money thus collected went indi-
rectly back, to a great extent, to those contributing it,
as it was largely devoted to the maintenance of a hos-
pital open at all times to the members of this unfor-
tunate class.
Apparently well-informed writers, as well as many
of the leading physicians of the city, could discern
salutary effects after the law had been in operation
but a short time. Venereal diseases decreased in a
marked way, and the evil itself was lessened, many
of the members of a bad class preferring to leave the
community sooner than subject themselves to the re-
quirements of the new law. This latter movement,
this shifting of prostitution, can be ranked only among
the salutary effects if viewed from the selfish point of
a comparatively limited area, a city, or even a State.
The sanitation of the United States was surely not
improved through it. The Missouri AJedical Record
' A contribution to the transactions of the International Con-
ference for the Prevention of Syphilis and Venereal Diseases, held
in Brussels, September. 1899.
(May 15, 1874), in an article printed a few weeks
after the repeal of the law, stated that the system had
operated most beneficially in the interests of the com-
munity, as well as the welfare of the prostitutes; that
many of the inmates of the hospital, influenced by
the ministrations of good men and noble women, have
been seeking a "purer, a better'' way, and have be-
come so fully aware of the physical advantages arising
out of the law that not a few of them voluntarily sub-
jected themselves to the inspection, at their own ex-
pense, after the abrogation of the law. It is to be
regretted that the absence of statistics detracts so
much from the scientific value of these observations.
For about a year only this law remained on the
statute books of the State. The incidents — I quote
the language of a St. Louis law journal {Morning Ad-
vertiser, January 12, 1895) — attending its repeal were
dramatic. Throughout the State there was a moral
uprising against what was regarded as the licensing
of vice, and the lobbies of both branches of the legis-
lature were taken complete possession of by the clergy
of the various denominations, and earnest co-workers
of the other sex. A petition praying for the repeal of
the obnoxious law, signed by more than one hundred
thousand good people, was presented. The document
was cumbersome. A wheel-barrow, decorated with
white ribbons and accompanied by a group of inno-
cent young girls, attired in spotless white gowns, was
brought into service, on which the gigantic and em-
phatic protest against the licensing of vice was wheeled
up to the clerk's desk to be read. There were, of
course, counter-petitions from the cities, and con-
spicuous among the signers of these latter were mem-
bers of the medical profession. But the overwhelm-
ing sentiment was against the law, the members,
without exception, representing a country constituency
voting against it.
Thus ended the short-lived and solitary experiment,
and we may well ask why, during a period of almost
thirty years, not one of the many States which consti-
tute the Union has again approached this subject, and
why, to-day, the enactment of a social-evil law in
the United States is as remote as ever.
Assuming State intervention to be desirable, there
are difficulties opposing its introduction, and these
are public opinion, probable lack of constitutional
power, and also the difficulty of uniform regulations.
As to the law, it must be remembered that every
State of the L^nion that is known as the United States
of America is a separate and distinct sovereignty.
Each State has its respective constitution. The
United States, a federal government, has its constitu-
tion. Excepting so far as each State has surrendered
its sovereignty, each is as distinct the one from the
other as Greece from Italy. The federal constitution
embodies power which each State altogether has sur-
rendered. Back of the constitution of the United
States lie the sovereign people, who can change that
constitution. This, however, is exercised exception-
ally.
Every law, then, that is enacted by any or all of the
forty-five separate sovereignties may have to stand the
test of each State constitution, and ultimately that of
the 'Jnited States, and such would be the case when a
law is passed that in any way infringes upon individ-
ual liberty. The law of the United States, generally
speaking, is based upon the law of England. It
breathes forth that spirit of individual rights, personal
liberty and freedom, that reverence for the sanctity of
the private home and life within it, that has ever been
the pride of Englishmen and Americans. The constitu-
tion of the United States (in the Fourteenth Amend-
ment) provides that "no State shall deprive any per-
son of life, liberty, or property without due process of
law, nor deny to any person within its jurisdiction the
58
MEDICAL RECORD.
[January 13, 1900
equal protection of the law." That amendment limits
the powers of the individual States. Anj' law regu-
lating prostitution must be so formed as not to violate
that amendment. Most of the State constitutions con-
tain similar provisions, and all laws must be subject
to them, and under scrutiny of the highest State courts.
It may, therefore, very reasonably be a question
whether any effective laws could be passed that would
not violate either the State or federal constitutions or
all of them.
There is a further difficulty. The federal govern-
ment has only the powers enumerated in the federal
constitution. In that constitution there is no pro-
vision, I am advised, that would permit of a federal
regulation of prostitution. Accordingly there is no
power to compel an unwilling State to pass such regu-
lations, and it can be readily seen that, unless a vast
majority of the forty-tive States adopted the same, or
similar, regulations, no beneficial consequences could
ensue. This is no imaginary or purely academical
difficulty. In matters wherein public sentiment is in
accord, uniform laws throughout the States are want-
ing. I am advised that in this great commercial com-
munity the laws pertaining to commercial paper differ
in different States, leading to much embarrassment.
Such is likewise the case in regard to many other
laws, commercial and criminal. Here, then, is a prac-
tical difficulty, that of uniform legislation; and this
leads us to the next consideration — that of public
opinion. Public opinion is largely public sentiment.
Public opinion, of necessity, must be in accord
throughout the Union in order that the individual
State legislatures should enact uniform laws on this
subject. It is not necessary to analyze public opinion
in America. Let it suffice to say that in no country
of such magnitude does public opinion exert so much
direct influence on those who are placed in authority,
both to make and administ';r the laws. This condition
of affairs will assist us in enacting regulations, if pub-
lic opinion be in accord, but all the indications are
that it is in opposition to the matter under discussion.
First, there is the sentiment that prostitution should
not, upon moral grounds, receive recognition by the
State. That view is shared by very many people. It
is that sentiment that permits street-walking in Lon-
don. Here it is that more or less strong laws are en-
acted punishing adultery, fornication, street-walking,
and the various States have a variety of penal laws
against such crimes. Separation by a husband or wife
from the other is allowed by the courts because of dis-
ease communicated. Impotence is a ground for annul-
ment of the marriage. On the whole, however, the
sentiment exists that abhors State interference, on
moral grounds. That disease is communicated is said
to be fit punishment for sexual indulgence.
Another sentiment is based upon personal liberty.
Each citizen is conscious of his position as one of the
sovereign people, and those in power are his servants,
and there at his will. The administration of such
laws as would have to be enacted to prove effectual
would be a practical impossibility. The natural pri-
vacy that accompanies indulgence in sexual inter-
course is invaded. As illustrative of the above senti-
ments, as well as the further one that such regulations
debase the individual, is the short and calamitous life
of the laws enacted in 1870 in Missouri. Amid wild
enthusiasm, where young girls in pure white, bedecked
with flowers, paraded, symbolical of purity and chas-
tity, was the law repealed.
Public sentiment looks, however, to therapeutics as
the solution. The Americans are progressive and
ready to learn. Could it be demonstrated beyond a
doubt, by the experience of other countries, that the
result of such regulations is, as a matter of fact, highly
beneficial, and that mankind is not debased thereby.
public sentiment would doubtless change. That time,
however, has not yet come, and the United States will,
I feel, still stand by and watch the experiments made
abroad before adopting measures foreign to the spirit
of its people and its laws.
Copaiba in Diabetes. — Dr. Bettmann {Berliner kli-
nisihe Wochenschr., S. 479, 1899) has observed that the
administration to diabetic patients of copaiba, even
in small doses, causes an increase in the excretion of
sugar; the urine contains double, sometimes treble the
quantity normally excreted. Turpentine and essential
oils have a similar action.
Observations on the Relation of the Uterus to
the Thyroid Gland. — Dr. Charles R. Dickson
(Charlotte Medical Journal, October, i8ggl summa-
rizes as follows: In treating diseases of the thyroid
gland in women it is wise to inquire into the condi-
tion and habits of the uterus, and to devote some at-
tention to it as well as, if not instead of, the thyroid.
Very active measures should be omitted before
puberty, during menstruation and pregnancy, while the
climacteric is a time for especial suspicion.
The Influenza Heart. — After mentioning the vari-
ous forms in which influenza manifests itself. Dr.
Robert Saundby (Birmi/igliam Mediial Revie'LV, No-
vember, 1899) says that among the more frequent
sequelae we must reckon affections of the heart.
These are more frequent than is suggested by the
number in which the relationship can be stricily
proved, for the initial attack of influenza which has
set up the cardiac disturbance may pass unrecognized.
The cardiac troubles of influenza may be either func-
tional or organic. The functional troubles are altera-
tions in the cardiac rhythm, tachycardia less often than
bradycardia. These conditions have not been al-
ways obvious. The alteration of the pulse in many
cases has been variable, or has been absent, except at
certain times or under special conditions. The pa-
tients complain of weakness or faintness on exertion,
or may express themselves as only generally weak and
inapt for their ordinary business. On examination
the pulse may be too quick, feeble, and small; more
often it is slow, irregular, and intermittent, but is
subject to great variations. The irregularity may be
noticeable only, in the early morning, and disap-
pear later, or be brought on by exertion, fatigue,
digestion, the use of alcohol, tobacco, tea, etc. He
has noticed that these patients referred their symp-
toms rarely to their hearts, so that without examina-
tion such cases may be overlooked. In the other
group, where there is definite organic disease, the
heart is dilated, and there are all the indications of
insufficiency of the left ventricle, breathlessness,
oedema of the feet, etc. There is always danger of
the functional cases becoming organic — that is, of the
neuro-motor mechanical derangement resulting in
muscular degeneration. The mischief probably be-
gins in the cardiac ganglia or nerve, but when the in-
toxication is sufficiently intense and persistent the
myocardium sooner or later becomes implicated.
Dilatation is due to a subacute myocarditis. With
proper care compensatory hypertrophy takes place.
There is a marked tendency to recurrence of the car-
diac trouble whenever a renewal of grippe infection
occurs. The cardiac enlargement is, as a rule, easily
made out, and dulness may extend to beyond the an-
terior axillary line. There may be no mur.mur; occa-
sionally there is a systolic murmur at the apex trans-
mitted to the axilla associated with an accentuated
pulmonary second sound. The urine is free from
albumin. Gastric complications are very common.
January 13, 1900J
MEDICAL RECORD.
59
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 51 Fifth Avenue.
New York, January 13, 1900.
THE HOUSING OF THE POOR.
This is a difPculty which becomes more embarrass-
ing and increases in importance year by year. Indeed
it would be no exaggeration to say that it is one
•of the paramount questions of the hour. Legislators
and philanthropists are at their wits' end to devise a
satisfactory scheme to house the working-classes, and
to dispose of the surplus population. The rush of
people from rural districts in commercial countries to
the large towns shows no tendency to abate, and the
consequence is that in unwieldy, overgrown cities
like New York and London, the working and pauper
classes are for the most part compelled to live under
conditions which are not only in a high degree preju-
dicial to their own health, but also constitute a stand-
ing menace to the physical well-being of the entire
community. The point that it is to the interests of
the public as a whole for the poorer classes to be
housed in a sanitary manner, and that their environ-
ment generally should conform to the requirements of
modern hygiene, is one that does not seem as yet to
have been thoroughly grasped and its true significance
appreciated by municipalities. In order that a nation
should prosper it is necessary that its individual
members should be sound physically and mentally.
To gain this end, disease must be eradicated as far as
is possible, and to curtail the spread of disease the
most effective measures must be taken to insure to
everyone the means of living in healthy surroundings.
The obstacles in the way of successfully accomplish-
ing this object are undeniably hard to overcome, but
they are not insurmountable.
The problem of housing the poor in London has so
thrust itself to the front that thoughtful men have de-
cided that it must be promptly faced, and methods of
various kinds have been suggested as a solution. It
is true that in the British metropolis the municipal
authorities and county council have taken up the
matter vigorously, and have effected many improve-
ments Acres of unsavory rookeries have been cleared
away, and on the site fine, well-built sanitary dwell-
ings have been erected. Unfortunately this remedy is
but partial. The people ousted from the old houses
are not able to afford the rents demanded in the new
buildings, and are thus compelled to settle in some
other poverty-stricken and overcrowded district. A
suggestion has recently been advanced that houses for
workmen should be built outside the boundaries of
London, and which might be reached by trains run at
specially cheap rates. If such a plan could be suc-
cessfully carried out, undoubtedly a great part of the
working population could be housed more healthily
and at a less cost than in London itself. However,
at present red tape blocks the way to this scheme,
and until existing law's are repealed the poor must
stay within the limits of London. .
The situation of the working-classes of New York,
so far as house accommodation is concerned, is said
to be— by those who have had experience of these
matters— much worse than in London. It is com-
puted that the population in the tenement district of
the former city is twice as dense as in the most
crowded parts of the latter. At the time when there
was no restriction on immigration, the scum of the
nations came to New York, herding like cattle in the
poorer portions of the town. 'I'he efforts of the organ-
ized charities in the direction of improving the lot of
the poor have been attended with much success, but
little has been done toward the provision of clean and
healthy homes.
The report of the tenement-house committee of the
Charity Organization Society has just been published.
This committee was formed in 1898 with the object
of considering the necessity and advisability of tak-
ing action looking toward the improvement of the con-
dition of the tenement houses in the city. Two bills
to amend some objectionable points in the charter
were introduced into the State legislature, but were
not manipulated through that body. The committee
also framed a series of proposed ordinances, which,
while in no respect conflicting with any sections of
the present charter, would at the same time have great-
ly bettered the state of the tenement dwellings. The
Building Code Commission did not see their way to,
or were not desirous of, adopting any of these sugges-
tions, and thus so far the labors of the tenement
committee have been of no avail. However, although
discouraged, its members have no intention of giving
up the struggle, and as the sentiment of the intelligent
part of the community would seem to be with them,
there is reason to hope that in the end their philan-
thropic efforts will have a satisfactory issue. It is a
decided slur on the rich and influential inhabitants
of New York that the poor should be forced to live
under conditions so insanitary.
THE SANITARY ASPECT OF THE WAR IN
SOUTH AFRICA.
Despite the healthfulness of the South African climate
it cannot be reasonably anticipated, with so large a
body of men living under the conditions to which sol-
diers in the field are compelled to submit, that disease
will not claim its share of victims. The exigencies of
war do not permit an approach to perfection in the
sanitary arrangements of camps, but unless every effort
is made to place these upon as satisfactory a basis as
possible, disastrous results will inevitably follow.
6o
MEDICAL RECORD.
[January 13, 1900
The truth of this statement is so fully recognized that
it would be idle to multiply instances in proof. The
state of some of our camps during the Spanish war
is a sufficiently striking object-lesson. The surgeon-
general of the United States army, referring to this
feature, speaks as follows: "The sanitary condition
of the permanent camps before the war was excellent,
but tiio new camps formed on the outbreak of the war,
and filled with undisciplined volunteers, speedily be-
came hot-beds of disease, especially of typhoid fever,
from which they suffered severely in July and August."
The British troops in Africa are disciplined, and,
moreover, the greater portion of them have had experi-
ence of tropical climates, but with all these facts in
their favor unceasing vigilance will be needed on the
part of their medical officers to ward off and hold in
check the maladies common to South Africa at this
season of the year. Enteric fever is very prevalent,
particularly in the high lands, and February, March,
and April are the months in which it is most rampant.
Dysentery and diarrhoea are said to be epidemic in the
Transvaal before the rainy season. Parasitic diseases
due to eating uncooked vegetables and some forms of
uncooked meat are of frequent occurrence. In addi-
tion to these complaints indigenous to South Africa
an outbreak of smallpox is reported at the Cape, while
at Delagoa Bay and vicinity are many cases of bubonic
plague.
The duty of supervising the sanitary arrangements
of the camps will, it appears, devolve upon the army
surgeons. The London Lancet says : " No special
sanitary officer is appointed to the forces, nor is any
such appointment provided for in war establishments,
but the medical arrangements entail ceaseless vigilance
over his particular charge upon every medical officer,
who is thus constituted an ex-officio sanitary officer."
It is therefore clear that the already confessedly in-
sufficient British army medical corps will have a most
onerous task to undertake successfully the double duty
of attending to the sick and wounded and of insuring
the proper sanitation of the camps. Indeed, the ques-
tion as to whether its members will be equal to the strain
has been mooted in some of the British journals. The
London Practitioner makes the following suggestions:
" For the protection of the forces in South Africa
against the dangers that may arise from official igno-
rance or apathy the government would be well advised
if they appointed one or two consulting physicians to
the forces, who should hold the same relation to the
royal army medical corps as the consulting surgeons
who have been sent out. These sanitary commis-
sioners, in addition to their special knowledge, would
be in a disciplinary sense independent of the military
authorities, and could therefore offer advice not merely
' when it is wanted,' as Lord VVolseley graciously al-
lows, but when it is not wanted, and they could insist
at least on its receiving serious attention. The ser-
vices in such a capacity of a man of independent
position, combining medical knowledge with official
experience in sanitary administration, would be in-
valuable."
It is probable, and in fact now seems certain, that
the war in South Africa will drag on for many months,
during which time the British soldiers must live in
camps. In order to keep the camps in a healthy con-
dition strict overlooking by men experienced in sani-
tary matters will be necessary. It would seem that by
following the advice of the Practitioner a long step
toward attaining the desired object would be made.
INTRA-ABDOMINAL BILOCULAR HYDRO-
CELE'
BiLocuLAR or hour-glass hydrocele is not a common
affection, although Monod and Terrillon, in their ex-
cellent treatise on " Les Maladies du Testicule," treat
of it at considerable length. The affection has also
been studied by Dupuytren, who described it under
the name of " hydrocele en bissac," Chelius, Berger,
Malgaigne, and Duplay, and more recently by Kocher,
Trendelenburg, Humphry, and Bazy. The unique
characteristic of the tumor is that it consists of two
sacs, one abdominal, the other sciatal, which com-
municate more or less freely by means of a narrowed
part lying in the inguinal canal. It sometimes attains
colossal dimensions. In a case reported by Rochard,
the abdominal portion of the tumor extended upward
to the umbilicus, passing the median line, and losing
itself behind and below in the iliac fossa. On punc-
turing it, nearly three litres of fluid were withdrawn.
The tumor was still larger in one of Bazy's patients,
passing considerably above the umbilicus, and beyond
the median line.
In the Wiener klinische Wochenschrift, No. 46, 1899
Dr. Winiwarter reports a like case in a man, thirty-
one years of age, who gave the history of having had
a hydrocele the size of an egg in the right scrotum
since his youth. For two years the swelling had in-
creased in size, reaching the volume of about two fists,
and it also extended up into the abdomen. About a
year before, the hydrocele had been punctured, giving
exit to seven litres of clear, straw-colored fluid. Five
weeks later it was again punctured, yielding about the
same quantity of fluid. After eleven weeks a third
puncture was made. When the patient was received
into the hospital, he was much emaciated, anajmic,
pale, having an extremely rapid pulse, and a tempera-
ture a little above normal. The feet were somewhat
swollen. The urine was free from albumin; the lungs
and heart were sound. Within the abdomen was a
large swelling, clearly cystic in character, which ex-
tended from the right scrotum to the ribs. The cir-
cumference of the abdomen at the umbilicus measured
93 cm. The scrotal tumor could not be pressed toward
the abdomen, though a percussion wave could be trans
mitted from one sac to the other. After removal o
the sac, its length was found to be 40 cm., and its
greatest breadth 23 cm. A bilocular hydrocele is
generally spherical in shap6, though in Kocher's case
it was elongated like a thick sausage. Whatever
may be its shape or size, the intra-abdominal part is
always a pouch closed at the top, and absolutely inde-
pendent of the peritoneal cavity.
As to the exact relations between the hydrocele and
peritoneum, there is still much to be learned. Biloc-
January 13, 1900]
MEDICAL RECORD.
61
ular hydrocele may be bilateral (Kocher, Fano), but
it £;enerally occurs on one side only. The diagnosis
is as a rule easy. A differential point of great value
is that reduction is never absolute as in congenital
hydrocele. In children, the abdominal sac may be
so deeply placed that exploration by external palpa-
tion alone is impossible, and examination under nar-
■ cosis as recommended by Kocher, by means of
abdominal palpation and rectal touch, will alone clear
up the nature of the case.
Authors disagree concerning the pathogeny of this
affection, particularly as to the mode of formation of
tiie abdominal part. Some think it is developed by
the simple expansion of a common hydrocele through
an accumulation of fluid; others, that the upper
pouch exists from the first. The occurrence of biloc-
ular hydrocele depends on faulty development of the
coverings of the testicle. The prognosis depends
especially on the size of the tumor and its relations
to the peritoneum. The treatment is the same as that
of simple hydrocele, namely puncture, puncture fol-
lowed by the injection of iodine or other irritant, sim-
ple incision, or excision and removal. The latter is
to be recommended when simpler methods have-proved
unsuccessful. This was employed in Winiwarter's
case with complete success.
I^tcws of the 'S^eeli.
Suing for Professional Services. — Dr. Branth of
this city recently sued a wealthy client for $600 as a
well-earned fee, but received only $200, the defendant
repudiating all promises as to proper remuneration.
The old story. The ordinary juryman believes in
cheap medical services.
New Hospitals. — An additional orthodox Jewish
hospital having been projected in the southern section
of Philadelphia, to be known as the Beth Israel Hos-
pital, a dissenting faction has secured a charter for
another hospital, which is to be conducted as a non-
sectarian institution, and is to be known as the Mount
Sinai Hospital.
The Medical Inspection of Schools. — From among
more than three hundred physicians recommended by
the deans of medical colleges, the authorities of the
hospitals, sectional school boards, and citizens, the
Philadelphia board of education has been able to
assign physicians to about two hundred and ten
schools to make daily medical inspection of pupils
presentin^j symptoms of illness. The work of ex-
amination in the schools is expecte'd to begin on
January 8th. Each physician will be expected to
visit the school to which he is assigned between 9 :3o
and 10 each morning, and he will examine such chil-
dren as are brought to him by the principal. If any
pupil has, or is threatened with, any disease that is
infectious or contagious the child will be sent home,
with instructions to the family to consult a physician,
and it will not be permitted to return to school with-
out a proper certificate from a medical inspector of
the bureau of health that it is safe to do so. Should
the pupil require medical treatment for any other
complaint notice will be sent to the family with the
child on its return home. For the present the work
is to be done without remuneration, but it is hoped that
fair compensation will be paid for the service when
the time for making appropriations comes.
The Progress of the Christian Science Movement.
— Mrs. Mary Baker Eddy, the head of the Christian
Science cult, has, it is announced, given her son a
check for $10,000 and a house worth §15,000 as a
Christmas present.
The Schuylkill County (Pa.) Medical Society
elected the following officers on January 2d: Presi-
dent, Dr. W. C. J. Smith ; Vice-President, Dr. A. L.
Gillars; Treasitrer, Dr. D. Taggart; Secretary, Dr. G.
W. Farquhar; Censor, Dr. A. P. Carr.
The Study of Cancer at Harvard University
By the will of Mrs. Caroline Brewer Croft, who died
about two years ago, a sum amounting to nearly $100,-
000 has been placed in the hands of the corporation
of Harvard University to be used in the investigation
of the nature and therapy of cancer. Mrs. Croft was
a native of Boston, but had lived for many years in
England. ' Her early charitable efforts impressed
upon her the horror of malignant disease, and for
many years before her death she gave large sums an-
nually for the relief of the poor who suffered from
cancer.
College of Physicians of Philadelphia. — At a
stated meeting held January 3, 1900, Dr. F. Savary
Pearce read a paper entitled " The Gastro-Intestinal
Tract in Nervous Diseases," in which he dwelt upon
the necessity of eliminative treatment directed to the
digestive tract for the relief of varied nervous manifes-
tations, and reciting numerous illustrative cases. Dr.
Frances R. Packard read a paper entitled " A Brief
History of the Medical Societies which Existed in
this Country Prior to the Founding of the College
of Physicians of Philadelphia, in 1787." It was
shown that only three societies, the New Jersey State
Medical Society, the Massachusetts State Medical
Society, and the New Haven Medical Society, had
an earlier and continued existence than the College
of Physicians. Dr. Packard read also a paper entitled
" Some Old Certificates of Proficiency in Medicine."
Dr. John G. Clark delivered an address, with lantern
demonstrations, upon "The Vascularization of the
Ovary and its Bearing upon the Differentiation of Sex,
Origin, Development, and Degeneration of the Graafian
Follicle, Inauguration of Ovulation, Organization of
the Corpus Luteum, and the Final Cessation of Ovula-
tion (Menopause)." Dr. W. W. Keen was elected
president and Dr. Horatio C. Wood vice-president for
the ensuing year.
Jefferson Medical College.— At a meeting of the
Philadelphia Chapter of the Alumni Association of
Jefferson Medical College on January 2d, Dr. Law-
rence F. Flick discussed the prevention of tuber-
culosis. He said that to this end the people must be
educated as to the contagious nature of the disease;
62
MEDICAL RECORD.
[January 13, igoo
State hospitals for the treatment of cases in the in-
cipient stages must be erected, with registration of cases
and the application of the general principles of isola-
tion and disinfection. Dr. J. C. Wilson expressed hope
for an anti-tuberculous serum, and emphasized the
importance of improving the nutrition by means of
abundant alimentation, an open-air life, long hours of
sleep, and the discipline of a sanatorium.
The Altoona (Pa.) Academy of Medicine and
Surgery elected the following officers on January 2d:
President, Dr. S. L. McCarthy; Secretary, Dr. E. S.
Miller; Treasurer, Dr. J. U. Blose; Trustee, W. M.
Findley.
Munificent Bequests.— By the will of Captain
Jacob Jay Vandergrift, who died recently at Pittsburg,
Pa., the following bequests are made: The Homoe-
opathic Hospital of Pittsburg, $5,000; the Allegheny
General Hospital, $2,500; the West Penn Hospital,
$2,500; the Pittsburg Free Dispensary, $2,500; the
Home for Incurables, $1,000.
Plea for Pure Water. — Dr. Benjamin Lee, secre-
tary of the Pennsylvania State board of health, Dr. A.
C. Abbott, bacteriologist to the Philadelphia bureau
of health, and Dr. George Woodward, a member of
the common council of Philadelphia, appeared before
the town council of Norristown recently for the pur-
pose of encouraging the erection of a sewage-disposal
plant for the borough. Their efforts were, however,
met with the response that the city should first cleanse
the waters of the stream at its own doors before asking
the boroughs to take action.
Episcopal Hospital, Philadelphia. — At the annual
meeting of the board of managers on January 4th
attention was called to the large and increasing num-
ber of dispensary patients. The necessity for a new
dispensary was shown, and a recommendation was
made for the erection in the near future of the " As-
pinwall Ward" for poor, white, female orphan chil-
dren who have been ill and are convalescent. The
fund for this purpose was bequeathed to the hospital
a few years ago by Anna Ross Aspinwall, of Pittsburg,
and has a cash value of $200,000. During the past
year 2,737 patients were admitted to the hospital, and
34,100 i->ew patients w-ere treated in the dispensaries,
with 72,595 return visits.
Philadelphia County Medical Society. — W. a
stated meeting held December 27 th, Dr. M. A. Bunce
read a paper entitled, "Vasomotor Ataxia," and he
presented illustrative cases. The designation is ap-
plied generically to conditions attended with abnormal
vascular contraction or dilatation, in association with
local changes in color, from white to pink and red or
blue, and allied phenomena, in consequence of undue
susceptibility to various stimuli, extrinsic or intrinsic.
Dr. G. Betton Massey read a paper entitled "Some
Cases in Conservative Gynecology," in which he
made a plea for the employment of electricity in a
wider range of cases than are now treated by this
means. Dr. W. Joseph Hearn read a paper entitled
"Appendicitis; the Proper Time for Operation and
its Mortality,'' citing statistics showing a death rate
of from four to six per cent. Dr. S. Solis-Cohen pre-
sented a communication entitled " The Use of Pal-
ladium Chloride Internally in the Treatment of
Tuberculosis," detailing the results of an experience
extending over a period of three years. The prepara-
tion employed consisted of a solution of 5 gm. to the
ounce made with the aid of hydrochloric acid, and of
which from 5 to 10 drops were administered thrice
daily. Fever seemed to subside, the cough to dimin-
ish, and weight to increase. The drug is thought to
be in no wise a specific, but simply an additional aid
in the treatment of a disease whose most important
therapeutic factors are hygiene and nutrition.
Dr. Thomas Lauder Brunton, physician to St. Bar-
tholomew's Hospital, London, and formerly editor of
The Practitioner, has been knighted by the queen.
Typhoid Fever is raging in Kiao-Chau, Germany's
new Chinese possession, twenty-nine members of the
garrison having died of that disease during Novem-
ber. The governor, Herr Jaeschke, has suffered among
others.
Medical Matters in the Boer War. — The British
government has appointed from civil life four addi-
tional consulting surgeons for the army in South Af-
rica. These are Sir William Stokes and Mr. Kendal
Franks, of Dublin, and Messrs. W. Watson Cheyne
and G. L. Cheatle, of London. Mr. Kendal Franks
was for some time before the war resident in Johannes-
burg.— At a meeting held recently in London a com-
mittee of women was formed to equip an hospital base
for the yeomanry who have been called out to reinforce
the troops in Natal. The membership of the commit-
tee comprises most of the women of the British nobil-
ity.— Typhoid fever and dysentery are reported to be
spreading in Ladysmith and other beleaguered towns.
— The British troops are harassed greatly by the heat,
to which they are unaccustomed, and the wounded es-
pecially suffer from it. In a letter to the British Med-
ical Journal, Mr. Makins,oneof the civilian consulting
surgeons with the troops at Orange River, writes:
" During an eight days' stay some six hundred
wounded men have passed through the hands of the
royal army medical corps here. In one night alone
three hundred patients arrived from the fight at Mod-
der River. Yesterday the thermometer registered
115° F. in some of the tents. The fact that the jour-
ney from here to the base hospital at Wynberg takes
twenty-eight hours emphasizes the difficulties due to
the immense length of the line of communication."
He adds his testimony to that of the surgeons in our
recent war concerning the benignity of the Mauser and
the Lee-Metford bullets. A wounded Boer referred to
the latter as a "gentlemanly bullet," "and this re-
mark,'' he said, " is equally applicable to the Mauser.
The wounds made by them are small, clean, and little
disposed to suppurate."
The Chair of Psychology at Columbia.— Mr.
John D. Rockefeller has given Si 00,000 to endow the
chair of psychology at Columbia University. In their
January 13, 1900]
MEDICAL RECORD.
63
resolution of thanks to the donor, the trustees of tlie
university state that Dr. James McKean Cattail, who
holds the chair at Columbia, was the first professor of
this science to be appointed in any university, Ameri-
can or foreign. There are now five special instruc-
tors in this department at Columbia, and the new dona-
tion will make it possible for them to carry on their
work to much greater advantage.
Measles is epidemic in Newburg, N. Y., among all
classes of the community. On January 5 th there were
over three hundred cases of the disease in the city,
and from fifteen to twenty new cases are reported
daily. Adults as well as children have been attacked.
The New York Academy of Medicine has paid
the last item of its indebtedness, amounting to $2,000,
and is now wholly out of debt for the first time since
the completion of its building. The latter cost nearly
a quarter of a million dollars.
American Delegates to the International Con-
gress.— The President has designated the following
officials to represent the United States government at
the International Medical Congress in Paris August
2d, and at the Congress of Hygiene and Demography,
which assembles at the same place August loth: For
the army, Surgeon-General Sternberg and Surgeon La-
garde; for the navy, Surgeon-General Van Reypen ;
for the Marine-Hospital ser\'ice, Surgeon-General \Vy-
man and Passed Assistant Surgeon Rosenau.
Professor Schenk Removed. — Dr. S. L. Schenk,
professor of embryology and histology, and director of
the Embryological Institute at the University of Vi-
enna, has been retired on a pension. 1 lis action is
in answer to a petition from the medical faculty of the
university alleging the publication in the lay press of
scientific theories constituting a form of advertise-
ment. Dr. Schenk, it will be remembered, is the man
who, not long ago, published a saccharine theory of
se.x production and made a little noise in the news-
paper world. He had been director of the Embryo-
logical Institute for twenty-si.^ years.
A Poison Bottle. — Senator Wilcox, of Auburn, pur-
poses introducing into the New York legislature a
bill providing that any bottle containing poison shall
be of such peculiar shape that it can be readily distin-
guished in the dark by the touch. A similar bill was
introduced at each of the two preceding terms of the
legislature, but was defeated on the ground of dis-
crimination in favor of some particular manufacturer
who might secure a patent upon his design. To avoid
this a provision will be incorporated in the bill that
the style of bottle sliall be determined by a committee
of the State Medical Society, acting in conjunction
with the State board of health.
Shorter Hours for Drug Clerks Dr. Nelson H.
Henry, of tliis city, w'ill introduce in the State Assem-
bly a bill providing that drug clerks in cities of the
first class shall not have more than seventy hours of
work a week. It permits six hours' overtime during
any week for the purpose of making a shorter succeed-
ing week, but the aggregate number of working-hours
in any two weeks shall not exceed one hundred and
forty. No proprietor of any drug store shall require
or permit any clerk to sleep in any room or apartment
in or connected with the store, which does not comply
with the sanitary regulations of the local board of
health. The bill has been indorsed by many of the
pharmaceutical associations in New York City. The
Druggists' League for Shorter Hours has prepared
another bill for introduction this year. It differs from
Dr. Henry's in that it provides for one hundred and
thirty-two hours of labor in two weeks instead of one
hundred and forty, and empowers the city board of
health to frame regulations and secure the enforce-
ment of the law.
A Busy New Year's Day. — The ambulance de-
partment of Bellevue Hospital broke the record on
January ist of this year. All told fifty-six calls were
answered. The majority of the p^ltients were treated
in the alcoholic ward.
The New York Neurological Society. — At the an-
nual meeting of this society, held January,2d, the fol-
lowing officers were elected: President, Frederick
Peterson; First ^/a'-/'/-M/V/c«/, Joseph Collins; Second
Vice-President, L. Stieglitz ; Pecording Secretary, Pearce
Bailey; Corresponding Secretary, Lewis A. Conner;
Treasurer, Graeme M. Hammond; Councillors, C. L.
Dana, M. A. Starr, B. Sachs, E. D. Fisher, and J.
Arthur Booth.
The Rhyme of the Bramble Bush in Real Life.
■ — A street car struck Giuseppe Marate, a sailor, in
Philadelphia, Christmas Day, knocked him down, and
dislocated his shoulder. He was put into a wagon
and hurried off toward the Pennsylvania Hospital.
The wagon jumped over a rut in the pavement and
the jar reset the shoulder. When he got to the hospi-
tal the surgeons found the shoulder all right, bandaged
it, and sent him back to his vessel.
An Electric Ambulance — St. Vincent's Hospital
has now a horseless ambulance. It is operated by an
electric motor supplied with power from a storage bat-
tery. In many respects it is similar to the present
city ambulances in use, but it is equipped with slid-
ing glass doors for use in stormy weather. The oper-
ator will sit on a seat at the front similar to the seats
of the old ambulances, and will be able to get up a
speed of ten miles an hour. The vehicle is a gift of
Mr. Edward Kelly.
The Plague is extending in Brazil, and has now
been declared epidemic in the city of Sao Paulo. — In
Honolulu, up to the first of the year, there had been
seventeen cases officially recognized as plague. There
had been a number of deaths from what was probably
plague, but had not been declared to be such. The
board of health has adopted measures which can be
called energetic at least. The infected district has
been surrounded by a military cordon, and several
buildings in which the plague cases occurred have
been burned. The invasion of the Hawaiian Islands
has caused alarm on the Pacific coast, and special pre-
64
MEDICAL RECORD.
[January 13, igoo
cautions will be taken to prevent the introduction of
the disease into any of the ports of this country and
British Columbia. A quarantine has been declared
against vessels from Honolulu, and all vessels coming
from any infected or suspected place will be required
hereafter to use funnel guards over their hawsers to
prevent the rats from going ashore. — The plague has
broken out among the Chinese laborers on the Man-
churia railroad, and it has been decided, at the in-
stance of the Russian minister of finance, to dispatch
a sanitary corps of doctors and Sisters of Mercy from
St. Petersburg to Manchuria to combat the disease. —
On January 8th it was reported that there had been
six cases of plague with four deaths at Manila. All
the cases thus far have been among the native's. The
disease was probably imported from Hong Kong.
The medical officers at all times have been on the
watch to prevent this, but owing to the short distance
from Hong Kong to Manila, and the large amount of
traffic carried on in a small way by native junks and
dhows, the ultimate introduction of the disease into
Manila was inevitable.
Navy Department, Bureau of Medicine and Surgery,
Washington, D. C. — Changes in the medical corps of
the United States navy for the week ending January
6, 1900. December 30th. — -Passed Assistant Surgeon
A. W. Dunbar ordered to duty on the AloHongahdd,
immediately. January 2d. — Passed Assistant Surgeon
R. K. Smith detached from the naval hospital. Mare
Island, Cal., on reporting of relief, and ordered to duty
on the Pe7isacola ; Assistant Surgeon J. H. Payne de-
tached from the Indiana and ordered to duty at the
naval hospital. Mare Island, Cal. January 3d. —
Medical Director A. F. Price promoted to medical
director from April g, 1899; Surgeon G. M. Pickrell
promoted to surgeon from September ig, i8gg; As-
sistant Surgeon R. Spear ordered to duty in connec-
tion with the naval recruiting rendezvous, Phila-
delphia, Pa., January gth. January 4th. — Pharmacist
J. N. Hurd ordered to duty at the Key West naval
station, January nth.
A New Hospital in Brooklyn.— The new St. John's
Long Island City Hospital was blessed by Bishop
McDonnell last Sunday. The building is of brick, is
five stories high, and comprises a main structure and
a wing with an extension in the rear containing the
kitchens and laundry. In the main building on the
first floor are the bishop's room and the children's
room, while 'in the wing are the rooms of the house
staff, and a suite of rooms for visiting clergymen.
Private rooms for patients are on the second floor,
while the women's ward occupies the wing. The third
floor is taken up by the medical ward and the fourth
floor by the surgical ward and nurses' rooms, while the
operating-room is on the fifth floor. The patients will
be moved from the old building the latter part of the
month.
An Invalid Will. — The surrogate has refused pro-
bate of a will executed recently by an old woman one
hour before her death. The will was signed by a
mark, and it is asserted that the woman was kept
alive long enough to sign it only by injections of
strychnine and brandy. By the terms of the will
$1,000 was left to the nurse, and the remainder of the
estate, about $19,000, to the attending physician.
The Chief of the Sanitary Corps in the Boer
Army is a German, Dr. M. Reinhard, from Bavaria.
An Australian Hospital Corps for South Africa.
— The government of New South Wales has decided
to send a field hospital corps and a battery of artillery
to South Africa in addition to the mounted contingent.
A Case of Iodoform Poisoning in an Infant Two
Weeks Old. — We have received a report of a case
with the above title, the author of which omitted to
send his name. If he will declare himself we shall
be pleased to publish the case.
Obituary Notes.^DR. William Alexander Ham-
mond died very suddenly at his residence in Washing-
ton on January 5th. He was born at Annapolis, Md.,
August 28, 1828, and was graduated from the Univer-
sity Medical School in this city in 1848. He entered
the medical service of the United States army in 1849,
but resigned in i860 to accept the professorship of
anatomy and physiology in the University of Mary-
land. Upon the breaking out of the civil war, how-
ever, he re-entered the army, and in April, 1862, was
commissioned surgeon-general. He was later tried
by court martial for irregularities in the award of con-
tracts, and was dismissed from the army in 1864.
While surgeon-general he established the Army Medi-
cal Museum, and suggested the plan of the " Medical
and Surgical History of the Rebellion." After dis-
missal from the army he began practice in this city.
He was professor of mental diseases in the Bellevue
Hospital Medical College and later in the University
Medical School. He was one of the founders of the
New York Post-Graduate Medical School. In Au-
gust, 1879, he \Vas restored to the rank of surgeon-
general U. S. A., retired, but without pay. Dr. Ham-
mond was a man of undoubted ability, but his meth-
ods were not always in conformity with the unwritten
code of professional ethics.
Dr. Joseph E. Arrowsmith died at his home in Key-
port, N. J., on January 3d, at the age of seventy-seven
years. He was a graduate of the University Medical
School in this city in the class of 1844, and had prac-
tised in Keyport for over half a century. He was a
member of the New Jersey State Medical Society and
of the Monmouth County Medical Society, and was a
consulting physician to the Monmouth Memorial Hos-
pital in Long Branch.
Dr. Robert H. Hine died of nephritis at Phila-
delphia, on December 30th, at the age of twenty-seven
years. He was graduated from the dental department
of the University of Pennsylvania in 1892.
Dr. Josiah Reeves died at Medford, N. J., on Decem-
ber 2Sth, at the age of fifty-eight years.
Dr. William Cromwell McFetridge died at Phil-
adelphia on January 3d, of pulmonary tuberculosis,
at the age of tliirty-five years. He was graduated
from the medical department of the University of
Pennsylvania in 1886.
January 13, 1900]
MEDICAL RECORD.
65
^f00ress of l^cxlical Sicicnce.
Ne7ci York Altdical Journal, Ja>iua>\ 6, igoo.
Injuries of the Kidney and Traumatic (Parenchy-
matous) Nephritis. — T. J. Yarrow briefly states the
causes, symptoms, and results of contusion and lacera-
tion of the kidney, and gives the history of a personal
case, that of a boy aged seven years, who was run over
by a coal cart, the wheel passing over the right leg
and region of the right kidney. Immediate catheteri-
zation gave two ounces of normal urine, but two liours
later he voided twelve ounces of bloody urine. His
temperature was at first subnormal, but he soon de-
veloped a febrile movement, never over 100.6" F.
In the course of six weeks he had entirely recovered.
A very complete series of urinary examinations was
made and is recorded in full. In addition to the
usual findings, crystals of ha;matoidin were observed
on several occasions. Yarrow believe^ that cases of
nephritis due to trauma are far more common than is
generally supposed.
The Limitations and Value of Fluoroscopic Ex-
aminations C. L. Leonard states that this method
is dependent upon the personal equation of the ob-
server, and differs from the skiagraphic method of
employing the Roentgen rays, in that the picture on
the screen transfers the image through the eyes and,
while forming a mental picture, produces no me-
chanical record. Hence we have no fixed data in
comparing impressions made at one time with those
/.lade at another. He believes that the value of the
.r-ray lies not in its power to penetrate everything,
but in distinguishing between the less dense tissues,
and thus enabling us to study organs and viscera that
are hidden from ordinary vision. The fiuoroscope is
incapaljle of detecting these shades of difference, and
does not mechanically register what it shows.
Hemorrhoids : The General Practitioner and the
Ubiquitous Charlatan. — J. W. J. Doyle calls atten-
tion to the fact that rectal diseases are frequently pre-
scribed for by the physician without the making of
any systematic examination rf the patient. Eut little
value is to be attached to the patient's own statement
of his symptoms. These may all be referred to the
rectum, but examination may show affections of the
uterus and bladder, stricture of the urethra, prostatic
troubles, and various abdominal growths. Rectal ex-
aminations are not extraordinarily difficult and do not
require any complicated apparatus. The vast major-
ity of diseases within the rectum can be detected by
the educated finger, the speculum being but seldom
required.
On a Grave Possible Error in Skiagraphy —
Carl Beck shows by several illustrations the necessity
of making skiagraphs in cases of suspected fracture,
not only in an antero-posterior but also in the lateral
direction. The picture of either one alone may lead
to serious errors in diagnosis.
Monstrum per Defectum A. Moore figures and
Jescribes a monstrosity recently seen by him. It was
delivered as the result of a miscarriage, and was a case
of acrania with pseudo-encephalocele.
Report of a Few Cases of Chronic Empyema of
the Antrum of Highmore, by A. W. De Roaldes.
See Medical Record, vol. Iv., p. 842.
The Sudan III. Stain for the Tubercle Bacillus.
— Bv D. M. Cowie.
The Mcdiml AVrcj, Januaiy 6, igoo.
Latent Infection and Subinfection, and the Eti-
ology of Haemachromatosis and Pernicious Anaemia.
— J. George Adami concludes from his own experi-
ments and those of others that, normally, leucocytes
pass through themucosee on to the free surface of, more
especially, the alimentary tract. These leucocytes
pass back between the epithelial cells bearing food-
stuffs, solid particles, and bacteria. This action of
the leucocytes is increased during digestion ; after
their return they pass either into the lymphatics or
the portal venules. It can be demonstrated that even
in the healthy liver and kidney in a large number of
cases, at least in the rabbit, a certain number of liv-
ing microbes are present at any one moment. It is
probable that in ordinary health a certain number of
bacteria pass either through the thoracic duct or
through the liver into the systemic blood. Apart from
this latent infection Adami believes in the intermedi-
ate condition — "subinfection," a condition of chronic
inflammatory disturbance. He also thinks hx-machro-
matosis and pernicious anaemia to be of bacterial
origin.
The Principles of the Treatment of Fractures by
Systematic Movements and Massage Without Ap-
paratus for Immobilization.— Lucas-Championniere
enumerates the advantages of his method of treating
fractures. Moderate movement favors the repair of
fragments of bone. Where movement is permitted the
callus will be greater in quantity, will be more solid,
and will be more rapidly thrown out. Moderate move-
ment preserves the vitality of the limb as well as the
suppleness of the articulations, muscles, and tendons.
It prevents muscular atrophy. To this passive move-
ment should be added massage, which should never
cause pain. Threatened deformity is the only contra-
indication to the application of this treatment to all
fractures.
Some of the Causes of Failure to Relieve Asthe-
nopia and Allied Symptoms. — F. W. JMarlow divides
these cases into two main classes: (i) curable; (2)
incurable. The curable cases fall into three groups:
{a) In which the failure is the fault of the patient —
often from carelessness in wearing the prescribed
glasses. (/') Fault of the oculist, from failure to cor-
rect astigmatism or latent hypermetropia with suffi-
cient accuracy; or in over-correcting myopia, or from
neglecting to consider the influence of latent strabis-
mus. ((■) Fault of the case, due to extreme latency of
errors of refraction and equilibrium. Incurable cases
are of two classes: {a) Congenital asthenopes. {b)
Cases with symptoms due to organic disease of eye or
brain or to some general disease.
A Series of Cases of Pistol-Shot Wounds of the
Head. — Charles Phelps reviews nine cases of this na-
ture, and says that at present there is no doubt that all
cranial pistol-shot wounds should be carefully ex-
plored, and as far as possible both the bullet and
fragments removed.
A Case of Polydactylism. — A. L. Benedict reports
this case, giving illustrations of the deformed hand
and foot. The patient is a Jew. Each extra digit has
a distinct articulation with the fifth metatarsal or
metacarpal bone, respectively, the tendons being ap-
parently the same as for the fifth digits.
Aseptic Catheterism.— Carl Beck states that the
precautions to be observed in catheterism are: sterili-
zation of instruments, the hands of the surgeon, and
^he field of operation.
66
MEDICAL RECORD.
[January 13, 1900
Journal of the American Medical Ass'n, Jan. 6, igoo.
Ophthalmia Neonatorum Dudley S. Reynolds
says that ophthalmia neonatorum means infectious
conjunctivitis, always the result of contagion, very
rarely, if ever, occurring in the process of delivery, the
infecting agent being introduced by unskilled hand-
ling of the eyes by the nurse, or in an attempt to
practise the Crede method or some similar mode of
prevention. The clinical forms of the disease may be
divided into mucopurulent and gonorrhoeal. The only
efficient mode of prevention is that which avoids infec-
tion, and the methods of Crede and others cannot be
too strongly condemned. In the treatment the thing
to be constantly borne in mind is the necessity for fre-
quent and thorough washing away of all inflammatory
matters from the surface of the affected membrane.
" He-who cleanses well cures well," must be the phy-
sician's motto.
Appendicitis from a Medical Standpoint. — I. N.
Love argues strongly against the administration of
sedatives in cases of severe abdominal pain until an
approximate diagnosis has been reached, which cannot
be done without free lavage and evacuation. The
diagnosis once reached, appendicitis is to be regarded
as a surgical case calling for — and this is the author's
main contention — the interference of the trained ab-
dominal surgeon. He claims for ideal surgery a mor-
tality of one or two per cent. Failing the special
abdominal surgeon, he would advocate medical or ex-
pectant treatment rather than place these cases in the
hands of average general surgeons or practitioners.
Observations on Asch Operation for Deviation of
Cartilaginous Septum. — ^Max Thorner describes the
instruments devised by Asch for correction of deflec-
tions of the cartilaginous septum, and explains their
use in full detail. There have been a large number
of cases subjected to this operation since it was first
performed in 1882, and with results almost uniformly
good. The writer wishes to emphasize the fact that
in his personal cases the operation has proved signally
successful for the relief of scoliosis of the nose, which
is often more distressing to the patient than the ste-
nosis.
The Tuberculin Test, and the Need of a More
Complete Diagnosis of Tuberculosis. — Charles Den-
ison urges tlie need of earlier and better diagnosis of
tuberculosis, and claims that among the most accurate
means to this end is the tuberculin test. He says the
experience of veterinarians in every State of the Union
and of divers physicians all over the country was
amply sufficient to convince an over-cautious profes-
sion of the comparative harmlessness of this test. He
thinks that boards of health, dispensaries, and hospi-
tals ought specially to be supplied with this means of
diagnosis.
A Case of Chronic Inversion of the Uterus ;
Spontaneous Reduction After Three Years. — A. F.
Jonas reports a case in which, after renewed and pro-
longed but futile efforts at reduction, the patient was
dismissed. Subsequently spontaneous reduction and
complete regeneration of the uterine mucous mem-
brane took place, the woman passing through a nor-
mal confinement.
Continental Views of Alcohol in Therapeutics
T. D. Crothers says the therapeutic use of alcohol in
Europe is not so universal as is generally supposed.
He concludes that the use of alcohol as a therapeutic
drug must be modified, and that in the near future the
agent will be put aside as worthless and dangerous.
Appendicitis with Gangrene and Rupture of Ap-
pendix and Caecum. — Harry Greenberg reports a case
of this description in which operation resulted in re-
covery.
Modern Therapeutics Warren B. Hill discusses
modern therapeutic methods, especially the use of anti-
toxic serums and glandular extracts.
From Saddlebags to Pocketbooks. — By B. T.
Whitmore. See Medical Record, vol. Iv., p. 892.
Laminectomy. — By John C. Munro. See Medical
Record, vol. Iv., p. 835.
BostoJi Medical a?td Surgical Journal, January 4, igoo.
Epistaxis. — Frederic C. Cobb says that the local
causes of epistaxis are apt to be ulcerations of the
blood-vessels from scabs and crusts on the septum due
to irritation by deflected septum, ne\v growths, and
operations for sarcomata. General causes are plethora
and ansemia, •hemorrhagic diathesis, acute fevers,
vicarious menstruation, kidney disease, syphilis,
phthisis, and alcohol. The bleeding point on the sep-
tum may be cauterized with chromic acid or the gal-
vano-cautery, after cocainization. Suprarenal extract
may.be tried. Plugging should be done with strips of
gauze along the floor of the nose, the Eustachian
prominence not to be occluded.
Nitrate of Silver in Hyper chlorhydria. — M. P.
Smithwick says that, to do the best for patients suffer-
ing from this disorder, one must treat them as neuras-
thenics, and assist them to live without unnecessary
expenditure of nervous energy. Proteid diet has been
found suitable in severe cases. Medicinal treatment
is discouraging as regards cure. The administration
of silver nitrate, one-fourth grain in a half ounce of
distilled water twenty minutes before breakfast, has
been followed by good results, markedly diminishing
gastric sensitiveness. The necessary use of the stom-
ach tube is a disadvantage, and the possibility of
argyria must be kept in mind.
Three Unusual Cases of Angioneurotic (Edema
in Infancy. — John Lovett Morse, stating that the
usual seats for this somewhat unusual affection are
the lips and cheeks or the external genitals, repor's
three cases in which the location of the swelling was
the arms and hands. In the first case there was no
known exposure or injury. In the second case an
over-cold bath is supposed to have caused the trouble
in one attack, and various exposures to cold the sub-
sequent attacks, while in the third case no cause was
found, but the trouble appeared most markedly in cold
weather.
What Position Shall Universities Take with
Regard to Investigations? — Thomas Dwight thinks
that it is not the duty of universities either to force or
urge original investigation upon students, which, how-
ever, should be on hand for the very zealous. Prizes
should not be too common, but there cannot be too
many scholarships for deserving men. In addition a
sum of money should be placed in the hands of the
professor at the head of each scientific department, to
be spent for the good of that department, including
publication.
Appendicitis in a Hernial Sac — Benjamin Tenney
reports a case in a woman aged seventy-nine years who
was successfully operated upon, the patient making a
good recovery.
Quantitative Analysis of the Gastric Contents
Henry F. Hewes gives an improved method for this
analysis, for use in clinical work.
January 13, 1900]
MEDICAL RECORD.
67
Philadelphia Medical Jo7irnal, January 6, jgoo.
The X-Ray Diagnosis of Nephrolithiasis Charles
Lester Leonard has devised a method by which he
claims he can make the absolute negative as well as
the positive diagnosis in all cases of suspected renal
calculus. This he does by using rays that will differ-
entiate between the shadows of tissues less dense than
the least dense calculus.
White Gangrene — George G. Hopkins discusses,
under this title, .v-ray injuries which result from the
destruction of the nerve supply of the affected tissue.
He says they can be avoided by using proper appara-
tus, making a not too long exposure, and having not
too small a distance between the tube and the object
skiagraphed.
Practical Points in the Use of the X-Ray
Louis A. Weigel insists upon the necessity for accu-
racy in .v-ray work. He says there is often a striking
difference between the image as seen with the fluoro-
scope and that on an -r-ray negative, and the former is
of limited utility as an aid to diagnosis.
I. A Bullet in the Popliteal Sphere. II. A Case
of Dilated (Esophagus — W. W. Keen reports two
cases showing the value of the cv-rays in diagnosis.
In the first case, however, the bullet seemed to be pos-
terior to the head of the tibia, yet was, in fact, em-
bedded in the bone.
The Practical Use of the Radiograph and Fluoro-
scope in Diseases of the Lungs T. Mellor Tyson
and William S. Newcomet are inclined to believe that
errors in mistaking normal processes for pathological
ones, in .r-ray diagnosis, are due to hasty observation
or want of experience.
The X-Rays in the Study of the Heart Reflex.
— Albert Abrams says the heart reflex (contraction of
the myocardium induced by irritation of the skin in
the precordial region) is best studied with the fluores-
cent screen approximating the anterior chest-wall.
The Technique of X-Ray Work.— Arthur VV. Good-
speed thinks that some of the now antiquated features
of .r-ray work are excellent, and attributes the special
merit of much of his work to the constant adherence
to one or two of these features.
Foreign Body, Chisel, Embedded in the Naso-
pharynx and Posterior Pharyngeal Wall.— Gary B.
Gamble, Jr., and L. M. Tiffany report this case, in
wiiich the chisel was located by the -v-rays, and was
successfully removed.
Two Cases of Simultaneous Fracture of the Pa-
tellas, Treated by Wiring the Fragments.— J. S.
Wright advises delay in wiring a fractured patella, his
plan being to wait two weeks and sometimes four be-
fore operation.
The X-Rays as a Diagnostic Agent in Pulmo-
nary Diseases.— J. Edward Stubbert holds that the
fluoroscope is an accurate agent for corroborating and
extending diagnosis made by ordinary methods.
X-Ray Examinations in Diseases of the Chest.
— Francis H. Williams reports on the work of this
kind he has done at the Boston City Hospital and in
private practice.
An X-Ray Demonstration of Some of the Effects
of Shoes and Stockings upon the Human Foot H.
Augustus Wilson shows a number of .v-ray pictures of
deformed feet.
The Skiameter.— A. W. Crane describes an instru-
ment by which he seeks to measure and record the
density, size, shape, and movements of the fluorcscopic
shadows.
Treatment of Lupus by X-Rays Philip Mills
Jones reports two cases of lupus successfully treated
by .r-ray exposures.
The X-Ray in Military Surgery.— N. Senn says
the .v-ray is an indispensable diagnostic resource to
the military surgeon.
The Use of the X-Ray in Orthopaedic Surgery
Robert W. Lovett presents a number of .r-ray pictures
of arthritic disease.
The Lancet, December jo, i8gg.
Measures taken at Tor and Suez against Ships
Coming from the Red Sea and the Far East.— M.
A. Ruffer describes the organization of the sanitary
department of Egypt, and speaks particularly of the
measures taken to prevent the transmission of cholera
and the plague. The measures differ as the ship may
carry pilgrims or ordinary travellers. In former years
the danger was minimized by the long period of travel
required by the camel caravans, but now that rail and
steamboat are used by the pilgrims, the danger is
greatly increased, as the journey is so quickly made.
The means of transport for these devotees is totally
inadequate, and there is frightful overcrowding with
all its filth and want of sanitary arrangements. De-
tails of quarantine routine are given, but the people
reach' the quarantine stations in such enormous num-
bers that it is difficult if not impossible to carry out
all the official regulations. In addition to the most
thorough cleanliness possible, each pilgrim passes
under the direct observation of a physician who takes
his pulse, examines all the superficial glands, and care-
fully inspects the tongue. The incubation period of
plague does not exceed five days. In a really bad
case the patient is so sick that it is not likely to be
overlooked. With cholera, the case is somewhat dif-
ferent, as the vibrio cholerre frequently persists fifty
days or more in the dejections of those who have had
cholera. Pilgrim's diarrhcea, so-called, includes every
form of intestinal derangement from typhoid to chol-
era. Hence it is extremely difficult to detect true
cholera cases, as it is quite impossible to make bac-
teriological examinations in every case. Fear of de-
lay at quarantine leads to the concealment of many
cases. Hence Ruffer expresses the belief that all
measures for ships going through the canal should be
confined to landing of the sick and the disinfection of
the sick person's quarters and linen. It is better to
do a little and do it well, than to attempt a great deal
and do most of it imperfectly.
The Treatment of Surgical Tuberculous Affec-
tions— W. Watson Cheyne devotes the third Harveian
lecture to the consideration of genito-urinary tubercu-
losis, discussing in turn castration, epididymectcmy,
and operations on the prostate, bladder, and kidney.
Various' operative details are given, the author prefer-
ring epididymectomy, the method of Bardenheuer, who
was the first to describe the operation. This operation
is often to be preferred to castration. One cannot be
sure that the removal of one testis will arrest the dis-
ease. The loss of both testes exercises a very delete-
rious effect on the patient. Apart from their genera-
tive function, they exert by means of their internal
secretion a very great influence on the well-being of
the patient. Moreover, there is reason to believe that
after removal of both testes patients succumb more
rapidly to the attacks of the bacillus. These objec-
68
MEDICAL RECORD.
[January 13, 1900
tions to castration are to a great extent met by the
operation of epididymectomy.
Some Notes on Sero-Therapy. — H. W. Mills
records the following clinical experiences: (i) Tet-
anus in a boy aged eighteen years following lacerated
wound of the foot. There were symptoms of tetanus
on the sixth duy, with injection of anti-tetanic serum,
followed by a fatal result in twenty-four hours; at that
time (1897) intra-cerebral injections were not in vogue
and the serum was injected under the skin of the ab-
domen. (2) Puerperal fever treated with anti-strepto-
coccic serum, 140 c.c. being given within a period of
five days. It seemed to control the septic features of
the case, but the patient died from syncope coming
on after incautious over-exertion. (3) Antitoxin in
twenty-seven consecutive cases of diphtheria, all of
which ended in recovery. Six patients showed post-
diphtheritic paralyses, while five had rashes from the
seventh to the thirteenth day. A most emphatic in-
dorsement is given to the practical utility of immuniz-
ing injections.
Extensive Mediastinal Emphysema in a Fatal
Case of Laryngeal Diphtheria. — \V. Ewart and H.
B. Roderick report the case of a girl aged five years,
illustrating a complication to which diphtheria of the
larynx and trachea is liable in spite of tracheotomy
and of antitoxin, and the fatality of which is probably
attributable to the cardiac and pulmonary embarrass-
ment set up by the increasing distention of the areolar
tissue of the anterior and posterior mediastina and of
the root of the lung.
Anatomical and Age Distribution of the Tineae
of Southern Assam. — S. A. Pow-ell, who has practised
eleven years in Assam, says that he has never seen a
single case of ringworm of the scalp, but that nearly
every one has at some time or other tinea of the body.
Tinea of the nails is very common in that country.
The article is a study of 1,407 cases of different varie-
ties of the disease.
Our Position and Outlook. — An inaugural address
by J. A. Lindsay at the opening of Queen's College,
Belfast.
British Alcdical Joiinia!, Decemhcr ^O, l8gg.
The Essential Toxic Symptoms of Diphtheria
John Eiernacki draws his deductions from notes of
fatal cases in which the toxic symptoms are extreme,
as they obviously afford the best material for observa-
tion, taking care to exclude those cases in which the
directly toxic element is masked by secondarily in-
duced phenomena. He says that for a time the only
symptoms are those ascribable to sore throat and fever,
the first specific signs being undue pallor, moderate
compressibility of the pulse, and lassitude. In a few
days the pallor becomes more marked, the pulse more
coijipressible, and the pyrexia less. Later the pulse
is irregular, the urine is diminished in quantity, and
the extremities are cold. Toward the end the surface
of the body is blanched and cold, the temperature sub-
normal, and the radial pulse disappears. Other symp-
toms are jactitation and dimness of vision. These
symptoms are accompanied by a fall in blood pressure,
and are probably caused by it.
A Case of Malignant Pustule : Necropsy, with
Bacteriological Investigations George H. Temple
reports the death from malignant pustule of a seven-
teen-year-old girl. At the autopsy microscopical ex-
amination failed to re\eal bacilli in the pustule or
any of the organs. Potato cultures, however, were
made from a clot found in the pulmonary artery, and
resulted in a sufficient growth to enable a diagnosis of
anthrax to be made microscopically. Inquiry in the
village w'here the patient had visited revealed that five
animals had died under somewhat suspicious circum-
stances two days before the girl's visit. Three points
are noted : the rarity of cases of malignant pustule in
women, the possibility of such cases being overlooked,
and the great difficulty of detecting anthrax among
stock before an epidemic occurs.
Poisoning by the Application of Glycerin of
Belladonna H. P. Joseph reports a case of a woman
who after being delivered of a still-born child com-
plained of pain in the breasts. An application of gly-
cerin of belladonna was ordered, resulting in all the
symptoms of belladonna poisoning. She recovered
slowly after a hypodermic injection of liquor strych-
nine.
A Case of Membranous Conjunctivitis Treated
by Antidiphtherial Serum. — A. D. McQueen reports
a case in which bacteriological examination of the
membrane detached from the eye showed diphtheria
bacillus. The case was then treated as one of true
diphtheria, v> ith the result of prompt recovery.
Piperazin in Gout. — William Fearnley reports a
case showing the good results of piperazin in gout.
He says that the expense and trouble of taking this
drug are its only drawbacks, but for the gouty he con-
siders it as necessary as their daily bread.
The Treatment of Diphtheria.— A. Jefferis Turner
sums up this matter by saying that the treatment of
diphtheria consists in the administration of antitoxin
early and in sufficient close.
Surgical Treatment of Tuberculous Diseases By
\V. Watson Cheyne. See Medical Record, ^^ol. Ivii.,
p. 67.
Lectures on PhariDacy and the British Pharma-
copoeia.— By Xestor Tirard.
Medical Press and Circular, December 2J, l8gg.
On the Examination of Sick Children. — Langford
Symes gives an abstract of the mode of procedure in
history taking and examinatipn of the naked child.
The order he recommends is: facies, head, frame, re-
flexes, eyes, glands, abdomen, heart, lungs, spine, neck,
mouth, nervous system. The following are the chief
points to be attended to so far as the nerves are con-
cerned: (1) Motor phenomena; (2 ) reflex phenomena ;
(3) sensory phenomena; (4) trophic phenomena; (5)
electrical phenomena; (6) bladder phenomena; (7)
rectum phenomena; (8) mental capacity; (9) speech
(aphasia, nasal speech, stammering, idioglossia, or
even dumbness); (10) power of sitting, standing,
walking, reading, writing, or singing. He finds that
some children with cerebellar tumor can sing very
well. The advantage of the plan he gives is that the
hands once placed upon the child need never be re-
moved until the entire investigation is complete. E.x-
amination is more difficult than in the adult.
Gastric Ulcer : Perforation, Recovery ; Ulcerative
Endocarditis; Death. — W. H. Carthew Davey reports
the following case : A woman, aged twenty-two years,
was attacked with sudden abdominal ]^ain and vomiting
of black-colored fluid. Treatment was by morphine
hypodermatically and rectal feeding. In three weeks
peptonized milk v.as retained by the stomach and im-
provement continued. At the end of a month parotitis
developed with facial paralysis, first on one side, then
on the other. General sepsis, ulcerative endocarditis,
and death followed after four months.
January 13, 1900]
MEDICAL RECORD.
69
Case of Caesarean Section. — G. Cole Baker operated
on a woman who had borne living children, though
the true conjugate was but 6 cm., having been preg-
nant ten times before. The child weighed nine
pounds. The mother was up on the twent)'-eighth day.
Cases of White Swelling of the Knee. — A. B.
Judson describes ten cases. He does not insist on
absolute fixation if the knee is capable of full exten-
sion.
Surgical Treatment of Tuberculous Diseases. —
Bv. W. Watson Cheyne. See Medical Record, vol.
Ivii., p. 67.
Miiiichener med. Wochenschrijt, December ig, i8gg.
Experiments in Hand Disinfection. — Paul and
Sarwey come to the following conclusions on this sub-
ject: Contrary to Ahlfeld's assertion that the normal
" every-d.iy " hand yields fewer bacteria after its disin-
fection by means of hot water and alcohol, and that
after a longer soaking in warm water, combined with
energetic mechanical manipulation, its bacteria are de-
creased, these investigators are certain that the hands
are not freed from bacteria by hot water and alcohol
disinfection. They add that the question as to
whether hot water and alcohol disinfection is superior
to other methods can better be answered after experi-
ments shall have been made with artificially infected
hands, and after other methods shall have been thor-
oughly tested.
A Case of Acromegaly Complicated by Symp-
toms of Raynaud's Disease. — A. Boettiger gives the
history of a case in which the diagnosis of acromegaly
is absolutely certain. Of especial interest, however,
is the color of part of the skin of the fingers and
hands, which was bluish-black, while here and there
were scattered brick-red patches of irregular outline.
The hands felt cold and moist. Tactile sensation was
normal for the hands, sensation of pain being dulled.
The skin temperature was subnormal. Heat and cold
were clearly distinguished. The faradic sensation of.
pain was altogether absent in the skin of the fingers.
Reflexes were normal. For both affections there
seems to be a toxic etiology, the poison probably not
coming from without, but being elaborated in the body
itself. Autopsy frequently shows the same alterations
in the vessels in both diseases.
The Value of Urine as a Culture Medium for
the Diagnosis of Typhoid Fever. — Ernst Unger and
Ernst Portner give the following points as important
in relation to cultures made for diagnostic purposes.
The lack of long-thread colonies is a proof of the ab-
sence of typhoid. Numerous long-thread colonies
prove the presence of typhoid. Shorter-thread colo-
nies are of use for diagnosis only in combination with
the clinical symptoms of typhoid. Urine as a culture
medium is a great advance in bacteriology, for since up
to this time the proof of typhoid bacilli in the stools
was difficult and required from four to five days, they
can be demonstrated in the urine in from two to three
days, and with much greater certainty.
Dionin. — Meltzer says that dionin has a milder
analgesic affect than morphine, and on the other hand
a more powerful and lasting effect than codeine, hav-
ing neither the bad features of the above preparations
nor the bitter taste of peronin.
The Effect of Dionin and its Use in Diseases of
the Respiratory Organs — Th. Janisch asserts that
dionin induces sleep quite promptly in nearly all cases,
and is of the greatest use in chronic bronchitis, em-
physema, asthma, and phthisis.
Results of Vaccination in the Kingdom of Ba-
varia in the Year 1898. — By L. Stumpf.
Berliner kliniselie Wocheiischrift, December 18, l8gg.
Sequelae of Singers' Nodes.— A. Rosenberg has
noticed in the cases of vocalists suffering from this
affection a certain change in those individuals who do
not give themselves the proper respite from continu-
ous vocal exertion. The circumscribed nodule seems
to disappear, and in its place there is noticed a broad-
ening of the cord itself, so that it presents a convex
rounded edge. Proper rrst restores the characteristic
nodular appearance. \\'hen the patient phonates, the
cords approximate normally in their anterior half, but
not in the posterior owing to the convexity mentioned,
so that at the posterior end of the glottis there is a
triangular cleft made at the expense of the affected
side. If both sides are affected tliis is symmetrical
and of course larger. R. claims that by noting this
appearance of the cords he can tell whether or not his
directions as to vocal rest, etc., have been observed by
these patients.
Changes in Circular Insanity — A. Pick treats of
certain changes in type of circular insanity which he
thinks have been gradually taking place. These
changes are particularly interesting as demonstrating
that mental diseases are not all stereotyped in charac-
ter, but that they undergo gradual changes in type
just as do the organic affections.
Congenital Complete Bilateral Anosmia. — Placzek
reports such a case occurring in a woman aged sixty
years, and claims that it is the second on record. He
also states on the authority of Roscoe that the famous
Lorenzo di Medici was similarly affected.
La liijorma j\ledica, December jj-i8, i8gg.
Pulmonary Hypertrophy, Ectasy, Swelling, and
Emphysema. — Edoardo Maragliano calls attention to
the fact that many pulmonary conditions have ordi-
narily been erroneously grouped together under the
name of emphysema. Among these are a physiologi-
cal hypertrophy, vicarious emphysema, and pulmonary
swelling. In true emphysema there is alteration of
the lung tissue and increase of endo-alveolar pressure.
Moreover, true pulmonary emphysema is always gen-
eralized and diffuse in both lungs, whereas hyper-
trophy and dilatation are localized in certain deter-
mined areas. An exact diagnosis in these cases is
necessary to intelligent and successful treatment.
Microscopical Findings in a Case of Idiopathic
Partial Neuritis of One Hypoglossal Nerve.— Ales-
sandro Marina found in the right hypoglossal nerve of
a patient who had for four years suffered from unilat-
eral glossoplegia and hemiatrophy of the tongue, and
who died of pneumonia, microscopical signs of a pri-
mary neuritis of the middle third of the nerve. Only
a third of the nerve bundles were affected, the rest
being absolutely healthy^ This demonstrates tr.at par-
tial paraly ■£■ of an area innervated by a single nerve
trunk does not alone indicate a central affection.
Researches upon the Pathogenic Action of the
Casein Ferments. — R. Jemma concludes from hio ex-
periments that the usual ferments of casein belong to
the bacillus subtilis group, which exhibits no patho-
genic action in animals used for laboratory experi-
ments; that among the ferments belonging to the
mesentericus vulgatus group we find some endowed
70
MEDICAL RECORD.
[January 13, 1900
with pathogenic action upon the intestinal mucosa.
Injected into the peritoneum, the circulation, and sub-
cutaneously they are inactive. That the bacillus buty-
ricus of Hiippe and the varieties related to it, isolated
from milk, are always non-pathogenic.
Methylene Blue in Epilepsy.— Giuseppe Paoli
used this remedy in nine cases with favorable results.
It is best given by the mouth in pills ot 0.30 each,
twice a day.
Freruh Journals.
The Danger of Sexual Connection in Inflamma-
tory Affections of the Uterus and Its Adnexa. —
Rene Eelin reports an observation of double pyosal-
pinx in which two double pockets were plainly made
out by manual palpation before the patient entered the
hospital. A laparotomy done at once revealed the
presence of but one of these tumors, the other having
ruptured before operation. It was subsequently ascer-
tained that after the first consultation and on the eve
of entering the hospital the woman had had coitus
with no less than three of her friends, in the last of
which she experienced a sensation like a tear, fol-
lowed by severe pain. The author believes that vio-
lent coitus is often accountable for ruptured tubes
and general peritonitis of obscure causation. — Jour-
nal de Mi'dccine de J'aris, December ij, i8gg.
Subcutaneous Injection of Gelatinized Serum in
Hemorrhagic Variola. — Boy-Teissier, in an epidemic
just now raging at Marseilles, has been led, by the ob-
servations of Costinesco in purpura hemorrhagica, to
try injections of gelatin in the hemorrhagic form of
smallpox. In one series of seven cases, two cf which
were very severe, he injected a a single sitting 200 gm.
of gelatinized artificial serum in the strength of two
per cent. Six of the patients died, and one recovered.
No abscesses resulted, nor was there even any redness
of the skin. In a second series of thirteen cases, three
of which were fulminating and ten simple hemorrhagic,
he injected 200 gm. at two sittings, of the same
strength. The three severe cases ended fatally, and
among the milder ones there were two deaths and six
recoveries, while at the time of the report two patients
were convalescent without complications. The injec-
tions were begun with the onset of premonitory signs,
namely, epistaxis, hemorrhagic tint of the lids and
conjunctiva, and a violaceous tint of the integument.
Three abscesses were caused by the injections in this
series. — La J^resse Me'dieale, December i6, i8gg.
The Indication for Caesarean Operation Compared
with Symphyseotomy, Craniotomy, and Premature
Artificial Delivery. — Fancourt Barnes believes that
the limits of Cajsarean. section may be extended, since
the mortality, which before 1880 was 81.2 per cent.,
has gone down to from 8 to 6.8 per cent. These re-
sults are due entirely to improvement of the technique
of abdominal operations and uterine suture. The
mortality to the mother in premature artificial delivery
is one or two per cent., while that of the infant, on the
contrary, is thirty-three per cent. He concludes that
symphyseotomy has not proven its reason for existence,
and he cannot help believing that the eminent men
who have sung its praises will, in the future, cnme to
abandon it. Premature artiftial delivery will, within
certain limits, always have a useful place in obstetrical
operations. After an attentive study of the more re-
cent publications upon Cesarean operation, he has
come to believe that it is an operation both scientific
and justifiable, and that it will be carried out in the
future in many more cases than hitherto. — Journal de
Mcdecine de Paris, December ij, i8gg.
Triple Stricture of the Intestine of Neoplastic
Origin : Entero- Anastomosis. — P. Goullioud reports
an observation in which a laparotomy revealed three
distinct strictures in the intestine of a woman, thirty-
three years of age, due to cancerous growth as indicated
by the examination of mesenteric ganglia removed at
the operation. The reason that operative procedures
for occlusion or intestinal obstruction still give such
undesirable results is because they are often under-
taken at too late a period. In the case reported the
resection of 50 cm. of the small intestine would have
been necessary, without taking into account the enor-
mous infiltration of the mesenteric ganglia. The
operator, therefore, did an entero-anastomosis, the im-
mediate result of which was good, but the treatment
of the case had been undertaken at too late a period
to be of permanent benefit. — Lyon Medical, December
16, i8gg.
Premorbilliform Erythemas.— Eugfene Deschamps
relates a series of seven observations in which ery-
thema of short duration, sometimes of the measles type
and sometimes of the scarlatina type, had been ob-
served by him and others shortly before the outbreak
of measles upon the skin. He also reviews the ery-
thematous eruptions which have been described as fol-
lowing shortly after measles. While these eruptions
are habitually without serious consequence so far as
the outcome of the disease is concerned, they seem,
however, to furnish a precise indication for the neces-
sity of disinfecting the child's nose and throat and of
supervising the state of his digestive organs. — La
I-'rance MedUalc, December 22, l8gg.
Eye-Reflexes Considered in Relation to Recruit-
ing for the Army. — F. Lagrange believes that many
men could be enlisted for the army who are now re-
jected because of defective sigb.t. As to the question
of astigmatism, he thinks it a simple matter, with the
present use of the skiascope and ophthalmometer, with
which every military hospital should be supplied, to
test the eyes and accept those for whom correcting
glasses can be given. Astigmatism should not be given
as the reason for exclusion of many cases which can
be readily brought up to or above the medium, 'i he
higher degrees of abnormal vision due to astigmatism
should cause exclusion because of the frequency of
intra-ocular lesions. — Zt' Bulletin Medical, December
16, i8gg.
A Case of Ludwig's Angina. — G. Marchese de
Luna relates an instance of sublingual phlegmon in a
man aged thirty-nine years, terminating fatally. He
calls attention to the importance of early diagnosis,
and believes that energetic surgical treatment is the
only one of utility. In the present instance he was
not permitted to operate at the time he made the diag-
nosis. General infection supervened, with pneumonia
in the last stages proving the presence of a general
infection. — Gazcil' dcs Libpitaux, December jg, i8gg.
Transmission of Tuberculosis by Means of Post-
age Stamps Busquet relates an instance of a soldier
admitted to the hospital for tuberculosis of the lungs,
who was a collector of postage stamps, which he was
in the habit of fastening in albums almost daily, either
moistening the stamp itself or strips of adhesive paper
by applying them to tiie tongue, frequently exchanging
these same stamps with other collectors, t'ultnres
made from these stamps showed the presence of tuber-
cle bacilli. — L.e Bulletin Medical, December 16, l8gg.
Rupture of the Tympanum following a Blow
upon the Ear. — Paul Viollet reports the case of a
married woman who received a blow upon the ear re-
sulting in rupture of the tympanum, and recalls an
instance of traumatic ecchymosis of the tympanum fol-
lowing a kiss upon the ear, reported recently by Thol-
lon. — Gazette des LJbpitaux, December ig, j8gg.
January 13, 1900]
MEDICAL RECORD.
71
American Journal of the Alcdical Sciences, fanuary, igoo.
On Splenic Anaemia. — William Osier reports fifteen
cases of splenic anaemia, a term which indicates the
two essential features of the disease. This series em-
phasizes the long duration of the affection. In all,
the enlargement of the spleen, which was consider-
able, appears to have preceded the anajmia. In seven
cases, hemorrhage from the stomach was the feature
for which relief was sought. Watson explains hsma-
temesis in enlarged spleen: "The stress of the con-
gestion is continually felt in the submucous capillary
system, and the hemorrhage, which is apt in such cases
to occur from the loaded membrane, receives a simple
solution upon principles almost purely mechanical."
Ascites was present in three cases. In no case were
the external lymphatic glands especially enlarged.
Any grade of anaemia may exist. Melanoderma was
seen in six cases. There was a relatively high blood
count, relatively low hemoglobin, and lew leucocyte
count. A differential diagnosis must be made from
pernicious anajinia, splenic leukamia, Hodgkin's dis-
ease with enlarged spleen, cirrhosis of the liver with
enlarged spleen, alcoholic, .syphilitic, and hypertrophic
cirrhosis. The treatment is that of severe anaemia.
Report of Five Cases of Endocarditis Occurring
in the Course of Tonsillitis. — Frederick A. Packard,
in his report of these cases, believes them to have
been pure examples of acute tonsillitis and pharyngi-
tis, having no connection with rheumatism, the endo-
carditis arising as a direct consequence either of in-
fection of the endocardium by micro-organisms, which
gained entrance by way of the tonsils, or of structural
change in the mitral leaflets, brought about by coagu-
lation necrosis or other result of the chemico-vital
action of toxins produced by micro-organisms present
in the throat and absorbed from the inllamed tissues.
• Facial Spasm and Its Relation to Errors of Re-
fraction. —Stevens, in a report on facial spasm, says
that the symptom picture differs but little in all forms,
the spasm being usually confined to the distribution
of the facial nerve. The etiology is often obscure,
but may be from an affection of the nose or rhino-
pharynx or from cortical or subcortical disease. Ocu-
lar defect is more usually responsible. The refrac-
tion and muscle balance should be corrected and
systematic after-treatment should be pursued.
The Relation of Migraine to Epilepsy. — William
G. Spiller states that migraine, especially the ophthal-
mic form, is related to epilepsy. Generally, no con-
vulsions are detected in migraine, though they may
develop after many years. These cases may be re-
garded as abortive cases (formes frustes) of migraine
that later become associated with epilepsy, or as abor-
tive forms of epilepsy (sensory epilepsy) in which the
convulsions later become apparent.
Report of a Family Outbreak of Trichinosis —
George Blumer and Leo Haendel Newman report nine
cases of trichinosis in two families. Blood examina-
tions showed an eosinophile leucocytosis, a relative
decrease in the neutrophiles, and in many cases a de-
crease in the small uninuclear leucocytes.
Tracheal Diastolic Shock in the Diagnosis of
Aortic Aneurism.— J. N. Hall holds that the crucial
test of the value of this sign is in differentiating aneu-
rism from solid thoracic tumor in cases not involving
the chest- wall.
A Critical Summary of Recent Literature on
Gonorrhoea in Women. — John G. Clark, in his review
of this subject, lays stress on the chronic or persistent
course of gonorrhoea.
Cystinuria and Its Relation to Diaminuria. —
Charles E. Simon states that diamins have been en-
countered in the urine in cases of cystinuria, and in
these cases only.
International Medical Magazine, Dccetnber, i8gg.
On the Relative Frequency of Hernia in the
Sexes and the Various Types in the Female ; a
Statistic Comparison. — Thomas A. Manly states that
hernia statistics are most unsatisfactory. Kingston
says that for all ages the proportion of hernia is two
males to one female. Cloquet concluded after large
experience that ruptures are nearly three times more
numerous in men than in women. After the age of
forty-five years hernia has about the same frequency
in both sexes. Heath says in the adult female the
proportion of inguinal to femoral is about equal.
Typical adult umbilical hernia is par excellence an
infirmity of married women.
Obstructive Diseases of the Male Urethra J. D.
Thomas enumerates the obstructive diseases (and ob-
structions) of the urethra as: Foreign bodies; acute
prostatitis; false passage; rupture; stricture; spasm
of the cut-off muscles; injury to, or in the neighbor-
hood of, the anus; chronic hypertrophy of the pros-
tate; small meatus; phimosis; pediculated tumors;
congenital atresia. With very few exceptions, the va-
rious obstructive diseases all require different treat-
ment— the method to be governed by the cause of the
disease.
The Diagnosis of Iritis Walter L. Pyle says there
should be no difficulty in differentiating iritis from
conjunctivitis. The chief distinguishing points are:
Discoloration of the iris when compared with its fel-
low; contracted, sluggish, or fixed pupil, turbidity of
the aqueous, and ciliary injection. From acute glau-
coma, the diagnosis is more difficult. Here, besides
testing for increase of tension, we have the size of the
pupil as a guide in iritis, more contracted than usual
and perhaps fixed; in glaucoma, dilated and sluggish.
Generally, in these acute inflammations satisfactory
ophthalmoscopic examination is impossible.
Neurosal Conditions Involving Excessive Secre-
tion of the Gastric Juice (Hyperchlorhydria, Hy-
perchylia, Gastroxynsis, Reichmann's Disease,
etc.). — Boardman Reed states that the differential
diagnosis of the forms of hypersecretion must turn
almost entirely upon the chemical and microscopical
examinations of the stomach contents. The diagnosis
from gastric ulcer is not always easy. The diet should
be carefully regulated, and a complete rest from men-
tal occupation is most important.
The Importance of the Early Recognition of Car-
cinoma Uteri, and the Methods by which It is
Attained. — E. E. Montgomery states that carcinoma
uteri in its very early stages is quite amenable to treat-
ment. When suspected, the surgeon should first try
dilatation for digital exploration — the next step being
microscopical examination of the tissues obtained
either by excision of a specimen or by curettage.
Gall-Stone Crepitus and Friction, with Illustra-
tive Cases. — J. M. Anders says that while the pres-
ence of gall-stone crepitus and friction in typical cases
of cholelithiasis is corroborative, it is not essential to
an absolute diagnosis. In irregular cases, either symp-
tom often serves as a deciding factor.
Laboratory Methods of Diagnosing Tuberculosis :
The Staining of Sputum. — W. \^'ayne Babcock de-
scribes carefully the technique of staining the tubercle
bacillus by means of carbol fuchsin and Loeffler's al-
kaline methylene blue.
72
MEDICAL RECORD.
[January 13, 1900
Journal of Experimental Medicine, November, i8gg.
Experimental Investigation of the Treatment of
Wounds of the Heart by Means of Suture of the
Heart Muscle. — Charles A. Elsberg, from numer-
ous experiments on animals, concludes that suture of
a wound of the heart, as a final resort, is an operation
worthy of consideration and often justifiable. In ani-
mals, and also in man, it is devoid of the danger
of sudden arrest of the heart, unless Kronecker's co-
ordination centre be injured. The suture should be
an interrupted one of silk, if possible penetrating only
the epicardium and superficial layers of the myocar-
dium, and tied during diastole. No rules can be laid
down, but each case must be considered separately as
to indications for operation.
Acute Endocarditis Caused by Micrococcus Zy-
mogenes. — William G. MacCallum and Thomas W.
Hastings state that from a case of acute endocarditis
of the aortic and mitral valves with infarctions in the
spleen and kidneys, a micrococcus was twice isolated
in pure culture from the blood during life and demon-
strated after death in the valvular vegetations, infarc-
tions, and other parts. It is small, and occurs mainly
in pairs. It is pathogenic for mice and rabbits, caus-
ing abscesses or general infections. The authors, after
much research into the nature of micro-organisms, feel
justified in recognizing this organism as a new spe-
cies, and from its fermentative properties name it
" micrococcus zymogenes."
Chronic Interstitial Nephritis and Arteries in
the Young. — N. G. Brill and E. Libman present a
case whose chief points of interest are: (i) The oc-
currence of a very advanced primary chronic inter-
stitial nephritis at the age of fourteen years. (2) Its
presence in other members of the same family. (3)
The e.xtensive and marked arterial changes present.
(4) The hemorrhagic diathesis, and the occurrence of
a large hemorrhage in the mesentery. (5) The occur-
rence of calcified deposits in the liver. (6) The evi-
dent existence of latency of some cases of chronic
nephritis in children.
Bacillus Pyocyaneus and Its Pigments. — Edwin
O. Jordan separates this bacillus into four varieties:
f/, Pyocyanigenic and fluorescigenic (most common);
fj, pyocyanigenic only (rare); y, fluorescigenic only
(not uncommon, closely related to " B. fluorescens
liquefaciens '■) ; ", non-chromogenic. The different
varieties are not so plastic as is sometimes assumed,
and cannot be readily converted into one another by
subjection to varying conditions of life. The signifi-
cation and correlation of the almost countless physio-
logical variations among the members of this group
in respect to growth in gelatin, behavior to tempera-
ture, indol production, etc., remain to be determined.
A Study of the Neuron Theory. — Martin H. Fi-
scher claims that there is not independence of neu-
rons, as anastomoses have been found, and that the
dendrites may have a nutritive as well as a nervous
function.
Fibro-Sarcoma of the Brain Alice Hamilton
reports a tumor resembling glioma, but in which the
fibrils were arranged in circumscribed masses, and
took the differential stains for connective tissue. It
was decided that it was an unusual form of fibro-sar-
coma.
The Differentiation and Classification of Water
Bacteria. — George W. Fuller and George A. Johnson
call attention to several modifications which experi-
ence has led them to believe are of assistance in the
study of water bacteria.
A Preliminary Note on the Fractional Precipi-
tation of the Globulin and Albumin of Normal
Horse's Serum and Diphtheritic Antitoxic Serum,
and the Antitoxic Strength of the Precipitates. —
By James P. Atkinson.
Leukaemic Lesions of the Skin — Horst-Oertel de-
scribes leukemic cutaneous nodules whose structure
supports the theory that secondary leukremic nodules
are essentially composed of cells derived from the
blood.
Lymphoma. — E. R. Le Count describes a small
tumor which he considers to have been a benign, non-
inflammatory new growth of lymph nodes.
A Case of Addison's Disease with Simple Atro-
phy of the Adrenals. — Carlin Philips. See Medi-
cal Record, vol. Iv., p. 407.
Montreal Medical Journal, December, i8gg.
Some Remarks on the Symptoms and Operative
Treatment of Bronchocele, Especially in Relation
to Graves' Disease. — Francis J. Shepherd, after enu-
merating the well-known symptoms of Graves' disease,
reports several cases showing the effects of operative
treatment. He considers it most important in choos-
ing the form of operation to be guided by the nature
of the case. Enucleation and the after-treatment are
carefully described.
The Wisdom of Surgical Interference in Hsema-
temesis and Melaena from Gastric and Duodenal
Ulcer. — G. E. Armstrong, in defining cases of hcema-
temesis suitable for operation, gives two classes:
those, first, of frequently repeated small hemorrhages,
which persist in spite of medical and dietetic treat-
ment, and which threaten to destroy the life of the
patient; and, secondly, those having large hemor-
rhage which, in spite of medical and dietetic treat-
ment, recurs. He reports two successful cases.
Two Cases of Ephemeral Mania, Uncomplicated
with Epilepsy, Intemperance, or Parturition.— T.
J. W. Burgess records two cases of mania transitoria,
both patients being women. The cause of the first
was supposed to be the excitement of a railway jour-
ney and the consequent fatigue — this being her first
experience ; the second w as caused probably by the
shock of a sudden fright.
Goitre : Its Etiology and Incidence in the Dis-
trict of Montreal. — J. A. Springle. after summing up
the causes which are generally considered as etiologi-
cal factors of goitre, mentions some conclusions inci-
dent to Kocher's recent investigations. He believes
that certain waters contain the materies morbi, empha-
sizing the fact that water from the so-called fresh-
water sandstone is particularly goitrous.
Notes from Practice in the Argentine Republic.
— F. G. Corbin reports three cases: (i) Fecal fistula
following pelvic abscess cured by operation; (2) ne-
phrectomy without a ligature; (3) interstitial preg-
nancy mistaken for a myoma uteri; operation, recov-
ery.
Endo-Enteric Suture. — E. Reavlev describes the
endo-enteric suture originated by F. G. Connell, illus-
trating the steps of this method by plates. He claims
the following advantages: Rapidity, simplicity, only
one line of union and that the shortest, less injury to
the intestine, all intestinal walls included, and the
greatest attainable strength.
A Case of Lues Venerea with an Unusually
Protracted Incubation Period. — A. Mackenzie Forbes,
in reporting this case, says that all penile abrasions,
January 13, 1900]
MEDICAL RECORD.
72,
appearing both with and after urethral discharges,
should be most carefully watched.
A Rare Surgical Case. — T. M. Calnek reports tlie
case of an aneurism situated just at the trifurcation
of the gluteal artery, the three main branches arising
from the sac of the tumor.
Tuberculosis of the Flat Bones of the Skull A.
Primrose reports such a case, observing that it is ex-
tremely rare and that it is apt to be confounded with
syphilis.
A/r/iircs of Pediatrics, December, i8gg.
A Case of Heart Lesions.— A. C. Cotton reports a
case of this nature in a child eleven years old. ■ The
necropsy showed stenosis of the pulmonary conus;
malformation of the pulmonary valve (two cusps);
aneurism of the right -ventricular wall; acute mural
endocarditis; defective (perforate) ventricular septum;
fibrinous pleuritis; old healed and recent metastatic
abscesses of both lungs; cloudy swelling of the liver
and kidneys; chronic splenitis and acute perispleni-
tis; general anajmia; anasarca, hydrothorax, hydro-
pericardium, and ascites; panophthalmitis of the left
eye. Bacteriological examination revealed the strep-
tococcus pyogenes in the lungs and the vegetations,
and adherent clots in and about the aneurism of the
heart wall. The colon bacillus and two micrococci,
wiiich could not be identified, were also obtained from
the lungs.
The Importance of Prolonged Rest in Bed after
Acute Cardiac Inflammations in Children. — L. Em-
mett Holt asserts that there are three reasons why car-
diac inflammations are likely to be especially serious
in young children: (i) The frequency with which
both the endo- and pericardium are involved; (2) the
great tendency to acute dilatation; (3) the liability of
these attacks to be complicated by pneumonia. The
cardiac muscle, like the voluntary muscles, in young
children, has not the resistance which it attains later.
For these patients, rest as nearly absolute as possible
is necessary, even for two or three months after acute
symptoms.
Diphtheria and Serum Therapy, with Especial
Reference to Experience in Cuba.— Joaquin L.
Ouenas asserts that, in his own personal experience,
he has not lost any patient from pharyngeal or laryn-
geal diphtheria since his employment of antitoxin.
A Case of Hydrocele of the Cord following an
Operation for Strangulated Inguinal Hernia Burr
FiJurton Mosher reports this case of hydrocele which
was immense, and which, with the exception of the
reducible protrusion, was wholly within the abdomen.
Peliosis Rheumatica in a Lymphatic Child. — J.
Park West reports a case of that rather unusual dis-
ease described by Schonlein in 1829 as peliosis rheu-
matica. No satisfactory cause could be found.
Scorbutic Membranous Colitis.— J. Henry Fruit-
night describes this case as the only instance of scurvy
accompanied by the expulsion of a pseudo-membrane
with which he is acquainted.
Infantile Scurvy— Mild Type.— Francis Huber
reports several cases of infantile scurvy, all of the
patients belonging to the better classes and all being
rachitic.
Strangulation of the Foetus in Utero by the
Umbilical Cord.— Joseph VV. Irwin reports this un-
usual case, due, probably, to the mother falling from
a street car in the seventh month.
The Use of Gruels as Diluents of Cow's Milk.
—By Henry Dwight Chapin. See Medical Record,
vol. Ivi., p. 181.
A Case of Multiple Osteomyelitis in an Infant.
— T. M. Rotch presents this case as one of pathologi-
cal rather than of clinical interest.
Pediatrics, January i, igoo.
Complications of Diphtheria J. A. Abt does not
regard septic diphtheria as, strictly speaking, a compli-
cation of the disease, but believes with Huebner that it
would be more appropriate to call these cases diphtheria
gravissima or maligna, since pyogenic cocci may be ab-
sent and nearly pure cultures of diphtheria bacilli are
obtained. Baginsky says that in nearly every case in
which antitoxin is administered early sepsis rarely, if
ever, develops. A case is cited to show that such vio-
lent toxins may be produced that it is impossible to
neutralize them with the ordinary dosage of antitoxin.
Heart complications may occur in the mild as in the
severe forms. Paralysis may be early or late. The
most feared cardiac complications cccur after the local
disease has disappeared. There are characteristic
symptoms which should warn us: exceedingly rapid or
slow pulse during convalescence, but, more important,
disturbance of normal rhythm. The characteristic
irregularity shows an intermission of one or two beats,
or it may become double. Antitoxin can have no in-
fluence on a heart already damaged by diphtheria
poison, but it is believed that the antitoxin partially
or completely neutralizes the poison if given suffi-
ciently early. It is observed that since the use of
antitoxin became general severe nephritis is becoming
less frequent.
Double Paralytic Varus from Peripheral Neuritis.
■ — Henry Ling Taylor says the commonest cause of
acquired clubfoot is poliomyelitis. Among the rarer
causes of acquired varus or equino-varus is peripheral
neuritis. The case of a girl of thirteen years is given.
The neuritis is distinguishable by its sudden onset
with pain, absence of fibrillar tremor and degenerative
reaction, non-progressive character, and tenderness of
the nerve trunks.
A Case of Interstitial Emphysema Max Girsdar-
sky records with illustrations a boy's history. After
asthma, and bronchitis with emphysema of the lungs,
there were sudden choking, thickening about the neck,
and tumor formation, giving crepitation, and a fremi-
tus-like sensation to the fingers. Improvement began
on the sixth day. In two weeks the interstitial em-
physema had disappeared.
Annals of Gynecology and Pediatry, December, l8gg.
The Neuroses of the Menopause Caused by In-
testinal Fermentation.— Charles J. Aldrich says that,
without regard to sex, the physiology of life is marked
by distinct epochs: Dentition; pubescence; and the
climacteric of age. The first two are developmental,
the last the epoch of degeneration and decay. To
woman nature has added another, the menopause.
This is a physiological process, and not a process of
decay. At this time the spleen becomes fnaller; the
lymphatic glands waste; Peyer's patches smooth down,
and lose their peculiar structure; the intestinal villi
shrink and become less vascular ; the muscular coats
of the intestines atrophy, and lessened peristalsis en-
sues. The power of propelling the mixed products of
indigestion and fermentation is lessened, and innumer-
able micro-organisms flourish and excite fermentation
and elaboration of toxic alkaloids. Consequently con-
stipation, anorexia, eructations, flushes, vertigo, head-
74
MEDICAL RECORD.
[January 13, 1900
aches, and insomnia follow. Cathartics, nux vomica,
and hot-water enemas will clear the tract. Massage,
electricity, diet, and intestinal tonics will aid in keep-
ing it clear.
Surgery in its Relations to the Female Pelvic
Organs. — John B. Wheeler observes that in operative
cases the best prospect of a complete and speedy res-
toration to health is afforded by a radical operation.
In the case of a young woman, with most of her child-
bearing life before her, it may be justifiable to offer
the less reliable aid of a partial operation, in order to
give her every chance to preserve the function of re-
production. In the case of a woman approaching the
menopause (and a fortiori if she has passed it), there
is no valid reason for refusing her a radical opera-
tion.
Report of a Case of Puerperal Sepsis and what
It Teaches. — Charles H. Glidden says that, taking
into consideration the frequent inconveniences to
which the obstetrician is subject, time is well spent
in considering the management of puerperal sepsis
from the curative as well as the preventive standpoint.
A Case of Cystitis of Long Standing, Compli-
cated by Chronic Malaria, Together with Slug-
gish Liver and Habitual Constipation — J. VV. Walk-
er, in treating this case of cystitis, used quinine and
thialion besides, and a prostatic catheter of block tin.
A Clinical Study of the Lymphatic Glands in
One Hundred Cases of Scarlet Fever. — Jay F.
Schamberg has carefully tabulated the results of his
work on this subject, which was carried on at the Mu-
nicipal Hospital for Infectious Diseases, of Phila-
delphia.
Puerile Indigestion. — F. C. Morgan states that
ignorance and carelessness of nurse or mother are
primary causes of puerile indigestion. Four facts
govern the matter: Quality of food, quantity of food,
frequency of administration, method of preparation.
Sudden Increase of Intra-Abdominal Pressure a
Possible Danger in the Operation for the Cure of
Old, Very Large, Retained Hernia. — By Henry O.
Marcy. See Medical Record, vol. Ivi., p. 641.
Eclampsia. — F. L. Brigham, in reporting several
cases of eclampsia, asserts that, in his opinion, vera-
trum viride will successfully supplant the use of the
lancet in this affection.
Some Practical Experience in Asepsis and Anti-
sepsis in Obstetrics. — By Douglas Ayres. See Med-
ical Record, vol. Ivi., p. 636.
Intestinal Obstruction from Biliary Calculi. — By
J. Wesley Bove'e. See Medical Record, vol. Ivi., p.
569-
Typhoid Ostitis. — Charles F. Painter reports two
cases of ostitis due to typhoid, one situated in the
hip joint, and the other in the spine.
Indigestion in Infants and Children — By James
H. Taylor. See Medical Record, vol. Ivi., p. 602.
The Tlierapeiitic Gazette, December, i8gg.
The Prevention and Treatment of Puerperal
Eclampsia. — Edward P. Davis says the convulsions
may be readily controlled by chloroform, large doses
of morphine, veratrum viride, or nitrite of amyl. Re-
cent observers estimate that in women subjected to no
care during pregnancy one in eighty-five has eclamp-
sia. The mortality varies from fifteen to twenty-five
per cent. Serum albumin is important only when in
large amount and appearing with kidney debris. As
a preventive measure the patient's excretion should be
stimulated. An appropriate diet composed largely of
milk, bread and butter, green vegetables, and fruit,
with an abundance of pure and soft water, is the Jirst
prerequisite ; a warm tub bath at night and a cool sponge
in the morning should be taken. Thin wool or silk
and wool should cover the entire surface. Fresh air
and gentle exercise are necessary. Alcohol should
not be allowed. The craving for tea or coffee may
usually be appeased by the use of very hot water, effer-
vescent drinks, and occasionally, for a short time, small
doses of nux vomica or stiychnine.
The Treatment of Eclampsia.— James Clifton
Edgar' takes up first the preventive, then the curative
treatment, under which latter he discusses a method to
control the convulsions. Among other things he ad-
vises that the uterus be emptied'under deep anaesthesia
by some method that is rapid and that will cause as
little injury to tlie woman as possible. He then goes
on to consider elimination of the poison or poisons
which we presume cause the convulsions. A protest
is entered against the careless use of the term "ac-
couchement force, ' and to the easy confidence with
which it has been recommended as the best if not the
only means of controlling eclamptic seizures, without
attaching sufficient importance to the condition of the
cervical barrier.
The Treatment of Eclampsia Richard C. Norris
thinks prevention the most efficient treatment. Neu-
ralgia of obstinate cliaracter, irritable temper, excessive
vomiting, marked salivation, coated tongue, hebetude,
and signs of inactive liver are indications for treat-
ment. The formation of toxins is to be prevented by
diet, while the liver must be aided to destroy them
and the excretory organs to eliminate them. The
colon should be flushed daily with at least two gallons
of salt solution. Chloroform is preferable to mor-
phine in controlling convulsions.
The Treatment of Puerperal Eclampsia.— A. F.
A. King assumes the convulsions to be of urjemic na-
ture, and prescribes hydragogue cathartics and hot
baths or wet packs, dry or wet cuppings, one applica-
tion of mustard plaster, then hot poultices of flaxseed
and digitalis leaves. Absolute quiet is necessaiy.
He places a gag betiveen the teeth, and pulls forward
the tongue after the convulsion to prevent its falling
back and endangering respiration, which are practical
points of importance.
The Treatment of Puerperal Eclampsia.— Edward
Reynolds is a strong believer in the efficacy of diuresis,
catharsis, and diaphoresis, rest in bed, milk diet, and
mild sedatives, such as the bromides. Immediate
delivery under ether is advocated for all cases in
which one convulsion has occurred. He occasionally
uses a single injection of one-sixth grain of pilocar-
pine. He prefers chloral to morphine.
A Case of Fibroma Molluscum and Dermatolysis.
— H. Clarence and F. G. H. Edwards report the case
of a man who had two heavy pendulous folds of skin,
one on the face and the other on the chest and shoul-
der, and also numerous sm.all tumors scattered over
the trunk and arms. One of the tumors, which was
removed, weighed 1,530 gm. (about three and one-
third pounds). The authors regard dermatolysis and
fibroma molluscum as the same aff'ection at different
stages, and propose the term "fibroma molluscum
multiforme." — Journal of Tropical Medicine, December,
January 13, 1900]
MEDICAL RECORD.
75
^Jizv^pcutxc glints.
Arsenic Antidote
I^ Tinct. ferri chlor. . «
Sodii (vel potass, ) bicarb aa %i.
Aqu^ ( warm) J viij .
M, S. Ad libitum.
Styptic Collodion. —
H Acidi bcnzuici 3 iij.
Tannini 3 v.
Phenol J i.
Collodion | xiij.
Iodoform Gauze. —
^ Iodoform 3 xiiss,
Elemi resin 3 i. gr. xv.
Ster. vaseline oil 3 iiss.
Rectified benzene 5 xvi.
Ether ; xxij .
Add the resin to the mixed liquids; filter and dis-
solve the iodoform by agitation.
lodol Gauze. —
^ lodol,
Resin,
Glycerin aa 10
Alcohol 100
Epistaxis
I? Antipyrin 0.5
Tannin i.o
Fowd. sugar 10. o
M. S. Dusting powder.
— Rendu.
Rigid Perineum. —
IJ Chloroform ? i.
Sulphuric ether,
Spir. of cologne aa | ss.
M. S. Apply locally.
SOUTHWORTH.
Acute Laryngitis. —
I^ .Sodii sozoiodolat.,
Sulphuris sublim aa 15
M. S. Apply with powder blower every four hours.
— Fritsch.
Whooping-Cough. —
I( Antipyrin gr. ss.-i.
Ammon. chlor gr. iiss. -v.
Syr. limonis 3 ss.
AquK q s. ad 3 i.
Or:
I^ Antipyrin gr. ss.-i.
Ammon. bromid gr. i.-ij.
Ammon. muriat gr. i.
Syr. simp q.s. ad 3 i.
S. At a dose every three hours.
■ — J. Madison-Taylor.
Or:
I? Phenacetin 2.5
Tinct. belladonnse 5.0
Extr. castan. vesc 30.0
Spir. rectific ad 50.0
M. S. For children over one year of age ten drops every
two to six hours, over ten years a teaspoonful.
— Lancaster.
Bronchitis.—
R Terpin lo.o
Glycerin,
Alcohol aii 1 50. o
Syr. of honey 125.0
Tr. of vanilla. 10. o
M. S. A tablespoonful three or four times dailv.
— Crinon.
Night-Sweats of Phthisis.—
R Agaricin gr. viiss,
Dover's powder 3 ij.
Powd. marshmallow,
Mucil of acacia aa 3 i.
M, et divide in pil.' No. c. S. One or two pills at night.
• — SlEFERT.
Broncho-Pneumonia in Children. —
IJ Sodii benzoatis gr. viij.
Ammon. acetatis gr, xxiv.
Spir. vini gallici 3 i j.
Mist, acacice,
Syrupi aa 3 iss,
M. S. From one-half to one teaspoonful every two hours.
— Marfan.
I? Ammonii acetatis gr. viij.
Sodii benzoatis gr xxx,
Oxymel scillse 3 iiss,
Syr, pruni virgin | j.
Aqux destill | iiiss.
M. S. Teaspoonful or more every two hours, according to
age.
— Perier.
Summer Complaint in Children
IJ Paregoric. j ij.
Extr. of witch-hazel | i.
Carbolic acid 3 i.
Fid. extr. of kino,
Jamaica ginger aa 3 ij.
Precipitated chalk 3 j.
Simple syrup up to 3 viij,
M. S. For adult a teaspoonful, for children in proportion
to age.
— T. B. Greenley.
Hemorrhoids. —
1$ Cocaine hydrochlor gr, vi.
Morph. sulph gr. X.
Resorcin gr. xv.
Hydrarg. chlor. niitis 3 ss.
Petrolati ? i.
M. ft. ungt. S. Apply to parts.
IJ Cocaine hydrochlor gr- 'j-
Pulv. opii gr, iv.
Resorcini gr, vi.
Acidi tannici gr. xij.
lodol 3 i.
01. theobrom q, s,
M. ft. suppos. No. xii. S. One every four hours.
— O. Hasencamp.
Myalgia. —
IJ Extr. cimicifugae fid. ,
Extr. erythroxyli lid, .
Tr. guaiac. ammon aa J ss.
M. S. A teaspoonful three times a day.
In Chlorosis. —
IJ Ferri sulphatis 5,0
Sacch. lactis 15.0
Pulv. frangulK 25.0
M. ft. pulv. No. c. S. One powder after each meal.
— LlEGEOIS.
Syphilis.
IJ Acidi arsenosi,
Hydr. chlor. corros. ,
Auri et sodii chloridi aa o. i
Extr. sarsaparillre,
Extr. gentianas.
Extr. opii aa 0.2
M. ft. mass, in pil. xxx. div. S. One pill morning and
night.
J. D. RiBIERO.
Acute Enteritis
IJ Resorcini 5,0
Bismuthi salicylatis aa 15.0
Tannigen,
Sacch. alb,.
Sodii carbonat aa 20,0
M. ft. pulv. S. A small teaspoonful every two hours
— EWALD.
For Incoercible Vomiting. — ■
IJ Picrotoxin.
Morphin. hydrochlor aa gr. i.
Atropin. sulph g''- A
Ergotin gr. xx.
Alcohol q. s. (to dissolve)
Aquje 3 ij.
M. S. Eight to ten drops in small amount of water, re-
peated at intervals.
— Robin.
76
MEDICAL RECORD.
[January 13, 1900
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, January 4, igoo.
William H. Thojison, M.D., President.
Treasurer's Report. — This showed the Academy to
be now free from debt.
Pathology of Migraine — Dr. Coleman W. Cut-
ler presented a paper on this topic. He said that
migraine was a periodical or paroxysmal neurosis mak-
ing its appearance in childhood or early adult life,
and characterized by headache, often preceded by an
aura, and associated with vomiting. The visual aura
was the most common, and usually consisted of pecul-
iar color perceptions with perhaps spasm of the muscles
of accommodation. Olfactory or taste perceptions, as
a part of the aura, were decidedly rare. In the great
majority of cases migraine was transmitted in the
family as such, but coincident with it other minor
peuroses might occur. It was probable that epilepsy
might be accompanied by phenomena simulating
migraine, or alternating w^ith it. Symptomatic mi-
graine might be an early sign of tabes. The tension
of the eye should be tested in all cases of ocular pain,
especially if associated with scintillations of light.
The tendency of migraine was to begin in youth and
end in middle age. Heredity was a predisposing
cause in from ninety to ninety-five per cent, of all
cases. The exciting causes were exceedingly numer-
ous. A certain number of cases seemed to resist all
efforts at treatment. The relation of latent gout to
migraine was still an open question. In at least fifty
per cent, of the cases reaching the oculist the attacks
became less frequent and often ceased entirely after a
proper course of treatment.
Significance of Migraine in Graves' Disease. —
Dr. William H. Thomson read this paper. He said
that there was probably no other disease so decidedly
hereditary as migraine, and it had therefore been
classed as a neurosis. His own view was, that it was
more probably the result of an intermittent toxaemia.
No slight significance should be attached to the fact
that whole classes of individuals were free from mi-
graine, and other whole classes were victims of this
alfection. The persons forming the class subject to
migraine were those leading indoor and more or less
sedentary lives. In this respect migraine was very
different from epilepsy, for in the latter disease the
individuals affected were found in both indoor and
outdoor workers. Active bodily labor wholly prevented
stasis of the circulation, whereas sedentary life favored
stasis. In the former, good digestion was the rule;
in the latter it was the exception. He would call at-
tention to the fact that Graves' disease might often
exist, and severely too, without any exophthalmos.
In his experience the malady had ended fatally in a
larger percentage of cases in which there was no ex-
ophthalmos. He had detailed notes of sixty-five cases
of Graves' disease seen in private practice. Of this
number, thirty-two were without and thirty-three witli
exophthalmic goitre. The total symptomatology of
Graves' disease, with this one exception, was so char-
acteristic that there was no difficulty in making the
diagnosis. In all of the sixty-five patients there had
been persistent tachycardia, and this had been as
marked in those without as those with exophthalmic
goitre. Tachycardia he looked upon as an essential
symptom of this affection, and it was particularly im-
portant because without it one would be liable to mis-
take the condition for neurasthenia, hysteria, or dys-
pepsia. Tachycardia was usually one of the earliest
symptoms to appear and one of the last to go away.
Another very characteristic symptom was the sense of
general ner.vousness \ery commonly described by the
patient as an unreasonable fright. Another frequent
symptom was muscular tremor, worse in the morning,
and often passing off altogether by evening. Of the
sixty-five patients only sixty stated that all of their
symptoms were worse in the morning. Tremor of the
eyes was present in every one of the cases in which
there was no exophthalmos. These patients often
complained of pains in various parts, chiefly in the
legs, associated with tenderness. A peculiar hypera;s-
thesia of the external ear had been noted in a con-
siderable proportion of both classes of cases. Severe
vertigo had been present in about one-fifth of the
cases. A most striking parallel between the two
classes was to be found in derangements of the diges-
tive apparatus. In some of the cases there had been
a persistent nausea occurring independently of the
taking of food. Diarrhoea had been a leading symptom
in sixteen of the thirty-two cases in which there had
been no exophthalmic goitre, and had been character-
ized as painless. It was said to be worse in the
morning. It was quite uniformly asserted that the
other symptoms were aggravated with the occurrence
of diarrhoea, but tiie general course of the disease had
been about the same in the cases showing diarrhoea as
those charaterized by constipation. Persistent vomit-
ing was a serious symptom in many cases of both
classes. One very severe case was that of the wife of
a physician who had assiduously watched her for two
years, but who had never suspected the existence of
Graves' disease because of the absence of exophthal-
mic goitre. This should impress upon us the evil of
naming diseases after one symptom. He believed the
primary cause of Graves' disease was an auto-infection
from the alimentary canal, and that it was associated
with a peculiar inability properly to digest nitrogenous
food. It was conceivable that the presence of such
poisons in the blood in excess might overstimulate
the thyroid gland, and might occasionally lead to
atrophy of the gland and to myxoedema. The speaker
said that only since 1S96 had his attention been
specially directed to the frequency of migraine in
connection with Graves' disease. He had seen but
one case in which migraine and epilepsy had been
found in the same individual. This person had had
epilepsy from the age of seven until coming under
observation at the age of eigliteen years. The epilepsy
had been made to disappear entirely, but some yeais
later she had developed an exophthalmic goitre, and
still later migraine had appeared. The occurrence of
migraine as a family complaint in Graves' disease
had been noted in sixty-five of the cases.
Dr. C. L. Dana said that at tlie present lime most
neurologists looked upon migraine as an hereditary
constitutional neurosis, paroxysmal in character, and
occurring in the same periodical way as epilepsy and
certain other neuroses. It was considered to be a dis.
charging neurosis affecting more highly evolved psy-
chical nerve centres than were affected in epilepsy.
Such centres one would naturally expect to find more
highly developed in brain-workers than in ordinary
laborers. While the disease was incurable, much relief
could be afforded by lessening the irritation and the
exhaustion of the centres. Py relieving eye-strain,
removing sources of intestinal irritation, and securing
more outdoor life, much could be accomplished. Next
in importance to treatment directed to the mode of life
was that having for its object the improvement of the
digestion. He was not in a position at present to dis-
cuss the interesting clinical studies presented in the
last paper regarding the relation of migraine to
Graves' disease. One of the most interesting features
of the pathology of migraine was that it certainly had
January 13, 1900]
MEDICAL RECORD.
n
neurotic equivalents. He had seen cases of migraine
with the headache at intervals for years, and then this
pain would be replaced by attacks of periodical ptosis.
He had not noted that migraine and epilepsy occurred
very frequently in the same family, or were very
closely allied in their pathology.
Dr. B. Sachs said that the occurrence of migraine
and epilepsy in the same individual was undoubtedly
rare; he could not recall more than two such cases,
and in these the migraine had followed the cessation
of the epilepsy. That migraine was the result of
toxajmia seemed to him purely speculative. Toxemias
might act as exciting causes, but nothing more.
Reference was made to the case of a young man suf-
fering from epilepsy who had developed acute pulmo-
nary tuberculosis, and on the occurrence of this inter-
current disease he had exhibited no further epileptic
seizures. This relation of epilepsy to acute infectious
disease was interesting, and to him novel. It seemed
to him rather injudicious to diagnosticate as Graves'
disease every case exhibiting tachycardia.
Dr. Thomson, in closing the discussion, said that
he would not make the diagnosis of Graves' disease
on persistent tachycardi^i alone, but he would be will-
ing to make the diagnosis, even in the absence of ex-
ophthalmic goitre, if along with the tachycardia there
were muscular tremors, parassthesise of one kind or
another, persistent constipation or diarrhoea — in a
word, clear evidence of a serious constitutional dis-
order. The object of his paper was to call attention
to the frequency of this malady without any associated
exophthalmic goitre.
SECTION OX GEXERAI, MEDICINE.
Stated Meeting, December ig, i8gg.
Louis Faugeres Bishop, M.D., Chajrman.
The Relative Intensity of the Second Sounds at
the Base of the Heart : A Study of One Thousand
Cases. — This paper, by Sarah R. Creightox, M.D.,
was read by Lewis A. Connor, M.D. (See page 45.)
Dr. Emily Lewi said that the explanation of the
phenomena was perfectly satisfactory to her, and that
there were a number of anatomical factors in the posi-
tion of the child's heart and the adolescent's heart, as
compared to the adult heart, that would account for
the clearness of the sound. The heart of the infant,
of the child, and of the adolescent lay more vertically
in the thorax than it did later in life; incisions made
into the frozen subject showed this. If a transverse
incision was made through a child's heart at the level
of the aortic valve it would pass through the thick
right ventricle. Another anatomical peculiarity of
the child's heart was that the left pleura hardly went
to the left edge of the sternum, whereas the right
pleura went to the left margin of the sternum. These
were additional factors in making increased intensity
of the second pulmonary sound as heard in the child.
The speaker had noticed for some years that anaemia
or chlorosis, in girls from fifteen to twenty years of
age, caused an accentuation of the second pulmonary
sound; whereas in girls who had no marked chlorosis
— hremoglobin seventy or eighty per cent. — this sound
was merely a click, probably due to the condition of
the blood. The speaker believed that one should have
some standard for comparison, for it would not appear
that the same heart sound could be heard in a girl of
twenty years as would be heard in a man of si.xty ; nor
should we expect to have the same quality of sound at
the base as at the apex.
Dr. James K. Crook said that, in an experience
covering many years in both teaching and in examin-
ing many patients, he could bear testimony to the fact
that the aortic first sound was more intense than the
pulmonary second sound in the adult. The pulmonary
second sound was more responsive to disturbances of
the circulation. In the presence of excitement the
pulmonary second sound was more quickly responsive
than the aortic second sound. What conditions led
to variations in the pulmonary second sound? Mitral
stenosis caused a marked increase of the aortic second
sound. The blood was dammed back on the lungs
through the pulmonary capillaries, back to the pul-
monary artery, and in consequence there were in-
creased pressure and increased tension of the pul-
monary artery, and greater recoil against the valves.
This was marked in emphysema and in pneumonia,
i.e., the acute lobar form. In this disease the study of
the second sound was a very important point; so long
as the power held out the pulmonary second sound was
accentuated; but when it began to fail it was always
an ill omen. The application of a tourniquet to the
limb influenced pressure in the aorta, and there fol-
lowed a little accentuation of the second sound. This
was increased in conditions of general arterial tension,
as was found in Bright's disease, in chilling of the
surface after exposure to cold, and in epilepsy. Bal-
four claimed that whenever there was accentuation of
the second sound there was hypertrophy of the left
ventricle.
Dr. Lewis A. Coxnor said the fact that not all the
cases were normal cases, some patients having anamia,
others pulmonary tuberculosis, etc., might interfere
with the accuracy of the records; but many of those
examined were not at all ill. The doctors, the nurses,
the parents who accompanied children, were examined,
and as great care was taken the probabilities were that
the records were not far from right. Most text-books
made a mistake in not distinguishing between the
sounds heard in the adult and the sounds heard in
children. From the age of thirty years on there was
marked accentuation of the second sound; this accent-
uation was more marked and constant with each
decade. Dr. Creighton did not think her explanations
adequate; they w-ere only suggestions. Regarding the
.taking of the aortic second sound as the standard,
that could be done only when we were sure that the
individual was perfectly normal.
A Case of Bilobar Pneumonia ; Purulent Peri-
carditis; Pericardotomy ; Recovery. — Dr. Morris
Manges presented the patient, whose history briefly
was as follows: The boy, aged fifteen years, was ad-
mitted to the wards of the Mt. Sinai Hospital on July
6th last. His illness began two days previous with
fever, chill, etc., and he presented a pneumonic proc-
ess at the right base and left apex. He was then
suffering from a bilobar pneumonia. His condition
remained the same until July 9th, when there was
flatness at the right base; he was aspirated, in the
expectation of finding fluid; but none was found.
Two days later he became worse, and a trilobar pneu-
monia was found, the left lobe being involved. In
spite of all his general condition remained relatively
good. Respiration was 92, with pulse and other
things corresponding. Resolution began on July
13th, and 'his condition improved rapidly. On the
following day there was found a to-and-fro friction
murmur at the base. The pulse was irregular and
paradoxical. Resolution continued until his general
condition improved. The pericardial area soon be-
came smaller, and the temptation to tap the peri-
cardium was resisted. The boy's condition continued
to improve until August 6th, when a friction murmur
was readily obtained over the base of the heart. The
heart became more rapid, and the case looked like a
septic one. On August 13th things suddenly changed;
there was an increase in the dyspnoea and vomiting
occurred ; the pulse became irregular, and gradually the
MEDICAL RECORD.
[January i 3, 1900
dulness increased so that the area became advanced
one-half an inch outside the left nipple line. It was
decided that the pericardium then should be emptied,
and eighteen and one-half ounces of purulent fluid was
taken away; the microscope showed this to contain
pure cultures of the pneumococcus of Frankel. The
relief was transitory. Next the pericardial sac was
opened, and forty fluidounces removed. The patient
continued to improve, although there was a consolida-
tion of the left lobe posteriorly. On September 4th
the boy was out of bed and was then discharged. The
patient was then shown to have had a typical adher-
ent pericarditis; the cardiac area was normal, and
there was no murmur. His general condition was
good, and the boy was now following his occupation
of a district telegraph messenger.
In Dr. Meyer's analysis of five hundred cases of
lobar pneumonia, fifty-eight cases were bilateral, of
which only twenty-seven per cent, resulted fatally.
Pericarditis was a complication in eleven cases; in
forty-one cases there was an endocarditis; of these
there was a mortality of forty-five per cent. Regard-
ing the patient shown, he said the pericarditis per sc
did not influence his recovery in any way. It was
not until one month had passed that the pericarditis
developed. The septic condition being of a moderate
type was e.xplained probably by its not being due to
the streptococcus or the staphylococcus, but to the
pneumococcic infection. Although pericardial effu-
sion occurred in pneumonia it did not call for imme-
diate interference. The pneumococcus was the cause
of many cases of pericarditis. Regarding pyo-pericar-
ditis, it might occur in pneumonia, osteomyelitis, trau-
matism, etc. As a rule the attention was called to
the occurrence of pericarditis by a to-and-fro murmur;
one should bear in mind that this might last but a few
hours, and so might often be overlooked; pericarditis
with effusion was often present without giving rise to
symptoms, even when the effusion was very large.
Pyo-pericarditis was not rare. There had been six
cases in the Mt. Sinai Hospital, three of which re-
sulted in recovery, and three were fatal ; three patients
died after aspiration. Aspiration did good in all but
one case. In one case one ounce was drawn oii\ the
patient was cured. In the second case two ounces of
blood and serum, were removed, but the patient died.
In another case two ounces was withdrawn ; the patient
recovered. The fourth case was the one cited ; eigh-
teen and one-half ounces was drawn off, and the patient
recovered. On the other hand, in some cases aspirated
it would have been better to have left them alone. A
small needle should be inserted to get the serum for
diagnosis. If simply serum was found and the symp-
toms were not urgent, the case should be let alone; if
pus was found, the patient should be handed over to
the surgeon. In the patient presented, eighteen and
one-half ounces of pus was removed the first day, and
forty ounces the next, making fifty-eight and one-half
ounces removed, which was an exceedingly large quan-
tity to be taken from a boy of his size. There must
be some good indication for aspirating. Skoda
said that there were two good rules for entering the
pericardial sac: (i) when the sac was distended with
a large exudate which showed no tendency to absorb,
and the patient was running down; (2) a vital indica-
tion was intense dyspnoea.
Dr. Howard Lilienthal's remarks were read by
Dr. Manges. On account of the intense dyspncea, and
the boy's bad condition, it was decided to use eucaine
as a local anaesthetic. During the operation the boy's
attention was drawn away from the work by talking to
him. He was not told that an incision was to be
made; he thought that he was to be aspirated again.
He felt no pain at all. A trap-door was made as sug-
gested by Roberts, It was a triangular one, begin-
ning one-half inch from the sternal border. The
hemorrhage was insignificant. A stitch was used to
make the wound patent. The pericardium was thick
and so rigid that the skin was drawn in instead of the
pericardium being drawn out. Irrigation was made
with a soft-rubber tube. Si.-c weeks after the operation
the patient was discharged. Pyo-pericarditis was a
surgical disease, and harm could result only from de-
lay in treating it surgically. Tapping had invariably
failed in all cases treated. Eucaine seemed to the
author to be the best anaesthetic in these cases.
There was danger of infecting the pleural cavity if
special care was not taken.
Dr. Lewis A. Connor related a curious and re-
markable case which occurred during his service at
the Hudson Street Hospital. The man was thirty-five
years of age, and came into the hospital in a condition
hardly showing a case of pericarditis. The patient
went on from bad to worse, and finally his condition
became so grave and his state so critical that he was
aspirated, and thirty ounces of fluid was removed.
The patient was then turned over to Dr. Stimson. He
was placed on the operating-table, and a four-per-cent.
cocaine solution was used ap an aneesthetic. A rib
was exsected, and an enormous quantity of pus was
discharged, probably sixty or seventy ounces. A
slight nick in the left pleura was made, and the
operators were surprised to find that- the left pleura
extended so far to the right. The patient lived for
some days afterward, but died of sepsis, which could
not be explained by the condition in the pericardium,
which was thoroughly and completely drained. There
were some obscure and indistinct signs over the chest.
The autopsy showed that the pericardium had been
doing well, but there was a sacculated empyema of the
left pleural cavity which it was difficult to recognize
clinically. If the pleura had not been infected the
speaker believed the man might have recovered.
Premature Burials. — Dr. H. L. Garrigues read a
brief paper on this subject. He said that physicians
differed much in their views as to whether burials of
living persons were frequent or not, some declaring
that they never occurred, and one, who had made a
special study of the question, saying that one person
out of every two hundred was buried alive. He did
not believe that premature burials were very rare — first,
because, though graves were so rarely opened, yet it
was found in a number of cases that the inmate of
the grave had revived in the cofiin ; second, because
there were so many narrow escapes from being buried
alive; third, because of the unreliability of the so-
called signs of death, with the sole exception of un-
questionable putrefaction of vital organs; fourth,
because of the absence of proper laws to protect the
apparently dead against live burial ; fifth, because
of the carelessness with which death certificates were
signed by physicians. The speaker favored waiting
mortuaries, where bodies should be kept under proper
supervision till decomposition had begun. He con-
cluded liis paper by stating that only authorized prac-
titioners of niedicine should decide whether a person
was dead or not; that blanks for certificates of death
should contain questions in regard to the chief signs
of death, and the physician signing the certificate
should answer each question with " yes " or " no," be-
sides declaring that he personally had examined the
body; that it should be made a crime to do anything
to the supposed dead that would cause pain or injury
to a living person, before the certificate was signed.
As long as nothing of the kind was done, nobody had
any guarantee that he would not be buried alive,
thrown into a glowing furnace, or be killed by the
performers of autopsies, the undertakers with their ice-
boxes, or the embalmers with their solutions of ar-
senic.
January 13, 1900]
MEDICAL RECORD.
79
Demonstration and Description of Apparatus to
Prevent Premature Burial. — M. Emile Camis, of
Paris, demonstrated the life-saving apparatus, " le
kainice," whicii was composed of a tube four inches in
diameter, resting on the casket, and connected at the
other end to a rectangular metallic box containing
signals. The metallic box alone was visible above
the grave; the other parts were buried in the ground.
A metal rod passed through the axis of this tube, its
lower end going into the casket and being placed in
communication with the signals in the metallic box at
its upper end. The part of the rod entering the cas-
ket terminated in a ball which was placed one and
three-fourths to two inches from the sternum of tlie
interred person. Should a movement of the body in
the casket occur the bail was displaced; by the aid of
simple mechanism a general simultaneous action took
place; the box was opened, and the signals, bell, flag,
shining ball were put in motion or were displayed;
the sound of the bell was sufficiently sonorous to at-
tract the attention of the cemetery watchman. Also
the buried person received air and light, even at night,
and his voice was carried through the tube and heard
over a large radius.
Election of Officers. — The following officers were
elected for the ensuing year: Chairman, John H.
Huddleston, M.D. ; Secretary, E. Franklin Smith, M.D.
.SECTION ON OBSTETRICS AND GYN.ECOLOGY.
Stated Meeting, December 28, i8gg.
Brooks H. Wells, M.D., Chairman.
Imperforate Uterus with a Large Haematoma of
the Ovary Dr. H. J. Garrigues presented a speci-
men taken from a young girl, twenty years of age, who
had never menstruated. Slie had suffered from epi-
leptic seizures coming not only at the time of the men-
strual molimina, but in the intervals. Vaginal exam-
ination had revealed a normal vulva and a vagina two
inches deep. Above this was a large, round mass, one
portion of which was much harder than the rest. On
October 25, 1S99, he had performed laparotomy. This
had revealed a uterus about the normal size and shape,
though a little thicker antero-posteriorly than normal.
The right ovary was slightly enlarged, and showed a
fresh corpus luteum filled with blood. The right tube
was normal. The left tube was bound to a cyst nearly
filling the pelvis, and adherent to the intestine. He
had removed the uterus, and had then extirpated the
cyst, nhich proved to be a hasmatoma containing ten
ounces of chocolate-colored bloody fluid. Seventeen
days after the operation three pints of old blood,
mixed with pus, had been evacuated through the
vagina. A sound had passed through an opening in
the upper vagina in the direction of the right iliac
fossa. The opening had been dilated, and the cavity
drained. The patient did not now suffer from the
menstrual molimina, but she had had several epileptic
seizures during her stay in the hospital. The tubes
were found to be lined with normal mucous mem-
brane. Tiiere was no evidence of a canal in the
uterus. The fact that the uterus was of nearly normal
size and shape made the case almost unique. The
haematoma was an evidence of vicarious menstruation
internally which, according to the history, had been
going on for about four years.
Dr. p. a. H.4RRIS asked what had intervened be-
tween the cervix and the depression representing the
vagina.
Dr. Garrigues said that he had seen one other
solid uterus, but it had not presented the usual shape
of a normal uterus. In reply to the question of Dr.
Harris he said there had been about half an inch of
soft tissue intervening. In two other cases he had
succeeded in making a connection between a stenosed
vagina and the uterus, and such a procedure would
have been indicated here haa lie not been informed
that a competent gynaecologist had already attempted
something of the kind. In view of the epileptic
seizures and the diminished intelligence of the girl it
had seemed to him that laparotomy was justifiable.
A Combined Endoscope and Cystoscope. — Dr. A.
H. Goelet said that he had been interested in endo-
scopy of the uterus for the past two years, but had
been unable to accomplish what he had desired be-
cause he had been working with reflected light. At
present he was using direct light with much better
results. An instrument constructed on this principle
was exhibited, and its action demonstrated. For more
minute inspection, when that was desirable, a magni-
fying glass was attached. The source of illumination
was a tiny electric light. He had found the instru-
ment principally of value in the determination of the
necessity for curetting. By such inspection one could
decide whether there was an active endometritis pres-
ent or only a hypereemia. One could also determine
by such examination whether the endometritis was
confined to the cervix or implicated the body, and
could inspect the orifices of the Fallopian tubes. The
complete apparatus cost $30; the lamp could be re-
newed at a cost of $2, and was guaranteed to last at
least thirty consecutive hours. The four dry cells
could be replaced at a cost of $1. He had found the
magnifying glass a great aid in passing the ureteral
catheter.
Dr. Garrigues remarked that it might be possible
to introduce the smaller size of this instrument with-
out anaesthesia, but the degree of dilatation required
for the other two sizes would certainly demand the
employment of an anaesthetic. He was of the opinion
that such inspection of the interior of the uterus would
prove a valuable aid to the clinician.
A Case of Ectopic Gestation with Unusual Symp-
toms.— Dr. Ralph Waldo reported the following
case: A married woman, twenty-nine years of age,
had been admitted to the Lebanon Hospital with the
history of having weaned her last child four weeks
previously. She had had an excessive bloody flow,
which she had taken to be her menses. As it had
been profuse she had been curetted, but with no con-
trol of the hemorrhage. On admission, she had stated
that she had had only very slight abdominal pains.
She was very much exsanguinated, and was flowing so
freely that a tampon was required. Examination had
revealed a mass the size of a hen's egg situated be-
hind the uterus. On November 3d she had been
etherized and the uterus curetted, with negative result.
The diagnosis of tubal pregnancy had been made in
spite of the fact that the tumor was not sensitive, and
that there had been severe and persistent uterine hem-
orrhage. The tumor had been freely movable, and
had involved the upper half of the right tube. After
an interval of twenty-four hours the bleeding had
returned, and on November 27th it had been so pro-
fuse as to necessitate tamponade of the uterus to save
the patient's life. The following day laparotomy had
been done. This had revealed an ectopic gestation
in the outer half of the right tube, and a clot protrud-
ing from its fimbriated extremity. The tumor had not
ruptured. There was a large quantity of blood in the
abdominal cavity. The foetus had not been found,
although other products of conception had been pres-
ent in the tube. The left ovary was three inches in
diameter, and was composed of several well-defined
cysts. This ovary and its tube had been removed, and
the patient had made an uninterrupted recovery. The
case was reported because of the absence of tender-
ness and the profuseness of the hemorrhage.
Dr. H. J. BoLDT also presented a specimen of
8o
MEDICAL RECORD.
[January 13, 1900
ectopic gestation. It had been taken from a woman
who had been seized nine days ago with severe pain
in the lower part of the abdomen. From her extreme
pallor, the excessive tenderness of the abdomen, and
the sensitiveness and fulness in the vaginal cul-de-
sac, he had suspected ectopic gestation. The woman
also had a complete procidentia of the uterus. She
had been kept in the hospital for a few days for obser-
vation, but as she had not improved he had opened the
cul-de-sac two days ago, and at once a quantity of
blood had gushed out. He had then removed the
uterus, and had discovered that the impregnated tube
had ruptured near its abdominal extremity. The last
menstruation was said to have been on time, but he
had just learned that the last period had been of only
two days' duration, whereas the preceding one had
lasted nine days. With this exception the history had
been absolutely negative as regards pregnancy.
Intussusception Mistaken for Ectopic Gestation.
— Dr. Boldt also presented a specimen from a case
which had been supposed to be one of extra-uterine
pregnancy. It had been removed from a woman who
had been taken ill with severe vomiting She was
supposed at that time to be pregnant about six weeks.
Albuminuria was present. For the next two or three
days there had been a slight rise of temperature, and
an increasing and diffused abdominal tenderness.
She had stated that she had not menstruated for six
weeks, and had had some abdominal pain, during
which time there had been a slight bloody discharge
— a " spotting." When seen by the speaker the pulse
had been small and rapid, and the temperature a little
over 100° F. The greatest tenderness had been in
the left iliac fossa. On vaginal examination the
uterus had been found soft and rather large, and to
the left was a large doughy mass filling the cul-de-
sac. A few hours later he had opened the abdo-
men, and had been rather surprised not to find any
blood. A peritonitis was present. A portion of the
intestine was found in the pelvis, and this was gan-
grenous for a considerable length. On opening the
bowel he had found an intussusception, due to the
presence of a polypus which measured seven and one-
half by eleven and one-fourth inches. The case was
of interest because he had at first made a provisional
diagnosis of intussusception, but had changed it after
having made a vaginal examination. On looking over
the literature of the subject he had found one case
reported by Otto Kustner in which menstruation had
suddenly ceased in a woman having a retroflexed and
adherent uterus. After nine weeks the woman had
consulted Kustner, and he had found a sensitive tumor
to the left of the uterus. About this time there had
been a slight bloody flow for a few days. On auscul-
tation of the abdomen a sound had been heard which
had been taken for the placental souffle. Having
skipped her third period she had been examined under
anesthesia, and then it had been discovered that the
above-mentioned tumor had increased to the size of a
gestation at the third month. A diagnosis of ectopic
gestation had then been made, and laparotomy had
been performed. The operation had revealed, not
ectopic gestation, but a sarcoma of the ovary with
numerous hemorrhagic infarctions. This woman had
previously never missed her menstrual periods.
Dr. p. a. Harris remarked that in two or three
cases of ectopic gestation coming under his care there
had been an excessive bloody flow, although in addi-
tion tliere had been pain and tenderness.
l)u. Waldo called attention to tiie fact that in his
case the hemorrhage had been so excessive that tam-
ponade of the uterus had been demanded on two occa-
sions as a life-saving measure.
Soft Myoma in a Young Girl ; Wrong Diagno-
sis.— Dr. H. J. Boldt reported the following unusual
case occurring in a virgin aged eighteen years. Men-
struation had beeri established only about two years.
On examination he had found a freely movable tumor
extending nearly up to the umbilicus. Examination
under an anaisthetic had failed to show the presence
of ovaries. The tumor had presented marked fluctua-
tion. A diagnosis of ovarian cystoma had been made,
but on introducing a trocar nothing had been removed.
The abdomen had then been opened, and this had
revealed an exceedingly soft myoma. The fact that it
had occurred in a patient so young was of peculiar
interest.
Fibroma of the Ovary. — Dr. A. Brothers said
that he had seen at his clinic, last summer, a woman
aged forty-seven years, the mother of seven children.
She had been well until six years ago, when she had
noticed a swelling in the abdomen. This had steadily
increased in size. A hard tumor, apparently a fibroid,
could be easily mapped out. Seven weeks later she
had been admitted to the Post-Graduate Hospital
with a pulse of 136, a temperature of roi.8° F., and
excessive tenderness of the abdomen. A few days
later laparotomy had been done, revealing a tumor
separate from the uterus. A considerable quantity of
pus had escaped during the effort to remove the tumor.
The latter had proved to be a fibroma of the ovary.
On account of the suppurative condition present,
through drainage had been established by way of the
vagina. After the operation the temperature had risen
to 104" F. and the pulse to 144. Two days later the
dressings had been found soiled with fa;ces. A few
days after this the urine had shown evidences of ne-
phritis, and the patient had become delirious. Sus-
pecting iodoform poisoning, as well as nephritis, the
parts were flushed and all iodoform was removed.
She had improved steadily after this, but a secondary
operation had been required to secure closure of the
wound. The pathologist, Dr. Henry T. Brooks, said
that he could find no trace of ovarian structure, yet he
inclined to the diagnosis of fibroma of the ovary.
Dr. Garrigues said that a number of years ago two
large tumors had been brought to him for micro-
scopical examination. They were ovaries, yet there
had been no trace of ovarian tissue remaining, the
masses having been entirely converted into fibrous
tissue.
Dr. Boldt said that a few years ago Dr. F. Ferguson
had examined for him a fibrorna of the ovary. He
had seen one other case in which the appearance had
been that of a fibroma, but no microscopical examina-
tion had been made. With regard to the case just
reported by Dr. Brothers, he would say that the sup-
puration was due either to a complicating appendicitis
or to traumatism. The latter cause was not uncom-
mon when, as in the case under discussion, several
students had been allowed to make a pelvic examina-
tion.
Imperforate Hymen — Dr. A. Ernest Gallant
presented a specimen of imperforate hymen. A young
woman who had been married seven weeks had pre-
sented herself because sexual intercourse was impos-
sible. On examination he had found a crescentic
hymen with a band at the upper portion, which had
constituted the obstruction.
Dr. Brooks H. Wells referred to two cases which
he had seen in which there had been a tiny opening
through a thick and fleshy hymen.
Dr. p. A. Harris said that about twelve years ago
he had operated upon a woman who had been married
six years. Sexual intercourse had been inipossible
because of a very small opening. He had removed
portions at a time, and had practised dilatation. She
had been very grateful for the relief afforded, and
about one year later had been delivered of a child.
Subsequently she had expressed her sorrow at having
January 13, 1900]
MEDICAL RECORD.
Si
submitted to the operation, because tlie children were
coming so rapidly.
A Second Contribution to the Study of Ulcerative
Lesions of the Vulva, Commonly Called Lupus or
Esthiomene Dr. Grace Peckham-Murray read a
paper with this title. She stated that the case forming
the basis of this paper had been first reported upon to
the Academy of Medicine in May, 1887. The patient
was a woman, forty-eight years of age, who at that
time had passed the menopause two years. She had
had six children and one miscarriage. In 1879 she
had married the second time, her second husband
being a Norwegian sailor who had had syphilis.
Microscopical examination of the growth about the
vulva had been made by Dr. H. C. Coe, at that time
the patliologist of the Woman's Hospital, and he had
reported evidence only of inflammation of connective
tissue. The question had arisen as to whether the
ulcerative condition present was non-specific or was
the result of tuberculous or syphilitic infection. Dr.
Murray said that since her first paper on this subject
there had been only five others published. She had
succeeded in collecting from the literature only sixty
cases of this affection, showing its rarity. Pozzi had
given, in his text-book, one of the best descriptions of
this disease. In 1889 Dr. J. Nevins Hyde had de-
scribed these cases under tiie title " Syphiloma of the
Vulva." In 1890 Dr. Robert W. Taylor had presented
an article on the same subject, elaborately illustrated.
He divided these cases into six classes. One class
represented simple ulceration; the other five were va-
rious forms of syphilitic ulceration. Dr. Taylor had
repudiated the idea of these cases being lupus. All
observers agreed concerning the slowness of growth.
The speaker said that she believed that the disease
might be the result of prolonged irritation. She was
not prepared to say tliat these cases were never lupus,
but she believed that this form of ulceration might be
tuberculous, syphilitic, or non-specific. In the case
reported by her the original intention had been to re-
move the tissue by operation, but the patient would
not consent. There had been only one microscopical
examination made, but in view of the fact that a num-
ber of cases had been reported in all of which the
microscopical appearances had been the same, she
had not thought it necessary to have the examination
repeated.
Dr. J. H. Emerson said that he had seen an almost
identical case, and had had it examined by a patholo-
gist, with like result. In that case the history had
been one of alternate healing and breaking down.
After a long course of antisyphilitic treatment without
benefit, she had been sent to St. Luke's Hospital, and
Dr. B. Farquhar Curtis had done an extensive resec-
tion, but the patient had not remained in the hospital
long enough to secure proper healing.
THE MEDK:AL SOCIETY OF THE COUNTY
OF NEW YORK.
Stated Meeting, Decemher 26, i8gg.
George B. Fowler, M.D., President.
Successful Removal of a Large Encephalocele from
a Child. — Dr. A. Palmer Dudley reported a case of
hydrencephalocele which had been admitted to the
Harlem Hospital on October 17, 1899, and had been
operated upon by him when the child was only six
days old. The child was the seventh born to its pa-
rents, and all of the previous children and all of the
confinements had been normal. According to the his-
tory, the mother had suffered severely from nausea
during her pregnancy, and had been in labor for two
days, and had then been delivered by a midwife. On
admission, the ciiild's temperature had been 99 " F.,
the pulse 120, and the respirations 26. The child
had a microcephalic head and was poorly nourished.
There was general skeletal evidence of rickets. About
one inch below the posterior fontanelle was a distinct
pedicle which supported a large hernial tumor. This
tumor was translucent except at its neck, and the fundus
of the sac was about on a level with the middle dorsal
region of the spine. The anterior and posterior fon-
tanelles were large, the sutures of the skull were sep-
arated, and all of the bones of the cranium were poorly
ossified. At a point just above the external occipital
protuberance was an opening through which protruded
the encephalocele. The tumor gave no impulse on
coughing, but was fluctuating and irreducible. The
longest diameter of the tumor was nine inches, the
transverse five inches, and the diameter of the opening
in the occipital bone one and a half inches. There
were no special constitutional symptoms, and abso-
lutely no cerebral or localizing symptoms. On Octo-
ber 21st he had done a complete amputation of the
hernial sac and its contents without anaesthesia of any
kind. A ligature of catgut was applied around the
pedicle 'and slowly tightened. During this process
there were general contractions of the muscles of the
left half of the body. Two flaps of good size were
dissected up. Over two pints of a straw-colored fluid
were evacuated on making an incision. The ligature
at this time had slipped, and had been removed en-
tirely. There had been hut little hemorrhage in spite
of this accident. The cerebral hernia had then been
divided at its neck, thus completing the amputation.
No vessel had required ligature. The child had
seemed to suffer no pain during the operation, and had
certainly made no outcry. Very little shock had fol-
lowed the operation, and during the next nine days
the temperature had remained at about 100^ F., and
the pulse between 100 and 124. Slight suppuration
had occurred about the stitches, and the latter had
been removed on the ninth day. On the evening of
that day the temperature had fallen to 96° F., and
there had been slight convulsions on the right side of
the body and face. There had also been some spastic
rigidity. During the next twenty-nine days the tem-
perature had been remittent. On the fortieth day the
temperature had fallen to the normal point, and had
remained there since that time. The stump had healed
well, but there had been no ossification about the her-
nial opening. The child had taken nourishment well.
Ophthalmoscopical examination showed the vessels of
the retina to be apparently normal. The pupils did
not react to light. The speaker said that, of seventy-
nine recorded cases, in fifty-three the opening had
been in the occipital bone. In six instances the sub-
ject had reached adult life ; the others had died in early
childhood. The case reported was not a simple
meningocele or a simple encepholocele, but a hydren-
cephalocele. He had removed 57 gm., or nearly two
ounces, of brain substance at the operation. Micro-
scopical examination showed the portion removed to
be brain tissue, but the pathologist was unable to
locate the part. Both child and specimen were ex-
hibited.
Dr. William M. Leszynsky said that it was a ques-
tion in his mind whether such an operation was justi-
fiable save for cosmetic purposes. The very fact that
57 gm. of brain substance had been removed showed
how dismal must be the outlook for this child; even
if the baby should live for Some time it was not likely
that it would be able to see — indeed, the lack of
pupillary reaction pointed strongly in that direction.
Acquired Non-Malignant Stricture of the Rectum.
— Dr. W. Duff Bullard read a paper with this title
(see page 47).
S2
MEDICAL RECORD.
[January 13, 1900
Dr. Otto Kiliani said that at first one might be
surprised at the statement that the majority of rectal
strictures were of syphilitic origin, but those who saw
many cases of rectal disease knew this to be a fact.
When a stricture assumed the form of a complete ring
it was not uncommon to find two or three other such
rings situated a short distance apart. When the
ulceration was severe and obstinate to treatment he
would favor an early resort to inguinal colostomy.
Proctotomy would not be sufficient in all cases; some-
times e.xtirpation would alone meet the indications.
Dr. Jaimes p. Tuttle expressed his great surprise
at the statement that syphilis was only a predisposing
factor of rectal stricture. Of course, a man with
syphilis might have a benign stricture of the rectum,
or even a stricture in which tubercle bacilli were pres-
ent, but this did not prove the stricture to be tubercu-
lous. Tuberculosis of the rectum rarely manifested
itself by such an amount of infiltration as one would
expect would be necessary to cause rectal stricture. If
both traumatic and non-traumatic strictures were con-
sidered, he would say that it was perfectly true that a
majority of rectal strictures were non-malignant; but
if only pathological strictures of the rectum were
under consideration, then he would assert that fully
sixty-six per cent, were due to syphilis. In a case of
traumatic or simple inflammatory stricture the micro-
scope showed an increase of fibrin and fibrous tissue
with little cell increase, and no characteristic change
in the blood-vessels. Before one could say positively
that a stricture was syphilitic or non-syphilitic, the
tissue must be subjected to careful microscopical ex-
amination. Ulceration and cellular infiltration, or
fibrous cicatrization, were the essential elements in the
production of rectal stricture. Pathology had certainly
demonstrated the characteristic dift'erences between
syphilitic and simple inflammatory stricture. Regard-
ing the treatment he would say that he had been deeply
disappointed with the operation of posterior proctot-
omy because these strictures persistently returned.
For a well-formed stricture of the rectum he knew of
only one method of cure, and that was extirpation.
Dilatation came next in importance. He had never
seen a case of posterior proctotomy in which the stric-
ture had not returned in time. After much study and
experiment on the cadaver he had become firmly con-
vinced that it was impossible to introduce the Kelly
tube into the descending colon.
Dr. Frederick Ka.mmerer said that his personal
experience had been that he had never seen a well-
developed rectal stricture that was not syphilitic. Of
course, by a " stricture" he meant a narrowing of the
rectum sufficient to give rise to symptoms. He had
occasionally obtained a good result from posterior
proctotomy, being able to keep it in abeyance by dila-
tation. Resection of a large stricture of the rectum
was an operation of much difliculty and danger, and
therefore he would favor posterior proctotomy as a
first resort. Resection of the stricture itself was also
sometimes followed by stricture.
Dr. Tuttle explained that he would not recommend
resection of the rectum except in cases that did not
prove amenable to milder measures.
Dr. Palmer Heath Lyon recalled a well-developed
stricture of the rectum seen recently in a patient upon
whom a homteopathic practitioner had endeavored to
operate for the relief of hemorrhoids by injecting them
with carbolic acid. In this case there had been no
evidence of the stricture being other than of traumatic
origin.
Dr. Bullard, in closing, said that he was not yet
convinced that syphilis was the cause of rectal stric-
ture; to his mind, adequate microscopical proof had
not yet been presented. No case had yet been re-
ported in which there had been degeneration of the
embryonic nucleus, which was essential in a syphilitic
gummous formation. If some rectal strictures were
due to gumma, then it should be possible for patholo-
gists occasionally to find these gummata.
Opinion of Legal Counsel on the Case of Drs.
Purdy and Maier.— Robert C. Taylor, Esq., counsel
for the society, having been asked for his opinion on
the recent arrest of Dr. Harry R. Purdy and Dr. Otto
Maier, and as to the best means of preventing- such
outrages in the future, replied that it was his opinion
that the police captain had acted entirely without re-
gard to the law, and that these physicians had a right
to bring a civil suit against Police Captain Delaney.
Regarding the circumstances of the arrest, the state-
ment was made that physicians were not specially lia-
ble to unjust arrest, as witness, for example, the fre-
quent arrests of drivers and motormen in connection
with accidents occurring in the streets, such arrests
being made entirely without warrant. In the judg-
ment of counsel the trouble was not with the law, but
with those who administer the law in this city, and
consequently the remedy was not to be found in
amending the present law. Instead he would recom-
mend that a formal communication be addressed to
the police department, setting forth the circumstances
of the case under discussion. This might result in a
general order to the police captains regarding the
future conduct of cases of this kind.
As a committee had been appointed by the New
York County Medical Association to consider this
same case, a joint meeting of the two committees had
been held. Dr. John Blake White, of the latter com-
mittee, sent a communication stating that the commit-
tee had agreed to recommend the following resolution :
" Resohcil, That it is the sense of the committee that
a vigorous protest be sent to the various medical soci-
eties of Greater New York, to the commissioners of
police, and to the board of coroners, condemning the
unlawful arrest of Drs. Purdy and Maier, two physi-
cians of reputation and standing in the community,
and requesting the board of police to instruct the
police captains to exercise greater care in the future
where reputable physicians are concerned, before
making arrests."
Action Taken. — On the recommendation of the
comitia minora the society voted to send a communi-
cation to the board of police, requesting that more
care be exercised in arresting physicians on suspicion
only.
STATE CARE OF CONSUMPTIVE POOR.
Hearing before a Committee of the State Board oj
Charities, at a Meeting Held in New I ork, December
13, i8gg.
Dr. George G. Wheelock: I believe in the estab-
lishment of a State sanatorium intended exclusively
for incipient cases. This should be located, I be-
lieve, preferably in the Adirondacks, where perhaps
the State could allow a portion of the forest reserve
for the purpose. I say in the Adirondacks by prefer-
ence, because there is in the State nowhere else a
similar expanse of nearly continuous forest growth,
with but little cultivated soil, located in pretty high
altitudes; and experience also has shown, gathered
from the highest medical authorities, that up to the
present time patients coming from a residence for
cure in the Adirondacks have shown better conditions
of improvement and restoration than those in a similar
stage of the disease coming from other climatic resorts.
The question of distance is not a vital one, inasmuch
as all patients should be expected to remain at least
six months; and a single trip of a few hours more or
less only would have to be considered. Moreover,
January 13, 1900]
MEDICAL RECORD.
83
not all places in the State are as far removed as is
New York City from the Adirondack Mountains. If
our purpose is to. cure and not merely relieve, the
best climate should be found for the purpose. As to
the outlay called for, I believe not less than $200,000
should be asked for, as was contemplated in the bill
of last year. It would be a mistake to begin with an
inadequate appropriation.
In this connection the subject of the Farm Colony
should be considered, as the criticism of that plan
will help to emphasize the reasons for selecting the
Adirondacks in preference to the Catskills, or even
Liberty, in Sullivan t'ounty. The Farm Colony can
hardiy be compared with the Craig Colony, for in the
latter employment is the means of promoting a cure,
while with tuberculous patients nearly absolute rest in
fresh air is the prime requisite. Reduction of tem-
perature and arrest of tuberculous processes have been
found after many trials to be impeded rather than
aided by manual labor; hence the occupation of a
spot where there is arable land is not a necessity, and
the less arable land there is about — as in the Adiron-
dacks— the better is the atmosphere for curative pur-
poses.
If as a means of keeping the family together the
Farm Colony is proposed, it would certainly seem
wiser not to advocate it for several reasons, viz. : (i)
The family members are nearly if not quite as much
in contact with the patient as in their city home;
hence infection, which we seek to avoid. (2) The
State would hardly be likely to pay for the support of
a family as well as the patient, and we have seen that
work such as would support a family is bad for the
process of cure. (3) If the family are kept together
it increases the chances of the birth of feeble children,
who, in turn, will perhaps become victims.
As to location, I may say that the late Dr. Loomis,
who originated the sanatorium at Liberty — himself a
victim to the disease — always went for his own cure
to the Adirondacks.
I think the suggestion a wise one to urge the build-
ing of hospitals for advanced cases near the cities,
where tuberculous patients may die comfortably, re-
membering also that as the disease advances the
dangers of infection of those in the immediate vicinity
'ncrease rapidly; and hence, for the comfort of the
dying as well as the preservation and protection of the
family, the patient's removal from home is desirable,
and we know that few private hospitals will receive
him — hence the need of public institutions. Having
arrived at the above conclusions myself, and being
anxious lest they were not fully established, I saw my
friend Dr. Trudeau a few days since, whose experience
and faithful care of tuberculous patients are surpassed
by no one in this country, and whose patient and in-
telligent study of the disease over a period of years
has brought wisdom. We went fully into the above
topics, and I am happy to say that he confirmed in
every particular the views which I have expressed.
Edw.-^rd T. Devine, general secretary of the Char-
ity Organization Society: Three distinct but not in-
compatible methods of fighting tuberculosis are ad-
vocated : First, more strict dietetic and therapeutic
treatment of individual patients in their own homes,
accompanied by educational work to prevent such con-
tagion as can be prevented by reasonable care on the
part of the patient. Second, the isolation of advanced
cases, which are, of course, the most dangerous as
centres of infection, the object of such isolation being
merely to insure better care for destitute patients at
the end of their lives and the elimination of contagion.
Third, the isolation and curative treatment of incipient
cases.
There is entire agreement about the first two methods.
It has been demonstrated that many cases of tuber-
culosis are cured in their own homes, even in cities,
and there has been great advance in the possibility of
diagnosing consumption in its early stages. Aside
from increased vigilance in the medical profession in
the treatment of individual cases, what remains to be
done is the circulation of suggestions and information
through printed leaflets, public addresses, instruction
in schools, and advice given by church and charity
visitors.
The plan of isolation hospitals for advanced cases
meets with equally unanimous indorsement. In New
York City Seton Hospital and the wards recently set
apart in the almshouse hospital are achievements al-
ready secured in this direction, and the prospective re-
moval of insane patients from Blackwell's Island will
give increased opportunities of which the department
of charities will doubtless be quick to take advantage.
If these facilities are not sufficient, and if it becomes
necessary, the Henry law authorizes the city to arrange
for an isolation hospital outside the city limits. In-
creased facilities for caring for such patients are still
imperatively needed, but the indications are that the
rapid progress of the past year or two will be continued
until there is something like an adequate provision
for the need. It is only when the plan of caring for
incipient cases by a State institution is proposed that
there arises difference of opinion, and this on close
examination is found to be a difference of emphasis
rather than of principle.
A State sanatorium for incipient cases is urgently
needed in addition to all that can be done by local
isolation hospitals and by improved treatment of pa-
tients in their own homes. It is needed, first, because
it will cure a large number of patients who cannot be
cured at home, and whom it is a disgrace to the com-
munity to leave until they are fit subjects for the isola-
tion hospital. In the sanatorium proper diet, favorable
climatic conditions, the absence of severe physical
labor can all be secured, and incidentally the patient
can be taught lessons which will be useful to him, to
his family, and to his neighbors. The saving of lives
in this way has a direct money value to the State, as
is recognized by our attempts to prevent murder, to
protect from fire and other public calamities, and by
ample precedents in other directions. If nothing else
could be said for the State sanatorium than that it
would save annually a dozen lives by curing consump-
tion in its early stages, this would be ample justifica-
tion for the proposed expenditure. This is especially
true since its object is not to prolong the lives of those
who have at best a few months to linger, but in many
instances those who are young and strong and who on
being cured of their incipient disease may live long
and useful lives.
Second: Of all the objects which the State may
legitimately pursue, none is more clearly justified
than the safeguarding of the public health from con-
tagion and from such diseases as are due to social
causes rather than to the neglect or misfortune of the
individual. This is recognized in the efYorts made in
every progressive community to secure a pure and
healthful water supply. The resident of the country
may perhaps dig a well and secure water for his own
family without either the consent or the aid of his
neighbors. Residents of cities and towns, however,
are entirely dependent upon the conclusions which
may be reached and the action which may be taken by
the community as a whole. If the water supply is
tainted or defective he has no recourse within himself.
Even those who are the most extreme opponents of
paternalism and the most earnest advocates of sturdy
individualism concede that there are nimierous duties
thus devolved on the State or its political subdivisions,
and that among these the protection of the public
health from dangers which lie in social conditions is
84
MEDICAL RECORD.
[January 13, 1900
perhaps the foremost of all. It becomes, therefore, a
question whether there is especial danger from con-
sumption marking it out as a disease which should be
attacked vigorously and by every means at the com-
mand of society. The facts that have been brought
out in regard to this by the vital statistics, by the dis-
cussions in medical periodicals and in medical so-
cieties, and by the experience of those who work in
public and private charities, are perfectly clear and are
admitted on all sides to be appalling. It is not neces-
sary to enumerate them. Tuberculosis claims so large
a number of victims relatively to other diseases that
it stands without rival as the great scourge of man-
kind. It is in its incipient stage curable; it is in all
stages communicable. The duty of the State, there-
fore, to expend large sums if necessary, and certainly
to expend the moderate sum contemplated for the
establishment of one State sanatorium stands out more
and more clearly the more the subject is examined.
Its victims are by no means the poor alone. That it
has claimed one member of the State board of charities
since the present investigation was begun, and that in
every discussion of the subject, even in the smallest
group, it is necessary to use discretion on account of the
sensitive feelings of those whose immediate kindred
already bear its mark, are a sufficient indication of its
universal and as yet unchecked way. Yet it is to a large
extent preventable, and awaits only aggressive, intelli-
gent, and courageous action. Half-hearted measures
will not suffice. There are no such poverty-stricken
condition of the State and no such rival claims upon
its resources as wall excuse our dallying with the
problem. One need not be a socialist to favor State
action in matters of this kind, while the fear of being
charged with paternalism in the face of an obvious
public duty is as absurd as would be the charge of
militarism if the nation were to expend money for
coast defences in the face of an actually impending
invasion. The State sanatorium would not merely
save some lives and restore to life and activity a cer-
tain number of human beings each year. It would
also be an experimental station in which our knowl-
edge of how to treat the disease would be constantly
advanced, and which would be a constant source of in-
spiration and information to the great body of the
medical profession, on which we must, of course,
chiefly rely. It is only by limiting in this way the
various complications which are always present when
patients are living at home, and especially when they
are engaged in their ordinary occupations, that the
disease can be closely observed and the effects of dif-
ferent kinds of treatment can be positively ascertained.
Private sanatoria are excellent in their way, but they
are for the rich or for the limited few for whom pri-
vate assistance is forthcoming. Not all of the re-
mainder who should be treated can be induced to give
up their work and to be absent from their homes for
the period necessary to secure results in a sanatorium,
but throughout the State there are many who would be
able to make special arrangements of this kind and
who could be persuaded to do it when they realized
that their lives are at stake. Even the hard-working
mechanic who has a family to support will often be
able, by the help of relatives and friends it may be,
to leave his family for six months, and he can be per-
suaded to make the necessary sacrifices to do this if
he realizes that the present temporary absence may
mean, and possibly will mean, that he can continue to
support his family for many years and to bring up his
children, whereas if he does not have this opportunity
they will be left within a year or two entirely depend-
ent and without their natural support. Of course, not
all can do this. Otherwise the problem would be
unmanageable. By caring for the limited number
who could be received under conditions favorable for
good results we shall benefit not merely them but the
communities in which they live, and this would be
done not merely by restoring them to lives of useful-
ness, but by preventing the development of an ad-
vanced case of tuberculosis with all its dangers.
The question remains where the State shall draw
the line. The only answer to this is that there is no
absolute dividing line between what the State should
and should not undertake in the protection of the
public health, but that the question must always be
one of expediency, in which the conclusions will be
reached by balancing in a rough way the cost of pre-
vention and the cost of failure to act. So far as
tuberculosis is concerned the cost of acting is reduced
by the fact that in the Adirondack preserves, and pos-
sibly also in other sections, the State has a valuable
working capital already in its possession. There is
some dispute as to whether an unfavorable climate or
the proximity of cultivated land, or the presence of
large numbers of cattle, is chiefly responsible for the
presence of tuberculosis in districts where population
is congested. Whichever view is correct, we are re-
markably favored in that the Adirondack region has a
suitable climate if there is such a thing, has a large
uncultivated tract which many believe to be an espe-
cially valuable consideration, and it is a community in
which it is easy to take any necessary precautions re-
garding contagion, from the small number of cattle
necessary to supply the needsof its limited population.
Other States with far less taxable property have not
found the expenditure for a sanitarium burdensome.
With our advantages in the particulars mentioned the
burden would be still lighter upon us. On the other
hand there is no State in which the frightful cost of
failure to act is as great as here. With crowded popu-
lations at both ends of the State and with the great
majority of our population living in cities, with our
supply of fresh milk necessarily coming from at least
three States, and with the meat supply of most of our
population coming from many States, there are some
phases of the problem with which it is especially diffi-
cult for us to deal. It becomes the more important
that we shall adopt such measures as lie within our
power.
Citizens of the State as taxpayers naturally look to
the State board of charities to sound a warning note
against extravagance or abuses of any kind in the
State charitable institutions. To act in such ways as
a watchdog of the public treasury is an exceedingly
useful service which will alwa3S be appreciated. On
the other hand, it is quite as important that the State
board of charities shall carefully consider the public
needs of the State, and shall sound a note of warning
when the State is neglecting or omitting to do what
the public interests require. This may require greater
courage, but it is a kind of leadership which will in
the long run be appreciated by the citizens of the
State quite as much as protection against extravagance.
Justifiable expenditure for a necessary purpose is not
extravagance, and a responsible board to which the
public looks for leadership should no more be fright-
ened by a false and misleading cry of extravagance
than by the equally false and misleading charge of a
tendency toward paternalism. Those who are inter-
ested in the welfare of the poor, and who believe that
the State is neither extravagant nor unduly paternal
when it takes reasonalile precautions to ward off from
them their most insidious and dangerous foe, look
now to the State board of charities for aid and en-
couragement in the establishment of a State sanatorium
for incipient cases of tuberculosis.
Dr. Alfred Mevf.r: The answer to the question.
Shall or shall not the State lend its aid to the con-
sumptive poor by the erection of properly located and
properly equipped sanatoria? will depend, in my
January 13, 1900^
MEDICAL RECORD.
85
judgment, upon the answers given to three cognate
questions: (i) Is it or is it not better for the con-
sumptive poor to remove them from their unsanitary
surroundings and to place them under medical super-
vision with attention to all the details of hygienic liv-
ing? In other v.-ords, do they or do they not have a
greater chance of recovery in the country under con-
tinuous medical supervision, than in the crowded
centres with an occasional visit from their lodge
physician, a visit to the dispensary or to the hospital?
This is a distinctly medical question. (2) Is there
or is there not some constitutional objection to State
aid in New York? This is a distinctly legal question.
(3) Is it or is it not expedient for the State to exercise
this right, if permitted so to do by the constitution?
This is a distinctly sociological question.
Unless we say that American consumption differs
from the consumption of other nations, the first ques-
tion must, I believe, be answered in the affirmative,
because of the accumulated experience of medical men
the world over. For, whatever difference of opinion
there may be upon the question of the relative value
of altitudes, the relative value of dryness and moisture,
and of other meteorological conditions, there is general
agreement upon the need in these cases of abundant
fresh air and light, and good food, and intelligent
supervision, and the greater probability of recovery if
these conditions are fulfilled. It is the sifting down
of the treatment to these primordial hygienic prin-
ciples that has shown us why our efforts in the great
population centres are so futile; but, though the road
we should follow has been clearly pointed out to us,
it is only the well-to-do citizen who can follow it. It
will not do to answer, as some have done, that patients
sometimes get well under bad surroundings, while
they continue at work and have only occasional medi-
cal advice. You might as well say there is no need
of guard rails in front of a trolley-car because occa-
sionally a citizen escapes being hit and run over by
the exercise of unusual agility; or, to make a more
distinctly medical comparison, that there is no need
of disinfecting the dejecta of typhoid-fever patients
because at times this wise precaution is neglected
with impunity. Though exceptions have their value
in teaching us lessons and in enlarging our views,
they should not be mistaken for the rule or blind us
to the fact that they are exceptions. Nor is it just to
characterize those interested in this movement as
dreamers — though to be called such is not always a
reproach, for often the dreams of one age are the facts
of the next. But it is not dreaming to accept the
teachings of science; it is not dreaming to accept the
evidence of the post-mortem table that pulmonary
tuberculosis is a curable disease; it is not dreaming
to listen to the testimony of medical men of every
country as to the essentials of treatment; it is not
dreaming when modern civilized communities devise
methods for alleviating the suffering and disease of
the unfortunate in their midst; nor is it dreaming to
say that pulmonary tuberculosis is by all odds the
greatest scourge with which we have to deal. We are
not holding out for ourselves any false hopes; we
know that man is born to die, and that he will con-
tinue to die whether we have a State sanatorium or
not; but we feel that we are awake when we are try-
ing to make practical application of the things that
have been learned in the last fifty years — that we are
awake, yes, wide awake, when, in the language of one
who has advocated this movement, we wish to care for
the patient in the right place, at the right time, until
he is cured, rather than in the wrong place, at the
wrong time, until he is dead.
With reference to the legal aspect of the question I
believe no objection has been raised against the State
sanatorium. Neither in the Senate nor in the As-
sembly aid any of the numerous members of the legal
profession in those bodies assail the bill on account
of its supposed unconstitutionality.
With reference to the third question, the expediency
of this measure, I believe, after what has been said,
that this must also be answered in the affirmative. Or
should the great and wealthy State of New York hesi-
tate because it involves the expenditure of a paltry
$200,000? What are $200,000 compared to the un-
told advantages of suffering alleviated and of lives
saved to the State? It almost seems sacrilegious to
figure in money value the dead who might have been
saved to the State during the past year. And yet, in
view of the fact that reasons of economy prevented the
success of this measure last winter, I may be pardoned
for making this c?:lculation. So far as I know, the
only clew as to how high the State of New York values
the life of a citizen is the statute now repealed per-
mitting the heirs of a citizen dead by violence to sue
for $5,000. Now if only one out of every fourteen of
the fourteen thousand consumptives who died last year
had been saved, the sum total measured by this stand-
ard would have represented a saving to the State of
$5,000,000.
With reference to the expediency of such a move-
ment as this, we must also be guided by the stand
taken toward it by medical societies and by private
philanthropic and charitable organizations. So far as
I know, there has not been any opposition on the
part of any organized body of men or women, lay or
professional. On the other hand, the movement has
been indorsed by the New York State Medical Society
and by the Section on General Medicine of the New
York Academy of Medicine. This was done at a
meeting of the section held at the Academy on October
17th last. The interest in this matter was shown by
an attendance larger than that on any other evening
in the past three years; a number of medical men
from neighboring States expressed themselves favor-
ably upon this movement, and the resolutions adopted
were practically an indorsement of the Massachusetts
State Hospital for Tuberculosis, the first of its kind
to be opened in this country, and an indorsement of
the movement for a similar institution in this State.
In all candor I must add that the full Academy has
not as yet passed judgment in the matter — the resolu-
tion will not come up for action until next week.'
With reference to the expediency of this movement,
one other objection must be answered. There seems
to be a fear that the opening of a State sanatorium
for tuberculosis will encourage the opening of State
institutions for a multiplicity of diseases. The ques-
tion is asked. Why not a State hospital for cancer?
And if not, why not? I should answer that every
bridge will be crossed when it is reached — that the
intelligent public opinion of this State will settle each
question as it arises, on its merits and intelligently;
and that not until it is made clear that cancer is as
prevalent among the poor as tuberculosis, that pro-
visions for its care are as inadequate as they are for
tuberculosis, and that cancer is as much a menace to
the healthy citizen as cases of tuberculosis — not until
then will there be that intelligent sentiment behind
the demand for its State care that there is to-day for
the State care of tuberculosis.
Dr. S. a. Knopf : As to the danger arising from
tuberculous patients there seems to be a general idea
that the more advanced and hopeless cases are a
greater danger to the community than the early ones.
This assumption is a mistake. The advanced hope-
less or even helpless case is confined to his room, and
the danger of infection is limited to his immediate
' Since this was written the Academy of Medicine, at a general
meeting held December 21, iSgq, adopted resolutions favoring
the establishment of both State and municipal sanatoria.
86
MEDICAL RECORD.
[January 13, 1900
environments. On the other hand, the tuberculous
patient who is still able to be up and about, and who
often pursues his daily occupation, has an opportunity
to expectorate anywhere, and thus propagate the dis-
ease to a greater extent than his brother consumptive
confined to his bed. From this it is evident that the
need of institutions for incipient cases is as important
as for advanced ones. Wliile we may congratulate
ourselves on the willingness of the State to create one
institution for either incipient cases or advanced, let
us hope that through a combination of State and pri-
vate charity we will soon have a sufficient number of
institutions of both kinds; for only through such
methods can we hope to cope successfully with the
tuberculosis problem. That the exoense of maintain-
ing a patient in a sanatorium is not any greater than
in a general hospital, may be seen by the following
figures: The daily cost of a patient in the general
hospitals of New York under the direction of the
commissioners of charities is Jr. 16. In the Adiron-
dack cottage sanatorium it is $1.
Dr. Van Fleet: The Adirondack bill of last year
was very strongly urged by our committee, and espe-
cially by our representative in Albany, Dr. Root, who
did nearly all the work. All physicians recognize
the necessity of some sanatorium of this kind. The
objections to the bill of last year were, first, the item
of expense, and, second, that it dealt only with in-
cipient cases. Speaking as an individual, this matter
presents itself to me in a different form than it seems
to present itself to others. The State should not go
into the establishment of a sanatorium through any
philanthropic motive. The only justifiable reason for
the State would be that of self-protection. If the
State is going to all this expense for a few, it is un-
justifiable. But if it is going into this matter for the
treatment and isolation of all cases, in order to pre-
vent the spread of this dreadful disease as a matter of
self-protection, then the State has no right to stop at
the question of expenditure. The cost of doing is
only to be compared to the cost of not doing. The
choice of the Adirondacks for the site of the sana-
torium is a very good one. The Henry bill allows
cities to establish sanatoria outside their municipal
limits. This should not be, as you cannot go outside
the limit of one municipal corporation without coming
into the limit of some other municipal corporation.
[This statement was corrected by the chairman.] The
object of the Henry bill was that a certain menace to
property values in Spuyten Duyvel might be removed.
The State has a vast tract of land in the Adirondacks,
where a sanatorium could not injure anybody. This
seems to me a very strong point. Another objection
is a purely sentimental one. If the State goes into
this thing for self-protection, it has the right to de-
mand that all these cases be reported for the protection
of the rest of its citizens. They ought to be obliged
to go to the sanatorium, and be taken away from the
crowded sections of our towns and cities. I am
heartily in favor of a measure of this kind, and the
institution siiould be situated so that it cannot inter-
fere with the rights of others.
There was no work for our committee to do after
the adjournment of the legislature. The matter will
come up again at the next meeting.
Tinnitus Aurium is regarded by Robin and Men-
del (Mevwriihilien, July, 1899) as due to direct or
reflex irritation of the auditory nerve. For its relief
they recommend the fluid extract of cimif uga racemosa ;
gtt. XXX. pro die being a moderate dose. According
to the observation of these authors, this drug has a
sedative effect upon the aural circulation as well as
upon the auditory nerve.
LETTER FROM NAPLES.
(From our Special Correspondent.)
THE UNIVERSITY OF NAPLES MEDICAL SCHOOL HOSPI-
TAL INTERNES — NEED OF TRAINED NURSES.
Naples, December i8, iSgo.
A MEDICAL degree is conferred by the University at
Naples after six years of study. The first year phys-
ics, chemistry, and descriptive anatomy are the only
obligatory subjects. The course for the second year
comprises zoology, botany, and comparative, physio-
logical, and descriptive anatomy. In the third year
human, descriptive, and preparatory (much like our
regional) anatomy, human physiology, and general
pathology are studied. The remaining three years are
given over to clinics, with therapeutics, hygiene, and
special pathology in addition.
The clinical material here is, of course, immense,
and the students have many more opportunities for
practical work in surgery than is possible with us.
One of the reasons for this is that there are no trained
nurses, and the student does the work of the nurses
and assists at the operations constantly.
There are two thousand men now taking the medical
course. Women are admitted on equal terms, but few
have availed themselves of the opportunities, eight
only having taken degrees here, and these are nearly
all Russians. At the end of six years the men are
considered qualified for hospital positions, which are
given to those considered' by their friends to be most
fit. Their positions correspond to nothing in America,
for the doctors have their offices outside and attend to
any private practice. A certain number of men are
chosen for each division, not necessarily from the
graduating class. Some may have been physicians for
one or two years, and each one remains in the hospi-
tal a given night during the week. Most of the men
are about during the day for a few hours, when opera-
tions are to be done by their chief, and they have
most of the minor operations to perform. Many ma-
jor ones also fall to their lot.
Surgery is apparently much more advanced than
medicine, their methods in this branch being those of
the best German and English schools.
Morisini and Spinelli are perhaps the leading sur-
geons in gynecology among the older men. Ver)' lit- ,
tie work is done here on malaria, all of the best-known
men being in Rome. In fact, there is absolutely
nothing in Naples for American students. Nursing
is only a name, the work being done mostly by a very
low class of servants, who have no training whatever,
and by the Sisters of Charity. This is true of all hos-
pitals except a few small wards at the " Gesii e Maria,"
where Miss Baxter, a young woman who took her
course at Johns Hopkins, has established a small
training-school (during the three years of its existence
eleven nurses have been graduated), and these little
wards show plainly enough the traces of her splendid
efforts.
DISCOURAGING EXPERIENCE OF A PUBLIC-
SPIRITED CITIZEN.
To THE Editor of the Medical Record.
Sir: The Medical Record is eminently qualified
and ever prompt in challenging the rights and uphold-
ing the dignity of the profession, as was so recently
illustrated by its able editorial of November 4, 1899,
"An Unpardonable Indignity," defending Drs. Purdy
and Maier. Your strong protest against such a fla-
grant outrage certainly meets with the approbation of
every honorable member of our noble profession. As
January 13, 1900]
MEDICAL RECORD.
87
evidence of this, witness the manner and spirit with
which the leaders of the profession came to the rescue,
as revealed in your correspondence column of your
issue of December 16, iSgg.
It is only by concert of action we may hope to enact
and enforce laws to protect us from dangers within
and without the profession. To illustrate, I am here
prompted to report my very recent experience in a case
in which I attempted, in a legal way, to enforce the
law that bears on empiricism in Kentucky, to wit:
Last May, by the advice of the county attorney, I
had a warrant issued for the arrest of a man for vio-
lating the law and he was released on his own recog-
nizance until the time of trial, which was made a
commonwealth case. The first trial resulted in a hung
jury, although ten of the jury voted for fining the
accused. On tiie second trial he was acquitted, as a
result of the testimony of three of the local physi-
cians, one of whom, strange to say, is on the county
board of health, who testified in favor of this notori-
ous quack.
This would have ended the matter had not one of
the above physicians inspired him to bring suit against
me for malicious prosecution. The man admitted on
the witness stand that he had been in communication
with one of these three physicians, and further ad-
mitted that if I had any malice toward him he was not
aware of it.
My attorneys motioned for peremptory instruction
by the judge for the jury to dismiss the case on the
plaintiff's own testimony, and absolute failure to show
malice. However, the case was allowed to go to the
jury, who flagrantly disregarded the plain law and
evidence, and rendered a verdict for $500 in favor of
plaintiff. Of course I will appeal. Medicus.
^edicat Items.
Pectoriloquy. — Pectoriloquy — so named by Laen-
nec, its discoverer — is a complete transmission of the
voice to the ear. The words spoken are heard dis-
tinctly articulated. It closely resembles the resonance
heard over the larynx, and is usually limited to a small
space in the chest, where it also may or may not have
a hollow, ringing character. It was formerly believed
always to indicate the presence of a pulmonary cavity,
but auscultators are now agreed that this is not neces-
sarily the case in every instance, but that it is some-
times simply an exaggerated bronchophony; the only
distinction between these two being that bronchophony
is the transmission of the voice, pectoriloquy that of
the speech. Well-defined pectoriloquy is not a com-
mon phenomenon. — Loomis; "Lessons in Physical
Diagnosis."
Quinine Making in Bengal. — ^Major Prains' inter-
esting report for 1898-99 has recently been published.
The total number of living plants in stock amounts to
considerably over two millions. The out-turn of the
factory was 10,335 pounds of sulphate of quinine and
3,92 1 pounds of cinchona febrifuge. This large amount
is absorbed in the issues to the medical store depots
at Calcutta and Mian Mur and to the Alipur jail, for
manufacture into "pice packets" for sale through the
post-offices. Another large amount was sold to hospi-
tals and dispensaries and to the public. There appears
to be no quinine exported to other countries. — Indian
Medical Gazette.
Why Quackery Succeeds. ^In concluding an ad-
dress upon ancient and modern quackery. Dr. Eden
says in The Lancet, November i8th: "In the earlier
days it was inevitable that such primitive methods as
were then known should often fail, but it is a reproach
to us that with all our boasted scientific progress the
practice of the healing art, except in the domain of
surgery,- is making such scanty advancement. We are
all so keen on scientific problems that we are apt to
lose sight of the fact that in the eyes of our patients
our value mainly depends upon the amount of relief
which we are able to bring them. What they expect
from us is not an elaborate diagnosis or a learned dis-
course on their disorder, but simply something that
will do them good. One of the most accomplished
physicians whom I have ever known took little or no
interest in his patients between the stage of clinical
diagnosis and that of post-mortem examination. That
is the kind of medical attendant from whom people
flee to find refuge in a quack. I take it that our duty
is to spare no pains and leave no method untried which
promises to be useful in combating disease, for we
shall be ultimately judged, not by our academic dis-
tinctions or our contributions to science, but by the
measure of success we have attained in discharging
the task which society has committed to us — namely,
the relief or mitigation of suffering and the preserva-
tion of health."
Appendicitis Said to be Caused by the Habit of
Crossing the Legs. — A foreign surgeon has put for-
ward the suggestion that appendicitis is caused by the
habit of crossing the legs, which restricts the action of
the digestive apparatus. The appendix is only loosely
attached to the ceecum, and there is always some half-
digested food in the caecal bag. By crossing the legs
there is liability that the undigested food may pass
into the vermiform appendix and set up inflammation;
in a few hours pathological processes set in, and an
attack of appendicitis is developed. — Scientific Ameri-
can.
Fortune Making by Hypnotism. — Occult influence
as a road to wealth may appeal to many people as
being a fantastic notion born of a wild freak of the
imagination (writes a well-known English lawyer), but
I can tell you that in recent years various sciences
bordering more or less on the occult have played an
all-important part in many a stirring but unrecorded
legal drama, and that mysterious agencies are much
more resorted to in order to gain the ends of unscrupu-
lous persons than the public is aware of. One in-
stance I have in my mind among others was that of a
retired business man whose will I proved not long
ago, and among the bequests was one to his medical
attendant for _£"5,ooo ($25,000), a larger sum than had
been left to any of the testator's own family. It would
be too long a story to go into all the remarkable facts
of this case, but for months previously the doctor and
the patient were continually together. The doctor had
something of an uncanny reputation as being a believer
and dabbler in occult science, and under his tuition
the man of business soon became a convert and con-
sented to various hypnotic experiments being tried
upon him, with a view to the benefit of his health.
His sudden death came as a great shock to his rela-
tives, but they experienced another shock when they
found that the doctor had been made executor and
chief legatee of his will.
Escape of Cerebro-Spinal Fluid from the Ear
after Injury That the cerebro-spinal fluid can
escape from the cranium in cases of injury has been
known for some time. As early as the year 1727, Stal-
partius van der Wiel published a case in which large
quantities of a thin, clear, watery fluid had escaped
from the ear for several days after a severe injury to
the head. O'Halloran and Dease published cases,
but these appear to have been lost sight of until Lan-
gier called attention to the coexistence of a watery
MEDICAL RECORD.
[January 13, 1900
discharge and rupture of the merabrana tynipani in
some cases of fracture of the base. The character of
the fluid was not recognized at first, but it was estab-
lished by Ne'laton, Robert Rabourelin, Chatin, and
Deschamps. Guthrie lield that the fluid probably
came from the cavity of the arachnoid, and pointed out
that it was symptomatic of great danger. This acci-
dent is now of course a matter of common observation.
— St. Clair Thomson.
Smoke of Burning Leaves Injurious — The board
of health of Plainfield is considering the question of
adopting a rule which will prohibit the burning of
leaves within the city limits, as it is claimed that
the practice is conducive to much ill-health during the
fall season. Several physicians have said that the
smoke and smudge which come from burning leaves
are the causes of many of the ailments of the throat,
lungs, and eyes. — Scientific American.
Meat and Cancer. — The question how far the in-
crease of cancer among the more highly civilized na-
tions, which has appeared so marked during recent
years, is caused by the greater quantity of meat which
is eaten in prosperous countries, is a matter of very
considerable interest. That man is by nature not a
vegetarian, in other words that he is naturally not a
mi.xed feeder, may be taken as pretty certain ; but it
is also certain that as the result of hard necessity meat
has generally in times past been to him a luxury, and
has but rarely found a preponderating element in his
diet. But with prosperity and with the greater ease
with which animal food can now be obtained we find
whole nations falling upon meat as a necessary ingre-
dient of their daily diet; and in the very nations
among whom this change is most noticeable we are
told that cancer shows the greatest increase. In sup-
port of the connection between meat and cancer Dr.
Roger Williams points to the rarity of cancer in pris-
ons and workhouses where but little animal food is
allowed, and hard work is exacted. He has lately
found additional evidence as to the small amount of
cancer among the convict population, which he says
strongly supports this view. . . . We need scarcely
say, however, that convicts are a somewhat " selected "
class of people, and that diet is not the only matter in
which convicts differ from those outside prison walls.
— Hospital.
Typhoid Fever in South Africa. — Professor Sam-
bon, writing in the Journal of Tropical Medicine, says :
" Typhoid fever is the most prevalent and fatal dis-
ease in South Africa. In the Galeaka Gaika war it
was stated by the principal medical officer to have
been undoubtedly the most serious disease during the
war. In the Zulu war of 1878 typhoid appeared at the
headquarters at Helpmakaar and at Rorke's Drift in
the middle of February, accompanied by diarrhoea and
dysentery. Helpmakaar became so unhealthy that
it had to be evacuated. The troops were moved to
Utrecht and Dundee, but the fever immediately broke
out at both these places. ... It is an almost unani-
mous opinion that all outbreaks of typhoid may be
traced to the polluting of the water supply by the ex-
crements of a typhoid patient. I do not contend in
the least that water may not be a vehicle, and possibly
the principal vehicle, of typhoid infection, but I think
it is very obnoxious to generalize a theory, however
plausible it may be. Indeed, there are many out-
breaks that cannot receive so comfortable an explana-
tion. Some of them are strikingly limited, and their
limitation is rarely in accordance with the distribution
of the water supply supposed to be polluted. Dr.
James Allen, of Pietermaritzburg, from his observa-
tions in South Africa came to the conclusion that
typhoid fever depended chiefly upon infected cattle.
He describes a specific enteritis occurring in calves,
subject to relapses and very contagious, and holds
that the excrements of animals affected with this dis-
temper, on gaining access in any way into the human
body, will give rise to typhoid fever. He holds that
typhoid fever thus arose in a great measure among the
British troops in the Zulu war."
French Regulations Against the Use of Lead
Oxide. — In France, says the Sanitary Record, we un-
derstand a regulation exists making it illegal to use
lead oxide in glazing pottery. It was interdicted by
a ministerial circular so far back as 1878, but the reg-
ulation has been practically allowed to remain a dead
letter. For this state of things the manufacturers are
not wholly to blame. The ultimate responsibility
rests on the shoulders of the public, who prefer ware
glazed by means of lead because it is cheaper.
Excision of Bowel for Malignant Disease. — Treves,,
in his work on intestinal obstruction, says: "I would
estimate the present mortality of excision of the bowel
for malignant disease at about twenty per cent., and
the mortality of short-circuiting operations at about
twelve per cent. It is to be remembered that the
majority of these operations concern the colon. As
in like measures for other forms of obstruction, the
great element in success depends upon the performance
of the operation at the earliest possible period. The
danger in an excision of the bowel or in a short-cir-
cuiting operation is to be measured mainly by the de-
gree of distention of the bowel at the time of the opera-
tion. When abdominal section is performed as early
as possible the mortality of the operations in question
will still further decline. The mortality of colotomy
performed for chronic intestinal obstruction may be
placed at between five and ten per cent."
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon -general of the United States Marine-
Hospital service during the week ended December
5, 1900:
Cases, Deaths.
Smallpox — XJnitf.d States.
Dist. of Columbia, Washington, December 22d 5
Illinois, Cairo December 23d to soth 12
Indian Territory, Choctaw
Nation December loth 30*
Louisiana, New Orleans December i6th to 30th 21
Shreveport December i6th to 30th 9
Massachusetts, Chelsea December i6th to 30th i
Lowell December 23d to 30th i
Nebraska, Omaha December 23d to 30th i
New York, Amsterdam December ifth to 31st 1
New York December i6th to 23d i
Ohio, Cincinnati December 23d to 30th 1
Cleveland December i6th to 30th 3
Pennsylvania. Allegheny December i6th to 2 ;d 3
Pittsburg December 16th to 30th 2
South Carolina, Greenville. . . .December 7th to 30th 4
Tennessee. Nashville December 23d to 30th a
Utah. Salt Lake City December i6th to 23d i
^'irginia, Portsmouth December 23d to 30th 10 2
* In mining camps.
Smallpox — Foreign.
l^elgium, Antwerp December 2d to 9th 5
lirazil, Rio de Janeiro November 3d to 17th
(nbraltar December ;d to 17th 3
Greece, Athens December id to 9th 5
India, Pombay November 2 ist to 28th
Russia, Moscow November 25th to December 2d, i
Odessa December 2d to oth 3
Warsaw November 23d to December 2d, , . .
Spain, Madrid December 2d to 9th
Turkey, Smyrna December 3d to 10th
Brazil, R
Colombia
Cuba, M,
Yellow Fever.
. November 3d to i7lh , ,
, . December 19th to 26th,
,, December 29th
■• Soldier.
,GUE— United States.
..December nth to i8th,.
India, P.ombay November 21st t
Calcutta November 4th tc
K urrachee November i8th t
28th.
i8th ..
. 25th .
Medical Record
A I'Veekly yonnial of Medicine and Surgery
Vol. 57, No. 3-
Whole No. 1524.
New York, January 20, 1900.
$5.00 Per Annum.
Single Copies, loc.
©riQ-iiial Jirticlcs.
COMPARATIVE STATISTICS IN THE TREAT-
MENT OF APPENDICITIS.
By EDWIN MARION COX, M.I).,
There is very frequent comparison by statistics of the
medical with the surgical treatment of appendicitis,
and to the superficial observer the medical men some-
times seem to make out a fairly good showing for
what many of them like to call the conservative
method. We are also occasionally offered " new "
methods of treatment, the chief part of all of which is
avoidance of operation. Many series of cases have
been reported with a mortality of from eight to twelve
per cent, in which a non-surgical form of treatment
has been employed, and the reporters have seemed to
ask, apparently with a touch of pride, whether the sur-
geons can show any better results. There are several
objections to the accuracy and fairness of such series,
seemingly not often enough or strongly enough em-
phasized. For example, one series, that of Sahli, con-
sists of 7,213 cases from Swiss sources, among which
473 were operated upon with a mortality of twenty-one
per cent, and 6,740 treated without operation with a
mortality of 8.8 per cent. It is admitted that recur-
rence was observed in 20.8 per cent, of these cases, but
the observer does not give the period during which the
cases were watched, and of the cases represented by
the 8.8 per cent, mortality we do not know how many
could have been saved by timely surgery. Other ad-
vocates of the medical treatment, mostly foreign, offer
appro.ximately the same results, in some instances with
even less mortality for the treatment they prefer. The
first element in such series that attracts the attention
of the American surgeon can hardly fail to be the high
mortality after operation, explicable only by a close
analysis of the figures, unless we wish to say that Eu-
rope has not reached the same proficiency in treating
this disease as America. The medical man usually
sees the patient with appendicitis before the surgeon,
and in many instances the latter never sees the pa-
tient at all, so that there is no opportunity afforded
him to say whether in his judgment operative treat-
ment at once or later would be suitable. Many such pa-
tients pass through the attack and live to have another,
within or without the ken of the first physician. Others
are treated for several days by medical means until
the physician calls the surgeon, perhaps too late to
save life, and at best with a very good chance of in-
creasing the mortality figures to which the physician
objects so strongly in the records of the cases treated
by operation. The advocate of medical treatment
seems to assume always that the surgeon would operate
upon every case of appendicitis almost at once, and
therefore feels justified in classing every patient who
survives an attack as cured by medical means, either
forgetting or ignoring the fact that the surgeon is con-
tinually seeing more or less mild cases in which he
advises waiting either for a return of symptoms or un-
til a suitable time after the subsidence of the attack.
for operative treatment. The medical statistician as-
sumes the right to keep any of these cases under his
observation as long as he sees fit, and then to call the
surgeon, saying: "All that medical treatment can do
has been done; now let surgery save him." He as-
sumes also the right to place in his list of cures mild
cases of the so-called catarrhal form of the disease,
omitting to consider that such are not cures when there
is a large percentage of recurrences, and that in many
cases operations are done for subsequent attacks, often
with diminished prospects of good result on account
of inadequate treatment in the first instance. A fur-
ther, though less important, source of inaccuracy in
drawing conclusions from the statistics of appendicitis
is error in diagnosis. Several mild inflamniatory proc-
esses in the right iliac fossa simulate appendicitis,
and recoveries might easily be placed in a list of
cures, to the material reduction of the mortality per-
centage. The reason that a surgeon is less apt to be
led into errors of this sort is that surgeons are usually
called to see suspected cases of appendicitis because
they are known to have had e.xperience, and are there-
fore, in this particular condition, less likely to be
deceived than the less experienced medical observer.
The only fair means of comparing the surgical results
with the results of cases treated without operation
would be the impracticable arrangement of comparing
two large series of similar consecutive cases, one
treated in each way. I think that one series would
very quickly develop cases which would require sur-
gical aid, unless the medical men were prepared to
take the responsibility of unnecessary deaths. It is
obvious that death should not be attributed to the
operative method of treatment in cases in which that
treatment is undertaken under stress of emergency,
and not at the time that the surgeon would have chosen.
The opponents of the operative treatment of appen-
dicitis have in some instances assumed the entirely
unjustifiable attitude of doubting surgical statistics
offered by men of good repute, with what reason is not
clear. There is not the slightest doubt that in com-
petent hands the mortality after the removal of the
diseased appendi.x in suitable cases during the quies-
cent period is practically nothing, and that in acute
cases of various kinds (abscess, perforation, etc.) the
figure is much lower than any medical form of treat-
ment can possibly show, and will become still lower
in proportion to the recognition which timely surgery
receives as the only proper way of handling the dis-
ease.
The obvious physiological disadvantage under which
the normal appendix must work in order to keep itself
free from intestinal contents must be clear to any one
who has ever seen an appendix, but the great increase
in these disadvantages which occurs after an attack
of inflammation is apparently not so well understood.
The mucous lining of the appendix is subject to and
liable to be involved in any inflammatory process oc-
curring in the cscum, but in the latter organ the heal-
ing of a small ulcerated area with the subsequent
cicatricial contraction is of no consequence. When
there is destruction of mucosa and subniucosa in the
appendix, the healing results in the formation of cica-
tricial tissue which must soon produce a certain
90
MEDICAL RECORD.
[January 20, 1900
amount of distortion and narrowing of the lumen of
the organ. This state of affairs can only make the
ability of tiie appendix to keep itself clear greater, with
a consequent probability of a second attack of the
same general character. All who have seen many
appendices removed will remember how often the type
suggested by this description occurs. There may be
several points of narrowing which is of various de-
grees of development, with almost always a collection
of muco-purulent fluid in a more or less distended
organ behind the last stricture. The danger of perfo-
ration in many of these cases is extreme, for in many
of them there has never been any formation of adhe-
sions outside of the appendix. There are, of course,
many cases of appendicitis in which the inflammatory
process within the appendix is more intense from the
first, and there is early local or general gangrene of
the organ, with perforation and its various results de-
pending on the conditions in the peritoneum of the
iliac fossa at the time. Cases of this kind ought to
have prompt surgical attention, so that the amount of
necessary surgical work shall be as small as possible,
and the danger of general sepsis as remote as we can
make it. The idea of waiting for " adhesions to form "
or "the abscess to develop" is just as rational as wait-
ing for adhesions in a case of strangulated hernia.
I should like to describe briefly a few cases, all but
two of which I have operated upon during the past
eighteen months. The others I saw in consultation.
I have chosen them because they illustrate some points
made in calling attention to the untrustworthiness of
the rredical statistics of the treatment of appendicitis.
Case I. — Man, aged twenty-one years. He had had
several attacks, only one of which compelled him to
go to bed. Intervals of about six weeks occurred be-
tween the attacks. He came to St. Francis' Hospital
for removal of the appendix, if advisable, so that he
could go safely on missionary trips. Examination
showed that there was tenderness on deep pressure in
the iliac fossa, but the appendix could not be felt with
certainty. McBurney's intermuscular operation was
done, and in ten days the patient was up. There were
no adhesions about the appendix, which was freely
movable. One inch from its extremity there was an
almost impervious stricture, and between this and the
extremity the organ was distended with about a drachm
of greenish pus. About three-fourths of an inch from
the first stricture there was another, not so tight, and
between the two there was more pus. A man could
hardly carry a more dangerous article than a thin-
walled sac of pus suspended in his abdominal cavity,
yet medical treatment would have "cured " any attack
that this patient had had, and he might thus have
enriched several statistical lists before the sac rup-
ttired.
Case II. — Boy, aged fourteen years. He had one
sharp attack a number of weeks before admission to
St. Francis' Hospital. The boy was in excellent gen-
eral condition, and was sent to the hospital because his
physician believed that an operation was the best treat-
ment for his condition. There was no tenderness, and
the appendix could not be felt, as the boy was fat and
muscular. The same operation was done as in Case
I., and the patient was well in two weeks. The appen-
dix was lying along tiie postero-internal aspect of the
csecum. It was about three and one-half inches long,
and one and a half inches from its extremity there
was a sharp angle, so that the organ was doubled with
its tip pointing almost directly back to the base. Tlie
angle thus formed was tightly adherent to the ccecum,
and the rest of the organ was perfectly free. The ap-
pendix beyond the angle was tensely filled with muco-
pus, and it burst during removal. A small area of
granulation tissue remained on the wall of the crecum
where the appendix had adhered, so that a small strip
of gauze was left in the wound for four days. This
appendix was on the point of rupture when the opera-
tion was done, and the boy is certainly better off now
than if a four-inch incision had been necessary later
with the unavoidable division of muscular tissue.
Case III. — Girl, aged ten years. This case was
much like Case I. There had been several attacks,
and the child was brought to St. Francis' Hospital for
treatment. There was distinct tenderness, but no mass
in the fossa. The last attack had occurred about three
weeks before operation. The operation was the same
as before, and the patient was well in ten days. The
appendix was free, and distended toward its tip with
fecal pus, and it contained several calculi. There
was no actual closure of the canal, but the middle
inch was much narrowed and was cicatricial. The
last calculus could not pass this area; the others were
on the proximal side. This appendix was certain to
have behaved badly, and the attacks would undoubt-
edly have increased in severity.
Case IV. — Woman, aged thirty years. Her history
was obtained with diflSculty. When brought to St.
Francis' Hospital she was evidently recovering from
an attack of appendicitis, and as soon as we could get
an interpreter a history of other attacks was elicited.
Examination showed marked tenderness in the iliac
fossa, and the appendix could be felt. This patient's
temperature ran pretty regularly to 99.5° or 100° F. at
night for several days during which she was under ob-
servation, and then the intermuscular operation was
done. The w'oman left the hospital well in two weeks.
The appendix was three inches long, free, and contained
several calculi and some pus, but there was apparently
no stricture. The tip was moderately distended, and
the largest calculus was in this locality. Operation
was certainly the only way of putting this patient in a
safe condition.
Case V. — Well-developed and muscular young wo-
man, aged about twenty-eight years. She gave a his-
tory of a number of attacks, most of them mild. She
came to St. Francis' Hospital for diagnosis and treat-
ment, although she was not ill at the lime. The ap-
pendix was distinctly tender, but there were no other
local signs. The same operation as before was done,
and she was well in tvi'o weeks. The condition in the
appendix was almost exactly the same as in Case IV.,
and there was just as little prospect of spontaneous
cure.
In addition to these cases, I should like to add a
short description of two cases, seen in consultation and
operated upon by another surgeon :
Case VI. — Man, aged fifty-three years. He had
had five well-marked attacks, but had steadily refused
operation. His last attack kept him in bed with an
evening temperature from 100° to 102.5° ^-t ^"d
marked tenderness and rigidity with flexion of the
right thigh. He refused operation for a number of
days, during which all kinds of non-operative means
were used to help him, and several times he threat-
ened to get up and go out. His tenderness remained,
and the mass which had begun to form became more
and more distinct. His fever continued and he began
to look septic. At the end of two weeks from the be-
ginning of the attack he consented to operation. This
disclosed an abscess surrounded by quite dense adhe-
sions, filled with pus containing necrotic shreds. The
appendix was not searched for. Recovery was un-
eventful. The case of this patient is a good example
to use in calling attention to the advantages of the
interval operation. As it is now he has a long scar;
his appendix could not be safely sought for, and the
consequences of this state of affairs are obvious.
Case VII. — Man, aged thirty years. He had one
sharp attack in 1898, and had been well until the
second attack occurred one year later. It was sudden,
January 20, 1900]
MEDICAL RECORD.
91
marked by intense pain and the usual symptoms of
perforation. Operation was performed about twenty-
four hours after onset. The appendi.x was free and
perforated. The pelvis was full of turbid fluid, with
flakes of fibrin. He was treated with hot surgical salt
solution and a drain in the pelvis. Recovery was
rapid and uneventful. The appendix was in much the
same condition as in Case I., plus the perforation. If
this patient had been operated upon in the quiescent
period, he would have escaped the comparatively long
muscle-dividing incision and the consequent danger
of hernia. If this patient had been treated by some
medical observers, his first attack would have per-
mitted them to put him in a list of cures.
The figures given by Sahli have been quoted because
they are extensive, and because, with some other sim-
ilar series, they are frequently grouped together. A
recent notice of them with others may be found in
Boas,' in the remarks upon the treatment of perityph-
litis. The mortality as mentioned above was given as
8.8 per cent, in the cases treated without operation,
but we do not know how many of this 8.8 per cent,
were carried through to death without operation, or
how many were operated on in a desperate condition
after the inefficacy of medical treatment had been
shown; though perhaps under the latter circumstances
such cases would be made to add to the mortality after
operative treatment. It is admitted that in over twenty
per cent, of the cases that ended in recovery under
medical treatment there were recurrences, but no period
of observation is given. This twenty per cent, is prob-
ably less than one-quarter of the real figure represent-
ing recurrences, and insufficient and inaccurate obser-
vation of the subsequent histories of the cases must
account for the low figure given. Furthermore, it is
important to know how many among even this twenty
per cent, come to require surgical treatment, sometimes
when it is not available. Periods of a year between
attacks of appendicitis are very frequent ; two years
are a common enough interval, five-year intervals oc-
cur, and I have known twelve years to elapse. Medi-
cal statistics as usually offered are, therefore, untrust-
worthy. A twenty-one-per-cent. surgical mortality is
entirely too high, and such a series must contain many
cases in which timely surgical relief was not afforded.
With our present knowledge of the disease, it seems
safe to say that one attack of appendicitis makes
another almost certain, that medical treatment is use-
ful only as an adjunct and with every preparation
ready for a prompt operation, and that operation in
the quiescent period is a safe measure, especially be-
cause we can leave the abdominal wall strong after it
is done. This is a very important consideration for
any patient, and for the ordinary workingman it is
everything.
In addition to these cases, there were twenty others
operated upon by me in various stages of acute appen-
dicitis during the same period of eighteen months in
St. Francis' Hospital. All were cases with more or
less extensive suppuration and varying degrees of
sepsis at the time of operation. Death followed in
three cases, and a few words in regard to these may
be instructive.
Case I. — Man, aged about thirty-five years, weigh-
ing three hundred and ten pounds. He had been ill
several days. There was a large mass in the fossa.
Temperature was 106° F. at the time of operation, and
the patient had diabetes. The mucous membrane of
the appendix was gangrenous, and there was turbid
fluid in the fossa. Death occurred in twelve hours,
with coma and rising temperature.
Case II. — Man, aged twenty-five years. He had
been ill four days. His temperature had been be-
Diagnostik und Therapie der Darmkrankheiten," Theil ii.,
1899.
tween 103 and 104° F. for the period of illness.
The abdomen was distended, with great tenderness
and marked resistance in the iliac fossa. The appen-
dix was very large and riddled with gangrenous per-
forations. There were very few limiting adhesions.
The patient died rather suddenly at the end of about
thirty-six hours. He had some jaundice.
Case III. — Man, aged twenty-one years. He had
been ill four days, and came to the hospital. He
showed all the clinical appearances of general peri-
tonitis. A large incision was made, with free salt-
solution irrigation. The appendix was gangrenous
and perforated. Death took place in twenty hours.
At least two of these cases had a very good chance
if an operation had been done earlier, for among the
seventeen recoveries there were several which seemed
clinically almost if not quite as bad. In one of them
there was a large secondary abscess of the liver which
was operated upon successfully.
INVERSION OF THE UNCUT APPENDIX.
Bv J. F. BALDWIN, A.M.. M.U .
OHIO,
OF OBSTETRICIANS AND GVN.GCOLO-
In the issue of the Medical Record of November
25th, Dr. George M. Edebohls presents an exceedingly
valuable historical review of the literature of appen-
dicitis. In this article he refers to his method of
treating the appendix by inversion, the chief argument
in favor of his method being that it obviates the neces-
sity of opening the bowel, with the resultant risk of
infection. He states that his procedure, so far as he
knows, has found but one imitator, whose first and
only case ended fatally. Over against this result,
however, he states that in his own hands he has had
considerably more than one hundred cases of inversion
without a single death.
Some time last year I noticed in some journal a
reference merely to a method of treating the appendix
by inversion, as advised by Edebohls and Dawbarn.
No description was given of the technique of either of
these surgeons. The idea impressed me favorably,
and I at once adopted it, but devised my ovin tech-
nique. Since the appearance of the article by Dr.
Edebohls I have corresponded with him on the sub-
ject, and find that my technique is radically different
from his.
I have practised inversion in considerably more than
one hundred cases; just how many I am not able to
state, but I find over eighty in my records for about
six months past. I have practised inversion not only
in cases in which the operation has been made for
appendicitis alone, but also in the great majority of
cases in which I have opened the abdomen for any
reason whatever. It is now a routine procedure with
me to examine the appendix in all such cases, and in
practically all I immediately invert it. The excep-
tional cases are those in which the appendix is found
atrophied, or in which the preceding operation has
been of such a character as to render it unwise to
prolong operative procedures by even the two or three
minutes necessary to secure the inversion.
VVhile I have not kept a definite record of all the
cases, I am satisfied that I have found a healthy ap-
pendix in less than ten per cent, of all abdomens which
I have opened. The evidences of disease usually con-
sist in thickening of the appendix, more or less oblit-
eration of its lumen, or adhesions. Occasionally a
fecal concretion is found, and not very infrequently
evidences of recent acute inflammation, the symptoms
92
MEDICAL RECORD.
[January 20, 1900
of which had been entirely obscured by the greater
disease present.
How much of disease, discomfort, and danger have
been obviated by this routine removal no one can state.
My patients have been uniformly pleased when told
afterward that the appendix had been removed. On
three occasions I have been obliged to operate for
acute appendicitis occurring in cases in which the ap-
pendages had been previously removed on account of
disease. One of these cases had been operated upon
by a distinguished Chicago surgeon, and I had myself
operated on the other two. I have now in mind in
addition several patients in whom I did not remove
the appendix, during previous years, and who are now
annoyed at times by a very suggestive tenderness and
grumbling in the region of McBurney's point.
The technique of inversion is beautifully simple,
and I did the operation very many times, to tlie de-
light of visiting surgeons. I did it eight or ten
times during the week of the meeting of the American
Medical Association, the manoeuvre being witnessed
on each occasion by quite a number of prominent sur-
geons. So much satisfaction has been expressed by
those who have witnessed these demonstrations, that I
am quite certain a number of them have adopted the
procedure in their practice.
The appendix is freed from adhesions if present and
brought up into view in the usual way. The tip of
the appendix is held by my assistant with one hand,
while with the thumb and forefinger of the other the
colon is supported just below the origin of the appen-
dix. With a ligature carrier a catgut ligature is then
introduced at the base of the appendix, so as to in-
clude the meso-appendix, care being taken to embrace
the small artery that runs along close to the appendix.
The meso-appendix is then ligated, the ends of the
ligature being left long. With scissors the meso-
appendix is severed just beyond the ligature, and the
tissues constituting it are then seized either with fin-
gers or forceps and stripped off from the appendix
from the base to the tip. This is usually accom-
plished with a single effort, but occasionally they will
have to be removed in pieces. Not infrequently, and
quite usually when operating on an acutely inflamed
appendix, great thickening of the peritoneal and mus-
cular coats will be found present. These coats will
be so infiltrated that inversion is impossible. In such
a case a longitudinal incision can be easily made with
either knife or scissors, cutting tlirough these two coats
down to the mucous mertibrane. This having been
done, the thickened coats are very easily peeled off,
leaving merely the mucous membrane intact, which is
so thin and soft as to offer slight obstacle to inversion.
Not infrequently, however, the distal extremity of this
mucous-membrane tube is obliterated as a result of
previous inflammatory attacks. In such an event the
obliterated end must be snipped off with scissors be-
fore proceeding to the next step. Care should be
taken, however, not to open into the lumen of the tube.
The appendix having thus been prepared for inver-
sion, the tip is seized between the thumb and fore-
finger of one hand and inverted by pressing upon it
with the blunt end of a patent-eyed needle. The
nianceuvre is accomplished by a manipulation some-
what similar to that employed in putting a fish-worm
on a hook. The tip having been inverted for about
the length of the needle, an inch or more, the needle
is removed and an ordinary long probe substituted.
With this the inversion is completed in an instant.
If, as the probe is being introduced into tiie colon,
carrying with it the appendix, it meets with a fold
offering obstruction, it should be withdrawn and the
rest of the inversion completed with the fingers. This
is accomplished without any trouble whatever. In-
version now being complete, one end of the ligature
which had been previously used is threaded into the
needle and a single stitch taken across the opening in
the bowel, which marks the point of disappearance of
the inverted appendix. If it seems desirable two
stitches can be taken. The catgut is drawn through
until the stump of the meso-appendix is brought up
against tiie opening, and then by tying the two ends
the operation is completed.
The operation can be usually made in very much
less time than it takes to describe it.
The vascular supply is so completely cut off by the
ligation of the meso-appendix that I have no doubt the
inverted organ promptly sloughs off, or possibly under-
goes a species of digestion. I have had but one op-
portunity of investigating the post-operative appear-
ance of the appendix. In that case death resulted at
the end of about a week after the operation ; the
operation for the removal of the appendix being only
incidental, and death occurring not as the result of the
operation. The autopsy showed the appendix very
much softened and evidently rapidly breaking down.
Healing seemed to be complete at the seat of the
operation.
In a very few cases in which operation is made for
appendicitis, conditions will be found which will ren-
der inversion impossible or so difficult as to be unwise.
These will be cases usually of gangrene of the tissues,
or in which there is a tight constriction near the base
of the appendix. Fecal concretions if present can
usually be readily forced into the colon, and open the
way for more easy inversion.
The only possible objection to the operation is that
no specimen is secured to display to the patient and
his friends. This objection, however, is of no im-
portance, of course, when considered in connection
with the manifest advantages of inversion over open-
ing the bowel.
The operation of inversion is made in a very few
moments. There is no hemorrhage connected with it,
and there is no danger of infection. When made in
connection with other operations requiring opening
the abdomen, it can hardly be said to have any mor-
tality whatever. Considering the fact that it removes
once for all every possibility of appendicitis in the
subject of the operation, and considering the great
mortality of the disease which is thus obviated and its
enormous morbidity, it seems to me that it would be
wise for operators in general to adopt some form of
this manoeuvre as a routine procedure in connection
with their laparotomies.
A CONSIDERATION OF THE FAILURE OF
ANTITOXIN IN OPERATIVE CASES OF
DIPHTHERITIC CROUP.
Bv J. EDWARD HERMAN, M.D.,
Since the publication of the writer's previous articles
in opposition to the serum treatment of disease, the
committee on antistreptococcic serum appointed by the
American Gynaecological Society reported to the meet-
ing held in Philadelphia, May, 1899: "The outlook
for the antitoxin-serum treatment is quite discourag-
ing." Statistics showed the results to be no better, if
as good as those obtained without it in the treatment
of puerperal fever.
There was a disposition to claim for tetanus anti-
toxin a very exalted therapeutical value, but recent
events have probably convinced most men of its
absolute failure. During the past year the obstetri-
cal and gynecological clinic of the Czech LTniversity
of Prague had to be closed because tetanus became
epidemic, and many of the patients died despite
i
I
January 20, 1900J
MEDICAL RECORD.
93
the use of tetanus antitoxin. In the epidemic of teta-
nus which prevailed last July in New York City
antitoxin was generally used, and the disastrous conse-
quence is well known and cannot be denied. The
superlative merit of the Baccelli carbolic-acid treat-
ment of this disease was entirely overlooked in the
blind craze for serum therapy.
When in 1896 Winters showed the bad effects of
diphtheria-antitoxin treatment in the Willard Parker
Hospital of New York City, Brannan said he was sur-
prised that Winters should distrust the bacteriological
diagnosis as shown by the presence of the Klebs-
Loeftler bacillus. That there is no etiological rela-
tion between diphtheria and this micro-organism is
made clear by the following observations:
Of one hundred cases of chronic nasal catarrh, Vas-
sant by bacteriological investigation found the Klebs-
Loeffler bacillus in twenty-six patients, in none of
whom was any symptom of diphtheria present.
Grenet and Lesne, in fourteen cases of purulent
coryza in children, found a bacillus resembling the
Klebs-Loeffler bacillus which in seven instances
proved fatal to guinea-pigs and in four produced
pseudo-membranes. Yet in none of these children
was there membrane present or glandular enlargement.
MacFadyen and Hewlett, after examination of a
culture from a swab which was sent to them, reported
that the diphtheria bacillus was present. They were
then told that the swab had been used on the throat of
a pigeon suffering from canker, a disease common on
the scalps and in the throats of these birds. The
bacillus was also found in the throat of every healthy
pigeon examined.
J. Price-Brown reports cases of non-diphtheritic
pseudo-membranous rhinitis, which he concludes is as
common as primary nasal diphtheria.
Engelmann has seen cases which demanded intuba-
tion, although it had not been possible to demonstrate
the Klebs-Loefller bacillus.
Peabody, when called to attend a nurse and being
in doubt about the diagnosis, first gave antitoxin and
then took a culture, which was negative. At the same
time he took cultures from the throats of three chil-
dren who had been in the company of the nurse the
same day. The cultures from two of the children de-
veloped the Klebs-Loeffler bacillus, though none of
the children ever showed any throat symptoms.
Hennig, in a study of thirty-five cases of clinical
diphtheria, of which number only about one-half were
infested with the Klebs-Loeffler bacillus according to
the report of two eminent bacteriologists, states that
the number of cases of post-diphtheritic paralysis was
greater in those which did not show the presence of
the Klebs-Loeffler bacillus.
In one of the London infectious-disease hospitals
there occurred an epidemic of rhinitis in which it was
found that the Klebs-Loeffler bacillus was present in
every one of the fifty-one cases. In no instance was
there membrane in the nose, or glandular enlargement,
or fever, or any other indication of disease. In mor-
phological character and by every test known to labo-
ratory workers this micro-organism corresponded to
the Klebs-Loeffler bacillus. Todd and Washbourn,
who report this epidemic in the London Laficet, 1898,
p. 1458, say there was no evidence that these cases
were the cause of producing diphtheria in people with
whom they came in contact.
Soerensen, of Copenhagen, describes a similar ex-
perience in the Zeitschrijt Jiir Hygiene, Bd. 29 u. 31
He found the Klebs-Loeffler bacillus in three hun-
dred and twenty-six scarlet-fever patients during three
years, and during the last years by investigation on
guinea-pigs the virulence of the germs was demon-
strated fifty-eight times in seventy-nine cases. The
remarkable thing brought out by this study was the
fact that eighty-five per cent, of these convalescents
from scarlet fever developed no symptoms of diph-
theria. In fifteen per cent, there was membrane in
the throat. Of the entire three hundred and twenty-
six not one died, if we except the case of a two-year-
old weakling whose death was due to pneumonia.
The mortality of real clinical diphtheria following
scarlet fever is notoriously great. Soerensen's cases
were simply bacterial laboratory diphtheria. The
good result was not due to the use of antitoxin, for of
the whole number of patients only two received injec-
tions of serum.
Finally may be mentioned the table in the German
collective report, which shows a mortality of 14.9 per
cent, in cases positively diagnosed by bacteriological
investigation, and 15.8 per cent, mortality in those in
which the bacteriological examination was negative.
Dogmatic statements, especially if sanctioned by
college teachers, take a very firm hold on the medical
mind, but criticisms and corrections do not so easily
reach the profession. Though the claim of etiological
relationship between diphtheria and the Klebs-Loeffler
bacillus has for a long time been shown to be un-
founded, the statement that this particular bacterium
is the cause of diphtheria is still being made by men
who are acquainted with only one side of the ques-
tion.
So it is with the whole antitoxin theory — the evi-
dence is all against it, but yet it is being taught in
the schools as if it were an established scientific fact.
To-day the student leaving college has a great deal to
unlearn about this matter. If he seek an appointment
in the medical department of our army, he will be
handicapped in his examination unless he can accept
tiie fantastic vaporings about antitoxin for science;
because the question may be, and has been, asked
about the treatment of diphtheria — and the bigoted
position of the surgeon-general on this subject is well
known.
It is an easy thing to suggest a theory, but quite a
different matter to force it into the minds of others;
especially when you completely fail to fortify it with
facts. Even the evolution theory exists only as a hy-
pothesis, and its correctness is still denied by many
scientific men of the highest standing. This state-
ment may seem hardly credible to those who had not
read much about the matter, but nevertheless it is
true. To refer to only a few men who stand as high
as any in their own particular lines of work, and who
see no convincing proof to sustain the evolution theory,
may be mentioned J. William Dawson, late principal
of McGill University, who had just died, and Max
Midler and Rudolf Virchow. Probably evolution will
never be scientifically proved. The writer has read
Darwin's work several times with a great deal of in-
terest, but can remember no convincing argument
derived from this fascinating study.
When we come to the consideration of the antitoxin
theory, we approach a subject which is capable of
proof if it contains a germ of truth. But so far nothing
has been proved to favor the idea that it is true.
And right here attention will be directed to remind
the profession of the dissimilarity between toxin and
antitoxin inoculation for the production of immunity.
There is evidence indicating that immunity can be
obtained from toxin injection, but there is no proof
that immunity has been conferred by antitoxin treat-
ment. There is a widespread tendency to jumble the
two things, and claim for antitoxin therapy all the good
which has so far been derived from toxin treatment.
In a previous article the writer endeavored to make
this distinction clear, but in the abstract of thig com-
munication in another journal the reviewer made the
usual error of confounding the two things by placing
vaccination and the Pasteur hydrophobia cure under
94
MEDICAL RECORD.
[January 20, 1900
the head of serum treatment. This same mistake was
committed by Fraser before a late meeting of the Brit-
ish Medical Association. He declared that the mor-
tality of diphtheria and hydrophobia had been reduced,
and the reader was expected to believe that the decrease
in the death rate in both instances is due to the use of
antitoxin treatment. Of these two diseases only diph-
theria is treated by the antitoxin method. Hydropho-
bia is subjected to the toxin form of treatment. In
antitoxin treatment the serum of another animal is sup-
posed to contain the remedy which is injected into the
patient. By this method the attempt has been made
to cure diphtheria, tetanus, tuberculosis, typhoid fever,
etc., but every effort in this direction has ended in
failure. In toxin treatment the serum of another ani-
mal is not used, but the patient is directly treated with
the disease germ or its product, or some virulent por-
tion of the body of an infected animal. Hydrophobia,
sarcoma, and smallpox are diseases which have been
successfully treated by this method of toxin inocula-
tion. Antitoxin advocates are sailing under false col-
ors when they appropriate for serum therapy the ad-
vantages which have been attained by toxin treatment.
We have satisfactory evidence of cures established
through toxin treatment; but no convincing proof has
ever been presented, either in the laboratory or at the
bedside, of any virtue in antitoxin serum treatment.
Tracheotomy in the hands of many operators in the
past, before antitoxin and intubation were introduced,
gave better results, everything considered, than are
now obtained with intubation in connection with the
administration of antitoxin. O'Dwyer called himself
a disappointed tracheotomist : if he could have saved
as many as one case in ten by tracheotomy, he says he
would not have turned to intubation. Other men also
were unfortunate with tracheotomy, yet that is no rea-
son to condemn the operation utterly, which was only
displaced because intubation offers relief in a simpler
way in many cases which would not be subjected to
tracheotomy until a much later time, because of the
horror entertained by most people for the latter opera-
tion. Intubation is now performed on very many
cases which would never have been given the advan-
tage of tracheotomy. Shaw, like many others, found
"it almost impossible to get consent to tracheotomy
until the favorable time had passed"; but now, since
the improvement in intubation by O'Dwyer, this diffi-
culty has largely been removed.
Pilcher wrote in 1893: "It is difficult to make a
proper comparison of results owing to the possibilities
of differences in the character of the cases submitted
to the two different procedures. It is undeniable that
intubation is much more likely to be resorted to in
cases of less critical nature than would be traclieotomy."
These considerations should be kept in mind when
making comparisons between antitoxin cases of laryn-
geal stenosis which have been intubated and the results
which followed tracheotomy in the past when antitoxin
was unknown. It will also be seen that to-day anti-
toxin-treated cases v;hich require tracheotomy do not
give any better results than follow when tracheotomy
is performed and antitoxin is not used.
As an indication that a larger proportion of stenotic
cases will receive operative aid from intubation, Pil-
cher states that while in the seventeen years prior to
1893 he had been operating in Brooklyn, and during
which time he had been called upon to do tracheotomy
in a considerable proportion of the operative cases, he
had operated but sixty-six times. On the other hand,
during the four years preceding 1893 McNaughton
performed intubation one hundred and forty-two times.
In a recent letter Dr. Pilcher tells me that tracheotomy
is now very rarely called for; and Dr. Fowler informs
me that during the past ten years he has done very
little, if any, tracheotomy for croup. Pilcher and
Fowler believe that antitoxin is largely responsible for
the decline in their tracheotomy work. The correct
explanation is that intubation has largely displaced
tracheotomy. The use of antitoxin has not reduced
the relative proportion of operations necessary in cases
of diphtheritic croup.
A reference to the compilation of statistics by Mad-
dren and McNaughton in the Brooklyn Medical Jour-
nal, 1893, makes it clear that operative relief by intu-
bation is now much oftener sought for than was the
case when only tracheotomy could be performed for
the relief of suffocation. The figures collected by
Maddern and McNaughton embraced the experience
of about two hundred and fifty medical men with sev-
enty-nine hundred and sixty-three operations. The
statistics were founded on tlie operative work of these
men, extending from the beginning of practice up to
1893, and included the six hundred and fifty tracheot-
omies by Jacobi, whose experience with diphtheria
dates back to the middle of this century. The first
one hundred intubations by O'Dwyer with eighty-three
per cent, mortality were excluded.
We find these operators, during the short time that
intubation was available, performed this operation
5,546 times; while the whole number of tracheotomies
reported by them, representing their work with the lat-
ter operation during their entire practice, amounted to
only 2,417 tracheotomies.
Experience of two hundred and fifty operators with
tracheotomy and intubation :
Operatic
'I'racheotomy .
Intubation , . ,
' Time of Experience.
Course of entire practice . .
A few years I 5,546
The conclusion has been drawn from these figures
that intubation saves six more patients than tracheot-
omy in every one hundred operations. When it is
considered that a vastly greater number of patients
are now operated on, and at a more favorable time, by
intubation than used to be possible when we had only
tracheotomy to suggest, it is probably an underestimate
of the present results of operation to say that the differ-
ence in favor of intubation is only six in one hundred.
While the Maddren-McNaughton statistics include
much too small a number of operations to be of final
value, yet they unmistakably point to the conclusions
above indicated.
That antitoxin has reduced the number of operations
is a statement easily made, but not so easily proved.
It is often said, about fifty per cent, of laryngeal cases, if
antitoxin is injected, result favorably without operation.
But the same percentage of recoveries was recorded in
five hundred and five cases of croup treated with calo-
mel inhalation, included in the excellent Maddren-
McNaughton table — which cases did not receive anti-
toxin. And yet the American Pediatric Reports state,
" Formerly only ten per cent, recovered from croup
when cases were not operated upon."
A light dawns on the good antitoxin intubation fig-
ures when we read tiiat one man intubated fifty-six
cases out of (me hundred patients. Another physician.
Levy, of Brooklyn, writes to me that he intubated
about fifty per cent, of the sixty-three cases he has
treated in general practice with antitoxin. Be it un-
derstood that these men have not operated on fifty per
cent, of laryngeal cases, but on fifty per cent, of all
the cases of diphtheria they were called to treat.
These men, as would be expected, produce very low
mortality figures. So does the man who operates on
every case of appendicitis. Intubation by itself, when
properly performed and with efficient after-care, ought
to be a practically harmless procedure. When fifty
January 20, 1900]
MEDICAL RECORD.
95
per cent, of all cases of diphtheria have to be intu-
bated, one is irresistibly led to think one of two
things: either the operation is often done before other
means are adopted to cure the patient without mechan-
ical intervention, or else that antitoxin is directly
responsible for the aggravation of laryngeal stenosis.
When antitoxin statistics show a small proportion of
operations to all cases of diphtheria in general, the
explanation probably always is that many cases of bac-
terially diagnosed diphtheria are included to give the
good figures; and the bacterial diagnosis has so often
been proved to be a farce that it is becoming weari-
some to repeat the fact.
Jacobi has been particularly unfortunate with tra-
cheotomy. Up to 1893 he performed this operation
six hundred and fifty times and saved only one hun-
dred and twenty-four patients. Yet in 1893, before
the antitoxin-serum chimera had deluded the profes-
sion, he was not deprived of all hope, for he then
wrote: " Results would now be more favorable; results
differ in different seasons." But remember that Ja-
cobi's experience dates back to almost the revival of
tracheotomy in this century. It was in 1825 that
Bretonneau was made supremely happy by being able
to save the life of a dear friend's child with his first
successful operation; and in 1852 Jacobi was already
studying the disease. He reported a case of diph-
theria in New York City in that year, the first case of
which the health department contains any record. The
statistics of Jacobi's own operations, therefore, em-
brace the work done by him during a number of differ-
ent epidemic waves of the disease, which fact should
not be lost sight of when comparison is made between
his figures and the results of a different operation and
a new method of treatment, both extending over only
a comparatively few years.
In 1852, Bouchut reported seventy-two per cent, mor-
tality in one hundred and ninety-eight tracheotomies.
After that, from 1864 to 1884 there was a mortality of
66 1 per cent, in the Boston City Hospital. A mor-
tality of 66 J per cent, resulted also in Pilcher's pri-
vate practice from 1876 to 1893 in sixty-six operations.
In 1876 the mortality in English and Scotch hospitals
and private practice was found to be sixty per cent.
There were three hundred and thirty-three tracheot-
omies reported in Basle, Switzerland, with fifty-nine
per cent, mortality. The reports of Revilliod in 1876
and Sanne, of France, in 1877 give a mortality of fifty-
six per cent, in two hundred and fifteen operations.
Since the above-mentioned work was done even bet-
ter results have followed tracheotomy, as shown in the
following table :
Tracheotomy Without Antitoxin. Mortality,
Per Cent.
Soerensen, Copenhagen, 1895 25
Zurich, 1883-S4 40
Drobrink, 1 76 cases 37
Cohen, 166 cases 33
Strassburg Hospital, iSgi 25
Geneva, 1872-8S 49
Strassburg, 1891-94 44
London University College, 1884 47
Dower, Brooklyn, 67 cases .' 25
The figures in the above table give the mortality of
tracheotomy without antitoxin treatment. Not only is
it impossible to match this table with equally good
results with antitoxin-treated tracheotomy cases, but
in New York City, Boston, and Philadelphia the much
more favorable operation of intubation in connection
with antitoxin is followed by a greater mortality than
shown in this table of tracheotomy without antitoxin.
The following list is useful for comparison:
Intubation With Antitoxin.
Per Cent.
New York City, Willard Parker Hospital, 9 months, 1895. 68
New York City, Willard Parker Hospital, 6 months, 1897. 82
Boston City Hospital, 1895-96 53
Philadelphia Municipal Hospital, 1S96 56
Philadelphia Municipal Hospital, 1897 68
The next table shows the result obtained by Ameri-
can operators with tracheotomy without antitoxin in
three hundred and eighty-seven cases with forty-seven
per cent, mortality:
Tracheotomy Without Antitoxin.
Cases Lost Mortality,
Lases. L-ost. p^^. ^.^^
Boldt, Cocks, and Denhard, New York City. 66 31 47
Twenty Brooklyn physicians 238 iii 47
Hartwig, Buffalo 3 I 33
O'Shea, Chicago 3 I 33
Townsend, Bergen, N. Y 13 6 47
Niner and Jennings, Detroit 64 34 53
3S7 184 47
The following table contains one hundred tracheot-
omies without antitoxin by eight Brooklyn physicians,
with twenty-eight per cent, mortality :
Traciieotumy Without Antitoxin.
Operations, f"'],^^^'/-
Fuller 6 50
Dower 67 25
Maddren 4 5°
Spencer 7 29
Phillips ^. 3
Beach 6 17
Corbally 2
Stuart 5 60
100 28
Tracheotomy in Children Under Two Years of Age.
ll'ithont Antitoxin.
n^ T,- .1 Mortality,
Cases. D.ed. p„ cent.
Barzeau 12 8 66
Kevilliod 16 10 62
Sonnenberg Hospital, 1896 8 3 37
Total 36 21 41
IVith Antitoxin.
London Hospitals, 1S96 30 21 70
According to the Maddren-McNaughton idea, that
intubation saves six more cases in each one hundred
operations than tracheotomy (which was the operation
done on the one hundred cases in the above table),
had these cases been intubated, the mortality would
have been only twenty-three per cent, without the use
of antitoxin.
In one of the preceding tables was given the result
of tracheotomy without the use of antitoxin, in Den-
mark, Germany, Switzerland, England, and the United
States, all the statistics given showing a mortality of
less than fifty per cent. In the next table is shown
that such good results have never been achieved with
the same operation when the patients at the same time
receive antitoxin treatment:
Tracheotomy With Antitoxin. Mortality,
Per Cent.
London, Western Hospital, l8g6 63
Cassel 61
Baginsky, Berlin • 7^
Antitoxin advocates would have us believe that it
used to be a very rare occurrence for young children
to recover after tracheotomy before antitoxin was
known. Such, however, is not the fact.
In an article entitled " Is the Operation of Trache-
otomy in Diphtheritic Croup Dangerous?" in the
Medical Record, December 13, 1884, Winters gives
a list of ninety-three successful tracheotomies on chil-
dren two years of age and under. This table contains
two, three, four, and in one instance six successful
operations by one man. Barzeau saved twenty-five
96
MEDICAL RECORD.
[January 20, 1900
per cent, of twelve cases, and Revilliod thirty-seven
per cent, of sixteen cases, by this operation in chil-
dren under two years of age, to whom no antitoxin was
given.
When intubation does not relieve a stenotic patient
^which sometimes happens — and the attempt is made
to effect a cure with a secondary tracheotomy, it is not
surprising that a very high rate of mortality ensues.
If antitoxin confers any benefit, it might be reasonable
to expect to look for better results in this class of
cases which also receive antitoxin than are obtained
in patients on whom a secondary tracheotomy is nec-
essary after intubation and to whom no antitoxin is
administered. But no such benefit can be claimed in
favor of antitoxin-treated cases. For comparison, fifty-
six cases requiring tracheotomy after intubation have
been taken from the Maddren-McNaughton table, to
place beside fifty-six cases which occurred in the
Hopital Trousseau, which latter cases received anti-
toxin treatment, while those in the Maddren-McNaugh-
ton table were not subjected to the serum treatment.
In 1897, in the Hopital Trousseau, fifty-six secondary
tracheotomies were performed, and eleven patients re-
covered. Taking, fifty-six tracheotomies from the
Maddren-McNaughton table without selection and just
in the order as printed, it is found that ten patients
recovered. When it is. considered that the fifty-six
Trousseau patients weTe all operated on under one
roof by specially trained physicians, and watched
after treatment by nurses well qualified through con-
stant daily experience with diphtheria patients, while
the fifty-six Maddren-McNaughton cases were operated
on by twenty-three different operators in twenty-three
different places, and aided by such nursing as it is
possible to secure in average general practice, this
difference of one case in fifty-six in favor of those
treated with antitoxin (or less than two per cent, dif-
ference), cannot be considered an indication that bet-
ter results followed in those treated with serum. Abso-
lutely no superiority can be claimed for antitoxin from
this experience; all the advantages as regards treat-
ment and after-care were on the side of those treated
with antitoxin. As the ages of the patients were not
given in either table, it is impossible to consider this
important factor, without which the figures given are
really without value.
In a previous article mention was made of an experi-
ment which was tried in Trieste by the physicians of
that city, who in 1895 treated practically all cases of
diphtheria in general with antitoxin. The result was
that more patients died in that year than ever before.
Kassowitz called Baginsky's attention to this fact,
and in reply Baginsky contented himself by saying he
didn't know anything about the circumstance. It
seems as if some optical perversion prevents him from
seeing that which he does not want to see. When the
foolish ostrich shoves his head in the sand to cover
his eyes, that act does not mislead or extinguish his
pursuer any more than this evasive answer deceives
the profession or removes the above-mentioned fact.
Treatment of Poisoning by Carbolic Acid — Hypo-
dermic injections of ether. Rectal injections of
sodium sulphate, two ounces to three pints of water;
irrigate as high as possible after the fnethod of Can-
tani. Give an ounce of the same drug in a quart of
warm water per os, or by means of a stomach tube.
If necessary perform venesection, followed by hypo-
dermoclysis or intravenous transfusion of a quart of
decinormal saline solution. Give morphine and apply
heat to the extremities. If the rectal injection has
returned, inject a quantity of a strong infusion of
black coffee. — Landouzv.
A COMMON CASE AND ITS PRACTICAL
SUGGESTIONS.'
P.Y JOSEPHINE M. WETMORE, M.D.,
CRINNELL, IOWA.
When our president requested me to present before
this society a paper, or report a case, I looked about,
as we all do, for some object of interest occurring in
our practice, or pertaining to a subject in which others
would be interested; when my attention was arrested
by the visit of a patient who came to report progress.
This patient is a type of a large class of cases that
are so common and so unsatisfactory to treat, unless
the cause of their indisposition can be ferreted out and
removed, as rather to weary the busy physician. And
because of long-continued symptoms, that are seldom
alarming, the case is apt to be catalogued chronic, and
is not thought deserving of much valuable time and
attention. It is to this class of cases that I wish to
call special attention, and endeavor to relieve if pos-
sible one great element so conducive and active in
their etiology.
This patient came to me some time ago, in the per-
son of a bright, intelligent, rapidly growing boy of
fifteen years. His father, dying some years ago of
acute stomach trouble, was never strong, was extreme-
ly nervous, restless, irritable, and ambitious. His
mother, who accompanied him, is of more than ordi-
nary intelligence, education, and refinement. This,
the youngest of her three children, all boys, is the
most difficult to manage. His restless, uneasy man-
ner, manifested particularly in the schoolroom, has
caused him previous to the present term to consider
his instructors his greatest enemies. He refuses to
apply himself to his studies, to the preparation of
which he is expected to devote the waking and some
of the necessary sleeping hours. He therefore lives in
an atmosphere of discontent and forced depression,
most of the time at variance with all his surround-
ings.
As he sat in the consulting-room, and I tried to se-
cure a full and complete history of his case, he was in
constant motion. His capricious appetite is allowed
its unnatural demands. He feels tired, is pale and
thin in fiesh, the bowels are sluggish, the breath is
offensive, the tongue is coated, and the gums are
spongy. He has a dull headache, and the two symp-
toms of which he complains the most, and has com-
plained for two years, and for which his mother requests
relief, are pain around his heart and dyspnoea. These
two symptoms have of late given himself and mother
much uneasiness; heretofore they had ascribed them to
his rapid growth. By pressure over the point of exit
of the spinal nerv'es this pain is greatly aggravated.
There are also several points of hypera;sthesia along
the spinal column. A thorough physical examination
and careful questioning as to bad personal habits, the
latter of which are denied, reveal no organic trouble
of any kind. A rapid, slightly irregular heart action
and diminished lung capacity are the only signs
present.
What shall I do for this patient ? Shall I insist
upon uninterrupted confinement in the schoolroom,
prescribe some nerve sedative, or stimulant, and lull
for time at least these crying needs? He is from a
family financially independent of any physical exer-
tion or denial of any reasonable wish. He has only
to occupy himself with that which will educate and
refine him. He has ambitions in a mechanical line,
enjoys employment with tools, and is naturally a
mechanical genius, but has been rather discouraged,
or at least not encouraged, by his mother, who would
'- ve him a scholar, with no thought of his health to
' Head before ti.c annual meeting- of the Iowa Central State
Medical Society.
♦
January 20, 1900] MEDICAL
interfere with lier ideal plan. It was with much difti-
culty and after continued reasoning that I persuaded
this mother to relax her ambition and take the boy out
of school. I then laid out a plan of work, exercise,
and rest; he was to rise at 6 a.m. instead of 8:30,
take his cool sponge bath, with his mother's assistance
until accustomed to it, have a little exercise, and par-
take of a plain, nutritious breakfast. During the meal
he should form the habit of eating slowly and thor-
oughly masticating his food; then take exercise, in
which he should accomplish a definite amount of work.
He should attend school, recite one lesson during the
forenoon, have his heavy meal at noon-time, afterward
rest in the recumbent position one hour, sleeping if
possible; recite another lesson in the afternoon, study-
ing for a sufficient length of time to prepare these two
lessons; he should have recreation and work of a prop-
er kind, and retire at 8 p.m. In fact, he was to live
like a child and not a young man. His only medicine
after cleansing and disinfecting the gastro-intestinal
tract was, along with continuous use of astringent dis-
infectants for the mouth and teeth :
If Blaud's mabs gr. iij.
Soc. aloes gr. \
E.\t. nux vom gr. fV
Arsenious acid gr. y^jj
It is needless to tell you the results of this plan of
treatment. The relief from constant attendance to
school duties stimulated his ambition in his studies,
the change being quickly recognized by his teacher,
who had exercised great patience and forbearance, and
understood the great strain under which her pupil
labored with this enforced education.
This rather lengthy description of a very common
case fits many others which have come under my ob-
servation, not only boys, but more frequently girls,
ranging in age from twelve to sixteen years. At this
age ordinarily they reach a grade in school where they
are obliged to devote their entire time until nine and
ten o'clock at night, Saturday included, bending over
their books, applying themselves as diligently as the
mature adult student who is taking up a profession,
with only a thought of high grades at whatever expense
to the physical health.
At this very important developmental age, functions
heretofore unknown are asserting themselves, and
rightly demand the best and purest blood for the prop-
er growth and development of the organs concerned
in these functions — blood rich in oxygen, unburdened
by vitiated air and poisons of gastro-intestinal origin,
blood that flows freely with the assistance of well-
developed muscles that are growing strong by suffi-
cient physical exercise. Perhaps now, more than at
any other time in life, should the activity of the
unstable ner\ous system be kept in abeyance. As far
as the child is concerned it should not know that it
lias nerves, but how often is such a one brought to us
because of extreme nervousness !
In the girl, particularly at this age, the most impor-
tant organs of her body, so far as her future health and
happiness and that of her offspring are concerned, are
coming to the front and eagerly demanding their right-
ful supply of nutrition. The languor and indisposi-
tion for mental e.vertion are only mute messengers to
us requesting precedence for reproductive development.
Our present system of education completely reverses
the natural law, and our young girls about to become
women are made to suffer untold agonies, mortifica-
tions, and heartaches the remainder of their lives
through dysmenorrhrea, the torture of which can be
second only to the pangs of parturition, and must be
experienced twelve times each year with ofttimes no
relief excepting of an operative nature, and even this
is followed by other as distressing and incapacitating
ailments.
RECORD.
97
The lack of proper and sufficient exercise during
this period may well cause a debility of muscles and
ligaments, whose function it is to support; this in turn
allows flexions, versions, prolapsus of uterus and
ovaries; the insufficiently supported blood-vessels al-
low a varicosity or perchance menorrhagia, or amen-
orrhcea, coupled with which are neuralgic horrors of
various degrees and regularities. And this is not all;
but constipation adds its quota to the already overbur-
dened system ; the patient suffers from frequent head-
aches, insomnia, and that stigma of Americans, ner-
vousness, with all that follows in its wake.
The young girl, with more sad experiences than her
great-grandmother ever dreamed of, reaches a crippled
womanhood. Ofttimes she has been a regular attend-
ant on the gynsecologist. If perchance she engages in
public work, she must absent herself from work from
one to four days, and suffer all the attendant mortifi-
cation and embarrassment in proportion to her worfianly
modesty. In fully seventy-five per cent. — and I think
I am not overestimating — she must seek the gynaecol-
ogist's assistance sooner or later, and not infrequentlj-
be brought to death's door reaching the crown of her
womanhood — maternity.
Should we not as physicians and guardians of the
public health use our influence to prevent, in so far
as preventable, causes which strike at the heart of
physical health?
I believe that when the physical development of
womankind — and by this I do not refer to the gym-
nasium, bicycle, or tennis courts — is put in the ascen-
dancy during her period of special development, we
shall have reached the millennium in health both of
men and women. Of course we cannot expect all the
results in the next two generations, nor will such a
reform probably eradicate all deformities. Every girl
should have work during this period of partial mental
suspension; she should under no circumstances be
allowed to idle away her time, do fancy work, read
light, trifling novels, or attend parties, balls, etc.
There is no better time in her life than now to put her
at work which is often considered undignified, viz.,
housework. There is no \.ork in gymnasiums, cook-
ing-schools, etc., equal to everyday dutiessu pervised
by a thrifty, intelligent mother. It is not drudgery,
but is elevating and broadening; the very precision
used in the artistic arrangement of table or china
closet, the preservation and proper preparation of
plain articles of food, economically handled, can be
made of far greater value in the future welfare and
happiness of mankind in general than all the trigo-
nometry and astronomy known. Do not understand
me to deprecate the higher and college education of
our women — far from it; I only plead your attention to
the more perfect physical development during this im-
portant period.
When nature has well established her higher task,
there is plenty of time for further mental education,
which has been held in check for a time only. No
more unreasonable is it to tear open tlie beautiful bud
to see its beauty and hope to enjoy its fragrance, before
nature is ready, than to crowd a young creature beyond
the limits imposed by this common law. The results
are comparatively as disastrous in the one as in the
other. In the great struggle for education and mental
attainments, the suitability of such crowding and over-
encouragement to young minds, aside from the effect
upon health, is overlooked. Not every pupil will
make a scholar; some who are educated at great
expense and sacrifice for the learned professions would
achieve far greater success and happiness following
the plough.
Because our neighbor's boys and girls are brilliant
professional workers is no reason that our children
should follow in their footsteps. Ofttimes the ambi-
98
MEDICAL RECORD.
[January 20, 1900
tion for the child overcomes the belter judgment of
the parent, and a life-work from which the young man
feels ashamed to turn back is entered upon, and his
discontent finds its only relief in pleasures that de-
grade rather than elevate. It seems to me that this
period of lessened mental strain might be one in
which a child could show its natural capabilities.
What I have said applies equally to both boy and
girl; the higher education should be secondary to the
physical. Neurasthenia, in its various degrees, is our
prevalent condition. Why is it so? Is there not a
close relation between our developing young and our
adult neurasthenic? Where is the trouble, and who
is at fault?
But, many will say, we are not consulted in regard
to these cases until they are practically incurable.
They mistake; they do not recognize the necessity for
a careful examination and diagnosis in the little
patient who is brought, complaining of headache,
backache, or stomach-ache, and is so tired, and, the
mother explains, so nervous, but accept too readily the
diagnosis so unhesitatingly offered, of some stomach
trouble, eye-strain, or worms; treatment for either of
which will result in a slight improvement for a time
at least, and the case is discharged, probably with sat-
isfaction to the mother, but it should not be so to the
physician.
A few years later he may be called to care for a
nervous wreck which might have been prevented had
sufficient time and attention been given years before.
When we physicians take time from our busy lives
carefully to diagnosticate these cases, and to lay out a
plan of treatment which shall include exercise and
rest, and do it definitely, with as much precision and
insistence of its importance upon our patient as we
prescribe arsenic, strychnine, etc., this being coupled
with this judicious administration of a little medicine
as indicated, we shall be spared the anxiety that will
come to us while attending these same children, older
grown, through some acute disease when we know their
nervous resistance to be low.
When we have done our duty in these seemingly
minor details, then and then only may we hope truly
to benefit humanity, which is the ambition of every
worthy physician. We ask pardon for using the time
allotted for other than scientific technicalities, for not
relating some very unusual case, instead of calling
your attention to a subject which, if recognized and
attended to, means far more to humanity at large than
many severe and interesting operations. This is a
matter that confronts every general practitioner, per-
haps every day of his life, and upon his intelligent
appreciation and management a large amount of the
good he does depends. Our patients come to us for
advice far oftener than for medicine or the knife.
They are well informed regarding foreign topics, pol-
itics, and war problems; but how helplessly ignorant
of the proper care of themselves tliey are only the doc-
tor knows.
I do not advise closing up our public schools, but I
do advise modifying and arranging the work of our
boys and girls at the age of puberty, that they be con-
fined in the schoolroom a much shorter time than
now, that studying out of regular school hours be en-
tirely prohibited, that during their time spent outside
of the schoolroom they be systematically employed at
occupations that shall rest and refresh and fit them for
future life-work. They must not be idle.
Their occupations should bring into play all parts
of their growing bodies, give them healthful exercise
and fresh air, work as unlike their studies as is possi-
ble, that they may during this period be allowed to
cultivate natural ambitions, unhampered by over-zeal-
ous parents and teachers, who are to temper and cor-
rect, hold in abeyance rather than over-stimulate.
Some pupils will stand more crowding in mental work
than others; each one is a law unto himself. We
caniTot lay down hard-and-fast rules for the school to
go by ; we cannot look to the school board, superin-
tendents, or teachers for this help, for the direction of
such matters is entirely within the province of the
family physician, and the accomplishment will be
obtained with the co-operation of the parents whom
we now educate for the coming generations.
After the functions of the adult being are thoroughly
established, then may our student take up higher stud-
ies and find himself able to accomplish much with-
out detriment to his physical body or mental capacity.
Undoubtedly this nervous strain causes many a
young and promising woman to lose her ambition and
gradually drift into semi-invalidism because she feels
incapable of keeping up with the demands made upon
her; the pity and compassion of over-sympathetic
friends magnify and intensify her symptoms until she
easily resigns herself a martyr to her feelings. Not
even the physician or sensible friends can persuade
her otherwise; not until some actual necessity arises
by which she is obliged to forget herself and uncon-
sciously accomplish a reasonable amount of work does
she awaken to her possibilities, and her invalidism
becomes a thing of the past.
In conclusion, does it not seem reasonable to be-
lieve that by a proper direction of the education of our
young at puberty, they will be better able to withstand
the great strain incident upon any line of work? May
we not in a great measure prevent these complete
wrecks, which the physician is expected to endow with
life and ambition, and in which in so far as he is suc-
cessful is his professional ability estimated by the
laity ?
GYNAECOLOGY AND GYNECOLOGISTS IN
EUROPE.'
By ABR.-\M brothers. B.S., M.D.,
NEW YORK,
In the present communication I purpose to describe
some of my experiences in the clinics and hospitals
of Berlin, Paris, and London during the two months
dating from September 20 to November 15, 1899. As
my object in going abroad was primarily for rest, the
scientific work was necessarily limited and followed
up rather in the sense of diversion than active work.
But for the physician abroad in pursuit of pure scien-
tific knowledge, it is wonderful how much can be ac-
complished in the short space of two months.
Although I was fully armed with letters of introduc-
tion, I wish to state at the outset that they are not es-
sential, and that the ordinary visiting-card will serve
all practical purposes. A knowledge of French and
German is necessary, however, for immediate and rapid
work, otherwise the visitor may flounder about for
months accomplishing very little.
As at home, very little is done abroad during the
summer months. In Berlin a special preliminary
course of instruction is given by " Privat-Docenten "
toward the end of September and beginning of Octo-
ber. Some of the professors take part in these courses.
In France and England very little will be seen before
November.
Naturally my chief interest w'as centred in gynaecol-
ogy and surgery, although from time to time I tres-
passed upon other branches of medicine.
At Berlin, the best location for the medical visitor
is the neighborhood of the Friedrichstrasse Bahnhof,
' Read at a meeting of the Kastern Medical Society, held
December S, iSgy.
1
January 20, 1900]
MEDICAL RECORD.
99
which is centrally located and within walking distance
of the principal hospitals and clinics. It is well to
call at the Langenbeck-Haus (5-9 Ziegelstrasse) and
make inquiries of the secretary regarding the courses
one chooses to take. In order to be admitted to the
operating-rooms it is customary for the visitor first to
call on an operator and present his card. With the
exception of Olshausen I found the operators very
cordial during one or two visits, after which it was
made painfully clear that, in the absence of " taking
the course," such visits would be cheerfully e.xcused.
Olshausen is the chief of the Universitats-Frauen-
klinik(at 20 Artillerie-Strasse). He is a man of about
sixty-five years, with full gray whiskers and thin hair.
His face is wrinkled and puffed under the eyes. His
sight is good and he works without glasses. He has
the best record for Cassarean section. His methods
are precise. Everything about him has an air of quiet
dignity, and nothing in tiie course of an operation
seems to disturb the gentleness and serenity of his
disposition. He talks very little, and that in a quietly
subdued tone of voice. He works with wonderful
rapidity, helping himself to his own instruments from
a little tray at his elbow. I saw him remove an im-
mense ovarian tumor, and close up the abdominal
wound in three layers of sutures, within fifteen min-
utes. He works in a small room, and the visitors are
requested to leave at the end of each operation. Al-
though my notes are very copious, I shall content my-
self by stating that I saw Olshausen do quite a num-
ber of major operations — laparotomies for different
tumors and hysterectomies. I saw him do his first
Alexander operation, and, although working more
slowly than usual, he succeeded in finding the liga-
ments. He very seldom resorts to drainage or flush-
ing of the peritoneal cavity (relying on gentle wiping
with gauze}, and closes the abdominal wall in tiers
(three or four) of sutures. He uses catgut exclu-
sively. After the wound is sewed, he dusts the line
of approximation with powdered bismuth and seals it
with gauze and collodion. He does not rely on clamps
for permanent hasmostasis, but uses ligatures. One
assistant gives chloroform. His house surgeon simply
holds retractors; one nurse threads needles, and al-
most everything else down to applying the bandage he
does himself. I fear, however, that he is a little ultra-
conservative, and I have seen him leave diseased tis-
sues which most operators would have removed. In
hysterectomies (abdominal) he leaves the cervix in all
cases, although he confessed that recently one of the
women in his wards had succumbed to secondary car-
cinoma developed in such a stump.
Koblanck assumes full charge in the absence of
Olshausen. He is a thin-built individual of about
thirty-five years, with dark sandy hair and whiskers,
the latter trimmed to a point. I saw him do a laparot-
omy for a intraligamentary ovarian cyst which was
adherent to the anterior peritoneal wall, small intes-
tine, and mesentery. Although a very difficult case,
he handled it like a master. In a second operation
for prolapsus uteri the vagina was narrowed by plastic
work, and then the uterus ventro-fixated by wormgut
and catgut passed simultaneously in the eye of one
needle. In this case, as in several other chloroform
cases which I witnessed, the patient almost succumbed
to the narcosis. Olshausen frequently enters the op-
erating-room when the younger m.en are at work, and
does not hesitate to criticise and reprove them when
he finds the technique faulty. In one case of perineor-
rhaphy he obliged the operator to remove his sutures
because the vagina was too much contracted.
Gebhard, the pathologist to the Universitjits-Frau-
enklinik, is a remarkable individual. He is under
forty, combs his hair (which is jet black) :l la Pompa-
dour, and has a thickly scarred face, adorned with a
little mustache. He is equally at home at the operat-
ing-table and in the pathological laboratory — a most
unusual state of affairs for a German clinic. He has
written recently a most excellent book on gynaecological
histology. When I asked him how long it took him to
w-rite it, he quietly replied: "Two years for the writ-
ing, and all of my medical life for the preparatory
work."
Landau's private hospital is located at 21 Phillip-
strasse. The chief of the clinic is Leopold Landau.
He is assisted in its management by his brother Theo-
dore. The house surgeon is Thumim ; and Pick is in
charge of the laboratory. The medical visitor to Ber-
lin must not fail to call at this little hospital (which
is a model of its kind). Under Pick, I spent nearly
four weeks almost daily in the laboratory, preparing,
staining, and mounting specimens. Pick has discov-
ered a method of preserving the natural color of tis-
sues indefinitely. There are hundreds of jars in the
laboratory containing specimens of gynaecological pa-
thology. The system followed is ideal. After oper-
ation the specimen is sent up to the laboratory, where
it is placed in a jar and labelled. A gross report is
added to the clinical history and description of the
operation. Slides are mounted with sections for mi-
croscopical study, and the result is added to the former
notes. These slides are preserved in special cases
where they are carefully numbered and labelled; so
that, in any given case, not only are the histories
available, but the gross and microscopical specimens
are ready for immediate consultation.
The Nitze and Casper methods of examining the
bladder are almost universally employed in Germany,
and I determined to master the subject. I found
Thumim giving instruction in this field, and took a
course with him. After six or seven sessions, work-
ing on a model and on a number of women, I felt
quite at ease in the use of the cystoscope and ureteral
catheter.
Leopold Landau seems to be a man aged nearly
fifty, with full beard trimmed to a point and progres-
sive baldness beginning at the back of the head. I
saw him operate on three occasions: three vaginal
hysterectomies, one abdominal hysterectomy, and sev-
eral laparotomies. He is extremely radical in his
work, and in my presence he stated that he had al-
ready done eight hundred and thirty hysterectomies.
He frequently removes two or three uteri in the course
of a morning's operations. He takes no stock in leav-
ing a portion of an ovary to prevent the sudden onset
of the menopause. I shall not enter into the details
of his methods of operating beyond stating that he is
one of the chief exponents in Germany of the clamp
method in hysterectomy. His last one hundred and
twenty or more cases have been done with the Thu-
mim angiotribe (which is a modification of the instru-
ment devised by the French surgeon, Tuffier). As a
matter of fact, I witnessed the successful employment
of the instrument in the hysterectomies done in my
presence. The abdominal hysterectomy was done after
the method published by Doyen, but Landau said that
the operation was original with himself. Excepting
the first inspiration from Pe'an, he claimed originality
for all his technique, as far as the French were con-
cerned, in connection with hysterectomy. Be that as
it may, he is one of the best operators in the world.
I will simply add that he rapidly closes his abdominal
wounds after laparotomy with one row of silver-wire
sutures.
Diihrssen's "Privat Heil-Anstalt " is an old private
residence converted into a hospital, and is situated at
N. W. Schiffbauerdamm 31. He is a tall, handsomely
built man of forty-five, with blond mustache and short
cheek-stubs. I saw him do a vaginal hysterectomy
with a new ligature material known as 'Celluitz-
MEDICAL RECORD.
[January 20, 1900
wern." The patient was a spinster, aged tiity years,
who had once suffered from gonorrhcea, and recently
had been troubled with excessive hemorrhages due to
a soft submucous fibroma. As an operator, I consider
Diihrssen slow and painstaking. He seemed to be
exceedingly irritable toward his assistants. Like
Landau and Olshausen he employs a nurse to thread
needles and hand instruments. Two assistants are at
the wound, and a third gives the anfesthetic. I
noticed a Snegirelif vaporizer in the room, which Diihr-
ssen told me had done him good service in a num-
ber of cases of uterine hemorrhages.
Mackenrodt has a private hospital at Johannis-
strasse 10. He looks to be about forty-five, and has
reddish pointed chin-whiskers. He was courteous
enough to send me an invitation to an operation which
I was unfortunately unable to attend.
I saw Gusserow do several vaginal operations for
diseased adnexa at the Charitd (13 Luisenstrasse).
He is a stout, thick-necked, thin-haired, plethoric in-
dividual of sixty, with a heavy dirty-gray mustache.
He is very rough toward his assistants, and has a very
uninviting appearance. I did not talk to him, having
been warned that he sometimes treats his visitors
rather discourteously.
Martin is no longer at Berlin, but his former private
clinic is under the management of Orthmann, who made
me feel good by telling me that he had read my name
in the medical journals, particularly in connection
with the proceedings of the Obstetrical Society. He
is a heavy, stout person with blond whiskers trimmed
to a point, who sweats profusely and incessantly while
operating. I saw him do a laparotomy for tubercu-
lous adnexal disease, and after two hours' work when
I left he was just beginning to close up the abdominal
wound.
Konig, Jr., is the first assistant to v. Bergmann.
He is an exceedingly modest but able surgeon. Un-
der his supervision 1 enjoyed the privilege of rehears-
ing quite a number of intra-abdominal operations on
the cadaver and on living dogs.
Besides my work in gynascology I made single vis-
its to various places. Thus, I was invited by Nagel
to attend his class when he was teaching the various
gynecological operations on formalin-preserved geni-
tals removed from cadavers and sewed into obstetric
phantoms. I visited Virchow's museum and saw some
of the famous specimens which have been collected by
the master during a half-century.
One day I called at Rosenheim's polyclinic, where
clinical instruction is given in the disorders of diges-
tion. It is a filthy set of apartments situated in an
upper story of a rear building. The dust in places
was quite thick. Rosenheim himself, however, is a
very clever diagnostician, and I think his course can
be taken with advantage by visitors interested in gen-
eral medicine.
At the Charite, Konig, Sr., was operating for the
benefit of military surgeons, and at the Kaiserliche
Krankenhaus I saw quite a number of the younger
men do all sorts of general surgery. Some mornings
three operations were being done simultaneously in
the one operating-room.
Altogether, I am satisfied that at Berlin a great deal
of good work can be done by the medical visitor in
every branch of medicine and surgery. Unfortunately
the work is scattered and quite expensive. One morn-
ing I visited at the large public Kaiserliche Kranken-
haus the surgical clinic of a young surgeon named
Lexer in company with two American colleagues, and
he actually sent the janitor up to us to find out if we
had taken tickets for the "course."
There are a good many foreign physicians studying
in Berlin — -Russians, Turks, Japanese, Belgians, and
Americans The last variety is rated very low. One
Privat-Docent told me that the American physician
had very little standing, unless he was a graduate of
Johns Hopkins, Harvard, Vale, or Princeton. He
thought that Columbia was beginning to assert herself
— which was a slight relief to me.
At Paris, I could see no evidence of a systematic
course of instruction for foreign graduates in medi-
cine as we understand this in America. Unfortu-
nately for the visitor interested in gynaecology, all the
operators in Paris have selected the same three morn-
ings in the week (Tuesday, Thursday, and Saturday),
at the same hour in the morning (10 a.m.), for perform-
ing operations. The consequent waste of time (in
case one of them fails to operate) can readilv be un-
derstood.
It is necessary to speak French at these clinics.
Only a few of the Parisian operators (notably Pozzi)
speak English. Even broken French is better than
nothing, for the Frenchman is much more charitable
toward the foreigner speaking the language imper-
fectly than his German colleague. Again, the sense
of constraint in the atmosphere of the German clinics
is entirely absent in the French hospitals. The visit-
ing surgeon often enters the operating-room with a
cigarette in his mouth. The signs on the walls of the
German operating-room, " Favete Unguis" and "Noli
tangere," do not haunt the visitor in France. The
visitor is usually invited to a seat at the back of the
operator's chair. In Germany also he is permitted to
stand close to the operator. In England he is placed
behind a railing at a distance. In France, as well as
in Germany, the visitor is given a linen coat — except-
ing at Landau's clinic, where the visitor simply removes
his coat. In England these precautions are regarded
as superfluous.
With the exception of a few like Pozzi, the French
gyna2Cologists prefer to be called surgeons; and, as a
matter of fact, many of them do all sorts of ■ general
surgery. This is notably true of Doyen and Tuffier.
Pozzi, being a senator, seems to have a mighty "pull,"
for the government has erected the magnificent " An-
nexe Pascal" at I'Hopital Broca (iii Rue Broca),
where a pure gynascological service is maintained.
The walls are decorated with beautiful oil paintings,
which must have a happy ;ind cheering effect on the
patients as they gaze at them from their beds. These
walls are regularly scrubbed as if the paintings were
not present. There are two operating-rooms, of which
one is reserved for purely aseptic operations. Every
modern arrangement for ventilation, heating, plumbing,
etc., will be seen here. The largest sterilizing appa-
ratus in the world will be found in one special room.
The out-patient department is isolated from the hos-
pital proper, and on one of the walls I read the notice,
" Never introduce the sound without first inquiring as
to the date of the last menstruation " — a very sugges-
tive recommendation.
Pozzi is a dark-haired, swarthy-complexioned man
with black whiskers, tinged with gray and carefully
trimmed to a point. His nose is somewhat aquiline,
his forehead recedes, and he wears a skull cap while
in the hospital. I met him a number of times on the
street, dressed in the height of fashion and presenting
a scrupulously elegant appearance in his tall silk hat
and snugly fitting, long English overcoat. Although
present during operations by his assistants, I failed
during these visits to catch the master himself at work.
I saw Segond operate at La Salpetriere, which is
situated on the Boulevard de I'Hopital on the other
side of the Seine. It is the largest hospital I ever
\ isited, although I am told that it is smaller than the
Vienna hospital. It accommodates nearly four thou-
sand patients. Imagine a town enclosed in four
stone walls and containing many dozens of stone build-
ings separated by lanes, streets, and large courts.
January 20, 1900]
MEDICAL RECORD.
Most of these buildings, or " pavilions," are wards for
patients, and have been named after the famous men
of France. They are usually two or three stories
high. In other buildings are housed the engineer,
the machinist, the blacksmith, the barrel-maker, the
laundry, the kitchen, etc. Under a large shed quite
a number of ambulances and hospital wagons were
seen. Opposite was the barn with a few horses. Then
there were different kinds of stores in which fruits,
vegetables, and tobacco were exposed for sale. In
some of the oldest buildings (probably four centuries
old) which seemed to present a dilapidated, crumbling
appearance, signs of " To Let " were visible in the win-
dows. They were probably intended for hospital in-
ternes residing on the premises. Of course the usual
chapel was present and occupied a building for itself.
It faced the beautiful, large, tree-lined main entrance
or main court. Several groups of fine old statuary
occupied the hall of the central building, and just to
one side of the outside entrance gate was the statue of
Charcot recently presented by the friends and disciples
of the master who has made the Salpetriere famous
throughout the civilized world.
The grounds of this hospital are so large that it has
been found necessary to lay tracks over which small
wagons with their loads of food or clothing are pushed
by women. A quaint sight is that of women, in the
open courts, washing linen and underwear on stone
slabs with soap, water, and scrub-brushes ; then rins-
ing in little tubs and placing the wash on the grass to
dry. It is the same picture that one sees below tlie
surface of the street in the little compartments along
the borders of the Seine, where sometimes a dozen
women can be seen washing in this antiquated fashion.
Although La Salpetriere is ancient and crumbling,
and far behind our ideas of a modern hospital, one
cannot avoid a sensation of pleasure at the air of
quaint neatness and cleanliness which everywhere
prevails. One sees the picturesque atmosphere of
centuries ago, handed down in all its primeval fresh-
ness. The contrast with the rest of Paris (which is
so glaringly modern in everything else) is so sharp
that one certainly misses a most interesting feature of
internal Paris in failing to visit La Salpetrifere.
Segond is a man of fifty, with waxy complexion and
gray color to the hair, mustache, and chin-stub. He
is an incessant cigarette smoker. He operates on a
table which he brought back from his recent visit to
New York. He is pushing the American method of
abdominal hysterectomy. I saw him do three vaginal
hysterectomies with clamps, besides a number of
smaller operations. When I called his attention to
the fact tiiat one of the hysterectomies took just five
minutes by my watch, he replied: "That's nothing,
mon enfant ; on my prize-days [Jours de fete) I do
them in three minutes."
Tufiier is a slim individual, nearing forty, with
black mustache and whiskers trimmed to a point.
He has the dark complexion and tendency to wrinkles
so noticeable among the French. Unlike Se'gond,
who is constantly cracking jokes during operations,
he is very quiet and serious while at work. He does
most of his operating at the Hopital Lariboissiere,
on the Boulevard de la Chapelle, and named after a
countess who left her entire fortune to the state. I
saw him do quite a number of operations: an abdomi-
nal hysterectomy (by the Howard Kelly method),
several laparotomies for tumors of the ovaries and
ectopic gestation, and a transperitoneal nephrectomy
for an unrecognized cystic kidney. He drains most
of his abdominal cases with a specially constructed
metal drainage tube. He also does general surgery.
Thus he tried to remove a bullet from the hard palate
of a case of attempted suicide; and he showed me a
successful case of gastro-enterostomy. He is the in-
ventor of the angiotribe (which, by the way. Doyen
denies), and he applied it in one case in my presence.
I noticed that after sufficient tightening of the screw
he immediately removed the instrument from the
broad ligament, and all bleeding was controlled. He
ridiculed Thumim's claim of having discovered any
improvement on his instrument. Just the same, how-
ever, he does most of his operations with hemostatic
forceps and ligatures.
I cannot help alluding to a little building on the
Boulevard de Clichy, at which Tuffier also operates,
and which is known as the " Dispensaire Gratuite'."
It was constructed from the private funds of a mar-
chioness, and is managed by the same lady, who
resides in the little institution. Although accommo-
dating only six patients, it controls an immense out-
door service among the poor of the neighborhood.
The neatness and simplicity of everything in the
place are exquisite. The plain wooden operating-
table, Tuffier told me, cost just ^5; and all the other
furnishing in the operating-room, including steril-
izers, vessels, tables, chairs, etc., cost just $20 more.
And Tuffier does hysterectomies, gastro-enterostomies,
and all sorts of major operations in this cheaply fitted
operating-room, with brilliant results. There was one
ornament in this little operating-room, evidently placed
there through the religious zeal of the estimable lady
in cliarge. On one of the window-sills (but excluded
from the room proper by the intervention of a thick
plate of glass) could be seen a little group of plaster
casts in colors representing the Virgin and Child
with two kneeling angels.
Le Dentu mixes a little gynaecology with much
general surgery at the Hopital Necker. He is one of
the best "all-round" men I ever saw. He is over
fifty, has gray hair and whiskers, and wears glasses.
Besides several general surgical operations I wit-
nessed the removal of a large suppurating intraliga-
mentary cyst. Most operators, under the circum-
stances, would have contented themselves with simply
evacuating the liquid and sewing the sac into the
abdominal wound. Le Dentu, however, separated the
tumor from surrounding adhesions, taking painfully
close chances of seriously injuring the intestine, and
finally succeeded in completely enucleating the sac.
I saw Richelot at the Hopital St. Louis — one of the
oldest and largest of the Paris hospitals, and known
to Americans chiefly because Fournier (the eminent
syphilographer) is on the visiting staff. R-ichelot is
under fifty, and has the index finger of one hand com-
pletely ankylosed after a surgical injury, and which
he told me caused him no difficulty in his work. His
beard was closely trimmed and quite gray. He was
very cordial, and invited me to be present during the
ensuing week, when he proposed doing a hysterec-
tomy. As I left Paris several days later I was unable
to take advantage of this invitation. He did a small
operation in my presence. After locating a vesico-
vaginal fistula by injecting the bladder with milk, he
touched its edges with the Paquelin cautery. The
fistula was the disagreeable sequel of a vaginal hys-
terectomy which he had done several weeks pre-
viously. ■
Reclus, whom I met at the Hopital Laennec, is a
small, wiry man over fifty, with grayish beard and a
very high forehead. Contrary to the custom of most
of his fellow-colleagues, he arrives punctually at the
hospital each morning at nine o'clock, where he meets
a dozen to twenty students and visitors, who follow
him from bed to bed. He is an exceedingly clever
diagnostician, and one of the best teachers I ever lis-
tened to. Without any ado, he picks out a man from
the surrounding group, and, giving him a patient,
makes him explain every step in the process of rea-
soning, essential to a correct diagnosis. At my first
MEDICAL RECORD.
[January 20, 1900
visit I was a little nonplussed at being requested to
examine several patients, and express an opinion.
This was not at all very agreeable with my imperfect
French in the presence of a large class — especially as
he did not hesitate to criticise my views. But alto-
gether he is such an amiable person that I shall al-
ways recall with pleasurable feelings my three or four
visits to his clinics. At one of these he did an inter-
val operation for appendicitis, but was unfortunate in
losing the patient. As luck would have it, the case
was one in which we were opposed as to the advisabil-
ity of operating just at that time.
The sessions of the Congress of the French sur-
geons were held while I was in Paris. Among other
things I remember that Championniere advocated the
novel theory of passive motion from the start, instead
of the customary immobilization in cases of diseases
of the joints. Another surgeon presented a series of
beautiful Roentgen-ray pictures of bone tumors. Do-
yen— a blond-bearded individual of fiei7 tempera-
ment— savagely attacked the reader and his paper.
He reminded me of some of our ultra-positive
surgeons at home, who have no use for anybody on
this earth but themselves. I was told that he had a
great many personal enemies in France, the ■ reasons
for which I could readily understand.
I also attended a meeting of the French Surgical
Society, of which Pozzi is president. I shall never
forget the noise and turmoil of that meeting. During
the reading of a paper or its discussion, the audience
was divided into talking groups. There were such a
buzz and clamor that the chairman kept continually
rapping his desk and jingling a little bell in his vain
and hopeless efforts to preserve a little order. Segond
is made responsible for the criticism that the French
Surgical Society is a " lot of crazy dogs let loose."
The Academic de Me'decine on the Rue des Sts.
Peres is a dilapidated old building no longer made
use of by the profession, and given over to the health
authorities for vaccination purposes.
The magnificent addition to the Pasteur Institute
(known as the Institut Biologique) which cost the
Baroness de Hirsch $400,000, is nearly completed,
and faces the institute proper on the opposite side of
the street.
Dupuytren's Museum is situated on the ground of the
Ecole de Medecine. It is an antiquated, crumbling
structure. It contains a nice but not a very large
collectioB of prepared pathological specimens. It is
particularly rich in illustrations of bone pathology.
The museum of the Hopital St. Louis is, however,
one of the features of Paris not to be missed by the
medical visitor, particularly if he is interested in skin
and venereal diseases. The specimens are master-
pieces in wax representing all the varieties of derma-
tological lesions and tumors. These are reproduced
with such extreme faithfulness that a feeling of nausea
overcomes the visitor when looking at the specimens
representing ulcers and the various lesions of syphilis.
The coloring is truthfully natural, and the artist has
not even failed to imitate the glossy conditions de-
pendent on sebaceous secretions. This museum is in
a building by itself. The walls of the main floor and
gallery are lined with shelved closets containing
several thousand of these wax models, which have
been prepared after original lesions presenting at the
clinics chiefly of Fournier and Pe'an. Each specimen
is described on the label — sometimes with explanatory
remarks. In an outside room a library, rich in litera-
ture referring to this special branch of medicine, can
be consulted by the visitor. I could easily devote
much more than the space of this paper allows in enu-
merating the specimens to be seen and studied in this
wonderful museum. The visitor with plenty of time
can profitably spend several weeks in this one build-
ing, and would probably emerge a fairly full-fledged
dermatologist.
I shall not have much to say about London, where
I spent nine days. Most of the surgeons begin work
in the afternoon, about two o'clock. A great deal of
general surgery can be seen. At St. Thomas' Hos-
pital (facing the houses of Parliament on the opposite
shore of the Thames), operators are usually at work
in two operating-rooms separated by a wooden parti-
tion; so that one needs only to look to either side of
this partition in order to see two simultaneous opera-
tions. I did not, however, see very much gyngecologi-
cal surgery, for some of the operators, like Herman,
do not post their operations. As a rule it is only
necessary to spend the mornings visiting the various
hospitals and consulting the bulletin boards, in order
to select the operations one cares to witness during
the afternoon. The medical journals (Lancet and
British Medical Jottrnal) devote a page to the opera-
tive work for the ensuing week at the hospitals, a de-
cided advantage for the stranger.
I had the pleasure of meeting CuUingworth, one of
London's prominent gynecologists, at the St. Thomas'
Hospital. He operates Thursdays in a small room at
the back of the Adelaide ward. He looks like a man
of fifty, has thin hair, large nose, grayish mustache, and
wears glasses. He operates with a very few instru-
ments. He opened the abdomen in one case of fibroid
uterus, and, after accidentally injuring the bladder
wall, decided the case to be inoperable, and closed up
■the wound.- In a second case he succeeded in doing
a supra-vaginal hysterectomy after a very slow and
tedious operation. When I suggested the Trendelen-
burg position he said he had tried it once, but had got
no benefit from it; and besides he had become accus-
tomed to the old method. I noticed that he left a
large portion of the uterus in the stump. Although
very slow and tedious in his work, I was told that his
results are excellent.
I was surprised to find a very young man of thirty-
five in Bland Sutton, who works at the Chelsea Hos-
pital for Women. He has a thin black mustache, a
boyish face, and thick black hair carefully parted and
brushed. For an English hospital, the Chelsea Hos-
pital for Women is rather small. It is a newly built
modern hospital of ideal construction. Before enter-
ing the operating-room the visitor is required to sign
his name and address in a register, in which he reads
the printed notice that he is expected during the pre-
ceding forty-eight hours not to have visited the dis-
secting or autopsy rooms, or to have attended a septic
case. He then may enter the operating-room, where
he stands at a distance from the operating-table on a
graded platform guarded by railings.
During my hour-and-a-half stay I saw Mr. Sutton
do the following operations: 1, Laparotomy for an
ovarian cyst about the size of a large orange; 2,
operation for umbilical hernia in which the whole
umbilicus was exsected, and the extensive abdominal
wound closed up with a buried layer of wormgut and a
superficial layer of catgut; 3, removal of a small
mammary cysto-fibroma; 4, flap operation for exten-
sive perineal laceration, during which the operator
unintentionally buttonholed the vaginal flap; 5, cu-
rettage and cauterization with pure zine chloride of
suppurating inguinal glands. To four patients
ether was administered by means of the Clover appar-
atus by a woman anjEsthetist. I noticed that ether is
pushing its way rapidly in the operating-rooms of
Germany, France, and England. CuUingworth em-
ploys ether and oxygen after the method of C. S. Cole,
of New York. I noticed the free employment of
nitrous oxide to start anesthesia in some of the Eng-
lish hospitals.
Without entering into possibly wearisome details,
January 20, 1900]
MEDICAL RECORD.
103
I will say that I have seen the following eminent
English surgeons at work: Cullingworth, Sutton,
Pitts, Glutton, Butlin, Battle, and Hurry Fenwick.
I shall simply allude, in passing, to an interesting
gastro-enterostomy done by Battle, and to two kidney
explorations done by Hurry Fenwick. In these kid-
ney operations the operator separated the kidney from
its fat capsule, and brought it clear out of the lumbar
incision. After e.xploring the region of the pelvis —
in one case actually opening and probing it, the kid-
ney was dropped back, and the wound closed and
drained. In neither case was anything found, although
a stone was suspected in each. But Mr. Fenwick as-
sured me that he had done forty or fifty operations of
this kind, and had never seen any ill results.
Of course in the short space of nine days one can
hardly begin to form a fair conception of the amount
and quality of work done in a large city like London.
But of one thing I am certain, and that is that there
is less purely aseptic surgery done in London than in
Berlin, Paris, or New York. Phis is rather a serious
accusation to make against the birthplace of Lister-
ism, but I think a few examples, which I witnessed in
the largest hospitals in London, v^'ill bear me out.
Thus I have seen the nurse in charge of sponges dur-
ing an abdominal hysterectomy push tables, hand over
basins, and otherwise subject herself to infection
without washing her hands a single time. I have
seen operators of surpassing skill wipe the nose,
scratch the forehead, twirl the mustache, or adjust
eye-glasses, and proceed with the same hand in their
work (sometimes in the aTsdominal cavity), without
dipping it even in water.
I spent a number of mornings pleasantly in taking
notes and making sketches of pathological specimens
in the museum of St. Thomas' Hospital. It is in a
new building, and consists of a main floor and two
galleries, the walls of which are shelved and piled
with hundreds of jars containing pathological spec-
imens. There are four descriptive catalogues giving
very interesting details regarding each specimen. In
the reading-room of the hospital I noticed only one
American journal — the Medical Record.
At 20 Hanover Square, a very fashionable neigh-
borhood, I attended a meeting of the British Gyne-
cological Society. Several dozen members were
present, mostly in evening dress. Contrary to the
atmosphere of the French Surgical Society ("and some
of our American societies, I am sorry to add), every-
thing presented an air of order and quiet refinement.
McNaughton Jones presided. He has come over from
Dublin (I was told by a member), and has immediate-
ly taken rank among the foremost of London's fash-
ionable consultants. He looks about sixty, and has
magnificent thick steel white hair and beard. His
bearing is very distinguished, and his discussions
were exceedingly logical and convincing. I was par-
ticularly gratified to hear in the course of the evening
continuous allusions to the work of American gyne-
cologists.
I cannot close these brief extracts of my experience
with the profession abroad, without alluding to the
fact that the American surgeon — particularly the
gynecologist and abdominal surgeon — is positively
forcing himself in a very emphatic manner upon the
notice of our colleagues across the ocean. The time
has already arrived when the names of Thomas, Em-
met, Murphy, Senn, Frank, Kelly, Noble, Polk, VVylie,
Munde, Boldt, and others are perfectly familiar to the
workers in surgery and gynecology on the other side ;
and it was a great pleasure to me to note that, in
England and France particularly, the stars in our
firmament were alluded to with the same feelings of
reverence and respect as at home.
113 East Sixt^--first Street.
On the Free Use of Drinking-Water in Acute
Hemorrhage.^ — ^Louis Kolipinski says that the prime
indication in the treatment of acute hemorrhage, after
the temporary or permanent closure of the bleeding
vessels, is to refill the vascular septum with its normal
fluid without delay. A plan which yields brilliant re-
sults is the very liberal exhibition of drinking-water.
He cites the case of a girl, aged eighteen years, suf-
fering from typhoid hemorrhage, vi'ho drank twenty-
four tumblers of water in one night. The next morn-
ing the patient had revived completely and her radial
pulse was strong at 108 beats per minute. Cold-poul-
tice treatment was also used. — Maryland Medical Jour-
nal, December 30, 1899.
Deformity following Excision of the Knee. —
Henry Ling Taylor says the knee of a child should-
practically never be excised for ostitis. Excessive
shortening often follows from destruction of the epi-
physeal junction, and there is often recurrence of de-
formity from failure to get bony union. Opening and
washing out, with erasion when necessary, will pre-
serve the epiphyseal line. — Pediatrics, December 15,
Incipient Insanity. — J. Outterson Wood says that
some of the most distressing cases of uncertifiable
mental disorder are those in which the patient, al-
though otherwise sane, is tormented by "horrid
thoughts." There is danger of a breakdown of mental
control and the development of an impulse which may
end in disaster. The general health should be im-
proved, insomnia overcome by twenty grains of sulpho-
nal on alternate nights, indigestion carefully treated,
and cheerful surroundings provided for the patient, or
some new and healthful outside elements introduced
into the family. A nervine tonic may be given, and
hypnotic treatment is sometimes of value. ^ — Treatment,
December 14, 1899.
Cases of Bullous Eruption of Undetermined Na-
ture.— T. Colcott Fox relates an unusual instance of
bullous eruption affecting the entire body in a woman
aged thirty-six years, which differed from pemphigus
in commencing as inflammatory nodules of consider-
able size, which rapidly became vesicular and the con-
tents blood-stained. The patient steadily lost ground
and died. The total duration of the eruption was nine
weeks. After rupture of the bulle there were ulcera-
tions which spread as in phagedena. The first suspi-
cion was that the affection was due to iodide of potas-
sium, but no history could be obtained that this drug
had been taken. Another theory was based upon the
possibility of glanders infection. — British Journal of
Dermatology, December, 1899.
The Offspring of Congenital Syphilitics.— George
Pernit relates the history of a congenitally syphilitic
mother who, out of seven pregnancies, gave birth to
only one living child at full term. This boy was a
weakling who showed no actual signs of syphilis.
The father, although blind, could not be made out to
be syphilitic. The mother showed unmistakable signs
of congenital syphilis. — Britisit Journal of Dermatol-
ogy, December, 1899.
Extra-Genital Chancre. — W. T. Freeman records
an instance of chancre upon the outer side of the right
gum in a girl, aged sixteen years. It was not known
how long the ulcer had existed. There was some swell-
ing of the submaxillary gland, but it was not notice-
ably hard. A consultation on admission to the hos-
pital confirmed the diagnosis. The ulcer steadily
healed under mercurial treatment. An erythematous
rash subsequently developed. — British Journal of Der-
matology, December, 1899.
104
MEDICAL RECORD.
[January 20, 1900
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO. 51 Fifth Avenue
New York, January 20, 1900.
A SET-BACK FOR OSTEOPATHY IN KEN-
TUCKY.
Kentucky, in striking contrast to some of the other
States, has ever studied the best interests of the com-
munity at large, and of the medical profession in
particular, in stoutly and persistently discountenancing
the practice of osteopathy within its borders. Quite
recently a decision has been rendered in the Jefferson
circuit court of Kentucky which is probably the most
discriminating and apposite of any that have yet been
delivered in regard to osteopathy.
The judgment referred to was the result of a suit
brought by a professor of osteopathy against the State
board of health of Kentucky, to enjoin it from prose-
cuting him for practising osteopathy in the State. By
the statutes of Kentucky the following regulations must
be complied with in order to practise medicine:
" I. A diploma from a reputable medical college
legally chartered under the laws of this State. 2. A
diploma from a reputable and legally chartered medi-
cal college of some other State or country, indorsed as
such by the State board of health. 3. Satisfactory
evidence from the person claiming the same that such
person was reputably and honorably engaged in the
practice of medicine in this State prior to February
23, 1884. 4. Satisfactory evidence from any person
w'ho was reputably and honorably engaged in the prac-
tice of medicine in this State prior to February 23,
1884, who has passed a satisfactory practical exami-
nation before the said board."
The plaintiff in the case against the Kentucky State
board of health did not possess the first, third, or
fourth qualification named in the above-quoted regu-
lations, but had received a diploma from the Ameri-
can School of Osteopathy at Kirksville, Mo., a legally
chartered school under the laws of that State. There-
fore, as by another section of the Kentucky statutes it
has been enacted that there should be no discrimina-
tion against any institution, school, or system of
medicine, the question to be decided was whether the
American School of Osteopathy at Kirksville, Mo.,
was a reputable medical college. The State board of
health fully investigated the said school. It sent a
committee of three of its most prominent physicians
to that institution, who after an exhaustive examina-
tion of its equipment and facilities for teaching, and
after satisfying themselves as to whether its profes-
sors were competent or incompetent educators, came
to the conclusion that the American School of Oste-
opathy at Kirksville was not a reputable medical col-
lege, and that consequently the diploma from it held
by the plaintiff was entitled to no respect. That this
decision was justified by the facts of the case was
undoubtedly proved absolutely. Of the fifteen profes-
sors of the faculty only three were possessed of a de
gree in medicine, while the explanation of osteopathy
given in the catalogue of the institution is a farrago
of the greatest conceivable nonsense. The plaintiff
had the unblushing assurance to testify that osteopathy
cures all diseases except cancer, syphilis, and con-
sumption ; that he treats Bright's disease by manipula-
tion, and diabetes by manipulation stimulating the
renic splanchnic; that he treats diphtheria by mani-
pulation, stimulating the vasomotor centre in the
back of the neck, and by putting the finger down
the throat of the patient, and manipulating the soft
palate or fauces; that he treats scarlet fever, lock-
jaw, milk leg, varicose veins, dropsy, retention of
urine, fistula in ano, anal fissure, acute rheumatism,
hip-joint disease, simple, benignant and malignant
tumors, chronic syphilis, eczema, shingles, carbun-
cles, bone felons, bruises, puerperal convulsions,
flooding after child-birth, laceration of the cornea
of the eye, all by man'^juration ; but he refused to
state how or in what manner this manipulation is
applied. Many of tlie foremost physicians of Ken-
tucky gave evidence for the defence, among whom was
Dr. J. M. Matthews, the president of the. American
Medical Association, who testified that he understood
the theory and practice of osteopathy, and that oste-
opathy is not a system for curing diseases, and is to
be feared for dangerous results which would naturally
be caused thereby. He furthermore stated that man-
ipulation of the body, instead of being a cure for
Bright's disease and diabetes, and for scarlet fever,
appendicitis, retention of urine, and other diseases
which osteopaths aver could be cured by manipula-
tion, would do the patient no good, but on the con-
trary positive harm. Dr. Matthews even went so far
as to assert that osteopathy, upon the lines of the
treatment laid down by the plaintiff, was as a system
very foolish and would be more likely to kill patients
receiving it than benefit them. According to the testi
mony proffered in the foregoing trial, massage is the
magical means by which osteopaths perform their
vaunted cures. The fact that massage exerts a bene-
ficial effect upon a certain class of maladies will be
denied by no physician. But when its exponents
claim that it will relieve and cure organic disease, it
is time indeed that the gullible public should be de-
fended against itself.
Perhaps even in the middle ages, before medicine
was a science and quackery of every description was
rampant, there has never been a time when charlatans
abounded and flourished as they flourish in this coun-
try now. Four or five States — in this enlightened age
and in a land which proudly lays claim to possessing
among its inhabitants the most acute brains to be
found in the world — actually legalize osteopathy,
while faith healers, Christian scientists, hypnotists.
January 20, 1900]
MEDICAL RECORD.
105
and many others of tlie irregular fraternity swarm at
every corner. The action of Kentucky, in excluding
from the practice of medicine all those who have not
gained by a course of study and by practical experi-
ence the knowledge of how to treat the ills of their
fellow-men, is just both to the general public and to
the qualified medical practitioner, and it is a matter
for deep regret that all the States of the Union do not
follow its good example.
TYPHOID FEVER IN SOUTH AFRICA.
The prediction was made, some considerable time
ago, by those familiar with South Africa and with the
diseases incidental to the country, that the evil most
to be dreaded by the British soldiers campaigning
there, and especially by those besieged in the towns,
was enteric fever. In every waF yet undertaken ty-
phoid fever has probably claimed a larger share of
victims than has any other disease. The explanation
of this is comparatively easy. Soldiers in camp do
not live under healthy hygienic conditions ; their drink-
ing-water supply is often impure, and their food and
cooking, despite the utmost care that may be taken in
these respects, are frequently bad. The season has
now arrived when typhoid fever, the most prevalent
and deadly disease of South Africa, rages most viru-
lently.
In the Galeaka-Gaika campaign of 1877-78, and in
the Zulu war of 1879, the British troops suffered so
severely from its inroads that Helpmakaar had to be
evacuated. Professor Sambon, writing in the Jour-
nal of Tropical Medicine of December 15th, says that
in these two wars the British appeared to have suffered
principally from a mixed infection of enteric and in-
termittent fevers, and refers to the fact that the term
" typho-malarial " was applied by Dr. Woodward to
the mixed infection while serving in the federal army
of the Potomac in 1861. Dr. Sambon, however, does
not think that this condition is of frequent occurrence,
but is rather inclined to hold the opinion that although
in a malarious region intermittent fever may develop
in a patient suffering from typhoid, it happens far
more often that the typhoid fever attacks a man act-
ually suffering from malarial paroxysms, or it evokes
into activity a latent malarial infection.
The origin of typhoid fever in South Africa will be
doubtless thought by the majority of medical men to
be the same causes which are usually considered
to occasion its outbreak in other countries. On this
point Dr. Sambon is not altogether in agreement with
the majority, for while allowing with a certain degree
of reservation that the most common cause of typhoid
epidemics in South Africa is a polluted water supply,
he points out that many medical practitioners in South
Africa assert that the origin and dissemination of the
malady depend chiefly on infected cattle. A much
more potent vehicle of infection than diseased cattle
is probably flies. A bright light was cast upon the
harm wrought by these insects as carriers of disease
by the finding of the United States commission ap-
pointed to inquire into the cause of camp epidemics
of typhoid fever in this country during the war. The
commission inspected the camps at Chickamauga,
Huntsville, Fernandina, and Jacksonville, and found
that the typhoid fever in each instance was brought
by the volunteers from their State camps. The water
supply was in most places good, and was not respon-
sible for the spread of the fever. This was effected,
in the opinion of the members of the commission, by
the flies which swarmed in all the camps, and devoted
their attentions impartially and alternately to the fecal
matters in the open and not disinfected sinks and to
the food of the troops. The great prevalence of en-
teric fever in South Africa during the hot season
would appear to add further confirmation to this
theory, as the statement may be made without fear of
contradiction that in no other portion of the world do
flies abound in such numbers.
Whatever may be the predominating cause of the
origin and spread of typhoid fever, the fact remains
that the disease has broken out among the British
troops at the front, and especially in two of the towns
encompassed by the Boers. Of the three besieged
towns, Kimberly is in every respect the most healthy;
its situation is good, its water supply is pure and
sufficient, and its sanitary arrangements are conducted
on approved modern principles. Mafeking, which is
but a small place, is constructed and its sanitation
managed on much more primitive lines. In addition
its water supply is inadequate and impure; conse-
quently much sickness is there present. But it is
when we come to Ladysmith that we find by far the
most serious condition of affairs, both on account of
its natural insalubrity and owing to the large number
of soldiers who have been cooped up within its
boundaries for the past two months. This town even
in times of peace is by no means healthy. It lies
low and amidst swampy surroundings; its sanitation
is defective, while its water supply is lacking in qual-
ity and quantity. It has been a military station since
May, 1897, and has always suffered from a prevalence
of enteric fever, dysentery, and ague. The news then
that enteric fever and dysentery have broken out on a
large scale in Ladysmith can be matter for no sur-
prise, and must add greatly to the difficulty besetting
the beleaguered garrison on every side.
With regard to the question of immunity to typhoid
fever, or rather of comparative immunity of the British
troops in South Africa, past experience teaches us that
those from India and those who had been previously
stationed in the country are not likely to suffer so
much from the disease as are the young soldiers who
have come direct from England. When typhoid fever
gains a foothold among bodies of men living under
the conditions in which the British troops in South
Africa are compelled to live, the likelihood is that
the disease will continue to spread, and that it will
be very difficult to put into force measures for its suc-
cessful suppression. Doubtless the medical and sani-
tary officers of the British army will e.xercise a strict
supervision over the sanitary arrangements of the
camps and towns, but the fact is evident that their
skill and energy will be taxed to the utmost.
io6
MEDICAL RECORD.
[January 20, 1900
THE STREET AMBULANCE SERVICE
GREAT BRITAIN.
IN
usually somewhat phlegmatic British public to the
necessity for reforms in this line.
The London Lancet, in an editorial in its issue of De-
cember gth, severely criticises the defective arrange-
ments for removing to hospitals those individuals who
may be injured or attacked by illness in the streets of
British cities, and at the same time pays a well-merited
and graceful tribute to the excellence of the ambulance
service in American cities. Comparison in this re-
spect between London and New York is certainly
startling, and does not augur well for the intelligence
and enterprise of the inhabitants of thelargest and
richest city in the world. The facilities provided for
conveying to a hospital those in need of prompt sur-
gical or medical care appear in London to be primitive
to a degree.
The Lancet comments on the matter thus: "Con-
sidering the wealth of London, its position as a centre
of civilization, and the enormous number of its street
accidents, there is probably no city in the world where
such inadequate provision is made for dealing with
these misfortunes. The unhappy victim of accident
or sudden illness in our streets depends for his safety
on the intelligence of the chance passer-by and the
nearest policeman. ... A little crowd of well-mean-
ing but ignorant and therefore dangerous persons sur-
rounds the patients, limiting the supply of fresh air
and precluding any medical man, if he happens to be
near, from even seeing that there is a case in which
his presence might be of immediate service. By this
time a policeman has arrived, and with the help of
one of the original witnesses of the accident the victim
is helped into a cab, and probably arrives at a hospital
with a compound instead of what was at first a simple
fracture, or with an extensive cerebral hemorrhage
where there might have been only a limited one had he
been in medical hands before removal from the street.
Obviously the seoner that medical aid can reach the
victims of illness or street accident the better. Yet
there is absolutely no method for quickly bringing
such aid to the injured, and as a community we rely
simply on the dangerous alternative of getting the
injured by the best means that chance to be available
to the nearest place where we may expect to find
medical aid."
The foregoing strictures are decidedly pungent, but
to the person who is acquainted with London they
will appear to be fully justified by the facts of the
case. Horse ambulances and ambulance calls are
unknown in Great Britain, and the sick or injured
person in the street is either hustled into a cab or
borne by policemen on a hand-stretcher, and, as The
Lancet puts it, horse ambulances are a dream of the
future for the injured Londoner. Americans are oft-
times accused by Britishers of unduly extolling the
methods and conveniences of their own country. It
is therefore grateful and refreshing when a journal of
The Z(7«trA repute freely acknowledges the superiority
of our system of dealing with the sick and injured in
the streets, and furthermore advises the towns of its
own land to go and do likewise. The article in The
Lancet will doubtless tend to arouse the sense of the
THE WAR IN SOUTH AFRICA: ITS MEDICAL
ASPECTS.
The war in South Africa between the British and the
two Boer republics is going to be a protracted affair,
and the lessons to be learned from it by other nations
will certainly be of the first importance. In military
circles the operations are being watched with intense
interest, for since hostilities broke out questions have
been started relating to the management of artillery,
to the value of rough-riding cavalry, to the difficulty
of sea transport, and to the methods of maintaining
long lines of communication — we mention only the
points which occur immediately to our mind — whose
answers are of the greatest importance to all military
powers. The medical arrangements of this campaign
will similarly form an object-lesson for all medical
men, as well as for those who in a business or human-
itarian capacity have to take into consideration the
way in which the modern soldier is cared for during
war.
We have therefore decided to give our readers week
by week a resume of medical events as they occur in
South Africa, prepared for us by a special correspon-
dent who is in an exceptional position for hearing all
that is to be heard from official or private sources.
Our readers may rely upon his facts.
(From our Special Correspondent.)
A Summary of Past Events : Sir George White's
Force. — It will be convenient to summarize as briefly
as possible the medical events of the war up to the end
of 1899, so that the whole story may be consistently
told from beginning to end.
In October, when war broke out, the British War
Office sent out the Natal field force under Sir George
White, who took with him Lieutenant-Colonel R. Ex-
ham, R.A.M.C., as principal medical officer. Sir
George White's business was to arrest the rush of the
Boers down to Natal to the coast, and with some losses
and much hardship he succeeded. But although he
saved Pietermaritzburg and Durban by hard fighting,
he was hemmed in at Ladysmith, where he and his
medical officers at present are. The medical experi-
ences of this force have yet to be given to the world,
and the beleaguered garrison will be fortunate if there
is not a dismal tale of typhoid fever to tell. At the
battles of Glencoe and Elandslaagte, as viell-as during
the retreat from Dundee to Ladysmith, the members of
the Royal Army Medical Corps behaved with great
bravery, and all the arrangements for the care and
transport of the sick worked satisfactorily. Surgeon-
Captain Buntine, an Australian medical volunteer, was
mentioned in the dispatches for conspicuous gallantry,
."^t Dundee the British wounded, among whom was Gen-
eral Symoiis, the British officer in command, were left
in the hospital, for undoubtedly the retreat was a iiasty
one. The Boers took possession of the hospital and
looked after the wounded with every consideration,
availing themselves also of the services of the British
surgeons for the Boer wounded. These circumstances
make all the stories of the persistence with which the
Boers fire upon ambulances and hospitals rather doubt-
ful. The Boers were found to have but rough-and-
ready arrangements for dealing with their wounded.
January 20, 1900]
MEDICAL RECORD.
107
The South African Field Force. — Hard upon the
heels of Sir George White the army corps followed
under Sir Redvers Buller. This consisted of the com-
mander-in-chief's staff, two brigades of cavalry, three
divisions of infantry, three brigades of artillery, cer-
tain companies of engineers, and certain regiments to
maintain lines of communication. Surgeon-General
W. D. Wilson, -who had great Indian experience, went
out on the staff as principal medical officer of the
force; and the other principal medical officers were :
Colonel Townshend, R.A.M.C., with the first division
under Lord Methuen; Colonel Gallwey, R.A.M.C.,
with the second division under Sir Cornelius Clery;
Lieutenant-Colonel Edge, R.A.M.C., with the third
division under General Gatacre; Colonel Donovan,
R.A.M.C, with the cavalry under Lieutenant-General
French; and Colonel Stevenson, R.A.M.C, with the
lines of communication. The army corps consisted of
52,000 officers and men with 114 guns, making with
Sir George White's troops, Indian and colonial troops,
and local garrisons some 70,000 men. The medical
equipment for the corps consisted of 155 officers in
addition to those already mentioned. Of these, 53
were detailed to the different regiments by battalions;
24 were in charge of eight bearer companies, whose
duty takes them !o the lighting line to bring in the
wounded to the field hospitals; 64 were in charge of
twelve field hospitals; 4 were in charge of stationary
hospitals, 8 were in charge of general hospitals, and 2
were in charge of medical stores at the base.
Hospital Ships. — Two hospital ships were sent to
South Africa by the War Office, and two were after-
ward dispatched at the expense of private donors, viz.,
the Princess of Wales and the Maine, whose outfit was
defrayed by the American women of London. All the
hospital ships were transformed passenger ships, but the
transformation was very complete, for in each case the
insides were ripped out, the familiar furniture abol-
ished, the woodwork painted, and the saloons trans-
formed into airy wards containing swinging cots.
Lay Assistance. — ^Hardly had the war commenced
when Sir George White met with a serious reverse,
losing two infantry battalions, and a battery of moun-
tain infantry amounting to a force of thirteen hundred
men. To lose the men was bad, but the loss of more
prestige was worse for the British. It must be re-
membered that the seat of war, especially in northern
Cape Town, was occupied by British subjects allied by
blood to the Boers. These men were sitting on a
fence until this event decided many of them to throw
in their lot with the temporary victors. Thus the
British forces were decreased as the Boer forces were
increased, and the British government at once de-
cided to send out more troops. The Royal Army
Medical Corps was by this time becoming depleted,
and lay assistance was required to carry on the work
left behind them by those who had gone to South
Africa, when it occurred to the director-general that
as he must fall back upon laymen he might as well
have the advice of great civil surgeons. Accordingly
Sir William MacCormac, the president of the Royal
College of Surgeons^ of England, Mr. Frederick
Treves, and Mr. G. H. Makins were appointed civil
surgeons to the forces; and later Mr. Watson Cheyne,
Mr. Cheatle, Sir William Stokes, and Mr. Kendal
Franks were similarly requisitioned. The Royal
Army Medical Corps did not resent having the lay
surgeons put over their heads in an advisory capacity,
but on the contrary welcomed their assistance. This
fact will have an important development in Great
Britain, it is believed, for it will lead to the formation
of a sort of scientific reserve to the Royal Army Medi-
cal Corps, consisting of operating surgeons whose ser-
vices can be obtained by the army in times of peace.
Such a system exists in Germany, and will probably
be adopted in Great Britain.
The Progress of the War. — The progress of the
war became most unfortunate for the British. When
Sir Redvers Buller arrived at the Cape, he was com-
pelled to abandon his plan of marching at the head of
an army to the capitals of the Orange Free State and
the Transvaal, as British forces surrounded at Lady-
smith and Kimberley demanded immediate relief.
Consequently Buller and Clery went to Natal to try
to get into Ladysmith, Methuen went to try to get into
Kimberley, French went to Colesberg, and Gatacre to
Stormberg to check the Boers in north Cape Town,
now become numerous by rebellion reinforcements.
The army corps thus split up met with reverses in
every direction, and reinforcements were ordered out
under Lord Roberts.
This brief summary of previous events may be
known to most readers, but it seemed to me to be nec-
essary, if the information to follow about the medical
events with the various columns is to be quite com-
prehensible. I shall in my next article describe in
detail the equipment of the Royal Army Medical
Corps, and give an account of the way in which the
wounded have fared in the engagements which have
now taken place all over the field of war.
^cixis of tixe ^ccfe.
The Genito - Urinary Section of the Academy of
Medicine. — At a recent meeting of the Genito-Urinary
Section of the New York Academy of Medicine, Dr.
W. K. Otis was elected chairman for the ensuing year.
The date of meeting was also changed from the second
Tuesday to the third Wednesday of the month.
Delaware County (Pa.) Medical Society.— At the
annual meeting held at Chester on January 12th the
following officers were elected for the ensuing year:
President, Dr. McMasters, of Ridley Park; Vice-Pres-
ident, Dr. Gallagher, of Glenolden ; Secretary, Dr. Leon
F. Fussell, of Media; 'Ireasurer, Dr. D. W. Jefferies,
of Chester; Librarian, Dr. Trimble, of Lima; Reporter,
Dr. M. A. Neufield, of Chester; Censors, Dr. D. W.
Jefferies, of Chester, and Dr. Bartleson, of Clifton
Heights.
Symptoms of Sanity in a Christian Scientist
A woman in Boston was run ower by the cars while re-
turning from a Christian Science meeting, and her
foot was crushed. She refused to go to a hospital and
insisted upon being taken to a Christian Science healer.
The latter, however, was strangely sane, and refused to
give the woman any treatments, but advised her re-
moval to a hospital at once. She was taken to the
City Hospital and the foot was amputated. The healer
said the woman had attended only one meeting, and
was evidently carried away with the idea that the sci-
ence of Christian healing included surgical cases,
which, however, " scientists " were not prepared to treat.
The healer's remarks were manifestly heretical and
call for a bull of excommunication from " Mother."
English as She is Wrote in Philadelphia. — The
putative editor of a medic journal some miles below
New York, with that fatal fatuousness which impels
men of his sort to rush in where angels fear to tread,
has set himself the task of teaching others how to write.
The following is a sample of how he does it. He is
io8
MEDICAL RECORD.
[January 20, 1900
berating a correspondent for daring to criticise one of
his myriad lapses, and says: "The word-fetich man,
the aneerer^at change and progress in philology, are
amusing people, at least until dogmatism and silliness
reach madhouse-intensities. To refract a person, or
his eyes, are terms used thousands of times every day
by all oculists, and aid us so much in expressing facts
that if they were as illogical and absurd as the per-
nickety sticklers themselves, could not be killed; nor
can they be kept from the written language when so
habitual in colloquial use."
A Scientific Study of the Results of Hanging has
been begun under the auspices of Jefferson Medical
College. In the case of a murderer hanged recently in
Philadelphia it was found that death had not resulted
from either fracture of the vertebrae or asphyxia, but
from traumatism of the structures of the neck, which
were much lacerated. The crystalline lens was intact.
Life persisted for eighteen minutes after the falling of
the drop, although it is thought consciousness was lost
at once.
The Plague. — Assistant Surgeon Havelburg of the
Marine-Hospital service reports from Rio de Janeiro
on January nth that there had been one death from
the plague in that city, the diagnosis having been con-
firmed by bacteriological examination. A Brazilian
of this city, in a communication to the daily papers,
denies this report, affirming that he had received a dis-
patch on January 12th in which Dr. Nuno Andrade,
chief of the health department at Rio, is quoted as
saying that no cases of the disease had yet been found
there. Paraguay has declared a quarantine against
all vessels which had sailed from suspected ports since
the first of this month. — In Bombay the plague is re-
ported to have reappeared, the number of deaths in
the city on January 12th having been three hundred
and seventy-six. The average death rate, when no
epidemic prevails, is seventy-five. — In Japan the dis-
ease still exists, but the authorities have succeeded in
preventing any epidemic as yet. In Kobe and Osaka,
where the danger is greatest, there is an average of
only about one case a day reported. The health
officials in Tokio have instituted a thorough cleansing
of the city, every house being visited and, if necessary,
swept out and disinfected. — In Honolulu twenty-two
deaths had occurred from the plague up to January
9th. Nearly every case has ended fatally. Among
the deaths one was of an American woman, and this
has caused alarm, as it refutes the statements made by
the health authorities that the disease was confined to
the natives and the Asiatics. The lifting of the
quarantine on Chinatown just before Christmas is
thought to have been responsible for the fresh out-
break of the disease. On December 31st it was de-
cided to destroy all infected houses. Since then five
sections of Chinatown have been destroyed. As soon
as a case of sickness is found or a suspect discovered
the board of health physician examines it. If found
to be the plague the victim is removed to one of the
two camps and the premises are burned. In this way
it is hoped to stamp out the infection. In the mean
time a house-to-house inspection is going on, espe-
cially in the Asiatic quarter. This inspection has
revealed several cases of leprosy that had escaped the
vigilance of the authorities. The port quarantine is
absolute. No passengers are allowed to depart until
they have spent ten days in quarantine, and in-coming
steamers cannot put any passengers ashore nor can any
one board them. Many tourists on th& island are un-
able to get away. Freight is carried to the steamers
in lighters, and no vessel is permitted to tie up at the
wharf. — Two cases of the plague are reported from
Adelaide, South Australia, one of them terminating
fatally. The patient was a runaway sailor from a
British bark. — The disease is apparently beginning
to spread in Manila, a dispatch from there dated Jan-
uary 1 6th reporting three additional cases. — Several
cases have occurred at Noumea (or Port de France) in
the island of New Caledonia, lying about half-way be-
tween Australia and the Fiji Islands.
Influenza is very prevalent in England, in the prov-
inces as well as in London, and many deaths have
been caused by the disease. In Barcelona also it is
said that half the residents of the town are ill, and the
mortality has largely increased.
Mr. William Cadge, the well-known surgeon of
Norwich, England, has been seriously ill, and a report
of his death was published on December 23d. He
was not dead, however, and has had the opportunity to
read many kindly obituaries in both medical and lay
journals.
Surgeons of the Thirteenth Regiment, N, G. S.
N. Y Colonel Austen, of the Thirteenth Regiment
in Brooklyn, has appointed Dr. James P. Warbasse as-
sistant surgeon with the rank of captain to succeed Dr.
Henry P. De Forest, who has become surgeon with the
rank of Major.
Sale of Tuberculous Meat in Berlin — The un-
pleasant discovery was made a few days ago in Berlin
that, through the connivance of officials in the city
stockyards, large quantities of condemned tuberculous
beef have been smuggled through and sold to a large
restaurant and to several big sausage-makers. An
official investigation has been ordered.
War on the Cigarette.— A bill has been introduced
into the New York legislature to regulate the sale of
cigarettes. Dealers must obtain a tax certificate and
must make oath that the cigarettes to be sold contain
no injurious drugs or narcotics. The application for
a certificate must be signed by five reputable citizens
of the place where the applicant resides, and no ciga-
rettes can be sold to persons under eighteen years of
age.
Yellow Fever in Mexico. — It was officially declared
some time ago that Vera Cruz was free from yellow
fever, but a number of new cases have broken out re-
cently, and several deaths have occurred in the mili-
tary and civilian hospitals. The sanitary agent sta-
tioned in Orizaba reports that the yellow fever has also
reappeared in that city. One case was noted in Te-
huantepec on January 2d, but since that date no cases
have been reported there.
January 20, igooj
MEDICAL RECORD.
109
A Physician to be Court-Martialled.— It is reported
from Cape Town that Mr. Hoffman, a member of the
Cape Assembly, who joined the Boers as a surgeon,
is a prisoner at De Aar, and in all probability will be
court-martiailed.
The Berks County (Pa.) Medical Society, at its
annual meeting held at Reading on January gtii,
elected the following officers for the ensuing year :
President, Dr. F. W. Frankhauser; Secretary. Dr.
James W. Keiser; Treasurer, Dr. A. S. Raudenbush.
Consulting Phj^^sicians for the State Hospitals. —
A bill has been introduced into the New York legisla-
ture by Senator Ambler, amending the insanity law, so
as to provide for the appointment of a staff of consult-
ing physicians for hospitals for the insane, whose
duties shall be similar to those of a staff of consulting
physicians to a general hospital.
Dismissal of Hospital Internes. — The internes of
the Metropolitan Hospital (the Homoeopathic City
Hospital on Blackwell's Island), in order to express
their dislike for the superintendent, hung the latter in
efifigy one night and then danced around the dummy.
Their prank was discovered and reported to the com-
missioner of charities, who at once, without a hearing,
e.xpelled the entire house staff, consisting of twelve
young graduates.
The Cumberland County (Pa.) Medical Associa-
tion, at its annual meeting held at Carlisle on January
9th, elected the following officers for the ensuing year:
President, Dr. J. C. Davis, of Carlisle; Vice-Presidents,
Dr. M. M. Daugherty, of Mechanicsburg, and Dr.
George W. Borst, of Newville; Secretary, Dr. Hilde-
gard Lonsdorff, of Carlisle; Assistant Secretary, Dr.
J. A. Lefever, of Boiling Springs; Treasurer, Dr. J.
H. Bowman, of Riverton.
A Mineral Diet. — A dime-museum performer, who
was called "the man with ostrich stomach," has been
earning an honest living for a year or so by swallow-
ing pins, nails, coins, watch chains, and other dainties.
He got along fairly well until he began to gorge him-
self with pins, when his stomach rebelled, and he was
forced to go to a hospital in Brooklyn. There he was
operated upon, and two nickel watch chains, one brass
chain, two latch keys, six hairpins, one hundred and
twenty-eight common pins, ten two and one-half inch
iron nails, two horseshoe nails, one finger ring set
with a stone, and several other equally digestible arti-
cles were removed.
An Epidemic of Typhoid Fever due to Drinking-
Water. — A small epidemic of typhoid fever has oc-
curred in a section of Wayne, a suburban town near
Philadelphia, in which investigation disclosed that
in all of the houses in which cases occurred the water
supply was derived from a spring and two dug wells.
On chemical analysis of the water the presence of a
large percentage of chlorine was found, indicative of
sewage contamination. The surface of the ground in
the neighborhood of the wells was covered with stable
manure. The first of the cases occurred in a man
who returned from Europe with the disease, and was
treated at a house the drainage pipe of which runs
within forty feet of the spring and one of the wells
from which the water supply was obtained. The dis-
ease developed shortly afterward in the neighborhood
supplied with water from this source. No cases oc-
curred in the districts supplied with water from the
two other sources.
A Female Hygienic Exposition will be opened in
St. Petersburg the latter part of January. The object
of the exposition is to bring before the public all that
has been done by women to make hygienic living
more attainable.
The Brooklyn Society of Neurology.— At the
annual meeting of this society, recently held, Dr.
William Browning was elected president; Dr. R. C.
F. Coombes, vice-president; and Dr. W. H. Haynes,
secretary.
Dr. Victor C. Vaugljan, professor of hygiene and
of physiological chemistry in the University of Michi-
gan, and late lieutenant-colonel Thirty-third Michigan
vplunteers, U.S.A.^ has been elected surgeon -general
of the Spanish-American War Veterans.
Philadelphia Medical Club. — At the annual meet-
ing held January 5th, the following officers were
elected for the ensuing year: President, Dr. J M.
Anders; First Vice-President, Dr. H. A. Wilson;
Second Vice-President, Dr. W. L. Rodman ; Secretary,
Dr. Guy Hinsdale; Treasurer, Dr. F. Savary Pearce.
Malaria in Central Asia.— According to the Tur-
kestan Messenger, five hundred and ninety-five persons
died from malaria in the latter half of September in
Tashkend. The number of persons severely ill with
the disease during that time was one thousand seven
hundred and eighteen.
Marine Hospital for Honolulu The President
has issued an order setting apart seven acres, more or
less, out of the government reservation east of the
" Punch Bowl," in the island of Oahu, Hawaii, as a
site for a United States marine hospital for the port of
Honolulu.
An Unusual Breach-of-Trust Case — A claim of
$5, 000 has recently been brought against a Hartford,
Conn., physician on the following somewhat extraor-
dinary grounds : The doctor had agreed to take charge
of a maternity case, but was not present w'hen the
child was born; a few days later the child died.
The physician was then sued for breach of trust in
the case and as being responsible for the death of the
child. The defence demurred to the complaint, stat-
ing that the father could not have acted as the agent
for the child, and that the doctor did not contract
with the unborn child for its delivery. As the case
was brought because of the death of the child, the
defence claimed that it should be quashed. The
judge ruled that suit may be brought in behalf of a
child unborn when its parents had made a contract to
deliver and care for it after its birth, and found true
cause for action on the part of the parents. The case
no
MEDICAL RECORD.
[January 20, 1900
has caused considerable interest tliroughout the State,
and is the first of the kind brought under Connecticut
statutes. — Boston Medical and Sur-^ica/ Jounia/.
Drs. James A. Roache and James P. Glynn, of
Brooklyn, have been appointed physicians in the de-
partment of charities in that borough.
Dr. Sidney L. Laselle, of Orange, N. J., has started
for Hainan, China, where he will serve as a medical
missionary. He has gone out under the auspices of
the Presbyterian Board of Foreign Missions.
A Breisky Memorial — On December 14th, in the
obstetrical clinic of the German University of Prague,
a memorial to Professor Breisky was unveiled in the
presence of a large assembly.
Insanity in the Army — Fourteen soldiers, declared
to be insane, have been sent to Washington from the
Presidio military reservation in California. Nearly
all of them became insane while on duty in the Philip-
pines.
Medical Practice in Brazil. — According to a re-
cent decree the holder of a medical diploma from. a
foreign university of recognized standing is now-
allowed to practise in Brazil. Formerly foreign
physicians desiring to practise in that country were
obliged to pass an examination in the Portuguese lan-
guage.
The German Balneological Congress will be held
in Frankfort-on-Main on March 8-13, 1900. The
sessions will be held in the forenoon of each day,
three of the afternoons being devoted to e.xcursions to
Soden, Nauheim, and Homburg. Information regard-
ing the congress may be obtained from Dr. Brock, 18
Melchiorstrasse, S. O., Berlin.
The Second Cuban Medical Congress. — The fol-
lowing is the constitution of the executive committee
of the proposed congress of Cuban physicians: /'resi-
dent. Dr. Vicente B. Valdcs; First Vice-President, Dr.
Diego Tamayo; Second Vice-President, Dr. Rudesindo
Garcia Hijo; Ireasiirer, Dr. Antonio Gonzalez Cur-
quejo; Secretaries, Drs. Enrique Niinez, Jose A. Pres-
no, and Jorge Le Roy.
Quack Medicines in Vienna. — The Austrian gov-
ernment has forbidden the sale in Vienna of " pink
pills," a quack remedy made in Paris. Physicians
are forbidden to prescribe them, druggists and others
are forbidden to sell them, newspapers are forbidden
to advertise them, and the distribution of circulars,
through the mail or otherwise, setting forth their
alleged virtues is also forbidden. The reason given
for this action is that the composition of the pills is
kept secret, and further that the remedy is put forth
as a cure-all.
The Montefiore Home We learn from the fifteenth
annual report, just issued, that six hundred and nine
patients were treated during the year at the Montefiore
Home for Chronic Invalids, with a death rate of 16.91
per cent. One hundred and ninety-four were dis-
charged, of whom thirty-six w^ere cured, and one hun-
dred and fourteen improved. Only about a third of the V
applicants for admission during the year could be re- ^
ceived, owing to the lack of sufficient accommodations.
The directors of the home are building a sanatorium
at Bedford Station, Westchester County, to which it is
purposed to remove all of the patients suffering from
pulmonary tuberculosis.
A Foreign Body Removed from a Bronchus
Professor Schraetter, of Vienna, recently removed a
piece of lead from the lung without a cutting opera-
tion. The foreign body, which had entered a bron-
chus, was located by means of the a-rays at the level
of the fourth rib. By means of the bronchoscope and
a specially contrived forceps the lead was extracted
without the necessity of a resort to tracheotomy.
The Tri-State Medical Association of North Caro- ■
lina, South Carolina, and Virginia will hold its second '
annual meeting at Charleston, S. C, on February 20,
1900. The meeting last year was in Charlotte, N. C.
The set discussion at the coming meeting, to be opened
by Dr. Paul A. Barringer, of the University of Vir-
ginia, will be on the negro, his sexual life, his charac-
ter, and the influence of his past and present surround-
ings.
Virchow Jubilees. — A man whose life has been so
full and so varied as Virchow's finds, after passing his
three-score and ten, the jubilees crowding thick and
fast. On November 25th the University of Wiirzburg
celebrated the lapse of fifty years since Rudolph Vir-
chow delivered his first lecture there. In the vesti-
bule of the Pathological Institute was placed a bust of
the great pathologist crowned with a wreath, and
Prof. V. Rindfleisch delivered an oration in which he
reviewed the development of the science of pathology
during the half century, and dwelt upon Virchow's influ-
ence in that development.
A Duel between Hospital Internes. — Two hospital
internes at Bordeaux quarrelled, and the trouble ended
in a duel in which the four seconds were also internes.
One of the principals was killed, and the other was
tried for murder, and the four witnesses were also
brought into court as accessories. Thus far the case
was e.xceptional, for French duels as a rule are noted
for their bloodlessness; but the subsequent proceed-
ings were eminently Gallic. When arraigned in court
the accused said the murder was a pure accident, for
each duellist shot at the word of command without
having time to take deliberate aim ; therefore of course
neither could have intended to kill the other, since he
had not aimed at him. The survivor expressed his
regret at the unfortunate occurrence, and the four wit-
nesses, who were also on trial, assured the court that
they thought he really was sorry ; so the judge acquitted
them all.
The Craig Colony. — The following constitute the
board of consulting physicians and surgeons for this
colony : Neurologists — M. Allen Starr, New York City;
George W. Jacoby, New York City; Henry Hun, Al-
bany; James W. Putnam, Buffalo. Surgeons— QhnxXes
McBurney, New York City; Roswell Park, Buffalo;
January 20, 1900]
MEDICAL RECORD.
John W. Whitbeck, Rochester. Physicians — Charles
E. Jones, Albany; Charles Cary, Buffalo; William S.
Ely, Rochester. Orthopedic Surgeons — ^Henry Ling
Taylor, New York City; Louis A. VVeigel, Rochester.
Ophthalmologists — Lucien Howe, Buffalo; Wheelock
Rider, Rochester; George M. Gould, Westfield.
Gyna:cologist—M?X\he.\N D. Mann, Buffalo. Pathol-
ogist— Ira Van Gieson, New York City. Bacteriologist
— Harlow H. Brooks, New York City. Psychologist —
Boris Sidis, New York City. Pathological Chemist —
Christian A. Herte«, New York City. Dentist —
Charles J. Mills, Mourit Morris.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
January 13, 1900. January 5th. — Assistant Surgeon
R. W. Plummer detached from the New Orleans and
ordered to the Petrel and also to the Cavite naval
station. Assistant Surgeon D. G. Beebe detached
from the Benningtoft and ordered to the Petrel.
Hospital Fire in Santiago de Cuba.— The yellow-
fever hospital, situated on an island across the bay
from Santiago, was destroyed by fire on December
20th. The building had been used by the Spanish as
a pest house before the American occupation. During
the epidemic last summer many hundreds of American
soldiers and civilians were treated there. The ad-
joining building, containing a hundred bodies of
American soldiers in sealed caskets, ready to be
shipped to the United States, was saved by the fire-
men. The fire was of incendiary origin. A new hos-
pital will be erected immediately on the same site.
Mr. Felix Morris, a well-known actor, who died
in this city on September 13th from pneumonia, was
educated as a physician at Guy's Hospital, but after
obtaining his qualifications abandoned medicine for
the stage.
The Late Dr. Charles E. Jones. — At a meeting of
the board of managers of the Craig Colony, held at
Sonyea, N. Y., January 9, 1900, the following note was
recorded in the minutes:
" The board of managers of the Craig Colony record
with genuine sorrow the death of one of their number.
Dr. Charles E. Jones, of Albany, N. Y., who died in
that city December i, 1899. ^^ ^^^ ^ ™^" ^^'^ ^^^
won a high place as a skilful and faithful physician,
a man of upright dealing always, and a man who was
regarded with affectionate consideration by patients
and friends alike. He was the late Governor Flower's
family physician, and upon signing the bill creating
the Craig Colony, the governor appointed Dr. Jones a
member of the board of managers, which position he
held from the founding of the colony to the day of his
death. He took the deepest interest in this charity,
and greatly aided its development by his earnest zeal
and broad-minded consideration of all matters relating
to it. We feel his deatii to be a public loss which
this board especially deplores.
"Signed for the board of managers of the Craig
Colony: Frederick Peterson, President; H. E.
Brown, Secretary."
Obituary Notes. — Dr. Charles A. Siegfried, med-
ical inspector United' States navy, in charge of the
naval hospital at Coaster's Harbor Island, died at his
cottage in Newport on January 14th, of pneumonia,
after an illness of only two days. He was a graduate
of the Jefferson Medical College in 1872, and entered
the medical corps of the navy in the same year. He
had had charge of the naval training-station at New-
port for several years, though during the war with
Spain he was temporarily stationed at Key West. He
was to have been an official delegate to the Interna-
tional Medical Congress at Paris in August.
Dr. Ernest Schroder died at his home in Brook-
lyn on January 12th, of apoplexy. He was born in
this city in 1852, and was a graduate of the Long
Island College Hospital Medical School in 1882.
Dr. John Clark Cleary died in Port Chester, N.
Y., on January 14th, from typhoid fever. He was
born in Clyde, N. Y., thirty-one years ago, and was
graduated from the medical department of the Uni-
versity of Buffalo in 1898.
Dr. William H. Lyons, aged fifty-three years,' died
January 13th, at his residence in this city. He was
born in Ireland, but his parents removed to New York
when he was three years old. He was a graduate of
the College of Physicians and Surgeons in the class
of 1877, and had been an active practitioner in this
city for twenty-five years.
Dr. Gustave Mahe, formerly of New York, died
suddenly in Sioux City, Iowa, on January nth. He
was born in Paris, but came to this country with his
parents when he was nine years old. He was a grad-
uate of the Bellevue Hospital Medical College in 1889.
Dr. J. C. MuLHALL, of St. Louis, was found dead in
his office on January nth, having killed himself with
a pistol. He was forty-nine years of age. He was a
graduate of the St. Louis Medical College in the class
of 1873, and the following year obtained the licentiate
of the Royal College of Surgeons in Ireland. He was
professor of diseases of the throat and chest and of
climatology in the Beaumont Hospital Medical Col-
lege. He was a member of the American Laryngo-
logical Association, the American Climatological As-
sociation, the American Medical Association, and the
Missouri State Medical Society.
Dr. Washington L. Atlee, of Philadelphia, has
died at his home of heart disease. He was born in
May, 1842. At the outbreak of the Civil War he en-
listed as a hospital steward, and served until the end
of the war. He afterward entered the Jefferson Medi-
cal College and was graduated in medicine in 1870.
He was a son of Dr. Washington L. Atlee, who per-
formed the first ovariotomy in Philadelphia in 1849.
Dr. J. Elmer Cook died at Harrisburg, Pa., on
January 13th, at the age of fifty-six years. During the
Civil War he was a soldier in the Union army.
Dr. I. Leo Mingle died at Reading, Pa., on Janu-
ary 9th, at the age of sixty-one years. He was a
graduate of Jefferson Medical College.
Dr. William A. Cantrell died at Philadelphia
on January 7 th, at the age of fifty-eight years. He was
graduated from Jefferson Medical College in 1862,
and was for a time a surgeon in the United States army.
MEDICAL RECORD.
[January 20, 1900
grogress 0t Medical Science.
Journal of Americaii Aledkal Association, Jan. ij, igoo.
Chalicocis Pulmonum, or Chronic Interstitial
Pneumonia Induced by Stone Dust.— In this paper
William Winthrop Betts remarks on the increased dan-
ger to human life involved in the advent of the cyanide
process of milling, and then reports on his observa-
tions among the workers of such a plant. He says
that every man who works in the mill for two or three
weeks becomes subject to attacks of acute bronchitis,
due in great measure to the irritating effects of the
dust. The bronchitis is followed by soreness along
the course of the trachea and bronchial tubes, with
loss of weight, shortness of breath, and general malaise.
Treatment is of little avail, though much can be done
to prolong life by improving hygienic conditions and
stimulating the general nutrition.
Contagiosa Bullosa — John S. Windisch records
under this title his observations of epidemic pemphigus
during the late Spanish-American war. He says that
people from northern climates are more prone to the
affection than are natives, as is seen among the English
who go to China and India, the English families born
and bred in India being less liable to it. This was
also true of the troops encamped in our Southern States
daring the war; few cases were found among the South-
ern troops, while, on the other hand, few Northern
regiments escaped. Windisch thinks it can hardly
be doubted that the disease is caused by some local
agency, but neither the microscope nor culture tests
have shown any specific organism. The treatment is
chiefly local. Mercury acts like a specific, either in
the form of an ointment or as a mild antiseptic wash.
Poliomyelitis Anterior Acuta Adultorum Her-
man H. Hoppe says that because of the newer views
of the pathology of poliomyelitis, and especially be-
cause of the difficult differential diagnosis, he desires
to place on record two cases of this rare disease which
are beyond dispute. In treating of this disease in the
"Twentieth Century Practice of Medicine," Drs.
Bruns and Windscheid stated that poliomyelitis is
almost always seen as a complication of or sequel to
acute infectious disease. The author, arguing from
the two cases reported, takes a radically different vie.w,
and claims that it may occur as a primary affection, at
least in the adult.
Notes on Catelectrolysis (Electrolysis) in the
Treatment of Skin Disease. — Erederick J. Leviseur
says that the list of skin diseases in which catelec-
trolysis is recommended is continually increasing.
The operation is indicated whenever it is important to
avoid scar formation, and when strictly limited local
action is desired.
Case of Spinal Anterior Subacute General Par- .
alysis — C. Eugene Riggs reports a case of this dis-
ease in its bearing upon the difficulties of diagnosis
that may arise between poliomyelitis and polyneuritis.
Practical Use of Radiograph and Fluoroscope in
Diseases of the Lungs. — By T. Mellor Tyson and
William S. Newcomet. See Medical Record, vol.
Ivii., p. 67.
Case History. — B. Merrill Rickets presents an il-
lustration of supposed axillary sarcoma in which pain
was checked by applications of .v-rays.
Medicine and Law. — l!y Duncan Eve. See Medi-
cal Record, vol. Ivi., p. 565.
Formaldehyde Disinfection — W. K. Jaques claims
numerous advantages for formaldehyde over all other
methods of disinfection.
Boston Medical and Surgical Journal, Janiuuy 11, I goo.
A Case of Perforating Gastric Ulcer. — F. B. Lund
reports a case of this nature in which operation was
performed sixteen hours after perforation had occurred.
The patient, a laborer, thirty years old, made an excel-
lent recovery. The author reviews the literature of the
subject and tabulates the stati^ics of the operation.
These show forty-five per cent, of recoveries, and in
cases operated upon within twelve hours seventy-nine
per cent.
A Pistol Wound of the Abdomen. — C. A. Atwood
reports the case of a man who died from shock follow-
ing a pistol wound in the abdomen. Laparotomy was
performed but the ball was not found. At the autopsy
it was found in the iliacus muscle.
The Case Method of Teaching Systematic Medi-
cine.— W. B. Cannon approves of this form of teach-
ing, because it requires of the student accurate judg-
ment, close reasoning, precise expression, and wise
employment of knowledge.
Relapsing Fever.— George O. Ward reports and
describes a sporadic case which occurred in an Ar-
menian immigrant in New York in 1899. Cases of
the disease are rare in this country.
Tabes Dorsalis. — Alfred H. Lindstrom obtained
marked success from postural or mechanical stretching
in a case of this disease. General tonic treatment as-
sisted in the cure.
Medical iV'-7l'S, January ij, igoo.
Experimental Tests at Vera Cruz, Mexico, of
the Doty-Fitzpatrick Serum for the Prevention and
Cure of Yellow Fever. — A. Matienzo concludes from
numerous experiments with the Doty-Fitzpatrick serum
that, ( I ) although both intravenous and subcutaneous
injections of the serum produced a general reaction,
revealed by the hyperthermia and acceleration of the
pulse, (2) they neither controlled the disease nor mod-
ified in the least the appearance, development, or dur-
ation of the symptoms of yellow fever. (3) It is not
possible to form conclusions regarding the value of
this method on account of the small number of cases
in which it was employed. (4) The reaction caused
by the injections of the toxin in the convalescents of
yellow fever demonstrates Sanarelli's assertion that the
curative powers of the serum in animals is not due to
the antitoxin substances, and confirms by its analogy
to the typhoid serum the opinion, given by some bac-
teriologists, that the icteroides is an Eberthiform ba-
cillus.
Report of a Case of Scorbutus in an Infant. —
Walter Lester Carr reports a case of scorbutus in a
female infant of twelve months, from improper food.
Beef-juice, orange-juice, and a small quantity of fresh
milk were ordered; also an opiate if necessary, for
excessive pain and restlessness. In three days there
were few signs of the scurvy. The opiate did not
have to be given, and recovery was uninterrupted.
Myomectomy Per Vaginam Combined with Short-
ening the Round Ligaments for Retroversion, etc.
^A lecture by J. Riddle Goffe.
January 20, 1900]
MEDICAL RECORD.
New York Medical Journal, January ij, igoo.
The Lung Reflex. — A. Abrams has found that
when an ether spray is directed over the borders of the
kings posteriorly, the borders of these organs can be
nude to descend (as determined by piiysical signs and
the fliioroscope) from two to four inches; that is, an
irritation of the skin will cause the lungs to dilate.
Dilatation may be recognized by diminished excursion
of the lung border, extension of pulmonary percussion
note, and obliteration of areas of cardiac and hepatic
dulness, hyper-resonance of the lungs, and obliteration
of the apex beat. From these results is deduced the
following procedure to determine whether an area of
dulness, say in the broncho-pneumonia of children,
is due to consolidation or to atelectasis: If the latter
is present, vigorous irritation of the skin will cause
the dulness to disappear because the irritation leads
to dilatation of the lung. If the dulness is due to con-
solidation, irritation will have no effect upon it.
The Therapeutic Application of Carbonic Acid
Gas. — A. Rose concludes an enumeration of the vari-
ous diseased conditions in which carbonic acid gas
has proved of service. The list includes scorbutic
ulcerations, oza3na, hyperaemia of the Schneiderian
membrane, cancerous ulcerations, various neuralgias,
and different skin affections. Rose has used the gas
with good effect in whooping-cough, dysentery, vomit-
ing of pregnancy, sexual neurasthenia, and vaginismus.
Previous practical difficulties in the use of the gas
have been the necessity of cumbersome gas-holders,
defective working of the same, dangers connected with
pressure, etc., and, as a consequence of all, the expense
of using the gas except in the case of the well-to-do.
These difficulties have all been overcome by the intro-
duction of the steel flasks or capsules, some of which
are so small that they can be carried in the pocket.
The Anaesthetic Properties of Nirvanin — C. A.
Elsberg says that this new remedy has valuable anaes-
thetic properties when injected into the tissues accord-
ing to the infiltration method; it is less poisonous
than cocaine or eucaine; it has distinct antiseptic
properties; and it is a stable compound.
Echinacea Angustifolia — This is the name of a
remedy highly extolled by J. C. Stinson as a powerful
aphrodisiac.
Taking Cold.— By G. V. Woolen. See Medical
Record, vol. Iv., p. 846.
President's Address before the Society of Alumni
of Bellevue Hospital, by C. E. Quimby.
Philadelphia Medical J otirnal, January ij, igoo.
The Anatomical Relations in Pelvic Haematoma
following Labor. — W. Reynolds Wilson says that
haematomata in the labial and perineal regions are due
principally to the accumulation of blood from the
branches of the pudic vein. Hfematomas are often
multiple, this showing an inherent tendency to venous
rupture.
Cerebral Rheumatism. — Francis P. Morgan denies
that cerebral rheumatism is a sequel of hyperpyrexia.
^He inclines to the belief that rheumatism is a pya-mia
and that the cerebral, cardiac, and other complications
are simply toxic manifestations. His treatment is
symptomatic.
Diplococci — A Case of Erysipelas.— G. E. Pfahler
has found and isolated a diplococcus in eight cases of
erysipelas, and has produced the disease in rabbits by
inoculation.
Varicose Veins of the Vulva. — William Edgar
Darnall pictures a case of this sort, and says that the
condition usually does not seriously complicate labor.
Excretion in the Treatment of Acute Infectious
Diseases. — H. A. McCallum advocates thorough purg-
ing in the early stages of typhoid fever and pneumonia.
Certain Essential Points in the Technique of
Staining Nerve Cells. — By Stewart Paton.
7'he Lancet, January 6, igoo.
An Address on Acidity.— J. F. Goodhart believes
that all the clinical forms of acidity are due simply to
uric-acid excess. This acid should be regarded as an
ash common to the various metabolic processes going
on in the body. The causes of the condition which
presents itself for treatment include visceral sluggish-
ness from nervous exhaustion, an hereditary condition
which works itself out in gouty attacks, a sudden
shock, an exhausting illness, an early defect of the
kidney, or a primary manifestation of advancing age.
The author finds that many persons who try to remove
their acid tendencies by strict adherence to a vegeta-
ble diet will find far quicker relief from a diet con-
taining a generous allowance of beef and mutton and
less vegetable matter. The article is written in an
attractive vein, and is a protest against wholesale die-
tetic rules without reference to the problems in each
individual case.
The Histology and Prevention of Blackwater
Fever. — \\'. H. Crosse describes a case of this affec-
tion ending in death on the sixth day. The vomitus
was markedly green in color, the urine was finally
suppressed, and hiccough with some dyspnoea and pain
in the limbs persisted to the end. A microscopical
examination of the various organs showed nothing that
could not be found in the tissues of a patient who had
had several attacks of malaria. The author suggested
that blackwater fever bears to malaria a relation similar
to that borne by hyperpyrexia to rheumatic fever. As
regards prevention, he believes that all the precautions
useful in guarding against malaria should be taken
here. These include especially the destruction of all
breeding-grounds of mosquitoes.
Internal Derangements of the Knee Joint (Popu-
larly Called "Slipped Cartilage "). — Basing his
paper upon an experience of three hundred cases, W.
H. Bennett discusses the causes, symptoms, and treat-
ment of the condition and utters a plea against indis-
criminate operation. Even under modern antiseptic
precautions the operation is attended with some risk,
and should, therefore, not be undertaken lightly.
Report on '< Henpuye " in the Gold Coast Colony.
— A. J. Chalmers describes a peculiar disease called
" henpuye," or dog-nose, which occurs in the regions
named. It consists of a nasal deformity produced by
the deposition of new bone under the periosteum on
the external aspect of the nasal bones, the nasal proc-
ess of the superior maxilla, and the body of the latter
bone itself. It is more common in men than in wo-
men, and comes on during or after an attack of yaws.
Three Cases in which Movable Kidney Produced
All the Symptoms of Gall Stones.— F. Treves reports
three cases, all in women aged about thirty-five years,
in which attacks of hepatic colic were followed by
jaundice. The latter was due, he thinks, to the press-
ure of a movable right kidney on the bile ducts.
Hemorrhagic Ascites. — T. Fischer's patient was a
woman aged thirty-eight years who suffered from chil-
114
MEDICAL RECORD.
[January 20, 1900
liness, abdominal swelling, pain, occasional vomiting,
and constipation. The greater part of the belly was
resonant, but shifting dulness was present in the
flanks. Autopsy showed the presence of twelve pints
of deeply blood-stained fluid.
Bullet Wound in the Head : Removal of the Bul-
let from the Nose Twenty Months Afterward — C.
Woakes records a case in which the bullet entered the
skull just below the left frontal eminence. The man
recovered, and came under the author's observation
twenty months later with a foul discharge from the left
naris. Probing detected a hard substance, which was
removed, and proved to be a mass of lead covered with
a bit of khaki cloth.
The Differential Diagnosis of Mongolism and
Cretinism in Infancy G. A. Sutherland gives a
table of differential diagnostic signs, but says that the
final test is the therapeutic one. In the cretin thy-
roid extract renders wonderful senice. while the Mon-
golian infant remains unaffected. Mongolism is a
form of congenital imbecility in which.certain facial
appearances suggest a Chinese origin, hence the name.
Multilocular Cystic Epithelial Tumor of the Jaw ;
Excision of Half the Lower Jaw ; Recovery — G. P.
Newbolt reports the case of a woman aged sixty-six
years who had complained of the growth for twenty
years. The cysts were laid open and scraped, but re-
filled, and a radical removal was made. No history
of tooth irritation as the exciting cause could be made
out.
An Unusual Case of Embolism in the Fundus
Oculi. — -H. W. Thomson reports a case in which an
embolus was arrested in the common macular or cilio-
retinal artery. The occlusion lasted eight days, dur-
ing which time the nutrition of the part of the reUna
involved was maintained by the arteria centralis retinae,
through its small branches.
The So-Called Danger from the Use of Boric
Acid in Preserved Foods. — O. Liebreich regards the
popular prejudice against this agent as used for pre-
servative purposes as illogical and not borne out by
any information at our disposal, so far at least as con-
eerns the absorption of either borax or boric acid from
the intestine.
Case of Impacted Extra-Capsular Fracture of the
Neck of the Femur. — H. E. Belcher reports a case of
this sort in a man, aged twenty-six years, who was
thrown from a wagon. The chief signs of injury were
eversion of the foot, broadened appearance of the thigh,
and the helplessness of the limb.
The Orchitis of Mumps. — C. Dukes says that the
orchitis of mumps is not a metastasis; that it never
arises before puberty, and that it does not occur after
puberty if the patient can be kept in bed over the eighth
day.
A Boy's Ear Bitten Off by a Horse.— J. M. Mote
reports a case of this kind in which the ear had been
taken off as cleanly as if cut by a knife.
British Medical Journal, January 6, igoo.
Observations on General Metabolism and the
Blood in Gout. —Chalmers Watson sums up the result
of his observations as follows: (i) The alkalinity of
the blood is not diminished during an attack of gout.
(2) The excretion of uric acid is not diminished, but
the reverse ; there is, therefore, no reason for suppos-
ing that there is temporary diminution in the capacity
of the kidneys to excrete uric acid. (3) The amount
of uric acid in the blood is not greater during an at-
tack than at other times. If these points are accepted
we must search elsewhere for the cause of the acute
paroxysm. The author adds that it would be well in
this connection if less attention were paid to the excre-
tion of uric acid alone as the all-important factor in
attacks of gout.
Scarlet Fever Without Eruption. — H. Ward Irvine
reports this case, in which diagnosis was finally made
after microscopical examination of the urine, showing
the presence of large quantities of renal and vesical
epithelia, and was verified by the subsequent desqua-
mation.
A Case of Acquired Syphilis in a Child. — C. Ham-
ilton Whiteford reports the case of a boy aged six years
who presented himself with a sore on the eyelid diag-
nosed as Hunterian chancre. This diagnosis was con-
firmed by the appearance of secondary phenomena.
The Unimportance of the Presence of a Trace of
Albumin or Nucleo-Albumin in Urines of Extremely
Low Specific Gravity F. Parkes Weber argues that
"a very faint trace of albumin" in otherwise healthy
urine has no diagnostic value whatever.
Injuries Produced by a Six-Pounder Hotchkiss
Shell. — J. R. Dodd reports a case illustrating the ter-
rible effects of modern shells, and points out the vast
amount of work they will entail on medical officers
after a serious engagement.
A Case of Sodium Salicylate Poisoning. — H. Hil-
ton Heffernan reports this case as being worthy of in-
terest owing to the large dose of the drug taken (130
grains), the long period of sleeplessness (nearly four
days), and the absence of depression.
Treatment of Molluscum Contagiosum with So-
dium Ethylate. — Thomas F. Raven reports a case of
this disease in a pregnant patient. He found the
treatment by sodium ethylate entirely satisfactory.
Primary Nephrectomy for Rupture of the Kid-
ney.— William Rogers reports a primary nephrectomy
for rupture of the kidney in a girl aged fifteen years.
Death ensued the following day.
Salol in Smallpox. — Charles Begg urges the use of
salol in smallpox on account of its power to control
irritation, to take away the desire to scratch, and thus
to prevent suppuration.
The Political Aspects of Current Medical Topics.
— -Vn address delivered at a meeting of the Aberdeen,
Banff, and Kincardine branch of the British Medical
Association, by R. Farquharson.
Dislocation of the Radio-Carpal Joint — Guy J.
Branson reports this case as being of interest on ac-
count of the rarity of the accident.
Retention of Menstrual Blood from Atresia of
the Vagina. — X clinical lecture by Charles J. CuUing-
worth.
Minor Epilepsy. — A clinical lecture by Sir William
Gowers.
Illustration of an Improved Prostatic Catheter —
By John Ward Cousins.
Midical Press and Circular, January j, igoo.
Anuria, Transfusion of Saline Fluid, Nephrec-
tomy, Death. — Murrell relates the case of a woman
in a semi-comatose state, who had passed no urine for
January 20, 1900]
MEDICAL RECORD.
115
two days. The temperature was subnormal. A diag-
nosis of toxic anuria was made. A quart of saline
infusion was injected into the vein of the right arm.
Although the pulse improved in quality no urine was
secreted. Right nephrectomy was advised with a view
of relieving a possible obstruction suggested by ten-
derness. Upon incising the capsule there was free
escape of a serous fluid mixed with venous blood. No
further exploration was attempted. Death occurred
six hours after the operation. The kidneys were found
to be granular, each weighing three and a half ounces,
and were highly congested.
Cinematograph in Teaching Surgery. — E. Doyen
advocates the use of the cinematograph, having demon-
strated its advantages in a number of operations. One
of these advantages is, he holds, that surgeons will be
able to teach the real progress made. It has enabled
the writer to correct, simplify, and perfect operative
technique. The most delicate manoeuvres, such as
suturing the pelvic peritoneum in abdominal hysterec-
tomies, opening the dura mater in craniotomies, etc.,
may be followed.
Otorrhoea and its Treatment. — Paul Rauge says
that when pus from otitis media is collected aseptically
and examin'ed immediately, it is, as a rule, found to
contain only a single species of microbe. The moment
an artificial or spontaneous opening in the membrane
occurs secondary infection becomes possible. Preven-
tion is the best treatment for otitis.
Miinchener mcd. WochenscJirift, December 26, iSqq.
Chorea and Fever. — Kurt Witthauer calls attention
to the peculiar influence of fever on the whole symp-
tom complex of chorea as noted by him in two cases
recently under his care. There was no other feature
of special interest in either case. The first was of
hysterical chorea in a boy, aged six years, the affec-
tion first coming on suddenly after punishment at
school. The second, in a girl of twelve years, was of
the rheumatic form. In b.oth cases, immediately upon
the onset of fever the twitchings became diminished,
and after a few days ceased.
Dermatitis Herpetiformis. — F. Kohler reports a
case of this nature in a woman twenty-one years old,
and gives the four cardinal symptoms which serve to
separate it from similar skin affections, such as ery-
thema multiforme, urticaria bullosa, pemphigus, etc. :
(i) Tendency to polymorphous appearance; (2) cu-
taneous or deep-seated paraesthesia; (3) almost con-
stant recurrence ; (4) relatively good general health.
Tuberculosis of the Nasal Duct — O. Seifert be-
lieves the three most probable channels of tuberculous
infection of the nasal duct to be: (i) Extension of
the infection from the bony walls of the duct; (2) ex-
tension from the nose; (3) extension from the connec-
tive tissue of the eye.
The Early Diagnosis of Carcinoma Uteri. — Adolf
Gessner states his belief that scrapings from the lin-
ing of both the fundus and the cervix uteri will estab-
lish a sure diagnosis at an early period, before any
other methods could be employed.
Annual Review of the Work of the Royal Gynae-
cological University, Polyclinic of Prof. Dr. Amann
for 1898. — Carl Braun gives a brief resume of the
work of the University Polyclinic for 1898.
The Effect of Heroin on Respiration. — C. J. San-
tesson, judging from numerous experiments on animals,
says that heroin in small doses does not appear always
to deepen respiration.
Wiefier kliiiische Wochenschrifi, December 21, iSgg.
Etiology of Tuberculous Pneumothorax — Drasche
gives the results of his experience with this affec-
tion in more than forty years of general hospital
practice. Of 10,212 patients with pulmonary tuber-
culosis 6,586 were men and 3,526 were women. Of
all these, 198, or 1.93 per cent., developed tuberculous
pneumothorax, 2.36 per cent, being men and 1.13 per
cent, women. As to age, the greatest number of pa-
tients were between twenty and thirty years. Of the
198 cases, the trouble was in 108 cases, or fifty-five
per cent., on the right side, and in 90 cases, or forty-
four per cent., on the left side. Three cases were
bilateral. Coughing, vomiting, straining at stool, lift-
ing heavy weights are etiological factors. As tuber-
culosis develops earliest and most often in the apex,
so pneumothorax is found most often in the upper lobes.
History of Carcinoma of the Pancreas C. Hodl-
moser reports a case in a man twenty-seven years of
age. The points of special interest in this case were
the youth of the individual, the absence of undue
quantities of fat and albumin in the stools, and the
absence of sugar in the urine. A tumor could be felt
in the median line. The patient had suffered intense
pain at first; he hardly complained at all in the last
weeks. Examination of the stomach contents showed
absence of hydrochloric acid and but little pepsin, on
which account a diagnosis of carcinoma of the stom-
ach was made. The true condition was discovered at
autopsy.
Rupture of the Symphysis Pubis — Rudolf Savor
says that cases of rupture of the symphysis appear in
the last ten years to have markedly decreased, prob-
ably because the forceps is much less frequently em-
ployed now that we are acquainted with many other
methods of delivery.
Measure of Blood Pressure by Gaertner's Tono-
meter.— George Kapsammer describes this very sim-
ple but ingenious instrument, which was presented by
its inventor July 16, 1899, to an assemblage of physi-
cians at Vienna.
Berliner klinisihe Woclicnschrift^ December 25, l8gg.
The Specific Treatment of Tuberculosis — J.
Petruschky concludes a temperate article upon the
specific treatment of tuberculosis with special refer-
ence to tuberculin. He is in accord with the dictum
of the recent Berlin Congress, that no true specific is
as yet known to us, and calls attention to the very im-
portant fact that the cessation of reaction to large
doses of tuberculin must not always be taken as evi-
dence of the disappearance . of previously existing
tuberculous tissue. He traces the gradual develop-
ment of Koch's theories, and also touches upon the
substance prepared by Klebs, from which much was
at one time hoped. To the inquiry, " Can cases be
cured by tuberculin? " .he gives an affirmative reply,
showing a tabulated list of twenty-two cases which
had been under his own care and resulted in cure by
this means. He call attention to the fact that those
patients who in the course of the tuberculin cure have
ceased to react thereto may after three or four months
again become sensitive, so to speak, to the remedy.
This he regards as a favorable circumstance, for it
enables us again to bring the system under the effects
of the remedy. From the serums of Behring and
Maragliano he expects but little. Moreover, for cases
of mixed infection sanatoria are best. But for the
purely tuberculous, tuberculin offers in many cases a
certain arrest of the disease. Its use should be only
ii6
MEDICAL RECORD.
[January 20, 1900
in the most careful hands, preferably in institutions,
and should not be entrusted to assistants who are fre-
quently changed.
Endolaryngeal Treatment of Cancer of the
Larynx. — E. Meyer reports the case of a man aged
fifty-eight years, who had complained of husky voice
for eight months. A nodular growth was found on the
anterior two-thirds of the left vocal cord, which was
reddened and congested throughout its whole extent.
A projecting process of the tumor overhung the right
cord toward the anterior commissure, but the cord
itself was unaffected. Diagnosis of carcinoma was
confirmed by the microscope. Glandular enlarge-
ments were not noted. The tumor was removed in
eight sittings by means of forceps and curette. The
author discusses the advantages and limitations of the
endolaryngeal method.
Total Extirpation of a Large Cyst of the Mes-
entery.— J. Schramm reports the case of a widow aged
torty-eight years, from whom he removed a large cyst
of the mesentery. Jlecovery was uneventful. He
then discusses the question of the origin of these tu-
mors, and refers to the literature of the subject.
French Journals.
Capillary Emboli Following Injections of Calomel.
— A. Renault publishes an instance of embolism fol-
lowing injection for syphilis, and gives the literature
briefly of similar instances. From 189 1 to i8g6 the
author made 8,353 injections of thymol-acetate of
mercury, and in nine per cent, of these cases the in-
jections were followed by pulmonary phenomena of
more or less severity, with subsequent symptoms of
hemorrhagic infarctions due to an embolic process.
In conclusion he states that we have no means of pre-
venting with certainty the penetration into the blood
current of soluble mercurial salts. He calls to mind
the fact that calomel, even in fine powder, is composed
of particles which show a very appreciable volume
under the microscope, and alone may obstruct capil-
laries of the lungs. He believes that while the solu-
ble mercurial salts are very powerful they should be
used only under e.xceptional circumstances, when life
is endangered, and it is necessary to act energetically.
Injections she ' be given only after a careful exami-
nation as to the general integrity of the emunctories,
while taking all precautions of technique. — Le Frn-
gres Medical, December 23, 1S90.
The Functions of the Thymus Gland Based upon
its Physiology and Pathology — L. M. Bonner says
that the thymus represents, so far as its functions are
concerned, a double organ. It is a hasmatopoietic
organ, and it is also a gland having an internal secre-
tion. This has a multiplicity of influences, especially in
connection with nutrition. Physiology and pathology
are in accord in demonstrating that the thymus pre-
sents physiological connections with other analogous
viscera. There is, in the normal state, an equilibrium
between the various internal secretions: when one of
these glands is injured, the equilibrium is broken. It
is, perhaps, to re-establish it(^in any case it is because
of this disparity of normal equilibrium) that we see
some other vascular gland become hypertrophied.
The thymus is, perhaps, that which presents the most
freijuently, and under the most variety of circum-
stances, this vicarious hypertrophy. — Gazette des JJopi-
taiix, December 19, 1899.
Stercoraemia Following Delivery. — A. Brindeau
relates several cases showing that elevated tempera-
ture, not otherwise accounted for, is wrongly attrib-
uted to puerperal fever in some instances. There is
usually intense headache, absolute anorexia, foul
tongue, fetid breath, and tenderness of the abdomen,
all of which symptoms are relieved after salines have
been given to produce several abundant passages
which are usually fetid. The symptoms may come on
anywhere from one to fifteen days even in patients
whose bowels have appeared to be regular before de-
livery. The temperature may go up gradually or at
one bound. At times the condition is serious, and
may prove fatal. Perforation has been reported, while
intestinal hemorrhages and ulcerations have been
noted. — Le Bulletin Medical, December 30, 1899.
The Remote Results of Perineal Urethrostomy,
a Clinical Study Based on Twenty-Three Obser-
vations.— In a connnunication to the Academy of
Medicine of Paris in 1892, Antonin Poncet described,
under the name of perineal urethrostomy, an operation
consisting in the creation in the perineum of an arti-
ficial meatus in patients with incurable strictures. He
now takes a somewhat less favorable view of the results
of this operation than he originally held. He reviews
twenty-three cases, in seven of which the stricture re-
turned seven years after the operation; in two, five
years; and in two, three years after operation. — Ga-
zette Hchdonadaire, December 27, 1899.
Heredity in Chronic Nephritis. — R. Romme relates
a family history in which there were eighteen instances
of chronic nephritis in three generations. The num-
ber of such reports is very rare, there being only five
authentic instances in literature. — Le Frogres Aledical,
December 23, 1899.
Respiratory Gymnastics in Pulmonary Tuber-
culosis.— F,. Ripard supplies, with illustrations of the
movements, a scheme for giving tone to the respira-
tory muscles, developing the thoracic cavity, and in-
creasing the breathing capacities. — Le L'rogres Medical,
December 23, 1899.
Vratch, December i r and 18, l8gg.
A Peculiar Disorder of Respiration in Hysteria.
— Y. P. Gorshkoff reports a case of hysteria in a sol-
dier, twenty-five years old, who suffered several times
a day from laryngeal and diaphragmatic spasms dur-
ing which respiration was temporarily arrested, all
the abdominal muscles were in a tetanoid condition,
and several inarticulate expiratory sounds were
emitted. The lines of the face were drawn and ex-
pressed suffering. Accompanying the respiratory
spasm was a tremor in the hypogastric region. There
were no special psychical disturbances during these
attacks; memory and the reasoning faculty were un-
changed, but the patient's spirits seemed a little de-
pressed.
Sanatoria for Consumptives — S. F. Unterberg
treats of sanatoria for tuberculosis and of their edu-
cational value. But he says that efforts to prevent
infection are not sufficient, that the mere employment
of sanitary spittoons will not abolish tuberculosis, and
that tiie most effective means of combating the disease
are hygienic and dietetic measures to strengthen the
organism. He advocates the adoption of many of the
sanatorium regulations in the household, and says
that even the nursery should be converted into a
domestic sanatorium.
Malarial Insanity.— I. E. Tikanadze reports three
cases of this sort, the first of mania, the second of
acute confusional insanity, and the third of melan-
cholia recurring with each febrile paroxysm. The
author regards as the chief causes of malarial insanity
an intensity of infection and a special predisposition,
January 20, 1900]
either inherited or acquired. The prognosis is favor-
able, and the proper treatment is the exhibition of
quinine in large doses together with warm baths.
Disinfection with Formaldehyde. — As a result of
numerous experiments, together with a review of the
literature of the subject, \'. A. Levasheff concludes
that the disinfectant action of formaldeh)'de is exerted,
ordinarily, chiefly on the surface of objects, and be-
comes rapidly attenuated from the periphery toward
the centre. The best means of destroying the odor of
formaldehyde is the employment of ammonium car-
bonate, which when heated separates into CO,, and
NH .
Sclerosis of the 6pine. — Under this title M. O.
Shaikevitch describes a case of gradually acquired
posterior curvature of the dorsal spine, occurring in a
man thirty-nine years of age. The actual disease
present was somewhat indefinite. There was no
spinal caries; the case was not one of rheumatism,
although cold seemed to have played the role of ex-
citing cause, and the author was inclined to regard it
as a diffuse sclerotic affection of the spinal column,
first described by Bechterew in 189:'.
Thomsen's Disease with Tabes Dorsalis — S. S.
Malbandoff reports a case of myotonia congenita ob-
served in a man twenty-five years of age, who pre-
sented also marked symptoms of locomotor ataxia. The
patient's brother, eighteen years old, was also a sufferer
from Thomsen's disease. He reports briefly also an-
other case of tabes dorsalis combined with myotonia.
Pyramidon and its Therapeutic Uses. — K. 1.
Korovitski describes this new drug, which is a deriva-
tive of pyron, having a formula of C,,H|.ON.. Its
action is similar to that of antipyrin, though more
prompt, and as a rule smaller doses are required.
The Dental Division of the Clinical Institute. —
A. K. Limberg describes the course of instruction in
dentistry given at the Elena Pavlovna Clinical Insti-
tute at St. Petersburg.
The Crusade against Consumption — I. N. Lange
enters a plea for the use of tuberculin in cattle as a
protection to man.
four, oj Ciitau. and Genitn- Urinary Dis., January, i<;oo.
A Case of Macular Lepride of the Scalp, with
Remarks on the Localization of Leprous Lesions.
— Prince A. Morrow says that a curious fact about
leprosy is that the two principal forms, although etio-
logically identical, show marked differences in char-
acter of the cutaneous lesions, and also in their local-
ization. It may be said that the erythematous patches
of the tubercular form are transient in duration and
may disappear and reappear a number of times before
becoming the seat of tubercular infiltrations, while
those of the anesthetic form are essentially permanent.
The case reported is unique in so far as it is the only
one which the author has found recorded presenting a
macular lepride of the scalp. The distribution of the
eruption over the cheek and forehead, extending into
the hairy scalp, is shown in the illustration.
The Urethroscope in the Treatment of Strictures.
— H°nry Koch relates a case showing that the present
urethroscope with heatless light is not only an instru-
ment for diagnosis, but can be used for other and very
important practical purposes for which the endoscope
could not be used. The tube used in the case related
differed from others so far constructed by having the
lamp carrier and lamp held separately in a small tube
MEDICAL RECORD.
117
under the larger endoscopic tube proper. Light is
thrown through the opening on the surface to be illu-
minated.
The Etiology and Rational Treatment of Urethro-
Arthritis and Allied Affections.— A. MacKenzie
Forbes says that urethral arthritis is due either to the
migration of the gonococcus or some other microbic
habitant of the urethra to the joints, or to the absorp-
tion of the toxins eliminated by these habitants. To
effect a cure the urethra must be kept as absolutely
sterile as it is possible* to keep that canal, and its mu-
cosa must be without abrasion. Notes of cases are
given.
A Case of Blastomycetic Dermatitis Engrafted
on Syphilitic Ulceration. — Henry G. Antony and
Maximilian Herzog report the casg of»a patient who
had suffered from extensive ulcerations for twenty
years, which were distinctly syphilitic in character,
being of the type of syphilis cutanea vegetans. After
staining sections of the tissues blastomycetes were
found. Under iodide of potassium in large doses
marked improvement occurred.
S/. Louis Courier of Medicine, December, i8gg.
Complete Inversion of the Uterus from Fibroids ;
Vaginal Hysterectomy; Recovery — Henry H. Mudd,
in the last contribution of his life to medical literature,
reports a successful operation for the rare condition of
total inversion in a non-puerperal uterus. After oper-
ation interstitial fibroids were found. The Rotunda
Hospital had but one instance of acute inversion in
one hundred and ninety thousand births; at St. Peters-
burg this complication did not occur in two hundred
thousand nor in Vienna in two hundred and fifty thou-
sand deliveries.
Suprapubic Prostatectomy. — A. E. Rockey says
operations for enlarged prostate by sexual mutilation
have failed so often that they are to be condemned.
He has evolved from McGill's method one of his own
— a combined morcellation, enucleation, and evulsjon
through a short suprapubic incision, with an assist-
ant's finger in the rectum raising the gland. He has
been satisfied with suprapubic drainage. Opening
the bladder when symptoms warrant is eferable to
attempts at fine diagnosis beforehand.
Some Phases of Lues in Early Life. — Charles
W. .Allen relates several instances of infantile syphilis
evidently of congenital origin, in which evidences of
the disease could not be found in the parents. The
acquired disease of unexplained origin was also found
in young children. In one of the instances of family
syphilis recorded, an infant contracted the disease
from a wetnurse, and inoculated the mother, who in turn
infected the father and at least one other child.
Beef-Gall Enemata in the Treatment of Post-
Operative and Intestinal Obstruction. — F. C. Ameiss
recommends fresh bile enemata (four cases), claim-
ing that, aside from mechanical effect, absorption of
bile salts acts as an exciter of cholagogue action.
Reopening the abdomen is not always advisable.
Indications for Caesarean Section, Symphyseot-
omy, Craniotomy, and Induced Premature Labor. —
By Leopold. See Medical Record, vol. Ivi., p. 497.
Archives of Pediatrics, January, igoo.
A Clinical Study of Laboratory Milk in Substi-
tute Infant Feeding.— Louis Starr declares that al-
though laboratory milk is theoretically the most
perfect substitute for normal human milk now known.
ii8
MEDICAL RECORD.
[January 20, 1900
this theory is not upheld by clinical experience. He
does not absolutely condemn this milk, for its intro-
duction has called attention to the importance of
cleanliness and accuracy in the cjuantity and chemical
composition of cow's milk foods. It is also of great
use in feeding infants who must be artificially nour-
ished from birth, and may often be used with advan-
tage to the end of the second month. However, its
applicability is limited, and much more so than the
process of modification in which unseparated milk is
employed.
Cerebro-Spinal Symptoms in Influenza in Infancy.
■ — Thompson S. Westcott reports two such cases. This
condition has been described as pseudo-meningitis grip-
palis, and simulates meningitis in every particular, but
in the event of death it shows at the most hyperaemia
of the pia ancf brain, or a permeation of these parts
with serum.
A Case of Fracture of the Pelvis with Rupture
of the Urethra. — Joseph B. Bissell reports this case,
of a boy aged nine years, and believes the favorable
result to be due to the youth and good health of the
patient, and to early incision, perfect drainage, and
simplicity of technique.
The FriU-titioiicr, December, l8gg, and January, igoo.
The Relationship of Membranous Inflammation
of the Nose to Diphtheria Eugene S. Yonge deiines
membranous rhinitis as a subacute or chronic affection
of the nose, characterized by a fibrinous or membra-
nous exudation on the mucous membrane of one or
both nares. The deeper tissues are not, as a rule, in-
volved, and the membrane rarely extends to the throat.
The course may exceed eight weeks. The Klebs-
Loeffler bacillus "in various degrees of virulence is
found in the majority of instances. The disease in
both children and adults may be ushered in by chilly
sensations or more rarely by a definite rigor, which is
soon followed by a general febrile condition. Symp-
toms of acute rhinitis rapidly supervene. The dry
stage is omitted, and the discharge begins at once.
In three days a membrane will have formed. Nasal
stenosis becomes severe and is associated with head-
ache and loss of smell. The thermometer registers
101° to 103° F., but f; "Is to 100° or 101° F. in a day
or two, and in childrer. remains at this point during
the entire attack of lhi;;e to six weeks. The clinical
course does not seem altered by the fact of the pres-
ence or absence of the Klebs-Loeffler bacillus, while
true primary diphtheria of the nose, which is rare,
runs a very malignant course.
Mongolian Imbecility in Infants. — G. A. Suther-
land says that subjects of Mongolian or Kalmuc idiocy
usually drift into asylums if they survive long enough.
Mental and physical characteristics easily distinguish
them from normal infants. Their resemblance to one
another is very striking. Growth proceeds at a slow
rate. Antero-posterior shortening of the skull may
render the face and occipital regions flat. The fonta-
nelle is large and slow in closing. The mouth is usu-
ally kept open, and the tongue often protrudes and
tliere may be a habit of drawing it in with a smacking
noise. The abdomen is large and distended. Intel-
ligence lags; the infant usually requires no attention
through excess of "goodness."' Dentition is much
delayed, while muscular power and co-ordination are
slowly acquired. There is strong predisposition to
disease and to early death, 'i'he thymus, thyroid, and
suprarenals are structurally healthy, and treatment by
the extract of thymus and thyroid has proven useless;
treatment in the absence of any known cure must be
general and symptomatic.
The Operative Treatment of Fibroids.— In a clin-
ical lecture, delivered by G. E. Herman, the reasons
pointed out for operating are: First, hemorrhage suffi-
cient to weaken the patient, which is not brought un-
der control by ergot and similar drugs. Secondly,
size, making the patient unwieldy or bedridden; or
the tumor may be relatively large in relation to the
space in which it lies, and may press upon adjacent
parts, causing symptoms which warrant operation.
Thirdly, a fibroid may rapidly increase in size, indi-
cating that the tumor is degenerating, or is a sarcoma
rather than a fibroid. The best operation is one which
removes the tumor without taking away anything else.
One advantage of the vaginal over the abdominal
route is that it is easier to separate the ureters
from the bladder from below than it is from above.
Vaginal treatment is only appropriate, however, when
the tumor is not larger than a child's head and can be
pressed down into the pelvis. The electrical treat-
ment is looked upon as now almost extinct.
Temporo-Maxillary Ankylosis, and its Relief by
Excision of the Neck and Condyle of the Lower
Jaw. — David M. Greig claims that the results of oper-
ation in temporo-niaxillary ankylosis are eminently
satisfactory, the muscles, after years of disease, reas-
suming their functions almost at once. The causes
are traumatic or non-traumatic. The first are extra-
articular or intra-articular; the second suppurative or
non-suppurative. Cases and illustrations are given.
Affections of the Cornea — Marcus Gunn calls atten-
tion to the anatomy of the cornea and the especial clini-
cal importance of the smoothness of its anterior surface
and its transparency, the latter being due to the dispo-
sition of the lamella; of fibrous tissue. Disease of the
cornea may be recognized by lack of one of these qual-
ities.
Pneumonia. — Sir William Broadbent treats of the
etiology, symptoms, signs, prognosis, and treatment.
From time to time the pneumococci seem to acquire a
degree of virulence whic^i renders the disease conta-
gious, causing epidemics. Apparently the diplococci
are carried about in the mouth and pharnyx. Should
the crisis not have come by about the ninth day it
may be concluded that there is some underlying cause
such as tubercle or septiccemia. Unabsorbed pneu-
monic deposits are practically unknown post mortem.
Catarrhal pneumonia is the form which complicates
measles and pertussis, or, later in life, may supervene
upon bronchitis. No definite line can be drawn be-
tween the catarrh of the finer bronchial tubes and
broncho-pneumonia. The temperature is not a source
of danger. We can afford to wait. Antipyretic drugs
given continuously are not only useless but dangerous,
and in exceptional cases a considerable amount of
spirits, such as brandy in champagne, may be given.
For ihe persistent sleeplessness morphine should be
given, especially if there is delirium. , Venesection
is advisable when the right ventricle is unable to cope
with the constant resistance in the pulmonary circula-
tion, and is paralyzed by oVer-distention. There are
cyanosis, turgid temples, small and short pulse. The
pulse improves and the breathing is relieved when six-
teen to twenty ounces of blood have been taken.
Pneumonia from a Public-Health Standpoint. —
Arthur Newsholme says it is clear that the heaviest
rate of mortality falls in the earliest, and the next
he'aviest in the last, years of life. He considers ques-
tions of transference between pneumonia and phthisis
and bronchitis, and the influence of seasons, weath-
er, race, occupation, and epidemics of pneumonia.
Hirsch's statistics show that the largest number of
cases occur from February to May. He maintains
January 20, rgoo]
MEDICAL RECORD.
119
that the death rate rises to its maximum in December.
It is a cold-weather disease. This by no means dis-
proves its specific febrile character.- Iron-workers
and coal-heavers give the largest percentage of cases,
lock laborers the next, then hotel servants, cabmen,
and innkeepers. Doctors and musicians stand an
equal chance. The history of many localized out-
breaks favors the idea of a direct infectivity. Cases
are cited showing exceptionally direct personal infec-
tion due to overcrowding, defective house sanitation,
etc., which accounted for certain epidemics.
Etiology and Symptomatology of Goitre J. G.
Adami reviews at length the whole question of the
cause of goitre, especially as it concerns the island of
Montreal. In some French Canadian villages scarce-
ly a family is to be found without one or more goitrous
members. It is generally accepted that weather has
to do with its development, but how it does so is ab-
solutely unknown. In favor of the infective origin
not a few facts have been brought forward. In one
instance one thousand and nine soldiers of a regiment,
whose quarters had been changed to a goitrous region,
became affected. Lustic and Carrele found a bacillus
constantly present in goitrous waters. If the individ-
ual is removed from the goitrous region sufficiently
early, the tendency is for the enlargement to disap-
pear.
The Mortality and Frequency of Pneumonia as
Affected by Age, Sex, Seasons, and Habits Hec-
tor Mackenzie says that pneumonia causes very nearly
as many deaths as typhoid fever, diphtheria, smallpox,
measles, and scarlet fever together. Deaths from
pneumonia amount to 5.6 per cent, of the total num-
ber of deaths from all causes. In males between the
ages of twenty-five and sixty-five years, eight per cent,
of all deaths are due to this disease. Alcoholism
appears to diminish the chances of recovery. A his-
tory of rheumatism is to be obtained in about six per
cent, of the cases, and pericarditis occurs in about
twelve per cent, of the fatal cases.
The Treatment of Pneumonia Sir Willram
Gairdner reviews old methods and dwells upon histori-
cal and personal matters. Antimony and blood-letting
are valuable in very exceptional cases. His treat-
ment is mainly expectant. Opium he considers a
dangerous remedy, especially about the period of
crisis, having a tendency to increase the cyanosis,
there being practically a paralyzing action upon the
respiratory centres.
The Journal of Tnpical Medicine, Decembe?-, i8gg.
Possible Causes of Sickness among the British
Troops in South Africa. — In the present instalment
of a continued article, L. VV. Sambon discusses bil-
harzia disease, or endemic hematuria, and the plague.
The true endemic region of plague, he says, is in Thi-
bet, whence it makes incursions into China, India, and
Persia. He regards (leas as the chief conveyers of the
disease from rat to rat, from rat to man, and from man
to man.
A Case of Parasitic Haemoptysis.— J. Preston
Maxwell reports the case of a man, sixty-four years
old, who suffered from occasional attacks of haemopty-
sis. There were no signs of tuberculosis. The blood
coughed up contained many ova, which, however, the
author did not succeed in hatching. The administra-
tion of thymol and santonin was followed by the
passage from the bowels of about fifty round worms.
Malaria and Anopheles in Lagos, West Africa.
— Henry Strachan discusses, from the point of view of
his experiences in West Africa, the relation of mos-
quitoes and malaria, and mentions several points of
distinction between Anopheles and Culex in both the
larval and the imago stages.
Further Results of Haffkine's Anti-Cholera Inoc-
ulation.— Arthur Powell presents some statistics of
cholera inoculations in nine estates and villages in
India. There were 198 cases with 24 deaths among
6,549 not inoculated, and but 27 cases with 14 death;
among 5,778 inoculated.
On Tropical Anaemia and its Relation to the
Latent and to the Manifest Forms of Malarial
Infection. — This is an instalment of a continued arti-
cle by F. Plehn of Kamerun.
Edinburgh Medical Journal, January, igoo.
The Infectivity of Malignant Growths G. Bell-
ingham Smith holds from experimental research that
these growths are local in origin, possessing the power
of affecting adjacent and distant parts; that inocula-
tion may take place from one part to another of the
individual, apart from transference by the natural
channels; that one individual may be infected with
growth from another ; that growths may be transferred
from animal to animal of the same species by inocula-
tion. There have been found in many malignant
growths bodies resembling micro-organisms, which
are regarded as either protozoa or blastomycetes. A
new growth with the structure and behavior of carci-
noma has twice arisen from inoculation with a form
of blastomyces. The experiments suggest that the
bodies found in cancer cause the disease.
Febrile Albuminuria F. Parkes Weber prefers
the term "rheumatic albuminuria" to that of "febrile
albuminuria" in cases of rheumatism accompanied by
albuminuria, because he thinks it cannot be maintained
that the symptom is caused merely by pyrexia. It is
much more likely that in most cases it is due to the
causes of the pyrexia — to the presence of irritants in
the kidneys or from a toxaemia condition of the blood,
and such toxasmic conditions of the blood may be due
to infectious (microbic) causes or maybe the result of
any kind of abnormal tissue change in the body.
Some Observations on the Excretion of Uric Acid,
with Especial Reference to its Connection with
Leucocytes. — Carstairs C. Douglas from clinical
studies concludes that there is a discrepancy between
the amount of uric acid thrown off from the body and
the number of leucocytes. That nuclein containing
tissues or ingestion may increase the amount of uric
acid excreted is proved by experimentation, but the
observations made do not support the view that nor-
mally the source of uric acid is to be found in the
'nuclein of the leucocytes.
Urinary Calculus. — George Buchanan reports a
case of calculus whi'ch was impacted in the prostatic
urethra, and was removed by perineal section. It
measured two and one-fourth by one and three-fourths
by one and three-fourths inches.
Purulent Ophthalmia. — A. Maitland Ramsay con-
siders nitrate of silver the best remedy, so long as
there is much secretion ; when the discharge lessens
this should be replaced by sulphate of copper.
Dysentery as it Occurs in Fiji. — Charles T. W.
Hirsch says that dysentery is endemic, and occurs
among the European settlers, natives, and Indians,
and Polynesian immigrants in May, June, and July.
MEDICAL RECORD.
[January 20, 1900
Canadian Journa! of Medicine and Surgery, Jan., igoo.
The Hospital Room in Each Dwelling. — W. J.
Telfer describes the advantages of the home hospital
room. This apartment should be the favorite ons
when there is no sickness in the family; nevertheless,
when occasion arises, it may in half an hour be
changed into a more or less complete hospital. The
ceiling, walls, and floor must be finished so that they
can be washed clean. The furniture should be such
as to be readily rendered aseptic. Water and toilet
adjuncts should be at hand. A special bath and
water-closet should be accessible; movable substi-
tutes could be used in the country. When isolation
is imperative either the front or back entrance may be
temporarily monopolized by the patient's attendants.
Anaesthesia by Chloroform and Ether. — William
B. Jones emphasizes the importance of employing a
skilled anesthetist. He should be acquainted with
the patient's history and present condition. The right
stage of narcssis must be obtained under all circum-
stances, the least possible amount of ether or chloro-
form being used. The hue of the face tells more than
the pulse as to the condition of the circulation. The
pupils should be almost continually watched, they
being the best inde.x of the patient's condition.
Cases of Puerperal Sepsis Treated with Anti-
streptococcus Serum, with Notes. — George T. Mc-
Keough, after noting several cases of this nature, de-
clares that, although the reports of the use of the
serum are conflicting, and possibly not very encourag-
ing, yet it exerts no pernicious effects and does merit
a continued use.
The History of Medicine Ezra H. B. Stafford
states that the history of medicine teaches the unity of
aim, the singleness of purpose, the undeviating alle-
giance to an unchanging ideal through long ages, that
can be claimed by no other art, no other fraternity.
The Treatment of the Acute Digestive Disorders
of Infancy. — By Andrew R. Gordon. See Medical
Record, vol. Ivi., p. 424.
Mo7iatsschrift fiir Geburts. und Gyndk., December, i8gg.
The Clinical Significance of Retroversion of a
Movable Uterus. — B. Kronig and J. Feuchtwanger
assert that since we accept Schultze's teaching that
anteversion of the movable uterus is its normal posi-
tion, we must admit that retroversio'n is a patho-
logical condition. Symptoms of retroversion are both
local and general. The more or less localized symp-
toms are profuse menstruation, dysmenorrhcea, back-
ache, abdominal pain, and " bearing down " sensations.
Among the general symptoms are dyspepsia, vomiting,
meteorism, palpitation, and headache. Some author-
ities believe that retroflexion should not be treated
unless it is accompanied by troublesome symptoms,
while others believe in treatment as soon as the con-
dition is discovered, even if no symptoms present them-
selves.
Pseudo-Myxoma of the Peritoneum. — C. Peters
states that Werth in 1884 defined pseudo-myxoma of
the peritoneum as a peculiar affection which often
made its appearance after the bursting of a pseudo-
mucinous cystoma. He notes as most worthy of men-
tion, in several cases which he reports, the complica-
tion of metastases, which frequently occur after the
spontaneous rupture of pseudo-mucinous cystomata or
from the soiling of the abdominal cavity by the cyst
contents during operation. The prognosis is not very
good. A perfect cure cannot be claimed till the
patient has remained free from recurrence for a year.
The Influence of Sugar on Metabolism in Preg-
nancy and Labor. — Adolf -Payer comes to the conclu-
sion on this. subject that small quantities of sugar
(30-60 gm.) given once, or several times, increase
uterine contractions and hasten labor, especially in its
initial stage. The whole course of labor is influenced
by the administration of a large dose (100-130 gm.)
before it begins. Sugar has a sedative influence on
labor pains. For all these purposes sugar may be
recommended.
A Metal Instrument as a Substitute for the
Balloon in Cervix Dilatation. — Schwarzenbach de-
scribes an instrument for dilating the cervix in preg-
nancy, called the " tulip.'' It is used to induce prem-
ature labor; also in the course of labor coming on
at the usual time when pains grow weak and other
measures fail.
Ovarian Tumors Arising from the Origin of
Accessory Supra-Renals. — Heinrich Peham gives a
resume of his work on these tumors, including a care-
ful microscopical study of the tissue.
Monatsherichte fur Harn- u?i(( Sexual-Apparate, De-
ce?nl>er, j8gg.
Lubricants for Urological Instruments. — Felix
Schlagintweit calls attention to the difficulty of keeping
ordinary fatty lubricants sterile, and the further diffi-
culty of removing them from instruments after use.
They are likewise often destructive to the prism of the
cystoscope. Glycerin has the disadvantage of exciting
a watery flow from the mucous membrane of the canal,
which interferes with instruments of observation.
Finding an objection to almost all soapy and other
substitutes advocated, he has at last settled upon the
one recommended by Guyon : Gum tragacanth, 2.5;
glycerin, 10; carbolic solution (three per cent.), go;
this he encloses in tubes which have been previously
sterilized.
Annalcs des Maladies dcs Organes Genito- Urinaircs,
December, i8gg.
Impotence in Man. — J. Zabludowski, in discussing
the treatment of impotence, shows that the bed of the
patient who suffers from pollutions should be changed;
he should be made to sleep on the sofa instead of the
bed. He should also take up some unusual bodily
exercise. In a very obstinate case, in which the dis-
ease had lasted more than twenty years, a good result
was obtained by advising the patient to wear a condom,
instead of bathing-trunks which he was in the habit of
wearing at night to prevent soiling the bed linen. The
pollutions ceased at once. These patients should also
be advised not to take their habitual drink at night,
and to change their dining-hour. Patients who suffer
from spermatorrhoea, and who give a history of having
practised interrupted coitus, as well as those who suf-
fer from prostatorrhcea, being often subjects of poste-
rior urethritis, should be given massage of the prostate
and abdomen, and be advised to avoid interrupted
coitus. In cases of general depression following vio-
lent emotions, excellent results have been obtained by
general massage, especially dorsal tapotement. This
variety of massage will take the place of a strict
re'gime in cases complicated by diabetes 01 general
obesity. It is absolutely necessary to give a good
prognosis from the start, especially to candidates for
marriage, who do not dare to enter into the contract
because of previous experiences. In cases compli-
cated with difficulties of urination, the whole attention
should be directed to the prostate, perineum, and blad-
der. As an aid to general treatment, the whole make
up of the bed should be changed, especially in the
coverings and draperies, etc., to impress the mind.
January 20, 1900]
MEDICAL RECORD.
Etiology of Infectious Cystitis. — R. P. Van Calcar
concludes, as the result of his researches, that, in a
large number of cases of infectious cystitis, the infec-
tion has not taken place from without by way of the
urethra, but directly from the intestine, not by way of
the kidney or through the circulation. It is very prob-
able that the microbes follow the subperitoneal route.
The chief predisposing conditions are retention and
dilatation of the bladder. These conclusions are based
upon the following facts: (i) The organisms which
are found in cases of cystitis differ completely, as a
rule, from those which we find in the urethra. (2) The
urethra, be it diseased or healthy, is most sterile for
the special organism of cystitis, the bacterium coli
communis. (3) In circumstances predisposing to cys-
titis the microbes of the urethra show no tendency to
ascend. (4) The microbes of cystitis, at least the
chief ones among them, are found pre-existing in the
intestine. (5) The presence of microbes, which, un-
der the influence of pathological conditions, infect the
bladder from the intestine, is revealed in this organ
sooner than in the urine from the ureters.
Treatment of Prostatic Suppurations F. P.
Guiard, after reviewing the various methods of surgi-
cal treatment of prostatic suppurations, gives his ex-
perience in puncturing with a trocar through the rec-
tal wall, followed by antiseptic washings, and gives
the special technique for incision under the eye and
for applying the ligature in cases of hemorrhage. He
believes that puncture, followed by antiseptic lavage,
could be applied to various suppurations more or less
deeply situated, so as to do away with the more seri-
ous operations, and he questions whether it should not
be attempted in regions where it is desirable to avoid
disfiguring cicatrices.
Jievue d^ Medecine, December, iSgg.
Malarial Infection and Epilepsy. — Marandon de
Montyel, while not in opposition to the recent theory
that, the infectious diseases exercising a beneficial
action upon epilepsy, the latter may be cured or mod-
ified by inoculation with the germs of various mala-
dies, believes that infection is a two-edged sword, and
that its influence is not always beneficial, but some-
times indeed injurious. Malaria has by some author-
ities been held to be a sovereign remedy, so that they
had advised the construction of epileptic hospitals in
malarial regions, or the sending of epileptics to mala-
rial districts, with the view of substituting the latter
disease for the former and then curing it by the ad-
ministration of quinine. The author reports fourteen
cases in which malaria distinctly aggravated the epi-
lepsy, or caused a return of attacks which had long
been absent, or even induced attacks for the first time
in some neuropathic patients. Therefore he thinks
that caution should be exercised in the treatment of
epilepsy by other infections, although it is very pos-
sible that in some cases the influence exercised might
be a beneficial one.
The Sonorousness of the Abdomen. — De Sigaud
says, in regard to the tympanitic sounds, that they con-
sist (i) of a simple initial sound produced by the vi-
brations of the sonorous membrane; (2) harmonic
sounds superadded to the first, and giving it its vol-
ume and characteristic tone. There are four varieties
of tympanitic sound: sharp, amphoric, deep, and cav-
ernous. The tone varies with the dimensions of the
resonant cavity — the sharp tone corresponding to the
minimum capacity and the cavernous to the maximum
capacity. There are other and perhaps more impor-
tant factors in the production of the sound, but as yet
we are not familiar with them.
Exophthalmic Goitre — Edouard Boinet says that
the complex pathogenesis of this disease and that of
diabetes offer many resemblances. Just as the over-
activity of the liver in diabetes proceeds from the cen-
tral nervous system, so are the hypersecretion of the
thyroid gland and the dilatation of its vessels, of the
base of the neck, and the retro-ocular tissue usually
dependent upon an initial stimulation of the Base-
dow ian centres. Later, a secondary thyroid intoxica-
tion may occasion the serie^of Basedow symptoms of
toxic origin, and even react upon the nerve centres.
Cracked-Pot Resonance — Fr. Duplant reports facts
from which he concludes that this form of resonance
is produced in pulmonary cavities: (i) When there
is a large superficial cavity containing much air and
communicating with a bronchus; (2) when a deep
cavity is separated from the thoracic wall by indurated
parenchyma; (3) when a small, superficial cavity con-
taining little air and communicating but slightly with
the bronchi is situated within resistant tissue, such as
hepatized lung tissue.
Stomatitis and Pseudo-Membranous Angina
Vincent Griffon reports a case which occurred in a pa-
tient suffering from pneumonia accompanied by a
typhoid state, in which, thanks to serum diagnosis, the
pneumococci were found in the early stages.
Revue de Chirurgie, December 10, i8gg.
Intralaryngeal Cysts. — E. Louys says that these
growths are usually benign, but the great sensitiveness
of the organ in which they are situated, the delicacy of
action of the apparatus of phonation, and the necessity
of free aperture of the larynx for respiration render
them of importance. The author believes that many
of these cysts are of embryonic origin, some of them
being branchial, some proceeding from the lateral lobe
of the thyroid gland, and some from the thyro-lingual
duct. The symptoms of these cysts are those of any
foreign body — dyspnoea, dysphonia, sometimes accom-
panied by pain and cough. Indirect treatment con-
sists in the use of revulsives to the neck, these acting
upon the symptoms of laryngitis to which the cyst
may give rise, or in the use of medicated inhalations or
of mineral waters. Direct treatment may consist of
endolaryngeal puncture alone, or with aspiration, or
incision and excision of portions of the laryngeal wall.
The galvanic cautery is sometimes efficacious. Laryn-
gotomy is the operation to be preferred, and can best
be performed ^der local ana;sthesia by cocaine.
The Infection and Disinfection of Wounds due
to Fire-Arms. — E. Tavel's experiments upon rabbits,
described at great length, lead to the conclusion that
a masterly inactivity is apparently the best treatment
for wounds by contaminated missiles. Iodoform gauze
he found to be not very harmful, retarding recovery by
only six days, while glass drainage tubes caused a de-
lay of sixteen days. Disinfection of the wounds is
impracticable as a rule, and the chemical or physical
means employed for the purpose merely serve further
to injure the tissues and put them in a condition to
be invaded by the microbes carried into the wound by
the ball.
Abdominal Hysterectomy. — F. Terrier reports fifty-
nine operations performed by him during the past year,
with a mortality of 8.47 per cent. His preference is
for total hysterectomy when practicable.
Inguino - Scrotal Lymphangioma. — Brant Paes
Leme reports a case in which embryonic filaria san-
guinis hominis, although not found in sections of the
tumor, were found in the patient's blood.
MEDICAL RECORD.
[January 20, 1900
^etJicaus and Notices.
Treatment of Skin Cancers. By Dr. W. S. Gott-
HEIL. International Journal of Surgery, New York, 1899.
A SMALL book, in which is briefly reviewed the etiology,
pathology, diagnosis, and treatment of cutaneous carci-
nomata. The author dwells especially, in his chapter on
treatment, on the value of caustics for the radical cure of
skin cancers. He fails, ho\#ver, to indicate to what partic-
ular types of these malignant new growths caustics are more
applicable than is excision.
Lectures upon the Principles of Surgery, deliv-
ered at the University of Michigan. By C. B. Nancrede,
A.M., M.D. , etc. ; with an Appendix containing a Resume
of the Principal Views held concerning Inflammation, by
W. A. Spitzley, A.B., M.D., etc. Illustrated. Phila-
delphia: W. B. Saunders. 1899.
This volume contains the lectures of the author, as given at
the University of Michigan, upon the subject of the title.
There is no pretence that the book is any more than a collec-
tion of lectures, so that we may expect and understand a
certain amount of lack of continuity. The subjects are dis-
cussed interestingly, though we cannot say that anything
novel or particularly worthy of comment is offered. The
students who come under the immediate supervision of the
author viill undoubtedly find the book a very valuable one,
and we suppose that it is intended primarily for their use as
a text-book in connection with didactic lectures.
Lehrbuch der Kinderkrankheiten fur Aerzte
UND Studirende. Von Dr. Adolph Baginsky, a.
o. Professor of Diseases of Children in the Berlin Univer-
sity, and Director of the Kaiser und Kaiserin Friedrich
Children's Hospital. Sixth improved and enlarged edi-
tion. In two parts. Braunschweig : Published by Fried.
Wredn. 1899.
This new edition, consisting of over one thousand pages,
has just appeared in two volumes. Part I. commences with
the description of the physiological functions of an infant,
mentions the growth and development of a child, and then
enters into the details pertaining to infant feeding — ^both ar-
tificial and natural methods. Whoever has followed the
previous publications of Baginsky will be greatly impressed
with this chapter, which we consider the most vital and
valuable in the new edition. To begin, the author does
not only ignore the most recent publications of Heubner,
but discards the theories of that writer. Baginsky is em-
phatic in his assertions that we must recognize the value
of studying each child individually and responding to the in-
dividual needs of children. Some children will thrive on a
given feeding which is wholly inadequate for another child
of the same age. He emphasizes the valu^f examining the
fsces, quoting Escherich in this regard. Speaking of the
decomposition of milk, particularly in summer, the author
calls attention to the dangers by the formation of poisonous
peptone bodies which he calls '*pepto-toxins." His deduc-
tions are based on personal observations in the nursling pa-
vilion. Next follows the description of the usual methods of
examining a sick child in making a diagnosis, and all the dis-
eases of the new-born are detailed. Following this chapter
we are brought into the description of the eruptive (exan-
thematous) disorders. All typhoid lesions are thoroughly
described, and every detail pertaining to the diagnosis, pa-
thology, and especial therapeutic management is carefully
considered. In mentioning the general infections like diph-
theria we ask : ' ' Who is more competent than Baginsky to
speak on serum therapeutics, and to whom is the profession
of the whole world more indebted than to this author for dis-
seminating the true status pertaining to the value of anti-
toxin?" In reading the author's views on tuberculosis we
cannot but call the chapter a masterpiece. The chapters on
cerebral and, in fact, all diseases of the nervous system are
complete in every detail, based as they are on studies in
which anatomical and pathological details are considered.
It is interesting to note en passant that although the author
is one of the first to attach to bacteriology its true value from
an etiological standpoint, he does not believe that, when we
are not absolutely positive, all pathological conditions must
be included and compelled to conform to either (i) specific-
ity, (2) infection, (3) sepsis. The author believes that other
agents equally important are frequently at work and de-
serve distinct etiological recognition. Based as this work is
on the experience of one of the largest children's hospitals in
the world, with a ver)- large staff of assistants in the various
departments, we have the latest wrinkles, views, and thera-
peutics in paediatrics. The work appeals to every one desir-
ing a complete insight into any and all details of the diseases
of children.
Transactions of the Association of American
Physicians. Vol. XIV., 1899. 8vo, pp. 366.
This is an unusually interesting volume of its series, which
is saying a great deal for the general excellence and practical
value of its contents. The papers contributed by the mem-
bers are on practical subjects, are exhaustively treated, and
well selected.
Lectures on Tumors. By John B. Hamilton, M.D.,
LL.D., Professor of Surgery, Rush Medical College, Chi-
cago. Third edition. Philadelphia: P. Blakiston's Sons
& Co. 1899. Pp. 143.
The third edition of this work comes in its original form.
, In a condensed and lucid manner it treats of morbid growths
in all their bearings, and is in all respects a practical book
for the student and practitioner.
Transactions of the American Gynecological
Society. \o\. XXH'., for the year 1899. 8vo, pp.
520.
This volume contains a large number of monographs on all
the more recent gynecological operations, numbering nearly
thirty in all. The reader cannot fail to notice that in all the
operative manoeuvres advocated there is a disposition to con-
ser\'atism which is in striking contrast to gynaecological prac-
tice years ago. Radical methods are being replaced by sim-
pler ones, and altogether gynaecology is making rapid strides
along rational lines.
Deaver's Surgical Anatomy : A Treatise on Human
Anatomy in its application to the Practice of Medicine and
Surgery. By John B. Deaver, M.D., Surgeon-in-Chief
to the German Hospital, Philadelphia. In three royal oc-
tavo volumes. Volume I. Philadelphia: P. Blakiston's
Son & Co. Royal octavo, pp. 632.
The author informs us in his preface that his work, the first
instalment of which appears in the present volume, has oc-
cupied his earnest thought for twelve years. To say that
the time has been well spent is perhaps sufficient commenda-
tion in a general way. In many respects the plan and scope
of the book are unique, and follow the intention of the au-
thor in representing what a model and practical treatise on
applied anatomy should be, not only for the surgeon but for
the every-day practitioner as well. "To the former the numer-
ous and finely executed plates, representing superficial and
deep anatomy, with their accurate regional relations, it will
serve as an ever-ready and reliable guide in times of emer-
gencies, when cadavers are beyond reach, and where there
are no similar means for refreshing the memory ; while to
the busy physician abundant opportunities are afforded for
readily acquainting himself with "every phase of anatomy
superficial or deep, as applied to disease, and the most mod-
ern methods of treatment of injuries." The first volume of
this remarkably elaborate and profusely illustrated work treats
of the upper extremity, back of the neck, shoulder, trunk,
cranium, scalp, and face. The reader is not only taken by
easy and natural stages from the more superficial to the
deeper regions, but the various important regional landmarks
are also indicated by schematic tracing upon the limbs. Thus
the course of arteries, veins, and nerves are indicated in a
way that makes the lesson strikingly impressive and easily
learned. No expense, evidently, has been spared in the
preparation of the work, judging from the number of full-
page plates it contains, not counting the smaller drawings.
Most of these have been " drawn by special artists from dis-
sections made for the purpose in the dissecting-rooms of the
University of Pennsylvania." In summing up the general
excellences of this remarkable work, we can accord our un-
qualified praise for the accurate, exhaustive, and systematic
manner in which the author has carried out his plan, and we
can commend it as a model of its kind, which must be pos-
sessed to be appreciated.
January 20, 1900]
MEDICAL RECORD.
123
THE MEDICAL ASSOCIATION OF THE
GREATER CITY OF NEW YORK.
Stated Meeting, January 8, igoo.
Austin Flint, M.D., in the Chair.
Report of a Case of Properitoneal (Interstitial)
Hernia. — Dr. L. Grant Baldwin reported this case.
On December lo, 1899, Mrs. B was referred to
his service at St. Peter's Hospital with a probable
diagnosis of intestinal obstruction. She was thirty-
eight years of age, had never borne children, and her
previous health had always been good. On admission
the patient stated that five days previous she was com-
pelled to go to bed on account of a feeling of nausea,
but this was relieved by the use of home remedies, and
the next day she was able to be up. Two days later,
December 7th, she was seized with severe vomiting,
which continued until her admission into the hospi-
tal; the vomiting was very severe and was accompa-
nied by marked abdominal pains, chiefly located in the
epigastrium. The vomiting at no time became fecal,
and was constant except when the patient was under
the influence of morphine. The bowels last moved
on the morning of the 5th. On admission to the hos-
pital the pulse was 130; temperature, 99° F. There
was no abdominal distention, and doubts were enter-
tained as to the case being one of intestinal obstruc-
tion. Abdominal exainination revealed nothing defi-
nite. Hot saline solution was administered by the
mouth, as were copious enemata. Six hours after ad-
mission there was felt a small lump in the left ingui-
nal region about an inch and a half above Poupart's
ligament. It first gave the impression of a distended
Fallopian tube that had become adherent to the pari-
etal peritoneum; there was only the slightest ocular
evidence of swelling. Bimanual examination elimi-
nated tubal or ovarian trouble, so it was learned that
the tumor was intestine. There seemed to be no
doubt whatever that the hernia was incomplete, and
was interstitial. Operation on the following morning
confirmed the diagnosis. The internal ring was dis-
placed upward and toward the median line. The tu-
mor, which consisted of a coil of small intestine with
some serous fluid, was not larger than half of an Eng-
lish walnut; it had come through the peritoneum and
struck the transversalis muscle at least three-quarters
of an inch above its lower border or the ordinary loca-
tion of the internal ring, and then was deflected in-
ward almost to the border of the rectus muscle. The
fleshy part of the transversalis muscle was cut for a
distance of an inch and the constriction relieved from
without inward. The sac was opened and the con-
striction was found to be absolute and complete, yet
the entire calibre of the gut was not through the open-
ing, the constriction being complete by the sharp bend
rather than by the involvement of the whole gut. The
sac was cut off flush and stitched carefully with catgut.
This having been done and the parts being allowed to
resume their natural relations, the internal ring with
its contents was the full width of the hernial opening
below and external to it. A modified Bassini was
done, and convalescence was uninterrupted. The chief
point of interest seemed to be the ease with which the
true condition might have been overlooked, and a diag-
nosis not made in time to save the patient's life. A
median abdominal section done in search of the cause
of the obstipation might not have located the trouble.
All cases hitherto reported have been in males, and
have been very generally due to an undescended
testicle.
Dr. William B. De Garmo mentioned a case of a
woman, aged seventy-six years, seen by him two years
ago, who had a properitoneal hernia probably due to
the wearing of a poorly fitting truss. Shj; too, had
symptoms of intestinal obstruction, but the tumor
could be felt. A loop of intestine was found to be
strangulated under the transversalis fascia. There was
a pocket extending almost to the median line.
The Etiology and Treatment of Acne Vulgaris.
— Dr. Robert Alfred Sands read this paper. Pub-
lished statistics showed that this name included about
eight per cent, of all skin diseases. What was acne?
There were no less than seventeen distinct diseases
included under this term of acne. Unna claimed that
the term meant nothing definite. He stated that " it
is a disease of the skin limited to the cheek, nose,
forehead, chin, and shoulders, and to the period of
puberty. It rarely extends to the whole back, <*till
more rarely to other parts of the body, and usually
disappears with adolescence. It is characterized in
the first stage by a superficial hyperkeratosis of the
epidermis, which, extending to the follicular mouths,
leads to the formation of comedones. While the seba-
ceous glands with the follicles are stopped with liorny
plugs, the coil glands are active; indeed there is often
hyperidrosis oleosa. . . . On this basis a more inflam-
matory development of the disease takes place in two
directions, one progressive, dry, and inflammatory, with
thickening of the whole skin, hypertrophy of the seba-
ceous glands, and formation of the inflammatory nodes
(acne indurata), the other accompanied by secondary
suppuration of the sebaceous glands (acne pustulosa)."
Constitutional Causes Favoring the Formation of
Acne Text-books led one to infer that acne was a
local manifestation of a general systemic disturbance,
such as ancemia, dyspepsia, constipation, and derange-
ments of the genito-urinary apparatus, etc. Some even
believed that it was a disease of the blood. The speaker
disagreed with this. A careful analysis of five hun-
dred cases of acne showed that seventy per cent, were
free from constipation. He had noted the fact that
patients did not develop new lesions during the men-
strual period with any greater frequency than dur-
ing the intervals, although many complained that the
pre-existing nodules became somewhat more tender.
The point he wished to emphasize was that while pos-
sibly an acne already in existence might be slightly
modified by the health of other organs, the relation-
ship between the two was so slight that one could
disregard it in the treatment.
External Treatment. — First, asepsis, which meant
a separate soap for the face, a separate rag for the
face, washing the hands prior to washing the face, and
a nightly changing of the pillow in the case of pa-
tients having much pustulation. The patients must
keep their hands from the face. A watch-key should
never be used, because its hollow tube was so diflicult
to disinfect. Second, the comedones should be ex-
pressed, softening the face with hot towels or the
steam atomizer for ten minutes, and expressing the
comedones with the finger covered with sterilized
gauze. Third, pustules and indurated nodules were
dealt with according to the case. If suppuration had
advanced so far that only a thin film of necrotic skin
covered the pus, they should be opened ; otherwise
not. If it should be decided not to open them, then
a forty-per-cent. salicylic plaster could be applied, or
a drop of carbolic acid. This frequently would abort
them. Laying the pustules wide open and scraping
out the contents were never done. Fourth, as to med-
icinal agents, mercury, sulphur, and resorcin easily led
the list in the choice. If the case was a very bad one,
the patient should remain in the house and wear a
mask formed of mercurial plaster; this should be worn
constantly for three days, when the skin should be
124
MEDICAL RECORD.
[January 20, 1900
cleansed with benzene and all comedones and pustules
emptied. This plaster treatment should be kept up un-
til no new pustules formed, when Lassar's paste should
be applied for a few days. Sulphur was preferable for
office work, but it should be used in far greater
strength than usual. It was of special value with oily
skins, when the following lotion should be ordered to
be applied:
IJ Sulphur lac 30
Alcohol 30
Water 37
Gum arable 3
100
On drying, this formed a thick powder and rapidly
produced a scaling of the skin in most instances. If
seborrhea oleosa was present, resorcin was of special
value, but it should be used strong enough to get its
caustic effects and so reduce the thickened outside
layer of the skin ; thus :
IJ Zinc oxide . . . .- 10
Resorcin 40
Benzoated lard 50
100
This should be applied for fifteen minutes and then
wiped dry. The application should be stopped as
soon as desquamation appeared, and soothing pastes
should be applied. In any case the scaling had to be
done repeatedly. He had never seen a single case
end in recovery under the use of sulphur ointments.
Dr. Samuel Sherwell, of Brooklyn, said that acne
did not occur in children, but in young adolescents
or young adults. He did not believe the speaker had
laid sufficient stress upon the cases of constitutional
origin, i.e., the so-called diathetic or constitutional
causes. Acne stood in great and close relation to the
general economy. It was essentially connected with
developmental causes and developmental troubles of
the pelvic organs; also with dyspepsia of the lower
bowel. Some people were constitutionally prone to
acne — those with the hard, butcher type of skin, who
had thickening of the mucous membranes, which did
not appear silky as occurred in more healthy persons.
He thought there was certainly some direct causal re-
lations between pelvic troubles and acne, as well as
between uterine functions and acne. He had seen at
the periodic disturbances aggravation of the skin trou-
ble; he had seen women either cured or greatly re-
lieved of acne by the employment of catharsis and an
o.\ytocic such as ergot, which acted upon the unstriped
muscular fibre. In persons at the menopause he in-
sisted upon catharsis and fewer but regular meals,
thorough mastication of the food, and the relief of the
pelvic viscera, for he believed that pelvic stasis was
the determining etiological factor of acne. It may be
due to sluggishness of the nervous system. Treatment
of the reflexes from below the waist he considered to
be the best for acne. Startin's tonic was advocated;
this consisted of sulphate of magnesia, sulphate of
iron, dilute sulphuric acid, syrup, and water. Al-
though Startin was not a scientific man, he was accus-
tomed to cure his patients in cases of acne by purging
with sulphate of magnesia, by giving anti-rheumatic
treatment and wine of colchicum, and, in cases of
women, by tonic doses of ergot.
Dr. E. B. Cragix said that acne should be more
prevalent at puberty when the glandular organs devel-
oped : it seemed perfectly natural that the sebaceous
glands should be stimulated as well as the other
glands at puberty. He had often thought that if the
male sex were as particular about their complexions
as the female, and went to the doctor, acne would be
found in them as frequently as in women. After the
age of puberty it was seldom that we saw cases of acne,
except at the menstrual period. He had seen exacer-
bations of acne during menstruation.
Dr. Beverley Roeinsox had seen a great number
of young men and young women at the time acne
showed itself, and he begged leave to differ from some
of the opinions of those present. The general condi-
tions were all important, more so than local ones. It
was rare to find young women with acne without some
functional disturbances of their pelvic organs, with
abundant, slight, or no menstrual flow. Sometimes
the bowels were regular, and acne showed itself when
there was some great strain upon the nervous system
or bodily strength. He found acne more or less con-
nected with the condition of anamia, more or less
pronounced. Personally he did not believe in allow-
ing these patients to be in the hands of the specialist
too much; we should keep control of these patients,
although many specialists in cutaneous medicine man-
aged these cases with great skill. The general health
should be built up, and if the patients did not then
improve, they should be sent to the specialist. He
was skeptical regarding the treatment instituted in
curing these patients unless they were kept in the best
bodily shape. In view of the past he would insist
upon the all-important influence of the general condi-
tion.
Dr. Frank C. Raynor, of Brooklyn, believed that
the treatment of acne bore out the fact that we could
not disassociate one organ from another. In the clinic
with Dr. Sherwell the administration of a tonic com-
bined with a laxative was employed, methods directed
toward restoring the patient's general health.
Dr. L. Grant Baldwin, of Brooklyn, referred to
one condition being present more than any other in
cases of acne; that was, posterior deflection of the
uterus. One case, treated by the dermatological de-
partment for a considerable time, without any effect,
was brought to the gynaecological department and a
complete retroversion was found; as soon as it was
corrected and held in place the acne was practically
cured in a week's time. There certainly was a close
relation between the pelvic-organ disturbances and
acne.
Dr. Sands closed the discussion by stating that he
had never seen a case of acne in children, but he had
seen it before the menstrual period set in, in one case
three years prior to that event. The causal relations
between acne and pelvic disturbances should be proven.
If the replacing of a pelvic organ cured an acne, the
placing of it again in its bad position should bring
on acne again. The statement made by him in his
paper, that only eight per cent, of all skin cases were
acne, he thought to be too small ; this was taken from
the report of tlie American Dermatological Associa-
tion, from their collection of eighteen thousand cases
of skin diseases.
Officers Elected President, Dr. Robert F. Weir;
Viee-rirsideiit, Dr. \\'iniam McCollom; Recording Sec-
retary. Dr. P. Brynberg Porter; Corresponding and
Statistical Secretary, Dr. Frank C. Raynor, of Brook-
lyn ; Treasurer, Dr. Augustus D. Ruggles; Members oj
t/ie Executive Committee, Dr. John H. Hinton (for four
years), Reynold \V. Wilcox (for two years';: Chair-
man for Borough of Manhattan, Dr. J. Blake White ;
Chairman for Borough of the Bron.x, Dr. S. Carrington
Minor; Chairmanfor Borough of Brooklyn, Dr. Charles
P. Gildersleeve; Chairman for Borough of Queens, Dr.
Joseph F. Bloodgood; Chairman for Borough of Rich-
mond, Dr. U'illiam C. Walser.
Erythrol Tetranitrate is especially useful as a
prophvlactic in preventing the onset of anginal pains.
— C. R. Marshall.
January 20, 1900]
MEDICAL RECORD.
125
NEW YORK! ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meeting, January 8, igoo.
Charles N. Dowd, M.D., Chairman.
Aneurism of the Innominate. — Dr. A. L. Fisk
presented a case of this kind as a contribution to the
special subject for the evening, i.e., aortic aneurisms.
Recurrent Spindle-Cell Sarcoma with Glandular
Involvement, Treated Successfully with the Mixed
Toxins. — Dr. William B. Coley presented this case.
The patient was a man forty years of age, a carpenter
by occupation. In September, 1S96, he had first
noticed a swelling in the parotid gland. This had
gradually increased in size, until it was as large as an
English walnut. It had then been removed by opera-
tion in March, 1897. It had quickly recurred, and
had grown more rapidly, so that in May, 1897, a
second operation had been performed by Dr. J. \\'.
Wright at the Bridgeport Hospital. It had been
found impossible to remove the whole tumor. The
latter had continued to grow, and by July, 1897, had
involved the submaxillary gland. Having at this
time been regarded as a totally inoperable case, the
use of the mixed toxins of erysipelas and bacillus
prodigiosus had been begun by Dr. VVright. Very lit-
tle improvement having been noticed after three weeks
of this treatment, the patient had been referred to Dr.
Coley for advice and treatment. Inasmuch as only
moderate doses had been given, and in view of the
fact that the patient's general condition was sufficient-
ly good to warrant giving very large doses, it had been
decided to give this treatment a further trial. The
man had accordingly been admitted to the New York
Post-Graduate Hospital on August 18, 1897. Physi-
cal examination at that time had shown a tumor occu-
pying the entire left parotid region, and extending
from the left auditory meatus forward nearly to the
angle of the mouth, and from the angle of the jaw
nearly to the orbit. The tumor was circular in shape,
and measured three and one-half by four inches in
diameter. It was markedly protuberant and ulcerated
in the central portion over an area the size of a silver
half-dollar. Just beneatli the angle of the jaw was a
secondary tumor the size of a hickory nut. The
tumor had every appearance clinically of malignancy,
and was hopelessly inoperable. The microscopical
examination, made at the Bridgeport Hospital, had
shown the growth to be a spindle-celled sarcoma.
Daily injections of the mixed toxins had been made
directly into the tumor, and the dose had been rapidly
increased up to the point of giving a severe chill and
a temperature reaction of 104° or 105" F. After
about a week slight improvement had been noticed,
as evidenced by diminished vascularity and decrease
in size. This improvement had steadily continued,
and the treatment had been kept up about ten weeks.
.\t the end of this time the neoplasm had apparently
disappeared, leaving a bright granulating area in the
region of the ulceration. This had rapidly cicatrized,
and a few weeks later the patient had been presented
to the New York Surgical Society entirely free from
any trace of the tumor. He had remained in good
health up to the present time, nearly two years and a
half since the beginning of the treatment.
Successful Double Resection of Caecum and
Small Intestine. — Dr. Coley also presented a pa-
tient upon whom he had successfully performed a
double resection of the c.'ecum and small intestine for
carcinoma seven and one-half months before. The
patient was a physician, forty-three years of age, who
had enjoyed good health up to the sprijig of 1898,
when he had had symptoms referable to the right iliac
region, and apparently characteristic of recurrent ap-
pendicitis. There were pain, slight fever, temperature
reaching 102° F., marked local tenderness, and con-
stipation. These attacks had confined him to bed for
a period of about a week, after which his condition
had slowly returned to the normal, the pain and ten-
derness entirely disappearing without leaving any
trace of tumor behind. In October, 1898, he had had
a second similar attack. After this, although the tu-
mor had decreased very markedly, it had not entirely
disappeared. There had been no loss of weight. In
April, 1899, the induration had increased somewhat
in size, and had become more tender. As there had
been every reason to believe that he was suffering
from chronic appendicitis, an operation to relieve this
condition had been performed by Mr. Irving W. Cam-
eron, of the Toronto General Hospital. The abdomen
having been opened there had been found a hard mass,
involving the caecum and adherent portion of the small
intestine, and making removal impossible without a
double resection, for which both the patient and the
surgeon had been obviously unprepared. The patient
had come to Dr. Coley for examination on May j8,
1899, and, after a careful consideration of his general
condition, aided by the accurate description of the
condition found by Mr. Cameron, a radical operation
had been advised. This operation had been done on
May 26th, with the assistance of Dr. William T. Bull.
The caecum and about seven inches of the small intes-
tine had been resected. The divided ends of the
small intestine had been united by means of a Mur-
phy button, reinforced by suture. The divided end
of the ascending colon had been inverted and closed
by means of a continuous suture. The same proce-
dure had been adopted with the corresponding end of
the small intestine beyond the ileo-cascal valve. A
lateral anastomosis had then been made by means of
a large oblong Murphy button, and had been rein-
forced by interrupted silk sutures. Gauze drainage
had been introduced and left for four days. The pa-
tient had suffered scarcely at all from shock, and had
made an uninterrupted recovery. Both buttons had
been passed on the ninth day, and the patient had re-
turned to his home in Canada on the 21st day. He
had remained perfectly well since, and had recovered
his normal weight. At the present time, seven and
one-half months after operation, careful palpation
failed to reveal any evidence of return.
Dr. J. A. Wyeth, referring to the first case, asked
what had been the object of introducing the toxins
directly into the substance of the tumor, and was it
Dr. Coley's custom to do this?
Dr. Coley replied that this was his practice when-
ever it was feasible, his experience having been that
the results were far more satisfactory and more rapid-
ly obtained when this could be done. He had, how-
ever, had good results in several cases in which it had
been necessary to make the injection at some distance
from the growth.
Dr. Wyeth asked if the temperature and inflamma-
tion had been exaggerated by this direct injection
method.
Dr. Coley said that he thought this was apt to be
the case, especially if sloughing were present, but
such a pyogenic infection could be largely avoided
by careful cleansing and disinfection before making
the injections.
Sarcoma Cured by Acute Inflammation. — Dr.
Wyeth said that he had asked these questions be-
cause his own experience had led him to believe that
much of the beneficial results following the injections
of the toxins was due to an acute inflammatory process
not directly connected with any special virtue of these
toxins. This statement was not intended as any criti-
cism on the use of these toxins, because he believed
126
MEDICAL RECORD.
[January 20, 1900
they were directly beneficial. Fifteen years ago he
had had a sarcoma of the abdominal wall examined
by Dr. W. H. Welch, and proved by him and others
to be a spindle-cell sarcoma. After every extensive
operation Dr. Wyeth had resorted to injections of
arsenious acid. The method had been so painful that
after about ten days the patient had begged to have it
given up. The speaker said he had been impressed
with the marked reaction excited by the injections.
The man had returned to his home, and much to Dr.
Wyeth's surprise had completely recovered, and was
to-day alive and well. This was a clear case of cure
of sarcoma by an acute inflammatory process set up
by injections of arsenious acid. In another case, one
of very large sarcoma of the abdominal wall, he had
exposed the tumor to the atmosphere, packing gauze
around it, for the purpose of securing infection. This
exposure had led to extensive suppuration, and the
man had recovered, and had since been entirely well.
The tumor had not been examined microscopically,
but it had been a very large neoplasm, and to all ap-
pearances was a sarcoma.
Dr. Coley said that he had a case now under ob-
servation showing that cure was ordinarily not the
result of a pyogenic process. The case was one in
which the clinical diagnosis of all who had seen it
was sarcoma of the fascia. Fluctuation having been
noted, an aspiration had been made, and a large quan-
tity of sterile, broken-down material removed. This
proved that the destruction of the tissue had gone on
as a result of the toxic agent, pure and simple, and not
because of any infectious process.
Coley's Method Commended. — Dr. Wyeth said
that he considered it essential to secure infection with
the erysipelas coccus. He knew that Dr. Coley's
treatment had not been very popular with the profes-
sion, but personally he was sure that it was both
scientific and successful.
The Treatment of Aortic Aneurisms. — Dr. J. M.
T. Finney, of Baltimore, read a paper on this subject.
It was recognized, he said, that there were three
essential conditions for treatment: (i) the aneurism
must spring from the front of the vessel; (2) the sac
must be perfect; (3) there must be a coagulating
propert}' in the blood. Macewen's method of needling
the inner lining of the sac offered good chances of a
cure, but the process was tedious, and months were re-
quired before the necessary coagulation would take
place. In abdominal aneurisms only those sacs lying
closely in contact with the abdominal parietes could
be so treated, and obviously the diagnosis of this con-
dition was impossible.
Gelatin Injections. — Since October, 1898, the
French gelatin-injection treatment had been em-
ployed at the Johns Hopkins Hospital. In all nine
cases of aortic aneurism had been treated by this
method. In all these cases the blood-coagulation
time had been carefully noted. Not a single patient
had been cured, though in one case the size of the
aneurism had been decidedly diminished. It seemed
quite certain that the injection of the gelatin did not
markedly affect the coagulability of the blood. These
injections had been painful and sometimes had been
followed by chill and an elevation of the body tem-
perature to 103° F. There was, however, apparent
merit in the treatment sufficient to warrant giving it a
further trial. From a very recent experience he was
now inclined to advise a combination of the gelatin
injections with the wiring method.
The Wiring Method. — Charles H. Moore, of the
Middlesex Hospital, had first undertaken the cure of a
thoracic aneurism by the introduction of a foreign
body into the aneurism. Although this first attempt
had resulted in failure because of faulty technique
and consequent sepsis, the originator of this method
had felt impressed with the soundness of the theory
upon which the treatment was founded. Dr. D. D.
Stewart, of Philadelphia, deserved the most credit
among American surgeons for the development of the
proper technique. The needle should be large enough
for easy passage of the wire. A drop of sterile oil
would materially facilitate the passage of the wire.
The escape of blood was very slight. The needle
should be covered from the shoulder to within 1 cm.
of the point with some insulating material, so that the
electric current would not be dissipated at the point of
entrance of the needle into the sac wall. The speaker
recommended insulating the needle with the best black
French lacquer. The needles so insulated could not
be boiled, but they could be sterilized by exposure for
one hour in a chamber in which the air was heated to
160° F. The disposition of the wire in the sac was an
important factor. A small quantity of fine wire, hav-
ing a fine springy quality, should be selected. The
corrosion of the wire by the electric current made a
rough surface, which facilitated the deposit of fibrin;
hence, within proper limits, the wire giving the rough-
est surface was the best. The treatment could be
carried out experimentally by using flasks of different
capacities. Experiment of this kind had shown that
ten feet of fine and highly springy wire would fill a
500 cc. flask. They had found at the Johns Hopkins
Hospital that the best wire was one made of seventy-
five parts of copper to one thousand of silver, drawn
down from No. 8 to No. 27. Such a wire gave a closer
coil than steel wire. Experiments had been made also
regarding the comparative value of steel and silver as
electrical conductors for this work. The experiments
had been made at an abattoir in a jar of freshly drawn
hog's blood. After a current of 100 milliamperes had
been passed for an hour both wires had been examined,
and it had been found that the silver wire' had been
more disintegrated. Experiments made on dogs had
shown that a current of 20 milliamperes was effective
and better than one of 100 milliamperes. Such treat-
ment was particularly suitable for cases of thoracic
aneurism because it could be done under cocaine an-
esthesia. If after passing in a small portion of the
wire a kink should occur, more wire should be inserted
through another needle, and then both portions of wire
connected with the same pole of the battery.
Dangers Of course, sepsis was an omnipresent
danger. One of the greatest dangers, particularly in
multilocular aneurisms, was rupture of a secondary sac,
due to the rapid filling of the main sac with coagulum
and the shunting of the blood against a portion that
had hitherto not received such a strain. General arte-
riosclerosis would, in general, weigh against this oper-
ation. While clinical experience had shown that wire
without galvanism would collect fibrin in the lesser
sac, it probably would not do so when exposed to the
full force of the aortic current. The size of the sac
opening could not be diagnosed from the character of
the bruit. Another danger was that of emboli break-
ing from the sac wall during the introduction of the
wire. There was a possible danger of puncture of the
sac wall by the wire, especially if the wire was made
of steel, but this danger was rather theoretical than
real.
Results. — In all of the cases upon which autopsies
had been held, the effect of the wire in whipping out
fibrin from the blood had been marked. Thirty-five
per cent, of the reported Cases attested the value of the
opeiation by the palpable improvement and the pro-
longation of life. In one of the cases that had come
under his own observation the wiring had been done
three times, and after each operation there had been
comparative comfort for a number of months. Of the
two thoracic aneurisms reported in the paper, one had
been wired Tast August, and was now considered by
January 20, 1900]
MEDICAL RECORD.
127
Dr. Osier to be cured. Of nine other cases, death had
been apparently hastened in six; however, none of
these patients could have lived long. Clinical and
post-mortem evidence certainly pointed to the efficacy
of the method; its great drawback was the lack of ac-
curacy in diagnosis. His first case had been one of
abdominal aneurism occurring in a man who had been
admitted to Dr. Osier's service on July 19, 1898. \\'ir-
ing had been done on August iSth. Considerable
difficulty had been experienced in exposing the sac.
Only five feet of the silver alloy wire had been used,
and a current of from 30 to 70 miliiamperes had been
kept up for one hour. The sac had been made imme-
diately smaller and firmer. The patient had experi-
enced more pain, however, immediately after the oper-
ation. He had died on the twentieth day, and the
autopsy had revealed no actual rupture, but there had
been a very rapid oozing of blood. His second case
had been admitted on April 24, 1899. Seventeen in-
jections of one-per-cent. gelatin had been previously
given on the medical side of the hospital without any
appreciable benefit save some relief to the pain. On
August I ith wiring liad been done, ten feet of the sil-
ver alloy having been used with a current varying from
10 to 20 miliiamperes. Following this there had been
an improvement in the symptoms for about one week,
and then there had been a sudden increase in the size
of the chest, but the patient would not consent to an-
other wiring. Fifteen more injections of gelatin had
been given. Tliis was the case in which Dr. Osier
now thought a cure had been effected, although so far
it had been classed only as a case showing improve-
ment from the treatment.
Conservatism Advised — Dr. J. A. Wveth said that
these desperate cases certainly justified desperate
measures. The treatment so well outlined in the pa-
per was certainly desperate, yet the results fully justi-
fied the means. Many years ago he had had occasion
to look up every case reported in which operation had
been done. As a result of this study he had been led
to feel that distal deligation was not contraindicated
in cases of aneurism of the ascending and transverse
segments of the aortic arch, complicated or not compli-
cated by orifices of tha large vessels. The results ob-
tained in this way were probably as good as any others
that could be shown. Dr. Wyeth then cited an inter-
esting case — that of a man of twenty-six years, a syph-
ilitic, with an aneurism almost at the point of rupture
when first seen. Under aseptic precautions he had
inserted twenty-four hare-lip pins into the aneurism,
just like the pins in a pin-cushion. Eighteen hours
later he had removed the pins. There had evidently
been coagulation of the blood on the walls of the an-
eurism, because the pulsation was distinctly less. The
operation had been repeated four days afterward, and
the pins had been left in for twelve hours. The pa-
tient had been put upon increasing doses of iodide of
potassium, and he had rapidly improved. He had left
in two months witii evident solidification of the aneur-
ism. He had returned to his work as a carriage pain-
ter, and two years afterward had fallen dead, appar-
ently as a result of a cerebral embolism. In one of
the cases upon which he had operated he had been
surprised to find that the aneurism had already solidi-
fied. Personally he would prefer to give the rest and
iodide treatment a very thorough trial before subject-
ing the patient to deligation or to wiring. He was of
the opinion that if the profession at large understood
better the proper treatment of syphilis there would be
fewer cases of aneurism to be treated.
Dr. p. Bolton spoke of the experience at the Hud-
son Street Hospital with the gelatin injections. Four
cases had been treated at that hospital with these in-
jections during the past year. The method had been
found to have many disadvantages, and none of the
cases had resulted in a cure. The injections were fol-
lowed in every instance by severe pain, and sometimes
by chill and fever.
Dr. Finney said that he agreed with Dr. Wyeth re-
garding the advisability of attempting the rest and
iodine treatment before resorting to the other methods.
It had been tried in one of his cases without avail;
another patient had been so unruly that it could not
be continued, and in a third it could not be employed
because the patient had been unable to lie down.
^Ixerap Otitic Hints.
Endermic Application of Salicylic Acid. — Sigalas
and Combemalie have called attention to the fact that
salicylic acid is absorbed through the epidermis. In
an oily vehicle, when rubbed on the skin the acid may
be detected in the urine after five minutes. If, after
rubbing, the area is covered with oiled silk and en-
veloped in fiannel, the effect is enhanced. Oil of
wintergreen may be employed. A favorite formula is:
I^ .\cidi salicylici lo
Alcolio! 50
01. ricini loo
— Alerck's Archives.
Haematemesis. — Rest in bed, absolute immobility,
a hypodermatic injection of ergotin over the epigas-
trium, and ice locally over the same region. Inter-
nally one or two grains of opium, and every two hours
a teaspoonful of the following mixture:
If Ergotin 3 i.
Acidi gallici gr. x.
Extr. opii gr. ij.
Syr. terebinthina? | i.
Aqua" 5 iv.
In case of syncope employ horizontal decubitus,
injections of ether, flagellations, mustard leaves to the
legs, etc. Upon the development of signs of perito-
nitis indicating perforation of the stomach give mor-
phine hypodermatically.
Scarlet Fever. — All children ill with scarlet fever
should be kept in bed during the rash, no matter how
mild it may be; and furthermore, such children
should be confined to warm rooms, or, better still, to
bed, for four or five weeks from the appearance of the
initial symptoms. At least twice a week during this
time the urine should be examined, and upon the ap-
pearance of the slightest unfavorable symptom the
child should be sent back to bed again if he has al-
ready been allowed to be about the room. If scanty,
albuminous urine and dropsical effusion appear the
physician must direct the most energetic efforts toward
making the skin or intestines temporarily assume, as
far as possible, the functions of the kidneys, throwing
on the latter, at the same time, as little work as possi-
ble in the way of excretion of nitrogenous refuse.
The copious use of water, if tolerated by the stomach,
will act as one of the very best of diuretics. Should
the urine still remain scanty, then diaphoresis must
be induced in order to increase the action of the skin
— first, by means of baths, and then, if necessary, by
drugs. The warm bath (98'-ioo° F.) every fifteen
to twenty minutes is often grateful to the child, and if
supplemented by a flannel pack is very efficacious.
Any of these methods will be assisted by the internal
use of diaphoretics, chief of which are the prepara-
tions of jaborandi. Sips of the hot infusion of the
leaves ( 3 i. to Oi.) act both as a powerful diaphoretic
and sialagogue. To avoid the latter action Smith
prefers the alkaloid pilocarpine, gr. J^tOTrV, conjoined
with an alcoholic stimulant, every four to six hours.
128
MEDICAL RECORD.
[January 20, 1900
Should this fail, the same writer speaks highly of the
following:
IJ Potassii acetatis,
Potassii bicarbonatis,
Potassii citratis aa 3 ij-
Inf. tritici repentis 3 viij.
M. S. A teaspoonful every three or four hours to a child
of five years.
Most palatable and efficacious is the following:
1} Liq. ammonii acetatis,
Syr. acidi citrici aa 5 'j-
M. S. Teaspoonful every hour in hot lemonade.
— Marcus P. Hatfield: "American Text-book
of the Diseases of Children."
Cystitis. —
IJ E.xtr. hyoscyami,
Extr. cannab. indie aa o. 4
Sacch. alb 5.0
M. ft. pulv. No. xii. Sig. One powder t.i.d.
— Ultzmann.
Chronic Laryngitis. —
IJ Alum, crud.,
Sacch. alb aa 5.0
Morphinse hydrochl o. 5
M. S. Use as insufflation.
Vox SCHROTTER.
Malaria. — Dr. Nelson W. Wilson, in the Buffalo
Medical Journal for November, in an article on " Pen
Pictures of Malaria," says that the severe chills were
broken up by the administration of what the soldiers
called " knock-out drops." This was made up as fol-
lows:
V, Spir. chloroformi,
Tinct. opii aa 1.33
Spir. frumenti 60. o
M.
As an Adjuvant in Epilepsy. —
5 Zinci oxidi o. 10 cgm.
Pulv. valerian o. 10 "
Pulv. bellad o. 01 "
Saponis med q.s.
For one pill. Give four daily.
— Jules Voisin.
To Apply Locally in Pertussis —
IJ Acidi phenici cryst 1.50
Glycerini puri 10.00
Syr. tolutan 5.00
M.
Apply to the throat in children below one year of
age. After the age of three years substitute a two-per-
cent, solution of cocaine for the tolu, and for extensive
applications decrease the strength of carbolic acid. —
GUIDA.
Internally:
IJ Coccionell. subt. pulv 0.05-0.2
Ammon. carb I.OO-2.0
Syrup aurantii 20.0
Aqure destil q.s ad 100. o
M. S. Shake and give a teaspoonful every two hours.
— Naegeli-Akerblom.
Odontalgia. —
IJ Orthoformis,
Ac. carbol aa lo.o
Camphorse,
Chloral hydrat aa 4.0
M. S. Apply with absorbent cotton to the previously dried
tooth cavity.
— Danchez.
Burns. — Apply ichthyol, dust with talc, and band-
age. In more severe forms ichthyol vasogen should
be applied on compresses. — Mueller.
Urotropin decomposed by acid urine into ammonia
and formaldehyde destroys bacteria in the urine in
one or two days. — Blech.
@ovrssp0titlciice.
OUR LONDON LETTER.
(Frc
Special Correspondent.)
PRINCE OF WALES HOSPITAL FUND — SUNDAY FUND
— SURGICAL TREATMENT OF CIRRHOTIC ASCITES
PERFORATING GASTRIC ULCER — CONCLUSION OF THE
DEBATE ON TABES AND GENERAL PARALYSIS OF THE
INSANE — DEATHS OF SIR R. THORNE THORNE AND
CAPTAIN HUGHES.
London, December 22, 1899.
Yesterday the Prince of Wales presided over a meet-
ing to consider the distribution of his hospital fund
for the year. The total receipts for the year have been
^-/y47,8o6, or about _£,'9,ooo more than last year. The
expenditure has also diminished by more than £,\,^oo.
This is certainly an encouraging statement for a treas-
urer to have to make. It had been intended to make
a special effort to secure ^,'50,000 for distribution, but
considering the appeals made to the public through
the outbreak of war this project was wisely abandoned.
The committee was able to distribute ^^^42,000 among
hospitals and convalescent institutions. Last year only
^"32,500 was the amount. The amount allotted will
cause two hundred and eighty-seven closed beds to
be reopened — but there are still four hundred beds un-
occupied for want cf funds.
The Sunday fund meeting was held last week, when
it appeared the total sum collected was ^£^53,504, iij-.
\d. The grand total for the twenty-seven years in
which the fund has been at work has now passed the
million sterling, on which the council congratulated
Sir S. Waterlow, who has all along taken a leading
part in the management, and who is understood to
have desired to see this sum collected. I regret that
I cannot congratulate him on some points in his man-
agement. He is too prejudiced, and allows his preju-
dices to carry aviay his judgment. Then he suffers
the secretary to imitate him and exceed him, as most
subordinates are apt to do.
It is satisfactory to find that the Prince of Wales
fund has not caused any injury to either the Sunday
or Saturday organizations. ISy tapping a different
stratum it has brought fresh sums to the hospitals, and
would seem to have stimulated charity generally, so
that an increase has taken place all around. The Lord
Mayor remarked that the meeting lasted little more
than half an hour, and considered that that showed
the business-like methods of the fund. I cannot in-
dorse his view ; it seems ratlier to indicate that the
meeting merely accepted the statement of the officials
and left Sir S. Waterlow and the secretary to carry on
their policy by boycotting some institutions and irri-
tating the managers by injurious favoritism.
Dr. Rolleston and Mr. Turner related at the last
meeting of the Medical Society two cases of surgical
operation for the production of peritoneal adhesions
in cirrhotic ascites according to the plan introduced
by Dr. Drummond and Mr. Morison. 'I'hey have thus
added two to the ten cases recorded, and that others
have been operated on but not recorded is more than
probable, for they remarked they knew of one such
unsuccessful case. As to their own cases, one patient
improved — lost his ascites, but has an enlarged spleen ;
in the other the iluid accumulated again and again,
and they claim at the most only a slight amelioration.
In both the cases brought forward the liver and omen-
tum were stitclied to the cut abdominal parietes, and
this was urged as necessary to secure good adhesion.
Early operation was recommended. On referring to
the records of previous cases (Medical Record, Feb-
ruary 4, 1899), it would appear that four out of the
ten patients recovered, while three of the remainder
January 20, ic,oo]
MEDICAL RECORD.
129
died from the operation. If the other three improved,
the figures are not specially encouraging, and with the
one death mentioned and the two new cases somewhat
better, the proceeding is evidently a grave one. But as
to its value I may mention some of the remarks made
by the speakers present. Dr. P. Weber referred to a
case in which the patient recovered after tapping, and
said that when the specific gravity was over 1.020 there
was probably inflammation, and one or two tappings
might result in cure.
Dr. F. J. Smith objected to the old method of tap-
ping, and thought a scientific laparotomy might be
bettes. He thought that when ascites appeared in
cirrhosis, the end was near, and so a simple operation
was preferable. Dr. Middleton had published a case of
hemorrhagic ascites which resulted in recovery after
tapping. If done with a fine trocar, it was not a serious
affair. Mr. Wallis mentioned another case of recovery
after four tappings. Dr. Ewart mentioned a patient
who had undergone fifty tappings. Mr. Turner tapped
as before, proceeding with his incision, as it saved
time and he had never seen any ill effect. Dr. Rob-
erts (president) could not agree that ascites rendered
the prognosis as bad as had been stated. He had seen
many cases of undoubted cirrhosis end in recovery
after simple tapping. Dr. Rolleston admitted that
some patients did so recover, but not as a rule. He
attributed the hemorrhage into the fluid to previous
tappings.
Perforating gastric ulcer was discussed at the last
meeting of the Clinical Society. Mr. A. Barker gave
a review of twelve consecutive cases on which he had
operated of late years, all treated on similar condi-
tions. Five patients out of the twelve recovered. In
two of the fatal cases the patients survived fifteen and
fourteen days respectively, one dying of subphrenic
abscess, causing pleuro-pneumonia, the other from
bleeding of the ulcer into the stomach. In all twelve
cases mopping out the abdomen was done instead of
flushing, which he used in former cases but gradually
discarded. Of the five successful cases, all the pa-
tients were well for considerable periods, some for
years, after the operation.
On the question of flushing or mopping, consider-
able divergence of opinion was expressed by the sur-
geons present — some agreeing with Mr. Barker, others
holding flushing to be better, and others again think-
ing that mopping was equal to some cases but flushing
was required in some. One held that flushing should
be carried out thoroughly, the intestines being al-
lowed to float out of the body. All agreed that the
earlier the operation the more hopeful was the case.
Mr. Bidwell had collected fifty-five cases, in thirty-three
of which the time before operation was mentioned, and
found that one-third of the recoveries had been oper-
ated on within six hours and five others within twelve
hours. All within twelve hours were successful, and
half of those between twelve and twenty-four hours.
With regard to symptoms it seemed generally agreed
that liver dulness, so often spoken about, gave no indi-
cation. It was admitted, too, that pain is very uncer-
tain, Mr. Bowlby saying cases are overlooked because
almost every one expected pain. When present, pain
is not located as might be expected — it was said by
one surgeon it " might be almost anywhere or indeed
absent." Another had found it all in the pubes or in
the lumbar region. In a number of cases it seems
limited to the lower part of the abdomen. This ques-
tion of pain is one of great importance when the patient
is first seen.
The pathological debate was concluded on Tuesday.
Dr. Beevor thought it was exceptional for tabes to end
as general paralysis. He dwelt on the slowness of
tabes compared with general paralysis. In thirty-
nine cases of tabes he traced syphilis in eleven, chan-
cre without secondaries in seven, gonorrhoea without
chancre in ten, doubtful gonorrhoea without sore in
five, and no history of venereal in six. Until changes
in the cortex were found, in the majority of cases he
would hardly like to pronounce the two diseases iden-
tical.
Dr. Henry Head said he had been at work on the
course of the sensory fibres in tabes, and gave some
account of his research, which has yet to be published.
He came to the conclusion that the two diseases are
due to an identical process affecting different portions
of the nervous system.
Dr. P. Stewart said there must be an additional fac-
tor besides syphilis, and this he thought was over-
strain, bodily in tabes and mentally in general paral-
sis. He referred to Edinger and Heber's experiments
on rats as agreeing with this view, which was supported
by many clinical facts.
Dr. Robert Jones admitted syphilis to be the most
important factor, but could not go so far as to assert
there would be neither of these two diseases without
it. Out of five hundred and twenty autopsies on gen-
eral paralytics, the proportion of tabetic cases did not
exceed two percent. In twenty thousand cases of syph-
ilis collected by Lewin, one per cent, of the patients
became insane but not one a general paralytic. He
thought that syphilis injured the constitution and pre-
pared the ground for other factors — overstrain, alco-
hol, and excitement or excesses — singly or combined.
Dr. B. Abrahams said that to apply the meta- or
parasyphilitic doctrine to every case, as Hirschl did,
was going too far. No doubt it was the most impor-
tant factor in the production of degeneration of neu-
rons, but not the only one. Strain was to be reckoned
with, and arterial degeneration played no slight part
in determining the localization of syphilitic sequela;.
Dr. Mott had proved that both diseases were primarily
neuronic degenerations — not interstitial outgrow'ths.
Probably the neurons were affected at the time of the
syphilis, but not in a way that we could detect by the
microscope, though the injury resulted in lessened
vitality and death years after the prime cause.
Dr. Beach had found thirty-six cases of juvenile
general paralysis in literature, and could add two
which he had met with. He found evidence of syph-
ilis in tvienty out of twenty-five cases in which the
history was given. He held that it was commonly,
though perhaps not always, due to congenital syphilis.
Dr. Mott replied to various points mentioned in the
very notable debate elicited by his paper. He was
naturally satisfied to find the preponderating views
agreed with those he had put forward. He admitted
the influence of strain, both mental and physical, but
syphilis was the primary injury and produced loss of
durability of certain neurons. The two diseases were
thus due to the same morbid process, but he did not
say they were clinically identical. The prevention
and treatment, however, would be the same.
Sanitary science has lost an enlightened leader in
Sir Richard Thorne Thorne, M.D., K.C.B., F.R.S.,
principal medical officer to the Local Government
Board, and as such the head of the sanitary depart-
ment of the country, who died on Monday last, the
17th, aged fifty-seven years. He was a crown member
of the General Medical Council, and took an active
part in its recent session. On the last day, the 5th
inst., he carried resolutions on preliminary education
and on public health diplomas. His many masterly
reports, his work at international conferences, his
measures to meet the possible invasion of plague and
cholera, and other scientific and sanitary labors are
known everywhere. We who knew him as a man feel
we have lost one pre-eminently qualified for the great
position he held, and one with whom it was a privi-
lege to meet and confer.
I30
MEDICAL RECORD.
[January 20, 1900
Captain Hughes, R.A.M.C., who was killed in the
fight at the Tugela River, was also a notable sani-
tarian. He was one of the sanitary officers at Alder-
shot when Sir R. Buller selected him to be adviser on
his staff. His death is a decided loss to the army
medical service.
THE STATIC INDUCED CURRENT.
To THE Editor of the Medical Record.
Sir : In his reply to my letter Dr. Morton diverts
attention from the main points of contention : First,
that he makes extravagant and utterly unjustifiable
therapeutic claims; secon.d, that he has persistently
exploited his own originality at the expense of the
originality of others. It is not a question whether
Mauduyt and other authors now almost forgotten ever
used the term " static induced," or whether in connec-
tion with it physiological tetanus was described previ-
ous to 1881, but whether Dr. Morton was the origi-
nator of the principle upon which the whole subject is
based. Most assuredly he was not. It needs but a
glance at these old illustrations to make it evident
that the more recent ones of Dr. Morton are in their
essential characteristics absolutely the same, and that
from the arrangements represented by these illustra-
tions the spark-gap could be so adjusted as to produce
the so-called static induced current with the power to
induce continuous muscular contractions.
A. D. Rockwell, M.D.
Jauuary 6, 1900.
THE NOMENCLATURE OF APPENDICITIS.
Sir: Will you allow me to add a few words to what
Drs. Carstens and Edebohls have said, in your issue
of December 30th, in regard to the nomenclature of
" appendicitis." First of all, this term well illustrates
that a private individual, especially one who knows
little or nothing about etymology, has no more right
to coin a word than to coin money. All new medical
words should be submitted to some national body for
approval or disapproval before passing current. Per-
haps a committee of the A. M. A., perhaps a commit-
tee of medical editors, perhaps the American Academy
of Medicine, could be agreed upon. Meantime edi-
tors should unite to keep out of print some of the more
recent abuses of language.
It is a plain, common-sense rule that a Greek end-
ing, such as itis, should be attached only to a Greek
stem. In other words, a Greek translation of '' pro-
cessus vermiformis " must first be made. Of the vari-
ous words suggested — epityphilitis, scolecoiditis, sco-
lecitis, ecphyaditis, helminthitis, etc. — it seems to me
that scolecitis is the most euphonious. Scolecoiditis
— inflammation of the worm-like — is unnecessarily
accurate. U'e do not say salpingoiditis, staphyloiditis,
am\'gdaloiditis, etc., but simply name the organ after
the object which it resembles. Epityphlitis is satis-
factory enough, except that we often want to qualify
with other prepositions, and peri-epityphlitis or para-
epityphlitis is awkward.
A. L. Benedict, M.D.
Buffalo, N. V.. January 2, igoo.
To THE Editor of the Medical Record.
Sir: In Dr. Carstens' letter to you, published in the
Medical Record December 30, 1899, I read with
great satisfaction that Dr. Henry Draper, in 187 i, had
apologized for using the hybrid term appendicitis.
The time of which Dr. Carstens speaks as having
brought forward the monstrosity in question was the
time of the " per orem " man.
Napoleon, on December 26, 1805, without furtlier
preliminaries, pronounced and proclaimed through the
Moniteiir, " The dynasty of Naples has ceased to reign."
Dr. Edebohls surpasses the great man in so far as he
wapes out altogether a fact established in literature as
if it had never existed. Perityphlitis is indeed a syn-
onym for appendicitis, as shown in my paper, '' On
the Term Appendicitis," in the AV71' York Medica! Joiir-
}ia!. May 20, 1899, and with this fact we have to
reckon. Dr. Edebohls' history and biblicgraphy of
appendicitis are rather incomplete, since he leaves out
publications in which the disease has been called by
the name "perityphlitis." Two such papers, and
most important ones they are, by Ludwig Herzog, Dr.
Edebohls could have seen mentioned in my article just
spoken of. Cardialgia is a synonym for gastralgia,
although calling gastric pain cardialgia is as non-
sensical as speaking of headache in the feet. Tech-
nique means technical; nevertheless it is a synonym
for the good English (Webster's Dictionary) word
technics. True, all this is to be regretted, but the
fact remains. A. Rose, M.D.
NEEDED REFORMS IN THE AMBULANCE
SYSTEM.
Sir : An article from your pen in the issue of Janu-
ary 6, 1900, gives me quite a surprise. The article
on " Needed Reforms in Our Ambulance System,"
while putting certain features of the ambulance service
as it is conducted in a very proper light, supplies but
a very poor remedy.
The very reprehensible habits of refusing to re-
ceive patients apparently about to die, and of trans-
ferring patients under similar conditions, are old
ones. Now for the first time this matter can be
brought under direct control, and a positive and
prompt halt can be, and I doubt not will be, called.
The comptroller can cause all hospitals to report to
him under the present law, r.nd hospitals can thus be
made to report all cases received in a condition in
which any one can see that the patient is about to die
and from whence the dying patient comes. This will
prove an effectual check at once. The comptroller
has tills matter under consideration, and this method
of checking the abuse has been called to his attention.
Only a few days ago a woman died from want of
prompt attention. Nearly two hours elapsed before
help arrived, and then it was too late, because all am-
bulances were busy — all this when there were fifteen
doctors' offices within four hundred feet of the woman
who was so much in need of immediate medical ser-
vices, with no call upon these doctors.
Can we not see that to have ambulances take all
cases without question is not right? Or, in the words
of your editorial, "there should be no such thing as
questioning the fact whether a given patient. . . .
Every institution should take every case presenting
itself."
There surely are many cases in which the people pre-
fer to go to their homes when injured in the street, and
are able to procure without public aid every attention
they require, and surely when they are in their homes,
as in the case mentioned in this newspaper report,
with physicians all about, some of them would undoubt-
edly be willing to attend even if the person is unable
to pay for services, and officers should be instructed
not to call ambulances for such as wish carriages to
go to their homes; and when persons require immedi-
ate attention frequently the neighborhood doctors
can supply it for those who prefer it quicker than an
January 20, 1900J
MEDICAL RECORD.
131
ambulance could reach the sufferer; and police should
call such physicians when the sufferer so desires. Nor
should the ambulance surgeon, even when he has
reached a case, and possibly dressed a slight wound,
compel the person to go to the hospital, especially if
the injured one is quite competent in every way to
decide for himself and prefers to go home.
To return to the hospital without the injured person
should not be considered anything against the ambu-
lance surgeon, as it seems to be now.
As the matter now stands, it is a grab game, and
only when there are an extra number of ambulance
calls all at once is there any lack of opportunity for
any one, rich or poor, to go to a hospital.
W. Washburn.
January 6, 1900.
LIGATION OF THE STUMP IN APPENDICITIS.
To THE Editor of the Medical Record.
Sir: Apropos of the question of ligation of the stump
in appendectomy, so illustratively discussed by Dr.
John A. VVyeth in your last issue, I beg to call atten-
tion to the modus operandi advised in my publication,
"Is Appendicitis a Surgical Disease?" in the JVaa
York Medical Journal, December lo, 1898, from which
I quote the following:
" After squeezing the contents of the appendix into
the caicum, the fundus of the appendix is tied with a
formalin catgut ligature. The same procedure is re-
peated about half a centimetre below. Then with one
stroke of the scissors the appendix is severed closely
above the lower ligature. By previously having
squeezed out the contents of the appendix and by
tying doubly afterward, the exit of any fecal matter is
prevented. The protruding mucous membrane of the
appendix, after being disinfected with a strong solu-
tion of bichloride of mercury, is then seized with an
artery forceps and pulled out as far as possible. Now
it is cleanly cut off with the scissors. There is then
left a muscular-serous (lap, which can easily be united
by three Lembert sutures. After the removal of the
mucous membrane some iodoform powder is dusted
over the remainder of the mucous menibrane in the
depth; but dusting the little wound margins, which
are to be united, is to be carefully avoided. All these
manipulations take place after the neighboring intes-
tines, particularly the area situated directly below the
appendix, are protected extensively with sterile com-
presses."
If no perforation has taken place, it is evident that
the only possible source of infection during appen-
dectomy could come from the interior of the appendix;
that is, mainly from its mucosa and submucosa. The
removal of such area is certainly the safest way of
eliminating its infectious property.
Carl Beck, M.D.
Immunity against Malignant CEdema.— Malig-
nant oedema was one of the first diseases against which
immunity was produced by infection toxins. The fil-
tered cultures of the bacillus in sufficient doses pro-
duced death with the same symptoms as those caused
by the living organisms, but a relatively large quan-
tity is necessary. Chamberland and Roux (1887)
found that if guinea-pigs were infected with several
non-fatal doses of cultures, sterilized by heat, or freed
from the bacilli by filtration, immunity against the
living organism could be developed in a comparatively
short time. They found that the filtered serum of ani-
mals dead of the disease is more highly toxic and also
gives immunity when injected in small doses. These
experiments have been confirmed by Sanfelice, Muir,
and Ritchie. — Manunl of Bacteriology.
I^cdical Items.
An Alpine Ambulance Association. — Among the
increasing number of Alpine accidents many are of a
kind which no prudence could prevent nor medical aid
benefit. Many cases, however, occur in which some
knowledge of the principles of " first aid "might di-
minish the severity of the results or even save lives.
A movement has recently been inaugurated, somewhat
analogous to that of St. John's Ambulance Associa-
tion, for the practical instruction of Alpine guides in
the treatment of wounds, fractures, frost bites, etc.
Dr. O. Bernhard of the Engadine has published in a
book form a course of lectures on mountain accidents,
which has recently been translated into Italian and
which has gained for its author the decoration of the
cross of a Knight cf the Crown of Italy. — Aledical
Magazine.
Practical Patriotism. — At a meeting of the West
London Medico-Chirurgical Society on December 1st,
it was unanimously resolved to organize a scheme for
affording gratuitous medical attendance in their own
homes to distressed wives and families of soldiers serv-
ing with the colors. A committee was appointed to
carry out a scheme similar to that which the Chelsea
Clinical Society had organized in certain districts in
connection with the Soldiers and Sailors' Families
Association. As the West London Medico-Chirurgi-
cal Society has over five hundred members, its action
in this matter will assure free medical attendance to
distressed families of soldiers through a very wide dis-
trict.— The Lancet.
Sarcoma of the Stomach in a Child Three and
One-Half Years Old. — Finlayson {British Medical
Journal, December 2, 1899, p. 1535) reports the case
of a boy, three and a half years old, who presented an
aspect of feebleness, with great pallor or anaemia, and
with slight indications of rickets, especially in the
lower e.\tremities. The pallor was extreme, and did
not seem to be accounted for by anything in the pre-
vious history, which was one of failing health for three
months following an attack of vomiting of short dura-
tion. This vomiting was not associated with the ap-
pearance of blood. It was followed by disturbed
action of the bowels, at first constipation, but subse-
quently intercurrent diarrhoea. A vague account of
some tarry stools was obtained, but no blood was ob-
served during the three and a half months the child
was under observation. On one occasion only some
brownish fluid like altered blood was brought up from
the stomach, and even this might have been due to the
use of raw meat juice. There seemed to be no pain
anywhere and no tenderness in the abdomen, which
was slightly distended, as might be expected in a ra-
chitic subject. No tumor could be felt, but after a
time, on careful search, the spleen, as supposed, was
felt high up under the left ribs, in the lax abdomen.
Such enlargement as was thought to be present was at-
tributed to rickets. The aspect of the child through-
out was one of extreme apathy. He lay listlessly
nearly all day, often curled up, with the head bent
forward. During the periods of slight improvement
that occurred several times, he would brighten up for
a few hours, and amuse himself with toys, but this was
of short duration. Even when dullest, however, he
could speak and tell his name. An examination of
the blood disclosed no excess of white blood-corpus-
cles. The number of erythrocytes was 3,200,000 per
cubic millimetre, without pbikilocytosis. In the course
of five weeks the number had fallen to 2,560,000, and
the haemoglobin percentage was twenty. After the
lapse of another month the number of red cells had de-
132
MEDICAL RECORD.
[January 20, 1900
clined further to 1,812,500 and the haemoglobin to fif-
teen per cent. After an additional interval of three
weeks the red cells numbered 1,593,000, and the white
were estimated as 1:177 '■^^- ^° alteration in the
shape of the corpuscles was found. A few small glands
were felt in the neck, and one or two in the axilla.
With the gradual diminution in the number of red
corpuscles there was progressive pallor, with a sallow
tinge almost of a lemon color. There was slight but
almost continuous pyrexia, the temperature ranging
from 100° to 1 01. 5'' or 102° F., occasionally reaching
103° F. Toward the close the temperature continued
at 104° F. for a few days, when some pulmonary dis-
order ended the case. Ophthalmoscopic examination
disclosed only a little passive congestion of the veins
of the fundi. On physical examination of the thoracic
organs wheezing rales were heard at times in the lat-
ter part of the course of the case, and a systolic mur-
mur at the apex. Toward the close of the case a little
puffiness of the feet and hands, and even of tiie face,
was noticed. During the time the child was under
observation the weight declined from twenty-five to
twenty-two pounds. The appetite was impaired, the
child seeming to prefer milk to anything else, but he
was so apathetic as to seem rather indifferent to food.
Vomiting was a prominent symptom, at first being only
occasional, but subsequently becoming more persis-
tent. It could not be traced to have any special rela-
tionship to feeding or to any definite cause, and the
vomited matter was not suggestive of anything special
except on the single occasion referred to. Death re-
sulted from exhaustion, with a terminal pyrexia asso-
ciated with pulmonary congestion. Upon post-mortem
examination a bulky tumor was found in tiie posterior
wall of the stomach closely impinging on the greater
curvature, and rather nearer the cardiac than the py-
loric orifice. It projected almost equally externally
and internally. On the mucous aspect it measured 2.5
by 2.5 cm., the submucous infiltration being about 3 cm.
in length. On the serous aspect it measured 4 by 4.5
cm. and the projection was 1.8 cm. The tail of the
pancreas was somewhat closely related to the tumor
posteriorly, but dissection showed it to be distinctly
separated by a thin veil of connective tissue. On the
mucous aspect of the stomach, and immediately distal
to the main rounded, projecting mass of the tumor,
there was a small circular area with a depressed centre
and obviously infiltrated edges. The central portion
of this area was the only part conveying the impres-
sion of ulceration, and even there the appearances
were not conclusive. Many of the glands in the mes-
entery were slightly enlarged, but on microscopical ex-
amination they exhibited no evidence of involvement
in the new growth. On microscopical examination the
tumor was found to be a highly cellular sarcoma, with
both large and small spindle cells.
Disinfection of Railway Carriages in Germany.
— Dr. Navarre (^Joitrnal (T Hygiene) contends that third-
class compartments, which have been found in Ger-
many to be four times as rich in bacteria as those of
other classes, ought to possess smooth surfaces and
rounded angles. The woodwork should be protected
by varnish, which may be readily washed and disin-
fected. The floor should be covered with linoleum,
which may also be readily cleansed and changed.
The partitions and other woodwork should be carefully
washed with water containing soda, to be followed by
a 1 : 1,000 sublimate spray. For the second- and first-
class carriages Dr. Navarre would do away with stuffed
cushions, which become full of dust impossible to dis-
place thoroughly. He v;ould cover the seats with flex-
ible leather and the floor with lineoleum. If movable
cushions are retained they should be beaten mechan-
ically at regular periods. Formaldehyde gas should
be generated in these carriages, being not only an ex-
cellent deodorant, but a reliable disinfectant. The
smell of the gas disappears rapidly after a short ex-
posure of the interior of the carriage to the air. —Pub-
lic Health.
Milk for Diabetes — Dr. R. T. Williamson sug-
gested the following method of preparing for diabetic
patients an artificial milk practically free from milk
sugar: "To about a pint of water placed in a large
drinking-pot or tall vessel, about two or three table-
spoonfuls of fresh cream are added and well mixed.
The mixture is allowed to stand for twelve or twenty-
four hours, when most of the fatty matter of the cream
floats to the top ; it can be skimmed off with a teaspoon
easily, and on examination it will be found practically
free from sugar. (The milk remains dissolved in the
water.) This fatty matter thus separated is placed in
a glass and mixed with water. Then the white of an
egg is added and the mixture well stirred. The water
and white of the egg are added in sufficient quantities
to make a mixture which has the exact color and con-
sistence of ordinary milk. If a little salt and a trace
of saccharin be added a palatable drink is obtained,
which has almost the same taste as milk and which
contains a large amount of fatty material and is prac-
tically free from milk sugar. With very little practice
the right proportions can be easily guessed, and of
course much larger quantities than those mentioned
can be prepared. — Medical Chronicle.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended January 1 2,
1900 :
Cases. Deaths.
-United States,
-jd to January 4th. . . 6
30th to January 6th... 17 i
22d to January 6th. .. 8
22d to January 6th.., 19 x
3d to December 29. . . 37 4
26 th to January 6th. . . 3
2£d to January 6tii.. . . 3
22d to January 6th... i
22d to January 6th. . . i
27th 12
27th 14
27th 4
zf ih to January 6th. . , i
22d to January 6th,.. xo
2zd to January 6th. . • 4 4
Geogia, Brunswick December
Illinois, Cairo Decemb<
Indiana. Evansville December
Louisiana, New Orleans ....December
Massachusetts, Boston September
Nebraska, Omaha December
North Carolina, Charlotte. ..December
Ohio, Cincinnati December
Hamilton December
Youngstown December
Oklahoma, Shawnee., December
Oklahoma City., December
Yukon December
Pennsylvania, Pittsburg December
Salt Lake City December
Virginia, Portsmouth ....... December
Austria, Budapest.
Belgium, Antwerp.
Bohemia, Prague . .
Brazil, Rio de Janei
Egypt, Cairo,
Smallpox — Fore
. .December 17th ti
. .December 8th to
, .December 8th
.No
nber 20th
Engia
idon.
;, Athens...,
Bombay . . . ,
0, Chihuahu;
Wa
Madrid
Straits Settlements, S'
Turkey, Constantinople
Smyrna
Tiber i8th
December 8th to
.December 8th to
November 26th tc
.December 23d to
.December 21st to
.December 2d to 1
.December 18th t(
.December 8th to
.November ^othtc
December 8th to
.December 8th to
5 24th
14th
=5th
D December 1st.
3 December 2d.
i6th
.-&
30th. .
28th .
nber 5th.
December 4th.
'3d
14th
November 4th to i8th . . .
.December 18th to 25th. .
.December loth to 17th .
7th to December 1st.
2d to 30th
.November 17th to December ist.
, December 22d to 30th
Plague— United States.
Hawaii, Honolulu December S2d
Plague— Foreign.
Brazil, Santos October 19th to December gth . .
China, Hong Kong November i6th to 25lh
India, Bombay November a6th to December i8th
" Kurrachce November 2slh to December 9th.
Japan, Formosa. Tamsui October 17th to November 28th..
Kobe Decemherjth
Osaka and Hiogo November 25th to December 2d.
Madagascar, Tamatave November nth to December ?d.
Medical Record
A IVeekly Joitriial of Medicine ami Surgery
Vol. 57, No. 4.
Whole No. 1525.
New York, January 27, 1900.
$5.00 Per Annum.
Single Copies, loc.
©rigtnal Articles.
LEPROSY IN HAWAII.
By E. S. GOODHUE, M.D.,
AUI, HAWAII.
Leprosy is the name of a disease more terrible than
it can be pictured even by the most sensational, and is
so prevalent in the Sandwich Islands that the govern-
ment has been forced to provide an island upon which
the unfortunate victims could be permanently placed.
The subject has been written and lectured about;
made the theme for romance; and used by some to
frighten timid strangers away from Hawaii. It was
lately advanced as a reason why the islands should
not be annexed to the United States. Leprosy is one
of the most incurable, loathsome, and shocking dis-
eases known to man. A reason why we dread the dis-
ease worse than we do other diseases is because its
causation is still wrapped in partial obscurity. All
unknown things are dreadful. While a specific germ
has been discovered, it will not multiply out of the
human soil in which it is found. We cannot trace a
particular case back to a certain infecting source.
We do not know how long the victim stays well after
the germs get into him, or how long it alw.iys is be-
fore he shows the effects of their work in his system,
or exactly what the earlier manifestations of the dis-
ease are. VVe are not able to cure the man. We
doubt if he can be cured. One section of the medi-
cal world says that the disease is not contagious, and
that segregation is therefore useless and cruel; the
other, and we believe the more scientific party, says
that leprosy is contagious, and that there is unassail-
able basis for the position. Granted that the disease
is communicated by one person to another — how is it
communicated? Do the germs fly, walk, swim, or
smuggle themselves down our throats in food? Do
they require special soils for growth? Must these be
moist or dry; mucous membrane or blood? If the
germs fly, they come in the dust from the street and
carpet, circulate in the breeze, and leave us no escape.
If they swim, they seek our milk and water, and so
get into all foods. Do the mosquitoes, flies, fleas, and
bedbugs bring the bacilli? We do not know; we
only suppose. So the gnome of uncertainty glorifies
itself, and we are ready to be alarmed. The disease
has existed since the very earliest period of the world's
history. Although Biblical writers gave the name of
leprosy to several different diseases, some of them not
specially severe, there were certain external changes
in the skin and nutrition which made the disease re-
semble leprosy, at least to an untrained observer.
The observers, not being specialists, took much for
granted. Manetho, an Egyptian historian, who lived
two hundred and sixty years B.C., says that ninety
thousand Jewish lepers were expelled from his
country. The Hebrew name for the disease meant a
stroke or blow, and the description of Job's affliction
is a fair picture of one form of leprosy. This places
it some five hundred years further back, while certain
papyri refer the malady to 4166 B.C. It prevailed in
China, India, Africa, Phcenicia, Egypt, Arabia, Syria,
Italy, and Greece in very ancient times, and from the
second to the seventh centuries it was the common
disease in Europe. Many persons used to cast their
horoscope to see whether or not they were to be
afflicted with leprosy. In 630 a.d. Italian law de-
clared that lepers were civilly dead. Tamerlane
caused them to be burned. Religious fervor had
much to do with the spread of leprosy in Asia Minor,
as in those days pilgrimages were made from one
place to another. It is claimed that the Saxon pil-
grimages spread the disease greatly. Lombardy was
a leprous hot-bed. Leper hospitals began to be estab-
lished in Great Britain and the Continent. In 1200
there were three leper hospitals in England, contain-
ing ninety-one inmates. Robert Bruce, of Scotland,
died of the disease in 1329. Between the years iioo
and 1472 A.D. in Great Britain alone, there were es-
tablished one hundred and eight lazarettos. It was
even worse on the continent, where laws were passed
for and against it, and one king "ordered lepers to
be burned that their bodies and souls might be puri-
fied together." France built leper asylums in nearly
every village, and in 1226 had segregated two thou-
sand lepers. So numerous were the victims that the
special religious order of St. Lazarus was organized
in Palestine in 336 a.d. to care for them. Some of
the leper institutes became very wealthy and influen-
tial. Norway, Sweden, Denmark, Germany, Russia,
and Iceland suffered from the ravages of the advanc-
ing scourge, while Spain, Portugal, Madeira, and the
Canary Isles were not immune. It is supposed that,
until the arrival of negroes from Africa, America re-
mained free from the disease. If the American
Indian came from Asia, he had successfully left
leprosy behind. In 1300 the disease began to abate
in England, then in Scotland, where it limited itself
to the isle of Papa, continuing there until 1740. In
the sixteenth century hardly any lepers were to be
found in France or Italy, the few cases there being in
the Pyrenees. Leper houses were abolished in Den-
mark during the same century, but remained in Swe-
den until the eighteenth. In Norway the disease is
still found. Why, the scientists cannot say. A dis-
tinguished leprologist writes:
" Within a few centuries of its first spreading into
these countries, it had multiplied to such an extent as
to have inspired the whole of Christendom with horror
and fear. The disgust and terror which it evoked
roused the whole population of these parts to drive
the unfortunate lepers from their midst. The genius
of Christianity, fortunately, was true to itself, and
tempered this act by providing houses for the recep-
tion of the unfortunate outcasts. With extraordinary
rapidity, considering the nature of the infirmity, it be-
gan to disappear simultaneously with the adoption of
the strict measures that were put in force, the disap-
pearance being as rapid and complete as the onset of
the disease amongst the populations had been swift
and intense."
The disease still exists in more countries than the
general reader would imagine, being found in all the
134
MEDICAL RECORD.
[January 27, 1900
states of Europe, excepting Great Britain, Holland, nervous and tubercular, according as the germs find
and Denmark. Norway has quite a large number of their home in the nerves or in the skin, with paral-
her people segregated by law. But Asia is the great yses, contractures, and anesthesia in the one case, and
tubercular swellings and ulcerations in the other;
with final mutilation in both.
The two forms of the disease may exist in the same
individual at the same time, and often do. It is most
common in men, from the ages of fifteen to thirty
years, but it attacks all classes at all ages. It may
terminate fatally in one year, or run a course of thirty
years, but its average lease is about thirteen years.
The best authorities are agreed that the disease is
contagious; that is, transmissible from one person to
another.
The history of the disease in all countries, and
among every class of people, points to the certainty
of contagion. It has been traced to sources. Its
course has been progressive when segregation has not
been enforced, and retrogressive when it has. In pro-
portion to the failure to carry out segregation, the dis-
ease has advanced. Families which in England are
and have been free from the taint of leprosy, go to
India, China, or elsewhere where leprosy prevails, and
become leprous. Dressers, nurses, and physicians in
leper hospitals contract the disease quite frequently.
To Louisiana the disease came with some French set-
tlers; to New Brunswick with Frenchmen; to Minnesota
with Norwegians, and so on. In each location where
the disease developed, carriers had come from leper-
infected places. It can be traced back as certainly as
we trace our individual characteristics. For this rea-
son it was supposed to be hereditary and congenital.
As in tuberculous disease of the lungs, there is no
doubt a tendency transmitted, a peculiar make-up
furnished, which is more susceptible to certain speci-
home of leprosy, British India having nearly one hun-
dred and twenty-five thousand cases. There the sick
and well mix without regard to care. This indiffer-
ence and the prevalence of the malady are signifi-
cant. Many of the English physicians do not "be-
lieve in the contagiousness of leprosy," which opinion
does not seem to have any bad effect on the microbe.
In regard to numbers China ranks next. Dr. Cantlie
says: "Leprosy is endemic in every district in China,
and the Chinese dread lepers and avoid them syste-
matically, or expel them from their midst." Next
follow Africa, Japan, and the islands of the Pacific
Ocean. In Japan, the probable aborigines, the Ainos,
who do not associate with the Japanese, are free from
leprosy, while it is common among the latter. Other
places where it is found are the states of South Amer-
ica, Australia, New Zealand, Mexico, Central Amer-
ica, and the West Indies. In New Brunswick there
has been an average of about thirty persons confined
in the lazarettos. In Louisiana in 1891, seventy-five
cases were reported; about one hundred in Minnesota
(Norwegians); many in California (Chinese); and
sporadic cases occurring in South Carolina, Wiscon-
sin, Michigan, Oregon, Texas, Maryland, Illinois,
New York, and Nebraska. Between 1876 and 1886
ten persons died of leprosy in Minnesota. In all the
States, excepting California, Louisiana, South Caro-
lina, and Maryland, the disease was brought mainly
by Norwegians, and is largely confined to them;
while in California, of the fifty-two patients received
into the hospital during ten years, all save one were
Chinamen. In the Southern States the persons af-
fected are negroes and Acady French.
This is not a place for a description of the symp-
toms of the disease. It is enough to say that its
earliest manifestations are insidious, and largely
unrecognizable at present; that it is progressive, per-
sistent, and fatal. The one disease has two phases.
C.tsc showing Swollen Cilands.
fic inoculations. I think that this is evident in the
Polynesian. Its members readily acquire leprosy,
and the tendency is increased by their habits of life.
The causes of leprosy have been variously stated.
Some have said that eating fish, fresh or salt, was a
cause, citing Norway and other sea-washed countries
January 27, 1900]
MEDICAL RECORD.
135
where leprosy abides. It requires a long, tedious,
painstaking series of observations and experiments, a
peculiar mental attitude, and much particular knowl-
Appearanc
. Advanced Stage of ihe Dis
edge to be able to trace accuratel)' the relations of
cause and effect. Without this necessary equipment,
the most honest inquirer is very apt to fall into grave
error and draw false conclusions. So leprosy has
been attributed to the eating of pork, maize, spoiled
rice, salt, olive oil, cheese, intoxicating liquors, awa
drinking, and "moral emotion." The differentiation
of the germ peculiar to leprosy, the bacillus leprae,
has set at rest much discussion, but as yet the micro-
organism will not show us how it works outside of the
human body. Dr. .\rning, w'ho came from Germany
to Hawaii at the request of this government, very
carefully and conscientiously carried on some experi-
ments, and was successful in inoculating a convict
with the bacillus. The patient afterward died of
leprosy. But, as he was a native, he may have had
the disease in an incipient stage. Dr. Arning, with
commendable conservatism, considered his experi-
ment inconclusive. Dr. Fitch, an American quack
who came there during the reign of Walter M. Gib-
son, took the kingdom by storm with his brilliant
methods of treating disease. He had gone to an
Eastern medical school, the University of Pennsylva-
nia, where he was seen at lectures for two years, leav-
ing before the examinations of the second year, on
account of his aunt's advanced age and feebleness,
entering the last year of a Western school. Here he
got through by the skin of his teeth. But he ahvays
liked to talk about the University of Pennsylvania,
the colors of which he wore. He began in Hawaii
as physician to the Honolulu dispensary, where he
had three large bottles labelled only with a number.
From these jars the doctor supplied the natives with
whatever they wanted in the line of treatment. If a
patient came in. Dr. Fitch took a look at him, and called
out to his assistant to fetch a ladleful of Number 335,
which he administered to the dazzled native. Crowds
began to pour into the office. Crutches were hung
outside of the door; the poor, the halt, the blind, the
deaf, thronged the portals, and twice a day the glass
jars had to be replenished. Dr. Fitch was one of
those men who, suddenly coming across an idea, catch
it up in a hurry, run off with it, and never wait to see
whom it belongs to, where it fits, or how it can best be
used. Its antecedents were nothing to him. Correla-
tion be damned ! He took up his idea and began to
blow it up, until — it collapsed. He read very little
medical literature. He had a horror of theoretical
men, laying great stress on practical work; forgetting
entirely that an ignoramus and a fact are incompati-
bles. He used medicines, like a great many others of
his tribe, not because they were indicated in a particu-
lar case, but because they had helped such and such
a case. This he called his " experience," which he
set up against the tli,eory of all the text-books. Un-
fortunately for America, there are several such men
around loose; men who ought to be chopping wood.
Well, in that strange age, when the wisdom and hon-
esty ledges had all panned out. King Kalakaua saw
the diamond-cut-diamond he had in Dr. Fitch, and
made him superintendent of the leper branch station,
because the doctor said, just as positively as he said
other things he didn"t know, "Leprosy is only the
fourth stage of syphilis." But he didn't deceive Drs.
Emerson and Arning, and others who had been in
Hawaii over two years. The following reports of cases
are taken from some clinical data Dr. Fitch took the
pains to secure:
" Kine. Female, aged eighteen ; sick four years.
Is the last born of seventeen children, all dead, by a
strong, fat, short mother and a tall, slim father, both
living.
" Kahoe. Female, aged twenty-three; sick eigh-
teen months. Had lived, ate, and slept together with
her mother-in-law, who was a leper."
Vaccination has been blamed for the spread of
: Swellings on Cheek and Hand,
leprosy, but without good reason. It would be as
impossible to prove that vaccination produced a par-
ticular case of leprosy, as to prove that it was Dr.
136
MEDICAL RECORD.
[January 27, 1900
Arning's inoculation which caused the leprosy that
followed. Either might cause the disease; and so
might a mosquito bite. The predisposing causes are
clearer: Filth, promiscuous, tenantry, want of air in
sleeping-apartment, scurvy, diet, and alcoholic bever-
ages, anything which lowers the normal standard of
health.
The first leprous man in Hawaii who came to the
notice of the general public was a native named
Kaea, who died in 1852, after being a leper for about
ten years. His case was reported by Dr. D. D. Bald-
win, of Lahaina, who in 1863 discovered that there
were fifty leper communicants in his church. He
was a physician as well as a minister. The same
year Dr. Hillebrand, surgeon to the Queen's Hospital,
wrote: "I wish to bring to the public's notice a sub-
ject of great importance. It is genuine, Oriental
leprosy. Repeated investigations leave but little
The Face and Hands in n Market! Case.
doubt in my mind about the contagious character of
the disease, as I have followed its gradual spreading
from a single person to many people in the same vil-
lage. It will be the duty of the next legislature to
devise and carry out some efficient, and at the same
time humane, measure by which the isolation of those
affected with the disease can be accomplished."
The disease was called " Mai pake" by the natives,
and this meant Chinese sickness. In April, 1864, the
board of health appointed Mr. Jourdan to take a leper
census, and report the same. It was found that a sur-
prising number were about tha country, and that the
contagion was being rapidly disseminated. The mat-
ter was discussed, and in January, 1865, the king
signed an act providing that certain lands " be set
apart," for the "isolation and seclusion of lepers";
that the board of health or its agents " be authorized
and empowered to cause to be confined all leper pa-
tients who shall be deemed capable of spreading the
disease of leprosy." Arrangements were then made
for the "establishment of a hospital where leprous
patients in the incipient stage may be treated." Dr.
Baldwin sent his note of alarm from Lahaina: "We
are beginning to have a crop of leprous young chil-
dren."
One thousand dollars was now appropriated by the
board of health toward defraying the expenses of Dr.
Hillebrand, who went to China and the East Indies to
investigate the subject of leprosy, while $30,000 was
allowed for general expenses at home. In October of
this same year, a "receiving station" was established
at Kalihi, with Dr. Hoffman as resident physician.
Dr. Hutchinson then selected and purchased the land
upon which the present leper settlement is located.
It is a portion of the northern part of Molokai, as
effectually separated from the mainland as if it were
separate island. It includes some five thousand
acres, and a very fertile valley called Waikolu. The
ocean washes three sides, while the south side, or base,
is separated from the body of the island by a steep
precipice, in some places nearly three thousand feet
high. On each side of this peninsula, east and west,
is a little village forming the unfortunate colonies.
The assessors of the islands were required to gather
not only taxes but the sick, and send them from the
various islands to Honolulu. One hundred and forty
lepers were sent to Molokai in 1866, and during the
three years following over $81,000 was spent by the
board of health in carrying out the law of segregation.
In 1873 more active measures were taken to segregate.
Bill Ragsdale, a bright but dissipated half-caste, to
whom reference is made in Mark Twain's book, vol-
untarily surrendered himself, and went to Molokai as
superintendent of the settlement, where he did' satis-
factory W'ork for the board. A boat was secured to
carry provisions to the settlement. New taro patches
began to be cultivated by the lepers, making it much
more satisfactory both for the government and for the
colony. During this year the Evangelical Association
adopted resolutions advocating " more effective meas-
ures, or our Hawaiian people will become a nation of
lepers." Between 1881 and 1882 the estimated num-
ber of lepers in Hawaii was four thousand. Of one
hundred and fifty-seven lepers in 1S66 two were Ger-
mans, two Americans, twelve Chinamen, and one was
English. Dr. Arning said in 1866: "Among the
white population, numbering 17,935, I know of thirty-
five leprosy cases."
There are at present seven hundred and sixteen
buildings in the settlement on Molokai, six hundred
and nine being hospital, offices, schoolhouses, resi-
dences of ofticers, churches, a Young Men's Christian
Association building, and bath houses. The Baldwin
Home comprises a group of fifty-one buildings, and
the Bishop Home ninety-eight buildings. There are
Protestant and Catholic missions, while the Francis-
can Brothers and Sisters have the "homes" in charge.
The board owns cattle, horses, mules, and asses to the
number of some seven hundred. There are now liv-
ing in the colony 1,100 lepers, 625 males and 448
females. Of tliese 984 are Hawaiians; 62 half-
castes; 37 Chinese; 5 American; 4 British; 4 Ger-
mans; 6 Portuguese; 2 South Sea Islanders, and i
Russian.
During the past two years fifty-four children were
born to leper parents. Kapiolani Home, a place for
the care of girls of leprous parents, managed by the
Sisters, adjoins the receiving station. The dedica-
tion of this institution was the occasion for a speech
by his excellency W. M. Gibson, which was afterward
embodied in a special report. A long array of high-
nesses and excellencies were present. Mr. Gibson
was a spouter. " It may be mentioned in this place
that as a delicate compliment to the Kapiolani Home,
which was to be opened formally by her majesty, the
king and queen, his excellency W. M. Gibson and
Colonel Judd, the king's chamberlain, wore the star
of the Order of Kapiolani. His excellency Mr. Gib-
January 27, 1900]
MEDICAL RECORD.
137
son also wore the star and the ribbon of Pius the
Ninth." Never was it worn by a more pious fraud.
All this majesty, excellency, and Potiphar-chaniber-
lain-butler business was in a little dark-skinned
kingdom, with Americans at court. Think of it!
Mr. Gibson then began to speak in his effervescing
way :
" Your Majesties, Your Royal Highnesses, My Lord
Bishop, ladies and gentlemen" [thus the minister
of the interior, chairman of the sanitary committee,
president of the board of health, began], "the mem-
orable occasion which unites us to-day marks an-
other day's advance in the onward march of the
Hawaiian kingdom on the highway of humanity and
civilization." [The Highnesses were smiling with
pleased appreciation.] . . ." My task is ended, but let
me add a few words. Hawaii has taken her stand
among the nations" [since the Premier arrived] "and
the nations of the earth honor our king and this king-
dom for the attitude we take."'
Then the official report goes on : " His excellency
Mr. Gibson then stepped forward and presented the
keys of the Home, attached to a gold chain and ring,
on a crimson velvet cushion," while the highnesses,
excellencies, chamberlains, and other people made
obeisance. With all his talk Mr. Gibson delayed the
good work of segregation, and during the time that he
was president of the board of health very little effec-
tive work was done. When, later on. Dr. Emerson
and others took up the health matters of the country,
it was with added difficulty. It is said that only by
great presence of mind, on one occasion, was the doc-
tor able to save himself from the assassin's bullet.
Some natives had come to kill him for carrying out the
obnoxious law. It was the sad fate of Dr. J. K. Smith
to die by the hand of a man whose wife the doctor had
ordered to Molokai. Dr. Smith was a man of quick
sympathies and warm impulse. He appreciated the
pathos of these separations, even between natives, who,
probably, are not so deeply sensitive to such events as
we would be; and, I am sure, made the way as easy
as he could for the poor mother who is torn from her
babe, or the fond father who must let his only child
go from him forever. Every one is familiar with the
graphic picture in " Ben Hur," of the leper mother
and sister; that story cannot be more pathetic than
many of the incidents which are brought to a govern-
ment physician's notice.
It will be seen, from what has been stated so far,
that there is almost less danger to the average repu-
table foreign resident here, so far as leprosy is con-
cerned, than there would be in other parts of the
United States. To begin with, he expects to see
lepers, and therefore knows how to avoid them. If
he should not be able to recognize the disease, which
is improbable, others will do so for him. As soon
as a leper becomes known, he is isolated. If a man
with a contracted finger or a suspicious face is seen,
he is avoided. Examinations are made in schools
and elsewhere, by physicians, and servants and nurses
are usually selected with care. I never let a servant
enter my house unless he or she be free from any taint
of syphilis, leprosy, or other contagious disease. Food
sources are looked into; water is boiled and filtered,
and, in our home, the milk is all boiled as well.
Everybody is on the qui vive, as it were ; not fearful,
but careful. These same precautions ought to be
taken on the mainland east of us, against both leprosy
and pulmonary consumption. Here physicians all
recognize leprosy. In most of the States it is very
different. Although there are a great many cases dis-
tributed throughout the States, there is no law to pre-
vent its spread. A white leper may go from here and
travel in any American city unmolested. He not
only can, but does. Physicians there, looking upon
it as a rare disease, do not recognize it except in its
grosser forms. They do not expect to see it, and the
laity have not the faintest idea what a leper looks
like. I remember we had a leper in quite an ad-
vanced stage of the disease, at our clinic in Chicago.
He had wandered about the country for four or five
years, staying wherever he had money to pay his way,
and no doctor had been able to tell him what his
trouble was, until he reached Chicago. There are
lepers in the North, from Oregon to New Brunswick,
and in the South, from Central America to South
Carolina, travelling criss-cross, with no one to say
them nay. The thought is startling when we consider
that these unfortunates can travel without being recog-
nized as lepers. I once saw a man in a New York
hotel, where he was a regular guest. I didn't know
it then, but I know now that he was a leper; and I
feel certain that none of the other guests knew what
ailed the man. A specialist in the West speaks of
having under his treatment in Nebraska a father and
daughter who are lepers; while one of the ablest au-
thorities upon diseases of the skin says: "It is not
generally known, but it is a fact, that one of the most
distinguished clergymen in the United States has
been a leper for years."
Dr. Hyde of Rush Medical College says: "In its
prodromic periods, no suspicions of its existence
would be awakened in countries where the disease is
not endemic. In this country, where leprosy, in con-
sequence of its comparative rarity, has not yet awak-
ened the attention of legislators beyond the point of
forbidding the importation of infected persons, the
proper care of lepers in a community only too ready
to take alarm at even the name of the disease is a
serious matter." I desire to call the attention of our
legislators to this fact. It is high time that some
steps be taken toward segregating all the lepers now
on the mainland, and providing them with the com-
forts and medical care they need.
The proposal of the San Francisco authorities to
place California lepers in the Hawaiian settlement
should be considered, now that Hawaii has become an
American possession. While Hawaii was an inde-
pendent republic, its government very justly resented
such a proposal, but now the removal of all our home
lepers to Molokai would be the safest and most hu-
mane action that our government could take. It
would work no injury to any one, reduce the danger of
contagion to a circumscribed area, and cost little more
than the maintenance of the Hawaiian colony. Be-
sides, the territorial government of Hawaii is the
only administration capable of caring for the lepers.
It has capable, honest, sympathetic officials, who have
learned by long experience just what to do for the
settlement, and it has able physicians and experi-
menters who are carefully watching all the phases of
the disease. To a normal person of intelligence and
moral and social discrimination, I should consider, so
far as the danger of acquiring leprosy is concerned,
that Hawaii, or any other country practising segrega-
tion, offers substantial advantages.
Dionin (Ethyi-Hydrochlorate of Morphine) —
Heim, who has studied the eft'ects of this new drug
upon a large series of patients, concludes that dionin
is quite a useful preparation, whose action as an ano-
dyne, hypnotic, and sedative places it between mor-
phine and codeine and entitles it to a more general
use. A habitus is only exceptionally acquired. Ex-
cepting in diseases of the heart muscles, disagreeable
effects are usually absent. Administered per rectum,
its action is as prompt as when given per os. — Cf. orig-
inal article in Klinisch-tlierap. Wochetischr., 1899, No.
46.
MEDICAL RECORD.
[January 27, 1900
SANATORIUM TREATMENT AT HO:\IE FOR
PATIENTS SUFFERING FROM TUBERCU-
LOSIS.'
Bv S. A. KNOPF. M.I).
This title in itself will tell )-ou that I have no new
antituberculous remedy to offer. Even the system of
treatment, to which I have to refer frequently, is not
new. Many,- and myself among them,^ have described
the typical sanatorium treatment for consumptives be-
fore. The only excuse I have for appearing before
you is my hope that what I have to say of the system
as applicable bj' the general practitioner in the house
of the patient may arouse an interesting discussion
from which we all cannot fail to profit, and through
which the cause of modern phthisio-therapy will cer-
tainly gain.
Years of study of the treatment of consumptives in
special institutions have made me an enthusiastic advo-
cate of this therapeu-
tic system. The in-
sufficient number of
sanatoria in propor-
tion to the number
of consumptives has
led me to treat many
a patient as best I
could by imitating the
sanatorium treatment
at home. But before
detailing what might
be done under such
circumstances, let me
rapidly enumerate the
essential factors of
the typical sanatori-
um treatment.
There is, first, a so-
called general hy-
giene ; second, a
special hygiene ;
third, an excellent
table; fourth, an ar-
rangement for the
open-air treatment;
fifth, a hydrothera-
peutic establishment;
and last, but not least, the constant medical super-
vision of the patient.
To these six prophylactic and therapeutic factors we
must adhere, no matter what climatic conditions may
surround the patient.
General Hygiene. — Let us presume that for some
reason or other the patient must be treated at home,
and that he lives in a city. If he has not a home of
his own he will probably consult his pliysician as to
the best place for a residence. I would tell him to try
to live in the highest portion of the city; to seek as
' Read before the New York State Medical Association at its
sixteenth annual meeting, held at New York, October 24-26, 1899.
'•' Dettweiler, P.: "Die Behandlung der Lungenschwindsucht
in geschlossenen Heilanstalten." Berlin, Reimer, 18S4. — Breh-
mer, H. : " Die Therapie derchronischen Lungenschwindsucht."
Wiesbaden, Bergmann, iSS". — Moeller : " l.es Sanatoria pour le
Traitement de la Phtisie." Brussels, 1 894. — Petit, L.H.: "Hy-
giene des Sanatoria." Revue de la Tuberculose, December,
1894. — Otis, E. O. : "The Sanatorium or Closed Treatment of
Phthisis." New York Medical Journal, June 13, 1S96. — Tru-
deau, E. L. : "Sanatoria for the Treatment of Incipient Tuber-
culosis." Medical Record, February 13, 1897. — Walters, E.
R. : "Sanatoria for Consumptives." London, Sonnenschein &
Co., 1899. — IJowditch ; "Sanatoria in the Treatment of Tuber-
culosis." Medical News, October 14. 1S99.
' Knopf, S. A. : " Les Sanatoria, Traitement et Prophylaxie de
la Phtisie Pulmonaire." Paris, Carre et Naud, 1S95. 2nie edi-
tion, 1900. — ".Sanatoria for the Treatment and Prophylaxis of
Pulmonary Phthisis." New York Medical Journal, October 5
and 12, 1 8.);. Alvarenga Prize Essay, Phila., 1S9S.
enient and Safe Spittoon.
quiet a neighborhood as can be found, where there is
relatively little traffic. If the patient can reside in the
outskirts of the city on high, non-malarial ground, so
much the better. The largest, sunniest, quietest, and
best-ventilated rooms, preferably on the second floor,
so as to avoid the fatigue of climbing stairs, should be
selected for the patient. If the dwelling is a modern
apartment house with elevator, the top floor, of course,
would be the best of all for our purpose.
In the room mainly occupied by the invalid velvet
or plush covered furniture should be replaced by such
as will not accumulate dust. Raising dust by sweep-
ing with a broom should never be allowed in any sick-
room, but particularly not in one occupied by a pul-
monary invalid. A moist mop should be used to
remove the dust from the floor, and the furniture should
be wiped carefully. The carpet, heavy curtains, and
superfluous furniture should be removed, without, how-
ever, leaving the room cheerless. Small rugs and cur-
tains that can be washed may be retained.
A tuberculous patient should always sleep alone and
in a bed which should be freely aired during the day-
time. A very weak patient who does not lea\e the
bed should, whenever it is possible, have a second bed
placed in his room so as to be able to change. A
brass or iron bed, with wire mattress, is preferable.
Feather beds should not be used. The bed should be
placed with the head against an inside wall. Drafts
should be avoided as far as possible, but this precau-
tion must not be carried to extremes so as to make the
patient afraid of a breath of fresh air. If the bedroom
is too small to make it possible to place the bed so as
to avoid the direct draft from the open window, a sub-
stantial screen should be used as a protection.
Under the heading of general hygiene is comprised,
of course, sanitary plumbing, a sufficient supply of pure
cold and hot water, and for heating purposes an open
fireplace whenever practical. The patient should be
guarded against the unwholesome influence of the very
dry heat which comes from the furnace in the average
.American home. Some humidifying arrangement
(evaporating pan, Barnes humidifier, etc.), whereby the
air may be kept moderately moist, should be used.
Special Hygiene. — The special hygiene deals with
the careful disposal of the sputum and other secretions
which may contain the bacilli ; the care of the patient's
linen, and finally his clothing and manner of dress.
To an audience of physicians and sanitarians there
is no longer need to speak of the importance of the
precautions to be taken with the tfiberculous sputum,
and I shall confine myself simply to the description of
a few utensils which I think indispensable in a private
home, hospital, or even dispensary for consumptive
patients. They are to my mind the best means to stop
the propagation of tuberculosis through carelessly de-
posited tuberculous expectorations.
Here is an ordinary enamelled iron spittoon. To
make sure that the patient always hits it, I recommend
this simple stand which is elevated three feet from the
ground ( l"ig. 1 1. The cuspidor is supported by a metal
ring attached to the door of the cupboard. The patient
desiring to expectorate opens the little door, thus bring-
ing the spittoon within his reach, and closes it again
when he gets through. An automatically closing extra
cover makes it impossible for flies and other insects to
sojourn in the interior. With this arrangement there
is no excuse for not being able to hit tlie spittoon and
thus soiling the brim. The unpleasant appearance
of numerous spittoons placed on the floor, in places
where much expectoration is going on, makes the ele-
vated spittoon preferable from an aesthetic as well as
from a hygienic point of view. The cuspidor of metal,
elevated and covered, has additional advantages over
the usual uncovered vessel of porcelain or earthenware.
.Animals, such as dogs, cats, etc., will not be able to
January 27, 1900]
MEDICAL RECORD.
139
reach the contents of the cuspidor; and there is less
danger of its bursting when placed outdoors at freezing
temperature if covered and enclosed in a box. Again,
I prefer metal spit-
toons to glass or por-
celain, because the
persons entrusted
with cleaning them
are not exposed to the
possible danger of
inoculation by break-
age.
For a patient con-
fined permanently to
his bed I think this
plain aluminum cup
with cover answers
all practical purposes.
'""'"""BcdJKk.""' '"'"""" '" It is light and easily
cleaned (Fig. 2 ). It
has the additional advantage of not having the typical
aspect of a spittoon. This as well as all other sta-
tionary cuspidors should be filled to about one-third
with some antiseptic solution, preferably wood vin-
egar. For those who can conveniently destroy the
sputum by fire, Seabury &: Johnson's well-known
paper spitting cup is a handy and useful utensil.
I take pleasure in showing it to you in its new form
with an aluminum frame and cover (Figs. 3, 4). Pa-
tients who are too weak even to make use of this
light aluminum cup should have at their bedside a
number of moist rags, which should be burned imme-
Fig. 3.— Frame. Fig. 4.— Folded Cardboard.
Seabury & Johnson's Spitting-Cup.
diately after use, or at least before they have had a
chance to dry. For the patients who are up and
around and who go outdoors the pocket flask is the only
rational utensil to receive the expectoration. There
exist a number of them. I have described the cele-
brated Dettweiler pocket flask (Fig. 5) and also my
own (Fig. 6) on several occasions before this. I have
given detailed descriptions and illustrations of these
and others in my recent book on tuberculosis,' and I
fear to trespass on your time to say any more about
them. I show these two to you, and confess frankly I
consider neither of them perfect. I hope some day to
be able to present you an ideal pocket flask, but I think
that either of these will answer the purpose in the
mean time.
To encourage the use of the pocket tiask one must
make its manipulation and the process of cleaning it
as simple as possible. I direct my patients to empty
the flask into the water-closet or to fold a newspaper
into several layers, pour the contents on to this, and
throw the whole at once into the fire, being careful not
to spill any. One should, however, not forget to insist
that the patient washes his hands carefully afterward.
' Knopf, S. .\. : ' ' Pulmonary Tuberculosis, Its Modern Prophy-
laxis and the Treatment in Special Institutions and at Home. "
Philadelphia: P. Blakiston's Son & Co., i8r,g.
Larger quantities of tuberculous sputum, collected
from the spittoons, should be gathered in a separate
pot partially filled with water and the whole be boiled
for half an hour. To increase the boiling-point a few
degrees, ateaspoonful of soda might be advantageously
added for each quart of liquid.
Some consumptive individuals will not use the
pocket flask in spite of all persuasion, for the simple
reason that they do not wish to attract attention to
their malady. For these there is but one thing to
do— to tell them to use squares of muslin or Japanese
paper handkerchiefs specially manufactured for that
purpose, which can be burned after use. IJut I should
insist that they place in their pockets a removable lin-
ing of rubber or other imperme-
able substance which can be
thoroughly cleaned. This addi-
tional pocket could be fastened
to the inside of the ordinary poc-
ket by clamps, and thus be of no
inconvenience to the patient. Of
course, all individuals using
handkerchiefs as receptacles for
sputum take their chances of in-
fection through contact with the
expectoration, and they should be
particularly enjoined never to
touch any food without having
thoroughly washed their hands.
The soiled linen of consump-
tive patients should be placed in
water immediately after removal
from bed or body, and be handled
as little as possible before that.
^ 1 lu. 5, — jLT. jjettweiier s
The handkerchiefs especially, Hustenflaschchen.
even if they have not been used
to receive expectoration, should be washed separately
or at least boiled before being given to the general
laundry.
In the private home, with loving friends and rela-
tives about the patient, everybody should be told that
kissing on the mouth is unhygienic. The saliva of
tuberculous invalids is certainly not free from bacilli.
If the patient cannot have his own table utensils, as
forks, spoons, glasses, etc., it is well for the physician
to insist that all these utensils shall be placed in boil-
ing water for a few minutes each time after use. In
view of the undeniable fact that during the dry cough,
or while speaking loudly, small particles of tubercu-
lous sputum or saliva can be expelled, the patient
should be taught to place a liandkerchief before his
mouth during the dry cough. The danger of infection
from these small particles of saliva expelled while
Fig. 7. — Talien apan
Knopf's Pocket Sputum Flask.
talking is, however, relatively small, since the num-
ber of bacilli found in the minute drops of saliva are
few, and the little masses are never expelled beyond
three feet from the mouth of the patient.
140
MEDICAL RECORD.
[January 27, 1900
In hospitals where many advanced consumptives
congregate, the precaution to have the patient wear
Professor Fraenkel's mouth mask is doubtless of utility
and constitutes justly one of the modern measures to
prevent the spread of tuberculosis. I take pleasure
Moiith-JIask.
in showing you here such a mask, the mechanism of
which is easily understood. At the Charity Hospital
in Berlin all tuberculous patients are obliged to wear
such masks when in the common room, and only re-
move them while eating or expectorating. The pa-
tients soon become accustomed to the mask, as by
impregnating the gauze, which is held in place by the
metallic frame, with some medicinal substance they
suppose it is to be worn exclusively for their own per-
sonal benefit. Bacilli are not infrequently found in
the gauze. It is, of course, self-understood that the
gauze, lint, or cotton removed from these respiratory
masks should be burned immediately, and the masks
disinfected at regular intervals.
I hardly think that in ordinary private cases the
wearing of such a mask is practical or absolutely nec-
essary; but I would instruct nurses, relatives, and
friends who are much with the patient not to approach
him unnecessarily close while he is speaking or
coughing, or for any lengtli of time.
As far as dress for the tuberculous invalid is con-
cerned, we might summarize the whole subject by say-
ing that he should dress sensibly, comfortably, and
according to the season. He should avoid heaping
successive layers of underclothing upon himself, espe-
cially in the line of chest-protectors. As underwear,
Jaeger's or other similar sanitary wool suits of the
lighter or heavier grade, according to the .season, are
to be recommended. In cold weather the outer gar-
ment should be warm, but not so heavy as to hamper
free movements. For ladies I recommend the Lady
Habberton or Jenness Miller system of dress reform,
vfhich does away with the corset and the numerous
skirts fastened tightly around the waist, and, last but
not least, the unclean and unhygienic mode of long
trailing dresses. The footwear of all phthisical pa-
tients should be warm, but never tight, and in wet
weather, of course, they should wear rubbers. As a
matter of personal hygieiie I might suggest that long
beards or thick untrimmed mustaches are often retain-
ers of particles of sputum and thus may constitute a
source of infection. Whether we may allow our pa-
tient occasionally a cigar will depend upon the indi-
vidual case. I never permit the smoking of cigarettes,
and, of course, it is out of question to allow smoking
in the sick-room.
Dietetic Treatment — We now come to the patient's
diet. My distinguished teacher in modern phthisio-
therapeutics, Herr Geheimratii Dettweiler, is in the
habit of saying, " La cuisine est ma pharniacie." This
maxim is as appropriate for the private practitioners
who treat consumptives as it is for the sanatorium phy-
sician. When we have to treat our patient at his own
home we must not only have a good table for him, but
our cooking-recipes and directions concerning his diet
must be carried out as faithfully as if we had pre-
scribed a medicinal mixture. A fair understanding of
how to prepare good nutritious and easily assimilated
food for invalids is indispensable to every physician,
but especially so to the phthisio-therapeulist. I hope
the time is not far distant when instructions in the
principles of cooking for the sick will te included in
the curriculum of our medical schools. We all know
the importance of dietetic treatment in pulmonary
tuberculosis, but we are not always aware of the diiifi-
culties which we encounter when the patient is in his
own home and has something to say about the daily
menu. His aversion to fats, his not infrequent dislike
to take larger quantities of milk, or other caprices re-
garding the preparation of food or the time of taking
his meals, are matters which must be overcome; other-
wise the successful treatment of a consumptive at heme
is an illusion. Certain conditions of anorexia will
often yield more rapidly through the aid of the culinary
art than through the administration of pharmaceutical
preparations. While we may consider the patient's
idiosyncrasies for certain dishes as well as for certain
medicines, we must know how to distinguish idiosjn-
crasies from caprices. One important truth that he
should be made to understand is, that his digestive
powers are far greater than his appetite indicates.
I will give here briefly what I consider an average
re'ginie for a consumptive accustomed to our American
way of living. As soon as the patient awakes in the
morning, while yet in bed, a glass of hot milk, half
milk and tea, or half coffee and milk, with a slice of
milk-toast, should be given him. After a little while
he will rise to prepare for his douche, friction, or
massage, whatever the physician's prescription may
call for. After this it will probably be nine o'clock,
and the patient may take his ordinary breakfast. He
should have eggs, and may have his choice as to the
way they may be cooked — soft-boiled, poached, raw,
etc., or in form of eggnog, witli sherry or one or two
teaspoonfuls of whiskey. If he is accustomed to a
meat breakfast, he should have broiled steak, chops,
poultry, sweetbreads, etc., or raw chopped beef. Bread
a day old — preferably whole-wheat bread or French
rolls, but not hot — with plenty of butter or honey,
either milk, cacao, coflee with milk, but not too strong,
or a cup of bouillon, should also form part of the meal.
Whether the patient likes to iiave his mush (cereals)
for breakfast or supper may be left to his choice; some
fruit should always precede his eggs or meat in the
morning. If fish is served in the morning it should
be either broiled, or boiled, or baked.
The patient should take the heartiest meal between
the hours of twelve and two o'clock (four hours after
breakfast). Broths or soups should be the first course.
Oysters and clams are most easily digested raw. Any
kind of fresh fish may be served again at dinner, and
in any form except fried; and there will be, of course,
roast meat of some kind, rare roast beef, mutton, poul-
try, etc. Of vegetables, spinach is particularly to be
recommended on account of the large proportion of
digestible and assimilable iron. Next to this in nutri-
tive power come lentils, peas, beans, cauliflower, pota-
toes. Fresh vegetables should be given whenever it is
possible to have them. Lettuce and other salads pref-
erably prepared with lemon-juice instead of witli vine-
gar, are permitted. Light puddings, fruits, and nuts
may constitute the dessert.
At about four or five o^clock .some milk with toast
may be taken, or, if the patient cares for it, he should
have a cheese or meat sandwich. At tliis time the
milk may be replaced by bouillon or chocolate.
The supper should not be quite so voluminous as
the dinner: cold or warm meats, rice with milk or
gruel, jellies, fruits, etc. At bed-time again a glass
of milk or some milk-toast.
January 27, 1900]
MEDICAL RECORD.
141
It is, of course, impossible to lay down an absolute
rule of what to allow and what not to allow. At times
the patient may be permitted to indulge in such things
as ham, smoked tongue, and even pickled or salt her-
ring, sardines, or sardelles, as these articles seem to
stimulate the appetite without producing any bad re-
sults. All bouillons and soups taken regularly at the
principal meals aid the digestion by increasing the
flow of the gastric secretions. Raw scraped beef is a
most valuable ad'uvant in the feeding of tuberculous
invalids. It is always indicated, but especially when
meats prepared in the ordinary way do not seem to be
digested very easily. The supply of meat-pulp for
the day may be made in the morning, but it must be
kept in a cold place, as it taints easily. It is better,
when possible, however, to make it fresh just before it
is to be eaten. The patient may take the pulp in any
way he pleases. It can be eaten plain with pepper
and salt, mixed with milk, with warm bouillon, with
mashed vegetables, or with sweets. The latter method
will make it tempting for children. It can be rolled
into balls easy to swallow, or made into sandwiches
with a few anchovies or a little anchovy paste, pickled
herring, or some other relish, according to the patient's
taste. The yolk of a raw egg added increases the nu-
tritive quality of the meat-pulp. Thus it will be seen
that the ways in which the raw meat may be taken are
so numerous that it can be made palatable to almost
any patient.
To eat a great deal of butter and cream is especially
to be recommended to pulmonary invalids, and milk
should be allowed at any time without restriction.
However, some patients, in their eagerness to get fat,
overdo in this respect. \^'hen drinking numerous
glasses of milk between meals interferes with the
proper appetite at meal-times, the number of glasses
should be reduced accord-
ingly. Again, neither milk
nor cream agrees well with
some consumptives. To
make the former more digest-
ible, one may add to each
wineglassful one-half or one
teaspoonful of cognac,
kirsch, or rum, with or with-
out hot water. Milk may
also be rendered more di-
gestible by adding to each
tumblerful about six grains
of bicarbonate of sodium and
five grains of common salt,
dissolved in two tablespoon-
fuls of hot water. It should
always be taken slowly and
in small swallows.
Patients should be taught
to eat regularly, slowly, chew
their food well, and keep
their teeth in good condi-
tion. When the weather
permits, let them take their
meals outdoors. A patient
who has fever should eat
when his temperature is
lowest, and only the most
easily digested substances.
Alcohol is indispensable in some cases, but it should
always be dealt out carefully and preferably in the
diluted form of eggnog, wine, or beer.
Open-Air Treatment. — The open-air treatment, that
is to say, remaining in the open air during most of the
day, is essential if we wish to make our hygienic and
dietetic treatment at the home of the patient a success.
The patient's bedroom is, of course, always airy, and
day and night one or more windows, according to the
season, should remain open. Deep breathing is done
as often as the patient thinks of it; regular respiratory
exercises every half-hour or iiour; these exercises
should be taught gradually, and as often as it is possi-
ble they should be superintended by the physician.
A good rule is to tell the patients never to take their
exercises when they feel tired, nor to the extent of
becoming tired.
The rest cure (or " Liegekur '') on the reclining-chair
is the most important feature of the open-air treatment.
For that purpose the patient may install himself in the
garden near the house, on the porch, on the balcony,
roof, or fire-escape, or near the open window. For
those who have the advantage of a garden, an installa-
tion, of which I show you here a picture taken from
my book, might make an ideal rest-cure arrangement.
A large beach-chair of wicker-work, such as is seen in
seaside resorts, is procured. After the seat has been
removed the inner walls are lined with padding. A
reclining-chair is placed with its back in the interior,
and the whole arranged so that the patient is protected
from the wind and sun. There the patient installs
himself for the day, with his books or writing mate-
rials at his side, placed on a little table, on which his
meals may also be served. Being light, the whole can
be shifted whenever the wind changes and according
to the position of the sun, so that the invalid's body
may be bathed by the rays of the sun, while the head
remains in the shade. However, a plain steamer-
chair, padded with a quilt or blanket, and a large um-
brella will answer the purpose where such an installa-
tion cannot be arranged.
The length of time to remain on the reclining-chair
outdoors must be regulated by the physician according
to the weather and the condition of the patient. But
the endurance at which the patient can arrive in this
respect by gradual training is simply wonderful, and
cold weather, when the patients are warmly wrapped
up, should certainly not be a hindrance to a prolonged
rest cure.
On the question as to whether or not we should al-
low our phthisical patients walking-exercises, even if
they have fever, all phthisio-therapeutists do not agree.
Let me state here briefly the position I take in this
matter, which I have published before, and to which I
142
MEDICAL RECORD.
[January 27, 1900
still adhere. Rest cure should alternate with walking-
exercises. The duration of a promenade for a phthis-
ical patient should be regulated with the utmost care.
One should commence with a walk of a few minutes
until a walk of an hour or an hour and a half can be
taken without producing fatigue. Whenever it is prac-
ticable these excursions should begin uphill, so that
the return is easy. After his promenade the patient's
temperature should be taken. If it exceeds the normal
it is an indication that the patient has overtaxed his
powers. Whether complete rest or simply shorter
walks are then indicated will be decided by the varia-
tion of the temperature before and after exercise.
When the temperature of the patient rises only slightly
in the evening (99-99.5° F.), short walks in the morn-
ing, while in the apyretic state, may be permitted. A
lasting temperature of 100° F. or over is an absolute
contraindication to exercise. Tachycardia should
also be considered as such. If there is, however, a
chronic tachycardic condition, absolute rest might not
be the best policy. But these patients, more than any
others, should be warned against the slightest over-
exertion. When the patient is ambulant, and you have
a pneumatic cabinet in your office, a daily seance of
from five to eight minutes will be a considerable aid
in your efforts to make a partially solidified lung do
its normal work again, for there is no doubt about the
therapeutic value of this useful instrument. It has
rendered me excellent services with the patients who
could come to my office. My time will not permit me
to speak here at length of the virtue of the pneumatic
cabinet as a diminisher of vascular compression, alve-
olar and tubular obstruction, and a restorer of oxygena-
tion. Those who are interested in the study of this
subject I must refer to the excellent article of Quimby,
"The Pneumatic Cabinet in the Treatment of Pul-
monary Tuberculosis," which appeared in the Interna-
tional Aledual Magazine for January, 1893.
Hydrotherapy. — The consumptive patients whom
we are to treat at home will probably all have a bath-
room where we can arrange to give a general douche
as a tonic, a jet over the apices for the purpose of caus-
ing a revulsion, or a lateral douche in order to break
up old pleuritic adhesions. In case there is no bath-
room, or the visit to the douche-room is either incon-
venient or not safe, I resort to the following simple
method: A wooden chair is placed in a large, circu-
lar, English bath-tub, and the patient sits astride the
chair, holding the back with his hands and bending
his head slightly forward. Then two, four, or more
pitchers of cold or tempered water are rapidly poured
over the shoulders. In cases in which the reaction is
feeble the patient is quickly put back into his warm
bed, even if he is not thoroughly dry.
The best time to make the hydrotherapeutic appli-
cation is in the morning, half an hour or so after a
very light breakfast. Patients accustomed to heavy
breakfasts should, as I have already mentioned, take
such after their douche and morning walk, but should
take a glass of milk with a slice of buttered toast be-
fore leaving their room. A morning walk should, if
possible, always precede the douche. This is for the
purpose of creating what French hydrotherapeutists
call a preaction.
Every douche or affusion should also be followed
by a short walk or return to bed, according to the in-
dication of the case. The cold douche must never last
longer than twenty to twenty-five seconds, and one
should always begin gradually, not giving more than
five seconds at first. The temperature may vary from
60° to 40° F. ; only in exceptional cases would one
need a more precise graduation of the temperature.
The complicated procedure of the dripping sheet
seems to entail too great a strain on the patient, and
I do not favor it in phthisio-therapeutics. Wet packs,
on the contrary, over the thorax seem to exert a sooth-
ing influence whenever there are pleuritic or intercos-
tal pains, or a vague or undetermined feeling of dis-
comfort in the chest.
All hydrotherapeutic applications should be di-
rected by the physician. He must educate the skin
and nervous system of his patient to the use of the
douche by the gradual application of the water through
friction and affusion. He must teach his patient how
to take an occasional warm or stiam bath to eliminate
the toxins without taking cold afterward.
Constant Medical Supervision. — The good results
in sanatoria are to be ascribed to the constant medical
supervision of the patient by the physician in charge,
or his assistants, who direct all the details of the hy-
gienic, dietetic, and symptomatic treatment. We must
do the same if we want to institute a sanatorium at
home. But there are a few points in the ed'-.^ational
treatment of consumptives in which the family physi-
cian has the advantage over the sanatorium physician.
The former can make his authority felt whenever there
is a question of marriage. I admit that the families
will not always listen to such advice; still I claim that
in many instances marriage between tuberculous indi-
viduals could be prevented by an energetic protest on
the part of the family physician. Another important
issue, which will present itself more frequently to the
family physician than to any one else, is the question
of prevention of conception when either one of the
married partners suffers from pulmonary tuberculosis.
I have no hesitation to declare publicly my position
in this matter. To cut short a conception in a tuber-
culous mother is useless; she has a better chance of
getting well if left alone, and if a thorough dietetic
and hygienic treatment is immediately instituted and
prolonged for at least a year after confinement. Of
course, it goes without saying that the tuberculous
mother is not to nurse the child herself. Thus through
a very judicious management two lives have a chance
to be spared, while through abortive proceedings
mother and child would most likely have succumbed.
On the other hand, when it comes to the prevention of
conception in a tuberculous woman, or from a tuber-
culous man, I believe it is the sacred duty of the fam-
ily physician to teach these people legitimate means
that they may not bring into life a being tainted with
a predisposition to this disease. Furthermore, there
is no doubt that the pregnant state in a tuberculous
woman, while it may temporarily arrest the disease,
causes in the majority of cases a more rapid decline
after confinement. In view of our present knowledge
of tuberculosis I do believe that to teach a tuberculous
man or woman how to prevent conception is not a sin
before either God or man.
The symptomatic treatment of pulmonary tubercu-
losis must be the same everywhere, and I have nothing
new to offer. But I desire to say one more word in
regard to the prophylactic treatment, which I admit I
have also said on previous occasions, but which I like
to repeat again and again.
The treatment of tuberculosis in the private home
by the family physician should be prophylactic in the
broadest sense of the word. It is the family physi-
cian who will see the incipient cases first; it is he who
will discover a predisposition to phthisis when a wise
and judicious treatment will save the patient. The
intimate relation which exists between the family phy-
sician and all the members of the family give him
here again the superiority over the sanatorium physi-
cian. The latter can help only the patient placed un-
der his caie, while the family physician can at the
same time prevent the breaking out of tuberculosis
among the other members of the family.
-After all that has been said you will agree with me
that the sanatorium treatment is feasible even in the
January 27, 1900]
MEDICAL RECORD.
H3
average home, provided the patient's social and finan-
cial conditions permit the carrying out of a rigorous
hygienic and dietetic regimen under the careful guid-
ance of the family physician. But with the vast
majority of tuberculous patients, and this majority
constitutes the consumptive poor, to carry out success-
fully the precepts of modern phthisio-ther; py without
special institutions supported by the State or munici-
pality, or private philanthropy, is utterly impossible.
Thus you will pardon me if I conclude my paper with
a fervent plea for a decided action on part of this so-
ciety in the matter of the creation of public sanatoria
— that is to say, institution for that class of sufferers
who deserve the greatest sympathy, and through whose
hospitalization the public health will gain most and
the commonwealth be morally and financially benefited.
It was in our great State of New York, through the
efficient and energetic work of my esteemed teacher,
Professor Bryant, then health commissioner, and who
now graces our presidential chair, that the combat
against bovine tuberculosis was first taken up. The
work of the New York City board of health, concern-
ing the prophylaxis of tuberculosis in man, inaugurated
a few years ago, has won the universal admiration of
sanitarians in this country and abroad. But of late
we have not kept pace with even our sister States, much
less with foreign countries. Pennsylvania and Illinois
have a society for the prevention of tuberculosis, with
growing funds for the erection of sanatoria. Massa-
chusetts has its State Hospital for Consumptives.
New York, the most densely populated and richest
State in the Union, with the greatest number of con-
sumptive poor, has neither a society for the prevention
of tuberculosis, nor a sanatorium, nor a State hospital.
May the New York State Medical Association, in its
last meeting in the nineteenth century, not adjourn
without taking some active step in this important
matter.
A CRITICISM UPON A NEW METHOD OF
PREPARING THE SKIN FOR VACCINA-
TION BY DENUDATION WITH CAUSTIC
POTASH SOLUTION.
By frank S. fielder, M.D.,
V, CORNELL UNIVEKSITV MEDICAL
ORK CITY HEALTH DEPARTMENT.
In a paper published April 2.3, 1898, in the /o urn (j/ of
the American Medical Association, Dr. Hutchins, of
Georgia, recommended a new method of preparing the
skin for vaccination by denudation with caustic potash
as a substitute for scarification by the usual methods.
The advantages which Hutchins claims for his method
are, that it is painless; that it is not terrifying to the
child because no instrument is used; that it causes no
bleeding, and is for this reason more likely to be suc-
cessful than when an instrument is used which draws
blood.
Hutchins at first used the officinal liquor potass^
(a five-per-cent. solution of KOH in water), soaking a
small pledget of absorbent cotton in the solution, let-
ting it lie upon the arm for two or three minutes until
the skin was denuded of epidermis, then wiping the
surface with another piece of absorbent cotton damp-
ened with water. Later he used the deliquescing
stick of KOH, applying it to the surface for a moment
only, and immediately wiping ofi: the denuded area as
before.
The experiments upon which this paper is based
were performed by the writer in October, 1898. The
cases vaccinated were all " primaries," i.e., they had
never been vaccinated before, and were twenty-two in
number. The virus employed was in each instance
controlled by using it upon other cases by the ordinary
method of needle scarification. Different strengths of
KOH solution were used, but none so weak as the
officinal liquor potassse.
These experiments are described in detail as follows :
Experiment i. — October 4, 1898. Virus No. 510,
collected September 20, 1898.
Control, October 4, 1898: One case vaccinated in
three spots by needle scarification. Result, six days
after vaccination : three good-quality, large, compound
vesicles on large papules.
Experiment: Five children vaccinated in one spot
each by denudation with KOH, as follows: Deli-
quesced KOH applied with a very small swab, made
by rolling a bit of absorbent cotton around the end of
a wooden toothpick. After it was evident that the
epidermis was dissolved the denuded surface was
wiped off with a swab of absorbent cotton dampened
with water.
Appearance after denudation : In each case the
denuded spot was slightly depressed and covered with
a bluish or bluish-red eschar of a peculiar parchment-
like appearance. No blood flowed.
Upon these areas glycerinated vaccine virus was
smeared, then thoroughly worked in with the sharp
corner of the broad end of an orange-wood toothpick,
just as is done after scarification by the usual method.
Results, six days after vaccination: Case i, good
quality and size compound vesicle on papule; large
dry scab from eschar. Case 2, small vesicle one-eighth
inch in diameter at one edge of dry scab from eschar.
Case 3, failed. Case 4, good quality and size com-
pound vesicle on papule; moderate-sized dry scab.
Case 5, good quality and size vesico-pustule on papule ;
moderate-sized dry scab (this case inspected at seven
days). We thus obtained from five insertions four vesi-
cles, three good and one very small, and one failure.
Experiment 2. — October 10, 1898. Virus No. 525,
collected October 5, 1898.
Control, October 6, 1898: Five children vacci-
nated in three spots each by needle scarification.
Result, five days after vaccination : Fifteen vesicles
of good size and quality.
Experiment ; Five children, vaccinated in one spot
each with deliquesced KOH, as before; the spots then
were washed off with dilute acetic acid to neutralize the
KOH and stop further destruction of tissue if possible.
Appearance after denudation : Same as in Experi-
ment I.
Results, five days after vaccination: Case i, good
compound vesicle on papule; moderate dry scab, not
depressed. Case 2, good compound vesicle on papule ;
moderate dry scar, not depressed. Case 3, failed (in-
spected again eight days after vaccination. No ves-
icle resulted). Case 4, good compound vesicle on
papule; moderate dry depressed scab. Case 5, good
compound vesicle on big papule; moderate dry de-
pressed scab. We thus obtained from five insertions
four good vesicles and one failure.
Experiment 3. — October 10, 1898. Virus No. 526,
collected October 6, 1898.
Control, October 7, 1898 : Six cases in three spots
each by needle scarification. Result, five days after
vaccination: Eighteen vesicles, as follows: nine of
good quality and size; six of fairly good quality, fair
size; three of good quality, fair size.
Experiment : Two children vaccinated in two spots
each, one with needle as usual (A) and one with KOH
solution, followed by acetic acid, as in Experiment 2,
the KOH solution being somewhai: weaker than in
Experiment 2 (B).
Appearance after denudation of (B) spots: Same
as in Experiments i and 2.
144
MEDICAL RECORD.
[January 27, 1900
Results:
Case ]
Case:
A {Needle Scarification).
Small compound i
cle on papule.
Small compound ^
cle on papule.
Fair compound pus-
tule, moderate areola.
Fair compound pus-
tule, moderate areola.
Failure .
Failure .
Eight
Days afte
Failuri
Failun
We thus obtained : A (needle scarification) , two fair
vesicles; B (KOH denudation), two complete failures.
Experiment 4. — October 22, 1898. Virus No. 529,
collected October 20, 1898.
Control, October 20, 1898: Five cases in three
spots each by needle ■scarification. Result, five and
six days after vaccination : Fifteen vesicles, fourteen
of good quality and size, one of fair quality and size.
Experiment: Five children vaccinated in two spots
each (A and B) as in Experiment 3, except that KOH
solution was somewhat weaker than in Experiment 3,
though still strong.
Appearance after denudation of (B) spots: Same
as in Experiments 1,2, and 3, except that eschars were
perhaps not so thick.
Results, five days after vaccination:
A (Needle Scarification).
E (KOH Denudation).
Case I.
Fairly good quality and size,
Failure (seen also at thirteen days,
compound vesicle on papule.
failure).
Case 2.
Good quality, fair size, compound
Good quality but only just begin-
vesicle on papule.
ning coalescing, vesicle on pap-
ule. Scab larger than on (A),
and depressed.
Case 3.
Fine quality, large compound
vesicle on papule.
Only fair quality and size, coal-
escing vesicle on papule. Scab
larger than on (A).
Case 4.
Good quality and size, com-
Good quality and size, compound
pound vesicle on papule.
vesicle on papule. Scab larger
than on (A).
Good quality and size, coalescing
Case 5.
Good quality and size, com-
pound vesicle on papule.
vesicle on papule. Scab dry and
depressed.
We thus obtained : (A), five vesicles — three good,
one fairly good, and one fine large; (B), four vesicles
— -one small beginning coalescing, one only fair coales-
cing, one good compound, one good coalescing, and
one failure. The virus is evidently not so active in
(B) cases as in (A) cases.
Experiment 5. — October 31, 1898. Virus No. 534,
collected October 27, 1898.
Control, October 28 and 29, 1898 : Five cases vac-
cinated in three spots each by needle scarification.
Result, seven days after vaccination : All the cases
"took," but only thirteen vesicles were obtained — six
good, six fair, one poor. This was the original test of
this virus and showed it to be distinctly below the
standard in quality.
Experiment: Five children vaccinated in two spots
each (A and B) as in Experiments 3 and 4, except tliat
successively weaker solutions of KOH were used and
that after the application of the acetic acid the surface
was washed with water and then dried.
Appearance after denudation is noted under each
case.
Results, seven days after vaccination:
r.ood quality and size, co
pound vesicle on papule
B (KOH Denudation).
LKOH solu
ments 3 i
dation s
i.]
eaker than in E.xperi-
Surface after denu-
LS in former experi-
Small beginning vesico-pustule around
edge of depressed eschar.
[KOH solution weaker than in Case i.
Surface after denudation a little more
red around edges.]
Good quality and size, compound vesi-
cle on papule. Vesicle is even larger
and better quality than in (A).
A (Needle Scarification).
B (KOH Denudation).
Case 3.
Good quahty and size, com-
[KOH solution still weaker than in
pound vesicle on papule.
Case 2. Surface after dt-nudation
reddish, also more red in centre.]
Rather poor quality, small single vesi-
cle on papule.
Case 4.
Good quality, fair size, com-
[KOH solution same strength as in
pound v ^sicle on papule.
Case 3. Surface after denudation
reddish.].
Good quality, fair size, compound vesi-
cle on papule.
Case 5.
Good quality and size, com-
[KOH solution same strength as in
pound vesicle on papule.
Cases 3 and 4 Surface after denu-
dation bluish and parchment-like, as
in experiments with stronger solu-
tions.]
Good quality and size, compound vesi-
cle on papule, but not quite so good
as (A).
We thus obtained: (A), five vesicles — four good
quality and size, one good quality and fair size; (B),
five vesicles — one small beginning, two good quality
and size, one good quality and fair size, one rather
small and poor quality.
Note, made at time of inspection of these cases:
" In all this lot, the vesicles seven days after vaccina-
tion looked as they usually do six days after vacci-
nation. The less vigorous denudation with a weaker
solution of KOH seems to result in vesicles more like
those of usual method of scarification with needle.
The vesicles are of better quality, with smaller eschars
and less depression than when the stronger solutions
of KOH are used."
A study of the cases in detail, however, not only in
this experiment but in those which preceded it, shows
that in almost all the cases in which vaccination by
the (A) and (B) methods have both been successful the
(A) vesicles were of better quality and size than
the (B) vesicles.
Summary of results of all the experiments:
I- ^
Character op Vesicles Obtained.
II
Good.
7 (7o«)
3 (25«)
Fairly
Good.
Fair.
P-Oor.
8
9
17
CI, to
KOH denudations:
KOH alone
KOH (on same arm
with needle scari-
fication).
I (16.67?)
I (8 33!«)
I do?)
3 (25!0
80.
75-
10 (45.4S:<)
8 (66.67?)
= (9-"«
2 (.6.67)
t (4-S4:<)
2(16.66?)
4 (18.18?)
77- =7
Needle scarifications:
(On same arm with
KOH denuda-
tion).
From these results it appears that vaccination per-
formed by denudation with solutions of KOH is less
likely to be successful than when performed by needle
scarification. This fact the writer believes to be due
to the formation of an eschar by the KOH which makes
the surface denuded resemble parchment. This coag-
ulation of the albuminous elements of the tissues closes
the mouths of vessels and lymphatics, and renders the
entrance of the vaccine organism and its absorption
difficult. This action of KOH solutions upon the
skin was studied, at the writer's request, by Dr. Anna
L. Williams, one of the bacteriologists of the New
York City health department. After application of
the KOH to the skin upon the abdomen of a calf, sec-
tions of the skin through the denuded area were cut
out and examined microscopically.
A summary of Dr. Williams' report is as follows:
" I. Epidermis completely destroyed, as also some
parts of true skin.
"2. The lower parts of the hair bulbs remain; also
lower parts of sweat and sebaceous glands.
"3. The remaining portion of the skin is covered
with a layer of necrosed tissue, which takes a deep
blue stain, and its structure is indistinguishable. This
January 27, 1900]
MEDICAL RECORD.
145
layer is about as thick as the epidermis and penetrates
irregularly into the true skin.
" Conclusion : There may be an obstacle to the
entrance of the vaccine organism either in the pres-
ence of the necrosed tissue or in the alkalinity of it."
The writer's conclusions as the result of these exper-
iments are as follows: It is possible that a person of
great skill and experience in the use of this method
of KOH denudation would learn to apply the caustic
potash in such a way as not to produce an eschar
thick enough to prevent success; but the well-known
local effect of KOH upon the skin makes it evident
that some cauterization cannot be avoided, and that
in so far as an eschar results the entrance of the vac-
cine organism will be interfered with.
The denudation method is slower than scarification,
and if acetic acid is used to neutralize the KOH, the
method is not less painful, as the acid causes a marked
smarting effect. The use of the acid, however, might
be omitted, as it did not appear in any of these experi-
ments to diminish the tendency to the formation of an
eschar.
Very active virus, such as is issued by the New
York City health department, will give vesicles of too
large size unless the scarified area be very small, not
more than one-eighth of an inch square. It is difficult
to denude so small an area with a liquid application.
The KOH method is naturally less terrifying to the
child than the use of any sharp instrument. It is less
painful if acetic acid is not used, and so far as the
drawing of blood is concerned, it also has an advan-
tage over scarification. It is, however, the opinion of
the writer, and he believes this will be supported by
the opinions of vaccinators of large experience, that
no ordinary blood flow interferes with the "taking'' of
good virus thoroughly rubbed or scratched in. It is,
of course, better for cosmetic reasons not to draw
blood, and it must be admitted that it is difficult to
avoid doing so by the usual methods of scarification,
but it is a mistake to think that a little flow of blood
will endanger the success of the vaccination.
To summarize these conclusions, then, the advan-
tages of the KOH denudation are: (i) It is less
painful and less terrifying ; (2 ) it does not draw blood.
The disadvantages are: (i) It takes more time.
(2) It requires more skill. (3) It is difficult by this
method to denude an area small enough; the vesicles
are likely to be too large if the virus is very active.
(4) It is less certain than scarification, no matter how
skilfully done, because of the formation of an eschar
which interferes with absorption.
Finally, the writer believes that the disadvantages
named, together with the fact that a rather elaborate
equipment is required, make the KOH method imprac-
ticable for use in wholesale vaccinations such as are
performed by public vaccinators. As to its value in
private practice, if it be deemed important in any par-
ticular case, such as that of a very nervous child, to
avoid terrifying him, or to spare him the slight pain
caused by scarification, this method may very well be
tried; but unless the physician is skilled in the use of
the method, or unless the virus is so active that.it will
"take" no matter how it is applied, he must not be
surprised if failure is the result.
The Diplobacillary Conjunctivitis of Morax. —
Auguste Collomb found the diplobacillus in about
three-fifths of the cases of conjunctivitis and blepharo-
conjunctivitis, whether acute, subacute, or chronic,
■which he examined, or from six to ten per cent. This
was during several months when he was able to make
complete and satisfactory examinations. Under other
circumstances the cases represented about four per cent,
of the patients examined.' — Revue Altdkale de la Suisse
Jiomande, December 20, 1899.
The Semeiological Value of Laughter. — J. M.
Raulier analyzes laughter as expressed in pathological
and patho-psychiatric conditions and in psychoses. —
Arc/lives Gcnc'rales de Aledeciiie, December, 1899.
Eruptions Caused by Picric Acid. — H. Cathelineau
gives a description of affections of nails and epidermis
due to picric acid used in the arts or medicinally.- —
Anhhcs Ghierales de Mcdecine, December, 1899.
Typhoid Fever and Pregnancy. — De Grandmaison
reports a case in which the typhoid infection caused
an abortion which then reacted upon the fever with a
fatal result. — Archives Gene rales de Mcdecine, Decern
ber, 1899.
Fatal Hemorrhage during the Course of Chronic
Gastritis. — M. Pehu reports a case, and concludes
that the hemorrhage of the exulceratio simplex is the
result of a vascular lesion independent of small sub-
mucous abscesses; that the exulceratio simplex cannot
be considered as the first stage of Cruveilhier's simple
ulcer, for in the case reported the hemorrhage was ap-
parently the result of a diffuse general gastritis, with-
out ulcer, the process involving the blood-vessels.
The patient was an alcoholic who had suffered for ten
years from gastric symptoms resembling those of ulcer.
— Archives Generales de Mi'decine, December, 1899.
Sensory Aphasia. — Dr. Touche performed autop-
sies upon nine patients who had suffered from sensory
aphasia. In one case the affections interfering with
speech were to be attributed to the interruption of com-
munication between the various speech centres rather
than to lesions of the centres themselves. In another
the speech area was affected only in ils inferior por-
tion. In a third a slight subcortical softening near
the second temporal convolution produced verbal deaf-
ness and jargon aphasia. Lesions of the second parietal
and part of the ascending parietal existed in subjects
who had apparently been cured of aphasia. — Archives
Generales de Medecine, December, 1899.
Infectious Diseases. — Jules Renault has pursued a
series of researches into the phenomena known as ag-
glutination, or the effect produced upon certain bac-
teria by the action of immunizing serum. They are
rendered immobile and gathered into little groups or
agglomerations. This fact is of use in the serum diag-
nosis of typhoid fever ; agglutination has been found
in fourteen out of fifteen cases of Asiatic cholera, in
the Malta fever of Mediterranean countries, in the
latter weeks of Bombay pest, in infections due to the
pneumococcus, and in glanders. It is not present in
infections due to the coli bacillus, in tetanus, in diph-
theria, nor in staphylococcus 'vcAe.c\\oviS.^ Archives
Generales de Medecine, December, 1899.
Fracture of the Anterior Superior Spine of the
Ilium by Muscular Contraction. — Jacques L. Rever-
din reports the case of a young muscular Englishman,
who slipped on his left running down an incline,
just as the right leg was about to be carried forward.
To avoid falling on his back, he instinctively bent
the trunk over the left thigh. The flexors were
strongly contracted, among them the sartorius and
the tensor vaginse femoris, which are attached to the
iliac spine, and which pulled it so violently as to
cause its fracture. — Revue Medieale de la Suisse
Romande, December 20, 1899.
Massage is beneficial in ulcers, especially centripe-
tal effleurage at the sides and below the ulcer in pro-
portion to the induration of the edges. — Hartschek.
146
MEDICAL RECORD.
[January 27, 1900
Medical Record:
A Weekly Journal of 31edicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
PUBUSHERS
WM. WOOD & CO., 51 Fifth Avenue
New York, January 27, 1900.
THE BACTERIOLOGY OF ENDOCARDITIS.
That endocarditis is of bacterial origin there is little
room for doubt, but there is good reason to believe
that the etiological factor is not alwaj's the same,
various observers having found different micro-organ-
isms. While often an associated, or secondary, phe-
nomenon of other infectious diseases, the inflammation
of the endocardium may take place as an independent,
or primary, disorder, the infecting agents gaining en-
trance through any one of a number of portals, of
which evidence has recently been adduced that the
tonsils constitute one. The lesions and the symptoms
vary widely in individual cases in accordance with
the virulence and the pathogenicity of the micro-organ-
isms concerned, and naturally also with the character
of the primary disorder when the endocarditis is
secondary.
To the cases of endocarditis already recorded in
which bacteria were isolated, MacCallum and Hast-
ings {Jourtial of Experimental Medicine, vol. iv., Nos.
5 and 6, p. 521) report an additional instance in
which they found a hitherto undescribed micrococcus.
The patient was a man, thirty-seven years old, who
presented symptoms of acute endocarditis of the aortic
and mitral valves, with infarctions in the spleen and
the kidneys. From the blood during life, and from
the valvular vegetations, the infarctions and other
parts after death, there was demonstrated both micro-
scopically and in pure culture, in large numbers, a
small micrococcus, occurring mainly in pairs, some-
times in short chains, staining by Gram's method,
growing in small, pale, grayish-white colonies on
gelatin and agar, at first clouding bouillon, which
then becomes clear with a whitish sediment, not pro-
ducing gas in glucose media, liquefying gelatin slow-
ly, and to some e.vtent also blood serum, and charac-
terized especially by its behavior in milk, which it
acidifies, coagulates, and subsequently liquefies. It
produces a milk-curdling ferment, and also a proteo-
lytic ferment, each of which is separable from the
bacterial cells. It remains viable for months in old
cultures, and it is tolerably resistant to the action of
heat and antiseptics. The micrococcus is pathogenic
for mice and rabbits, causing eitlier abscesses or gen-
eral infection. Typical acute vegetative endocarditis
was induced experimentally by intravenous inocula-
tion of the organism in a rabbit and a dog, and the
cocci were demonstrated in pure culture in the vegeta-
tions and other parts of these animals after death.
Although the micrococcus described bears some re-
semblance to the pneumococcus and the streptococcus
pyogenes on the one hand, and to the pyogenic sta-
phylococcus on the other hand, it is readily distin-
guished from each of these species by the cultural
features that have been described, and that are so ob-
vious that the differentiation of these species from the
micrococcus in question need not be discussed in de-
tail. The organism is, therefore, considered to be
a new species, and on account of its fermentative
properties the name micrococcus zymogenes has been
proposed.
THE CIGARETTE QUESTION.
Few physicians, probably, would recommend the
use of the cigar, pipe, or cigarette as an aid to
the preservation of good health or as a remedy
for disease. Notwithstanding these adverse views,
there are yet many medical men who think that the
harm said to be effected by the use of tobacco has
been somewhat exaggerated. There is, too, another
point in connection with smoking concerning which
opinions widely differ; that is, in regard to the par-
ticular form of the habit calculated to do most injury
to the system. It would seem to have become, of late
at any rate, in the minds of the general public almost
an "article of faith" that for its deleterious effects
the palm must be awarded to the cigarette. If one
could believe the statements which often appear in
certain of our lay journals, the cigarette is as insidious
and as far-reaching in its death-dealing operations as
is the bubonic plague. In sooth, the term "cigarette
fiend " would seem to have taken its place as a per-
manent addition to our American vocabulary.
The cigarette has been stigmatized as poisonous in
all its component parts. The assertion has been made
times without number that the tobacco of which it is
compo-sed is adulterated with opium and an "unclass-
ified alkaloid," and that the paper is poisoned with
arsenic, copper, or chlorine. In 1888 The Lancet
Analytical Sanitary Commission was appointed to
probe into this matter, the result being that the cigar-
ette left the court without a stain on its character, at
least so far as the foregoing allegations against it were
concerned. The same verdict was brought in for the
cigarette under examination in this country. Not-
withstanding this acquittal the minds of the American
publicrwere by no means set at rest on the point, and
in 1891 a veritable crusade against the cigarette was
inaugurated, which has been carried on more or less
energetically up to the present day. Agitation to the
same end has been proceeding, but to a lesser extent,
in Great Britain. In consequence of this The Lancet
procured four brands of cigarettes in New York and
six in London, in the majority of instances the brands
being the same, and subjected them to careful analysis
in its laboratory. The report says that foreign
toxic substances were not found in a single instance,
January 27, 1900]
MEDICAL RECORD.
147
and among those looked for, both in the paper wrapper
and the tobacco, were morphine, phosphorus, arsenic,
mercury, copper, and other heavy metals. The report
sums up by declaring that "there is not a single factor
in these numerous results upon which can be fairly
based any allegation of the presence of a substance
producing injury to health."
We hold no brief for the cigarette, and there is no
intention on our part to uphold smoking in any form.
Attention has been drawn in these columns on several
occasions to the fact that cigarette smoking by the
young cannot be practised with impunity. Before the
age of sixteen years the use of tobacco should be abso-
lutely tabooed. But to assert that cigarette smoking
per se exerts a more pernicious influence on the health
than the seductive cigar or the soothing pipe, is to put
forth an argument for which there is no sufficient proof.
Probably the following rules, if adhered to, would meet
the requirements of most of the case: Don't smoke
when young; don't inhale the smoke; and don't smoke
to excess.
THE WHOLESALE DESTRUCTION OK
FORESTS.
In newly settled countries which are thickly tim-
bered it is a matter of prime necessity for the purposes
of agriculture to clear the land. In many regions
where population is sparse, timber felling as a means
of livelihood is largely followed. This is of course
as it should be, although even in such cases a wise
discretion should be exercised. Unfortunately, how-
ever, the same course is followed in districts where the
conditions are different. In Northwest Canada, for
instance, there is as yet no fear that any great harm
will be done by the lumber operations there carried
on, as the virgin forests are so vast in extent that there
is seldom necessity for re-logging before the trees
have had time to arrive at maturity. But in parts of
this country the situation as regards the forests differs
greatly, and it is asserted authoritatively that, if the
present system is proceeded with, the virgin forests of
the South bid fair to be soon destroyed. The same
authority, Dr. Schenck, is responsible for the state-
ment that if the forests are lumbered out rapidly as at
present, and if the fires are allowed to rage unchecked,
the same condition will speedily prevail in the South
that now prevails in the Lake States.
To prevent the occurrence of this deplorable con-
summation the committee on parks and forestry of the
Asheville, N. C, board of trade has decided to appeal to
the nation. This committee has issued a call for an in-
terstate meeting to be held in Asheville, on November
2 2d, to form an association to further the project of a
National Southern Park, and to induce Congress to
appoint a commission to inquire into the feasibility
of the project, to investigate its desirability, and to
ascertain if it is practicable to secure such a park.
It is to be hoped that the project may find favor with
the ''powers that be." Trees are not only to be de-
sired from the standpoint of beauty, but also play a
very important hygienic part in the scheme of the
universe. In a treeless, hilly country floods are fre-
quent and destructive. Trees are the chief factor in
distributing and regulating the rainfall, and in dry
seasons by their action in holding back evaporation
preserve the water supply.
THE PLAGUE A MENACE TO BRITISH AND
BOER TROOPS IN SOUTH AFRICA.
There have been cases reported of bubonic plague in
and about the Transvaal during the past year. In
February, 1899, a supposed case of plague was an-
nounced at a small town near Pretoria. Another case
of a like nature occurred at another town nearer the
Portuguese boundary, and it is now definitely known
that the disease has broken out in the neighborhood
of Delagoa Bay. This is perhaps the most serious
news in connection with the campaign in South
Africa that has yet been published. The conse-
quences of the plague attacking the armies in the field
are too awful to contemplate. But the possibility of
such an occurrence must be taken into account. The
conditions under which soldiers are compelled to live,
and the inevitable lack of efficient sanitary arrange-
ments in their camps, by which alone* the disease can
be stayed, present peculiarly favorable features for its
spread. Cantlie, Simpson, and Manson have already
uttered notes of warning on this point, and now Pro-
fessor Sambon has emphasized these admonishments
in an article contributed to the British Journal of
Tropical Medicine. Sambon thoroughly agrees witii
Manson that the plague is not a water-borne but a rat-
borne disease, and in addition draws attention to the
fact that it can Ije conveyed by mice, squirrels, mon-
keys, dogs, cats, and man himself. He also gives as
his opinion that fleas, bugs, and flies are likewise very
important agents in the dissemination of plague, and
that it is probably through fleas that the disease is
most frequently conveyed from rat to rat, from rat to
man, and from man to man. These are the principal
measures recommended by Sambon to check the in-
r(Jads of the plague : {a) The avoidance of importing
grain and other food stuffs from infected places, as
rats invariably accompany such cargoes. It is well
known that grain ships have been a principal source
of plague epidemics; {b) the destruction of rats in
ships, especially when plague-infected or leaving
plague-stricken localities; (r) the destruction of rats
in towns exposed to infection; ((/) the destruction of
stray dogs and cats, which may become carriers of the
disease when rats begin to die; (e) the destruction of
fleas in houses and on pet animals; (/") the isolation
of plague patients; {g) the disinfection of all that
comes in contact with the latter.
The belief that rats were an important factor in
spreading the plague was firmly held by the ancient
Greeks, and Sambon relates that in Asia Minor, at the
very door of the plague, they worshipped Apollo
" <t:a-jU()i;" "that is to say, Apollo the rat, whose ar-
rows spread the plague, and at the same time as the
destroyer of rats." This awful divinity was repre-
sented on monuments as treading on a rat. In Roman
times, when Esculapius replaced the more ancient god
MEDICAL RECORD.
[January 27, 1900
of medicine, we again find the same fact recalled on a
coin of Lucius Verus struck at Pergamum. It repre-
sents Esculapius with a rat at his feet, and a small
naked figure standing by with arms outstretched. It
is, however, not absolutely proven that the plague is
disseminated by rats, although the evidence in sup-
port of the theory is remarkably strong — so strong
indeed that the destruction of these vermin in infected
regions and ships is a course that should, in all in-
stances, be pursued.
With regard to the plague in Portuguese South
Africa, there can be no doubt but that it constitutes a
grave menace to both the armies in the field. In the
first instance it will find an eminently congenial soil
amid the filth of the Portuguese towns, and in the sec-
ond place the transportation of provisions from Lo-
renzo Marques to the Transvaal will afford favorable
facilities for its introduction to that country. In
order to prevent so frightful a catastrophe, pressure
should be brought to bear upon the Portuguese
authorities to induce them to exercise the strictest
supervision both over cargoes coming in by sea and
over the food stuffs sent inland.
A DUBIOUS DISCOVERY.
The announcement made in several British lay jour-
nals, that Professor Metchnikoff of the Pasteur Insti-
tute has discovered the means of almost indefinitely
prolonging life, will be received by the medical profes-
sion with feelings akin to disgust. The Paris cor-
respondent of the London Morning Post reports the
wonderful new theory in the following well-chosen
words: "Professor Metchnikoff 's experiments show
that the explanation of senile atrophy hitherto obtain-
ing is erroneous. The theory was that certain blood
cells devoured others when the vital functions began
to weaken. The organic poisons thrown off ener-
getically in youth were believed to remain in the sys-
tem in old age, or at least to be less energetically
ejected, and to poison the finer cells while without
action on those of the conjunctive tissues. The noble
cells died and became the prey of the other or plebeian
cells, thus bringing about the atrophy of the organ
wherein the metamorphosis took place. This explana-
tion is erroneous. Professor Metchnikoff has discov-
ered and proved conclusively that the noble cells are
not dead in organs atrophied by senility, and, more-
over, that they may be multiplied. By assisting them
in their struggle with the plebeian cells they will con-
tinue to live as actively as in youth. Theoretically,
the organism will cease to grow old, and in practice
life will be prolonged."
Serums of all kinds have been discovered in pro-
fusion in recent times, several of which have been
altogether discredited, while others have failed to give
the results claimed for them by their authors; but this
is only the second occasion within tiie memory of the
present generation that a prominent scientific man has
publicly asserted that he had found out how to prolong
life to practically an unlimited extent. The reputed
discovery carries one's thoughts back to the Middle
Ages, when many charlatans averred that they pos-
sessed the secret of the elixir of life. A discreet scep-
ticism will assuredly be the attitude of mind of the
medical profession with respect to Professor Metchni-
koff's reported successful investigations. Probably,
however, the public is being hoaxed in the matter, and
the professor's name is being used without his knowl-
edge. It is to be hoped that such may prove to be the
case. Already too many scientific men of note have
besmirched their reputations and the noble calling to
which they belong by claiming for their discoveries
wholly preposterous curative qualities.
THE TREATMENT OF TUBERCULOSIS WITH
TUBERCULIN.
Although the furore that followed the announcement
by Koch, in 1890, of a specific remedy for the treat-
ment of tuberculosis soon subsided, in consequence of
misguided zeal, unrealized anticipations, and disap-
pointed hope, the distinguished bacteriologist who, at
the time, appeared to be forced by his government into
a premature publication, has persisted in his investi-
gations along the same lines, and a number of the
more conservative of those who adopted his sugges-
tions still continue in the use of his products. ' It has
been shown at least that tuberculin is capable of in-
ducing local and general reaction in the presence of
tuberculosis, and that by the systematic injection of
gradually increasing doses it is possible to render the
infected individual resistant to the toxic activity of
the products of the tubercle bacillus. The former
of these phenomena has been successfully applied in
the early diagnosis of the disease, particularly in ani-
mals; and the latter in the treatment of the developed
disease.
In a thoughtful address delivered recently before
the tuberculosis commission of the Society of German
Naturalists and Physicians, Petruschky (^Berliner
klinische WocJienschriJt^ 1899, Nos. 51 and 52), director
of the Bacteriological Institute of the city of Dantzic,
pointed out the impossibility of curing tuberculosis
with a single brief course of treatment with even spe-
cific remedies, by reason of the nature of the anatom-
ical lesions of the disease. Such cure must consist in
the permanent suppression of the infectious agents and
their toxins, and treatment, to be successful, must there-
fore be extended over long periods of time. Mere res-
toration to physical activity and earning capacity is
not sufficient. Upon the basis of nine years' experi-
ence, Petruschky expresses tlie opinion that the de-
sired result can be obtained with the aid of tuberculin,
and he reports twenty-two cases in which cure in this
sense was effected, the patients being freed of symp-
toms and not reacting to injections of tuberculin, and
tubercle bacilli being absent from the sputum for pe-
riods of from six to twelve months. A graduated plan
of treatment was pursued, the injections being discon-
tinued with the cessation of the reaction to tuberculin,
and being resumed at intervals of three or four months,
when it was found that the reaction to tuberculin was
agaiH present.
January 27, 1900]
MEDICAL RECORD.
149
^cws of ttxe ^meeli.
Typhoid Fever is prevailing to an unusual extent
in Trenton, N. J. During last week there were forty
cases and five deaths.
Dr. Conan Doyle, the author, has returned to med-
icine, according to the Medical Press, and will start
soon for South Africa to take charge of a field ambu-
lance.
The Prescription of Proprietary Remedies At
a recent meeting of the Memphis (Tenn.) Medical
Society a resolution was passed condemning the use
of proprietary medicines.
<< The Maryland MeOical Journal " appears with
the new year as a monthly instead of a weekly. The
change is an improvement in a journal which Jias
always held a high rank in American periodical lit-
erature.
Diphtheria in a Children's Home. — The Fairfield
County (Conn.) Home for Destitute Children at Nor-
walk is under quarantine on account of two cases of
diphtheria occurring there recently. There are also
several cases of measles in the same institution.
A Death from Seasickness — A four-year-old boy
died on an Atlantic steamer just after it reached the
pier in this city last Sunday, and the ship's physician
attributed the death to exhaustion following seasick-
ness, fi^m which the child suffered severely during the
entire voyage.
Carbolic Acid to be Dearer. — The price of carbolic
acid has risen quite rapidly during the past week or
two, owing to the impossibility of importing any from
Great Britain. The scarcity there is said to be due
to the fact that this substance is necessary in the man-
ufacture of lyddite.
"A New Auto-Extension Fenestrum Splint" is
the name given to a form of splint described at a
meeting of the Tri-State Medical Society at Memphis.
The apparatus is ingeniously constructed and will
doubtless be serviceable in many cases, but what in
the world is a fenestrum?
Smallpox is reported from many towns in North
Carolina, and in some places prevails to such an ex-
tent that schools and churches have been closed and the
holding of courts has been stopped. The disease has
appeared also at Blackstone, Va., where the schools
have been closed.
Medical Students Robbed One of the porters em-
ployed in the Bellevue Hospital Medical College was
recently arraigned in the police court charged with
having stolen clothing and other property from stu-
dents, and was held for trial. There have been nu-
merous complaints of theft of various articles in
addition to overcoats and canes.
To Guard against Premature Burial. ^The So-
ciety of Medical Jurisprudence recently presented a
communication to the New Vork City board of health,
calling attention to the manner in which death is now
ascertained and certified to. In the communication
it is asserted that the " distinction between real and
apparent death, according to the scientific authorities
who have paid special attention to this question, being
a delicate task and requiring precise scientific tests —
first of all, only authorized practitioners of medicine
should decide whether a person is dead or not. As
it is now, any person without any medical knowledge
or trained capacity of observation who happens to be
present when a person stops breathing can report him
to be dead, and in most cases the physician who has
seen him alive will certify to his death without even
having seen his body, much less having tested the
reality of actual death. We therefore respectfully
suggest a change in the blank forms of death certifi-
cates so that they be made to contain the declaration
that the physician personally has examined the body.
We furthermore recommend that the chief signs of
death be enumerated in the blank, and that the physi-
cian shall indicate the presence or absence of each
with ' Yes ' or ' No. ' The questions which we would
suggest to ask would be: Has the respiration stopped
permanently? Has the pulsation of the heart stopped
permanently? Do the dependent portions of the body
show a purple discoloration? Is rigor mortis pres-
ent? Are the corneas dull ? Are the pupils dilated?
Are there unmistakable signs of putrefaction ? Fur-
thermore, we suggest that by ordinance your honorable
board make it illegal to do anything to the body of
the supposed dead which, if he were alive, would
cause him pain or injure him, before the certificate of
his death has been signed by the physician."
Professional Men in Cuba. — An Havana newspa-
per says that the number of doctors and lawyers in
the island is out of proportion, both as regards the
number of inhabitants and the money in Cuba. Nev-
ertheless, a great many students in both professions
will soon be qualified, and many Americans are prac-
tising medicine illegally on the island. Owing to the
lack of other occupations for young Cubans under the
Spanish re'gime, those who could not afford to go
abroad to study engineering or other professions were
forced to become lawyers or doctors, these being the
only degrees that could be obtained in the island.
Military Hospitals for South Africa. — We learn
from the British Aledical Juttrnal that Lord Iveagh
has offered to provide at his own cost a completely
equipped hospital for the lines of communication in
South Africa. The hospital will be known as the
"Irish Hospital," and the chief surgeon will be Sir
William Thomson, lately president of the Royal Col-
lege of Surgeons in Ireland. The staff will consist
of four surgeons and six dressers. The ofifer of Mr.
Langman to equip a station hospital of one hundred
beds for the lines of communication has also been ac-
cepted by the War Office, and Mr. Robert O'Calla-
ghan, surgeon to the French Hospital in London, will
be the senior surgeon.
The California Crusade against Consumptives.
— The board of health of Oakland, Cal., has advised
the board of education of that city to dismiss from
I50
MEDICAL RECORD.
[January 27, 1900
the public schools any teacher or pupil suffering from
pulmonary tuberculosis and to prevent the admission
of any such sufferer in the future. One of the pro-
posed regulations provides for a compulsory bacterio-
logical examination of any pupil or teacher under pain
of dismissal.
Typhoid Fever is still very prevalent at Lady-
smith, twenty deaths having occurred there in two
days.
A Congress for the Study of Tuberculosis will
be held in Naples in the spring of the present year,
in connection with an exposition of hygiene.
Accidental Poisoning of a Physician — Dr. Wil-
liam J. Kelcher, an English physician, died a short
time ago in consequence of his having accidentally
swallowed carbolic acid by mistake for solution of
magnesia, when mixing a draught for his own use.
A Gift to the Flower Hospital. — The widow and
the daughter of the late Roswell P. Flower have given
$200,000 to the hospital founded by him, the only
condition attached to the gift being that the name
■' Flower Hospital '' shall be retained in perpetuity.
The New York State Anti-Vivisection Society
held its annual meeting at Saugerties last week.
Officers were elected for the year as follows : Presi-
dent, Dr. John Vedder; First Vice-President, Mr.
Renssalaer Potts; Second Vice President, Dr. Luigi
Galvani Doane; Secretary, Anna Sargent Turner;
Jrcasurer, Grace F. Reed.
An Indictment against a Christian Healer.— The
grand jury in Council Blutls, Iowa, lias returned two
indictments against a Christian Science healer and a
woman for compassing the death of the daughter of
the latter. The girl is reported to have died of appen-
dicitis while the "healer" was praying over her, the
mother having refused to have medical advice for the
child.
A Question of Diagnosis. — There is a dispute be-
tween the Indiana board of health and the physicians
in the western part of the State over the differential
diagnosis of smallpox and chickenpox. The board of
health officials assert that a smallpox epidemic pre-
vails at Clay City and other places, but many of the
physicians say the disease is chickenpox and point to
the fact that there has not been a death, and also that
vaccinated persons as well as those not vaccinated
have had the disease. The disease, whatever it is, is
increasing, and many persons are seeking vaccination.
The presidents of the State Normal School and the
State University have advised all the students to be
vaccinated, and over one thousand have submitted to
the operation. The State board of health announces
that the disease prevails in fourteen counties in
Indiana.
No Use for Bent Needles.~A new student in the
training-school was detailed a few days ago to help in
the out-patient department of one of the city hospitals.
.\fter a man had had a scalp wound sewed up the neo-
phyte was asked by the dispensary surgeon to wash the
needles. There were two dozen of them. Two or
three were straight, tiie rest curved in various shapes.
She washed the straight ones and threw the rest away.
When remonstrated with for the waste, she was greatly
astonished to hear that surgeons prized such things as
bent and twisted needles.
«< The Archives of Pediatrics." — Dr. Walter Les-
ter Carr, of New York, will take editorial cliarge of
this journal with the new year. Dr. Carr has been a
frequent contributor to the literature of pediatrics,
and his assumption of the editorship promises a better
future for the Archives.
The Plague is reported to have made its appear-
ance at Noumea, capital of the French penal colony
of New Caledonia. Ten Kanakas have succumbed to
the disorder and four whites have been attacked. The
disease is said to be spreading.
A Prolific Descendant of Distinguished Ancestry.
— There died on January 9th, at Philadelphia, a man
aged fifty years, who was a descendant of Benjamin
Franklin. His father was an officer in the war of
181 2, and he was iiimself the father of twenty-one
children.
Relief Work in Puerto Rico. — .\ report of the
relief work for October and November in the island of
Puerto Rico has just been published. The population
of the island is estimated at 918,926. The average
daily indigent during the two months was 221,087 P^""'
sons; the average weekly sick 17,372, and the average
weekly deaths 632 persons. The annual dei^h rate
was 35 per 1,000 inhabitants, while the normal rate
of deaths is 26 per 1,000 inhabitants. The increased
mortality was confined to the mountain districts,
where, in some localities, the death rate increased
three hundred per cent. The amount received for the
relief of the suffering people of the island up to No-
vember 30th was $15,224. The amount disbursed up
to the date mentioned was $7,417. Up to November
30th the total amount of food received to relie\ e the
sufferers was 17,162,788 pounds. Of this 16,548,316
pounds has been issued up to November 30th. The
amount of unissued food on hand at San Juan Novem-
ber 30th was 614,272 pounds. It is estimated that
not less than 2,000 additional tons of food will be re-
quired before the end of January, when the plantains
and bananas will be ripe. Four-sevenths of this
amount should be of rice; two-sevenths should be of
beans, and the remainder of the amount required
should be either codfish or bacon. With the food
already issued and now on hand, and with the 2,000
tons required in addition to that already issued, the
total i.ssue will be 20,162,788 pounds.
College of Physicians of Philadelphia.— At a
stated meeting of the section on general medicirp
held on January 8th, Dr. F. Savary Pearce and Dr. J.
M. Swan read a paper entitled " Friedreich's Ataxia,
with the Report of a Fatal Case." The patient was
a girl, seventeen years old, in whom the symptoms
were first noticed at the age of tiiree years. The
knee-jerks were present for a long time, but were lost
in the last years of life. .Xystagmus also appeared
January 27, 1900]
MEDICAL RECORD.
151
late. The patient died of pulmonary tuberculosis,
probably acquired from a brother, who died of the
same disease. An autopsy could not be secured. Dr.
Herman B. Allyn presented a communisation entitled
"A Case of Rheumatic Pericarditis, with Sero-Fibrin-
ous Exudate; Recovery." The case was characterized
by moderate elevation of the temperature, violent de-
lirium, a duration of five weeks, and the occurrence of
pleurisy as a complication. Dr. Hobart A. Hare read
a paper entitled " A Case of Aortic Aneurism, in which
Electrolysis was Performed Three Times." The oper-
ation consisted in the introduction into the aneurismal
sac, through a hollow needle, of about ten feet of coiled
gold wire, and the passage for about an hour of an
electric current gradually increased from 2 to 100
milliampcres. For a time injections of gelatin also
were employed, a mixture of gelatin gr. xviii., sodium
chloride gr. xviii., and water fl. \ ii. being used, and
some seventy injections being made. Although fatal
rupture eventually ensued, the patient's life was pro-
longed for some eight months. In another case simi-
lar palliation was effected. Dr. D. D. Stewart also
reported a case of aneurism of the aorta, in which
coils of wire were introduced on three occasions, and
an electric current was passed, resulting in the pres-
ervation of life for a number of months. The speci-
men from this case was exhibited, and disclosed a
fusiform aneurism of the ascending portion of the
arch of the aorta, with an added saccular dilatation,
in which the coils of wire were found surrounded by
clot. Dr. Alfred Stengel presented a communication
entitled "The Definition and Significance of Accent-
uation of the Second Pulmonary Sound." It was
pointed out that the character of this sound depends
essentially upon the relation between the pressure in
the ventricle and that in the artery, and that the term
accentuation is employed with relation to the first
sound and to the other sounds rather than as an abso-
lute qualification. The sound may undergo alteration
in intensity, in pitch, and in quality. Dr. H. A. Hare
was elected chairman and Dr. S. M. Hamill clerk for
the ensuing year.
German Hospital, Philadelphia. — According to the
annual report of the German Hospital, 2,890 patients
were admitted during the year 1899 to the wards, while
37,071 visits were made to the dispensaries. In the
Mary J. Drexel Home 382 patients were admitted dur-
ing the year, and 5,797 visits were made to the dis-
pensary. Reference was made to the increase of
abuses in the dispensaries, and the insolence and ar-
rogance of some of the applicants, who labor under
the delusion that the city authorities furnish the
means for the support of the free dispensaries.
A Great Question Tentatively Settled. — A com-
mittee appointed at the Northfield Summer Conference
of Christian Workers, last August, to investigate the
statements of Professor Atwater of Wesleyan Uni-
versity on the nutritive value of alcohol, has made an
exhaustive report in a sixteen-page pamphlet. The
committee acted in co-operation with the Non-Partisan
National Women's Christian Temperance Union, the
permanent committee on temperance of the general
conference of' the Methodist Episcopal Church, the
Presbyterian Woman's Temperance Association, and a
number of other scientific bodies, and has decided that
alcohol is not a food.
Dr. V. Czerny, professor of clinical surgery at
the University of Heidelberg, has accepted the invita-
tion of Dr. Robert F. ^^'eir, president of the American
Surgical Association, to be present at the meeting of
the association in Washington in May. He will read
a paper on the " Surgical Treatment of Gall Stones."
Bequests to Charities By the terms of the will
of the late Dorman B. Eaton several large bequests are
made for educational and charitable purposes. Colum-
bia and Harvard universities receive $100,000 each.
The New York Skin and Cancer Hospital gets $10,000
and the Society for the Suppression of Vice $25,000.
The Fifth District Branch of the New York State
Medical Association. — The sixteenth annual meeting
of this branch will be held in Brooklyn on Tuesday,
May 22, 1900. It is proposed to choose diabetes as
the topic for discussion. Fellows who are particularly
interested in this topic, and have any clinical data to
present or theories to offer, are requested to correspond
with Dr. J. C. Bierwirth, president, or Dr. E. H.
Squibb, secretary, P. O. box 760, Brooklyn, N. V.
A New Hospital for Boston. — By the will of the
late Robert Breck Brigham, of Boston, the bulk of an
estate estimated at $5,000,000 is given to charity.
Provision is made for the establishment of a new hos-
pital in Boston, to be known as the Robert B. Brigham
Hospital for Incurables. The new hospital is to be
maintained as '" an institution for the care and support
and medical and surgical treatment of those citizens
of Boston who are without the necessary means of sup-
port and who are incapable of obtaining a living by
reason of chronic and incurable disease or permanent
physical disabilities." Nearly every charitable insti-
tution in the city is remembered, the most of them by
$1,000 annuities. Some of them received larger be-
quests outright.
The Fourth International Congress of Psycholo-
gists will be held in Paris, August 20-25, 1900- The
fee for members is 20 francs, which is to be sent to
Dr. Pierre Janet, 2 i Rue Barbet-de-Jouy, Paris. The
work of the congress will be divided among seven sec-
tions, as follows: i. Relation of psychology to anat-
omy and physiology; 2, relation of psychology to
philosophy; 3, experimental psychology and psycho-
physics; 4, pathological psychology and psychiatrics;
5, the psychology of hypnotism and suggestion and
related questions; 6, social and criminal psychology;
7, animal psychology, comparative psychology, anthro-
pology, and ethnology.
The Consolidation of Medical Missions.— The In-
ternational Order of the Dduble Cross was organized
recently in this city. One of the primary objects of
the order is the uniting of all medical missions and
missionaries throughout the world. The membership
is open to physicians, medical students, and nurses of
152
MEDICAL RECORD.
[January 27, 1900
both sexes, the active membership to be divided into
four guilds^ — physicians, students, nurses, and help-
ers— and all medical missionaries are to be considered
as honorary members. The emblem of the order, from
which it gets its name, consists of the double cross
formed by the crosses of St. George and St. Andrew.
The following officers have been elected: President,
Dr. G. D. Dowkontt; Secretary, Cyril H. Haas;
Treasurer, the Rev. W. W. Smith, M.D. ; Registrar, the
Rev. Theodore F. Hahn. These four officials, to-
gether with Drs. William Steward, John B. Busteel,
and H. Zeckhausen, form the executive council.
The Population of Cuba. — According to the returns
thus far received from the 1,550 census enumerators
in Cuba, whose work is nearly completed, it is esti-
mated that the population of the island is about 1,200,-
000, or 400,000 less than the Spanish census of 18S7
showed.
The Study of Tropical Diseases in Germany. —
In the budget of the German empire for 1900 there
appears a subsidy for the Institute of Tropical Hy-
giene which it is proposed to establish in Hamburg.
The empire will contribute 20,500 marks yearly to the
maintenance of the Institute, which is to be opened in
October of the present year.
For the Restriction of Tuberculosis A joint
meeting of the Philadelphia County Medical Society
and the Pennsylvania Society for the Prevention of
Tuberculosis was held on January loth, and a series
of papers dealing with the various phases of the pre-
vention and the treatment of tuberculosis were pre-
sented. Dr. L. F. Flick read a paper dealing with the
" Plans of the Pennsylvania Society for the Prevention
of Tuberculosis." These include the education of the
public by means of tracts describing the nature of the
disease, its mode of spread, and the measures neces-
sary to prevent its dissemination; and the erection of
hospitals and sanatoria for the treatment of the dis-
ease throughout its various stages, particularly in the
poor. At present the society, having no hospital of
its own, is compelled to pay for the care of a number
of patients in the few hospitals that will receive cases
of the kind. Dr. J. C. Wilson read a paper entitled
" The Necessity of Hospital Care of the Consumptive
Poor." Hon. W. N. Ashman presented a communica-
tion entitled, "Work at Present Being Done through
Private Charity in the Treatment of Consumption," in
which he described the good accomplished particularly
by the Rush Hospital for Consumptives. Dr. Howard
S. Anders read a paper on "The Necessity for State
Aid in the Treatment of Consumption among the
Poor," in which he pointed out the duty of the com-
monwealth to its dependent sick. Rev. Charles Dick-
ey discussed " The Cost of Maintenance and Manage-
ment of Hospitals and Sanatoria for the Treatment of
Consumption," contending that for the present it would
be wisest to utilize existing resources by the isolation
of special wards or the setting apart of special build-
ings for the tuberculous, instead of erecting costly
plants and perhaps antagonizing the community rather
than inviting its co-operation. Dr. Guy Hinsdale read
a paper entitled, "Localities Suitable for the Treat-
ment of Consumption in Sanatoria throughout Penn-
sylvania," showing that at least several parts of the
State are admirably adapted for the location of such
institutions by reason of their elevation and their cli-
matic conditions. Dr. E. O. Otis, of Boston, read a
paper entitled " The Necessity for City Hospitals for
the Treatment of Advanced Cases of Consumption
among the Poor," and he laid particular emphasis
upon the necessity for the registration of cases in or-
der to reduce to a minimum the liability of infection
through otherwise undiscoverable foci of disease. Dr.
J. M. Da Costa pointed out that by reason of the
knowledge of the transmissibility of tuberculosis, as
the result of scientific investigation, the general hos-
pitals had been closed to tuberculous subjects, so that
the necessity for providing for their special hospital
care was particularly urgent and devolved upon the
State. Other speakers were Major William H. Lam-
bert, formerly president of the bureau of charities and
correction. Dr. J. E. Stubbert, of the Loomis Sanato-
rium, and Mr. William B. Hackenburg, president of
the Jewish Hospital.
Philadelphia Pediatric Society — At a stated meet-
ing held January 9th, Dr. S. M. Hamill exhibited a
case of pulmonary obstruction in a girl about twelve
years old, in which there had previously been attacks
of tonsillitis and of measles, with a systolic murmur,
most audible in the second left intercostal space adja-
cent to the sternum. The lesion was thought possibly
to be a congenital one, although there was an absence
of cyanosis and of clubbing of the finger-ends. The
possibility of associated persistence of the ductus arte-
riosus was also considered. Dr. J. P. Crozer Griffith
read a paper entitled "Miliary Scarlet Fever, with a
Report of Cases." The opinion was expressed that
the occurrence of a miliary eruption in cases of scar-
let fever is unrelated to the severity of the primary
disease and to the intensity of the cutaneous eruption.
Dr. Alfred Stengel was elected president, Dr. Alfred
Hand, Jr., secretary, and Dr. Herbert B. Carpenter
treasurer, for the ensuing year.
Philadelphia Hospital Dr. H. Augustus Wilson,
clinical professor of orthopedic surgery in Jefferson
Medical College, has been elected orthopedic surgeon
to the Philadelphia Hospital, a newly created position.
New Medical Fraternity. — The Jefferson Society
of Jefferson Medical College was installed as the Ep-
silon chapter of Alpha Kappa Delta Fraternity on
January 6th.
The Pathological Society of Philadelphia. — At a
stated meeting held January :itli, Dr. E. A. Woldert
read a paper upon " Some New Stains for the Sporo-
zoa of Malaria, with Specimens." Drs. F. A. Packard
and A. Hand, Jr., exhibited specimens from a case of
status lymphaticus, with gastric tetany. The patient
was a child, three years old, with excessive secretion
of glairy mucus and pronounced symptoms of tetany.
Death occurred suddenly, without apparent cause, and
post-mortem examination disclosed an enlarged thy-
January 27, 1900]
MEDICAL RECORD.
153
mu3 gland and unusual development of the lymphatic
glandular apparatus of the small intestine, particularly
the lower portion of the ileum. Dr. Joseph Sailer
exhibited a specimen of syphilis of the spinal cord,
presenting thrombosis in the floor of the fourth ventri-
cle. The patient had received numerous arrow-wounds
in South America, and it was thought that the instru-
ments used might have been infected with syphilis
through the saliva of the natives. Dr. Sailer exhibited
also two specimens of mitral obstruction, one presenting
the classical funnel-shaped appearance, and attended
with a large e.xcavated thrombus in the left auricle;
the other showed apparer.i. atrophy of the right ventri-
cle, and the remains of multiple infarction of the
spleen and of the kidneys. He exhibited besides the
heart from a degenerate, whose death had resulted
from a fall in consequence of acute intoxication with
a small amount of alcohol. The aortic valve was
constituted of only two cusps. Dr. Simon Flexner
presented a human lung, showing actinomycosis. The
lungs were indurated, and exhibited the characteristic
sulphur-yellow granules. Dr. S. M. Hamill exhibited
a specimen of hemorrhage into the suprarenal capsule
and the connective-tissue capsule of the kidney, from
an infant, seventy-eight hours old, born without com-
plication. Dr. F. A. Packard exhibited caseous tuber-
culous adrenal glands from a man in whose case a
diagnosis of Addison's disease had been made during
life. The semilunar ganglia of the sympathetic also
appeared thickened and altered. Dr. Alfred Hand,
Jr., exhibited specimens of tuberculosis of the lung,
spleen, and kidney, from a colored child. The lung
was extensively tuberculous, and the remaining organs
were the seat of miliary tubercles.
The Medical Service at the Paris Exposition has
been organized by Dr. Gilles de la Tourette, formerly
chief of clinic at the Salpe'triere under Charcot. He
has ten assistants, Drs. Donbre, Reymond, Critzmann,
Bourges, F.mory, Goubert, Laborde, Dandieu, Des-
champs, and Gaillard.
Regulation of Ritual Circumcision The Hun-
garian government has issued a decree regarding
ritual circumcision, placing the operation under medi-
cal supervision, and insuring that it shall be per-
formed under the rales of surgical antisepsis.
Sanitary Progress in Guam. — In a recent report
by Captain Leary, governor of Guam, it is stated tliat
all precautions are being taken to improve the sani-
tary condition of the station as far as present means
and facilities permit, but a suitable water-supply sys-
tem is necessary in order that the ground cisterns and
wells may be closed and sealed, as they are contami-
nated by absorption of drainage impurities. The
evaporating-plant at the station is nearing completion,
and the sewage system from the government houses to
the ocean will be finished in a short time. Dr. Philip
Leech, surgeon United States navy, in his report says
that Assistant Surgeon Stone has persuaded the peo-
ple of Agat to establish a hospital with ten beds. So
striking have been the results that the authorities of
the village are now building and have nearly finished
an additional hospital for twenty beds. The people
appear to be grateful for what is being gratuitously
done for them, and seem to appreciate the importance
of co-operating with the American physicians, not only
in their medical work, as shown by their building
hospitals at Agat, but also in their efforts to make
sanitary improvements.
Philadelphia County Medical Society — At the
stated business meeting held January 17th, new mem-
bers, delegates to the convention for revision of the
Pharmacopoeia, to the American Medical Association,
and to the Medical Society of the State of Pennsyl-
vania, and officers for the ensuing year, were elected,
and the reports of the directors, the treasurer, the cen-
sors, and tlie publication committee were read. Dr. B.
F. Stahl, chairman of the committee appointed to secure
the admission of medical students to the Municipal
Hospital for instruction in the diseases treated there,
namely, diphth'eria, scarlet fever, and smallpox, made
a report stating that with the co-operation of the board
of health and the physician-in-chief to the hospital.
Dr. William M. Welch, courses of instruction had
been instituted to classes of ten students each from
the various medical schools in the city. The follow-
ing officers were elected for the ensuing year: Presi-
dent, Dr. John Musser; First Vice-President, Dr. George
Erety Shoemaker; Second Vice-President, Dr. Francis
M. Perkins; Secretary, Dr. Ell wood R. Kirby; As-
sistant Secretary, Dr. William S. Wray; Treasurer,
Dr. Collier L. Bower; Censor, Tir. Thomas H. Fenton.
Navy Department, Bureau of Medicine and Surgery,
Washington, D. C. — Changes in the medical corps of
the United States navy for the week ending January
20, 1900. January 12th (changes by cable from
Asiatic station). — Assistant Surgeon D. L. Wright
detached from the Monterey and ordered to the Isla
die Luzon; Medical Director D. Dickinson ordered
to duty as a member of the naval medical examining-
board, Washington navy yard, January 20th; Medical
Director G. S. Beardsley detached from the naval
retiring-board, Washington navy yard, and ordered
home to wait orders; Medical Inspector J. C. Wise
detached from the naval medical examining-board,
Washington navy yard, January 20th, and ordered to
duty as member of the retiring-board same day.
January i6th. — Surgeon L. G. Heneberger detached
from the naval recruiting rendezvous, Detroit, Mich.,
and ordered to the training-station, Newport, R. I.;
Surgeon O. Diehl detached from the Michigan and
ordered to the naval recruiting rendezvous, Philn-
delphia, Pa.; Passed Assistant Surgeon A. R. Alfred
detached from the New York navy yard and ordered to
the Texas; Passed Assistant Surgeon F. W. Olcott
detached from the Texas and ordered to the naval
recruiting rendezvous, Detroit, Mich.; Passed Assist-
ant Surgeon H. D. Wilson ordered to duty on the
Michigan; Passed Assistant Surgeon C. E. Riggs de-
tached from the naval recruiting rendezvous, New
York, and ordered to the New York navy yard ; Surgeon
H. N. T. Harris ordered to temporary duty on the
Vermont in connection with the crew of the Albany ;
Assistant Surgeon R. Spear detached from the naval
154
MEDICAL RECORD.
[January 27, 1900
recruiting rendezvous, Philadelphia, Pa., and ordered
to the Constdlation temporarily; Assistant Surgeon H.
A. Dunn ordered to the naval proving grounds, Indian
Head, Md. January iSth (changes by cable from
Asiatic station). — Passed Assistant Surgeon L. Morris
detached from the Helena, and ordered to the Brook-
lyn; Assistant Surgeon D. H. Morgan detached from
the Iris and ordered home; Medical Director G. S.
Beardsley placed on the list of retired officers of the
navy from January 22, 1900; Medical Director J. M.
Plint placed on the list of retired officers of the navy
from February 7, 1900; Pharmacist J. H. McGuigan
detached from the naval proving-grounds, Indian
Head, Md., and ordered to the New York navy yard ;
Pharmacist S. Englander detached from the New York
navy yard and ordered to the naval hospital, New York.
Heart Injury Without Immediate Death. — The
case of a man at Brunswick, Md., is reported in which
life persisted for sixty hours after the reception of
several gunshot wounds, one of which, it was found
on post-mortem examination, had perforated the heart
and another the intestines.
Pennsylvania Board of Medical Examiners —
Dr. Henry Beates, of Philadelphia, a member also of
the State Medical Council, has been reappointed a
member of the Pennsylvania medical examining-board;
and Dr. Hiram S. McConnell, of New Brighton, and
Dr. R. W. Ramsey, of Chambersburg, were appointed
members of the same board in succession to Dr-
Joseph K. Weaver, of Norristown, and Dr. Samuel \\'.
Latta, of Philadelphia.
The Burlington County (N. J.) Medical Society,
at its annual meeting held at Mount Holly on Janu-
ary 1 6th, elected the following officers for the ensuing
year: President, Dr. Frances S. Janney; Vice-Presi-
dent, Dr. W. P. Melcher; Secretary, Dr. A. \V. Taylor;
Treasurer, Dr. Enoch Hollingshead; Censor, Dr. ].\\.
Hollingshead; Chainnan oj Medical Section, Dr. V. H.
Shipps; Chairman of Surgical Section, Dr. A. Small;
Diseases of IVomen and Children, Dr. Emma Weeks.
The Montgomery County (Pa.) Medical Society,
at its annual meeting held at Norristown on January
18th, elected the following officers for the ensuing
year : President, Dr. J. J. Kane, Norristown ; Vice-
Presidents, Drs. D. W. Shelley, Ambler, and P. H.
Corson, Plymouth; Pecordirig Secretary, Dr. H. H.
Whitcomb, Norristown; Corresponding Secretary, Dr.
J. K. Weaver, Norristown; Treasurer, Dr. S. N.
Wiley, Norristown.
Dr. Howard Kelly, of Baltimore, while lecturing
at the Johns Hopkins University a few days ago, was
bitten on the finger by a rattlesnake. He sucked the
wound for a minute and then continued his lecture
none the worse for his accident. The reptile had
probably exhausted its supply of venom in striking at
various inanimate objects before getting a bite of
human flesh.
The Late Dr. W. A. Hammond.— The board of
directors of the New York Post-Graduate Medical
School and Hospital record with profound sorrow the
death of theirformer colleague, William A. Hammond,
M.D., surgeon-general of the United States army, re-
tired. On the 4th of April, 1882', Dr. Hammond, who
was then professor of diseases of the mind and ner-
vous system in the University Medical College of this
city, assisted in the organization of the faculty for the
Post-Graduate Medical School. He was professor in
the college from the date of its opening, October i,
1882, at 209 East Twenty-third Street, until 1888,
when he resigned his position and removed to Wash-
ington, D. C, where he suddenly died on January 5.
1900. Dr. Hammond was an accomplished executive
officer, punctual, scientific, and thorough in his work
as a clinician, and he always attracted large classes
by the force and clearness of his teaching. It was.
perhaps, owing to his effort more than to any other
member of the faculty who resigned from the Univer-
sity of the City of New York, that the initial step was
taken which led to the organization of the Post-Gradu-
ate Medical School. During the early years of its
struggle for existence, Dr. Hammond gave most un-
sparingly of his talents, his time, and his pecuniary
resources, toward its successful establishment, which he
saw achieved during his term as professor.
He was most genial and courteous in his relations
with his fellows. His memory will always be cker-
ished by them with hearty appreciation of his gseat
qualities.
The directors order this record to be spread upon
their minutes, and a copy thereof sent to the surviv-
ing members of his family.
D. B. §T. John Roos.'k, President; Andrew H.
S.MiTH, Vice-President; George N. Miller, Secretary.
Obituary Notes Dr. A. L. Boughner died at
Chester, Pa., on January i6th, at the age of forty-four
years, from septicaemia, due to a wound of the finger
received three months ago. He was graduated from
the Normal University, at Lebanon, Ohio, in 1882,
and from the University Republique, at Ann Arbor,
Mich., in 1885.
Dr. Thomas H. Franklin died suddenly on Janu-
ary 9th, at Atlantic City, at the age of fifty-nine
years. He was a graduate of the medical department
of the University of Pennsylvania, and he served in
the Pennsylvania Cavalry during the Civil War.
Dr. S. p. Bartleson died suddenly at Clifton, Pa.,
on January i6th, in the sixty-ninth year of his age,
apparently as a result of angina pectoris. He was a
graduate of Jefferson Medical College.
Dr. Abraham H. Witmer, first assistant physician
to the Government Hospital for the Insane in Wash-
ington, died on January i8th of cardiac disease. He
was born in Lancaster County, Pa., fifty-four years
ago, and was graduated from the Jefferson Medical
College in 1866. He became connected with the hos-
pital in 1876.
Dr. Lyman Rodgers, of Bennington, Vt., died
suddenly on January 2 2d. He was a graduate of the
medical department of the University of Vermont in
the class of 1858. He was an ex-president of the
Vermont State Medical Society, and had served a term
as State Senator.
January 27, 1900]
MEDICAL RECORD.
155
Dr. Alfred J. Watts died at his home in Brook-
lyn, N. Y., on January 22d, of apoplexy. He was
born in England in 1825 and studied medicine there,
obtaining his qualification shortly before coming to
this country in 1848. He practised first in Utica and
later removed to Brooklyn. He was the inventor of
crystal or "fern-leaf '" gold used in filling teeth, and
he soon gave up practice and devoted his time to the
perfection of his invention.
Dr. John Cargill SH.'iwdied on January 23d, from
pneumonia, at his home in Brooklyn, in his fifty-fourth
year. He was born in Jamaica, W. I., and came to
this country in his seventeenth year. He was a
graduate of the College of Physicians and Surgeons
in this city in the class of 1874. For several years
lie was attached to the medical staff of the Long Island
College Hospital and of St. Mary's Hospital, and he
also served for four years as superintendent of the
Flatbush Asylum.
Dr. Columbus W. Krlse, of Carlisle, Pa., died
suddenly on January 23d, at the age of fifty-two years.
He was born in Gettysburg, and was graduated from
the medical department of the University of Maryland
in 1871. He was a member of the Cumberland
County and Pennsylvania medical societies and the
American Medical Association.
progress of |Teic(tical J»cicncc.
New York Medical Joiinial, January 20, I goo.
Chronic Abscess of the Frontal, Ethmoidal, and
Sphenoidal Sinuses followed by Meningitis and
Death. — J. H. Bryan records a case of this nature
which upon operation siiowed thick pus and granula-
tion tissue in the frontal sinus, with caries of its front
wall and of the entire ethmoid bone. All dead bone
which could be detected was removed. On the sixth
day after operation, the temperature began to rise and
sepsis developed. In spite of prompt intervention,
including the use of anti-streptococcus serum, death
resulted two days later. Autopsy revealed acute lep-
tomeningitis secondary apparently to ethmoid caries.
Sphenoid disease undiscovered at operation was also
present.
The Therapeutics of Heroin. — M. Manges con-
cludes an elaborate article upon this new remedy.
Replies to a circular letter show success in three hun-
dred and eighteen and failure in ninety-eight cases
of various affections, principally of the air tract. A
valuable bibliography is appended.
The Influence of School Life on Vision. — P. A.
Callan has examined many school children during the
last twenty-five years. He thinks that they are over-
crowded in their studies, and that this has much to do
with the large number of visual defects met with in
this class of patients.
Cholelithiasis E. C. Davison gives a general de-
scription of this affection. He reports one personal
operative case, and compares the advantages and rela-
tive indications for cholecystectomy and kindred oper-
ations.
Diarrhoea. — C. O. Molz enumerates the general
causes, varieties, characteristics, and therapeutic meas-
ures of the various forms of diarrhoea. He follows the
teachings of William Osier and L. E. Holt.
Enucleations of the Eye — D. Webster reports
cases of enucleation for panophthalmitis, for degen-
erated cataract with secondary hemorrhagic glaucoma,
and for ophthalmitis, the result of injury.
On the Detection of Calculi in the Liver and
Gall Bladder. — By Carl Beck. See Medical Record,
vol. Ivi., p. 642.
Suppurative Ethmoiditis and Its Treatment. —
By F. S. Milbury. See Medical Record, vol. Ivi.,
p. 684.
Medical JVews, Ja?iiiary 20, igoo.
Gonorrhoea; Its Dangers to Society.— Albert
Neisser, in discussing this subject, states that one
feature of gonorrhcea of special significance is the fact
that its infectiousness may persist for a very long time
in spite of seemingly successful treatment of the local
affection of the genitalia. The affection does not re-
main limited to the primary focus of infection in the
mucous membrane, but progressively invades other
parts: neither does it limit itself to the superficial
mucous membrane. Special mention is made of gon-
orrheal arthritis with its tendency to relapses, anky-
losis, and disability. At least ten to twenty per cent,
of all blindness is due to gonorrheal infection. An-
other important factor to be noted in this disease is
the sterility which results from it. Neisser concludes
that we now know that this disease is always infec-
tious, communicated from one person to another, and
we can take measures to prevent its spread.
Diuretics in Renal Dropsy : Their Indications
and Uses. — E. R. Axtell divides diuretics into two
classes, the direct and the indirect. For practical
purposes lie further divides the direct diuretics into
two classes, the saline and the stimulant diuretics.
Axtell believes that much harm can result from the
use of these drugs unless they are judiciously chosen,
and he contends that all diuretics should be withheld
in acute nephritis until the acute inflammation has
subsided. Renal diuretics siiould be used in those
cases of dropsy in which there is great need of a drug
that will make the rernaining kidney tissue do its work
actively — but not then, until diaphoretics and hydra-
gogue cathartics have been tried. A brief considera-
tion of each of the following drugs concludes the pa-
per: scoparius, squill, caffeine, pilocarpine, digitalis,
diuretin, sweet spirits of nitre, and calomel.
A Visit to the Newest Psychopathic Hospital. —
Frederick Peterson describes the psychopathic hospi-
tal at Giessen — about an hour from Frankfort-on-
Main.
The Operative Treatment of Myopia of High
Degree by the Removal of the Crystalline Lens. —
By Charles Stedman Bull. See Medical Record,
vol. Ivi., p. 636.
Boston Medical and Surgical /onrnal, January 18, igoo.
Otitis Media in All Grave Diseases of Infancy.
— E. H. Pomeroy calls attention to Ponfick's table of
autopsies performed upon one hundred children who
had died of various diseases, as heart disease, gastro-
enteritis, burns, pneumonia, etc., in only nine of which
the ears were found to be normal. He believes that
most of the diseases of infancy are more positively
and demonstrably infectious from bacteria than we
can easily prove in adults, and considers the mid-
dle ear as an incubator and generator promoting gen-
eral toxic disturbance in many cases of localized in-
fectious diseases. He urges careful examinations of
the ears in all diseases.
156
MEDICAL RECORD.
[January 27, 1900
Gun-Shot Wounds by the Reduced-Calibre Rifles
in the Santiago Campaign. — Major Louis A. La
Garde, who thoroughly tested the Krag-Jorgensen rifle
or present service gun, compares the results of his
experimental work with wliat was observed in the San-
tiago campaign, and concludes that the experiments
and conditions found agree, and that, in addition to
other advantages claimed by Professor Hebler for the
reduced-calibre rifle, it possesses the greatest advan-
tage of all, that the wound produced, though sufficient
to disable, is much more humane than that produced
by the old-style projectile.
A Rhode Island Philosopher. — A biographical
sketch of Elisha Bartlett, by William Osier.
Philadelphia Medical Journal, January 20, igoo.
Case of Tuberculosis of the Kidney without
Marked General Symptoms. — J. M. Da Costa re-
ports the case of a man twenty-three years of age, who
did not appear to be ill, whose only symptom was a
sudden pain in the region of the kidneys lasting two
weeks, accompanied by fever and weakness. The di-
agnosis of renal tuberculosis was made after finding
the tubercle bacillus in the urine.
The Absorption cf Iron from the Gastro-Intesti-
nal Tract, and the Dietetics of Anaemia. — John C.
Hemmeter discusses aniEmia due to (i) food deficient
in iron, (2) the presence of an excess of sulphur com-
pounds in the digestive tract, and (3) a disturbance of
metabolism. When iron is indicated, he advises re-
course first to the inorganic compounds.
An Outline of the Principles of Malpractice as
Related to Medicine and Surgery. — William C.
Woodward defines malpractice as conduct on the part
of the physician which does not conform to certain
standards and which results in the injury of the pa-
tient. The unjustly accused physician has practically
no redress.
Origin, Development, and Degeneration of the
Blood- Vessels of the Ovary. — An abstract of a lan-
tern demonstration by John G. Clark. The author
ascribes the cessation of ovulation and the menopause
to a gradual impairment of tiie vascular systems of
this organ.
A Pneumatic Sigmoidoscope. — William V. Laws
describes an instrument for inspection of the upper
part of the rectum and the sigmoid flexure after inflation
with air.
Creolin Poisoning. — E. W. Pressly reports a case in
which poisoning followed rectal irrigation with a one-
per-cent. creolin solution.
Jountal of American Medical Association, Jan. 20, /goo.
City Milk Routes and Their Relation to Infec-
tious Diseases. — Ernest Wende advocates the regis-
tration of city milk routes as the most certain way to
insure the purity of the supply. He gives instances
of epidemics in the city of Buffalo which were in this
way traced to their true source and promptly checked.
He says that while chemical analysis and bacterio-
logical tests are both of great utility, the register takes
the place of all in its importance and possibilities in
the way of prevention of milk epidemics.
Typhoid Fever in a Leper, Following Imme-
diately but Accidentally on Treatment with Anti-
venomous Serum. — J. F. Schamberg reports this case
as interesting because there is no recorded instance of
the simultaneous existence of these diseases. The
patient recovered from the typhoid, his original dis-
ease remaining entirely unaffected by either that or
the serum injections.
Ectopia Lentis C. P. Pinkard reports two cases
of this disease which he examined in 1893. The
writer says that the outcome of these cases, being so
characteristic of certain changes in the zonule, warns
us to be careful in our prognosis as to the possible
inheritance of this disease by the children.
The Present Status of Surgical Tuberculosis
Ralph Elmergreen reports three cases : one of tuber-
culosis of the skin, another of tuberculous lymphade-
nitis, and the third of tuberculosis of the epiphysis
of the femur resembling sarcoma.
Extension Massage of the Ossicles with a New
Aural Masseur. — Hamilton Stillson describes this
instrument, which he has used for the last ten years
with excellent results in the treatment of certain forms
of deafness.
The Physician in Hawaii — E. S. Goodhue pre-
sents notes of some experiences while government
physician and medical superintendent of the Govern-
ment Hospital in Hawaii.
Sarcoma of the Face and Temporal Region By
Joseph H. Branham. See Medical Record, vol. Iv.,
p. 880.
Influence of th^ Medical Practitioner on Medical
Progress. — By Joseph D. Bryant. See Medical Rec-
ord, vol. Ivi., p. 635.
Surgical Treatment of Perforation of the Bowel
in Typhoid Fever. — By VV. W. Keen. See Medical
Record, vol. hi., p. 641.
J'/ie Lancet, January ij, igoo.
A Mode of Operating in Appendicitis. — C. B.
Keetly describes a mode of operating which he be-
lieves is adapted for use on any day or at any stage
of an acute or subacute attack, though not indicated
in every case. The skin and external oblique aponeu-
rosis are incised above the anterior superior spine and
the outer half of Poupart's ligament, parallel to the
latter. Deeper muscles are penetrated by separation
of their fibres and toward the outer part of the incision
with scissors. The transversalis fascia is divided,
and the peritoneum carefully separated from the iliac
fascia, the surgeon palpating for the deep surface of
the appendix or surrounding inflammatory products.
A strong light is thrown into the wound and the signs
of pus (infiltration of tissue, etc.) are looked for. If
pus is found, the infiltrated tissue is torn open with
two pairs of dissecting-forceps. In all cases two
drainage tubes are carried to the bottom of the wound.
The douche and syringe are avoided.
Volkmann's Ischaemic Paralysis : its Treatment
by Tendon Lengthening. — H. W. Page narrates a
case illuslrating this condition, whicii seems to be an
old lesion with a new name. It is the paralysis en-
suing in the forearm from prolonged immobilization
in fractures by apparatus which impedes the free cir-
culation through the part: lience the term ischtemic.
Page alludes to the difficulty in restoring the muscu-
lar structures to functional acti\ity in these cases, and
describes the wasting and other trophic disturbances
which ensue. In the case alluded to, he exposed the
flexor tendons at the wrist, each one in turn being
split longitudinally, severed to the right and left at
the opposite end of each incision, extended, and su-
tured with silk in the usual wav. While entire re-
January 27, 1900]
MEDICAL RECORD.
157
covery of function has not yet been realized (one
year), results in the case have been extremely grati-
fying.
Diet in Typhoid Fever. — R. W. Marsden fed two
hundred typhoid patients with milk, bread and milk
with custard, fish with mashed potato, chicken, bread
and butter, and finally minced meat. In the series of
cases diarrhcea was absent throughout in sixty-one ; in
twenty-nine, though it was present when fish was
given, there was no interference with its steady im-
provement; and in one hundred and seven, in which
it was present, it was not increased by diet. Hemor-
rhage occurred six times, in no case being fatal. No
case of perforation occurred. Relapses were noted in
forty-eight. In one hundred and eighty there was not
the slightest evidence of any alteration in the temper-
rature due to ingesta. Marsden believes that there is
no justification for resisting a craving appetite in the
manner at present in vogue.
Malaria and Mosquitoes.— G. Bastianelli and A.
Bignami maintain that energetic treatment with qui-
nine from the commencement of the infection of the
malarial fevers has a great importance for general
prophylaxis, since the parasites by its means can be
prevented from developing into those forms which
continue their life in the Anopheles.
Hypothermia E. B. Hulbert narrates the case of
a man, aged thirty-six years, admitted to hospital for
chronic headache and drowsiness. Syphilis was de-
nied, and no gross lesion could be discovered on
autopsy ten weeks later. Interest centred upon his
temperature range, it ran from 81.6" F. (rectal) to
normal and a little above. An epitome of the litera-
ture of subnormal temperature is given.
A Simple and Trustworthy Method of Quantita-
tive Estimation of Mercury in Urine. — H. Schu-
macher and VV. L. Jung advocate the addition to the
suspected fluid of stannous chloride and the pouring
of the resulting mixture on an asbestos filter contain-
ing gold. The filtrate is clear, and the whole of the
mercury is retained by the gold asbestos. The latter
is dried, weighed, and then ignited, the loss equalling
the mercury in the given quantity of fluid.
Poisoning by Corrosive Sublimate in a Pregnant
Woman. — M. 1). Eder records a case in which thirty
grains of the sublimate were taken by mistake. The
woman was six months pregnant: prompt intervention
saved her life, and she was delivered of twins at full
term. A severe hemorrhage occurred two hours after
delivery, but was controlled.
A Case of Enormous Nasal and Post-Nasal Poly-
pus : Paralysis and Death. — A. C. Mukherji describes
a case occurring in a young Mohammedan who refused
operation and died apparently from the effects of pres-
sure upon the brain by the mass. The nature of the
polypus is not stated, but in places it was cartilagi-
nous.
Prescribing Alcohol against Our Own Interests.
— F. C. Coley believes that physicians should do all
possible to discourage the use, in every way, of alco-
hol among the poor. The latter will then have money
enough to employ a physician when sick, and thereby
the abuse of medical charity will be greatly lessened.
Protracted Gestation. — J. Phillips records the case
of a primipara, aged seventeen years, in whom con-
finement took place on the three hundred and twenty-
third day after her last period, and three hundred and
sixteen days after coitus.
Cancer of the Penis. — Marmaduke Shield prefers
for this affection the operation of Gould, and condemns
the use of the hot galvano-ecraseur wire. He details
his personal experience with six operative cases.
British Medical Journal, January Jj, igoo.
A Case of Excessive Hemorrhage from a Vari-
cocele of the Labia Majora. — In this case reported
by J. E. Rosenstein, the patient, a young married wo-
man, four and a half months pregnant, had always
been well until the bursting of the varicocele while
she was stooping to remove a shoe. There was no
evidence of heart trouble, and no trace of varicose
veins was to be found elsewhere.
Hypodermic Administration of Mercury in Syphi-
lis.— W. Hubert S. Fosbery reports two cases in which
he used intramuscular injections of 7 minims of mer-
curial cream made according to the formula of Sur-
geon-Major Lambkin (about one part of mercury to
four of excipient). The writer found this preparation
too strong, causing pain and mercurialism, although
effective as regards the syphilis.
Carcinoma of the Ascending Colon and its Treat-
ment.— VV. McAdam Eccles reports two cases of this
disease tending to prove that for the success of a co-
lectomy it is almost essential that the operation should
be performed before the chronic obstruction has be-
come an acute one, and also showing with what suc-
cess the mass can be dealt with extraperitoneally.
Concussion of the Retina. — Sydney Stephenson
gives notes of retinal changes noted in the case of a
boy who had been struck in the eye with a cricket
ball. Similar retinal changes were first noted several
years ago by R. Berlin, who described a series of
cases.
A Case of Rupture of the Ureter or Renal Pel-
vis.— E. Percy Paton reports this case, in which re-
covery took place after lumbar incision and drainage,
which procedure the author prefers in most cases to an
immediate nephrectomy.
Enterectomy for Gangrenous Hernia. — W. P.
Montgomery reports two successful cases of resection
and primary suture in gangrenous hernia. These
cases were both operated on in the Manchester Royal
Infirmary.
Valvular Drainage Tubes in Empyema — William
Williams presents a diagram of an apparatus for drain-
ing or pumping out an empyema, and reports a case of
tuberculous empyema in which this tube was used, re-
sulting, as far as the writer could ascertain, in the first
cure in a case of this kind.
Acute Orchitis in an Infant Eleven Weeks Old.
— In this case, reported by F. Ashton Warner, the
cause of the orchitis could not be found. It recovered
completely after treatment with opium internally, hot
followed by cold fomentations, and support of the
scrotum.
Fracture of Both Clavicles. — James Battersby re-
ports a case of this unusual double accident, a man
engaged in shunting railroad cars having been struck
on both shoulders by the buffers of two cars, which
were being shunted against one another.
Rectal Feeding in Exhaustion following Chil-
dren's Ailments. — Christopher A. A. Coulthard has
found nutrient injections by the bowel very valuable
in the case of children suffering from extreme exhaus-
tion following diarrhoea.
1.8
MEDICAL RECORD.
[January 27, 1900
A Calcified Lipoma in a Hernial Sac. — R. A.
Milligan describes this specimen, which he found
while performing an operation for strangulated hernia.
It was the size of a nut, so hard that it could not be
cut with a knife, and the author had no doubt that it
w^as calcareous.
Description of Ambulance for the Mounted Ser-
vice.— T. F. S. Caverhill strongly advocates the pro-
vision of mounted bearer companies for cavalry bri-
gades.
Retention of Menstrual Blood from Atresia of
the Vagina. — The second of two clinical lectures by
Charles J. Cullingworth.
A Century of Surgery. — A lecture bv Christopher
Heath.
Medical Press atid Circular, Jattuary lo, igoo.
Otorrhoea. — Paul Range concludes his article on
treatment. Paracentesis is indicated whenever yel-
lowness, tenseness, and bulging outward of the tympa-
num shows the presence of pus. It is easy and harm-
less. The canal should be first washed with soap, then
v.ith alcohol, and then sprinkled with i : 1,000 bichlo-
ride solution. The incision should be made in the
infra-umbilical region; the vertical cut being pre-
ferred. Simple otorrhoea is treated by expectation or
by active attack, destroying the source of pus by chemi-
cal action, removal of necrosed tissues, etc. Irriga-
tion of the canal is advised, but only by sterile solu-
tions. Surgical intervention is indicated in cases in
which no improvement has been obtained by antiseptic
treatment; when the probe reveals the existence of
osseous lesions; when a cholesteatoma is detected or
suspected; when hearing is completely lost, so that
no further damage can be wrought in tliis direction:
and when there is the slightest symptom pointing to
encephalic complication.
Diphtheria. — W. R. Smith gives the English statis-
tics since 1855, when they began to be recorded. The
mortality in recent years is not so high as a generation
ago. The cat has been found by Klein to be suscept-
ible— the lungs being cliiefly affected. The disease
can be transmitted by those apparently well. The
most fatal form is that associated with the streptococ-
cus group. The majority of patients seem to retain
the bacilli in the throat from two to nine weeks,
and in one in whom antitoxin was used they were
found for over two hundred days. It is not unusual
to find bacilli after the hundredth day.
Hepatic Multilobular Cirrhosis. — Murrell reports
a case in which post-mortem findings showed a liver
of four pounds and eleven ounces, wrinkled on its sur-
face, tough, slaty in color, tlie microscope showing the
fine-framed variety of nniltilobulnr cirrhosis. The
patient had been well until four months before admis-
sion, when he noticed blood in the stools followed by
ascites and jaundice.
The Hyssop. — John Knott studies the botanical
history, symbolism, toxicology, and therapeutics of tiie
hyssop. There are two varieties, tiie Hyssopus vul-
garis and Hyssopus infrequens. There are two kinds
of the common garden hyssop, the ordinary and the
white or red flowered kind, difficult to distinguish from
each other. The medicinal advantages are question-
able.
Deutsche 7ned. Wochenschrift, Decemher 21 and 28, iSqq.
Speech and Sense Perception in Idiots. — Kellner
tabulates the results of the examination of 544 idiots.
Of this number 291 showed defects in one or more of
the special senses. The power of speech was wanting
in 81, but of these 42 could understand what was said
to them, and of the latter 5 were capable of work. In
addition to these there were 15 deaf-mutes, and 11
had the use of a few words only. Sixteen were blind
in one or both eyes; 170 were more or less color
blind; 6 were very hard of hearing or totally deaf;
the sense of taste was perverted or absent in 102;
smell was wanting in 75; both taste and smell were
absent in 34; sensation in the integument was de-
fective in 105; and organic sensation (hunger, thirst,
desire to evacuate the bladder or bowel, pain in ab-
dominal troubles, etc.) was dulled in 68.
The Diagnostic Significance of Acute Exudations
into the Abdominal Cavity. — H. Praun regards the
occurrence of a rapid effusion into the peritoneal
cavity as significant of a twist in the small or large
intestine, especially the latter, or of strangulation of
a knuckle of intestine in some abnormal opening,
either congenital or formed by peritoneal bands, an
adherent diverticulum, or the like; it is less common
in cases of intestinal invagination, and does not occur
in cases of obstruction by foreign bodies or tumors.
Of course, in order that the sign may be of value one
must be sure that the effusion has taken place rapidly
and that it is not a case of long-standing ascites.
The Etiology of Epidemic Cerebrospinal Menin-
gitis.— Leo Zupnik reports a case of this disease in
which he isolated a diplococcus resembling Weichsel-
baum's meningococcus, but which on culture tests was
found to differ from it. Pie reviews the literature of
the subject, and comes to the conclusion that there is
no unique specific etiological factor in epidemic cere-
brospinal meningitis. The micro-organisms found in
different cases of this disease are (i) Fraenkel's
pneumococcus, (2) V\'eichselbaum's meningococcus,
of which Pfaundler distinguishes two types, (3) the
microbe isolated by the author and by Pfaundler, and
(4) possibly also a meningococcus described by Kister.
Two Cases of Perigastritis Adhaesiva. — H. West-
phalen and W. Pick report two cases of this condition
in which Rosenheim's symptoms were well marked.
These are: ( i ) The persistence of pain after thorough
treatment of gastric ulcer with large doses of bismuth
or with nitrate of silver, and (2) the absence of im-
provement following mechanical therapy when the
latter has been indicated by motor disturbances of the
stomach. Operative treatment is indicated only when
the gastric function is interfered with by the adhesions
and consequent fixation of the pylorus.
Renal Diabetes. — Eger reports two cases of chronic
nephritis in which glycosuria occurred, but that the
latter was due to an acute onset of renal insufficiency
he does not venture to assert. He suggests, however,
a more careful study of hospital material to determine
this point, and thinks it not improbable that a sud-
denly occurring glycosuria may be found to be in
some cases a symptom of renal insufficiency or uramia.
A Case Showing the Necessity of Medical In-
spectioa in Schools. — R. Lohnstein reports the case
of a boy who had been operated upon successfully for
congenital cataract. The child needed strong convex
glasses, and with these could see quite well. He
had been sent away from the public school and placed
in a school for the blind. He was readmitted to the
public school on the author's certificate, but was
quickly returned to the blind asylum by the leach.er.
A Death Under Ether. — J. Schneider reports a
case of this nature. The patient had a very weak
heart with marked excentric hypertrophy of the left
January 27, 1900]
MEDICAL RECORD.
159
ventricle, advanced arteriosclerotic changes, contracted
kidney, and cirrhosis of the liver, and the author
thinks the ether had little to do with the death specifi-
call}. and it would be better to describe the case as one
of death during rather than from ether narcosis.
Renal Diabetes. — Paul Friedrich Richter has made
a number of experiments with cantharidin, corrosive
sublimate, and other kidney poisons, the administra-
tion of which is followed by glycosuria. He also
cites a few cases from medical literature which would
seem to point to the existence of a glycosuria of renal
origin.
The Origin of Leucocytosis. — P. Lengemann dis-
cusses the production of leucocytosis through changes
in cells emigrating from the bone marrow.
Wiener kliiiische IVoc/ie/iSchrift, December 28, l8gg.
The Influence of the Mechanical Irritation of
the Liver on the Heart. — M. Heitler states that the
relation between the liver and the heart, in the sense
that disturbances of the heart occur through disturb-
ances of the liver, has long been known. Recently
de Giovanni and Potain have made careful investiga-
tions in this direction. A definite symptom complex
in the lungs and heart has been shown to be depend-
ent on disturbances of the stomach and liver, op-
pression, dyspnoea, a feeling of suffocation, dilatation
of tlie. right heart, and further consecutive changes.
Heitler finds, with a large area of heart dulness and a
small pulse, a large area of liver dulness and spleen
dulness, and vice versa. He also finds that if he
strongly percusses or shakes the liver, the pulse, which
was previously small, immediately becomes large and
full and the area of heart dulness is decreased.
The Dietetic Treatment of Diabetes Mellitus
Rudolf Kolisch advocates a strict vegetable diet
which he has modified for the special use of diabetic
patients. I'his diet has many times met with excellent
results in severe cases. The vegetable diet keeps the
body in good condition with the least possible ex-
penditure of heat and the least disturbance of nutri-
tion. This diet also supplies to the organism more
carbohydrates than is possible with a meat diet. The
first result of the vegetable diet in the diabetic is a
decrease in the quantity of urine. Often acetone and
acetic acid disappear from the urine. For light cases
a mixed diet has proved beneficial. He considers an
exclusive milk diet to have very good results in
diabetes.
The Relations of the Anterior Corpora Quadri-
gemina to the Eye Movements. — S. Bernheimer finds
from experiment that the anterior corpora quadri-
gemina are neither a reflex centre for the eye move-
ment, nor do the neurons to the cortex pass through
them. The connecting neurons from the nuclei of
the eye muscles to the periphery of the angular gyrus
all decussate. The decussation must be in the median
line under the surface of the aqueduct of Sylvius, for
after taking away the anterior corpora quadrigemina
the synergistic eye movements emanating from the
angular gyrus remain just the same, and apes, after
their anterior corpora quadrigemina are destroyed,
still have perfect and spontaneous eye movements.
New Experiments Concerning the Absorption of
Casein. — Wilhelm Knoepfelmacher declares as a re-
sult of new experiments that a part of the casein phos-
phorus in the faeces is separated out unused.
Berliner klinische Wochenschrift, Jatiuary i, igoo.
Artificial Production of Gout. — H. Kionka calls
attention to the fact that gout is observed in certa-in
animals and birds as well as in man. Ln the common
fowl of the barnyard, gouty manifestations may be
produced by the introduction into the body of chromic,
oxalic, and carbolic acids, acetone, aloin, sublimate,
and sugar candy. Kionka was led to experiment
along this line, and placed a number of hens under
good conditions, confining them entirely to a diet of
chopped lean horse-Hesh which was fed to them twice
daily. They were able to drink as much water as
they wished. After a varying interval averaging
about four months (during which time the fowls ap-
peared perfectly well) they began to show evidences
of a disease which gradually assumed the character-
istics of true gout.
New Words and New Conceptions in Pathology.
— R. Virchow speaks of the signification which has
been given to various medical terms in the past, and
calls attention to the modifications in meaning neces-
sitated by the growth of our pathological studies and
their results. He admits that he himself has been
responsible for the introduction into the nomenclature
of pathology of not a few new words, but finds his
justification in the fact that they were needed. The
fact, too, that they have been received by the medical
world without protest confirms the wisdom of his
choice of terms.
Operation for Fibroma of the Mesentery with
Extensive Resection of the Small Intestine. — F.
Lexer describes the case of a man aged forty-one years
from whose abdomen a fibroma attached to the mesen-
tery was removed along with over six feet of intestine.
The greatest measurement of the tumor was 25 cm.
and its weiglit five pounds. The patient was up on
the twentieth day.
Endemic Bath-Conjunctivitis.— Fehr alludes to a
group of cases of conjunctivitis seen in one of the eye
institutions in Berlin. Investigation showed that the
patients all lived in the same locality and frequented
the same public bath. The disease seemed to be an
infection and at first was mistaken for trachoma. Clos-
ing of the bath checked the spread of the malady.
A Contribution to the Character, Course, and
Treatment of the Recent Epidemic of Trachoma
in Berlin. — P. Schultz insists upon the necessity of a
more frequent«renewal of the water in the swimming
pools of the public baths in Berlin. A description is
given of the methods employed to bring the epidemic
mentioned to a close.
The Significance of Glycuronic Acid in the Phenyl-
hydrazin Test in Urine P. Mayer does not believe
that the presence of this acid in urine vitiates at all
the value of the phenyl-hydrazin test for glycosuria.
A Case of Chyliform Ascites in Syphilitic Cir-
rhosis of the Liver. —By V. Poliakoff. See Medical
Record, vol. Ivii., page 29.
Bulletin de F Academie de Alcdecine, December 26. i8gg.
The Respiratory Reflex and its Fundamental
Mechanism in the Cardio-Respiratory Function, as
Demonstrated by Radioscopic Observation — J. V.
Laborde describes an experiment upon a dog, in which
every step in the process of asphyxiation by means of
a cannula with a stop-cock introduced into the trachea
was observed in detail, thanks to the .v-rays. When
the animal was at the very point of death, rhythniical
tractions of the tongue, without the introduction of
air through the cannula, restored the respiratory and
cardiac mechanism. The introduction of air then
brought the apparently dead animal back to life.
i6o
MEDICAL RECORD.
[January 27, 1900
Remote Results of Perineal Urethrectomy — M.
A. Poncet describes an operation which has for its
object the formation of an artificial perineal meatus,
and reports excellent results in twenty-three cases in
which the operation was performed two, three, five,
and even seven years ago.
Multiple Sebaceous Epitheliomata. — Poncet, Leon
Berard, and Lumiere report the case of an old man
who for forty years has suffered from tumors of the
sebaceous glands which from an anatomico-patho-
logical standpoint are epitheliomata.
La Riforma jSledica, Decetnber 21-28, l8gg.
Variety and Significance of the Encapsulated
Bacilli Frequently Found in the Diseased Nasal
Mucosa. — A. de Simone examined the nasal secretion
in fifty cases of catarrhal rhinitis, and succeeded in
isolating thirty-five kinds of encapsulated bacilli,
some of them possessing the culture characteristics of
the bacillus mucosus, some of Frisch's bacillus, and
ethers of the pneumo-bacillus. He believes that these
bacilli, which so frequently lodge in the pharynx,
migrate into the nasal mucosa, and then cause the dis-
turbances which many writers have supposed to be
due to some special variety of micro-organism.
Apyretic Fevers. — G. B. Ughetti says that the title
of his article sounds like a contradiction of terms, but
insists that fever does not necessarily mean high tem-
perature. He describes cases of typhoid, etc., in which
there was hyperthermia, and gives it as his theory
that in infective apyretic fevers there is usually such
an immense amount of toxin produced, either from the
specific agent or from associated microbes, that their
constant hyperthermic effect is counteracted in some
way as yet unknown.
Vratch, December 2J, j8gg.
The Influence of Suprarenal Preparations in Ad-
dison's Disease. — L. A. Kushnir reports two cases of
Addison's disease in which he made a careful study
of metabolism and of the influence upon it of prepara-
tions of the suprarenal body. In this affection, he
says, metabolic activity is reduced, but it is increased
by the administration of suprarenal extract. He
found the action of this drug was to increase the
rapidity of the pulse and respirations, and to reduce
the appetite. There was no improvement whatever in
the patient's condition ; the pigmentation of the skin
continued and the asthenia increased from day to day.
The conclusion was that there is nothing to hope for
in the administration of suprarenal preparations in
Addison's disease.
Supervision of Prostitution in the Kazan Gov-
ernment in 1897-98.— N. N. Poroshin presents a
statistical study of prostitution, its causes and sanitary
aspects.
French Journals.
Eosinate of Sodium in the Treatment of Epi-
lepsy— Bourneville and Chapotin have undertaken a
series of therapeutical studies upon the composition of
the eosinate, and upon the hypothesis of Le Goffe and
Sainton. The practical results obtained by them
differ from the theoretical hopes as to the advantages
of the remedy. In various experiments the drug was
given in does of 25 cgm., gradually increased until in
the ninth week 3 gm. were administered. A series of
tables and observations upon the various forms of epi-
lepsy are presented. In ninety-four per cent, of cases
accidents implicating the skin chiefly were noted, but
these did not occur when less than 2 gm. were given.
The lesions consisted chiefly in redness followed by
swelling of the face and hands. Later under slight
traumatisms atrophic troubles of severe nature may
come on, with ulceration, etc. The eruptions differ,
as a rule, from those produced by bromism.- — Le Pro-
gres Medical, December 30, 1899.
The Therapeutic Problem of Regeneration of
Organs. — Paul Carnot refers to his work published
last year. From a general point of view we may say
that every time an organ has been profoundly impli-
cated, the only truly curative therapeusis consists in
replacing anatomical elements irreparably damaged
by new cells. The regeneration of organs constitutes
the natural process of cure, developed especially in
the inferior animals and in the young. He studies
the influence of mechanical agents on cellular pro-
liferation, the influence of infectious agents and their
toxins, the influence of nutritive materials on the pro-
liferative activity, and he concludes by showing how
far we are from a complete solution of the problem. —
La Fresse Medicale, January 6, 1900.
Hydrotherapy in Infancy. — J. Combe studies the
question of cold-water bathing, whose adversaries are
beconling more and more scarce, in fevers and acute
diseases. He gives indications and contra-indications.
He thinks that sea-bathing or sea-air is very beneficial
in chronic diseases, especially for city children, but
should be avoided in the nervous, excitable, hysterical,
epileptic, and choreic children. Also when they suffer
from blepharo-conjunctivitis, keratitis, otitis, bron-
chitis, rheumatism, heart disease, eczema, pertussis,
and itching affections, they should be removed from the
sea-side. Rachitic and scrofulo-tuberculous children
should remain months and even years. Repeated so-
journs are probably more beneficial than prolonged
stays. — La Medecme Moderne, January 3, igoo.
The Danger of Administering Chloroform in the
Presence of a Gas-Flame. — G. Maurange refers to
the dangers pointed out by Catrin based upon an arti-
cle in The Lancet, and goes on to give his personal ex-
perience in a number of instances in which chloro-
form, administered in a closed room with the gas
burning, produced in the attendants mucous-mem-
brane irritation with cough, dyspnoea, and a feeling
of malaise. The intoxicating agent is the chloride of
carbonyl, the phosgene gas of Sir Humphry Davy, one
of the products of decomposition of chloroform evap-
orating in the presence of the flame. — Gazette Heb-
domadaire de Medecine et de Chirurgie, December 3 1 ,
Traumatic Intra-Peritoneal Rupture of the Blad-
der.— J. Vichard reviews the whole question, and, in
conclusion, agrees with Pousson that, after having
sponged with care all tissues touched by the urine,
the attempt should be made to suture the bladder in
two planes, one for the mucous and muscular coats and
the second for the peritoneum, unless, for instance,
the mucous membrane has been too much injured.
Catgut is employed for the first plane and silk for the
second. — Gazctie Hchdomadaire de Medecine et de Chi-
rurgie, January 7, 1900.
Complete Section of the Median Nerve at the
Wrist; Suture; Cure. — Albert Monchet gives the
result of operation in a girl aged thirteen years, whose
wrist was cut with glass. The tendon of the palmaris
longus was found cut through; it was sutured, and
after three or four months the wound opened, and the
silk was thrown off; after which permanent healing
took place. — Gazette Llebdomadaire de Medecine et de
Chirurgie, January 4, 1900.
January 27, 1900]
MEDICAL RECORD.
161
Tuberculosis in Workingmen. — Grandmaison says
no occupation is exempt from tuberculosis, and lie
bases his studies on thirty-five patients taken from
various employments. Closed working-rooms are the
chief centres for dissemination. Sanatoria are advised
for the laboring classes, but they will always be in-
sufficient to accommodate all. It is scarcely within
the bounds of realization that a city can protect itself
against the dissemination of this disease by the work-
ing classes.- — La Fresse Modernc, January 3, 1900.
Senile Atrophy. — Weinberg give a resume of a
critical study which Metchnikoff has himself made
during the past year of his researches relating to the
prevention of senility. Documents are still too few
to determine the cause and mechanism of senile atro-
phy. It is to be hoped that the day will come when
serums obtained by the aid of appropriate elements
may counteract atrophic and hypertrophic lesions of
organs. — La Fresse Medicale, January 6, 1900.
Dysenteriform Enteritis. — H. Roger gives a bac-
teriological research into the cause of an epidemic of
dysentery nostras, illustrated with culture results. He
describes a bacillus differing from those previously
found, and thinks his observations show the existence
of a special form of dysenteriform enteritis. — La
Fresse Medicale, January 3, 1900.
The Fhysician and Surgeon, December, i8gg.
The Contagiousness of Pulmonary Consumption.
— Ernest L. Shurly questions whether tuberculosis is
contagious in the ordinary acceptation of the term,
and does not believe that the individual right of
patients should be prejudiced by the method of re-
porting his name or quarantining him. He agrees
with Professor Hueppe that strict cleanliness, fresh
air, and proper marriage relation will do more toward
the prevention of tuberculosis than any quarantine
measures. In any case it is for the medical profes-
sion and not for sanitary boards of laymen to decide
the matter.
Sympathetic Ophthalmia. — M. R. Beaudoin-Ben-
nett thinks that in this affection operative interference
has no place, the only admissible operation being
scleral incision or puncture after the subsidence of
the acute symptoms, if there is extreme tension.
Uterine Fibroids W. P. Manton believes that
when these growths cause pain, hemorrhage, and dis-
comfort, medicinal and electrical treatment means time
wasted, and eradication is the only rational measure.
Tuberculosis of the Peritoneum. — Hal C. Wyman
reports and describes several cases of this nature
The leading feature was always an ascites not to be
accounted for by other diseases.
A Survey of Modern Therapy. — Frederick McD.
Harkin thinks that if we will endeavor not to over-
dose our patient, and if he has an enduring constitu-
tion, he will very likely get well in spite of our medi-
cation.
Conservatism in Medicine and Surgery. — By
Frederick W. Robbins. The retiring president's ad-
dress before the Detroit Academy of Medicine.
A Case of Hip-Joint Amputation by Wyeth's
Bloodless Method.— By R. B. Baird and G. L. Cornell.
Medicine, January, igoo.
A Study of Aural Vertigo. — Lewis S. Somers
states that vertigo may be objective or subjective, two
groups of phenomena being invariably associated with
the affection, the first being the motor disturbances,
the second circulatory. Aberrant vasomotor disorders
are frequently noted, such as sweating and superficial
congestion, while nausea and weak pulse are quite
frequent. Anaemia, hyperemia, and inflammatory
changes may cause vertigo. It may be of cerebral or
ocular origin. It may depend upon disorders of the
viscera or toxaemia. The sudden suppression of long-
continued discharges is sometimes attended with this
symptom, and it also takes place in lithaemia, while
reflex vertigo may result from affections of the stomach
and uterus. The labyrinth is an indispensable factor
in its production.
Some Considerations in Sugar Testing, with De-
scription of a Method for the Detection and Esti-
mation of Sugar in the Urine. — Arthur R. Elliot
submits the following reagents:
I. Sulphate of copper, c. p gr x.wii.
Glycerin, c. p 3 iij.
Distilled water 1 iiss.
Liquor potass;e q.s. ad 3 iv.
Dissolve the sulphate of copper in the glycerin and
water; gentle heat will facilitate solution. When
cool, add the liquor potassa;, mix thoroughly, and filter.
2. A saturated solution of c. p. tartaric acid in dis-
tilled water. Method: A drachm of No. i is brought
to the boiling-point in a test-tube; 3 drops of No. 2
are added and the solution is boiled again. The urine
is added drop by drop, boiling and shaking the test-
tube after each addition until reaction. If no change
follows the addition of eight drops of urine, sugar is
not present.
Nursing in the Lying-in Period.— Gustav Kolischer
calls attention to a few important points to be observed
in nursing during the puerperium. He approves of the
administration of ergot after confinement. Micturition
should be watched but the catheter avoided if possible.
If there is pain in the pelvic articulations, a firm
bandage should be applied. Fissures of the areola of
the nipples should be cauterized. If the bowels are
obstinate the faradic current should be employed.
Spondylitis Deformans, Spondylarthritis, or Os-
teoarthritis of the Spine. — O. M. Steffenson considers
this a chronic affection of the vertebrce, producing
osteophytes between their articular surfaces, which
terminates in partial or complete ankylosis of the
spine. Efforts at increasing the nutrition of the pa-
tient, and the use of tonics, are followed by the best
results.
Secondary or Membranous Cataract.— Henry D.
Noyes describes the operation through the sclera by
the knife-needle for secondary cataract. He com-
mends the method for general adoption in this affec-
tion, having found it, from his own experience, prac-
tically devoid of serious risks.
Serious Heart Disease Without Rheumatism ; A
Further Report. — A. L. Benedict declares that while
rheumatism is especially related to endocarditis,
nevertheless, scarlet fever may produce the lesion as
well as the other infectious diseases. To support his
statement he reports a number of cases.
Annals of Surgery, January, j-goo.
The Employment of Local Anaesthesia in the
Radical Cure of Certain Cases of Hernia, with a
Note upon the Nervous Anatomy of the Inguinal
Region. — Harvey Gushing tabulates notes of thirty
cases of hernia operated upon under cocaine anaes-
thesia. Interesting diagrams are given showing the
areas of anaesthesia produced by the injections. The
solution employed was cocaine mur. o.i, morph. mur.
l62
MEDICAL RECORD.
[January 27, 1900
0.02, sodii chlor. 0.2, aq. dest. ad loo. The advan-
tages are absence of vomiting and retching, less lia-
bility to urinal disturbances, rare necessity of cathe-
terization, and ability to operate safely in patients
who would not bear a general anajsthetic. The disad-
vantages are the longer time required for operation
and the infliction of a certain amount of pain.
Note on Mortality After Operation for Large
Incarcerated Herniae. — H. O. Marcy reports two fatal
cases. The object of the paper is to discuss how we
are to determine the danger to life because of the in-
crease of intra-abdominal pressure. When any con-
siderable portion of the abdominal contents has been
for a long time displaced, Marcy thinks it advisable
to keep the patient for quite a while in bed with a
limited diet and moderate purgation : this lessens the
amount of abdominal contents and thereby occasions
a corresponding reduction in the hernial contents to
be returned. In even a greater degree will the ab-
dominal wall be thinned and relaxed.
The Surgical Aspects of the Modern Small-Bore
Projectile. — A. Schachner discusses the change in the
character of projectile wounds as illustrated by recent
wars, and considers the conditions governing the be-
havior of projectiles in general. He sums up the
results of his discussion in thirteen distinct conclu-
sions, emphasizing the fact that the rotary action of
projectiles may continue after the penetrative action
ceases, and that the character of the wound is partially
dependent upon this rotation.
On Vesico-Urethro-Vaginal Fistula.— J. S. Hors-
ley describes a successful operation for this lesion
done on a primipara of twenty-two years. Nearly all
of this class of cases require several operations before
cure is complete.
Mammoth Ovarian Tumors. — P.y J. B. Bullitt.
See Medical Record, vol. hi., p. 570.
British Journal oj Dennato!oi::}\ January, jgoo.
Multiple Epithelioma Developing upon Lupus
Erythematosus J. J. Pringle adds one more to the
extremely limited number of cases in which epithe-
lioma developed upon a patch of lupus erythematosus.
Among previous cases two liave been reported in this
country, one by Riesomeyer in the .SV. Louis Courier,
1 885, and one by J. D. Wyer, in the 'J'exas Medical
Journal, 1892-93. Dr. Taylor, of Liverpool, has seen
two cases, and Kreibich, Kaposi's assistant, is about
to publish an instance, from which quotations are
made from the advance sheets.
A Case of Chronic Interstitial Nephritis ; Der-
matitis Exfoliativa ; Uremia ; Death. ^Sir Dyce
Duckworth relates the history of a woman who died
with ura^mic symptoms after presenting the signs of
pityriasis rubra, or dermatitis exfoliativa, such as is
usually encountered in elderly people.
Pciliatrics, January /j, igoo.
An Enlarged Liver in Rickets. — R. Turnstell
Taylor reports the case of a boy, two and a half years
of age, who, up to the age of one year and nine
months, seemed healthy. He then had fever, followed
by Parrot's paralysis, and the diagnosis of rickets was
made. On admission, the case was a typical one of
rickets. Everything was against the specific origin,
but because improvement did not take place under
other means inunctions were begun, when improve-
ment was rapid and progressive. The case, the author
thinks, points to a relationship between syphilis and
rickets, and suggests, in all cases of rickets in which
the liver is enlarged, that antisyphilitic treatment
should be instituted, although the history may be neg-
ative as to its specific nature.
A Case of Patent Meckel's Diverticulum. — R.
Abrahams gives an instance in which during the first
week it was noted that the cord became inflated at its
distal end when the baby cried. The cord soon fell
off, when an elongated mass, an inch and a half long,
protruded from the umbilicus, simulating highly con-
gested mucous membrane. A probe passed into its
central opening entered the abdominal cavity, and
when it was withdrawn fiisces were seen upon its tip.
Fecal matter and flatus escaped. The tumor was
ligated and excised, and the stump cauterized, with
resulting cure. Four months later the diverticulum
was found still closed.
Alveolar Catarrh in Children. — J. C. Gettings and
Charles H. Judson relate instances of this condition,
which was described by Douglas Powell. They also
present the conclusions reached by Duerck and Beco.
They suggest the possibility that alveolar catarrh may
originate and run its course without the agency of the
tubercle bacillus, that the lesion resulting may offer a
suitable nidus for the growth of the bacilli, and, though
the number of cases is small, the physical signs are
sufficiently definite to warrant a classification under
this heading.
Congenital Lateral Curvature of the Spine —
Henry Ling Taylor reports two cases of this deform-
ity in children aged three months. Ketch made a
study of two hundred and twenty-nine cases and found
that a great number occurred before the age of twelve
years, and Eulenberg found five cases under one year
of age in one thousand examined.
Deutsche Aerste-Zeitiing, January i, igoo.
Carbonic Oxide in Tobacco Smoke. — C. Binz says
there are three kinds of poison in tobacco smoke; (i)
nicotine; (2) that which is obtained by the slow ash
formation, pyridin, etc. ; (3) carbonic oxide. The re-
sults of his studies of the question are given in the
following conclusions: (i) Carbonic oxide is always
easily shown to be present in tobacco smoke. (2) Its
percentage, depending upon the volume of the smoke
gas, varies ijetween 0.6 and 7.6. The variations de-
pend upon the rapidity of the ash formation and the
quantity of atmospheric air drawn in or the lung-air
blown out. (3) A never-so-slight acute poisoning
from carbonic oxide of to'bacco smoke is, under ordi-
nary conditions, scarcely to be expected. (4) VN'hether
the daily taking in of the small quantity of carbonic
oxide which, tiirough many years of smoking, gets into
the blood of smokers, cannot set up a chronic injury,
is a question still to be settled. For the qualitative
determination of small quantities of carbonic oxide
in the blood tiie test with tannin in definite watery
solution, and at a temperature of about 40^ C, is bet-
ter than that by the spectroscope alone or that with
the spectroscope and ammonium sulphide.
Tetanus and its Treatment.- I".. Stadelmann says
that in a disease like tetanus, which may recover spon-
taneously, a definite conclusion as to the result of se-
rum treatment is difficult to establish. The views of
von Jaksch and others are given, and four cases are
briefly related. Ordinary tetanus he believes starts
from the spinal cord and not from the brain, it is,
therefore, rational treatment to inject the serum into
the canal, and in the future it is his intention to inject
part of the serum into the vein, and part intradurally
by lumbar puncture.
January 27, 1900]
MEDICAL RECORD.
165
Pneumothorax in Secondary Sarcoma of the
Lungs. — Ulrich Rose quotes the statistics of Bich,
who shows that malignant tumors of the lungs are rare
precursors of pneumothorax. Out of twentj'-one cases
of pneumothorax one showed multiple secondary sar-
coma of the lung as the cause in a woman forty-five
years of age. Morphine is here naturally to be advised
more than in any other form of pneumothorax.
Zeitschrijt Jiir Diat. it. Phys. Thera/>ie, Decetnbcr, iSgg.
Treatment of Nephritis with Mineral Waters
and Baths. — Felix Schlagintweit has treated one hun-
dred cases of Bright's in various forms and stages at
Briickenau. In chronic diffuse nephritis the diuresis
is markedly increased, and the specific gravity rarely
shows a tendency to fall. There is usually a decrease
in albumin, sometimes an increase. After the admin-
istration of mineral waters and milk the specific grav-
ity and percentage of albumin may vary thus: (a)
Specific gravity sinks, albumin remains the same; (b)
specific gravity and albumin sink; (r) specific gravity
sinks, albumin increases; (d) specific gravity in-
creases, albumin remains the same; (e) specific grav-
ity and albumin increase; (/) specific gravity and
albumin remain the same.
The Border Line of Normal Temperature. — Marx
concludes that(i) the temperature in health is nor-
mally under 37° C, and usually between 36 and 37 C.
(2) Occasional rises of 37.2° C. are observed in
health, but are attributable to special circumstances
(indigestion, fever). (3) Temperatures above 37.2
(". are usually combined with subjective symptoms
and thus out of the normal. (4) Temperatures under
36° C. occur without collapse. (5) Many phthisical
patients have temperatures varying within the normal
boundary.
Fermentation of Slowly Fermenting Sugars. —
Ernst Bendix shows that such sugars as milk sugar,
galactose, and xylose, which have heretofore been con-
sidered as slowly fermenting, or not at all capable of
fermentation, are, after the addition of various organic
substances (pancreatic powder, organ powder, liver
powder, spleen, ovarian, and intestinal powders) eas-
ily fermented by certain bacteria.
Experimental Observations upon the Excretion of
Hydrochloric Acid in the Human Stomach with
Various Food-Stuffs. — Chr. Jiirgensen and J. Jus-
tesen give at length secretory phenomena of the stom-
ach with various food-stuffs, as shown from experi-
ments. The gastric contents were aspirated at various
periods and tested. A table of cases and charts ac-
company the article.
Bathing and Swimming from a Hygienic Stand-
point.— Julian Marcuse claims that bathing and swim-
ming produce a variety of hygienic effects, which prove
from a prophylactic standpoint an excellent protection
against the invasion of disease. They perfect the
skin, harden and strengthen the body, and benefit tiie
heart, lungs, and nervous system.
Aix las Bains in Savoy : Sulphur Baths ; Douche
Massage. — Von Leyden gives a description of this
bathing-place and its baths. Douche massage as prac-
tised here is described. Patients suffering from gout,
asthma, chronic joint affections, neuralgia, paralysis,
muscular atrophy, and syphilis seek treatment at this
place.
Therapy of Impotence By J. Zabludowski. — See
jMedical Record, vol. Ivii., p. 120.
Archives Generaks de Medeciiie, January, jgoo.
Glossodynia — C. Chauveau classifies this affection
in the following manner: i, Glossodynia secondary to
neuralgia of the trigeminal; 2 glossodynia of the
insane; 3, tabetic glossodynia; 4, hysterical glosso-
dynia; 5, rheumatism of the tongue muscles; 6, glos-
sodynia from local causes such as dental affections,
pharyngeal granulations, hypertrophy of the posterior
pillars of the fauces or of the tonsil, lingual varices,
chronic glossitis, and especially papillary hypertrophy
of the " foliaceous region '' first described by Albert.
Pain is the chief symptom. The use of the galvano-
cautery is the best treatment.
Umbilical Tumors.— Nicolas Giannettasio reports a
case in a woman, aged forty-four years. The tumor was
the size of a walnut, and was situated partly within
the umbilicus. It was removed and the patient made
a good recovery, there b'eing no trace of a recurrence
two years later. The histological examination showed
that the neoplasm was a fibrous myxoma. Many par-
asites belonging undoubtedly to the blastomycetes
were found in the peripheric, growing portions of the
tumor.
Unusual Resistance and Tolerance of the Organ-
ism and the Liver to Alcohol — Dr. Follet reports
the case of a man, aged forty-eight years, who died of
pneumonia, who for thirty years had taken at least
three litres of red wine daily, besides several appe-
tizers. The liver, kidneys, and the organs were
normal.
Caseous Infection in Pulmonary Tuberculosis. —
M. Solies and M. Baillet, whose work is reviewed by
Henri Benjamin, hold that the bacillus kills the pha-
gocytes and transforms them into a mass of dead cells,
/.(•., tubercles. As a result each tubercle is transformed
into casein, which constitutes phthisis and causes
death.
Laennec's Cirrhosis in the Preascitic Stage. —
Emile Boix reports and describes a case due to alco-
hol and daily drinking of a litre of black coffee. It
was cured by milk diet, calomel, and salol.
Preparalytic Hemichorea. — E. Boinet reports two
cases of this rare affection, which bring the number
up to thirteen of known cases due to hemorrhagic foci
or to cerebral softening.
Origin of the " Charite " Hospital of Paris P.
Tillaux gives the history of this celebrated institu-
tion, which is soon to be torn down by order of the
municipal council.
Diseases of the Respiratory System. — By Louis
Renon.
Revista Ihero-Amerkana de Ciencias Med., Dec., i8gg.
Sciatic Neuritis — M. Otero Acevedo gives the re-
sult of a study of 276 cases of sciatica, of which 203
occurred in males. There was one case in a child of
eight years, and four in children from eleven to four-
teen years of age; the greatest number of cases was
in individuals between forty and fifty years old: only
two of the patients were over seventy years of age.
The most common cause was rheumatism (145 cases):
then cold and wet (85), trauma (18), influenza (7),
malaria (5), gout (2"), and hysteria (i) ; in 13 cases
the cause was not definitely recorded. The author
makes a sharp distinction between sciatic neuralgia,
which is purely a symptom, and sciatic neuritis, which
is a disease. The neuralgia always precedes and ac-
companies the neuritis, and there are cases of the lat-
164
MEDICAL RECORD.
[January 27, 1900
ter in which pain is the only symptom, but the pain
of neuritis is deeper and more continuous than is that
of neuralgia sine materia.
Treatment of Pneumonia at the Beginning and
at the End of the Nineteenth Century. — Federico
Rubio makes a comparison of the treatment of pneu-
monia at the beginning of this century with that in
vogue at the present time. The main reliance of the
therapeutist then was on bloodletting and counter-irri-
tation. Now, some resort is still had to counter-irrita-
tion, but apart from that therapeutic nihilism pre-
vails. In comparing the results of these two methods,
the author inci ines to regard the abandonment of blood-
letting as a distinct loss; the practice was formerly
abused, no doubt, but this is no excuse for the present
neglect. The antiphlogistic treatment of the begin-
ning of the century left the organism more weak, per-
haps, but it left the organs with fewer lesions.
Phosphaturia. — F. Murillo studies a case in which
the relation between phosphaturia and hyperchlorhy-
dria was manifest, and concludes that in many cases
the hyperchlorhydria is the determining cause of the
phosphaturia. In the case reported, however, the pa-
tient was neurasthenic and arthritic, and the author
believes that arthritism, which is thought by many to
be tlie cause of neurasthenia, was also here the cause
of the hyperchlorhydria. He opposes the view of
Klemperer that phosphaturia is not a result of hyper-
chlorhydria. but is rather a manifestation of disease
of the nervous system. He holds that the gastric dis-
turbance and the nervous e.xhaustion are concomitant
affections, neither dependent on the other, but both
due to a precedent arthritism.
Surgical Neurology. — Eulogio Cervera reports two
cases showing the benefits of surgical treatment in
certain nervous affections, and demonstrating also the
advances of modern surgery in the direction of greater
conservatism. The first was one of degenerative le-
sions in the lower e.xtremity following section of the
sciatic nerve in a stab wound. An incision was made
close to the cicatrix and the divided ends of the nerve
were freshened and sutured. The man made an excel-
lent recovery. The second case was one of disloca-
tion of the ulnar nerve of eighteen months' standing,
accompanied by neuritis. An incision was made, and
the nerve was exposed and returned to the epitrochleo-
olecranon gutter. The pain was relieved and the man
recovered with full use of the forearm and hand.
A Gigantic Lipoma of the Neck.— Juan de la Sola
y Lastra reports the case of a boy, eight and three-
fourths years old, who had a tumor depending from
the right side of the neck which rested in his lap as
he sat on a chair. The circumference of the pedicle
was 40 cm., of the widest part of the tumor 70 cm., and
its weight was 7.8 kilos (over 17 pounds). Thetumor
was noticed at birth as a small projection the size of
a hazelnut, and had grown steadily. The growth was
removed and tlie boy made a good recovery. The mi-
croscopical diagnosis was a fibro-myxo-lipoma.
Anatomy of the Ethmoidal Cells P. L. Pelaez
Villegas says that the arrangement of the ethmoidal
calls is exceedingly variable, and in consequence there
is no regularity in the topography and arrangement of
the openings leading to the frontal, maxillary, and
sphenoidal sinuses. He proposes a new division of
the etiimoidal cells in place of the classical division
into anterior and posterior.
A Rare Lesion of the Hand. — Antonio Martinez
reports the case of a woman whose left hand was
greatly swollen; on the dorsum were several ulcers
which gave exit to a lymphatic fluid, and the fingers
were flexed. An incision showed the presence of
sclerotic tissue, and then an investigation brought out
a history of hereditary syphilis. The patient was sub-
jected to an antisyphilitic treatment by mercurial in-
unctions and large doses of potassium iodide alter-
nately, and a speedy cure was obtained. The author's
diagnosis was syphilitic sclerosing periangitis.
The Book, the Review, and the Periodical.^
Federico Rubio compares these .three forms of scien-
tific literature, giving the preference i\j general to the
review over the book.
Application of the Experimental Method in the
History of Medicine. — Under this title Luis Co-
menge gives a sketch of the early history of medicine
in Spain.
Four Cases of Tubal Pregnancy. — G. Abascal re-
ports four cases of this nature in which operation was
performed at an early period.
An Operating-Table. — R. Martin Gil describes and
pictures a new operating-table, the position of which
can be varied in numberless ways.
// Polhlinico, December ij, l8gg.
Experimental Researches into the Pathogenesis
of Concussion of the Brain and Spinal Cord. —
Francesco Saverio Cavicchia and Umberto Rosa in
all their experiments have observed spasm of the
blood-vessels in the early stages of concussion. Ma-
croscopic and microscopic examinations have given
absolutely negative results. The degenerative lesions
observed by Schmaus and others they believe to be
the result of more serious lesions in the spinal cord,
rather than of simple concussion.
Ovarian Cysts Alberto Pepere concludes that in
the genesis of follicular cysts, at least in a certain
number of cases, the epithelial cells of the follicle
play the chief part. Cystic adenomata may arise from
the papillary residua of the hilum, or from the epithe-
lium covering tlie superficies of the ovary. These new
growths may become intensely malignant, while retain-
ing their glandular formation. The majority of der-
moid cysts are to be regarded as productions with an
embryonal character of the ovum cell, rather than as
fcetal inclusions.
The Treatment of Hemorrhage in Pregnancy —
J. Keogh Murphy considers that accidental hemorrhage
is not due to external injury, but to disease of the uterus,
often accompanied by kidney mischief. When con-
tractions are present, rupture of membranes and deliv-
ery will suffice; when absent, vaginal plugging, uterine
binding, and general stimulation should be used, until
the cervix dilates sufficiently to allow of delivery. If
internal hemorrhage continues, Porro's operation will
probably have to be performed. Saline infusions,
rectal, subcutaneous, or intravenous, can be used with
gooA&'A^cX.^ Treatment, December 28, 1899.
Irido-Choroiditis due to Intestinal Auto-Infection.
— Elia Baquis reports a case in which tlie eye symp-
toms were clearly referable to prolonged attacks of
enteralgia and obstinate constipation. That there is
a close connection between intestinal lesions and dis
eases of the eye is well known. Given an infected
area in any part of the organism, distant portions may
be affected by living germs or their toxic products. In
the case reported the author believes that the process
was a ciiemical one. Toxic products of digestion, not
having been eliminated, were absorbed into the circu-
lation and injuriously affected the eyes. — La Settimanu
Medica, December 23, 1899.
January 27, 1900]
MEDICAL RECORD.
16c;
A New Combination for hypodermatic injection in
syphilis is the following:
^ Hydrarg. chlor. mit gr. Ixviiss.
Orthoform gr. xij .
01. petrolat 3 iiss.
M. S. From fifteen to thirty drops can be injected: secur-
ing the analgesic effect of the orthoform.
■ LOZA.
Vaginal Irrigation for leucorrhoea:
I^ Potass, chloral 12 parts.
Vini opii lo "
AqujE picis 300 ' '
M. S. Add two or three drachms to a quart of warm water.
■ — LUTAUD.
In Mercurial Stomatitis. —
I? I'otass. chlorat 3 v.
Sapo. medic 3 iiss.
Calcii carbonat 3 v.
01. menth. pip '. . . . fH xv.
01. carj'ophylli ni iv.
M. S. Use as dentifrice.
— Practitio7ier.
Neuralgia of the Face. —
'S, Butyl chloral hydrat. ,
Spt. vini rect aa 3 iiss.
Glycerin! 3 v.
Aquce § iij-+ 3 vi.
M. .S. A teaspoonful once or twice daily.
— Progres Aledical.
Cough in Phthisis
IJ Codein gr. iss.
Terpin. hydrat gr. xv.
Ext. hyoscyami gr. iss.
Ext. belladonna gr. ll
Mas. cyroglossi gr. viiss.
M. ft. pil. No. X. .S. One four times daily.
— Joiirn. des Pratic.
Digestive Infections in infants at the breast.
I^ Uenzo-naphtliol o. 30-0. 50 cgm.
Cretfe prceparat.,
Bismuthi subnit aa 2-3 gm.
Mucil. acac 60 "
Elix. paregoric gtt. vi.-xij.
M. S. Shake and give a teaspoonful every hour, decreasini;
as improvement occurs.
— SCHOUI.L.
Painless Blister
I^ Mentholis,
Chloralis aa gr. xx.
Ci\. theobrom 3 ss.
Spermaceti 3 i-
M. ft. past. S. Apply.
A General Antidote for Poisons. — Borate of sodium
mixed with milk is said to be the best general anti-
dote after the stomach has been emptied. For vege-
table poisons permanganate of potassium in one-per-
cent, solution. For carbolic acid, vinegar. This is
said to act well also externally.
Acute Alcoholic Delirium.—
If Chloralamid gr. xv.
Hyoscin. hydrobrom gr. fiir
IVI. S. Also useful in acute alcoholic mania.
— D. R. Brower.
Vomiting in Phthisis. —
R Cocaine 0.25 cgm.
Elix. cinchonre 20 gm.
AquEe 150"
M. .S. Dessertspoonful every two hours.
— Barie.
Or—
If Menthol i gm.
Spt. vini gal , . . . 20 "
Syr. simp 30 "
M. S. Dessertspoonful in a little water every hour.
— LiCHTENSTEIN.
Seborrhoeal Eczema. —
If Sulph. prai'cip 10 gm.
Spt. camphor.-e 10 "
AqUiT; 2;o "
M. S. Apply.
— HiLLAIRET.
Bronchitis. —
If Terpinol,
Sodii benzoatis aa gr. ij.
Sacch. alb q. s.
Ut ft. pil. No. i. S. Six to twelve daily.
Arthritis. —
If Ext. hyoscyami gr. xv.
lodoformi gr. xxx.
Sodii salicylat 3 iss.
Petrolat ad 3 v.
M. S. Apply externally.
— Therapist.
Goitre.^
If Zinci sulphat.,
Ac. salicylici.
lodoformi aa 3 ij-
.•\c. boric 3 iij.
Ac. oleic 3 \'i' j •
Keep at boiling heat for several hours, pour off the
liquid, and bottle when cold. Apply by friction twice
daily until slight desquamation occurs; after this once
daily. — Charette.
Anaesthesia of Urethra. —
If COCIE I
Aqua; 10
M. S. Apply.
— Her.max.
Bromoform Syrup. —
If Bromoform ni xl.
Tinct. aconit IH I.
Syr. codein 3 iss.
Syr. tolu,
Syr. rhoead aa 3 ivss.
.Spt. vini rect 3 iiss.
M. S. Graduate dose according to age in pertussis, pneu-
monia, and bronchitis after measles.
— Med. and Surg. Bull.
Hemorrhoids. —
If Tinct, camph. comp 3 i.
Camphome 3 i.
Ung. bellad 3 xv.
M. S, Apply.
— Nehigax.
Palatable Effervescing Quinine —
If Quinin. sulphat 4
Acid, citric 10
Syr. simplicis,
Syr. aurantii cort aa i
Aqus destillat q.s. ad 20
M. S. Add ten or more drops to 50 gm. of water contain-
ing 30 cgm. of bicarbonate of sodium.
— Therapist.
Influenza. — In twenty cases treated by A. Claus there
was remarkable amelioration of pain, fever, etc., after
from two to four half-grain doses of salophen.
Succus Cinerariae Maritimae is said to act in the
absorption of cataract when dropped into the eye daily,
two or three drops at a sitting. The editor of E.xpe-
rience says of it, that in many instances the results
are "nothing short of miraculous."
Permanganate of Potash in Dysentery is recom-
mended in the form of injections by Gastinal, who
gives to adults about 500 c.c. of a solution equal to
0.5 gm. to the litre and at a temperature of 45^ R.
For children 0.2 gm. and for very young children o.i
gm. to the litre is recommended. The injections,
which are to be retained from one-half to two minutes,
must be given slowly; being preceded by a cleansing
enema and followed by an hour's rest in bed. Their
action is both astringent and antiseptic. Excellent
results are said to be also obtained in proctitis.
1 66
MEDICAL RECORD.
[January 27, 1900
Ororresponttcncc.
OUR LONDON LETTER.
(Fronjour Special Correspondent.)
CLOSING CENTURY OF COLLEGE OF SURGEONS — BRAD-
SHAW LECTURE — ARCHIVES OF NEUROLOGY THE
WAR — THE SCIENTIFIC BRANCHES OF THE ARMY —
SMALLPOX AT HULL — DEATHS OF VETERANS —DEATH
OF SIR JAMES PAGET — THE CINEMATOGRAPH IN TEACH-
ING OPERATIVE SURGERY— NEW YEAR'S HONORS —
A LIVINGSTONE EXHIBITION — " LANCET " RELIEF FUND
— INFLUENZA.
London, December 29, iSgo.
The closing year marks the close of a century since
the Royal College of Surgeons received its first char-
ter in iSoo. Mr. H. G. House, who is the senior vice-
president, delivered the Bradshaw lecture at the col-
lege on the 13th inst., and marked the occasion by
taking for his subject "A Review of Surgery during
the Past One Hundred Years." But it was a large
order, and could not be executed in a single lecture
except in the form of a few samples. So Mr. Howse
discoursed of amputations and epidemics, leaving a
host of other subjects untouched. Most of the time
was, in fact, devoted to infectious diseases (anthrax,
typhus, typhoid, diphtheria), as the lecturer thought
that in this direction there is the most hope of advance
in the immediate future. In some of these diseases
advance has been made by methods which differ in
different cases, and which are most likely susceptible
of further improvement. But in most zymotic diseases
we still are searching for clear, easily applied diag-
nostic tests. The need of such a test for tetanus was
illustrated by reference to Larrey's memoir, in which
cases were included among jiis illustrations which evi-
dently were not tetanus at all. This was for want of a
definite test, for which we are still searching and which
the new century may give us.
While admiring the great advances of the last one
hundred years and hoping for similar progress in the
next, encouraging our bacteriologists and pathologists
to persevere in their investigations, Mr. Howse con-
cluded with a word of warning on the tendency to con-
clude too much from a single instance. Errors in this
direction will produce more serious errors in the future.
We are too apt to be dogmatic in our views which fur-
ther knowledge may oblige us to modify. Nowhere is
this more strikingly shown than in the rapid changes
of antiseptic and aseptic details in the treatment of
wounds. " It may reasonably be doubted how far
some of these are really scientific and how far they
are mere fads." Mr. Howse clenched this remark by
quoting a saying of the late Master of Trinity: "We
are none of us infallible; no, not even the youngest
of us."
The day after his lecture Mr. Howse, as vice-presi-
dent, took the chair at the council of the college in
the absence of the president. At this meeting he re-
ceived a formal vote of thanks for the lecture and was
requested to print it. The council further agreed
upon its usual /w/i possmnus in reference to the reso-
lutions carried at the annual meeting of fellows and
members. The council also considered the great
clothes question, settled how much narrower the crim-
son facings of the member's gown must be than those
on that of the fellows, and gave the tailor a good ad-
vertisement. It is really very amusing to see these
eminent surgeons discussing the cut of a gown ; but
they went oiie better than this and formally resolved
that "members who are graduates of universities shall
be entitled, if they please to do so to wear their uni-
versity gown on the occasions on which the member's
gown may be worn." I cannot tell you which of tlie
councillors originated this ridiculous resolution. He
may pride himself on the success of his joke, but it
seems rather hard to reduce the proceedings of the
council below the level of broad farce. The council
having assumed the right to authorize gowns for fel-
lows and members, now seems to arrogate to itself the
further authority to tell graduates of the universities
when they will be graciously permitted to wear their
legally authorized gowns.
If any of your readers desire to follow up my ac-
count of the late debate on tabes and general paralysis
of the insane, they will find material for further study
in the "Archives of Neurology from the Pathological
Laboratory of the London County Council." This
work extends to five hundred and fifty pages and has
many illustrations. It is edited by Dr. F. W. Mott,
F.R.S., who opened the debate at the Pathological
Society, and is issued by the county council at \^s.
It is to be followed by other volumes annually. You
will remember that when the Claybury Asylum was
built the county council determined to erect and fit up
a first-rate laboratory for neurological research. This
was done, and Dr. Mott was appointed director. A
better appointment could not have been made, and the
account of Dr. Mott's researches and those of his col-
laborators will interest all neurologists. These re-
searches are original and well planned. They deal
with questions that are surrounded with difficulties
and doubt, eschewing the restatement of those which
are settled. The questions relating to general par-
alysis, tabes, and syphilis are stated with clearness,
and the investigations respecting them bulk largely in
the " .\rchives." Other neurological researches are,
however, reported, all of which are of the highest im-
portance.
The war in South Africa is absorbing the attention
of all classes, and already reputations seem to be
ruined by the neglect and folly of some at the Jiead of
affairs. It is satisfactory to find that up to the pres-
ent the medical department has come out of the trial
with great credit, although it has been half starved by
the War Office and reduced to such a dangerous degree
that large numbers of civil surgeons have been hastily
engaged for service both at home and abroad. Four
additional consultants have also been engaged to go
to the front, viz. : Sir William Stokes, surgeon to the
Queen in Ireland, who sails to-morrow, and Mr. Ken-
dal Franks, surgeon to the lord-lieutenant, and at one
time resident in Johannesburg. These will well repre-
sent Irish surgery, so we may hope to hear no more of a
grievance on the score of Dublin men being forgotten.
From London, Messrs. Watson Cheyne and G. L.
Cheatle, both of Kings College, will start shortly.
Professor Ogston is also off to the Cape, but not on
the government's behalf. He is going as an indepen-
dent observer. You will remember his criticism at
Plymouth on the way in which the army and navy
medical departments are managed.
No fault can be found with the selection of the gov-
ernment if civil surgeons are to go. But what a reflec-
tion it is on the War Office and its boasted readiness!
Nemesis seems on the track of Lord Wolseley. He
has followed tiie evil example of his predecessor in
starving the medical staff and insulting its members.
Now at the first brush he has to acknowledge he must
supplement it with civil surgeons — the civilians he
has so much despised. That he blundered, too, in his
estimate of the enemy's resources he has had to admit
publicly. Now we are lamenting that he was allowed
to abolish the cliief office of artillery, and that against
the opinion of every expert. So our guns are too few
and too feeble. Wliat has this to do with the medical
department.' Much in every way. The public can-
not well understand the medical position, but the fail-
ure of the artillery is obvious and provokes a demand
Jajjuary 27, 1900J
MEDICAL RECORD.
167
for immediate change of the system and removal of
the man, whoever he may be, who is responsible. The
commander-in-chief of course is the expert'of the govern-
ment; as such Lord Wolseley represented that every-
thing was ready. He pooh-poohed all suggestions
from those who know the country, and relied entirely
on the infantry, despising, as he always has done, the
scientific branches. His ineptitude is further mani-
fested by the sight of his officers scouring the two
hemispheres for horses, because he would not accept
those on the spot; calling for volunteers because he
fancies Cape horsemen are "mere civilians"; and
snubbing the engineer, artillery, and medical depart-
ments out of sheer prejudice against scientific corps.
Surely the revenge of these corps is at hand! But
alas, the tragedies that are bringing it about! "
The epidemic of smallpox at Hull has held its
ground, and between seven hundred and eight hun-
dred cases have been reported.
Death has been busy among our aged brethren.
James Adams, of Aberdeen, died on 'he 20th inst.,
aged eighty-two years; J. F. Hodges, of Belfast, on
the 13th, aged eighty-four years; R. H. Meade, of
Bradford, aged eighty-five years, on the 23d; Andrew
Spearing, of Belfast, aged seventy-four years, on the
17th; J. E. Brodie, of Glasgow; F. J- -^. Waring, a
retired surgeon in the Royal Navy, of Hove. These
and other veterans have well served their generation
and left their memory green where their lot was cast.
The death of William Cadge, of Norwich, was an-
nounced this week, but was afterward contradicted.
He has been very ill with influenza, but I hear to-day
there is hope of his recovery.
Januarj- 3. 1900.
Paget is dead. With these three words doctors
greeted each other on Sunday, for the great and vene-
rated surgeon died on Saturday night, "full of days
and full of honors." For many years Sir James Paget
occupied the foremost place in the profession and en-
joyed the complete confidence and reverence of his
brethren. He had retired for a long time from prac-
tice, but his personality was so distinct and his influ-
ence so unexhausted that he seemed to be still among us.
His intellect was keen, his acquirements were numer-
ous, his researches careful, and his judgment was well
balanced. All his faculties were brought to bear on
the case or subject under his notice, and his decisions
were often regarded as almost infallible. Then out-
side professional topics his attainments secured the
respect of all, and his views excited the greater inter-
est by the felicitous way in which he expressed them.
His essays could not fail to attract attention by their
literary excellence, while they were full of instruction
or well-sustained argument, often stated with remark-
able force and charming eloquence.
Sir James Paget reached the age of eighty-five years.
He was a Barts' student, and remained connected with
that hospital all through his career. He took the
membership of the College of Surgeons in 1835. and
was, of course, one of the first batch of fellows when
that order was instituted. In 1847 he was Arris and
Gale professor; in 1865 he entered the council; was
vice-president in 1873-4, and president in 1875. The
next year he entered the General Medical Council, in
which he represented the college until 18S1. There is
a fine bust of him by Boehm in the college, and his
portrait, presented to Lady Paget in 1873, is in St.
Bartholomew Hospital. Other colleges and societies
offered him their highest honors, and universities did
not lag behind. Thus the Dublin College made him
an honorary fellow and the University M.D. Oxford,
Cambridge, and Edinburgh presented their respective
highest degrees. Of the London University, which
grants no honorary degrees, he was for a considerable
time vice-chancellor. Of societies it would be tedious
to enumerate his distinctions; suffice it to mention
the F.R.S. and the Paris Institute, with the presidency
of more than one of the medical societies.
He was created a baronet in 1871, and appointed
serjeant-surgeon to the Queen in 1877. He had long
before been surgeon to the Prince of Wales. His
" Lectures on Surgical Pathology," his " Clinical Lec-
tures and Essays," and his " Studies of Old Case-
Books" are classics as far as medical works can be
classical, and no one can do better than look into
either of them for an hour's delight and instruction.
There are many other important contributions in St.
Bartholomew's Reports, the Transactions of the Royal
Society, and some of the medical societies. But these
samples of his distinctions merely serve to show the
esteem in which he was held as a surgeon and a sci-
entist. They can only dimly suggest what he was as
a man. Courteous, kindly, sagacious, genial, modest,
his presence was ever welcome. A good talker, an
eloquent lecturer, he charmed both young and old.
As a surgeon, thoroughly informed and conscien-
tiously careful, he was also possessed of that insight
which so often looks like intuitive diagnostic power.
His operative procedures were always steady, safe, and
sure, and he never sought after the speed which some
younger men call brilliant. His nature could not
"appeal to the gallery."
Sir James leaves four sons — the eldest, John, of
course, succeeds to the baronetcy; two are clergymen,
and Stephen follows his father's profession and is
already well known as a surgeon. Two daughters
also survive him. The funeral took place yesterday.
The first part of the service was held at Westminster
Abbey and the actual interment at Finchley cemetery.
Representatives of the many institutions with which
he was connected were present; as some said, "every-
body was there." The Queen, the Prince and Princess
of Wales were also represented and sent wreaths.
V'ou may perhaps remember that a good deal of in-
terest was felt by some of those present at the Edin-
burgh meeting of the British Medical Association
(1898) in a demonstration given by Dr. Doyen, of
Paris, on the cinematograph. Some, indeed, were in-
clined to regard the exhibition as scarcely scientific,
but others, knowing that M. Doyen was one of the
foremost French surgeons, were well aware that he
needed no clap-trap and was unlikely to bring forward
anything that was not serious. Well, he has followed
up his- work with animated pictures and demonstrated
their utility in teaching operative surgery. Dr. Doyen
is not only an operating general surgeon, but also an
eminent gynaecologist, and he has applied the cine-
matograph to that branch. At the invitation of the
British Gynaecological Society he came over to London
and gave a demonstration at their December meeting.
The modus operandi in a number of operations was
demonstrated by slides showing separately and con-
secutively the instruments required and the steps of
the operation. This was followed by showing the
operation complete as recorded by the cinematograph.
In this way Dr. Doyen's ovariotomies, abdominal and
vaginal hysterectomies, w^ere exhibited in actual per-
formance, to the evident delight of those present. A
vote of thanks was proposed by Dr. Routh in a neat
little French speech, and carried unanimously after
complimentary remarks by Drs. Spanton, Godson, and
MacNaughton Jones.
It would seem that the cinematograph has come to
stay as a useful educational apparatus. Not a few,
however, still regard it as a toy. But that was the
case with the camera in time past, and yet what has
photography accomplished for science! There may be
a considerable role for the cinematograph.
The New Year's honor list is a short one, and so
1 68
MEDICAL RECORD.
[January 27, igpo
will disappoint many. Surgeon-General Lovell and
Dr. Lauder Brunton are knighted. Dr. Cockburn,
agent-general for South Australia, gets a K.C.M.G.
Dr. Pringle, of the privy council of Jamaica, Dr. Pat-
rick Manson and Dr. Wordsworth Poole, P.M.O., of
the higher force, received a C.M.G. Dr. A. D. Mac-
Kinnon, of Uganda fame, receives the same order.
An interesting e.xhibition was opened on the ist
inst. by the Livingstone College. Many relics of the
distinguished medical missionary and traveller were
lent for the occasion, and there was a considerable col-
lection of articles intended for travellers in unexplored
regions. Major Ross discoursed on malaria and mos-
quitoes, and to-day Dr. Battersby is to lecture on
" Health in the Tropics."
The eleventh annual report of The Lancet relief
fund shows that ^"245 has been distributed to twenty-
four practitioners who were suddenly in urgent need.
This fund was established to help cases of real emer-
gency, in which immediate aid would be likely to
enable the recipient to tide over his difficulties. It is
entirely supported by The Lancet. The sums granted
this year ranged from _£,'5 to ^20.
Influenza is again taking a heavy toll in London,
and many of the doctors are down with it. In Novem-
ber there were about fifteen deaths a week from it,
but in December the number rapidly increased until
in the week ending the 30th there were one hundred
and seventy-three deaths registered from this disease.
In the two preceding weeks the deaths were thirty-
eight and sixty-nine. The increase is therefore great,
and with it of course the epidemic is widespread, the
non-fatal cases being very numerous. The deaths
from all respiratory diseases last week were eleven
hundred and seventy-two, above double the average.
THE APPENDICITIS QUESTION.
Sir: Allow me to add my humble mite of commenda-
tion of the remarks made by Dr. John Wyeth relating
to the " appendicitis question," and published in a
recent issue of your journal. Most heartily do I ap-
prove of what he advises in the treatment of abscesses
occurring in connection with an inflamed appendix
inaccessible to the gentlest and readiest manipulation.
It is very well for men like Dr. Morris and Dr.
Deaver to practise and even publish " ideal surgery "
respecting these cases. It is quite another thing for
such operators to encourage and even demand such sur-
gery at the hands of the general profession, in which,
in these latter days, surgeons have multiplied with
such amazing rapidity. Armed with a diploma and
the certificate of an " up-to-date " post-graduate course
in New York City, who will question the right, nay,
the duty, of such men to undertake the most compli-
cated operations in surgery ? But do these legal au-
thorities necessarily confer either natural or acquired
surgical abilities? Rather do they not too often
authorize and stimulate surgical temerity? Probably
it would surprise Dr. Morris to know with what com-
parative infrequency an experienced and thoughtful sur-
geon is called in to operate for tiie average so-called
country practitioner, who now considers himself lost in
the race unless he has been to the cities, where he is
imbued with the daring and enthusiasm of the great
surgical pioneers. The results of the latter must be
attempted, if not equalled, no matter what the cost.
Now if it be true that fifty thousand persons die an-
nually in the United States from appendicitis, will Dr.
Morris tell us, if he knows, how many succumb to
reckless and indiscriminate operating? Notwith-
standing increased facilities in the United States for
learning surgery, how will Dr. Morris lessen this great
mortality under existing conditions likely to be con-
tinued, so that his statistical assumptions, vehemently
protested, will be taken at the value which he places
upon them in support of the treatment that he advo-
cates? Already, in this locality at least, the teaqhing
of Drs. Morris, Deaver, and others is having the effect
perhaps intended. Abscess cavities are opened and
the deeply embedded appendix is laboriously and
exhaustively sought after. If the limiting exudation
wall is freely broken down by the manipulation, the
post-mortem consolation to the family often runs like
this: " I should have been called in earlier; the ab-
scess had broken into the peritoneal cavity." More-
over, how annoying to an operator in an abscess case
to be confronted with the reproach that he did not re-
move the appendix, when his neighbor, who had per-
haps operated during the quiescent period, is able
triumphantly to exhibit an appendix which, " follow-
ing the surgical rule," he had skilfully removed! For
the laity is not educated to make any distinction be-
tween these conditions, but rather the contrary. In
the public view appendicitis is only appendicitis.
Therefore the appendix must be removed at any haz-
ard.
If it be a fact, as Dr. W'yeth avers, that in the vast
majority of cases these abscess cavities soundly heal
after proper opening and drainage, no further opera-
tion being required, is it not wise to inculcate his
timely warning and advice? Certainly my experience
strongly supports Dr. Wyeth in his contention. I have
often questioned the feasibility of the advice of Dr.
Deaver to antisepticize the abscess cavity and then
safely to remove the appendix no matter how situated.
In my last abscess case I am sure it would have been
impossible to render thoroughly aseptic the pus-bear-
ing area, including several minor pus cavities irregu-
larly and remotely located in the septic exudation wall
of the primal abscess. No amount of irrigation or
wiping out with antiseptics would have accomplished
this; and to break down the intervening trabeculas
would have been fraught with certain disaster to the
patient. The abscess cavity was properly drained
and granulated up, being now soundly healed. Judg-
ing from past experience I have little, if any, fear that
a second operation will be required.
Henry K. Leake, M.D.
Sir: Allow me to make an analysis of Dr. Horner's
defense of medical treatment of appendicitis, in the
Medical Record for December 30, 1899, and com-
ment upon some points that he makes.
Dr. Horner says he "believes that physicians can
draw more practical conclusions from the means in
their possession than the hospital surgeon with all his
statistics. The general practitioners mingle with
physicians of their own vicinity and have the benefit
of one another's experience and observations." This
is all very well, provided that the general practitioners
are men of trained observation and accustomed to
making accurate records of their cases in a scientific
way. If the physicians in Dr. Horner's vicinity are
men of this sort, I wish to have their reports upon ap-
pendicitis cases. I have tried for several years to get
reports from physicians who had kept accurate records
of their appendicitis cases, and have not been able to
get such reports. On the other hand, the statistics are
accurately kept in the best hospitals, and they are the
very data upon which we must depend for our conclu-
sions. The memory of one's experience, impressions,
and observations is extremely treacherous unless one
can turn to carefully recorded data; as I myself find
J-anuary 27, 1900]
MEDICAL RECORD.
169
in trying to quote at society meetings without the
figures at hand.
Dr. Horner says: "It does not follow at all that
appendicitis cases are alike because they are caused by
bacterial infection, except it be in their etiology." I
insist that they are alike in this respect, that no prog-
nosis can be made of the extent of bacterial infection
in any progressing case, and that the character of any
given case is always determined afterward, never in
advance. Cases which are found to have progressed'
to a complicated stage are complicated cases at the
time when the surgeon is called to operate. The spe-
cial reasons for the treacherous nature of appendicitis
are fully described by authorities and need no further
discussion.
Dr. Horner says: "If every one who has an appen-
dix were to go to a surgeon and have it removed, and
granting the surgeon the low mortality of one per
cent., there would still be a great many deaths from
the operation in cases without infection." Does the
doctor know of any responsible surgeon who will oper-
ate for removal of the normal appendix.'
The doctor further says : " That physicians are none
too conscientious in refusing to advise operation in
every primary case that comes along, will in my opin-
ion be conceded by physicians and surgeons alike."
Some of the most desperate cases with which we have
to deal in everyday practice are primary cases that
have been watched by physicians from the days when
they were slight cases. The reasons for surprises have
been fully described.
The doctor says: "The physician is always open to
conviction, and if Dr. Morris can convince the general
practitioner that his way is the right way and will save
more lives than ours, we are prepared to follow, but
not merely on his say-so." I have not always found
that physicians were open to conviction. I have
found that they were quite like other men in this re-
spect; that men with trained minds had the habits of
men vi'ith trained minds, that men who depended upon
impressionist views preferred impressionist views, and
that some preferred controversy for its own. sake. The
right way for saving lives does not depend upon my
methods, but upon the classified knowledge of author-
ities which is accessible to all who read.
The doctor further says: " Dr. Morris asks us to tell
him as to our cases, length of time wasted in bed, state
of health after subsidence of acute attacks, and the
state of the appendix as learned by accurate palpation.
Let Dr. Morris also tell us of hernia pads worn for
months after operations that do not relieve pain, of
subsequent operations for adhesions; of operation for
diseased appendix and removing an inflamed ovary
which was the real cause of the trouble; of operation
only to push the dislocated kidney back into position,
of those who succumb to anaesthetics, of those whose
kidneys and other internal organs have been damaged
by the ether or chloroform, and of other little things
we physicians consider before we send a perfectly
healthy man who has had appendicitis once, and prob-
ably never will have it again, to be operated upon."
Dr. Horner evidently has not closely witnessed the
work of men who are successful in their operative
work, or he would not quote the above list of casual-
ties, which certainly do occur in the hands of men
who have not properly equipped themselves for the
management of these cases. Hernia pads should not
be worn by patients of the surgeons in whom I have
confidence. The days of post-operative hernia follow-
ing appendicitis operations are about past. Subse-
quent operation for adhesions means that the phvsician
did not give his case to the surgeon until it had be-
come a complicated case. Operating for diseased ap-
pendix and removing an inflamed ovary u'hich was the
cause of the trouble means usually that the diagnosti-
cian did not use quite all of his resources before pro-
ceeding to assume a grave responsibility. Operating
to push a displaced kidney back into position means
carelessness usually, and if that was all that was done
to the kidney the whole case was apparently misman-
aged. As to patients succumbing to ana-sthetics, I
have never had that accident occur, either in appendi-
citis work or in any other department of surgery.
Cases in which the kidneys or other internal organs
have been damaged by the ether or chloroform were
cases in which these organs had been previously dam-
aged by some other cause, and in which they would
presumably have been more damaged by the toxins of
bacteria if the operation had not been done. Unless
one has confidence in the ability of a surgeon to use
judgment in these matters, he should make a study of
surgeons as part of his duty toward the public. As to
sending a perfectly healthy man to have operation
done, the doctor would probably find it difficult to find
a responsible surgeon who would operate upon such a
patient.
I hope that the doctor will not find any spirit of
discourtesy in my direct manner of statement. I have
the highest regard for the good intention of physicians
who, like Dr. Horner, are working for the best interest
of their patients from their point of view. P'or the
sake of progress it is important to have the point of
view based upon our well-classified knowledge of the
subject. We have abundant statistics showing the
comparative results of medical and of surgical treat-
ment in appendicitis. We know the reasons for these
statistics. I have published the letters of a series of
unselected consecutive appendicitis patients, all of
whom stated that they sufl^ered less under surgical
treatment than under any form of medical treatment.
If patients suffer less under proper surgical treatment,
if the loss of time is less, if the death rate is less, the
way is clear for physicians who Dr. Horner says are
always open to conviction.
Robert T. Morris, M.D.
THE TREATMENT OF PNEUMONIA.
Sir: I have read with great interest the editorial in
your issue of January 6, 1900, referring to the recent
paper of Dr. A. H. Smith, of New York, on " The
Treatment of Pneumonia in the Light of its Newer
Pathology."
I agree with you in the doubt you express on the
pathology of the pneumonia as outlined by Dr. Smith.
.\s regards the treatment also I believe, as you do, that
" if the toxic effects are greater than the body can
combat, the patient must die; if not so great, the body
will wage its own war, and the methods of treatment
are but turns in the scale one way on the other."
Here I may repeat what I expressed in an article
which appeared in Sieroierapia, Fascic. 7, 1899, that
every physician had until now his own (empirical)
treatment for pneumonia, and (I am translating) if the
patient did not die, his recovery was due only to his
natural constitutional strength and not to the ordinary
treatment administered by the attending physician.
In the Neiv York Medical Jounml of August 26,
1899, was published a second article of mine on the
same subject, in which, reporting six cases of the
grave form of pneumonia cured with antipneumonic
serum, I said: "There is a great deal of satisfaction
in the knowledge that we now have a remedy which
attacks the cause of the disease, and that it is no
longer necessary to witness the progress of pneumonia
witli the feeling that we are powerless and can do
nothing except try to stimulate the heart, to give ex-
MEDICAL RECORD.
[January 27, 1900
pectorants, and to attempt to reduce the temperature
by some antipyretic measure." Since then I have suc-
cessfully treated nine additional cases by the same
method.
Many well-known directors of clinics in Italy have
used this serum with success, and many convincing
laboratory experiments have been made by the Royal
Academy of Medicine of Naples, as well as by Drs.
Eyre and \\'ashbourn at the Guy's Hospital laboratory
in London. The last-named found [Lana-t, April and
October, 1899) that the serum possesses the potency
claimed fcr it. One cubic centimetre protected a rab-
bit against three thousand fatal doses of living pneu-
mococci, and they think they may affirm that in the
future other successes will be obtained with the serum
in the treatment of pneumonia in man, and in other
affections produced by the pneumococcus.
I am really surprised that so eminent a physician
as Dr. Smith, in his search for the best weapon against
pneumonia, has not taken notice of the rational one.
In the interests of humanity I hope that Dr. Smith
will soon relegate to empiricism the creosote with
which he has supplanted his remedies of yesterday.
Antonio Fanoni, M.D.
66 West Tenth Street.
J>ocietg Slqjorts.
NEW YORK MEDICO-SURGICAL SOCIETY.
Staied Meeting, January 12, igoo.
Egbert H. Grandin, M.D., President.
The Physiological Effects of Alcohol in Health and
Disease — IIr. Henry Ling Taylor read a paper with
this title. He said that there were three principal
views held regarding the effects of alcoholic bever-
ages, viz., (i) The ignorant, (2) the biassed, and (3)
the scientific. Belonging to the first class were those
persons who seem to place no limit to the strengthen-
ing and healing virtues of alcohol, and who drink it
when tired, weak, or sick, or indeed whenever there
was even the slightest excuse for so doing. (The
reader then passed around some of the text-books
used for the purpose of compulsory instruction of
children in the public schools regarding the alleged
effects of alcohol.) Many of the statements quoted
were astounding in their misrepresentations. Such
teaching indicated the views of the biassed. Accord-
ing to the scientific view alcohol was powerless to
prevent but temporarily allayed fatigue. In old age,
and in certain conditions of debility, moderate in-
dulgence in alcohol was beneficial. Alcohol should
not be used by healthy people habitually as an appe-
tizer. Mixed drinks and alcoholized tonics were
much more harmful than pure spirits. Alcohol was
often useful, sometimes indispensable, in pneumonia,
typhoid fever, diphtheria, sepsis, and other serious
acute diseases. It was a dangerous remedy in many
nervous disorders, or if continued regiilarly for long
periods. It was his opinion that alcohol was not so
often or so frequently prescribed as formerly. It was
thought that the practice of English liospitals of re-
porting the annual consumption of alcohol per capita
might be profitably imitated in this country. Lord
Roberts had stated recently that the admissions to the
hospital in the British army were 208 '_• per thousand
for abstainers and 301 '_■ for non-abstainers. In con-
clusion. Dr. Taylor said that physicians should pre-
scribe alcohol only when physiologically indicated;
they should insist that the physiology taught in the
public schools should not be a distorted physiology;
they should discountenance the giving of alcoholic
beverages to children except on a physician's pre-
scription, and they should demand that the amount of
alcohol contained in bitters and tonics be printed on
the bottle.
Dr. H. H. Seabrook said that the physiological
effects of alcohol in health were shown in the eye by
the action on the blood-vessels. In chronic cases one
frequently saw changes in the motor nerves, which
might be peripheral or due to changes in the brain.
These changes did not differ essentially from the
changes occurring in other portions of the bodv. In
the retinal and choroidal vessels there would be found
arterial sclerosis in those who had taken alcohol for a
long time. The special changes observed in the eye
were those seen in the optic nerve of a chronic drunk-
ard. The central fibres of the optic nerve underwent
an inflammatory change, which was followed by
atrophy, and which destroyed the central vision to a
considerable extent. This change differed somewhat
from the changes observed in other diseases. The
change was similar' to that observed in cases of poi-
soning from tobacco, iodoform, or bisulphide of car-
bon, and less intense than the change due to poi-
soning by lead. Certain changes were sometimes
observed in the peripheral fibres. The ingestion of
alcohol, therefore, when long continued seemed to act
as a poison, though not as a virulent one. In slow
forms of corneal ulceration stimulation of the heart
and dilatation of the peripheral vessels resulting from
the administration of alcohol was often most benefi-
cial. The healing process in these cases was often ex-
ceedingly tedious, even under the use of the usual
tonics; it was very materially hastened by taking
alcohol. It was well known that syphilitics, and
those using tobacco to excess, were most apt to ex-
hibit the changes in the nerves already mentioned as
a result of the use of alcohol.
Dr. S. E. Jelliffe said that one of the best argu-
ments, to his mind, in favor of the good effects of
alcohol was the almost universal use of it in all ages.
He believed alcohol -was a blessing, and when used in
moderation in health conduced to that intimate social
intercourse so necessary for one's success in life.
Dr. \V. Oilman Thompson spoke more particularly
regarding the use of alcohol in disease. It was well,
he said, for physicians to ask themselves whether it
was not possible to order less alcohol in the treatment
of disease. Alcohol had some diuretic action in dis-
ease, but there were so many better diuretics that it
certainly was not required for that purpose. In the
majority of nervous disease alcohol was also not only
uncalled for, but was positively injurious. On the
other hand, there were conditions of nervous exhaus-
tion and certain neuralgic affections which yielded
well to alcohol. The effect of alcohol on the vascular
system was the most important one for the therapeut-
ist to consider. He was of the opinion that in a very
large proportion of cases in which alcohol was used
other and better remedies could be employed. Some
years ago it had been customary to use much larger
doses of alcohol in typhoid fever than now; the rea-
son was found in the fact that its stimulating effect
had been largely superseded by that secured by the
judicious use of hydrotherapy. This former too lib-
eral use of alcohol was certainly capable of develop-
ing a neuritis when the alcohol was administered for
a considerable time in this fever, and it had seemed
to him that there had been less neuritis since less al-
cohol had been given. In pneumonia alcohol was
useful as a temporary stimulant. In alcoholic pneu-
monia it was certainly wrong to withhold alcohol, and
so give an additional shock to the already depressed
system. If, in such cases, the alcohol made the
tongue moist, softened the puLse, aided respiration.
January 27, 1900]
MEDICAL RECORD.
171
reduced the temperature, and did not impart a strong
odor to the breath within an hour or two after its in-
gestion, one might be sure that it was doing good.
The habitual use of alcohol certainly tended, in a
most insidious way, to excite premature degenerative
changes. Some years ago he had been interested in
collecting certain statistics from his hospital practice
regarding alcoholic drinking. In his own division at
Bellevue Hospital in the year 1898, there had been in
all five hundred and six patients. Of this number
there had been one hard drinker in every four, and
only thirty-five total abstainers among three hundred
and eighty men. Among one hundred and twenty-six
women the proportion of hard drinkers had been one
in sixteen. In examining these patients one was con-
stantly struck with the large proportion of cases ex-
hibiting arteriosclerosis. He had never been able to
trace any case of alcoholism to the ordinary and tem-
porary therapeutic use of alcohol in severe acute dis-
ease, and the same seemed to be true of the morphine
habit, but it was an entirely different problem in
chronic disorders when the patient continued for a
long time to use alcohol or morphine without the
physician's knowledge or consent. With regard to
the use of alcohol in chronic disorders of the stomach,
he was of the opinion that, as a general rule, it should
be advised to leave alcohol alone. Late in life the
moderate use of alcohol often prevented insomnia and
added to the comfort of closing years. It was probable
that many persons would become chronic alcoholics
if it was not that they were blessed with bad stom-
achs, which did not allow them to become " full " with-
out speedily getting empty again. In his opinion,
alcohol was absolutely unnecessarj' for the preserva-
tion of health. The social side of this question was
an entirely different matter. It was probable that the
majority of persons would live longer if they did not
use alcohol habitually, even in moderation. The use
of alcohol could not be continued for long without
lessening the resistance of the tissues and leading to
more or less deleterious effects. Much depended upon
constitutional peculiarities and general habits of life.
Of course, alcohol should be distinctly prohibited to
persons having a strong hereditary tendency to its
excessive use. Finally, alcohol used properly for
medicinal purposes undoubtedly saved life in acute
diseases, as it constituted a valuable means of tiding
over a crisis. In some of these cases he believed that
alcohol acted not only as a cardiac stimulant, but as a
true food.
Dr. William H. Porter said that when this ques-
tion was considered from its standpoint as a food, one
obtained a clearer conception of it. To his mind al-
cohol belonged to the same class of foodstuffs as
starch, sugar, and fat. Assuming the natural intake
of oxygen by the lungs to be 750 gm., by using 600
gm. of oxygen all of the starch, sugar, fat, and proteid
matter could be burned that was required to generate
the necessary amount of heat and keep up the construc-
tive work of the body. This would leave 150 gm. of
oxygen per clay. Figured from a chemical basis this
would allow nearly two ounces of clear alcohol to be
burned without exceeding the oxygenating capacity of
the system. He had been very much interested in the
experiments of Professor Atwater at the government
station, as they had demonstrated that this amount
could be actually consumed in the body without over-
taxing the oxygenating capacity of the system. It
should be remembered, then, that this quantity could
be burned in the system if its ingestion was properly
distributed over the twenty-four hours. It had been
pretty conclusively demonstrated by Anstie that alco-
hol did not enter the blood, as such, in any considera-
ble quantity. Alcohol was very rapidly transformed
into some other compound. It was his belief that
alcohol was drawn up into the epithelial cells of the
alimentary canal, and was there quickly oxidized, with
the production of heat, carbon dioxide, and water.
As a result, it had a tendency to overstimulate the
nervous mechanism. This overstimulation was fol-
lowed by depression, and unless the ingestion of the
alcohol was evenly distributed ever the twenty-four
hours there must be inevitably an overstimulation.
With this overstimulation there would be temporary
contraction of the blood-vessels, thus interfering with
the nutrition of the system. However, greater harm
came from tlie use of alcohol by its disturbance of
digestion, thereby exciting in the alimentary canal pu-
trefaction, fermentation, and the formation of toxic
products, and so indirectly affecting the system dele-
teriously. Physiologically speaking, there was no
occasion for the use of alcohol in any individual in
health until after the age of fifty or sixty years, and,
in the majority of cases, its use before that time tend-
ed to cause derangement of digestion, and to affect the
system injuriously through the absorption of the toxic
products formed in the intestinal canal by the putre-
factive fermentation of the proteid constituents. This
opinion seemed to be strengthened by the position
taken by insurance companies, who claim that beer-
drinking people are the poorest risks. Such persons
did not take in as much alcohol as spirit drinkers, but
they eat more, and have more digestive derangement.
He believed that in disease alcohol was very service-
able when the individual was unable to digest sufficient
starch and sugar to yield the requisite amount of heat.
In that sense alcohol might be looked upon as a food,
though never as a good food. He quite agreed with
Dr. Thompson in the assertion that more alcohol was
given in disease than was needed. Assuming that
typhoid-fever patients were able to take only one-half
the usual amount of food, then such a person should
not require over three ounces of alcohol in twenty-four
hours. This would generate all of the necessary
heat, and to go beyond this point meant only that the
nervous system would be overstimulated, and that this
would probably lead to neurotic conditions subse-
quently. He believed very positively that as people
advanced in years and the digestive functions waned,
the judicious use of a small amount of alcohol materi-
ally improved digestion and enabled such people to
live longer and more comfortably than without this
use of alcohol. This was especially true in cases in
which the individual had not been accustomed to the
use of alcohol. He believed that alcohol should never
be given to the healthy individual under the age of
fifty or sixty years, and that it should be used very
cautiously in disease, the greatest care being taken
that it did not cause disturbance of digestion. If this
did occur, even in disease, then one might be sure that
the alcohol was doing more harm than good. If the
urea rose and the uric acid diminished under its util-
ization, then it was evident that the alcohol was doing
good. With reference to the teaching of the effects of
alcohol, Dr. Porter said that the more nearly the abso-
lute truth could be brought before the youthful mind
the greater the likelihood of doing good; in due time,
the truth would come out in any event. He knew of
a student who had been absolutely compelled to falsi-
fy his opinion on the physiological action of alcohol
in order that his book might be brought before the
schools.
Dr. Ernest W. Auzal quoted statistics collected
by Jacquet and presented in a report recently made
regarding alcoholism in the hospitals of Paris. The
report had been based on a study of 4,744 cases seen
in twenty-three hospitals. Of this number, 3,416 had
been seen in the out-patient departments, and 1,328
among the in-patients. Of the former, 23.27 per
cent, and of the latter 45.93 per cent, had been alco-
172
MEDICAL RECORD.
[January 27, igoo
holies. The drinks used chiefly were wines, liqueurs,
and rum, but the use of absinthe was specially com-
mon. Of the 4,744, 217, or 4.57 per cent., had shown
some disease dependent upon the alcoholic habit, such
as gastritis, gastro-enteritis, various hepatic diseases,
and paralyses. Of the whole number, 252 had ad-
vanced tuberculosis of the lungs, and of these 180, or
71.42 per cent., had been addicted to the use of alco-
hol before the first symptom of tuberculosis had made
its appearance. The mortality had been greatest
among those notoriously intemperate, such as liquor
dealers, saloon-keepers, drivers, and cooks. Jacquet
was of the opinion that physicians had unthinkingly
contributed to the alcohol habit, as the annual con-
sumption of alcohol in the Paris hospitals had doubled
in the last twenty years. During the past year, how-
ever, there had been a marked decrease. He suggest-
ed that every patient leaving the hospital should be
given a memorandum setting forth the dangers of alco-
hol. He also suggested that a permanent committee
be appointed to consider this question of the effects of
alcohol, and report annually.
Dr. E. Eliot Harris thought there was a proper
use, as well as an abuse, of alcohol. He believed it
was a valuable agent in relieving congestion of the in-
ternal organs, due to sudden chilling of the surface of
the body. Alcohol relaxed the cutaneous arterioles,
thereby retaining blood in the capillaries of the skin
and adjacent tissues, and in this way it acted as a
preventive of many diseases of the internal organs
which followed what is popularly known as "taking
cold." Alcohol had the power to bleed a man into
himself, as it were, which made it a valuable agent in
relieving embarrassment of the heart in pneumonia.
There seemed to be a useful niche for alcohol in acute
infections diseases, in which its power as an antiseptic
became manifest. When one considered the trouble
arising from the abuse of so valuable an agent as alco-
hol, one could not but feel convinced that mankind, as
a whole, would be benefited if it ceased to be manu-
factured.
Dr. McMurdy said that in hospital practice, in
which tub baths were readily given, it might be easy to
reduce the quantity of alcohol used in typhoid fever,
but hydrotherapy was not applicable to tenement-house
practice, in which alcohol must consequently be used
freely. In diphtheria alcohol was often absolutely de-
manded, even though antitoxin was also used. He
would not wish to practise medicine without alcohol.
Dr. J. Henry Frihtnight, in answering the ques-
tion as to whether children in health should have alco-
hol, said that he would reply most emphatically " no."
He would not dare to treat a severe broncho-pneumo-
nia in a child without the administration of alcohol.
He would be cautious about the use of alcohol in
scarlatina because of the liability to nephritis. Years
before the use of antitoxin excellent results in the treat-
ment of bad septic cases of diphtheria had been
secured by the free use of alcohol, and he still advo-
cated its use in such cases, even if antitoxin was em-
ployed.
Dr. Theodore K. Tuthill expressed the opinion
that alcohol was always a positive poison in health,
and sooner or later its continued use must work to the
injury of the individual.
Dr. William M. Leszynsky referred to the case of
a child, aged five years, who had been brought to him
at one time with an alcoholic multiple neuritis and
paralysis, which soon terminated in death. The igno-
rant mother had thought she was doing a good thing
for her little one by giving it regularly two bottles of
beer and several drinks of whiskey daily. The speak-
er thought the text-books exhibited would prove use-
ful, by impressing upon the older children the truth
that alcohol was a poison and should be avoided.
Dr. Robert A. Murray spoke of the very common
use by the laity of proprietary medicines containing a
large percentage of alcohol. He believed such nos-
trums were often responsible for giving to individuals
a taste for alcohol. He had never seen a case of acute
disease treated with alcohol in which there had been
any deleterious after-effects, except when the family
had continued to give the patient during convales-
cence alcoholics instead of proper food.
Dr. Frederick Holme Wiggin said that with in-
creasing experience he found himself depending less
and less upon alcohol in the after-treatment of cases
of abdominal surgery. His results had been much
better by relying more on attention to digestion and
the use of peptonized milk for nourishment than on
alcoholic stimulation. As he believed shock was al-
most invariably due to hemorrhage, the best treatment
was the introduction of saline solution either into the
bowel or directly into the circulation.
Dr. a. E. Bieser spoke of the therapeutic efhcacy
of alcohol in septic conditions associated with various
diseases, such as diphtheria, pneumonia, and typhoid
fever. In these diseases alcohol seemed to fortify the
cells so as to enable them to meet the demands made
upon them by the invading bacteria.
Dr. E. H. Grandin said that he used much less
alcohol now in septic conditions than he had done
ten years ago, though he was free to confess that he
still found it very useful in very low grades of sepsis.
He agreed with Dr. Wiggin that shock was chiefly the
result of hemorrhage, and therefore he relied upon the
introduction of saline solution.
Dr. Taylor, in closing, read a letter from Prof. R.
H. Chittenden, of Yale, expressing regret at his ina-
bility to be present, and stating that a recent investi-
gation by Swedish chemists had fully established the
results of Professor Atwater regarding the food value
of alcohol. It was evident from the discussion, Dr.
Taylor said, that the medical profession in this coun-
try used alcohol less than formerly, though clinging to
it tenaciously to meet certain therapeutic indications.
In this respect the habits of physicians here seemed to
be in sharp contrast with those of the medical profes-
sion in Europe.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, January 18, igoo.
William H. Thomson, M.D., President.
Myocarditis Dr. John H. Mlsser, of Philadelphia,
read a paper on this subject. He said that when the
heart muscle was healthy few or no symptoms arose as
the result of a valvulitis. The symptoms of myocar-
ditis were intermingled with those due to other neural
changes. A case was cited exemplifying the occur-
rence of myocarditis following, and secondary to, peri-
carditis. Myocarditis with dilatation was frequently
seen as the terminal event in such lung diseases as
emphysema. Myocarditis, both local and general,
was often the result of coronary-artery disease. To
the group of cases of myocarditis of toxic origin be-
longed the curious and puzzling cases of myocarditis
associated with arrhythmia. In all forms of myocar-
ditis there were certain common phenomena, particu-
larly the sallow complexion of the individuals and
the similarity of the physical signs. When this pecul-
iar pallor was present one would not go wrong in
assuming that the coronary arteries were implicated.
These cases gave evidence of endarteritis in the ves-
sels. The physical signs given by the lieart were
those of myocarditis alone, or of myocarditis plus
hypertrophy or plus dilatation. The apex beat would
January 27, 1900]
MEDICAL RECORD.
^7Z
be displaced to the left, and the cardiac dulness would
be somewhat increased. Quite early there was " gallop
rhythm," a cantering or reduplication of the systolic
sound. It was more commonly heard about the fourth
rib, and was sometimes more marked in the supine
position, and usually more marked after exercise.
Myocarditis was often overlooked in fevers because
of the temporary disappearance of " gallop rhythm."
Murmurs were not heard constantly until late in the
disease unless complications were present. He be-
lieved, with Sewall, that the papillary muscles were
the source of the auscultatory phenomena of myo-
carditis. It was not so much the presence of redupli-
cation, or of gallop rhythm, or of murmurs, as the
variability of the auscultatory phenomena which was
so characteristic of this pathological condition. When
dilatation supervened the physical signs changed in
keeping with the physical condition of the heart. The
terminal events of myocarditis varied; there might be
apoplexy or ruptured aneurism, or renal phenomena.
Again, there might be sudden and severe angina, or
a gradual cardiac exhaustion lasting for a few days
and terminating in cedema of the lung. In cases of
myocarditis with angina, the attack might come on
suddenly or be preceded by more or less dyspnoea. In
the very large majority of the cases myocardial dis-
ease was present; whether it was causal or not he
would not state. The course of these cases might be
slow or rapid; one attack might terminate life, or the
attacks might recur only at very long intervals. They
might be preceded by a moderate amount of dyspnoea,
and perhaps also by some arrhythmia. The pain was
the predominating feature. Notwithstanding the
temporary abatement of the symptoms the disease
would progress, and eventually death would follow,
and apparently from trilling causes. In some cases
a slight change in the nutrition or general health
would be sufficient markedly to affect the pain. In
cases of myocarditis with dyspnoea, the latter might
come on only after exertion, or when at rest, or
perhaps only at night. In these patients the face
was generally pale and anxious, and the forehead
bathed in perspiration, the patient presenting all
of the usual signs of profound shock. Examination
of the heart would show its action to be rapid, feeble,
intermittent, and irregular. Such an attack might at
first occur at intervals of a year, but as the disease
progressed this interval would be shortened. These
attacks should be distinguished from those of acute
dilatation of the heart occurring in certain cases of
cardiac debility, because this was necessary in order
to institute a proper treatment. This differentiation
could be made, in a measure, by estimating the degree
of cyanosis, and by a consideration of the fact that
the signs in the lungs were those of oedema, in the
case of heart failure, rather than congestion, while in
cases of dilatation the phenomenon of congestion was
the more prominent one. In cases of acute dilatation
there was tachycardia, whereas in cases of cedema,
with temporary arrest of ventricular action, the heart
action was more apt to be slow. In the myocardial
cases there was no congestion of the other organs, as
for example the kidneys. In cases of dilatation, re-
lief could be promptly afforded by venesection or by
local blood-letting, whereas in myocarditis few phy-
sicians would care to resort to this procedure. The
character of the breathing in myocarditis was very
suggestive; the patient would speak to you for a
short time, and would then have to rest in order to re-
gain his breath. However, the frequency of respira-
tion was not so great as that which attended dilatation
of the heart. Cases of myocarditis presenting the
so-called Stokes-Adams syndrome — ^pericarditis and
pseudo-apoplexy — were very interesting to the clin-
Myocarditis in Infants and Children Dr.
Henry Koplik read this paper. He said that, in
spite of the little space devoted in the text-books on
diseases of children to the consideration of myocar-
ditis, it was not at all rare, being a very common ac-
companiment of such acute infectious diseases as
diphtheria, scarlatina, and typhoid fever. Romberg
had called attention to the important fact that even
in the severest cases all of the muscular fibres of the
heart were not affected. Experimental research had
made it probable that the myocarditis in these cases
was the result both of the high temperature and of the
toxins of the disease, and it was evident from clinical
experience that high temperature alone was not re-
sponsible for its causation, as it was frequently found
in rapidly fatal cases of pneumonia, for instance, in
which the temperature had been low. In severe
cases of pertussis, myocarditis would be found, partly
as the result of the strain on the heart produced by
the paroxysms of coughing, and partly as the result of
the action of the toxins of the disease. While it was
true that a most extensive myocarditis was often found
at autopsy, in cases in which no symptoms referable
to the heart were observed during life, there were many
cases in which the feeble apex beat and heart sounds,
with or without pallor and dyspnoea, should be suffi-
cient at least to put the physician on his guard and
cause him to suspect the presence of myocarditis.
Semeiology of Myocarditis is Complex. — Dr. E.
G. Janeway said, regarding the value of the facial ex-
pression as evidence of a myocarditis, that he could
recall cases in which eminent clinicians had told the
person during life that they had no heart disease, and
yet the autopsy had shown extensive myocarditis. If
there had been anything significant about the facial
expression in these cases it certainly could not have
escaped the notice of such acute and experienced
clinical observers. Again, it was no unusual thing
for angina to be mistaken for dyspepsia. This was
largely owing to the proneness of attacks of angina to
occur after partaking of a hearty meal.
Dr. I. Adler said that we could no longer divide
sharply, as was formerly supposed, cases of myocar-
ditis into two classes, viz., interstitial and parenchy-
matous. At a very early stage the muscle fibres un-
derwent degeneration. In cases of simple atrophy or
brown atrophy, in which the muscle became primarily
affected and destroyed, the connective tissue under-
went proliferation. He had never seen a specimen
of myocarditis under the microscope in which both
types had not been visible. Even in the most ad-
vanced cases of myocarditis the microscope would
almost invariably show very many muscular fibres un-
affected, and this might explain the apparent absence
of cardiac symptoms during life. It was highly prob-
able that the degree of the disturbance of the heart
depended very largely upon the localization of the
myocarditis. His clinical experience had led him to
believe that in those cases of myocarditis characterized
by Qidema and dyspnoea the myocarditis was prin-
cipally localized in the auricles. Arteriosclerosis
was not by any means confined to the later years of
life, and it was in these youthful cases of arterial dis-
ease that myocarditis was especially noted. This
arterio-sclerosis was sometimes noticed shortly after
puberty, chiefly in males. It was commonly the result
of various toxjemias, the most notable of which was
perhaps that resulting from the use of tobacco. Then
there were cases of hereditary myocarditis without
any toxic element, occurring almost wholly in young
males.
Dr. Musser closed the discussion. He said that
he had not intended to convey the impression that the
peculiar pallor alluded to by him was a constant sign,
but only that when present it was very significant.
174
MEDICAL RECORD.
[January 27, 1900
SECTION ON MEDICINE.
Stated Meeting, January 16, igoo.
John H. Huddleston, M.D., Chairman.
The Plague Bacillus. — Dr. W. H. Park gave a
demonstration of the plague bacillus, the material
having been obtained from two men sick with the dis-
ease on the steamer Taylor from Santos, Brazil. He
had seen the men on the day of their arrival, and as
they presented only an abscess of the lymph nodes in
the groin they probably would not have been suspected
of having the disease had it not been for the history
of illness on board the ship. He had removed some
of the pus from these abscesses, and had been much
disappointed the following morning to find that there
was no growth. After some difficulty he had succeeded
in getting the culture. There w-as no difficulty in cul-
tivating the bacillus when the material was obtained
in the early stages of the disease. From what he
knew now of the bacillus and its mode of growth, he
felt that there should be no difficulty in the future in
making the bacteriological diagnosis of the plague in
the course of about twenty-four hours.
A Criticism of a New Method of Preparing the
Skin for Vaccination by Denudation with Caustic
Potash Solution. — Dr. F. S. Fielder read a paper
on this subject (see page 143).
Dr. S. F. Morris said that he had known nothing
until this evening regarding this caustic-potash method
of vaccination, and he could not see that it possessed
any advantage, excepting in the one matter of not
causing pain ; but that should not be considered very
seriously, for he was able to vaccinate a sleeping baby
without awakening it. If caustic potash alone was
applied to the skin, and no vaccine virus was rubbed
in, the skin would probably closely simulate the ordi-
nary vaccination scar. There was no such thing as
"pitting" of vaccination. The large, hard cicatrix
left by the present method of vaccination with bovine
virus was entirely different from that formerly pro-
duced by the humanized virus. At that time the
method in vogue had been to scrape ofif the superficial
layer of the epidermis without drawing any blood
whatever. In these cases the pitting seemed to be
produced because the ulcer did not penetrate through
the skin into the cellular tissue. With proper care
scarification with the needle could be done in such a
way that there would be no flow of blood unless press-
ure was made on the surrounding tissues. When the
surface of the skin was denuded with caustic potash
the serum was coagulated by the potash; hence, if
great care was not taken to rub in the virus, it was
probable that a much larger percentage of failures
would result than had been noted by the reader of the
paper. The speaker said that he had used almost
every known method of vaccination that had been pro-
posed and practised during the past thirty years. As
a medical student he had been taught to make a little
pocket with the lancet in the epidermis and introduce
into this a "scab" when no liquid virus could be
obtained. He had vaccinated many thousand chil-
dren in the schools by using the lancet, but the great
drawback to this method was the difficulty of properly
cleansing the lancet when vaccinating such a large
number of children. Subsequently he had found that
the needle was far better than the lancet for such work.
He had recently reported to the health department on
fourteen hundred and si.xty-five vaccinations performed
with a certain lot of virus. Of this number there had
been only one hundred failures, and a large number
of these failures had been due entirely to the wilful
removal of the virus by the colored children. These
children had varied in ages from six to eighteen years,
and the vaccinations therefore had been secondary
ones, yet he had obtained, even under these adverse
circumstances, over ninety per cent, of successes.
This seemed to him an excellent showing for the
method of needle scarification. He had never found
it necessary to make any preliminary cleansing of the
surface ; he got no bad results except from the med-
dlesome after-treatment of ignorant mothers. Years
ago, when he had been in the habit of scarifying a
large area, he had sometimes seen erysipelas during
the summer months, but never, even by this method,
during the winter months. For this reason he ordi-
narily preferred to vaccinate in the winter time.
(Edema following Vaccination.^ — Dr. W. H. Park
said that he had understood that Dr. Hutchins had
claimed better results from the caustic-potash method,
and he would like to ask Dr. Fielder if Dr. Hutchins
had really made any careful comparative tests to sub-
stantiate such a claim. He would also call attention
to the fact that in some individuals vaccination seemed
to be followed by oedema of the whole upper extremity
without any really septic condition being present.
This oedema usually subsided in two or three days
without anything more serious than a little incon-
venience.
Dr. Fielder closed the discussion. He heartily
agreed with Dr. Morris that there was no such thing
as a characteristic vaccination scar. He had person-
ally found it difficult to make an adequate scarifica-
tion with the needle on a struggling child without
drawing some blood. The health-board vaccinator
who had secured the largest percentage of successes
had made a practice of needling deeply and drawing
blood, and then depended upon a very thorough rub-
bing in of the virus. He certainly believed if he had
not taken great pains to rub in the virus after using
the caustic potash there would have been many more
failures. He had not understood that Dr. Hutchins
had made any comparative tests. He did remember
that Dr. Hutchins claimed to have had '"only two
failures in thirty-six primary vaccinations " ; such a
showing among primary vaccinations was not con-
sidered a good one at the present day among experi-
enced vaccinators.
A Critical Study cf tho Justus Blood Test for
Syphilis Dr. D. H. Jones read this paper. The
test depended upon the assertion that a single inunc-
tion of mercury, in all untreated cases of syphilis,
caused a reduction in the hemoglobin due to the sen-
sitiveness of the red blood corpuscles to the action of
this drug. Justus claimed that this reduction followed
intravenous and subcutaneous injections of mercury
as well as inunctions, but that no reaction was obtained
if the mercury was administered by tiie mouth. Justus
had reported on three hundred cases he had studied
in this way. During the past six months, the speaker
said, he had applied this test frequently in some of
the hospitals in this city. The quantity of haemoglobin
had been determined by means of the specific gravity
test of Hammerschlag. After having tested the
quantity of ha;moglobin in this way, the patient was
told to rub into the breast from gr. xx. to gr. Ix. of
mercurial ointment, and after an interval of from
twenty-four to seventy-two hours the ha-moglobin was
estimated again. The fifty-three cases were divided
into thirty-five syphilitics and eighteen controls, and
the thirty-five syphilitics were again divided into
seventeen cases of active syphilis not under treatment,
one under treatment, two latent cases, eigiit cases of
chancre with adenitis, and seven cases of chancre with-
out adenitis. Of the seventeen cases of syphilis not
under treatment, thirteen had responded to this test.
Of these thirteen twelve had had a macular or papular
syphilide, and a history of chancre. They had been
tested from three to ten weeks after its appearance.
The remaining case had had a characteristic mucous
January 27, 1900]
MEDICAL RECORD.
175
patch on the inner side of tlie cheek, but no chancre
could be found, and syphilitic infection had been de-
nied. Nevertheless this case had improved with sus-
picious rapidity under mercurial treatment. Three of
the four negative cases had been pronounced syphilitic
by experienced diagnosticians. Of the eight cases
of chancres with adenitis only two had reacted posi-
tively. The author concluded that the test had a
positive value, yet it often failed in the latent cases
of syphilis. Its range of usefulness had not yet been
determined; like the diazo reaction in typhoid fever
it had a certain positive, but no negative value.
Dr J. EwiNG said that he had no criticism to offer
regarding the methods employed, except as to the esti-
mation of the haemoglobin. Personally, he believed
that the Fleischl hsmoglobinometer afforded a more
accurate means than the specific-gravity method for
the estimation of the haemoglobin. The fact that the
administration of mercury caused ana?mia had been
noted before it had been described by Justus, but this
investigator had perhaps been the first to call atten-
tion to the fact that a recognizable anaemia might fol-
low from a single dose of mercury. Justus believed
that this ansmia was the result of an alteration of the
serum, and also of the direct globulicidal action of the
mercury itself. It had been shown that immediately
after an inunction many of the cells containing a
diminished quantity of haemoglobin had been removed
from the circulation; apparently, therefore, there was
a reduction of the red cells immediately after the ad-
ministration of a large dose of mercury. Such a re-
sult did not follow if small doses of mercury were used.
The Test Probably Operative in Other Diseases. —
The question naturally arose here, Was this change
in the blood specific, and characteristic of syphilis
only.' Personally, he thought there v\'as reason to be-
lieve that such a change might be observed in many
other diseases, notably in cases of malaria and in all
forms of sepsis. There were certainly many cases in
which there was a distinct increase in the globuli-
cidal action of the serum, and here Justus' test would
be likely to fail. Of the thirty-three cases which
Cabot used as controls the haemoglobin percentage
had been between ninety-five and one hundred, except
in two cases, and in these two the administration of
the mercury had' given a positive response, although
the individuals were not distinctly anaemic. When
there was no increased globulicidal activity of the
serum from other causes than syphilis he thought it
exceedingly probable that further investigation would
show that Justus' test would respond.
Dr. B. Lapowski called attention to a later state-
ment published by Justus in i8g6, in which he ad-
mitted that his test could be made to respond even
when the mercury was administered by the mouth in
the form of pills. Justus' method of estimating the
haemoglobin had not been by the specific-gravity
method, but by means of the Fleischl hjematometer.
Again, Justus had simply stated that the test was ob-
served after the absorption of mercury— not that it
occurred after a single dose of mercury. It did not
necessarily follow that the mercury had been absorbed
even if a single dose had been given. Moreover,
Justus did not ordinarily employ a large but a medium
dose of mercury, from 2 to 5 gm. of mercurial ointment.
Dr. Jones, in closing, said that in the article by
Justus, published in 1897, the statement had been
made that reduction of the haemoglobin was observed
only immediately after the inunction, and th?t the per-
centage increased ultimately. He agreed with Dr.
Ewing that the specific-gravity method of estimating
the haemoglobin was somewhat crude.
Chronic Vertebral Rheumatism and its Pseudo-
Neuralgic Form. — Dr. H. Forestier, of Aix-les-
Bains, read this paper. He said that the chronic
spondylitis observed by him had exhibited a temporary
rigidity of the vertebral column without any ankylosis,
pain radiating from the back to the loin and simulat-
ing in some cases tabes, and an affection of other
joints pointing to its rheumatic nature. In most of
the cases the posture and gait had been stifif, and
there had been tenderness along the spine with more
or less neuralgic pain. These patients had walked
with the feet far apart, keeping the trunk immobile.
A peculiar feature had been the backache occurring
in the early morning, or when the patient had been
lying down for a number of hours. As a rule, the
knee jerk had been exaggerated, and in some cases there
had been ankle clonus. There was no ankylosis of
the spine in these cases; the immobilization was due
to the pain. The dorsal and lumbar regions had been
chiefly affected, the cases involving the cervical region
being quite rare. The treatment had consisted in the
application of sulpliurous waters in the form of " a
douche massage." The condition was to be differ-
entiated chiefly from spinal irritation and external
pachymeningitis of the spine.
Dr. V. P. GiBNEY said that he had been familiar
with this class of vertebral rheumatism for the past
fifteen years, his attention having been first called to
it by a paper from one of the bath establishments in
France. He had taken an additional interest in it
because of the discussion that had occurred as to
whether spondylitis was a hyperplasia or a caseous
degeneration of the bodies of the vertebrae. To the
orthopedic surgeon differential diagnosis was most
important. Some of the clinical symptoms given in
the paper this evening resembled those of disease of
the bodies of the vertebrte. He was glad to hear of
the good results obtained from the treatment. In this
country massage and counter-irritation, douches, etc.,
were employed in conjunction with constitutional
treatment and local support.
Dr. Forestier, in closing, said that a "douche
massage " was given with the person in a sitting
posture, a stream of water being directed forcibly
against the different regions of the body while the
parts were subjected to vigorous massage. The
douche to the spine was most conveniently given while
the patient was lying in the prone position on an in-
clined table. The douche massage is given in a
stone chamber containing more or less steam, and the
temperature of the water is regulated by the physician's
prescription. A tremendous stream of water is dis-
charged from a large nozzle with great force against the
patient.
Vertical Jtcms.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending January 20, 1899 :
Tuberculosis
Typhoid fever
Scarlet fever
Measles
Diphtheria
Laryngeal diphtheria (croup)
Cerebro-spinal meningitis. . . .
Chicken-pox
Smallpox
24
10
245
13
777
28
2S7
41
Clean Paris. — An English weekly journal says that
Paris is probably the cleanest city in the world.
Every morning two thousand male and six hundred
female scavengers, divided into one hundred and
176
MEDICAL RECORD.
[January 27, 1900
forty-nine brigades, turn out to perform the toilet of
the capital. The men work from four in the morning
till four in the afternoon, less two hours off for meals,
or ten hours a day. The women are engaged in the
morning only.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended January 19,
1900 :
Smallpox — Un
States.
Cases. Deaths.
Delaware, Wilmington January 6th to i;ith
Florida, Jacksonville January 6th to 13th 2
Georgia, J essup January 1 6th i
Illinois, Cairo January ist to 7th 5
Chicago. . . January 6th to 13th 4
Louisiana, New Orleans January 6th to 13th 13
Nebraska, Omaha January 6th to 13th i
New York, New York January 6th to 13th 1
North Carolina, Greensburg ..January isih.
Ohio, Cincinnati January sth to 12th i
Cleveland January loth 25
Oklahoma, Blackwell January 8th Prevalent.
Newkirk January Sth Prevalent.
South Carolina, Greenville .... January 6th to 13th 2
Tennessee, Columbia January 6th 24
Mount Pleasant January 6th 8
Nashville January nth to 18th .... 6
Texas, Houston December .^ist to January 6th . 5
Virginia, Portsmouth January 6th to 13th 10
Smallpox— Foreign.
Belgium, Antwerp December i6th t(
Bohemia, Prague December i6th ti
England, London December i6th t»
France, Lyons December i6th t(
Germany, Konigsberg December i6th tc
Gibraltar December 24th t
Greece, Athens December i6th t
India, Bombay December 12th t
Calcutta November 25th ti
Japan, Yokohama N ovember 1 8th t
30th
30th . . . .
30th
aad
23d
' 31st
• 30th
' 19th
Decembei
, Chihuahua December 31st to January 6th . .
Vera Cruz. December 31st to January 13th.
Russia, Moscow December i6th to 23d
Odessa December 24th 10 30th
St. Petersburg December i6th to 23d
Warsaw December 9th to 23d
Spain, Corunna December 24th to 30th
Madrid December i6th to 23d
Uruguay, Montevideo December gth
Yellow Fever— United States.
Florida, Key West January 8th
Yellow Fever— Foreign.
Cuba, Habana December 31st to January 6th.
.December 20th.
ntiago de Cuba December 31st to January 2d . .
/era Cruz December 29th to January 13th.
India, Bombay December 12th to 19th i
Calcutta November 25th to December 9th . . 74
Plague— United States.
Hawaii, Honolulu January ist to i6th 5 4
Philippine Islands, Manila .. .January i6lh 5
Plague— Foreign.
Brazil, Santos October 15th to December 23d. 38 13
China, Hong Kong November 25th to December 7th 43 42
India, Bombay December 12th to 17th 248
Calcutta November 25th to December 9th .. 138
Japan, Kobe December 10th to 20th 3
Naga.saki December gth 1
Osaka and H logo December 2d to 23d 12 9
New Caledonia, Numea January 1st to 9th g S
Portugal, Lisbon. . , January 1st i
Masau December 25th 9 7
Congenital Hypertrophy of the Pylorus in an
Infant. — Batten {Lancet, December 2, 1899, p. 151 1)
reports the case of a male infant, eleven weeks old,
who at the age of five weeks had begun to vomit, while
at the sam; time the bowels became very costive, and
wasting set in. The food was ejected in from five to ten
minutes after feeding. The child had been fed by the
breast until the age of nine weeks, and was then tried
on cow's milk, but as this did not agree he was given
Nestl^'s food. The child was thin, and weighed seven
and a quarter pounds. The abdomen was flaccid, and
easily palpated without pain. On inspection the peri-
staltic movements of the stomach could be seen dis-
tinctly passing from left to right, and following one
another in quick succession. On deep palpation in
the right hypochondrium, about a finger's breadth out-
side the nipple line, a firm transverse mass, in shape
like the pylorus, could be felt, but which was not
always palpable when no peristalsis was taking place.
The child was at first fed on equal parts of cow's milk
and barley-water, but the vomiting persisted. He was
then given two ounces of cow's milk and one ounce of
barley-water through a nasal tube every two and a half
hours. During the succeeding few days, although the
vomiting did not entirely cease, the child improved
and passed a digested stool. He improved in appear-
ance, and the vomiting became less. Subsequently a
teaspoonful of cream was added to the nasal feeding,
and then some cod-liver oil. Eight ounces in weight
were gained in two weeks. An attempt to resume
feeding by the mouth was followed by repeated vom-
iting, so that nasal feeding was again resorted to.
The pylorus had become less distinctly appreciable
than it had been, and at times could not be felt at all.
Subsequently the child was applied to the breast, and
although the vomiting returned it eventually ceased.
The possibility of operative relief was considered, but
owing to the feeble and wasted condition of the child
it was at the time deemed inadvisable. Steady im-
provement, however, took place, so that in the course
of six months the weight had increased to sixteen
pounds. The child was now seized with a fatal bron-
cho-pneumonia. On post-mortem examination the
walls of the stomach were found to be unusually thick,
and the pylorus was firm and hard. On microscopical
examination the mucous membrane and the muscular
coat appeared to be perfectly normal in structure,
while the circular coat was considerably thicker than
normal.
While the Medical Record is pleased to receive all nexu pub-
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the distinct understanding that its necessities are such that it can-
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tion received by it which in the judgment of its editor will not be
of interest to its readers.
Operations-Vademecum. By Dr. Edmund Lesser. 8vo,
igo pages. Illustrated. Verlag Von S. Karger, Berlin.
Recollections of a Rebel Surgeon. By F. E. Daniel,
M.D. 8vo, 264 pages. Von Boeckmann, Schutze&Co., Aus-
tin, Te.xas.
Children, Acid and Alkaline. Bv Thomas C. Duncan,
M.D., Ph.D., LL.D. 8vo, 14S page's. Boericke & Tafel,
Philadelphia.
The Cost of Living. By Ellen H. Richards. Svo, 121
pages. John Wiley & Sons, New York.
Progressive Medicine. By Ilobart Amory Hare, M.D.
Vol. IV. Svo, 408 pages. Illustrated. Lea Brothers & Co.,
Philadelphia and New York.
A Manual of Surgical Treatment. By W. Watson
Cheyne, M.B., F.R.C.S., F.R.S., and F. F. Burchard, M.D.
and M.S. (Lond.), F.R.C.S. Vol.11. Svo, 382 pages. Illus-
trated. Lea Brothers & Co., Philadelphia and New York.
Care and Treatment of Epileptics. By Williar.i Pryor
Letchvvorth, LL.D. Svo, 246 pages. Illustrated. G. P.
Putnam's Sons, New York and London.
A Manual of the Practice of Medicine. By A. A.
Stevens, A.M., M.D. 8vo, 519 pages. W. B. Saunders, 925
Walnut Street, Philadelphia, Pa.
Masters of Medicine : Hermann Ludwig Ferdinand
VON Helmholtz. By John Gray McKendrick, M.D., LL.D.,
F.R.SS. Lond. and Edin. Svo, 288 pages. Longmans, Green
& Co. , New York.
Les Armes Blanches. Par H. Nimier. Ed. Laval. Svo,
4SS pages. Illustrated. Felix Alcan, Paris.
Consumption and Chronic Diseases. By Emmet Dens-
more, M.D. i2mo, 200 pages. Illustrated. The Stillman
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Svo, 604 pages. Illustrated. W. B, Saunders, Philadelphia.
Diseases of Women. By Charles B. Penrose, M.D., Ph.D.
531 pages. Illustrated. W. B. Saunders, Philadelphia.
Medical Record
A IVeekly yourual of Medicine and Snygciy
Vol. 57, No. 5.
Whole No. 1526,
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©riQiwal %xX\t\zs.
THE SIGxXIFICANCE OF INTRA-OCULAR
HEMORRHAGE AS TO PROGNOSIS OF
LIFE.
Bv CHARLES STEDMAN BULL, M.D.
NEW YORK.
It is a well-known and generally recognized fact that
certain diseased conditions of the blood and of the
blood-vessels cause certain lesions in the interior of
the eye. From the standpoint of the clinician a care-
ful study of these changes is of great importance, be-
cause they not only affect the vision, but because they
are frequently of significance in judging of the gen-
eral health of the patient.
Close observation of the retinal circulation and
blood-vessels affords a certain amount of definite in-
formation in regard to the condition of the blood-cur-
rent and blood-vessels throughout the body, especially
of those of the brain, and to a minor degree of the
heart and aorta. We know that the intraocular circu-
lation is subject to influences and conditions similar to
those which prevail in the general systemic circula-
tion. An increased supply of blood to the brain can-
not well occur without a similar increase in the eye,
and the same may be claimed also for the anxmic con-
dition resulting from a weakened force of the heart's
action or from the diminished volume of the blood.
One fact which is not generally recognized may here
be mentioned, and that is, that the eye is relatively
but sparingly supplied with blood, as a very large part
of the blood going to the region of the eye from the
external and internal carotid arteries is distributed to
the eyelids and orbit. Hence it follows that a hyper-
Eemic or anaemic condition of the parts, occasioned by
changes in the calibre of the vessels, will be induced
more easily the nearer to the eye the vascular disturb-
ance occurs. If the cause is remote, acute conges-
tion of the blood-vessels is rarely accompanied by
retinal hemorrhage with resulting damage to vision.
It may be stated thr.t the cause of the intra-ocular
hyperaemia being remote from the eye,,hemorrhagic
extravasations rarely occur if the blood-vessels are
healthy. If this were not so, we should meet with
retinal hemorrhages in violent paroxysms of cough or
in epileptic convulsions, as frequently as we do with
subconjunctival hemorrhages.
In obstruction of the trunk of the central retinal
artery, the chanf-es in the blood-current marked by a
breaking up of the column of blood in arteries and
veins, with venous pulsation, are of transient duration,
and frequently are followed by increased fulness of
the vessels with the appearance of hemorrhages.
When the vessels remain contracted, hemorrhages
rarely occur, or, when they do, not until a number of
days after the onset of the trouble. One interesting
fact, to which Haab has called attention, is that when
the obstruction is in a branch of the central retinal
artery and not in the main trunk, hemorrhages in the
retina almost never occur.
When the case is one of thrombosis of the central
retinal vein, hemorrhages into the retina are certain to
occur, and sometimes even subhyaloid extravasations
are found. In this condition general albuminuria is
very frequent and leads to a grave prognosis. Hence
in all cases of thrombosis of the central vein or of any
of its branches, the urine should be carefully analyzed.
Experience has taught us that if the patient is young
the condition is apt to be connected with constitu-
tional syphilis.
In senile angiosclerosis, marked by thickening in
the coats of the vessels, with marked differences in the
calibre of the vessels at different points, one of the
commonest symptoms is retinal hemorrhages, which
resemble those met with in thrombosis of a venous
branch. This is an important symptom and signifies
marked degeneration of the vascular walls. In this
condition we also meet with hemorrhages between
retina and choroid, between retina and vitreous, into
the vitreous, and very frequently with subconjunctival
hemorrhages. Attention is here called to the fact that
the more carefully these patients are examined for
syphilis and albuminuria, the more rarely do we meet
with cases of real senile retinal hemorrhages, for syph-
ilis produces changes in the vessels very similar to
those met with in senile angiosclerosis. In this con-
nection it should not be forgotten that arteriosclerosis
with accompanying hemorrhage is very closely related
to glaucoma.
The recurrent hemorrhages, not infrequently met
with in young persons, are due to this degeneration of
the vascular coats. They may be of any shape, but
are more apt to be crescentic. They are usually sub-
hyaloid, between the retina and vitreous, and the
prognosis is good, the number of relapses not influ-
encing materially the ultimate result. If, however,
the extravasation is extensive and in the vitreous, the
prognosis is grave, especially if there is a history of
recurring epistaxis; for in these cases of vitreous
hemorrhage the blood comes from the peripheral ves-
sels and indicates disease of the choroidal vessels as-
well.
In all these cases of intra-ocular hemorrhage in the
young the fundamental disease is an affection of the
vessel-walls of a really unknown nature, which causes
an abnormal brittleness of the coats. Inherited syph-
ilis is probably influential in the production of the
lesion. The prognosis as to the integrity of the eye is
always doubtful. If the hemorrhages are in the retina,
or between the retina and the vitreous, they are less
serious than if they occur in the vitreous, and if inher-
ited syphilis is present the prognosis is more favor-
able.
We have the authority of Gowers for the statement
that passive congestion of the retinal vessels, or venous
hypereemia, with or without hemorrhages, accompanies
cardiac lesions in which the return of the blood toward
the heart is impeded, as in disease of the mitral valves
and in fatty heart, and that the retinal hyperemia is
part of a cephalic congestion. If pulsation of the
retinal arteries is also present, there is general aortic
insufficiency. In mitral disease there is also hyper-
trophy of the left ventricle, so that the blood pressure
is increased during its contraction and the venous
hyperaemia results from the regurgitation which ac-
companies the ventricular diastole.
178
MEDICAL RECORD.
[February 3, 1900
Simple retinal hemorrhage without retinitis indi-
cates an increased blood pressure, or disease of the
vessel walls, or a morbid condition of the blood, and
sometimes all three conditions.
Gowers also states emphatically that the existence
of angiosclerosis in the retina is a positive indication
of a similar condition existing in the vessels of the
brain, and that when accompanied by retinal hemor-
rhage it is a warning signal of impending cerebral
apoplexy, especially when accompanied by high arte-
rial tension.
One of the rare ophthalmic lesions is embolism of
the central retinal artery or of one of its branches, and
this is sometimes accompanied by hemorrhages into
, the retina. This has been known to be the first indi-
cation of an insidious endocarditis.
The same vascular changes are very frequently en-
countered in chronic nephritis and in diabetes. The
tendency to hemorrhage which exists in so marked a
degree in many cases of nephritis leads to extravasa-
tions in the retina. They are mainly in the nerve-
fibre layer, are striated or flame-shaped, and follow
the course of the vessels. They are of grave prognos-
tic significance, and independently of the typical signs
of retinitis albuminurica point to a not far distant fatal
termination of the disease.
In diabetes the retinal hemorrhages appear as small
rounded spots. They always occur if the disease has
lasted a number of years, and are of unfavorable prog-
nostic significance. The association of nephritis with
the later stages of diabetes should not be forgotten, as
well as the possibility of the dependence of the retinal
hemorrhages on the latter disease, though here the
hemorrhages are generally striated.
Dr. Herter, of this city, has made an interesting
suggestion with reference to general arterial sclerosis,
which may have a bearing upon the causation of cer-
tain cases of retinal hemorrhage in which the origin
seems obscure. He states that in rare instances a gen-
eral arteriosclerosis has its beginning in a series of
acute seizures of gastro-enteritis, which leave behind
them marked impairment of intestinal digestion.
When this occurs in persons under twenty-five years of
age, there can be little question that the gastro-enter-
itis stands in a causal relation to the alterations in the
vessels and similar changes in the kidneys.
Germane to this suggestion are the remarks of Mr.
Marcus Gunn before the Ophthalmological Society of
the United Kingdom in 1898. In speaking of general
arterial disease, he says: "In many of these patients
the primary cause is probably a form of poisoning due
to indigestion, a mal-assimilation and imperfect elim-
ination producing disordered nutrition, and the blood-
vessels suffer in consequence. Chronic alcoholism is
undoubtedly a strong factor in causing this affection,
for old age alone does not produce these changes.
While confined to the arteries hemorrhages are very
infrequent, but as the condition extends to the capil-
laries and veins hemorrhages are the natural result."
In many anamic conditions there is a state of di-
minished blood-pressure which, after prolonged dura-
tion, leads to, spontaneous retinal hemorrhage. In
cases of blindness after sudden and great loss of blood
the blood-pressure falls materially, and the elastic in-
tra-ocular pressure forms an obstruction to the circula-
tion in the retina, and as a result retinal hemorrhages
are frequent. The loss of sight is here probably due
to a hemorrhage within the optic nerve. With return-
ing circulation vision is sometimes partially restored,
and then occur the retinal hemorrhages.
Retinal hemorrhages due to a diseased condition of
the blood occur in infectious diseases, in pyaemia and
septicfemia, in profound pernicious anaemia, in mala-
ria, and in cases of poisoning. While the diagnosis
of infectious diseases is not dependent on the existence
of retinal hemorrhages, they are frequent occurrences
and of prognostic importance. They may occur at all
stages and form an unfavorable complication, espe-
cially when found early in the disease; they indicate
a condition of profound toxemia. When hemorrhages
occur early in acute septicaemia, a fatal termination
may be expected in a few days.
The presence of retinal hemorrhages affords valu-
able evidence in the differential diagnosis between
chlorosis and pernicious anaemia, for they are frequent
in the latter and never occur in the former. An inter-
esting diagnostic fact is that retinal hemorrhages rarely
occur in the cachectic conditions resembling anamia.
In 1886, in a paper read before the American Oph-
thalmological Society, I called attention to cases of
intra-ocular hemorrhage occurring in persons of mid-
dle and advanced life who had been subjected to se-
vere malarial poisoning, and my interest in the subject
was revived during the summer of 1898 and 1899 by
the number of such cases seen in our troops returning
from Cuba. In these cases the blood was extravasated
into the vitreous humor and occasionally in the aque-
ous humor, and was entirely unaccompanied by any
sign of intra-ocular inflammation. The hemorrhages
always occur suddenly and usually in the posterior
part of the vitreous humor. They are generally uni-
lateral, though they may be found in both eyes, and
they appear during the febrile or congestive stage.
The recurrences of these hemorrhages are spontaneous
and frequent, and the process of absorption is always
slow. They indicate a condition of profound malarial
toxaemia, and the prognosis as to life is decidedly un-
favorable.
In a paper read before this society in 1897 attention
was called to the occurrence of retinal hemorrhages in
typhoid fever, with reference to the stage at which
they occurred and their prognostic significance.
In progressive pernicious anaemia the tendency to
retinal hemorrhage is very marked. The extravasa-
tions are numerous, are striated or flame-shaped, and
are most abundant round the optic nerve. The small
ones may be absorbed, but the large ones remain and
point to an unfavorable termination of the case.
In leucocytha:mia retinal hemorrhages are almost
an invariable symptom. They are widely scattered in
the nerve-fibre layer and are of no particular signifi-
cance. But if they occur in the optic nerve or vitre-
ous their prognostic significance is unfavorable.
In purpura small retinal hemorrhages are of com-
mon occurrence, but more rarely they are subretinal
and are then significant of a severe type of the dis-
ease.
In jaundice retinal hemorrhages are not common,
and when met with they indicate a severe type of
disease. ,
In all hepatic diseases small retinal hemorrhages
are common, especially in cirrhosis, and are of no
special importance. But in the severe types of cir-
rhosis and acute atrophy of the liver, large hemor-
rhages between retina and vitreous or in the vitreous
are occasionally discovered, and their prognostic sig-
nificance is most unfavorable.
Summarizing what has preceded, the following con-
clusions may be drawn from our experience :
1. Hemorrhages into and beneath the conjunctiva
are of little importance in the young, as they usually
occur as a result of violent muscular effort, as in
coughing or long-continued sneezing. The vessels in
the conjunctiva, having little or no suJDport in the loose
connective tissue, readily give way to paroxysms of
violent expiration. In the aged they occur spontane-
ously and point to a general weakened condition of
the vascular walls.
2. Hemorrhages in the interior of the eye are always
of prognostic significance. In senile angiosclerosis
February 3, 1900]
MEDICAL RECORD.
179
retinal hemorrhages are very frequent, and point sig-
nificantly to the probable occurrence of cerebral apo-
plexy.
3. Recurrent retinal and subhyaloid hemorrhages
in the young are of slight prognostic importance, espe-
cially if due to syphilis, whether inherited or acquired.
4. Hemorrhages into the vitreous in the young are
of grave prognostic importance and point to the exist-
ence of general vascular degeneration.
5. In chronic interstitial nephritis and in diabetes
retinal hemorrhages are of very grave prognostic sig-
nificance, and independently of the presence of exu-
dative retinitis point to a fatal termination of the dis-
ease. The mere presence of thrombosis of the central
retinal vein with hemorrhages in the retina should
arouse suspicion of the existence of albuminuria, and
if this suspicion is confirmed by urinary analysis the
prognosis in the case is more unfavorable than in those
cases in which the hemorrhages do not exist.
GASTRECTOMY FOR ADENO-CARCINOMA;
RECOVERY.
By H. BEECKMAN DELATOUR, M.D.,
HOSPITALS, BROOKLYN.
Since Schlatter, of Zurich, proved, by his successful
case in 1895, that it was possible for a person to live
after complete removal of the stomach, a number of
operators have followed his example. It is only in
those cases in which the growth is entirely limited to
the stomach that gastrectom.y is permissible, for in
these it offers a chance for permanent cure.
The general indications and contraindications for
the operation have so recently been considered by
Richardson' that it seems hardly necessary to review
them here. It is my desire in reporting this case to
assist in developing the statistics of this procedure,
and to add the following to the reported cases of gas-
trectomy :
Mrs. S , aged twenty-six years, Norwegian,
housewife, was admitted to the Norwegian Hospital,
giving the following history: She became pregnant
about a year before we saw her. Previous to this she
had suffered with symptoms of dyspepsia, distress,
vomiting, etc., but during pregnancy these became
much more distressing and constant, and persisted
even after the termination of pregnancy. During the
three months intervening between labor and her ad-
mission to the hospital the vomiting continued, be-
coming more and more frequent, until finally all food
was rejected within a few hours. Pain began and be-
came more and more intense; there was a rapid loss
of strength, and her weight had fallen from one hun-
dred and forty pounds to ninety pounds. Examination
revealed a tumor, visible to the eye, along tha margin
of the left costal cartilage; by palpation this could
easily be located as at the pylorus.
On May 2, 1898, under ether ansesthesia, a four-inch
incision was made, beginning one inch below the ensi-
form cartilage. The tumor was found to occupy and
to be limited to the pylorus and stomach, and to be
freely movable. It wf.s my intention to do a gastro-
enterostomy, but the case seemed so favorable for
complete removal of the disease that gastrectomy was
decided on. The mass was dragged well into the
wound and the omentum tied along the greater curva-
ture with catgut sutures one-half inch apart. Then
with scissors this edge of the stomach was cut free.
With the fingers behind the stomach so as to direct
the ligature carrier, the margin of the lesser curvature
' Boston Medical and Surgical Journal, September 28, 1899.
was freed in the same manner. Now the stomach was
free from the duodenum to the cesophagus. A clamp
was next applied to the duodenum, and the intestine
was cut across one inch from the pylorus. The field of
operation was carefully protected with gauze sponges
before the ctsophageal incision was made, and this
was fortunate, for considerable fluid escaped from the
dilated stomach. The entire pylorus, the whole length
of the lesser curvature, and nearly the entire cardiac
end of the stomach were removed, the incision extend-
ing well into the wall of the cesophagus (see diagram).
This left the cesophageal opening somewhat larger
than the duodenal, so a few silk sutures in double
layer were used to reduce this opening. The duo-
denum was then siitured into the oesophageal opening
with fine silk sutures. Thorough cleansing of the field
of operation, a small strip of iodoform gauze intro-
duced, and closure of the wound completed the opera-
tion. The time required for the operation was fifty
minutes.
The patient reacted well, and on the following day
had the highest temperature of her convalescence, 99°
The shaded portion represents
section. At the pylorus the growtl
in thickness.
F. The pulse was 120. Rectal feeding was main-
tained for seven days. The nourishment consisted of
peptonized milk and other predigested foods, the bowel
being washed once in twenty-four hours. The gauze
packing was removed on the fifth day, and as there
was no discharge was not replaced. At the end of
the week, feeding by mouth was commenced with one
ounce of peptonized milk every two hours. As the
patient bore this well it was rapidly increased and
other articles of food added, so that at the time of
her discharge from the hospital on June 5th she was
taking the ordinary mixed diet.
The only unpleasant feature of convalescence was
hunger. Before operation the patient had begun to
hate the sight of food, but within the first week after
removal of the disease it was almost impossible to
prevent her being fed by other patients, on the sly, so
piteous w-ere her pleadings.
After the patient left the hospital her condition
continued to improve, so that at the end of six months
she had gained thirty pounds. About six months ago
she came to me complaining of nausea, but no vomit-
ing. Examination revealed no evidence of a return
of the disease. The cause of this nausea I discovered
in September, when I visited her to ascertain her con-
dition, over seventeen months having elapsed since
the operation. At this visit I found her tending her
two children, looking perfectly well and strong and
seven months pregnant. Since then she has removed
from Brooklyn, and I do not know what the termina-
tion of the pregnancy has been, nor what her general
condition is.
In May, 1898, the specimen was presented to the
Brooklyn Surgical Society, and in the following Octo-
i8o
MEDICAL RECORD.
[February 3, igoo
ber the patient was presented. The growth was exam-
ined by Drs. J. M. Van Cott and A. MuiTay, and pro-
nounced an adeno-carcinoma.
-3 Eighth Avenie.
REPORT OF A SEVERE A'-RAY INJURY.
By PATRICK CASSIDY, M.]).,
The following is the history of an instructive case of
.v-ray injury. The patient was Dr. John Weldon, of
Willimantic, Conn., a man forty years of age, weighing
one hundred and eighty-six pounds, and si.x feet in
height, a member of the non-resident staff of this hos-
pital, and a surgeon of large practice. The main
points of interest are the following:
(i) The patient during the time of exposure,
although perfectly conscious, suffered no injury nor
pain. (2) Eight days elapsed before the appearance
of any injury, and then only a slight dermatitis. (3)
The rapidity of the changes in the tissue involved a
truly mummified condition in which the lesion appeared
dead, yet had sufficient vitality to be indestructible.
(4) To the touch the induration was hard and unyield-
ing and not at all sensitive, but at certain points it
would bleed on friction. (5 ) The severe paroxysms of
excruciating pain upon the application of any poultice
or wet dressing, showing the induration to be highly
absorbent. (6) The marked constitutional symptoms
and rapid wasting without much rise of temperature.
This is a brief synopsis of the case to which I was
called on September 12, 1899. ^ found the patient
prostrate upon his bed ; temperature, 99" F. ; pulse, 104;
a mere shadow of his former self, having lost over
forty pounds in weight, pale and emaciated; he had
no appetite, and could not sleep night or day except
under the influence of large doses of morphine. The
inability to sleep was the result of a severe pain, burn-
ing in character, which he described " as if red-hot
coals were applied to the part."'
On examination I found in the left groin a large
lesion, oval in form and five inches in the longer
diameter. The centre of the lesion was at the point
where the femoral artery emerges from beneath Pou-
part's ligament. The accompanying illustration (Fig.
i) represents the injury as I found it. The color was
a very dark gray, except here and there were dots,
slightly red; there was neither discharge nor odor;
the skin on the edges appeared healthy.
The patient gave the following history : " On March
18, 1899, for the purpose of procuring a skiagraph of
my left hip joint, I exposed the part for forty-five min-
utes at a distance of five inches from the tube, which
was of medium vacuum, of a static machine the plates
of which revolved two hundred and twelve times a
minute. During the time of exposure there was no
sensation of any injury nor of the slightest pain. My
first sensation of any harm was an itching in both
groins, a little more intense- in the left, whicli occurred
a week after. Inspection revealed an acute dermatitis
in that region, which rapidly increased, so that at the
end of the second week the erythema covered the lower
third of both sides of the abdomen and upper third of
both thighs. At this time the pain became so intense
on both sides, but more on the left, that I was obliged to
give up my practice and take to the bed. The inflam-
mation went on to the formation of vesicles, then bul-
ls, and at the end of the third week the epidermis of
the affected area came away. By the application of a
powder of the stearate of zinc in about ten days the
right side had entirely healed, and the left also, with the
exception of a space in the groin as large as the hand,
which presented a red, shining appearance and radi-
ated a great amount of heat, with irregular, sharp, lan-
cinating pain. About the middle of June, three
months after the exposure, the surface of this lesion
commenced to be covered by a thin yellowish mem-
brane, at first easily removed, but only to return quickly,
and which soon became so firmly adherent that I could
not remove it.
" .^bout July I St the pain became so intense that
rest or sleep could be procured only b}' large doses of
morphine. On advice, I went into the country for a
change and in search of rest, which proved so bene-
ficial that the use of morphine was discontinued, but
there was no improvement in the healing of the injury.
-August I St, I returned to Willimantic with the hope
of resuming my practice, having been encouraged by
th:> relief from pain. This hope was doomed to dis-
appoi'itment, as in a few days the pain returned in a
form niore severe than ever, and again I was com-
pelled to re.iort to morphine. Through the use of this
drug I tried n continue my practice, but the system
becoming toler.int, the pain more severe, in the last
days of August, completely exhausted in body, broken
in spirit from four and one-half months of suffering,
I was again forced to take to the bed, and then the
removal of the membiane was attempted by the use of
the curette.
" During these monthi I consulted many experts in
different cities, both by person and by mail, communi-
cated with every physician of whom I had heard as
having any experience with .r-ray injuries, and read
every scrap of literature I could reach on the subject.
The consensus of opinions was, 'Use mild remedies,
nature will effect a cure.' U'jon this advice I have
used almost every sedative ointment in the pharmaco-
pceia and applied many lotionf and poultices. Some
of the ointments afforded relief, but any poultice or
wet dressing of whatever nature, when applied, would
in a half-hour or less produce the most agonizing pain,
as if live coals of fire were placed upon the part."
Recognizing the gravity of his case, I advised his
immediate removal to the W. VV. liackus Hospital at
Norwich, Conn., in which advice the doctor acquiesced,
and he entered the institution on the following morn-
February 3, 1900]
MEDICAL RECORD.
ing, September 13, 1899. At this time liis pulse was
112; temperature, 99.2° F. ; respiration, 26.
I hoped to avoid a radical operation by assisting
the separation and causing the softening of the leathery
tissue, and so ordered the application of Labar-
raque's solution 1:15. This at first was grateful,
but pain was soon present and rapidly increased
to such a degree that at the end of an hour the
patient suffered such agony as I never before wit-
nessed. The dressing was promptly removed, and
a large dose of morphine gave the patient relief in
the course of about three hours.
The hospital staff was called in consultation, and
it was decided to remove the diseased tissue by the
knife. The following morning, September 14,
1899, the patient was etherized, and in the pres-
ence of the staff I operated as follows: Begin-
ning at a point one inch external to the femoral
artery, I made an exploratory incision two inches
in length down through the diseased tissue, which
was as difficult to cut as sole leather, and found
it, to my surprise, to be fully one and one-half
inches in thickness and firmly attached to the mus-
cles of the thigh by the coalition of the healthy
with the diseased fibres. To remove the diseased
tissue, I dissected the skin around the circumfer-
ence of the oval lesion, and found that the indura-
tion extended nearly two inches under what
appeared on the surface to be the line of demarca-
tion; this making the external injury seven and
three-fourths inches in diameter, as is shown by
illustration (Fig. 2). Beginning at its external
border, I dissected the lesion from its deep mus-
cular attachments. In so doing, on the thigh I
split the sartorius, pectineus, adductor longus, on
the abdomen the external oblique and rectus. I'ou-
part's ligament was exposed. The femoral artery,
which was found to be embedded in the induration
where it formed a complete sulcus, was carefully dis-
sected from the diseased mass and stood out promi-
nently from the floor of Scarpa's triangle uninjured,
with small tufts of the diseased tissue adherent to its
coats, which were clipped away later.
The time required for the operation was about one
and one-half hours. The shock was slight, and the
patient rallied very nicely. The first dressing was
bichloride i : 2,000. The next day hot Labbaraque's
solution 1:10 was substituted, to be changed every
three hours, with irrigation daily with the same solu-
tion. This treatment was continued until September
28, 1899, when the wound was found to be in a condi-
tion to receive skin grafts, and saline dressing was
used. On the morning of the 29th, by Reverdin's
method two hundred and ninety skin grafts were
placed in position and properly protected. On Octo-
ber 2, 1899, the wound was inspected, and it was found
that fully eighty per cent, had taken. These had
coalesced so rapidly that on the 8th of October the
entire surface was bridged over, but on the 9th the new
skin did not appear so healthy; to stimulate and pre-
vent sloughing, a mixture of bovinine two parts and
balsam of Peru one part was applied. This treatment
had not the effect desired, and many of the dusting
powders were tried, but in spite of any treatment, to
my chagrin, many of the grafts sloughed.
From the day of the operation all pain ceased, and
all opiates were withdrawn except small closes of de-
odorized tincture at night to give sleep, and this was
discontinued September 26th. The only medicine
administered was strychnine, gr. -Jjj- every four hours,
and tincture of iron, 8 drops every two hours. Sleep,
appetite, and strength rapidly returned, and the patient
was able on the 10th of October to ride out. The
wound had contracted and now was four and one-half
inches in diameter; many of the skin grafts were still
adherent. On October 14th he left the hospital and
returned home fairly well, though walking lame.
The doctor visited me at my office on October 21st,
and said he had been in active practice since his re-
turn and was fast regaining his strength. The wound
had contracted to four inches, but every graft had
sloughed. He was still lame. He was using a dust-
ing-powder of aristol and zinc. I advised the contin-
uance of the powder and again to try skin grafts.
On December 6th he again visited me. The wound
had contracted to two inches. He had not tried the
grafts, as he considered them unnecessary. He had
regained his former weight and strength. The lame-
ness remained, but with some improvement and with
the partial loss of important muscles, and the healing
of the wound by cicatricial tissue. I fear some grade
of permanent lameness, the only evil resulting from a
serious injury which once aimed at destruction and
death.
THE TONOMETER, A NEW INSTRUMENT TO
DETERMINE THE AMOUNT OF BLOOD
PRESSURE.
Bv HEXRV L. K. .SH.\^V, M.D.,
Dr. Morison,' in a recent address on the use of mer-
cury in heart disease, spoke of the control of the blood
current as being as necessary to the therapeutic domi-
nation of the body as the possession of a naval power
is to the domination of the world. The main signal
station of the arterial system is the radial pulse, which
warns us of the approach and keeps us informed of
any advance or retreat made by our enemy — disease.
One of its most important junctions lies in the indica-
tion of the amount of blood pressure. Rightly to de-
termine this is very difficult and requires practice and
much experience. Recently ten American physicians,
all of whom had spent a year or more in hospital or
general practice, were given a number of cases in Noth-
nagel's clinic to examine with special reference to the
arterial tension. The answers were so varied and con-
I82
MEDICAL RECORD.
[February 3, 1900
tradictory that it seemed to have been mere guesswork,
and yet some of these men had had large experience.
The result can be taken as an index of the average
physician's ability to estimate correctly the amount of
blood pressure. Most physicians are content with
noting the pulse frequency and rhythm, and make the
common error of considering a bounding pulse to be
one of high tension.
A number of appliances have been constructed to
determine the amount of blood pressure, but most of
them are complicated and require much skill to mani-
pulate. Sahli" says that any improvement in the
methods for registering the blood pressure is greatly
to be welcomed owing to the extremely great clinical
importance of arterial tension. The best-known later
instruments are those of Mosso,' Hiirtle,'' v. Frey,^ and
v. Basch." The sphygmomanometer of Basch is the
only one that could be called a practical clinical in-
strument, and it has many faults. It consists of a
metal manometer connected by rubber tubing with a
small cup-like attachment called the pelotte. This
instrument is air-tight and filled with air. The pelotte
is placed directly upon the radial or temporal artery
with sufficient pressure to stop the blood stream. The
pressure is slowly reduced until the pulse is felt by a
finger placed on the distal side of the pelotte. The
instant this is felt the amount of pressure recorded by
the manometer should be the amount of arterial blood
pressure. The personal error here is liable to be great,
as the accuracy depends upon the delicacy of the sense
of touch, which we have shown is not always reliable,
so that in reality very little is gained from the employ-
ment of this apparatus.
Professor Gartner, who holds the chair of experi-
mental pathology in the University of Vienna, demon-
strated last June before the Gesellschaft der Aerzte in
Vienna an instrument he had devised to estimate the
amount of blood pressure. This instrument he called
the tonometer." It consists of a pneumatic ring, mer-
cury manometer, rubber ball, and rubber tubing. The
ring is the most essential part of the apparatus. This
is made of metal, and is about an inch in diameter and
half an inch in height. A hole is bored through one
side, in which a small metal tube is inserted, which
§erves for the attachment of the rubber tlSbing. The
inner surface is covered with a very thin rubber mem-
brane, which is tightly wired above and below on the
outer surface of the ring. A piece of rubber covers
the outside, and no air can enter or escape save
through the small metal tube.
The mercury manometer is very simple, consisting
of a glass tube with a bulb filled with quicksilver. A
scale is attached to the glass tube, which registers as
high as 260 mm. The rubber tubing is T-shaped,
with the ring, manometer, and rubber ball attached on
the free ends. These parts are separable, and by the
use of leather washers the joints are air-tight. Pressure
on the ball forces air into the mercury bulb and rubber
ring, raising the mercury in the one and distending
the membrane in the other. With sufficient pressure
the lumen of the pneumatic ring will become obliter-
ated. To regulate slowly the pressure on the ball
there is a small wooden press with a thumb-screw at-
tachment, and the ball is placed inside this press.
Professor Gartner has designed a metal manometer
which is more convenient for transportation, and the
whole apparatus can be carried in the pocket. As the
metal manometer is not always accurate, its reading
can easily be corrected by a comparison with the mer-
cury tube. This is done by removing the pneumatic
ring, attaching the small manometer, raising the quick-
silver to the height of 100 mm. in the tube, and see-
ing the amount registered by the metal manometer.
To ascertain the amount of arterial tension the
pneumatic ring is slipped over the second phalanx of
one of the fingers or the first phalanx of the thumb.
It must not cover a joint and is so placed that the fin-
ger can easily be bent. The end phalanx is then
made anasmic by slipping a small rubber band over
the finger tip and rolling it down the finger as far as
the ring. A pressure is now made upon the rubber
ball stronger than the arterial blood pressure. The
rubber band is removed and the finger remains ana?mic.
The pressure on the ball is slowly and evenly released
until the finger tip becomes hyperamic, and the amount
of pressure is read on the manometer. The hyperasmia
is very easy to recognize, and owing to the compres-
sion of the veins the return flow is hindered and the
finger tip becomes intensely red.
The principle of the apparatus is as simple as it is
ingenious. The digital arteries are so compressed by
the pneumatic ring that no blood can pass through.
This is shown by the finger tip remaining anaemic.
The pressure in the ring is gradually reduced, and the
instant the pressure in the ring is equal to or a little
less than the pressure in the arterial system the blood
will flow through the arteries and the finger tip will
become hypersemic. The manometer records exactly
the amount of pressure exerted upon the finger, so
when the finger tip becomes red the amount registered
by the manometer is approximately the amount of
blood pressure in the digital arteries. These arteries
are admirably adapted for the purposes of the tonom-
eter. The}' are close to the surface and near the bone,
and so can be completely compressed by the pneumatic
ring. The epithelium over the arteries is generally
thin and soft, and cases in which the epidermis is thick-
ened enough to interfere with a correct reading are
very rare. The great advantage this instrument pos-
sesses is in the substitution of the sense of sight for
the sense of touch. The instant the finger tip be-
comes red the patient experiences a marked pulsation
and can, if intelligent, control in some measure our
sense of sight. I have made many correct determina-
tions upon myself without rendering the finger anajmic,
and depended solely on feeling the pulsation.
The ease and rapidity of application and determi-
nation make the tonometer a thoroughly practical in-
strument. The entire process need take but fifteen to
thirty seconds. It is very easy to apply on children
from earliest infancy. The measurement may be taken
with the patient sitting up or in the recumbent posi-
tion. It is necessary, however, that the hand be on the
February 3, 1900]
MEDICAL RECORD.
183
same level as the heart, for well-known hydraulic rea-
sons. I have found that the difference in blood
pressure in my hand between the sitting and standing
positions registers nearly 30 mm. This shows the
delicacy of the tonometer. The patient must rest
quietly during the estimation, because coughing, strain-
ing, etc., raise the blood pressure. From a vast num-
ber of trials Professor Gartner has found that the
normal blood pressure as registered by the tonometer
is between 100 and 130 mm. Anything above or below
these figures indicates an abnormal pulse tension.
The highest reading obtained as yet by Professor
Gartner is 240 mm. A number of physicians are now
working on the blood pressure with the tonometer, and
within a few months many articles bearing on this
subject will appear in the German periodicals.
My attention was directed to the Gartner tonometer
in the first clinic held by Professor Nothnagel last
October, where he demonstrated the use of the tonom-
eter and recommended it very strongly. I subse-
quently learned that it was employed as a matter of
routine in his clinic, in which his assistants warmly
indorse its use. It is also used in the medical clinic
of Professor Neusser. Before the recent congress in
Munich, Professor v. Ziemssen said that the determi-
nation of the blood pressure was taken systematically
in his clinic, and often was of diagnostic value.
Three American physicians who spent some weeks
this past summer studying the treatment of heart affec-
tions at Nauheim have told me of the regular use of
the sphygmomanometer by Professor Schott and his
assistants.
The object of this article is to call the attention of
the profession in the United States to the Gartner
tonometer, and to point out a few of the conditions
in wiiich it could be employed with advantage.
Broadbent," in his classical work on the pulse, speak-
ing of high tension, says: " Unduly high pressure in
the arterial system or high tension of the pulse is a
condition worthy of careful attention and study. It
explains many of the forms of failing health at and
after middle age through lesions of the brain and heart.
It points out tendencies which later result in serious
illness or fatal disease, and its recognition often di-
rects us to measures by which ailments may be re-
lieved, and enables us to foresee and sometimes to
avert premature death."
A most important condition to recognize early is
the so-called idiopathic cardiac hypertrophy. Seitz,
of Zurich, was the first to describe this disease, which
he found very frequently among the peasants in Switz-
erland, who are accustomed to climb mountains, carry-
ing heavy loads. If care is not taken, it will finally
result in relative valvular lesions and insufficiency of
the heart muscle with its accompanying anasarca,
ascites, and passive congestions. In the stage of com-
pensation there is always a high-tension pulse. There
is little doubt that many of our active college ath-
letes develop this condition. Professor Gartner" has
made .some interesting experiments upon bicycle riders.
A long ride with severe exertion causes only a slight
increase in the pulse tension if the rider is in good
training. On the other hand, it was found that the
riders who were not in training had after a short pre-
liminary rise a prolonged and marked low arterial
tension. This opens an important field for further
investigations.
In arteriosclerosis we have a loss of elasticity in
the vessel walls, and in order to maintain the circula-
tion the left ventricle works harder and hypertrophies,
and the blood pressure is greatly raised. The impor-
tance of recognizing the amount of pulse tension is
well known, and in advanced cases it is impossible to
determine it from the radial artery. The tonometer
renders great service in these cases, as the digital
arteries are so small that even in a high grade of gen-
eral arteriosclerosis there is no difficulty in making a
correct estimation.
In nephritis the increase of tension is constant and
forms one of the leading symptoms. Recently in Noth-
nagel's clinic I saw two cases of- chronic contracted
kidney which will illustrate the diagnostic value of the
tonometer. One was a stout individual who was pass-
ing daily from 1,800 to 2,600 c.c. of urine with low
specific gravity. A trace of albumin was present, but
very faint, while repeated examinations failed to reveal
casts. Owing to the extremely thick chest walls the
apex could scarcely ije felt, the heart dulness was not
accurately mapped out, and the heart tones were not
distinctly heard. The pulse was small, and the tonom-
eter registered a blood pressure of over 200 mm., and
thus confirmed a diagnosis otherwise presenting some
difficulties: The other case was similar in many re-
spects, only the heart dulness and sounds were obscured
by a marked emphysema. Here the blood pressure was
225 mm. The tonometer may render a diagnosis of
chronic nephritis without a microscopical examination
of the urine. The great importance of this disease
and of its early recognition to life insurance companies
suggests the employment of the tonometer as a part of
the routine in all their medical examinations.
In chronic lead poisoning there is always a high-
tension pulse, and the tonometer may here be of diag-
nostic value.
An increase in the volume of blood brings about a
higher arterial tension, and in such cases a copious
bleeding would be beneficial. If this condition con-
tinues the left ventricle becomes hypertrophied.
Broadbent '° claims the high tendon in acute nephritis
is due to an increase in the blood volume caused by
retention of the urinary water. This might explain
the high tension in the "Munich beer heart," espe-
cially when a certain subjective sense of pressure is
not frequently relieved by the beer drinkers.
Capillary resistance is a most important cause of
increased pulse tension. A lack of oxygen in the red
blood cells causes a higher blood pressure. This is
the case when carbon dioxide is in excess and accounts
for the high tension in cyanosis and dyspnoea. In
Professor Neusser's clinic the high-tension pulse in
pleurisy with effusion is taken as the indication when
to aspirate.
Foster" has proved experimentally that many drugs
and poisons injected into the blood raise the pressure
by increasing the capillary resistance. The products
of auto-intoxication and imperfect metabolism circu-
lating in the blood act in the same way, and the origin
of some obscure symptoms may possibly be traced by
the presence of a high-tension pulse.
The tonometer is useful to control the effects of cer-
tain drugs and tp indicate the line of remedies required
in particular cases. It thus favors a rational use of
therapeutic measures. The knowledge obtained by its
employment can be utilized in the prophylaxis of many
disorders. The value of recognizing high or low arte-
rial tension in the prognosis of certain diseases is too
well known to be repeated here.
In conclusion I would say that the state of the
pressure in the arterial system plays an important role
in medicine, and it is not always recognized by the
average physician ; that in the Gartner tonometer we
have a simple, practical, and accurate clinical instru-
ment to determine the amount of arterial tension ; that
its value lies not only in scientific investigations, but
also in the daily practice of the general practitioner.
BIBLIOGRAPHY.
1. London Lancet, October 2S, iSgg.
2. Sahli : Lehrbuch der klinischen Untersuchungs-Methoden.
p. 139-
MEDICAL RECORD.
[February 3, 1900
3. Mosso ; Archives italiennes de biologic, Bd. xxiii.
4. Hurthle : Deutsche med. Woch.. 1896, No. 36.
5. V. Frey : Festschrift fiir Benno-Schmidt, Leipsic, 1896.
6. V. Basch : Berl. klin. Wochenschrift, 1S87.
7. Gartner : Wiener med. Wochenschrift, iSgg, Xo. 30.
8. Broadbent : The Pulse, chap. i.x.
9. Personal communication. Article will appear shortly.
10. Broadbent : Loc. cit.
11. Foster: Physiology, vol. i.
mucin accumulated in or introduced into tlie blood of a
normal organism produces a certain depressive effect
upon the central nervous system ; that it is not fatal
to a normal organism, and is decidedly fatal to one
deprived of its thyroid. Mucina^mia then, one may
conclude, is the pathological condition of an organism
resulting from the absence of the thyroid function;
but this conclusion does not exclude the possibility
of other abnormalities arising from the same cause.
MUCIN^MIA, AND ITS ROLE IN EXPERI-
MENTAL THYROPRIVIA.
3y I. LEVIN", M.D.
GOXORRHCEA IN ITS RELATIONS TO THE
MALE ADNEXA.'
It is a well-established fact that an organism deprived
of its thyroid, either through disease (myxcedema,
cretinism) or through an operative removal of the
gland, is suffering from some kind of an auto-intoxi-
cation. Some substance, which has either been pre-
viously transformed by the cells of the thyroid, or else
neutralized by some other substance produced by the
gland, accumulates in its absence in the blood and
poisons the organism. But what is the nature of the
substance or substances? This question has hardly
been approached yet experimentally in a direct way.
The discovery of an increased amount of mucin in
the tissues in myxcedema as well as in thyroidectomied
animals led Horsley and others to suppose, o priori,
that the symptoms of cachexia thyropriva may be
due to accumulation in the blood of mucin, which is
normally transformed by the thyroid. It seemed to
me all the more desirSble to test the matter experi-
mentally, as I was unable to find in the literature any
physiological or pharmacological study of the influ-
ence of mucin on an organism. I shall limit myself
here to an epitome of my work. A more detailed
account of it, together with the tracings and other ex-
periments bearing on the subject, is now in course of
preparation and will appear elsewhere.
In order to study the relation between mucinaemia
and the thyroid I availed myself of the fact that rab-
bits stand thyroidectomy a great deal better than car-
nivorous animals. Until lately it was universally ac-
cepted that thyroidectomy was not fatal to rabbits.
Gley in his work endeavors to show that the operation
is fatal to rabbits if all the parathyroids are also en-
tirpated. But even with him only a small percentage
get an acute cachexia, and these die not later than
within three days after operation. The rest either
recover entirely or emaciate and die a few months
after the operation. I have obtained identical results
in my simple thyroidectomies on rabbits. A few of
the animals die within twenty-four to forty-eight hours,
but by far the greater part survive. Taking this as a
basis I did the following experiments: A solution of
mucin in one-per-cent. sodium carbonate was injected
hypodermically into eight normal and nine thyroid-
ectomied rabbits. The former remained healthy,
while of the latter only one survived. Some of the
thyroidectomied rabbits died within forty-eight hours
after the injection, while they had previously survived
the thyroidectomy from eleven to twenty-five days.
Further to study the influence of mucin on the nervous
system of a normal animal, I examined the influence
of an intravenous injection of a mucin solution on the
blood pressure of the dog. The experiments showed
uniformly a fall of the blood pressure, even after both
vagi and the splanchnic nerve were cut. Subsequent
stimulation of the splanchnic again increased the
blood pressure. The fall W-as consequently due to the
direct depressing action of mucin on the vasomotor
centre in the medulla.
The conclusion to be drawn from this work is, that
3v E. WOOD RUGGLES, A.M., M.D.,
A QUARTER of a century ago it probably seemed as if
the last authoritative word on the subject of gonorrhoea
had been said. But just as the discovery of the tuber-
cle bacillus, by Koch, gave a new and almost violent
impulse to the study of tuberculosis, simplifying its
diagnosis, explaining its symptoms, and giving hopes
— alas, not yet realized! — of a successful specific treat-
ment, so the discovery of the gonococcus by Neisser,
of Breslau, in 1879, has wonderfully broadened and
deepened our knowledge of the character of gonor-
rhoeal processes and led to really remarkable results
in their treatment.
For example, many cases, such as were formerly
diagnosed as gonorrhoea and supposed to be rapidly
cured by some new method of treatment, are now
known to be simple urethritis, caused by leucorrhoeal
contagion, or even by decomposing secretion under a
tight foreskin.
On the other hand, the previously unsuspected viru-
lence of the gonorrhceal infection has been clearly es-
tablished, by the discovery of the gonococcus in sup-
purating buboes, in inflamed joints, in suppurative
epididymitis, in palmar abscess, and recently in the
endocardium, in two cases of death from gonorrhceal
endocarditis following gonorrhceal rheumatism.
But my subject limits me to the consideration of the
effects of gonorrhcea upon the " male adnexa," if I
may be permitted thus to christen the testicle, epididy-
mis, vas deferens, ejaculatory duct, seminal vesicle,
and prostate gland. Acute inflammation of these
organs may occur at any period of the disease, though,
as a rule, rather late than early. This is to be ex-
plained, not merely by the somewhat later development
of posterior urethritis, but more particularly by the
minuteness of the ejaculatory and prostatic ducts and
their oblique opening into the prostatic urethra, which
without doubt causes their occlusion during the hy-
pera^mic stage. As the swollen membrane loses its
turgidity, the mouths of the ducts become more patu-
lous and the entrance of germs less difficult. In cases
which occur early, imprudence on the part of the
patient, such as coitus, bicycle or horseback riding,
drinking, etc., are at fault, or else meddlesome treat-
ment— for example, the injection of astringent, non-
gonococcicidal remedies, passage of sounds, rectal
massage.
Inflammation of the testicle itself caused by gonor-
rhcea is comparatively rare, or, if it does exist, is of
minor importance, compared with the extreme severity
of gonorrhceal epididymitis. The symptoms of the
latter are what might be expected from the peculiar
conditions — the swollen tissues being constricted from
without and thus caused to press with double force on
the hypersensitive testicle. The literature of epididy-
mitis is easily accessible to all, so I will only pause
' Read before the Rochester Pathological Society, December
15. 1899-
February 3, 1900]
MEDICAL RECORD.
185
to consider its most far-reaching consequence, in the
tendency to obliteration of the vas deferens at some
portion of its lumen. Occurring on one side only,
this would matter less, as the diminution in number of
the spermatozoa in the semen, oligozoospermia, rarely
causes sterility. But when epididymitis has affected
both sides, azoospermia and absolute sterility are the
rule. Finger collected the histories of two hundred
and forty-two cases of bilateral epididymitis, in two
hundred and seven of which, eighty-five per cent., the
semen contained no spermatozoa.
He also found, in his investigations concerning
sterility, that in several cadavers one or both ejacula-
tory ducts had been obliterated at or near their open-
ing by a posterior gonorrhoeal urethritis. When bilat-
eral this condition would, of course, cause sterility.
The sharp pain at the instant of ejaculation, which we
not infrequently meet, is without doubt in many cases
referable to the impingement of the semen upon the
mouth of the duct, pathologically narrowed in the same
manner. This pain, in some cases, produces a reflex
disturbance of the ejaculatory act and its sudden inhi-
bition, so that little or no semen leaves the urethra,
and thus may also give rise to sterility.
Funiculitis, or inflammation of the spermatic cord,
may cause obliteration of the vas deferens quite inde-
pendently of epididymitis, and, if bilateral or in con-
nection with epididymitis of the opposite side, also
produces sterility.
Acute prostatitis is a much rarer complication of
gonorrhoea than epididymitis, though without doubt it
is often unrecognized, the symptoms of its milder
forms being the same as those of posterior urethritis —
frequent micturition, tenesmus, pain at the neck of the
bladder, radiating into the scrotum or thighs, dull
pain or uneasy feelings in the rectum, etc. With rest
in bed, elevation of pelvis, hot rectal douches, and
calming suppositories these cases can generally be
confined to the follicles of the gland and do not go on
to suppuration. If this does occur and breaking down
in some direction seems inevitable, it is better to cut
down upon the abscess through the perineum, rather
than run the risk, however slight, of a rectal or urethral
sinus.
Chronic prostatitis is a far more frequent disease
than is generally believed. It is my conviction that
sixty per cent, of the cases of chronic gonorrhoea which
have run for a year or longer (excluding those with
pronounced stricture), especially those cases which,
seemingly cured, recur after coitus, use of beer, etc.,
depend upon the prostate for their continuance by ob-
taining from it a fresh supply of pus and inflammatory
bacteria each time that the urethra has been rid of
their presence. In my investigations these bacteria
have rarely proved to be gonococci ; they are far more
often the ordinarily non-pathogenic colon bacillus or
the diplococcus urethrae, which we may be sure that
the most virgin urethra here present is supporting at
this moment.
This is a question to which too little study has been
given — that of the virulence which some non-patho-
genic bacteria develop under certain conditions. The
bacteriologist devotes practically his whole attention
to the pathogenic bacteria and to newly discovered
forms of germ life, and does not interest himself in
such problems as the changed life of the colon bacil-
lus; first, when inhabiting the large intestine as a
peaceful and probably helpful guest, and again in an
acute attack of cholera morbus, or as an inflammatory,
pus-producing germ in the urethra, the bladder, the
kidney, or the prostate.
The diplococcus urethrae presents the same anom-
alies. Ordinarily perfectly innocuous to the urethra,
It often is the agent which keeps up a post-gonorrhoeal
discharge for years, and it is a question whether it can
ever be completely dislodged from the prostate which
it has once invaded.
The pathology of prostatitis has been verified by
only a few autopsies. Not being a fatal disease, ma-
terial could be obtained only by dissecting every pros-
tate in a large number of cadavers. Finger pursued
this course for several months at the Rudolf Hospital
at Vienna, and from all the autopsies collected only a
dozen cases. He found two kinds of lesions. In the
one the follicles were cystic and filled with an enor-
mous amount of desquamated proliferating epithelium.
In the second group the lesions were similar, with the
addition of numerous pus cells. This corresponds to
what we should expect from the changed secretion,
only I am positive that in the latter group nearly every
case would have furnished a fine culture of colon ba-
cilli or diplococci urethrce, or both, had they been
bacteriologically examined. In regard to the first
group, I must say that, in my experiencf . in all the
cases in which symptoms seemed to be produced by
the prostate, its secretion contained numerous pus
cells. In my opinion group first consists of cases of
true prostatorrhoea and not prostatitis.
The physical diagnosis of prostatitis is not easy with-
out long practice by tlie finger, and even then it seems
as if each observer has a different idea of what the
feeling of a normal and of a diseased prostate is. To
my finger the normal prostate feels like a smooth,
rather resistant, firm, rounded body, ordinarily as large
as an average horse-chestnut, with a longitudinal fur-
row separating its lower surface into two lobes. The
alterations which I find associated with disease are
principally in the line of loss of firmness, a doughy,
boggy feeling, not as a rule general, but forming com-
pressible areas — " Dellen," the Germans call them —
between hummocks of normal or hardened tissue, uni-
lateral as a rule, though frequently found in both
lobes. Out of these " Dellen " the discharge can often
be literally milked. Frequently, however, no change
in its contour or firmness is ascertainable, and yet the
expressed secretion contains abundant pus and bac-
teria.
The microscopical finding is then the true arbiter
as to the condition of the prostate, and without-»it no
satisfactory results can be accomplished. This is no
less true of the diagnosis and treatment of acute and
chronic gonorrhoea in general. The indications
change with the alterations in, or absence of, bacteria,
and there is not the slightest doubt that it would be
exactly as just to the patient to treat any febrile dis-
ease without the clinical thermometer as to treat gonor-
rhoea without the frequent, almost daily, use of the
microscope. In fact, given the enormous prevalence
of the disease and the widespread evils which result
from chronic gonorrhoea, including the martyrdom and
unsexing of innocent wives, the consequences are per-
haps worse. And, after all, the pulse and feel of the
patient are far more accurate indications of the pres-
ence or absence of fever than are the looks and con-
sistency of a urethral discharge guides as to its bac-
teriological condition.
The prostatic secretion, if diseased, has lost its fat
granules and generally the amyloid bodies, and shows
a considerable amount of pus, an increased number of
epithelial cells, often of the pear-shaped type, and as
a rule motile bacteria.
This fact I have not seei; mentioned elsewhere and
attribute it to the omission of closely approximating the
cover-glass and slide before completing the examina-
tion. If this be done, little specks will be seen, about
pin-point size, or moving lines which either visibly
oscillate, make short excursions, or else show they are
in motion only by appearing at one instant as dark
specks and then a few seconds later as brilliant, light-
refracting points, this being caused by their leaving
1 86
MEDICAL RECORD.
[February 3, 1900
and approaching the point of exact focal distance.
This phenomenon can be seen only by following in-
tently one particular speck. On staining, which is
difficult because of the prostatic secretion not adhering
well to glass, they generally prove to be diplococci
urethrae or colon bacilli, or both.
Following are the abridged histories of several cases
in which the prostate gland was the real corpus delicti,
though not previously recognized.
B, M , salesman, twenty-six years old; heredity
and general health good. His first gonorrhrea, in
1 89 1, lasted four or five months. The second, in
1893, lasted six or eight weeks. The third, in 1896,
lasted acutely only three or four weeks, but since that
time he has had recurrence of the discharge after each
coitus and after violent erections. He has been the
whole time under treatment. In November, 1897, a
St. Paul physician performed meatotomy so effectually
as to produce hypospadias, an error generally com-
mitted, even by specialists. No improvement, but in-
creased discharge, followed the operation.
Status prnesens, October 12, 1898: The rather
scanty, muco-purulent discharge contains pus, epithe-
lium, and a few pus cells enclosing gonococci.
Urine, first glass cloudy, second clear. Under treat-
ment with protargol he made good progress for two
weeks. Then he suspended treatment for two days
and had a nocturnal emission. He returned with a
thick, ropy discharge full of pus cells.
After two weeks more of similar history, on Novem-
ber 14th, I examined the prostate and found the right
lobe boggy and expressed considerable secretion con-
taining numerous pus and epithelial cells, ^^'ith
massage and irrigations of permanganate the char-
acter of the prostatic secretion rapidly improved, till
on November 20th there were no pus cells. The night
of the 2ist he had an emission, and next day the pros-
tatic secretion again showed pus. On the evening of
the 30th he drank eight or ten glasses of beer. Next
morning there was no discharge, only a slight moisture
of the urethra. Removed with platinum loop, it
showed some pus, epithelium, and fibrin, no bacteria.
The first glass of urine was clear, with few filaments;
the second clear, no filaments. He left the city for a
business trip of several weeks. While away he sent a
slide with specimen of discharge after first intercourse.
On staining, it contained principally epithelium and
almost no pus. Subsequently he practised coitus re-
peatedly with no return of discharge at all.
L. I ; health and heredity good. He had gonor-
rhoea in 18S7, 1890, 1893, and the last time in 1894.
Since then he has always had a discharge, which di-
minishes on treatment but never disappears. His
wedding-day was set for Thanksgiving, one month
hence. With difficulty I persuaded him to postpone it
till New Year's, hoping in the mean time to gain his
consent to a still longer delay.
Status pra;sens, October 23, 1898: He has a muco-
purulent discharge; it contains pus, epithelium, and
fibrin, and is swarming with secondary bacteria; no
gonococci. First glass of urine was cloudy, the sec-
ond clear. Under treatment with bichloride of mer-
cury the bacteria disappeared, and the discharge was
asepti,c for six days, when unmistakable gonococci
appeared, these having been undoubtedly kept isolated
in the fundus of the Littrt? glands or in the prostate
by the superior power of resistance of the secondary
bacteria. The gonococci not disappearing so speedily
as desired, I massaged the prostate and obtained a
secretion containing many pus cells and some gono-
cocci. Massage and irrigations got rid of the gon-
ococci in sixteen days. For some time afterward the
very slight watery discharge contained extra-cellular
diplococci, proven non-gonorrhoeal by Gram's stain.
With prostatic massage, irrigations of permanganate,
and posterior instillations of protargol, this case pro-
gressed gradually to perfect recovery.
As a medical curiosity I might mention that, though
my patient's fiance'e knew of his having gonorrhoea,
they both absolutely refused to postpone the wedding
later than New Year's, but consented not to practise
intercourse till I should permit it. Four weeks after
their marriage his condition had so improved that I
was able to allow the practice of coitus condomaius.
He has now for some time abandoned the use of con-
doms, without infection of his wife, and remains per-
fectly well himself.
M. W was also a candidate for matrimony. He
had acquired gonorrhcea for the third time in Novem-
ber, 1898. Status prcesens, February 8, 1899 : He feels
smarting in the urethra, sometimes itching. The lips
of the meatus are glued together. The discharge, muco-
purulent, contains pus, epithelium, and a few intra-
cellular gonococci. First glass of urine is cloudy and
contains filaments; second cloudy. The prostate is
boggy and I expressed considerable secretion contain-
ing pus and epithelial cells.
Treatment : Massage of prostate, permanganate irri-
gations, anterior injections and posterior instillations
of protargol, gradual dilatation to 34° French during
two and one-half months. The patient was married in
May. He is perfectl)' well now, as is also his wife.
A further indirect effect of chronic prostatitis is the
production of dead spermatozoa, necrospermia, and
consequently sterility. Fiirbringer discovered the
fact, subsequently confirmed by Burckhardt and Fin-
ger, that the spermatozoa in the seminal vesicles are
motionless, and that the admixture of the acid prostatic
secretion is necessary to impart motility and thus ren-
der them capable of fructifying the ovum. In these
cases of prostatitis, attended with the formation of
pus, the reaction becomes neutral, and with consider-
able pus alkaline. These patients have necrospermia
and are sterile.
Seminal Vesiculitis. ^Owing to the length of this
paper I must refer my readers for a full description of
the etiology, pathology, symptoms, and treatment of
this disease to Dr. Eugene Fuller's most excellent
work on " Disorders of the Male Sexual Organs," in
which he handles the subject in a masterly manner.
According to him, gonorrhcea is the cause of almost
all the cases. He certainly errs, however, in practi-
cally denying the existence of chronic prostatitis and
attributing these cases to perivesicular inflammation.
In several of my cases the contents of the vesicles, as
obtained by massage, were absolutely normal, with no
pus cells whatever, and yet the prostatic secretion was
frankly purulent.
The histories of two cases, one acute, the other
chronic, will serve to give a fair clinical picture of
many phases of the disease:
G. H , twenty years old; heredity and previous
health good. His last coitus was on April 3d. He
noticed smarting April 7th, and discharge April 9th.
Status prajsens, April i, 1899: Small penis, very
long foreskin; profuse, thick, yellowish discharge,
containing pus, epithelium, and a moderate number
of gonococci. Urine, first and second glasses cloudy,
third clear. He has great pain on urination, and
painful erections. Treatment: irrigation with per-
manganate 1 : 6,000, protargol injections i : 200. Part
of the irrigation fluid entered the bladder, though I
was trying to confine the irrigation to the anterior
urethra. I believe that this atonicity of the external
sphincter accounted for the development of posterior
urethritis so early in the disease. Under this treat-
ment all the symptoms improved for a few days. Dur-
ing this time he noticed blood on urination, and I
found just within the meatus and occupying the lower
half of the anterior one-eighth inch of the urethra an
February 3, 1900]
MEDICAL RECORD.
187
ulcerated surface, covered with a thin, whitish mem-
brane. He already had enlarged inguinal glands in
both groins, too indolent in character for phancroid,
and I believed I had to do with a urethral hard chan-
cre, acquired through a previous .coitus. Following
the Vienna school, I used no treatment, but awaited
the development of secondary lesions. The ulcer
healed quickly; no roseola nor other secondary mani-
festations have occurred. (Recently I have seen
another case of acute gonorrhoea with a similar lesion
in the urethra, and am awaiting the development of
secondary symptoms or the contrary to see if a new
symptom of acute gonorrhoea should be described.)
At the end of the first five days of treatment he felt
so much better that, contrary to my directions, he took
a long bicycle ride. The next day there was an in-
creased discharge, with more gonococci, and both
glasses of urine were frankly cloudy. Two days later
he had chills and fever, 99.8 ' F. Also complained of a
muscular spasm in the penis, with sudden stoppage of
urination. The ne.xt day, April 24th, he felt consider-
able pain after the irrigation, so I instilled T^ xxx. of
a two-per-cent. cocaine solution into the posterior
urethra. This seemed to accentuate his distress, and
he ejected it immediately, following which came a
gush of pus. Microscopical examination showed this
to contain a mass of pus cells, some epithelium, and
many spermatozoa. The diagnosis was made at once :
acute seminal vesiculitis, gonorrhceal in character, for
a fair number of these pus cells contained gonococci.
The temperature was 99.8 " F. ; pulse, 94. On gentle
rectal palpation the right seminal vesicle proved to
be dilated to the size of a small hen's egg, smooth and
hot. I put him to bed, elevated the hips, drew the
scrotum well over on to the pubes, and gave him
urotropin gr. vi. t.i.d., and suppositories of opium,
belladonna, and hyoscyamus every four, then every six
hours.
April 25th: -He feels better. There is no discharge,
but the meatus is moist (the discharge generally stops
entirely till the acute attack is over). There are less
tenesmus and sudden stoppage of urination. Temper-
ature, 101.4° F. ; pulse, 98. He was given quinine,
gr. viii. at 9 a.m.; gr. vii. at noon daily.
April 26th: Temperature, 9 a..m., 98° F. ; 5 p.m.,
98.6^ F. He feels better and has less pain on urina-
tion. The right seminal vesicle is a trifle smaller
and is not hot.
April 27th: Temperature, 98.4° F. There is a quite
profuse discharge, containing pus, epithelium, fibrin,
and numerous diplococci, none intracellular. Both
glasses of urine were cloudy.
April 29th: Temperature, 98.2" F. He has no pain
except in the glans. The rrine is much clearer; it
contains pus, epithelium, colon bacilli, and gonococci
(many of them extra-celluiar, but verified by Gram's
staining). The patient is up and around the house
part of the day.
April 30th • His condition is the same, save that the
seminal vesicle is smaller; it is not larger than the
end of the second finger.
May 2d: He has improved considerably. There is
some pain in the glans on urinating, with much tick-
ling in the urethra. The seminal vesicle is about the
same size. I used some pressure in examination, and
at the end of urination there was a considerable gush
of grayish, inspissated matter, consisting of pus, some
crystals of calcium oxalate, and spermatozoa.
From this time on he gradually improved, a hot rec-
tal douche (with Kemp's tube) assisting greatly in
restoring tone to the vesicle, and a little later I em-
ployed massage, beginning very gently. The patient
was discharged June 24th. He returned for examina-
tion August 7th, after a week of beer drinking and
furious bicycle riding. There was no discharge; the
first and second glasses of urine were clear as crystal
and contained no filaments.
Chronic seminal vesiculitis. I shall make orUy one
remark in preface to this interesting case, that the
difficulty of recognizing the normal or only slightly
altered seminal vesicle at all with the examining finger
is as much more pronounced over that of finding the
prostate as is the normal ovary more difficult to pal-
pate than the uterus. With large development of adi-
pose tissue it becomes almost impossible.
W. W , twenty-nine years old. Heredity neu-
rotic; the patient was formerly fairly healthy, though
a hypochondriac. He first had gonorrhoea in 1894.
The discharge lasted several months; he was then
treated by dilatation with sounds, which was followed
by epididymitis. He has never been well since, and
has morning drop daily.
Status praesens, March 19, 1899: He micturates
five or six times between meals, rarely after being
abed. When the desire comes, he feels a stinging
sensation, and if situated so that he cannot urinate,
the pain increases, even to making him faint. He
showed several symptoms of general neurasthenia
which I will not enumerate. The morning drop con-
tains pus, fibrin, and epithelium, but no bacteria. The
urine is slightly alkaline; first glass cloudy with fila-
ments, second slightly cloudy. The centrifuge showed
pus, epithelial cells, particularly pear-shaped and
active bacteria. The next day he appeared to be suf-
fering from an attack of cystitis. Micturition occurred
every half-hour in the forenoon, and every fifteen or
twenty minutes in the afternoon, till he was fairly ex-
hausted. As he said, "the urine fairly shoots out,"
sometimes before he was ready. He has stinging,
burning pain in the glans after urination.
Suspecting the seminal vesicles or prostate to be at
fault, I examined them gently per rectum and found
the right seminal vesicle as large as a small hen's egg
and extremely painful. I expressed part of the con-
tents, and had the patient urinate in a conical glass.
There appeared a sediment seven-eighths of an inch
deep, composed of the characteristic moonstone-like
bodies, varying from the size of a pinhead to that of a
small pea. Examined microscopically, these consisted
principally of pus, motionless spermatozoa, and a few
epithelial cells. The massage was followed by instil-
lation of a one-half-per-cent. solution of nitrate of sil-
ver into the posterior urethra.
March 2 2d: He feels considerably better, and uri-
nates less often. The instillation of silver was
repeated.
March 24th: He is very much improved, and uri-
nates only once or twice between meals. Last even-
ing he did not urinate from 6:30 till 11 o'clock, and
then had no tenesmus. Massage was done, with about
the same quantity of moonstones. This was repeated
every four, then every six days till April i8th, at
which date the amount of moonstones was very much
smaller and the bladder irritation had ceased. The
patient then went on a business trip for two months.
During the first weeks he felt well. After six weeks
the irritation returned, and he had a constant desire to
urinate by day, but none when abed.
June 2ist, at his return : There was a small urethral
discharge containing pus, epithelium, and fibrin; no
bacteria. Massage resulted in giving one inch of
moonstones in the urine. There were much pus and
some spermatozoa in them. He received an irriga-
tion of permanganate, 1 : 6,000.
June 22d: He feels about the same. There is a
gush of pus after irrigation, probably from the seminal
vesicles, though no spermatozoa were visible. Urine,
first and second glasses cloudy, with much pus and
many active bacteria. Urotropin, gr. vi. t.i.d., was
given.
MEDICAL RECORD.
[February 3, 1900
June 23d: Improvement; he urinates only two or
three times between meals.
June 2Sth: Massage showed a much smaller quan-
tity of moonstones and pus relatively less.
On returning from my vacation (June 28th to July
17th) the patient informed me that he had felt well
during the whole time. But very little material could
be expressed from the seminal vesicles, and its char-
acter was greatly improved. On July i8th, 19th, and
20th he received irrigations, and on July 23d massage
and irrigation.
He then went again on a business trip, and wrote me
nearly two months later, to say that he had no tenes-
mus or irritation whatever.
As might be expected, inflammation of the seminal
vesicles produces important, yes, vital, changes in the
fructifying power of the semen. These organs are not
merely storehouses for the semen ; they are also glands
and supply an intrinsic part thereof, which serves to
dilute the testicular product and preserve the viability
of the spermatozoa. This is proved by the fact that in
both the acute and the chronic form of seminal vesicu-
litis the spermatozoa in the ejaculated semen are
found to be dead, or at least motionless and thus in-
capable of performing their function.
THE CHEMICAL RELATIONSHIP OF COL-
LOID, MUCOID. AND AMYLOID SUB-
STANCES (A PRELIMINARY COMMUNI-
CATION).'
By p. a. LEVENE. M.D.,
The morphological study of diseased organs reveals
frequently the presence in the cells and tissues of the
latter of substances which do not occur in the same
places of the normal tissues. The nature of the sub-
stances can be detected by microscopical investiga-
tion only very rarely. The microscopical technique
is inadequate to disclose the chemical nature of most
of the " pathological substances," and they are then
identified by their physical properties. And yet only
a thorough knowledge of their chemical constitution
can elucidate the process of their formation and their
relationship to the normal cell constituents.
The substance predominating over any other one in
the protoplasm, and most peculiar to it, is one of a
proteid nature. It is, therefore, natural to expect the
most changes in the proteids of the tissues, when the
latter are affected by some disease. Such is, in fact,
the case. Pathologists have described several forms
of pathological transformations of proteids in tissues
under the name of coagulational necrosis, amyloid,
colloid, mucoid, hyaline substances, etc. Originally
but one distinction between the latter substances and
the physiological proteids was detected; while the
normal proteids were found to be in the tissues in a
state of solution, the " pathological " ones were coagu-
lated. In all other respects they were similar to any
proteid material. .Amyloid, colloid, mucoid, and hya-
line substances were for certain physical properties
classified under a special group of " colloidal " sub-
stances. The studies on mucin and allied substances,
however, soon disclosed that the latter were not simple
proteids; that the proteid was combined in them with
a reducing substance, a '' carbihydrate " or "animal
gum." Thus mucoid and colloid had to be regarded
as substances distinct from the other colloidal sub-
stances, amyloid and hyaline.
Later it was discovered that amyloid was also not a
simple proteid. As mucin and mucoid, so amyloid
' Read before the New York Pathological Society, December
13. 1899.
contained a substance capable after certain treatment
of reducing Fehling's solution. There was, however,
a pronounced difference between mucoids and amy-
loid: while in the former the "animal gum" was sup-
posed to be combined directly with the proteids, it
was in the latter combined indirectly by the aid of
sulphuric acid — in a word, in amyloid the substance
capable of reducing Fehling's solution was described
as chondrotin-sulphuric acid.
On the ground of the latter discovery three different
forms of colloidal substances had to be established:
I, Mucoid and colloid; 2, amyloid; 3, hyaline. How-
ever, certain chemical and tinctorial properties of mu-
cin justified to my mind the supposition that the latter
must have contained in its molecule an acid radical.
To find the acid radical of mucin was the object of
this investigation. The work was begun on tendo-
mucin, and it was soon found that, similarly to amy-
loid, the mucin was a compound of proteid and of an
ethereal sulphuric acid. Further, it was found that,
similarly to chondrotin-sulphuric acid, the ethereal
sulphuric acid of the mucin was nitrogenous, and that
. it yielded, similarly to the former, chondrosin. With
the same object in view submaxillary mucin and col-
loid of a colloidal carcinoma were analyzed. These
two substances were also found to be compounds of a
nitrogenous ethereal sulphuric acid.
Thus it seems that the acid radicals of amyloid,
colloid, and mucoid substances are very similar to
each other. The investigation into the question
whether the substances are only similar or identical is
now in progress.
State Revenue from "Patent Medicines" in
Great Britain. — According to 2'it-Bits the popularity
of proprietary or patent medicines seems to suffer no
diminution. These pay a stamp duty which varies
according to the price at which they are sold. In the
last financial year a study of the inland revenue ac-
counts brings out the facts that a duty of 3 cents was
paid on 27,856,686, bottles or packages of medicine,
a duty of 6 cents on 5,076,805; of 12 cents on 856,-
057; of 25 cents on 108,280; of half a dollar on 11,-
309; of 75 cents on 5,703. Thus the government
stamp on 33,914,840 parcels of these popular medi-
cines yielded to the national exchequer the handsome
sum of ^1,832,860.
Pain in the Region of the Aorta. — This is fre-
quently referred to as characteristic of aneurism, but I
have not found it a \aluable or constant indication.
The pain of pressure and tension, so often mentioned
in the books, is not only often absent, but is almost
exactly simulated in many cases of neurasthenia— in
fact, in the latter condition it is of frequent occurrence.
One of the most prominent physicians of my acquain-
tance has borne the burden of fear of aneurism for
three years on account of the so-called characteristic
pain, while a most careful physical examination has
failed to find one confirmatory sign. Far more indi-
cative and just as frequent, in aneurism of the arch, is
a pain in the region of the fifth or sixth dorsal verte-
bra. I well remember a case in which this was the
only symptom, so far as I could learn, though I had
no personal knowledge of the history; the patient, a
man forty years of age, died from rupture a few min-
utes before my arrival. He had been treated by a
noted neurologist for spinal irritation, and the autopsy
showed vertebral caries from pressure. The pain may
also be found in the neurasthenic, but in these cases
it is lower, opposite the solar plexus, or, as a point of
second selection, about the fifth cervical. — Dk. \\'il-
LiAM Porter, in the I^'ew York Mtdiail Journal, De-
cember 9th.
February 3, 1900]
MEDICAL RECORD.
Medical Record:
A IVcck/y Journal of Medicine and Surgery ,
GEORGE F. SHRADY, A.M., M.D., Editor.
PlELISHERS
WM. WOOD &. CO., £1 Fifth Avenue
New York, February 3, 1900.
OUR AMBULANCE SYSTEM.
Our ambulance system and our ambulance surgeons
continue to excite from time to time unfavorable crit-
icism in the news columns of the public press, the
only channel by which such criticisms can reach the
general public. .The wide dissemination of these crit-
icisms or attacks makes them worth considering, espe-
cially because they are always ex parte and made by
a more or less excited and inexperienced observer, and
because the unfortunate victim of the attack, the am-
bulance surgeon, has no chance of making an imme-
diate reply of equal prominence to the attack in the
paper publishing it. This would introduce an ele-
ment of fairness which the critics do not want.
There are many things about the ambulance system
which the public does not understand, and in many
particulars there are things which ought to be done
better, but which under the present arrangement can-
not be materially changed. The only source of any
radical alteration in the methods of management of
this department of hospital work is the non-medical
board of managers, and if its members could be in-
duced to accept advice from those who know about
this particular department, and to spend a little money
sometimes where it might not show, much could be
done.
The arrangement as now in force in most hospitals
in this city is that the whole of the ambulance work
shall fall upon the surgical house staff. This is
wrong and ought to be changed. A careful analysis
of the ambulance statistics for a year in a large hos-
pital in this city has shown that more than one-third
of all calls were for individuals suffering from alco-
holism with or without some slight injury, and a large
number of other cases were of alcoholism combined
with some disease or injury in which the alcoholism
was of subsidiary importance. Furthermore, there
was a very large proportion amortg the other calls in
which the patients were purely medical, in which the
clement of emergency was rare or non-existent. In
hot weather there were many cases of insolation, and
in winter exposure and pulmonary diseases were re-
ponsible for many calls. In order to do efficient work
a man must not be overworked, and if ambulance duty
were evenly divided between the medical and the sur-
gical house staffs, as it ought to be, much would be
gained. This is a perfectly fair arrangero<?nt, since
the figures prove beyond question that any given am-
bulance call is as likely to be for a medical as a sur-
gical condition. The arrangement would not appeal
to medical juniors for obvious reasons, and probably
not to boards of managers, whose vis inertia against
change of any kind is always considerable; but it
would undoubtedly simplify matters, and by lighten-
ing the ambulance surgeon's work make carelessness
and inefificiency less likely, ("oupled with this change
there ought to be a rule, rigidly enforced, that every
person for whom the ambulance is summoned should
be taken to a hospital, where definite disposition of his
case might be made by suitable authority. This rule
would protect every one concerned in the matter, and
would be really of special advantage to the ambulance
surgeon. If he observes it, he need take hardly more
responsibility than that of a trained nurse, and he will
never have any unpleasant newspaper prominence, un-
less he is foolish enough to do something objection-
able, or apparently objectionable, at the scene of the
call.
When possible in large hospitals it might be well
to appoint a special ambulance surgeon, perhaps with
a small salary, who might be relieved at certain times
by a member of the regular staff, and whose whole
work should be on the ambulance and in the accident
room. The emergencies which are encountered by
ambulance surgeons are not such as require profound
knowledge and experience, because, as we have noted,
the patient has only to be taken at once to a hospital
in order to place the responsibility on some officer in
the hospital, presuming that the man on the ambulance
has acted with ordinary care. We know that ambu-
lance surgeons do not always behave with perfect po-
liteness, circumspection, and good temper, but they are
not the only ones who may be found fault with in this
regard; and the proper way to correct such things is
not to condemn the whole arrangement and all amou-
lance surgeons. The public is under the impression
that the ambulance surgeon is getting valuable profes-
sional experience from ambulance work, and a large
number of people seem to think that all hospitals re-
ceive a generous appropriation of public money for
the maintenance of this part of their establishments.
The work is the dreariest kind of drudgery, and the
only experience in it is in learning self-control and
restraint in the matter of temper. Only public hos-
pitals receive enough public money to support their
ambulance establ ishments. Considering the enormous
number of calls, we think it remarkable that there are
really so few blunders with any evil consequences —
evidence, it seems to us, that a high order of skill and
knowledge is not required on an ambulance; for the
ordinary ambulance surgeon cannot possibly have had
experience in making a rapid and intelligent diagnosis
of all sorts of conditions, such as he meets continually.
Another source of friction exists in the method of
sending calls for an ambulance. Most of the calls
come through the police, and, reform and instruct them
how we will, there will always be an irreducible resi-
due of gross stupidity to contend with. The charge
against hospitals that dying patients are driven long
distances to Bellevue Hospital in order to keep down
igo
MEDICAL RECORD.
[February 3, 1900
mortality figures is not well founded, as will be evi-
dent if we stop to consider that patients dying within
twenty-four hours of admission do not influence the
general death rate, but are put in a separate classifi-
cation, "moribund on admission."
The reforms which we should suggest, and should
like to see introduced, are: (i) Division of ambu-
lance work equally between surgical and medical
Internes; (2) appointment, whenever possible, of a
special ambulance surgeon; (3) rigid enforcement of
the rule that every person for whom an ambulance is
summoned should be taken to a hospital ; (4) some
reform, if possible, in the present method of sending
calls, especially "police station calls." The ambu-
lance surgeon himself changes too often to make it
worth while suggesting reform for him. However, if
he has the instincts of a gentleman, they will be evi-
dent on the rear seat of an ambulance as much as
anywhere else.
THE MENACE OF THE BARBER SHOP.
In some respects New York is the slowest of Ameri-
can larger cities. Improvements, advances, and re-
forms are to be noted in many smaller communities
long before the necessities of the case have sufficiently
impressed themselves upon the minds of our city
fathers. Though the Empire City may be late in mak-
ing beneficial changes, it has usually so far benefited
by the experience, and often the mistakes, of other
places that, when improvements are inaugurated, they
are up to date. New York has been backward in
"barber-shop hygiene," which the Medical Record
has advocated for a number of years. Paris has con-
tinued in the praiseworthy reforms started several
years ago, and now only metal combs are allowed, and,
so far as it is possible, all instruments have to be made
of metal, or some substance which can be readily ster-
ilized along with the towels, while the operator him-
self is expected to keep his hands reasonably clean.
Pennsylvania is to be congratulated upon starting a
movement in the proper direction, to secure an im-
provement in the conditions surrounding the barber
and his work. The State board of health has circu-
lated a series of recommendations, which, if followed,
would vastly decrease the chances of spread of conta-
gious disease in this way. Doing away with sponges
and powder puffs, not using on one customer after an-
other the same piece of alum to stop bleeding, and
taking care in the use of cosmetics not to let them
serve as media of transmitting disease from one per-
son to another, are all wise suggestions.
Last month Missouri made a stand for scientific and
sterile barbering. A board of examiners will see to
it that the barber is qualified, among other things, to
give a clean shave.
Canada is following in the footsteps of France, Aus-
tria, and Germany. The province of Quebec requires
the barber, first of all, to be himself a healthy subject,
free from transmissible affections. Then he must pass
an examination in disinfection, and promise to apply
his knowledge for the benefit of his patrons.
In connection with this important subject it is in-
teresting to learn that Huebener, of Breslau, found
pyogenic microbes in the beards of physicians eleven
times in twenty-six examinations.
Fliigge found that in a bearded subject there was a
marked increase in the number of colonies when the
beard was left uncovered near agar culture plates.
It is not, however, necessary for us to go into the
minutise of scientific refinement in order to convince
the thinking of the necessity for some regulation of
the barber's business. In the October number of the
Journal of Cutaneous and Geiiifo- Urinary Diseases is a
report on favus in which we read: "The two children
now presented by Dr. Allen were American born, and
they exhibited much the same appearances as the girl
shown at the previous meeting. Another point was that
these boys had never had medical treatment, but had
been treated regularly by a barber, the applications
being made in his shop. The speaker said that one of
the worst cases of favus that he had ever seen in this
country had been treated in a barber shop." Would it
not be well for us at least to attempt to regulate the
practice of medicine and surgery by the barbers of this
city, compelling them to confine themselves to non-
contagious diseases.' For the present it would seem
superfluous to tell them that Sabrazes gives in the
October number of Xht. Journal des Maladies Cutanies
a practical method of perfect sterilization for brushes,
combs, razors, etc., without injuring them. Three
grams of paraform tablets per cubic metre of space are
evaporated in a closed space at a temperature of 40°
C, the instruments being exposed for four hours, which
has been found to rid them entirely of all microbes.
MEDICAL ADVERTISING IN RELIGIOUS
JOURNALS.
The decision recently arrived at by the proprietor of
The Christian Herald, not to permit in future the in-
sertion of any advertisement of a medical character
within its pages, is one which will meet with the ap-
probation of all decent-minded persons. The Medi-
cal Record has on several occasions called attention
to this reprehensible custom. Paragraphs extolling
the curative and remedial virtues of drugs for all com-
plaints under the sun are a familiar feature of modern
journalistic enterprise. In the ordinary everyday
newspaper, so long as the bounds of good taste are
not too flauntingly overstepped, and so long as the
public is not gulled in too barefaced a manner into
paying with good coin for useless and frequently
really harmful nostrums, there can be no strong ex-
ception taken to this particular form of advertise-
ment. After all, when a rational being has come
to the years of discretion the presumption is that he
or she should be a fairly competent judge of ques-
tions concerning health, and if such an individual
prefers to patronize the venders of patent medicines
rather than to seek the advice of a duly qualified
medical practitioner, no restriction can be placed on
this exercise of free will.
Many of these advertisements, however, do not fall
February 3, 1900]
MEDICAL RECORD.
191
■within the category of either decency or utility and
are unworthy of insertion by any self-respecting editor.
Advertisements of this nature may be truly said to
befoul the columns of the journal in which they are
printed, and it would be matter for universal congratu-
lation were measures enforced to compel their exclu-
sion. It is bad enough when this nauseous literature
is permitted a position in the sheets of lay journals,
but the case is far and away worse when the readers
of a paper devoted solely to religious subjects are
nolens volens forced to have their eyesight offended by
advertisements lauding the qualities of some unfailing
remedy for impotence or an absolute specific for all
female irregularities. Such a mingling of religion
with affairs of so pre-eminently a mundane character
is, to use the mildest language possible, in a high
degree unseemly.
The question has also its comic side, and must ap-
peal to any one endowed with but a faint sense of
humor. Imagine an eloquent exposition of the Scrip-
tures, contributed by the pen of some famous divine,
while immediately underneath are to be read words
of something to this effect : " Dr. B , the celebrated
specialist on complaints of women, can be consulted
daily at his office, and will guarantee a complete cure
to all suffering females in a very short time. N. B. :
the drugs used are all of vegetable composition and
are warranted not to injure the most delicate organiza-
tion."
The resolution of The Christian Herald to bar alto-
gether medical advertisements from its columns re-
flects the greatest credit on those in control of that
journal, and its example should be promptly followed
by other papers whose reading matter is of a denomi-
national nature.
OSTEOPATHY IN GEORGIA.
The General Assembly of Georgia, at its recent ses-
sion, passed a bill legalizing the practice of osteopathy
in that State, and at the same time advertised " The
American School of Osteopathy, of Kirksville, Mis-
souri," concerning which school the Jefferson circuit
court of Kentucky rendered so notable a decision a
few weeks ago. Fortunately Georgia possesses in its
governor a man endowed with both courage and com-
mon sense, and who, although strongly pressed to give
his assent to the legalization of osteopathy, refused to
do so, but on the contrary, exercised his power of
veto.
For this action Governor Candler is entitled not
only to the thanks of the medical profession, but also
to the applause and respect of all good citizens. In
his veto the governor pointed out that there is no need
for the creation of another examining-board in Georgia.
There are already three of these boards, and any
graduate of any "lawfully chartered medical college"
may go before either of them, present his diploma, and
be examined. If he passes an examination satisfactory
to the board, the members of which are selected be-
cause of their eminence in the profession and their
skill in medical science, he is authorized to practise
medicine anywhere in this State, and to apply any
treatment he may deem best, including the methods
of osteopathy. If he is not a graduate of a reputable
medical college and cannot pass a satisfactory ex-
amination in the usual branches of medical education,
he ought not to be licensed to engage in the practice
of medicine.
This pronouncement places the whole question in a
nutshell, and is a decision the justice of which can be
gainsaid by no sane man. It will also be observed
that no unfair discrimination is made against any
particular school. The fact was proved to the hilt in
the Kentucky suit referred to above, that the Kirks-
ville School of Osteopathy in Missouri was not a rep-
utable school in the proper acceptation of that term,
and it is more than questionable whether the course
of training considered sufficient there could impart to
its graduates the medical knowledge necessary to
satisfy the requirements of any of the three Georgia
medical exaniining-boards. It would therefore be
manifestly unjust to the medical profession as well as
to the general public that incompetent men should
be permitted to undertake the treatment of disease.
However, the matter is not regarded by every one from
this point of view. Indeed a prominent minister of
the evangelistic persuasion contributed to the Atlanta
Journal of December 30th a violent tirade, sharply
criticising the public-spirited action of the governor
and jeering at the medical profession for standing up
for its rights. Some of the remarks of this clerical
gentleman are gems of thought and diction. The fol-
lowing paragraph is an example of the manner in
which a presumably cultured man may allow himself
to be carried away by the force of his feelings:
"The little petty jealousies and envyings among
doctors have made them the laughing-stock of intelli-
gent people. A minister of the gospel can advertise
in the papers a wonderful work of grace which led
three thousand souls to Christ, but the very minute a
medical doctor whispers it out that he has done some-
thing for suffering humanity he is jumped on for un-
professional conduct and outlawed by his profession.
A lawyer can spurt and blow about himself, and his
profession tolerates him at least, but wherever and
whenever a doctor has spouted and spurted he has
spouted and spurted himself to death."
The remainder of the Rev. Sam. T. Jones's dis=
course is conceived in the same prejudiced strain,
which fact very considerably weakens the effect of his
arguments. Probably he has a private grudge against
the medical profession or is desirous of giving himself
a cheap advertisement.
The rebuff to osteopathy in Georgia, following so
close on the heels of the yet more decisive one in Ken-
tucky, should go far toward strengthening the position
of the medical profession throughout the length and
. breadth of the land. The methods employed by the
emissaries of this " new science " are deserving of
the severest reprobation, and must be met by the re-
spectable medical practitioners with the most uncom-
promising vigor. The temporary check given to oste-
opathy in Georgia it is to be hoped will not lull its
opponents into a state of false securit)'.
192
MEDICAL RECORD.
[February 3, 1900
^cius at ttxe 'Wicch,
The Chester County Hospital at Westchester, Pa.,
has been bequeathed $2,500 by the will of the late
Samuel Greenwood as a memorial to be known by
his name.
Heroic Treatment for Corns A man in a Con-
necticut town — and an Adventist — having been trou-
bled with corns, from which many remedies brought
no relief, is reported to have removed the offending
members by means of a chisel and mallet.
The Buncombe County (N. C.) Medical Society.
— At the recent annual meeting of this society officers
for the ensuing year were elected as follows: I'resi-
dent. Dr. H. L. Bond; Vice-Presideiit, Dr. T. P. Chees-
borough; Treasurer, Dr. C. G. Reynolds; Recording
Secretary, Dr. J. T. Sevier; Corresponding Secretary,
Dr. E. R. Morris.
The Famine in India The Indian officials esti-
mate the cost to the government of the famine relief
works, etc., to the end of March will be 40,000,000
rupees. About twenty-two million persons are now
affected in British territory, and about twenty-seven
million in the native states. About three million two
hundred and fifty thousand persons are constantly re-
ceiving relief. Not only have the crops failed, but
water is becoming very scarce, and many hundred
head of cattle have perished.
Philadelphia Neurological Society. — At a stated
meeting held January 22d, Dr. A. Ferree Witmer
exhibited a case of left hemiplegia, in which, follow-
ing an injury to the left wrist in consequence of a
fall, a condition of over-extension of the proximal
phalanges occurred, with flexion of the terminal
phalanges. The peculiar claw-like hand resulting was
thought to be accidental, and dependent upon the in-
jury received. Dr. F. X. Dercum presented two cases
of primary neurotic atrophy, one in a man and the
other in a woman. In both the symptoms were pres-
ent in the upper as well as the lower extremities, were
of gradual development and of long standing. In the
second case pain was present, while it was absent in
the first. In the former no etiological factor could be
ascertained, v.hile in the latter there was a history of
moderate indulgence in alcohol. Dr. D. J. McCarthy
exhibited a case presenting trophic changes following
injury of the supra-orbital nerve. The patient was a
young woman who had been struck eight years pr-'vi-
ously upon the top of the head, to the right side of the
middle line, suffering an incised wound of the scalp,
with division of a branch of the supra-orbital nerve.
In the sequence of this accident the outer two-thirds
of the eyebrow and a portion of the hair on the cor-
responding side of the head became gray, while the
soft tissues appeared firmer than normal and the bone
was somewhat flattened; sweating was absent and sen-
sibility was much impaired in the distribution of the
affected nerve. Dr. McCarthy exhibited also a case
of paraesthetic meralgia, in which this condition was
present upon both sides of the body. It occurred in
a man who wore a double truss for the support of bi-
lateral herniiE, and the symptoms were more pro-
nounced upon that side upon which the truss exerted
the greater pressure. Dr. W. G. Spiller exhibited a
man of advanced years presenting hysterical tremor
resembling the tremor of paralysis agitans. Other
members of the family had presented a similar tremor.
The condition had been present for ten years, and the
movements could be varied by suggestion. There was
an absence of rigidity, of the ciiaracteristic facies, and
of the sense of heat often present. In the discussion
opinions were expressed that the tremor, while not
hysterical, was perhaps one of heretofore unclassified
character, and also that it was really that of paralysis
agitans. Dr. A. A. Eshner reported a case of rhizo-
melic spondylosis. The patient was a man, twenty-
four years old, who presented marked posterior con-
vexity of the spine, with rigidity, and also stiffness
and impaired mobility at the shoulder joints and the
hip joints. In addition, the reflexes generally were
exaggerated, while sensibility was unaltered. The
condition was believed to be one of inflammatory hy-
perplasia of the vertebras and their appendages, per-
haps associated with meningitis or with inflammation
or degeneration of the spinal cord itself. Dr. F. X.
Dercum reported a case of cerebral diplegia of child-
hood with hemiantesthesia. The patient was a girl,
upward of twenty years of age, who presented the ordi-
nary phenomena of spastic diplegia dating from early
life, but the hemianassthesia was emphasized as an
unusual condition. Dr. W. G. Spiller exhibited pho-
tographs and the brain of a boy with extreme contrac-
tures, and unilateral internal hydrocephalus. The
case was one of cerebral spastic paralysis. Upon
post-mortem examination, after the fluid had escaped
from the greatly distended lateral ventricle, the cor-
responding hemisphere was found to be much smaller
than its fellow, while the opposite half of the cerebel-
lum likewise was diminished in size. Degenerative
changes were found further in the right half of the
spinal cord. The following officers were elected for
the ensuing year: President, Dr. William G. Spiller;
Vice-Presidents, Drs. J. K. Mitchell and F. S. Pearce;
Secretary, Dr. A. A. Eshner; Treasurer, Dr. Guy
Hinsdale.
Philadelphia County Medical Society. — At a stated
meeting held January 24th, Dr. E. La Place reported
a case of tetanus treated by the subdural injection of
antitoxin, with exhibition of the patient. The symp-
toms of tetanus had developed in the, sequence of a
nail wound of the foot. An injection of 20 c.c. and
subsequently 40 c.c. of tetanus antitoxin had been
made beneath the dura mater, through a trephine
opening in the parietal region. In addition, injec-
tions of carbolic acid were made, HI v. being given on
forty-eight occasions. Dr. Orville Horwitz presented
a communication entitled "A Brief Account of a Few
Surgical Cases of Unusual Interest." Among the
cases reported was one of cyanosis of the arm, appar-
ently due to vascular obstruction, and relieved by sur-
gical intervention, although no obv. , is cause for the
condition could be discovered; one of control of ve-
February 3, 1900]
MEDICAL RECORD.
^93
nous hemorrhage in the pelvis, occurring in the course
of an operation for appendicitis, by the application of
hceniostatic forceps, whicli were permitted to remain
for a week, and another of similar application of for-
ceps to the femoral vein for the control of hemorrhage
due to division of the saphena vein at its junction
with the femoral; one of incarcerated omental hernia,
with beginning gangrene, but unattended with consti-
tutional symptoms; one of rupture of an appendicular
abscess into the sac of an inguinal hernia; one of
chronic ha;matocele of the vaginal tunic of the testis
following traumatism ; one of fatal extirpation of spleen
for enlargement of the organ ; one of suprapubic cystot-
omy for the removal from the bladder of two hundred
and eighty grains of white wax that was introduced
into the urethra to prevent insemination; and one of
intussusception in an adult, with recurrence requiring
a second operation, and death from asthenia. Dr. T.
J. Mays read a paper entitled " Notes on the Silver-
Nitrate Injections in the Treatment of Phthisis."
The treatment consisted of an anresthetic injection of
cocaine followed by the injection of TTlv. of a two-and-
a-half-per-cent. solution of silver nitrate into the sub-
cutaneous tissues of the neck over the pneumogastric
nerve on the side corresponding to the seat of the dis-
ease. It was reported that in a large number of the
cases thus treated weight improved, cough diminished,
expectoration grew less, physical signs cleared up,
night sweats disappeared, dyspncea lessened, and gen-
eral improvement took place. Drs. W. W. Mborhead
and L. J. Hammond read a paper entitled ".Report of
Two Cases of Brain Abscess, One Multiple." Both
terminated fatally in spite of operative intervention.
A resolution was adopted protesting against the enact-
ment of the Gallinger antivivisection bill before
Congress.
Pathological Society of Philadelphia. — At a stated
meeting on January 25th, a symposium upon typhoid
fever was held. Dr. A. C. Abbott discussed the epi-
demiology. He pointed out that while ordinarily
typhoid fever is an autumnal disease, in communities
supplied by surface water or polluted subsoil water
the greatest prevalence of the disease may occur at
varying periods in the year. Dr. J. H. Musser dis-
cussed the value of clinical laboratory methods in
diagnosis. He pointed out the importance of the
Widal test, which can be depended upon in about
ninety-eight per cent, of cases, and of the diazo re-
action, which can be depended upon in perhaps ninety
per cent, of cases; the significance of leucocytosis as
indicating the occurrence of an inflammatory or sup-
purative complication; and the occasional presence
of typhoid bacilli in the blood and their detection in
the stools. Dr. A. O. J. Kelly summarized the results
obtained at the German Hospital in the application of
the Widal test. He pointed out the difficulties attend-
ing the employment of the dry method, partic ilarly
that in obtaining accurate dilution. Dr. Joseph Mc-
Farland stated that the personal equation is a not
unimportant factor in the decision as to whether the
reaction is present or not. Dr. H. W. Cattell reported
the results of some observations made at the Woman's
Hospital, and pointed out that in rare instances the
presence of the Widal reaction might be utilized in
distinguishing human from other varieties of blood.
Dr. A. C. Abbott stated that in the bacteriological
laboratory of the Philadelphia board of health the
hffimoglobinometer is used for the purpose of securing
a definite and constant and appro.ximately accurate
dilution of the blood. Dr. J. D. Steele, in reporting
the results of observations made at the Presbyterian
Hospital, stated that a satisfactory method of dilution
consists in the use of the haemocytometer, securing a
dilution of 1:10 and then diluting this with an equal
quantity of distilled water. Dr. R. C. Rosenberger
reported tlie results of observations made in the Jeffer-
son Medical College Hospital, showing a high pro-
portion of positive results. Dr. N. B. Gwynn, of
Baltimore, referred to the relative frequency with
which typhoid bacilli, often in large numbers and in
pure culture, are present in the urine, in association
with symptoms referable to the urinary tract. A
case was related in which typhoid bacilli had been
found in the urine seven years previously, the patient
recently again coming under observation with symp-
toms of cystitis and the presence of typhoid bacilli in
the urine. Dr. Simon Flexner discussed the subject
of typhoid septicaemia. He stated that occasionally
the difficulty of making a diagnosis of typhoid fever
is as great on post-mortem examination as during life,
inasmuc'i as the disease is in a not inconsiderable num-
ber of ii stances unattended with intestinal lesions.
In rare cajes, further, the bacteria appear to have no
special localization, and not merely circulate but also
multiply in the blood, a condition that might be des-
ignated typhoid bactera;mia. Dr. T. G. Ashton read
a paper entitled "The Duty of the Physician in Pre-
venting the Dissemination of the Disease," in which
he pointed out the importance of careful disinfection
of all of the discharges from the typhoid patient in
order to prevent the spread of the disease from the
sick to the well. Dr. Joseph McFarland discussed
the present outlook for the serum treatment. He was
unable to make a favorable forecast, inasmuch as little
is as yet known concerning the toxins of the disease,
and there is reason to believe that so much serum
would be required for the introduction of the neces-
sary amount of antitoxin as to make such a mode of
procedure, for the present at least, impracticable. Per-
sonal experiments in an endeavor to immunize horses
and secure an effective antitoxin had proved unsuc-
cessful.
Proposed Investigation of the Native Drug Plants
of the United States One of the good works initiated
by the Pan-American Medical Congress is the scien-
tific investigation of the medicinal flora of each coun-
try on this continent. This has been carried o^c fur-
ther in some countries than in this; in Mexico, for
example, the investigation has been almost practically
completed by the Instituto Me'dico Nacional. In his
annual report the secretary of agriculture, Hon. James
Wilson, states that the committee of the Pan-Ameri-
can Medical Congress for the United States has re-
cently submitted to him a proposition to co-operate
194
MEDICAL RECORD.
[February 3, 1900
with the Department of Agriculture in a technical and
statistical investigation and classification of our native
drug plants. " By accepting this proposal," he says,
"we shall secure, in a research of which we have long
felt the need, the cordial assistance and support of an
influential association of learned physicians ; we shall
encourage each of the other American nations, all of
which are represented in the Pan-American Medical
Congress, to proceed with a similar investigation of
their own medical flora; we shall furnish a basis for
the remunerative employment of much land and many
people, and we shall stimulate the great growth and
growing trade in drugs between the countries of North
America and South America." He concludes by ask-
ing for an appropriation of $10,000 to enable the de-
partment to co-operate in this investigation.
Lehigh Valley (,Pa.) Medical Association. — At the
twelfth winter conversational meeting, held at Allen-
town on January 25 th, papers were read by Dr. J. C.
Biddle, of Fountain Spring; Dr. John B. Roberts and
Dr. L. Boardman Reed, of Philadelphia; Dr. Edgar
Moore Green, of Easton; Dr. A. H. Halberstadt, of
Pottsville; Dr. Mary McCay Wenck, of Sunbury; Dr.
Charles B. Knapp, of Wyoming; and Dr. Charles
Miner, of Wilkesbarre.
Medical Practice in Honduras. — Dr. Francis T.
B. Fest, of the Honduras army, writes, in answer to
frequent requests for information regarding practice
in that country, that every intending practitioner has
to appear before a board of examiners to obtain a
license. There are no openings; on the contrary. Dr.
Fest says that he knows several gentlemen there who
would like to hear of an opening somewhere else.
A Colossal Legacy. — Mme. Medvednikova, the
widow of a wealthy merchant, died recently on her
estate near Moscow, leaving 5,000,000 roubles (about
$3,000,000) to charity. Of this sum i, 000, 000 roubles
is designated to establish a hospital for incurables in
Moscow, 600,000 to build an asylum for idiots and
epileptics in Moscow, 500,000 to build a hospital for
the treatment of chronic diseases in Irkutsk, and
smaller sums for various other institutions.
A Bill to Define the Status of Acting Assistant
Surgeons in the Army. — Senator Piatt, of New York,
has introduced "A bill to issue warrants to acting as-
sistant surgeons of the IJnited States army who served
as medical officers either in the late Civil War or the
Spanish-American war or the Philippine rebellion."
The bill provides "that all acting assistant surgeons
of the United States navy who served as medical offi-
cers, agreeably to army regulations, either in the civil
war or the Spanish-American war or the Philippine
rebellion, and whose services were honorably termi-
nated, and those acting assistant surgeons of the army
who are still serving as medical officers, be issued
warrants by the Secretary of War as acting assistant
surgeons of the United States army in a similar man-
ner with the warrants issued to the acting assistant
surgeons of the United States navy by the Secretary
of the Navy, the date of their warrants to be the date
of their entry into the service of the United States as
medical officers, and the date when their services as
medical officers were or will be honorably terminated
to be the date of their discharges from the service of
the United States: Provided, that no back pay or al-
lowance be made to any such acting assistant surgeon
by virtue of this act." Acting assistant surgeons in
the navy are commissioned by the Secretary of the
Navy, and this bill only provides for similar treatment
of acting assistant surgeons in the army.
The Gallant- Allis Ether Inhaler.— Dr. A. Ernest
Gallant writes: " As the best means of acknowledging
the many kind words of commendation, and in reply
to numerous letters of inquiry, allow me to say that
the Allis inhaler described in my article on ' Etheriz-
ation ' in the Medical Record of December 30, 1899,
is for sale by most surgical supply houses. The pur-
chaser should insist on having the rubber cover not
less than eight and a half inches deep. The threaded
bandage should be cut out, and the gauze diaphragm
adjusted, and half a yard of loosely bunched gauze
inserted in the empty frame."
Antitoxin in Diphtheria Dr. J. Edward Herman
writes: "In the table of mortality following tracheot-
omy in children under two years of age treated with-
out antitoxin, appearing in my article in a recent issue
of the Medical Record, the rate printed did not rep-
resent the deaths but the recoveries. The corrected
table should give seventy per cent, mortality for anti-
toxin-treafed cases of tracheotomy in children two
years of age and under, and fifty-nine per cent, mor-
tality in the same class of cases which were treated
without antitoxin."
An Antivivisection Accusation. — At the seven-
teenth annual meeting of the American Antivivisection
Society, which was held in Philadelphia on January
25th, the corresponding secretary, Mrs. Richard P.
White, gave us all away and exposed our wicked prac-
tices to the view of a horrified world, .'^mong other
temperate remarks this veracious lady is reported by
the Philadelphia Ledger to have said that the "vivi-
section of human beings is the legitimate outcome of
vivisection of animals. If the practice of torturing
and dissecting dumb beasts be permitted to continue,
it soon will become a menace to the human individ-
ual, not only to patients who lie in the wards of char-
ity hospitals, but to citizens outside of institutions."
Then having become thoroughly warmed up to her
subject, she continued : " There is no longer any doubt
as to the truth of the account that numbers of most
atrocious and inhuman experiments have been and are
being made upon poor patients in the hospitals of va-
rious European cities, and in at least one of our own
States. That State is Massachusetts."'
Sanatoria for Consumptives in New York State.
— Drs. Enoch V. Stoddard and Stephen Smith and
Mr. Harvey W. Putnam, constituting the committee
on State sanatoria for consumptives, have made their
report to the State board of charities. While they
recognize that a State hospital in the Adirondacks
February 3, 1900]
MEDICAL RECORD.
195
would work great benefit, yet they do not think that
that is the only way in which the disease can be suc-
cessfully combated and eradicated. A better scheme,
they think, would be to establish local sanatoria.
This would work well for the poor, who object to go-
ing far away from home, especially if they have large
families. Another important fact is that the cure will
undoubtedly be of greater permanence when it is
effected in the same climate in which the persons will
always reside. The commissioners, therefore, recom-
mend that the State board of charities advise for the
relief of the poor suffering from tuberculosis such leg-
islation as will lead to the establishment of a State
system of hospitals on these lines. They say that if
tuberculosis is officially recognized as a contagious
affection, cases of which must be reported to the health
authorities, the local boards of health could protect
the community by establishing hospitals for the treat-
ment of the disease to which sufferers could be re-
moved.
Food Poisoning. — Dr. S. S. Bogert, of this city, re-
ports two cases of ptomaine poisoning from eating
veal, occurring twenty and twenty-four hours respec-
tively after the ingestion of the meat. The vomiting
and purging were severe and the prostration was
marked, but both.patients recovered.
A Reception in Honor of the "Maine." — The
American women resident in Cape Town held a re-
ception on January 23d at the Mount Nelson Hotel,
at which Lady Churchill, the staff of the hospital ship
Maine, the United States consul, and many other
Americans were present.
Opposition to Female Nurses.— The London cor-
respondent of the Commercial Advertiser says that, ac-
cording to a private letter from Sir William MacCor-
mac, there is excessive ill feeling Uetween the army
medical officers in South Africa and the female nurses
at the base hospitals, some of the former urging the
sole employment of male orderlies.
A Jewish Physician Honored in Russia. — During
the Russo-Turkish war in 1877 an army surgeon, Dr.
Griinkrug, distinguished himself for bravery on sever-
al occasions, and was rewarded by the bestowal of the
cross of St. Vladimir, an order which carries with it
promotion to the nobility. The Assembly of Nobility
of Smolensk Province recently refused to inscribe Dr.
Griinkrug's name on the list of noblemen on the
ground that he is a Hebrew, but the College of Her-
alds reversed the decision, affirming that the physician
was a Russian nobleman.
The Health of Havana — According to the report
of the health department of Havana, recently issued,
there were, during the year 1899, 8,153 deaths in the
city, or at the rate of about 36 per thousand, the esti-
mated population being 225,000. The chief causes
of death were: enteritis and dysentery, 1,163; mala-
ria, 822; heart disease, 623 ; typhoid fever, 240; men-
ingitis, 397 ; pneumonia, 322; marasmus, 173; can-
cer, 142; and yellow fever, 103. The mortality
decreased progressively from January, with 1,260
deaths, to November, with 493 ; but in December the
number increased to 534. There were in all 284 cases
of yellow fever with 103 deaths. Up to August ist
there were but 7 deaths from this disease, and the
great increase during the latter part of the year, which
continued even through December, is attributed to the
influx of unprotected immigrants from Spain and
America. Of those who died 58 were Spaniards
and 32 Americans. The death rate from yellow fever,
in spite of this, was the lowest in the past ten years,
the figures for the years 1890-98 being 327, 363, 362,
512, 418, 570, 1,540, 1,056, 162.
The Plague is spreading gradually throughout the
islands of the Pacific, having already invaded Japan,
Formosa, the Philippines, Australia, New Caledonia,
and Hawaii, and not improbably other places from
which reports are yet to come. In Honolulu up to
January 17th there had been thirty-nine deaths, one of
a white woman and the others among natives and Asi-
atics. The board of health has burned ten blocks of
houses in the plague-infected section. A Red Cross
society, formed by some of the ladies of Honolulu,
has done most effective work, and the local physicians
and clergymen have continually gone among the sick
and dying, submitting to voluntary isolation in order to
minister to the needs of the sick. — In Noumea, New
Caledonia, the disease has prevailed since early in De-
cember. There were sixteen deaths during the first ten
days following the development of the malady. Up
to December 23d there had been no deaths among the
whites, eight of whom had been infected, but nine
Kanakas, two Japanese, and five Tonkinese had died
of the disease. The part of the town where the infec-
tion first developed has been surrounded with a . high
galvanized iron fence seven hundred yards long. The
principal business houses, official buildings, and the
banking and shipping offices are guarded by posses of
soldiers. Twenty buildings in the infected quarter of
the town were demolished by the health authorities,
but, despite all the precautions, the plague has contin-
ued to spread, the number of new cases averaging three
daily. — At Sydney, New South Wales, general alarm
is felt in consequence of the arrival of eleven passen-
gers from Noumea, who landed before news of the
plague's presence was received. Extraordinary pre-
cautions have been taken throughout Australia and
strict quarantine is established. In the case of a
wharf laborer in Sydney, who was attacked on January
24th, the inoculation was apparently traced to a flea
bite. — In the Argentine Republic the plague is offi-
cially announced to exist at Buenos Ayres and Rosa-
rio, both of which ports have in consequence been
closed.
The Tuberculin Test in Cattle. — An interesting
experiment bearing upon the value of the tuberculin
test, the details of which we find recorded in the Utica
Herald, has been conducted at the Storrs Agricultural
College in Connecticut. Four cows were subjected to
the tuberculin test in March, 1896, and did not re-
spond. In the next October they were tested again
and all four responded. They were then placed in a
196
MEDICAL RECORD.
[February 3, 1900
light, airy stable, where it is estimated each cow had
fifteen hundred cubic feet of space. They were tested
again in January, 1897, and all four again responded.
The following April another test brought responses
from only two and the other two showed no reaction
whatever. In July of the same year still another test
was made, and there was no symptom indicating the
presence of tuberculosis in any of the four. For two
years their milk was fed to eight healthy calves, only
one of which contracted the disease, and in that in-
stance it appeared six months after it had stopped
drinking the e.\perimental milk, so that in all proba-
bility tuberculosis came from some other cause.
Antidote to Carbolic Acid. — A correspondent, re-
ferring to a paragraph on the treatment of carbolic-
acid poisoning in a recent issue, recalls the use of
cider vinegar or acetic acid in equivalent strength as
an efficient antidote.
Influenza is prevalent to an alarming degree in
Italy, Turin and Rome being especially afflicted, al-
though few cities are free. There are estimated to be
over thirty thousand persons ill with the disease in the
peninsula, and the pope has ordered general prayers
for the abatement of the epidemic. The disease pre-
vails also in Spain, where in Barcelona alone one hun-
dred and twenty-four deaths were attributed to it on
January 26th.
Hsat in Australia. — We suffer occasionally from
warm summer days and nights in this part of the
world, but the inhabitants of parts of Australia would
be glad to put up with the worst that we have to en-
dure. Almost every winter we have reports of exces-
sive hciit, and this year is no exception. It is stated
that on New Year's Day in Melbourne the thermome-
ter indicated 114° F. in the shade at five o'clock in the
afternoon, and in the sun during the middle of the day
it stood at 156°. There were five deaths from heat
stroke.
An Insane Physician Kills a Child. — The news-
papers recently reported a horrible case from an Iowa
town. It is said that a physician of that State was in
a friend's office when a ten-months-old child was
brought in for examination. The doctor being called
to attend an urgent case asked the visitor to examine
the child. He did so and took the child in his arms,
handling it so roughly that the parents protested.
Suddenly he crushed the child's head between his
hands, and then seized it by one foot and swung it
around his head. The physician was apprehended
and sent to the State hospital for the insane.
A State Home for the Aged. — A bill has been
introduced into the New York legislature by Assem-
blyman Harburger, providing for the establishment of
a home for the aged of both sexes, residents of New
York, Kings, Queens, Suffolk, Richmond, Westchester,
Nassau, and Rockland counties. Dependents over
sixty years old shall be eligible for entrance. An ap-
propriation of $100,000 is made for the purchase of
land, erection and equipment of buildings, and tem-
porary maintenance of the inmates.
Dr. D. A. Carmichael of the Marine-Hospital ser-
vice, until recently in Honolulu, has been appointed
chief quarantine officer at Manila, and is now on his
way thither.
The Cuban Medical Congress The executive
committee charged with the organization of the second
Cuban Medical Congress has determined upon the fol-
lowing subjects for formal discussion: Local anthro-
pology, medical topography and statistics, yellow fe-
ver, malaria, blackwater fever, chronic enteritis of
warm countries, and atypical febrile states in infancy.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
January 27, 1900. January 24th. — Surgeon H. N. T.
Harris ordered to the Albany via the Prairie. Passed
Assistant Surgeon L. L. Von Wedekind ordered to
duty on the Richvwnd. January 25 th (changes by
cable from Asiatic station). — Assistant Surgeon R. C.
Holcomb detached from the Solace and ordered to the
Helena.
The Late Dr. Mulhall.— The following resolutions
were adopted at a recent meeting of the Beaumont
Hospital Medical College of St. Louis:
" Whereas, In the loss we have sustained by the de-
cease of our respected friend and esteemed associate,
Dr. Joseph C. Mulhall, we, the faculty of the Beau-
mont Hospital Medical College, are desirous of testi-
fying our respect for our departed member, and of
expressing our earnest and sincere sympathy with the
family in their great bereavement, and with the medi-
cal profession in the loss of one of their ablest and
most enlightened fellow; therefore, be it
"Resolved, That we express our sincere condolence
to the family o^ our deceased conjrere in this, their
hour of affliction.
" Resolved, That the Beaumont Hospital Medical
College has lost one of its most valued and efficient
teachers.
"Resolved, That the entire medical profession, of
which our departed fellow was a shining light, has
sustained an irreparable loss.
"Resolved, That these sentiments be duly inscribed
in the records of the college, and that an engrossed
copy thereof be presented to the family of the de-
ceased."
Obituary Notes — Dr. William S. House died at
his home in Haverstraw, N. Y., on January 27th, at
the age of sixty-two years. The cause of death was
apoplexy. He was a graduate of the New York U^ni-
versity Medical School in 1859.
Dr. L. H. Lawall died at Bethlehem, Pa., on Jan-
uary 24th, as the result of an apoplectic attack, at the
age of seventy years. He was a graduate of the medi-
cal department of the University of Pennsylvania.
Dr. M. a. Booth, of Newport, Del., died at Wash-
ington, on January 24th, at the age of eighty-four years.
Dr. E. Eugene Weston died at West Pittston, Pa.,
at the age of forty-eight years. He was a graduate of
the Baltimore Medical College.
February 3, 1900] MEDICAL RECORD. 197
the patient put to bed until active symptoms disap-
'^VOQVCSS of ^EdCtliCal <§'CicnCC. P'^^''- "^^^ following prescription has been of service
to the writer:
Journal of tlte American Medical Assoc, /an. 2J, /yoo. ^ Acetanilid ' gr. ij.
Caffeine gr. ss.
The Treatment of Aneurisms by Subcutaneous Camphor monobromide gr. i.
Gelatin Injections.— Thomas B. Futcher reports cases Capsicum gr. ss.
of aneurisms treated by gelatin, and draws the follow- 5^,^^^^ Questions Relative to the Diagnosis of
ing conclusions from his experience: (.) In no case Anesthetic Leprosy.-J. G. McDougal discusses the
^vas the aneurism cured, although in one case of ab- ^^^^ ^j ^^^.^ ^- ^^^^^^3 ^j Ohio, who manifested
dominal aneurism still under treatment there has been ^ ^^.-o.^^^,, ^f o„.,,o*u„*;„ i„.„„o„ \ uu u »u *
, , , / , . appearances 01 anaesthetic leprosy. Although the true
considerable diminution in size; (2) in seven cases ^^^^^^ „f ^^^^^ ^^^^^ ,^^3 been questioned, the author
out of nine there was an appreciable diminution of ^^^^ ,^^j ^j^j^^ ^j^^^ ^^^^^ diagnosis thus far ad-
subject.ve symptoms; {3 it seems certain that the ^^^^^^ ^^,^ ^e considered tenable
subcutaneous injection of gelatin does increase the
coagulability of the blood; {4) the injections are fre- Syphilis from Dental Instruments. — William L.
quently very painful; (5) the injections were often Baum quotes several cases, and says that the dentist
followed by rise of temperature, although Lancereaux should personally supervise the disinfection of instru-
states the contrary from his experience; (6) although ments by boiling, and immersion in formalin or creolin
in no case has a cure yet been obtained, the author is solutions.
convinced that the method has some merit and deserves ,, .^r,^ ,t ^ , , « „ ^ .
further trial "^^^ ^^ ■^°* frequently do Great Harm, Rather
than Any Good, by Office Treatment of Female
Evidences that Bovine Tuberculosis is Commu- Generative Organs? — Milo Buel Ward thinks that
nicable to Man by Direct Contact, or by Food this question may be answered affirmatively in a great
Infection. — John A. Robison, after a wide review of the majority of cases.
literature of this subject, concludes that we have not „,.,.,,„ „ , . „
sufficient evidence of the intertransmission of bovine 5^?^^'^ °/ *^ Nervous System and the Use
and human tuberculosis, yet we must admit that there ^°^ ^,^"ff. "* Mercury and Iodine in its Treatment,
may be danger in tuberculous milk. The danger is- 7j^>' Wilhain M. Leszynsky. See Medical Record,
sufficient to call for laws insuring pure milk and food ^° ivii., p. 38.
products on general principles, but until the exact Physical Standard of National Guardsmen By
danger attending the use of tuberculous milk can be Gen. T. Francis Calef.
proven, it is better to turn the attention of the public
to other, and better proven, exciting causes of the ,, ,.,,,,,,
disease lyew i ork Medical Journal, January 2J, igon.
An Intestinal Suture.-Raymond Custer Turck Flexion or Bent-Knee Marching.-E. H. Bradford
presents diagrams of a modified form of the Halsted analyzes and illustrates by diagrams the ordinary
suture. The writer says that this new suture might straight-leg gait of the civilian and of the con,ientional
properly be called a " lock stitch," because each loop "I'l'tarj' parade, and shows its inferiority to the bent-
is locked through the adjacent ones, and stitch leak- '^"e^ ^^'^ ^^;'^^". '^ comes to the matter of getting sol-
age is rendered impossible. An exhaustive series of f '^"^^ °' pedestrians rapidly over uneven ground. This
experiments with this stitch are being conducted at the '^j'^y resembles a run except that both feet are never
Post-Graduate Laboratory of Anatomy and Operative °'t/^ ^\?ll^ f ''^ same time It is described as
Surgery, the results of which will be given later and I'^Y^T'- J^^ ''"^^' ™"'' ^^ ""'"'^^ ^^"*'. ^^^ ^T
at length lifted no higher than necessary to clear the inequali-
* ' ties of the ground; the advancing foot must be placed
Contagion in Leprosy as Observed in San Frail- flat on the ground, the step being made neither by the
Cisco. — Douglas W. Montgomery says that from his toe nor by the heel. The footfall should be noiseless,
observations the Pacific coast is not merely a tempo- and the steps at first short and frequent. The body
rary abiding-place for a few lepers who have come by must lean well forward, the back must be straight and
accident, but that the disease may be contracted there, the head erect, the chest open and shoulders low."
thus rendering this part of the United States a veri-
table leper focus. The writer draws these deductions Staphylitis and Elongated Uvula — T. W. Kilmer
from cases of leprosy in aliens occurring in his own describes acute and chronic inflammation and elonga-
experience, and adds that the remedy must be in the t'O" of the uvula together with the technics of uvulot-
segregation or deportation of the lepers already there om}'- Special stress is laid upon the necessity of
and the more stringent examination of immigrants from severing the offending portion with one cut of the scis-
leper countries. " sors, as a smooth surface is the ideal one in surgery of
the nose and throat.
Probable Brain Tumor with Recovery. — In this
case, reported by W. A. Jones, although the diagnosis Remarks on Intranasal Operations — For the re-
was a matter of extreme difficulty, the general symp- moval of spurs when small and anterior, the use of the
toms of headache, vertigo, vomiting, ocular palsy, left- annular knife is recommended. For intranasal splints
sided paralysis, with ankle-clonus and increased knee- the Barnays sponge is preferred. For splints embrac-
jerk, subnormal temperature and pulse, together with ing the full width of the septum a special form is de-
extreme irritability, all pointed to a tumor as the prob- vised, consisting of two hollow plates, one for each
able explanation. The treatment was mainly experi- side, connected by a spring. The hollow plates carry
mental, consisting in calomel and saline for the bow- an additional plate so arranged that after introduction
€ls, morphine for the pain, hypodermics of strychnine the posterior end is elevated after the shape of a fan.
for the slow and irregular pulse, a.id iodides by inunc- „,. ^ . ,.,.... ,,,, ^ ,, .
tion. After a slow convalescence recovery was com- ^he Study of Inhibition.-The following theory
„]p|.g of inhibition is proposed by J. Y. Gonzales: Every
vital organ exhibiting inhibitory phenomena con-
Influenza. — G. E. Crawford, 'discussing influenza, stantly receives two currents of nei"vous vibrations in
says that every case should be regarded as serious and opposite directions, and as these are partly neutral-
MEDICAL RECORD.
[February 3, 1900
ized there remains a resultant working in the direc-
tion of functional activit}' as ordinarily manifested by
the organs.
A Treatment for Acute Serous Synovitis Per-
mitting of Joint Functions — P. Hoffmann extols the
compression treatment, which consists of filling all
th^ depressions about the joint with cotton and the
subsequent application of strips of rubber plaster in
such a way as completely to encircle the joint and sev-
eral inches of the limb above and below it so as to
make firm and equable compression.
Pony, Montana, as a Resort for Cases of Pul-
monary Tuberculosis.— The advantages of the local-
ity are set forth by J. C. Schapps. Patients often do
better here, he says, than in Colorado. The winters
are cold and dry, the altitude is sufficient, and sun-
shine is prevalent.
Antitoxin Results and Definitions.- — A. Rupp does
not believe that all the problems of diphtheria have
been solved, and again expresses his doubts regarding
the value of antitoxin in this disease.
Clinical Memoranda on Otitis Media Chronica
Suppurativa.^}. F. Oaks summarizes the usual ther-
apeutic measures in the different stages of this affec-
tion.
Medical News, January 27, igoo.
Experimental Researches on the Effects of In-
creased Barometric Pressure and of Foreign Bodies
in the Pharynx, CEsophagus, Trachea, and Larynx.
— George W. Crile gives a description of his experi-
ments, with tracings showing the changes in blood
pressure. He says that experiments with increased
barometric pressure, as well as those on drowning,
show tRat a sufficient increase in the intrapulmonary
pressure may produce a collapse of the circulation.
It robs the left heart directly of blood, and therefore
causes a greater collapse than can be produced by
severing either the superior or the inferior vena cava
alone. The symptoms produced by foreign bodies of
considerable size lodged in the pharynx and certain
portions of the oesophagus closely resemble those
caused by foreign bodies in certain parts of the re-
spiratory tract. Choking produces symptoms of reflex
inhibition, partly through the superior laryngeal and
partly through the trunk of the vagus. In a given
case of threatened asphyxia, if operation is to be un-
dertaken for dislodgment of a foreign body, it would
be well to give a preliminary dose of atropine to pre-
vent a great collapse or possible death.
Hernia in Pregnancy and Pregnancy in Hernia,
with Note on Umbilical Hernia. — Thomas H. Man-
ley's experience has been that groin ruptures, gener-
ally, are neither produced nor aggravated by child-
bearing, but navel ruptures often greatly augment in
volume during pregnancy, if they are not sometimes
produced by it, and with repeated confinements may
attain enormous proportions. Cases are reported of
the impregnation of the uterus lodged in the sac of an
umbilical, ventral, femoral, or inguinal hernia. Um-
bilical hernia; of large size are rarely seen except in
child-bearing women. There is no evidence tliat the
gravid uterus is ever a cause of strangulation.
Pruritus Ani — By J. P. Tuttle. See Medical
Record, vol. hi., p. 66.
The Great Drainage Canal at Chicago. — J. A.
Stewart describes this canal, which is an open channel
one hundred and sixty feet wide at the bottom and
thirty-eight feet deep. Its purpose is to unite the
south branch of the Chicago River to the Desplaines
at Lockport, 111., whence it will flow to the Missis-
sippi River.
Boston Medical and Sitrgical Journal, January 2^, igoo.
The Value of X-Ray Examinations in the Less
Frequent Diseases of the Chest, Illustrated by
their Use in Those Cases in which Aneurism is
Present or Suspected — Francis H. Williams con-
cludes that -v-ray examinations should be made with
both fluorescent screen and a-ray photograph. Nor-
mal outlines in the upper part of the chest give us the
best assurance that an aneurism of the aorta is not
present. A'-ray examinations enable us to determine
the extent of an existing aneurism, whether or not it
is increasing, and in some cases to make a diagnosis
before there are physical signs.
Sixteen Years' Experience in Food and Drug
Inspection. — Samuel \V. Abbott reports the work of
the State board of health of Massachusetts in this line,
and urges the general establishment of such work.
States that have no such system of inspectiq;i, he says,
have an inferior food supply, so far as relates to arti-
cles liable to adulteration. The system is now in force
in almost every large city on the continent of Europe
as well as in Great Britain.
A Sterilizer and Equipment for Confinement Cases.
— Frank A. Higgins describes a convenient outfit of
his devising to be carried in the physician's obstetric
bag.
On the High Operation for Diseases within the
Scrotum. — J. G. Mumford believes that this useful
procedure may be employed in most cases of disease
in this region.
Ptomain Poisoning. — VV. P. Coues reports a severe
case, in which treatment by heat, strychnine gr. ^,
tincture of digitalis Til xv., and morphine gr. \ was
followed by recovery.
A Rhode Island Philosopher (Elisha Bartlett). —
By William Osier. Concluded from a previous num-
ber.
Philadelphia Medical Journal, January 27, igoo.
A Case of Multilocular Pseudo-Mucinous Cyst-
adenoma of the Right Ovary Associated with Pro-
nounced Symptoms of Diabetes — Henry D. Beyea
reports a case of this description occurring in a woman
fifty-three years of age. The tumor was removed by
operation; the patient recovered, and the glycosuria
and other diabetic symptoms disappeared.
Athetosis and Kindred Affections.— Frank Fischer
reports a case of athetosis in a boy, aged twelve years,
following an attack of rheumatism. He discusses the
nature of athetosis, chorea, and epilepsy, and suggests
that in these affections the lesion is frequently located
in the sensory tract, and that the disorders are there-
fore largely reflex.
Diet as a Method of Diagnosis. — C. D. Spivak
advocates putting patients with gastro-enteric troubles
on special diets for a day or two at a time, noting the
symptoms felt while on each.
New Staining-Forceps.^ — F. J. Kalteyer describes
and pictures an ingenious forceps devised by himself.
It is made of nickel-plated steel wire, and by means
of it a cover glass can be held immersed in staining
fluid in a Slender ^ish, the forceps supporting itself
on the table.
February 3, 1900]
MEDICAL RECORD.
199
Medical Societies in this Country Founded Prior
to the Year 1787. — Francis R. Packard presents an
historical sketch of nine medical societies founded
before the College of Physicians of Philadelphia. Of
these, three— the New Jersey, the Massachusetts, and
the New Haven medical societies — still exist.
Selections from the Lane Lectures. — Clifford All-
butt describes in this lecture, delivered in San Fran-
cisco in 1898, the physics of the heart.
Medical Press and Circular, January I J, igoo.
Excision of the Vesiculae Seminales for Tuber-
culous Disease Mansell Moullin gives two cases in
which he has removed the vesicles, dividing the vas
deferens as high up as possible. He had previously
removed ono seminal vesicle in another patient for
chronic inflammation following gonorrhcea. He em-
ploys the Zuckerkandl incision, slightly modified.
The vesicles were found filled with caseous masses.
Few instances are recorded in literature and none in
that of England. The patient is placed in the lithot-
omy position, but lying upon the side. The operation
is useless when the disease has extended beyond the
vesicula;.
Notes on Recent Cases of Enteroptosis. — A. A.
Symons Eccles relates four out of the twenty-two his-
tories recorded in 1899. In all there were neuras-
thenic symptoms and failing health, in some depression,
gloom, and prostration. One was a typical instance
of Gle'nard's disease with gastritis, dyspepsia, entero-
stenosis, nervous and muscular prostration. In all
there was eructation upon taking food and generally
constipation with flatulent distention. Two were
treated by rest, uplifting diet, and manipulation with
subsequent wearing of the belt. In the others a belt
was ordered which gave relief from the local discom-
fort. Diagrams are given of the stomach's position.
Tabetic Ophthalmoplegia. — Leonard Guthrie re-
cords the clinical features of a case and draws atten-
tion to the frequent occurrence of paralysis of ocular
muscles as a pre-ataxic symptom. The paralysis is
frequently cured by the ophthalmic surgeon or spon-
taneously subsides, and perhaps years afterward other
signs of tabes appear.
Diphtheria. — By William R. Smith, the second of
the Harben lectures.
The Lancet, January 20, igoo.
On the Feasibility of Carrying Out the Open-
Air Treatment of Consumption at the Patient's
Home. — T. A. Somerville and E. S. Yonge report the
case of a man aged thirty years with acute tuberculous
broncho-pneumonia, who was unable to leave home and
so was put on creosote, maltine, and an inhalant, and
advised to spend as much time as possible in the open
air near his own house. Subsequently, over-feeding
and graduated exercise were added to the regime.
On one day in a week he was allowed to go to his
office for a few hours. On other days he spent seven
hours out-doors or in wet weather sat in a sheltered
summer-house facing the south. The windows of his
sitting-room and bed-room were kept widely open.
Under this mode of living he gradually improved, and
in two months appeared perfectly well. The writers
believe that this plan of treatment is worthy of a
much widsr application than it has yet received.
On Some Points in the Natural History of Uterine
Fibroids. — F. H. Champneys answers four ques-
tions: I. Frequency. Of 40,615 gynaecological out-
patients, fibroids were diagnosed and treated in two
and one-half per cent.; of 5,875 in-patients, in nine
and four-tenths per cent. 2. Their symptoms are due
to pressure and weight, bleeding, pain, and uterine
catarrh. 3. The mortality from operation is seventeen
per cent, while that apart from operation is repre-
sented by the figures 0.000138 per cent.; in other
words, deaths from fibroids apart from operation are
excessively rare. 4. He discusses the ethics of oper-
ations, basing his statistics in this and otiier respects
on the records of St. Bartholomew's Hospital.
Tubercle Bacilli in Milk, Butter, and Marga-
rin. — H. E. Annett's experiments show that bacilli
are found in samples of milk in English cities in from
three to thirty per cent., the test being inoculability
in animals. They have been found in butter by other
observers in from ten to forty-seven per cent., but
there is some doubt whether the germs described by
these other observers have been the true bacilli of
Koch. Tubercle bacilli keep their virulence in butter
for twelve days. Out of twenty-eight samples of mar-
garin, only one proved to contain the germ of true
tuberculosis.
Case of Perforated Gastric Ulcer on the Posterior
Surface of the Stomach ; Operation, Recovery
The patient, a woman aged thirty years, was seen by
S. Davy and operated upon by F. Eve. Symptoms
which had occurred suddenly were those of collapse.
In six or seven hours she had rallied sufficiently to
justify operation. The perforation was on the pos-
terior surface close to the lesser curvature and attach-
ment of the lesser omentum.
A Note on Some Further Experience of Opera-
tions under Local Analgesia Produced by Eucaine B.
— A. E. Barker enumerates fifty-three various opera-
tions done under the conditions specified. He says
that at first the surgeon suffers from the feeling that
he may be causing the patient pain, and that makes
him hesitate. Practice in the method, however, soon
removes this.
Tetanus following Nephropexy. — H. Thompson
operated on a woman aged forty-seven years with a
loose right kidney. On the eighth day initial symp-
toms of tetanus set in, gradually increased, and caused
death on the fourteenth day. No antitoxin was used.
The author discusses the possible relation of mental
shock to the affection.
Some Facts Gathered from Experience Respect-
ing Miscible Black Carbolic Disinfecting Fluid and
Carbolic Disinfecting Powder F. W. Alexander
calls attention to the varying results of analyses of
these compounds and the confusion caused thereby.
He advocates the necessity of adopting uniform stand-
ards of testing.
Plague in Relation to Singapore M. F. Simon
gives some statistics from the official health records
of that city. Details are given in brief of some ten
individual cases.
Results which Have Been Obtained by Anti-
typhoid Inoculations By A. E. Wright. See Medi-
cal Record, vol. Ivii., p. 199.
British Alcdical Journal, January 20, igoo.
Results which Have Been Obtained by the Anti-
typhoid Inoculations. — A. E. Wright and W. B.
Leishman summarize the more important results which
have been obtained up to date by the application of
the antityphoid inoculations which were inaugurated
MEDICAL RECORD.
[Februarj^ 3, 1900
at Netley in July, 1896, among the troops in the In-
dian service. The men under observation numbered
11,295, o^ whom 2,835 ^^^ been inoculated. The
number of cases among the inoculated was 27, or 0.95
per cent., and among the uninoculated 213, or 2.5 per
cent. The number of deaths was 5, or 0.2 per cent.,
among the inoculated, and 23, (Jr 0.34 per cent., among
the unprotected. Assuming that these figures would
be the same relatively if applied to the entire army, the
authors estimate that general inoculation would effect
a saving of one thousand cases of typhoid fever and
nearly two hundred lives. A detailed account is given
of the methods which had been employed in the
preparation of the vaccine.
The Bromide Sleep ; A New Departure in the
Treatment of Acute Mania. — Neil Macleod presents
notes of cases he has treated by means of " the bro-
mide sleep," which he explains to mean a condition in-
duced by large doses of bromide lasting from five to
nine days, in which the subject sleeps day and night
and from which he cannot be roused. The writer
•claims that during this period the higher nerve cen-
tres are rested to an extent that cannot be reached in
any other way. In his experiment with nine cases
the results were satisfactory with one exception, a case
of morphine and cocaine habit, in which a double
pneumonia supervened with fatal result.
The Insane and their Treatment. — J. B. Spence
contrasts the present humane and scientific treatment
of the insane with older methods. He also touches
upon the duty which the general practitioner owes to
the insane in the early identification of functional and
curable phases of mental disease. In this connection
the writer deprecates the consignment to asylums of
those cases of drink madness which in many instances
might just as well be cared for elsewhere, thus avoid-
ing the stigma which is incurred, in the eyes of the
public, by residence in an insane asylum of however
short duration.
A Case in which Three Hundred Grains of Sul-
phonal Were Taken in Two Doses. — R. Percy
Smith reports this case. The patient was promptly
treated by apomorphine hypodermically and a purga-
tive by the mouth, and no toxic effects of the sulphonal
followed except drowsiness. This case illustrates the
ease with which the laity can obtain large doses of
drugs which are toxic if taken in sufficient quantities.
Case of Brain Tumor Simulating Myxoedema. —
David Sommerville reports this case, in which all the
symptoms pointed to myxoedema. There was no evi-
dence of syphilis, and the patient improved somewhat
under thyroid treatment. The necropsy revealed a
large glioma in the right occipital lobe. The thyroid
gland was normal. The author points out the useless-
ness of the thyroid extract as a therapeutic test.
A Criticism of the Mechanical Hypothesis of the
Origin of Carcinoma.— Samuel G. Shattock exhibits
a specimen of "spontaneous" carcinoma of the uterus
in a rabbit, which he thinks argues against the experi-
ment upon which Lambert Lack bases his theory of
the mechanical origin of cancer.
Spasmodic Closure of the Larynx during the
Administration of Ether. — W. J. McCardie reports
a case illustrating the fact that some patients with
compensated mitral stenosis are unable to take ether
as an anaesthetic.
Formic Acid and the Inhalation of Formalin
J. Lardner Green reports good results from this treat-
ment as a preparation for and aid to the open-air
treatment of phthisis.
A Case of Jacksonian Epilepsy Cured by Opera-
tion.— This case is reported by H. Drinkwater as being
of interest because the patient is now, more than four
and a half years since operation, in perfect health and
working regularly.
A Case of Imperforate Vagina. — Stephen M.
Laurence reports this case, in which, with an appar-
ently complete absence of uterus and vagina, there is
yet a perfectly normal development of vulva, mons
veneris, and mamnife, leading to the supposition that
a light thickening felt at the sides may possibly be
ovaries.
Twin Pregnancy with Central Placenta Praevia.
— Collingwood Fenwick reports a case of this condi-
tion occurring in a twin pregnancy. There were two
placentae, one lying across the outlet and the other
attached to the lower segment of the uterus.
Imperforate Anus F. Ormrod reports a case of
imperforate anus in a male child. Fecal matter was
passed through the urethra. The bowel was cut into
with some difficulty, and the child made a good re-
covery.
Ulcer of the Stomach. — A clinical lecture by
Robert Saundby.
Berliner klinische Wochenschrift, January 8, jgoo.
Contribution to the Pathology of Lead Paraly-
sis.— M. Bernhardt describes the various types of this
affection as set forth by difterent observers since the
time of Duchenne, and then records two interesting
cases of isolated paralysis of the small muscles of the
hand occurring in two painters of the ages of nineteen
and forty-one years respectively. In both instances
the extensors of the hand and finger, which generally
are most constantly and the earliest aff'ected, remained
intact throughout. M. Bernhardt regards this group-
ing of symptoms as very unusual.
Psoriasis and Glycosuria.— F. Nagelschmidt al-
ludes to the rare association of these two affections
and gives an account of some experiments made to
determine whether psoriasis patients are more disposed
to alimentary glycosuria than are healthy persons.
Out of twenty-five persons with the skin affection,
eight showed evidences of alimentary glycosuria when
fed on grape sugar, a certain quantity being given
each morning. But the author admits that persons
with other cutaneous affections are also liable to this
form of glycosuria, and is not willing to admit that
there is any special predilection thereto among pa-
tients with psoriasis.
A New Method of Treating Syphilis by Inhala-
tion.— R. Kutner has used with success the following
procedure: Mercurial ointment is carefully rubbed
over the inside of a box by means of a special device
which the patient can use himself. The latter breathes
the vapor of mercury given off from the rubbed surface,
by means of a mask attached to a tube leading from
the box. A heating device can be employed to keep
the interior of the box at the proper temperature for the
volatilization of the mercury.
Leprosy Hospitals Past and Present — M. Kirch-
ner alludes to the various institutions throughout the
world, and describes a model house for the care of this
disease, situated at Memel in Germany.
Miinchener medicinische IVoe/ienu/irift, Jan. 2, ipoo.
Clinical Experiments in Regard to the Influence
of Irrigation of the Vagina during Labor on the
Puerperium. — Kronig submits the followmg statistics
February 3, 1900]
MEDICAL RECORD.
which are based upon the results of his experiments.
Of 515 patients in whom irrigation was performed
the rectal temperature was above 38° C. in the
puerperium in 235, or 45.6 per cent.; above 38.5° in
121, or 23.5 per cent.; 39° in 75, or 14.5 per cent.;
39.5° in 41, or 7.96 per cent. ; and 40° in 17, or ^.^
per cent. One patient died of sepsis, giving a mor-
tality of 0.19 percent. Of 465 patients in whom irri-
gation was not carried out the rectal temperature was
above 38° C. in the puerperium in 177, or 38 per cent. ;
38.5° in 86, or 18 per cent.; 39° in 45, or 9.6 per
cent. ; 39.5° in 25, or 5.1 per cent. ; and 40° in 12, or
2.5 per cent. One patient died of sepsis — a mortality
of 0.21 per cent.
A Peculiar Influenzal Eruption on the Skin
Rieger describes a skin eruption which was followed
by marked swelling of the head and face, and which
he attributed to the retained poison of influenza. The
ordinary symptoms of influenza were present in the
patients, and Rieger, suffering from the malady him-
self, concludes that the organism though an energetic
reaction sought to destroy the stored-up poison, and
through a kind of scalding drowned the poison in the
heated exudate, for after subsidence of the swelling
perfect health was restored. Other analogous cases
have been noted, but according to Rieger have been
incorrectly diagnosed as erysipelas.
The Influence of Fluorescent Material on Infu-
soria.— ^H. V. Tappeiner states that light causes acri-
din, phenylacridin, eosin, and quinine in solution to
have a very baneful influence on paramecia, while in
the dark these substances are not at all, or at least
very slightly, poisonous. This injurious eff3Ct is de-
pendent on the excitation of fluorescence.
Diagnosis and Therapy of Suppuration of the
Eyes in the New-Born.— Von Ammon gives the re-
sults of the bacterial examination of many affected
eyes, and finds that gonorrhoeal infection at birth is
relatively infrequent compared to the later infection.
Therapy in the beginning of eye suppifration must not
be of an irritating nature.
A New Guaiacol Preparation — Alfred Einhorn
calls this new preparation the hydrochlorate of di-
ethyl-glycocol-guaiacol. It is easily soluble, and is
split up into guaiacol in the organism. It is entirely
non-poisonous, is non-corrosive, is easily absorbed, is
ana;sthetic, antiseptic, and deodorant.
Blue-Blindness in Contracted Kidney.— C. Ger-
hardt gives some interesting observations on this
subject. In the cases he has noted all blue objects
appeared black.
Wiener klifiische Rundschau, January 6, igoo.
Contribution to the Knowledge of Pemphigus
Vegetans — Neumann states that this affection used
to be regarded as syphilis. The prognosis is always
gloomy. In Neumann's first cases the average dura-
tion of the disease before death was three-quarters of
a year. Kaposi and Hebra have reported cases of
ten years' duration. As to treatment, tincture of io-
dine and trichloride of iodine have given temporary
relief. The best results are obtained from surgi-
cal treatment because by excision of the growths the
exuding surface is diminished and the loss of the body
juices decreased.
A Rare Combination of a Bullous Eruption of
the Skin (Epidermolysis Bullosa) with Hydrops
Hypostrophos. — Max VVilheim gives Schlesinger's
characterization of this affection as a recurrent, oede-
matous, often extensive swelling of the skin, mucous
membranes, and other parts. It is not inflammatory,
neither is it painful. The etiology is not settled.
Quincke thinks it depends upon an angioneurosis. It
may be that auto-intoxication plays an important role
in this disease, .^n interesting feature in a case
quoted is that an acute nervous oedema is established
by the influence of a local injury.
Mathematical Talent. — P. J. Mobius divides math-
ematical talent into four grades. In the lowest he _
places most women and not a few men. The second
he designates as normal and includes in that those
who can understand what is taught in high schools.
In the third belong engineers, seafaring men, and
physicists. The fourth comprises those who can grasp
the whole subject of mathematics. He also adds that
a fifth class might be made for mathematical geniuses
— those who contribute original work to the subject.
In examination of the brains of mathematicians an
excessive development ot the convolutions has been
found, but the skull has never been described.
Wiener klinische Wochenschriji, January 4, jgoo.
The Clinical Significance of a Displaced Kidney.
— J. Hochenegg reports a case operated on by him of
a kidney which was found in the pelvic cavity. The
patient, a woman fifty-two years of age, had for yearg"
suffered from constipation with its well-known train
of evils. The nervous expression of her trouble had
grown so severe that the symptoms were hysterical.
It was found necessary to extirpate the kidney, which
was abnormally formed, being round in shape like a
cake, still retaining the embryological lobes, and hav-
ing a hilus which looked forward. Otherwise it was
normal. This was undoubtedly a congenital malpo-
sition having no connection with the wandering kid-
ney. Although, as a rule, there are no special clinical
symptoms in this affection, when they do occur it is
from pressure on neighboring organs, as in this case
on the intestine. Anuria from compression of the
ureter has been reported, also different forms of ne-
phritis. The progress of labor has been affected — one
case of rupture of the uterus being recorded.
Some Unusual Concretions in the Human Jri-
nary System — O. Zuckerkandl states that urethral
stones are infrequent as compared with bladder con-
cretions. He describes three of the former, giving
illustrations. The first was almost as large as a cherry
and ovoid. The second, walnut-shaped, measured 28
mm. by 12 mm. The third was like a bean. He next
presents three preputial stones. Two were flat ovoid
and the third was fashioned with two facets. They
were the size of grape-seeds. Three more concretions
were ureteral and were each composed of two parts
united by a very narrow neck.
Contribution to the Knowledge of the Origin of
Urinary Casts. — Ernst v. Czyhlarz believes that
many hyaline casts are found in urine with no albu-
min; that granular casts are composed chiefly of de-
tritus, and that desquamation of epithelium occurs
mostly in the collecting tubules.
A New Cystoscope for Catheterization of the
Ureters. — M. Schlifka describes, with an illustration,
a new cystoscope which he thinks will prove more
convenient than earlier instruments.
Frenc/i Journals.
Bilateral Intermittent Ranula. — Andre' says the
exact anatomical origin of ranula has not been defi-
nitely established in spite of the great amount of at-
tention given the subject. He relates an observation
on a woman, twenty-two years of age, in which a
202
MEDICAL RECORD.
[February 3, 1900
double or bilateral ranula of intermittent character
took its origin in the dilated canal of Wharton. This
is a rare condition which has not been mentioned in
books. The permeable orifices on both sides made it
possible to enter into a fairly large pouch, but in spite
of the permeability of the duct the fluid contents
reached a point interfering with deglutition and pho-
nation. To effect a cure the tumor is to be emptied
every morning by dilating the canal with a lead probe
of gradually increasing size. — Le Bulletin Medical,
January 10, 1900.
Pott's Disease of the Cervical Region with
Brachial Paraplegia. — Broca observed, for several
months, a boy, six years old, with cervical Pott's dis-
ease and Goll's paraplegia. After a few months he
had difficulty in the use of the left arm, and paralysis
quickly followed. Continuous extension was carried
out, both to the hip and lower extremities, and marked
amelioration followed. Pain came on early, extending
to the arm even before there was stiffness of the neck.
It was pointed out that, contrary to the rule, there were
no subsequent motor disturbances in the lower
limbs. — Gazette Hebdomadaire de Mcdecine ct de Chi-
riirgie, January 11, 1900.
Cinnamate of Sodium in Pulmonary Tuberculo-
sis.— A. Mann treats tuberculosis by the intravenous
injection of an aqueous solution of cinnamate of sodium
which, he says, can be used without the least danger.
An increase of leucocytes is to be made out shortly
after the injection; granulations begin to form and the
necrosed tuberculous masses are absorbed. A solu-
tion of one to five per cent, of an active substance is
used. One or two minims of the weaker solution is
injected and gradually increased in strength, being
repeated every forty-eight hours. The median basilic
or cephalic vein is chosen for the injection, and an
antiseptic bandage is applied. — Journal de Medecine de
Paris, January 14, 1900.
Expression of the Foetus by the Abdominal
Method. — G. Keim describes his method of aiding the
expulsion of the child by manual pressure causing
uterine contraction and expression. He confines him-
self to the delivery of the foetus at or near term. He
finds that these manipulations are without danger for
the foetus, and that they do not cause the phenomena
of asphyxia or fatal compression. There is, however,
a possibility of meningeal or medullary hemorrhage
in certain cases. These facts, added to the harmless-
ness to the mother and the possibility of its applica-
tion without asepsis, make it valuable, but it is not in-
tended to exclude entirely the use of forceps and other
operative measures. — La Presse Medicale, January 13,
1900.
The Cardiac Complications during Convalescence
from Typhoid Fever. — J. Mollard has made fifty-two
observations bearing on this question, and concludes
that in four-fifths of the cases cardiac troubles are
found, in about one-half of which there is a true syn-
drome having the following features: (i) Eflfacement
or attenuation of the precordial impulse, slight dis-
placement of the apex in cases in which it can be
localized; (2) disturbances of rhythm; tachycardia,
embryocardia, arrhythmia; (3) change in the sounds
of the heart, medio-cardiac systolic souffle, bruit de
galop, enfeebleuient of the first sound or both sounds
together. — La Presse Medicale, January 10, 1900.
Periodical Vomiting in Infancy and its Treat-
ment.— ^R. Romme says that periodical vomiting is
observed almost exclusively in large children in whose
history, either hereditary or personal, a neuro-arthritic
source is found. This gives us a therapeutical in-
dication of the first order and our efforts must be
directed toward the diathesis itself. The child's tem-
perament must be changed by hygiene, proper alimen-
tation, etc. Constipation must be obviated, and an
occasional purgative be given containing jalap and
scammony. In the attack itself there should be free-
dom from all excitement, and a very rigid diet. — La
Presse Medicale, January 10, 1900.
The Treatment of Psoriasis — Hallopeau and
Leredde review the internal and external treatment of
psoriasis. The external is considered the most im-
portant and quickest way of ridding the surface of
scaly lesions. After this comechrysarobic acid, pyro-
gallic acid, eugallol, anthrarobin, oil of cade, tar, cal-
omel, and beta-naphthoj. Among the water cures
Lonesche, Uriage, and Bourboule are recommended.
Sulphur baths are given as an after-treatment. — Bul-
letin General de Thcrapeutigue, January 8, 1900.
The Technique of Total Abdominal Hysterectomy
in Suppuration of the Adnexa. — J. L. Faure says it
is better to take away the uterus at the same time that
the adnexa are removed, because it is always infected
and can serve only to keep up pain and various trou-
bles. The abdominal route is preferred for every case
attended with severe suppuration and those that are
acute and virulent. He goes on to describe his tech-
nique.— Journal des Praticieus, January 13, 1900.
The Mechanical Treatment of Sciatica Paul
Fre'tin gives, with illustrative drawings, the technique
he employs, including frictions, massage, vibrations
of the nerve trunk itself, passive extension of the
sciatic nerve, and gj-mnastic movements of the lower
extremities and trunk. — Journal de Mcdecine de Paris,
January 14, 1900.
The Reduction of Fractures by the Aid of the
Radiograph Th. Tuffier gives, with numerous draw-
ings, the employment of the .v-rays before, during, and
after the treatinent of various fractures, especially of
the arm and about the shoulder. — La Presse Medicale,
January 10, 1900.
Revue de Chirnrgie, January fo, jgoo.
Endothelioma of the Bones. — Paul Berger reports
a case of tumor of the humerus with spontaneous
fracture; and disarticulation of the shoulder, per-
formed by the author to remove the growth, was
shortly followed by the appearance of tumors in the
orbital and frontal region, on the thigh with fracture
of the femur, and in the spine. A histological ex-
amination of the tumor showed that it could not be
classed with the epitheliomata. The form of the cells
and the arrangement of the capillaries excluded sar-
comata. It was evidently of a class of neoplasms
which have been called endotheliomata or perithelio-
mata.
The Surgical Treatment of Genital Tuberculosis
in Men. — L. Longuet considers that castration as an
operation of predilection is a mistake, as is preserva-
tion of the organ by abstention. The truth lies be-
tween these two extremes, and the proper treatment
consists in a variety of operations, adapted to indi-
vidual cases. In some instances a portion of the
organ must be removed, in others the whole, but there
must be conservatism in the surgical procedures.
Accidents due to Epileptic Attacks — Charles
F(fre writes of the disastrous results of the tonic con-
tractions of muscles during an epileptic attack which
are liable to occur. Such are asphyxia from spasm of
the neck and chest muscles, rupture of heart, liver, or
February 3, igoo]
MEDICAL RECORD.
203
diaphragm, section of the tongue and wounds of the
cheek from contraction of the masseters, luxation of
the jaw, fracture of bones, abdominal hernia, and even
muscular hernia of the leg. The author reports a case
of the last-named lesion.
Appendicitis. — ^F. Terrier gives it as his opinion
that there is no such thing as medical treatment of
appendicitis. The diagnosis once made, prompt sur-
gical intervention is the only logical sequel.
Anaesthesia. — Oscar Bloch urges the more frequent
use of chloride of ethyl even in major operations.
"Psychic pain" can be dispelled by a few preliminary
whiffs of chloroform.
Revue Hebd. de Laryngohgie, etc., Dec. p and j6, j8gg.
A Case of Complete Anosmia occurred in the
practice of P. Jaques in the person of a man aged
forty-five years when first seen. He had not the
slightest recollection whatever of ever having had an
olfactory sensation. The superposition of sensorial
anesthesia and a notable diminution of tactile sensi-
bility led Jacques to conclude that the condition w-as
due to a previous alteration of the mucosa by a sup-
purative inflammation rather than to a paralysis by
either destruction or compression of the olfactory
nerves.
Diagnosis and Treatment of Sinus Affections. —
O. Seifert has adopted for the diagnosis of this class
of nasal troubles a procedure which he styles "nega-
tive politerization." After cleansing and cocainizing
the nasal fossae, he introduces into one naris a com-
pressed air-bag and then as the patient swallows a
mouthful of water he slowly allows the bag to distend.
This negative suction draws the sinus contents out
into the nostril. He claims that this procedure will
cure even chronic cases.
Giornale Jnternazionale delle Scienze Med., Dec. /j, j8gg.
The Prophylaxis of Tuberculosis in Children.—
Olimpio Cozzolino says that it is easier to treat chil-
dren than adults, because, being subject to parental
guidance, they are more tractable. Infectious diseases
often lead to pulmonary tuberculosis, and children
predisposed to phthisis should be especially guarded
from infection. Every hygienic precaution should be
observed, and an open-air life insisted upon, with due
regard to cold, rain, and wind. A carefully graded
course of cold bathing is excellent. Antisepsis of the
air passages and care of the teeth are of especial im-
portance. Milk, fats, honey, cocoa, are valuable foods.
The Curve of Fatigue with the Natural Rhythm.
— Luigi Simonelli gives the graphic results of studies
upon healthy individuals, whose muscles were con-
tracted rapidly and without artificial periods of rest
between the contractions.
International Medical Magazine, January, igoo.
On the Treatment of Acute and Curable Forms
of Melancholia. — Warren L. Babcock classifies, for
the purposes of treatment, curable forms of melan-
cholia as acute, agitated, and stuporous cases. In
acute cases, the first indication is to combat sleepless-
ness. The second is to keep the patient well nour-
ished. When auto-intoxication is present, the use of
saline laxatives, mineral water, and intestinal antisep-
tics is indicated. Suicidal tendencies should be
carefully guarded against. In agitated melancholia,
forced feeding and hypnotics are generally necessary.
In stuporous cases, Weir Mitchell's rest cure has met
with excellent results, as has also the administration
of thyroid extract.
Nervous Manifestations in the Diseases of Chil-
dren.— John Madison Taylor declares that two influ-
ences stand prominent in forming the lessened resist-
ance in infancy and childhood — cellular instability
and the incomplete development of the nervous system.
Hereditary transmutations, inheritance peculiarities,
and the degenerative neuroses should be considered.
The subject of nutrition neuroses would have here a
practical bearing. Fatigue states merging into ex-
haustion neuroses deserve attention. The child
should be observed while entirely naked. Spasmodic
states are often of the gravest significance. The ex-
istence of paralyses is frequently difficult to determine
in early life. The pupils and fundus of the eye
should be studied. Disturbances of speech should be
noted. The knee-jerk is a variable phenomenon in
children.
What Are the Doctor's Duties to Pregnant Wo-
men Before Labor ? —Edward A. Ayers gives the car-
dinal rules of gestation as follows: frequent but never
prolonged out-door exercise, alternating with brief
rests recumbent, with low-heeled shoes and shoulder-
strap support to the skirts, the corsets being laid aside;
a sensible diet that avoids an excess of meat; regula-
tion of the bowels. Careful pelvic and abdominal
examinations should be made. At least one vaginal
examination should be made a few weeks before labor
time. The urine should be carefully watched. The
nipples should be examined a month before labor;
milk scabs, abrasions, and fissures should be treated,
and depressed nipples elongated by traction daily.
Nervous Dyspepsia (Gastric Neurasthenia).—
Boardman Reed thinks that in more than half of the
cases of so-called nervous dyspepsia the trouble is
dependent upon actual disease somewhere in the
gastro-intestinal tract, and he prefers to limit the
term strictly to forms of indigestion or gastric symp-
toms which cannot be traced to any organic lesion,
and are not the manifest results of even any well-known
functional affection.
Some Ocular Inflammations of the Newly Born
and their Treatment — Frederick Krauss states that
the two diseases which are most frequent in the new-
born are a simple catarrh of the conjunctiva, and
ophthalmia neonatorum or purulent conjunctivitis.
Clinical Report of a Case of Myxoedema. — Henry
Beates, Jr., reports a case of myxcedema in a child
brought to him at the age of two years, which has ap-
parently been cured by the administration of the ex-
siccated thyroid gland.
The Medical Chronicle, January, jgoo.
Typhoid Affections of the Larynx. — R. W. Mars-
den reports four cases, three of which required trache-
otomy. In one case the laryngeal affection came on
at the end of the seventh week, and the inflammatory
process left such thickening that the patient has to
wear a permanent tracheotomy tube. In the second
case the inflammation began at the end of the fourth
week; in the third there were hoarseness and laryngeal
obstruction in the fourth week. The fourth case was
really one of superimposed diphtheritic inflammation,
to which typhoid patients are specially predisposed.
The Treatment of Nephrolithiasis with Glycerin.
— A. Hermann has given this remedy in one hundred
and fifteen cases. In sixty per cent, it was efficacious
either by removing concretions or by removing the
pains accompanying the disease. He gives the glyc-
erin in accordance with the weight and age of the
patient, keeping within the limit of from one to four
ounces (by weight.) The remedy was dissolved in
204
MEDICAL RECORD.
[February 3, 1900
an equal amount of water and always taken at one dose
between two meals, and repeated two or three times
in an interval of several days. Larger doses some-
times caused headache in nervous people or diarrhoea
in dyspeptics.
Administrations of a Mixture of Ether and
Chloroform in Gynaecological Operations.— F. Mc-
Farlane Fellows considers that a mixture of two parts
pure ether to one of freshly prepared chloroform pos-
sesses the advantages of safety and convenience.
A Case where Torsion of the Pedicle of an
Ovarian Cyst Gave Rise to Attacks Simulating
those of Recurrent Appendicitis. — F. A. Southam
reports such a case.
The Present Aspect of the Antitoxin Treatment
of Diphtheria. — F. Villy reviews the statistics of the
subject, which are all in favor of the remedy.
Journ. of Laryngology, December, i8gg, and Jan.,igoo.
A Case of Nasal Hydrorrhosa — U. Melzi reports a
case of this kind occurring in a woman aged forty years
and having lasted six years. Chemical analysis of the
fluid seemed to exclude the possibility of a cerebro-
spinal source. It seemed more nearly to approach
^e lacrymal fluid, but no alTection of the lacrymal ap-
paratus could be found. Sense of smell was appar-
ently unchanged. Translumination of sinuses gave
negative results. All therapeutic measures, including
vibratory massage, atropine, and protargol, were with-
out effect.
The Contagiousness of Acute Suppurative In-
flammation of the Middle Ear.— M. Lermoyez,
while not asserting that all suppurations of the middle
ear are contagious, firmly believes that such inflam-
mation often has no other cause. A series of cases is
narrated in which the element of direct contagion
seems to have been present. He therefore lays down
the rule that we should isolate patients, especially
children, with acute median otitis.
A Case of Retropharyngeal Abscess of Auricular
Origin. — Dr. Urbano Melzi has been able to find
recorded only twenty-two cases of retropharyngeal
abscess due to chronic suppuration of the middle ear.
He adds a third case occurring in a child aged two
years. Pus from the ear and the abscess contained
the same bacteria.
Bulletin oj the Johns Hopkins Hospital, December, i8gg.
The Recognition of the Poisonous Serpents of
North America. — Howard A. Kelly states that the
poisonous species of snakes are few in number. Those
indigenous to thfs country, with the exception of the
little harlequin snake (Flaps) of Florida and the
South, belong to the " pit viper " group, i.e., they have
a conspicuous blind depression over the upper lip be-
tween the eye and the nostril in the loral region.
Another differential point is the triangular head with
massive maxillary development. They have few^er
large scales on the head and a greatly increased num-
ber of small scales giving tlie head, a warty appear-
ance. The snake is thicker in proportion to its length
and has a shorter tail. The dorsal surface is rough.
The pupil is elliptical. There are two sets of teeth,
upper and lower. Just outside of the upper teeth,
under the lip, are two long mucous folds hanging over
the principal fangs, while a number of smaller re-
serve fangs are found behind. Kelly describes the
copperhead, the water moccasin, and the rattlesnake,
and then speaks of the harmless snakes, the Colubers.
On the Chemistry, Toxicology, and Therapy of
Snake Poisoning. — Thomas R. Brown declares that
the whole question of the exact position of the various
constituents of venom in the proteid family must be
left /// statu quo until a more definite and scientific
means of ditferentiation of the various members is
possible. In treating snake bite, a tight ligature
should be applied above the wound if it is on an ex-
tremity. The poison should be removed by scarifi-
cation, cauterization, excision, cupping, or sucking.
About the wound should be injected some substance
destructive to the venom. The internal remedies
most used have been alcohol, ammonia, and strych-
nine. Brown then speaks of experiments with anti-
venomous serum, reports of which make it probable
that a real antidote to snake poison has at last been
found.
The Mensuration and Capacity of the Female
Bladder. — Guy L. Hunner and Irving P. Lyon review
their experiments on this subject. All measurements
were made on living women, generally with healthy
bladders. The women were all in the knee-breast
posture, with the rectum, vagina, and bladder all (with
few exceptions), dilated with air. The follow^ing re-
sults were obtained:
Atmospheric capacity : With anaesthesia, 306.7 c.c.
(average 17 cases); without anaesthesia, 295 c.c. (aver-
ages cases) ; total, 303 c.c. (average 25 cases). Fluid
capacity: With anaesthesia, 449.6 cc. (average 15
cases); without anssthesia, 387.1 c.c. (average 7
cases); total, 429.7 c.c. (average 22 cases).
The average measurements obtained for the four
following points were: To vertex, 7.14 cm.; posterior
wall, 5.77 cm. ; left lateral wall, 6.70 cm. ; right lateral
wall, 5.92 cm.
Treatment, January 11, igoo.
Acute Rheumatism. — H. W. Syers writes of the con-
nection between rheumatism, pneumonia, and pleurisy.
It would seem that subjects showing rheumatic ten-
dencies but not necessarily sufferers from acute rheu-
matism may, after sufficient exposure, manifest symp-
toms of ordinary pneumonia and pleurisy, and these
maladies may run their course with but little indica-
tion of the rheumatic tendency which has certainly
had much to do with their causation. Often there is
no rheumatic history, no heart affection, and the rheu-
matic alliance is shown only by the presence of pro-
fuse acid sweating, by pain and swelling of joints, or
by both these signs in association.
On the Biliousness Sometimes Induced by Sea
Air. — F. Parkes Weber says that gouty patients, fat
and plethoric persons, and those who have recently
led very sedentary lives, in fact those in whom the
special metabolic functions of the liver and the func-
tions of the excretory viscera are carried out only
sufficiently to satisfy the ordinary demands made
upon them, are specially liable to be affected with
biliousness at the seaside. Tissue catabolism is more
rapid than in inland towns, and this throws extra
work on the excretory organs. \A'hen these are rela-
tively inactive, biliousness ensues.
The Treatment of Leprosy by Injection of Cal-
mette's Serum Antivenomieux. — R. S. Woodson re-
ports a case in which improvement was wonderful,
with a prospect of future recovery.
Revue de Mcdecine, January 10, igoo.
Intermittent Hysterical Ptosis — Jean Abadie re-
ports two cases of neuropathic patients, who as a re-
sult of emotional shock were affected by visual dis-
order, characterized by attacks of bilateral occlusion
February 3, 1900]
MEDICAL RECORD.
205
of the eyelids. The attacks were usually of short
duration and induced by some psychical disturbance.
Bilateral compression of the pre-auricular region,
whenever applied, was able to overcome the trouble in
one case, and gave partial success in the other. Dur-
ing the attacks there was no physical or mental dis-
turbance, absolutely the only phenomena present being
inertia and complete fiaccidity of the upper lids.
Direct Communication between the Portal Veins
and the Supra-Hepatic Veins in the Human Liver.
— Charles Sabourin, judging from this anatomical
condition found in the course of many researches,
thinks it possible that there may be two portal circu-
lations, one for the state of rest in especial, and the
other for the period of activity. This he thinks would
account for the rapidity of elimination by the kidneys
of liquids taken between meals, and for the prompt
and energetic action of the medicines, poisons, or alco-
hol taken at that time, and for the remarkable rapidity
with which the supra-hepatic veins become filled with
coloring- matter when this is injected through the
portal vein.
Tolerance of the Bromides in Epileptics of Ad-
vanced Age Ch. Fe're' reports a number of cases to
show that the bromides are sometimes very well borne
by epileptics over sixty years of age. He says that
renal insufficiency offers a contraindication to the use
of this remedy, but this condition is not peculiar to
advanced age. In many cases of seeming intolerance
success may be obtained by beginning with very
moderate doses and increasing gradually.
Lesions and Role of the Lymph Glands in Epi-
thelioma.— By Maurice Soupault and Marcel Labbe.
A continued article.
Functions of the l^yroid Gland — By Gabriel
Gauthier. A continued article.
Finska LdkaresaHskapcts Handlingar, December, i8gg.
Syphilis and Life Insurance.— J. V. Runeberg
presents a statistical study of mortality among the
policy holders of the Kaleva Life Insurance Company
of Helsingfors. The total number of deaths among
the insured from 1875 to 1897 was seven hundred and
thirty-four, and of this number eighty-four, or 11.4
per cent., were due to affections of syphilitic origin.
But the influence of syphilis is greater than these
figures would indicate, the author believes, for there
were many deaths from other causes which were un-
doubtedly hastened by the fact that syphilis had low-
ered the resisting-powers of the organism.
Uterine Fibroids in Members of the Same Family.
■ — Otto Engstrom has observed five hundred and thirty
cases of fibroid tumors of the uterus, and among them
has seen the affection in two or three sisters in thir-
teen families. He thinks this coincidence is not an
accidental one.
Fibro-Sarcoma of the Broad Ligament. — Axel R.
Limnell reports two cases of fibro-sarcoma of the broad
ligament occurring in women aged thirty-five and fifty-
one years respectively. The patients were alive and
in good health four and three years after the removal
of the growths. In both cases the neighboring organs
were healthy.
Vesico-Vaginal Fistula with Atresia of the
Urethra. — L. Gratschoff reports a case in which a
vesico-vaginal fistula was situated 3 cm. above the ex-
ternal orifice of the urethra, and this canal was oc-
cluded by a thick membrane. The author pierced
this membrane and inserted a catheter, and then re-
paired the fistula. The operation was successful.
MEDICAL
Jiocictij Sleparts.
SOCIETY OF THE
NEW YORK.
STATE OF
Ninety-Fourth Annual Meeting, Held in the City Hall„
Albany, January JO and ji and February j, igoo.
Willis G.
m.\cdonald, m.d., of albany,
President.
First Day — Tuesday, January joth.
President's Inaugural Address. — The session was
opened by the delivery of the presidential inaugural
address by Dr. Willis G. Macdonald, of Albany. He
alluded to the present popularity of Christian Science,
osteopathy, and similar sects in medicine, and ex-
pressed the belief that the cause was to be found in an
inadequate legal definition of the term " practice of
medicine." The efforts of the society's committee
and of the New York Bar Association to improve the
status of medical expert testimony had unfortunately
resulted in nothing more than a better general under-
standing of the intricate problems involved. In the
opinion of the speaker the legal profession is respon-
sible for the present order of things. Presiding judges
could readily remedy existing abuses by excluding
medical advocates from the witness box. A voluntary
society of men doing expert work could do much to
regulate the condition. On the topic of State control
of such chronic diseases as tuberculosis and syphilis,
the speaker stated that the tendency at present was
toward such State control and isolation in sanatoria.
The plan had been put in operation in Germany and
in Massachusetts, but was still in the experimental
stage. This society had endeavored to secure legisla-
tion in favor of the organization of State hospitals for
tuberculous persons. But, while working in this di-
rection, one should carefully consider whether all our
resources for the local control of this malady had been
exhausted. What had been done to prevent the herd-
ing of people in crowded tenements, and to improve
the food supply of these people? The address then
dealt with the subject of the long-standing schism be-
tween the Medical Society of New York and the Amer-
ican Medical Association. The speaker stated that
after a critical personal examination of the subject he
could find no difference in the ethical behavior of the
members of the two societies, and it seemed to many
that honesty and good manners were not matters for
legislation or codes, but rather the results of home
training. The present medical law of the State of
New York, possibly somewhat modified and with some
additional safeguards, constituted what might be called
the code of ethics of the Medical Society of the State
of New York, and practically unified the profession in
this State. The address concluded with a reference
to the odious and mischievous antivivisection bill for
the District of Columbia, and to the necessity for the
medical profession going to the assistance of the med-
ical corps of the army, and making Congress feel the-
need for prompt and favorable action on the reorgani-
zation and expansion of that body.
Report of the Committee on Hygiene — The report
was presented by Dr. Henry R. Hopkins, of Buffalo,
and, after tracing the movement of public opinion re-
garding tuberculosis since the time of the announce-
ment of Koch's discovery, the committee unreservedly
recommended State care of consumptives.
Report of the Committee on Legislation — Dr.
Frank Van Fleet presented this report. He said that
two hundred and sixty-five bills of a medical nature had
claimed the attention of the committee during the four
months' session of the last legislature.
2o6
MEDICAL RECORD.
[February 3, 1900
Committee on State Board of Medical Examiners.
— Dr. M. J. Lewi, the secretary, presented this report.
He stated that in the coming year four licensing ex-
aminations only would be held instead of five as here-
tofore. The total number of rejections in the past
year had been one hundred and sixty-iive, or 19.73 per
cent. Before the committee of the State society seven
hundred and thirty-eight candidates had appeared for
examination, and of this number 18.69 per cent, had
been rejected.
Committee on the United States Pharmacoposia —
Dr. Reynold W. Wilcox presented this report, which
favored the establishment of a bureau of materia med-
ica for the disinterested investigation into the charac-
ter and value of new drugs, the bureau to be under the
authority of the dicennial convention of 1900, subject
to the provision that this bureau should report annu-
ally. The society formally indorsed this recommen-
dation.
Appropriation for Pathological Laboratory of
State Insane Asylums Dr. A. Jacobi, of New
York, moved, and Dr. D. B. St. John Roosa heartily
seconded the adoption of a resolution, instructing the
committee on legislation to take immediate steps to
secure from the legislature a continuance of the ap-
propriation for the support of this laboratory. Both
gentlemen, however, made clear their disapproval of
the fact that this laboratory had deviated in its work
from that originally intended, and did not hesitate to
state that the resulting absence of immediate and prac-
tical results explained the disinclination of the State
to continue its appropriation.
The resolution was adopted.
Carcinoma of the Stomach, with Report of Cases
Showing Increased Hydrochloric Acid. — Dr. A.
MacFarlane, of Albany, read this paper. He stated
that the symptomatology of carcinoma of the stomach
varied with the diffuseness of the growth, the pres-
ence of ulceration, and whether or not the growth was
primary in the stomach. Special attention was di-
rected to a series of sixteen cases in which the symp-
tom generally thought to be most characteristic — i.e.,
the absence of hydrochloric acid in the gastric juice —
had not been present. Undoubtedly the absence of
hydrochloric acid was of the highest diagnostic signifi-
cance, yet many excellent observers had reported cases
showing that the presence of hydrochloric acid was
not inconsistent with the diagnosis of gastric cancer.
In twelve of the sixteen cases reported in the paper
the diagnosis had been confirmed by operation or by
autopsy. In six the history had been suggestive of a
preceding ulcer. Hydrochloric acid had been contin-
uously present in thirteen of the cases, while in three
it had been present for a time, and was afterward re-
placed by lactic acid. The latter acid had appeared
late in the disease in four cases, and in one it had
been associated with the presence of hydrochloric acid.
All of the patients had suffered greatly from vomiting.
Retention of food, emaciation, and prostration had
been marked in every instance. In nine cases the
gastric symptoms had been present for less than one
year; in seven they had existed for a number of years.
In seven cases pain had been the prominent symptom.
Eleven of the patients had been men and five womerr.
Their ages had varied from thirty to seventy-two years.
Dr. Samuel Lloyd, of New York, remarked that
in several cases of carcinoma of the stomach that had
come under his observation, in which the new growth
had been in the posterior wall, and the gastric mucous
membrane had not been involved, hydrochloric acid
had been found present after each test meal.
Age, Sex, and Season as Factors in Nervous
Disorders. — Dr. VVillia.m C. Krauss, of Buffalo, read
a paper with this title. He divided the life history
of the individual into six epochs, viz.: (i) infancy, or
up to the second year; (2) childhood or from the
beginning of the third year to the seventh or eighth
year; (3) boyhood and girlhood, from the seventh
year to the fifteenth or eighteenth ; (4) adolescence,
from puberty to the twenty-fourth year in the male and
the twentieth in the female; (5) manhood and woman-
hood, reaching to the fiftieth year in the man, and the
forty-fifth or fiftieth in the woman ; (6) old age, em-
bracing the years of decline and senility. Each period
of life had its own disturbances, dependent upon nerve-
cell perturbations occurring during the evolution of
the nerve centres. Many acute infectious processes
seemed to have a predilection for the early years of
life. During childhood the nervous system underwent
a transformation. The period of adolescence was one
of increased reflex irritability — a time when the pas-
sions and appetites were at their zenith. It might
well be called the emotional period of life. Of
course, there were diseases peculiar to no period of
life, but affecting all alike.
Strabismus. — Dr. D. B. St. John Roosa, of New
York, read a brief summary of his paper on this sub-
ject. He stated that at the time of presenting his
communication on this subject last year he had done
only six operations by Panas' method, but now he had
performed it twenty-four times, and his colleagues in
the hospital had done it twenty-two times. This gave
a total of forty-six operations, but of this number only
two still required further operation. This operation
made it possible, in almost every instance, to cure com-
pletely strabismus at one operation. The operation
consisted essentially in stretching the muscles to be
divided, before dividing them. The other important
features consisted in doing the operation at one sit-
ing, and in insisting that the operation should not be
done on ambulant cases, but only at the hospital or
at the patient's home. He no*' felt that he could con-
fidently recommend this operation of Panas in both
convergent and divergent squint with the assurance
that in ninety-five per cent, of the cases the correction
of the strabismus could be secured at one operation.
Non-Operative Treatment of Strabismus ; its Pos-
sibilities.— Dr. a. Edward Davis read this paper.
The author's principal points were: (i) Hypermetro-
pia and hypermetropic astigmatism were the causes
of convergent strabismus in the majority of cases; (2)
as contributory causes might be mentioned, (<?) differ-
ence in acuteness of vision, either congenital or
acquired, but usually the latter, and due to an unequal
state of refraction in the two eyes, and (/') anything
that interfered with the acuteness of vision, such as
opacities on the cornea and in the vitreous or lens;
(3) faulty structure, insertion, or innervation of the
extrinsic muscles of the eye may cause convergent
strabismus; (4) the amblyopia present in most cases
of convergent strabismus he believed to be functional
and acquired, and not congenital except rarely; (5)
the non-operative treatment of strabismus (the use of
atropine, the exclusion pad. and, in patients old enough,
glasses and the use of the stereoscope) should be be-
gun as soon as the squint is observed. Just as soon
as the non-operative treatment ceased to improve the
condition of the squint, it was time to operate. De-
lay in operating after this time was not only useless
but harmful, because the habit of suppressing the
image in the squinting eye became fixed, and the am-
blyopia was made worse. After the eyes had been
operated on, the use of the stereoscope, bar reading,
the pad and glasses were of the utmost \alue in com-
pleting the treatment by maintaining parallelism and
establishing single binocular vision. The rational
treatment of strabismus meant its early treatment.
The Differentiation and Treatment of Ocular
Affections Commonly Met with in Family Prac-
tice.—Dr. Frank \'an Fleet, of New York, read a
February 3, 1900]
MEDICAL RECORD.
207
paper with this title. He divided cases of conjuncti-
vitis into four classes, viz.: (i) Simple; (2) gonor-
rhoea!; (3) trachomatous; (4) traumatic. All of
these varieties were purulent and contagious unless it
might be the traumatic form, in which the conjuncti-
vitis was mild, and in which only a soothing eye lo-
tion would be required; in the more severe ones a
solution of nitrate of silver would be needed, and
possibly also the application of iced cloths. Nitrate-
of-silver solution was best applied on a cotton-wrapped
applicator, and, if the conjunctivitis was mild, it was
better not to exceed a strength of five grains to the
ounce. In gonorrhceal conjunctivitis Dr. Van Fleet
said he made use of a solution of the strength of twenty
to forty grains to the ounce, applied as early as possi-
ble and followed by the use of iced cloths. In tracho-
matous and follicular conjunctivitis expression short-
ened the duration of the disease. After the acute
stage sulphate of copper should be applied. Nitrate
of silver, alum, and sulphate of copper all gave good
results, but should not be used continuously for too
long a time, as they then aggravated the trouble. In
chronic cases he recommended the alternate use of
alum and sulphate of copper. As to the diagnosis,
the speaker said that conjunctivitis was most likely to
be confounded with keratitis, iritis, scleritis, and glau-
coma. In conjunctivitis the discharge of pus was
characteristic, and, as distinguished from keratitis,
there were, in addition, swelling and redness. In ker-
atitis there was a loss of brilliancy of the cornea which
was not observed in conjunctivitis, and in the major-
ity of cases of keratitis there was an opacity of the
cornea. In differentiating from glaucoma the size of
the pupil was an important guide; in keratitis the pu-
pil was contracted, while in glaucoma it was dilated.
In keratitis the irritation temporarily disappeared un-
der cocaine, whereas in iritis cocaine had little or no
effect. The pain was generally more pronounced in
iritis and glaucoma than in keratitis. The increased
tension of the eyeball in glaucoma was also a charac-
teristic sign. In conjunctivitis ice applications gave
relief, in keratitis and iritis hot applications were
generally more grateful to the patient. Episcleritis
and scleritis were often met with in private practice
as accompaniments of rheumatism and gout, and they
were best treated by the use of atropine and hot water
locally, and by the internal administration of salicy-
late of sodium, cathartics, and alkaline waters.
Teaching of Therapeutics to Undergraduates. —
Dr. Eli H. Long, of Buffalo, presented a brief ab-
stract of his communication on this subject. He ad-
vocated teaching therapeutics by beginning with a de-
scription of the physiological action of drugs, and
adopting what is knowns as "the conference method "
of teaching. It was possible to do this in a most in-
teresting way.
Teaching of Therapeutics to Post-Graduates.^
Dr. Reynold W, Wilcox, of New York, read this
paper. He expressed the belief that post-graduate
instruction, to be effective, must be intensely practical.
The Significance of Earache in Children.— Dr.
T. H. Halsted, of Syracuse, presented this communi-
cation. He said that there were two principal varie-
ties of earache in children, viz., (r) the neuralgic;
(2) the pain accompanying inflammation. The for-
mer was usually caused by disease external to, and per-
haps quite remote from, the ear. If with the acute
pain in the ear there were no tinnitus, no deafness, and
no redness or swelling of the drum, it was probable
that the pain was neuralgic. Earache in children was
usually caused by inflammation of the middle ear.
When an infant was in pain, without evident cause,
the physician should at once think of otitis media.
Purulent otitis media was nearly always present in
acute infectious diseases of the gastro- intestinal and
respiratory tracts of young children, especially in gas-
tro-enteritis and broncho-pneumonia. In many of the
acute infectious diseases and in gastro-enteric disor-
ders death was the result of an unrecognized abscess
of the middle ear. When children had recurrent at-
tacks of deafness, it was almost certain that the cause
was the presence of adenoids in the pharynx.
Dr. Wendell C. Phillips, of New York, empha-
sized the importance of keeping the nasal passages
clean in the acute infectious diseases. If properly
treated acute suppuration of the middle ear should
never become chronic. Pliaryngeal adenoids were cer-
tainly responsible for many cases of chronic suppura-
tion of the middle ear.
Dr. a. Jacobi, of New York, said that as prevention
was better than cure, he favored the daily washing out
of the nasal passages in all children. It should not
be done with a syringe, but by the use of the nasal cup.
Dr. William S. Ely, of Rochester, said that when
an infant was suffering from pain of obscure origin,
the mother should be directed to place her little finger
first in one ear of the baby and then in the other. If
either ear was painful and tender, it would be shown
by the child shrinking when the finger was inserted
into the affected ear. If the physician personally made
this test he might be led astray by the child shrinking
from fear rather than because of pain.
Weil's Disease, with a Pathological Study.— Dr.
Harlow Brooks, of New York, presented a paper with
this title. He stated that acute infectious icterus, or
Weil's disease, was characterized by a sudden onset,
the prodromata being those usually observed in typhoid
fever. Within eight or ten days the temperature usu-
ally fell by lysis, but relapses were common. The
disease was often epidemic, though it did not seem to
be contagious. It generally attacked young adults,
most frequently healthy males. Nearly all the report-
ed cases had been those of Germans, French, and Rus-
sians. He had been able to find only three cases re-
ported in America. The disease was undoubtedly an
infection, the source being almost certainly putrid ani-
mal flesh. For this reason butchers were specially
subject to this disease, as were also those persons sub-
sisting largely on sausage and other uncooked meats.
This probably explained the comparative rarity of the
disease in this country. Both clinically and patho-
logically there was a close resemblance between Weil's
disease and acute yellow atrophy of the liver.
Treatment of Temperatures and Heart Failure.
• — Dr. a. Jacobi, of New York, in this communication
dwelt upon the possible value of Credt's colloid sil-
ver. His own experience with this method of dealing
with temperature in disease was limited to a few cases
of phlebitis, puerperal fever, and pyaemia.
Pathogenesis and Treatment of Acute Croupous
Pneumonia in the Light of the Newer Pathology. —
Dr. James K. Crook, of New York, read a paper with
this title. He stated that the pneumococci were not
invariably present in pneumonia, nor did they invari-
ably cause pneumonia. Fraenkel's microbe appeared
to be present in all conditions, yet was not invaria-
bly present in one. On the other hand, it had been
demonstrated that pulmonary hepatization might be
produced by the colon bacillus, the Loefifler bacillus,
and the bacilli of typhoid fever and of erysipelas.
He was not disposed, therefore, to place much reliance
on the pneumococcus either as the cause of acute lobar
pneumonia or as a basis for treatment. It had been
proved that the serum from the blood of animals
suffering from pneumonia conferred temporary immu-
nity upon animals into which it had been injected.
Although various remedies had been recommended as
effective in pneumonia, there was still no proof that
any of these agents influenced the pneumococcus in
the body in any way.
208
MEDICAL RECORD.
[February 3, 1900
Dr. Andrew H. Smith, of New York, said that he
■wished he could sufficient!)- emphasize the importance,
to a correct conception of pneumonia, of the double
circulation in the lung. A fact well known to every
iirst-year medical student had heretofore been entirely
overlooked in its relation to the one disease in which
it afforded the indispensable condition upon which the
•disease depended. Like all other organs the lung had
a circulation by which its structure was nourished, and
which derived its blood from the left side of the heart,
but in addition it had an entirely independent circula-
tion for functional purposes, which received its blood
supply from the right side of the heart. This latter
circulation was not interested in maintaining the struc-
tural integrity of the lung. This circulation might be
entirely suppressed without structural damage, as when
the lung was compressed by intrapleural effusion. It
was his belief that the essence of a true lobar pneu-
monia was the infection of the air cells with the pneu-
mococcus — the specific parasite. Other organisms
might participate in the infection, but in proportion as
they did so the case would not be typical. The one
clinical feature that, in his opinion, always indicated
the predominance of the pneumococcus as the causal
factor was the defervescence by crisis. When this oc-
curred, he believed one might always be sure that the
infection was chiefly by the pneumococcus. When
the defervescence was by lysis, one might suspect that
other germs were taking a prominent part. It could,
however, only be suspected, for lysis might occur with
pneumococcic infection if the local process spread
slowly, and one portion after the other of the lung kept
up the supply of to.xin. The pneumococcus was pres-
ent in the upper air passages and, to some extent, in
the large bronchial tubes of most persons in health.
It did not grow rapidly in these localities, only indi-
vidual bacilli being found ordinarily. It grew freely,
however, on serous or synovial membranes. With the
former might be classed the lining membrane of the
air cells. If the pneumococcus penetrated this far,
a colony was started, and the irritation so produced
caused an exudation, in which the growth continued
until the medium became loo much contaminated to
serve longer as such, and then the process was stayed.
This organism was peculiarly sensitive to acid, and
the pneumonic process seemed to increase the acidity
of the lung. The speaker then contrasted pneumonia
with diphtheritic infection, more particularly as regards
the direct action of the pneumococcus and its toxin,
and the fact that while in diphtheria the microbe grew
in the tissue itself, in pneumonia it grew on an exudate
that was poured into the air cells and was not a part
of the pulmonary structure.
Dr. Henrv R. Hopkins, of Bufifalo, insisted most
emphatically on the necessity of supplying an abun-
dance of pure air to the pneumonia patient.
Classification of Infectious Diseases. Dr. Wii-
■LiAM H. Thomson, of New York, presented a com-
munication on this subject, in which he dwelt upon
the important, and often disastrous, results from the
careless use or misuse of the terms " contagious " and
""infectious.'" We had fortunately got rid of that
nightmare " miasm," or a deadly gas. The following
classification was recommended: All diseases due to
the presence of their specific living micro-organisms
in the body were "infectious"; hence, all infectious
diseases were communicable from the sick to the well.
They were divisible into three classes, /.(■., (1) the
contagious; (2) the non-contagious; (3) the inocu-
lable. The contagious communicable diseases were
those in which simple proximity to the infected was
sufficient to communicate the infection to those sus-
ceptible to it. The noncontagious communicable
■diseases were those in which the communication was
■not by -imple proximity to the sick, but through inter-
mediate means of communication. The inoculable
diseases were those which gained entrance through
wounds, as in' hydrophobia. All infectious diseases
could be prevented by measures of disinfection ap-
plicable to each. Dr. Thomson suggested that the
foregoing facts be summarized and presented to the
public.
Discussion on Prophylaxis in Gynaecology : the
Etiology and Prevention of Uterine Disease Before
Pregnancy. — Dr. W. Gill Wylie, of New York,
opened this discussion, taking up the special topic
indicated. He said that for a young girl to develop
well into a healthy young woman she must have a
surplus of strength ; otherwise the generative organs
were almost sure to suffer. Up to the age of abou^t
ten years girls and boys should be allowed the same
freedom, and should be prevented from undue use of
the brain and the excitement incident to frequent as-
sociation with older ones. He believed that the large
number of women of the better class, having poorly
developed generative organs, owed their defective con-
dition very largely to the pernicious custom in this
country of encouraging education and precocious ma-
turity in young girls. The disastrous effect of such
unwise early training on parturition and on the subse-
quent life of these individuals was clearly pointed
out. Next in importance was the avoidance of habit-
ual constipation. The deleterious influence of the
customary dress of women and the tendency to a
sedentary life also received attention. He advised
rest during the menstrual period only when pain and
other symptoms indicated that this function was not
strictly normal. An exception was made in the case
of young girls in whom this function had not been
thoroughly established. Dysmenorrhcea and profuse
menstruation might be successfully treated in many
instances solely by removing these young girls from
school, and encouraging a free out-door life and asso-
ciation with those younger than themselves.
Prophylaxis After Marriage.— Dr. Ralph Waldo,
of New York, discussed this topic, touching more
especially on the results of early venereal infection,
of prevention of conception, and on the Credc method
of preventing opiithalmia neonatorum. The speaker
stated that most of the cases of pyosalpinx coming
under his observation were the result, not of gonor-
rhoea, but of septic endometritis following abortion,
usually intentionally induced.
Dr. M. D. Mann, of Buffalo, said that in the first
year of menstrual life girls should be kept away from
school and quietly at home during the menstrual
period. Some mothers applied a small corset to their
girls when they were yet very young, and made them
wear the same size for a number of years. In this
way all of the evils of tight lacing were produced
almost unconsciously to the wearer of the corset. All
abortions should receive careful treatment, for nature
had never intended that they should occur and had
consequently made poor provision for them.
State Care of Tuberculous Patients. — The even-
ing session was held in the assembly chamber of the
State capitol, and members of the legislature and the
general public were invited to be present. The topic
for discussion was "The State Care of Tuberculous
Patients."
The Attitude of the State and Municipality in
the Care of Pulmonary Tuberculosis among the
Poor Dr. Kdward (3. Otis, of Boston, Mass.,
opened the discussion with a paper on this subject.
He said that pulmonary tuberculosis was the cause i)f
about one-seventh of all deaths. It went almost every-
where that man went, and was worse where human be-
ings were crowded together. Tiiree-fourths of its vic-
tims were stricken at the most valuable period of life.
The disease was curalde in its early stage.s, but such
February 3, 1900]
MEDICAL RECORD.
209
treatment was expensive and beyond the means of the
poor. The latter were a constant menace to those im-
mediately about them, and also to the public, through
their ignorance and carelessness regarding the proper
care of their sputa. On the ground of economy, pro-
phylaxis, humanity, treatment and care should be given
the poor consumptive. The city and State had already
assumed that it was their duty to provide treatment
and care for the unfortunate poor suffering from other
diseases and defects. For the defective class the State
had established insane asylums and institutions for
dipsomaniacs and for the feeble-minded. There was,
however, an enormous mass of consumptives for which
no provision had been made. The curable cases lost
their chance for cure, and the more advanced ones
must go to the poorhouse. The interval of time be-
tween the inception of the disease and the manifesta-
tion of symptoms was so long that the cause was often
forgotten. Only recently had it been shown that the
old theory of hereditary transmission was inadequate.
When the public once awakened to a realization of
these facts, it would rise and demand State and mu-
nicipal care. To this end he suggested that the cru-
sade against tuberculosis should be made a popular
one; if need be, a fashionable one. In England the
daily press had been a powerful factor in moulding
public opinion. In the speaker's opinion, two sets of
institutions would be required, viz., (i) hospitals for
consumptives in or near the city, for the reception of
poor consumptives in all stages of the disease, erected
and maintained by the municipality ; (2) several State
sanatoria favorably situated climatically and not too
far from the city, which would furnish the majority of
its clientele. These sanatoria should receive only the
incipient cases. Undoubtedly other hospitals for con-
sumptives would be erected and supported by private
charity, but the initiative must come from the State.
A portion of the expense could be collected in some
cases from the patient or his friends, or from the city
or town from which he came. Of course the entire
maintenance could be provided for by a per-capita tax.
As a matter of fact, the State and the municipality
must ultimately provide for the poor consumptive if
the early and more effective provision recommended
should be withheld. By reducing the number of con-
sumptives by this enliglitened method there would re-
sult a yearly saving of lives, having a distinct money
value to the community. Knowledge ever brought
responsibility, and in this instance certainly we should
not shrink from it. The probable expense per capita
would be $300 or $^50 annually. Undoubtedly favor-
able sites would be found in the central and western
parts of the State. The great desideratum was pure
air. Proper treatment could not often be obtained at
home. The modern treatment of consumption was an
exacting, long, and expensive one, and was entirely be-
yond the grasp of the poor. Hardly a single European
country at the present time was without one or more
sanatoria for consumptives. England had seventeen
hospitals, homes, and sanatoria of this kind, and it
was probable that before long such sanatoria would be
scattered thickly all over Europe, just as at one time
leper-houses were to be found all over that continent.
The physician was the one who must properly mould
public opinion on this important matter.
Remarks upon the Work Accomplished at the
State Hospital for Consumptives at Rutland, Mass.
— Dr. Vincent Y. Bowditch, of Boston, read this
paper. The patients, he said, had been first admitted
to this hospital in October, 1898, and at first the more
advanced cases had not been excluded; hence, it was
probable that still better results would be shown at the
end of the second year. The number of patients com-
ing upon his service there was 212. Of these, 126 had
been discharged. Of this number, 35 had been " ar-
rested " ; 37 much improved ; 17 moderately improved*,
and 24 not improved at all. One patient had diedj
and one had had only a bronchitis. Of the 35 "ar-
rested" cases, 27 should be considered as incipient at
the time of their admission, and 8 had presented evi-
dences of rather advanced disease in both lungs.
Founded upon this experience certain suggestions
were offered. The ravenous appetites engendered by
out-door life required a large supply of nourishing
food, particularly an abundance of milk and eggs.
The fact that in every such sanatorium amusement
must be provided should be kept steadfastly in mind.
It had been very properly suggested that an effort be
made to give the patients light occupations consistent
with their state of health. One very important result
of the establishment of such sanatoria was the educa-
tional part which they played. It was, perhaps, well
to caution against an excess of enthusiasm, for there
was a strong temptation to exaggerate in connection
with any subject which had caught the popular
fancy.
Similar Results of the Climatic and Sanatorium
Treatment of Tuberculosis in the Adirondacks.—
Dr. Edwin R. Baldwin, of Saranac Lake, read this
paper. Great efforts had been made to trace the pa-
tients, he said, who had been discharged in fifteen
years. During this period 1,200 patients had been
cared for, exactly three-fourths of whom were recorded
as being " advanced." This left only one-fourth really
" incipient." During the last two years, however, one-
third of the new cases had been incipient. Of the
whole number, 277, or twenty-three per cent., had been
discharged apparently cured; 669, or fifty-six percent.,
with the disease arrested; 230, or nineteen percent.,
were in a stationary or improved condition; 24, or two
per cent., had died at the institution. By " apparent
cure " was meant cases in which the rational signs of
phthisis and the bacilli in the expectoration had been
absent for at least three months, or who had no expec-
toration at all, any abnormal physical signs being in-
terpreted as indicative of a healed lesion. " Arrested
cases" were those in which cough, expectoration, and
bacilli were still present, but in whom active signs had
been absent for about three months. One-fourth of
the whole number, or four hundred cases, were perfectly
well, or believed to be. Of the incipient class, sixty-
eight per cent, had been discharged apparently cured,
while only eleven per cent, of the advanced ones had
recovered. It should also be noted that only two hun-
dred are known or believed to be living, who still had
cough or expectoration, who were otherwise well. All
of the remainder were known to be or believed to be
dead. Present experience showed that only one out of
fifteen applicants to the institution was in the incipi-
ent stage, or was favorable for recovery. But these
figures did not take cognizance of the large number of
persons who had been saved from infection with tuber-
culosis. Out of two hundred and forty-eight perfect
recoveries recorded up to 1898, two hundred and fif-
teen, or twenty-two per cent., of all those discharged
up to that time were known to be, or believed to be,
perfectly well at present. .\ period of two years had
been, in their experience, a fair test of permanency,
but it had been clearly shown to be dependent upon
the habits, occupation, intelligence, and vicissitudes
of life of the individual rather than an inherent ten-
dency of the disease to relapse after having been
healed for so long a time. Indeed, the results would
be better if the patients could remain longer in the
institution. The patients were drawn from a fairly
intelligent class of people The cost to the patient
per week was only $5. The administration expenses
had been so slight that the cost of maintenance had
been only $7 per week. Dr. Trudeau received no sal-
ary for his services.
MEDICAL RECORD.
[February 3, 1900
Infectious Character of Tuberculosis, and the
Prognosis of Incipient Pulmonary Consumption. —
Dr. George Blumer, of Albany, read this paper. He
stated that the disease now known as tuberculosis had
existed as a separate clinical entity for a comparatively
short time. It was not until after the middle of the
nineteenth century that its infectious character had
been clearly recognized. In 1865 had come the first
announcement of the infectious nature of the disease,
as proved by inoculation experiments on animals. In
1882 Koch had published his celebrated observations
on the tubercle bacillus, in which he showed that this
organism was always associated with tuberculosis, that
it could be cultivated outside of the body, and that
even after many generations of cultivation the bacilli
were capable of reproducing the disease when inocu-
lated into susceptible animals. The claim that the
mortality from tuberculosis in the first year of life was
twenty-three per ten thousand gave some color to the
theory that at times the disease might have a prenatal
origin. Experiments had shown that when the sputum
was received into spit-cups and the room was absolutely
clean, the air of the room was free from tubercle bacilli.
Strauss had found tubercle bacilli in the nasal passages
of nine out of twenty-nine healthy physicians and
nurses in hospital. In confirmation of the belief in air
infection were the relatively numerous cases in which
previously healthy individuals had developed pulmo-
nary tuberculosis after living in rooms formerly occu-
pied by tuberculous individuals. The researches of
Flick regarding infected houses were interesting as
showing that only ten per cent, of the tuberculous
houses in Philadelphia were isolated houses. It was
also shown that the distribution of tuberculosis corre-
sponded almost exactly to that of the other more acute
infectious diseases. Other confirmatory evidence of
air transmission was to be found in the sudden out-
break of many cases of tuberculosis in small towns
following the introduction of one or two cases into the
community. Experiment had shown that individuals
in coughing and speaking threw off spray containing
tubercle bacilli. The rarity of primary intestinal tu-
berculosis in adults was shown by the fact that in one
thousand autopsies at Munich there had been but one
of primary intestinal tuberculosis. Northrup, in one
hundred and twenty-five post-mortem examinations on
children, found only three of tuberculosis of the mes-
enteric glands alone. Cheese, whey, and particularly
butter, had been found to contain tubercle bacilli in
many instances. In Berlin, Robinowitch found four-
teen per cent, of the butter examined to be infected
with the tubercle bacilli. The weight of evidence was
against the flesh of animals being a source of infec-
tion, largely, no doubt, because it was usually cooked
before being eaten. Various methods of skin infec-
tion had been reported. Primary infection through
the genito-urinary tract was probably e.xceedingly rare;
both in men and women the deeper rather than the su-
perficial portions were the first attacked. As to prog-
nosis, the speaker said that no other chronic disease
showed a greater tendency to heal. Clinically there
was good evidence that, taken in its incipiency, pulmo-
nary tuberculosis was very amenable to treatment.
The report of the Loomis Sanatorium for 1898 showed
about fourteen per cent, of cures, and the cures at the
Falkenstein Sanatorium in Germany are said to be
about fifteen per cent.
Legislation concerning Tuberculosis ; Past, Pres-
ent, and Future. — Senator Horace \\'hite, of Syra-
cuse, spoke on this topic, reviewing the evidence that
had been presented by the medical profession, and pre-
dicting enthusiastically and positively that the desired
establishment of sanatoria could not fail of speedy
accomplishment as soon as the public had grasped the
problem, and appreciated the vital interests at stake.
The Policy of the State Relative to the Spread
of Tuberculosis.— Dr. Enoch \^ Stoddard, of Roch-
ester, read this paper. He said that the sanitary wel-
fare of the community had been for a long period a
source of solicitous attention, and there had thus grown
up a department of public health. One of the com-
mon causes of pauperism was the prevalence of dis-
ease. It was well known that the annual death rate
from pulmonary tuberculosis in this State was about
fourteen thousand, and that the incipient and advanced
cases made a total of nearly sixty thousand. Compar-
atively few recalled the fact that the State was con-
tributing in a greater or less extent to the mainte-
nance of one in every two hundred and fifty-one of its
population. It would seem, therefore, that the prov-
ince of the State was not so much to assume the direct
and total care of such patients as to establish such a
system, by well-advised legislation, as would enable
the several communities of the State to bear their jbart
in this care. The great desideratum was to educate
the patients and the public in general in the means of
prevention as well as of cure. The province of the
State should be, therefore, mainly educational, and only
custodial so far as might be necessary to insure those
object lessons in care that might be required by a few
communities. It was well known that consumptives
were exceedingly averse to being removed to any great
distance from their homes, and hence the importance
of what might be termed "home sanatoria." The
State of New York presented suitable sites for such
sanatoria within easy distance of almost every- large
centre of population within its borders. It had been
found that the cure of pulmonary tuberculosis in a
home sanatorium was less likely to be followed by
relapse than in the more distant sanatoria. More-
over, such home sanatoria possessed a great educa-
tional value. The chronic cases should be cared for
by the municipalities in which such cases occurred.
The State already possessed a well-organized system
of protecting the public health. The enactment of a
law along the lines just indicated would lead to the
establishment of a system of local sanatoria for both
incipient and advanced cases.
Taxation with Relation to State Care of Con-
sumptives.— Hon. Otto Kelsev, of Geneseo, spoke
on this topic. He pointed out the enormous expense
now borne by the State, and, as a member of the leg-
islature, expressed his belief that it was unwise at
the present time to make the large appropriation asked
for. It was not only the sum asked for now, but the
indefinite and probably very large appropriations that
would be demanded for this work in the future.
Dr. John H. Prvor, of Buffalo, made a most vig-
orous and telling speech in advocacy of State care of
consumptives. He showed the fallacy involved in the
oft-repeated assertion that consumption was decreasing
among us. Michigan had seen fit, six years ago, to
adopt a plan of State care, and already it was evident
that tuberculosis was decreasing in that State more
rapidly than elsewhere. What was asked for was that
the consumptives be taken care of at the right place
and the right time until they were well, and not to
take care of them at the wrong place and at the wrong
time until they were dead. We had just been told
that the State could not afford to make the appropria-
tion asked for because of the large sum needed for the
canal system, but it seemed to him that the saving of
human life was more important than the canals.
Dr. Daniel Lewis, of New York, argued that the
movement under discussion should be begun by pro-
viding for the advanced cases, as they were a great
menace to public health.
Dr. Arthur G. Root, of Albany, spoke of the edu-
cational value of consumptive sanatoria, and the eco-
nomic aspects as shown by the desire of organized char-
February 3, 1900]
MEDICAL RECORD.
ity to co-operate with the medical profession in this
movement.
Dr. Samuel B. Ward, of Albany, pointed out that
the legislature had not been asked to take care of the
sixty thousand consumptives in the State, but only to
make provision, as an object-lesson, for a few of these
persons.
Dr. George R. Fowler, of New York, commented
upon the encouraging change of opinion on this sub-
ject that had recently taken place in the medical pro-
fession.
Dr. Henry R. Hopkins, of Buffalo, urged immedi-
ate action on the ground that delay meant to thousands
a cruel and unnecessary fate. When thousands were
marching to the grave, and it was in our power to save
them, how could an enlightened and humane profes-
sion withhold this succor?
Dr. Brush, of Brooklyn, discussed further the eco-
nomic side of the problem, and pointed out the small
beginning made last winter in the passage of the
Henry law.
Dr. Nelson H. Henry, of New York, a member of
the assembly, commented upon the general lack of
information and wide differences of opinion among
physicians on this subject. He advised being con-
tented with a small appropriation, if more could not
be obtained.
Dr. Z. Taylor Emory, of Brooklyn, deprecated the
lack of enthusiasm and co-operation evinced by the
medical members of the legislature.
Second Day — Wednesday, January jist.
The greater part of the morning was given up to
a personal inspection of the new Albany Hospital,
and to an interesting clinic at that institution.
Human and Bovine Anthrax. — Dr. Frank W.
Ross, of Elmira, in this paper detailed an interesting
experience with this disease. Regarding the diagno-
sis, he said that the typical lesion could hardly be
mistaken for anything else, although it vi'as true that
there was a somewhat striking resemblance to vacci-
nation. Cattle dying in virulent epidemics sometimes
showed no gross lesions at first. The advantages
claimed from vaccination for this disease by the Pas-
teur method were certainly noteworthy. In the prep-
aration of the serum the absolute destruction of the
anthrax spores must be assured by experiment. The
wonderful results secured from this serum certainly
justified its use in man. Dogs, pigs, and rats were
practically immune. Excision, curetting, and cauter-
ization of the pustules were justifiable in any stage.
The virulent systemic poisoning should be overcome
by symptomatic treatment.
Bovine Tuberculosis. — Dr. James Law, of Ithaca,
discussed this topic. He stated that experience with
the tuberculin test showed that in most herds tubercu-
lous generalization was not observed. The average
bacillus of bovine origin habitually failed to produce
a rapid extension and generalization of the disease.
The tubercle bacilli of cattle were thicker and shorter
than tubercle bacilli in man, but they often presented
almost exactly the same morphological characteristics.
Our neighboring States demanded that the tuberculin
test be applied to cattle, and, as a result, the tubercu-
lous animals, as determined by this test, were sorted
out and sent into New York State, there being at pres-
ent no law preventing ths.
The Preparation of Tuberculin ; its Value as a
Diagnostic Agent, and Remarks on the Human
and Bovine Tubercle Bacilli. — Dr. V. A. Moore, of
Ithaca, presented a resume' of his paper on this sub-
ject. He said that properly prepared tuberculin could
not possibly contain living tubercle bacilli, because
it was twice raised to a temperature which killed these
germs. It was usually prepared from sputum bacilli.
The tuberculin reaction consisted simply in a tempo-
rary rise of temperature on the part of the tuberculous
animal ; it produced absolutely no effect on the healthy
animal, as shown by the thousands of tests already
made. This presupposed that one was familiar with
the normal variations of temperatures. This was es-
pecially important in cattle, because in them there was
often a normal variation of three or more degrees.
Excitement, food, variations in surroundings, and the
application of cold water all produced marked changes
in temperature which might last for three or four hours.
Dr. James K. Crook, of New York, spoke of his
experience with the tuberculin in several cases of sus-
pected tuberculosis, and expressed the opinion that it
afforded but little aid to diagnosis in the human sub-
ject.
Dr. F. W. Ross, of Elmira, said that seventy-two
cattle affected with tuberculosis all gave the tubercu-
lin reaction, and in seventy of these the gross lesions
were apparent at post-mortem examination. The old
cattle were infected through the lungs, and the young
cattle through the intestinal tract, showing that the
latter had become infected secondarily from the spu-
tum.
The Medical Examiner for Life Insurance and
His Responsibilities Dr. S. Oakley Vander Poel,
of New York, read a paper with this title. He said
that formerly all life insurance Companies were obliged
to decline from twelve to fifteen per cent, of their ap-
plicants, in consequence of some impairment of family
record or physical disability. Of late the most pro-
gressive American company had studied all its de-
clined applications between the years 1875 and 1890,
and had ascertained the outcome of each individual ;
if alive, the condition of health, and if dead, the cause
of death. From the data thus obtained it had been
able to differentiate and collect aggregated groups of
persons suffering from the same disorder, which had
supplied a basis by which to adjudicate upon a special
case under consideration. Now, practically all of this
fifteen per cent., who had been formerly declined, were
accepted on a sub-standard basis, provided they were
not acutely ill, or there was no moral hazard. This
company now required its examiners to present all the
facts in the case ; or, in other words, to give a pen
picture of the applicant, upon which the home office
of the company based the insurance value of the risk.
The examiners were relieved from the embarrassment
of declining an individual, but their responsibility
toward the company remained the same. The com-
pany was still as conservative as heretofore, as an ap-
plicant, to obtain a standard policy, must still possess
the same degree of physical excellence as formerly ;
the standard was simply separated from the sub-stand-
ard with the same care as when insurance was denied
the latter class. The medical examiner should remem-
ber the difference in the mental state of the patient
and the applicant for insurance. The latter was ner-
vous, fearing the development of some hidden ail-
ment, and, if young, the examination might induce, as
it were, a mild form of shock. The patient concealed
nothing from his physician ; his attitude was one of un-
reserved co-operation. The memory of the insurance
candidate was less acute, and his state of mind was one
of antagonism. The skilled examiner had learned this
lesson. The company now insured under-average as
welPas selected lives, offering insurance to practically
all who apply. In each case it adjusted the plan of
insurance to the insurance value of the risk. The
medical examiner's report served as a basis of valua-
tion, and determined the plan upon which the insur-
ance was offered.
Experience with the Angiotribe — Dr. J. Riddle
GoFFE, of New York, read this paper. He used the
212
MEDICAL RECORD.
fFgbruary 3, 1900
latest and best modification of the instrument in six-
teen cases, fifteen of which were hysterectomies. He
had found that the use of this instrument shortened
the operation, facilitated convalescence, and made the
treatment more convenient.
Dr. W. S. Stone, of Washington, D. C, said that
he had used the same angiotribe about twenty-five
times, for the most part in abdominal hysterectomy,
and in no instance had he experienced any trouble
from hemorrhage. The use of the angiotribe, he be-
lieved, avoided both hemorrhage and suppuration in
pelvic surgery.
The Importance of Early Recognition of Acute
Inflammation of the Middle Ear by the General
Practitioner. — Dr. Edward B. Dench, of New York,
after calling attention to high temperature in young
children, otherwise unaccounted for, as good ground
for suspecting inflammation of the ear, described in de-
tail the mode of examination. In the treatment, early
and free incision of the drum was advised, and the use
of such "ear drops'" as oil and laudanum was charac-
terized as worthy of being made a criminal offence.
Dr. James F. McKernon, of New York, took ex-
ception to this wholesale condemnation of "eardrops,"
claiming that the instillation of a warm four-per-cent.
solution of cocaine in camphor water was often bene-
ficial.
Uterine Fibroids Complicatedby Pregnancy.— Dr.
\y. F. Ford, of Utica, presented a paper on this sub-
ject in connection with photographs and histories of
several illustrative cases. I'he dangers from this com-
plication were chiefly overdistention or rupture of the
uterus, interference with a normal first stage of labor,
and sepsis resulting from infection after delivery.
When the Irwer third of the cervix and the entire
uterus were free from neoplasm, nothing need be done.
If, however, the neoplasm was 1 >rge enough to block
the birth canal, the obstetrician was called upon to
decide between Ca;sarean sectioi and hysterectomy.
If the tumor was in the anterior \\M, Ca;sarean sec-
tion could not well be done.
Anniversary Address by the President: <• The
Relation of the Clinical Laboratory to Modern Sur-
gery."— Dr. Willis G. Macdonald, of Albany, de-
livered this address. He recommended the practice
of taking at irregular intervals, and without notice,
specimens of surgical dressings, ligature and suture
material, and from the skin of the patient. Each new-
lot of catgut or other similar material should be tested
in the laboratory before being accepted and used. The
speaker said that delayed shock and fac embolism had
been a very acceptable refuge in many cases of over-
whelming sepsis. The use of the antistreptococcus
serum in cases of surgical sepsis, he declared, had
proved sadly disappointing, but further study of the
streptococci might quite possibly change these re-
sults. Tetanus serum certainly possessed antidotal
properties. When gi\en in suitable quantities he had
seen improvement invariably follow. Modern sur-
gery demanded that urinary examinations before oper-
ations should include an estimation of the total solids
for twenty-four hours, together with examination for
indol, peptone, and similar abnormal ingredients.
Routine examination of the blood was also very im-
portant. The determination of the percentage of hae-
moglobin often afforded the surgeon valuable informa-
tion. Microscopical examination of the blood was a
valuable aid in making a differential diagnosis be-
tween chills due to nervousness, to malaria, to sepsis,
and to other causes
New Rectal Instruments. — Dr. Samuel G. Gant,
of New York, exhibited several new rectal instruments,
including a convenient rectal speculum, and a pile
clamp having parallel blades, thus greatly diminish-
ing the chance of hemorrhage.
A Unique Case in Obstetrics.^ — Dr. F. H. Parker, of
Auburn, reported a case in which he had extracted a
small macerated foetus from a woman, and a few days
later had del i vered her of a fully developed and healthy
child. The history of the case seemed to indicate that
the dead foetus had been carried for upward of two
years. There was nothing unusual in the appearance
of the secunui:^es.
Further Investigations into the Cause of Cancer.
— Dr. Roswell Parker, of Buffalo, presented a com-
munication on this subject. He stated that the con-
clusions presented by him last year had been unex-
pectedly sustained and corroborated by other observers,
both at home and abroad. The speaker reiterated his
assertion that cancer was undoubtedly on the increase,
and added that this could not be wholly explained by
the improved methods of diagnosis. It should be
remembered that just in proportion as methods of
diagnosis were improved, the number of deaths would
be reduced. It was probable that we must assume a
certain predisposition of the tissues, either inherited
or acquired, before cancer formation was possible.
Cancer was virtually never seen on the back, save in
points within easy reach of the hands. It appeared
on the face chiefly in those who did not use soap. It
did not occur, as a rule, on the lips of women because
they did not smoke. Cancer of the ear usually began
on the upper and outer border, /.£•., the least resisting
part. Dr. Parker presented a list of cases collected
by him, bearing upon the age at which cancer most
frequently developed. In two of these cases, carci-
noma of the uterus was present in infants of two years
of age. In conclusion, the speaker asserted that he
saw in the work of the State cancer laboratory con-
stantly increasing evidence in support of his belief
in the parasitic nature of cancer. The experience in
the .State laboratory showed that histology alone would
not give the necessary information concerning certain
bodies that had been found in the course of the study
of carcinoma.
The Curability of Leprosy. — Dr. George H. Fox,
of New York, presented this paper. He stated that
in the large proportion of cases leprosy terminated
fatally, but exceptionally all traces of the disease dis-
appeared, and the patient probably became immune
to it thereafter. A change in habitation, a cheerful
prognosis, and a resort to certain drugs were charac-
terized as important factors in securing a cure. The
number of reported cures was certainly very small.
When these individuals were removed from the local-
ity in which the disease was contracted, and trans-
ferred to a region in which leprosy was not endemic,
an improvement, often temporary, was very com-
monly noted. He had found chaulmoogra oil a valu-
able remedy. In some instances it caused a degree of
nausea that was prohibitive; in others, large doses
would be tolerated for a long time. Cases could be
cited in which tubercular leprosy had subsided under
treatment, and the individuals had been apparently
cured completely. He attributed much of his success
in this disease not only to the use of chaulmoogra oil
but to the cheerful prognosis given.
Some Questions about the Care of the Hair.—
Dr. (;eori;e Tho.mas Jackson, of New York, read
this paper. He said that in serious illness, especially
in fevers, nothing could be done to prevent the fall of
the hair, because this was the result of temporary in-
terference with its nutrition. The physician should
vigorously oppose cutting off tiie hair, particularly in
women, as the advantages were slight and the risk of
unpleasant consequences was great. The hair should
be combed and brushed daily, unmindful of the amount
of hair falling out, and once in a week or two the hair
should be washed. The most convenient soap was the
ordinary tincture of green soap. At short intervals it
February 3, 1900]
MEDICAL RECORD.
213
was well to rub into the scalp a pomade of precipi-
tated sulphur of the strength of one drachm to the
ounce. He now believed that the present custom of
abandoning the use of pomades and wetting the hair
was responsible for much of the prevalent baldness.
If the head was rubbed night and morning, and a lit-
tle pomade, not liable to become rancid, was rubbed
in, he felt sure there would be less baldness. It was
not wise to have the hair of a girl cut after the age of
ten or twelve years, as this rendered it less silky. Of
all the present customs of caring for the hair, perhaps
the most ridiculous was that of hair-syringing, a pro-
cedure founded on antiquated and erroneous notions.
Some Remarks on Surgery of the Nasal Septum.
— Dr. Robert C. Myles, of New York, said in this
connection that Bosworth's operation was to be recom-
mended for that very large class of cases in which
large formations were present along the natural line of
the bone. In properly selected cases brilliant results
had followed resort to the modified Asch operation.
The most marked relief had been afforded in those
cases in which there had been pressure against the
fossa of the superior maxillary bone
Address * " Education and the Profession of Med-
icine."— ^A. V. V. Rav.mond, D.D., LL.D., president of
Union University, delivered this address. He began
by asking the question, " Was the great aim of educa-
tion to give one an ability for a certain occupation or
profession? " and answered it emphatically in the neg-
ative. The true theory of education, he declared, com-
prehended the development of all the powers belong-
ing to the individual as a man; he was to be educated
because he was a man, not because he was to be a
merchant, or a machinist, or a lawyer. The speaker
then discoursed upon the comparati\e value of such
studies as mathematics and languages in the prepara-
tory school. By a reorganization of our whole system
of primary and secondary school instruction it was
possible, he believed, to give a man a good school and
collegiate training, a full course in the medical school
and a service in hospital, and still allow him to enter
upon the practice of medicine at about the age of
twenty-five. The speaker predicted that this change
was sure to come here, as it had already occurred in
other countries.
Address : " Rational Therapeutics versus Chris-
tian Science and Similar Superstitions." — Ja.mes
M. BuLKLEY, D.D., LL.D., of New York, editor of the
Christian Advocate, delivered this address. He stated
that anti-medicine faith-healing was based on the propo-
sition that disease was always the work of the devil,
and that a special kind of faith was requisite, and that
if that special faith was e.xercised the disease would
disappear. The speaker declared that it was a sad
fact that a large part of the medical profession firmly
believed that there was no distinction between anti-
medicine faith-healing and Christian Science , whereas,
as a matter of fact, there was only one point of simi
larity, i.e., they both refused to use medicine. Chris-
tian Science was more subtle. He had been familiar
with the evolution of the high priestess of that so-called
science. He possessed the only complete copies in
existence of all that Mrs. Eddy had set forth. If the
theory of the Christian Scientists was true, food would
not be necessary to life, but, according to Mother Eddy,
it would be foolish to stop eating until we were able to
get a fuller comprehension of the living God! Mrs.
Eddy claimed that she discovered the great truths of
Christian Science by experiments made by her while
she was practising homceopathy. The discovery of
the effect of the mind over disease had been impressed
upon her by the results obtained with medicine " atten-
uated until not a trace of the original remedy was left."
In conclusion the speaker declared that Christian Sci-
ence, as a system of therapeutics, would have died ere
this if it had not been put forward as a religion; and
it would have died as a religion if it had not been put
forward as a system of therapeutics. He predicted
that the forces which had raised this intellectual bal-
loon would in time be the means of its final destruc-
tion.
A Contribution to the Surgery of the Stomach.
— Dr. H. Beeckjian Delatour, of Brooklyn, pre-
sented in this report the histories of several illustra-
tive cases, and particularly reports of a case o£
gastrotomy, and one of gastrectomy for adeno-car-
cinoma. In the latter case, after recovery from opera-
tion, the woman became pregnant, and at full term was.
delivered of a healthy child. After delivery there had
been uncontrollable nausea and vomiting, and an ex-
ploratory incision had revealed a recurrence — theni
twenty months after the gastrectomy. He raised the
question as to whether this recurrence might have beert
prevented by terminating pregnancy some months-
earlier.
The Management of Puerperal Infection. — Dr. L.
W. Seers, of Syracuse, presented this communication.
He stated that Dr. Bacon, of Chicago, had shown that
seventy per cent, of all the deaths from childbirth were
due to sepsis, and that two hundred persons die annu-
ally in that city from that cause. He advised against
delaying treatment for the results of a bacteriological
examination, and against the use of the curette until
it was evident that intra-uterine irrigations were im-
potent to control the affection. Curettage should theri
be done cautiously, and the cavity of the uterus be
packed lightly with gauze. True septic infection he
considered a contraindication to the use of the curette.
( To te concUiied. I
THE PRACTITIONERS' SOCIETY.
One Hundred and Fijty-Jirst Regular Meeting, Held oir
Friday, December 8, i8gg.
A. Alexa.vder Smith, M.D., President, in the
Chair.
A Case of Acromegaly. — Dr. F. P. Kinnicutt re-
ported in brief a case of acromegaly. The patient, a
man, twenty-nine years old, was admitted to the Pres-
byterian Hospital in November, 1899. His family
history was negative, his personal history unimportant
previous to the onset of his present illness, six years
ago. At about this date he began to suffer from head-
ache of an intermittent character confined to the left
supraorbital region and the left side of the head. The
headache, which was very severe, continued to be in-
termittent in character until two years ago. Since
this date it had been almost continuous during his
waking hours, and had often prevented sleep. Three
years ago his friends first noticed that his face was.
growing larger, and this enlargement had gradually
increased up to the present time. The hands and feet
had also gradually increased in size, the lips and
tongue had become thicker, and the nose more promi-
nent. Three years ago he wore a six and seven-
eighths hat; the size he now required was seven and
a half. Aside from his headache he had suffered fron»
few if any subjective symptoms. On admission to hos-
pital the patient presented a characteristic appearance.
The following notes were made by Dr. Kinnicutt:
The face was without expression. The head was en-
larged as a whole, the increased size being especially
marked in the face. The malar prominences were
much exaggerated. Both maxillae were greatly en-
larged, the inferior to a greater degree than the supe-
rior. The enlargement was next marked at the sym-
physis. There was only slight prognathism. The
214
MEDICAL RECORD.
[February 3, 1900
lips were thick; the mucous membrane was everted,
that of the lower lip especially so. The tongue was
greatly increased in volume. The alveolar processes
were hypertrophied; the teeth of the lower jaw were
separated. The nose was greatly enlarged, particu-
larly toward its tip; the alae were much thickened, and
the anterior nasal passages dilated. The frontal emi-
nences were enormously exaggerated and the orbital
ridges enlarged. The forehead above the frontal emi-
nences was retreating. The ears appeared to be nor-
mal in size. The hands w^ere massive, the increase
in size being in their width and thickness. The fin-
gers apparently were not increased in length, but
greatly in width and thickness. The enlargement
appeared to be chiefly in the soft structures. The
skin was moist. The distal ends of the radius and
ulna were enlarged ; the muscles of the arm and fore-
arm were flabby and diminished in volume. Similar
changes were present in the lower extremities. The
increase in the volume of the soft structures of the feet
was even more marked than in the hands. The in-
crease in the size of the feet was in their width and
thickness; the great toe was especially large; the heels
were covered with enormous fleshy pads. The distal
ends of the tibia and fibula were but slightly if at all
enlarged. The clavicles were greatly increased in
size and their curvature was exaggerated. The ribs
were massive; their width was especially increased.
An antero-posterior curvature of the cervical and
dorsal regions was present. The heart was not en-
larged and no murmurs were appreciable. The areas
of liver and splenic dulness were not- increased, and
the edge of neither liver nor spleen was palpable be-
low the costal arch. The lungs gave only negative
signs. The abdomen was normal in appearance and
on palpation. The thyroid gland was not increased
in size. The superficial glands were everywhere
slightly enlarged. The pulse did not show increased
tension, and the vessel-walls were not appreciably
thickened. The temperature was slightly subnormal.
The daily quantity of urine was 2,850 c.c. ; specific
gravity, i.oii (the patient's normal weight is about
two hundred pounds). There was a faint trace of
albumin and a trace of glucose by the phenyl-hydrazin
test. There were a few granular, liyaline, and epithe-
lial casts. The urea execretion was 23.05 gm. ; the
uric-acid excretion, 0.910 gm. The ophthalmoscopic
examination by Dr. Stedman Bull showed the media
to be clear. There were no hemorrhages in the fun-
dus. The optic discs were slightly pale, and the.
arteries reduced in calibre. There was no pulsation.
There was no disturbance of the motor apparatus.
There was no sign of atrophy of discs. The examina-
tion of blood showed: Red cells, 5,109,000; white
cells, 8,000; polymorphonuclear neutrophiles, fifty-
eight per cent.; large mononucleated, thirty-six per
cent. ; small mononucleated, five per cent. ; eosino-
philes, one per cent.
The patient complained of intense and constant
pain over the left supra-orbital region and over the
left side of the head as far back as the ear. It was
sufficiently acute to prevent sleep. During the two
months of residence in the hospital many drugs had
been used to control the pain. The pituitary and
thyroid extracts had also been employed. No relief
had been obtained except by the use of large doses of
morphine. A typical reaction to the tuberculin test
was obtained; a single milligram was used for the
injection.
A Case of Acromegaly.- — This case was reported by
Dr. M. Allen Starr. The patient was a man who
had been under his observation since 1892. The case
was a typical one of acromegaly, and the chief symptom
complained of, as in Dr. Kinnicutt's case, was head-
ache, which was constant over the forehead and back
of the eyes, and was very agonizing and distressing.
It prevented his sleeping at times, and had given his
face an expression of suffering that was really pathetic.
In his case, Dr. Starr said, all the bones in the body,
as well as the soft parts, were enlarged. The hands
and feet were enormously enlarged, and the soft por-
tions of the skin were thickened. In addition to the
general features of acromegaly, the patient had a
progressive diminution in his visual fields, witli begin-
ning atrophy of both optic nerves and gradually in-
creasing blindness. His vision was now -|{|, whereas
when he first came under observation it was |^. The
treatment with thyroid extract had apparently proved
beneficial in this case. The value of this method of
treatment was shown by the following measurements,
which were made on the middle phalanx of the middle
finger: In October, 1894, when the patient was first
put upon the thyroid extract, the circumference of this
phalanx in the left hand was 7.2 cm., and in the right
hand 7.6 cm.; under the influence of this remedy the
fingers grajiually decreased in size until the circum-
ference of the phalanx in both hands was 6.5 cm., a
corresponding reduction in size occurring in the other
fingers and in the hands themselves. The size of the
hands was decreased by 1.5 cm. In addition to this
the thyroid extract had given him much relief from
his headaches. If he intermitted the treatment for a
month or two he felt worse and his headaches became
more severe. Dr. Starr said that his experiments with
thyroid extract in this case had convinced him that
the various preparations on the market differed very
much in strength.
Dr. W. Gil.max Thompson said he had seen four
cases of acromegaly. The one reported by Dr. Kin-
nicutt was remarkable because of the enormous in-
crease in size of the soft parts, as well as the bones —
especially of the lips and tongue. In a case which
the speaker saw last summer the development of the
disease was very slow, and the bones attained consid-
erable size without giving rise to much inconvenience.
The patient was a clergyman: he noticed that his
bones were growing larger, and he found it necessary
repeatedly to buy hats and gloves of larger size. He
was able to continue his preaching, although he was
far from being a well man. He suffered chiefly from
dyspepsia and was easily fatigued. His jaws were
very much increased in size, producing separation of
the teeth. His family had long noticed his changed
appearance, but they were desirous of keeping his true
condition from him, and on this account a very thor-
ough examination was impracticable. Acromegaly,
Dr. Thompson said, should not be confounded with
pulmonary hypertrophic osleo-arthritis; in the latter
disease the longitudinal diameter of the bones was
increased rather than the transverse, and the bones of
the extremities were affected, not those of the face,
head, and tliorax as well.
Dr. J. W. Brannan asked Dr. Kinnicutt if he at-
tached any significance to the reaction to the tubercu-
lin test in tlie case he had reported.
Dr. Kinnicutt said he had regarded it merely as
interesting and possibly suggestive. In thirty-four
recorded cases of acromegaly, with full autopsy, a
microscopic lesion of the pituitary body had been
found in every instance, and in the majority of the
cases it proved to be either a simple hyperplasia or a
tumor growth of some kind.
Dr. Kinnicutt said that as a rule a typical tuberculin
reaction was obtained only in persons who have some
tuberculous focus in the body. Of course such a focus
might be located anywhere, but in the present case it
had been impossible to locate such a focus by physical
examination.
Dr. Charles L. Dana said that Brooks, in his re-
cent pathological work in connection with this subject,
February 3, 1900]
MEDICAL RECORD.
215
came to the conclusion that the trouble was probably
due to a cellular hyperplasia of the granular elements
of the pituitary body; that unless this existed we might
have a tumor or a destructive lesion or even enlarge-
ment of the glands without the symptoms of acro-
megaly. It was, of course, possible that a tuberculous
or other variety of growth might irritate the gland
and produce this peculiar form of cellular hyperpla-
sia.
Dr. T. Mitchell Prudden said that the hypothesis
advocated by Brooks in his admirable paper on acro-
megaly, namely, that the disease was dependent upon
a glandular hyperplasia or adenoma of the pituitary,
while most plausible and ably set forth, might still
wisely be heldjtib Judice until more data were at hand
for proof. The Brooks hypothesis was closely bound
to the wider conception of the close dependence of
connective-tissue growth upon the stimulus of an
hypophysis secretion. Even should this be true, it
might be wise to consider carefully whether we were
justified from the analogy of other organs in assum-
ing that glandular hyperplasia or adenoma was al-
ways, or was likely to be, coincident with hypersecre-
tion.
Dr. Beverley Robinson referred to an article on
the subject of acromegaly by Drs. Walton and Cheney
in the current number (December 7, 1899) of the Bos-
ton Alcdica! and Surgical Journal, which contained a
summary of the more recent investigations in the
pathology of this disease. He said that in the earlier
years of his practice he could recall cases which were
probably e-xamples of acromegaly, but which he had
failed to recognize as such. The speaker said he was
not aware that tuberculous changes in the pituitary
body had been found in any of the cases on record :
at least he had seen no reference to it in recent works
on the subject.
Dr. Kinnicutt said that he had employed the ex-
tract of the pituitary gland made by an English firm
in the treatment of the case of acromegaly related by
him, without producing any effect up to the present
date. The two-grain tablets were given, the dose
being gradually increased until gr. xx. were taken in
twenty-four hours. In fifteen recorded cases of acro-
megaly which he had collected, in which the pituitary
extract was used, it had produced some amelioration
of the symptoms, particularly of the headache and
neuralgic pains, in about half the cases.
Dr. Dan.\ said he had used the pituitary extract in
the treatment of many diseases, but he usually gave as
much as gr. Ix. daily before getting any effect. It
gave no results in acromegaly.
Dr. Starr said he had given as much as gr. xx.
daily for some time without effect.
Dr. Robinson referred to the obscure relationship
which seemed to exist between acromegaly and myx-
cedema. He called attention to the fact that thyroid
extract, the use of which was indicated in the latter
disease, had also proved beneficial in the former.
The Significance of Intraocular Hemorrhage as
to Prognosis of Life. — This paper was read by Dr.
Charles Stedman Bull (see page 177).
Dr. E. G. Janeway said that in former years, when
he met with a case of chronic nephritis with retinal
hemorrhages, especially with neuro-retinitis, his prog-
nosis was that the patient W'ould not live over two
years. Since then, however, he had met with several
cases which had induced him to be less positive upon
this point. He recalled one such case in which a dis-
tinguished oculist made that prognosis, and the patient
was alive seven years later. Another similar case
came under iiis observation more recently. Dr. Jane-
way also referred to the intraocular hemorrhages occur-
ring in pernicious anaemia, which were formerly re-
garded as very significant. A case had been reported,
however, in which all the symptoms of pernicious
anaemia, including hemorrhages into the retina,
promptly disappeared after the expulsion of a tape-
worm: so-called pernicious ana;niia from tapeworm.
Dr. Robinson said he was recently called to see a
patient, who in addition to retinal hemorrhages com-
plained of intense headache. The question arose
whether the case was one of brain tumor or chronic
nephritis. The urine contained neither albumin nor
casts, but its specific gravity was low. The ophthal-
moscopic examination seemed to be in favor of
changes in the kidney, which later developed. The
speaker called attention to the fact that retinal hemor-
rhages might occur without interfering to any extent
with vision, and ^at they might escape detection un-
less the examiner was skilled in the use of the oph-
thalmoscope.
Dr. Janeway reported the case of a lady who lost
the sight of one e)'e through a hemorrhage into the
vitreous, with glaucoma. She was told that she had
nephritis, but the speaker said he was able to find only
evidences of a calculous pyelitis of one kidney. The
urine contained pus and uric acid, but he had not
found albumin or casts to such extent as to prove the
implication of both kidneys, although previous to that
time some one else had found albumin and casts and
had in consequence considered the case as nephritis
of both kidneys. There was a plentiful secretion of
urea. This case was still under observation. We
should not be too apt, Dr. Janeway said, to attribute
these eye lesions to nephritis. In one case of neuro-
retinitis which he recalled the patient's urine had been
collected for twenty-four hours, and its sediment was
found to contain a trace of albumin and a few hyaline
casts. The neuro-retinitis was thereupon attributed
to ad\"enced nephritis, and a bad prognosis was given
by the oculist. The oculist himself had been dead for
ten years, while the patient was still alive. The true
cause of these eye lesions could not always be made
out. In another case which the speaker recalled the
patient had a neuro-retinitis and was treated for
nephritis. The true cause of the loss of sight proved
to be a syphilitic meningitis, which disappeared under
treatment.
Dr. a. Alexander Smith reported the following
case : A lady, while visiting in Paris, was stricken with
partial blindness while seated at dinner. She was im-
mediately afterward seen by an oculist, who regarded
the case as one of probable nephritis. A distinguished
French physician later found a trace of albumin and
some hyaline casts in her urine, and her husband was
informed that she was likely to die at any moment.
Her condition was regarded so serious that a physician
was requested to accompany her to this country.
Since her arrival her urine had been repeatedly ex-
amined ; it at first contained a trace of albumin, which
soon disappeared. No casts were found. She passed
sufficient urea. Her loss of sight was due to a retinal
hemorrhage, from which condition she gradually im-
proved. Previous to her visit to Paris she had spent
the summer in Mexico, at an elevation of eight thou-
sand feet, where she became somewhat ana;mic, and
while she was there she had a very slight retinal hem-
orrhage. The second hemorrhage occurred in Paris,
and a third one, also slight, during a second visit to
Mexico. She had since returned to New York and
was still under observation. Her health was steadily
improving, and Dr. Smith said he was inclined to
doubt that a sufficient degree of nephritis existed to
justify the hopeless prognosis given by the oculists
who saw her. He thought the retinal hemorrhages
could perhaps be explained on the basis that there
was a moderate amount of degeneration of the blood-
vessels, and that the blood-pressure at a high eleva-
tion had caused them to rupture.
2l6
MEDICAL RECORD.
[February 3, '900
THE MEDICAL ASPECTS OF THE WAR IN
SOUTH AFRICA.
We publish a continuation of our special correspon-
dent's summary of the medical events of the South
African war, which will enable our readers to under-
stand what has been done by the British up to the sec-
ond week in January for their sick and wounded. Of
the Boer's military medical service our correspondent
says : " Little is known for certain, but enough to show
that in hospital and ambulance matters, as in all their
other arrangement for this war, the Boers have been
underrated. They have a good ambulance service and
competent medical men, chiefly German by birth. I
shall send you information upon the matter when
there is any that is reliable. At present certain Eng-
lish journals give one view and certain continental
journals give another, but in neither case are the ac-
counts founded upon facts."
(From our Own Correspondent.)
The Medical Arrangements of the Field Forces.
■ — The general arrangements of the Medical Division
of the War Office, made for the first army corps de-
spatched to South Africa, were followed in subsequent
reinforcements. The equipment is in accordance with
a pattern which was drawn up as recently as 1898, and
to its modernity must be attributed the highly pleas-
ing fact to all medical men that it has been found
completely satisfactory. It includes, along with all
ordinary surgical paraphernalia, such extra articles as
acetylene lamps, Japanese air cushions, anajsthetics,
antiseptics, antiseptic cases, creolin, folding, dark-
rooms for .v-ray work; antiseptic dressings, various;
inhalers for ether, and Clover's; Murpliy's anasto-
mosis buttons (in sets); platinum studs for .v-ray
coil; anti-streptococcic serum and syringes; anti-tet-
anic serum and syringes; aseptic absorbent sponges
(three sizes) ; Schimmelbusch's sterilizers.
Ten sets of Roentgen-ray apparatus were provided,
since which as many more sets through private gener-
osity have been placed at the disposal of the Royal
Army Medical Corps or its voluntary auxiliaries.
Two portable disinfectors, of the pattern made and
patented by Dr. J. C. Thresh, the medical officer of
health for the county of Essex, were sent out, one to
be stationed at Durban and one at Capetown, while
there were added to the ordnance equipment a large
number of approved apparatus for the filtering of
water and the sterilizing of milk.
The two hospital ships, the S()artan and the Trojan^
were supplied with, over and above the army rations,
the following additional articles: Arrowroot, corn-
flour, oatmeal, pearl barley, ground rice, sago, cocoatina
(tins), condensed milk (sweetened), condensed milk
(unsweetened), calves' feet jelly, bovril (in four-ounce
tins), Liebig's extract of meat (in four-ounce pots),
Brand's essence of beef. Brand's essence of chicken.
Brand's essence of mutton, mutton broth, chicken
broth, solidified soup, Stower's Cordial lime juice, re-
fined sugar, pickles (various), Hennessy's three-star
brandy, Scotch and Irish whiskey, champagne (in pint
bottles), port wine, sherry wine, claret. Burgundy,
Australian, Emu, and Hermitage, Bass' or Allsopp's
beer, lager beer, Guinness' stout. The Spartan was
provided with a full .r-ray plant by the Duke of New-
castle, an enthusiastic photographer, and an anony-
mous donor did the same for the Tro;an.
The Central British Red Cross Committee.— The
relations of the Red Cross Society to the medical ser-
vice of the army in Great Britain are very intimate,
and during the war the work of the society in behalf
of the sick and wounded soldiers has relieved incal-
culable misery. The British army medical service
makes but little provision for the after-care of the
sick and wounded, but has always been wont to de-
pend upon the efforts of volunteers for much of the
nursing, when the invalids have been deported to the
base. Immediately after w^ar broke out the Central
British Red Cross Committee — the British branch of
the International Red Cross Society — was placed in
the pleasing position of being able to announce that
the application for employment from medical men
and laymen, and the oilers of contribution of ambu-
lance material, were so varied and numerous that "for
the present, ample provision has been made in the
direction of supplementary aid to the army medical
service in the field." Colonel J. S.'Young was at
once sent to South Africa, amply provided with funds
and material, to co-operate with the principal medical
officer of the British field force (Surgeon-General
W. D. Wilson) as to the best way of providing for the
sick and wounded, not only of the British army, but
also of the two Boer republics. The equipment of a
hospital train was despatched to Durban, where Sir
George White's movements foreshadowed the earliest
struggles; a hospital ship was placed in preparation;
nurses, over a hundred in number and all highly
trained, were obtained ; while arrangements were made
with the St. John Ambulance Brigade to meet any re-
quirements in connection with a supply of ambulance
officers and hospital orderlies. Besides all this, the
Red Cross committee took over the work of organiz-
ing all the numerous private off^ers of assistance to
make them effective. In this way they have the re-
sponsibility of the volunteer hospital ships — the frin-
irss of IFa/cs, directly equipped by the committee,
H. R. H. the Princess of Wales providing ;^io,ooo
toward the cost, and the Maine, equipped by the gen-
erosity of American ladies in London; and the volun-
teer iield hospitals, viz., the Portland Hospital, the
Langman Hospital, the Sivewright Hospital, and the
Imperial Yeomanry's Hospital. The Frincess oj Wales
started from London at the beginning of December,
and took a month to get to the Cape, as an un-
fortunate breakdown at the beginning of the voyage
detained her some days in the Thames. Major A.
Hickman-Morgan, D.S.O., a retired member of the
Royal Army Medical Corps, went out on the Frin-
cess of Wales as senior medical officer, having under
him one military and three civilian surgeons. The
ship contained about one hundred beds all told, and
was staffed in addition by four nursing sisters, seven-
teen privates of the Royal Army Medical Corps,
and twenty-three members of the St. John Ambulance
Brigade — to act as ward orderlies, compounders, store-
keepers, etc. The Maine, which followed three weeks
later, contained provision for two hundred and twenty
patients, the Royal Army Medical Corps and the St.
John yVmbulance Brigade supplying the service. Col-
onel Hensman, R.A.M.C., sailed on the Maine to rep-
resent the War Office, while Surgeon-Major Cabell
directs the medical services of Dr. George Eugene
Dodge, Dr. Harry H. Hodman, and Dr. Charles H.
Weber.
The Size of the British Medical Force at the
War. — The size of the medical establishment sent
out by Great Britain becomes of particular interest
because it has been able to cope with disasters which
were clearly not expected by the British War Office.
Had the campaign proved the pleasant saunter to
Pretoria, which some amiable officials seem to have
believed that it would, the number of medical men,
bearers, and Army Service Corps sent would have
appeared unnecessary, but, as circumstances fell out,
all were wanted. With the original force there were
sent, all told, two hundred and eighty-two medical
February 3, 1900]
MEDICAL RECORD.
217
officers of the Royal Army Medical Corps, sixty-eight
civilian surgeons, fifty-six nursing sisters, twenty-eight
quartermasters (R.A.M.C.), and twenty-eight hundred
and fifty Army Service Corps for transports and nurs-
ing duty, making a total of thirty-two hundred and
eighty-four. The very small number of female nurses
is accounted for by the fact that the War Office will
not allow women to assist in the field hospitals. This
force was afterward increased by one hundred medi-
cal officers and about fifty civilians, while the private
field hospitals have contributed some twenty more
medical men with a due quantum of lay assistants.
The complete total is now over thirt3'-five hundred,
and more are going out.
The General Hospitals The first general hospi-
tal arranged at the base was at Wynberg. Wynberg
is a beautiful suburb eight miles from Capetown, and
the large permanent barracks were requisitioned as a
hospital to accommodate five hundred persons. The
building stands upon an ideal site overlooking a
lovely country interspersed with fine residences. The
medical officers, thirty-six in number, are put up in the
vacant married men's quarters of the barracks, while
the officers' quarters are occupied by the nursing staff.
Lieutenant-Colonel Hodson, R.A.M.C., was placed
in charge of the surgical side, and Major Barnes,
R.A.M.C., of the medical side, the whole being under
Surgeon-General Wilson. Completely equipped oper-
ating-rooms were soon in readiness, while Sir George
White's early operations provided patients almost as
quickly. The Wynberg Hospital is in communica-
tion with the Cape Town forces under Methuen, Gat-
acre, and French by the railway, upon which a hospi-
tal train service was immediately established; and
with the Natal forces under White and Buller, by a
service of transports from Durban. The first batch
of wounded to arrive in the hospital were brought by
the transport Jelntiga from Durban, and consisted of
ninety-five men who had been engaged in the battles
of Glencoe and Dundee in the third week of October,
and who reached Wynberg at the beginning of No-
vember. Almost immediately afterward the Sumatra
arrived at Cape Town from Durban, bringing two hun-
dred more wounded. Most of the first wounds were
of a trivial nature, wounds of the forearm and thigh
predominating; but had not the Royal Army Medical
Corps, within the short space of four days from the
arrival of the plant at Capetown, organized to its
completest detail a general hospital, undoubtedly some
of these cases, which under prompt treatment recovered
immediately, would have gone to the bad. The x-ray
apparatus proved invaluable for the detection of bul-
lets, and only one amputation was necessary in the
first lot of patients; and in a great number of cases
the ordinary field dressing proved sufficient to bring
about complete healing. By the first week in Decem-
ber No. I General Hospital was full, for Lord Me-
thuen's advance northward to the relief of Kimberley
was signalized by three battles in one week, all of
them frontal attacks. In the first two the British
were successful with considerable losses, though an
insufficiency of cavalry (and some say, openly, an ini-
efficiency of tactics) prevented them from utilizing
their victories. In the third, the fight at Modder
River, the relieving force was checked with great
slaughter. Certain Highland regiments lost thirteen
per cent, of their strength, and hospital trains bi ought
relays of terribly wounded soldiers down to Wynberg.
The medical staff here were by this time reinforced
by nine civilian surgeons, mostly fresh from the best
class of hospital work; and the plant for No. 2 Gen-
eral Hospital having arrived, accommodation was
quickly provided for twelve hundred sick and wounded.
At the same time the Spartan brought more wounded
round from Natal.
Modern Bullet Wounds. — The surgical lesson to
be learned from the war became clear as soon as the
general hospitals at Wynberg, as well as the stationary
hospitals behind the fighting columns, became full of
seriously wounded men. The lesson is that the mod-
ern bullet, with its small calibre and enormous veloc-
ity, does not leave behind it the after-effects of the old-
fashioned French chassepot, or the Martini-Henry.
The wounds of both the Mauser bullet used by the
Boers, and the Lee-Metford used by the British, have
generally small entrances and exits, while their ten-
dency is to heal like clean cuts by first intention.
Truly wonderful stories, vouched for by Sir William
MacCormac, president of the English Royal College
of Surgeons, and serving in the Cape as chief surgical
adviser to the army, as well as by the surgeons of the
Royal Army Medical Corps, have already been pub-
lished. Men shot through the brain have been only
temporarily inconvenienced; the abdomen has been
pierced from before backward and from side to side,
and recoveries have ensued ; the bladder and the stom-
ach have been traversed and the men have continued
to charge! It is abundantly clear that in a long cam-
paign a man might be shot half a dozen times, and
half a dozen times return to duty as good a man as
ever.
OUR LONDON LETTER.
(From our Special Correspondent.)
the war increase of influenza the registrar
general's office — excision of vesicul^ semi-
NALES — hysterectomy FOR FIBROIDS — RUPTURE OF
THE UTERUS SOME RECENT DEATHS.
London, January 12, igoo.
The war is naturally the most absorbing topic. Amid
our many errors and shortcomings the one bright spot
has been the medical department, which has done
nobly at the front and at the base. Its devotion ought
to go far to abolish the mischievous military jealousy
which might have paralyzed it — did in one sense, for
the War Office has been obliged to engage large num-
bers of "brave civilians" to take places rendered va-
cant by its own fault. It is the old story — unready in
every department while the authorities were studying
braid and buttons. The anger of the country is but
feebly expressed in the newspapers, severe as are their
criticisms. A clean sweep of the War Office is hoped
for.
More consulting surgeons have gone out, and further
surgical aid is being scratched together. Nothing
could well be more condemnatory of the authorities,
who ought to have been prepared with the full comple-
ment of army surgeons for the work, whereas they had
numerous vacancies in the stafif, which was known to
be too small, and so were obliged to ask for civilians'
help.
Among the numerous kindly efforts to succor the
sufferers is the undertaking of doctors at home to attend
gratuitously the families of soldiers on service. It is
not likely any such would have had any difficulty in
obtaining all they might need, but I cannot feel sure
that it is wise for the British Medical Association to
endeavor to organize such assistance, and at the time
when so many complaints are made as to the encroach-
ments of the public on medical service. The profes-
sion has always been too ready to extend its charity,
and might have been trusted to act in such cases with-
out any organized arrangement to do so.
The epidemic of influenza steadily increases and
looks like lasting longer. From the royal household
as from the most crowded slums the news is the same
— the "flue" prevails. The deaths last week in Lon-
don rose to three hundred and sixteen and the deaths
2l8
MEDICAL RECORD.
[February 3, 1900
from the class of respiratory diseases to twelve hun-
dred and twenty-one. In the epidemic of 1892 the
highest number in a* week reached five hundred and
six. In 1895 i'^ ^'^s ^^^^ hundred and seventy -three.
The London total mortality for last week exceeded the
average for ten years by more than eleven hundred.
From the country come similar reports. Ireland, Scot-
land, and Wales are suffering too. Nottingham is
very heavily stricken, eight thousand cases being said
to be down in the town yesterday. At Northampton
half the factory hands are absent, and the same tale
comes from other places, showing that the epidemic is
very widespread.
As the registrar-general's office will shortly become
vacant, there is much speculation as to whether the
government will have the courage to appoint the
superintendent of statistics to succeed him. The lat-
ter is a medical man. Probably }'0u may be under
the impression that the chief is also. Not at all; his
post has been the best paid, but with little to do ex-
cept to indorse his subordinate's statements. I hope
the sinecure will be abolished and the medical man
promoted to continue his valuable work with the honor
of the chief office.
On Monday, at the Medical Society, Mr. M. AIoul-
lin related two cases of young men with tuberculous
disease of the epididymis extending upward, for which
he had removed the vesicula seminales, and he advo-
cated the operation in all cases in which the vesicute
could be felt per rectum. Very little hemorrhage
occurred in either case. In one a small urinary fistula
remained for several months. Mr. Edwards and Mr.
Wallis considered the operation less simple than had
been represented, and a modification of Kraske's
operation was suggested.
Dr. Gow then reported his results in hysterectomy
for fibroids, showing a mortality of about two per cent.
— one death in forty-seven cases. With so low a rate,
Dr. Blacker said, many operations might be under-
taken, but when adhesions existed the cases were more
serious. He described a case in which he had been
unable to remove the tumor on account of extensive
adhesions. Mr. Wallis complimented Dr. Gow on his
results, which he thought largely due to the simplicity
of his procedure.
Rupture of the uterus was the subject of some dis-
cussion at the Obstetrical Society on the 3d inst. Dr.
H. Spencer began it by relating four cases which he
had successfully treated by packing the tear per vagi-
nam with iodoform gauze. These four cases are the
only ones he had thus treated, and the only cases he
had known to result in recovery. He had seen about
eight others, and they ended fatally, either from shock
and hemorrhage or later from sepsis. In two cases he
performed abdominal hysterectomy. By way of bring-
ing out the views of others he formulated his views
thus: (i) Abdominal section is rarely required, and
that almost solely when the foetus has passed partly or
completely into the peritoneal cavity. 1 i) Abdominal
hysterectomy is hardly ever necessary ; when the broad
ligaments are so much damaged as to endanger the
vitality of the uterus, vaginal hysterectomy should be
performed. (3) All incomplete tears implicating the
broad ligament, also most complete tears, should be
treated by packing the rupture per vaginam with iodo-
form gauze, after removing clots and fluid blood.
The president, Mr. A. Doran, remarked that absorp-
tion of iodoform might produce a very rapid pulse,
leading to a suspicion of sepsis, a point to remember
in these cases, as well as when the gauze drainage is
used after ovariotomy.
Dr. Horrocks said that rupture confined to the cer-
vix and broad ligament was much less serious than
when the peritoneal cavity was opened. In one he put
in two stitches and packed with sal-alembroth gauze,
which was renewea under ansesthesia every twelve
hours for three days, then once a day. In another
case he opened the abdomen and stitched the tear.
In aseptic cases he saw no objection to sewing up the
wound. He did not think hysterectomy was ever ad-
visable, and he thought sterilized gauze as good as
the iodoformed.
Dr. Lew'ers had a case in which the rupture extended
through the posterior wall into the peritoneum. He
packed with iodoform gauze. The patient recovered
after a very critical time. He had used the gauze
often in abdominal sections and observed the rapid
pulse from absorption. He attributed it to an extra
percentage of iodoform in some samples. He found
carbolic gauze as good.
Dr. Handfield-Jones said much depended on whether
rupture was complete. In thirteen cases lately reported
from Vienna packed with iodoform gauze eight were
complete and all were fatal; five incomplete and all
recovered. Lateral tears into the broad ligament gen-
erally recovered whether treated by packing or simple
aseptic douching.
Dr. Herman advocated packing for most cases, but
if the packing could not be passed right up to the top
of the rent the uterus should be removed through the
vagina. Dr. Spencer had given the useful suggestion
to pass a large tube through the rent in order to evac-
uate the blood in the peritoneal cavity.
Dr. Drummond Robinson had packed two cases;
one patient died; the other recovered and had since
borne a child. In another case he intended to pack
an incomplete rent, but on going next day to do so the
patient was so much better that he did not, and she
recovered.
Dr. Spencer, in his reply, said most of the cases
were, he believed, incomplete. He did not approve
of repacking every twelve hours — the gauze should be
left for three or even six days. He did not think
aseptic gauze would remain sweet, and he therefore
considered it not so good as iodoform gauze.
Among recent deaths are the following:
Dr. Gardner Dudley, consulting physician to the
Metropolitan Hospital and the North London Con-
sumption Hospital, died on the 2d inst., aged seventy-
two years. He was a Cambridge M.D. and M.A., a
cultured gentleman, and it was a pleasure to meet
him.
Mr. George Taylor, justice of the peace for Norfolk,
who had for some years retired from active work, died
on the 6th inst., aged eighty-two years.
Mr. Henry Thompson, surgeon to the Hull Infirm-
ary, died on the 28th ult., aged only forty-nine years.
Dr. Ginison died suddenly at the bedside of a pa-
tient, from the rupture of an aneurism of the aorta.
Dr. George Elder, one of the younger teachers in the
Edinburgh School, only thirty years of age. died on
the 6th inst., from influenza. He was joint author
with Dr. Fowler of a "Manual of Diseases of Chil-
dren."
Surgeon-Major Alexander Grant, honorary surgeon
to the Queen, died at the age of eighty-two years. He
was retired since 1869, after an honorable Indian ca-
reer.
Deputy Surgeon-General David Cullen, who also
saw service in India, as well as in the Crimea, being
present at the taking of Sebastopol and Lucknow, died
on the 4th inst., aged sixty-seven years.
Dr. W. J. Belcher, of Bandon, died on the 29th
ult., aged sixty-two years, from the effects of carbolic
acid put in mistake into a draught he mixed for him-
self. Medical friends hastily summoned reached him
only to find him dead.
Dr. Robert Robinson, physician to the City and
Consumption Hospitals, died at Liverpool, aged fifty-
eight vears.
February 3, 1900]
MEDICAL RECORD.
219
HOSPITAL AND DISPENSARV WORK IN
KOREA.
To THE Editor •
Medical Recor
Sir: The main difference in the practice of medicine
and surgery out here in Asia, and in America or
Europe as I have had to do with it in all these places,
consists mainly in the very small financial outlay we
are allowed to work on. I am writing of what is
essentially charity work and carried on as an ac-
knowledgment of the obligation, which is one of the
general results of Christianity, to provide systemati-
cally for the sick, the sorrowing, and the very poor.
This obligation, however, doesn't press very heavily
when it comes to people in America or Europe pro-
viding for the natives of Africa or Asia, and so ^500
a year is a big sum to expect, for my average for the
past three years from the LFnited States has been but
$400. And with this, all expenses but my own salary,
which is excepted, must be met, and of course we have
to bring our little dispensaries and hospitals down to
a standard of which this is the basis. But even with
this, much can be done. One's surgical work is limit-
ed only by his ability, which the natives soon recog-
nize, and by the appliances and facilities provided.
This is my experience based on thirty thousand pa-
tients.
The lack of money drove me into eye surgery as a
sort of specialty, for I found that the easiest, cheapest,
happiest, and most effective branch I could turn to.
During a cholera epidemic I turned specialist on that,
but since then eye surgery has taken my best efforts,
though the plague is threatening these shores, and, if
it comes in, I'll have to neglect my eye work and see
what there is to be learned clinically in that.
Taking a few notes, somewhat at random, from the
past year's work, we find that in December, i8g8, nine
cataract operations were done. In one the lens be-
came dislocated, and after several ineffectual attempts
to get it out with the wire loop the eye was bandaged
and the patient allowed to rest. Next day on remov-
ing the dressings we found that spontaneous expulsion
had taken place, for there lay the lens in the dress-
ing. In another of these cases the same thing hap-
pened, but we got the lens easily with the loop. In
yet another very excessive bleeding, with gaping of the
incision and loss of the aqueous,'took place. Every-
thing appeared normal and the operation seemed all
right, but a few hours after severe pain and excessive
hemorrhage took place. What made it more marked
was that exactly the same result followed the operation
in the other eye; thus showing a peculiarity in that
patient. Notwithstanding all this, good results were
obtained in all nine cases.
I amputated the forearm of a man aged sixty-three
years, and very nearly lost him by the accident of the
ligature slipping off the artery. It was discovered by
feeling for the pulse in the remaining arm, and finding
none. The patient had not been taken off the table,
but the stump had been bandaged. The saturated
dressings were hurriedly jerked off, the wound was
opened, and the spouting artery secured. A pint of
saline solution was injected into the abdominal tissues,
and considerably more into the rectum. A prompt
reaction followed, though three weeks afterward (the
man had other diseases and was in the hospital a
month) a cold abscess developed at the site of the in-
jection into the abdominal wall. Very careful pre-
cautions had been taken, and this was the '■esult.
This hypodermoclysis was used recklessly in many
cases of cholera, during an epidemic, and trouble fol-
lowed in but one instance, and in that the injection
was into the thigh instead of the abdominal tissues.
As to the number of patients, twelve thousand a
year is about the average, which includes dispensary
patients, medicine buyers, and in-patients, the latter
numbering two hundred and fifty last year. The total
expense last year, which includes salaries for natives,
support for indigent patients, drugs, fuel, and every-
thing else, was S539.03. During the three years just
past, there have been sixty-four cataract operations,
one hundred and twelve iridectomies, and correspond-
ing numbers of other such work. A medical class of
seven young men is under instruction, and this is one
of my important duties. It is absurd to think of mak-
ing modern doctors out of them, versed as we ought
to be in all the allied medical sciences; so I aim
simply, after three or four years, to make fairly good
druggists, expecting them to prescribe and treat cases,
as must necessarily be the case in the evolution of
the natives into "doctors."
The main object of these little institutions, how-
ever, is not charity, but in the eyes of those who have
much to do with the voting of funds, etc., they are
"philanthropic institutions limited by the possibility
of their evangelistic utilization and influence" — a
sentiment expressed by the words, " A small develop-
ment of such work contributing powerfully in the
direction indicated is better than a large development
of but feeble or indirect evangelistic influence."
This is the sme qua noil which we work on, though
there was nothing of that spirit shown by the Good
Samaritan when he picked up the man who had fallen
among thieves.
The economic value of the services rendered to the
natives here, last year, which was made possible by
the $539.03 from the United States of America, was,
estimating on a minimum basis, over $100,000.
J. Hunter Wells, M.D.
PvENGVANG, KoREA.
^MicaX Items.
Quarantine Regulations to Insure Safe Scientific
Passenger Traffic from an Infected Locality to a
Non-Infected One. — The following rules are suggested
by Dr. Edmond Souchon (^Neu' Orleans Aledical and
Surgical Journal) for the successful conducting of pas-
senger traffic in epidemics, especially yellow fever:
1. Persons from an inlected locality wishing to go to
non-infected localities shall send to the railroad depot,
eight hours previous to the departure of the train, a
suit of clothes and their baggage, which shall be disin-
fected by the officers of the United States Marine Hos-
pital Service. 2. They shall be present at the railroad
depot one hour before the hour of departure, to change
the clothes they have on for the suit disinfected under
the supervision of the said officers. 3. They shall be
given a certificate to that effect. 4. They shall then
be admitted to a seat in a disinfected coach. 5. The
baggage shall be checked and placed in a disinfected
baggage-car. 6. The healtii officer of the locality to
which they are going shall be informed of their com-
ing by telegraph. 7. Upon their arrival at the point
of destination they shall be met by the health officer
or shall at once report to him. 8. They shall present
themselves to him for inspection in the morning and
in the evening for five consecutive days. 9. A bond
may be required of them to insure their appearance, or
they may be placed under the surveillance of a special
officer. 10. If they have been well all that time they
will then be free to go anywhere and everywhere. 11.
Should they present any symptoms of fever they shall
at once be isolated and be treated scientifically to
prevent infection. 12. By thorough disinfection of all
that comes from the patient as soon as it leaves him
or has touched him, the disease will not affect any one
else around him nor infect the household effects nor
2 20
MEDICAL RECORD.
[February 3, 1900
the premises. 13. As soon as the patient has recov-
ered he must be disinfected, and also all his effects.
14. Also the nurse. 15. Also persons and things
which have been in the room and the house. 16. Also
the premises, yard, privies, and gutters. 17. All this
must be done according to the instructions to the med-
ical inspectors. 18. Non-immune persons who had
been in the house or on the premises must also be
kept under observation for five days after the disin-
fection of their clothing and effects.
The Sensory Capacity of the Female Genitals
from a Forensic Point of View A midwife in Bres-
lau some years ago was arrested charged with pro-
curing an abortion bypassing an "instrument" and
causing the "waters'" to come away; the ftttus being
expelled two days later. Experts called were of the
opinion that the patient could not be sure whether the
instrument was passed into the vagina and uterus, or
into the bladder. Dr. Calmann (Archiv f. Gyncik., Bd.
Iv., Heft 2), who has recently investigated this sub-
ject of genital sensibility, concludes as follows: i.
The sense of localization is very defectively developed
in the female urino-genital system; the local differen-
tiation between the urethra, bladder, and the vagina is
quite uncertain; and a similar sense of locality be-
tween the vagina, portio, and uterine cavity does not
exist at all. 2. The sense of touch, especially of the
portions of this region which lie above their respective
entrances, is likewise defectively shown. All judg-
ment is absent as to the length of an object intro-
duced; the thickness is fairly well recognized, but no
correct estimate of it is made with certainty. There
is great obscurity as to the form and other characters
of objects introduced. The number of objects intro-
duced into the vagina is often falsely given. There is
no sense of touch in the portio vaginalis and the
uterus. 3. The sense of pressure is somewhat well
developed in the urethra, in the vagina it is very fee-
ble, and in the uterus and outer surface of the portio
it cannot be demonstrated. 4. The sense of temper-
ature is also fairly good in the urethra. In the vagina
it is feebly developed, especially toward the hotter de-
grees of temperature. It fails entirely in the uterus
and portio. 5. Sensation of pain is quick in the ure-
thra and in the vagina ; in the portio and cervical canal
it is only moderate, in the utgrine cavity it is often
marked. This forms the only subjective difference
between the uterus and vagina. 6. Vaginal douches
and the customary disinfectants diminish the sensibil-
ity of the vagina.
The Cost of Sickness. — The records kept in Ger-
many in regard to sick insurance, which is now com-
pulsory upon workmen, are beginning to show how
serious a strain sickness produces upon a country. It
appears that nearly eight millions of persons in Ger-
many subscribe to the Krankenkassen, that is to insure
against sickness, and that in 1898 one-third of this
number reported illnesses of one sort and another, the
average duration of sickness being seventeen days.
Now if we reckon wages at only fifty cents a day this
comes to a loss of more than twenty-two and one-half
millions of dollars a year in wages alone, besides what
has somehow to be provided for food, physic, and
maintenance. This, of course, is among working peo-
ple during the working period, which is presumably the
most healthy part of their lives. — London Hospi/aL
Nerve Suture and Sensation. — In the French sup-
plement to La Grhe Medicale, Dr. Petridis relates a
case of secondary suture of the radial nerve after
eighteen months, in which restoration of sensibility
was practically instantaneous. The patient had been
wounded by a bullet in the forearm during the recent
Greco-Turkish war so severely that the surgeons pro-
posed to amputate, and would have done so " had not
the Greek troops been obliged to retire." The wound
left a painful cicatrix with atrophy and ankylosis of
the arm and hand, especially the thumb, index, and
middle finger. There was entire loss of sensation
over the region supplied by the radial nerve. After
operation, while the patient was still on the table and
recovering from the anaesthetic. Dr. Petridis pricked
with a needle the dorsal surface of the hand in a spot
which had been totally anaesthetic for eighteen months,
and the patient at once responded. Four hours later
sensation over the affected part was almost normal.
The writer gives a summary of other cases in surgical
literature showing the capricious and still unexplained
manner in which sensibility returns after suture of di-
vided nerves. Perhaps the most interesting is an ob-
servation of M. Remy in two cases of division and
suture of the median, in which touching the tip of the
index finger gave rise to sensation in the thumb and
middle finger respectively : " This transformation of
sensibility is not transitory, for I have observed it
more than a year after the commencement. Paget has
published a case of the same VauA." —Medical Maga-
zine.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-gengral of the United States Marine-
Hospital service during the week ended January 26,
1900:
Cases. Deaths.
Smallpox— United States.
Colorado, Denver January 7th ',, i
Huerfano County. January 9th 3
District of Columbia, Wash-
ington Januarj' 12th to tSth 2
Georgia, Blackshear January nth 16
Brunswick January nth 10
Darien .January nth 3
Jesup January iilh 3
Liberty January nth x
Indiana, EvansviUe January 13th to 20th a
Kentucky, Covington January 13th to 20th 4
Louisville January nth to i8th 1
Louisiana, Calcarien January 7th to 13th 3
East Feliciana .... January 13th 50
Livingstone January 13th Several.
New Orleans . . . .January 14th to 21st 54 s
Shreveport January 13th to 20th %
Massachusetts, Maiden January 1 3th to 20th i
Nebraska. Omaha January 13th to 2olh 1
New York, New York January 13th to 20th 1
Ohio, Cleveland January 13th to 20th 20
Youngstown January 15th to 22d 7
Oklahoma, Beaver County . .January loth Reported.
Blaine County .. .January 10th I
Noble County. . . . J.inuary loth Reported.
Pawnee County. :January 10th Reported.
Pennsylvania, .Mlegheny.. . .January 13th to 20th x
Texas, Butte January ist to i6th 75 I
Houston .January 6th to 13th 4
Virginia, Portsmouth January 13th to 20th .. .. , 20 Z
Smallpox — Foreign.
Brazil. Rahia December 2d to 9th 1
Rio de Janeiro December 1st to 'Slh 5a
Canada, Ontario December 30th 243
Egypt, Cairo December 23d to 31st 7
England, London December 22d to January 6th. . . 15
Southampton December 31st to January 6th., 1
France, Lyons December 7th to 23d ^ ^ 2
Marseilles January 2d Epidemic.
Nice December 12th to January 8th,, 3
Greece, Athens December 31st to January 6th .. 3 x
India, Calcutta December "sth to i6lh »
Mexico, Chihuahua January 6th to 13th ^
Vera Cruz January 6th to 13th x
New Brunswick, Campbell-
town ... . January 13th to 2olh 5
Russia, St. Petersburg December 23d to 30th 12 7
Scotland, Leith December 31st to January 6th . . I
Spain. Corunna December 23d to January 6th. .. 3 4
Turkey, Smyrna December 17th to 24th 3
Yellow Fever— United States.
Florida, Key West January i6th I •
Yellow Fever— Foreign.
Brazil, Rio de Janeiro December ijt to Sth I i
Colombia, Barranquilla December 2 id to 30th I I
Cuba, Havana January 6th to 13th 4 J
India, Calcutta December Sth to 1 6th
Plague— United States.
Hawaii, Honolulu From Outbreak to January Sth . . ..
Plague— Foreign.
India, Calcutta December Sth to 16th
Kurrachee December Sth to 23d 3
Japan, Formosa, Tamsui ... November 28th to Deccmberiath 14
Paraguay. Asuncion November 7lh to 21st
Portugal From outbreak to January 6th . , 387
Medical Record
A JVeekly yournal of Medicine and Surgery
Vol. 57, No. 6.
Whole No. 1527.
New York, February 10, 1900.
$5.00 Per Annum.
Single Copies, loc.
@ri0inat Articles.
REMARKS ON SUBPHRENIC ABSCESS; WITH
A REPORT OF THREE CASES.'
Ey a. a. berg. M.D.,
ADJUNCT SURGEON
HOSPITAL.
To Leyden belongs the credit for calling attention to
suppuration in the subphrenic region, as distinct from
purulent collections above the diaphragm. In his
descriptions he had reference to large cavities filled
with gas and pus, lying underneath the diaphragm,
but pushing the latter upward, so as to occupy rela-
tively the lower thoracic region and giving physical
signs somewhat resembling pyo-pneumothora.x. In
contradistinction to the latter affection, he named this
new one pyo-pneumothora.x subphrenicus. From a
number of cases that came under his observation he
sought to establish a clinical basis upon which to rest
the differentiation of the supra- from the infra-diaphrag-
matic suppuration. His observations made in 1880
have been added to from time to time, notably by
Barlow and Pfuhl, but, although it is almost a decade
since his classical descriptions of this affection ap-
peared, our differential diagnosis is to-day by no means
perfect.
The name which Leyden gave to this affection, viz.,
pyo-pneumothora.x subphrenicus, would lead us to in-
fer that all these abscess cavities are gas-containing.
This condition does not, however, always obtain, for
very many of these subphrenic abscess cavities are
non-gaseous. This variance in the presence of gas,
along with the pus, necessarily causes a variance in the
physical signs that suppuration in this region would
give. To arrive more easily at a basis upon which to
rest our clinical diagnosis of these abscesses, we must
therefore divide the subject into two main classes:
(a) Those abscess cavities that contain gas and pus;
(1^) those that contain pus alone. Again, in either
class we must consider whether or not there has been
a secondary involvement of the pleural cavity.
I shall consider each class separately, pointing out
the physical signs that are usually obtained from the
presence of such an abscess, and attempt to show how
to differentiate subdiaphragmatic suppuration from the
other affections with which it is likely to be confounded.
First, as to those subphrenic abscesses that contain
gas. The classical signs that such an abscess would
give are as follows: An enlargement more or less
marked of the lower thoracic region, with downward
displacement of the liver and spleen, so that these
viscera become distinctly palpable. Fremitus is di-
minished, or even absent, over the lower part of the
chest on the affected side. Percussion of the chest
from above downward gives a note, increased in pitch
and intensity above, and merging below into a full
tympanitic sound ; splenic and hepatic dulness is more
or less obliterated. On auscultation there is normal
vesicular murmur at the apex, with increased or bron-
chial breathing just below it, and still further below
' Read before the Medical Association of Greater New York.
amphoric breathing, or metallic tinkle, or both; suc-
cussion is present; the apex beat is but little, if at all,
displaced. An abscess giving rise to such physical
signs can be confounded only with pyo-pneumothorax,
in which the physical conditions are of the same na-
ture as obtain in subphrenic pyo-pneumothorax.
Leyden in his earliest papers indicated the lines on
which our differential diagnosis can be made: («) The
previous history of the patient, which points to a pri-
mary trouble somewhere in the abdomen, and not in
the chest. (/') The absence of cough and expectora-
tion, or of any pulmonary lesion which could give rise
to a pyo-pneumothorax. (c) The presence of normal
vesicular murmur, with normal fremitus at the apex,
with a sharp line of differentiation from the amphoric
breathing below; furthermore with deep inspiration
the line of normal breathing descends to where the
amphoric breathing had been, (d) The very slight
displacement of the apex beat, {e) The rather incon-
siderate bulging outward of the intercostal spaces, and
the absence of immobility of the chest wall. Neuser
has added the observation that the basal line of thorax
dulness is crescentic, with the convexity downward,
instead of horizontal as in encapsulated pyo-pneumo-
thorax.
When we come to consider those cases of gas-con-
taining subphrenic abscess that have become compli-
cated by the presence of a pleural effusion, we find
that there have been added to the physical signs of the
subphrenic abscess those of fluid above the diaphragm.
This would seem to render the differentiation of these
cases from simple pyo-pneumothorax much more diffi-
cult; but the acute observations made by Barlow in
such a case that came under his observation have ren-
dered the diagnosis very much simpler in those cases
in which the pleural effusion is free, and especially if
it is serous in character. For it must be remembered
that the pleural effusion may be either serum or pus,
that it may be free or encapsulated, and that the pus
may or may not have the same characteristics as that
in the subphrenic cavity.
I shall consider the simplest complication first, viz.,
the presence of free fluid, whether serum or pus, above
the diaphragm. The physical signs by which Barlow
has enabled us clearly to differentiate such a status from
pyo-pneumothorax are as follows: {a) In addition to
the physical signs I have detailed above, due to the
subphrenic abscess, there were undoubtedly the signs
of a pleural effusion lying above this gas-containing
abscess cavity; (b) the maximum intensity of the
amphoric resonance and breathing was underneath
the false ribs. If these observations are added to
those made by Leyden, and which I have just quoted,
viz., the previous history of the patient and the ab-
sence of any pulmonary lesion that could have called
forth a pyo-pneumothorax, the diagnosis is rendered
comparatively simple; and it is rendered more certain,
as was also pointed out by Barlow, by exploratory as-
piration. For if on aspirating through one of the upper
intercostal spaces we draw out clear serum, and on
aspiration at a lower level pus, the probability is very
strong that the diaphragm is separating these two cav-
ities; for it is very unlikely that a membranous sep-
tum in the pleural cavity could be so complete as to
MEDICAL RECORD.
[February lo, 1900
separate the latter into two compartments, the one con-
taining pus and gas and the other serum.
VVhen the pleural exudate is encapsulated, the diffi-
culty in reaching a diagnosis is considerably increased.
Should the exudate happen to be serum, exploratory
aspiration, witli the result of finding serum at an upper
intercostal space and pus at a lower level, would help
us very much ; but should pus be obtained from both
punctures, we would have to depend for making our
diagnosis upon the two points so strongly insisted
upon by Barlow, and which I have already mentioned,
viz., "the level of maximum intensity of the amphoric
resonance and breathing," which, in a pyo-pneumo-
thorax subphrenicus, is underneath the false ribs; and,
secondly, that " the signs of fluid are distinctly above
a cavity containing both gas and pus."
This brings me to consider the second class of sub-
phrenic abscess, viz., those cases in which there is no
gas within the abscess cavity, but only a focus of sup-
puration in the subphrenic spaces. Such abscesses
may even be due to ulceration of the hollow viscera,
in which the communication with the viscus has been
scess shows the signs of compression, which diminish
with a deep inspiration. These physical signs, with
a pus temperature, and an absence of any preceding
pulmonary history, or of any cough or expectoration,
are sufficient to enable us to make the probable diag-
nosis in most cases.
When such an abscess has excited, either by rupture
or by its vicinity, an inflammation in the pleural cav-
ity, with a resulting exudation into that cavity, the
diagnosis is very much more difficult. Here we have
to depend upon the history, which points to an ante-
cedent abdominal inflammation, and upon aspiration,
which, if the needle withdraws pus at a lower level and
serum at an upper intercostal space, decides the diag-
nosis, and to the manometric test of Pfuhl.' Should
there be pus both above and below the diaphragm, our
diagnosis is very difficult and must be decided by the
extent of the downward displacement of the liver and
spleen, and by the observation of the lowest level at
which we can aspirate pus.
This variety of subphrenic abscess must be differ-
entiated from an abscess of the liver, that causes the
Fig. I.— Left Pyo.Pneumotho
-Left Pyo-Pn
shut off by an adhesive inflammation around the ulcer-
ation, before perforation has really occurred. In this
class of cases it is not the differential diagnosis alone
that presents the difficulty, but the actual diagnosis of
the existence of the abscess itself. For it is very evi-
dent that there may even be quite a considerable col-
lection of pus in the subphrenic region, without giving
any physical signs whatsoever; and the frequency
with which we fail to detect subphrenic abscess in
obscure cases of suppuration should be a warning to
us to have constantly in mind the possibility of the
existence of pus in this region, without any distinct
signs pointing thereto. Very often these cases of sub-
phrenic abscess remain undetected until they have
ruptured into the pleural cavity or caused a secondary
empyema.
When they have become large enough to give rise
to physical signs, these must be sought in the chest
rather in the abdominal cavity. Inspection of the
affected side may reveal a slight bulging or oedema of
the lower thoracic region. The liver or spleen is
slightly displaced downward and can be palpated.
There is very likely to be a distinct area of pain and
tenderness underneath the false ribs. Percussion
shows " dulness " over the lower thoracic region, which
may be more or less marked. The breathing is not
much changed in frequency, but the lung over the ab-
latter to be enlarged upward and backward; and from
a splenic abscess that bulges the latter upward. This
difl^erential diagnosis is most frequently impossible,
for tlie same causes that call forth an abscess of the
liver and spleen also give rise to subphrenic suppura-
tion. The physical signs that are to be elicited in
either case are identical in character, and unless there
is a distinct history pointing to a liver or splenic ab-
scess, or the pus on microscopical examination shows
the presence of liver cells, the differential diagnosis
cannot be made.
I have gone thus carefully into the differential diag-
nosis of subphrenic abscess, because a knowledge of
the exact location of tiie pus, whether it is above or
below the diaphragm, has considerable influence upon
the lines of our operative attack. I shall call attention
' The manometric test of Pfuhl is based upon the negative
pressure existing inside the chest during inspiration, and the
increased pressure therein during expiration, and the very re-
verse of these conditions in the abdominal cavity, viz., an in-
creased pressure during inspiration and a dimmished pressure
during expiration. Therefore if a cannula connected with a
manometric tube is inserted into an abscess cavity above the
diaphragm, the mercury in the tube will fall with inspiration and
rise with expiration on account of the physical conditions named
above ; and vice versa, a manometric tube connected with an
abscess cavity below the diaphragm will show a rise of pressure
during inspiration and a fall of pressure during expiration.
February lo, 1900]
MEDICAL RECORD.
223
again to this, when I consider the treatment of sub-
phrenic abscesses.
It might be of interest here rapidly to run over the
etiology of subdiaphragmatic suppuration. Here again
we can divide our subject into the two same classes
as before, viz., those abscesses that contain gas and
those that are non-gaseous. The gas which is present
in a subphrenic abscess arises from a perforation of
one of the hollow abdominal viscera, or from a sec-
ondary rupture into a bronchus, or from gas-producing
bacteria. It must be remembered, however, that a sub-
phrenic abscess may be due to ulceration of one of the
hollow viscera without the presence of gas in the ab-
scess cavity, as the visceral fistula may have been
closed by adhesive inflammation to neighboring or-
gans before actual perforation has occurred.
Gas-containing abscesses may be due to (a) wounds,
ulcerations, whether benign or malignant; inflamma-
tions, with ulcerations, of any one of the hollow vis-
cera, as the stomach, duodenum, intestine (small or
large), or appendix; (/') wounds or ulcerations of the
bile ducts, (r) Simple subphrenic abscesses may be-
come gas-containing, from perforation into a hollow
viscus or into a bronchus.
Non-gaseous subphrenic abscesses are (</) usually
metastatic — the primary focus being situated in any
part of the body, but most frequently in the abdomi-
nal cavity; (i) secondary to liver or splenic ab-
scesses or perinephritic abscesses; (c) due to the
echinococcus; (if) traumatic in origin; (e) second-
ary to disease of the costal cartilages or vertebra;.
Treatment. — We can dismiss this with a few re-
marks. The only therapeutic measure is operative
procedure to evacuate the pus, both below and above
the diaphragm, when the latter is present. As regards
the technique of the operative attack upon the sub-
phrenic pus, in case the pleural cavity is normal I
prefer to resect the tenth rib, from the anterior axillary
line to the scapular line. This takes the wound be-
low the limits of the pleura, and if it is necessary to
gain more room I carefully strip up the costal pleura
from the eighth and ninth ribs, resect these ribs to a
similar extent as the tenth, and then peel up the pleura
from the diaphragm. I prefer this low point of at-
tack to the higher trans-pleural operation, because
we can thereby avoid invading the pleural cavity. In
the trans-pleural operation, I have found great diffi-
culty in walling off the general pleural cavity, so as
to prevent its infection; and the suture of the dia-
phragmatic pleura to the costal pleura, with the view
of shutting off the pleural cavity, I have found to be
very unsatisfactory, because the sutures are firstly very
difficult to apply, and, when in place after considerable
difficulty, they invariably tear out when an attempt is
made to tie them. After the pleural layers have been
stripped upward, the diaphragm is incised and the
pus evacuated. Drainage is established by tube and
gauze, and an aseptic dressing is applied. Should the
pleural cavity have been opened, the operator must be
on his guard for the evil consequences of the acute col-
lapse of the lung, and be ready to use artificial respira-
tion, or, even better, the " Fell-O'Dwyer " apparatus
for artificial respiration, until the pleural cavity can be
closed by packing or sutures. Should there be serum in
the pleural cavity, this will be found to disappear spon-
taneously, on removing the primary cause of trouble;
but when pus is present this must be evacuated, pref-
erably by resection of a rib. I would prefer to drain
the cavities by separate openings, retaining the lower
incision for the subphrenic space, and using a higher
one (over the seventh rib) for the pleural drainage.
With the preface of these remarks on this subject I
beg to submit to your attention the clinical records of
the three following cases that came under my care
during the past summer:
Case I. — Hannah D , sixty years of age, a house-
wife, was admitted to the medical service of Dr. Brill,
at the Mount Sinai Hospital, on May 10, 1899. Her
family history was negative. She had had rheumatism
several times. There was no specific history ; she had
passed the menopause twelve years previously. Her
present history began three months before admission,
with fever, chilly sensations, and general weakness.
At the same time she became short of breath, and had
occasional attacks of cardiac palpitation. Urination
had been scanty and painful. The feet and legs had
been swollen since the onset of her illness. She had
had some cough and muco-purulent expectoration;
there had been loss of appetite and constipation.
On admission to the hospital the physical examina-
tion gave the following data: A very obese woman,
pale and flabby, with moist and coated tongue; pulse
rate of 98, regular; considerably sclerosed arteries;
temperature, 103° F. ; respiration, 30-36. The lungs
and heart were normal. There was a slight cough,
and a very moderate expectoration. The liver and
spleen showed nothing abnormal in size or position.
The urine was likewise negative in pathological con-
stituents. The patient remained in this condition,
with a daily rise of temperature between 101° and
103° F.; pulse, 96-1 16 ; and respiration, 26-36. On
May 17th she gave the first indication as to the site of
her trouble. On this day she complained of consider-
able pain in the left hypochondrium posteriorly. On
May 22d there were resistance and marked tenderness
in the left hypochondrium. On May 24th the physi-
cal examination gave the following signs: In the left
lung, fine crepitant riles at the base in the axillary
line; behind, at the extreme base, there were slight
dulness, slightly increased voice, roughened breathing,
and marked crepitations, extending downward for
three inches. The liver was negative; the spleen was
displaced downward, and merged above into a hard
indurated area, w-hich extended forward to the mam-
mary line, and downward to two fingers' breadth above
the umbilicus. This area was flat to percussion and
painful and tender. Doctor Brill aspirated this mass
in the axillary line, tenth interspace, and withdrew a
syringeful of yellowish pus which showed no liver
cells.
On May 2Sth the general condition was worse; the
pain was intense, and her fever had been continuously
between 101° and 103° F.
On May 26th Dr. Lilienthal operated upon her un-
der chloroform anaesthesia. He first made a lumbar
incision for the purpose of exploring the perine-
phritic tissues, but found these normal. He then
made a second incision at right angles to the first one,
and extending upward from its middle for about three
inches. The aspirating-needle introduced directly in-
ward at the upper limit of this second incision revealed
the presence of pus. The tenth rib was excised be-
tween the anterior and posterior axillary lines; the
pleural cavity was opened, and when found to be nor-
mal it was immediately closed by suture. The dia-
phragm was then incised, and a large quantity of pus
evacuated. The pus was of a yellowish-brown color,
and showed tyrosin cystals and fatty and degenerated
liver cells. The cavity was drained by tube and gauze
and dressed dry.
May 27th: The patient reacted well from the opera-
tion; there was a profuse purulent discharge from the
wound. The highest temperature was 101.6° F. ; pulse,
100; respiration, 24. The urine contained granular
and hyaline casts.
June 5th: During the week the patient had lost
ground. The temperature ranged between 100° and
103° F. each day; pulse, 1 10-130, and weak; respira-
tion, about 40. The wound looked pale and flabby,
and discharged profusely. During the next fortnight
224
MEDICAL RECORD.
[February lo, 1900
the patient continued losing ground. The temperature
ran a little higher course, reaching 105° F. at times;
the pulse became more rapid, 146, and there were
signs of mental wandering with hallucinations. The
patient appeared septic, but no other focus of pus
could be found, and the wound itself appeared well
drained, and was filling up with granulations. On
June 2sth, on the suspicion that there might be an
encapsulated focus of pus in the vicinity of the wound,
which had not been drained, an exploratory aspiration
was made in several directions around the old wound,
but with negative result. The liver, which was slightly
enlarged, was also aspirated, but with like negative
result.
July 1st: The patient was still in the same condi-
tion. She complained of pain and tenderness in the
epigastrium, in which a marked resistance could be felt.
There was also considerable ascites.
July 3d: The resistance in the epigastrium could be
distinctly felt, and it was thought to be the left lobe
of the liver. Exploratory laparotomy was decided
upon, which I proceeded to perform at once. Under
chloroform anaesthesia I made a median laparotomy
in the epigastric region. The peritoneum was found
intensely cedematous, and there was considerable as-
citic fluid in the general peritoneal cavity. The left
lobe of the liver was enlarged. The surface of the
liver was smooth, and of normal consistency. Aspi-
ration of the left lobe showed the presence of multiple
miliary abscesses. Nothing was to be found in the
right lobe. Nothing could be felt in the portal vein
as it lay in the gastrohepatic omentum. The sub-
phrenic abscess appeared to have no connection with
any of the hollow viscera. The abdominal wound was
partly sutured and drained and an aseptic dressing
applied.
July 4th : The patient bore the operation very badly ;
her pulse became very rapid, and she died twenty-four
hours later. A culture of the liver pus obtained by
aspiration showed the presence of streptococcus longus.
Autopsy : A complete post-mortem not having been
permitted, an examination was made through the
wound by Dr. Libman, the assistant pathologist of the
hospital. The report was as follows : The liver showed
marked degeneration. In the left lobe were numerous
miliary abscesses, varying from a pea in size to one
inch in diameter, and containing thick green pus. In
the neighborhood of some of the abscesses were small
hemorrhages due to aspiration. The portal vein con-
tained no thrombus. The stomach was entirely nor-
mal, with no ulceration and no connection with the
abscess cavity. The spleen was moderately enlarged.
A depressed white scar ran across its centre trans-
versely. In the upper pole was a white nodule about
1 cm. in diameter. Both these seemed to be healed
abscesses. The splenic vein contained a purulent
thrombus. Heart- the mitral flaps had calcareous
deposits. The left ovary was cystic, about the size
of a large walnut.
Case II. — Becky B , aged thirty-six years, ad-
mitted to the gynecological service at the Mount Sinai
Hospital on July 2d, with the following history : She
had been confined four weeks previous to her admis-
sion, by a midwife. The day after confinement she
had several chills and fever, the next day she was
curetted for retained secundines. The fever continued
with sweating; there was no vomiting, but a constant
pain in the epigastrkim. There had been no pain in
the chest, and no cough or expectoration, at any time
during her illness. On admission the physical exam-
ination gave the following data: Her general condi-
tion was poor, and she was sHgluly icteric; the tongue
was moist but coated. Temperature, 100° F. ; pulse,
80; respiration, 20. Lungs: anteriorly there were no
abnormal signs; posteriorly, on the left side, there
was dulness from the mid-scapular region to the
seventh rib, with flatness below; breathing and voice
were absent at the extreme base, but distant bron-
chial at the level of the angle, becoming normal
above; there were no rales and no friction sounds.
Fremitus was diminished at the angle of the scapula,
but lost below. On the right side there was dimin-
ished breathing at the base, but this was less marked
than on the left side. Heart: sounds feeble but oth-
erwise negative; no displacement of the apex beat.
The liver extends from the fourth space downward
to two fingers' breadth below the costal margin. The
left lower margin of the liver descends to a lower level
than is usual. There were pain and tenderness over
the gall bladder. Spleen: enlarged to percussion, but
not palpable. Abdomen : muscles tense. There was
pain in the right side of the epigastrium and in the
left lumbar region ; nothing was to be felt in the left
lumbar region, but a mass could be palpated in the
right epigastrium, most likely the gall bladder. The
extremities were normal. The urine was normal.
The pelvic organs were normal.
On July 2gth, Dr. Allen, the house surgeon, aspi-
rated through the ninth intercostal space, left side, in
the scapular line, and withdrew pus. The patient was
transferred to the general surgical service for opera-
tion.
On August 4th she was operated upon, in my pres-
ence, by the house surgeon, under chloroform anaes-
thesia. About two and one-half inches of the eighth
rib, from the middle axillary line to the scapular, was
resected, and the pleural cavity opened. It was found
to be normal, except that the lung was adherent at its
base to the diaphragm. The pleural cavity was pro-
tected above by a wall of packings, the diaphragm
incised, and about a pint of pus evacuated. The
cavity was drained by tube and gauze; the pleural
packings were left in place, and an additional tube
drain was inserted into the pleural cavity; dry aseptic
dressing was applied.
August 5th: The patient reacted well from the op-
eration, but was extremely dyspnctic, the respirations
being 54 to the minute, evidently due to the collapse
of the lung. The temperature was 102.4° F- ^t its
maximum; pulse, 100-104 per minute.
August 7th: The w-ound was dressed. There was
no empyema present, but the left lung was still col-
lapsed, as the pleural cavity had not as yet been closed
by adhesive inflammation around the packings. There
was a profuse discharge from the subphrenic wound.
August isth: The pleural cavity had become shut
ofif by adhesions; the respirations had fallen to 24-
28; pulse, 120; the temperature had fallen to 99.8° F.
The general condition was much improved, and there
was much less discharge from the wound, which was
commencing to granulate nicely.
August 30th: The temperature, pulse, and respira-
tion were almost normal. The wound was closing
by granulations and there was very much less dis-
charge. From now on tlie abscess cavity gradually
contracted and filled up by granulations, and the pa-
tient made a good and rapid convalescence, being
discharged cured on September 24th.
I should like here to call attention to the urgent
dyspnosa produced in this patient by the opening of
the pleural cavity, with the consequent collapse of the
lung; also to the inefficacy of the pleural packings as
a means of closing the cavity, as these were being con-
stantly displaced by the movements of the chest wall.
Case III. — Annie R , nineteen years old, an
operator, was admitted to the Mount Sinai Hospital
on August 29th, at 10:30 p.m., with the following his-
tory: She had been perfectly well until three weeks
before admission, when she was taken suddenly ill,
with collapse, severe general abdominal pain, and high
February lo, 1900]
MEDICAL RECORD.
225
fever, 107^ F. The pain and fever continued until
three days before admission, when the abdominal pain
became less marked, and the patient began to cough
and have pain in the left chest. The physical exami-
nation gave the following data: General condition
poor; temperature, 103°; pulse, 118; respiration, 20.
Lungs: In the left chest, in front there were dulness
on percussion over the left supra-clavicular region,
and hyper-resonance below the clavicle. There were
bronchial voice and breathing at the base. In the
axillary region there were dulness on percussion, and
diminished voice and breathing. Crepitant rales were
over the entire left chest. In the right lung, over the
base posteriorly, there was slight dulness, with in-
creased voice and breathing, and crepitant rales. The
abdomen was soft and collapsed. The liver extended
one and one-half fingers' breadth below the free bor-
der of the ribs. In the left hypochondrium, from the
seventh rib downward, there was flatness to percus-
sion; the spleen was displaced downward and for-
ward, reaching to the level of the umbilicus. Beneath
the false ribs was a tender, indurated mass, which
extended forward to the mammary line, and merged
below with the spleen. This mass gave a sense of
deep fluctuation: there was no succussion. In the
epigastrium was a tender, indurated mass, about the
size of a small orange. There was no sign of fluctua-
tion. The urine was acid; specific gravity 1.020;
otherwise negative.
The patient was sent to the operating-room at once,
and under chloroform I proceeded to operate. I first
aspirated the indurated mass in the left hypochon-
drium, through the ninth intercostal space, and with-
drew thick, extremely fetid pus. I resected the ninth
rib for two inches, and found the costo-phrenic sinus
obliterated by adhesions. I incised the diaphragm,
and opened into a large abscess cavity, non-gaseous,
containing about one pint of extremely fetid pus, a
culture of which showed the presence of streptococci
and bacteria coli. The spleen bulged into the wound;
it was covered by a thick coating of lymph. At its low-
er pole was a whitish spot which seemed to me to be
scar tissue. I excised a wedge-shaped piece of this
for examination. The pathologist reported that it
showed only the evidences of congestion and peri-
splenitis. The abscess was well walled off on all
sides. To afford better drainage, I resected the eighth
rib, and displaced the pleural layers upward. The
cavity was drained by tube and gauze. Exploratory
aspiration of the left pleural cavity withdrew only
clear serum ; this was left undisturbed. I considered
the advisability of exploring the indurated mass in
the epigastrium ; but in view of the extremely septic
condition of my own and assistant's hands, the instru-
ments, etc., I decided to wait for further developments,
rather than expose the patient to the risk of infection
of the general peritoneal cavity.
August 26th : The patient had reacted well from the
operation. Her temperature was 103.8° F. ; pulse,
104; respiration, 30. There were frequent vomiting
and muco-purulent expectoration. Examination of the
blood showed a moderate leucocytosis. The wound
was dressed; there was a slight amount of discharge.
August 30th : The patient's temperature still per-
sisted, ranging from 101.8° to 103.2° F. daily; the
pulse rate from 102 to 112. There were considerable
cough and muco-purulent expectoration. The physi-
cal signs in the left chest still persisted, but aspira-
tion of the left pleural cavity resulted negatively.
The mass in the epigastrium was still present, but it
was not tender, and there was no sign of fluctuation
therein. The general condition of the patient was
fair. The wound was covered with pale granulations,
and there was less discharge. There was nothing to
be found to account for the daily rise of temperature.
September 2d: The temperature still persisted.
The sputum was examined, but no tubercle bacilli
were found.
September 6th: The patient was in about the same
condition : there was continued high temperature, and
rapid pulse rate. The sputum was again examined and
found negative. There was a trace of albumin in the
urine.
September 13th: During the past week the general
condition of the patient had slightly improved, but the
temperature persisted, varying between 100.4° and
103.2° F. The wound looked clean and discharged
very little. The epigastric mass was somewhat larger
but not tender. In the right lumbar region was a
round, smooth swelling, which I could displace up-
ward; it was very tender. The house surgeon took
this swelling to be an enlarged and distended kidney;
I considered it to be the lower pole of a floating kid-
ney. The urine was of a specific gravity of i. 010, and
contained a trace of albumin, pus cells, and bacteria,
and was alkaline in reaction.
September 14th: The epigastric mass was painful
and tender, and I decided to make an exploratory
laparotomy to ascertain the nature of this.
September isth: Under chloroform I made a me-
dian laparotomy, directly over the mass. I at once
opened into an abscess cavity, which was adherent to
the anterior abdominal wall; the same thick pus that
was contained in the previous abscess was also here
evacuated. The walls of the cavity were formed by
adherent coils of intestines, and the cavity reached
considerably below the umbilicus. There was no vis-
ible connection with the stomach or the other abscess
cavity; its extension downward suggested an appen-
dicitis, and the odor of the pus was remarked at the
first operation to be appendicular in character; but
even under the anesthesia there was absolutely noth-
ing to be felt in the right iliac fossa, and there had
been no pain or tenderness there. The cavity was
non-gaseous. The abscess was drained by tube and
gauze and dressed dry.
September 16- 19th: The temperature fell the next
day to 99" F., but rose again in the evening to 102°
F., and then continued on the same plane as before.
The patient's general condition was getting worse;
the pulse was more rapid and feeble, and there was
evidently more pus somewhere, which had not been
evacuated. The rigiit kidney was so painful and ten-
der, and the urine contained so much pus and bac-
teria, that I decided to explore the kidney.
September 19th: Exploratory nephrotomy was per-
formed imder chloroform. A small incision was made
in the lumbar region ; the kidney was exposed and as-
pirated in all directions, but no pus was found. I did
not open the pelvis of the organ. The wound in the
soft parts was closed at once by sutures and sealed
off from the abscess cavities on the left side. I then
aspirated the left pleural cavity again, and drew off
some very fetid pus, the odor being similar to that in
the other abscess cavities. I resected a portion of the
seventh rib, and evacuated about eight ounces of pus
from a sacculated cavity. This was drained by tube
and gauze and dressed.
September 20th : The patient reacted well after the
operation : the temperature at its highest point was
ioi° F. ; pulse, 100; respiration, 28. She took con-
siderable nourishment; the urine was the same as
before.
September 28th: The general condition of the pa-
tient had improved considerably; the temperature
ranged between 98.8° and 101° F. ; pulse, 100. The
kidney wound had completely healed and the sutures
were removed. The other wounds were granulating
and contracting.
October 5th: The temperature has become almost
226
MEDICAL RECORD.
[February lo, 1900
normal. The general condition was much improved,
the patient sitting up in bed. The wounds were granu-
lating nicely. There was still some odorous dis-
charge from the first perisplenic wound, but nothing
could be felt on probing it.
October 9th: The patient was convalescing in the
hospital.
Commeats on these Cases — -As to their etiology.
Case I. : There was no positive conclusion reached
either at the operation or during the course of the ill-
ness, or at the autopsy, as to the cause of the original
subphrenic abscess. As to the possibilities, there may
haCe been an abscess of the spleen, subsequent to an
infected thrombus or embolus. In favor of this there
were the calcareous condition of the arteries and heart
valves, and the whitish nodules in the spleen, that the
pathologist thought might represent a healed abscess.
If this was the primary cause, then we must suppose
that there was a secondary rupture into the subphrenic
space, with a resulting abscess formation there; then
a suppurative thrombosis of the splenic vein, and me-
tastatic miliary abscesses of the liver; or the thrombus
may have lodged originally in the splenic vein.
Case II. : This subphrenic abscess was undoubtedly
metastatic, from an infection in the uterus.
Case III. : Here again I am not positive as to the
cause of the trouble. The possibilities here are: (u)
An appendicitis which gave no signs whatever; the
odor of the pus was very suggestive of this trouble.
{d) A perforation of a gastric or duodenal ulcer. The
high temperature observed by the patient's physician at
the very beginning of her attack, while it would seem to
oppose this view, yet does not altogether rule it out; for
there may have been an adhesive inflammation around
an ulcer that was about to perforate, so that when actual
perforation occurred there were no bleeding and no
extravasation into the general peritoneal cavity.
In both Cases I. and III. there was no primary
focus to give rise to metastatic abscesses.
As to diagnosis : This should have been easily made
in all three cases. In Case I. it was made by Dr.
Brill, and in Case III. by the writer. In Case II. the
physical signs were classical, but the high site at
which pus was aspirated led me to expect rather a
sacculated empyema. Had I but kept in mind Ley-
den's earliest points, viz., that in the absence of any
previous pulmonary lesion, and in the presence of a
primary abdominal trouble, we should strongly sus-
pect subphrenic pus, I would have made the diagnosis
in this case also.
As to treatment: The important point, as I have
already indicated, is to avoid opening the pleural
cavity. This was avoided in two cases. In the third
the pleural cavity was opened and packed with gauze.
The acuts collapse of the lung which occurred in this
case illustrates the danger of such invasion of the
healthy pleural cavity, and in debilitated persons it
is enough to turn the chance of recovery against our
patients. I cannot lay too much stress upon this
point, for the " trans-pleural " route is very frequently
used in opening hepatic abscesses as well as sub-
phrenic abscesses.
Note. — In the discussion, among other remarks. Dr.
H W. Berg called attention to the comparative frequen-
cy of subphrenic suppuration. In dififerentiating sub-
phrenic abscess on the right side from an abscess of the
liver, he laid great stress upon the "marked fixidity ''
of the liver in the former atTection, due to the adhesive
inflammation of the liver to the diaphragm, which lat-
ter organ had become paralyzed to a marked extent.
In abscess of the liver, on the other hand, the liver re-
mains perfectly movable, and shares in the movements
of the diaphragm. Furthermore, as regards pyo-pneu-
mothorax, he called attention to the extreme impor-
tance of the following physical signs: The tympanitic
resonance in pyo-pneumothorax extends up to the apex
of the chest, and over this tympanitic area there is an
absolute absence of any respiratory murmur. In sub-
phrenic abscess, on the other hand, the tympanitic
resonance and the amplioric voice and breathing are
at the base of the chest, and there are distinct respi-
ratory murmur and voice at the upper part of the chest.
In the cases of right-sided subphrenic abscess that had
come under his observation, the patients had com-
plained of pain in the right shoulder. To explain the
comparatively greater frequency with which subphrenic
suppuration accompanies purulent collections in the
iliac fossa, he instanced the experiments which showed
the free communication of the lymphatics in the iliac
fossa with those in the subphrenic region.
THE RESULTS OF THE SO-CALLED CON-
SERVATIVE TREATMENT OF APPENDI-
CITIS.'
By S.\MUEL LLOYD, ^[.D..
PROFESSOR OF SURGERY. NEW YORK rOST-GRADl'ATE MEDIC
Gentlemen : When Dr. Morris, a few days ago, asked
me to read a paper before you this evening, I had just
been reading his reply to some of his critics in the
Medic.>\l Record of December 9, 1899, and was re-
minded that for some years I have been following the
histories of a number of patients who had been treated,
in their first attacks of appendicitis, upon the theory
that the disease belonged to the domain of medicine
rather than that of surgery. I immediately looked
over my histories, with the following results:
Case I. — ^A physician, who had had several attacks
of abdominal pain, never diagnosed as appendicitis.
In 1885, he had a severe attack and was treated by
means of calomel and opium. He suddenly collapsed
and died in a few hours. The autopsy revealed a per-
foration of the vermiform appendix, through which a
small concretion had escaped. There was no attempt
at "walling off " of the peritoneum, so that the open-
ing communicated directly with the peritoneal cavity.
Case II. — .\ woman came under my observation in
1887. She was forty-three years of age, married, and
had been for many years a patient of the physician
whose case I have just related. She had for many years
been subject to abdominal pain on the right side,
which had always yielded to rest, diet, and opium.
As she had always recovered after a short illness, she
persistently refused operation. After she moved out
of the city, I have ascertained that she had two attacks,
between November, 1891, and February, 1892, and the
last and fatal one during the summer of 1893. At the
autopsy the appendix was found badly diseased and
perforated, and the ovary and tube of the same side
were also diseased. There were a ruptured abscess in
the appendical region and many old adhesions through-
out the whole peritoneal cavity.
Case III. — A woman, thirty years of age, married,
no children, no uterine or pelvic disease, was sud-
denly attacked in 1888, after a heavy day's work, by
abdominal pain, which was supposed to be simple
colic. Home remedies were tried without relief, and
I saw her in the morning. She had a temperature of
102.5° ^■'' pulse, 120: with marked tenderness over the
abdomen and great distention. In the course of a few
days, it was possible to make out a tumor in the right
iliac region, but she was treated conservatively and
finally recovered. In May, 1892. I saw her again.
' Read by invitation before the New York Medical Union,
December 26, iSgq
February lo, 1900]
MEDICAL RECORD.
227
She had been under the treatment of another physician,
who had diagnosed, first, peritonitis from a salpingitis,
and then abscess alDout the rectum. When I examined
her, I found a marked swelling in the right iliac fossa
which could be readily felt bagging down into the rec-
tum. The vesical symptoms were also well marked and
urination was exceedingly painful. There was a well-
marked induration in the vagina, and fluctuation could
be made out between the rectum and vagina. As there
was no time to lose on account of the patient's condi-
tion, operation was performed at once. An incision
over the appendix evacuated an immense abscess. An
opening was also made in the vagina, and both cavities
were found in communication. Just at the end of the
flow of pus from the vagina there was a gush of urine,
and on injecting the bladder it became evident that
there was an opening into that viscus. It was impos-
sible to prolong the operation in order to find and re-
pair the opening in the bladder. No examination of
the urine was made before operating, because of the
necessity of haste in our preparation. The patient
made a complete recovery.
Case IV. — A man, fifty-five years of age, was at-
tacked in 1889, at his country house, some miles from
New York. I saw him the next day and made out a
well-marked case of appendicitis. Operation was de-
clined. On the twelfth day the abscess evacuated
itself into the bowel, and the patient made a rapid
recovery. Up to the time of his death from typhoid
fever, three or four years later, he had no recurrence.
Case V. — In October, 1891, I saw a woman forty
years of age, who declined to allow me to operate. In
the past eight and a half years she has had but one
recurrence, and that was six years ago.
Case VI. — In May, 1892, 1 saw a young man, twenty-
four years of age, in consultation with Dr. Louis Mor-
ris, of New York. He was then recovering from a
well-defined attack of appendicitis, and afterward had
several attacks, but always recovered under conserva-
tive measures. Later, he had another attack and was
operated upon by Dr. William T. Bull, in New York
Hospital, for suppurative appendicitis. He recovered.
Case VII. — In April, 1892, a young man, aged
twenty-six years, consulted me about a tumor in his
abdomen. He gave the history of an attack of pain
and tenderness in the right side, with fever, constipa-
tion, and vomiting about ten days before. He had
been treated for intestinal obstruction, he claimed. A
tumor, the size of an egg, in the right iliac fossa, pain-
ful on pressure, with considerable rigidity of the right
side of the abdominal wall, was made out, and the
diagnosis of appendicitis was easily reached. He de-
clined operation and continued medicinal treatment,
but never fully recovered. Constipation, with more
or less pain, indigestion, and loss of flesh persisted,
and he finally concluded, six months later, to be oper-
ated upon. An ulcerated and thickened appendix,
much enlarged and in a very dangerous condition, was
removed; he has had no discomfort since.
Case VIII. — In 1892, I saw a boy aged twelve
years, who was brought to the hospital with a distinct
attack of appendicitis. He improved so much within
the next twelve hours, under the continued use of the
ice coil and rectal enemata, that his friends declined
to have him operated upon. In ten days he was dis-
charged. About a year later, this boy had another at-
tack, with suppuration, and was operated upon.
Case IX. — The next case was a young man aged
nineteen years, who gave the history of constant indi-
gestion. When I saw him, he had a well-marked at-
tack of appendicitis, but was evidently improving.
He was advised to have an interval operation, but
claimed he was too busy to attend to it. He recov-
ered, and resumed business, but had, within the next
four or five months, several very mild attacks; finally,
while away from the city, severe symptoms intervened,
necessitating immediate operation, and death fol-
lowed within a few hours.
Case X.- — In March, 1893, a young man, twenty-five
years of age, was attacked while visiting out of town.
The attending physician made a diagnosis of renal
colic, for which he was treated for several weeks.
When I saw him, he had a large tumor in the right
iliac fossa, peritonitis pretty well over the right side,
pyrexia, and a pulse of high tension. Neverthe-
less, he was allowed to get out of bed, and was com-
pelled to do so to attend to the calls of nature. As it
was impossible to operate with any safety in the place
where he was, he was treated conservatively and re-
turned home some weeks later. About a year later,
also while away from home, he had a second attack,
from which he also recovered. He then remained well
until November, 1898, when he had a third attack. I
operated upon him, and found the appendix and sur-
rounding tissues gangrenous, and he died of sepsis in
a few days.
Case XI. — In March, 1894, I saw a young woman,
about twenty-four years of age, in consultation with
the late Dr. William H. Helm, of Sing Sing, N. Y.
She had a tumor about the size of a small orange just
above the appendical region. She was evidently over
the severe part of her attack, and operation was ad-
vised against until all the acute symptoms had sub-
sided. She has had no recurrence.
Case XII. — In December, 1895, I saw with Dr.
Louis Morris a young woman, twenty-seven years of
age, who had been seized with appendicitis on her
way home from work a few days before. When I saw
her, she had been steadily growing worse. Her home
surroundings were distinctly unfavorable for any suc-
cessful surgical interference, yet both she and her
family absolutely declined to permit her removal to
the hospital. There was a large, exquisitely tender
induration filling the whole of the right iliac fossa,
and her symptoms were extremely grave. I saw her
several days in succession in connection with Dr.
Morris, and there was but little improvement. The
induration gradually extended upward toward the liver,
and we expected her death at any time. Pleurisy, and
then pneumonia, set in; finally she coughed up vast
quantities of fecal-smelling pus, and the induration
along the right side became distinctly less. She was
then removed to a hospital, and was supposed to have
phthisis, but finally recovered, and has had no further
attacks.
Case XIII. — On December 20, 1896, a young wo-
man, twenty-two years of age, walked into my office,
complaining that for two days she had had pain in the
right iliac fossa. She was in collapse, pupils widely
dilated, marked diaphoresis, vomiting bile, tongue
coated; pulse, 134; temperature, 99.8° F. ; respiration,
frequent and sighing. There was marked tenderness
over the right iliac fossa, with spasm of the abdominal
muscles and pain about McBurney's point. She was
immediately sent home and stimulated all day, in the
hope that her condition might improve enough to war-
rant surgical interference. The next day there was a
discharge of pus from the rectum, and she gradually
but slowly improved. For the next year she suffered
more or less constantly with pain in the right side, but
persistently refused operation. No severe attack has
as yet appeared since the first.
Case XIV. — It was also in December, 1895, that
Dr. EUery Denison, of New York, asked me to see a
boy of ten or eleven years of age, who had had a great
deal of so-called colic. This had been going on for a
year or more, and he complained, after each of these
attacks, of pain and soreness, and walked with a limp.
He refused to take part in any boys' sports, and was
disinclined to undertake any exertion. At Thanks-
228
MEDICAL RECORD.
[February lo, 1900
giving time he had a more than usually severe attack,
and Dr. Denison saw him. He found him with much
tenderness on the right side, fever, vomiting, constipa-
tion, and distention. After a few days, a thickening
was made out in the lower right side, and it was then
that I saw him. An involvement of the appendi.x was
evident. As he was almost over the attack, an inter-
val operation seemed possible, and this was advised.
A few weeks later, January 7, 1896, he had another at-
tack, and operation became immediately advisable; a
badly diseased and adherent appendix was removed.
Case XV. — On February 9, 1896, I was called by
Dr. E. H. Bergen, of Princeton, N. J., to see a young
man, aged twenty-three years, who gave the history of
having had two or three attacks of pain in the appen-
dical region, which had been treated by his family
physician, and from which he had promptly recovered.
The present attack had come on while he was at a ball
a week or more before I saw him, and he had been
treated conservatively from the first. Dr. Bergen was
finally called in consultation and insisted upon my
being sent for to operate. The abscess had ruptured
into the general peritoneum before I reached the
house, and in spite of early incision and careful lavage
of the whole peritoneal cavity, he died fourteen hours
later of general peritonitis.
Case XVI. — During the same year, one of my as-
sistants at the New York Post-Graduate Hospital,
while convalescing from an acute attack of articular
rheumatism, was seized with appendicitis. I saw him
at midnight, together with Dr. B. Farquhar Curtis.
He recovered under anti-rheumatic remedies, but had
another attack the following summer. He had another
attack in 1898, but has not yet been operated upon.
Case XVH. — In April, 1896, I was consulted by a
young woman from Sewickley, Pa., who gave the his-
tory of several attacks of severe abdominal pain during
the four years of her college course. About a year be-
fore I saw her, she had a severe attack of peritonitis,
and during the fall of 1895 she had had a severe ill-
ness that had been diagnosed as typhoid fever. It
was during her convalescence from this last illness
that she consulted me. She had constant pain in the
right side, and frequently had a temperature as high as
101° F. The appendix could not be made out, but on
palpation a tumor low down in the right side could be
felt. After carefully trying treatment, the patient
finally consented to operation, and the appendix was
found to have sloughed off, and to be the centre of an
abscess cavity, involving the right tube and ovary.
She maue a perfect recovery.
Case XVIIl. — In July, 1896, I saw a patient who
had been ill for several days with what was supposed
to be inflammation of the bowels. He had general
peritonitis, and his distention and tenderness were so
great that it was impossible to make a satisfactory ex-
amination. A few days later, I could make out a dis-
tinct tumor in the right iliac fossa, both through the
abdominal wall and through the rectum. Operation
was advised, especially as he gave the history of sev-
eral previous but mild attacks. An interval operation
was decided upon. On his recovery, he was so im-
pressed by the statements of the physicians who had
treated him during his previous attacks, that he had
only an inllammation of the bowels, brought on by in-
discretions in eating, that he was inclined to doubt
my diagnosis and thought I was riding a " fashionable
surgical hobby." In February, 1897, I saw him again
and examined him. He had had no discomfort since
the summer, and the induration had practically disap-
peared from the region of the appendix. A few days
later he went to his home in Rhode Island, and while
there had a sharp attack with an abscess that finally
ruptured into the bowel. He again recovered, and
now believed his troubles were over and that his at-
tacks had destroyed the appendix; but in the early part
of this year he was taken with severe pain while on
his way to business one morning, was removed from an
elevated railroad station to Roosevelt Hospital, and
operated upon at once for suppurative appendicitis,
from which he made a slow recovery.
Case XIX. — During the sumriier of 1896, a medi-
cal student, who had been troubled with occasional at-
tacks of indigestion, with abdominal pain, since child-
hood, was attacked in the night with diarrhoea and
vomiting, pain and slight tenderness over the whole
abdomen. There was also a slight rise of tempera-
ture. A few days' rest in bed with attention to the
bowels relieved all the symptoms without arousing
any suspicion of a distinct intraperitoneal lesion.
One day in August, he complained that all day he had
had severe abdominal distress, but it was not marked
enough to lead him to give up a bicycle trip. During
the ride he was obliged to dismount several times be-
cause of abdominal pain, and finally he was compelled
to give up the trip and return home by train. He
suffered intensely during the journey back to town.
By the time he reached home, his pain was intense;
temperature, loo"' F; and he was having diarrhcea and
vomiting. I suspected appendicitis, but could not
palpate the appendix In a couple of days he seemed
to be all right, and on the following Saturday went
out of town to spend Sunday. While he was away, he
ate very carelessly, and had another attack, which he
attributed to his carelessness. He then remained un-
usually well, until a few days before Cliristmas, when
he was taken ill again, and this time his appendix was
palpable. Operation became necessary and consider-
able pus was evacuated. Two concretions were washed
out, and during his convalescence two more escaped.
Case XX. — In October, 1896, I saw a young mar-
ried woman, who gave the history of several attacks of
peritonitis, dating back to childhood. She frequently
suffered from attacks of pain in the right side, coming
on usually in the night. There was some endometritis,
and the right ovary seemed to be in Douglas' culde-
sac, pushed down by a tumor on the right side. The
left ovary could not be made out. On palpating the
appendix, it was found pointing downward and very
tender. She was much constipated and suffered con-
stantly from intestinal indigestion. She absolutely
declined operation at this time. About a year ago she
had another very se\ere attack, and was several weeks
recovering. She then decided to be operated upon,
I found the appendix running downward, enlarged and
thickened, and its apex entering into the tumor on the
right side. This was found to be an abscess at the
tip of the appendix, which was walled off from the
general peritoneum by the right ovary and tube above,
the uterus on the inside, and the left ovary, which had
been drawn over, behind. Both ovaries and tubes
were infiltrated with septic material, and it was neces-
sary to remove them both with the appendix.
Case XXI. — During the same month 1 was con-
sulted by a man from Honesville, Ky., who gave the
history of three attacks of appendicitis. , The first at-
tack had occurred in the South. The physicians who
had attended him in both these attacks advised against
operatiorv, and are probably carrying his name among
their triumphs in curing appendicitis without the knife.
A few weeks before coming to me, the third attack
came on, and I saw him just after he was able to get
about again. He had an ectopic testicle in the in-
guinal canal of the right side, and a hernia; but one
could also palpate a tumor, which was exceedingly
painful and about the size of an egg, in the lower right
iliac region. While trying to make up his mind in
regard to operation, he had a slight return of the pain,
which settled the question. The incision was made
so as to include the liernia, and so effect a radical cure
February lo, 1900]
MEDICAL RECORD.
229
at the same time. This hernia was found to be the
caput coli, and an appendix fully six inches in length.
The part included in the hernia was closely adherent
to the intestine, but about two inches of the free ex-
tremity was movable in the abdominal cavity and was
strangulated by the hernial ring. It was intensely
congested and in spots almost gangrenous. Recovery
was prompt.
Case XXII. — In December, 1896, in consultation
with Dr. F. P. Williams, now of Kansas City, I saw a
young woman, a cloak model, who had been attacked
the day before, while at her business, with appendicitis.
Ail the symptoms were well marked, and there was a
very indefinite history of previous milder attacks of
colic. She was admitted to my service at the Post-
Graduate Hospital, but her mother, an ignorant woman,
refused to allow her to be operated upon. She made a
slow convalescence, and was discharged cured. About
ten months later, she was suddenly attacked again and
removed in an ambulance to a hospital, where an
emergency operation was performed for suppurative
appendicitis.
C.'^SE XXIII. — During the same month, I saw a
young woman, a physician, who was attending the
Post-Graduate Medical School. She had a well-
marked attack, and operation was not undertaken be-
cause her parents refused their consent. She had sev-
eral mild attacks during the winter, and was able to
attend to her studies only very irregularly in conse-
quence. This patient I have lost track of and cannot
tell whether she was operated upon later or not.
Case XXIV. — A young man from Georgia was taken
ill with appendicitis, while at a summer resort, and
gradually recovered without operation. He came to
see me on his way home, and I found a small tumor
involving the appendix and advised him to have it
operated upon at once. As he had already overstayed
his vacation, he felt that he must first go home and
arrange for the extra time, and he agreed to enter the
hospital for operation at the end of two weeks. On
his arrival at home, he had another acute attack, and
as soon as he was well enough started for the train to
come north. On the way to the station the appendix
perforated, and he died of peritonitis.
Case XXV. — In November, 1898, I operated upon
a man aged thirty years, who had an attack of appen-
dicitis in Mexico, a few months before. Following
that he had continued to have constant intestinal indi-
gestion. As he was contemplating a trip of the same
kind, he came to me. I found an enlarged appendix
filled with large fecal concretions. He then made a
complete recovery.
These twenty-five cases offer some suggestions in
regard to what happens in the so-called conservative
cases of appendicitis. I have frequently had physi-
cians tell me that they cure their patients by one
method or another, without operation. If it is not the
rest and opium idea, it is the administration of salines,
and then when the patient recovers from that attack,
he is recorded as cured. Unfortunately, they do not
go to the trouble, and it is a great deal of trouble, to
trace these patients through the hands of the other
medical men who treat them in their succeeding at-
tacks, until they yield to the surgeon's knife, or find
a final resting-place from the discomforts and torments
of an ever-recurring intestinal lesion. Of the twenty-
five cases, six (Cases I., II., IX., X., XV., and XXIV.)
terminated fatally. This is a mortality of twenty-four
per cent., and is rather startling when it is compared
with the statistics of experienced operators. Three of
these patients, it is true, were operated upon, but it
was then too late to save them. One patient had per-
foration and was in collapse when I operated, one had
gangrene of the appendix and of the surrounding parts
and died of general sepsis, and the third was also
operated upon after the abscess had ruptured and gen-
eral peritonitis was well under way. .All of these pa-
tients had several attacks, and could undoubtedly have
been saved had they been operated upon earlier.
These statistics do not compare very favorably with
the operative results. Taking my own simply as a
basis for comparison, and including the two in this
series that I operated upon /« extreDiis, I have had one
hundred and fifty-four cases with four deaths, a per-
centage of not quite 2.6.
Recurrences (I., II., III., V., VI., VIII., IX., X.,
XIV., XVI., XVII., XVIII., XIX., XX., XXL, XXII.,
XXIII., XXIV.): Only seven cases without history of
recurrence! This is contrary to the usually accepted
statements of the physicians who have reported that
their cases of appendicitis always result in recovery
under medical treatment. The explanation seems to
me to be a comparatively simple one: They do not
follow up their cases. Many of these patients I have
traced from one physician to another before their his-
tories were complete. The physician sees a patient in
one attack and he gets well after a certain time. He
wanders away from the town, or, finding that he is
having more or less trouble in the way of indigestion,
constipation, and so forth, he consults some one else,
who sees him in his second attack, and so on to the
end of the chapter.
There is nothing especially instructive about the
recurrences, except the gradual tendency to increase
in frequency and in severity. I do not mean by that
that every attack is worse than the last, but that the
general condition gets worse, and the sum total of the
attacks one year is apt to be greater than that of
the year before. Nor do I mean to be understood as
claiming that the attacks need necessarily follow one
another in rapid sequence. On the contrary, several
months or even several years may elapse between the
attacks, but in the end the testimony of the patient
will be that the colic is more frequent and more severe,
the constipation less readily combated, and the indi-
gestion more constant and more marked. The right
spasm is more distinct and more tense; the patient is
inclined to protect the right side and keeps it turned
away from danger as much as possible; the appendix
becomes more readily palpable and more painful to
the touch. Flesh is gradually lost, and the general
tone is decidedly below the proper and usual stand-
ard.
Operation. — This was ultimately performed in
fifteen of the cases, and three of them ended fatally.
Two of these have already been mentioned in speak-
ing of the deaths. The other one was also operated
upon when it was too late, general peritonitis having
already supervened. Of the remainder, ten patients
developed pus, and had to have the abscess opened;
one had the appendix included in a hernia with stran-
gulation of part of the appendix, and one had a con-
stant intestinal discomfort that led him to have the
operation performed, and his appendix was found over-
distended with large fecal concretions. Some of these
patients could possibly have continued longer without
operation, but every one of them must have had a
tedious recovery, with the usual slow absorption of the
pus, or its escape into some of the hollow viscera, or
gradual working through the abdominal wall, or it
would have ruptured into the general peritoneum, and
death would have promptly followed as in the three
patients who did die.
No Operation. — There were ten cases not operated
upon. Three of these patients died, one of perforation
of the appendix by fecal concretions and general sep-
tic peritonitis, one of general sepsis and peritonitis
from the rupture of an appendical-ovarian abscess,
and one of general peritonitis from perforation.
Every one of these might have been saved by early
2.^0
MEDICAL RECORD.
[February lo, 1900
operation, and every one had given abundant symp-
toms to permit a proper diagnosis to be made.
Seven patients recovered without operation ; one was
lost sight of completely, and I suppose should not ap-
pear in this group of cases that I have attempted to
trace from their first to their last attacks of appendi-
citis. One (Case V.) had her first attack in 1891 and
her second in 1893, and has been free since.
Two (IV^. and XIII.) had abscesses that ruptured
into the bowel, and one had no recurrence up to the
time, three years later, when he died of typhoid fever.
The other remains well (three years). I cannot help
calling attention, however, to the fact that it is not
always safe to assure the patient that he will be well
after the rupture of an appendical abscess into the
gut. Case XVIII. illustrates that fact very forcibly.
This man recovered from his first attack and then de-
clined an interval operation. Seven months later he
had another attack while out in the country, and the
physician who treated him assured him, when the
abscess ruptured into the bowel, that he was safe from
future attacks. In about nine or ten months, however,
he had another attack and had to be operated upon.
One patient (XI.) has never had a recurrence. One
(XVI.) has had a number, the last during last spring,
but as he has a marked rheumatic diathesis and the
attacks have yielded to anti-rheumatic treatment, he
continues to decline to be operated upon. He is,
therefore, still under observation. One other patient
(XXIII.) was a young woman, a physician, who con-
tinues to have several attacks each year, and who is
now practically invalided by the condition, yet her
parents decline to give their consent to operation.
The last patient (XII.) had an immense abscess, that
gradually burrowed upward, finally penetrating the
pleura and discharging through the lung. But she
has now been perfectly well for over a year.
On April 16, 1896, I read a paper before the Medi-
cal Association of Georgia, which has never been pub-
lished e.xcept in the transactions of that society. As
a basis for that paper, I took five hundred and fifty-
eight cases from literature and tabulated them. Four
hundred and forty-five resulted in abscess, perforation,
peritonitis, and so forth.
The following table was made up at this time:
Perforation without given cause 1 1
" with abscess lo
" " ulceration i6
" " peritonitis 32
" " concretion or foreign body 41
" " gangrene 7
" " gangrene and concretion 19
" " inflammation 13
" " hardened fsces 1
" " concretion and peritonitis 24
" " foreign body and peritonitis 7
iSi
Abscess without perforation, uncomplicated 136
with concretions 19
" " peritonitis 2
" " sloughing appendix :.
" " foreign body i
160
Foreign bodies 36
Fecal concretions 2C
Inflammation 8
Enteroliths 2
Gangrene q
Gangrene with concretion 2
Inflammation with concretion 3
S5
Genera Iperitonitis with concretion 5
" " foreign body and gangrene, i
" foreign body 3
ulceration i
10
Total number of cases 437
This collection of cases, taken at random from the
literature of the disease, illustrates the futility of med-
ical treatment in the vast majority of the cases, and
bears out most emphatically the conclusions arrived at
by most surgeons as a result of clinical e.\perience.
Symptoms following aa Acute Attack. — Consti-
pation and intestinal indigestion are by far the most
constant symptoms. These are accompanied by a
great deal of flatulence, by colicky pains in the abdo-
men, sometimes of considerable intensity and some-
times referable to the appendical region, though more
often near or immediately under the umbilicus.
The tongue is usually badly coated, especially
toward the back, and the breath is foul. Often eating
increases the discomfort, and occasionally the flatus
interferes with respiration by pressing on the dia-
phragm. On examination of the abdomen, tenderness
is nearly always elicited by pressure upon the ap-
pendix, and that organ is nearly always palpable.
In one patient, the acute symptoms were mistaken
for renal colic, and he suffered constantly from indi-
gestion. When he was dying and having fecal vomit-
ing, he said, " That is the stuff I have been tasting all
the tinie during the past year."
One need not go further, it seems to me, than the
study of a few series of cases similar to these, to reach
a conclusion that an attack of appendicitis predisposes
the patient to a recurrence, and it is also conclusively
shown, I think, in this resume of my own cases, or
rather cases I have been in a position to follow up,
that operation offers the best, the safest, and the short-
est method of treating the condition.
24 West Fiftieth Street.
HOW THE MILK SUPPLY OF NEW YORK
MAY BE IMPROVED.
By IlEXRV DWIGHT CHAPIN, M.D..
No subject of greater interest than the production and
care of cows' milk can come before those who are in-
terested in the public health. Its importance in large
communities, where the difficulties of delivery and
proper preservation are great, warrants much more at-
tention than is generally bestowed upon the problem.
The magnitude of the whole question can be appre-
ciated when it is known that 1,250,000 quarts of milk
are daily delivered into New York City, and that this
amount comes from five States, including thirty-four
counties, and some of it from a distance of five hun-
dred miles. The city itself, however, is no small dairy
ground, as 23,500 cows are contained within the mu-
nicipal limits, which furnish a certain amount of milk
for the inhabitants. The writer's attention was first
drawn to this question in studying the home modifica-
tion of cows' milk for infant feeding. The condition
and ingredients of the milk in any given locality as-
sume a great importance when this problem is ap-
proached. Hence an effort has been made to learn
something of the actual conditions of the milk trade
in Greater New York.
There are in the boroughs of Manhattan, Bron.x, and
Brooklyn over fifty wholesale and retail milk dealers,
whose capital ratings, according to the commercial
agencies, range from $3,000 to $1,000,000. A list of
questions was sent to these dealers asking, among other
things, whether they sold bottled milk to families;
where the milk is bottled, in city or country; what
percentage of butter fat their milk is guaranteed to
contain; whether the milk runs uniform in quantity
of butter fat; if there is any variation in quantity of
butter fat; in what months of the year is there the least
quantity, and in what months the greatest quantity ; is
February lo, 1900]
MEDICAL RECORD.
231
the milk run through a centrifugal machine to remove
dirt; how soon after milking is the milk delivered in
the territory covered; what territory is covered; is the
tuberculin test ever applied to the cows?
Nineteen replies were received, all from large deal-
ers, their combined capital ratings being about two-
thirds of the entire capital invested in the milk busi-
ness in these boroughs. These dealers all furnish
bottled milk, which they guaranteed to run four per
cent, fat and over, the least amount of fat being
found in the spring months. Three of the dealers use
separators to cleanse their milk, the others simply
claiming especial care in the matter of cleanliness.
The time of delivery is from twelve to thirty-six hours
after milking. Nine out of the nineteen dealers say
the tuberculin test has been applied to their herds,
although not regularly. Three simply stated that there
was oversight of the herd by a veterinarian. A few of
these dealers owned the cows producing the milk, but
the great quantity of milk is collected by companies
who have depots in various dairy districts and who
buy from farmers and dairies. These companies have
regular forms of contracts, which are generally based
on the " Fifty Dairy Rules" of the United States De-
partment of Agriculture. These contracts may allow
the companies' inspectors to examine the cows, stables,
and utensils, regulate the manner of feeding, handling
of milk, etc., and sometimes even provide for notice to
the company of any contagious disease in the family
or help of the producer. The milk is brought to the
depot at stated hours, cleaned if necessary, and imme-
diately bottled or canned, and shipped either in boxes
containing ice or in refrigerator cars, and delivered
within twenty-four to thirty-six hours after milking.
About seventy-five per cent, of the milk now received
in this city comes from these receiving stations, or, as
they are usually called, creameries.
There is no doubt that milk handled in this large
way is an improvement over the old plan of the
various milk dealers receiving their supplies from
numerous small, independent dairies. A system of
judicious control and oversight is likewise simplified.
In order to learn the actual amount of butter fat con-
tained in the milk supplied by our best dealers, thirty-
two assays were made during the past fall and winter
months of the milk purchased from these dealers in
the open market. These assays showed the lowest
proportion of butter fat to be 3.10 per cent., and the
highest 5.25 per cent. Twenty-two of the assays
showed four per cent, and over, and the other ten
showed very close to four per cent., such as 3.52 and
3.66 per cent. From this it seems fair to conclude
that milk containing four per cent, of butter fat is a
good average as supplied by first-class dealers in this
city.
When it came to cleanliness, the showing was not
so good. A large number of the bottles exhibited
particles of dirt in the bottom. It is a very diiScult
matter to keep milk from contamination, especially
when handled in very large quantiti'es. Much of this
dirt is doubtless innocuous, except that early souring
of the milk is induced. The prevention of any con-
tamination of milk, as handled at present, is a subject
for careful study and observation. In order to learn
what impurities get into milk, a visit was made to a
receiving station in the country where eighteen hun-
dred quarts of milk were run through a separator, con-
suming a little over two hours. The layer of foreign
matter was then scraped from the sides of the bowl,
and found to contain air, pus, blood, mucus, fibrin,
great numbers of bacilli and cocci, and detritus from
vegetable matter, probably from faeces. It seems that
with extra care at the source of the milk supply, these
impurities, even in small quantity, could be kept out
of the milk. If the milk is drawn from healthy cows
that are kept clean and in hygienic surroundings, by
healthy milkers who keep scrupulously clean, and is
received into absolutely clean vessels, and is then
strained, aerated, and kept cool until delivered, the
c|uestion of a proper milk supply for any locality thus
served will be solved. The real key to the situation
is the handling of milk on the farm, far away from the
inspectors of the health department. All the latter can
do is to see that the milk has not spoiled upon being
delivered, that it does not run below three per cent,
butter fat, and that no preservatives have been added.
In spite of the vigilance of the health inspectors,
there is a large sale of various preservative solutions
that are presumably used for the purposes for which
they are sold. Dairy supply firms openly advertise
the sale of these preparations. Their commonest ac-
tive ingredients are boric acid and its sodium salt
borax, and formaldehyde, "^'hile small amounts of
these substances may not always in themselves be di-
rectly injurious, they have a tendency to harden the
clot of casein and thus make the milk less digestible.'
.Anything that aims to take the place of strict cleanli-
ness in the handling of milk is reprehensible, as by
masking the effects of uncleanliness less care is nat-
urally taken, and various impurities will not be sus-
pected because their usual effects are not observed.
The great need of a city like New York is a strictly
clean milk that will require neither superheating nor
the addition of any preservative in order to keep it in
safe condition against the time of consumption. Such
milk should be available to every one at a fair price.
Considering the importance of milk in the nourish-
ment of infants and as the universal food, the subjects
of its source, care, and distribution are properly a
matter for consideration by the medical profession.
The writer believes that doctors have it in their power
to accomplish much toward settling this question on a
more satisfactory basis than it now exists. It might
take the form of a medical commission which would
make a careful study of the whole subject, and then
enter into friendly and advisory relations with any
milk dealers who would desire the benefit of their
counsel. If a few dealers take hold of this subject
and furnish an extra clean and fresh supply of milk,
collected and distributed under the strictest precau-
tions, physicians should know and approve of it. Self-
interest will compel other dealers to follow, and in
time an abundant supply of the best milk will be ob-
tainable by all, rich and poor alike, the demand for
milk will increase, and the dealers will be thus re-
warded for any bettering of their supply. The idea
of a commission of physicians becoming an advisory
committee in the production and handling of milk was
started some years ago by Dr. Coit, of Newark, and has
since been in successful operation with one of the
local dairymen. It is also carried out in New York,
Buffalo, and various other cities. If this system can
be made to work with one dealer, why cannot it be
enlarged to take in any dairyman or dealer who wishes
to take advantage of its provisions? It is in some
such way that the general supply of a large city can
be gradually but appreciably improved.
If physicians and daitymen will thus meet in ear-
nest council, we may gradually get what both should
desire — a strictly clean milk that runs fairly uniform
in its ingredients.
Salophen is prefered to salol by Caspar in typhoid
fever. It acts as an antifermentative in the intestinal
canal . — Medical Examiner.
' " Lactoform consists essentially of casein precipitated by
metallic salts and subsequently hardened by formaldehyde. It
is employed in place of horn, ivory, ebony," etc. — "Dairy
Chemistry," by Henry Droop Richmond. London : Charles
Griffen i; Co. , iSgg.
232
MEDICAL RECORD.
[February lo, 1900
ANEW "T" BANDAGE.
By W. O. green. M.D.
For the past three or four years, in private and hospi-
tal practice and at his clinic, the author has employed
a simple device for holding dressings in place about
the anal region. This
is known in the hos-
pitals and infirmaries
of this city — after his
name — as the " Green
T bandage."
It was devised first
for convenience and
to save time in the
infirmaries, and, later,
in private practice as
a substitute for the
various awkward con-
trivances made by
patients or inexperi-
enced attendants, who
failed to get an ade-
quate idea of the in-
structions given, or
who had a precon-
ceived notion of the
"proper" manner of
making a "binder."
It was devised also
because in some points
it seems to offer an
■^"^- '• improvement upon the
regular form of T
bandage, which has made it very useful to the writer
and which would appear to justify its more e.xtended
use.
The " Green T bandage " is quickly made and re-
quires no sewing, buttons, or pins. It is made of a
single piece, and can be more quickly loosened or tied
if the knot is properly placed than the other forms of
bandage of this type. When the material is of the
proper thickness and breadth it conforms nicely to the
parts and holds the dressings in place satisfactorily.
Sometimes it is found that after a T bandage is ap-
plied the waistband will be found too loose or too
tight, which will necessitate a removal of the pins to
readjust this portion of the bandage. It may happen
that when this change is made by the patient, the
dressings become disarranged and fall down, and re-
quire the assistance of the surgeon or nurse to be sat-
isfactorily replaced. The patient may readjust the
bandage under consideration by untying and relaxing
or tightening the perineal strip with one hand, while
the other hand is held against the dressings to allow
the perineal strip to slide smoothly over their surface.
One knot only is required, and this should be made
in front. Should the knot be placed at the back, when
the patient assumes the recumbent posture it becomes
exceedingly uncomfortable, and the same may be said
of a button and sometimes of a large-sized safety-pin
in this locality. In the ordinary improvised T ban-
dage, made from a roller, it is not uncommon to see
one or two knots in the back. The discomfort which
follows naturally will cause the patient to attempt to
readjust the bandage, which, in turn, will likely be fol-
lowed by a misplaced and uncomfortable dressing
about the perineal region.
It is customary in many infirmaries to keep a stock
of T bandages, which have been carefully made and
are intended for prolonged service. When one of
these bandages has been removed from a wound, if not
too much soiled, it is separated from the other dress-
ings, washed, and laid aside for another fresh dressing.
The simplicity and cheapness of the bandage under
consideration offer little temptation for washing and
a second application. In consequence, especially in
those cases in which he desires most careful aseptic
methods, the surgeon may feel less apprehensive that
other than a new and clean bandage will replace the
one which has been soiled and removed.
This bandage is always the proper length because it
is not made until applied, when there is sufficient ma-
terial provided for several bandages from the same
piece. Narrow or broad strips made of this material, by
movement of the muscles about the parts, are apt, in
the course of a few hours, to cause the abdominal
band to roll into a sort of string and become very un-
comfortable to the patient. For this reason it is nec-
essary to employ heavy, thick material. The material
best adapted to the purpose is the heaviest unbleached
cotton made in strips not less than four inches wide.
The average length of each bandage is two yards. It
has therefore been founa convenient to have the mate-
rial made into rollers six yards long, which will ordi-
narily be sufficient for three bandages. Rollers longer
than this are undesirable, because of the necessary
length of the cut in the back, through which the peri-
neal strip passes from the waistband.
In preparing the bandage for application, about six
inches of its length is unrolled and folded upon itself
at a point about three inches from the end. In the
centre of the presenting fold a cut is made with a pair
of scissors. In consequence of the fold the cut should
be made only one-half the desired length when un-
folded, and the limit of the cut at the outer point
should be at least an inch or an inch and a half from
the free end of the bandage. This will be about half
an inch or more than the diameter of the roller.
The following diagrammatic cuts are intended to
simplify the description:
Fig. I represents the waistband applied with the
perineal band brought through the cut a b (mentioned
above) placed in the centre of the back. In order to
make the bandage comfortable, it is necessary to have
the bands laid flat against the surface of the body,
thus avoiding
folding or rolling
into a sort of
string. Should
the patient apply
the bandage, the
roller should be
passed through the
cut (<? /') in front,
after which it can
be slipped around
to the centre of the
back, preparatory
to making the peri-
neal band. It will
be seen from this
arrangement hoV
pins, buttons, or
knots may be omit-
ted from the point
of attachment in
the back, and at
the same time the
perfect ease with
which the perineal
band and waist-
band can be made i.„. j.
to conform to the
parts. The broken line ej is intended to indicate the
course of the bandage across the front of the abdomen.
Fig. 2 gives a front view of the perineal strip con-
tinued up and passed under the waistband. This
February lo, 1900]
MEDICAL RECORD.
233
figure also represents the first stage of the knot, which
is a very important part of the bandage. It is impor-
tant, while tying, that sufficient tension be made to
hold the dressings
in place. It is
equally important,
while tying, that
nothing shall slip,
and that when it is
necessary to remove
the bandage no
trouble shall be
encountered in un-
tying. The method
which is here illus-
trated will fulfil
these requirements,
and the knot —
which is a re-en-
forced bow-knot —
may be made in
less than five sec-
onds with only mod-
erate dexterity.
After bringing
the perineal band
above the waist-
band at the point
X (same figure)
about eighteen
inches of the free end is unrolled, which is brought
down and held firmly to the side, Y. The other hand
is passed under the perineal band and the strip X V
caught near the waistband, Z, and drawn back in a
loop, making the tension from Z to A'.
Fig. 3 shows the loop slipped across the knuckles,
■which is drawn across the front of the perineal band.
The index finger catches the remainder of the strip //
y, the end of which has been brought up parallel with
the waistband, while the thumb maintains the tension
from above.
A second loop is made by drawing the band If J'
through at Z, and the knot is completed as represented
in Fig. 4. The roller is
cut off after the knot is
tied. The time required
for making and apply-
ing should not be more
than two or three min-
utes, even by one who
is awkward. ,
Thus far the bandage /
has been employed al- <
most exclusively for \
holding in place rectal :
dressings, but it can be ;
used with equal efficacy 1
for genito-urinary and
other perineal dress-
ings. For the first
dressing subsequent to
rectal operations the
writer does not employ
this bandage, because
sufficient pressure can-
not be brought to bear
to give firm support to the anal region to prevent
straining, and control, to a greater or less extent, the
capillary and venous bleeding. A special form of
perineal bandage is employed for this purpose.
Smallpox prevails to a large extent throughout the
South and West due, it is claimed to culpable negli-
gence in enforcing vaccination.
Fig. 4.
The Haemostatic Use of Gelatin It is perhaps too
early as yet to fix a final estimate of the value of gela-
tin in stopping hemorrhage. In cases which resist
other methods of treatment, it offers some hope — hee-
mophilia, inoperable aneurisms, etc.^J. B. Nichols,
Medical Nc^tis, December 2d.
Polyarthritis Deformans in Childhood. — M. Mon-
corvo reports a case in a child aged five and a half
months, which evidently began at the end of the sec-
ond month of life. About forty-nine cases are on rec-
ord as occurring between the ages of three months and
fourteen years. The author believes that the microbe
theory in relation to articular rheumatism is probably
correct. A few bacilli similar to the bipolar bacillus
of Bannatyne and Walman were found in a few drops
of blood taken near an affected joint in his little
patient. — Bulletin de I'Acadhnie de Mcdecitie, January
9, 1900.
The Staining of Gonococci with Neutral Red,
in Living Leucocytes.— Plato (Berliner kUtiische
ll'oc/iense/irift, December 4, 1899, p. 1085) reports the
results of observations with regard to the tingibility
of gonococci in the leucocytes of gonorrhceal pus. He
found that if a small drop of fresh gonorrhceal pus be
admixed with a platinum loopful of a dilute solution
of neutral red in physiological salt solution (i c.c.
of a cold saturated aqueous solution of neutral red and
100 c.c. of physiological salt solution) and the mix-
ture be examined in hanging drop or in the wet state,
a number of the intracellular gonococci will be seen
to be stained deeply red, in many instances without
any other portion of the cells being stained. At times,
in cells with and withoutgonococci, bright red granules
are visible that will not cause confusion. The speci-
fic granulations at times stain light yellow, but the
nuclei in general remain unstained. Not all intracel-
lular gonococci are stained, but stained and unstained
may lie side by side. If the leucocytes are stimulated
to amoeboid activity by gently warming the slide, gon-
ococci that were at first stained in the granular portion
of the protoplasm will at times gradually lose their
color if in consequence of the movement of the cell
they become displaced into the homogeneous marginal
zone of the leucocyte, and they become again stained
when they are subsequently resurrounded by the gran-
ular protoplasm. The conclusion that only degener-
ating or degenerated intracellular gonococci accept the
stain appears unjustified in view of this fact. Division
or spontaneous movement of intracellular stained gon-
ococci cannot be observed. Leucocytes that contain
only a small number of gonococci are at times charac-
terized by especially active amoeboid movement, while
pus corpuscles filled with gonococci as a rule exhibit
no manifestation of vitality and are provided with a
more or less deeply stained nucleus. Although nu-
merous other intracellular micro-organisms, also re-
sembling gonococci, were examined according to the
method described, in no instance were similar rapid-
ity and intensity of staining observed, so that possibly
neutral red may be considered an aid in the differen-
tiation of the gonococcus from similar micro-organ-
isms. Extracellular gonococci, as well as other micro-
organisms, cannot be stained in hanging drop in a
solution of neutral red of the concentration stated,
even after exposure for days. In fixed preparations
more concentrated solutions of neutral red (20 c.c.
of a cold saturated solution of neutral red to 100
c.c. of water) stain both the extracellular and the
intracellular gonococci a deep red within a few sec-
onds, and the nuclei invariably less intensely, so that
optic concealment of the gonococcus by the nucleus
does not take place.
234
MEDICAL RECORD.
[February lo, 1900
Medical Record:
A Weekly Journal of Aledicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
rrEi.i<;HF.RS
WM WOOD & CO, 51 Fifth Avenue
New York, February 10, 1900.
PRECAUTIONS AGAINST THE PLAGUE.
If it were not for wars and rumors of war, vliich al-
most monopolize public attention, tlie spread of the
plague to all quarters of the globe would give rise to
much more alarm and discussion than are at present the
case. The sinister fact, that the disease has for the
first time gained a footing in the western hemisphere,
does not appear to be regarded as an event of vital
importance, and although the occurrence of plague on
a vessel in New York harbor created a temporary sen-
sation of dread, this feeling was quickly lulled into
one of security, based chiefly on the widespread opin-
ion that it is virtually impossible for the malady to
make headway in places where a proper system of san-
itation is carried out.
These optimistic views are certainly to a large e.x
tent justified by the history of the course of the plague
in other parts of the world. Withm recent times proof
has constantly been afforded that plague rages most
virulently among dirty surroundings, and many experts
hold that where the environment is cleanly its ravages
are easily controlled. However, this latter contention
is thought by others to be more or less open to doubt,
as there are several nistances on record in which the
disease has made decided progress under conditions
presumably unfavorable to its spread. On more than
one occasion after it has been proudly proclaimed that
in a certain city or town the plague has been wiped
out by the energy displayed in rendering the sanitary
system complete, the news has come that a recrudes-
cence has occurred on a larger scale than before.
Nevertheless, in the light of experience during the
past decade it may be said that efficient sanitation is
the best safeguard against plague. In localities where
hygienic arrangements are good the bacilli of the dis-
ease will find no soil suitable for its incubation and
propagation, Again, our knowledge as to the best
means of treating the disease has advanced, albeit but
slowly. No absolutely reliable specific has yet been
discovered, but investigation has demonstrated its
cause, and it has been also shown that when possible
isolation of patients and segregation of those exposed
to infection are among the most prominent factors in
limiting the spread of plague. Consequently the en-
forcement of these measures, a rigid adherence to the
laws of sanitation, together with the prophylactic and
curative methods now at hand, would seem to provide
sufficiently strong barriers against the plague securing
any but a temporary foothold in this country.
There is unfortunately a dark side to the question.
The plague has not only planted itself in Brazil but
is gradually drawing into its net all the islands of the
Pacific, and from these, and especially from the Ha-
waiian islands, comes the greatest danger of importa
tion into the United States. The disease promises to
spread like wildfire among the inhabitants of this
group, while our traffic to and from Honolulu is con-
siderable and frequent. The conditions prevailing in
many of the American towns on the Pacific coast are
not such as tQ warrant the belief that, if the plague
were to obtain an entrance, its extermination would
be a matter of little difficulty. There is a large Chi-
nese population, and this race is peculiarly predis-
posed to plague infection. In addition the climate,
overcrowding, and uncleanly habits of the aliens in
that part of the United States favor diseases of this
description.
The various ways in which plague can be trans-
mitted have already been fully dealt with in former
numbers of the Medical Record, so that it will suffice
to consider the measures in force to prevent its ingress
into the United States. The maritime quarantine reg-
ulations contained provisions relating to the plague,
but the Treasury Department has deemed it expedient
under the exceptional circumstances to supplement
these with special regulations, which order that at
foreign ports and places infected or suspected of being
infected with plague the United States quarantine reg-
ulations referring to cholera shall be observed with re-
gard to vessels and cargoes bound to the United States.
Quarantine regulations relating to cholera are also to
be observed at ports and on the frontiers of the United
States. Dr. Wyman, the surgeon • general, Marine-
Hospital service, in a pamphlet recently published
by him, speaks thus of the quarantine equipment of
this country: "The government is well equipped with
quarantine stations for the disinfection of infected
vessels, and has besides several large stations where
immigrants can be detained in barracks under obser-
vation." Dr. Wyman goes on to say: " It seems im-
possible that the plague should ever again ravage the
earth as in previous centuries. Modern quarantine is
effective to a degree. Though old-fashioned and ab-
surd as administered by some of the European coun-
tries, and imperfectly executed in others, it neverthe-
less has proven and will continue to prove a powerful
shield against this Asiatic invasion.''- The following
suggestions with respect to public hygiene are ad-
vanced by Dr. Wyman: "The destruction of rats and
other rodent animals ; the prevention of congregations
of individuals, as fairs, celebrations, and pilgrimages;
the surveillance and supervision of markets; the clean-
liness of the soil ; the regular removal of garbage ; the
cleanliness of habitations; the particular supervision
of places, workshops, forges, etc., intended for occu-
pancy by the laboring and industrial classes ; the clean-
ing and regular disinfection of latrines and cesspools;
the care and cleaning of gutters, etc. Administrative
care should also be brought to bear to improve the
February lo, 1900]
MEDICAL RECORD.
235
sanitary condition of notoriously unsanitary quarters
and dwellings."
The primary and principal object in the fight against
the plague is to keep the disease out of the country,
and this, according to the views of the most distin-
guished authorities, can be effected only by a strictly
rigorous system of maritime quarantine. Our system
is undoubtedly a good one, but, if it requires strength-
ening, nothing should be allowed to stand in the way
of legislation tending to the preservation of the health
of the country at large. The next and scarcely less
important aim is to have our towns in so efficient a
state of sanitation that if the disease were to gain an
entrance it would be given no opportunity to spread.
In this respect many of our seaboard centres of popu-
lation will be found wanting. Therefore it would be
well if the advice profifered by Dr. Wynian regarding
public hygiene was taken to heart and promptly acted
upon by the city fathers throughout the land.
OSTEOPATHY IN NEW YORK.
The medical profession, in this and other States, has
none too easy a time in combating fraud and charla-
tanism on one hand, and ignorance and stupidity on
the other, and the development of something new un-
der these headings, called osteopathy, has added a
fresh source of difficulty and injustice. The supreme
court of New York, in Smith vs. Lane, 24 Hun, 632,
has decided that a man who practises massage does
not practise medicine, and prosecutions of osteopaths
have therefore been discouraged on the assumption
that osteopathy is massage.
We cannot see the justice or the force of this form
of argument. An osteopath pretends to diagnosticate
and treat by manual means many forms of disease, and
does not limit himself to working under the direction
of some one else, as is almost invariably the case with
the masseur. When the physician wishes a patient to
have massage, he prescribes it as he would any other
form of treatment, and it is given by an individual
trained for such work, the physician still being re-
sponsible for the welfare of the patient. When the
osteopath finds a victim, he makes his own diagnosis,
decides on and carries out his own treatment, and is
apparently neither legally nor morally responsible in
any way for the outcome of his ministrations. We
cannot see how the mere fact that the osteopath does
not order any drugs for his victim should relieve him
of the responsibility of practising or attempting to
practise medicine. Does the surgeon who straps a
sprained ankle or a fractured rib practise a branch of
medical science, or would the law relieve him of re-
sponsibility in case of a, bad result from such condi-
tions, if he should plead that he had used no internal
medication, and was, therefore, not practising medi-
cine? The answer does not require argument. The
important fact is. that the osteopath presumes to make a
diagnosis, and to institute what he dares say is proper
treatment, and this ought to render him liable to
prosecution under the medical law, without consider-
ing the fact of subsidiary importance that no drug has
been actually given.
If the osteopath cannot be reached under the present
medical law, there ought to be an amendment, for if
something is not done the regular practitioner will
actually have less protection than the impudent char-
latan. If a registered physician can be proved before
a jury to have been negligent, the complainant can re-
cover heavy damages, but it is very doubtful whether
the unregistered and unqualified osteopath could be
reached in this way. It would be an excellent thing
if the County Medical Society could find out whether,
in the eyes of the law, it is not the making of a diag-
nosis and prescribing of treatment which constitutes
practising medicine, and not merely the application of
treatment, with a difference between treatment with or
without internal medication. We should certainly try
to be sure that any person who pretends to treat or
prescribe for the sick or injured in any way, on his
own responsibility and initiative, should be compelled
to come up to a certain standard of proficiency in such
subjects as anatomy, physiology, and obstetrics, be his
system of therapeutics what he likes, and we should
be prompt to deny that the osteopath is not attempt-
ing to practise medicine, merely because he does not
prescribe drugs.
RECIPROCITY IN MEDICAL LICENSING.
A MOVEMENT has been set on foot in at least one State
of this country with the view of abolishing the present
anomalous, not to say absurd, conditions ruling the
laws of medical practice. As mentioned in the Med-
ical Record of October 14th, the Wayne County
(Mich.) Medical Society has despatched circulars to
the authorities of the different States anO Territories
requesting their opinions as to the best steps to be
taken which, in time, may lead to a uniformity in the
requirements for the license of practising medicine in
the United States. The State board of medical exam-
iners of New Jersey, in their report for last year, ex-
press their desire to recognize and indorse the medical
licenses issued by other State boards as far as their
academic and medical standards will admit. Several
other State boards would doubtless be willing to go
as far as the New Jersey board, but it is certain that
until the standard of medical education shall be placed
on a uniform basis in all the States, the existing dead-
lock, so far as interstate reciprocity of medical license
is concerned, must continue.
It is nevertheless a happy augury for the future that
even the " thin end of the wedge " has been inserted,
and if the members of the medical profession will band
themselves together and will use their utmost endeavors
to bring medical education in all the States and Ter-
ritories upon the same plane, the time cannot be far
distant when matters will be upon such a footing that
interstate reciprocity of medical licensing will at any
rate be brought within the range of practical politics.
The question will be considered in all its bearings by
the National Confederation of State Examining and
Licensing Boards at their meeting at Atlantic City in
236
MEDICAL RECORD.
[February 10, 1900
June next. This confederation, being composed of
representatives of the examining-boards of the different
States, can alone solve the problem. Their agreement
upon a minimum academic and medical standard
would bring about the desired result. Efforts should
be made, and these quickly, to remedy the prevailing
incongruous state of affairs. First establish a uni-
form standard of medical education, and then will
follow, "as the night the day," interstate reciprocity
in medical licensins.
NURSING IN THE BRITISH ARMY IN
SOUTH AFRICA.
Male nurses are rarely met with in Great Britain.
All the nursing at the large hospitals in Great Britain
is done by women. The British Medical Hospital at
Netley is probably the only large institution of its
kind in the United Kingdom where the nursing-ser-
vice is performed by men. In times of peace this
system works smoothly enough, and women on the
whole are found to do the duties required of them as
efficiently as men. But war places a different aspect
on the matter, especially in a campaign on so large a
scale as that now being carried on in South Africa.
The edict has gone forth from the War Office in Lon-
don that women nurses shall not be allowed to serve
in the field hospitals, but must be retained at the base
hospitals. In consequence of this order, and owing
to the fact before mentioned, that there are but few
trained male nurses in Great Britain, there is said to
be a deplorable scarcity of these necessary adjuncts
to the surgeon at the front. Of course the regular
army has with its medical corps orderlies who are
trained in and fulfil the duties of nurses, but when it
is considered that the army medical corps is far below
its proper strength, there will be no difficulty in com-
prehending that its trained nursing-staff is not numer-
ically so efficient as it should be.
Notwithstanding this reported state of affairs, the
New York Herald, in its Sunday edition, quoting from
a private letter from Sir William MacCormac, says that
there is much ill-feeling between the army medical
officers in South Africa and the female nurses at the
base hospitals, some of the former urging the sole
employment of male orderlies. The thought will nat-
urally strike one that the services of a well-trained
female nurse must be preferable to those of a half-
trained male nurse. It is satisfactory to note, how-
ever, that on the whole the much-decried medical
army corps in South .4frica has up to tlie present come
out of their trying ordeal with flying colors. This in-
deed is the one bright spot in the dark cloud of dis-
asters which have overtaken the British arms in that
country.
The Study of Cancer — The Massachusetts State
board has undertaken a collective investigation of car-
cinoma, with a view to secure more accurate informa-
tioYi regarding certain disputed points, especially the
alleged increase and the infectiousness of the disease.
^nus 0f the 'Smcek.
Sir Thomas Grainger Stewart, of Edinburgh, phy-
sician in ordinary to the Queen in Scotland, died on
February 2d, at the age of sixty-three years. He was
graduated in medicine from the University of Edin-
burgh, and after graduating studied in Berlin, Prague,
and Vienna. On his return to Edinburgh he became
resident physician in the Royal Infirmary. In 1876
he. was appointed professor of medicine and clinical
medicine at the University of Edinburgh, and held
this chair at the time of his death. He was at vari-
ous times president of the Royal College of Physicians
in Edinburgh, of the Medico-Chirurgical Society of
Edinburgh, and of the British Medical Association.
He was knighted in 1894. He was a writer and
teacher of note, the diseases of the respiratory organs
and of the kidneys being his favorite objects of study.
Among the best known of his works were a treatise on
Bright's disease and the article on diseases of the
trachea and bronchial tubes in the "Twentieth Cen-
tury Practice of Medicine." He was a member, active
and honorary, of many societies, among them the Col-
lege of Physicians of Philadelphia.
Typhoid Fever in Army Camps. — Dr. Victor C.
Vaughan, of Ann Arbor, who was commissioned by the
government to investigate the causes of typhoid fever
which prevailed to such a frightful extent among the
troops during the Spanish war, has sent his report to
Washington. In this report, according to a synopsis
published in The Sun, he says camp polluting was the
greatest sanitary sin committed by the troops. His
conclusions are that about one-fifth of the soldiers de-
veloped typhoid fever, and army surgeons correctly
diagnosed fewer than one-half the cases; that the per-
centage of deaths from typhoid fever was 7.5 ; that
about eighty per cent, of the total deaths were due to
this disease, but that the percentage of deaths fron:
typhoid fever is not so high '' if we accept the diag-
noses given in the official reports." He blames the
superior line officers for locating camps in the face of
the protests of medical officers.
The Antivivisection Bill. — Some changes have
been made in the constitution of the Senate committee
on the District of Columbia, upon whose action de-
pends the fate of Senator Gallinger's antivivisection
bill. The committee now consists of Senator James
McMillan, Michigan, chairman, and Senators J. H.
Gallinger, New Hampshire; H, C. Hansbrough,
North Dakota; R. Redfield Proctor, V-ermont; J. C.
Pritchard, North Carolina; Lucien Baker, Kansas;
George L. Wellington, Maryland; S. R. Mallory,
Florida; W. V. Sullivan, Mississippi; W. A. Clark,
Montana; Thomas S. Martin," Virginia: William M.
Stewart, Nevada; and Richard Kenney, Delaware.
Personal letters may be addressed to them or to other
senators. Petitions should be addressed to the Senate
of the United States.
Carbolic Acid is, we are informed, to become more
expensive. If those who have the price regulation in
February lo, 1900]
MEDICAL RECORD.
237
charge are acting in the interest of humanitj', and have
taken this means to diminish poisoning accidents and
the use of t'he drug for suicidal purposes, they deserve
all praise. The Medical Record has attempted to
point out to those who vi'ould reach other worlds by
the poison route, that there were other and better and
less painfully distressing drugs which could be em-
ployed; cheapness, ignorance, and ease of obtaining,
have been the reasons for the great popularity of car-
bolic. Perhaps the price, if sufficiently increased, will
tend to lower the record of victims. It is said that
both for internal and external burns by this acid
scarcely anything equals good old-fashioned cider
vinegar.
Contract Surgeons for the Philippines. — The med-
ical department of the army is now in need of some
additional assistance in the Philippines, and it is de-
sired that candidates for appointment as acting assist-
ant surgeons will make application to the surgeon-
general of the army. Applicants must be graduates
of reputable medical colleges, who have had practical
experience, since graduation, in hospitals or in private
practice. Candidates between the ages of twenty-five
and thirty-five are preferred. Candidates should for-
ward with their application one or more letters from
well-known professional men, giving testimony as to
their character and qualifications. Appointments will
not be made through political influence, and letters
designed to produce political effect will injure rather
than benefit the applicant. All applicants will be ex-
amined as to their physical and professional qualifica-
tions for service in the Philippines before they are
given a contract. Contracts are made for one year,
with the understanding that the approved candidate
will remain in service for a longer period if his ser-
vices are required.
Medico-Legal Society, Philadelphia. — At the an-
nual meeting held January 30th, the following officers
were elected for the ensuing year: President, Dr. A.
M. Eaton; First Vice-President, Dr. L. H. Adler;
Second Vice-President, Dr. Samuel Wolfe; Secretary,
Dr. C. H. Clewell; Treasurer, Dr. G. M. D. Peltz;
Librarian, Dr. J. D. Nash.
Leprosy and the United States At last this coun-
try has become recognized as a lepra centre. At the
last meeting of the Berlin Medical Society, no less a
man than Virchow stated that he had never observed
and did not know of an instance of contagion in
Europe by the intermediary of a leper coming, for ex-
ample, from the United States.
The Society for the Prevention of Cruelty to
Children has won its fight against the State board of
charities. The board had asked the courts for a writ of
mandamus compelling Mr. Gerry's society to submit to
its supervision and inspection. The president of the
society maintained that it was not a charitable institu-
tion within the meaning of the new constitution, and
that it did not come under the supervision or inspection
of the State board of charities. The question was
brought before the courts, and it has finally been decided
by the court of appeals that the society exists for the
sole purpose of enforcing the criminal laws to prevent
cruelty to children, and can be called a charitable in-
stitution only in the same sense that the term would
apply to any other corporation organized to aid in the
enforcement of any other branch of the criminal law.
The society is not over its troubles, however, for a
bill has been drafted repealing the provision of the
law whereby this city pays $30,000 a year to the soci-
ety, the ground for this repeal being that the society
has been adjudged by the court of appeals not to be
a charitable organization, and that being the fact it is
no longer entitled to this annual appropriation, which
has been made for the ostensible reason that the soci-
ety was carrying on a charitable work.
The Third Scandinavian Congress for Internal
Medicine will be held in Copenhagen on July ist and
subsequent days. The subject for discussion will be
serum treatment, which will be opened by Drs. Aaser,
of Christiania, Hellstrom, of Stockholm, and Soren-
sen, of Copenhagen.
Addition to a Hospital — A large and new annex
to St. Joseph's Hospital at Lancaster, Pa., was opened
on January 26th, almost doubling the capacity of the
institution by the addition of forty-four rooms and
four wards, including one for children, and also a
sun parlor for convalescents. The annex is four
stories high, and built of brick and stone. It con-
tains a pathological laboratory, and a specially de-
signed operating-room. The hospital is now one of
the most complete and perfectly appointed institutions
in the State.
Smallpox is spreading in Oklahoma, and it has
been necessary to close the post-offices in several
towns because of it. In the northwest also the dis-
ease prevails, and friction has arisen between the au-
thorities in British Columbia and those in Washing-
ton over the disinfection of the mails from Spokane.
It is reported from Louisville that smallpox is preva-
lent in about thirty-five counties of Kentucky, and the
State board of health finds itself without the necessary
means to fight the disease. The secretary has re-
ceived the resignations of the county boards of health
in at least a dozen counties in which the disease is
the most serious, the cause of the resignations in all
cases being the inability to fight the disease owing to
a lack of money. The protection afforded by vaccina-
tion is emphasized by the report of the Connecticut
State board of health recently issued. According to
this report there were but three cases of smallpox in
the State in 1899, and one of these was that of a pa-
tient who went to Stamford from this city after assist-
ing in the care of a case here. Dr. Lindsley, secretary
of the State board of health, attributes this immunity
to the thorough manner in which vaccination has been
done in the public schools, and to the wise and effec-
tive legislation which permits the exclusion of unvac-
cinated pupils from the schools.
Bovine Tuberculosis — Following the report of the
special investigating - committee on tuberculosis in
animals, a bill is to be introduced into the New York
legislature, embracing the following provisions; (i)
238
MEDICAL RECORD.
[February lo. igoo
That the protection of the herds of this State from tu-
berculosis and the examination and destruction of
glandered horses be placed with the commissioner of
agriculture; (2) that the commissioner of agriculture
will appoint a farmer well acquainted with the value
of cattle, whose duty it shall be to accompany and as-
sist the veterinarian in making examinations of sus-
pected herds and appraise those condemned; (3) that
the State can force the condemnation of only such ani-
mals as are found to have tuberculosis by physical
examination. But if a dairyman elects to have his
herd tested with tuberculin, and will enter into an
agreement with the State before such examination shall
be made, that he will disinfect his premises, and either
slaughter or hold in strict quarantine all of the react-
ing animals and their products, the State will assist
him in his efforts to rid his herd of the disease; (4)
that the appraisal of condemned animals shall be made
at the time of or immediately following the examina-
tion; (5) that the State shall pay the owner of all cat-
tle slaughtered under the provisions of this act, known
to have been owned in this State at least one year,
one-half of the appraised value for all cattle found to
have tuberculosis, and full appraised value for all
cattle found to be non -tuberculous upon post-mortem
examination.
Smallpox ia Mississippi. — In a communication
addressed to the State senate, Secretary Hunter of the
Mississippi State board of health stated that smallpox
exists throughout the State, and he advocated the pass-
age of a bill providing for compulsory vaccination.
Illegal Practice by Midwives — The board of
health recently obtained warrants for fifteen midwives
in this city who were conducting lying-in institutions
without permits. The business is one prohibited by
the sanitary code, the births are not reported to the
health department, and the deaths are reported from
some other place. A number of these women are also
strongly suspected of being abortionists.
Cremation of New York's Garbage A bill is to
be introduced into the legislature providing for the
establishment of a crematory plant for the consumption
of the garbage of this city. This will abate the
garbage-reduction nuisance on Barren Island, and will
provide New York City with an adequate and sanitary
process of disposing of its garbage.
Health Authorities Close a Library. — A public
library in Scranton, Pa., has been closed by order of
the board of health, which announces an epidemic of
scarlet fever and diphtheria in the city. The board
publishes its opinion that the germs of many infec-
tious diseases are carried from house to house by cir-
culating libraries, and so it has issued this order in
the hope of stopping the epidemic. The books will
be fumigated before the library is reopened.
Study of Tropical Diseases in the Philippines.
— By direction of the Secretary of War, a board of
medical officers, consisting of Lieutenants Richard H.
Strong and William J. Calvert, assistant surgeons, and
Acting Assistant Surgeon Joseph J. Curry, United
States army, has been appointed to meet at one of the
general hospitals near Manila, Philippine Islands, for
the purpose of studying tropical diseases as they occur
in those islands. The board is to receive its instruc-
tions from the surgeon-general, and will be under the
immediate direction of the chief surgeon at Manila. —
Boston Medical and Surgical Journal.
The Medical Control of Marriage. — A Colorado
legislator has introduced a bill forbidding the marriage
of medically unfit persons. The bill provides for
county boards of medical examiners, each to consist of
three physicians, no two of the same school, and one at
least, if possible, a woman. No licenses shall be
granted until a certificate is had from the board that
the man is not less than twenty-five years old, the
woman not less than twenty-two, and that both are
free from dipsomania, insanity or hereditary tendency
thereto, tuberculosis, cancer, epilepsy, and syphilis,
and that there is no blood relation existing between
them.
An Epidemic of Hydrophobia has broken out among
the cattle in Center County, Pa. It is believed the
disease w-as spread by a rabid dog which ran wild over
an extensive district a few weeks ago. Dr. Riter and
other officers of the State live-stock sanitary board are
making every effort to control the epidemic, but new
cases are continually appearing in unexpected places.
The German Hospital, Philadelphia, has received
$10,000 from Henry D. Justi for the endowment of
two free beds.
To Restrict Football. — Assemblyman Sullivan pur-
poses offering an amendment to a bill repealing the
present boxing-law which would prohibit the playing
of football games in this State. He has collected sta-
tistics showing that thirty-nine persons have been
killed in football games within Jwo years, while two
persons only died as a result of engaging in boxing-
bouts.
The Effect of Cold on Micro-Organisms. — Prudden
has shown that a temperature many degrees below the
freezing-point is ineffectual in destroying the typhoid
bacillus, but now it has been shown that no known
degree of cold will destroy these and some other path-
ogenic microbes. A paper was read last week before
the Royal Society in London, in which a number of
startling experiments by Professors Dewar and Mac-
Fadyen and Sir James Creighton Browne were reported.
In these experiments typhoid, cholera, diphtheria, and
other pathogenic bacteria were submitted for twenty
hours to the temperature of liquid air (—310° F.), and
were shown later by culture tests to be still alive.
Women Nurses in Military Hospitals A num-
ber of the women who acted as nurses in the army
and Red Cross hospitals during the Spanish-.Ameri-
can war have appointed a committee to secure the
passage of a bill by Congress to provide for the
permanent employment of women nurses in army
hospitals. Women are so employed now, but only at
the will of the army medical authorities. The bill
provides "that women nurses in the proportion of ntt
more than ten per cent, of the sick and wounded in
general and post hospitals of fifty beds and upward,
February lo, 1900]
MEDICAL RECORD.
239
shall be employed by and constitute the women's nurs-
ing-service of the medical department of the army;
that there shall be a superintendent of women nurses,
who shall be a woman graduated from a general hos-
pital training-school for nurses, having a course of
instruction lasting not less than two years, who shall
be appointed by the Secretary of War at a salary of
$2,000 per annum; that the nurses shall be graduates
of general hospital training-schools having courses of
instruction lasting not less than two years; that they
shall be appointed by the surgeon-general under regu-
lations approved by the Secretary of War; that they
shall receive $40 a month when on duty within the
limits of the United States, and J50 a month when on
duty outside of the limits of the United States." The
bill provides, further, that nothing in its terms shall
be construed to limit the power of the Secretary of
War in time of war or national disaster to avail him-
self of other duly qualified nurses.
The Sale of Diphtheria Antitoxin by the Board
of Health. — A bill has been introduced into the legis-
lature providing that when the board of health has
too much vaccine virus and diphtheria antitoxin on
hand it may sell the surplus at public auction, but
such sales shall not in any one year amount to more
than $5,000: The board of health is required to pub-
lish a detailed statement every six months showing the
amounts of vaccine virus and diphtheria antitoxin that
the board has made, the amounts it has used and dis-
tributed free, and the amounts it has sold.
The Plague In Honolulu, up to January 24th
there had been fifty-five cases of plague with forty-one
deaths. The health authorities, soon after the disease
appeared in the city, adopted the radical plan of de-
stroying by fire every infected building, but on Janu-
ary 20th the fires got out of control and spread from
one building to another in the native and oriental
quarter, until nearly the entire district was in ruins.
Four or five thousand persons vjeie rendered homeless
and Chinatown was wiped out, but it is believed that
the advance of the plague was stayed. — It is stated,
apparently officially, that Rio de Janeiro and Santos,
in Brazil, are now entirely free from the disease. A
few cases of plague have occurred at Ensenada, Argen-
tina, and the ships of the United States South Atlantic
squadron under Admiral Schley were quarantined on
that account when they arrived at Montevideo from
Ensenada.
Intense Heat in the Southern Hemisphere. — At
Buenos Ayres on Saturday and Sunday last the ther-
mometer registered 120° F. in the shade nearly all day.
On Saturday there were one hundred and two cases of
sunstroke, of which ninety-three were fatal, and on
Sunday there were two hundred and nineteen cases, of
which one hundred and thirty-four were fatal. In
Melbourne, as we noted last week, the weather has
been extremely hot, and in South Africa the British
troops have suffered exceedingly from the unbearably
high temperature. Indeed, the entire globe appears
to be warmer than usual, for the winter in this country
has been far from severe, in the Klondyke the weather
is reported to have been almost mild, and at Davos
Platz the season has been ruined by the warm weather,
which has turned the snow into slush and has house-
bound all the guests with pulmonary and bronchial
affections.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
February 3, 1900. January 31st. — Surgeon H. E.
Ames detached from duty in connection with the
Kearsarge and ordered to duty on board that vessel
February 20th. Medical Inspector J. C. Boyd com-
missioned as medical inspector from October 25,
1899. February ist. — Pharmacist R. Waggener de-
tached from the Petisacola navy yard and ordered to
be examined at Washington navy yard February 13th,
for retirement, and then home to wait orders. Febru-
ary 2d (changes by cable from Asiatic Station). — As-
sistant Surgeon J J. Snyder detached frorn the New
Orleans and ordered to the Jsla de Cuba.
Obituary Notes. — Dr. Lloyd Wilbur died at
Hightstown, N. J., on January 27th, at the age of
seventy-five years. He had recently been appointed
superintendent of the census for New Jersey.
Dr. Joseph F. Deppen died at Reading, Pa., on
January 28th, at the age of fifty-one years. He was
a graduate of the medical department of the Univer-
sity of Pennsylvania.
Dr. Mary J. Scarlett-Dixon died at Westchester,
Pa., on January 29th, at the age of seventy-eight years.
She was a graduate of the Woman's Medical College
•of Pennsylvania, and was for twenty years in charge of
the Woman's Hospital, Philadelphia.
Dr. Frank Hodgskin, of Chestertown, Md., was
found dead in a hotel at Wilmington, Del., on Janu-
ary 30th.
Dr. D. S. Marquis died on January 31st at Roch-
ester, Beaver County, Pa., at the age of seventy-nine
years. He was the only living charter member of
Pennsylvania State Medical College.
Dr. Ernest G. Metcalfe died at his home in Brook-
lyn on February 2d, of nephritis, at the age of forty-
nine years. He was born in Canada and was gradu-
ated from the Long Island College Hospital Medical
School in 1872.
Mrs. Annie Wittemeyer died at her home at Sar-
atoga, Pa., on February 2d. She was born in Ken-
tucky seventy-two years ago. At the outbreak of the
Civil War she entered the Union army as a nurse and
soon became famous for her many practical innova-
tions. Among other things she established a special
diet kitchen in army hospitals. After the war she lec-
tured in the interests of missionary societies of the
Methodist Church, and was at one time president of
the Temperance Crusade, which organization pre-
ceded the present Woman's Christian Temperance
Union. She was also a prominent member of the
Women's Relief Corps, and was at one time its presi-
dent. She was the founder of the Soldiers' Orphan
Home at Davenport, Iowa, and was one of the pro-
moters of the Pennsylvania Memorial Home for Sol-
diers.
240
MEDICAL RECORD.
[February 10, 1900
groorcsB 0f |]tXetlical J>ctence.
Boston Medical and Surgical Journal, February i. igoo.
Valvular Heart Disease — Richard C. Cabot, from
a study of one hundred and eighty-six cases, states
that he thinks he has reason to deny that there is any
one form of valve lesion which is constantly associ-
ated with the clinical evidence either of hypertrophy
or of the lack of hypertrophy of either ventricle. He
has seen many cases of marked aortic regurgitation
without any evidence of hypertrophy of the left ven-
tricle, and of apparently pure mitral stenosis in which
the left ventricle was undoubtedly enlarged, while in
most of the cases of mitral regurgitation the enlarge-
ment of the heart seemed to affect the left ventricle
rather than the right.
Intestinal Indigestion and its Relation to Pul-
monary Disease. — Chauncey Rea Burr says that the
intestinal tract and the liver are the two points at
either one of which, if a departure from the normal
occurs, auto-intoxication may result. The intestine
becomes a veritable culture tube foi micro-organisms,
which give rise to toxins, ptomains. and toxalbumins,
which pass to the liver, poison its cells, and the filter
leaking floods the circulation with poisons. The lungs,
being excretory organs, suffer greatly, and the author
describes the various pulmonary affections due pri-
marily to intestinal intoxication.
Epilepsy. — Walter E. Paul says that institutional
treatment has been inaugurated in several States, and
the result of six years' trial is encouraging. The car-
dinal measures carried out have to do with the diet,
hygiene, out-of-door life, and, most important of all,
systematic occupation. Very little bromide is used.
Some of these institutions have a waiting-list of sev-
eral hundred eager to be admitted.
Cases of Cholecystotomy. — Edgar Garceau reports
three cases. One case was complicated by appendi-
citis. In one the value of the Murphy button in an
emergency was well shown.
Combined Superior and Inferior Poliencephalitis.
— G. L. Walton describes a case the etiology and prog-
nosis of which are still undetermined. The further
progress will be communicated later.
Journal 0/ the American Medical Ass'n, Feb. j, igoo.
Etiology of Non-Malignant Rectal Stricture in
Women. — In discussing this subject, Reuben Peter-
son confines his attention to acquired rectal strictures,
which he says are much more common in women than
in men. He discusses them under the lieads: (i)
Strictures due to pressure from without; and (2) stric-
tures resulting from organic changes primarily affect-
ing the rectal walls, due to trauma, dysentery, gonor-
rhoea, tuberculosis, or syphilis.
A Case of Carcinoma of the Nasal Passages. —
This case is reported by J. L. Goodale. The patient
had had nasal polypi removed at regular and frequent
intervals for thirty-three years. There was no evi-
dence of syphilis and the general health had been
good. At the age of fifty-one years the growths be-
came carcinomatous, resulting in the patient's death
in fifteen months.
Spasmus Nutans. — I. A. Abt reports t\.o cases of
this disease which improved under good hygienic con-
ditions and the administration of bromide of sodium.
He refers to the frequent confusion in diagnosis be-
tween spasmus nutans and eclampsia nutans, a much
more serious disorder terminating in epileptic attacks
and paralytic conditions.
Electricity in Diseases of the Nose, Throat, and
Ear. — \\'. Scheppegrell reviews the uses to which
electricity is put in the treatment of these troubles,
and says it is to be hoped that some part of the longer
period of study now obligatory in all advanced medi-
cal colleges will be applied to teaching the principles
of electro-therapeutics.
Bassini's Operation for the Radical Cure of Her-
nia.— G. M. Woods reports seven cases successfully
operated on by Bassini's method, for which he claims
great advantages over the Wood and Wiitzer opera-
tions which were formerly the rule. The writer says
that in the majority of cases this method results in a
radical cure.
Vasomotor System, and the Importance of the
Drugs which Act on it, in Ophthalmology. —David
W. Stevenson says it would be well if oculists would
always report the tension of the pulse with the same
care and use the same signs which are used in regard
to the eye, and it is even more important that they
should know the drugs that will control this tension.
Report of a Case of Echinococcus Cyst of the
Nose. — In reporting this case \V. K. Rogers says it
may be of interest to note that careful inquiry failed
to elicit any evidence of intestinal parasites. The
patient was under thirty-four years of age and- in good
health. The writer can find but one other case re-
corded in medical literature.
Report of Recovery from Traumatic Tetanus. —
L. B. ^"an Camp reports this case as being of interest
on account of the exceedingly small percentage of re-
coveries from tetanus. The case was a very severe
one, and the principal treatment consisted of the injec-
tion of tetanus antitoxin.
The Code of Ethics. — Samuel C. Busey says the
national code of medical ethics is the official declara-
tion of the policies of the regular medical profession
of this country, and the more it is studied the more
widely will it be accepted as the guide of good con-
duct.
Acute Suppurative Arthritis of Children. — James
E. Moore says that these cases are not generally un-
derstood, and many joints and lives are sacrificed on
the altar of ignorance, the most common error in this,
as in all other joint inflammations, being a diagnosis
of rheumatism.
Intranasal Angioma, Bleeding Polypus of the
Septum. — VV. E. Casselberry reports a case of this
nature. He does not think these tumors are as rare
as has been represented.
A Preliminary Investigation of the Theory of
the Inoculation of Malarial Fever through the
Agency of Mosquitos. — By Albert Woldert. A con-
tinued article.
Contributions of the Medical Profession to Gen-
eral Literature and Collateral Sciences — By George
R. Highsniith. A continued article.
Medical News, February j, igoo.
Prophylaxis in Gynaecology : Obstetrics — James
Clifton Edgar discusses this subject under three heads:
I. Pregnancy; 2. labor; 3, puerperium. i. A good
hygiene of pregnancy is of prophylactic importance
in two ways- (a) By providing the patient with healthy
blood; (/') by increasing the muscular and the general
February lo, 1900]
MEDICAL RECORD.
241
nutrition, factors of undoubted importance in tiie pre-
vention of subsequent subinvolution of the uterus and
•adnexa. 2. (a) Limiting the duration oE labor; (//)
the prompt surgical treatment of traumatism, the result
of labor; (c) and most important of all, the observance
of strict asepsis. 3. The patient's position in bed
during the whole of the puerperium shall be equally
divided during the twenty-four hours between the dor-
sal, abdominal, and right and left lateral postures.
Edgar describes a binder which he uses in the puer-
perium to sustain the pelvic floor and the lower por-
tion of the anterior abdominal wall. Strychnine in
the last part of pregnancy and during the puerperium
is beneficial. He also advocates the early use of the
vessel in bed or the commode at the side of the bed
in the puerperium.
Prophylaxis in Gynaecology. — Henry C. Coe de-
clares that it is to the family physician that the ques-
tion of prophylaxis is of peculiar interest. It is his
province to watch the development of the young girl
and to guard her against those numerous indiscretions,
harmless in themselves, which are common in careless
girlhood. Diet, dress, exercise, menstruation, bowels,
should all receive attention. The same principles of
prevention should be applied to syphilis and gonor-
rhcea in the female, as to other communicable affec-
tions. Through the general application of the prin-
ciples of aseptic midwifery the dangers of puerperal
sepsis have been minimized. Malignant uterine dis-
ease is still, from a prophylactic standpoint, hopeless.
The early recognition and treatment of specific infec-
tion is an advance in prophylaxis. The whole trend
of modern pelvic surgery is conservative, and conser-
vatism is prophylaxis.
Diagnosis of a Case of Cerebral Tumor ; Opera-
tion O. M. Steffenson cites the case of a man, thirty-
two years old, with the symptoms of vomiting, head-
ache, partial iridoplegia, choked disc, loss of patellar
reflex in the right leg, agraphia, aphasia, alexia, men-
tal stupidity, and listlessness. On operation a growth
was found involving the angular, supramarginal, and
the base of the first temporo-sphenoidal gyri.
The Relation of the Clinical Laboratory to Mod-
ern Surgery. — IW Willis G. Macdonald. See Medi-
cal Record, vol. Ivii., p. 212.
The Etiology and Prevention of Uterine Disease
Tiefore and during Pregnancy. — By W. Gill Wylie. See
Medical Record, vol. Ivii., p. 208.
New York Medkaljournal, February 2, igoo.
The Development of the Female Genitals and
their Life History. — B. Robinson studies the devel-
opment of the Wolffian body into the pronephros or
head kidney with its ureter and duct, which structure
quickly ceases to act in the human fcetus, the mesone-
phron or middle kidney, which is the kidney of fcetal
life, and finally the metanephron or adult kidney and
its ureter. He then considers the ducts of Miiller and
their transformation into the uterus and the vagina.
The article contains nothing especially new, but is
interesting as being a careful study in embryology
stated in terms of modern nomenclature.
A Visit to the Plague Districts in India. — L. F.
Barker and J. M. Flint, of the Johns Hopkins Hospi-
tal, give a graphic account of their recent travels in
the East, and describe the measures taken by the Eng-
lish authorities to lessen the spread of the plague and
minimize its inevitable misery and suffering. Their
recital, while not without some very grewsome features,
contains much that is interesting in itself both from
its professional value and its vivid portrayal.
An Experimental Research on the Tensile
Strength of the Sciatic Nerve. — G. W. Crile and
W. E. Lower have conducted experiments upon dogs;
also upon the bodies of patients from one to three
days after death. In the adult it was found that a
weight of one hundred and forty pounds was required
to rupture the nerve.
The Use and Abuse of Poultices. — S. E. Earp
advocates the use of flaxseed meal as the ideal con-
stituent. The poultice relieves congestion, reduces
inflammation, promotes absorption, diminishes ten-
sion, softens incrustations, encourages tissue relaxa-
tion, stimulates healthy granulations, deodorizes, and
disinfects.
A Case of Neurosis of the Heart : Palpitation. —
A case without any special features is described by
A. Goltman. He advocates the use of nux vomica as
a cardiac tonic. Bromide of potassium is recommended
for insomnia, and cold application over the heart dur-
ing exacerbations.
Aneurism of the Subclavian Artery and its
Treatment. — In the case of a man aged forty-five
years, A. B. Barkley placed a ligature on the distal
side of the aneurism, the exact point being as near the
junction of the first and second parts of the vessel as
possible. The patient was doing well at last report.
School Hygiene. — G. D. Hamlin describes the un-
favorable hygienic conditions found in some of the
congested districts of New York City, and makes a
plea for a better state of affairs.
Malarial Haematuria. — By B. Smith. A continued
article.
Philadelphia Medical Journal, February j, igoo.
Syphilis of the Stomach. — Max Einhorn reports
six cases illustrative of three groups of syphilitic dis-
ease of the stomach. These groups are : Gastric ulcer
of syphilitic origin, syphilitic tumor of the stomach,
and syphilitic stenosis of the pylorus. Cases of the
last-named group are the most interesting, for failure
to recognize the nature of the obstruction would prob-
ably result in operation. In both of the reported cases
recovery followed the exhibition of potassium iodide,
after the usual medical treatment of benign stenosis
had proved inefficient.
Notes on the Total Removal of the Human Stom-
ach, and on Gastroplication, with a Late History
of Two Cases G. Childs Macdonald recalls the four
successful cases of extirpation of the stomach by Schlat-
ter, Brigham, the writer, and Richardson, and discusses
the reasons why other attempts have been unsuccess-
ful. He advocates gastroplication in cases of loss of
nervomotor function of the stomach with resultant dila-
tation, and refers briefly to two cases in which he
recently operated successfully.
Remarks upon the Diagnosis and Surgical Treat-
ment of Perforated Gastric Ulcer.— Maurice H. Rich-
ardson discusses the symptoms of perforation of the
stomach and its operative treatment, and reports at
length four cases. In two of these cases an operation
was performed and recovery occurred in one ; the third
case, which terminated fatally, was not operated upon;
the fourth case was one of acute hemorrhagic pancre-
atitis, which is reported as an illustration of the diag-
nostic difficulties in certain cases.
Latent Cancer of the Stomach. — William Osier and
Thomas McCrae report seven cases of cancer of the
stomach unaccompanied by indicative symptoms. In
three cases the disease involved a large part of the
742
MEDICAL RECORD.
[February lo, 1900
stomach, in two the pylorus, and in two the cardia.
In one case the CESophagus was involved and in an-
other the duodenum. In three cases there was ulcer-
ation, and in five metastases were present.
Acute Dilatation of the Stomach. — Henry Wald
Bettmann says this condition is marked by vomiting
of large quantities of a bile-stained fluid, distention
of the abdomen while the right hypochondrium re-
mains flat, collapse, and death from exhaustion. The
treatment should consist in supportive measures, early
resort to lavage, and rectal feeding. Nothing should
be swallowed until the vomiting is under control.
Narcotics are injurious.
After-History in a Case of Successful Total Ex-
tirpation of the Stomach. — Charles Brooks Brigham
removed the entire stomach for cancer on February 24,
1898 {Boston Medical and Surgical Journal, May 5,
1898). The patient, a woman, sixty-eight years old,
is now in excellent health, eats three meals a day of
ordinary food, and takes no medicine except a dose
of castor oil once in ten days.
Histological Studies Relating to the Early Diag-
nosis of Cancer of the Stomach. — John C. Hemme-
ter discusses the diagnosis of cancer of the stomach
by means of microscopical examination of scrapings
from the mucous membrane. The diagnosis is based
upon changes in the character of mitoses peculiar to
the cells in malignant neoplasm.
Diagnosis of Gastric Ulcer with Report of Cases.
— Frank H. Murdoch gives three diagnostic signs of
ulcer in patients with dyspeptic symptoms: (i) Ha;ma-
temesis, (2) severe pain relieved by orthoform, (3) a
constant tender point in the epigastrium with or with-
out a corresponding tender spot to the left of one of
the lower dorsal vertebrre.
Auto-Insufflation of the Stomach. — C. D. Spivak
describes a tube with a lateral opening so placed that
when the tube is in the stomach the side opening is
situated in the anterior portion of the buccal cavity.
The end of the tube is now compressed, and the pa-
tient, by closing the lips around the tube and inllating
the cheeks, blows air into the stomach.
The Indications for Surgical Interference upon
the Stomach. — James H. Dunn says that operations
upon the stomach are often made in unsuitable cases,
and in suitable cases are made too late, and lays down
some general rules to guide the surgeon in his selec-
tion of cases for operative treatment.
Direct Electrization of the Stomach, Especially
by High-Tension Faradic Currents. — Boardman
Reed reports two cases of hyperchlorhydria in which
the faradic current was applied directly to the mucous
membrane. In the second case a high-tension coil
was used with marked success.
On the Newer Applications of Gastro-Enterostomy
in the Treatment of Diseases of the Stomach
Robert F. Weir reports three cases of gastro-enteros-
tomy conjoined with entero-anastomosis performed
after the method described by him in the Medical
Record, vol. liii., p. 541.
Stricture of the (Esophagus Resulting from Ty-
phoid Ulceration.— John S. Pyle reports a case of
this nature in which dilatation by hydraulic pressure,
applied by means of an instrument of his own inven-
tion, was entirely successful.
Perforating Gastric Ulcer and its Surgical Treat-
ment.— Martin B. Tinker presents an extensive study
of the literature of this subject, which contains re-
ports of two hundred and thirty-two cases, with a mor-
tality of one hundred and nine, or 48.81 per cent.
A Case of Traumatic Stricture of the (Esophagus
Treated by Electrolytic Dilatation.— Arthur G. Min-
shall reports a case of recent stricture, produced by
the accidental swallowing of a solution of caustic
potash, cured by electrolysis.
Motivity of the Stomach — Fenton B. Turck dis-
cusses under this title the etiology, pathology, symp-
tomatology, and treatment of motor insufficiency of
the stomach.
Gastroplication for Dilated Stomach — Randolph
Winslow reports a case of this operation, performed
with success in the person of a man aged sixty-four
years.
The Surgical Treatment of Diseases of the Stom-
ach.— William J. Mayo discusses the operative treat-
ment of gastric disorders, his conclusions being partly
based upon his own experience in about sixty cases.
Gastrosuccorrhoea H. W . Lincoln discusses the
etiology, symptomatology, and treatment of both the
acute and the chronic form of Reichmann's disease.
Case of Vertical Stomach.— George Macy Ekwur-
zel describes an instance of this rare anomaly discov-
ered at autopsy.
British Medical Journal, January 2J, jgoo.
Cases Complicated with Mental Disorder Treated
by Thyroid Extract.— Richard R. Leeper says that
treatment with thyroid extract is imperative in all
cases of insanity showing a steadily downward course,
in which there is reason to suspect thyroid insuffi-
ciency. In view of the cumulative property of the
substance its effects must be carefully watched. This
extract owes its remedial results to its direct stimula-
tion of the cortex and the increased metabolism thereby
induced among its elements. The rise of tempera-
ture is, however, not the most constant symptom of re-
action. To the increased pulse-rate and quickened
circulation must presumably be attributed most of the
good effects of the treatment. The writer concludes
by saying that wh^n we know more of the functions
and the mode of action of the secretions of the duct-
less glands, we shall find a solution to many of the
problems of psychiatry.
Remarks on the Pure-Air Treatment of Phthisis
at Home. — Under this heading Arthur Ransome dis-
cusses tiie treatment of tuberculous patients who are
unwilling or unable to leave home. He says that the
advantages of "open-air" treatment for this disease
are undoubted, but that it cannot be carried out in the
patient's own home save under certain stringent con-
ditions, such as a residence drained, ventilated, and
furnished with a special view to the treatment, strict
attention to asepsis, carefully regulated feeding, the
treatment of accidents, suitable amusement, etc. The
writer sums up his conclusions by saying that these
conditions cannot be met without the constant super-
vision of a medical man and the services of a trained
nurse or of an intelligent and trustworthy attendant.
For the poor, suitable sanatoria should be provided
at the public expense.
The Application of Bacteriology to Public Health.
— Walter C. C. Pakes discusses this subject under two
headings, viz., Diagnostic Examinations, including
tuberculosis, diphtheria, typhoitl fever, etc., and Pre-
ventive Examinations, including the examination of
water, milk, etc.
February lo, 1900]
MEDICAL RECORD.
H3
The Continuity of the Toxic Process in Fatal
Cases of Diphtheria John Biemacki gi\es some
deductions from his study of the blood-pressure curve
in cases of diphtheria. He says the gravity of this
disease may be in part explained by the diverse action
of its toxin, which causes a fall in blood pressure and
also a change in the cardiac and renal tissues.
Poisoning by Sodium Salicylate. — Gordon Sharp
quotes a case in which 130 grains of this drug were
taken at one time, in order to prove that the salicylate
within reasonable limits is not a cardiac depressant,
as is generally taught in the text books, but is, on the
contrary, often a calmative of great usefulness.
Poisoning by Oleum Eucalypti Frederic C. Wood
reports a case in which a child, aged three years, swal-
lowed between two and three teaspoonfuls of oleum
eucalypti. The symptoms were identical with those
of opium poisoning, except there was no stertorous
breathing. The child recovered.
Fracture of Both Clavicles.— In this case, reported
by William Semple Young, the patient was a boy, aged
six years. The patient was strapped and treated in
the recumbent position, with the result that in three
weeks the bones united well.
The Removal and Transport of Cavalry Wounded.
— ^T. F. S. Caverhill discusses at length the various
ways in which wounded cavalrymen may be most
promptly and efficiently aided by means of horse lit-
ters, etc.
Formalin in Rodent Ulcer. — F. Wyatt-Smith re-
ports this case, for which operation was refused, and
which he treated with a twenty-per-cent. solution of
formalin in glycerin and water, vi'ith excellent results.
A Case of Enteric Fever with Acute Nephritis.
— H. Reynolds Brown reports this case as being a
rare complication. The only treatment seriously at-
tempted was by the hot pack and intestinal antiseptics.
The Pathology and Treatment of Appendicitis.
— By C. B. Lockwood. See Medic.\i. Record, vol.
Ivii., p. 243.
Pericarditis A clinical lecture, by Graham Steele.
The Lancet, January 27, jgoo.
A Clinical Lecture on Sleeplessness. — W. H.
Broadbent discusses this question from the standpoint
of the difference in the vascular conditions of the
cerebral corte.x in the sleeping and waking states.
Common causes of insomnia include extremes of tem-
perature i.i the feet, both high and low vascular ten-
sion, and flatulent dyspepsia. Many cases are cured
by a relief of these conditions, while in others it may
be necessary to alter entirely the manner of living of
the individual. Insomnia often follows influenza, and
if the case is at all obstinate, an opiate with hyoscya-
mus is better than the bromides, chloral, or trional.
In the insomnia of the later stages of an alcoholic
debauch, strychnine with digitalis is indicated.
Excision of the Spleen for Injury. — Recital of a
case by O. St. J. Moses. Dangers of this operation
are peritoneal infection, and especially bleeding from
vessels at the hilum. Sharp probes were passed at
right angles through the stump of the pedicle, their
ends protected by cork resting on the surface of the
abdomen. The spleen was cut away external to the
outer ligature, and the remaining stump treated like
the stump of the uterus in a Porro operation. The
patient recovered.
The Process of Digestion after Resection (j about
Six Feet of the Small Intestine. — Carl j' ;hl after
says that the removal of this length of bowr closely
approaches the critical line between re' ery and
death. In his own patient the loss of th length of
ileum did not seem to make the slightest difference
in digestive function. The patient had a severe gen-
eral urticaria five days after operation, but no other
untoward symptom.
Pott's Disease or Fracture of the Vertebrae W.
R. Townsend reports the case of a girl, aged six years,
who after a fall presented a bony prominence in the
back of the neck accompanied by dyspnoea and the
habit of supporting the head by the hand placed under
the chin. Kyphosis was marked, and there was a de-
pression of the upper cervical vertebra. The patient
was seen by several physicians. Both diagnosesliamed
in the title were made.
Deaths Under Chloroform. — J. Edmunds insists
upon the same precision of dosage with chloroform
as with morphine or strychnine. An improved Krohne
inhaler affords a true volumetric dosage. Administra-
tion should always be begun with small volumes of
chloroform-air, such as to cause neither cough nor
resistance.
A Case of Rectal Deformity. — I. G. Modlin reports
a case of a woman with a well-formed perineum and a
dimple at the site of the anus, but without any opening
or sphincter. The vulva, externally normal, was oc-
cluded by a movable partition visible on separating
the labia. The urethra, vagina, and rectum all opened
into one common vulva.
Some Remarks on the Diaphragm. — R. Lee refers
to a symptom which he finds very common in influ-
enza. It is a pain around the lower part of the thorax,
which he believes to be due to a nervous affection of
the diaphragm. Spasm of this muscle may cause the
peculiar dry cough of the disease named.
The Use and Abuse of Preservatives — S. Rideal
gives the results of experiments upon milk with boric
acid and formaldehyde. Coagulability depends some-
what upon the percentage of acidity, and any preser-
vative is obviously more efficient if added at the time
of milking before changes have already begun.
Myoidema in Pulmonary Tuberculosis. — H. Wal-
sham finds this physical sign only in cases attended
by great wasting, and believes it to be valueless as an
early sign of pulmonary tuberculosis. It is, however,
a good index of the actual amount of wasting which
has taken place.
The Pathology and Treatment of Appendicitis. —
C. B. Lockwood believes that bacterial infection is
the great exciting cause of the malady, no matter what
type the symptoms may assume. He advocates the
oblique incision parallel to the outer half of Poupart's
ligament.
Depilation by Roentgen Rays. — Neville Wood
shows that exposure to the -v-rays may become avail-
able as a means of depilation. From thirty to forty
exposures are necessary to secure permanent alopecia.
Medical Press and Circular, January 24, igoo.
The Role of the Physician in Renal Affections.
— Professor Lancereaux says the physician must in
every case of renal disease and under all circumstances
meet two indications which never vary: To treat the
renal lesion or functional trouble, and to treat the in-
toxication which is the consequence of the affection.
Always and invariably the primary malady localizes
244
MEDICAL RECORD.
[February lo, 1900
its effects at the outset in one only of the anatomical
elements composing the kidney. In fever the epithe-
lium alone suffers; in late syphilis and saturnism the
vascular connective tissue is affected. In epithelial
nephritis cantharides acts as a specific on the epithe-
lium; in connective-tissue nephritis preparations of
iodine are capable of modifying the new sclerosed
tissue. The lesions of uraemia are focussed on the
digestive tract; there are two kinds of symptoms,
digestive and nervous. Rules of treatment are laid
down.
A Comparatively Rare Injury to the Distal
Phalanx of the Finger. — John Ewens records three
instances of injury involving the ungual phalanx,
which is bent forward as in dislocation by suddenly
impinging with great force upon some hard immovable
substance. There is no dislocation, nor is it likely
that there is rupture of the tendon in the usual way.
It is suggested that the termination of the tendon may
be torn through close to its insertion, or more prob-
ably the periosteum may be raised from the bone.
The Therapeutic Value of Salophen. — T. Poyntz
Wright recapitulates English experiences and has per-
sonally found salophen of great value in rheumatoid
sciatica, while its great value lies in the treatment of
influenza. It is a perfect substitute for salicylic acid
and its compounds without possessing the disadvan-
tages.
Diphtheria By William K. Smith. The third of
the Harben Lectures.
Wiener kliiiische ]VochenschriJt,Jaii.jr auii j8, igoo.
Polioencephalitis Superior Acuta and Delirium
Alcoholicum as an Introduction to Korsakow's Psy-
chosis without Polyneuritis Emil Raimann reports
a case of this kind in a man thirty-seven years old,
who had been addicted to the use of alcohol for years.
He was attacked simultaneously by alcoholic delirium
and by local and general somatic disturbances. In
the right eye there occurred an external and internal
ophthalmoplegia. There was also paralysis of the
abducens of the left eye. This paralysis lasted for
a considerable length of time. Consciousness was
much disturbed. Peripheral neuritis was not present.
The almost simultaneous occurrence of polioencepha-
litis and alcoholic delirium was not a chance event.
The chronically poisoned organism had only waited
the opportunity to express itself. The patient suffered
not only from loss of memory, but from delusions.
From this attack he made a good recovery.
Contribution to the Knowledge of Chyliform As-
cites F. Micheli and G. Mattirolo state that tlie
pathogenesis of the various so-called milky effusions
must be different, and their origin must depend on
varied etiological factors. They then give the quan-
titative constituents of "arious effusions in which the
quantity of fat or rather the ethereal extract — fat, cho-
lesterin, lecithin — was never greater than i gm. In
some of these effusions there was not enough fat to
cause opalescence — 1.5 gm. bring necessary for tiiat
(Letulle). Experiments were made which proved that
opalescence in these cases depended on lecithin. It
now remains to demonstrate what role lecithin plays
in the condition of opalescence of true fatty effusions
(ascites chylosus et chyliformis).
The Etiology of Congenital Defect of the Pecto-
ralis Muscle and the Elevated Position of the
Scapula — Hermann Schlesinger says that defect of the
pectoralis generally consists in the absence of the
sterno-costal part, while the clavicular part is present
at least in part. The right side is generally affected.
There is an apparent flattening of the sternum on the
affected side. The skin of this side is sometimes poor
in fat with few hairs. Schlesinger reports several
cases of this nature, and thinks the cause of the defect
is due to arrested development. The arm on the af-
fected side can be moved for the most part as well as
the opposite one, the deltoid generally assuming the
function of the defective muscle.
Haemolysin and Antihaemolysin. — Rudolf Kraus
tabulates the results of numerous experiments which
prove that the different micro-organisms develop haemo-
lytic poisons in relation to the blood-corpuscles of
different animals, and that normal blood sera can sus-
pend this hemolytic influence. The antihasmolytic
influence of normal serum is to all appearances due
to the influence of a ferment.
Some New Drugs in the Therapy of Phthisis. —
Jul. PoUak, in this list, first mentions ductal, which
is valuable in its influence on the appetite. Pyra-
midon is used for its antipyretic action, one of its
chief virtues being that it has no baneful effect on the
heart. Heroin hydrochlorate has a most beneficial
control o\er the cough of tuberculosis.
A Note on the Subject of Infantile Pseudo-Bul-
bar Paralysis M. Bernhardt states that H. v. Hal-
ban in his monograph on " Infantile Pseudo-Bulbar
Paralysis" has reviewed the literature on this subject,
which he himself has attempted to supplement.
A Case of Traumatic Periodic Paralysis. — Julius
Ponath records this case, stating that von Hartwig was
the first to describe this obscure disease.
Miiiiiliciier medie. Wochenschriji, Jnn. g and j6, J goo.
Convulsions in Childhood. — J. Lange writes that
convulsions in childhood can be classified as organic
and functional, and that functional convulsions may
be further subdivided into sympathetic and idiopathic.
He adds that eclampsia is not an essential disease, but
only a symptom, and that its diagnosis as such must
disappear from the inde.\ of text-books even as fever,
vomiting, or headache. Convulsions are frequently
caused by foreign bodies in the nose, throat, oesopha-
gus, ear, larynx, and trachea ; by irritation of the skin ;
by many aft'ections of the digestive tract. They often
occur at the beginning of an acute, febrile, infectious
disease, and are designated as an initial infectious
eclampsia. The chronic infections in which they are
most common are rachitis, syphilis, and scrofula.
Certain poisons excite convulsions, viz., opiates and
chloral hydrate. Carbon dioxide plays the greatest
role in the mortality statistics of convulsions. In the
attack the clothes should be loosened, baths may be
given, leeches applied to the neck. Bromides are
excellent sedatives in tliis trouble. Phosphorus is
sometimes given.
Treatment of Neurasthenia ^Otto Dornbliith ad-
vises a careful physical examination as the first step
in the treatment of neurasthenics. A careful dis-
crimination should be made between acute and chronic
forms of the affection. Rest stands foremost in the
treatment of acute neurasthenia- — rest in bed being most
efficacious. This can be continued from eight days
to six weeks. Next in importance conies diet, which
in most cases needs to conform only to normal nour-
ishment. Hydrotherapy is very beneficial, as well as
electricity — the application of a weak faradic current
being preferable. The patient's confidence should be
gained, and special attention should be paid to his
mental influences. As to drugs the author inclines to
February lo, 1900]
MEDICAL RECORD.
H5
the use of sanguinol in ancemic cases, and arsenic in
cases of the arthritic type. However, appropriate treat-
ment must be suited to the individual case. Codeine
is used in depressive forms. As to the treatment of
chronic cases, many are benefited by that just de-
scribed for the acute form. Those resulting from some
form of traumatism should of course have the injury
or its results attended to first, when often a desire to
resume the normal life will naturally follow.
The Present Reputation of Salt- Water Infusions,
with the Description of a Complete Infusion Ap-
paratus.— Hjiberlin slates that infusion is the younger
sister of transfusion. In general, the infusion of salt
water is indicated in all cases when the heart pump
lacks the necessary quantity of blood; when the body
is exsiccated through the loss of fluid; when the in-
put of fluid is below par, when the blood and the tis-
sues are saturated with poisons; and when the strength
of the heart is weakened, the glandular capacity dimin-
ished, or the nervous centres are stupefied. The contra-
indications generally depend upon heart insufficiency
with cyanosis, cedema of the lungs, and a high degree
of dropsy with nephritis.
The Treatment of Suppuration of the Frontal
Sinuses. — Winckler declares that all accepted opera
tions should be carefully considered in every case of
this kind, and that the one most appropriate be used
without regard to the operator's penchant for any one
particular method. In the after-treatment of his own
cases, he no longer flushes out the wound but carefully
dries with a gauze tampon, making use of insufflation
and inhalation.
Bleeding of the Endometrium from Sclerosis of
the Uterine Arteries. — M, Simmonds describes this
affection as " apoplexia uteri '' (Cruveilhier), and be-
lieves that there is a close connection between altera-
tions in the vessels and menorrhagia. Undoubtedly
arteriosclerosis is the etiological factor of importance
in hemorrhage of the uterus in old women, and after
all therapeutic measures fail, resort will have to be
had to the extirpation of the organ.
A Second Case of Removal of the Shoulder-
Girdle for Sarcoma of the Scapula. — Th. KoUiker
refers to the former case with scapular sarcoma on
wliich he operated. The patient died about two years
after the operation, of metastases in the brain and
lungs. The present patient recovered quickly from the
operation, but died six months later from influenza-
pneumonia. There was no recurrence.
Suture of the Heart as a Typical Operation. —
Emil Rotter thinks that in cases of heart injury, when
there is nothing to lose but much to gain, a typical
operation should be accepted by surgeons. The heart
should be well exposed, and the operation be accom-
plished as quickly and with as few assistants as pos-
sible. He carefully describes the technique, giving;
illustrations.
A Case of Puncture of the Ear with Loss of
Brain Fluid. — Lohnberg reports this case, in which
he made careful chemical experiments, proving that
the fluid exuding from the wound originated in the
brain. The injured part was kept carefully bandaged
and strict rest enforced, and the patient was discharged
cured at the end of a month.
A Case of Land Scurvy. — M. Rothschild describes
a case of sporadic scurvy in a woman twenty-five years
of age. None of the ordinary etiological factors was
present, unless we accept the damp, cold weather pre-
vailing at the time, as having a causative influence.
Adeno-Carcinoma of the Caecum ; Invagination,
Resection, Recovery. — Krecke cites the case of a
woman sixty-three years old, on whom resection was
successfully performed. It is now a year since the
operation, and there has been no trace of recurrence.
Experimental and Clinical Experiences with Or-
thoform. — August Luxenburger concludes that ortho-
form is an absolutely harmless anesthetic which nei-
ther diminishes secretion nor delays wound healing.
F. V. Birch-Hirscjifeld.— Obituary by Professor
Kockel.
Deutsche mediciiiische Wocheiiscltrijt, January ii, igoo.
The Diagnosis of Imbecility in Early Childhood.
— Martin Thieniich discusses the various means of
testing the mental condition of very young children.
These consist in the determination of pain sense,
taste, and attention or reaction to non-painful stimuli.
For the first he uses a needle, an imbecile child often
showing no signs of pain even when pricked repeat-
edly. For the second he employs solutions of sac-
charin, quinine, hydrochloric acid, and common salt.
A normal infant will usually express satisfaction when
the tongue is moistened with the first, but will resent
the application of bitter, sour, or salt solutions. As
regards attention one must note the possibility of at-
tracting this and also the length of time it can be fixed
upon a given object. Later diagnostic factors are the
development of the sense of cleanliness and the begin-
ning and progress of the power of speech.
The Taking of Nourishment by the New-Born
H. Cramer relates certain experiments made to deter-
mine the amount of nourishment necessary to main-
tain the physiological weight of infants during the
first ten days of life. He also estimated the suction
force necessary to draw milk from the breast and from
the nursing-bottle respectively, and suggests that the
difference in these forces may be of significance as
regards metabolism in infants.
The Valuation of Tetanus Antitoxin and its
Employment in Man and Animals. — E. Behring has
succeeded in preparing a stable tetanus virus for use
in estimating the potency of the antitoxin. He asserts
that the mortality of tetanus can be reduced to fifteen
per cent., provided the antitoxin is given in doses of
not less than one hundred units not more than thirty
hours after the appearance of the first symptoms.
The Physical Determination of Unilateral Deaf-
ness.— H. Rohr discusses Lucae's instrument for the
detection of simulated unilateral deafness (the " inter-
ferenzotoscop''), and concludes that it is unreliable.
In some cases in which deafness is present the ap-
paratus fails to indicate it, and in others it points to
the existence of deafness when the hearing is good.
On a Possibly Serious Skiagraphic Error. — By
Carl Beck. See Medical Record, vol. Ivii., p. 65.
Vratih, January i and S, IQOO.
Treatment of Inflammatory Affections of the
Uterus and Adnexa with Hot-Air Douches. — In a
preliminary communication, A. M. Mansvetoff de-
scribes an apparatus for the preparation and applica-
tion to the vagina and uterus of dry heat. The tem-
perature of the air is from 50° to 60° C. (122° to 140"^
F.), and the douches are given for one or two hours
every day or every other day. The author has never
seen any injurious effects of the douches, but on the
contrary claims for them the following advantages :
(1) They quickly and for some time quiet pain in the
246
MEDICAL RECORD.
[February 10, 1900
pelvic organs; (2) they soothe the nervous system, in-
duce sleep, and increase the appetite; (3) they lower
the temperature, pulse, and respirations, when these
are elevated; (4) they influence favorably the men-
strual flow; (5) they facilitate the perfect removal of
the products of inflammation; (6) they increase secre-
tion from the uterine cavity.
Anaesthesia by Injection into the Spinal Canal.
— Y. B. Zeldovitch reports four cases in which opera-
tions were performed under anaesthesia induced by the
injection of a solution of hydrochlorate of cocaine
into the spinal canal. He also performed a number
of experiments on dogs to determine whether the dose
of the injected substance might not profitably be in-
creased so as to increase the anaesthetic action and
avoid the unpleasant by-symptoms sometimes observed
to follow the puncture of the needle. As a result of
his experience he concludes with I!ier that, in the pres-
ent stage of the method, it ought to be employed only
in cases in which anesthesia by chloroform is espe-
cially contraindicated.
Vir Effeminatus. — A. S. Tauber reports with illus-
trations a case of hermaphroditism in a person twenty-
two years old. The subject was apparently a tall, well-
developed woman, with long hair on the head and no
beard. The breasts were large and pendent. There
was scanty, irregular menstruation. On palpation of
the abdomen a body resembling the ovary could be
distinctly felt on the right side. There was an imper-
fect vagina, together with a female urethra. But with
this there was a scrotum containing two bodies resem-
bling testicles, and the clitoris was greatly developed,
resembling a penis. The voice was of a masculine
character.
Corporal Punishment in Russia on the Eve of
the Twentieth Century.— By D. N. Zhbankoff. A
continued article.
Post-Partum Sloughing of the Uterus V,y V. G.
Bekman. A continued article.
Za m/orma Medica, January g-/8, igoo.
The Typhoid Bacillus as Found in the Blood. —
Aldo Castelani concludes from his experimental re-
searches that the bacillus is more frequently found in
typhoid cases than is usually supposed. By diluting
the blood with peptonized and slightly alkaline broth,
the bacilli sowed in it usually developed great mobil-
ity, giving the characteristic turbid appearance to the
culture medium. In some cases, however, they were
agglutinated on the bottom and sides of the vessel,
leaving the liquid almost entirely clear.
Fibroma Molluscum Sergi Trombetta reports a
case in a boy aged sixteen years. The affection dated
from infancy, and began as a small subcutaneous
swelling in the right tendo Achillis, which gradually
increased in size. Actual condition showed the right
foot in an atrophic condition, even the bones being
smaller than normal. A soft, fluctuating mass was
situated on the tendon. It was removed and was found
to be a fibroma molluscum. The histological examina-
tion is described in detail.
Necrobiotic Ischsemic Infarction of the Lung •
Giovanni Cagnetto reports a case and gives a minute
description of the anatomico-pathological condition
found at the autopsy. He believes the condition to
have been due in the first place to the action of Fran-
kel's diplococcus, found in abundance in the lung
tissue, in causing inflammatory lesions in the blood-
vessel walls, and secondarily to a resulting throm-
bosis.
Neuralgic Genital Herpes — Cesare Casarini re-
cords a case in which an infective origin could be
excluded. It was held to be due to nervous origin,
and related to phenomena of altered sensibility in the
superior interior region of the thigh through the geni-
to-crural nerve, and that of the posterior region through
the femoral branch oE the inferior gluteal.
Rare Anomaly of the Arteries in the Arms G.
Mollica describes an unusual arterial condition, and
holds that surgeons should have a thorough knowledge
of abnormal as well as normal conditions of the body.
Hivista Critica ili Clinica Alcdica, /an. 6 — 20, igoo.
Common Sense in Practical Medicine. — Augusto
Murri, in a lecture to medical students, urges greater
individual thought on the part of students and physi-
cians, and greater exactness in the use of language.
To the saying, " He who does not learn how to speak
forgets how to think," he adds, " and he who forgets
how to think cannot learn to operate." Well-trained
minds can best grapple with the problems of medicine.
The learning of technical details, such as feeling the
pulse, the weighing of excreted urea, the measurement
of the viscera, are of no use unless one is able to ap-
preciate the significance of the counting, weighing,
and measuring. The spirit of the article might be
summed up in the words: a physician's brain should
be of good quality, well trained, and in constant use.
Puerperal Eclampsia Ernesto Pestalozzi makes
a distinction between true, concealed, and pseudo-
eclampsia. The true and the pseudo are convulsive
forms of the auto-intoxication ; the concealed form is
due to this auto-intoxication, but the convulsions are
inhibited by some cause which prevents the cortical
substance from acting, such as a cerebral hemorrhage,
for instance. In pseudo-eclampsia the auto-intoxica-
tion has a secondary role, the convulsions apparently
being due to the stimulus of a cerebral tumor, or a
meningitis for example, upon a nervous system ren-
dered particularly susceptible by pregnancy.
Surgical Intervention in Marked Dilatation of the
Stomach. — A. Cardarelli thinks that when a diagnosis
of simple stenosis of the pylorus has been made, sur-
gical measures should be at once resorted to. Even
when the diagnosis is not quite clear, a recognition of
the fact that there is impotence of the stomach walls,
shown by the impossibility of its emptying itself of its
contents, and permanent retention, justifies operative
procedures. Marked dilatation calls for surgical in-
tervention. The author reports four cases.
Acute Hemorrhagic Poliencephalitis from In-
fluenza.— C. Bozzolo reports two cases in which head-
ache, stupor, rigidity of the neck, pupillary disturb-
ances, vomiting, and Kernig's symptom all pointed to
meningitis. It was, however, a severe form of influ-
enza, which the author believes induced an acute
hemorrhagic poliencephalitis. The diagnosis was
purely clinical.
J-'reiuli Journals.
Cardiac InsuflSciency and Forced Heart.— Pierre
Merklen understands by mur Joirl- an asystolic state
beginning with functional troubles, associated with
feeble and persistent dilatation, which have come on
suddenly after overtire or violent effort. A distinc-
tion must be made between cardiac insufficiency,
forced heart, and asystole, which are often regarded
as synonyms. Insufficiency is a term often employed
by foreigners, he thinks, to characterize feebleness
and dilatation with tiieir consequences, venous stases.
February lo, 1900]
MEDICAL RECORD.
247
It is the equivalent of the French term asystole. Car-
diac insufficiency is a state much more than a disease.
It should be early discovered, since treatment in car-
diopathies is, before all else, prophylactic hygiene. If
the patient belongs to the working class, he should
give up all but sedentary occupation; if to the
wealthy class, he should renounce an active life, and
adapt himself to general hygiene applicable to car-
diacs.— La Presse Mi'dkak, January 17, 1900.
Potatoes in the Diet of Diabetics — A. Mosse finds
that while potatoes have been rigorously excluded
from the dietary, and exceptionally allowed, they have
recently come to be recommended as a substitute
for bread. He has studied their effsct upon the urine,
and found in one case followed for two months that
the sugar diminished after their administration. As
a general rule, it has been found that potatoes which
swell up and burst open, or disintegrate when cooked
in water, contain more flour than those that remain
firm — the latter containing a larger proportion of al-
buminoid matter. According to authors quoted the
central portion of fresh potatoes, which have reached
perfect maturity, is the most watery, the poorest in
flour, and the richest in azote matter, and hence this
part should be chosen for diabetics. — Bulletin General
lie T/ierapeiili(]iie, January 15, 1900.
Treatment by Cold Baths in the Typhoid Fever
of Children. — F. Glenard, to give an idea of the mor-
tality under drug treatment, reviews 1,745 cases
studied and finds the mortality fifteen per cent. Un-
der strict bath treatment, the results of a number of
reporters gives a total of 503 patients with 18 deaths,
or 3.5 per cent. Studying cases treated by baths or
moist temperature lower than that of the patient's
fever, but not in a systematic manner, he arrives at
the conclusion that eleven per cent, represents the
mean mortality. Other statistical data are given, and
the article is to be continued. — Kcvice de Thempi-u-
iique, January 15, 1900.
Ichthyosis. — Hallopeau and Leredde consider the
disease incurable, but think much may be done to
keep down the scales as they are produced, and give
comfort to the patient. A seeming cure can be se-
cured by inunctions of oil of sweet almonds with vase-
line and five per cent, of boric acid, or two per cent, of
salicylic acid, or five per cent, of sulphur. In ichthy-
osis hystrix the concretions may be removed by ra-
clage. — Jonrnal dfs Fraticiens, January 20, 1900.
Jour, of Cuian. and Genito- Urinary Diseases, Feb., igoo.
Classification of Tumors. — B. H. Buxton gives with
diagrams a new classification. Epithelial tumors he
thinks are better classified according to the structure
rather than the origin of the epithelium from which
t'hey are derived. There are three main groups: flat
stratified, cubical, and flat single, calling the benign
tumors derived from them papfllomas, adenomas, and
benign endotheliomas, and the malignant ones epi-
theliomas, carcinoma.s, and malignant endotheliomas.
He objects to the Greek ending " omata " for the
plural, since the termination "oma" has been adopted
into our language.
The Role of Pus Organisms in the Production of
Skin Diseases. — George T. Elliot reviews at length
the whole literature, from which it is evident that al-
though micro-organisms, especially the staphylococci
and streptococci, are the particular cause of suppura-
tion, yet many other factors both internal and external
are active. Contradictory results are obtained by
different observers, and chaos still exists. Micro-
organisms, while the general cause, are not the exclu-
sive cause.
Prostatitis and Seminal Vesiculitis. — Charles H.
Chetwood gives his experience combined with that of
E. L. Keyes. Chronic prostatitis is differentiated from
prostatorrhoea, and both from seminal vesiculitis.
Figures show the employment of a new rectal irriga-
tor— a modification of the Tuttle and Kemp tubes.
The treatment of seminal vesiculitis resembles that of
prostatitis. During acute inflammation, rest, bland
diet, hot sitz-baths, etc., are recommeded. Massage
and rectal douches are only proper in the chronic stages.
Fediatriis, February I, igoo.
The Estimation of the Leucocytes of the Blood
as an Aid in the Diagnosis of Diseases of Chil-
dren.— George D. Head believes that the leucocyte
counts in the blood of children affected with certain
diseases are as characteristic and fixed as in diseases
of adult life. Pyemic infection is usually followed
by well-marked leucocytosis; in appendicitis with pus
formation a well-marked increase of white cells is
found, while in intestinal obstruction there is rarely
an increase, so that this would be of value in differen-
tial diagnosis. In the first week of typhoid the count
is normal or below normal ; in the second, third, and
often the fourth almost always below normal. This
would distinguish the condition from appendicitis,
osteomyelitis, enterocolitis, etc. Cases are given.
Two Cases of Infantile Hemiplegia Following
Convulsions in Scarlet and Malarial Fever. — E. E.
Montgomery quotes the opinions of many authors, and
gives two histories which have led to opinions of his
own not in strict accord with those prevailing.
Report on the Cause and Prevention of Infant
Mortality. — By Ernest Wende. See Medical Rec-
ord, vol. Ivi., p. 7 19.
Tlie .' lerapeutic Gazette, January /j, igoo.
The Therapeutics of Tuberculosis. — Lawrence F.
Flick says the therapeutics maybe predicted upon:
(i) The predisposition and resisting-power and ante-
cedents of the patient; (2) the tubercle bacillus; (3)
the disease germs which set up mixed infection and
so may be subdivided into germs which run an inde-
pendent course with the tubercle bacillus. The pre-
disposition may be natural or artificial. When natural,
little can be done to remedy it, and a fatal termination
is usual. .Artificial predisposition, such as is produced
by alcohol, may be abolished by removing the cause.
We should never say that a certain drug is useless,
but we should know when and how to use it, and more
attention must be paid to the use of adjuvants than to
endeavors to find specifics. One remedy which brings
comfort and encouragement is creosote. It is best
given in large draughts of hot water befora meals.
The dose should be gradually raised up to gtt. xl.-l.
three times a day. the hot water being likewise in-
creased; with the maximum dose a pint being given.
The Treatment of Gonorrhoeal Rheumatism. —
Charles H. Frazier regards the condition as an in-
fecting arthritis, in some cases the gonococcus alone
being the exciting cause, in others we have a mixed
infection. The first is the milder form. Firm pres-
sure should be applied to the elevated limb, preferably
by means of a rubber bandage, or strips of adhesive
plaster, with gentle massage. If these means fail, as-
piration and irrigation should be employed. In em-
pyema of the joint, immediate arthrotomy should be
done, with antiseptic irrigation and drainage. In
phlegmon of the joint the pain is more pronounced.
Ankylosis is almost sure to follow improper treatment.
248
MEDICAL RECORD.
[February 10, 1900
Proper immobilization should be carried out b\' means
of a plaster cast. Acupuncture is an efficient means
of relieving congestion. As to internal remedies it is
doubtful if they exert any specific effect, but the ure-
thral lesion should be simultaneously treated.
Chloretone a Safe Hypnotic. — W. M. Donald says
chloretone is made with caustic potash, chloroform,
and acetone. It has the odor of camphor. It is best
given in tablet form. It is of considerable value in
well-selected cases in doses of gr. xii.-xv., repeated
within two hours if necessary. Its relative value has
not been determined. The case of a morphine habitue
is related who took gr. xlviii. in one day without un-
toward symptoms. In all gr. cxx. were administered,
and sleep extending over the greater part of five or six
days was secured.
Electrolysis for Aortic Anemrism — Another Case
and a Report of One Previously Reported. — H. A.
Hare gives the history of a case, with illustrations,
one showing the results after three years' treatment.
In statistics published by himself and Holder of 951
cases of aneurism of the thoracic aorta, 570 occurred
in the ascending arch, 104 in the transverse, and 110
in the descending portion.
The Use of Creosote in Pulmonary Tuberculosis.
— Irwin H. Hance says that when creosote is tolerated
it is indicated in any form of tuberculous affection of
the lungs, but more particularly in afebrile cases with
free expectoration. It should never be forced at the
expense of the patient's digestion. The carbonate of
creosote has given satisfactory results in doses of gtt.
XXV. after meals.
The Use and Abuse of Drugs in Phthisis Pul-
monalis. — \V. G. Schauffler says individual idiosyn-
crasy must be taken into account. Cod-liver oil is of
use in the early stages, but loses its usefulness later
on. Attention should be given to making creosote
and other drugs palatable and digestible in the early
stages.
My Experience in the Treatment of Pulmonary
Tuberculosis by Drugs Holland says that creo-
sote and like drugs are useless in arresting tubercu-
lous disease of the lungs and larynx, but are often
of service in bronchial catarrh, which is such a trou-
blesome symptom.
The Journal of Tropical Medicine, /niiiiarr, jooo.
Metamorphosis of the Young Form of Filaria
Bancrofti in the Body of Culex Ciliaris.— Thomas
L. Bancroft describes observations made by him on
mosquitoes which were caused to bite a filariated sub-
ject. He found that actively moving filariru were to
be seen on the sixteenth or seventeenth day, sometimes
not until the twentieth day, and that no further devel-
opment occurred in tliem even after a sojourn of sixty
days in the insect's thorax. He also made the inter-
esting discovery that the filarias die after being three
or four hours in water, consequently this cannot be
the medium through which they reach the human sub-
ject. Both of these findings are at variance with those
of Manson.
On Tropical Anaemia, and its Relations to the
Latent and to the Manifest Forms of Malarial In-
fection.— ^In an article with this title, concluded in this
number, Albert Plehn discusses not only tropical anae-
mia but also the entire subject of malaria, including
blackwater fever. He objects strongly to the with-
holding of quinine (which he regards as the only spe-
cific for malaria) through fear of causing haemoglobi-
nuria. He also opposes the theory that the sole mode
of infection in malaria is transmission through mos-
quitoes, his opposition being based upon his experience
in Kamerun.
A Case of Goundou or Anakhre VV. Renner de-
scribes the case of a man, thirty-nine years old, in
whom the first symptoms were noticed in 1882. The
affection consists in a swelling the size of a pigeon's
egg, lying obliquely along the nasal process of the
superior maxilla on either side. It is apparently the
same affection as hempuye or dog-nose, described by
Chalmers in The Lancet oi January 6, 1900. See Med-
ical Record, vol. Ivii., p. 113.
Treatment of a Leper by Subcutaneous Doses of
Chaulmoogra Oil. — Tourtoulis Bey treated a leper for
five years intermittently with chaulmoogra oil in doses
of gtt. XXX. -1. three times a day. The treatment was
finally abandoned, as the oil was no longer tolerated by
the stomach. Later the oil was given subcutaneously
in doses of 5 gm., and improvement set in almost im-
mediately and has continued up to the present time,
during a period of five years.
Lightning Stroke. — R. E. Adamson describes the
damage done to a house and one of its occupants by
a stroke of lightning. The man felt a terrific blow on
the knee and fell off his chair unconscious. He was
unable to walk for about a week, but eventually recov-
ered.
Tumbe or Kroo Fly. — A. H. Hanley gives the life
history of this fly, which is common in some parts of
the Niger protectorate.
Pes Gigas. — P. B. Cousland presents a picture of
this affection, but gives no history of the case.
Zeitschrijt Jiir Krankenpjiege, December, iHgg.
Mode of Living for Migraine Patients.— August
Dobisch states that migraine is most common in per-
sons between fifteen and fifty years of age. In all
such patients there exist defects in the osseous sys-
tem, hereditary taint, or habits which result in defec-
tive nasal breathing and catarrh of the mucous mem-
branes. The physician should study the patient's
mode of living, in order to determine which of his
habits most readily produces an attack. Lymphatic
children suffer in later life from migraine. Close
questioning often elicits the fact that some irritation
of the upper air passages with consequent irritation of
the nervous system has caused the attack. The pa-
tients should live in a dry climate. Their clothing
should protect them against changes of temperature,
hence wool is better than linen. The foot-wear re-
quires careful attention. Sweating is to be avoided;
moderation is to be exercised in all things, especially
in eating and drinking. Hydrotherapy is best used in
the form of cold sponging or very brief baths; cold
water is to be taken only in small quantities, and
never when one is overheated. The nervous system is
to be hardened and protected; excess in wine and coi-
tus should be avoided. The treatment of the attack
consists in relieving the nasal obstruction with co-
caine solution (3.5 per cent.) and the administration
of a saline purgative in order to reduce intestinal
fermentation.
Pathogenesis and Prophylaxis of Croupous Pneu-
monia Hans lirunner mentions March, April, Au-
gust, and September as tiie four months which are of
most importance in their relation to the disease. The
characteristics of each, with its temperature changes,
winds, sunlight, etc., are given at length. A fall in
February lo, 1900]
MEDICAL RECORD.
249
the pressure of the air exposes the human organism to
danger; in the winter it induces perspiration, in the
summer a chilling. Individual calling also plays an
important role; under this heading are mentioned
trauma, exertion, marked mental excitement, chilling,
and tiring of the body, with sweating and psychical
depression. Under the head of prophylaxis, the
author says that exertion, sweating, and chilling are
to be guarded against at all seasons, especially, how-
ever, in the spring. Sudden .and extreme climatic
changes are extremely dangerous. A stable, relative-
ly moist season is preferable to a changeable one.
These changes are especially dangerous to old pneu-
monia patients, and to those suffering from influenza
or bronchitis, or weakened by disease.
Meditsinskoe Ol>oz7-enic, January, jgoo.
The Diagnosis, Symptoms, and Treatment of
Hydro-Pneumothorax. — Ts. I. Shabad presents a
study based upon the reports of seven cases, in which
he formulates the following conclusions: (i) Hydro-
or pyo-pneumothorax may be diagnosed with certainty
by means of the .v-rays. (2; In left-sided hydro-pneu-
mothorax, as in simple pneumothorax, the heart is
usually displaced as far as the right mammillary line;
when the right side is affected the heart is found in
the axillary line on the left side. (3) In left-sided
disease a metallic sound is sometimes heard in the
left side of the chest synchronous with the cardiac
pulsations and the respiration. (4) The patients them-
selves can feel the movement of the fluid in the chest,
and this may be a valuable early symptom. (5 ) In
tuberculous cases with extensive serous or purulent
exudations, thoracocentesis with evacuation of the
pleural cavity is indicated. In cases of purulent exu-
dation when the pulmonary opening has closed, in-
cision or resection of a rib is necessary. (6) In cases
in which life is imperilled, the pulmonary opening
not being closed, a drainage tube should be left in
situ for a time. (7) In many cases of empyema thor-
ough washing out of the cavity may take the place of
resection of the rib, but in this case pleural adhesion
occurs. (8) Even in cases of pyo-pneumothorax wash-
ing out of the cavity may be a good palliative measure.
Gastrostomy by Marwedel's Method. — A. Th.
Kablukoff reports two cases of impassable cancerous
stricture of the oesophagus in which he made a gastric
fistula after Marwedel's method. In this an incision
is made in the linea alba from the sternum to the
umbilicus, and the abdominal wall is divided layer by
layer until the peritoneal cavity is opened. The
stomach is drawn to the opening, and two sutures are
inserted into but not through the anterior wall of the
organ. Then the stomach wall is sutured to the sides
of the abdominal incision for a distance of 7-8 cm.,
and the remaining portion of the incision is closed.
An incision, 5-6 cm. long, is now made through the
serous and muscular coats of the stomach. In the
lowest corner of the mucous tunic a small opening is
made through which a drainage tube the size of a lead
pencil is passed into the cavity of the stomach. The
outer portion of the tube is laid along the bottom of
the stomach wound and the muscular and serous layers
are stitched over it. Thus is formed a canal 5 or 6
cm. long in the substance of the wall of the stomach.
If necessary food can be introduced at once while the
patient is on the operating-table.
A Case of Imperforate Vagina.— S. I. Bubnoff re-
ports the case of a woman nineteen years old, who had
been married four months. She had never menstruated
and coitus was found to be impossible. Examination
showed the vagina occluded by a tough membrane
bulging outward and fluctuating. On palpation of the
abdomen a tense and elastic tumor was felt in the
median line reaching over a little to the left. This
was about the size of a new-born child's head, and to
the left of this was another tumor the size of a hen's
egg, of a rather soft consistence and painful on press-
ure. A diagnosis was made of imperforate hymen
with retained menses and resultant hasmato-colpometra
and left hematosalpinx. This diagnosis was con-
firmed at the operation, the results of which were so
successful that the patient gave birth to a healthy girl
a year and a half later.
Late Spontaneous Hemorrhage from the Umbilicus
in the New-Born. — J. M. Lvoff reports two cases of
umbilical hemorrhage, one on the tenth and the other
on the thirteenth day of life. The bleeding in this
affection occurs at the end of the first or in the course
of the second week, after the stump of the cord has
fallen, and is a general oozing from the surface of the
umbilical wound rather than a hemorrhage from the
umbilical vessels. Hereditary syphilis and htemo-
philia are, in the author's belief, the main etiological
factors. Applications of styptic cotton or of gypsum
usually suffice to still the bleeding, but if this persists
a needle may be passed beneath the bleeding surface
and vessels constricted by a thread wound round the
base.
Castration in a Case of Imperforate Vagina and
Rudimentary Uterus. — A. Eberlin and S. Maloletkoft"
report the case of a woman aged twenty -three years,
in whom the following developmental defects were
found in the genitalia: The external sexual organs
were imperfectly developed ; the vagina was completely
wanting; there was a uterus rudimentarius solidus uni-
cornis; the adnexa on the left side were absent, but
were normally developed on the right side. There
was cystic degeneration of the right ovary. The
authors have found twenty similar cases of defective
uterus and vagina in which operation was performed,
and in all but two with success. In five of these cases
the adnexa were absent on one side, and that always
the left side.
Cases of Ptomain Paralysis. — P. A. Preobrazhen-
ski reports two cases, in a woman aged forty years and
lier son aged fifteen, of paralysis resulting from auto-
intoxication. The chief points of interest were the
absence of any prodromes; the apyretic course of the
disease; the involvement, in greater or lesser degree,
of all or nearly all the voluntary muscles; the greater
affection of the muscles of the upper part of the body
as compared with those of the lower extremities; the
entire absence of any sensory disturbances, vesical or
rectal involvement, or psychic disorders; the participa-
tion in the paralysis of the vasomotors of the face.
Contribution to the Pathology of the Lower Part
of the Spinal Cord. — L. S. Minor reports six cases
of traumatic lesions of the lower portion of the spine,
usually from falls, in all of which, the sensory, elec-
tromuscular, and trophic disturbances were most pro-
nounced and most persistent in the parts supplied by
the peroneal nerve. He concludes that in these cases
there was a special, purely anatomical lesion of the
origin and roots of the peroneal nerves of which the
paralysis of the parts was the expression.
Intramuscular Injections of Quinine Alexander
Ivanoff says it is possible to avoid all the accidents
which may follow the subcutaneous injection of
quinine by making the injections into the muscular
tissue. For this purpose he used a solution of bimu-
riate of quinine in distilled water (i :4), freshly pre-
250
MEDICAL RECORD.
[February lo, 1900
pared for each injection. Tlie amount injected is 2
gm,, the amount of the drug being therefore 0.5 gm.
The injections are almost painless, and in more than
twenty-five cases in which the author resorted to this
method he saw no untoward results at all,
A Case of Interstitial Pregnancy. — V. .Stezhenski
reports a case of this rare condition occurring in a
woman twenty-five years old who had had one normal
labor. The fcetus, of about the third month, was re-
moved by operation and the woman made a good re-
covery. As to the rarity of this condition the author
quotes Rosenthal, who collected thirteen hundred and
twenty-four cases of ectopic gestation, among which
were only forty of interstitial pregnancy.
Tumors. — P. Tikhoff presents an elaborate statis-
tical study of tumors, the chief conclusions from which
are that the influence of sex in the predisposition to
new growths is not apparent, that cancer occupies an
important if not the chief place among tumors as re-
gards frequency of occurrence, and that the extremities
are relatively infrequently the seat of neoplasms.
Practical Observations on Antisepsis in New-Born
and Nursing Children — A. N. Ustinoff describes and
pictures several forms of apparatus for the disinfection
and sterilization of napkins and other articles used in
the toilet of infants.
ClPorrespourtencc.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondenl.)
I AM thankful that it is only the medical aspects of
the war of which I am asked — and, for that matter,
am competent — to send an account. For the historic
and strategic aspects require great knowledge and
great tact in any writer who may try to place them
clearly and succinctly before his readers. Writing
as I do on the morning of January 24th, when all Eng-
land is holding breath in expectation of news concern-
ing Sir Redvers JJuller's relieving column, now de-
scribing a semicircle in the direction of Ladysmith, it
is sufficient to say that on the issue of the next few
hours hangs largely the fate of the war. I do not
mean that England will give up the struggle if she
meets with another rebuff; but that a victory now will
go far toward redeeming past losses. Further proph-
ecy I will not indulge in, particularly as by the time
that this letter reaches you the telegraph will have
told you so much more than I now know.
General Hospitals.— The first two general hospitals
at Wynberg having rapidly received their complement
after the reverse at Magersfontein and Colenso, a third
general hospital capable of accommodating five hun«
dred or six hundred patients was "set up at Rondebosch,
a beautiful high-lying spot between Wynberg and
Cape Town, while a fourth was established at De Aar,
the important junction three hundred miles or so north-
east of Cape Town, whence the railway branches east
into the Orange l-'ree State, and northwest to Kimber-
ley. There is a hospital at Pietermaritzburg, which
will now hold five hundred or six hundred patients.
These five hospitals will give care to at least twenty-
five hundred medical and surgical cases, and they
will, it is hoped, prove equivalent to the demand,
supplemented as they are by several smaller institu-
tions. The transport and hospital ships plying be-
tween Cape Town and Southampton have already be-
gun to bring back to I'.ngland regular relays of sick
and wounded who are able to travel, and with such ab
straction, amounting now to five hundred at least, from
the totals of the convalescents the accommodation pro-
vided by the general hospitals should be sufficient.
In Great Britain at various hospitals and institutions
five hundred and seventy beds have been placed at
the disposal of the government for the reception of
these convalescents, while similar offers are coming
in fast. The Herbert Hospital and Netley Hospital
will accommodate as many more, so that the after-care
of the wounded need not be a source of much anxiety
to the nation. In addition, many noblemen and gen-
tlemen are offering their country houses to be used
as convalescent homes, guaranteeing the expense of
support as well as giving the shelter.
A Half-Way Treatment for the Convalescents. —
In view of the fact that a great many of the sick and
wounded who have so far arri\ed home again have
been practically cured, and are ready to return to the
front, two proposals have been made: (i)That con-
valescent homes should be established in South
Africa; and (2) that such homes should be estab-
lished in the middle of the return journey, viz., in
Madeira and the Canary Isles. The first plan is not
indorsed by thinking people. There may at any time
be great strain on the resources of Cape Town, the
population of which has become wellnigh doubled
during the last few weeks; the sea voyage has prob-
ably counted for much in the excellent plight in which
many of the wounded have reached British shores;
and, lastly, as the transports must go from England
to the Cape carrying stores, furniture of war, rein-
forcements, and horses, they may as well convey the
sick to England, where ample provision for them can
be made. But half-way homes at Madeira are an ex-
cellent suggestion, to which practical effect may be
given. I do not expect, however, that it will.
The Stationary Hospitals and Bearer Companies ;
the R. A. M. C. Under Fire. — There are, of course,
stationary hospitals in Xalal, behind General Euller's
advancing force, and behind the columns which have
proceeded north against the Orange Free State, or to
the relief of Kimberley. Those in Natal had their
positions at Frere and Estcourt. The stationary hos-
pital at Frere was designed by Major R. Kirkpatrick,
R.A.M.C., and is manned by a quartermaster, four
members of the Royal Army Medical Corps, and
thirty-eight non-commissioned othcers, compounders,
cooks, etc.; it has also two army nursing-sisters. At
the battle of the Tugela River (sometimes called the
battle of Colenso) their hospital was moved to Chieve-
ly, and connected with the bearer companies by twelve
hundred civilian stretcher-bearers. The bearer com-
panies went quite up to the fighting line, an ambu-
lance train accompanying them so far that it had to
be turned back lest it should be hit by a shell. Each
bearer company was manned by a surgeon-major, ac-
companied by three junior medical officers, fifty non-
commissioned officers and military bearers, five hun-
dred civilian bearers, ten ambulance wagons, and a
general service wagon. When the battle commenced
stretcher squads picked up the wounded from just be-
hind the fighting line, and bore tiiem to a collecting-
station. Here the wounded were sorted and carried
by stretchers and ambulance wagons to the dressing-
tents. There they received first aid, and were
sorted in cacordance with their injuries, before being
conveyed to the stationary field hospital where the
operating-tables were set up. The scene in the opera-
tive tents at the station field hospitals beggars detailed
description. From 3 a.m. until late at night the opera-
tors were hard at work, and altogether eight hundred
patients passed under special treatment during the
time mentioned.
February lo, igooj
MEDICAL RECORD.
251
OUR LONDON LETTER.
(Fr,
: Special Correspondent.)
WAR ■ — INFLUENZA — • WATER SUPPLY — PATHOLOGICAL
SOCIETY; THROMBOSIS, CANCER, PNEUMOCOCCUS —
GYN/ECOLOGICAL ADDRESS — APPENDICITIS — SIR M.
FOSTER FOR M. P. SIR H. BEEVOR LOCAL GOVERN-
MENT BOARD APPOINTMENTS — DUBLIN MORTALITY
RECENT DEATHS.
London. January 26, igoo.
The war is almost the sole subject of interest, but in
this moment of tension I must not write about it.
You will have all the general news from other sources.
But I cannot forbear saying that amid all the criminal
blundering and neglect of the War Office to which the
attention of Parliament is about to be devoted, the
conflict in South Africa has shown one briglit spot,
viz., the medical department, the service which the
"combatant" influence has done its best to cripple.
The insane jealousy of all " civilians " of the command-
er-in-chief was always directed to snubbing '"mere
doctors," and has now reaped its reward. The colo-
nial horsemen he declined on the outbreak of the war,
and who were just the men for the work, are at once
engaged on the arrival of Lords Roberts and Kitch-
ener.
The wave of influenza is receding here, though not
yet in the northern towns. The deaths from the epi-
demic last week in London fell to two hundred and
eight. The rate per thousand for the last four weeks
has been3S.2, 37.1, 33.3, and 26.9. In the thirty-three
great towns the rate averaged 24.9 as against 29.1 the
previous week. In twenty-three of these towns there
was an absolute decrease. The highest rate was at
Nottingham — 32.2 — but even that was better than the
44.9 of the previous week, which was the highest rate
recorded anywhere during the epidemic. It is thought
that though there is an extension of the epidemic north-
ward, its virulence is declining.
The royal commission on the water supply of Lon-
don issues its final report this week. Their opinion
is against permitting the county council to buy up the
companies. Further, they say that the cost of bring-
ing water from Wales would be double that required
to make the present source adequate until 1941. This
plan would cost twenty-eight or twenty-nine millions
sterling, to meet which a three-per-cent. stock is rec-
ommended secured on the water charges. The com-
missioners favor the establishment of a new perma-
nent board to control the whole supply, and the
proceeding of which board should periodically be
brought automatically under the notice of Parliament.
At the last meeting of the Pathological Society Mr.
W. Pakes read a description of a case of thrombosis
of the right and left iliac and femoral veins, in which
he found post mortem bacillus proteus vulgaris. Al-
though this organism is often associated with decom-
position after death, he did not think that would ex-
plain this case, as the clot contained considerable
numbers and there was no obvious decomposition.
Dr. T. G. Stevens gave an account of a thrombosed
ovarian vein following hysterectomy. Cultures made
with every precaution against contamination showed
colonies of bacillus coli communis and bacillus pyo-
cyaneus. Considering our scanty knowledge of the
cause of thrombosis it seems desirable that further
bacteriological examinations should be made.
Mr. Shattock showed a specimen of spontaneous
carcinoma of the uterus of a rabbit, a disease the ex-
istence of which seems to have been unknown to many
pathologists. It was of interest in reference to Dr.
Lack's experiment last year, the result of which is re-
garded generally as a coincidence, a view taken by
Ml. Shattock on this occasion and supported by Dr.
Coupland and Mr. Bal lance, the latter remarking on
the frequency with which what in first experiments
may be taken for law turns out to be only an incident.
Dr. Auld read a paper giving an account of some
two hundred experiments, extending over two years,
with toxins of pneumococcus. Rabbits were princi-
pally used. In these an increased sensitiveness to the
pneumococcus was produced by inoculation of the
toxins, and that under all circumstances of dosage.
Attempts to immunize in this way, therefore, seem
contraindlcated. This result harmonizes to some ex-
tent with, what has been found in plague and some
other toxins. It was suggested that the intracellular
bodies of the micro-organisms might be more suitably
immunizing agents, as Eoa and Scabia had found a
watery glycerin extract of the dead bodies better than
the diluted virus itself. The occurrence of paralysis
of the fore-legs in two cases was notable as not previ-
ously observed, and may indicate that the poison has
an affinity for the nerves and centres supplying these
parts. Dr. Auld had been helped by Dr. Cartwright
Wood, and in reply to questions said the hypersensi-
tiveness to the toxins was certainly remarkable, but
had also been met with in plague, in diphtheria in
guinea-pigs, and he believed with tuberculin under
certain circum.stances.
At the annual meeting of the Gynecological Society
Dr. W. J. Smyly was elected president for the ensuing
year, and the retiring president, Dr. Macnaughton-
Jones, delivered a valedictory address on "The Corre-
lation between Sexual Function and Insanity and
Crime'in Women." From a careful study of the ques-
tions involved he concludes: (i) That the correlation
of insanity and disordered sexual function arising
from aft'ections of the generative organs is a factor to
be seriously considered in the treatment of the mentally
afflicted. (2) When there is ground to suspect disease
of the uterus or adnexa which might aggravate the
mental affection, a careful examination should be
made, anaesthesia being employed if necessary. (3)
In the investigation of crime committed by women
during the menopause or while the menstrual function
is either active or suppressed, due weight ought to be
attached to the influence on the mind of the woman of
the irregularity or abeyance, and her previous history
and temperament. (4) The special dangers of the
climacteric ought to be considered. (5) After opera-
tions on the female generative organs there is greater
predisposition to mental disturbance than after other
procedures. (6) Women who have been insane are
predisposed to relapse by the development of disease
in or operations on their generative organs. Taking
these conditions into consideration it seems that close
supervision and care are required to anticipate insane
impulses in patients who have shown any symptoms
of mental instability.
Dr. Macnaughton-Jones must feel well rewarded for
his labors as president by the very hearty vote of thanks
which was accorded him by acclamation on the mo-
tion of Dr. Routh, seconded by Dr. Smyly, and sup-
ported by Mr. Stanmore Bishop. The speeches of
these gentlemen were enthusiastic, and their warmth
found an echo throughout the audience.
On Monday the Medical Society was regaled with
a paper by Mr. Lockwood on that continually recur-
ring subject, appendicitis. The paper elicited a dis-
cussion, which was adjourned to February 24th. Mr.
Lockwood illustrated by a number of lantern slides
the appearances described. By means of photographs
of sections he traced the spread of infection through
the lymphatics to the peritoneum. He described the
varieties of the affection from mild appendicular colic
to catarrh, stenosis, ulceration, and gangrene. The
conditions appeared to him to be unfavorable to a
process of natural cure. Fecal concretions are al-
ways associated with ulceration, and JNIr. Lockwood's
2S2
MEDICAL RECORD.
[February lo, 1900
specimens seem to show that they are due to bacteria
— a point not previously noticed. Bacterial accumu-
lation in the appendix seems the cause of both the
ulceration and concretion.
Dr. Allchin admitted that much progress had been
made in our knowledge of this disease, but he de-
fended medical treatment in a considerable number
of cases, and thought surgical intervention only called
for when pus had been formed. In the ordinary run
of cases met with in the medical wards the symptoms
usually subsided in about two weeks, and the patients
seemed practically cured. These were the cases in
which medical treatment was useful, and he regarded
small doses of opium, supplemented sometimes by bel-
ladonna, as a valuable remedy. As to prognosis he at-
tached much importance to an increase in the rapidity
of the pulse. Of course in fulminant and acute cases,
and when pus was diagnosed, surgical intervention
must not be delayed. Relapsing cases were difficult,
but many would be benefited by rest and treatment.
Mr. Barker considered the infection of the lymphatics
as demonstrated in the paper and illustrations. Some
very difficult cases could be e-xplained in this way, e.g:,
those in which inflammation occurred at a distance,
including subphrenic abscess. He agreed that opium
was useful. He insisted on the bactericidal power of
the peritoneum, and was not in the habit of washing
out the abdominal cavity. Even in widespread sup-
puration he limited his intervention to the smallest
possible area of peritoneum.
Dr. F. Smith remarked that in a considerable num-
ber of ulcerated and some gangrenous cases there was
no previous history of pain, a fact also observed in
many cases of gastric ulcer. He said that even in the
post-mortem room it is practically impossible to cleanse
the peritoneum, so that he doubted if the surgeon
could effect it on the operating-table. From a large
number of autopsies he was led to conclude that the
most common position for the appendix was behind
the Cfficum or the ascending colon — so that the sur-
geon should make an incision which would give access
to that region. He regarded rapidity of the pulse and
the occurrence of night sweats as reliable indications.
Sir Michael Foster is a candidate for the represen-
tation of tiie London University in succession to Sir
John Lubbock, who has been raised to the peerage.
Sir Hugh R. Beevor, Bart., M.D., etc., has been ap-
pointed representative of the Society of Apothecaries
in the General Medical Council, vice Mr. Brudenell-
Carter.
Mr. W. H. Power, as was generally anticipated, is
promoted to the principal medical officership of the
Local Government Board, in succession to the late Sir
R. Thorne Thorne. Dr. Franklin Parsons and Dr.
Bruce Low become assistant medical officers.
The committee of inquiry into the excessive death
rate of Dublin, which I told you the lord-lieutenant
contemplated, has been appointed. It was time, for
the registrar-general reports a rate of 49.4 per 1,000
with further increase in deaths from zymotic diseases.
Dr. Grimshaw, registrar-general for Ireland, and
ex-president of the Dublin College of Physicians, died
on Tuesday.
Dr. John Gorham, who died last month, aged eighty-
five years, contributed various medical papers to the
journals, but devoted his work chiefly to science, espe-
cially optics and mineralogy. He was a fellow of the
Botanical and other scientific societies and the con-
tributor of many papers.
Another aged and retired veteran who died lately
was Dr. Humphry Minchin, who took his diplomas in
1838 and 1840. He was for some time professor of
botany at the Dublin College of Surgeons, and many
years treasurer of the Irish Medical Association.
Among other recent deaths are those of Inspector-
General E. T. Mortimer, lately in charge of Haslar
Hospital. He had a very distinguished career in the
navy, and retired in 1894, aged sixty-six 3ears.
Dr. Robert Collum died at the age of eighty-six
years. He served in the East India Company, and
after his retirement took a prominent part in the Soci-
ety of Members of the College of Surgeons.
Dr. O'Sullivan, professor of surgery. Queens Col-
lege, Cork, died aged sixty-four years.
Dr. Samuel R. Mason died suddenly on the eighth
inst. He was professor of midwifery R.C.S.I., and
had been master of the Coombe Lying-in Hospital.
He was only forty-seven years old, and his aged father
(born in 1817), who survives him, was joint founder
with Dr. Ledwich of the Ledwich School of Medicine,
Dublin.
Dr. C. P. Walker, R.A.M.C, died on the fifth
inst., at Ladysmith, from dysentery. He was in the
front at Dundee and Elandslaagte.
FORM OF LEGISLATION WHICH WILL EN-
ABLE CITIES, TOWNS, AND VILLAGES IN
THE STATE OF NEW YORK TO ESTAB-
LISH HOSPITALS FOR THE TREATMENT
OF TUBERCULOSIS.
To THE Editor of the Medical Record.
Sir: The proposition to establish local hospitals for
"consumptives" is based on the following considera-
tion: I. Consumptives must be under strict medical
supervision in order that rules relating to personal
hygiene may be rigidly enforced. 2. W'hh the poor
this supervision can be properly enforced only in a
hospital. 3. As these hospitals are for the poor they
should be located as nearly as possible to their homes.
4. It now appears that if these hospitals are well man-
aged, though located near any village or city on a dry
and protected place, patients recover quite as rapidly
as in a sanatorium on a distant mountain. 5. The
local hospital is a centre cf instruction to the neigh-
boring community of the utmost value, for experience
proves that the people quickly learn from those who
are being treated in the hospital how to prevent the
spread of the germs of tuberculosis, and strictly follow
the rules therein enforced. 6. The cures effected in
the local hospital are more likely to be permanent
than those obtained in hospitals under different cli-
matic conditions. 7. Vast numbers of sick poor will
cherfully enter the local hospital, where they can be
near their homes, who would not go to a distant sana-
torium.
Fortunately we have in tliis State a well-organized
system of public-health administration, which can be
made immediately available in the organization and
management of local hospitals in every community.
The public-health law requires the creation of boards
of health in every city, town, and village in the State.
These boards are composed of the best citizens in
each locality, and as a rule they choose thoroughly
competent medical men as health officers. Finally,
they are under the general jurisdiction of the State
board of health.
The question has arisen, What legislation would
be necessary to enable local boards of health to es-
tablish local hospitals for the treatment of " consump-
tives" within their respective jurisdictions.' The
following sections of a bill to accomplish that pur-
pose have been formulated from the " public-health
law,'' and from a " Circular of Information concern-
ing the Measures adopted by the State Board of
Health for the Prevention of Tuberculosis in the
State of New York." The first four sections are a
nearly literal transcript of that circular, and the pas-
sage of such a bill by the legislature would simply
February lo, 190c]
MEDICAL RECORD.
'■53
give legal effect to the rules and regulations of the
State board of health, now existing, for the preven-
tion of tuberculosis. These sections of a bill are
submitted as suggestions to those engaged in securing
legislation for that purpose.
"Section i. The board of health of the State of
New York having declared, officially, that the com-
municability of tuberculosis or consumption has been
so thoroughly established, and is now so generally
recognized by the medical profession throughout the
world, that it has determined to take such active
measures as may be consistent and possible for the
prevention of the disease among the people of the
State, it is hereby made the duty of said board and
local boards of health to co-operate, as far as practi-
cable, in the enforcement of the measures provided in
this act for the prevention of the spread of tuberculosis.
"Section 2. Local health officers hereafter shall
register the name, address, sex, and age of every per-
son suffering from tuberculosis within their respec-
tive jurisdiction, so far as such information can be
obtained, and all physicians shall forward such infor-
mation to the health officials in the respective jurisdic-
tions in which such cases may occur. This informa-
tion shall be solely for the use of health officers, and
in no case will visits be made to such persons by pub-
lic officials, nor will any public sanitary surveillance
of such patients be assumed, unless the patient resides
in a tenement house, boarding house, or hotel, or un-
less the attending physician requests that an inspec-
tion be made of the premises, and in no case where
the person resides in a tenement house, boarding-
house, or hotel, if the physician requests that no visits
be made by inspectors, and is willing himself to de-
liver circulars of information, or furnish such equiva-
lent information as is required to prevent the exten-
sion of the disease to others.
" Section 3. When a local health officer obtains
knowledge of the existence of cases of pulmonary
tuberculosis residing in tenement houses, boarding-
houses, or hotels, unless the case has been reported
by a physician, and the latter requests that no visits
be made, inspectors will visit the premises and fam-
ily, will leave circulars of information, and instruct
the person suffering from consumption, and the family,
concerning the measures which should be taken to
guard against the spread of the disease; and if it is
considered necessary, will make such recommenda-
tions for the cleaning or renovation of the apartment
as may be required to render it free from infection.
" Section 4. In all cases where it comes to the
knowledge of a local health officer that premises
which have been occupied by consumptives have been
vacated by death or removal, he or an inspector will
visit the premises, and direct the removal of infected
articles, such as carpets, rugs, bedding, etc., for disin-
fection, and will make such written recommendations
to his immediate superior concerning the cleaning
and renovation of the apartment as may be required.
An order embodying these recommendations will then
be issued to the owner of the premises, and compli-
ance with this order will be enforced for sanitary rea-
sons. No other persons than those there residing at the
time will be allowed to occupy such apartments until
the order of the health officer has been complied with.
"Section 5. Whenever any board of health of a
city, town, or village shall certify to the State board
of health that, as a means of preventing the spread of
tuberculosis within its jurisdiction, it is necessary to
establish a hospital or hospitals for the treatment of
persons suffering from that disease, said State board
shall cause an investigation to be made of the condi-
tions alleged to exist, and if it shall appear that there
is a necessity for the hospital or hospitals proposed
by the local board, the State board shall enter upon
its minutes an order directing the establishment of
one or more hospitals for the care and treatment of
persons suffering from tuberculosis within the juris-
diction of the local board making such application,
and shall cause a copy of said order to be forthwith
served upon said local board; on the receipt of said
order, the local board shall cause its entry upon its
minutes, and, as soon as practicable thereafter, shall
proceed to establish the required hospital or hospitals,
but no site or sites shall be selected, nor buildings
erected nor rented for that purpose, without the ap-
proval in writing of the State board of health and the
State architect. Hospitals established under the pro-
visions of this act shall be under the control of the
local board of health having jurisdiction of the dis-
trict within which it is located, except as hereinafter
provided, and shall have power to appoint attending
and resident physicians and such officers, nurses, and
employees as may be necessary for the proper and
economical management of any said hospitals; it shall
prescribe the conditions of admission of patients and
the rules and regulations governing their manage-
ment. All expenses incurred in executing the provi-
sions of this section shall be collected and paid as
provided in section 30 of the public-health law.
" Section 6. Whenever it shall appear to the State
board of health that a hospital or hospitals for the care
and treatment of tuberculosis can be located more ad-
vantageously and managed more economically if one
or more towns and the incorporated villages therein
unite in one sanitary district, as provided in Section
29 of the public-health law, said State board shall
notify the boards of health of the proposed sanitary
district of its decision, and the local boards of iiealth
shall, on receiving such notification, appoint one of
their members to meet representatives of the several
boards of health of the proposed sanitary district, at
such time and place as the State board shall direct,
for the purpose of effecting an organization to super-
vise the establishment and management of one or
more hospitals for the sanitary district thereby cre-
ated. The action taken by the representatives shall
be submitted to their respective boards, and if ap-
proved, each board shall appoint one of its members
to be a member of a board of managers of the hospital
or hospitals to be created, and said board of managers
shall forthwith proceed to establish the hospital or
hospitals authorized by the joint action of the several
boards of health, either by leasing existing buildings
or by the erection of new structures. All expenses
incurred in leasing or erecting buildings, and in the
furnishing and management of the hospital, shall be a
per-capita charge upon the people of each town and
municipality of the sanitary district, to be audited,
levied, collected, and paid in the same manner as the
other charges of , or upon, the town or municipality are
audited, levied, collected, and paid.
"Section 7. The board of managers hereby cre-
ated for the hospital of the sanitary district shall have
the same powers to lease existing buildings, or to
select a site and erect buildings, for the proposed hos-
pital, and to select a visiting and resident staff of
physicians, and to appoint officers, and fix their pay,
and make rules governing the admission of patients,
as local boards of health, as provided in section 5 of this
act, and it shall annually, on or before October ist of
each year, make an itemized report of all expenditures
for the preceding year, together with estimates of
necessary expenditures for the succeeding year; also
statistics of the patients, and the results of treatment;
with such suggestions as the board may deem useful.
A copy of said report shall be furnished to each of the
several boards of health in the sanitary district."
Stephen Smith, M.D.
640 Madison Avenue.
254
MEDICAL RECORD.
[February lo, 1900
J>0ciettj |.>qjorts.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, February 7, igoo.
Willia:m H. Thomson, M.D., President.
Amendment of Federal Tax on Legacies to Chari-
table and Educational Institutions — A petition,
praying for the amendment of the federal tax law re-
garding legacies to charitable and educational institu-
tions, was presented to the Academy for its indorse-
ment, on the ground that the tax was excessive. It
was stated, in the discussion, that the tax, according
to the present law, amounted to one-tenth of the whole
amount of the legac)'. On motion of Dr. Leonard
Weber, tiie Academy gave its official indorsement to
this petition to Congress.
Antivivisection Bill. — The Academy also formally
indorsed the opposition to Senator Gallinger's anti-
vivisection bill.
Causes of Failure of Compensation in Heart
Disease. — Dr. Morris Manges presented a commu-
nication on this subject. He stated that in one hun-
dred and two cases studied by Romberg, the average
duration of compensation had been found to be seven
years. To the myocardium one must look for compen-
sation, and what had been aptly called by Romberg
"decompensation." It was now quite generally ac-
cepted that fatty degeneration played only a minor
part in the production of decompensation. Even un-
due distention of the heart might be successfully met
by a sound heart muscle, but excessive tension of suffi-
cient duration to cause exhaustion of the heart muscle
was most dangerous. It should be remembered that
the rate of normal muscular fatigue varied with the
individual. It had been shown by Theodore Schott
that the normal heart could successfully cope with
acute dilatation. Littell claimed that in hypertrophy
the interstitial tissue increased as well as the mus-
cular fibres. In acute infectious diseases it was not
improbable that acute interstitial changes resulted
directly in an increase of the connective tissue. Ac-
cording to Deyo there might be a myofibrosis affect-
ing the whole heart, but this view had not been sus-
tained by later observers. The nervous system had
also been found at fault, changes having been discov-
ered in the heart ganglia. Hearts which have been
attacked by organic valvular disease from any cause
no longer had a normal myocardium, since the latter
had been involved in foci, or diffusely. While a hy-
pertrophied heart was more liable to arteriosclerosis
of the coronaries, and to chronic myocarditis, yet
proper care of the general nutrition and proper adjust-
ment of the work of the heart might postpone decom-
pensation indefinitely. From the clinical standpoint
it could be said that failure of compensation of the
heart was not a clinical entity. Changes in t-he heart
wall leading to failure of compensation might result
(i) from failure of the general nutrition of the body;
(2) from disturbance of the local nutrition of the
heart; (3) from increased work of the heart; (4) from
functional cardiac disorders. Gout, rheumatism, and
various other constitutional disorders were also potent
factors. More rapid in action were such acute infec-
tions as acute rheumatism, diphtheria, scarlet fever,
typhoid fever, pneumonia, influenza, and sepsis.
Chronic arteriosclerosis was by far the most common
of the causes afifecting local nutrition of the heart.
Hearts with valvular disease and hypertrophy were
specially liable to these disturbances of nutrition.
The danger to the heart of prolonged and violent
physical exercise was now generally recognized. In
this connection it might be mentioned that the muscu-
lar effort associated with parturition would often se-
riously damage the heart already enfeebled by valvu-
litis. Fright or extreme and prolonged worry must
be included among the causes. A final group could
be made of those cases in which much mischief was
caused by the irrational and unnecessary use of drugs
commonly known as cardiac tonics. The popular
abuse of coal-tar products and of the thyroid extract
came under this head, as did also an unv, ise use of
cures for the reduction of obesity.
Aortic Valvulitis and Aortitis Dr. Frank Jack-
son, in this paper, confined his attention chiefly to
the mechanical results of chronic inflammation of the
aortic valves. Chronic inflammation of the aortic
valves, he said, resulted most commonly from rheu-
matism, gout, syphilis, chronic alcoholic poisoning,
and excessive and continued muscular strain. The
result of chronic aortic valvulitis might be primary or
secondary. The primary result would be thickening
and deformity, or perhaps rupture of segments of the
valve. When there was much deformity of the aortic
valve, hypertrophy, dilatation, and irregular action of
the heart resulted. While pure aortic stenosis was
undoubtedly occasionally found, the condition most
commonly passing under that name was one in which
a thickened or stiffened valve was associated with a
systolic murmur heard over the base of the heart with-
out any true stenosis being present. When the valves
were greatly deformed, one found aortic regurgitation
arjd marked hypertrophy and dilatation of the heart.
Aortic insufficiency was as common as aortic stenosis
was uncommon. The causes of aortic insufficiency
were: (i) Congenital malformation of the valves; (2)
traumatic rupture of one or more valves, (3) acute
endocarditis; (4) chronic endocarditis, the result of
rheumatism, strain, syphilis, gout, or chronic alco-
holic poisoning. It was so commonly found in ath-
letes that it had been termed " the athlete's heart."
The effect of the regurgitation of the blood during
diastole might be very considerable. In many of these
cases the patient complained chiefly of a tumultuous
action of the heart, and more or less dyspncea on exer-
tion. In some instances, with moderate leakage of
the valves, compensation might be maintained for
years, and the individual might never know that there
was anything wrong with his heart. Such cases Usu-
ally followed an endocarditis, and were not a part of
a general arteriosclerosis. Sudden death was more
frequent in these cases than in any other form of val-
vular disease, though the majority of these persons
died feeble and emaciated, often of some intercurrent
disease. The physical signs were the murmur, the
enlargement of the heart, the action of this organ, and
the condition of the arteries. The murmur itself must
not be considered as evidence of heart disease. Like-
wise, the absence of a murmur, when there were other"
symptoms of cardiac disease, should not be regarded
as evidence that there is no valvulitis. A murmur
might, and frequently did, appear or disappear repeat-
edly. While such murnuus were most commonly heard
in connection with functional disorder of the heart,
they were also noted in conjunction with organic dis-
ease of the heart. Some murmurs were audible to the
ear and not with the stethoscope, and the reverse of
this was also true. He had no explanation to offer
for this peculiar phenomenon. Again, murmurs did
not always confine themselves to the classical situa-
tion. The murmur of aortic regurgitation particularly
was often heard only over the ensiform cartilage; less
frequently the murmur produced by this lesion was
audible only at the apex of the heart. The cardiac
murmur should be looked upon only as corroborative
evidence of the existence of heart disease, the diagno-
sis not being made on the presence of a murmur only.
February lo, 1900]
MEDICAL RECORD.
255
but upon the size of the heart, the character of its ac-
tion, the condition of its muscle, and the concomitant
symptoms. A tumultuous action of the heart was
sometimes the result of a neurosis, and an apparent
enlargement downward in some instances was to be
explained by a long, narrow thorax, with a thin mus-
cular covering. The condition of the arteries must
be noted, both as regards the presence or absence of
arteriosclerosis, and also as to the tension. In aortic
regurgitation the dyspncea was not very severe so long
as the mitral valve was competent. Painful sensa-
tions were especially common in this form of valvu-
litis, and least common in mitral regurgitation. The
pain was usually substernal and was developed on
exertion, though occasionally it was present when the
person was at rest.
Chronic Aortitis. — Chronic inflammation of the
aorta was usually associated with a similar condition
of the aortic valves. The causes were practically the
same as those of aortic valvulitis. The symptoms de-
pended upon the nature of the changes. If the aorta
was roughened by atheroma, there might be a systolic
murmur unassociated vvith the change in the size or
action of the heart. A thinning of the coats of the
aorta might result in the formation of an aneurismal
sac, and this, in turn, might give rise directly to no
symptoms further than those resulting from pressure,
and a simulation of other conditions.
Recent Methods of Treatment by Baths and Ex-
ercises.— Dr. Thomas E. SATTF;RTHWArrE described
in this paper the methods employed by him in the
past two years. He stated that the exercises consisted
of flexion, extension, adduction, abduction, and rotation
of the limbs, neck, and trunk by the patient, while the
operator resisted. Between each single movement
there was an intermission. Certain respiratory pas-
sive movements he had also found exceedingly useful.
For patients in bed, they were instructed to lie on the
back while the operator passed his hands under the
chest and raised it slowly without lifting the person
actually from the bed. This movement was specially
adapted to obese patients, or to cases of cardiac
dropsy. Each respiratory movement was in the direc-
tion of artificial respiration, and should be repeated
from one to five times a minute. For stronger pa-
tients, they were instructed to sit on a stool w'hile the
operator, standing behind, grasped the axillae, the arms
being raised, and raised the patient upward, at the
same time bending him backward. The various exer-
cises should be so interwoven as to give a pleasing
variety. The se'ance at first should not last more than
fifteen minutes. Slight albuminuria, slight glycosu-
ria, and slight dropsy did not absolutely contraindi-
cate the use of the baths. After the first week of the
baths it was his custom to begin to carbonate them.
The immersion should not be less than four minutes
nor more than fourteen minutes. As a rule, the tem-
perature at first should be 98° F., and an effort should
be made usually to reduce the temperature gradually,
but not more than one degree each time. A bath
should never be made of such a temperature that the
patient, on immersion, feels a sensation of chilliness.
Intermittent baths had been found more useful than
consecutive ones. In neurotic cases it was not advis-
able to use the more concentrated salts. Baths should
not be used in cases of Bright's disease in which the
parenchyma of the kidney was extensively involved.
Many cases of arteriosclerosis were not benefited. In
general, cardiac dropsy, if extensive and advanced,
was not likely to be benefited by such treatment. The
baths and exercises were applicable, in his experi-
ence, to about eighty per cent, of the cases of cardiac
disease with broken compensation.
Dr. Leonard Weber said that as long as the myo-
cardium was not diseased, simple attenuation and hy-
pertrophy would not shorten life. The case w'as very
different when the myocardium was diseased. Incases
of acute rheumatic endocarditis the myocardium was
the seat of an oedematous infiltration, which was, as a
rule, temporary. With reference to the Nauheim treat-
ment, he advised against neurasthenics with cardiac
neuroses being sent there, and likewise rheumatic sub-
jects, because of the great dampness of that place.
He called attention to the fact that physicians when
sending their patients to such bath establishments
were commonly negligent about sending with them an
accurate history, with suggestions as to the treatment.
It was very important that the baths should not be
given too frequently or be of long duration.
Dr. William H. Thomson explained that his rea-
son for arranging for this discussion on cardiac dis-
ease, occupying two meetings of the Academy, was to
direct attention to cardiac conditions that might nec-
essarily have no relation to cardiac murmurs. The
discussion of this evening had shown very clearly that
heart diseases were characterized by a great complex-
ity of symptoms, and Dr. Satterthwaite had insisted
upon leaving the heart alone and directing attention
to the betterment of the circulation through the mus-
cles, and to improving the functions of the various
organs of the body. Personally he believed one of
the greatest mistakes in cardiac therapeutics was the
placing any reliance for permanent benefit on such
drugs as digitalis, strophanthus, strychnine, caffeine,
nitroglycerin, sparteine, etc. These were all nervines,
and no nervine could have any effect on the nutrition;
they served only to stimulate function. Undoubtedly
they were useful to combat temporary danger, or as
adjuvants to what he would call the real remedies.
Throughout the whole animal kingdom muscular power
was in direct proportion to the amount of oxygen used.
In chronic atony of the stomach and intestine; in
chronic atony of the bladder, in chronic bronchitis
and emphysema, there was nothing like an abundant
supply of fresh air, and he believed the gynaecologist
would have to go out of business if all women worked
in the open air. In chronic cardiac disease he always
made it a point to give iron because this was the rem-
edy that helped us to breathe. The mineral ingredi-
ents of the Kissingen water and of the Saratoga Vichy
water were the same as those of the human blood. A
full dose of either of these waters, therefore, amounted
to a full dose of an excess of what was already in the
system; there was no foreign substance to eliminate.
In heart disease he made use of two drugs which he
could not do without, although he was unable to un-
derstand how they acted. One of these was sodium
iodide, which he gave continuously in doses of gr. v.;
the other was calomel, which he gave intermittently.
THE MEDICAL SOCIETY OF THE COUNTY
OF NEW YORK.
Stated Meeting, Janiiciry 2g, igoo.
George B. Fowler, M.D., President.
How the Milk Supply of New York May be Im-
proved Dr. Henry Dwight Chapix opened the
discussion with a communication on this subject
(see page 230).
The Work of the United States Department of
Agriculture in Connection with the Production and
Handling of Milk. — Major Henry E. Alvord, chief
of the dairy division. Bureau of Animal Industry,
Washington, D. C, took up this topic. He said that
the chief object of the department was to improve and
help the farmer, but the department also conducted a
large experimental station. The Bureau of Animal
2^6
MEDICAL RECORD.
[P'ebruary lo, 1900
Industry, he said, had been chiefly in the hands of
veterinarians, and had in years past devoted itself
largely to veterinary matters. Later, it had been en
gaged a good deal in the inspection of meats, and
since July i, 1S95, there had been the dairy division,
under his care. The function of this division was to
acquire and disseminate information useful to dairy-
men. Heretofore there had been but little surplus
dairy products in this country, with the exception of
cheese, but it was probable that in the near future
there would be a greater surplus, and hence the divi-
sion had been looking for foreign markets for such
products. The division had been engaged in a series
of experimental exports of dairy products. U'ith this
same end in view it was the intention to make a good
display of such products by the government at the
Paris Exposition this year.
Number of Cows in the United States. — The first
attempt to count the cows of the United States was
made in 1840, and although this attempt had been
repeated at each decennial census, there had been
no pretence that even an approximate count of the
cows in this country had ever been made. A spe-
cial effort was to be made in connection with the
next census to obtain a fairly accurate count. It was
probable that there were from five to five and a half
millions of cows kept in this country for the purpose
of producing milk for food, or about one cow to every
fourteen persons of all ages. But every cow in this
country does not give more than four quarts of milk
daily, so that the supply is only about half a pint a
day for each person in the United States — not a very
ample supply.
Milk as a Food — The speaker said that the value
of milk as food was not appreciated either by the pro-
ducer or by the consumer. Milk was certainly better
handled now than even a few years ago, and its trans-
portation and distribution were also better. Moreover,
the quality of the milk was better, as shown by the
proportion of butter fat and total solids, and also as
regards its freedom from bacterial contamination.
This improvement he attributed less to legislation
than to the individual enterprise of certain dairymen
and companies. He was of the opinion that the milk
supply was a great deal better than it was regarded by
many people. There had been much unnecessary
alarm over the possible danger of milk as a food.
That milk was sometimes harmful could certainly not
be disputed, but the number of such well-authenticated
cases was proportionately very small. The standard
of three per cent, of butter fat for food was enough for
all practical purposes, as milk containing four per
cent, or more of butter fat frequently had to be re-
duced in order to make it acceptable to the human
stomach. A moderately low percentage of butter fat
was not really harmful, except in a commercial sense.
From a careful survey of the milk supply of the
United States as a whole, the speaker said that he felt
entirely safe in saying that the actual presence of dis-
ease germs in such milk supply was very rare, and the
cases of actual injury from these germs was rarer still.
The great mass of evidence on this subject was nega-
tive, and in favor of milk rather than against it.
Any one could satisfy himself of this by personal
search of the official records.
Sterilization and Pasteurization Condemned •
All were agreed as to the undesirability of adding
preservatives to milk, for they were simply a premium
on carelessness, filth, and dishonesty. He felt strong-
ly disposed to make the same statement regarding both
sterilization and pasteurization. These methods
should be employed only under certain circumstances,
and by no means as the rule. Condensed milk was
much less digestible than good natural milk; there
should be further and more scientific research regard-
ing the digestibility both of condensed milk and of
milk that has been sterilized or pasteurized. He
would, at the present time, advocate pure natural milk
over all other preparations of milk as food.
Food Value of Skimmed Milk. — Concerning the
food value of skimmed milk the speaker remarked
that one hundred pounds of skimmed milk contained
more valuable food for the human being than one
hundred pounds of whole milk. Butter fat had its
function in the human economy, but it was not the
valuable portion of the milk as a food.
New York Health Board Arraigned. — With the
greatest energy possible the speaker characterized the
attitude of this city on this skimmed-milk question.
He declared that there was no difficulty in regulating
the sale of skimmed milk, if it was only energetically
undertaken. Of course, prohibition was easier, but
the attitude of New York City on this question was
that of a lazy man. There was no article of animal
food produced on this continent which could compare
in usefulness, and pound for pound when bought at
the market prices, with skimmed milk, and yet the
sale of this article was prohibited in New York City
simply because the city authorities had not felt like
exerting themselves sufficiently to regulate properly
this most desirable traffic. Skimmed milk was sold
in Boston, and very largely in the Connecticut valley
to the milk operatives, and the latter partook very
largely of this product, greatly to their advantage.
Another great inconsistency on the part of the authori-
ties of New York City was that they freely admitted
condensed skimmed milk (condensed milk sold at low
prices in the city) but barred out ordinary natural
skimmed milk.
Dairy Bacteriology Professor H. W. Conn, of
Wesleyan University. Middletown, Conn., discussed
this topic. He introduced it by saying that he did
not purpose to treat of it from the standpoint of an
alarmist, for he was far from being that. If the ordi-
nary sediment from milk was studied under the micro-
scope, it would be found, he said, to consist of sticks,
insects' legs and wings, of hay, of blood and pus — in
fact, almost everything possible in the way of dirt,
but, alas! a large part of it was excrement. It had
been estimated that New York City consumed at least
three hundred pounds of cow's excrement daily. He
was glad to say that some of the milk-supply com-
panies were endeavoring to bring about a better con-
dition of things.
The Centrifuge and the Strainer Actually In-
crease the Number of Bacteria. — The centrifugal
machine or the strainer only succeeded in removing
the coarser portions of this dirt, and certainly bacte-
rial contamination was not in the least affected by
straining or by the action of the centrifugal machine.
It was a well-known fact that both these processes
really increased the number of bacteria by actual
count. This was to be explained by the fact that a
large number of bacteria were often confined in
masses of dirt, and, as these masses \vere broken up
by the centrifugal macliine or by the strainer, the
bacteria were distributed throughout the milk.
Number of Bacteria in Milk. — The cow was the
great source of bacteria in milk. The number might
vary from three or four thousand per cubic centimetre
in very good milk up to ten or twenty million per cu-
bic inch. Ordinary city milk contained from three
to six million of bacteria per cubic centimetre. The
number of bacteria varied with the cleanliness of the
dairy, the age of the milk, and the temperature at
which it had been kept.
Flavor of Butter due to Bacteria. — The presence
of these bacteria had caused the development of the
milk industry as it existed in this country. To these
bacteria was to be attributed the delicate flavor of
February lo, 1900]
MEDICAL RECORD.
257
good butter. Butter made from cream free from bac-
teria was tasteless. While this was the kind of butter
relished and purchased in Europe, it was not at all
marketable in this country. The taste of cheese was
also largely dependent upon the presence of bacteria.
Pathogenic Bacteria in Milk.— Only a few of the
bacteria found in milk were parasitic, and they were
the pathogenic bacteria as distinguished from the non-
pathogenic. Fortunately, we could almost count on
the fingers of one hand the number of human diseases
that could be attributed to the milk supply.
Diseases Attributable to Milk. — These diseases
were divisible into three types. The first type came
from the cow ; the second type came from the second-
ary contamination, and tiie third type was the result
of poisons produced by the bacteria growing in the
milk rather than from bacteria growing in the human
organism.
Tuberculosis from Milk — There was only one
disease of any importance that could be traced to the
cow herself, i.e., tuberculosis. His own opinion was
that the danger of tuberculosis from milk had been
vastly exaggerated. In the first place, tuberculosis
was present to a considerable extent in the milch
cows of all civilized countries, though the extent
could not be stated by an average percentage because
of the very great variations in different herds. In the
next place, a tuberculous cow might produce milk im-
pregnated with tubercle bacilli. Again, if the tuber-
culosis was located in the udder, the cow would produce
milk that was impregnated with these bacilli. It was
still uncertain whether a cow having tuberculosis any-
where else than in the milk glands could, under ordi-
nary circumstances, produce milk with the tubercle
bacillus therein. Of course he did not refer to a con-
dition of general tuberculosis. Milk containing the
tubercle bacillus might produce tuberculosis in a per-
son using that milk. The foregoing statements he
believed no one would question, and, this being al-
lowed, the next question to consider was, How great
was this danger of contracting tuberculosis from par-
taking of milk.' It was probable that this danger was
vastly less than had been supposed for a few years.
The great seat for tuberculosis in mankind was the
lungs, and the entrance of the disease into the lungs
was, of course, by respiration, and not by swallowing.
Again, if the bacteria in milk produced tuberculosis
in man, they would more likely produce intestinal
tuberculosis; yet intestinal tuberculosis was not so
very common in mankind. Moreover, the bacteria in
milk must run the gauntlet of the gastric juice and the
hydrochloric acid contained in this juice, as well as
the intestinal juices before they had any opportunity
to enter the system and do any harm.
Probably Different Germs for Human and Bovine
Tuberculosis. — It was also extremely probable that
the variety of tubercle bacillus producing the disease
in man was slightly different from the one producing
the disease in the cow. They belonged to the same
species, but, within a few months, very good evidence
had been collected to the effect that the tubercle bacil-
lus for the cow was not particularly pathogenic for the
human being, and v/i<; 'iicrsa. It must also be remem-
bered that tuberculosis in mankind was decreasing in
all civilized communities, while tuberculosis in cattle
was increasing very rapidly. This decrease of tuber-
culosis in mankind was equally great in the United
States and in England, where milk was drunk raw, as it
was in Germany and continental nations generally
where the milk was customarily drunk in a practically
sterile state. All these facts seemed to the speaker
to indicate that the danger of tuberculosis from the
milk had been grossly exaggerated. Undoubtedly
there was a danger — to young children, perhaps, a
considerable danger — but there was danger in going
to the theatre, and he was inclined to think that the
adult ran more risk from going to the theatre than
from drinking ordinary raw milk.
Other Less Common Infections — It was probable
that the cow sometimes had scarlet fever and diph-
theria, and, if this was the case, these bacilli might at
times get into the milk, and distribute these diseases
to children. While there was a probability, such in-
fection was not very common. Another danger was
acute enteritis produced by milk. However, of the
first class of diseases — those coming from the cow —
tuberculous infection was the only one of much im-
portance.
Typhoid Infection. — Of the diseases coming to the
human being by secondary contamination, typhoid
fever stood out pre-eminently. It was well known
that many epidemics of typhoid fever had been traced
to the milk supply; within the last five years un-
doubtedly as many as fifty such epidemics had been
traced to such a source. The reason for this was that
the typhoid bacillus was capable of multiplying and
growing in the milk, so that if only a few typhoid
bacilli got into the milk, they would multiply rapidly.
This was in sharp contrast with the behavior of the
tubercle bacillus, which did not multiply and grow in
milk. An occasional epidemic of scarlet fever or of
diphtheria could be traced to secondary infection with
the germs of these diseases, though no cases of this
kind were on record in this country.
Diarrhoeal Diseases A large proportion of the
many intestinal troubles observed in hot weather
could be traced to milk, but not to any particular
bacillus or germ. They were the result of the abun-
dant growth of many bacteria in the milk and the
formation of certain toxins. Probably most cases of
cholera infantum could be traced to milk in which
there had been an undue multiplication of some of
the common forms of bacteria not ordinarily looked
upon as pathogenic.
Pasteurization. — It was impossible for milk dealers
to insure the cleanliness of their milk in the present
state of civilization in this country. Physicians and
scientists might demand it; they might hold it up as
an ideal, but we should not forget that " it was a con-
dition and not a theory that confronted us." The
speaker said that he heartily agreed with the preced-
ing speaker regarding the undesirability of steriliza-
tion and pasteurization ; nevertheless, with the present
state of our milk supply we could not reject steriliza-
tion and pasteurization on the theory that they would
encourage uncleanliness in the dairy. The significant
fact was recalled that pasteurized milk was sold on a
large scale in the city of Copenhagen at the same
price as other milk, and the reason given for this was
that less care was required in the cooling and handling
of milk intended to be preserved in this way before
being put on the market.
Good Milk Demands a Good Price. — He would
reserve pasteurization for special mstances. In con-
clusion, he would say regarding the quality of milk
that everything which tended to cheapen milk did
more to lower the standard of quality than almost
anything else that could be done. If good milk was
wanted, a good price should be paid for it.
The Work of the New York Board of Health.—
Dr. Herman Betz, chief inspector of the milk in the
health department, discussed the work of the board in
connection with the inspection of milk. He said that
the borough of Manhattan was divided into nine milk
inspection districts. There were ten milk inspectors,
and each district comprised about six or seven hun-
dred milk stores. In 1899 the inspectors had made
8,047 inspections, examined 48,832 specimens of
milk, and caused 117 arrests. The fines collected
had amounted to $3,705. It was worthy of note that
258
MEDICAL RECORD,
[February lo, 1900
only eighty-four quarts of milk had been destroyed in
the year 1899, although a total of ten million pounds
of foodstuffs had been condemned in that year by the
health department. Dr. Betz described in detail the
apparatus employed, and the method of conducting
the inspection of the milk, and the collection of sam-
ples for analysis. To facilitate the work of the depart-
ment in tracing any individual can of milk, the cover
of each can was marked with the name of the dealer,
the road bringing it into the market, and the number
of the station whence it came. If the analysis of a
suspected sample of milk showed that it was more
than five per cent, low in solids or three per cent, low
in butter fat, a warrant was issued for the arrest of the
milk dealer, and prosecution was commenced. Since
1896 every milk dealer had been required to obtain a
permit from the health department, which was issued
only after satisfactory inspection of the place from
which the milk was to be sold. This permit was re-
voked, and the dealer no longer allowed to continue
in the business, after he had been arrested and con-
victed twice for selling milk below the required stand-
ard.
Condensed Milk from Skimmed Milk Not on
Sale Here. — In reply to the criticism of Major Al-
vord. Dr. Betz said that no condensed milk made
from skimmed milk was allowed to be sold in this
city. Only that very day two warrants had been is-
sued for the arrest of dealers selling such an article.
The department had succeeded in absolutely driving
out from the city milk containing chemical preserva-
tives.
The Question from the Milk Dealers' Standpoint.
— Mr. a. Cuddebach took up the discussion from this
point of view. He said that the milk sold now con-
tained much more butter fat than formerly, and this,
he believed, was largely attributable to the quite gen-
eral adoption of bottled milk, and the education of the
people to look at the depth of the layer of cream in
the bottle. The general tendency to consolidation
among the milk dealers could also be traced to the
custom of bottling the milk, because small dealers
could not afford to bear alone the expense of such
business. This consolidation also permitted the use
of ice-cars for transportation where it would other-
wise be impossible. The milk within half an hour
after being received was packed in ice, and remained
so packed until sold to the consumer. He had found
that the centrifuge removed all dirt visible to the un-
aided eye. When the centrifuge was used, even
though no butter fat was removed, the cream did not
rise so readily, and hence to the public the milk did
not appear 10 be so rich as when it had not been sub-
jected to this process. The great obstacle that the
milk dealer had to surmount was the lack of apprecia-
tion on the part of the public of many of the efforts
made to secure better milk; hence such efforts were
not commercially successful.
Some Milk Dealers Possessed the Milk of Hu-
man Kindness. — Mr. L. B. Halsev spoke on the
same topic. The occasion seemed to him unique, for,
in a long experience in this city, it was the first time
the milk dealers had been cordially invited to meet
the medical profession in the discussion of tiiis very
important subject. The discussion had impressed
him chiefly with the thought that the milk supply of
New York City was not so bad after all, and, indeed,
was better than when the discussion had been opened.
It was a grievous wrong to suppose that there were not
in "this city some milk dealers who were desirous of
improving the milk supply purely for the good of
humanity, and entirely aside from selfish interest;
nevertheless it was but just that the milk dealer
should receive an adequate compensation for effecting
an improvement in the milk supply.
Adequate Compensation Essential. — Such improve-
ment presupposed that the dealer had required of the
dairymen better care, better food, and better environ-
ment generally for the cows, and better handling of
the milk. It meant that the milk must be aerated
and promptly cooled and quickly delivered to the
transportation company. All this certainly could not
be accomplished without proper remuneration. He
thought all milk dealers here would agree with him
that it was impossible, under present conditions, to
distribute milk in small quantities to families at less
than eight cents per quart.
The Wealthy Citizen Blocks Progress.— The
speaker called attention to the fact that the wealthy
citizens of New York actually blocked progress toward
getting an ideal milk supply, though perhaps uncon-
sciously. These people give a stated sum to their
chefs, and these high functionaries demand from ten
to twenty per cent, commission, and if the milk dealer
was sufficiently liberal in this respect almost any kind
of milk would pass muster. The hands of the con-
scientious and progressive milk dealers in this city
were upheld chiefly by the physicians and by those
earnest and intelligent mothers who spared neither
pains nor money to secure for their children the best
and most wholesome food.
Our Health Board's Methods Antiquated. — Dr. H.
PiFFARD said that the chief trouble with the milk sup-
ply of this city had been the improper regulations of
the milk traffic by the health board many years ago,
and which had been allowed to remain. He had been
informed that the improvement that had been made
had resulted from the efforts of the commercial men,
and not of the health board. The standard of three
per cent, of butter fat was very low when compared
with the general average for the cows in this country.
Dr. Piffard expressed himself as in favor of having
the standard of milk properly defined, and also allow-
ing other and inferior milks to be sold at a lower
price.
Double Standard Absurd. — The double standard
of three per cent, butter fat and four per cent, total
solids had been shown some time ago by Major Al-
vord to be injudicious. He had shoviJn that the farm-
ers would sophisticate the milk in order to bring it up
to the required standard of total solids. It had been
shown that the casein varied directly with the pro-
portion of butter fat. With the minimum of butter
fat and the maximum of casein one might feel pretty
sure that the milk had been sophisticated. In certain
counties, notably Cortland, this absurd double stand-
ard had demoralized the dairy interests. For example,
many of the cows would furnish four per cent, milk,
but as such milk would not bring one penny more in
New York market, and cows yielding only three pei
cent, milk were cheaper, the dairymen had sold their
better cows, and had bought in their place inferior
ones. This was the way in which this double stand-
ard had demoralized the dairy industry. Dr. Piffard
recommended that the milk for this city coming in cans
should be taken only from an area included in an east-
and-west line tlrawn through Albany, and a north-and-
south line drawn through Binghamton.
Special Committee Appointed — On motion of Dr.
Walter Lester Carr the president of the Medical
Society of the County of New York was requested to
appoint a special committee to consider the possibility
of a commission to improve the milk supply of New
York, the committee to report to the comitia minora
the result of its deliberations.
Nocturnal Enuresis. — Mullein oil in five-drop doses
on loaf sugar, on retiring. — Ed. Experiena\ December,
February lo, 1900J
MEDICAL RECORD.
259
MEDICAL SOCIETY OF THE STATE OF
NEW YORK.
-Ninety-Fnurth Annual Meeting, Held in the City Hall,
Albany, January JO and ;^ I atid February /, igoo.
Willis G. MacDonald, M.D., of Albany,
President.
Third Day — Thursday, February ist.
iC\„ul.;a-eJ /.■„,„ fag,- JIJ.,
Heport of Committee on Medical Expert Testimony.
— Dr. Ransom, of Dannemora, presented this report.
It stated that a bill had been introduced into the leg-
islature providing for the registration, certification,
and qualification of medical experts, and the passage
of this measure had been urged by the committee, but
to no avail, the bill failing to be reported out of the
judiciary committee. This failure was due to a lack
of proper support by the medical profession at large.
After consultation the committee felt justified in stat-
ing that there was no prospect of obtaining any cor-
rective legislation at this time in this direction, in
view of constitutional restrictions and limitations, and
more especially because of the attitude of the legal
profession concerning any innovation in this direction.
Indeed, it seemed to be the consensus of opinion that
no such legislation could be applied even if enacted.
The committee indorsed the suggestions made by the
president of the society in his inaugural address be-
fore the present meeting, i.e., an appropriation for a
State cancer laboratory.
On motion of Dr. Chauncey P. Biggs, the society
expressed its formal approval of the work being done
by Dr. Roswell Park and his associates at this labo-
ratory in Buffalo, and requested that State aid be con-
tinued to this institution.
The Spleen : its Shape and Relation to the
Chest Wall and Abdominal Viscera. — Dr. Luzerne
CovELLE, of Ithaca, read a paper with this title. He
stated that in four well-known text-books on anatomy,
the descriptions of the size, location, and shape of the
spleen varied considerably. His own observations
showed that the spleen lay obliquely across the ribs,
extending toward or to a line dropped vertically from
the posterior border of the axilla to the eleventh rib.
The angle of the ninth rib was approximately a rib-
space below the inferior angle of the scapula. The
posterior axillary line nearly touched the tip of the
eleventh rib The highest point of the spleen lay
about one rib-space below the inferior angle of the
scapula, when the arms were hanging naturally. The
innermost part lay about double that distance from the
spine. The outermost point about touched the poste-
rior axillary line. The anterior and posterior borders
lay under the cover of the ninth and tenth and elev-
enth ribs. The spleen was often very movable. The
child's spleen was much larger in proportion and
reached much higher and farther forward. The spleen
of old age is the reverse of this.
Supra-Vaginal Hystero-Myomectomy Dr. I. S.
Stone, of Washington, D. C, reported in this paper
twelve cases in which tumors of greater or less size
had been removed from the uterus, and in all of which
considerable traumatism had resulted. The object of
the paper was to show that there was relatively a
greater mortality from the operation of myomectomy
than from ordinary hysterectomy.
Atresia of the Vagina Dr. F. W. Higgins, of
Cortland, read this paper. He stated that in all the
varied etiology of atresia of the vagina, diphtheria may
be considered as one of the rarer causes. He had re-
cently operated successfully upon a typical case due to
this cause. Twenty-four ounces of blood iiad been
found in the dilated uterus and vagina. Attention was
called to the importance of early operation before the
Fallopian tubes were affected, and also to the neces-
sity of strict asepsis. He recommended flushing the
cavity with hot saline solution, wiping dry, and pack-
ing with iodoform gauze.
Spontaneous Discharge of Cerebro-Spinal Fluid
from the Nose. — Dr. W. Freudenthal, of New York,
reported a case of this kind, and stated that he knew
of only one such case having been previously reported
in this country. His patient used more than twenty
handkerchiefs daily because of a constant dribbling of
a watery fluid day and night. Before this flow had
commenced there had been serious symptoms of brain
pressure, and these symptoms had recurred once or
twice, when, for some reason, the flow had been inter-
rupted. The original cause was probably pressure
produced by a tumor, and life had been prolonged by
the formation of an opening and the discharge of suffi-
cient cerebro-spinal fluid to prevent dangerous cere-
bral pressure. A chemical analysis of the fluid showed
the presence of albumin and a substance which reduced
glucose.
Inguinal Hernia : Comparative Results of Radical
Treatment by Injection — Dr. Thomas P. Scully, of
Rome, in this paper spoke highly of the present results
obtainable by the Bassini operation. But for the la-
boring classes, to which long confinement in bed was a
serious matter, he recommended the Hecton injection
method. These injections should be made under strict
asepsis, being repeated once a week for about four
weeks. An accurately fitting truss should be applied
after the first injection, and should be worn at least
two months, though it was preferable to use some form
of light protection for six months longer. He had
treated one hundied and forty-eight cases by this
method. Of the one hundred and twenty single her-
nias, fifty-eight, or forty-eight per cent., had had no
recurrence after one year, and of forty cases traced
after two years twenty-six per cent, were not wearing a
truss. All of the sixty-two cases not resulting in cure
had been more or less benefited. The greatest success
had been achieved in the recent hernias.
Dr. a. M. Phelps, of New York, deprecated this
attempt to revive a method which had been proved by
a Boston commission to yield ninety-five per cent, of
relapses. Dr. Phelps then described his operation,
and the use of the network of fine silver wire to assist
in closing the canal.
Officers Elected. — Officers were elected as follows:
President, Dr. A. M. Phelps, of New York, Vice-Pres-
idenf, Dr. George Seymour, of Utica ; Secretary, Dr, F.
C. Curtis, of Albany; Treasurer, Dr. O. D. Ball, of
Albany.
THE NEW YORK MEDICAL UNION.
Meeting of December 26, l8gg.
Dr. Le Roy W. Hubbard, President, in the
Chair.
The Results of the So-Called Conservative Treat-
ment of Appendicitis. — Dr. Samuel Lloyd read a
paper with this title (see page 226).
Discussion. — Dr. Robert T. Morris-. We all know
what the real conservative treatment is to-day; it is
not a matter for discussion. It seems to me, at the
present time, we are to be guided by a knowledge of
the pathology of the disease, rather than by any per-
sonal experience. The time for that is past. There
are now few subjects better understood than appendi-
citis. We know the causation thoroughly, the patho-
logical changes thoroughly, the symptomatology thor-
oughly, and there is hardly any part of the entire
subject not within our knowledge. Therefore to-night
26o
MEDICAL RECORD.
[February lo, 1900
I shall confine my remarks to a few of the points
brought out in the paper.
In the first place, I am glad Dr. Lloyd is one of the
men who keep records of the cases not operated upon.
Few physicians keep good records, and they speak
from a standpoint of memory and of incomplete obser-
vation. It is a difficult matter to get a good collec-
tion of statistics such as Dr. Lloyd has. I have
operated upon many patients who are still reported as
cured by medical treatment. We know to-day that
more than ten per cent, of all appendicitis patients
have hard concretions in the appendix; we know to-day
that more than eighty per cent, of the patients who
have had one attack have mucous inclusions, more or
less complete. This percentage does not include soft
fecal masses which predispose to appendicitis. Na-
ture makes efforts to throw off this fecal matter, and I
am sure that a good many cases are caused by soft
fecal masses in the appendix. There follows a spasm
of the muscularis of the bowel which gives rise to a
catarrhal inflammation with consecutive infection of
the appendix. When the guarding epithelium of the
mucosa is damaged infection follows. In the report
of the cases treated without operation we note two
points not usually brought out by writers. Almost all
of the patients who come to me after having had one,
two, or three attacks give a history of ill health dating
from the time of their first attack; and yet they kept
about their work, appeared to be quite well, were con-
gratulated upon escaping operation, etc. Experience
goes to show that many persons who report themselves
in good health have had constipation, or gas forma-
tion, and do not feel vigorous or ambitious. They
do not enjoy the enterprise they formerly did, and yet
they say tliat they are pretty well. This condition of
inferior health is due to several causes: First, it is
often due to infection from a mucous inclusion; sec-
ondly, it is often due to adhesions of the bowel inhib-
iting peristalsis; thirdly, it is sometimes due to re-
flex disturbance of Auerbach's plexus and Meissner's
plexus, fermentation taking the place of digestion.
There is not much difficulty in palpating the appen-
dix; if one will give attention to it he will become
expert. I have no doubt that most of the members
present have no difficulty in palpating the ovaries and
tubes; any man who can palpate the oviducts can pal-
pate the appendix as well. I have frequently done it
before the class. To do it one must train his finger
ends. This matter of palpating the appendix should
be acquired by any one who intends to express an
opinion on the subject of appendicitis.
Patients refusing to have an operation performed is
an experience I do not have, so I do not know how to
discuss that point. It seems to me that patients are
always ready for an appendix operation. I count
upon that fact in consultations. Usually it is the
cook, or the mother-in-law, who is opposed to the op-
eration, not the patient. I have been called in to un-
ravel this knot many times, and, instead of arguing for
several hours at ten dollars per hour, I say, "Let us
leave it to the patient." Patients say, "Operate."
Of course I am referring only to acute cases, cases in
which there is an acute progressive inflammation. In
the interval cases I have frequently had occasion to
ask for delay, in those cases in which the patients have
had the management of large business affairs, and in
which they ask for a delay of one, two, or three months;
in these cases I often say: "Wait; we are ready to
operate ; but let me know at once when symptoms of
acute recurrence make themselves known." But I can-
not now recall a case in which there was acute suffering
and the patient did not say, "Operate." It is a com-
mon thing for patients to postpone operation because
of the idea that they might save time by it. One of
my patients, who has been but nine days in bed since
operation and goes home to-day, had previously been
eight weeks in bed trying to save time. An idea that
many patients have is that they lose time if operated
upon. If operated upon, they usually spend but nine
or ten days in bed, unless there is abscess complica-
tion at the time of operation.
Dr. Lloyd's point about recurrence after abscess had
emptied into the bowel is a common experience. No
one knows where the abscess is going to empty,
whether into the bladder, or into the iliac vein, or
elsewhere, and yet the patients may have recurrence
of the attack. This we know from the pathology of the
disease. I had one case in the sister of a physician
who evacuated pus from the mouth after perforation
of the lung, and from the vagina at the same time;
nearly one gallon of pus was thus evacuated. She re-
covered and was congratulated perhaps upon escaping
operation; yet she had a subsequent attack, was op-
erated upon, and the appendix was removed, and it
was a pretty good appendix. A mucous inclusion was
present.
Patients suffer less under proper surgical treatment
than under medical treatment. The replies of pa-
tients, ten in number, who had been operated upon,
were published in the third edition of my book; they
all made the statement that they suffered less under
the surgical treatment. Several of these ten were ab-
scess cases , several of them had had many attacks and
had been subjected to different kinds of treatment, and
all give testimony which I published.
After all, it seems to me that we are to be guided
by our knowledge of the pathology of the disease rather
than by personal observation.
Dr. Foot; I was called by a young surgeon of this
city about one year ago to see an unusual case of ap-
pendicitis. A young lady, in pretty good health and
well educated, asserted that she had passed hairs from
the rectum, and the doctor had been shown some of
the hairs, which were partly extruding. She was very
indignant at the suggestion that she had introduced
the hairs herself. The question of dermoid cyst was
gone over, and a history of chronic appendicitis was
elicited. We operated upon her and removed the ap-
pendix. She made an excellent recovery. A few days
ago I met her and I inquired about the hairs. She
told me she had passed hairs, had been operated upon,
and had been cured of all symptoms, no more hairs
appearing.
Dr. a. F. Currier: I cannot help thinking, as Dr.
Morris discussed this question, that while he always
discusses this question with great amiability, the ques-
tion of conservative treatment of appendicitis, yet it is
a great deal like the old bull and the piece of cloth.
I feel mucii gratified with the series of cases which
we had read to us to-night, because the older in expe-
rience I become in the treatment of this disease the
more convinced I become that these statements which
have been made are facts. That is to say, if a person
has an attack of appendicitis he may get well of
it; we cannot say he will not. We never can say
that a person will never have another attack. That is
the argument that I always make to people now, at the
time I first see them. Most of the cases that I now
see are in the acute period, and my experience has
been limited to that form of the disease. I can bear
out from recent experiences the statements of Dr. Mor-
ris regarding the relief which cases obtain after surgi-
cal work is done. I remember an operation done a
few weeks ago on a man weighing three hundred and
sixty pounds; in this case I defy any man, including
Dr. Morris, to palpate the appendix. He was a car-
penter and suffered for days and weeks, going around
with pain in his side. He suffered acutely. I op-
erated, and after he came out of the ether I asked him
about the pain, and he said it was all gone. He has
February lo, 1900]
MEDICAL RECORD.
261
not complained of pain since. I also remember the
case of a boy, operated upon a few weeks ago, and he
gave the same story regarding the pain. That is an
important point. In the course of quite a consider-
able number of cases operated upon I could recall but
two cases in which I could feel any regret at adopting
the surgical procedures. There is another class of cases
in which the patients feel that they are going to die,
and they decline operation. One of these cases I re-
member had the diagnosis made of appendicitis, and
the case seemed clear enough; there were pain in the
right side, induration, and other symptoms of this
trouble. I saw her one night. The next morning I
again saw her, and she stated that the pain was all
gone, and she declined to have the operation done.
The doctor in attendance said I had come to operate,
and so the operation must be done. I found the ap-
pendix not very large, but it was diseased. There was
some peritonitis, but I also found an enormously hy-
pertrophied liver. The husband threatened to sue me,
but the woman has been perfectly well since, and now
rides a bicycle. Another case was that of a woman
who had been ailing for some time, and the diagnosis
of appendicitis was made; the abdomen was opened,
but there was not found much inflammation of the ap-
pendix itself. Now, what impressed itself upon me
was the fact that all were cases of peritonitis, and
when peritonitis existed we could not always tell
whether we were dealing with an appendicitis or not.
I have often asked why it was that peritonitis chooses
this portion of the abdomen; is it because the appen-
dix lies there, and is subject to changes? It is cer-
tainly a fact that in a great many cases I have seen, in
which there is no abscess and the appendix was buried
in adhesions, the circulation was interfered with and
was a constant menace to life. The more experience
I get the more satisfied I am that true conservatism
means the relief of the offending organ.
Dr. p. J. Lynch: In olden times we generally
found the cases associated with peritonitis. I have
seen, what all gentlemen who have practised medicine
have seen, several cases which were treated conserva-
tively; a few of them got well after two or three re-
lapses, and some are now well after a period of five
or six years and have no constitutional disturbances
whatever. From my own experience with these cases,
and from the fact that the general consensus of opin-
ion is in favor of operative interference, I now turn
them over to the surgeon. There is only one thing I
regard as the probable reason why all patients do not
select the surgeon in the treatment of this disease; it
is because a certain percentage, surgically treated,
have died cured. That little fact impresses the un-
educated, and they are disinclined to have opera-
tion performed. I myself am disposed to turn my
cases over to the surgeon, even though I think that
many will get well without interference.
Dr. F. Huber: a long period of freedom took
place in appendicitis in my own case. Seven years
ago I had typhoid fever. During convalescence I de-
veloped appendicitis, from which I recovered under
the use of ice and small doses of opium and rectal
enemata. Seven years later I awoke one morning and
I knew then what I had. Thirty-six hours later I was
placed on the table, my belly was opened, and was
found to be filled with serum. My appendix was dis-
tended and a large concretion existed. In the inter-
val between the first and second attack I was abso-
lutely free from any manifestations at all.
Dr. a. Trautman : Of the last four cases I have had,
three were not operated upon and got well, and one
was operated upon and died the following day.
Dr. Ralph Waldo: I belong in the same class as
Dr. Huber, for seven years ago I was operated on for
appendicitis. There were two perforations, and it was
necessary to pack the wound. The operation relieved
the pain as well as many of the other disagreeable
symptoms.
There are several things you should properly im-
press upon your patients. One is that the operation
for appendicitis, properly performed, does not kill.
If performed at an improper time it may not cure your
patients. That is of vital importance to your patients.
You can tell them that it is just as proper to consider
that the glass of water that a patient took during his
attack of pneumonia caused the death of the patient.
I am sorry that I must disagree with Dr. Morris re-
garding the etiology of appendicitis. I recognize the
fact that in certain cases concretions and foreign sub-
stances have a good deal to do with the wounding of
the epithelial surfaces which is followed by infection.
The disease is an inflammatory one, and one or another
variety of inflammation affects the appendix and neigh-
boring structures in different degrees. There are many
cases of appendicitis associated with intestinal indi-
gestion, in which the latter is markedly improved, but
not completely cured, after operation. I am thor-
oughly convinced that quite a large percentage of cases
of appendicitis are simply an extension of an inflamma-
tory disease from the colon into the appendix ; the
same as catarrh of the nose extends into the Eustachian
tube, producing disease there and in the ear. In the
same \Vay an endometritis may extend and produce
inflammation of the Fallopian tubes. I am thoroughly
convinced that that is a prominent point in the pathol-
ogy of this disease. It has been referred to. Concre-
tions in the appendix, even hard ones or seeds, may
not cause disturbance for a long period of time. In
the same way one may have a hernia without any dis-
turbances; as soon as it becomes strangulated we then
have a local inflammation. The blood supply to the
appendix is bad, and sudden attacks of gangrene may
come on from conditions that in other portions of the
intestinal tract would amount to. little. Appendicitis
will not kill every patient if let alone. An)' one will
get the statements from his patients that Dr. Morris
did in writing to the ten he operated upon. All of
them will say that the operation afforded the greatest
relief from their suffering, even in many cases in which
the patients had marked sepsis before operation. If
these patients are takfen at the proper time, they will
probably all be cured. This operation does not kill
patients.
Dr. Hammond: It is hardly right for a neurologist
to discuss this subject. I was very much interested
and instructed by the paper. Of coutse, even though
we are neurologists, we occasionally see cases of ap-
pendicitis; all practitioners do. It always seemed to
me advisable in all of these cases to operate. When
I say operate, I mean operate at the proper time.. We
know that when a person has had one attack of appen-
dicitis he will probably have another attack. In con-
sidering the question of operation, we should look
into the present condition of the patient and consider
the history of the case. It is our duty to urge opera-
tion when we know that it can be done so safely and
without any danger at all, and that it will spare the
individual the chances of a future attack of appendi-
citis and death. Therefore I recommend that these
cases should be operated upon. If they have a mild
attack, conservative treatment may carry them through
it; but as soon as recovery takes place let them be
operated upon, and so have no chances of future
trouble.
Dr. Hubbard: Dr. Morris spoke of the ill health
of the people after recovery — or so-called recovery —
following the conservative treatment; I should like to
ask the doctor to tell us what, in his experience, is the
subsequent condition of the operative cases as to their
general condition ; also, whether the patients operated
262
MEDICAL RECORD.
[February 10, 1900'
upon had subsequent attacks; that is, of course,
whether they have had attacks presenting symptoms
similar to appendicitis. I should also like to ask
him if, from his experience, he would favor operating
after the first attack. I speak of this because, at a
discussion of a medical society recently, a man re-
ported some cases and made the statement in regard
to the cases operated upon, that he Vvould not advise
operation after an apparently perfect recovery from a
first attack.
Dr. Lloyd closed : In the title of my paper I used
the words " conservative treatment " because that is
the usual way of referring to the temporizing methods
in vogue; I do not believe in it. A few years ago
it was more difficult to obtain the patient's con-
sent than it is to-day ; I have no difficulty in per-
suading patients nowadays to be operated upon. A
few years ago the mortality was greater, because the
operation was undertaken at a less favorable time.
There is a set of patients who wait nowadays; that is,
they decline operation after we have tried to get them
into the interval. They put off the operation on ac-
count of social or business engagements; they enjoy
apparently good health, and they think they will select
a more convenient time for operation. The cases I
tried to get together in this paper are those that were
treated medicinally and were then carefully followed
up from the first attack to the final result. We find
cases constantly reported as cured after medical treat-
ment when we know they have had recurrences. Many
of these cases have passed through many hands before
they get to the operator. The idea I had in mind was
to get the actual results or the present conditions.
Regarding the question of continued ill health, there
is a good deal in that; many do not have ill health,
but many do have it. They often complain of a colicky,
flatulent condition in the abdomen. There is more or
less colic, and constant distress from intestinal indi-
gestion. These patients sometimes have diarrhoea,
and sometimes constipation. Every once in a while
they will tell you that they have pain upon pressure
in the right iliac region. Those cases that continue
to have more or less discomfort must be operated upon.
Regarding one of the fatal cases in the series reported,
the patient was treated in the country, in a town where
they did not know appendicitis; they never had made
the diagnosis of a case; he could not have been oper-
ated upon. Later, while in Montreal, he had another
attack, and the third attack came on wiiile he was at
business one morning; they sent for me and I called
an immediate consultation. Waiting was advised, to
see if the case was one of appendicitis or rupture of
adhesions following some severe exercise. That night
the appendix perforated. At the operation a gangre-
nous condition of the bowel was founil, including the
appendix and even extending to the aponeurosis of the
external oblique. He was acutely septic. These are
the cases that operation will not save unless they are
operated upon early.
Dr. Hubbard asked regarding the question of opera-
ting in the first attacks. I stated that I believed that
a single attack of appendicitis inclined the patient to
recurrent attacks, and to recurrences that were pro-
gressively more severe; that is shown by the histories
of the cases. I cannot recall ever operating in a case
the second time, because I began, early in my experi-
ence, to search for and remove the offending organ and
not to be satisfied with simple incision and drainage.
I cannot now recall a single patient who has had a
second attack.
Regarding the question of how long to wait, I be-
lieve that the interval operation is the best. 13ut the
question really is, how to decide whether the patient
will reach the interval or not. I believe that every
case, when the symptoms are progressive after twenty-
four hours, should be operated upon. If the symptoms
are not progressive, if no signs of an acute infection
are present in twelve hours, if the temperature goes
down and the tenderness is not increased, and the
pulse remains of good calibre, it is well to wait for
the interval; even then you should be ready to oper-
ate the instant there are any indications of an increase
in the inflammatory symptoms.
pXctUcal Items.
The Recognition of Renal Typhoid. — According
to Aniat the renal form of typhoid fever manifests
itself in a subsidence, sometimes an absence, of intes-
tinal symptoms, supplanted by signs of an acute hemor-
rhagic nephritis. The temperature from the outset
is hyperpyretic; the prognosis is very unfavorable, the
prostration great, and delirium frequent. Dr. Rostos-
ki (^Mi'mchencr med. Wochenschrijl, No. 7, 1899) dur-
ing the past summer observed two cases of typhus
renalis in Leube's clinic, which differed from the
general description of these cases. In the first in-
stance the acute hemorrhagic nephritis was plainly an
exacerbation of an existing chronic nephritis. It
lasted fifteen days, and was present before the roseola,
enlarged spleen, Widal-Gruber diazo reaction, or the
typhoid stool. The fever was not hyperp)'retic, and
the course of the typhoid was relatively mild. In the
second case the symptoms were ushered in by a mod-
erate rise of temperature without the characteristic
curve, and presented the picture of a hemorrhagic
diathesis with muscle pains and normal hemorrhages.
Casts were as yet absent from the urine. They first
appeared six days later, were abundant, and were pre-
ceded by a chill and a rise of temperature to 40.2° C.
Other signs of nephritis were absent throughout the
entire course of the disease. Two days later enlarge-
ment of the spleen was noticeable. A positive Widal-
Gruber reaction was obtained a few days after this,
and on the following day large numbers of typhoid
bacilli were found in the urine. Notwithstanding
this, the roseola was slight and evanescent, the fever
was markedly intermittent in character, and the ne-
phritic symptom persisted, although the quantity of
blood in the urine gradually diminished. The kid-
ney symptoms were aggravated by a complicating
peritonitis, and it was twelve weeks before the urine
was free from albumin. This case differs from
Amat's type in that the general condition of the pa-
tient remained good, and there were no delirium, no
hyperpyrexia, and no severe headaches.
Lord Curzon and the Plague. — The new viceroy
o£ India is adding to the harvest of golden opinions
he has already reaped by his courageous and energetic
behavior in the presence of the plague. Just as soon
as the dark and disquieting rumors of a steady smoul-
dering of pestilence in Bombay and Poona were con-
firmed by a sudden increase in the number of cases,
threatenin;; another epidemic, he promptly left the
cool security of Simla for a thorough inspection in
person of the sanitary arrangements of the infected
districts. Before leaving he took the wise precaution
of having himself and his entire party inoculated with
prophylactic serum, and is in consequence able to
urge its use with telling effect. As he shrewdly puts
it, " A measure which changes a death rate of from
seventy to eight}' per cent, into one of from fifteen to
twenty, even in those who are attacked after submit-
ting to it, to say nothing of the large proportion who
are completely protected by it, is one which no sensi-
ble man can afford to neglect." Is it any wonder that
February lo, 1900]
MEDICAL RECORD.
263
his speeches are said to be making a deep impression
upon the native population, and that inoculation is be-
coming positively popular? As a means of cure after
the disease has actually made its appearance serum
inoculations have not proved very successful, but while
still on trial their preventive effects have been most
encouraging, althougli the protection conferred does
not last a very long period, so that frequent re-inocu-
lations are advisable. — English Outlook.
The Effect of Colored Light on the Nervous
System. — It has long been claimed that colored light
has a special effect on men and the lower animals. It
has been asserted by some that the lower animals grow
more rapidly in violet than in white light. On the
other hand, Flammarion has found that silkworms
grow least rapidly in the violet rays. Experiments on
the nervous system are in better accord. They show,
according to Henri de Parville, writing in La Nature,
Paris, that the red end of the spectrum is exciting to
the nerves, while violet, blue, and green are calming.
It is well known that turkeys and bulls are excited by
red; on the other hand blue glasses are often used to
quiet horses. In the photographic establishment of
the Messrs. Lumiere, in Lyons, France, sensitive
plates are prepared in a large room by green light.
Formerly when red light was used the workmen always
sang or gesticulated at their work. Now they are
calm, never speak, and assert that they are much less
tired in the evening than they were previously. Every
sufferer from nerves knows that a gloomy day affects
him unfavorably, while the first ray of sunshine makes
him gay again. It has been suggested that the green
of vegetation, the blue of the sky, and the blue-green
of the ocean may thus have a powerful influence in
calming the spirits. Parville, however, cautions his
readers against too sweeping conclusions. All that
we can say is that colors certainly appear to affect the
organism, and that the subject will bear further inves-
tigation.— Public Opinion.
Do Animals Feel Pain Less than Men? — What
we call an '' ear for music " is almost an added sense
in some people as compared with others. Even in
animals of relatively high intelligence, such as dogs
and monkeys, there seems to be reason to think that
their perception of pain is much less acute than in
humans. After serious operations under chloroform
they are often frisking about a few minutes after recov-
ering consciousness, and even jumping from the floor
on to the operating-table in a way that forbids the
notion that they are in suffering. In all animals the
skin is possibly less sensitive than the human skin.
It is covered with insensitive hair, and, though no
doubt more sensitive than any other part of the body,
it is presumably on quite a different plane of sensi-
tiveness from the human skin. In human beings the
sensitiveness of the internal organs is very small com-
pared to that of the skin. Examples of this are famil-
iar to every one. While in health no one knows any-
thing of his "inside"; he has no sensations from it.
Even disease of a very serious kind can and often
does go on for years in the internal organs without
causing any sensation. The nerves of the internal
organs are much more concerned with regulating func-
tions and controlling the size of the blood-vessels than
with the conveyance of sensory impressions to the
brain. Life would, in fact, be unbearable if the func-
tions of animal life in a normal state caused sensation;
and they would cause it if the organs were richly sup-
plied with sensory nerves. Every surgeon knows, for
example, that the human intestine is, when its muscu-
lar coat is at rest, almost as insensitive as the hair or
nails. In the operation of opening the intestine often
required in the presence of malignant disease, the cut
in the skin and the business of fixing the gut to the
skin would be very painful, and deep anaesthesia is
required. Two days later, when the gut in its new
position has to be opened, the patient is told to shut
his eyes and he feels nothing; he does not even wince
while a wound nearly two inches long is made in the
intestinal wall with either knife or hot iron. This has
been proved by hundreds of cases, and certainly it is
not to be explained as due to stoicism on the part of
the patient. Other important operations have been
done without anesthesia, except for the skin cut, and
without giving rise to suffering at all of a severe kind.
It is most improbable that even the highest of the
lower animals would feel pain where man feels none.
On the contrary, from their smaller brain development
they probably are less sensitive than man. — Edinburgh
Review.
Sir William MacCormac— English Tit-Bits of No-
vember 25th has the following sketch of this distin-
guished surgeon: "It is safe to say that the public
do not know nearly as much of Sir William MacCor-
mac as they ought to do, for Sir William is in the
front rank of the world's surgeons, has had some stir-
ring experiences, and has obtained a unique reputa-
tion. This is as a surgeon of wars, a battlefield doc-
tor, and one of the best men in the world to take
charge of Tommy Atkins when a bullet has unhappily
made him unfit to fight for queen and country. Vet
when two or three weeks ago Sir William patriotically
offered his services to the government for the war
against the Boers, and now when he has at last reached
that vast operating-theatre in South Africa, many peo-
ple have little idea of what Sir William MacCormac
has really done. Many reasons account for this state
of things. For one thing, the man of science, be he
ever so distinguished, unless his science is of that
popular enticing sort, like Edison's and Marconi's,
does not get talked about in every home. Then the
wars in which Sir William has served happened long
ago, and they were not wars in which the soldiers of
Great Britain were engaged. Lastly, Sir William is a
modest man, and less has been said and written of
him than almost any other celebrity of the day. Sir
William is proud of the land of his birth. He is an
Irishman and comes of a good Irish stock, which has
had not a little to do with medicine. As a matter of
fact, his father, Dr. Henry MacCormac, of Belfast, was
about the first well-known advocate of the open-air
treatment of consumption. His mother also was a
Belfast lady, in which city Sir William was born in
1836. He received his education at the Royal Insti-
tution and Queen's College, taking his degree in 1856.
He also studied in Paris. At twenty-five years of age
he married Miss Katherine Chartres, of Belfast, and
three years afterward he was admitted to the fellow-
ship of the Royal College of Surgeons of Ireland.
He became F.R.C.S. England in 1871, and in that
year removed from Belfast to London, having secured
the appointment of senior assistant surgeon and lec-
turer on practical surgery at St. Thomas' Hospital.
When Mr. Le Gros Clark retired in 1873 he became
full surgeon and retained that office for twenty years,
when he was appointed consulting surgeon and emeri-
tus lecturer on clinical surgery. When the Interna-
tional Congress foregathered in London in 1 881, he
was elected to the responsible office of senior honorary
secretary. The duties were exacting, and to a large
extent the success of the congress depended upon the
way in which they were carried out. MacCormac per-
formed them admirably — so admirably, indeed, that
he was made a knight in consequence. He was then
elected to the council of the Royal College in 1883,
and has served as examiner since 1887. In 1887 he
rose to the vice-presidency, again in 1893, and now,
264
MEDICAL RECORD.
[February 10, 1000
as most people know, he has the honor of filling the
presidential chair for the fourth time. In 1897 a bar-
onetcy was substituted for his knighthood, and last
year he was further honored by admission to the knight
companionship of the Victoria Order. He has a re-
markable record of field service. When the Franco-
Prussian war broke out in 1870 he realized that in it
there might be an opportunity of discovering what
military surgery was like, a discovery which he was
very anxious to make. So he hastily packed up his
traps and was in Paris almost as soon as the declara-
tion of war had been made. To a certain extent he
was drawing a bow at a venture; for, to tell the truth,
he hardly knew what he might be able to do or even
whether the Frenchmen would let him do anything at
all. As soon as he reached the French capital he went
to the Palais de I'lndustrie, where the French Nation-
al Society for aid to the wounded had established
itself. In reply to his questions and his offer he was
told that no foreign surgeons would be permitted
to serve; but a few days later the Emperor gave his
special sanction and welcome to any English or Amer-
ican surgeons who might offer their help. There was
a little more delay, and then MacCormac was given
instructions to proceed to Metz and report himself to
the surgeon in chief there. . . . The young Irish sur-
geon was anxious to get to work as soon as there was
anything to do, and the surgeon in chief assured him
of the welcome his assistance would receive. But the
French in Metz suddenly conceived a most inordinate
dread of spies. It so happened that Prussian spies
had just scored heavily, and the word went round for
the keenest watch to be kept in the future. Several
arrests were made of palpably innocent persons, the
proprietor of the hotel in which MacCormac was stay-
ing being among the number. One evening, seated
at the dinner table, MacCormack happened to speak
a casual word to an American who sat next to him.
As it turned out afterward, suspicions were held about
the American, and the immediate result of the trifling
incident was that MacCormac himself was suspected.
Next morning he received a summons to attend the
office of the prev6t-mar{^chal. The surgeon's papers,
assisted by the evidence of a Metz surgeon, completely
cleared him, but the latter advised him to leave Metz
without any delay. Various French officers supple-
mented the advice in such a way as to make it almost
a command, numerous threats being held out against
him. Consequently, sadly disappointed and very nat-
urally indignant at the treatment, MacCormac jour-
neyed back to Paris. Still he was destined to get the
experience he desired, and in this campaign too. At
the beginning of the war the Americans in Paris ap-
pointed a committee to organize an ambulance. Ow-
ing to a dispute between this committee and its sur-
geons the latter separated, and in company with a few
English friends formed an Anglo-American ambu-
lance. There were eight English and eight American
surgeons, MacCormac being in command of the Eng-
lish section and ultimately of the whole ambulance.
Their services were promptly accepted, enthusiastically
so, for the French straightway gave them 15,000 francs,
horses, wagons, tents, and everything else they asked
for, and promised all the money and stores they might
need for the future. The ambulance was despatched
immediately to Sedan, and it arrived there on August
30th, taking possession the next day of the Caserne
d'Asfeld, which had been converted into a hospital for
its use. Almost immediately the cannon commenced
to roar, and the great battle of Sedan began. At
night the ambulance went over the battlefield and had
many of the wounded transported to their hospital.
MacCormac was performing operations one after the
other as fast as he could, and the same the next day,
when the wounded were being brought along in a con-
tinuous stream. The night was far spent before he
was able to leave the operating-table and seek a little
rest. All through the war the work of the Anglo-
American ambulances was a brilliant success. At
Asfeld during that bloody September and October of
1870, six hundred and ten cases of injuries were
treated, of which the comparatively small proportion
of one hundred and thirty-seven resulted in death, and
one hundred and thirty-eight operations were per-
formed, sixty-one of which had a fatal termination.
The experience Sir VVilliam MacCormac gained in the
Franco-Prussian war he backed up afterward by fur-
ther aid to the wounded in the Turco-Servian war."
Prognosis of Tetanus — Although the prospects of
recovery are poor in acute cases, the epigrammatic
French saying, " Tant de cas tant des morts," is not
justified. The prospects are better in the subacute
form and in cases of chronic and head tetanus. Any
patient who lives over six days has a fair chance of
recovery. Lambert claims that even with the older
methods of treatment the mortality is for acute cases
only eighty per cent., being an average mortality of
sixty per cent, for all forms. While the antitoxin
treatment has effected a reduction of only five per cent,
in the mortality of acute tetanus, it has reduced that of
the chronic variety to sixteen per cent., a very material
improvement. This increase in the chances of recov-
ery is unfortunately limited to cases in which the in-
cubation period is seven days or over. — Nancrede's
Principles oj Surgery.
The Operative Treatment of Uterine Fibroids. —
Lockhart i^American Gyiiaeologieal and Obstetrical Jour-
nal, December 18, 1899, p. 526) expresses the opinion
that a uterine fibroid should not be interfered with un-
less it gives rise to serious symptoms, mental or phys-
ical. Curetting is merely a palliative measure, as is
also in many cases ligation of the uterine arteries.
Removal of the appendages should be merely a dernier
ressort, as it practically never cures, and does not always
even relieve. The operation of election should be
either total hysterectomy or myomectomy. The latter
is to be chosen when the tumor is submucous and pe-
dunculated, when it is subserous and has either a ped-
icle or a well-defined border, or when several small
nodules lie immediately beneath the peritoneum. To-
tal hysterectomy is indicated when the tumor is sub-
mucous and non-pedunculated and the cervix cannot
be dilated sufficiently to allow of morcellement, or
when the tumor is interstitial, large, and subserous,
without a pedicle, soft, fibrocystic, or undergoing de-
generation, or when the presence of the tumor is com-
plicated by disease of the appendages.
Leprosy Cases in England. ^ — The members of the
London Medical College and Polyclinic have been
fortunate in the matter of leprosy demonstrations. We
are informed that during the past six months no fewer
than seven opportunities have been afforded for the
inspection of cases of this malady, which in England
is very rare. One of these patients, an excellent ex-
ample of the macular form with tendency to tubercu-
lar developments, is expected to attend again. All
the cases have been in Europeans who have lived in
leprosy districts, and in only one was the patient of
mixed blood. One patient had lived in India in the
army, another in Australia, a third in British Guiana,
and a fourth in the West Indies. In no single case
were there any facts suggestive of direct contagion
from any known source. All the patients were still
living with their relatives without precautions, and Mr.
Hutchinson pointed out that no suspicion of contagion
had occurred. In one the disease had been for some
years completely arrested, while all the others showed
the macular type. — British Medical Journal.
Medical Record
A IVeekly yoimial of Medicine a)id Surgery
Vol. 57, No. 7.
Whole No. 1528.
New York, February 17, 1900.
$5.00 Per Annum.
Single Copies, loc.
©rioinal Articles.
THE INOCULATION OF MALARIA BY THE
MOSQUITO: A REVIEW OF THE LITERA-
TURE.*
By IRVING PHILLIPS LVOX, M.D.,
CLINICAL PATHOLOGIST TO THB NEW YORK STATE PATHOLOGICAL LABORATORY,
f.NlvERSITY OF BUFFALO ; INSTRUCTOR OF CLINICAL MEDICINE IN THE
VNIVERSITY OF BUFFALO.
The idea that mosquitoes or other insects bear a causal
relation to the spread of malaria appears to have been
suggested in very early times, and has been expressed
during the present century by various writers. In an
excellent review of this theory, Nuttall '"• " narrates
that it was mentioned nearly two thousand years ago
by the Roman writers Varro, Vitruvius, and Columella,
was referred to in 1848 by Nott, of New Orleans, as a
fact already known, and was advocated in an elaborate
article by King, of Washington, in 1883. Among
more recent writers, the theory was suggested by Lav-
eran in 18S4 and 1891, by Fliigge in 1891, Pfeiffer in
1892, and Manson in 1894. The belief that mosqui-
toes cause malaria is also found among the inhabitants
of certain malarious regions in widely separated parts
of the world.
The first experiments undertaken to test this theory
appear to have been made by Bignami and Dionisi ' ''
in Rome, in 1S94, and resulted negatively.
The present scientific interest in the theory dates
from Manson's'" famous support of it in r894, and
subsequently in his Goulstonian lectures, in i8g6.
Manson, noting the fact that flagellated forms of the
malarial parasite were not obser\^ed in fresh blood, but
appeared only after an interval of twenty minutes or
more after withdrawal, concluded that the flagellated
forms probably represented the first stage of an extra-
corporeal \ development of the malarial organism des-
tined to preserve and continue its life cycle outside
its human host. He believed that " the crescent body
and the tertian and quartan spherical bodies which
proceed to flagellation are the extra-corporeal sporu-
lating homologues of the intra-corporeal sporulating
bodies; that the flagellum is the extra-corporeal homo-
logue of the intra-corporeal spore. Both types of
sporulating plasmodium have corresponding functions,
both arise from the same source ; one is the germ of
the Plasmodium inside the human body, the other is
the germ of the plasmodium outside the human body ;
both function in the propagation of the parasite." ' He
also pointed out certain resemblances between malaria
and filariasis, and completed the analogy by advanc-
ing the theory that, as mosquitoes remove from the hu-
man body filaria nocturna and in turn act as host to
this parasite, so also may mosquitoes remove and serve
the purpose of host to the malarial parasite.J It is to
* Read before the Buffalo Academy of Medicine, October 10,
1899.
t The words e.Ttra- and intra-corporeal are employed in this
paper always in reference to the body of the warm-blooded
vertebrate host, i.t., man, birds, monkeys, bats, cattle, etc., and
never to the body of the invertebrate host or insect.
X Laveran,' in 1884, first suggested the possibility that mosqui-
be noted that Manson'' "■ '" did not think of the mos-
quito as an agent for inoculating malaria in man by
its stick, but rather for removing the parasites from
man, harboring them in its body during their devel-
opment and reproduction, and then spreading them
abroad in water and dust to reinfect man, and thus
complete their double cycle of existence, just as in the
case of filaria. He thought that, after the mosquito
had fed on malarial blood, flagellated forms of the
parasite developed in the mosquito's stomach; the
flagella broke loose, penetrated the tissues of the mos-
quito, and there continued their extra-corporeal devel-
opment and reproduction.
In 1895, Surgeon-Major Ross,'-'* of the Indian
medical service, became interested in Manson's the-
ory, and, guided by personal directions given by Man-
son, began in India his epoch-making experiments
with mosquitoes, which resulted in the first experi-
mental evidence in support of the theory. At this
time Ross allowed mosquitoes to feed on the blood of
a patient containing the crescent form of the aestivo-
autumnal malarial parasite. These mosquitoes were
forthwith examined, and in their stomachs the para-
sites were found to have proceeded to develop into
"spheres"' and later flagellated forms. No less than
forty or fifty per cent, of all the crescents developed
into flagellates. Ross' investigations were then inter-
rupted, and no further progress was made in the study
at this time.
Manson" interpreted Ross' discovery in the follow-
ing words : " We may conclude with confidence that
Ross has thoroughly proved by direct observation my
hypothetical conjecture that the stomach of the mos-
quito is a suitable medium for the flagellated phase of
the Plasmodium malaria; to develop in; and it seems
to me that it is only a question of patience and tech-
nique to work out the remainder of the life-history of
the parasite in this insect."
In 1896, Bignami ' advanced the theory of the di-
rect inoatlation of malaria in man by the stick oj the
mosquito, comparing the process of infection to the
one already known for the production of Texas-cattle
fever by the "bite" of the tick, Pyrosoma bigeminum,
and after a critical analysis and rejection of the claims
of the air and water theories of malarial transmission,
he reached the conclusion that, considering all known
facts, "malaria behaves itself with regard to man as if
the malarial germs were inoculated by mosquitoes."
In 1897, Ross" was given an opportunity to con-
tinue in India his investigations, and in August of
that year succeeded in making a second and most im-
portant step toward the experimental demonstration of
the mosquito-malaria theory.
Obtaining specimens of a species of mosquito that
he had not previously observed, and which he described
as a "brown species" and later as "dapple-winged"
mosquitoes, he allowed them to feed on a patient whose
blood contained crescents, and later in two of these
mosquitoes he found peculiar large, round or oval pig-
mented cells, situated in the outer layer of the stom-
ach-wall. The pigment granules resembled malarial
pigment, and the pigmented bodies were found only
toes might " play a role in the pathogenesis of malaria similar to
that in filariasis."
266
MEDICAL RECORD.
[February 1 7. 1 900
in mosquitoes that had fed on malarial blood, and
were not observed in hundreds of mosquitoes that had
fed on healthy blood. Ross believed that he had at
last discovered the malarial parasite in the tissues of
the mosquito, a conclusion that has since, as we shall
presently see, been amply demonstrated. In Septem-
ber, 1897, Ross' ' obtained a third case similar to the
previous two, and also claimed to have found pig-
mented bodies in a "grey" mosquito that had fed on
tertian blood, but he subsequently* decided that this
case must be excluded, as due to a probable error.
In the spring of 1898, Ross," finding human malaria
scarce, turned his attention to the investigation of the
allied parasitic blood disease of birds, the so-called
bird malaria, of which two forms existed, due respect-
ively to proteosoma and halteridium. Working with
birds infected with proteosoma, and feeding " grey "
mosquitoes upon them, Ross subsequently found in
the stomach-wall of these mosquitoes pigmented cells
similar to those obtained previously by him in "dap-
ple-winged" mosquitoes fed on human malarial blood.
These pigmented bodies, which he called coccidia,t
were first observed in mosquitoes on the second day
after infection (feeding), and at this time were oval
bodies, 6 to 7 or 8 // in their long diameter, containing
fine pigment granules exactly resembling those of
proteosoma. In mosquitoes kept alive for three or
four days after infection, the coccidia were found to
have increased considerably in size and become spher-
ical ; their protoplasm showed granules, vacuoles, and
irregularities, and the wall had become dense and
showed a capsular appearance. They increased in
size until they reached a diameter of 60 or 70 n at the
end of a week, and were then seen as wart-like excres-
cences protruding from the outer stomach-wall into
the general body cavity. In some of these full-grown
coccidia peculiar striated appearances were seen, and
others contained several large sausage-like bodies. In
a letter to Manson," Ross summarized his conclusions
as follows: " (i) Pigmented cells are found in the
stomach wall of grey mosquitoes fed on crows, larks,
and sparrows with proteosoma. (2) Pigmented cells
are not found in control grey mosquitoes fed on healthy
men, or men with crescent plasmodia, on healthy spar-
rows, on crows and larks or on crows and pigeons with
halteridium. (3) These pigmented cells are found in
the external coat of the stomach, and grow from a size
of 6 ,". in thirty hours to 60 ,« at six days, and are prob-
ably coccidia. (4) Successive feeds by the same mos-
quito on the same bird are followed by fresh crops of
young coccidia. (5) Similar pigmented cells have
been found in mosquitoes fed on human gymnospo-
ridia (Labbe)."
Continuing his investigations during the spring and
summer of 1898, Ross"' ^' found that the mature coc-
cidia of proteosoma were of two kinds, one containing
closely packed within its capsule a large number of
delicate, tiiread-like bodies, often arranged radially
about central points, and the other containing several
large black spores. The mature coccidia on the eighth
or ninth day ruptured and discharged their contents
into the general body-cavity or coelom, which contains
the so-called blood or circulating juices, by which the
thread-like bodies or "germinal spores" and the large
black spores were distributed through the tissues of
the body of the mosquito. The empty capsules of the
coccidia remained in situ in the stomach wall. The
thread-like bodies, when free, were found to measure
from 12 to i6/i in length, i ,a in breadth, and were
* See British Medical Journal, July i, 1899, p. 4, footnote
No. II.
f Under date of December 31, 1898, Ross" wrote to the
British Medical Journal that his opinion that these bodies were
"coccidia" "is provisional. The true zoological significance
of the mosquito stage of the parasites is a difficult subject, and
will be discussed in the final report."
flattened in the third dimension. They contained
chromatin granules, tapered at the extremities, and
did not appear to possess independent movement:
The black spores were 16 to 20// in length and 2 or
3 :i in thickness, were straight, curved, or twisted, with
blunt ends, and were of dark brown or black color,
with a sharp contour. The ultimate destiny of these
black spores Ross did not succeed in determining.
Pursuing the thread-like bodies through the tissues
he found them collected in large numbers in the cells
and ducts of a gland located in the anterior part of the
thorax, whose main efferent duct passes forward and
emerges at the tip of the proboscis. Ross, unaware of
the previous description of this gland, which, in fact,
had been fully described in 1888 by Professor Maclos-
kie" of Princeton, supposed that he had discovered a
new organ, and correctly interpreted it as a venemo-
salivary gland, whose secretion was purposed to be in-
jected into the wound made by the prick of the mos-
quito's proboscis in the flesh of its victim, and thereby
occurred, he conjectured, the discharge into the circu-
lation of birds of the numerous thread-like bodies or
"germinal spores" found in the secretion of this gland,
and doubtless destined to begin anew in birds the
intra-corporeal life cycle of the proteosoma!
This assumption he proceeded to test, by allowing in-
fected mosquitoes, after the time at which he had learned
to expect the presence of the thread-like bodies in their
venemo-salivary secretion, to feed on healthy birds,
whose blood he had by repeated examinations assured
himself was free from proteosoma. The result was' as
follows : " (i ) Out of twenty-eight originally healthy
sparrows subjected to the bites of grey mosquitoes
previously fed on diseased sparrows, twenty-two, or
seventy-nine per cent., became infected, all with a very
large number of parasites, in from five to eight da.ys.
...(;) Out of two crows and four weaver birds, one
of the crows and all the weaver birds showed a copious
proteosoma infection within nine or ten days of being
bitten by gray mosquitoes fed previously on sparrows
with" . . . proteosoma. Control experiments with
healthy mosquitoes and healthy birds resulted nega-
tively, with one doubtful exception.
Ross had succeeded in these experiments in carry-
ing proteosoma from birds to mosquitoes and from
mosquitoes back again to birds. He had produced
experimentally the complete demonstration of the truth
of the mosquito-malaria theory as applied to proteo-
soma-malaria of birds, and he expressed his belief that
what he had found true of proteosoma in birds would
be found true of human malaria.
During the following winter (1898-99), Daniels,"
working in Calcutta under Ross' guidance, confirmed
in detail Ross' work on proteosoma, and expressed
some interesting speculations concerning the destiny
of the black spores.
In the mean time, also, Dionisi,"* of Rome, had
been working on birds, and though he failed to infect
them by mosquitoes, he nevertheless made the sugges-
tive observation that in pigeons parasitic blood infec-
tions occur most frequently at the time of moulting,
when, of course, mosquitoes have the best opportunity
of attack.
In a paper presented to the British Medical Associ-
ation, in July, 1898, Manson,'" reviewing the mosquito-
malaria theory in the light of the facts discovered up
to that date, pointed out that his theory had assumed
that the flagellum, developing in the mosquito's stom-
ach after the mosquito had fed on infected blood, was
the agent that penetrated the tissues of the mosquito
* Dionisi "■'' also at this time discovered in the blood of bats
parasites of two varieties, resembling morphologically the para-
sites respectively of quartan and astivo-autumnal malaria. (I
*ish to express here my indebtedness to Dr. Krancis E. Kronczak,
of Buffalo, for his kind assistance rendered me in digesting the
Italian literature. )
February 17, 1900]
MEDICAL RECORD.
267
to start the extra-corporeal cycle of the organism.
This view was incompatible with the fact discovered
by Ross that the coccidia found in the mosquito's
stomach wail contained pigment granules, because the
ffagellum was without such pigment. This hitch in
his theory might be overcome, he thought, by modify-
ing the theory in accordance with certain observations
which MacCallum, of Baltimore, had made in studying
halteridium, a blood parasite of birds, closely related
to the parasite of malaria and to proteosoma.
MacCallum,'- " in the summer of 1897, had ob-
served the following facts: The full-grown extra-cor-
puscular parasite of halteridium consisted of two
forms, one flagellated, the other non-flagellated. The
flagella, breaking loose from the flagellated form, ap-
proached the non-flagellated form and one of them
penetrated its substance and entered it, resulting in a
subsequent commotion of its pigment granules and a
gradual change of its shape into an elongated, motile,
pigmented body, which he termed, after Danilewsky,'
a vermiculus. This vermiculus moved about the field
of blood, penetrating and actually destroying the cor-
puscles that opposed its progress. MacCallum later
also observed the entrance of a flagelhim into an extra-
corpuscular spherical body of the cestivo-autumnal
malarial parasite, although in this case no resulting
vermiculus was observed. He interpreted his observa-
tions as showing a process of fertilization of the female
parasite by the male spermatozoon, or flagellum, with
the production of the vermiculus as the result of this
sexual conjugation.
Ross" later also observed vermiculi in the stomach
of a grey mosquito killed within an hour of feeding on
a crow infected with halteridium.
Lately, Koch "'• "' * also claims to have fully con-
firmed in many cases MacCallum's clever observations
in halteridium, and also to have found the vermicule
stage of proteosoma in the stomach of infected mos-
quitoes, though he failed to observe the act of fertiliza-
tion in proteosoma.
Marchoux f also, in Africa, working with pigeon's
blood infected with halteridium, has recently reported
his full confirmation of MacCallum's original observa-
tions.
Manson,| accepting these observations by MacCal-
lum in halteridium, applied them to proteosoma and
human malaria, to explain the pigment granules of the
coccidia in the mosquito's stomach-wall. Instead of
the non-pigmented flagella penetrating the stomach-
wall of the mosquito to develop into pigmented coc-
cidia, what was more natural to suppose than that the
pigmented, actively motile vermiculus was the pene-
trating agent? The development of vermiculi from
human malarial parasites has never been observed, but
their development may be provisionally assumed, and
this hypothesis accepted as tlie best theory of explain-
ing the origin of the pigment granules of the coccidia. §
* Koch'' claims to have made these observations prior to the
pubHcation of MacCallum's first report, though he fails to state
the exact time at which they were made. He acknowledges,
however, MacCallum's priority in publication. MacCallum first
announced his discovery in a paper read before the British Asso-
ciation for the Advancement of Science, in Toronto, on August
24, 1897 ; subsequently, also, before the Johns Hopkins Hospital
Medical Society, on October i8, 1897.
t " Processus de Reproduction sexuel chez les Hematozoaires
du Genre Laverania Grassi et Feletti " (Halteridium Labbe).
Comptes rendus hebdomadaires des seances de la Societe de
Biologie, tome vi., No. 9, March 17, 1899.
X Ross'* first suggested this idea in the following words :
"The entry of an entire vermicule of proteosoma into the ex-
ternal coat of the stomach of a gray mosquito and its develop-
ment there into a pigmented coccidium afford indeed an ex-
planation fascinating in its simplicity."
§ Since the preparation of this paper, Grassi '''•', and later also
Bastianelli and Bignami ^, have announced the discovery of the
vermicule stage of human malarial organisms within the stomach
of infected Anopheles.
The brilliant results which Ross had obtained had
meanwhile aroused the interest of the Italian investi-
gators and stimulated them to a series of researches,
and in the latter part of 1898 and during the present
year several important contributions from them have
appeared in the journals, each adding new evidence in
confirmation of the theory of the inoculation of mala-
ria by mosquitoes, until it is now possible to say that
every essential step in the experimental proof of this
theory has been obtained, and the theory has been re-
moved from the realm of speculation to that of estab-
lished fact.
Bignami,"' of Rome, in August, 1898, began inocu-
lation experiments on healthy men with mosquitoes
obtained from malarious localities, but in two such
trials failed to infect his human subjects. A possible
explanation of his failure he found in the assumption
that his mosquitoes were perhaps not a species suitable
to act as host to the malarial organism, as Ross had
found that only the " grey " mosquito had played the
part of host and inoculating agent of proteosoma for
birds. His suspicions were further confirmed, he
says, by the appearance, while he was still pursuing his
investigations, of an important article by Grassi,"" "
showing that in Italy and Sicily, where he had investi-
gated the subject, though mosquitoes were abundant
in places free from malaria, certain species of mos-
quitoes were absent from such places and were found
only in places where malaria was rife. He found three
species of mosquito thus exclusively associated, he
thought, with malarious localities, viz., Anopheles clav-
iger Fabr., Culex penicillaris Rondani, and Culex ma-
larias Grassi, and he assumed that these were the mala-
ria-bearing species of mosquito. Profiting by this ad-
vice,* Bignami started anew an experiment on a healthy
man with mosquitoes obtained from Maccarese, an in-
tensely malarious place. The subject of the experi-
ment was a man who had been for six years an inmate
of the Santo Spiriti Hospital suffering with a chronic
nervous affection, and who had never had malaria.
The experiment was conducted in a room in this hos-
pital, "where none of the physicians have ever known
an autochthonous case of malarial fever to occur, nor
has malaria ever been known to originate in any of
the neighboring houses." The man slept in a room in
which the mosquitoes found at Maccarese were at fre-
quent intervals liberated, and was subjected to their
bites from September 26th until the end of the experi-
ment. On November ist the patient developed a chill
and fever, and the temperature continued elevated until
after the administration of quinine on November 3d.
The blood examination on November 2d was negative,
but on November 3d showed numerous hyaline, pig-
mented, intra-corpuscular, a;stivo-autumnal parasites.
Specimens of the mosquitoes used in this experiment
were identified by Grassi and were found to belong to
the three species Anopheles claviger, Culex penicil-
laris, and Culex malariae,t species which Grassi had
already found, he thought, to be exclusively associated
with malarious localities. Thus Bignami had for the
first time succeeded in producing malaria experiment-
ally in man by the bites of mosquitoes.
This important success stimulated the Italian inves-
tigators to a more vigorous prosecution of this study,
and led to a series of investigations and reports, which
* Grassi '^ has recently claimed that this third and successful
experiment by Bignami was undertaken upon his (Grassi's) ex-
press advice as to the species of mosquito to be used, and that it
resulted successfully only after he (Grassi) had on October 20,
1898, brought into the experimenting-room some Anopheles
claviger. (He claims further that it was he alone who discov-
ered that a fourth species of mosquito. Anopheles superpictus,
propagates malaria, and that it was he who concluded that all
Italian Anopheles could propagate malaria.)
f From subsequent studies no convincing evidence has been
produced to show that these Culex species play any part in the de-
velopment of malaria.
268
MEDICAL RECORD.
[February 17, igoo
collectively have placed the inoculation theory on a
sound basis of scientific demonstration.
On December 4, 1898, Bastianelli, Bignami, and
Grassi "' published an article reporting a second suc-
cessful inoculation experiment, in which they caused
a case of double tertian infection in a man previously
free from malaria, by the bites of Anopheles claviger.
The stomach-wall of these Anopheles claviger on sub-
sequent examination showed the developmental stages
(coccidia) of tertian parasites. They also narrate
another experiment in which mosquitoes were col-
lected from a room occupied by four people all suffer-
ing apparently with sestivo-autumnal malaria. These
mosquitoes were found to consist of six Culex pipiens,
one Anopheles nigripes, and four Anopheles claviger.
Of these eleven mosquitoes, in only two. Anopheles
claviger, were they able to find ^n the stomach-wall
developmental forms corresponding to the coccidia de-
scribed by Ross.
An interesting paper by Grassi and Dionisi "' ap-
peared in the same journal (December 4th), treating
of the biological classification of the various human
and animal heemosporidia, to which it may be well to
devote a few lines here, as the biological terms used
are being generally employed in articles on malarial
parasites.
Considering the question, which of the two hosts of
the parasite, the warm-blooded, vertebrate animal, or
the invertebrate insect, should be regarded as determi-
nate and which as intermediary host, they concluded
that the vertebrate should be considered as the inter-
mediary host and the invertebrate insect as the deter-
minate host. In the intermediary warm-blooded host
the parasites develop to maturity, some proceeding to
sporulation to continue the life-cycle of the parasite
within this host, and others, the extra-cellular, mature
forms, being incapable of such sporulation, but being
destined to continue the life-cycle of the parasite in
the determinate host or insect. These non-sporulat-
ing forms are called gamet'i, and exist in two forms,
the female macrogameti, which do not become flagel-
lated, and the male microgametocytes, which do de-
velop flagella, when they find the conditions suitable
to their development in the stomach of the determi-
nate host or insect. Here the flagella of the micro-
gametocytes become free, and they are called microga-
meti. They are the male elements, analogous to
spermatozoa. They penetrate the female macrogameti
in a true sexual process, and as a result the fertilized
female macrogameti change their shape, become elon-
gated and motile vermiculi, which penetrate the stom-
ach wall of the insect, there to become encysted, the
so-called coccidia. In these encysted parasites sporo-
blasts develop, and become the sporozoits or germinal
threads, which, upon the rupture of the coccidia, are
carried to the salivary gland and thence by the bite
of the insect back to the intermediary host, to begin
again the double cycle of the development of the
parasite.
Continuing their work, Grassi, Bignami, and Bastia-
nelli"'* reported, Januarys, 1899, that seventy-five
per cent, of Anopheles claviger, caught in rooms that
were occupied by people infected with malaria, were
found to contain the malarial parasite, while control
mosquitoes were negative. They found that an ex-
ternal temperature of 30° C. was best suited to the
development of malarial parasites in mosquitoes, while
lower temperatures retarded or prevented their devel-
opment. In Anopheles claviger fed on blood contain-
* They also described in the cells of the salivary gland certain
peculiar bodies which they interpreted as degenerated sporozoits,
but in a subsequent paper^^ they withdrew this idea, and stated
that these forms were also found in the salivary glands of young
uninfected Anopheles claviger, and therefore must be either arti-
facts or else the normal secretion of the gland cells.
ing ripe crescents, they found the same developmental
stages that Ross had described for proteosoma, includ-
ing the sporozoits in the body-cavity and in the sali-
vary gland and ducts. They also infected Anopheles
claviger with tertian blood, and followed the develop-
mental stages of the parasite in the stomach-wall until
the fifth day.
On February 5, 1899, these same observers'"' an-
nounced that for the first time they had succeeded in
infecting Anopheles claviger with quartan blood, from
a woman suffering from a severe quartan infection of
long standing. Developmental stages of the parasite,
corresponding in size to those of the third day after
infection with aestivo-autumnal parasites, were found
in the stomach-wall.* They reported also a second
successful inoculation experiment with tertian organ-
isms. In still another case they allowed three Ano-
pheles claviger, ten days after these mosquitoes had
fed on a patient whose blood contained crescents, to
bite a healthy person, in whom, after an incubation
period of twelve to thirteen days, a severe aestivo-
autumnal infection developed. After the mosquitoes
had been used for this experiment, they were examined
and sporozoits were found in their salivary glands.
They also stated that Anopheles pictus was capable
of being infected with aestivo-autumnal parasites.
Bastianelli and Bignami °^ reported, in April, 1899,
further studies. They made out structural differ-
ences between the female macrogameti and the male
microgametocytes. In the former the nucleus is large
and peripherally placed and contains relatively little
chromatin; in the latter the nucleus is placed at the
centre of the cell and contains a larger amount of
chromatin. In the development of flagella or micro-
gameti from microgametocytes, the rods of chromatin
are seen to wander out and to enter into the formation
of the flagella. In tertian parasites the number of
flagella is usually six or seven, in ffistivo-autumnal
parasites only four, as a rule. Fertilization of the
parasites was never observed by them.
They described also the differences observed in the
encysted forms of tertian and aestivo-autumnal par-
asites in the stomach-wall, differences which were
characteristic of the two species, and by attention to
which they claimed to be able readily to differentiate
the tertian from the aestivo-autumnal encysted or coc-
cidial form. They did not find the dark spores, first
described by Ross in proteosoma, in the Anopheles.*
They recorded also three successful inoculation ex-
periments, the first a double tertian infection caused
by Anopheles claviger, the second a case of tertian
produced by Anopheles claviger (both these cases had
been previously recorded briefly), and the third, a
very interesting case, as follows: Fifty Anopheles
claviger, from Maccarese, were let loose in the sleep-
ing-room of a man already infected with aestivo-autum-
nal malaria, and whose blood contained crescents.
After about eighteen days this man developed a fresh
tertian infection, and the aestivo-autumnal parasites
disappeared from his blood. Most of the mosquitoes
were subsequently found to be infected with crescents.
Three of these mosquitoes were later allowed to feed
on another man, who after an interval of nine to twelve
days developed an EESlivo-autumnal infection.
The latest available published reports from Grassi,
Bignami, and Bastianelli " appeared May 7, 1899.
They reported the development of both aestivo-autumnal
and tertian parasites in Anopheles bifurcatus, just as in
Anopheles claviger, and suggested that the Anopheles
* Since writing this paper, announcement has been made of
the observation of all stages of development of the quartan i.n-
cysted parasite in the stomach- wall of Anopheles. '■'■'• "• **
t They have since"' ** observed the " black spores "or " black
bodies" in the mature, encysted forms in the stomach wall of
Anopheles, and interpret them as " representing probably a pro-
duct of degeneration of the contents of the sporozoon."
February 17, 1900]
MEDICAL RECORD.
269
bifurcatus is perhaps only a variety of Anopheles
nigripes. They thought it would probably be shown
that all the Italian species of Anopheles may act as
host to the malarial parasites. This role in Anopheles
pseudo-pictus remained still to be proved. They failed
to find sporozoits in the salivary glands of young Ano-
pheles claviger raised from the eggs of adult Anopheles
caught in malaria-infected houses, and the bites of
these young Anopheles on men proved harmless.
(The so-called brown spores obtained from Anopheles
were swallowed in considerable number by one of the
experimenters with negative results.)
Several papers have appeared during the past year
from Koch," ''■ " confirming, in general, the observa-
tions of Ross and the Italian investigators, though in
his latest article" Koch expresses the belief (for rea-
sons which appear indecisive) that Culex pipiens, in
addition to the Anopheles, acts as host to the malarial
parasite. Koch has also discovered an intra-corpus-
cular parasite in the blood of monkeys,"' " which ap-
pears very similar to the tertian organism of human
malaria.
At the present time, from week to week, reports are
appearing in The Lancet^' and \\\& British Medical Jour-
nal " from the malarial expedition, headed by Ross,
which was sent to Sierra Leone by the Liverpool
School of Tropical Medicine. From these reports it
appears that a new species of Anopheles has been
found which acts as host to the malarial parasite, and
that the quartan parasite was again, as it had been
previously by the Italian investigators,"' *' found to
develop in Anopheles.
From the foregoing summary it is seen that the the-
ory of the inoculation of malaria by mosquitoes (at
least certain species of the genus Anopheles) has been
thoroughly established and can no longer admit of
question. Practically every step of the process has
been followed with the tertian and astivo-autumnal
parasites, as well as 'with proteosoma of birds. The
quartan parasite has been followed up to its coccidial
stage in mosquitoes, though it has not yet been made
to return to its human host by the bite of mosquitoes.
The demonstration of this last link in the chain of
evidence we may confidently expect.
The question remains whether malarial infection is
produced only by the bite of mosquitoes. This can-
not be affirmed positively at the present time, but the
cumulative evidence tends strongly to support this
belief. All experiments hitherto made, and there
have been many, to produce malaria experimentally,
except by direct subcutaneous or intravenous inocula-
tion and by the bite of the infected mosquito, have
resulted negatively. The many attempts to cause
malaria by infection through the ground-air and water
of malarious regions have been unsuccessful. Even
subcutaneous injection of water and dew from the
malarious Roman Campagna has proved harmless.
The possibility that a resistant spore form of the
malarial parasite may be cast abroad by the mosquito,
and may subsequently infect man through the air or
water, cannot be denied, but the evidence thus far ob-
tained weighs against this hypothesis. Nor is there
any evidence that the mosquito may infect its eggs or
its young directly or indirectly. Considerable inves-
tigation of this possibility has yielded only negative
results. The facts thus far determined show only that
the malarial parasite is removed from the blood of
man by the bite of the female mosquito (the male is
not known to bite), develops and reproduces in this
same individual mosquito, and by its bite later may
be returned to man in the form of spores.
The mosquito theory of malarial inoculation seems
to correlate and explain all the various facts that have
been observed in relation to the appearance and
spread of malaria. The numerous conditions de-
scribed as favoring or opposing the spread of malaria
are found equally to favor or oppose the development,
activity, and spread of mosquitoes. I have been able
to find only one exception to this generalization,
namely, in the asserted fact that, in exploring unin-
habited lands, men among whom malaria did not pre-
viously exist may develop malaria. If this statement
is unreservedly true, and no satisfactory explanation of
it is forthcoming, it will require some modification
of our present belief, as it seems to show that man is
not a necessary host to the malarial parasite. But we
must require absolute proof of this claim before we
can admit it. There is, of course, a possibility that
future investigations may show that the human mala-
rial parasites may develop in other hosts than man and
the mosquito.
The discovery of the method by which malaria is
carried directs us to the rational means of combating
the spread of the disease. The mosquito must be the
object of attack. We need not attack all mosquitoes
indiscriminately, but only such kinds as are known to
act as host to the parasite, or, so far as yet shown,
mosquitoes belonging to the genus Ar.opheles. The
commonest house mosquito belongs to the genus
Culex, and seems to be harmless. Various other gen-
era of mosquitoes are recognized, but they are uncom-
mon and are not known to be carriers of malaria.
Ross'" is of the opinion that for practical purposes
of attack, we need only to learn to distinguish be-
tween Anopheles and Culex, which have certain differ-
ential characteristics. A wholesale crusade to ex-
terminate from a given locality the adult mosquito
would prove ineffectual, but such an attempt against
the eggs and larvae, he thinks, promises practical re-
sults.
The harmless Culex lays its eggs on the surface of
any artificial collection of water, such as pots, tubs,
cisterns, wells, drains, and ditches, as well as in stag-
nant pools and ponds in the vicinity usually of houses.
The Anopheles, on the contrary, seem to prefer, as a
rule, natural collections of water on the outskirts of
towns and in rural districts, as a place of deposit for
its eggs. It would not be necessary, therefore, in at-
tacking Anopheles to look to every bit of collected
water, but rather to the occasional ponds and stagnant
pools outside of towns.
According to Ross, the larvae of Culex are readily
distinguished from those of Anopheles by the fact that
the former are seen floating head downward on the sur-
face of water, due to the fact that they are provided
with a breathing-tube which is inserted in the rear end
of the body, whereas the larvas of Anopheles, which
are not so provided, float flat on the surface of the
water, like sticks. This difference " enables us to dis-
tinguish the grubs at a glance, and therefore the pools
in which they breed." The practical importance of
this, however, seems io be partly negatived by tne fact
that this rear-end breathing tube of the larval stage of
Culex disappears in the next stage, the pupal stage,"
and in this stage the Culex floats flat on the surface of
the water, a fact of which Ross makes no mention.
It is a surprising fact that comparatively little is
known by entomologists in regard to the distribution
and habits of the different kinds of mosquitoes, and it
is therefore necessary for us largely to develop our
knowledge of mosquitoes in this direction.
There are three principal methods of waging a war
of extermination against mosquitoes : first, by drain-
age of the breeding-pools; second, by the mtroduction
of fish into them; and third, by scattering petroleum
or other chemicals over them. The first method is
well known for its effectiveness; the introduction of
fish in the breeding-waters is of value, if they permit
the growth of fish, for fish devour and destroy the
grubs of mosquitoes; the use of petroleum or other
270
MEDICAL RECORD.
[February 1 7, 1 900
chemical substances on the water has been found to
destroy effectually the larvse and pups of mosquitoes.
Howard's' experiments show that one ounce of petro-
leum to fifteen square feet of water surface will destroy
mosquito grubs and prevent their subsequent develop-
ment for a considerable period, probably from two to
four weeks.
In conclusion I wish to emphasize the fact that
every case of malarial disease may be a menace to the
public health, provided the Anopheles be also found
in the same locality, by acting as a focus of infection
for the spread of malaria in the immediate vicinity,
and it is probable that the periodical appearance of
malaria in regions usually free from it is explained in
this way. It follows that cases of active malaria
should be isolated by mosquito netting or otherwise,
as a preventive of the dissemination of the disease.
BIBLIOGRAPHY.
1. Laveran : Traite des Fievres Palustres, Paris, 18S4, pp.
457-458.
2. Macloskie : The Poison Apparatus of the Mosquito. Amer.
Naturalist. 1888, pp. 884-8SS ; also Science, 1887, p. 106.
3. Danilewsky : Parasitologie comparee du sang. Kharkow,
1889, vol. i.
4. Howard : An Experiment against Mosquitoes. Insect
Life, vol. v., No. I, p. 12, September, iSg2 (issued by United
States Department of Agriculture, Division of Entomologj-).
5. Manson ; On the Nature and Significance of the Crescentic
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Journal, December 8, 1894.
6. Ross : Proceedings of the South Indian Branch of the
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7. Manson ; The Life-History of the Malarial Germ outside
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but not so fully reported).
8. Ross : Letters to Manson, dated May 25 and May 28,1895.
See Manson's third Goulstonian lecture, British Medical Journal,
March 28, 1896.
9. Bignanii : Hypotheses as to the Life-History of the
Malarial Parasite Outside the Human Body. Lancet, November
14 and 21, 1S96.
10. Manson : Hypotheses as to the Life-History of the
Malarial Parasite Outside the Human Body. Lancet, December
12, i8g6 (note especially the last paragraph).
11. Howard: United States Department of Agriculture,
Division of Entomology, Bulletin No. 4, new series, chap, i..
Mosquitoes and Fleas. Washington. 1S96.
12. MacCallum ; On the Haematozoan Infections of Birds.
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iSg7 (abbreviated report).
13. Ross : On Some Peculiar Pigmented Cells Found in Two
Mosquitoes Fed on Malarial Blood. British Medical Journal,
December 18, 1897.
14. MacCallum : On the Ilsematozoan Infections of Birds.
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15. Ross: Pigmented Cells in Mosquitoes. British Medical
Journal, February 26, 1898.
16. Ross: Report on the Cultivation of Proteosoma I.abbe in
Grey Mosquitoes, Calcutta, May 21, 1898.
17. Dionisi : Sulla Biologia dei parassiti malarici nell' am-
biente. Policlinico, V.-M., 1898, p. 419, seduta de R. Acca-
demia Med., M.iy 29, 1898.
1 3. Manson: Surgeon-Major Ronald Ross' Recent Investiga-
tions on the Mosquito-Malaria Theory. British Medical Journal,
June 18. 1898.
19. Manson : The Mosquito and the Malaria Parasite. Brit-
ish Medical Journal, September 24, 1898.
20. Grassi : Rapporti tra la malaria e peculiare insetti (zanza-
rone e zanzare palustri) ; nota preliminare. Rendiconti della R.
Accad. dei Lincei, vol. vii., 2d sem., October 2, 1898.
21. Ross: Preliminary Report on the Infection of Birds with
Proteosoma by the Bites of Mosquitoes. Simla, 1898, and Now-
gong, Assam, October 11, 1898.
22. Dionisi : I parassiti endoglobulari dei pipistrelli. Rendi-
conti della Reale .'Vccademia dei Lincei, vol. vii., 2d sem., seduta
del 6 Novcmbre 189S, pp. 254-258.
23. Grassi : La malaria propagata per mezzo di peculiari in-
setti. ii nota preliminare. Rendiconti della R. Academia dei Lin-
cei, vol. vii., 2d sem., 6 Novembre 1898.
24. Bignami : The Inoculation Theory of Malarial Infection.
Account of a Successful Experiment with Mosquitoes. Lancet,
December 3 and ro, 1S9S.
25. Bastianelli, Bignami, and Grassi : Coltivazione delle semi-
lune nialariche dell' uomo nell' Anopheles claviger Fabr. (sinoni-
mo : Anopheles maculipennis Meig. ) ; nota preliminare. R.
Accad. dei Lincei, vol. vii., 2d sem., December 4, iSy8.
26. Grassi and Dionisi : II ciclo evolutivo degli emosporidi ;
nota preliminare. R. Accad. dei Lincei, vol. vii., 2d sem.,
December 4, 1898.
27. Grassi, Bignami, and Bastianelli : Ulteriori richerche sul
ciclo'dei parassiti malarici umani nel corpo del zanzarone ; nota
preliminare. R. Accad. dei Lincei, vol. viii., ist sem., 8 Gen-
naio 1899.
28. Koch ; Ergebnisse der wissenschaftlichen Expedition des
Geheimen Medicinalraths Professor Dr. Koch nach Italien zur
Erforschung der Malaria. Deut. med. Woch., February 2, 1899.
29. Grassi, Bignami, and Bastianelli : Resoconto degli studi
fatti sulla malaria durante il mese di gennaio. R. Accad. dei
Lincei, vol. viii., 1st sem., February 5. 1899.
30. Nuttall : Die Mosquito-Malaria-Theorie. Centralblatt
flir Bakteriologie, Parasitenkunde und Infektionskrankheiten,
February 14, 21, 28, and March 18, 1899.
31. Brit. Med. Journ. , Editorial. February 18. 1S99, p. 432.
32. Daniels : On the Transmission of Proteosoma to Birds by
the Mosquito ; A Report to the Malaria Committee of -the Royal
Society. Proceedings of the Royal Society, vol. Ixiv. , pp. 443-
454 (read March 16, 1S99).
33. Bastianelli and Bignami : SuUo sviluppo dei parassiti della
terzana nell' Anopheles claviger. Bullettino della R. Accad.
med. di Roma, Anno xxv., 1898-1899, Ease. 3 (April 19, 1899).
34. Grassi, Bignami, and Bastianelli : Ulteriori richerche sulla
malaria, iv nota preliminare. R. Accad. dei Lincei, vol. viii.,
ist sem.. May 7, 1899.
35. Nuttall : Neuere Forschungen iiber die RoUe der Mos-
quitos bei der Verbreitung der Malaria. Cent. f. Bakt. , June 19,
26, and July 31, 1S99.
36. Ross : The Possibility of Extirpating Malaria from Cer-
tain Localities by a New Method. British Medical Journal,
July I, 1899.
37. Koch : Erster Bericht liber die Thatigkeit der Malaria-
Expedition. Deut. med. Woch., September 14, 1899.
38. Grassi: British Medical Journal, September 16, 1S99, pp.
"48-749-
39. Koch : Ueber die Entwickelung der Malariaparasiten.
Zeit. f. Hygiene und Infektionskrankheiten, September, .1S99.
40. Kossel : Ueber einen malariaahnlichen I5lutparasiten bei
Affen. Zeit. f. Hygiene u. Infect., September, 1899.
41. British Medical Journal, August 26, September 2. 9, 16,
23, and 30, 1899. .See also Lancet, August 26, September 2,
16, and 30, 1899 (to be continued).
42. Grassi : Ancora sulla malaria ; Nota preliminare. Atti
della R. Accad. dei Lincei, vol. viii., fasc. 6, 2d sem., Septem-
ber 17, 1899.
43. Grassi : Osservazioni sul rapporto della secunda spedizione
malarica in Italia, presieduta dal Prof. Koch, etc. Atti della R.
Accad. dei Lincei, vol. viii., 2d sem., October 15 and November
5, 1899.
44. Bastianelli and Bignami : Malaria and Mosquitoes. Lancet,
Jan. 13, 1900.
OBSERVATIONS ON THE SURGERY OF THE
BRAIN, BASED ON CLINICAL AND EXPER-
IMENTAL EVIDENCE.
By GEORGE W. CRILE, M.D.,
CLEVELAND
rROFESSOR OF CLINICAL SURCEh
LEGE OF PHYSICIANS ANC
CLEVELAND GENERAL HOSI'I
Elasticity of the Brain. — Grashey has proved that
the cerebral tissue is incompressible. The coefficient
of compressibility is even less than that of water. In
a series of experiments upon the elasticity of the brain
by Horsley and Levy, they concluded that the recoil
of the brain, after a given compression, was not at all
proportionate to the height of the blood pressure at the
time, but to the elasticity of the braifi tissue itself.
When the brain was subjected to a sudden pressure
the recoil occurred within ten to thirty seconds after
it, soon recovering its normal level. The recoil, how-
ever, was considerably dependent upon the height of
the blood pressure.
On the Effect of Increased Intracranial Pressure.
— The immediate effect of increased intracranial press-
ure is not marked until the brain is compressed from
five to seven per cent, of its volume. The effect upon
respiration is earlier noted and more pronounced than
that upon the blood pressure. There is first a slowing
of the respiratory rhythm, then arrest. Active expira-
tion is affected, then active inspiration. The amount
of pressure necessary to arrest respiration is somewhat
February i 7, 1900]
MEDICAL RECORD.
271
dependent upon the height of the blood pressure.
The higher the blood pressure the higher the intra-
cranial pressure necessary to produce respiratory ar-
rest. Even after arrest has taken place, if the blood
pressure has increased, respiration may be resumed,
and in fact the time when respirations will be resumed
can often be foretold by noting the rise of the blood
pressure. After respiratory arrest had taken place, if
the vagi had been previously severed, thus causing a
rise in blood pressure, respirations were sometimes
renewed. In the presence of arrested respiration, if
artificial respirations were produced, a rise in blood
pressure usually followed, and the natural respiratory
efforts appeared in the midst of the artificial.
The effect of increased intracranial pressure upon
the heart was, first, a slowing of its rhythm, with some-
times intermission, then later a complete arrest. If
the pressure was continued for a sufficient length of
time, the cardio-inhibitory mechanism became e.\-
hausted and a very rapid heart action followed.
Pari passu with the increase of intracranial press-
ure, the blood pressure fell. In some instances there
was a mechanical stimulation of the pressor action of
the vasomotors, producing a temporary rise in blood
pressure. As a rule, when the vagi were severed, al-
lowing a very rapid heart action together with the
normal rise of blood pressure attending such section,
the application of pressure upon the brain produced
an additional rise in the blood pressure which was
still more increased by means of artificial respiration.
On the Relation of the Depth of Anaesthesia to
the Foregoing Phenomena. — The deeper the ana;.s-
thesia the earlier and the more abruptly the respira-
tions failed. Conversely, when the brain was under
a considerable pressure, a less amount of anaesthesia
was necessary to reduce the animal to the state of so-
called surgical anaesthesia, while the effect of the in-
creased pressure of the brain upon the heart and upon
the blood pressure was also dependent upon the depth
of the anaesthesia. It was not so marked in the case
of the respiration.
Clinical. — Since having performed the experiments
leading to the foregoing observations, I have had
ample clinical opportunities for verifying them.
Whenever, as the result of a hemorrhage, an abscess,
a depressed fracture, or other cause of increased intra-
cranial pressure, the respiration, or the circulation, or
both, are modified by such pressure, it is fair to as-
sume that the brain has been subjected to a compres-
sion amounting to about five per cent, of its volume.
The exceptions to this deduction would appear in
cases in which the pressure is exerted more directly
upon the part of the brain representing the functions
modified. The elastic recoil of the brain is observed
in cases of depression due to hemorrhage on the re-
moval of the clots, on elevating depressed fractures,
and on evacuating abscesses. I have seen clinical
proofs of the effect of increased intracranial pressure
upon the circulation as striking as the experimental.
There is scarcely any mistaking the slow, full " press-
ure " pulse, nor the active inspiratory phase, and
finally the whole respiratory action under pressure.
The great significance of a rapid pulse alternating
with a very slow pulse at comparatively short inter-
vals is obvious. This signifies the dissolution or
breakdown of the cardiac centre. When this stage
has been reached, there is scarcely a doubt as to the
fatal termination. Operative procedures, undertaken
under such conditions, are nearly always fatal, as in
addition to the foregoing the vasomotor centre is
almost invariably exhausted. If the circulation of the
skin is studied, it will be found that the vasomotor
action is lost, or nearly so, and under no circumstances
should an operation then be undertaken. Experi-
mental and clinical evidences are in accord as to the
statement that the respiratory centre is far more sensi-
tive than the cardiac centre, and gives an earlier in-
dication of increased intracranial pressure. The ex-
piratory phase of the respiratory act is first aft'ected.
In performing an operation upon the brain under the
circumstances of an increased intracranial pressure, I
usually detail an assistant who is to administer artifi-
cial respiration in case of sudden respiratory failure
so likely to occur in the administration of an anaes-
thetic, before the stage of surgical anaesthesia is
reached. I also have hot water and pieces of ice at
hand, so that the assistant may, in the process of re-
storing respiration, apply cold alternating with heat
upon the abdomen and chest. Ice is a powerful in-
spiratory stimulant and heat a powerful expiratory
stimulant. Thus the alternating of the two extreme
temperatures Stimulates both sides of the centre. If
respirations fail as above indicated, the operation
should not be abandoned, but the skull should be
opened with as much dispatch as is consistent with
safety, the intracranial pressure being relieved by
cutting away a sutlicient amount of skull, when nor-
mal respirations will almost certainly be resumed.
On the Blood Supply of the Brain. — Sherrington
and others have been able to demonstrate the presence
of vasomotor nerves in the vessels of the brain. It
is probable that the cerebral circulation is wholly de-
pendent upon the general blood pressure, and, inas-
much as the general blood pressure is very markedly
regulated by the capacious splanchnic area, it is ob-
vious that the cerebral circulation may be better con-
trolled by modifying the blood supply of the splanch-
nic area than by any attempts at the modification of
the cerebral circulation itself. It is true that, as a
result of certain drugs, the amount of blood flowing
from the veins of the brain is increased, but this in-
crease is due to an increase in the rapidity of the flow
through the cerebral arteries and capillaries.
On the Immediate Effect of Traumatisms I
have been able to demonstrate experimentally that the
first eftect of a blow upon the skull, of compound frac-
tures, of rapidly increased intravQ.ntricular pressure, of-
gunshot injuries, etc., is respiratory failure. Gunshot
wounds in a large proportion of the cases produce sud-
den respiratory failure. Introducing a needle con-
nected with a pressure bottle raised to a considerable
height and containing decinormal salt solution, and
allowing the fluid rapidly to fill up. the lateral ven-
tricles, caused an almost immediate arrest of respira-
tion. In one gunshot experiment, the a-nimal was
killed by a pure respiratory failure, and the ball did
not even touch any portion of the brain but passed
close to the medulla. This structure was not even
touched by the bullet; the circulation was but little
affected. The concussion imparted was sufficient to
arrest respiration permanently. One of the earlier
casualties in the Spanish-American war, in the navy,
was that of a gunshot injury of the head. In the re-
port of this case, the surgeon observed that respira-
tions were arrested, but the heart continued to beat
for some minutes afterward, and I wish to direct atten-
tion to the probable indication for administering arti-
ficial respirations as a first aid in brain injuries. It
has been demonstrated experimentally and clinically
that the respiratory centre is extremely sensitive, and
that if artificial respirations are supplied for a time,
natural respirations may be resumed. It is well to
bear in mind that when respiratory failure does occur,
natural respirations will be resumed earlier if blood
pressure is'increased, so that even though the circula-
tion has not reached a dangerous depression, it should
be restored to its normal or even increased on account
of the favorable eff^ect upon the respiratory action.
On the Cortical Respiratory Centres. — It is true
that electrical or mechanical stimulation of any sensi-
272
MEDICAL RECORD.
[Eebruary 17, 1900
tive nerve may produce a change in the respiratory
action, increasing the respiratory tonus, sometimes the
respiratory clonus, and nearly always the respiratory
rhythm. This occurs under surgical anaesthesia.
There is in the dog an area of the cortex correspond-
ing with the upper end of the supra-orbital sulcus, a
stimulation of which produces a very marked increase
in the respiratory rhythm. The animal, in fact, liter-
ally pants. An over-inspiratory clonus is produced by
a stimulation of the cortex at the olfactory bulb and
tract. A well-defined area for producing arrest of res-
piration is found on the outer side of the olfactory
tract just in front of the junction of the tract with the
uncinate. There is in this portion of the cortex a
well-defined " arrest " area which, when subjected to
electrical stimulation, causes a complete arrest of res-
piration. The arrest takes place usually in the inspi-
ratory phase of the respiratory act. Now, this area is
in relation with the base of the skull, and it rests upon
a portion of the skull which is not well protected by
the so-called water bed of the brain; therefore, in an
injury of the brain in which the brain is thrown for-
cibly against the base of the skull, this portion is
likely to be injured and may produce thereby a respi-
ratory arrest due to a mechanical stimulation and in-
jury of this centre. In a case under my observation,
in which a patient in falling struck violently upon the
bottom of the hold of a vessel, producing respiratory
arrest, causing death in a short time, the autopsy
showed that there was marked laceration of the por-
tion of the brain corresponding with the cortical ar-
rest area just described. I am, of course, not certain
as to whether the local or the general injury caused
the respiratory arrest.
On the Cerebellum. — It has been only within re-
cent years that the physiology of the cerebellum has
been fairly well worked out. One of the most striking
facts, both clinically and experimentally, regarding
the cerebellum, is the remarkable compensation which
may take place after injuries and in disease. Luciani
and Russell have shown that an animal may live after
the ablation of the entire cerebellum. Owing to the
remarkable range of compensation, clinically, the ab-
sence of characteristic cerebellar symptoms must al-
ways be borne in mind. Extensive disease of the
cerebellum may exist with but little clinical evidence.
The effects of the removal of the lateral lobe of the
cerebellum are the following:
((t) There is a strabismus, such that the opposite
eye is directed downward and outward, while the eye
on the same side as the lesion is little, if at all, devi-
ated.
(/') The consequent nystagmus is such that the lat-
eral jerks of both globes are directed toward the side
of the lesion.
(c) The motor phenomena consist of a paresis affect-
ing chiefly the limbs of the same side as the lesion.
There is also increased muscular rigidity on the same
side as the lesion.
(^/) There is inco-ordination, so that there are ro-
tation and reeling toward the side opposite the lesion.
(e) The sensory phenomena include blunting of
sensibility, chiefly of the limbs on the same side as
the lesion.
(/) The reflexes are markedly increased, chiefly on
the same side as the lesion.
There has been much confusion and many differ-
ences have arisen among experimenters and clinicians
with regard to symptoms. Much of the confusion, in
regard to the reeling, may be due to the fact that ob-
servers do not adopt the same rule in describing a
reeling to the right or to the left, whether it applies to
the observer or the observed. Both experimenters and
clinicians are agreed as to the marvellous rapidity
with which compensation takes place after disturbance
of the functions of the cerebellum. This accounts tor
the destruction of large portions of this organ by the
slow development of tumors without producing symp-
toms, for, inasmuch as the growth is slow, compensa-
tion takes place part passu with the development of
the tumor, but in cases of hemorrhage or of rapidly
developing abscesses the cerebellar symptoms are
more pronounced, and the earlier the observations the
more clearly will the symptoms present themselves.
I have been able to verify on the human subject, in
three different instances, while performing operations
on the cerebellum, the effect upon the eye of irritation
of the cerebellum. In each of these cases I had occa-
sion to explore tiie lateral lobe of the cerebellum, and
in each instance I asked a colleague to watch the ef-
fect upon the eyes while exploring the structure of the
cerebellum. In each of the cases the opposite eye was
immediately deviated outward and resumed its normal
position as soon as the irritation ended. In none of
the cases was there any effect noted upon the eye after
the actual irritation caused by the exploration had
ended. From both experimental and clinical experi-
ence I regard the cerebellum as being a safe field for
exploration, and \iould not hesitate to extend the oper-
ation to any portion of this organ. The cerebellum
was formerly supposed to exert an important trophic
influence, but this is now known to be untrue. The
cerebellum was formerly believed to act as a whole,
but it is now known that its division mesially does
not interfere with the functions of either half of this
organ. Uhile tiie cerebellum has a crossed action on
the brain, it has a direct action on the spinal cord.
On the Technique of Opening the Skull. — I have
tried the trephine and the chisel each in a consider-
able number of cases, and have finally given almost
unqualified preference to the chisel. Neither the cir-
culation nor the respiration was appreciably affected
while the skull was opened with a chisel and mallet.
The observations were made by recording the results
on smoked drums. With the use of the mallet and
chisel there is a very great range of adaptibility wiiich
is not possible with the trephine. I use a very sharp
chisel which cuts the bone with the lightest taps of the
mallet, cuts it sharply and accurately, enabling the
operator to enter the skull in much less time than by
the trephine, and enabling him to control the size and
shape of the opening. The opening of the skull may
be witiiout injury to the brain, either from jarring or
from the chisel itself.
After the opening has been made, I prefer the use
of a sharp bone forceps to any instrument of special
design that I have yet used for the further removal of
the skull. The prismatic-shaped, pointed forceps, de-
vised by Mr. Horsley, answers the purpose admirably.
The hemorrhage coming from the diploe, while never
dangerous on account of its quantity, obscures so much
the field of operation that it is important to obviate it.
This is easily and readily done by the use of 9 ten-
per-cent. solution of olive oil and beeswax, making
a wax of sufficient consistency to press into the cut
edges of the bone, instantly stopping local hemor-
rhage. This wax is harmless and may be allowed to
remain.
I wish in conclusion to report a rather remark-
able case of the destruction of the so-called "name
centre" by a bullet wound. I will allude to it only
briefly iiere, as it will be reported later in detail. 'J'he
case is one in which a 22-calibre bullet took effect
just above Reid's base line on a vertical plane with
the anterior border of the ear. The force of the bul-
let was so far spent in traversing the bone that it
was arrested at a depth of seven-eighths of an inch in
the substance of the brain in the third inferior tem-
poro-sphenoidal convolution, cutting a circular hole a
little less than three-quarters of an inch in diameter
February i 7, 1 900]
MEDICAL RECORD.
273
and seven-eighths of an inch in depth, the lower mar-
gin resting on the base of the skull, tlie posterior bor-
der of the circular wound being in a vertical line with
the anterior border of the external auditory meatus.
The bone was cut away some dist.mce around the point
of entrance and lodgment of the bullet. The bullet
was readily removed. No other portion of the brain
was injured, neither was there any hemorrhage of con-
sequence. The operation was performed on the eighth
day after the injury. The only symptoms manifested
were the patient's inability to name common objects.
His conception and perception were perfect. Articu-
lation was perfect, and no other function was either
modified or destroyed, e.xcepting the ability to speak
common names. This case has been thoroughly
worked up from every standpoint, and is very definite
in pointing out the location of the centre.
The clinical observations upon which this paper is
based consist of forty-seven operations on the brain
and of a large series of experiments on animals, a part
of which has been published, and the greater part is
to be published in a later paper, the purpose of this
paper being to call attention to the value of placing
the experimental and clinical evidence side by side,
each reinforcing the other.
SPLENIC EXTRACT AND THE SPLENIC
FUNCTION.'
By CHARLES RAYMOND CARPENTER, M.D,.
Glandular extracts have during the last few years
attracted considerable attention in the domain of thera-
peutics; and it is the opinion of the writer that they
are destined to play a role in the near future, the im-
portance of which is but slightly appreciated at the
present time. The thyroid extract is the best known,
and until recently was almost the only one of this
class that yielded any definite practical results.
There is always danger of any new remedy being
pushed into new fields by experimenters, and being
lauded by them for effects which further investigation
shows were merely incidental. It is certainly to be
hoped that the new effects ascribed to thyroid extract
in the field of gynaecology will not prove illusory.
Its effects in cancer of the uterus have been reported
to be astonishing and felicitous, and to hold out the
hope at least that this dread condition may at last be
met by the physician with a therapeutic weapon which
he may wield with some assurance that his efforts will
not be wholly in vain.
Still more recently we find the extracts of the par-
otid and mammary glands being used with similarly
astonishing results in the intractable conditions of the
ovary and other pelvic organs, which, up to the pres-
ent time, have been relieved permanently only by total
extirpation of those organs.
But the object of this paper is to speak of another
extract with which the world is little acquainted, and
incidentally to discuss the splenic function in its rela-
tion to infectious disease. The extract of the spleen
has been made and used experimentally in various
ways for a long time, but there is not at the present
time any accessible record of its being used with suc-
cess as a therapeutic agent. It is therefore with un-
usual pleasure that I make the statement to this soci-
ety, and to the medical world, that my experience with
the splenic extract has demonstrated that along certain
lines it has a very decided and important therapeutic ac-
tion , so important, in fact, that if the future bears out
in any degree the promise of my experiments and ob-
' Read before the Leavenworth City and County Medical
Society.
servations, the use of the splenic extract will become
as classical as the use ot thyroid extract in myxoedema,
or the antitoxin of diphtheria in that disease.
Some two years ago, I was led into a somewhat crit-
ical study of the conditions which prevail in typhoid
fever, and, like every other physician who has ever
given the matter any thought, was impressed with the
utter helplessness of the vaunted science of medicine
in its presence, so far as curing or aborting the dis-
ease was concerned.
"They also serve who only stand and wait,'" says the
poet; and, unsatisfactory as it is, that is about the
sum of the physician's services in typhoid fever. We
ameliorate the conditions in various well-known ways,
and sometimes imagine we have shortened its course,
but no candid physician will claim that, with any
treatment in general use at the present time, he can
cure the disease. I do not say this to the dispar-
agement of any one, but the fact remains that there is
no specific treatment known to the profession for this
disease. The use of the splenic extract in typhoid
fever, however, produces such marked and rapid ef-
fects when given as hereafter stated, that when the
philosophy of the treatment is considered, it seems to
be as near a specific treatment as anything could be,
provided time and experience show that these effects
are uniform and always to b^ relied upon. So far,
they have been unvarying when the conditions were
complied with. Heretofore, when the disease has once
declared itself, the patient has been practically turned
over to the nurse. Systematic cold bathing, the milk
diet, and slightly astringent intestinal antisepsis when
the enteric symptoms are marked, have been most re-
lied upon. On the whole, these measures g'ive the
best results, mitigate the severity of the symptoms,
make the patient more comfortable, ni .' reduce the
mortality of the disease more than ?My (*her treatment
heretofore recognized. I do not sa; ;'iis to the dis-
paragement of Dr. Woodbridge or any one else, but beg
to adhere to my opinion. The Brana fie^tment, when
properly administered and accompan t i ' y the milk
diet, has been more and more recognizi .■ as the best
treatment for typhoid fever.
Very well, why do the cold bath and the n:.lk diet
do so much for the typhoid-fever patient?
Intestinal antisepsis is well understood; it is unnec-
essary to dwell upon it here, except to say that, as a
fundamental treatment, it has fallen far short of what
the medical profession has expected from it, ani. at
present it is not relied upon except as an adjuvant .>
the Brand treatment. The reason for this is to ue
found in the steadily increasing list of cases in which
the intestinal lesions have been either absent or of
trifling extent; and Osier's now famous observation
that the intensity of the disease bears no relation to
the intensity or extent of the intestinal lesions, is rap-
idly becoming the opinion of the profession.
But when the question is asked of almost any body
of physicians, "Why does the cold bath produce its
well-known beneficial effects in typhoid fever? " al-
most every one will respond unhesitatingly, " Because
it reduces the temperature."
I" beg to answer, " Not at all." To be sure it does
reduce the temperature, but so do many other reme-
dies which accomplish no good whatever, and do not
mitigate the condition of the patient a particle. Qui-
nine reduces the temperature unerringly and without
a break until it reaches the normal, or even a point
much below the normal; but what good does it do?
None whatever. Acetanilid, phenacetin, and the whole
list of the coal-tar series will do the same; but
we all know that while some slight mitigation of the
symptoms occurs, provided the heart is properly sup-
ported, it is much less marked than that which follows
the Brand treatment.
274
MEDICAL RECORD.
[February 17, 1900
Manifestly, then, the cold bath does something, pro-
duces in the physical economy some change in addi-
tion to the reduction of temperature which these other
remedies do not and cannot produce. What is that
change?
The only satisfactory answer to this question is to
be found in a study of the conditions of the blood in
typhoid fever as compared with the blood in the nor-
■ mal condition. Normally the blood contains from
five to five and a half million red corpuscles, and
about seventy-five hundred white corpuscles to the
cubic millimetre. These numbers vary widely, how-
ever, in both health and disease. In certain physio-
logical conditions, such as pregnancy and normal di-
gestion, the relative number of white corpuscles or
leucocytes is markedly and constantly increased. We
find also that in nearly all inflammatory and infec-
tious diseases there is a constant tendency to a simi-
lar increase of the leucocytes, or leucocytosis as it is
called. Careful observation also shows that with the
exception of a temporary decrease al the very begin-
ning of the disease there is a constant ratio between
the degree of leucocytosis and the severity of the dis-
ease. A mild disease with vigorous vital resistance
will be accompanied by a marked leucocytosis; a
more severe disease with good resistance, by a more
marked leucocytosis; and a still more severe disease
with still good resistance, by a still more marked leu-
cocytosis. But, in a very severe disease, with lethal
tendencies, we find leucocytosis absent (Cabot).
Now, what does all this mean?
The principle of phagocytosis enunciated by Metch-
nikoiif is still under the searchlight of scientific inves-
tigation; different observers differ more or less as to
whether the bactericidal action of the blood is due
more to the vital action of the leucocytes themselves,
or to a direct chemical action taking place in the
blood serum. But investigation brings to light only
more evidence that the blood does possess a bacteri-
cidal action, and whether or not this action is entirely
due to the vital action of the leucocytes, the degree of
leucocytosis is a fairly accurate index of the bacteri-
cidal power of tlie blood, and hence is an index also
of the body's vital resistance to disease. This is an
argument directly in favor of Metchnikoff's position,
and since he and other observers have watched the
actual process under the microscope, there can be no
doubt that the leucocytes exercise a directly germici-
dal effect upon the invading germs.
We have here, then, an explanation of the leucocy-
tosis found in so many diseases, increasing with the
severity of the disease. The proliferating glandular
system throws into the circulation, as it were, an op-
posing army to the invading host of the enemy. The
more numerous the invading army of germs, and the
more vicious tlieir assault, the more numerous the de-
fensive army necessary to meet them and hold them in
check. But if the attack is so severe or is made in
such a manner that the body's reserve forces cannot
be called forth, tire defence is a failure; leucocytosis
does not take place and the disease at once assumes a
grave if not a lethal aspect.
This seems to be true of most diseases; but there is
a certain class of grave diseases that seem to be not-
able exceptions to this rule — that is, they are excep-
tional in that at no time is there any tendency to leu-
cocytosis, except in the initial stage, or in case of some
complication of an inflammatory character, or other
condition such as hemorrhage when there is always a
tendency to leucocytosis. But such a leucocytosis is
incidental to the complication, and seems to have no
good effect on the primary disease.
Ooe of these diseases is typhoid fever. In the in-
itial stage we find a very transient leucocytosis, and
then begins a steady gradual diminution of the leuco-
cytes from the normal number down to one or two
thousand in some cases.
Again we ask, Why is this? Why, in a disease in
which the body so much needs the help of its defen-
sive army, does it fail even to put in an appearance?
Unless we may construe the initial increase of leuco-
cytes, transient as it is, to be a loyal effort on their
part to do their duty; an effort which is quickly throt-
tled by the disease. Is it not because the very citadel
of the body where this defensive army is garrisoned,
as it were, is besieged?
Whence comes this army of leucocytes?
We have intimated in a general way that the glan-
dular system throws them into the circulation. Phys-
iologists have not entirely determined the extent to
which the different portions of the glandular system
take part in the production of the leucocytes, but it is
admitted by all that they are probably elaborated most
largely in that great vascular gland, the spleen. An
enormous amount of blood passes through this organ,
and it has been shown that blood taken from the
splenic vein is very rich in leucocytes, while that
taken from the artery is not more so than blood taken
from any other artery. This shows that leucocytes are
produced in the spleen, and this flood of leucocytes
passes from the splenic directly into the great portal
vein, through the liver and into the general circula-
tion.
In 1895 F. Bezanron delivered a thesis in Paris, in
which he gave an exhaustive study of the spleen, and
arrived at the conclusion that it exercised the function
of elaborating the leucocytes and also acted as a defen-
sive organ against disease.
We admit, then, that the spleen is the great labora-
tory in which the leucocytes are produced, although it
must be admitted that they are produced also by the
lympiiatic glands; and we admit that it is from the
spleen principally that they are ejected into the circu-
lation when leucocytosis is produced. One of the
constant features of the typhoid-fever autopsy is a
softened, friable, and frequently enlarged spleen. In
severe cases it is sometimes found after death in a
totally disorganized condition. In other words, the
citadel which should furnish to the body its defensive
army has been captured and destroyed by the enemy.
Or, to speak anatomically, the organ upon which the
body must depend for its defence against disease is a
more or less disorganized wreck, incapable of perform-
ing its vital function of producing leucocytosis. Now,
correlate these facts and let us see what we have:
r. The white blood corpuscles or leucocytes consti-
tute the body's defensive army against disease.
2. The spleen is the great laboratory in which the
leucocytes are produced, and from which they are
thrown into the blood througli the portal circulation.
3. In typhoid fever there is an absence of leucocy-
tosis during life, and a more or less diseased or dis-
organized spleen found after death.
Do not these facts point directly to the conclusion
that the spleen is the vital point of attack in typhoid
fever? Is it not reasonable to argue that the method
of attack is to inhibit first and finally to destroy the
vital function of the spleen of producing leucocytosis?
And is not this destruction of function accomplished
by a direct action of the germs or their toxin upon the
organic structure of the spleen, producing progressive
softening and ultimate breaking down of its sub-
stance?
As has been seen, while the intestinal symptoms
have been so characteristic of typhoid fe\er as to mis-
lead the whole medical world as to the etiolog) of the
disease, and to give it the name "enteric fever," they
are by no means constant; and many fatal cases have
been recorded in which no intestinal ulceration was
found. Many observers claim that the Eberth bacil-
February 17, 1900]
MEDICAL RECORD.
275
lus does not produce pus, and that suppuration, when
it does take place, in Peyer's patches, the kidney, the
liver, or anywhere else, is due to secondary infection
from the staphylococcus pyogenes aureus or the strep-
tococcus. Notwithstanding the presence of the bacil-
lus in large numbers in the spleen, the formation of
pus in that organ, so far as I know, is unknown; and
all of the organs or glands where pus is known to
form, and where ulceration or sloughing does take place,
are more or less accessible to the pus forming cocci.
Particularly is this true of the intestinal glands. The
spleen on the other hand is a ductless gland, acces-
sible only through the circulation, hence we have no
suppuration there; but the suppression of the splenic
function seems to work some change in, and render
vulnerable all organs and glands that are accessible
through their ducts to the pus-forming cocci. The
intestinal glands being most accessible, and for some
reason in this condition most sensitive, sutfer most.
Witli this elucidation of the pathological anatomy of
the disease which has so long been overlooked or mis-
construed, we are prepared to answer the question
asked above, " Why do the cold bath and the milk diet
do so much for a typhoid-fever patient? "
The experiments of VVinternitz and Thayer in 1893
showed that the cold bath in health and disease pro-
duced, in the peripheral circulatioii al least, leucocy-
tosis. The former detailed his observations to the
Imperial Royal Medical Society of Vienna in Febru-
ary of that year, and Dr. Thayer in April of the same
year reported in the Johns Hopkins Medical Btilktin
twenty cases of typhoid fever in which an average of
7,724 leucocytes were counted before a cold bath, and
13,170 after the bath; an increase of nearly one hun-
dred per cent. Cabot says, in his excellent work on
the blood, in summing up the evidence on this sub-
ject, " Violent exercise, massage, and short cold baths
have been shown to cause a temporary increase in the
number of leucocytes in the peripheral blood, all vari-
eties of the cell being represented." Prolonged cold
baths, on the other hand, have been shown to produce
the opposite effect. But Cabot follows his remark
with the observation that ''the explanation usually
given is that the blood is concentrated by vasomotor
contraction and rise of blood pressure"; intimating
that the increase in the number of leucocytes is not
real but only apparent. To this opinion I beg to
offer the objection that it is illogical. By way of ar-
gument, take an example: Suppose you ha\e a hollow
rubber ball with a small hole in it, filled with blood,
which we will suppose you have the power to preserve
at the body temperature, in a normal fluid condition.
Suppose you make a microscopical count of the leuco-
cytes in this blood per cubic millimetre, and then
squeeze out half or two thirds of the contents of the
ball and make another count. Does any one suppose
for a moment that the second count would differ from
the first? Certainly not; and there is absolutely no
more reason for supposing that any amount of vaso-
motor contraction could in itself change the count of
the leucocytes in the blood. If there is an increase
in the number of leucocytes in the blood after a cold
bath, it must in the nature of things be a true leuco-
cytosis, and this we submit is exactly the reason that
the uniformly beneficial effects ensue which are always
observed when the bath is properly given. It would be
idle to expect beneficial effects from a leucocytosis that
was only apparent, and in which there was no actual
proliferation of the white cells; but it is reasonable to
expect benefit when the leucocytosis is real and marked.
If this be true, have we not arrived at the point
when we can justly say that any remedy which will
produce a true leucocytosis in typhoid fever will be
likely to produce at the same time an amelioration of
the symptoms and a tendency to recovery ?
It seems to me we have.
A large number of experiments have been carried
on with a view to showing what substances when taken
into the body produce leucocytosis and what do not.
Pohl showed, in 1889, that most of the so-called
tonics and stomachics produce slight leucocytosis;
and that iron, quinine, caffeine, and alcohol do not.
Von Limbeck and Binz procured the same condition
— that is, leucocytosis — by the administration of oil of
peppermint, oil of anise seed, and camphor. Lowit
experimented with a number of important organic
compounds such as blood serum, peptone, pepsin, nu-
cleinic acid, and nuclein, giving them subcutaneously
or intravenously, and all of those mentioned produced
leucocytosis.
In the light of our previous study of the blood, what
do we learn from these experiments?
Quinine, iron, and alcohol do not produce leucocy-
tosis; and they ha\e all been dropped from the list of
remedies likely to be of benefit in typhoid fever. Oil
of peppermint and camphor produce leucocytosis, and
the latter especially has been lauded as a remedy in ty-
phoid fever, while the former has long been known as
a powerful germicide, and I have myself used it with
benefit in typhoid in the shape of its camphor, men-
thol.
Nuclein, again, is found in greater or less abun-
dance in milk; and the milk diet is a part of the clas-
sical treatment for typhoid fever. The nuclein pro-
motes leucocytosis, according to Lowit and others, and
the watery portion of the milk supplies directly the
vast amount of the watery portion of the blood elimi-
nated and lost by high temperature and diarrhoea.
When we remember that not a little of the restless-
ness, delirium, and general distress that exist during
high temperature and diarrhoea is due directly to a
condensation of the blood, and that in such patients
the sensation of thirst is obtunded so that they do not
call for a corresponding amount of water, we can un-
derstand how the regular supply of fluid obtained
through the medium of a milk diet properly adminis-
tered would mitigate this condition.
A vast number of substances have been experi-
mented with, and almost without exception those sub-
stances which have been used with benefit in typhoid
fever have been shown to produce leucocytosis ; and
those which do not produce leucocytosis have failed
to be of benefit in that disease.
So we find that in 1893 Goldschneider and Jacob
experimented with the various organic extracts, and
found that extracts of the spleen, marrow, and thymus
gland produced decided leucocytosis; while extracts
of the pancreas, thyroid gland, kidney, and liver had
no such effect.
Here we have a most pregnant fact.
The extract of the spleen produces leucocytosis. In
typhoid fever the organic structure of the spleen is at-
tacked; the vital function is impaired; and leucocy-
tosis is absent. Without any other argument, what
we have seen from the above experiments ought to
lead us directly to the conclusion that the splenic ex-
tract would be of benefit in typhoid fever; but there is
still another reason. Observation has shown that when
the functions of the thyroid gland, the ovary, the tes-
ticle, or the spinal cord are impaired, the therapeutic
administration of the extracts of those organs supplies
the deficiency. Why not expect the same in the case
of the spleen?
In 1898 two Frenchmen, Drs. Lepine and Lyonnet,
detailed in the Revue de Mcdecine some experiments
upon dogs, in which they injected intravenously a so-
lution of the typhoid toxin. Among other things they
noted that in such dogs if the spleen was heated, which
increased its vitality, the dog revived from a dose that
was otherwise fatal. Does not this show that the
276
MEDICAL RECORD.
[February 1 7, i goo
spleen, when artificially stimulated tb exercise its
function, resists the typhoid toxin? Why, then, should
we not expect therapeutic action from the administra-
tion of the extract of the spleen ?
In the early part of my studies, relating to the ac-
tion of glandular extracts and the production of leuco-
cytosis, I attributed this action to the nuclein con-
tained in those extracts. But if the experiments of
Goldschneider and Jacob are to be relied upon, the
thyroid extract does not produce leucocytosis, although
it contains relatively a large amount of nuclein. Other ■
observers claim that it does produce leucocytosis ; so
the truth probably is that it produces some leucocy-
tosis, but not a marked degree. But the splenic ex-
tract does produce marked leucocytosis, and when ad-
ministered in typhoid fever in doses of gr. v. three
times a day, rapidly and steadily reduces the tempera-
ture, without undue diaphoresis, ameliorates all the
symptoms, and steadily and quickly restores the pa-
tient to the normal condition.
Such effects cannot be explained simply by the fact
that the splenic extract contains a certain amount of
nuclein; for it contains not anymore, and some ob-
servers say much less than thyroid extract, which pro-
duces little or no leucocytosis. Not only this, but in
one case in which I administered thyroid extract in
typhoid fever, the effect was only a very slight reduc-
tion of temperature, and little or no effect was pro-
duced on the general condition. As I was out of the
splenic extract at the time, I tried then to fill up the
gap with parotid extract, but its efi^ects were equally
inconclusive, and I was obliged to come back to the
splenic extract as soon as it was available in order to
produce decided effects. We must therefore conclude
that the splenic extract has a specific action entirely
apart from the nuclein it contains; and its action in
typhoid fever is so marked and so beneficial in its
character that, although it has been used in less than
half a dozen cases, it is impossible not to recognize it
as a powerful and important means of controlling the
disease. Indeed it is absolutely the only remedy
known to the medical profession at the present time
for which we can, with any reason, make the claim
that it cures the disease. A recent article advocating
the use of nuclein and protonuclein in typhoid fever
distinctly admits that it does not shorten the disease
or save any time for the patient. I wish as distinctly
to assert that in my hands the splenic extract has
shortened the disease in a most obvious manner, and
reduced the period of convalescence to almost noth-
ing. I wish also to make the statement that it is my
belief that any uncomplicated case of typhoid fever
may be aborted by the use of the splenic extract as I
shall indicate. I do not know that any ordinary com-
plication would furnish any obstacle to the treatment;
indeed I know that malarial fever, which is the most
frequent complication we meet with in this climate,
furnishes no obstacle at all, as I have myself proved
several times. Malarial fever indeed is one of the
class of diseases in which leucocytosis is absent; and
in which, therefore, the splenic extract is indicated,
even if we did not know that an enlarged and evi-
dently disordered spleen has from time immemorial
been recognized as characteristic of malarial fever.
There is, however, one thing to be observed in the
administration of this remedy, and that is, that its
best effects are not produced if the percentage of
haemoglobin or the number of the red cells is much
reduced. No matter how much the leucocytes are
multiplied in number, unless the red cells and the
haemoglobin are kept up, the leucocytes lack defensive
power. Indeed if we keep on multiplying the leuco-
cytes under these conditions, we simply produce a
condition of leukaemia, which is no improvement on
the previous condition. This is easily understood
when we remember that the leucocytes are produced
in the spleen at the expense of the red cells. Whether
the red cells which have arrived at an appropriate age
and condition are entirely destroyed in the spleen, and
the white cells are builded anew from the elements
that previously entered into the composition of the red
cells; or whether the Malpighian corpuscles have the
povier of selecting certain of the red cells of appro-
priate age and condition and elaborating them in
some way to endow them with the vital characteristics
of the leucocyte, while the rest of the red cells pass
through unchanged, is a matter that further and closer
study must determine. But, at any rate, the therapeu-
tic action of the splenic extract under circumstances
such as have been cited leaves no room to doubt, if
there was doubt before, that the leucocytes are created
at the expense of the red cells; and practically we may
not disregard the therapeutic hint thus given. Hence,
whenever I have had a case of this character, in which
the splenic extract did not seem to act promptly, and
the percentage of hsemoglobin was evidently deficient,
it has been my custom to administer alternately with
the extract one of the many excellent haematinic prep-
arations on the market, and have always had the
pleasure of seeing the characteristic effects of the ex-
tract begin to show themselves at once, and the patient
quickly on the road to recovery. Theoretically it has
seemed to me that a preparation or extract of the red
bone marrow would fulfil the conditions here better
than any other preparation, but as no stable prepara-
tion of this substance has yet come into my hands, I
have not been able to carry out the theory.
As previously remarked, I have no long list of cases
to report in connection with this paper, but the treat-
ment is so simple and harmless in its character that
there is absolutely no excuse for not trying it if you
have an appropriate case. If the treatment cannot
stand upon its own merits, it should not stand at all,
and no report of cases will make it stand.
To recapitulate the treatment more precisely, when
I make the diagnosis of typhoid fever, if the enteric
symptoms are at all marked, I order the milk diet;
and if the temperature is 104° to 105° F., and has
persistently stayed at those figures, I order splenic ex-
tract gr. V. every three hours for the first twenty-four
hours. By the end of the first twenty-four hours the
temperature has dropped steadily to 102° or 103°.
Then the extract is given in doses of gr. v. three times
a day. If the htemoglobin is deficient by actual test,
or if the patient is anamic in appearance, or whether
he is or not, if the extract does not act promptly, I
give a haematinic three times a day in addition. The
temperature will oscillate up and down for a few days,
but each oscillation bringing it lower, until in from
four to seven days it will be normal and remain at
that point. The period of convalescence will depend
entirely upon tlie extent of the lesions produced by
the disease before the splenic treatment was begun.
If the diagnosis was made early, it will be /;//.■ if
made after extensive intestinal lesions have been pro-
duced, necessarily those lesions must heal after the
disease has been checked, and the time necessary for
the healing will be in proportion to the reconstructive
power of the individual. But the time will be reduced
to the minimum by continuing the haematinic treat-
ment. After the functional activity of the spleen has
been once restored bv the destruction of the bacilli
and their toxin it is no longer necessary to give the
extract, but as long as the supply of hemoglobin is
kept up the spleen will effectively do its own work of
reconstructing the leucocytes, which, in the period of
convalescence, have ceased to be warriprs and become
peaceful laborers busily engaged in building up the
physical economy weakened by the vanquished enemy.
Before I close I desire to say that the therapeutic
February 17, 1900]
MEDICAL RECORD.
277
'principles here enunciated, in my opinion, will be
found applicable to other diseases besides typhoid
fever. I have myself found them very useful in ma-
larial fever, and it is a question with me whether they
do not apply in a greater or less degree to all that im-
portant class of grave diseases in which leucocytosis
is either absent or ineffective. This class includes at
present, as enumerated by Cabot, typhoid fever, mala-
rial fever, influenza (most cases), measles, rotheln, and
tuberculosis in all its forms. If only the first two and
the last are found amenable to this treatment, the good
accomplished by it would be simply incalculable. In
tuberculosis I have had no opportunity to try the treat-
ment, but it seems likely to me that, inasmuch as the
lymphatic glands are so largely affected in this dis-
ease, it will be necessary to combine with the splenic
extract an extract of the lymphatic glands. If, in
conjunction with these, an extract of the red bone
marrow is given or some easily assimilated haema-
tinic, I firmly believe that the dread disease consump-
tion, which has for ages been, and is to-day, the great
scourge of the human race, would be robbed of its ter-
rors. Unfortunately, for some reason I have seldom
had a case of this disease in my practice, and so have
had no opportunity to test the treatment of it.
There are two other grave diseases in which I
should like to see the splenic treatment tried, although
scientific investigation has not yet decided whether or
not leucocytosis is absent. Some observers say one
thing and some another, but most of them say noth-
ing. I refer to cerebro-spinal meningit'S and yellow
fever. I have myself used the splenic extract in one
case of cerebro-spinal meningitis, and the patient re-
covered with wonderful rapidity from a condition
which at first seemed hopeless; but I used at the same
time guaiacol, painted on the back of the neck and
head, and I was unable to determine whether the good
effect was due to one or the other or to both combined.
Observers differ also as to whether yellow fever be-
longs to this class. Jones, of New Orleans, found in
a study of yellow-fever blood some diminution of the
red cells, and profound changes in their appearance
and character, but says nothing about the white cells.
But when the red cells are so profoundly affected, it is
impossible that leucocytosis, even if present, should
be effective in resisting the disease. Hence it is my
belief that the splenic extract with some good hama-
tinic would prove effective in this dread disease.
During the outbreak of yellow fever at the Soldiers'
Home at Fortress Monroe this last summer, I sug-
gested to Surgeon-General Sternberg the use of splenic
extract, and was informed that my communication had
been received, but I have no reason to believe that
any further attention was given to the matter. If there
is anything in this study of the blood and the splenic
function, and I have reason to believe there is, it is
only reasonable to expect that the use of the splenic
extract in yellow fever, with some remedy to build up
the hemoglobin and red cells, would be found directly
curative.
In fact, when one looks down the vista of possibili-
ties which lie beyond the veil which we are just lift-
ing in this study of the vital conditions of the blood
and the splenic function, it seems as though we were
approaching a wonderland in medicine and therapeu-
tics where we may expect to meet with marvels of the
very existence of which we had not dreamed.
Physiology of the Pharynx. — In an elaborate
article C. Chauveau passes in review the deglutitory,
phonatory, secretory, and protective functions of the
pharynx. The article is chiefly historical and espe-
cially valuable from its extensive bibliography. — Ann.
des Mai. de l' Oreille, du Laryn.x, etc., Dec, 1899.
A Rare and Interesting Bullet Wound ; the Bul-
let Splitting in Halves, as Shown by the Skia-
graph.— Angus McLean reports this case, in which
the bullet must have been nearing the end of its flight
when it struck the humerus, probably at a downward
angle, and divided itself over its margin. — The Med-
ical Age, January 25, 1900.
Early Intubation in Laryngeal Diphtheria
William E. Lower reviews his experience, and finds
that in no small percentage death is due to obstruc-
tion. The advantages of early intubation are that the
child is then stronger, the time for wearing the tube
is shortened, and hence the amount of nourishment
required is less, and less opportunity is given for the
introduction of foreign matter into the trachea, dimin-
ishing the chances of septic pneumonia. Intubation
should be done when the breathing becomes labored,
not waiting for the cyanotic stage. — T/ie Cleveland
Medical Gazette, January, 1900.
Arterial Tension in Childhood. — H. L. K. Shaw
calls attention to the lack of knowledge upon this sub-
ject, and describes a new and simple apparatus which
easily affords the desired information. It is found
that in anemia the blood pressure is slightly raised
above normal. In acute endocarditis it is somewhat
depressed. In acute nephritis the increased tension
so constant in adults does not appear so marked in
children. In diphtheria with cyanosis and dyspnoea,
with or without intubation, pressure is increased.
Tension is not influenced in diphtheria cases with-
out laryngeal complications. — Albany Medical Annals,
February, 1900.
A New Method of Treatment of Carcinoma (Eso-
phagi.— \V. Zweig describes the plan suggested by
Rosenheim, which is as follows: The oesophagus is
first washed down to the point of stricture with not
more than 150 gm. of water. Then 50 gm. of olive
oil is poured in and the tube is taken out during the
act of pouring, so as to coat over the mucosa with the
oil. Kucaine (four per cent.) may be used instead of
oil. After a few minutes the patient can eat solid
food without much trouble, and the manoeuvre can be
repeated several times daily. The advantage is the
moral effect on the patient: he believes he can eat.
Increased ingesta delay the onset of cachexia, and the
time is prolonged before the inevitable gastrotomia. —
Albany Medical Annals, February, igoo.
Croupous Pneumonia in Children. — J. Park West
says about one-third of the pneumonia in childhood
is of the croupous variety. It is, as a rule, a primary
disease, often beginning by vomiting, more rarely by
convulsions, and still less frequently by chill. Fre-
quently the signs cannot be made out until the second
or third day, and may be absent altogether. One of the
important signs is a perverted pulse-respiration ratio.
In health there are about ten respirations to thirty-five
pulse beats, while here there may be ten respirations to
twenty beats. The left lower lobe is most frequently
affected next the right apex. The crepitant rale is
oftener absent than present. He considers the gastric,
cerebral, and migratory types, and differentiates from
bronchitis, pleurisy, and broncho-pneumonia. Under
treatment, he says, poultices have here no place. There
is no routine treatment, and often no drugs are called
for — a small quantity of whiskey and weakened milk are
the preferable foods. In depression following the cri-
sis, nitroglycerin frequently repeated is very valuable.
For the fever nothing meets the indications as well as
the bath of 95' to 100° F., with gentle rubbing for ten
minutes, repeated as needed. Rarely one or two cooler
or cold baths will be required. — The Cleveland Medi-
cal Gazette, January, 1900.
27»
MJbUlL-Ai. KtL,UKU.
[February 17, 1900
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
PlBI.ISHERS
WM. WOOD &. CO., 51 Fifth Avenue.
Nev/ York, February 17, 1900.
OVER-PRESSURE THE BANE OF MODERN
EDUCATION.
The harm done to children by the present methods of
education is too real to be ignored. The conditions
of civilized life have so completely changed within
the past half-century that it becomes daily more and
more evident that measures must be taken to meet the
new situation and to endeavor to propagate and raise
a race better fitted to withstand the strain of modern
existence. \\'hen children were brought up in the
country, spending the greater part of their time in the
fresh, open air, considerations as to physical develop-
ment did not enter into the question. The environ-
ment being healthy, and food plentiful and nutritious,
the natural sequence was that the human product grew
up hardy and robust, well equipped for the battle of
life. The ever-increasing tendency to desert the coun-
try for the town has placed a fresh problem before our
scientific men and sanitarians. Children are born and
pass their youth amid unhealthy surroundings, in
many instances improperly and irregularly fed. In
addition to these serious disadvantages they are still
further handicapped by the undue stress of school
life. The sole aim of modern education would seem
to consist in the attempt to develop the mind at the
expense of the body. The necessity of exercise and
fresh air as a part of a child's training is strangely
overlooked. Mental and physical education should
go hand-in-hand. Wherever possible playgrounds of
ample scope should be attached to schools, and, above
all, young children should never be expected to work
longer than two hours at a stretch.
Dr. J. S. Lankford, of San Antonio, Tex., read at
the annual meeting of the Western Texas Medical
Society, held in October, 1899, a paper dealing vi'wh
the evils of present metliods of education. Among
other home truths to which he gave expression were:
"What shall we say of the death-dealing mental bur-
dens placed upon our children ? Wq impart to the
child by heredity and example an ambition to know
everything, or if he doesn't happen to have that ambi-
tion, we proceed to hammer everything into him. We
reach out eagerly to grasp and incorporate all the af-
fairs of the universe in our course of instruction. Re-
gardless of aptitude or natural tendency of mind we
group the pupils in enormous classes and give them all
just the same. . . . The burden is too heavy, and just
as sure as effect follows cause in natural law, our gen-
eration of children is being weakened and unbalanced,
and a still weaker generation will follow. Our great
public-school system, designed to bless the nation,
will become a national curse. This is not a false
alarm or an idle prophecy. Visit the schools and see
the careworn teachers, always working beyond nature's
reasonable limits, and you can better understand why
she or he seeks your aid before the middle of the term
in order to be able to continue work. And here in
this broken-down condition of the teacher we see an
index to the heavy course and wrong classification.'"
The health of the young is a matter of vital impor-
tance to a nation. As with individuals, so it is with
races in the struggle for predominance,- the weakest
will go to the wall. To insure the physical and men-
tal well-being of the rising generation considerable
modifications in our existing system of education will
be necessary. Physical culture is not inconsistent
with mental culture, and when this significant fact is
thoroughly grasped by our boards of education, the
present faulty methods of training the young will be
changed to those more in harmony with the laws of
nature.
COMPENSATORY PROCESSES IN DISEASE.
Were not the animal organism endowed with struc-
ture and function in excess of its ordinary needs, dis-
ease would obviously be wellnigh universal. Nature
has, however, been almost prodigal in this respect, so
that destruction of tissue in one situation or loss of
function in one organ may be compensated for, in
whole or in part, by a readjustment to the new condi-
tions. This result may be brought about in one or
more of three ways, as is pointed out by Leube
(Detiischcs Arehiv Jiir klinische Medicin, 66 B., p. 80) :
(^1) Portions of a diseased organ may remain healthy,
and this residuum may assume the increased function;
or one of azygous organs, as for instance the kidneys,
may take up the work of the other, if this be diseased
or otherwise incapacitated. This form of compensa-
tion is illustrated by the hypertrophy of the heart
that takes place when the circulation is in any way
obstructed, by the hypertrophy of the muscular coat
of the stomach when obstruction to the movement of
its contents exists, and by the transformation of yel-
low into red bone-marrow in the presence of anaemic
states.
(2) One set of organs or tissues may perform the
functions of another set of organs or tissues having a
like action. Such reciprocity of function exists, for
instance, between the skin and the kidneys, the stom-
ach and the intestine, the spleen and the lymphatic
glands. A distinctly reciprocal relation exists be-
tween the action of the kidneys and that of the skin,
as pertains to both water and solids, and this fact is
often availed of in the treatment of nephritis. Only
in the presence of marked cutaneous oedema does
Leube consider sweating as contraindicated, as the
excrementitious matters left behind by the escape of
February 17, 1900]
MEDICAL RECORD.
279
the tluid may be absorbed and thus give rise to toxic
symptoms. Instead, he recommends multiple capil-
lary puncture of the skin. The salivary glands and
the bronchial mucous membrane are also capable in
some degree of assuming the functions of the kidneys,
and the gastro-intestinal tract also, but only in very
small degree. There is abundant evidence that the
intestines are fully capable of replacing the activity
of the stomach if this be diminished or abolished from
any cause. A mutually reciprocal relation exists be-
tween the blood-forming organs: the bone-marrow, the
lymphatic glands, and the spleen. In cases of pro-
found anaemia and in the sequence of profuse hemor-
rhage, evidence of increased htemogenesis in the bone-
marrow becomes appreciable from the change in color
from yellow to red, and in the presence of nucleated
red corpuscles. The spleen at times undergoes liyper-
plasia under such conditions, and is often found en-
larged. Leube has observed such enlargeniQnt in a
considerable proportion of cases of chlorosis, and these
cases have pursued a more favorable course than those
unattended with splenic enlargement. With regard to
the white blood-cells, the spleen and the lymphatic
glands appear to be concerned especially in the pro-
duction of lymphocytes, and the bone-marrow princi-
pally in that of the granular and amoeboid leucocytes.
Following splenectomy the lymphatic glands become
enlarged, and the number of lymphocytes in the blood
becomes increased.
(3) Organs and tissues may assume the functions
of other organs and tissues having a different action.
Of this fact application is made therapeutically,
diuresis, diaphoresis, and catharsis often being in-
duced with the object of causing absorption of exu-
dates. Having observed rapid disappearance of an
accumulation of fluid in the abdominal cavity in the
sequence of salivation occurring spontaneously, Leube
suggests that at times ptyalism might be induced arti-
ficially with the same object in view, and he reports
four of five cases of pleurisy with effusion and one of
two cases of ascites in which rapid absorption of the
fluid took place in connection with profuse salivation
excited by the chewing of gum.
M.\RINE-HOSPITAL SERVICE REPORT.
The surgeon-general of the Marine-Hospital service
has recently issued his report for the year ending June
30, 1899, which contains matter of general and special
interest. The service now owns and operates twenty-
two marine hospitals, and there are besides one hun-
dred and seven stations where patients receive hospi-
tal or dispensary treatment. The statement is made
that during the fiscal year 1899 the total number of
patients was 55,489, of which number 12,610 were
treated in hospital. A sanatorium has been estab-
lished for the use of consumptive patients of the Ma-
rine-Hospital service at Fort Stanton, New Mexico,
the abandoned military reservation at that place having
been handed over by the government for that purpose.
The surgeon-general again dwells upon the need of
a marine hospital for the port of New York, pointing
out that the present arrangement for the care of sick
and disabled seamen is unsatisfactory and unworthy
of the principal port of the United States. Many
u.seful scientific investigations have been carried out
in the hygienic laboratory during the past year, not-
ably those in connection with the pollution of the
Potomac River water, and car sanitation. The experi-
ments with regard to the immunization of a horse
against typhoid are said to have been progressing sat-
isfactorily, and the value of the serum obtained from
the animal is now being tested.
Of course the national quarantine service is the
most important department of the Marine-Hospital
service, and from the report it will be gathered that
on the whole this branch is in good working order.
At the various stations 3,838 vessels were inspected
and 370 disinfected during the fiscal year. The regu-
lations enforced for the suppression of yellow fever
had the desired effect, and it was chiefly due to the
arduous labors of the Marine-Hospital service that the
disease W'as kept so well under control. In January,
1899, the maritime quarantine of Cuba and Puerto
Rico was transferred to the Marine-Hospital service,
which naturally has largely increased the duties of the
department. At the present time there are some thirty
officers of the service in Cuba and seven in Puerto
Rico. Valuable investigations with regard to the
cause of yellow fever have been made by a com-
mission of medical officers of the JNIarine-Hospital
service, who have delivered a report on the subject.
They verify the findings of Sanarelli in his discovery
of the bacillus icteroides, and further demonstrate that
this disease is received into the human system through
the respiratory tract, holding out hopes that a protec-
tive and curative serum may shortly be discovered.
At the same time attention is drawn to the fact that
sanitation plays an essential role in checking the
prevalence of the malady. Every effort is being put
forth to safeguard America against an incursion of the
plague, but the surgeon-general regrets that the bills
introduced into the Senate and House of Representa-
tives with the object of strengthening the national
quarantine failed to pass.
The Marine-Hospital service has now been in exist-
ence for one hundred and one years, but the lapse of
time has only served to exhibit in a more and more
decided manner the value of its work.
SANATORIA FOR SAILORS.
At a meeting of St. John'j, New Brunswick, Medical
Society, held at that place in June, 1898, Dr. J. E.
March, a Canadian quarantine officer, read a paper
entitled " Tuberculosis and the Forecastle," in which
he expressed his opinions regarding the measures to
be taken with cases of tuberculosis occurring among
sailors on_ shipboard. There has been for some time
much discussion on the subject, so that views of ex-
perts are especially welcome.
The author of the paper in question, after alluding
to the circumstance that tuberculosis is a disease to
which seamen in a general way are particularly liable,
28o
MEDICAL RECORD.
[February 17, 1900
points out that their mode of life is peculiarly calcu-
lated to spread the malady, and quotes numerous in-
stances in which the unavoidable proximity of the crew
would appear to have been by far the most potent if
not the sole factor in disseminating the germs of in-
fection. Attention is drawn to the undoubted truth
that the older the ship the greater the chance of her
having become infected. But the subsequent sugges-
tion possesses the merit of novelty, namely, that ow-
ing to the presence of a quantity of wet cloth in the
forecastle, and taking into consideration the fact that
the bacillus not only lives but multiplies and liourishes
on the surface of wet cloth, many forecastles are there-
fore necessarily infected with the bacillus tubercu-
losis. This theory sounds plausible, and is decidedly
worthy of notice. The situation to be faced is conse-
quently this, that consumption is a prevalent disease
with sailors, chiefly owing to their manner of life,
which is highly conducive to the fostering and spread
of the disease. \A'hat, then, is the remedy? Dr.
March's panacea for, or rather palliative of, the evil is
that tuberculosis should be scheduled as a quarantin"
able disease.
The Medical Record, always allowing that it has
been demonstrated beyond a doubt that tuberculosis is
under certain conditions communicable, at the same
time has taken somewhat conservative views as to the
degree and scope of its infectivity. We know now
that the spread of tuberculosis is to be largely attrib-
uted to the inhalation of dried sputum distributed in
the atmosphere of houses and rooms in which sufferers
from phthisis live and in which sufficient ventilation
is lacking; but the argument that consumption is a
virulently infectious malady after the same manner or
to the same extent as the exanthemata will assuredly
not be put forward by any physician in the world. In
an editorial which appeared in a recent number of the
Medical Record the scheduling of tuberculosis was
adversely commented on as being a too radical meas-
ure, and one that did not altogether appear as likely
to have the magical preventive effects claimed for it
by its advocates. Notwithstanding these statements,
to which, although at all times open to conviction, we
still adhere, Dr. March is undoubtedly right when he
asserts that the more expeditiously consumptive sail-
ors are removed from the ship the better \^ill it be for
the health of the remainder of the crew, and if the
fact can be conclusively proven that this event can
be brought about only by the scheduling of tubercu-
losis as a quarantinable disease, then by all means let
this be done.
There is, moreover, another phase of the case which
is, perhaps, quite as important to the health of the
consumptive and to that of his fellow-men as the
prompt removal of the sufferer from the ship. Where
shall he be taken when removed? If he is transported
to the general wards of a hospital, the change will be,
as the old saying has it, but "jumping out of the fry-
ing-pan into the fire." The hospitals themselves are
foci of infection, and the consumptive man is as great
a source of danger there as he would be on board
ship. The proposition advanced by many physicians
of experience, that sanatoria should be established
for phthisical seamen, has much to be said in its
favor. Passed Assistant Surgeon J. O. Cobb, writ-
ing in the annual report of the Marine-Hospital service
for 1898, is a strong advocate of this proposal, and
says : " Granting the most liberal allowance for faulty
conclusions from the data at hand, it is quite probable
that the government can build sanatoria for these
men, transport them to these places, and take care of
them to a termination of the illness, for the amount
that would be expended on their care at hospitals.
The sanatorium is the ideal method of administration
for these cases. At the sanatorium these cases can be
closely studied, and all kinds of treatment tried.
Taking that, then, to be a fact, the eventual outcome
would, from a medical standpoint, be an ideal one."
Many difficulties will surely have to be surmounted
ere sanatoria for sailors are erected, but, when the
hardships of the seafaring class are considered, no
trouble, or expense should be spared to better the lot
of the ailing seaman.
WILL THKKK BK CONSCRIPTION IN GREAT
BRITAIN?
Whatever may be the ultimate result of the Trans-
vaal war, whether the issue will be that a Dutch re-
public is formed on the ashes of the British colony,
or that Great Britain establishes "7/ et aniiis''' her
paramountcy in South Africa, one fact stands out
with striking prominence, namely, that the British
military system must undergo radical reforms. With
the justice or otherwise of the British claims we have
no concern, but the comparative breakdown of the
methods controlling the management of the British
army, and the consequent suggestions thrown out en
all sides that some form of conscription should be
adopted in the L'nited Kingdom, is a matter of great
interest to America. Treating the subject from the
standpoint of health and disregarding its influence on
the commercial status of Great Britain, there is much
to be said in favor of partial conscription. The
system in the first instance inculcates habits of disci-
pline and method, and further is calculated to improve
the physical well-being of those who practise it. The
great argument against conscription in Great Britain
itself has always been that it would seriously injure the
trade of the country, and is besides directly opposed
to that love of freedom inherent in all those of the
Anglo-Saxon race. But, as is well pointed out in an
editorial in the London Lancet of December 23d, the
trade of Germany does not appear to have been disas-
trously handicapped by her military system, and in so far
as the physique and general health of her population
are concerned has greatly benefited by conscription.
The greater part of the inhabitants of Great Britain
live in cities and towns, and the melancholy truth that
the population as a whole has deteriorated physically
owing to this cause is too obvious to be lightly ignored.
Two or three years of healthy army life, followed at
just that age when a man especially needs to live un-
der favorable sanitary conditions, would do much
toward improving the British town-dweller mentally
February 17, 1900]
MEDICAL RECORD.
281
and physically. That the question of conscription is
thought worthy of consideration even in Great Britain
is a sign of the trend of public opinion, and the Boer
war, be the result what it may, will have the effect of
making the British " place their house in order."
JXcius of the ^xEceli.
What's in a Name ? — A Berlin physician recently
published an article in the Therapeutische Alonatshefte
extolling the virtues of the " Backhaus-Milch '" for in-
fants.
The Death Rate of Dublin has reached such an
excessive figure (49 per 1,000) that the lord-lieuten-
ant of Ireland has ordered an official inquiry into its
causes.
Professor Schenk, who was recently requested to
leave the University of Vienna, has announced his in-
tention to go to some other country, possibly America,
and establish himself as a specialist in sex regulation.
" Monatsschrift fiir Geburtshiilfe und Gynako-
logie." — The January number of this journal is a
" Festschrift '' dedicated to Dr. Friedrich Schauta,
professor of obstetrical gynaecology at the University
of Vienna, in honor of his twenty-five years of medical
life.
Measles on David's Island. — A small epidemic has
broken out among the soldiers at Fort Slocum, David's
Island. There were ten cases the first week. All the
patients have been placed in quarantine. There are
fifteen hundred men and about one hundred officers on
the island waiting for transportation to the Philippines.
Thermometer Fever. — Dr. Benjamin K. Hays, of
Oxford, N. C, writes that the physician to a certain
female college in South Carolina recently found that
the temperature of thirteen young ladies was two de-
grees above normal, did not vary through the day, and
was uninfluenced by quinine. The young ladies felt
tK) inconvenience from this rise of temperature, but
the physician forbade their attending school duties,
arxi kept them in the infirmary for two weeks. At the
er»d of this time it was discovered that the thermometer
registered two degrees high, whereupon the young ladies
were permitted to return to their duties.
The National Pure Food and Drug Congress. —
The third annual meeting of this association will be
held in Washington on March 7th and following days.
The executive committee of the congress in issuing
this call directs especial attention to the fact that the
National Pure Food and Drug Congress through its
authorized committees and officers has since the last
meeting of the congress used every effort to secure the
passage of the "national pure food bill," 'ndorsed by
the congress and introduced in the House of Repre-
sentatives by Hon. Marriott Brosius, of Pennsylvania.
The same bill has also been introduced in the Senate
by both Senator Hansbrough and Senator Allen. Tt
is believed that with a united effort the bill can be
passed and a national pure food law be enacted during
the present session of Congress. It is therefore greatly
to be desired that any interest entitled to representa-
tion in the congress should be represented at the third
annual session.
The Game of the German Emperor A cable
despatch from Berlin conveys the important informa-
tion that since 1872 Emperor William has killed 40,-
822 pieces of game. The list includes 34,813 small
game and 6,009 ^'§ g^'ne, besides : 2 i chamois, 7 elks,
3 reindeer, 3 bears, and i whale. If there happens to
be an antivivisection society in Germany, we would
commend the German Emperor to the particular atten-
tion of its members whenever they may enjoy an inter-
val of rest from baiting scientists.
The Eighteenth German Congress for Internal
Medicine will be held at Wiesbaden on April 18-21,
1900, under the presidency of Dr. v. Jaksch, of Prague.
The subjects announced for set discussion are " Endo-
carditis and its Relation to Other Diseases," to be
introduced by Litter, of Berlin, and "The Treatment
of Pneumonia." to be introduced by Koranyi, of Buda-
pest, and Pel, of Amsterdam.
Fysician is the way the agricultural editor of the
East Aurora Journal is now pleased to designate the
practitioner of the noble art of healing. Though ad-
vancing in years, he continues to have his monthly
periodicals of protest, and doubtless things to protest
against grow fewer every year in East Aurora. He is
himself, however, such a " Filistine " that he continues
to spell the name of his journal with a Ph.
Leprosy in Crete. — Drs. Ehlers, of Copenhagen,
and Cahnheim, of Dresden, who made a careful study
of leprosy in Iceland in 1894-95, have been requested
by Prince George of Greece, the governor-general of
Crete, to visit that island the coming spring to study
leprosy conditions there. They will go in March and
remain about three months, studying especially the
origin and spread of the disease in the interior of the
island, and making suggestions as to the best means
of keeping it in check.
A Discussion of Tuberculosis. — It is announced
that a congress for the discussion of tuberculosis will
be held in this city on February 21 and 22, 1900, un-
der the auspices of the Medico-Legal Society. The
first session will be held at the Hotel St. Andrews,
Seventy-second Street and Broadway, at 9 p.m. It
will bs preceded by a dinner at the same place at 7
P.M., at which it is hoped most of the members will
assist.
College of Physicians of Philadelphia.— At a
stated meeting held February 7th, Dr. Thomas G.
Morton read a memoir of the late Dr. Albert Fricke'.
Dr. J. Dutton Steele read " a paper entitled "A
Contribution to the Pathology and Diagnosis of Re-
troperitoneal Sarcoma." He reported the case of a
child, in which in the sequence of a fall upon a fence
an abdominal tumor developed. The neoplasm was
thought to be a sarcoma of the kidney. An opera-
tion was performed, and the growth found to be an
282
MEDICAL RECORD.
[February i 7, 1900
endothelioma of the retroperitoneal glands. Dr.
.\rthur V. Meigs made a verbal communication upon
the subject of the placarding of houses for contagious
diseases. He contended that the present practice of
placarding houses in which are cases of contagious
disease conduced to concealment and deception in
order to avoid the inconveniences attendant upon the
quarantine restrictions enforced.
New York State Medical Examinations — In the
examinations for medical license, held in this State
in September, 1899, one hundred and si.xty-t\vo candi-
dates presented themselves, of which one hundred and
twenty-seven, or 78.4 per cent., were successful. Eight
men passed with honors. The highest general average
was 93.3.
Fecundity. — Dr. W. S. Hulbert, of Winsted, Conn.,
writes that on February 3d he delivered a woman of
her tenth child. The ten children, all delivered
singly and at full term, were born within a period of
exactly ten years, ten months, and ten days. In this
last confinement the patient nearly lost her life from
post-partum hemorrhage.
Influenza is evidently pandemic in Europe. It has
been reported as seriously prevalent in England,
Spain, and Italy, and now it has invaded Central
Europe. In Berlin the hospitals are crowded, and
there is scarcely a house in which there are not
several victims. In Munich the sufferers are num-
bered by thousands
Pathological Society of Philadelphia — At a stated
meeting held February 8th, Dr. F. A. Packard pre-
sented a specimen of hemorrhagic pancreatitis from an
elderly man, who had suffered from abdominal pain,
and in whom death had occurred suddenly. Dr. J.
Hendrie Lloyd presented sections from a ca.se of
hajmatomj'elia, the condition having resulted in con-
sequence of a fall down-stairs. There was no frac-
ture or luxation of the vertebrfe, although there was
paralysis of all four extremities and of the respiratory
muscles, except the diaphragm. Drs. M. P. Ravenel
and C. Y. White presented specimens exhibiting ex-
perimental tuberculosis in a goat. Infection had
been induced by intrapulmonary injection of tubercle
bacilli, pneumonia developing, and tubercle bacilli
being easily found in all of the parenchymatous or-
gans. Typical tuberculosis lesions were wanting.
Dr. M. P. Ravenel reported the results of experimental
inoculation of calves with syphilitic virus. Two ani-
mals treated with the products of active syphilitic
lesions failed to develop the slightest indication of
syphilis. Drs. H. D. Jump and J. D. Steele exhibited
specimens of thrombosis of a coronary artery, con-
tracted kidneys, and malformation of the liver. There
had been no symptoms of angina pectoris, and death
had resulted from uraemia. A portion of the left lobe
of the liver was reflected upon itself.
Red Cross Work in the Philippines.— The special
committee appointed by Auxiliary No. 3 of the Red
Cross Society to continue in the Philippine Islands
the work of selecting and maintaining trained nurses
met recently at the residence of Mrs. Whitelaw Reid,
in this city. The auxiliary, which was organized for
work in Cuba, and was dissolved a year ago, was re-
suscitated when it was found that there would be work
for it in the Philippines. Under the authorization of
the Secretary of War, four Red Cross nurses were sent
on each of the transports Grant, Sherman, and Sheri-
dan. They cared for five hundred and fifty-two pa-
tients during the voyage, and, upon reaching the
Philippines, found their services so much in demand
that the committee sent a second detachment selected
in San Francisco, and later a third detachment
selected in New York. At one time over one thousand
sick and wounded men were under the sole charge of
these nurses. The auxiliary is now sending out libra-
ries to the hospitals in Manila.
Opposition to Reciprocity in Pharmacy Licenses.
—The Ontario College of Pharmacy has been notified
by the board of pharmacy of Greater New York that
in future foreign diplomas in pharmacy will not be
recognized in this city, and that candidates for regis-
tration here must pass an examination. The recipro-
cal privileges heretofore extended to New York gradu-
ates in Ontario are to be withdrawn.
Rough Voyage of a Hospital Ship — The hospital
ship Alissoiiri, which sailed from Manila on January
I ith for San Francisco, with two hundred and
seventy-two sick and wounded soldiers, had a very
unpleasant weather experience after leaving Japan.
During the greater part of the trip from Nagasaki to
Honolulu no meals could be served at the cabin
tables, and the passengers and crew were obliged to
receive their food at the galley and eat it standing.
Sixteen of the sick men died during the voyage.
New Quarantine Regulations — A bill has been
introduced into the legislature of this State making
more stringent the quarantine rules for the port oi
New York, and giving the ht;alth officer and the com-
missioners of quarantine additional powers to protect
the public health in cases of emergency. The health
officer is required to live at quarantine. The time
during which suspected persons may be detained is
extended from ten to twenty days. A vessel found to
be in a condition dangerous to public health may be
held, and treated as the health officer deems neces-
sary. At present the mayor may order a vessel to
quarantine, but the new bill gives the health officer
sole power in that respect, and he is to have the aid
of the health and police departments in enforcing
orders.
Smallpox has appeared in a number of counties in
New Brunswick, having been brought there from Que-
bec, and the authorities are enforcing the health regu-
lations in tJie hope of preventing the further spread of
the epidemic. The disease, which exists chiefly
among the employees of the Intercolonial Railroad, is
in very mild form, and few deaths have occurred.
.\bout sixty cases are under treatment. — In the island
of Luzon there has been some increase in the number
of cases of smallpox, as is usual at this time of year.
Two officers of the Thirty-sixth Volunteer Infantry
February 17, 1900]
MEDICAL RECORD.
283
have died of the disease, and one other is ill. Dur-
ing February and March the disease always becomes
more virulent in the Philippines, but there is nothing
alarming in the situation. Orders have been issued
for the vaccination of the troops, and also of the na-
tives wherever possible.
Competition among Undertakers. — The depart-
ment of charities of New York City has instituted an
investigation of the alleged practice by the employees of
the department, of selling information to undertakers
concerning the deaths of patients in city institutions.
The investigation was begun on the complaint of an
undertaker, who was losing trade because, as he said,
his rivals were willing to pay high prices for early
information.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
February 10, 1900. February 3d. — Passed Assistant
Surgeon M. S. Elliott commissioned passed assistant
surgeon from October 6, 1899. February 8th. — Medi-
cal Director J. A. Hawke commissioned medical di-
rector from September 24, 1899. Medical Director
R. A. Marmion commissioned medical director from
October 23, 1899. Medical Director D. Dickinson
commissioned medical director from November 11,
1899. Medical Director M. C. Drennan commis-
sioned medical director from February 5, 1900.
Medical Inspector T. H. Streets commissioned
medical inspector from April 16, 1899. Medical In-
spector G. E. H. Harmon commissioned medical in-
spector from November 11,1899. Medical Inspector
J. VV. Waggener commissioned medical inspector from
February 8, 1899. Surgeon T. A. Berryhill commis-
sioned surgeon from April 9, 1899. Surgeon E. P.
Stone commissioned surgeon from April 16, 1899.
Passed Assistant Surgeon R. K. Smith commissioned
passed assistant surgeon from April 3, 1899. Passed
Assistant Surgeon R. S. Blakeman commissioned
passed assistant surgeon from May 27, 1899. Passed
Assistant Surgeon J. C. Rosenbleuth commissioned
passed assistant surgeon from October 14, 1899.
Passed Assistant Surgeon G. W. Costigan commis-
sioned passed assistant surgeon from February 8,
1900. Passed Assistant Surgeon G. H. Barber
detached from the Naval Academy, February loth,
and ordered home and to be ready for orders to sea
duty.
The "Plague is believed to have been arrested in
Honolulu by the extensive fire in the Oriental quarter,
no new cases having appeared during the eight days
precedin'g February 2d, the date of the last advices.
In all there were forty-six deaths. Ten other blocks
outside of Chinatown were burned by order of the
board of health, and about fifty isolated buildings
were also destroyed. Following the destruction of
Chinatown and other similar places the number of
deaths from all causes fell off remarkably. The work
of inspection was most thorough. The sanitary com-
mittee divided Honolulu into forty inspection districts,
with a volunteer inspector in charge of each. Each
district was divided into sections or apanas, each con-
taining from seventy-five to one hundred and fifty in-
habitants, and a volunteer sub-inspector was placed
over each. Each sub-inspector went over his apana
twice a day, and personally saw each inhabitant, re-
porting every case of illness, however trivial, to the
board of health, which sent a physician at once, and
if any plague symptoms were discovered the patient
was isolated, and all who had come in contact with
the premises were quarantined. — In Manila the dis-
ease is reported to be gaining headway. It is said
that this is the first visitation of plague the city has
ever had. It was undoubtedly brought from Hong.
Kong, where during 1899 there were 1,486 cases with
1,428 deaths. — In Bombay the conditions are growing
worse owing to the influx of famine sufferers, who
present a fertile soil for disease of every kind. The
number of deaths in that city in one day last week
was 408, not all from the plague, however.
The Late Dr. Samuel Ketch — At a stated meet-
ing of the medical board of the Montefiore Home for
Chronic Invalids, held January i6th, the following
resolution was passed regarding the death of Dr.
Samuel Ketch :
" The medical board of the Montefiore Home ex-
presses profound sorrow at the death of Dr. Samuel
Ketch, consulting orthopaedic surgeon. As a surgeon
Dr. Ketch was skilful, clear-headed, conscientious, and
able; as a man, genial, courteous, frank, and loyal.
The board records in its minutes with profound grief
the"death of a valued counsellor, an expert surgeon,
an honest man.
" V. P. GiBNEv, Joseph Fraenkel, George R.
Elliott."
Obituary Notes. — Dr. T. Dana Fitzsimmons diejj
at his home in Brooklyn on February 4th, at the age
of twenty-six years. He was a graduate of the Long
Island College Hospital Medical School in 1897, and
later served on the house staff of St. Mary's Hospital.
Dr. Charles Carroll SMrrn, formerly a surgeon in
the navy of the United States, died at his home in
Philadelphia on February 5th, aged sixty years.
Death was due to locomotor ataxia. He was at one
time in charge of the government medical stores at
League Island. He was a graduate of the medical
department of the University of Pennsylvania.
Dr. Frank Standish Bradford died on February
8th, at his home in Morristown, N. J., at the age of
seventy years. He was a graduate of the Jefferson
Medical College in 1858. He practised first in
Providence, R. I., then in Charleston, S. C, and
served as surgeon of a Rhode Island battery during
the civil war. Then he removed to this city, where
he remained until 1887, when he went to Morristown.
For seventeen years he was professor of the practice
of medicine in the Homoeopathic Medical College,
and for ten years secretary of the faculty.
Dr. Abbie Hamlin MacIvor, a homoeopathic prac-
titioner of this city, died on February 8th. She was
born in 1842, and obtained her medical degree in
284
MEDICAL RECORD.
[February 17, 1900
^roQVCss 0f l^tXcxlical Science.
Journal of Ihe American Medical Ass' n, Feb. JO^ J<^00.
A Preliminary Investigation of the Theory of
the Inoculation of Malarial Fever through the
Agency of Mosquitos — Albert W'oldert gives some
results from his study of different species of mosqui-
tos collected in eastern and central Texas, eastern
Pennsylvania, and the eastern coast of New Jersey.
The writer has made some two thousand sections and
examined them microscopically. In determining the
relations of mosquitos to malarial infection he con-
siders the study of entomology very important, and
says that there is much room for improvement in the
classification of mosquitos.
Family Diseases. — F. Savary Pearce divides his
subject broadly into: (i) Hereditary maladies; (2)
family tendency to a certain disease in special gener-
ations without hereditary taint ; and (3) special family
types of nervous disease, as Friedreich's disease and
Huntingdon's chorea. The writer presents notes of
over fifty cases, and says that this study leads us to
surer ground as to modifications of family disease in
making statements about expectation of life in cer-
tain classes of them. It also teaches in a negative
way the importance of the so-called individual ele-
ment being given a high place in sociological con-
siderations in health and disease.
The Value of Cycloplegia in Optometric Exam-
ination.— C. M. Culver from a review of the records
of examination of one thousand eyes deduces the fol-
lowing conclusions: (i) A solution of 2.5 per cent,
of homatropine hydrobromate, instilled six times at
intervals of five minutes, provides trustworthy cyclo-
plegia in the average healthy human eye in from one
to three hours from thefiist installation; (2) as.i rule
the protracted use of a one-per-cent. solution oi atro-
pine sulphate is no more effective than is the 1:40 so-
lution of the alkaloid above mentioned; (3)11 te.> per
cent, of patients it is desirable to produce . iti :ial
cycloplegia.
Uncommon Pyogenic Infection of the Mi-.dle
Ear. — Robert Sattler reports a case illustratin} the
dangers attending the cauterization of posterio and
middle nasal hypertrophies. This danger is especially
great in the destruction of posterior hypertropny,
which often results in a fierce resentment on the part
of the cauterized region out of all proportion to the
slight local injury inflicted.
Clinical and Pathological Notes on Sympath-fic
Ophthalmia. — H. Gifford reports three cases, each o'
which indicates three important points, viz.: (i) The
absence of premonitory symptoms; (2) the importance
of daily tests of vision, and (3) the value of large
doses of salicylate of sodium.
Improve the Species. — In this address H. C.
Crowell argues from the results obtained through the
scientific breeding of domestic animals. Ht .vould
have certain reitiictiona and limitations enforced to
this end, and concludes by saying: "Degeneracy is
the result of fostering or permitting the perpetuation
of weakness, moral, mental, or physical."
Foreign Body in the Urethra L. M. Greene re-
ports the case of a man who, while using a lead pencil
for purposes of masturbation, allowed it to escape into
the urethra. After operation and drainage the patient
recovered.
Centrifugal Analysis of Urine Charles VV. Purdy
presents tables and describes the necessary equipment
and process for this mode of analysis. He claims
rapidity, precision, and facility for his method.
Contribution to the Treatment of Spinal Caries,
with Special Reference to the Woven Wire Corset ■
By George R. Elliott. See Medical Record, vol. Iv.,
p. 834.
Contributions of the Medical Profession to Gen-
eral Literature and Collateral Sciences. ^By George
R. Highsmith. An historical sketch.
Strangulated Hernia ; Some Practical Remarks
Concerning its Diagnosis and its Proper Manage-
ment.— By Parker Syms. See Medical Record, vol.
Ivii., p. 299.
Radical Cure of Strangulated Inguinal and
Femoral Herniae. — By Irving S. Haynes. See Medi-
cal Record, vol. Ivii., p. 300.
Treatment of Strangulated Hernia. — By John F.
Erdmann. See Medical Record, vol. Ivii., p. 300.
Diagnosis of Strangulated Hernia. — By Henry
Roth. See Medical Record, vol. Ivii., p. 299.
JVe7C' i'ork Aledical Journal, February lO, igoo.
A Few Clinical Studies of Cardiac Diseases in
Infancy and Childhood. — J. Zahorsky narrates a
series of clinical histories illustrative of the points
brought out in the paper. Endocarditis is often, he
believes, diagnosticated as malaria. Pain in the pre-
cordial region is not uncommon in childhood, and ton-
sillitis may be a frequent cause of pains in the chest.
Rarely the agonizing pain resembling angina is found.
Visible pulsation he regards as indicative of hyper-
trophy unless extreme emaciation is present. An
accentuated second sound is unreliable in infants but
becomes significant in older children. The author
advocates the practice of calculating the area of dul-
ness in square centimetres.
Malarial Haematuria B. Smith closes a continued
article upon this subject. He does not believe in cin-
chonizing the patient as is the general custom, but
prefers to rely on mercury and on diaphoresis to elim-
inate the poison. He believes that the administration
of quinine is a source of possible danger, and it has
Ijecome the custom of the physicians of his section
(Texas) carefully to avoid the remedy in malarial
hiematuria. During convalescence it is well to give
tincture of cinchona in the cold infusion of wild-
cherry bark, to which may be added later small doses
of nitro-muriatic acid. The blood state calls for the
phosphates of sodium, calcium, and potassium.
The Benefits of Medical School Inspection. — H.
G. IMcAdam describes the system as carried, out in
New York City. From the quarterly report of the
board of health, it is seen that out of 139,065 pupils
examined, 7,606 .were found to be suffering from com-
municable diseases.
A Case of Mixed Typhoid and Malarial Fevers.
— The patient, whose history is given by J. E. Bevans,
was a soldier in the army which had been in Cuba.
The blood responded to the VVidal test. The malarial
organisms were of the ai'Stivo-autumnal type.
A Suggestion for Tablet-Triturate Manufactur-
ers.— C. J. Proben thinks that all triturates contain-
ing the more narcotic drugs should be colored red in
order to prevent mistakes in dispensing.
February i 7, 1 900]
MEDICAL RECORD.
^85
Athletics in the Public Schools.— J. Gardner
Smith gives an account of the establishment of this
department of instruction in the schools of New York
City. He believes that half an hour out of every
school day should be given to pure bodily improve-
ment.
Fracture of the Patella. — J. B. IJissell reports a
case of a man aged forty-eight years in whom com
plete union was obtained by open operation seven
months after the injury.
Recovered Consumptives Who Remain Well. —
Paul Paquin tells of twenty-eight persons who have
been treated for phthisis during the last few years and
are still alive and seemingly well.
Medical News, Fel'ruary lo, igoo.
Atresia Vaginae ; Solid Uterus ; Haematoma of
Left Ovary. — H. J. Garrigues reports the case of a
girl twenty years of age who had never menstruated.
Every four weeks the patient suffered severe pain.
Epileptic convulsions also occurred. Laparotomy dis-
closed a solid uterus of normal size and shape, with
the right ovary slightly enlarged, having a fresh corpus
luteum filled with blood. The left ovary was changed
into a hrematoma, containing ten ounces of dark in-
spissated blood.
The Justo-Major Pelvis as a Factor in the
Causation of Perineal Injuries. — Joseph Brown
Cooke believes that the frequency of lacerated perinei
in patients witli justo-major pelves is most rationally
explained by the fact that the head does not "mould."
It has all the characteristics of a head in a breech
delivery.
The Policy of the State Relative to the Spread
of Tuberculosis. — By Enoch V. Stoddard. See Med-
ical Recorh, vol. Ivii., p. 2:0.
Report of Bacteriological Investigations upon
Yellow Fever. — By Aristides Agramonte. A contin-
ued article.
Boston Medical and Surgical Journal, Feb. 8, igoo.
Bradycardia. — Richard F. Chase reports a case
with the following conclusions: A pulse rate under
60, synchronous with the heart's systole, constitutes a
bradycardia according to Grob. The condition is of
common occurrence, especially in men. There are
three types: (i) Physiological. (2) Idiopathic, em-
bracing those cases of persistent slow pulse, usually
seen in advanced life, and more commonly in male
subjects. It is rarely attended by any discoverable
cause. The termination is usually fatal, though the
patient may live several years. (3) Symptomatic
bradycardia accompanies some usually apparent con-
dition, ordinarily of temporary duration. It may,
however, complicate cases terminating fatally from
injuries, sunstroke, and other serious conditions.
Grave Abdominal Lesions which Often Defy
Diagnosis. — Thomas H. Manley believes that imme-
diate section for violent contusions of the abdomen
should be discouraged, unless we are sure that a large
rent or rupture of a hollow organ is involved. It is a
desperate resource of very questionable expediency
under any circumstances before reaction is estab-
lished.
The Massachusetts State Hospital for Consump-
tives at Rutland. — Vincent Y. Bowditch gives a de-
scription of this institution. The work accomplished
■during the first year has been very satisfactory.
Multiple Cerebral Hemorrhages from Chronic
Lead Poisoning. — J. \V. Courtney reports a case of
this nature and gives in detail the autopsical findings.
Philadelphia Medical Journal, February lo, /goo.
Albuminuria, its Significance and Detection. —
Thomas P. Prout discusses first the fiveproteids found
at times in the urine, viz., serum albumin, serum
globulin, nucleo-albumin or mucin, peptone, and al-
bumose or propeptone, and then describes six tests
which he is accustomed to employ.
Locomotor Ataxia, Recovery in a Case Repeat-
edly so Diagnosed. — David S. Booth reports a case
in a man thirty-seven years old who presented many
of the symptoms of tabes. He was under treatment,
the nature of which is not stated, for a year, and his
symptoms disappeared.
Some Casual Remarks on Prostitution and Vene-
real Diseases in their Relation to the Public. —
Isadore Dyer discusses th^ means of reducing prosti-
tution and venereal disease — two evils which must be
combated together or at least simultaneously.
Celluloid Yarn. — J. Pagenstecher describes a new
material for sutures and ligatures. It is linen thread
impregnated with a solution of celluloid.
Syphilitic Fever. — A. C. Morgan reports a case of
evening pyrexia (ioo.5°-io3'' F.) which disappeared
after the exhibition of potassium iodide.
Position Symptoms in Joint Disease. — By Harry
M. Sherman. See Medical Rkcord, vol. Ivi., p. 494.
British Medical Journal, February j, igoo.
Dilatation of the Stomach from the Surgical
Aspect. —William H. Bennett says that dilatation of
the stomach is now generally admitted for all practi-
cal purposes to be a surgical complaint. He believes
that the cause of persistent dilatation will be found
to lie in permanent pyloric obstruction, in adhesions,
or in some other condition outside the stomach inter-
fering with its power of contraction. The writer calls
special attention to a class of cases in which explora-
tory abdominal section having been performed no evi-
dence of obstruction can be made out by manipulating
the organ from its external surface, yet in many of
these cases pyloric obstruction, sometimes to an ex-
treme degree, exists and is remediable. In all cases,
therefore, after abdominal section, the viscus should
be opened so that the condition of the pyloric sphinc-
ter may be examined.
A Case of Gastrostomy Treated by Franck's
Method. — Colon Macvicar thinks that this method is
practicable only when little or no cicatricial contrac-
tion of the stomach exists. In the case he reports
there was no contraction at the time of operation, but
probably considerable secondary contraction from the
invasion of the cardiac end of the stomach, so much
pain resulting from tlie traction that the operatftn was
a questional gain. The patient lived four months after
operation, two or three months longer than the average
expectation in malignant cases.
Renal Papillectomy. — E. Hurry Fenwick gives
some results of ten years' study of cases of unilateral,
painless renal iiemorrhages in the young adult. The
author is convinced that ignorance of the cause of the
hemorrhage is due to faulty operative technique. He
says that an examination with the finger is futile; that
the pelvis must be opened and every part examined by
a strong light.
286
MEDICAL RECORD.
[February 17, 1900
Removal of a Submucous Fibroid by Section of
the Uterus (Myomectomy). — James Braithwaite re-
ports this case. He says that although there are only
two other cases of the kind on record, he thinks time
and experience will show that it is the proper mode
of removing tumors which cannot be removed per
vaginam, or which are so large as to require the uterus,
or part of it, to be removed with the tumor.
On Removal of the Cancerous Uterus by the Ab-
dominal Route.— T. Henderson Pounds predicts that
the operation of the future for the cancerous uterus
will be the abdominal one. He says that although
this operation has a slightly higher immediate mor-
tality than that by the vaginal route, this is greatly
counterbalanced by a much longer respite to the patient
in successful cases.
On Suture of Fractured Patella by an Improved
Method. — R. Glasgow Patteson thinks that the causes
of failure of the various methods of suturing fractured
patella may be classed under two heads: (i) The
adoption of a subcutaneous ^lethod, and (2) the use of
unsuitable materials, and a faulty method of open
treatment. The author says that in young, healthy
subjects the ideal operation is primary suture.
The Disposition of the Utero-Vesical Pouch of
Peritoneum in Cases of Distention of the Vagina
and Uterus. — Arguing from cases observed \\'.
McAdam Eccles says that when the vagina is dis-
tended with fluid, the bladder is drawn up out of the
pelvis, the uterus also rising on the summit of the
vagina, and thus the natural relationship of the utero-
vesical reflection of peritoneum is preserved.
Hemorrhage through the Lacrymal Duct after
Plugging the Nares. — D. Richmond reports this
case in which the patient suffered from a severe at-
tack of typhoid fever. A sudden fall in temperature
from 104° to 98° F. was accompanied by severe hem-
orrhage from both nostrils. When the nostrils were
plugged the hemorrhage took place through the lacry-
mal duct.
Two Cases of Colectomy. — F. T. Paul describes a
mode of operation involving the establishment of a
temporary or permanent artificial anus, which he pre-
fers to any of the various methods in vogue for imme-
diately restoring the continuity of the bowel. He re-
ports two cases in which the method has been entirely
successful.
A Case of Abdominal Nephrectomy for Renal
Sarcoma in a Young Child. — Charles A. Morton re-
ports this case, in which the patient, a child aged
eighteen months, was operated on successfully and
discharged in good health. There was no local recur-
rence, but two months after the child succumbed to
tuberculosis.
A Case of Sodium-Salicylate Poisoning. — In this
case, reported by H. Ainslie Scott, the patient pur-
posely doubled the dose ordered, taking about gr. Ixxx.
in foi^een hours. She was treated with warm drinks,
potassium bromide, and aromatic spirits of ammonia.
Until the drug was eliminated there was considerable
hallucination.
Complete Atresia Vaginae A case reported by
\V. E. Fothergill in which careful examination failed
to reveal the presence of uterine body, of tubes, or of
ovaries. The writer says an artificial vagina will be
made should the patient care to undertake the trouble
of keeping it open during cicatrization.
Note on a Splint for Use aft:r Amputation A.
Marmaduke Sheild describes a splint he has devised
which, in most cases, maybe left on through the whole
iiealing-process, thus obviating the pain and trouble
which result from the removal of the usual splint for
each dressing.
Kernig's Symptom in Meningitis. — W. J. Bu-
chanan reports a case in which this symptom occurred,
and remarks on its great diagnostic value in cases of
meningitis.
Cases of Operation for Intestinal Obstruction.—
James Taylor reports seven cases of operation for in-
testinal obstruction. Of these cases three resulted in
The Lancet, February j, igoo.
The Value of Eye Symptoms in the Diagnosis
of General Diseases. — A series of cases is described
by H. F. Juler showing the intimate connection be-
tween various eye symptoms and lesions in other parts
of the body. A purulent conjunctivitis may prove on
examination of the pus to begonorrhoeal. Diphtheria
frequently affects the eye muscles and sometimes the
globe coverings. Syphilis may show itself as chancre
of the lids, inflammation of the iris, and keratitis.
Renal affections are frequently inaugurated by an
albuminuric retinitis, and the eye symptoms may be
the most prominent feature of many maladies of the
ner\-ous system.
Some Complications following Injuries about the
Elbow-Joint and their Treatment In a clinical
lecture by H. Littlewood he describes a peculiar de-
formity following elbow injuries which he has never
seen mentioned in the books. The deformity is this:
when the wrist is extended, then the interphalangeal
joints of the fingers and thumb are strongly flexed so
that the tips of the fingers touch the lower part of the
palm and no reasonable amount of force appears capa-
ble of straightening them, but as soon as the wrist
joint is flexed at a right angle then the interphalangeal
joints can be easily extended.
Septic Lymphangitis Along the Ureters Affecting
the Kidneys, Treated with Anti-Streptococcic
Serum : Recovery. — J. M'. Stenhouse gives the his-
tory of a woman aged twenty-eight years. The dis-
ease followed a urethritis of several years' standing
and a later cystitis. The use of the serum gave
prompt results, and it is recommended to combine
with it the administration of full doses of quinine.
The Treatment of Imperforate Rectum \V. P.
Montgomery analyzes ten cases, in nine of which
colotomy was performed. Seven of the patients died
within seven days after operation. The others were
living at last accounts. The relative advantages and
disadvantages of the perineal and iliac operations are
fully discussed.
Some Reflections upon Appendicitis. ^ — J. O'Con-
nor takes the usual surgical position in regard to oper-
ative intervention. He finds in an adherent appendix,
and in an abnormally short meso-appendix, explana-
tions of many of the symptoms of the relapsing cases
not operated on at the time of first attack.
Some Experinfents on the Sterilizing Properties
of Unconfined Superheated Steam. — L. Cobbett
and J. H. C. Dalton show by a series of experiments
that this agent may be used to disinfect bedding, that
it leaves it dryer than before, and that the time re-
quired for the process is not inconveniently long.
Day-Terrors. — G. F. Still describes a condition
analogous to night-terrors which is due to a rheumatic
inheritance, fright, and mucous colitis. In such chil-
February i 7, 1900J
MEDICAL RECORD.
287
dren all forcing roust be avoided and a careful search
made for the exciting cause.
Further Observations on Pernicious Anaemia as
a Chronic Infective Disease. — By VV. Hunter. A con-
tinued article.
Berliner kliiiische Wochenschrijt, January 22, igoo.
On the Poisonous Effects of Normal Urine.— ('.
Posner and M. Vertun call attention to the experi-
ments of Bouchard, who found that the introduction
into the veins of animals of urine at blood heat caused
myosis, dyspnoea, lowering of temperature, and som-
nolence, the animal dying without convulsions. The
introduction of the fluid mass itself regardless of its
nature may be fatal from thrombus in the right heart
or from lung embolus. Their own experiments lead
to the same general conclusions, but account must also
be taken of the degree of toxicity of the urine as well
as of its bulk. Furthermore, results vary according to
the saline percentages in any given urine.
Pneumatic Therapy from 1875 to 1900. — J. Laz-
arus describes the measures employed along this line
in one of the Berlin hospitals, and finds from the ex-
perience of the last quarter-century that pneumatic
therapy gives definite results in pleurisy, lung retrac-
tion, and chronic infiltration, chronic bronchial ca-
tarrh, consecutive circulatory disturbances without
organic cardiac disease, and in certain anomalies of
nutrition, as chlorosis and ana-mia. The limitations
and contraindications of the method are clearly
pointed out. Cases of ha;moptysis especially are not
to be subjected to this plan of treatment.
The Bacterial Contents of Milk Products and
Other Nutritive Media. — Dr. Bloch has investigated
this question with reference to preparations called
plasmon, nutrose, eulactol, hygiama, tropon, etc., also
including in his researches meal and oatmeal. In no
instance did he fail to find large numbers of bacteria,
but says that the utility and safety of a food product
are to be based not on the number but the kind of
bacteria found therein. Condemnation is rightfully
made with reference to those substances w'hich con-
tain micro-organisms which are definitely known to be
injurious to the human body.
The Development of Ophthalmology in the Nine-
teenth Century.— J. Hirschberg closes a historical
article with the statement tliat a large and grateful
field of activity awaits the physician wlio devotes his
energies to ophthalmological practice, and expresses
the hope that the coming century will see the mem-
bers of the profession better acquainted with its prin-
ciples.
Simultaneous Gunshot Wounds of the Thoracic
and Abdominal Cavities By F. Koenig. A con-
tinued article.
Deutsclic medicinische W'odirrischrift, January 18, igop.
Further Investigations of Arrow Poison. —
Brieger, having previously studied the arrow poison of
the Vakamba in East Africa, now reports on that used
by the Vagogo in the same part of the world. He
thinks these two poisons, as well as that of the
Somali, are practically the same. He had not suffi-
cient material to enable him to identify the poison
with certainty, but it is probably composed in great
part of the juice of a species of euphorbia.
Traumatic Tetanus Cured by Means of Orrho-
therapy. — Crone reports a case of tetanus in an eight-
year-old boy who, in a fall, received a scalp wound.
The first symptoms appeared ten days later. It was
four days after the disease declared itself before the
tetanus antitoxin was procured. Four injections in as
many days were made before any improvement was
noted, but then the boy began to grow better, and
finally recovered entire!}'.
A New Method for the Quantitative Estimation
of Mercury in the Urine. — Friedricli I'.schbaum ob-
tains a union of tiie mercury in the urine witii copper
in the usual way, breaks up this union by heat, and
then removes the mercury from the sides of the test-
tube by means of a little plate of metallic silver.
The difference in weight of this piece of silver before
and after the amalgamation gives the amount of mer-
cury.
Further Contributions to the Study of the Os-
motic Pressure of Animal Fluids.— M. Senator stud-
ies the density of the urine and of the blood in health
and disease by means of observation of the varying
freezing-point of these fluids.
Clinical and Experimental Studies of Dural In-
fusion.— By Paul Jacobi. A continued article.
AliincJiencr vwdiciiiisihi U'oclienschrijt, Jan. 2j, igoo.
Pathology of Miliary Tuberculosis.— Georg Mayer
cites the case of a man twenty-one years old, who
when first seen had a slight cough with expectora-
tion and shortness of breath on exertion. There
were fine bubbling rales over the left upper lung.
The pulse was soft and weak. On the right wrist
was a small, bright-red area exuding a yellowish-
white secretion. No tubercle bacilli were found in
the sputum. In less than three weeks there were a
severe cough, vomiting, and rise of temperature.
There was swelling of the skin of both thighs. Both
liver and spleen were palpable. The blood count
showed white to red corpuscles as i : 720. Later, there
were abundant rales over both lungs. The heart be-
came weak and irregular. On the day of death the
heart sounds were almost obscured by a loud friction
murmur. The patient had no subjective discomfort
till shortly before death, which occurred about a
month after he was first seen. Section disclosed mil-
iary tubercles throughout the lungs. In the pericar-
dium were 200 c.c. of serous fluid. Both endocardium
and myocardium were affected. In the heart cavity
were thrombi. Mayer appends photographs showing
a tuberculous hair follicle, a tubercle of the cephalic
vein, and an organizing thrombus of the right ven-
tricle.
Treatment of Chronic Constipation in Childhood.
— Heinrich Doerfler has for the last six years met
with flattering success in the treatment of chronic con-
stipation in children by the administration of butter.
It should be fresh and of the best quality. It should
be given in the natural state and not by means of any
vehicle. For the first month clysmata may be given;
in the second and third month from a half to a whole
coffee-spoonful of butter daily, morning and evening,
till the stools are normal; then only every two days.
The dose is further increased according to the age.
Local Disposition, Cold, and Hardening. — Carl
Kisskalt, in reviewing the results of experiments on
animals, says that arterial hyperaemia increases the
tendency to illness. Such increased disposition
through arterial hypera;mia of the internal organs, in-
cluding the mucous membrane of the respiratory tract,
occurs through the contraction of the skin vessels by
cold. Hardening against the influence of cold brings
about a condition in which the skin vessels do not con-
288
MEDICAL RECORD.
[February 17, 1900
tract so quickly, and thus disposition to disease is not
so great.
The Separation of Carbonic Acid by Repeated Cold
Baths. — A. Lode and A. Durig report as the result of
their experiments an extraordinary increase of the pro-
duction of carbonic acid during and after cold' baths.
The amount increased when the temperature of the
water was lowered, and 7'ice versa.
The (Esophagoscopic Diagnosis of Diverticula of
the CEsophagUS. — Gustav Killiar, in using the oesopha-
goscope, always has the patient in a sitting position.
He then inserts the tube into the sac, then down into
the oesophagus, then again into the sac, thus obtain-
ing a clear idea of all the anatomical relations.
A Case of Potassium-Iodide Parotitis. — G. Traut-
mann states that symptoms of poisoning by the iodine
preparations can be caused by their local application
as well as by their internal administration. He then
cites two cases of parotitis caused by potassium iodide.
One of these he takes from the literature; one came
under his own treatment.
Father Bernhard, a Predecessor of Kneipp. A
Chapter from the History of the Water Cure. —
Julian Marcuse relates that Father Bernhard belie\ed
in the use of fresh water mixed with ice or snow in
three ways: (i) External application of cloths satu-
rated in the liquid, or as a kind of massage by rubbing
with pieces of ice; (2) as a drink; (3) as clysmata.
Tuberculosis of the Lymph Glands. — Von Noor-
den shows by statistics how common this affection is,
and declares that the association of tuberculosis of
the lymph glands and pulmonary tuberculosis is e.\-
tremely common.
The Measure of Blood Pressure by Gartner's
Tonometer. — Hugo Weiss believes Gartner's tonometer
to be of great clinical use, and he calls attention to its
simplicity.
Wiener klinische Wochenschrift, January 2J, /goo.
The Radical Operation for Varicocele.— Albert
Narath describes this operation and gives some of its
advantages. The incision is made above Poupart's
ligament, and thus is in a region more easily ster-
ilized and less liable to infection than the scrotum.
The circulation in the internal spermatic vein is en-
tirely interrupted and the high blood pressure is sus-
pended at the origin of the veins. The injury of the
internal spermatic artery can be more easily avoided
than in other methods. The external spermatic veins
are much expanded, so they can be easily resected.
At the same time inguinal herniae and lipomata can
be operated. The inguinal canal can be securely
closed. The spermatic cord can be raised and em-
bedded in a narrow canal. The operation is very
neat; the venous plexus remains intact, the loss of
blood is small.
Multiple Stenoses of the Small Intestine of Tu-
berculous Origin. — Sigmund Erdheim has observed in
a short time five cases of this nature and has operated
on some of them. In four of the cases the position of
the stricture was entirely in the small intestine, in the
fifth it was combined with a tuberculous stricture of
the ascending colon. Combrnation with tuberculous
stenoses of the large intestine, especially of the caecum,
is often observed. All five of Erdheim's cases were
secondary infections.
The Technique of Gastrostomy — Robert Lucke
describes this method thus: P'irst a purse-string suture
is made in the stomach wall. A trocar is inserted,
and after its withdrawal a rubber tube is substituted
and the suture drawn up and tied.
Wiener klinische Rundschau, January 21, jgoo.
Indication for Employment Therapy in Func-
tional Nervous Diseases — Oskar Vogt declares that
work as a therapeutic measure can be considered only
when it is effectual in distracting the patient's atten-
tion from himself and when he is happy in its per-
formance. Work is indicated in nervous prostration
when it tends to relieve this condition. It is not of
much benefit in akinesia algera according to Vogt's
experience. But for neurasthenics with hypochondri-
acal tendencies and for such affections as are allied to
neurasthenia it is admirably adapted.
Epiploitis following Operation. — Julius Schnitzler
tabulates twenty-eight cases, the patients ranging in
age from seven years to sixty-nine years. Both sexes
are represented. Some of these terminated by spon-
taneous healing, some were subjected to further oper-
ative interference.
Two Cases of Tuberculosis of the Serous Mem-
branes in Man, with the Macroscopical as well as
the Microscopical Picture of Bovine Tuberculosis.
— By Josef Pelnar. .\ continued article.
French Journals.
Hemiplegia and Aphasia in Intestinal Helmin-
thiasis.— E. Maragliano makes an exhaustive study
of a patient found unconscious on the street with no
history obtainable. Melasna passed was examined
and found to contain the larvae and eggs of the anky-
lostonia. There was right hemiplegia with aphasia.
The literature of anaemia from ankylostomiasis is
passed in review. The worm in the intestines exer-
cises its perturbing action on the circulation in ab-
sorbing the blood directly through the mucous mem-
brane; in setting up hemorrhages and in secreting
toxins. The \arious possibilities in the case in point
are analyzed, and the conclusion is reached that mor-
phological changes in the red globules were produced,
which in turn determined a cerebral hemorrhage. The
treatment consisted in a tannin injection in one-per-
cent solution, followed the next day by a 2-gm.
cachet of thymol every three hours for four doses, and
two injections daily of i gm. of ergotin. — La Medecinc
Moderne, January 28, 1900.
Sflrgical Treatment of Club-Foot by Astragalec-
tomy. — P. Mauclaire relates an instance of varus
equinus of paralytic origin coming on at the age of
eleven months. Infantile paralysis implicated both
legs and compelled rest in bed for seven months, at
the end of which time there was considerable turning
in of the right foot. At the age of three years tenotomy
of the tendo Achillis was done without benefit. The
condition was in reality due to paralysis, the club-foot
becoming fixed because of tendinous retractions and
of subluxation of the astragalus forward and inward.
Radiography made a positive diagnosis possible, and
this procedure, the writer thinks, should be the guide
to treatment in all cases. In the present instance,
after the impeding bone was removed, the foot was put
into good position and a plaster bandage applied, for
twenty-five days. The results were good.^Z<7 J'resse
Mcdica/e, January 31, 1900.
Acute Pott's Paralysis Without Changes in the
Spinal Cord. — H. Verger and .\nt. Laubie give the
observation of a man, aged fifty-six years, without de-
formity of the vertebral column, who suffered from
February 17, 1900]
MEDICAL RECORD.
289
retention and weakness of the limbs followed by com-
plete paraplegia and death about a month later. At
the autopsy large tuberculous lesions of the bodies of
the seventh, eighth, and ninth dorsal vertebras were
found. The cord was not compressed, and there was
no change to be seen by the naked eye nor by the mi-
croscope.— Le Frogirs Medical, January 27, 1900.
Mental Pathology at the End of the Nineteenth
Century. — Roubinovitch studies the pathogeny of
menial alienation, its pathological anatomy, methods,
types, curability, and medico-legal aspects. Purely
medical methods of study founded on general pathol-
ogy are advocated, while the newer psychological meth-
ods are useful as contributing aids. Insanity is a
material disease of the brain or of the entire organism ;
it is not a disease of the spirit or of the soul, which
being immaterial cannot be diseased. — Le Bulletin
Medical, January 25, 1900.
The Plague in Ancient and Modern Times and
its Future in Europe. — I'h. Hauser makes a histori-
cal study of plague, which appeared in continental
Europe in 543, and traces its march down to recent
outbreaks. In its early pandemic form it was fatal
in ninety per cent, of those attacked. From 1720 on
the plague disappeared from Europe without known
cause, but remained endemic and epidemic in Asia
Minor, Syria, and Egypt until 1845. ^'^^ Hong Kong
epidemic of 1894 and the Bombay outbreak receive
especial attention. — La Medecine Moderne, January 31,
1900.
Appendicitis and Gastrorrhagia. — E. Kirmisson
refers to a similar instance reported last month by
Piechaud, and relates the history of a girl of seven
years upon whom he had operated. A few hours after-
ward there was vomiting of blood and eight hours later
death occurred. There was no httmophilia to account
for this outcome, and the most probable hypothesis
was thought to be that of septicemia. — Gazette Heb~
domadaire de Medcciiie et de C/iinirgie, January 3 1 , 1900.
The Cure of Drunkenness by Anti-Alcoholic
Serum. — Legrain reviews the various quack and other
methods which have been in vogue in alcoholomania,
and concludes that they all depend largely if not
wholly upon the patients' own efforts for their suc-
cess. The best prescription is '"an infusion of a
little will power and earnest desire in an abundance
of water." — La Presse Medicate, January 28, 1900.
Annals of Gynecology and Pediatry, January, igoo.
Cervical Flexions — their Importance and Means
of Curing them. — T. J. Bell believes that cervical
flexions do not command the attention which their
importance demands. Dysmenorrhoea in unmarried
and married women, with sterility in those who are
married, should raise a suspicion of flexion at the in-
ternal OS. Correction of flexions at the earliest pos-
sible moment should be advised, and the method em-
ployed should be thorough.
Beef-Gall Enemata in the Treatment of Post-
Operative Obstinate Constipation and Intestinal
Obstruction.— F. C. Ameiss declares that, after the
failure of simple means, enemata of eight ounces of
beef-gall and eight ounces of water have in several
of his cases obviated the necessity of reopening the
abdomen.
New Applications of the Undulating Current in
Gynecology. — G. Apostoli affirms, after an experi-
ence of three years with this current, that while being
harmless and well borne, it deserves to take rank in
the therapeutics of conservative gynecology because
of its two chief actions, on the one side analgesic,
on the other tending to resolution and the relief of
congestion.
Two Cases of Vesico-Vaginal Fistula. — John O.
Polak very carefully describes the closure of these
two fistula. The first consisted of several plastic op-
erations at different sittings. The second patient was
kept in bed in the right latero-prone position. The
edges of the fistula were stimulated with fused silver
nitrate. Both results were satisfactory.
The Different Phases of Electric Treatment.— J.
McFadden Gaston speaks of the various sources of
electricity and mentions the favorable results of its
use in extra-uterine pregnancy, its application in the
case of tumors and of goitre, varicocele, and hydro-
cele. He speaks of the .v-ray in the treatment of dis-
eased organs.
Tubal Pregnancy with Report of Cases. — J. M.
Black writes that the etiology of this condition is
still shrouded in mystery. It may occur at any age,
and in a woman who has borne several children, or it
may happen in the first pregnancy a few months after
marriage.
The Treatment of Congenital Dislocations of the
Hip by the Bloodless Method.— M. P. Redard states
that this method ought to be tried on patients from
two to twelve years of age. In young patients the
method, with proper technique, is free from danger
and generally gives excellent results.
Some Remarks on Heredity. — A. Macswain de-
clares that no marriage should ever be contracted
without a clean health record involving both male and
female. He believes that man is not what environ-
ment makes him, but is to a large degree what heredity
makes him.
Multiple Pregnancy with Report of Cases. — A.
W. Shea states that heredity is an important factor in
multiple pregnancy. In a few over seven hundred
cases, he finds nine instances — eight of twins and one
of triplets.
Gastro-Enteritis Complicating Congenital Syph-
ilis.— Robert \V. Hastings reviews four cases which
he observed in the Boston Floating Hospital last sum-
mer, all of which resulted fatally.
Experience in Operations for Typhoid Perfora-
tion.— By Hugh M. Taylor. See Medical Record,
vol. Ivi., p. 910.
A Brief Summary of the Indications for Opera-
tions upon the Stomach. — By Max Einhorn. See
Medical Record, vol. Ivi., p. 637.
Ureterectomy. — By J. Wesley Bove'e. See Medi-
cal Record, vol. Ivi., p. 905.
Canadian Journal of Med. and Surgery, Feb., igoo.
Extreme Emaciation in Hysteria, with Notes of
a Case. — T. Beath reports the case of a young girl,
who, in heavy clothing, weighed forty-three and three-
quarter pounds. She had never menstruated. Her
organs were normal, but she complained of deafness
without apparent cause. In the fecal evacuations for
the first two weeks was tough, slimy mucus. Four
weeks of partial segregation and Weir Mitchell treat-
ment saw her well on the way to recovery. Beath, in
reviewing this case, calls attention to: (i) The ex-
treme emaciation; (2) the comparative absence of
other symptoms; (3) the nosological place of mucous
colitis. He emphasizes the fact that there is an hys-
290
MEDICAL RECORD.
[February 17, 1900
terical symptom (indefinite abdominal pain associated
with the discharge of long strings of mucus per anum
and usually constipation) which is in no way associ-
ated with colitis.
The Relation of Insanity to Pelvic and- Other
Lesions. — A. T. Hobbs, after discussing this subject,
notes the relative value which the various lesions have
in the production or in the maintenance of cerebral
disturbance: i. Utero-ovarian disease of an inflamma-
tory origin received attention in ninety-six cases. The
recovery rate following the elimination of these de-
rangements was exactly fifty per cent. 2. Utero-ova-
rian displacements being corrected in forty-seven
cases were followed by thirty-six per cent, of recov-
eries. 3. Utero-ovarian tumors and vaginal lesions
of a non-inflammatory type being attended to in thirty
cases were succeeded by twenty-six per cent, of men-
tal recoveries.
The Smallpox Outbreak in Essex. — P. H. Brice
sums up four remarkable facts from the statistics of
this outbreak ; (i) The practically absolute protection
of a previous attack; (2) the practically absolute pro-
tection of a prior vaccination when a good cicatrix is
present; (3) the power of a recent vaccination running
concurrently in the system to modify greatly the sever-
ity of the disease; (4) a lymph of attenuated virulence
does not seem to have done more than modify the se-
verity of the disease.
A New Epoch in Hospital Evolution. — Ernest
Hall advocates the development of an institution spe-
cially adapted for the treatment of those who have
manifested psychic abnormality and have marked
physical lesion. While not conflicting with the gen-
eral hospital nor tiie asylum, its purpose would be to
receive and treat (i) aggravated forms of nervous dis-
ease, and (2) cases of insanity in which a definite
local lesion could be found.
Address in Surgery. — By W. E. Coley. See Med-
ical Record, vol. Ivi., p. 427.
Medicine, Ft'hruary, it)0O.
Curability of Epilepsy, and How it May be Ac-
complished William B. Spratling gives the treat-
ment of cases of idiopathic epilepsy at the Craig Col-
ony. The patient is under the entire control of
authority. First, he is to be reconstructed physically.
For this various means are employed — medicines,
systematic occupation, gymnastic exercises, baths, spe-
cial feeding, and moral agencies. .\\\ tlie while he is
being studied for aura and the cause of the disease.
He must not overeat, nor use tobacco to excess. Al-
coholic stimulants are forbidden. His former manner
of life is changed as much as possible. If he cares
for any particular work, he is encouraged in its pur-
suit. Excellent results have followed this treatment.
Gastro-Intestinal Infections in Infants I. A. Abt
states that the opinion is general among bacteriolo-
gists and clinicians that: x. The acute gastro-intesti-
nal disorders of children cannot be attributed to a
specific form of bacteria. 2. The toxic symptoms of
such infection depend upon the introduction into the
alimentary canal of poisonous substances contained
in food. 3. Bacteria may be introduced from without;
or the ordinary saprophytic bacteria in the canal may
assume special virulence. 4. The most severe dis
turbances are caused hy the metabolism of bacteria.
5. Specific intestinal infection may occur in infants.
Typhoid fever, though infrequent, may occur.
A Case of Blastomycetic Dermatitis— Clinically
and Histologically, an Epithelioma. — W. E. Coates
declares that the so-called blastomycetic growths oc-
cupy a position closely akin to tumor growths both
malignant and benign. He presents the case of a
man thirty-seven years of age who exemplifies the
statements he makes.
The Topical Application of Iodoform in the Treat-
ment of Tuberculous Affection of Serous Membrane,
with Cases — By Zera J. Lusk. See Medical Rec-
ord, vol. Ivi., p. 684.
Immunization through Vaccination. — By D. P.
Austin. See Medical Record, vol. Ivi., p. 643.
The Montreal Medical Jounial, January, igoo.
West African Medicine.— Charles G. L. Wolf states
that in malaria hot spirits and quinine are given, with
perhaps antipyrin or phenacetin. The treatment of
severe cases of malaria is practically identical with
that of Brand. " Craw-craw " is a very interesting
disease which has afflicted the white population and
is one of the most difficult things in the world to cure.
The most frequently used toxic agent on the coast has
been till recently the Calabar bean. It is used to poi-
son human beings as well as horses. The two poi-
sons next in use are those of sasswood and the strych-
nos bean. Two other methods used by the assassin
are the mixture of powdered glass in the victim's food
and the introduction of mud containing tetanus bacilli
together with grit into tlie victim's shoes.
Report of a Case of Colles' Fracture which Led
to a Suit for Malpractice and Prolonged Litiga-
tion.^T. M. Conerty gives the history of a case of
Colles' fracture treated by him. Some time after the
accident a "sore" developed on the patient's arm — a
strumous boy — due to the devitalization of tissue from
the fall and subsequent infection from gross negli-
gence on the part of the parents. There is now a
slight deformity due to cicatricial contraction. The
father of the boy, w ho has sued for damages, was at
the time he began the action under an order of com-
mitment to jail for debt. No matter, therefore, how
successful the defence may be, tlie physician must
pay the costs of defence.
Electrical Burns.— J. M. Elder gives Dr. Sharpe's
description of such injuries, adding any differences he
has himself noticed, i. The burn is at first dried and
crisp, the site being bloodless; later, oozing occurs.
.\I1 the symptoms of moist gangrene will be present.
2. Pain in some patients is slight, in others severe.
3. Some patients experience shock, some do not. 4.
As to prognosis, recovery is from one and one-half to
five times as long as in the case of other burns. 5.
The ascending degeneration following these burns af-
fects chiefly the striped muscle tissue, and is often ex-
tensive. Treatment is very unsatisfactory — excision,
amputation, and skin-grafting being often necessary.
A Case of Haematometra William Gardner oper-
ated on such a case, the microscopical examination of
whicii excluded all malignant characteristics. The
most probable explanation of the occlusion of the cer-
vix which led to the accumulation of the menstrual
flow seemed to be adhesive inflammation due to the
prolonged pressure of the cup of the prolapsus pes-
Some Retinal Complications in Chlorosis. — H.
McL. Kinghorn reports three cases in which the most
important points are: i. Only one eye was affected.
2. The onset was sudden. 3. Improvement was rapid
under iron. 4. The neura-retinitis and hemorrhages
occurred well on in the disease. 5. Hypermetropia
was present in both the cases with neuro-retinitis.
February 17, 1900]
MEDICAL RECORD.
291
A Case of Janiceps. — Andrew Macphail describes
this monster which was sent to him from Jamaica, of
which place the parents are natives. The specimen
shows the spinal columns and backs of the crania to
be separate, while the thoraces and faces coalesce an-
teriorly.
A Rare Form of Pyosalpinx Complicating Uter-
ine Myoma William Gardner and Maude E. Abbott
report the interesting features of this case to be : (i )
The existence of pyosalpinx without any signs of in-
flammation of the surrounding parts; (2) the combi-
nation of pyosalpinx with myoma; (3) excentric hyper-
trophy of the tube.
The Place of Physical Training in a School
System. — R. Tait McKenzie emphasizes the neces-
sity of scientific physical training in schools. The
years of most rapid growth are those of school life
between eight and seventeen years.
On the Etiology and Symptomatology of Goitre.
— By J. (ieorge Adami. See Medical Record, vol.
Ivii., p. 1 19.
Surgical Gleanings from Abroad By L. Coyteux
Prevost.
Dublin Journal of Medical Sciences, Fehruaty, 7 goo.
The Clinical Features of Beri-Beri. — C. Norman
enumerates and discusses the following features of
beri-beri : Disturbances of sensation, exaggerated re-
flexes, later diminished; paresis of the peroneal mus-
cles and foot flexors, affections of other muscles, eye
symptoms, absence of sphincter paralysis, later mus-
cular atrophy; joint relaxation, cardiac palpitation,
gastric weight and discomfort, and finally cedema.
The great danger always present in this disease is
sudden heart failure.
On the Examination of Sick Children. — L. Symes
recommends the following routine: Facies, head,
frame, bones and joints, reflexes, eyes, glands, abdo-
men, heart, lungs, spine, neck, mouth, and nervous
system. We frequently make mistakes, he says, not
because we do not know, but because we do not exam-
ine, and this is eminently the case in diseases of chil-
dren. Under each of the above headings he mentions
the various abnormal conditions to be looked for.
Hospitals; their Origin and History R. Dalton
gives a historical sketch of the establishment of hos-
pitals and their characteristics in the early centuries.
Zeitschrift fiir klinische Mcdicin, Vol. .v,v.v/.v., igoo.
Excretion of Pepsin in Diseases of the Stomach.
— Roth concludes that: (i ) In private practice Mett's
method is most practical for quantitative analysis of
pepsin; (2) the variations in excretion are as great
normally as that of hydrochloric acid; (3) examina-
tions must be conducted under the same conditions of
gastric contents; (4) some gastric juices contain more
pepsin than the normal (hyperpepsia) ; (5) the great-
est amount is found in gastric ulcer, the least in
atrophy of the stomach due to chronic catarrh, carci-
noma, or neurosis.
Transitory Spinal Paralysis. — L. Krewer states
that clinically there exists a group of spinal paralyses
which remind us of acute myelitis, which differs from
it pathologically and anatomically. Hence they must
be excluded and labelled as transitory spinal paraly-
sis. These paralyses occur as a rule suddenly without
any apparent cause and without previous predisposi-
tion. Sensory disturbances are entirely absent; pain-
less muscular twitchings are observed in the paralyzed
limb, and trophic disturbances are apparently wanting.
In a few days the condition improves first in the par-
alyzed extremities, later in the bladder and rectum.
The entire condition lasts from one to two months.
Changes in the Central Nervous System in Leu-
kaemia.^E. Bloch and Hans Hirschfeld say that in
leukaemia lymphomatous masses in the form of hetero-
plastic tumors occur in the meninges; symptoms of
compression may appear or there may be no clinical
evidence of the existence. Leukaemic cerebral hemor-
rhages are not uncommon: these may be cf various
sizes. Degenerative changes in the spinal cord are
rare, though they do occur. A pure leukaemic infiltra-
tion may take place within the spinal cord.
Chronic Myocarditis and Cardiac Aneurism in
Childhood. — Paul Rosenstein gi\'es the history and
post-mortem findings of a case of chronic cardiac
aneurism in childhood and its very probable connec-
tion with tuberculosis.
Glycolysis — F. Umber concludes that the role of
the pancreas in diabetes is to-day just as indefinite as
in the days of Mering and Minkowski. The article
presents a series of careful tables and experiments.
Monatsschritt J. Geburtsh. und Gyniik., January, igoo.
Ovariotomy in the Schauta Clinic. — Oskar Biir-
ger discusses ovariotomy very thoroughly, basing his
conclusions on the observations of three hundred and
ninety-four cases. He describes both the abdominal
and vaginal methods, comparing their respective advan-
tages, and bflie\es the former to be advisable in case
of adhesions, intraligamentary position of the tumor,
twisted pedicle, or malignity, while in simple, benign
growths the vaginal route is preferable.
Peripheral Tubal Sacks and their Significance
in the Etiology of Tubo-Ovarian Cysts. — Edmund
Waldstein explains these sacks as cystic growths which
have developed at the ends of the tubes. They are
enveloped by a connective-tissue wall and contain
either serous or sero-purulent contents. The tube
opens into it by its fimbria-. These sacks have a very
important influence on the development of certain
tubo-ovarian cysts.
Report on Cases of Prolapse- Operation Per-
formed in the Schauta Clinic with Especial Re-
gard to the Lasting Results. — H. Schmit carefully
tabulates these cases of prolapse operations, which
fall into the following groups: (i) Vaginal total ex-
tirpation; (2) vaginal hysteropexy; (3) abdominal
hysteropexy.
Artificial Premature Labor and its Final Re-
sults Ludwig Skovscheban reports that of thirty.
three mothers only two died, or six per cent. One
was a case of paratyphlitic abscess, so if this was not
counted the deaths would be three per cent. There
were thirty-four children born, twenty-seven of whom
were living, or 79.4 per cent.
Contribution to the Therapy of Extra-Uterine
Pregnancy. — Otto Th. Lindenthal thinks operation
is indicated in all cases of uninterrupted extra-uterine
pregnancy; in all cases in which through abortion or
rupture a dangerous hemorrhage takes place, or when
as result of infection fever and septic appearances
exist.
The End-Results of Operative Treatment of Re-
troversio-Flexion of the Uterus. — Josef Halban
gives the results of the three methods of operation as
292
MEDICAL RECORD.
[February 17, 1900
follows: Ventrofixation gave the best, 87.5 per cent.;
vagino-fixation, eighty per cent. ; vaginal shortening
of the round ligaments, seventy-six per cent.
A New Method of Internal Measurement of the
Living Woman. — Julius Neumann and Hugo Ehren-
fest describe their method and instrument for measur-
ing the pelvis. This latter they call the pelvigraph;
it consists of two parts, the indicating arm and the
exploring arm.
Clinical and Anatomical Contributions to the
Question of Complete Tubal Abortion. — Ludwig
Mandl, at the close of his dissertation on this subject,
quotes Schauta's opinion that the abdominal method
is pre-eminently the best in the operation for extra-
uterine pregnancy.
Contribution to Surgery of the Ureter. — E. Wert-
heim declares that it is more difficult to obtain suffi-
cient material to close old ureteral fistulas than recent
ones. In cases in which the defect cannot be repaired
on account of lack of material, nephrectomy is neces-
sary whether the kidney be sound or not.
Determination of the Pelvic Inclination in the
Living Woman Julius Neumann and Hugo Ehren-
fest give a diagram and cuts to describe their instru-
ment, the kliseometer, which consists of a rigid bow.
One end carries the indicator, and rests against the
back, while the other marks a point on the symphysis.
Indications for Caesarean Section. — Eduard Frank
says that Caesarean section is undoubtedly the easiest
coeliotomy, and he adds that it is the duty of every ob-
stetrician to be able to define his position in the case
of perforation of a living child.
Decidual Polyp of the Uterus.— Fritz Hitschmann
describes a tumor which came away spontaneously
at the normal end of an eventful pregnancy. It con-
sisted almost entirely of glands. It had no connec-
tion with the chorion.
Manual Treatment (Thure-Brandt-Schauta) in
Gynaecology. — Oscar Piering writes of the efficacy of
massage in gynaecological affections. He speaks also
of the good results of the manual treatment of floating
kidney.
The Anatomical Proof of Loss of Virginity. —
Albin Haberda declares tliat in some cases the elas-
ticity of the hymen preserves its integrity after coitus.
In other cases there are scars left which constitute an
undeniable proof.
Emphysema of the Uterus and Gas-Sepsis. — Josef
Halban states that the histological examination of the
case under his observation showed the chief changes
to be necrosis of the uterine musculature with an abso-
lute lack of inflammatory infiltration.
Researches Concerning Tuberculosis of the Fe-
male Sexual Organs.— Lucius Stolper declares that
the diagnosis of genital tuberculosis is very difficult.
The subjective symptoms are often slight or wanting
altogether.
^elanosarcoma of the Female Pudenda Franz
Torggler reviews the literature of this subject, and
cites twenty cases. As to age, three-quarters of the
cases observed were after the menopause. The ma-
lignancy of the disease is frightful.
Information concerning Carcinoma Psammosum
of the Uterus. — H. Schmit gives an account of this
tumor, which is characterized by its calcareous concre-
tions. Its metastases also possess this peculiarity.
Contribution to the Theory of Fetal Cystic Kid-
ney.— Sigm. Mirabeau concludes that the fetal cystic
kidney is not very different from that of the adult.
Diseases of the Pericardium and of the Cardiac
Vessels. — By G. Strube-Bremen. A review of recent
advances.
D'u- Therapie der Gegenwart, Jantiary, igoo.
Treatment of Carcinomatous (Esophageal Stric-
ture with Permanent Sounds. — H. Curschmann
states that when carcinomatous stricture of the oesoph-
agus renders deglutition difficult the regular daily
passage of a tube is indicated, and feeding occasion-
ally through it maintains the strength and nutrition.
Gradual dilatation is not productive of much good in
carcinoma. Permanent sounds are advisable only in
the case of strictures situated in the middle or lower
third; in strictures high up, surgical intervention is
more beneficial. If the sound is well placed, feeding
is easy, provided we use only fluid and semi-solid
food.
Castration in Tuberculous Epididymitis. — E. Al-
bert says that castration is contraindicated, because
many patients live in comparatively good condition
for many years with a tuberculous testicle, and also
because despite double castration the tuberculous
process is not stopped. If patients desire operation,
incision of the nodules with subsequent curettage is
all that is necessary.
Observations with the Stomach Tube in Infants.
— O. Heubner demonstrates his method of determin-
ing the motor power of diseased stomachs; this also
gives a clew as to the intestinal function. The tube
is mainly useful for the removal of stagnating and
decomposing contents, in cases of acute dyspepsia,
chronic gastro-enteritis, pyloric stenosis, etc.
Observations upon the Therapeutic and Diagnostic
Value of the Old Tuberculin. ^A. Neisser presents
his experience in cutaneous tuberculosis. If a typical
local reaction occurs after tuberculin injection, then
tuberculosis exists, and when it is constantly absent
after a given dose, tuberculosis does not exist.
A Rai^ Operation Under this title, J. Hi;schberg
describes with illustrations a magnet operation for the
removal of an iron fragment from the vitreous humor.
Annah-s de Dermato/ogic et Syf'hiligraphie, Dec, iSgg.
Hyperkeratosic Interdigital Eczema. — W. Du-
breuilh describes a chronic dermatosis of which he
has seen four examples, the histories being given.
The interdigital spaces of the toes are chiefly affected,
but it may occur upon the hands. The skin between
the toes is covered with a shining white, thickened,
horny layer, which is detached in layers. There is
not much pain or itching. Excessive sweating is not
noted, though the macerated appearances would sug-
gest hyperidrosis as one of the causes. Treatment is
unsatisfactory; but ichthyol in alcohol has caused
improvement, and chrysarobin ointment has been used
with some success.
Treatment of Ulcer of the Leg. — Yaroslav Bu-
kovsky has experimented with the products of the pyo-
cyanic bacillus. In one hundred cases complete cure
was effected in a relatively short time, when other
measures had failed. Compresses wet with the toxin
are changed two or three times daily. The beneficial
action is shown by the rapid cleansing of the ulcer,
epidermization, and healing with a solid cicatrix more
quickly than by other forms of treatment.
February 17, 1900]
MEDICAL RECORD.
29:
Annales de Gynecologic, January, ji^oo.
So-Called Therapeutic Foeticide. — Pinard believes
that the practitioner has no moral, legal, nor scientific
right to practise embryotomy on a living child, and
that to sacrifice a child in the mother's interests is a
legendary form of practice which ought to disappear
with other myths. The decision of life or death to
the child does not belong to any one, and the doctor's
only right of decision relates to the choice of the oper-
ation to be performed. A physician must always en-
deavor to save life, never to take it.
The Practice of Obstetrics. — F. J. Herrgott reviews
a recent work by Henri Varnier, which he says is so
truly descriptive that in reading it one truly seems to
be present at a labor.
The Value of Oxygenated Water in Uterine
Hemorrhage. — Dr. Platon has used this remedy suc-
cessfully, when ergot and ergotin, hot injections, and
tampons with the perchloride of iron had failed.
Annaks di Med. et de Chirurgie Infantiles, Jan. /, igoo.
Contribution to the Study of Malignant Tumors
of the Kidney in Children. — 1'. Sorgente says that
the preponderance of the round-celled variety of sar-
coma explains the rapid development of the majority
of renal tumors in children. Epithelioma is very rare.
Renal tumors are generally primary growths. They
are almost always unilateral, and the right seems more
often affected than the left. The kidney is the organ
in children most frequently attacked by malignant
neoplasm. As to age, the first year of life furnishes
the largest number of examples. Sarcoma in all its
varieties is the most usual form. In summing up the
' results of operated cases, it is found that death by
operation is frequent, recurrence is very frequent, and
a definite cure is exceptional. However, the results
of recent operations have been happier than the earlier
ones were.
Eczema in Young Children. — E. Perier gives the
history of an eczematous child who serves as a type in
this trouble. Baths were stopped, sponging with tepid
marshmallow water being substituted. For three
days local compresses of cold boiled water were ap-
plied, covered with oiled silk. After three days the
child was washed in olive oil, and then a coating of
zinc paste containing a little menthol was applied to
diminish the itching. Internally it was given from
two to three glasses of hot boiled water in which was
a small pinch of bicarbonate of soda.
Congenital Ocular Lesions in a Child Born of a
Mother Attacked with Typhoid Fever toward the
End of her Pregnancy. — A. Antonelli cites a case
of optic neuritis together with chorio-retinitis in a
child whose mother had typhoid fever in pregnancy.
He states that this disease often provokes profound
ocular complications.
Contribution to the Study of Paroxysmal Haemo-
globinuria. — R. Guita and C. Valvassori Peroni, in
reviewing a case of this kind, think that atmospheric
influence played considerable part in the causation of
this curious malady.
Russki Arkhiv Patologii, etc., December jl, iSgg.
Chyluria Nostras and its Causes. — V. E. Pred-
techenski says that chyluria is not an exclusively
tropical affection. About twenty cases are on record
in persons who had never been outside of Europe.
The author reports the first case seen in Russia. Ex-
amination of the urine showed the presence of large
numbers of small lymphocytes which could have es-
caped only through some solution of continuity of the
walls of the lymphatics. The eggs of tasnia nana
were also found in the urine. The parasites which
cause tropical chyluria are filaria sanguinis hominis
and distoma haematobium ; those accused of inducing
chyluria nostras are eustrongylus gigas and possibly
tffinia nana. Among the causes which may provoke
non-parasitic chyluria are probably tumors, peritoneal
adhesions, and other pathological processes w hich may
obstruct the lymphatic vessels and produce stagnation
of the chyle. The author obtained favorable results
in his case by the administration of gr. xv. of gallic
acid three times a day.
Meteorism in Typhoid Fever and its Treatment.
— V. E. Chernoff says that this occurs under two con-
ditions : ( I ) \\'hen there is greatly increased forma-
tion of gas in the intestine; and (2) when there is
atony or paresis of the intestinal wall, a result of
local poisoning of the nervo-motor apparatus by the
products of abnormal fermentation of the intestinal
contents. Inflammation of Peyer's patches and of the
mucous tunic in general is the usual cause of the ab-
normal fermentation, and often the extent and depth
of the inflammation occasion a localized peritonitis,
which in turn increases the meteorism. By limiting
the inflammation by means of the local application of
cold, reducing by the same means intestinal fermenta-
tion, and exciting the peristaltic movements, we better
and more speedily succeed than in any other way in
overcoming the meteorism with its attendant dangers.
Etiology and Pathological Anatomy of Werlhof 's
Disease. — ^^ N. Konstantinovitch reports a case of
purpura h;tmorrhagica occurring in a laborer, eighteen
years of age. At the autopsy he found hyperplasia of
the aorta, old tuberculous lesions of the bronchial
glands, pigmentation of Peyer's patches and the soli-
tary glands (probably due to a former typhoid fever),
small spleen, hemorrhages in various tissues and or-
gans, and anaemia, liacteriological examination was
negative. Histological examination showed fatty de-
generation of the endothelium of the capillaries in all
the organs — even in those in which no hemorrhage
had occurred, as the brain for e.xample. The author
had no theory as to the cause of this fatty degenera-
tion of the capillary vessels, upon which the petechial
eruption depended, but thought there was possibly
some form of auto-intoxication.
Myooedema and its Pathological Significance in
Mental and Nervous Diseases. — N. Bernstein has
found this phenomenon present in twenty-eight cases
of general paralysis, in forty-four out of forty-six cases
of precocious dementia, and in eight of idiocy, but in
none of five cases of mental confusion of Meynert, or
of eleven of mania and melancholia. He found it also
in all cases examined of epilepsy and cerebrospinal
syphilis, and in three out of four cases of tabes. He
believes that there is in these affections a special form
of auto-intoxication which acts directly upon the mus-
cular tissue.
Terpinol in Haemoptysis. — Th. G. Yanovski asserts
as the result of his experience that terpinol is useless
in hemoptysis from pulmonary congestion, but renders
signal service in many cases of hemorrhage dependent
upon tuberculosis. The good effects were usually
noted after from five to seven doses of three drops
each every two hours.
The Influence of the Toxins of Tetanus and
Diphtheria on Metabolism. — L. Sverzhevski studies
the alterations in the gaseous and nitrogenous ex-
change produced in dogs and rabbits by the action of
the toxins of tetanus and diphtheria.
294
MEDICAL RECORD.
[February i 7, 1900
THE STUDY OF MALARIA IX ROME.
CFrom an Occasional Correspondent.)
THE .-ESTIVO-AUTUMNAL PARASITE IN MAN AND THE
MOSQUITO— THE ROMANOWSKY STAIN MALARIA IN
THE CAMPAGNA.
Professors Bignami and Bastianelli do most of their
work on the malarial organism in the laboratories of
the Hospital Santo Spirito, on the left bank of the
Tiber, and it is worth a good climb up that old spiral
staircase to get a view of the mounted specimens they
are studying at present.
One morning last week I had the pleasure of going
over them with the professors, who are most enthusi-
astic in their research and who are doing some splen-
did work here. At present they have complete sets of
mounted specimens showing the morphology of the
parasite of the aistivo-autumnal variety — the only one
which they have yet been able to follow through its
entire life history; that is to say, from the time it is
taken into the human blood, through its various cycles
there with which we are all familiar, until it is taken
into the stomach of the mosquito; its rest in the stom-
ach walls, and thence to the salivary glands, ready for
transmission to man.
Among the most interesting slides are those showing
the parasite in the stomach walls of the Anopheles
claviger, usually lying in tiie muscular layer between
the fibres, but one very pretty specimen showed the
organism resting in the mucous membrane between
the epithelial cells. Other slides demonstrated very
clearly the sporulation of the organism and the fecun-
dation of the female.
The Romanowsky method is the only one used in
staining specimens, and Professors Bastianelli and
Bignami consider it tlie only one whereby it is possi-
ble to demonstrate the structure of the malarial organ-
ism. As they use it, it is very simple, consuming lit-
tle time and yielding most excellent and certain
results. They had the same difficulty with it at first
that we have had in America, but they find no trouble
whatever if they use the medicinal methylene blue
and the eosin B (brom-eosin). The proper solutions
are;
I. Methylene-blue saturated solution ( 10 gni. methy-
lene blue added to 100 gm. of water) : keep for twenty-
four hours at a common temperature — near 20^ C. —
and filter. The filtration fluid is immediately ready
for use.
II. Eosin. I gm. of eosin I! lo 100 gm. of water;
filtration is not needed.
Staining; Add 2 cm. of the metliylene-blue solution
to 5 cm. of eosin solution; place in a proper glass,
and, the slide having been prepared in the usual way
and fixed in absolute alcohol for twenty-five minutes,
stain for from thirty minutes to one hour. It is use-
ful to employ the glass recommended by Lieman.
Professor Bastianelli says that by following these di-
rections one is sure to have good results with every
slide.
The laboratory boy here is popularly known as
" Romanowsky," from the amount of this stain he is
employed in making up, its preparation being entirely
left to him.
Stained in this way the chromatin elements stand
out clearly and sharply, excellently differentiated, and
the structure of the nucleus and its nucleolus (as Pro-
fessor Bastianelli considers it should be called) shows
as perfectly as could be desired for purposes of study.
There are abundant opportunities here for the study
of malaria in all its manifestations, both clinically
and in the laboratory, and ihe physicians and directors
of the laboratories are most hospitably inclined toward
students from all countries, particularly America.
The pernicious forms of the disease abound, and the
hospitals get a very large share of the neglected cases.
The peasants of the Campagna suffer most of all, as
is natural from their mode of life. A straw hut with-
out a floor except that afforded by Mother Earth, gen-
erally built on the lowest possible level for protection
in winter, is the abode of the average farmer or shep-
herd. They go through the summer with their regular
or irregular chills as the case may be, accepting them
as part of their lives. This goes on until the malarial
cachexia or a particularly heavy infection in their de-
bilitated condition makes it imperative to visit the
Sancto Bambino, who is the oldest physician in Rome
— being a wooden doll crowned at the Vatican, sup-
posedly possessed of wonderful power of healing.
When this treatment fails the patient is brought to
the hospital, and quinine and arsenic get their turn.
Quinine subcutaneously is the method generally ad-
hered to in Rome. It is rarely given by the mouth.
The results are excellent, even in the very bad cases,
but of course there is also plenty of opportunity to
study post-mortem the effects of the malarial infec-
tions in a country where the mosquito is rampant and
the average hvgienic conditions so bad as they are in
Italv.
THE STATIC INDUCED CURRENT AND DR.
ROCKWELL.
Sir: It is impossible to confine Dr. Rockwell with
logic or facts; cuttlefish-like, he scurries off in a cloud
of speculative verbiage. In your issue of December'
23d he volunteered an entirely gratuitous attack upon
me, my methods of treatment, my cases, deductions,
and inventions. In your issue of' January 6th, I per-
force answered his letter, ignoring, however, as trivial
everything except the one question of the invention of
the static induced current. On this point he had stated
that he had in his possession "an old book in which
is given both in description and illustrative detail what
is now called the static induced current." Now here
was a definite assertion. I challenged him to prove
it, and even went further and said that if he would
prove it, I would withdraw any claim to originality in
the invention I had ever made. But what is his reply?
We have it in your issue of January 20th. Not a scin-
tilla of proof of his position is brought forward: not a
word to substantiate his charge; not a line is quoted
from his ancient book. And simply because there is
not a word in this book to show that the ancients ever
knew of " what is now called the static induced cur-
rent." Having no proof to offer of his initial asser-
tion, he shifts his ground and claims that "the prin-
ciple upon which the whole subject is based '' is given
in these books. He changes his base from a specific
assertion to a glittering generality. "It needs but a
glance," he writes, "at these old illustrations to make
it evident that these more recent ones of Dr. Morton
ar€ in their essential characteristics absolutely the
same, and that from the arrangements represented by
these illustrations the spark-gap <y'//'/</ be so adjusted
as to produce the so-called static induced current with
the power to induce continuous muscular contractions."
I have underscored the word aviiJ. This single word
betrays Dr. Rockwell and all his sophistry.
And such is the specific reply which readers of the
Medical Ricord are asked to accept. " The ancients
could have produced the static induced current," It
takes patience 10 say, in reply to such childishness,
that no doubt they could "liave done so, but that they
February i 7, 1 900]
MEDICAL RECORD.
295
didn't do so. On lines of argument of tins sort, one
could prove that every discovery and invention is
ancient or has been anticipated by some one else. The
ancients had zinc and copper and sulphuricacid, and
water and receptacles, and they could have adjusted
these things so as to produce a galvanic current; but
they didn't, until Galvani and Volta did it. They
had frictional electric machines, and Leyden jars, and
sparks and spark-gaps, and even adjusted these parts
to give measured and graduated individual shocks one
by one to the patient, but they never used these parts
nor these adjustments to produce any sort of a cur-
rent. Of course the principle upon which the whole
subject is based. is in these books and in many techni-
cal books. I never said that it was not, nor that I
discovered it. But, utilizing the principle, I did dis-
cover and produce currents before unknown and unre-
corded. To make an invention or to discover some-
thing does not by any means require a very big jump.
Reiss invented the singing telephone, in which the
electrodes just failed to touch, and Bell by a turn of a
millionth' of an inch of a screw, thus bringing the
electrodes into actual and continuous contact, invented
the speaking telephone. Reiss didn't do quite enough,
little as what he failed to do was, and, similarly, the
ancient electricians might or could have invented or
discovered the static induced current, but they didn't.
According to my critic's line of argument, Reiss was
the inventor of the speaking telephone and not Bell.
The instrument and the adjustments, in short " the
principle upon which the whole subject was based,"
were there, but Reiss unfortunately failed to make his
instrument speak, just as my critic's. ancients had ma-
chines, spark-gaps, and "arrangements," but failed to
produce a static induced or any other current, and
made no mention of the subject of currents. These
ancient w-riters on electricity described every effect
of their administrations and discoveries with the min-
utest detail. One is constantly surprised at the ac-
curacy of their descriptions. Is it to be supposed for
an instant that an effect like the static induced current,
so different from anything they do record, would not
have been recorded ? It is incredible. But, incredible
or not, they didn't record it, and that ends honest and
sane discussion. For what the ancients might have
done or could have done does not concern us. They
might have invented all the coming inventions of the
twentieth century; but we know they didn't. Dr.
Rockwell would have us believe that they universally
and by a sort of conspiracy refrained from describing
a thing so salient as a tetanizing effect upon a mus-
cle, and a method and the current which produced this
effect.
Now a word more to my assailant, since he says I
" divert attention from the main points of contention."
First, " he " (the writer) " has persistently exploited
his own originality at the expense of the originality
of others." As to the originality of others, this is
what I am still waiting to hear about from Dr. Rock-
well. Practically no one disputes my humble claims.
-Is for persistence, it is indeed a pity to fight persist-
ently for one's own. In this respect, I am reminded
of the doggerel :
" It is a very good world to live in.
To lend, or to spend, or to give in ;
But to beg, or to borrow, or to get a man's own.
It is the very worst world that ever was known."
Second, and finally, "he" (the present writer)
"makes extravagant and utterly unjustifiable thera-
peutic claims." All I can say to that is that it is a
matter of opinion, and furthermore, that I do not agree
with my very amiable critic. He reminds me of an
anecdote. After the entire Copernican and Newton-
ian philosophy of the rotation of the earth around the
sun had been explained to Brother Jasper, he walked
off, we are told, triumphantly remarking, " But, after
all, the sun do move.'' Now, to tell the truth, I never
did expect to have Brother Rockwell understand what
I write. Perhaps there are more things in heaven and
earth, and, say, in electro-therapeutics, than Brother
Rockwell's philosophy dreams of.
U'lLLiAM J. Morton, M.D.
New Vouk, January 27, 19)0.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From Our Special CorrespondenlJ
When the attempt of Sir Redvers Buller's relieving
force to get to Ladysmith by turning the right flank of
the Boers, or by carrying their intrenchments on that
side, failed, after the previous failure of the point-
blank attack at Colenso, it became at once apparent
that the plight of Ladysmith was very serious. Even
before this reaches you, it is possible that the be-
leaguered city may have fallen. If Sir George White
is forced to capitulate, the blow to the English empire
will be comparable only to that sustained a hundred
and twenty years ago (or so) by the fall of Yorktown,
and there are some who think that the consequences
will be no less far-reaching. The present population
of Ladysmith is over ten thousand ; there are a good
many women and children, and a very large number
of horses, and the accommodation generally is unfitted
for such numbers. The water supply is imperfect
though not actually scanty, and it is generally be-
lieved that, if the city has to surrender, it will be be-
cause of the ravages of typhoid fever, and not because
either of scantiness of supplies or ammunition or loss
of courage. By the third week in January the fatal
cases of typhoid fever amounted to ten per diem, and
although this figure afterward abated a little, every
day of confinement, under circumstances of such bitter
chagrin and apprehension as the garrison are now un-
dergoing, must tell against their nwraL' and render
them less able to resist the attacks of disease. If the
city is to be saved, it must be saved soon.
A New Hospital Ship. — Up to the end of the
second week in January, two thousand men of all
ranks, officers, non-commissioned officers, and pri-
vates, had been admitted to the two big general hospi-
tals at W'ynberg. With the unfortunate turn for Brit-
ish interests that affairs have so far taken, it became
clear that'another hospital ship would be wanted, and
one of the transport vessels belonging to Sir Donald
Currie's line, the Lismore Castle, was chosen for- con-
version. The tonnage of the Lismore Castle is 4,000,
and now that she is a hospital ship, she can accom-
modate two hundred and fifty sick. On the main deck
are situated an officers' ward, an orderly room, an
operating-theatre, fifteen convalescent officers' cabins,
a dining-saloon, and three bath-rooms. On the lower
deck there is accommodation in four wards for two
hundred and twenty-five men. Each ward runs from
side to side of the ship, and is ventilated by elec-
tric fans. The cost of this complete conversion of
a mail steamer employed as a transport into a hos-
pital ship was considerable, and the work was done
by the admiralty at Durban, with some civilian as-
sistance, in four and a half days. The new hospital
ship is under the command of Dr. Brodie, a civil
surgeon, who is assisted by three other civil surgeons —
for the supply of officers of the Royal Army Medical
Corps has run short — and who has under him one
army nursing-sister, four civilian nurses, thirty civilian
male medical attendants, two dispensers, and one ser-
geant with nine privates to be used as fatigue men or
guards.
296
MEDICAL RECORD.
[February 17, 1900
Some Remarkable Recoveries.— The list of re-
markable recoveries from injuries, which by all the
accepted canons of surgery should have been fatal, is
very large; indeed it is becoming abundantly evident
that at one thousand yards the modern rifle bullet
makes a wound that is serious only if the most vital
structures are perforated, and not always then. The
wounds of entrance and exit are small, and the track
is marked by none of the rending, splintering, and
crushing that were wont to make of the old bullet
wound so serious an affair. Accounts have been
given of the following extraordinary recoveries, and
they 'are only a tvpe of otJiers every whit as wonder-
ful:
A man was shot below the left clavicle. The bullet
emerged two and one-half inches above the angle of
the left scapula, i.e., at the level of the ninth rib.
After some hemorrhage, there was an empyema, but
the patient recovered.
A man was shot from behind through the right
sacro-iliac synchondrosis. The bullet emerged half-
way between the anterior superior spine of the ilium
and the ninth costal cartilage, wounding the cfECuni
in two places. There was extravasation of faices, but
the patient recovered.
A man was shot one inch above the right clavicle in
the line of the posterior border of the sterno-mastoid
muscle. The bullet emerged at the corresponding
spot on the left side. He could not swallow or speak
when picked up, but gradually his symptoms subsided,
and no complication ensued.
A man was shot an inch to the right, and the same
distance above the symphysis pubis. The bullet
emerged through the right buttock two and one-half
inches external to the anus. He ran one-third of a
mile, completing a long charge, after being wounded,
and recovered without any serious symptoms.
A man was shot half an inch external to the poste-
rior superior spine of the left ilium. The bullet
traversed the stomach, and emerged at the ensiform
cartilage. The wound healed by first intention.
A man was shot in the right side of the nape of the
neck, at the level of the third cervical spine. The
bullet emerged at the inner canthus of the left eye,
loose portions of ethmoid being picked out of the
wound. He recovered without symptoms.
These are only specimens of the cases among both
the Boers and the British, which have been recorded
by Sir William MacCormac and Mr. Treves, whose
respective letters in the T/ie Lancet and British Aledi-
eal Journal have done great work in restoring in Eng-
land the full confidence in the work of the Royal
Army Medical Corps which the supercilious attitude
and parsimonious behavior of the War Office toward
that branch of the service had done so much to de-
stroy. At the present time, the R. A. M. C. is practi-
cally the only department of the British army against
which serious charges of failure cannot be levelled.
The Heroism of a Member of the R. A. M. C—
.A.fter the battle of Colenso — the first unfortunate at-
tempt to relieve Ladysmith — an officer of the Royal
Army Medical Corps, Major Babtie, distinguished
himself by a feat of courage and daring which it is to
be hoped will be recognized by the military authorities.
The R. .\. M. C. already possess more Victoria
Crosses than any other branch of the service, and it
now seems possible that Major Babtie's name will be
added to the list of holders of this much-coveted
honor. During the thickest of the fight Major Babtie
rode into the donga — the dried-up watercourse in
which the British losses were most severe, and where
Colonel Long's guns had to be abandoned — and re-
mained with tlie wounded through a liail of bullets,
doing what he could for them. Among others whom
he attended under these terrible circumstances was
Lieutenant the Honorable Frederick Roberts, the only
son of Lord Roberts, V.C., the commander-in-chief of
the British army in South Africa. Major Babtie's
horse was killed under him, but he remained in the
donga until firing ceased, doling out minim doses of
water from his water bottle, and rendering such first
aid as was possible. It was extremely sad that Lieu-
tenant Roberts' life could not be saved, but he was
shot in the forearm, wounded in the knee by a shell,
and had in addition a perforating wound of the abdo-
men. When Major Babtie brought him back, he was
pulseless, and died without rallying. He had behaved
with conspicuous gallantry throughout the engagement,
and had been recommended for the Victoria Cross, a
decoration which his distinguished father gained in
1858.
OUR LONDON LETTER.
(From our Special Correspondent.)
INFLUENZA — ^OPHTHALMOPLEGIA IN TABES AND IN
graves' disease — TETANUS TOXIN — PAROXYSMAL
H.EMOGLOBINURIA — MALIGNANT GROWTHS OF THY-
ROID— ARTHRECTOMY OF KNEE — DUBLIN MORTALITY
SALVATION ARMY SHELTERS.
London, January ig, 1900.
Influenza has made a further advance all along the
line. The deaths from the epidemic reported last
week rose to 340. The deaths from all respiratory
diseases, which I last week said had risen to 1,221,
fell to 994, but that is 260 above the average for the
decade. Of course with so many fatal cases the num-
ber of mild ones and even severe ones that result in
recovery is enormous, and the widespread sickness
keeps the doctors very busy. Many are themselves
victims. London's total mortality last week was
2,930, being 642 above the average of ten years. The
deaths exceeded the births by 164. The epidemic
seems to have swept our island almost from south to
north. In some of the southern towns it is already
abating, and we are hoping London has seen the worst.
The following death rates for the last two weeks are
significant: Birmingham, 27.0, 33.6; Brighton, 44.9,
28.6; Croydon, 40.5, 37.4; Liverpool, 34.4, 34.6;
Norwich, 32.7, 43.6; Nottingham, 40.8, 44.9.
Ophthalmoplegia often has a certain association
with tabes; at any rate it has frequently been observed
to precede ataxia. Such cases naturally come first
under the notice of oculists, and may subside long be-
fore signs of tabes appear. Dr. Guthrie related a case
at the Harveian Society which he had had under ob-
servation some six months. At first there was doubt
as to the diagnosis, but at length it became obvious.
Mr. Juler, president, and Dr. James Taylor agreed
as to the frequency of ocular paralysis in early tabes.
The paralysis is usually transitory and the knee jerks
still present.
Cases of ocular paralysis occurring in Graves' dis-
ease.have been recorded by several observers, and Bal-
let's monograph on the subject makes three groups,
viz., ophthalmoplegia with Graves' disease; with
hysteria; with both Graves' disease and hysteria. A
case observed by Dr. Warner was related at the Medico-
Chirurgical Society on the 9th inst., and reference
was made to another case brought forward in 1882, the
sequel of which is given in Bristowe's "Diseases of
the Nervous System."
Mr. James Berry said he thought hysteria played a
very important part in these cases, and made some
interesting remarks on the pathology of Graves' dis-
ease. He held the theory of its sympathetic origin
to be entirely erroneous, and pointed out that experi-
ments on animals in this domain must be very falla-
cious. One advocate of division of the sympathetic
February 'i 7, 1 900]
MEDICAL RECORD.
297
had said he would only employ it when the cornea
was in danger of sloughing, but there was one case in
which it had sloughed after the operation. There
were still men who believed exophthalmos to be due
to dilatation of blood-vessels behind the globe; but
the conjunctiva was not more vascular than normal,
which it is whenever congestion of the orbit can be
proved to be present.
Mr. Foulerton and Dr. Campbell Thomson commu-
nicated to the Medico-Chirurgical Society at the last
meeting the results of an investigation into the nature
of the changes in the nerve cells of the cortex produced
by the tetanus toxin. They had carried out a number
of experiments in which the cerebral cortex was exam-
ined after the inoculation of tetanus toxin in rabbits,
guinea-pigs, and mice, the doses being varied and the
animals killed at different periods after inoculation.
Certain definite histological changes had been found
in the motor cells, though the appearances varied
somewhat with differences as to dose and time. The
research had been conducted more particularly with
reference to the nerve cells of the motor area of the
cerebrum, but evidence had been obtained that simi-
lar changes occurred in cells of other portions of the
cerebral cortex and also in the cerebellar cortex. The
changes were readily distinguished from those pro-
duced by other bacterial toxins, and the motor dis-
turbance in tetanus seemed to be due to these changes;
so that the incubation period must be regarded as the
time required for sufficient toxin to be taken up by
the blood and fixed in the cell substance.
Mr. Foulerton in reply to questions said every care
had been taken to exclude fallacy from post-mortem
changes or those which might arise from pyrexia. As
to the latter point, the temperature, taken three times
daily, had never risen more than 1.5° F.
A case of paroxysmal hsemoglobinuria in a girl,
aged six years, was shown at the Clinical Society by
Mr. Lunn. She was the tenth of twenty-four children,
of whom fourteen are living. From the age of one
year she had at intervals passed urine containing
normal red cells. The proportion of red to white in her
blood is about half normal. A sister had interstitial
keratitis.
Mr. Spencer referred to a case in a boy he had for-
merly shown, and remarked that in early life many
such cases ended in uremia or apoplexy.
Dr. Voelcker said that, as in this case, there was usu-
ally evidence of inherited syphilis. In one case he
had found a history of acquired syphilis. He had
noticed an undue tendency to cohesion of the red
corpuscles, forming snake-like coils, the corpuscles
themselves being elongated, lemon-shaped. Dr. Suth-
erland remarked that paroxysmal hfEmoglobinuria and
albuminuria had been observed to alternate. Excess
of oxalates was often present and persisted some time
after the haemoglobinuria had ceased.
Mr. Lunn said oxalates had been noted in his case,
but the intermediate urine seemed normal. He added
that the girl usually had a rise of temperature with
chill and collapse when an attack was imminent.
Her health seemed good between the attacks.
Among other interesting cases shown at the same
meeting was one of malignant growth of thyroid in a
woman aged fifty-eight years, supervening after nine
years' enlargement which had necessitated two opera-
tions on account of pressure on the windpipe. Mr.
Barker remarked on this that malignant growths of
the thyroid were usually very chronic; one of his had
lasted eighteen years. Mr. Symons said one of his
lasted over ten years, but another only twelve months.
Mr. Eve showed a girl, aged thirteen years, on whom
he had performed arthrectomy of the knee for tubercu-
lous disease. The semilunar cartilages were removed
and one crucial ligament had to be divided, but was
afterward refixed to the bone. The lower end of the
condyle, being ulcerated, was scraped. The result was
free movement almost to a right angle. Mr. Eve was
congratulated on this. He admitted the case was sub-
acute, and when there were much ulceration and casea-
tion he would not attempt so much. He hoped to show
the patient again later on.
The death-rate of Dublin has lately been so high
that the lord-lieutenant proposes to hold an inquiry
into its cause by a committee on which the local gov-
ernment board, the College of Physicians and Sur-
geons, and the corporation of the city shall have repre-
senlati\'es. The Medkal Pnss and Circular has called
attention to the high mortality again and again, attrib-
uting it largely to a disgraceful condition of the poor-
est tenements, and urging the corporation to provide
improved dwellings on sites said to be obtainable at
low prices.
The Queen's Bench has given a decision on a case
stated by the chief London magistrate, which will
bring the Salvation Army shelters under sanitary su-
pervision. No doubt the night shelters have been a
benefit to some of the poorest, and no one imputes any
but good motives to General Booth and his followers.
But very few will defend him for engaging in obstruc-
tive litigation for the sake of defying the sanitary au-
thorities. It was a gross blunder in tactics, and there
was no justification for thus using the funds of the
army. The shelters will now come under the common
lodging-house acts.
SMALLPOX IN THE PHILIPPINES.
To THE Editor of the Medical Record.
Sir : Although I only see a medical journal here oc-
casionally, I have been struck with the widespread
occurrence of variola throughout the United States
during the last year, and it seems to me that our rela-
tions with these islands have probably had something
to do with its spread. Smallpox may be truly said to
be universal here among all classes of natives, as is
attested by the fact that nearly every one is more or
less pockmarked. I doubt if many natives reach the
adult age without having had an attack. So common
is it that the people take it as a matter of course and
make no effort to guard against it in any way. Now,
these people have their own looms in their homes, and
they manufacture many varieties of fine " Josi " and
" Pina " cloth, which are much sought after by Ameri-
can soldiers as souvenirs, and by them sent through
the mails to their friends. When it is borne in mind
that ten to twelve natives often live, sleep, and eat,
and manufacture and store cloth all in one small, dirty
room, the result is obvious; their cases of smallpox,
leprosy, or any other illness are never isolated in the
slightest degree. To illustrate, I recently had personal
knowledge of the following incident: A native wo-
man who had been in the habit of bringing specimens
of " Josi " to the home of an officer for sale failed for
a little while to come with her usual regularity; after
a few days she did return, and when questioned as to
her absence casually explained that she had been too
busy with several cases of smallpox in her family!
She, however, brought a goodly supply of "Josi " from
the infected room ! Besides this source of infection, the
thousands of returning soldiers have all brought vv'ith
them and scattered over the country souvenirs of one
sort or another taken from these same places.
Charles F. Mason, M.D.,
Major attd Surgeon L'.S.V.
Iloilo, Panav, p. I., December 25, 1899.
Empyema of Tuberculous Origin, or from lung
abscesses, is benefited by a surgical operation only to
the extent of temporary relief. — Samuel C. Benedict.
298
MEDICAL RECORD.
[February 17, 1900
J«ocietij ^vcparts.
NEW
YORK COUNTY MEDICAL ASSOCIA-
TION.
Stated Meeting, January ij, igoo.
Frederick Holme Wiggin, M.D., President.
Secondary Osteoplasty. — Dr. Thomas H. Manley
presented a patient illustrating what might be accom-
plished in some severe and complicated fractures by
secondary osteoplasty. About fourteen months ago
this man had been knocked down by a broken belt,
and had sustained a fracture of the ulna in its upper
third, and a dislocation of the head of the radius on
to the acromion process. He had been treated at a
hospital by an eminent surgeon for five or six weeks,
and then had been treated as an out-patient for some
time longer. The arm had remained practically use-
less, being insensible, cold, and wasted, and the fingers
contracted rigidly so as to make a claw-shaped hand.
Rather curiously he had been advised not to submit
to further operation. He had, however, come to the
speaker in the hope that a better functional result
could be secured. This was two months ago. Dr.
Manley had laid open the injured region and had re-
sected the head of the radius, thus securing pronation
and supination. The median nerve had been greatly
reduced in size as a result of the compression to
which it had been subjected. Within two weeks the
man had been out of bed. Sensation had returned
quickly, and mobility had rapidly increased.
Gangrenous Perforation of the Sigmoid Flexure.
— Dr. Manley tlien presented a specimen removed
from a man who had entered the Harlem Hospital
with a history of having, in apparently good health,
been suddenly seized with severe abdominal cramps,
especially violent in the left iliac fossa. An enema
had been returned with almost no result. On admis-
sion to hospital the same evening the man had been in
a condition of profound collapse, and the abdomen
greatly distended. On percussion, there was greater
flatness in the left iliac region. A large oil enema
had failed to move the bowel. He had then performed
abdominal section, and at once a large quantity of
soapsuds and sweet oil had gushed out. Kxaminatiorr
showed a gangrenous perforation of the sigmoid flex-
ure.
Large Omental Hernia. — Dr. Manley also pre-
sented a portion of omentum weighing twenty-seven
ounces that he had removed in an operation upon an
omental hernia. Three weeks before coming under
observation, while lifting a barrel of beer, the patient
had felt something give way, and had then become
conscious of an enlargement along the course of the
inguinal canal. The operator opened up the inguinal
canal throughout 'its whole extent, and, after dragging
out tiie mass of omentum, had divided it slowly, se-
curing each vessel as it was cut. He had firmly fixed
the stump at the external ring in order to secure good
control of the parts in case of hemorrhage, and in the
event of infection to make it extraperitoneal. The
man had made a rapid recovery.
Fibroid Uterus. — Dr. Frederick Holme Wiggin
presented a fibroid uterus which he had removed a few
hours before by the intraperitoneal method.
A New Method of Retroperitoneal Drainage of
Pyosalpinx, with a Report of Five Cases Dr.
Leon F. Garrigues read a paper with this title. He
expressed the belief that all pelvic suppuration should
be drained through the vagina, vaginal drainage itself
being almost free from danger to life. As a rule,
after vaginal incision in cases of pyosalpinx the tem-
perature dropped to normal, the pain ceased, and con-
valescence was rapid. On the other hand, after lapa-
ratomy in these cases there were often considerable
shock and pain for a long period, and the patient
remained in bed at least a month. It was not uncom-
mon for a woman to be an invalid for the greater part
of a year after such an operation. Then there was the
danger of ventral hernia. It seemed to him irrational
to ligate and excise a tube when the part left might
contain virulent bacteria. Under such circumstances
the patient might be worse after than before operation.
Howard Kelly and others had advised puncture of the
abscess and packing the cavity with iodoform gauze.
This technique seemed to him faulty because he
had seen serious hemorrhage follow this procedure.
Moreover, the gauze packing was not only painful,
but being compressed it failed to drain the cavity
properly. It should not be forgotten that about half
of all cases of pyosalpinx operated upon were found
to contain virulent tacilli in the tube.
The Technique. — The technique recommended was
as follows: An incision was made at the anterior
vaginal junction, beginning behind the transverse line
drawn through the cervical canal on the side corre-
sponding to the pyosalpinx, and following the contour
of the cervix for three-fourths of an inch. This inci-
sion extended through the thickness of the vaginal
wall. The forefinger of the operator was next intro-
duced through the opening and pushed upward. The
peritoneum usually stripped readily from the uterus,
and it should be stripped off gently until the origin of
the Fallopian tube was reached. The tube should be
opened at this point only if it was the prominent part
of the sac. While an assistant pressed down from
above, blunt scissors should be pushed into the pyo-
salpinx. With the finger a thorough exploration
should be made, and then a T-shaped rubber drainage
tube was to be inserted. The abscess should not be
irrigated at the time of the operation for fear of a
minute opening being made, and infectious matter be
carried into the peritoneal cavity. As a preliminary
step all cases were curetted. In all of the five cases
reported the patients had been out of bed within a
week after operation, and all had recovered completely.
Four out of the five had been operated Uj^ion in tene-
ment houses, and had received only unskilled nursing.
This method of retroperitoneal drainage was not diffi-
cult of performance.
Another Method Preferred.— Dr. Riddle Goffe
said that he was a persistent advocate of the vaginal
route in attacking pelvic disease, and belie\'e(i that
no one was justified in doing a laparatomy until the
effort had been first made to reach tiie disease within
the pelvis by the vaginal route. He had never tried
the method advocated in the paper, and could not
speak of it critically imtil he had studied the details
of the histories reported. He objected strongly to
the opening up of the broad ligament for the purpose
of reaching pus in the pelvis. This was a layer of
cellular tissue unusually rich in lymphatic vessels, and
there was danger of opening up a cavity filled with viru-
lent pus and infecting this area. He was also opposed
to the method described, for the reason that it was a
temporizing measure. In cases of this kind a woman
should not be subjected to more than one operation to
effect a cure. It seemed to him preferable to open
the pelvic cavity freely and ascertain the extent of the
disease, and then radically treat it. His own method
was to open freely into Douglas' pouch, and carefully
explore tlie region. Later on he opened the anterior
portion of the vagina, and brought down the uterus
and its appendages through this vaginal incision. If
the abscess was large it was necessary to puncture it
and drain the cavity before delivering the uterus and
its appendages in this way tiirough the anterior fornix.
February i 7, 1 900]
MEDICAL RECORD.
299
Previous to doing this tlie peritoneal cavity should be
protected from infection by proper gauze packing.
He never removed the appendages of both sides when
it was possible to leave even a small fragment of one
ovary. By leaving such a portion behind, the woman
was relieved from many unpleasant nervous disturb-
ances.
Dr. J. E. Janvrin said that his own practice had
been to make a puncture through the posterior cul-de-
sac, inserting a tube, and securing free drainage. He
did not think that, as a rule, there was much danger
of peritonitis from such an operation, and in the ma-
jority of cases it would effect a cure. The objections
to Dr. Garrigues' technique made by the last speaker
seemed to him important and valid, though he had
not had any personal experience with the method. It
seemed to him that the danger of such method was
fully as great as from making the posterior opening.
The method recommended by Dr. Gofife was certainly
radical and thoroughly successful, as he could testify
from personal observation. He did not feel disposed
to criticise Dr. Garrigues' method until he had had an
opportunity to observe its workings personally.
Dr. H. J. BoLDT said that he too had had no ex-
perience with the method described in the paper, hav-
ing been in the habit of employing the posterior in-
cision. It seemed to him extremely difficult, if not
impossible, to remove a pjosalpinx located high up
in the pelvis in the manner described by the reader
of the paper. One trouble was that these abscesses
were usually sacculated; another was that the Fallo-
pian tube was not very greatly enlarged in many
cases, so that much difficulty would be experienced in
opening and draining the tube. His own practice
had been to open up the cul-de-sac widely enough to
admit the hand, and so be sure that he was actually
dealing with the Fallopian tube, and not with another
collection of pus in the pelvic cavity.
Dr. Garrigues said that the objections made to his
method seemed to him rather theoretical than practi-
cal. In every case the temperature had dropped to
normal within a few days, and hence there was no
reason to believe that the lymphatics had absorbed
the poison. He had been using this technique for
the past two years, and could speak confidently re-
garding the radical cure etifected in at least two of the
most difficult and severe cases. He made it a rule to
explore the region with the finger to be sure that every
portion was drained. All the cases in which he had
operated in this way had been large pus tubes, and he
could not say how the procedure would succeed when
the tubes were quite small.
Strangulated Hernia ; Some Practical Remarks
Concerning its Diagnosis and its Proper Manage-
ment.— Dr. Parker Syms read this paper. He said
that the arrangetnent of the vascular system of the in-
testine was such that strangulation of only a small
portion of the intestine led to the derangement of the
blood supply to the whole bowel. The symptoms of
strangulation were those of acute intestinal obstruc-
tion, and in no way resembled those of ordinary con-
stipation. The more prominent symptoms were pain,
tenderness, vomiting, obstipation, tympanites, local
changes, disturbance of the pulse and temperature,
a peculiar facial expression and mental condition.
The pain usually radiated at first from the umbilicus,
but afterward became general. Tenderness was ac-
companied by pain, and both continued until re-
duction had been accomplished, or gangrene had
occurred. Sudden cessation of pain and tenderness
without reduction of the hernia betokened gangrene.
The vomiting was at first reflex; later on it became
projectile, and was the result of obstruction of the
intestine and interference with the waves of peristal-
sis. Obstipation was present from first to last. The
tympanites increased until relief had been obtained.
The local symptoms, aside from those of hernia, were
those of acute inflammation, to which were added
loss of impulse on coughing and loss of tympanitic
resonance. The pulse became rapid, irregular, weak,
and thready. The temperature was often subnormal
from shock. When systemic infection took place the
temperature was elevated. The facial expression was
the drawn and pinched appearance characteristic of
abdominal injury, and known as the Hippocratic face.
The capillary circulation was always disturbed, as
evidenced by pallor and slight cyanosis of the extrem-
ities. Shock was always present to a greater or less
degree, and was an important clew to the correct diag-
nosis. Hiccough might come on at any time, or might
be absent altogether. Strangulated hernia unrelieved
always proved fatal; on the other hand, its early re-
cognition and proper treatment almost always resulted
in saving life.
Treatment Sometimes cold was applied to the
part, the pelvis being elevated and food withheld for
a short time in the hope that spontaneous reduction
might take place; but this seldom occurred. The
large mortality recorded against the surgery of
strangulated hernia was entirely owing to the use of
prolonged taxis, and the postponement of operation
until a late stage. In no case could taxis be looked
upon as free from danger, no matter how gentle the
manipulations, and it should be unreservedly con-
demned. When the vomiting was persistent and
severe, local anaesthesia was needed. It was his rule
to administer a full dose of morphine and one ounce
of whiskey, and then use cocaine locally in weak solu-
tion. After having made a free incision down to the
sac, the dissection must be carried on cautiously.
Having opened the hernial sac, the constricting band
should be sought with the finger, and with this as a
guide the point should be fully divided. In all
cases the bowel was dark and ecchymotic, necessitat-
ing the exercise of good judgment in determining
whether or not the vitality of the intestine had been
impaired beyond repair. Careful search should also
be made for any perforation. The intestine should
not be returned to the abdomen until the surgeon
had satisfied himself that no other point of constric-
tion remained, and that the intestine was not gangre-
nous. If the condition of the patient permitted a
prolongation of the operation, the radical cure of the
hernia should be attempted. If the intestine was
gangrenous, and the condition of the patient was very
bad, an artificial anus should be established; if, how-
ever, the patient's strength was fair, it was better to
make an end-to-end anastomosis.
Diagnosis of Strangulated Hernia.^ — Dr. Henry
Roth opened the discussion by a consideration of
this topic. He said that the interference with the
blood supply accounted for the tension, irreducibility,
pain, tenderness, dulness on percussion, and the ab-
sence of impulse on coughing. The cardinal symp-
toms were those of shock or collapse, and were very
similar to those of any acute intra-abdominal disease
or injury. The pain was referred to the hernia or to
the umbilical region. It was colicky in nature, and
was due to injury of the peritoneum, distention of the
intestine, and active peristalsis. Vomiting was fre-
quent, but afforded no relief, and soon gave rise to
intense thirst. From* the very onset there was com-
plete constipation, as a result of reflex paralysis of the
intestine. Indol, not being discharged from the in-
testinal canal, was changed into • indican, and was
found in the urine. The urine was diminished be-
cause of the low arterial pressure resulting from irri-
tation of the abdominal plexus of nerves. The pres-
ence of tension and the absence of impulse were
characteristic of strangulated hernia, and were not
MEDICAL RECORD.
[February i 7, 1 900
found in simple obstructed and irreducible or inflamed
herniae. An inflamed hernia was tender and painful,
and presented the signs of a local inflammation.
While there was a rise of temperature, as a rule there
were little or no vomiting and none of the signs of
collapse so ob\ ious in strangulated hernia.
Treatment of Strangulated Hernia. — Dr. John
F. Erdmann said that modern surgery had made the
treatment of strangulated hernia at the present day a
simple matter. He did not practise taxis for more
than a few minutes, and not at all if it had been tried
by others previously, or if a hard mass could be felt
at the seat of obstruction. Half an hour before try-
ing taxis he was accustomed to give a full dose of
morphine, and to apply heat over the hernia. In his
opinion, heat was more relaxing than cold. The sur-
geon should always obtain permission to operate at
once if taxis failed. His experience had taught him
to discard general ancesthesia, and rely entirely on the
local anajsthesia produced by a one- or two-per-cent.
solution of eucaine. Should the condition of the gut
after relief of the strangulation be questionable, and
the patient be not too feeble, hot towels should be ap-
plied to the bowel, and efforts made to restore the cir-
culation for half an hour before deciding upon return-
ing the bowel to the abdomen. An end-to-end
anastomosis was preferable if the bowel was gan-
grenous, and the patient in fair condition. Whenever
possible a radical cure should be performed.
Radical Cure in Operations for Strangulated Her-
nia.— Dr. Irving S. H.'Wnes discussed this part of
the subject. The sac, he said, should be carefully
isolated from the spermatic cord. This should be
easy if the sac was an acquired one; it would be
more difficult if the hernia was congenital. Tearing
a slit in the sac, even though it extended into the ab-
domen, need cause no apprehension, for it could be
easily closed by suture. Having exposed the canal,
traction should be made on the sac, the peritoneum
around the ring loosened, and the sac ligated and cut
away. He was opposed to retaining the sac because
such a pad, instead of preventing recurrence of the
hernia, woidd actually invite this very complication.
The more closely the construction of the normal body
could be imitated, the more lasting would be the re-
sult. All the veins but one or two should be removed
with an excess of loose tissue. In children the in-
ternal ring was nearly behind the external ring. If a
hernia was present the infantile condition would be
found; therefore the inguinal canal must be recon-
structed. The first step in this direction had been
taken in the preliminary division of the internal ob-
lique and transversalis muscles, and the transversalis
fascia. The sutures should be applied from without
inward behind the cord, about half an inch apart, and
should be of chromicized catgut. The first suture
was the most important; it should be placed close
enough to the cord so that when tied the fibres of the
fascia would hug the cord tightly, but not obstruct the
circulation in it. IJassini's operation, in his opinion,
was improved by constructing an internal ring. Silk-
worm gut and silver wire were the most objectionable
materials, he thought, for sutures in these cases. Too
much handling of the tissue, failure to remove masses
of fat, and failure to check oozing were common
causes of a poor result.
Femoral Hernia. — There wel-e greater natural diffi-
culties attendant upon operating on femoral hernia.
Theoretically one had only to bring the inner end of
Poupart's ligament down to the horizontal ramus of
the pubic bone and fasten it there, but, no matter
how skilfully this was done, there remained alongside
the obliterated ring and canal large veins which could
not be greatly compressed. This led to an inherent
structural weakness. The sac should be separated
from the surrounding parts, a ligature applied as high
as possible, and the sac removed. Interrupted sutures
of chromic gut, No. 2, should be used, and they should
be applied from the vein inward.
Truss Management of Hernia. — Dr. William B.
De Garmo took up this subject. He stated that the
profession had unfortunately been very negligent re-
garding the prescribing and application of trusses.
Patients who could wear light trusses, and whose
hernia; never protruded under such support, were safe
under such management; in those cases presenting
occasional symptoms of strangulation, or when the
patient was careless about keeping on the truss, opera-
tion was certainly indicated. He believed the opera-
tion for the radical cure should be done in almost
every case of strangulated hernia. The post-operative
treatment of such a case, in his practice, consisted
simply in the use of a bandage for four or five weeks,
and then dismissing the patient from observation.
This showed his great confidence in the present
method of operating for the radical cure of hernia.
The author of the paper had very justly spoken
against taxis; nevertheless, many would persist in
employing it. In this connection he desired to say
that, in performing taxis, instead of trying to put the
hernia back, the effort of the surgeon should be to
draw it further down. This did not imply the use of
any violence, but if this little procedure was tried re-
duction would follow in many cases.
Age No Bar to Operation. — Dr. Charles N. Dowd
opened the general discussion. He said that in glanc-
ing over the literature of this subject one could not
fail to be impressed with the disastrous results attend-
ing delay in operating. This error was so common
and so flagrant that it was a source of astonishment.
Regarding the age of the patient, the speaker said
that this was no bar to prompt operation. Recently
he had seen a man, seventy-five years old, in a very
feeble condition, and suffering from a strangulated
hernia. When first seen there had been no constitu-
tional disturbance, simply a painful and tender lump
near Poupart's ligament. Exploratory incision was
not permitted until the next morning, and then, on
cutting down upon this mass under cocaine anaesthesia,
a strangulated femoral hernia had been disclosed, and
the constriction had been easily relieved. The opera-
tion for radical cure had then been done. This man,
in his very feeble state, could not possibly have sur-
vived strangulation many hours. Dr. Dowd said that
he had also operated easily and successfully for
strangulated hernia on two infants, one four and the
other six months old. These little ones had stood
the operation just as well as adults.
The Operation Very Simple. — Physicians often
hesitated to operate on a strangulated hernia, because
they had a vivid recollection of the difficulties experi-
enced as medical students in grasping the anatomy of
hernia. This was unfortunate, for the operation was
simple. The chief point to remember was to cut
down to the aponeurosis of the external oblique mus-
cle, and divide this tissue above the strangulation.
Dr. Lucius W.. Hotchkiss indorsed what had been
said by the last speaker regarding the comparative
safety and simplicity of the operation if done at an
early stage of the strangulation, and even at the ex-
tremes of life. He had himself operated for strangu-
lated hernia upon a lady aged eighty-one years, and
under full ana-sthesia, with a perfectly satisfactory re-
sult. He had had equally good success in operating
upon infants. There should be no delay in resorting
to operation, except in those cases in which the diag
nosis was in doubt, and in which, owing to the pecul
iar variety of the hernia, it was difficult to clear it up
When such uncertainty existed, it was well to remem
ber that it was safer to operate than to wait and wonder
February 17, 1900]
MEDICAL RECORD.
Dr. Syms, in closing the discussion, said that while
it was true that in a few exceptional cases taxis had
succeeded, this result occurred so very rarely, and the
usual consequences of taxis were so disastrous, that it
seemed to him that the only safe rule was to discard
taxis altogether.
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, December ij, i8gg.
W. H. Park, M.D., Vice-President, in the Chair.
A Case of Elephantiasis of Both Ears. — Dr. J. H.
Larkin presented for Dr. Hodenpyl the specimens
and photographs from a case of elephantiasis of the
lobes of both ears, apparently produced by the irrita-
tion arising from the w'earing of earrings. The re-
moved portion measured 1.4 by 4 by 2 cm., and it had
been taken from a lady aged thirty-seven years who
was in good health. She stated that they had been
enlarging for the past year and a half. Microscopical
examination showed hyperplasia and a moderate exu-
date in the neighborhood of the blood-vessels. The
speaker said that while elephantiasis of the lobes of
the ears from wearing earrings was not unusual, the
increase in size in this instance had been excessive.
Papilloma of the Larynx ; Suffocation. — Dr.
James Ewing presented the larynx taken from a
woman, forty years of age, who had apparently been in
good health until about ten days before death, when
she had begun to suffer from very severe dyspnoea.
She had been seen at the dispensary of Bellevue Hos-
pital, and it had been noted that the obstruction to
breathing was extreme. The woman had been ad-
mitted to the medical side of the hospital, but no
definite diagnosis had been made. The peculiar
character of the dyspnoea had led one of the house
staff to suspect obstruction in the trachea. The laryn-
goscopic examination was negative, but had to be per-
formed under difficulties. She had died in a few
hours. The autopsy had shown the organs normal
with the exception of an extensive chronic diffuse
nephritis. On opening the larynx, just below the
vocal cords was to be seen a gray and apparently
necrotic mass, about 2 by 3 cm., attaclied by a small
pedicle to the mucous membrane below the right ven-
tricle posteriorly, and lying somewhat loose in the
cavity of the larynx. It had caused an acute catarrhal
inflammation in the upper half of the larynx and a
necrotic inflammation of the mucosa immediately sur-
rounding it. It almost completely obstructed the air
passages, and fully explained the cause of death. It
had been difficult at first to determine the nature of
this body. It had been necrotic throughout, but on
staining it in various ways remnants of an epithelial
layer could be made out, and, in general, the outlines
of a papilloma. The diagnosis, therefore, was papil-
loma of the subglottic mucosa; necrosis of this papil-
loma and suffocation. The speaker said that one or
two laryngologists had seen this case before a micro-
scopical examination had been made, and they had
stated that papilloma of the larynx never caused death
in this way. If this was true, the case must be looked
upon as unique.
Tuberculous Ulcer at the Base of the Epiglottis.
— Dr. Ewing also presented a larynx from a case of
chronic miliary tuberculosis. It exhibited an ulcera-
tion of considerable extent at the base of the epiglottis.
There were no gross lesions of the mucosa, but the
entire base of the epiglottis was infiltrated with tuber-
culous tissue, and the base itself was the seat of an
ulcer about 2 by i cm. Tubercle bacilli were found
in this ulcer. This was a rather rare localization of
tuberculosis of the upper air passages.
General Miliary Tuberculosis ; Thrombosis of
Superior Mesenteric Artery.— Dr. Ewing next ex-
hibited specimens taken from a girl aged seventeen
years, whose healtli had been failing for some months
before her death. The chief symptom had been an
irregular diarrhcea. About ten days before death this
diarrhoea had been more severe, and had been asso-
ciated with abdominal pain. The temperature had
then risen, and the case had afterward followed the
usual course of general miliary tuberculosis. At the
autopsy the colon had been found to be the seat of a few
rather old and not very extensive tuberculous ulcers,
which were partly healed. There were also an acute
catarrhal inflammation of the ileum and jejunum, and
a considerable swelling of the lymphatic tissues
throughout the lower ileum, but there were no tuber-
.culous ulcers of the small intestine and no involve-
ment of Peyer's patches. Beneath the stomach was a
large mass partly adherent to the adjoining viscera.
When dissected out it was found to consist of the
mesentery in a state of extensive bloody- infiltration.
There were thrombosis of the superior mesenteric
artery, and suppurative arteritis with miliary tubercles
surrounding the vessel, but not involving the clot.
Besides the lesions of general miliary tuberculosis in
this case, the lymph nodes at the root of the lung were
very slightly involved; on the side of the neck were
one or two which were slightly caseous. With the
exception of the chain in the neck the chief seat of
the lesions was the upper mesenteric region. The in-
fection had probably arisen from the initial ulcers in
the large intestine, and had lodged in these particular
lymph nodes, and death had resulted from infection
of the superior mesenteric artery, dissemination of the
bacilli through this artery, and a complete general
miliary tuberculosis.
Dr. Jonathan Wright said that if this growth of
the larynx was simply a papilloma, tiie case was, so
far as he knew, entirely unique. In tuberculous and
syphilitic lesions there were apt to be papillomatous
growths all over the mucous membrane of the larynx.
Sometimes on removing these there would be left a
deep ulcer beneath, and very frequently with syphilis
there would be an involvement of the cartilage. He
had seen these papillomatous masses in a case of
tuberculosis of the larynx so marked that laryngectomy
had been done and the inside of the larynx thoroughly
scraped out, with the idea that the patient would re-
cover with a sound larynx. Unfortunately the pa-
tient had died as a result of an accident. He would
be very sceptical indeed as to a non-specific condition
in the case just reported ; it would be interesting to
have sections made immediately around the ulceration
and deeper down in the tissues with the object of
searching for syphilitic lesions. The history pointed
very strongly to syphilis of the larynx. Such patients
often presented for a long time few, if any, symptoms
until the onset of dyspncea, which would then increase
so rapidly that unless the treatment was prompt and
effective the patient would be liable to die. A recent
case was cited in which, although the dyspncea had
not been urgent, he had sent the patient to the hos-
pital. The patient had, however, lost the note, and
consequently there had been some delay. As a result,
the man had nearly died before tracheotomy could be
done. In that case there had been nothing but an
abscess of the larynx of syphilitic origin. After hav-
ing had an opportunity of examining macroscopically
the specimen of papilloma of the larynx. Dr. Wright
was ready to admit that he could discover no evidence
of a syphilitic or tuberculous base to it. He had seen
several cases of tuberculosis at the base of the epi-
glottis; while not very common they were not ex-
302
MEDICAL RECORD.
[February 17, 1900
tremely rare. They were occasionally mistaken for
syphilis, but the finding of the tubercle bacilli would
easily settle that question.
Dr. W. H. Park asked if Dr. Ewing felt fairly
confident that he could usually detect the primary
lesion in cases of tuberculosis. He thought there
might be cases of incipient pulmonary tuberculosis in
which bacilli were swallowed, and thus intestinal
lesions started, making it difficult to determine which
lesions occurred first.
Dr. J. S. Thacher asked if there had been no
further appearance of interference with the circula-
tion of the intestine as a result of the cutting off of
the superior mesenteric artery ; under such circum-
stances there were usually very striking necrotic
changes.
Dr. Ewing replied that whatever syphilis might
have had to do with the first case of papilloma, he
could not understand how a constitutional disease
could produce a mass of this sort in the trachea. If
syphilis was present it must have been entirely
secondary as a cause of death. The anatomical con-
dition was such as could hardly have been produced
by syphilis. An interesting feature of the case was
the absence of cyanosis and the presence of extreme
pallor in spite of the marked obstruction in the
trachea. Several cases which had been presented to
this society seemed to emphasize this fact, namely,
that slow asphyxia was apt to be associated with ex-
treme pallor and not with cyanosis. It was, of course,
impossible to say definitely which lesions had de-
veloped first, but in the case presented he thought it
was highly probable that the intestinal tuberculosis
had been primary. With regard to the condition of
the intestine as a result of the thrombosis of this large
vessel, he said that it was a matter for surprise that the
changes had been so slight. There had been no areas
of necrosis and no ulcerations, although the blood
content of the intestinal wall was considerably in-
creased. The thrombosis was complete, and partly
organized.
A Case of Carcinoma of the Antrum of High-
more. — Dr. Leon T. Le Wald presented specimens
from a man forty-five years of age. The condition
had not been diagnosed before death; indeed, it was
difficult to detect the presence of these tumors in the
antrum of Highmore. The autopsy had disclosed a
tumor obstructing, the nasal fosste, and growing ap-
parently from the left antrum of Highmore into the
nasal fossa on that side. From thence it had appar-
ently extended upward through the sphenoid and
ethmoid bones into the skull in the anterior fossa, and
had produced a growth measuring about 2 by 1.5 cm.
This had pressed on the left frontal lobe. The growth
had also passed through the orbital plate of the frontal
bone and back through the sphenoidal fissure into the
middle fossa of the skull, producing a growth measur-
ing 1 by 0.5 cm. This had pressed on the temporo-
sphenoidal lobe of the brain. 'I'he tumor had also
extended downward through the hard palate and liad
involved the mucous membrane of the mouth, and ex-
tending down the pharynx had involved the lymph
nodes of the neck and even the bronchial lymph nodes.
There were also growths in the lungs, apparently of a
metastatic nature. Two nodules were also found in
the upper surface of the liver. The primary growth
appeared to have started from the left antrum, although
there was some difference of opinion on this point. A
number of sections of the tumor had been examined
by Dr. Dunham, and had been found to be carcinoma.
Dr. E. K. Di^NHAM said that the chief points of in-
terest in this specimen were in connection with the
lesions of the lung, where the neoplasm seemed to
have appropriated the stroma of the lung tissue for its
own purposes, and not to have developed any stroma
in that organ. The microscopical examination had
not been completed, but the specimen appeared to be
one of medullary carcinoma of poor nutrition, there
being large areas of necrosis. In the brain it had
had certain peculiar anatomical relations with the
blood-vessels. Sections of the growth wete exhibited
under the microscope.
Dr. Ira Van Gieson asked if the hypophysis or the
optic tracts had been destroyed.
Dr. Le Wald replied that it had not involved
either of these regions.
Dk. Jonathan Wright said that there were on rec-
ord in laryngological literature two or three cases which
had begun in the antrum of Highmore. One of these
he had seen clinically ^nd had examined microscopic-
ally. There had been some doubt regarding the nature
of the growth. It was a polyp of the antrum which had
gone down through the tooth socket and had appeared
in the mouth. The patient had been between forty-
five and fifty years of age. The growth having been
thought to be simply a polyp, an operation had been
undertaken, but it had been found that the antrum was
filled with grumous material. The tumor had been
about the size of a black walnut, perfectly round, and
having a rather large pedicle. It had evidently filled
the whole antrum. Thick sections had been made
through the w-hole polyp from one side to the other,
and deep down on the stroma it had presented a per-
fect picture of epithelioma, l^r. Prudden had con-
firmed this diagnosis of epithelioma. The case had
been followed for over a year, and there had been no
recurrence. This, and one other case in literature,
were the only ones he knew of in which it had been
definitely stated that the growth had originated in the
antrum of Highmore. It was quite possible that more
cases were on record, as most of them came under the
observation and care of the general surgeons.
A Case of Congenital Atresia of the Duodenum.
— Dr. J. S. Thacher jjresented a specimen in which
the small intestine appeared to be the continuation of
the common bile duct. It had been taken from a
child who had died at the age of six days, having been
operated upon two days before for an imperforate
anus. The child had vomited all food. No com-
munication could be found between the duodenum
and the stomach.
Extreme Stricture of the Urethra with Second-
ary Cystitis and Hydronephrosis. — Dr. Thacher also
presented specimens from a case in which the immedi-
ate cause of death had been poisoning by carbolic acid
taken with suicidal intent. The autopsy had, however,
revealed extensive disease of the genito-urinary tract,
and particularly a very narrow stricture of the urethra.
An opening about the size of the shaft of a pin had
been found after some searching, in the centre of an
oblique membrane which had occluded the urethra.
There had been no clinical history, but it had been
assumed that the membrane was of a cicatricial na-
ture.
Dk. Moschcowitz remarked that it was certainly
not such a stricture as would arise from traumatism or
from gonorrhcea, and consequently he would like to
know more regarding its nature. Might not this stric-
ture be congenital ?
Dr. Thacher said that he had, perhaps hastily,
assumed the stricture to be the result of inHammation,
or ])ossibly of inflammation aided by trauma.
Double Spleen. — Dr. Lewis A. Conner reported a
case of double spleen and exhibited the specimens.
Each spleen measured approximately 8 by 5 by 2.5
cm., and weighed 60 grams, and each had its own
branch of the splenic artery, and was, in other re-
spects, apparently normal. Of course, a small super-
numerary spleen was very frequently met with, but he
had never before seen two spleens of the same size.
February 17, 1900]
MEDICAL RECORD.
A Case of Perforating Duodenal Ulcer Dr.
Conner also presented a duodenal ulcer removed at
an autopsy made a few hours previously. The pa-
tient had entered the Hudson Street Hospital with
symptoms closely resembling those of appendicitis.
Dr. Bolton had made the usual incision for appen-
dicitis, and had found the right side of the abdomen
filled with a thin, purulent secretion, and the appen-
dix normal. Through a second incision the pus had
been seen to come from the region of the liver and
diaphragm. There had been no evidence of gas in the
peritoneum at the time of operation. The man had
lived for nearly a week after operation. The autopsy
showed a severe peritonitis localized around the
cjecum and along the ascending colon, but there was
no general peritoneal infection. An old oblong ulcer
was found immediately below the pylorus, which had
had the peritoneal coat for its base for some time, and
which had finally perforated by a minute opening.
Near this was what appeared to be the scar of another
ulcer. There was a history of a similar attack four
years ago. Surgeons were beginning to realize that,
in general, the higher up the perforation the milder
the infection and the better the prognosis, and the
case just reported seemed to bear out this view. In
this case there had also been a croupous inflammation
of the caecum and ascending colon — in other words,
that part of the intestine adjacent to the infected area
of peritoneum.
Dr. Park said that this idea about the mildness of
the inflammation in cases of high perforation was new
to him and most interesting. In the duodenum there
were usually but few bacteria, and those largely from
the food, which had escaped the deleterious action of
the gastric juice while in the stomach.
Dr. Harlow Brooks said that at the last meeting
he had presented three cases of duodenal ulcer, and
was therefore particularly pleased to observe the close
similarity between this case and his own. The pres-
ence of a non -odorous pus, and of symptoms of ap-
pendicitis, made the similarity very close, and em-
phasized again the importance of the character of the
abdominal exudate as indicating the presence of duo-
denal ulcer.
Dr. Conner said that he had been informed that
interesting bacteriological investigations had recently
been made by Dr. Gushing at the Johns Hopkins
Hospital regarding the intestinal tract, and these had
suggested the line of thought just presented.
Dr. Theodore Janeway asked if perforating ulcer
of the stomach did not often produce gas abscess un-
derneath the diaphragm, with the production of very
foul pus. He had seen such a case last year, in which
the first symptom of ulcer of the stomach had been
perforation. The woman had gone into collapse and
had developed a gas abscess. This had been operated
upon in four days, and she had lived a week sub-
sequently. The autopsy had shown a very general
peritonitis, but more especially localized in the region
of the diaphragm, liver, and stomach. The pus had
had a very foul odor, and the gas had formed rapidly
even after aspiration. In another case which he re-
called there had been associated with severe pain in
the upper part of the abdomen, and collapse, the de-
velopment of friction sounds over the spleen and evi-
dence of a slow abscess formation. After about one
hundred days the abscess had burst into the left
pleural cavity, and the pus had been found to contain
only streptococci. About forty days later, when ap-
parently doing well, the patient had died with symp-
toms of secondary abscess of the brain.
Dr. E. Libman mentioned a case of perforation of
c gastric ulcer associated with thrombosis of the upper
branch of the splenic vein. There were infarction
and gangrene of the upper half of the spleen, with very
foul pus and gas in the subphrenic space. Cultures
showed streptocococci and the bacillus proteus vul-
garis. With reference to the greater virulence of per-
forations in the lower part of the intestine, he referred
to an investigation made by him some years ago on
streptococcus infections of the bowel, as a result of
which he had found that the streptococci increased in
number from the duodenum down, and had been
most numerous in the caecum and lower part of the
ileum, and that the changes had been most marked in
the latter regions. This was possibly due to greater
stagnation in these places.
Carcinoma of the Liver Secondary to Small
Mammary Cancer. — Dr. George P. Biggs presented
a specimen taken from a woman, sixty-five years of
age. No history of the case could be obtained. The
liver was found at autopsy to be greatly enlarged and
to contain an enormous amount of carcinomatous
tissue (chiefly in the form of nodular masses i to
3 cm. in diameter). A careful search through the
abdomen and thorax failed to show any other carci-
noma. Finally an examination was made of the
breasts, both of which were quite small and of equal
size. There was nothing in their outward appearance
to suggest the presence of a tumor, but on palpation
the right breast was found to be very firm, and incision
revealed a scirrhus carcinoma involving the whole
mammary gland which measured but 6 by 5 by 15 cm.
Metastatic deposits were found in the right axillary
glands. Microscopical examination showed a marked
similarity in the type of cells found in the tumor tissue
from the breast and the liver, and suggested the prob-
ability that the involvement of the liver was second-
ary to that of the breast. Additional evidence in sup-
port of this conclusion was to be found in the fact
that it was the right breast which was involved, and
that from this tumor metastasis had occurred in the
axillary glands. It was of course possible that there
might have been independent development of tumor
tissue in each organ, but this seemed improbable.
The case served to emphasize the importance of great
thoroughness in making post-mortem examinations.
Dr. Van Gieson raised the query as to why the
tumor in the liver should have grown to such an
enormous extent while the carcinoma of the mammary
gland had apparently ceased growing.
Dr. Biggs replied that he had no explanation to
offer. There did not appear in the sections to be any
association of the growth with the bile ducts.
Dr. Ewing commented upon the gross appearance
of this liver. He asked if there had been any distinct
indications of secondary growth, or if it had been
uniformly distributed as in the section exhibited.
Dr. Biggs replied that it had been uniformly dis-
tributed.
A Case of Foreign Body in the Appendix Simu-
lating Gall Stone. — Dr. J. H. Larkin presented a
specimen removed from a man, fifty-four years of age,
who had given a clinical history of repeated attacks
of gall-stone colic for a number of years. About
three days before admission to hospital there had
been an unusually severe attack of pain, accompanied
by fever and depression. He had been in the hos-
pital only an hour or two when the symptoms had be-
come very urgent, and the man had died before he
could be operated upon. At the autopsy forty-one
gall stones had been found in the gall bladder, and
in the intestine three stones. The common duct had
been greatly dilated, and there had been evidence that
a number of large stones had passed through the duct
at different times. The vermiform appendix was
found twisted upon itself, and turned upward and
backward. The middle portion was free, but the tip
was adherent to the caecum and could not be separated.
The appendix being opened, it was found that its
304
MEDICAL RECORD.
[February 17, 1900
tip had perforated into the caecum, and projecting
through this opening was a stellate-shaped stone.
On slitting up the appendix further he had found
three stones — one in the shape of a clover-leaf and
the other two with facets, one having six and the
other four. Chemical examination of these stones
from the appendix showed them to be simply entero-
liths and not gall stones. They differed from ordinary
enteroliths in their shape and in the presence of facets.
The lumen of the appendix had been entirely obliter-
ated, and microscopical examination had revealed a
complete replacement fibrosis of the lumen, there be-
ing no remains of epithelial or glandular tissue.
Mitchell had made a rather recent contribution to this
subject, and had collected fourteen hundred cases of
foreign bodies in the appendix. Out of this large
number, cases of gall stones in the appendix had been
reported by only three observers.
Dr. Conner thought it not impossible that these
stones from the appendix were really gall stones, and
the fact that one of them presented six facets seemed
to point very strongly to this stone having been asso-
ciated with a number of other stones. He suggested
that such stones might lose some of their chemical
characteristics after having been for some time in the
bowel.
Dr. Larkin replied that in the chemical reactions
of the enteroliths in the appendix cholesterin had
not been found. The appendix itself showed that a
chronic process had been going on for a long time.
The chemical examination had shown very definitely
that these stones in the appendix were not gall stones.
The three stones present in the appendix might have
produced a large number of facets. The formation of
these facets seemed to him to be the result of muscular
action.
Dr. Theodore Janeway asked if the chemical ex-
amination had been made from the exterior, or whether
it had been made on the interior, or by section.
Dr. Larkin said that quite a large piece of one of
the stones had been chipped olf and subjected to
chemical examination.
Colonies of the Plague Bacillus. — Dr. W. H.
Park exhibited agar culture and stained preparations
from agar and bouillon cultures of the plague bacillus
obtained from the cases of bubonic plague found on
the steamer y. JV. Taylor. He said that although full
half a cubic centimetre of pus had been extracted from
the buboes of the ship's captain and cook, only three
to five colonies had developed in each case. The
rapid disappearance of the bacilli at the time of the
pus formation in the buboes had been noted by the
earlier observers. Theiii form, cultural and staining
characteristics were identical with those of two cul-
tures obtained from that disease which had been
brought to him from India.
Mucinaemia and its Role in Experimental Thyro-
privia. — Dr. Isaac Levin read a paper with this title
(see page 184).
The Chemical Relationship between Mucoid, Col-
loid, and Amyloid Substances in Normal and
Pathological Tissues. — Dr. P. A. Levene read this
paper (see page 188).
Dr. James Ewing asked what had been the result
of the examination of the blood in cases of thyroprivia
as regards the presence of mucin.
Dr. I. Levin replied that it was exceedingly diffi-
cult to detect such small quantities of mucin.
Dr. Van Gieson said that these papers, and par-
ticularly the second one, were interesting as showing
what it was possible for the physiological chemist to
do in the way of aiding the pathologist. One more
link would be added to the proof of the presence of
mucin in the system. If the animals deprived of
thyroid, after having been injected with mucin, had
been supplied with artificial thyroid extract it should
have, theoretically at least, prolonged their lives.
Dr. I. Levin replied that the trouble in experiment-
ing in this way with the thyroid extract was, that this
extract was of a most uncertain nature. The advan-
tage of working with mucin was that one knew the
nature of the substance with which one was working.
NEW YORK ACADEMY OF MEDICINE.
SECTION OX OBSTETRICS AND GYNECOLOGY.
Stated Meeting, January 25, igoo.
Brooks H. Wells, M.D., Chairman.
Removal of Fibroids through an Anterior Vaginal
Incision. — Dr. J. Riddle Goffe reported a case of a
woman, forty-three years of age, married twenty-three
years and the mother of two children. Examination
had revealed a small fibroid in the posterior wall of
the uterus, just above the internal os. He had oper-
ated for the removal of this tumor through an incision
in the anterior fornix of the vagina. Having delivered
the uterus into the vagina, the tumor had been very
accessible, and had been easily shelled out through a
longitudinal incision. He had then shortened the
round ligaments through the same incision. The
woman had made an uninterrupted recovery, .and had
left the hospital in three weeks.
Dr. Gofife also exhibited six fibroids removed from
another woman, forty-three years of age. The tumors
had been removed through the anterior incision by myo-
mectomy. The woman had come to him complaining of
backache and hemorrhage. He had previously curetted
and packed the uterus, and this had proved a useful
means of support during the subsequent insertion of
the sutures into the uterus. In this case he had short-
ened the round ligaments and sutured the perineum.
The patient had left the hospital on the twentieth day.
Dr. a. Brothers said that about eighteen months
ago he had presented to the New York Obstetrical So-
ciety a number of fibroids, of about the same size as
those just shown, and had been severely criticised
for having removed sucli small tumors, the statement
being made that such tumors never gave rise to symp-
toms of any importance. It was therefore reassur-
ing to know that a surgeon of Dr. Goffe's reputation
should see fit to do this operation. He would say
incidentally that the patient from whom he had re-
moved these fibroids had been restored to complete
health, and instead of being an invalid she was now
able to earn a living by laborious work.
Hysterectomy by the Clamp Method.— Dr. A.
Brothers presented three uteri removed by the clamp
method. The first case was that of a woman who had
had many attacks of pelvic peritonitis during the
previous twenty years, and who was anxious to have a
most radical operation done. The uterus had been
removed by the anterior median incision. The opera-
tion selected was vaginal hysterectomy by the clamp
method, no effort being made at hamostasis until the
fundus of the uterus had been delivered through the
vaginal incision. In the second case also he had be-
gun by slitting up the anterior uterine wall, but had
found it necessary subsequently to bisect the uterus.
It had then been possible to reach the tumor and shell
it out. The third specimen was a uterus which had
been removed in one mass. The woman had suffered
from frequent and severe uterine hemorrhages. An-
other gynajcologist had previously attempted to relieve
this patient by curettage and amputation of the cervix,
but without benefit. Dr. Brothers said that he had
February 17, 1900J
MtUlLAL KilCUKU.
305
tried intra-uterine vaporization, having been hitherto
very successful in stopping hemorrhages in such cases
by that method. For the first time this had also failed
him, and he had then removed the uterus, suspecting
the presence of malignant disease. In this case the
uterus had been simply drawn down and clamped in
three different portions from below upward. On one
side the adnexa had been completely removed. A
different technique had been employed in this case
because of the suspicion of malignancy.
Dr. p. a. Harris said that increasing experience
showed that quite a large percentage of cases of myoma
and fibroma ultimately proved to be malignant. This
brought up the subject of the advisability of removing
small tumors for slight symptoms occurring rather
late in life.
Interesting Complication following Cervical Dila-
tation for the Cure of Sterility. — Dr. A. Ernest
Gallant reported this case. The patient, a woman
of thirty-one years, had been married ten months. He
had first seen her last March, and as she had been
very desirous of becoming pregnant, he had corrected
a retroverted uterus and dilated the cervix. This was
on March i8th, and she had menstruated on March
31st and on April 26th, but missed her menstrual
period in May. Shortly after this she had an attack
of pelvic peritonitis. On July 13th he had found a
mass to the left of the uterus, and the organ was down
on the pelvic floor and pushed to the right. The
breasts were enlarged as in early pregnancy. He had
made a diagnosis of extra-uterine pregnancy, and this
diagnosis had been confirmed by Dr. Grandin. The
following day he had performed abdominal section,
and had found the omentum adherent to the tumor,
and blood clots scattered through the intestinal coils.
The fcetal sac had been found and removed. It was
an unruptured tubal pregnancy as proved by micro-
scopical examination. In the specimen no trace of
tubal structure could be detected. It was thought to
be a seven weeks' gestation. The hemorrhage had ap-
parently occurred so late from a small opening found
below the sac. The woman had insisted that one tube
and ovary should be left if possible, and the right
tube and ovary had accordingly been allowed to re-
main, although a cheesy mass had been found in that
tube. Just beyond this mass the tube was bent at a
right angle. When seen again on September 28th a
pelvic examination had shown the uterus to be in good
position. On September 4th she had menstruated
scantily, and on October 2d she had flowed freely.
In November and December the flow had been scanty,
and she had returned to him for examination in De-
cember because of an uncomfortable feeling in the
pelvis. A mass was found on the right side. Two
days later, while at the theatre, she had fainted and
had had to be taken home. A pelvic exudate had
been found, but this had disappeared within a week
under the use of hot douches. A second examination
then showed a large mass on the right side extending
up to the umbilicus. On January 15th he had operated
upon her again, and had found several thin-walled
cysts which had separated the broad ligament down
to the cervix on the right side. A portion of the
tube was allowed to remain. Microscopical examina-
tion of this specimen showed, to his surprise, a be-
ginning alveolar sarcoma of the right ovary.
Dr. Goffe said that he was inclined to think that
the restoration of the uterus to its normal position
had been quite as important a factor as the dilatation
of the cervix in causing pregnancy; however, the
promptness with which pregnancy had ensued was
certainly unusual. The malignant disease had de-
veloped so rapidly that it was rather difficult to be-
lieve that no indication of it had been present at the
time of the operation for the extra-uterine pregnancy.
Dr. Brothers said that some years ago he had suc-
ceeded in relieving an obstinate metrorrhagia by
means of curettage. The woman had returned after
her marriage, and he had treated her then by negative
galvanization because of a return of the metrorrhagia.
Subsequently she had come to him with symptoms in-
dicating that an extra-uterine pregnancy had ruptured
while she had been on her way to his office. The
diagnosis had been confirmed by Dr. A. J. C. Skene.
Dr. Brothers had operated upon her forty-eight hours
later, and had removed a ruptured ectopic gestation.
He felt that the galvanization had acted as had the
cervical dilatation in Dr. Gallant's case, and it was
probable that in both instances some tubal disease
had existed prior to the treatment.
Tuberculosis Complicating Pregnancy Dr. Hub-
bard VV. Mitchell reported two cases of women who
had had pulmonary tuberculosis complicating preg-
nancy. The first patient had consulted him in 1894
for advanced pulmonary tuberculosis. She was then
about eight months pregnant, and her condition was
so serious that it had seemed doubtful if she would
live to the end of her pregnancy. She also had an
extensive laceration of the cervix and perineum. On
April 30th she had been speedily delivered at full
term without any medical attendance of a well-formed
child. Two other children had been born to her
since then, and she was now in good health. Numer-
ous examinations of the sputum had failed to show
any tubercle bacilli. The second case was almost a
counterpart of the first one, except that numerous
tubercle bacilli had been found in the sputum. The
good results of the treatment of the tuberculosis in
these cases the speaker attributed to the use of an
antiseptic tonic internally.
Dr. Goffe remarked that it had been frequently
noticed that women in advanced stages of consump-
tion were very apt to become pregnant — indeed, the
same was true when the husband was tuberculous.
An Ovarian Cyst with Twisted Pedicle Mistaken
for Appendicitis. — Dr. Brooks H. Wells reported a
case showing certain difficulties in diagnosis. He
had been called recently to see a woman supposed to
be suffering from an attack of acute appendicitis. Up
to a few days before she had been in perfect health.
Constipation was marked, and a few hours before his
arrival she had gone into collapse. The abdomen was
enormously distended and extremely tender, so that
palpation was out of the question. She was operated
upon in the middle of the night, so great had been the
urgency. An incision had been made over the region
of the intestine. This had revealed a beginning gen-
eral peritonitis, and also had disclosed the fact that
the appendix was adherent to a mass about the size
of an orange situated below the brim of the pelvis.
The appendix itself was not inflamed. After making
a median incision he had found a small ovarian cyst
with two complete turns in its pedicle. The abdominal
cavity had been flushed out and closed with a quantity
of hot saline solution remaining in it. The woman
had made a rapid recovery.
Dr. p. a. Harris recalled one similar case, except
that the tumor had been sufficiently large to be detected
by palpation before operation. She had had three at-
tacks of severe pain, and, as a result of the twisting of
the pedicle, a hematocele had been produced.
Pyloric Obstruction. — In nineteen cases with recov-
ery and without relapse, Morison, of London, has oper-
ated by making an incision one and one quarter inches
from the pylorus, passing a guide through this open-
ing and incising through all the coats. Suturing the
incision is done in such a way that the line of union
is transverse to the incision.
;o6
MEDICAL RECORD.
[February 17, 1900
l^tccXicat Items.
New Jersey's Birth and Death Rate. — According
to the State board of health report issued on November
29th, there appears to be a decrease of about five thou-
sand births below last year's returns. The number of
deaths for the year was 30,999, and the estimated pop-
ulation is 1,855,872, showing a death rate of 16.7.
During the year there were 10,357 deaths of children
under five years, and 8,042 deaths of persons over sixty
years old. The victims of consumption numbered
3,584, and of acute lung trouble 4,322. The number
of deaths from consumption was 419 greater than the
average number for the previous twenty-one years.
Bravery of a Surgeon in South Africa. — Surgeon-
Captain R. A. Buntine, who is mentioned in de-
spatches for conspicuous bravery in the action at Bes-
ter's near Van Reenen's pass, is an Australian born in
Melbourne. He was educated at the Scotch college in
his native city and then at the University of Melbourne,
where he took his degree as a physician. Dr. Buntine
is in practice in Pietermaritzburg, the Natal seat of
government. When the colonial volunteers were called
out, Dr. Buntine and his partner, Dr. Currie, at once
set off. The Carabineers were given the duty of patrol-
ling the Free State border, and Dr. Buntine was out
with them when they had a brush with the Boers at
Bester's just under the Drakensburg, towering ten
thousand feet above them. The Carabineers were
compelled to retire, and a trooper who was wounded
had to be left where he fell ; Dr. Buntine, however,
rode back for him and got his trooper servant, Duke,
to accompany him. Dr. Buntine placed the severely
wounded trooper on his own horse and held on to the
stirrup leather of his servant's horse, and so ran back
to camp. — Lloyd's JSews.
Fees in the United States.— The West London
Medical Journal says: " Some attention was recently
directed in an American medical journal to the pro-'
fessional fees paid to ' physicians' in the States, and
the curious fact was pointed out that a fee of $500 was
quite exceptionally netted. In the land where mil-
lionaires abound as well as men of large wealth, this
certainly seems a surprising thing. A surgeon not
long ago operated successfully for appendicitis in
San Francisco, and his millionaire patient voluntarily
handed him a draft for $30,000. This fee must eclipse
any record we have in this country. If anything, how-
ever, there are signs everywhere that ' operation stock '
is a falling market. That is to say, the fees for opera-
tions are not what they used to be. Many causes no
doubt are contributing to this doleful state of affairs,
but perhaps the most active of all is the increasing
number of those in whose hands the public find that
their surgical needs can be placed. Thus by compe-
tition combined with efficiency the operation stock
market is being depressed."
Mr. Frederic Treves. — Few men who have gone
to the front to care for the wounded at their country's
call have more to lose and less to gain by so doing
than Mr. Frederic Treves. Still a comparatively
young man, his professional career of barely twenty-
five years has been one continuous succession of sci-
entific triumphs, and what is peculiarly gratifying to
the profession in both his self-sacrificing offer and the
high appreciation accorded to it by the government
is that Mr. Treves' bright position is based solely upon
purely scientific attainments and operative skill. He
is emphatically a surgeon's surgeon and owes nothing
of his reputation to medical politics or attendance
upon distinguished personalities or households. The
range of his work has been remarkably wide. Begin-
ning as an anatomist or "dissector," his first marked
success was a work which is to-day a standard text-
book in every dissecting-room in which the English
language is spoken. Then he turned his attention to
the structure of some of our animal cousins, and his
"Anatomy of the Intestinal Canal in the Mammalia"
is already a classic, while the growth of his latest
phase of reputation, the surgical, may be seen in his
great " System of Surgery," published two years ago,
and in the fact that within the past year he has been
compelled to resign his chair at the London Hospital
on account of the pressure of his private practice. And
the personality of the man is worthy of his reputation
— a commanding presence, a brilliant lecturer, with
a remarkable gift of keen, incisive epigram, each sen-
tence short, clear cut, and decisive, but with illumi-
nating bursts of sunniest humor, he is the idol alike of
his students and patients. His bearing in the operat-
ing-theatre is that of a general upon the field of haX-
t\t.~ Outlook.
Marvellous Draught of Fishes, Nine at a Birth.
— It was reported by The Z<7«<:f/ correspondent at Rome
that a marvellous story came from Casteldaccia near
Palermo, and which was actually credited by the sim-
ple-minded Italian peasantry. The story ran that a
woman at the above-mentioned place was, after a labo-
rious confinement, delivered of nine little animals in
the form of fishes, four of which weighed 15 grams
apiece, and five 10 grams each. It is satisfactory that
the latest news gave the mother as progressing as fa-
vorably as could be expected under the exceptional
circumstances. 77/tf Za/z^ir/', commenting on this Mun-
chausen-like tale, says: " Nihil sub sole novum." The
Palermitian monstrosity, which has been going the
rounds of the Italian press lay and professional, has
evoked references to other lusus natura;, of which Italy
appears to have been from time immemorial the chosen
seat. The painstaking and matter-of-fact historian of
imperial Rome, from the death of Marcus Aurelius —
Herodian to wit — has been laid under contribution,
and his statement of the portents that marked the close
of the reign of Commodus has had the honor of resus-
citation: iCoa rs T:aMZ(ila xal zi^v livjrihj <fouh ijr^ -TifiovjTa
ayfjfiafft rs aXXiiSaTzoii xa\ ixi/>sat awjiaTni; w/ai'iioaTmi
r.»kXax:(; aTzsxvrjOrj (animals of all kinds deviating from
their natural constitution were frequently brought to
birth in strange forms and with parts of their body
out of all harmony with each other). The time is ripe
for a new edition of Geoffrey St. Hilaire's classic work
on tetratology, were it only to utilize the material bear-
ing on the subject, and chiefly to be found in the ana-
tomico-pathological museums of the Italian medical
schools.
A Preliminary Note on the Experimental Intro-
duction of Cancer — For some years the author has
held the view that carcinoma is simply the result of
the entrance of the normal epithelium of the body into
the lymphatic spaces and its continued growth therein ;
his reasons being that the epithelium of cancer is prac-
tically identical with the normal epithelium of the
body, that the spread of cancer always takes place
along the lymphatics in the direction of the lymph flow,
and that carcinoma is infectious. The epithelial cells
themselves are in all probability the infective agent.
In order to put this view to test the following experi-
ment was made : The ovaries in a rabbit were incised,
the cut surfaces scraped, and the juice containing free
epithelial cells thus obtained was allowed to enter
the peritoneal cavity. The animal remained well for
nearly a year, then became thinner and weaker and
dyspnoeic, and was killed. On examination numerous
white, hard nodules, varying in size from a pin's head
February 17, 1900]
MEDICAL RECORD.
307
to an olive, were found in the mesentery, liver, uterus,
diaphragm, parietal pleura, lungs, and mediastinum.
In structure these nodules had all the characters of
ovarian cancer, consisting of alveolar spaces lined by
one or occasionally more layers of columnar epithelial
cells. — Journal oj Pathology and Bacteriology.
Increase of Cancer in Great Britain. — The asser-
tion that the increase in the deaths from cancer in
Great Britain is more apparent than real, owing to a
variety of causes, has been advanced frequently of late
by those who distrust statistics. This may be and
probably is the case to a certain extent, but to contend
that cancer has exhibited no increase is wilfully to
ignore incontrovertible facts. The Lancet, referring
to the matter, has this to say: "Perfectly accurate
figures show that the registered mortality from malig-
nant disease in England and Wales has at least dou-
bled within the last fifty years. Among males, in-
deed, there has been an uninterrupted increase from
19.5 per million of the male population to 571 per
million in the later years of the last century." No
verbal juggling or explanations can do away with the
significance of these figures, and the quibblers must
allow that, while admitting that an exaggerated view is
taken of the greater prevalence of cancer by some.
The truth is plain that there has been a very consid-
erable increase of malignant disease both in this
country and Great Britain.
Gunshot Wound of the Brain Through the Mouth.
— Barker (Lancet, December 2, 1899, p. 1508) reports
the case of a man, twenty-nine years old, who dis-
charged two shots from a small-bore revolver into his
mouth in a direction upward and backward. There
was at first free bleeding from the nose, and this was
plugged. On the following day the man was able to
sit up in bed, bleeding moderately from the right nos-
tril ; he was perfectly conscious and quite intelligent,
and complained only of a slight general pain in the head
over the right side. The pupils were normal, and the
only paralytic symptom was a slight droop of the right
eyelid, which was also slightly ecchymosed. There
was a round hole in the hard palate, just to the right
of the middle line, two inches from the edges of the
incisor teeth, and this was still bleeding. The plug-
ging was removed, the wound dusted with iodoform,
the patient kept at rest, and ice applied to the head.
Vomiting occurred a few days later, and was repeated
again after the lapse of two weeks. Ten days after
this weakness appeared in the left arm and leg; the
lines on the left side of the face were thought to be a
little less marked than on the right, and the tongue
deviated a little to the left. The pupils were still
equal, though small, and they reacted to light. In-
tense optic neuritis with hemorrhages was found in
the right eye, and also in the left though in less de-
gree. The knee-jerks were increased on both sides,
and ankle-clonus was present on the left. There was
slight tenderness on percussion over the right parietal
bone. The urine was normal, and the intellect per-
fectly clear. Vomiting without nausea recurred from
time to time. The temperature was but little above
normal. At no time did twitchings or convulsions
occur, though carefully looked for. For a period
there was steady improvement in all of the symptoms,
so that it was deemed unwise to attempt removal of
the bullets in the skull. Skiagrams showed that one
of these lay near the body of the sphenoid bone out-
side the brain, and the other exactly in the middle of
the brain. On careful measurement from the glabella
to the external occipital protuberance the latter bullet
was found directly under a point midway between the
two, and at a depth of about one and three-quarters
inches from the surface of the skull. Allowing for
the difference in size between the patient's cranium
and its shadow, it was thought that the bullet ought
to have rested on the corpus callosum at about two-
fifths the distance from its anterior extremity, and
against the lower border of the falx cerebri, one-
eighth of an inch to the right of the median line. On
the sixth day after the injury the patient had a con-
vulsion lasting from three to five minutes with
loss of consciousness, but without localizing symp-
toms. The attack was preceded by a feeling of
chilliness, then by a rigor, and the temperature was
found to be 100.6° F. Two days later two additional
attacks occurred, and the day after this a fourth.
Operation was now decided upon, and after some
difficulty the bullet was removed. On restoration of
consciousness sensation and motion were absent at
first upon the entire left side, except in the face. Im-
provement, however, in these symptoms took place, al-
though clonic contraction at the elbow occurred from
time to time, and also in the left calf. The knee-jerk
was exaggerated upon the left, and ankle clonus was
present. In the later history of the case secondary
trephining was practised, with separation of some ad-
hesions between the hemispheres. This was followed
by a large number of epileptic attacks within a few
days, but subsequently the patient improved.
Premature Maturityof the Japanese.— By examin-
ing statistics for the past five years, the/yV Shimpo finds
that the average age of students graduating from the
Imperial University is twenty-six years and one month.
The discovery causes that paper much disquiet. It
says that young men in Europe graduate at twenty-two
or twenty-three. On the other hand, the Japanese
mature at an earlier age than Europeans do, and their
lives of robust activity are shorter. In Western Eu-
rope a man is considered to be in his prime at
fifty, and at sixty and even seventy he occupies the
most important posts and discharges the most arduous
duties. In Japan, on the contrary, a man is thought
to have lost his capacity for usefulness at fifty, and is
expected to step aside and make way for his juniors.
So it would seem that there is a difference of ten
years in the length of active life, and a difference of
about five years in the time of concluding the scholas-
tic career, the total loss on the Japanese side being
fifteen years. Such figures naturally alarm our con-
temporary, and it appears to think that the only feasi-
ble plan is to reduce the standard of education. Be-
yond all doubt some means should be taken to enable
youths to finish their university course at an earlier
age. If twenty-si.x; years is the average age of gradu-
ation, there must be many men of thirty studying in
the university. But is it quite correct to say that
active life is over in Japan at fifty? A large number
of the leading merchants and statesmen of the present
day are nearer sixty than fifty.
Cotton-Seed Oil as Food. — In an editorial under
the above title The Lancet (July 29, 1899) says that
because cotton-seed oil has been employed as an adul-
terant a certain amount of prejudice is entertained
against its use as a dietetic. The ease with which it
saponifies would indicate that this oil is a useful food
and an excellent substitute for more familiar fats; in
fact, properly refined cotton-seed oil is as wholesome
as butter. The late Dr. Campbell Morfil devoted
considerable attention to this subject, and concluded
that the daily consumption of a small quantity of cot-
ton-seed oil produced results unattainable from any
other food, in cases of chronic dyspepsia, in which the
diet was restricted and the stomach intolerant of other
fat. It is less nauseating than cod-liver oil and free
from its laxative tendencies, and may therefore be ex-
hibited in tuberculous patients in whom excessive
3o8
MEDICAL RECORD.
[February 17, 1900
waste has to be combated without overtaxing the diges-
tive functions. When properly refined the oil has a
sweet, nutty flavor, and does not tend to become rancid.
It is well adapted for culinary and edible purposes,
but should not masquerade under a no7n de plume.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended February 9,
19C0 :
-Un
States.
Alabama, Mobile January 27th to February 3d . . i
Arkansas February zd *
California, Los Angeles January 18th 3
District of Columbia, Wash-
ington January 23d to 29th 3
Florida, Jacksonville January 27th to February 3d. . . 3
Illinois, Springfield January 21st to 27th i
Indiana, Clay County January 28th Prevalent.
Evansville January 27th to February 3d. . . 6
Louisiana, Calcasieu January 20th 8
De Soto January 20th i
Iberia January 20th 3
New Orleans January 27th to February 3d , . 28 3
Shreveport January 27th to February 3d. . . 8
Tangipahoa January 20th i
Massachusetts, Barton January 27th to February 3d . . . i
Lawrence January 27th to February 3d... i
Minnesota, Minneapolis January 20th to 27th 8
New York, New York January 27th to February 3d. . . 2
Ohio, Cincinnati January 27th to February 3d. . . 3
Cleveland January 27th to February 3d. . . 27
Oregon, Portland January a^d i
Pennsylvania, Philadelphia . , .December 24th to January 27th. 5
South Carolina, Greenville. . . .January 27th to February 3d. . . i
Tennessee, Nashville January 27th to February 3d . . . 6
Texas, San Antonio January ist to 31st 2
Twelve counties and
localities January 17th to 23d 43
L'tah, Salt Lake City January ^yth to February 3d. . . i
Virginia, Portsmouth January 27th to February 3d. . . 4
Roanoke January 1st to 31st 12
Washington. Spokane January 31st 75
West Virginia, Calhoun Co. . .January 31st Reported.
Gilmer Co .... January 31st Reported.
Mingo Co January 31st Reported.
Upshur Co. .. .January 31st Reported.
Wisconsin, Lafayette Co February 3d i
Laraonweir January 24th to February 3d . . . 5
Houston January 24th i
♦ Generally prevalent.
Smallpox— Foreign.
Austria, Prague January 6th to 13th 5
Belgium, Antwerp January 6th to 13th 5
Ghent January i3ih to 20th.
Egypt, Cairo January 7th to 14th
Engalnd, Liverpool January 13th to 20th
London January 13th to 20th 21
Southampton January 13th to 20th i
France, Lyons ... January 6th to 13th ...
Nice January 13th to 20th 2
Paris January 1 3th to 20th
Germany, Hamburg December ^ist to January 13th. 4
Kbnigsberg January 6th to 13th 4
Greece, Athens January 13th to 20th 4
India, Bombay December 26th to January 2d. . . . 6
Calcutta December 16th to 23d
Mexico, Chihuahua January 20th to 27ih
New Brunswick, Campbellton. January 27th to February 3d. . , 8
Russia, Moscow December 23d to 30th
Odessa , January 6th to 13th 3
Riga November ist to 30th 1
St, Petersburg January 6th to 13th 17
Warsaw , "December 31st to January loth. . . 1
Scotland, Edinburgh January 13th to 20th 1
Spain, Corunna January 6th to 13th 3
Switzerland, Zurich January 6th to 13th i
Yellow Fever.
Cuba. Havana January aoth to 27th 3
Mexico, Vera Cruz January 20th to 27th
Cholera.
India, Calcutta December 16th to 23d 26
Plague.
Hawaii, Honolulu January 21st 42 41
India, Bombay December 26th to January 2d . , . . 244
Calcutta December i6th to 23d 49
Kurrachee December 23d to 31st i 1
Japan, Kobe December 26th to January loth. 23
Osaka December ^6th to January loth. 34
Japanese Barbers and Infectious Skin Diseases, —
The Tokyo police have summoned all the barbers
of the capital and conveyed to them strict instructions
with regard to cleanliness and the use of disinfectants,
as well as the duty of not shaving persons that are
suffering from skin diseases or other maladies of a
contagious nature. The chief of police has also in-
structed the constables serving in the city to observe
the conduct of jinrikisha-men, and to interfere at once
if they detect any attempt to importune citizens, or to
behave rudely toward persons who refuse to employ
jinrikisha.
While the Medical Record is pleased to receive all new pub-
lications which may be sent to it, and an acknowledgment -will be
promptly made of their receipt under this heading, it must be 'with
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it which in the judgment of its editor will not be
of interest to its readers.
Christian Science : An Exposition. By William A. Pur-
rington. i2mo, 193 pages. E. B. Treat & Co., New York.
Report of the Bureau of Labor Statistics of the State
OF New York. 8vo, 1,179 pages. Illustrated.
The Treatment of Diseases of the Nervous System.
By Joseph Collins, M.D Svo, 601 pages. Illustrated. Wil-
liam Wood & Company, New York.
Diseases of Women. By E. C. Dudley, A.M., M.D. Svo,
717 pages. Illustrated. Lea Brothers & Co., Philadelphia and
New York.
Practical Text-Book of Midwifery. By Robert Jardiae,
M.D. Edin., M.R.C.S. Eng., F.F.P. and S. Glasg. i2mo, 245
pages. Illustrated. The Macmillan Company, New York.
Letter, Word, and Mind Blindness. By James Hinshel-
wood, M.A., M.D., F.F.P. and S. Glasg. i2mo, S8 pages.
H. K. Lewis, 136 Gower Street, W. C, London, England.
General and Local ANi«;STHESiA. By Aime Paul Heineck.
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The Nervous System of the Child. By Francis Warner,
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Macmillan Company, New York.
The Surgical Diseases of the Genito-Urinary Tract.
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The F. A. Davis Company, Philadelphia, New York, Chicago.
A Practical Treatise on Diseases of the Skin. By
Frank Hugh Montgomery, M.D. Svo, S63 pages. Illustrated.
Lea Brothers & Co. , Philadelphia and New York.
The International Text-Book of Surgery. Edited by
J. Collins Warren, M.D., LL.D., and A. Pearce Gould, M.S.,
F.R.C.S. Svo, 947 pages. Illustrated. W. B. Saunders,
Philadelphia, Pa.
The Lute and Lays. By Charles Stuart Welles, M.D
i2mo, 103 pages. The Macmillan Company, New York.
Experiments on Animals. By Stephen Paget. Svo. 274
pages. Illustrated. T. Fisher Unwin, Paternoster Square,
London, England.
Histology and Pathology. By John Benjamin Nichols,
M.D., and Frank Palmer Vale, M.D. Svo, 458 pages. Illus-
trated. Lea Brothers & Co. , Philadelphia and New York.
A Manual of Modern Surgery. By John B. Roberts,
A.M. Svo, S42 pages. Illustrated. Lea Brothers & Co.,
Philadelphia and New York.
The Principles of Treatment and their Applications
IN Practical Treatment. By J. Mitchell Bruce. M.A..
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The International Medical Annual Synoptical Index
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The Retrospect of Medicine, July to December, 1S99.
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liore et Fils, Paris.
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&Co., Philadelphia, Pa.
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Medical Record
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Whole No. 1529.
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©ricjittaX Jirtictes.
ON THE TREATMENT OF THE SLIDING
HERNIAS OF THE C.-ECUM AND SIGMOID
FLEXURE.'
l!v ROBERT F. WEIR, M.D.,
F THE AMERICAN SURGICAL ASSOCIATION. ETC.
The natural looseness of the peritoneum in the iliac
regions of the abdomen allows not very infrequently
the slipping or sliding of portions of the large bowel
into .1 hernia, and thus makes a decided variation in
the ordinary contents of a hernial sac. For instead
of this sac being formed by the pushed-out parietal
layer of the peritoneum, in which rests, ordinarily, free
or adherent omentum, small or large intestine, in these
slipped hernias, the "hernies par glissement" of the
French authors, there is found an important variation
in these usual conditions. It is, that the proper peri-
toneal sac is imperfect, usually on its postero-lateral
aspect, where, instead of passing around the included
bowel, the loose peritoneum rises up and passes over
the herniated bowel to its other side. In other words,
the protruded bowel is still outside the peritoneum.
Figs. I and 2 show this more clearly than words
can do. In these it will be seen that tlie bowel has
httxi forced down, carrying with it a fold of loosened
peritoneum into the scrotum, just as is done in
the descent of the testicle. And, indeed, the con-
genital form of caical hernia is produced by the same
a^ent that helps the descent of the testis, for the
g.ibernaculum testis is included in the duplication of
the peritoneum that contains the ca;cum, and hence the
bowel, from its action, is occasionally drawn down in
the wake of the testis. A similar occurrence, although
more rarely than with the Cfficum, may happen on the
left side where the gubernaculum ends under the sig-
moid fle.Kure.
Not every case, however, of cascal or sigmoid hernia
is of this kind; on the contrary, most of the caecal
variety and many of "the sigmoid ruptures are found
to have complete sacs owing to the fact that they are
generally covered all around by peritoneum in their
normal condition. This is particularly true concern-
ing the caecum and appendix, and it is a point of su-
preme surgical interest in connection with the surgical
lesions of the latter, for which we are largely indebted
to Treves for having made it widely known to us, al-
though Scarpa, as long ago as in 18 12, and later Bar-
deleben, in 1849, and other German observers early
proclaimed the fact and its value in connection with
perityphlitis. This mobility of the cascum with its
perfect peritoneal covering, which is only wanting in
about eighteen per cent, of the observed cases, and a
njarly similar condition in the sigmoid, where it is
limited only by a mesocolon, narrow and of varying
length, will explain why so many cases of csecal and
sigmoid hernias have been treated radically without
surgical difficulty and with success. Such conditions
' Read at a meeting of the Practitioners' Society, held January
5. I goo. ,
are not considered here. Moreover, when the colon
retains its long mesentery, which is its original devel-
opment, the ceecum can present itself in a left-sided
hernia or, vice versa, the sigmoid can show itself in
a rupture on the right side of the body. En passant,
this arrest of development from a long to a short me-
socolon additionally permits the understanding of the
left-side appendical difficulties which are occasion-
ally encountered, and does away with the need of call-
ing in the transposition of the viscera to help us in
such questions. Macready says, concerning the varia-
tions of hernias of the caecum, that in fifty-seven in-
stances thirty-six were right inguinal; five were right
femoral; nine were left inguinal, and one was left
femoral.
Most of the caecal and sigmoid hernias are reduci-
ble, which means that they generally have a complete
i. — Showing the Retroperitoneal Large
Intestine in a cro^s section of the hernia
with its incomplete sac.
sac and that the intestine rests free as it does in other
hernias. Merigot de Treigney' collected an interest-
ing number of cases of hernias of the large intestine
and presented them as follows;
Inguinal. Crural. Total.
Cxcuni and appendix 8 5 13
C^cum and end of ileum 11 11
Appendix alone 17 5 22
Transverse colon 4 . . 4
Totals 40 10 50
With such hernial contents this class of ruptures
can, as a rule, be readily reduced.
A brief digression may be here made to express
clearly the distinction which should be, but is not
generally, made between a caecal hernia and one of
the ascending colon and on the left side, between a
sigmoid hernia and hernia of the descending colon.
In reality it is anatomically well known, and it has
been already alluded to, that the caecum should be con-
sidered with a few exceptions as entirely surrounded
by peritoneum; it is, however, not so well known that
the sigmoid flexure, with a long or short mesocolon,
as it may be, is in its most mobile part below the edge
of the pelvis, only mounting above this line when dis-
tended into the upper pelvis, and that the descending
colon, 6 to 12 cm. long, terminates in the iliac fossa,
and is adherent to the iliac wall by the absence of peri-
toneum over one-fourth to one-eighth of its circumfer-
ence. The colon on each side, while usually attached
' These de Paris, 1SS7.
MEDICAL RECORD.
[February 24, 1900
as described, may be more movable by reason of a
mesocolon of variable length. Hernias, therefore,
such as are spoken of in the present article as those
of the slipped cacum and sigmoid, really are hernias
involving the ascending or descending colon.
This latter class of hernias — the subperitoneal, the
sliding or slipped hernias of the ascending or de-
scending colon, present difficulties of operative reduc-
tion which are not yet satisfactorily overcome, and in
which my own endeavors, to be soon narrated, are but
tentative, and yet need the corroboration of a larger
personal experience and, more important, the confir-
mation of other surgeons.
Treigney, whom I have just quoted, presents sundry
other cases of herniated large intestine which bear
more closely on the point now in question. They are
as follows:
Inguinal. Crural. Total.
Hernias containing caecum, end of
ileum, and ascending colon S i 9
Hernias containing sigmoid flexure , 14 i 15
Hernias containing sigmoid tiexure
witli small intestine 7 . . 7
Hernias containing ascending or
descending colon 5 . . 5
Totals 34 2 3b
Of twenty cases in which the ascending or descend-
ing colon, alone or accompanied by the ceecum or sig-
moid flexure, was involvd a whole sac was found only in
seven cases; in five it could not be determined, and in
eight the hernia wzs pa r g/issement. This will give some
idea of the frequency of this complication. When it
is present we have conditions that are prone to bring
about such an amount of irreducibility that it demands
a special surgical interference, or, if strangulation ex-
ists, which is possible, although rare, necessitates the
surgeon to relieve only the constriction present and
often to forego the intended radical cure of the hernia.
The bowels in these instances, in which they have
slidden into the hernial sac, are well seen in the dia-
grams, and are held in position by the connective
tissue, which is generally situated on the posterior or
postero-lateral aspect, and which from its long subjec-
tion to abnormal conditions is often dense and thick-
ened. Pressure under such circumstances accom-
plishes but little in replacing the protruded bowel in
the abdominal cavity, and hence sundry expedients
have been resorted to in order to bring about the
proper replacement of the intestine.
Before, however, proceeding to the surgical treat-
ment of such slipped or slidden hernias, a word or
two concerning their recognition may not be out of
order. They are more common on the left side and
in males in middle or advanced life. It is difficult
to determine their nature before the required surgical
intervention. Usually they present themsi^lves with
the history, in its early period, of reducibility which
is not always amenable to a truss or to taxis, and
which soon passes into a permanent irreducible con-
dition. They are usually scrotal when irreducible,
and sometimes one can in a left-sided hernia suspect
its being one of the sigmoid flexure or descending co-
lon, from the inability to inject per rectum but a small
quantity of fluid, or because by such an injection the
bowel in the scrotum distends appreciably. So uncer-
tain, however, is the diagnosis, and so often is the
slipped large bowel associated with small intestine or
omentum in the sac, that time is only misspent in en-
deavoring to solve the problem except with the scal-
pel. Only it is to be remembered that in a large irre-
ducible hernia, whether on the left or right side, but
particularly on the left side, on account of its greater
frequency, it is wiser to make the incision into the
sac well to the inner side of the scrotal swelling, and
not to carry it too low down, so as to avoid the acci-
dent of coming down to and incising an unrecognized
bowel deprived of its tell-tale peritoneal protection.
On opening the parietal portion of the sac wall, aside
from the probably associated omentum and small in-
testine which can be readily reduced and gotten out
of the way, if strangulation be not present, which is
first to be relieved, there may be encountered as a
hindrance to a possible reduction some enlarged epi-
ploic fringes. Their replacement can be attempted
one by one, but even if reduction of these be imprac-
ticable or only temporary, as they often reappear when
the finger pressure is relieved, their displacement will
frequently clear up the field of view so that the post-
peritoneal condition of the bowel will be detected.
Now, as to the treatment. Very little information
on this point is to be found either in text-books or
special works on hernia. Ladroitte,' in 1882, in a
cadaver in which he found a slipped sigmoid hernia,
stated that he could bring about its reduction only by
completely separating the bowel along its cellular at-
tachment up to the external ring. This published fact
attracted but little attention, and but few attempts on
this line have been resorted to by surgeons meeting
such cases. The majority of these hernias have been
unsatisfactorily treated either by being closed up after
an exploratory incision, or after a vain attempt has been
made to push up the attached bowel toward the exter-
nal ring and to hold it there by sutures carried from
below the intestine to the sides of the ring or through
the abdominal wall. Such a plan I was compelled,
like others, to use in my first cases, and, owing to my
inexperience, the operation resulted in no benefit.
Later I employed the separation of the bowel from its
subperitoneal bed. This, while generally easy, has at
times presented difficulties encountered by other sur-
geons from the den^eness of the tissue, and sometimes,
too, the nutrient vessels of the intestine may be so dam-
aged as to bring about its gangrene.^ Mayo'^ says it
is not always wise to attempt this. In the two cases
in which the method was resorted to by me, the fear
remained that this raw surface of a possibly now
greatly thinned and damaged bowel might materially
enhance the risk of the operation, and therefore while
the procedure permitted the proper suturing together of
the internal ring as a part of the due performance of
the well-known procedure of Bassini (which I prefer
to any), yet I remained not satisfied with the technique
of the procedure.
The difficulty of reducing these hernias and, in cer-
tain cases, the risk of separating them from their
changed resting-place will be appreciated by referring
to the collection of cases lately made by P'roelich, of
Nancy.' He has gathered some twenty-one instances,
ten strangulated and eleven in which a radical cure
was attempted " f?//!)/;/." There' were six ca'cal lier-
nias, leaving four strangulated sigmoid hernias and
nine non-strangulated. Of these Hydenreich had two
cases, both followed by fecal ftstula. Camplenon's
case was followed by an artificial anus. Reverdin,
Berger, Terrier, and Froelich all failed to cure their
hernias. Terrier and Hartmann reduced the sac and
the subperitoneal bowel and closed the ring in two in-
stances. Finally, disturbed by the failure to secure a
reduction in two cases, Juillard,' of Geneva, boldly
resorted to the severe measure of cutting away the pro-
truding bowel and joined the divided intestinal rings
by a Murphy button, and with success. He aided the
closure of the internal ring and inguinal canal by the
' Bulletin .Soc. Anatom., 1882, p. \bcj.
' Desbordes : " Des Hermes Adherentes de .S lliaquc," p. 37.
These de Paris. 1896.
'Mayo "Des Hernies par Glissement du Gros Intestin."
These de Paris, 1897.
' " De la Cure Radicale des Hernies par Glissement du Gros In-
testine." Gaz. Heb. de Med. et Chir.. No. 33, 1899.
■ Congr^s de Chirurgie, 1895. p. 43.'!.
February 24, 1900]
MEDICAL RECORD.
additional removal of the testis and spermatic cord.
These names of celebrity in the surgical world, exem-
plify the troubles that environ the satisfactory treat-
ment of these hernias, and their results cannot be
called brilliant. The successful outcome of Juitlard's
case will tempt only a rare repetition.
.Anderson' gives three cases in which the bowel, al-
though covered with peritoneum, could be pushed up
sufficiently to allow of the suturing of the inguinal
canal in two instances. In two of his cases the her-
nia promptly recurred. This looseness of the bowel
I have likewise met with.
My records show that I have surgically treated six
cases of sigmoid hernia and four cases of csecal her-
nia, in one of which the ca;cum was in a left-sided
inguinal hernia, and in one instance it formed a part
of a right-sided strangulated femoral hernia. In two
of the sigmoid hernias I resorted to separation of the
bowel by a dissection carried on mainly by the finger,
and after liberating it and then pushing it up into the
abdominal cavity I sewed up the ring and canal and
thus completed the operation. I have not been able
to trace many of these cases for any long period of
time, but I am informed by Dr. Coley that in two or
three patients on whom he operated similarly, and
whom he had long under observation, they remained
cured. In three others I succeeded in pushing back
with some effort the herniated bowel and sutured the
internal ring, but in a few months the hernia recurred.
In the four ca;cal hernias two of them were of the
caecum proper and reducible, having a complete sac;
one was found in a femoral hernia; another in a left
inguinal rupture. The remaining ctecal and sigmoid
hernias, one each, I ventured to attack in the following
manner. Thinking that the reduction of the bowel
after separation by dissection from the sac into the ab-
dominal cavity was a surgically incorrect measure, as
it left a raw and perhaps thinned bowel in the perito-
neal cavity, I made an essay, comparatively recently, in
these two cases, after freeing the bowel from its bed, to
cover the raw surface with peritoneum taken from the
sac, as in the manner shown in Fig. 3. This was ac-
complished by dissecting it up on each side of the
bowel, at the top, on a level with or a little above the
internal ring, and at the bottom to a short distance
below 'the bowel. The bowel is then loosened, b}-
peeling off with the finger or, if tightly fastened, by
cutting or snipping with scissors as widely as possible
from it until it is released up to or above the internal
ring, which is to be opened widely by retractors or
even enlarged by cutting if required to obtain a good
view. Then the loosened peritoneum is turned back-
ward and sutured behind the gut as far as practicable.
The peritoneal flap should be an ample one, so as to per-
mit to a satisfactory degree the unfolding of the bowel
loop and thus avoid kinking, which, however, is rarely
of importance in the large intestine. The ring is
afterward carefully sewed together after the newly cov-
ered bowel is reduced, and if the patient has con-
sented to the justifiable proposition to sacrifice the
testis on this side, a radical cure may be reasonably
looked for. I cannot but hope that the peritoneal
covering that is given by this procedure will, more-
over, aid in preventing recurrence, as the direction of
any further slipping or sliding is (if the upper inci-
sions have been carried high enough) turned more
away thereby from the hernial outlet. .In a rebellious
case a better exposure could be had by a hernio-laparot-
omy, as was practised by Terrier and Hartmann in
three cases with success. This would allow of a more
complete bowel separation and serous investment, and
would permit a resort to an intestinal fixation of the
intestine above if this extra means of cure was re-
quired to prevent any further descent of the bowel.
'Brit. .Med. Jour., October 29, 1895.
Of the uvo cases in which the procedure just described
was applied, one was of the sigmoid variety (descend-
ing colon) and the other of the caecum (ascending co-
lon), associated in the latter with the small intestine
and the appendix in an incomplete sac. There was in
neither case any material difficulty in carrying out the
idea. In both more than eight months have elapsed
since the operation was performed without any recur-
rence of the hernia, although in the cacal case this
good result was hardly hoped for, as the scrotal swell-
ing was of huge size and debarred the man from his
vocation as a waiter. He was informed that the best
that could be done for him was to render it possible
for him to wear a truss. I may add in concluding
that Froelich advises, in cases in which strangulation
exists with a slidden bowel, simply to relieve the con-
striction, to return the caught small intestine and
omentum, and to leave the large bowel alone. This
should be borne in mind as safe and judicious.
The cases in detail are as follows;
Case I. — Left inguinal hernia; slipped large intes-
tine; operation; reduction; suture of internal ring;
cure. W. S , male, aged sixty years, peddler; left
inguinal scrotal hernia
of twenty-five years'
duration ; reducible at
first and controlled by
a truss; later a hernia
appeared in the right
scrotum. Entered the
New York Hospital
January 30, 1885.
The hernias were
treated by Heaton's in-
jections of tincture of
oak bark, which served
to keep them up for
two months, when they
recurred after a severe
fall. A second injec-
tion was made at his
request, but one month later the left hernia recurred.
It was then the size of a goose's egg, resonant at its
top and partly reducible. On May 2 2d the sac was
opened up to the external ring; the sac was incom-
plete; its contents were the large intestine, the pos-
terior layer of the sac passing over the intestine. The
attachments of the bowel to the scrotal tissue were so
lax as to permit the bowel with some force to be pushed
back into the abdominal cavity. The sac was cut off
as high up as possible toward the internal ring, which
admitted the conjoined tips of three fingers. The
edges of the ring were sewed together by three silver
sutures and the outer wounds closed. He was dis-
charged cured on June 9th. He was seen ten months
later, and his rupture had not recurred.
Case II. — Incarcerated sigmoid hernia; operation;
incomplete sac; reduction; suture of internal ring.
F. B , male, aged fifty-eight years, priest; left in-
guinal hernia for twenty-eight years, reducible and
controlled by truss until within the past four months.
Since this time it has become more difficult to reduce,
and he has had more pain and distress in this region.
He has lost flesh from the discomfort. The hernia is
the size of a cocoanut, and on entrance to the New York
Hospital on February r2, 1889, it was in an irreduci-
ble condition and the size of a cocoanut and very ten-
der. The incarceration was overcome mainly by gentle
taxis after a morphine injection. The internal ring
was large, admitting two or three finger tips. Under
ether the next day an incision was made from the ex-
ternal ring to the bottom of the sac, exposing the her-
nia. There was an incomplete sac, the peritoneum
passing over and being adherent to a knuckle of the
sigmoid flexure, which was at the postero-lateral part
Fig. 3. — Outline of Peritoneal Lining of
Sac utilized as a flap to cover posterior
surface after it has been freed by dis-
312
MEDICAL RECORD.
[February 24, 1900
of the mass. Six or seven ounces of fluid were found
in the sac. With much difficulty the herniated bowel
was pushed up into the abdominal cavity, and with a
Macewen needle a strong silk ligature was passed
through the conjoined tendon and the outer edge of
the internal ring and Poupart's ligament, and duly se-
cured. Other sutures were similarly applied to the
large ring. The canal was closed by two other stitches,
a drain introduced, and the wound closed. Healing
was much interfered with by a sharp bronchitis, and
the major part of the wound healed by granulation.
The patient was lost sight of after leaving the hos-
pital.
Case III. — Strangulated right femoral hernia con-
taining ca;cum and appendix; sac complete; reduc-
tion; Bassini's operation. E. H , aged fifty-five
years, seamstress, has had a small irreducible femoral
hernia for ten years. Last evening, after a fit of
coughing, it became larger and developed the usual
signs of strangulation. A long tumor about six inches
long and three inches wide was seen in the right groin.
Under ether, on December 18, 1894, an incision was
made parallel to Poupart's ligament, opening a sac
containing a little adherent omentum, two loops of the
small intestine, the ca?cum, and the appendix, wliich
were free, and which, after nicking the roof of Gimber-
nat's ligament, were easily reduced into the abdominal
cavity. The omentum was tied off, the sac ligatured at
its neck, and the canal and opening were closed with
chromicized catgut after Bassini's method. On Janu-
ary 19, 1895, she was discharged cured. She was seen
a year later, and the hernia had not recurred.
Case IV. — Hernia of sigmoid flexure; complete sac;
Bassini's operation ; gangrene of testis; sepsis; death.
F. I , male, aged forty-seven years, engineer; ad-
mitted to the New York Hospital on December 24,
1894. He had a left inguinal hernia for ten years
and had worn a truss for about a year. The hernia
was reducible but frequently painful. Bassini's method
was used, and on opening the sac omentum and a loop
of the sigmoid flexure were seen free in a complete her-
nial sac. The internal ring was dilated to the size of
three finger tips. The omentum was tied off with cat-
gut, and the ring and canal were closed with kangaroo
tendon. The patient did badly, with scrotal swelling,
which was opened, revealing a gangrenous testis due
either to a possible twist, for the epididymis was for-
ward, or, more probably, to a too tight closure of the
internal ring. This was among my earliest Bassini
operations, when acknowledged inexperience might
have led to such a mishap. The testis and cord were
removed and the wound was left open and dressed with
iodoform. Sepsis prevailed, and the patient succumbed
on January 6, 1895.
Case V. — Sigmoid hernia; incomplete sac; reduced
by freeing bowel and completing rest of sac by peri-
toneal flaps; cure. C. W , male, aged forty-four
years, baker; admitted to the New York Hospital on
January 23, 1895. He had noticed hernia of the left
side for about eighteen months. Lately it has become
irreducible and painful, and he could not return the
hernia even when it was reducible. Operation was
done on January 26th, by the Bassini method; the sac
was incomplete; and the large intestine (descending
colon) was present behind the peritoneum on the pos-
terior aspect of the sac. The internal ring was enlarged
upward for better inspection and manipulation. The
herniated bowel was then dissected up from its bed of
connective tissue and pushed into the abdominal cav-
ity. The incomplete sac was cut off, and then the
reflection of the peritoneum at the internal ring was
incised laterally outward and inward so as to obtain
a closure of the peritoneal ring behind the intestine
pushed into the alDdominal cavity. The ring itself and
canal were closed seriatim. The result was a good
one. VVhen last seen, three months afterward, no re-
currence was present.
Case VI. — Right inguinal interstitial hernia con-
taining cacum and appendix; complete sac; Bassini's
operation. R. W , male, aged fifteen years; rup-
tured himself on the right side, while running two
years ago. The hernia was irreducible and did not
descend into the scrotum. He wore a truss, but had
a good deal of pain. On January 14, 1895, operation
revealed an interstitial congenital inguinal hernia,
containing the caecum and appendix free in the main
one of two sacs present. Ligature of the sac at its
neck and closure of the ring and canal after Bassini's
method were resorted to. He was discharged cured.
He was seen one year later; no recurrence.
Case VII. — Congenital left inguinal hernia contain-
ing caecum; sac complete; Bassini's operation; cure.
G. H , aged twenty-seven years, engineer, had a
hernia of thirteen years' duration, from heavy lifting.
Left inguinal hernia was irreducible up to four years
ago, the size of two fists. Operation was performed
on October 12, 1895, by Bassini's method. The hernia
was found to be congenital and to have as its contents
the omentum and the caecum free from adhesions.
The omentum was tied off and the cjecum returned.
Primary union occurred. He was discharged from
the hospital on November 4, 1895; he has not since
been traced.
Case VIII. ^ — Left inguinal hernia containing small
and large intestines; sac incomplete; reduced by pres-
sure; Bassini's operation; cured. W.I.N ', male,
aged sixty-four years; rupture in left groin from a fall
received eighteen years ago. Six months later a her-
nia also appeared on the right side. He was able to
wear a truss on the left side for eight years. Since
then, now ten years, he could not retain the hernia by
any appliance, though both ruptures could always be
readily reduced. Both scrotal rings were much en-
larged. Under ether both hernias were operated on
January 14, 1895, at the same sitting. On the right
side the small intestine and omentum were found ; four
inches of the latter were tied off in sections and re-
moved. Bassini's operation was completed. On the
left side a portion of the large intestine was found on
the posterior part of the sac covered loosely by perito-
neum. As a consequence an incomplete sac was
formed. Some small intestine was also present. The
sigmoid flexure could with some effort be pushed up
into the abdominal cavity so that the sac could be
tied off at the internal ring, which was thereupon nar-
rowed by sutures, and the other steps of Bassini's oper-
ation were carried into effect. There was no recur-
rence up to four months later, when the patient was
last observed.
Case IX. — Large right inguinal irreducible hernia
containing ca;cum, appendix, ascending colon, small
intestine, and omentum ; sac incomplete; plastic cov-
ering of separated colon by peritoneal flap ; reduction ;
Bassini's operation. C. H. D , aged forty-one
years, waiter, has had a rupture in the right groin for
about eight years without known origin. At first it
was reducible, and for its retention he used a truss up
to three years ago, when the hernia could not be re-
tained by such means, and he was forced to employ a
bandage for support. On entrance into the New York
Hospital a hernia as large as a child's head was seen
in the right inguinal region, irreducible and largely
containing intestine. He was urgent for operative
help, as the deformity was apparent tlirough his cloth-
ing and deprived him of work. It was candidly told
him that such large hernias had greater risk to life,
and that only a partial cure could at best be promised.
With this understanding, under ether, and using rub
bei gloves, which is yet the latest fad and not alto-
gether a satisfactory one, the sac was opened March
February 24, 1900J
MEDICAL RECORD.
8, 1899, revealing as its contents small intestine and
omentum, witli the caecum and appendix and a part of
the ascending colon. The small intestine was redu-
cible. The omentum was adherent in many places.
These were tied off, and when duly freed, a large
portion was tied off and its stump reduced. This
showed very clearly that the sac was an incomplete
one, and that while the cascum and appendi.x were free
and reducible, still the reduction of the ascending
colon, which rested at the back and outer part of the
]3rotrusion, was impossible by reason of its immobility,
it being firmly fixed behind the peritoneum by dense
connective tissue. This was carefully divided with
scissor snips or else separated by the fingers until the
bowel could be easily replaced in the abdominal cav-
ity. Before it was left there, however, the peritoneum
from the sac was loosened up and turned backward so
as to cover over the raised surface of the bowel, and
there held by interrupted fine silk sutures. Then the
sac thus completed was sutured at its neck, and the
other steps of a Bassini operation were proceeded with.
The patient made a prompt recovery, and when seen
eleven months afterward no tendency to recurrence
was found. He is presented this evening to you for
inspection.
Case X. — Sigmoid irreducible hernia; sac incom-
plete; release of intestine with plastic covering from
sac and its reduction; completion of rest of sac; Bas-
sini's operation. M. C , aged forty-seven years,
merchant; referred to me by Dr. De Plasse, January
24, 1899. By lifting a heavy pail of water, thirteen
years ago, the patient brought on a left inguinal her-
nia. This was kept under control by a truss for six
years, but since then this has proved comparatively
useless. The hernia was partly reducible, found to be
scrotal, and in size about three by five inches. Oper-
ation was done January 26, 1899. On opening the sac
it was seen to be incomplete, and the subperitoneal in-
testine, which was the lower end of the descending
colon, was held in situ by somewhat loose connective
tissue. The serous coat of tlie sac was cut on each side
a moderate distance from the bowel, which was lifted
out with the peritoneal flaps easily from its bed up to
the internal ring. These flaps were then passed be-
hind the bowel and sutured together, and the covered
intestine was reduced into the general abdominal
cavity. It was then seen that the just-covered loop
of bowel fell within tiie abdomen below or beyond
the region of the internal ring. The ring then com-
pleted by this little plastic efi^ort was duly closed by
sutures, and the remaining steps of the ordinary Bas-
sini operation completed the case. It progressed un-
eventfully. He was' lately seen, and has had no recur-
rence now nearly a year after the operation.
Of these ten cases, six were sigmoid hernias of
which there was a complete sac containing an ordinary
loop of the sigmoid with a long mesentery which al-
lowed of its ready reduction. Five, however, had slid-
den out behind the peritoneum and required in three
cases only firm pressure to force the bowel back into
its place in the abdomen. In the two remaining cases
the bowel was freed from its bed, then covered with
the peritoneum of its incomplete sac, and finally re-
duced. Four other cases were of the cascal variety.
Three of these had a complete sac, and the hernial mass
was readily reduced. In the remaining case the in-
testine (ascending colon) was freed by dissection and
covered by peritoneum from the incomplete sac and
successfully reduced.
Heidelberg University has opened its doors to the
other sex. Women can now attend the medical lec-
tures and examinations upon the same footing as the
men.
THE CLINICAL USES OF THE SPHYGAIO-
GRAPH.'
By R. van SANTVOORD, M.D.,
On considering how I might best fulfil my promise to
the president of the Academy in the preparation of a
paper on the clinical uses of the sphymograph, I de-
cided to restrict myself ♦' analysis of my own re-
sults obtained b' ,>. a single instrument, that
of Dudgen, duri ^e last fifteen years. As the
sphygmograph is an instrument which is not in gen-
eral use among physicians, it will be advisable to re-
call briefly some of the elementary facts which must
be borne in mind to order to interpret its tracings.
A sphygmogram is an approximately accurate record
of the variations in arterial tension. Arterial tension
is the lateral thrust of a column of fluid contained in
a closed tube and compressed between the force of the
ventricular contraction and the post-systolic arterial
retraction on the one hand, and the resistance to the
flow of the fluid on the other. This resistance con-
sists mainly in the friction of the blood on the walls
of the vessels, and is obviously directly proportioned
to the velocity of the current. Gravity is a second
important factor, which may, however, be neglected
in the present inquiry, as all the tracings to be pre-
sented were taken on the radial artery with the patient
sitting with the arm dependent and flexed at the elbow
or horizontal as he lay in bed.
The factors which influence the rapidity of the blood
current during the different periods of the cardiac
cycle are the amount of blood thrown into the aorta at
each systole of the ventricle, the rapidity of the heart
action, the condition of the aortic valves, the elasticity
of the vessels, the degree of contraction of the capil-
laries and arterioles, and, under exceptional circum-
stances, the pressure in tiie veins.
It is commonly stated that the amount of pressure
on the spring of the sphygmograph required to develop
a tracing of maximum amplitude, like the amount of
pressure required to stop the pulsation of the vessel
beyond the point of compression, is a measure of the
absolute arterial tension, i.e., the tension per unit of
surface of the vessel.
This is true only when comparison is made between
vessels of equal calibre. Marey found that the vessel
supplying an aneurism could be easily compressed by
a moderate amount of force, whereupon pulsation in
the aneurism would cease. The same amount of press-
ure applied to the aneurismal sac produced no appre-
ciable effect, a vastly greater amount of directly ap-
plied force being required to suppress its pulsation.
The explanation of this difference is that the trans-
mission of pressure through fluids under tension is
equal in all directions, each unit of surface being
acted on by the same distending power. The result
is that the sac of the aneurism, which at any part of
its diameter contains a larger number of units of sur-
face than a corresponding section of the vessel, re-
quires a correspondingly greater force to compress it.
This same law obviously applies to radial arteries of
different calibre. If we have two vessels, each having
the same pressure to the unit of surface but one hav-
ing twice the internal diameter of the other, it would
take double the pressure to obliterate the former than
it would the latter. Again, if in these two vessels we
have in the larger only half the pressure to the unit of
surface present in the smaller, it would require the
same pressure to obliterate either. To a palpating
finger the two latter vessels would seem to have the
same tension, although the absolute tension in the
smaller would be just double that in the larger. In
' Read before the New York Acacletiiv of Medicine. December
21, l8gq.
314
MEDICAL RECORD.
[February 24, 1900
the former instance of equal units of tension in vessels
of unequal size, the large vessel, requiring more force
to compress it, would to the finger appear to be of far
higher tension.
Now in order to develop the tracing of the artery,
the pad of the recording instrument is pressed down
upon it until it is transferred from a cylinder to a
body of elliptical section. The e-xcursions of the lever
are caused only to a very slight extent by actual dila-
tation of the vessel. They are caused mainly by the
rising and falling of the artery as it approaches and
recedes from its normal cylindrical shape under the
variations of tension which occur at different parts of
the cardiac cycle. If the pressure of the pad exceeds
the sum total of the units of tension which are brought
to bear upon it, the calibre of the artery will be oblit-
erated and no tracing will be made. If the spring
pressure is too light, the lever would be affected only
when the tensile force has partly expended itself, and
the tracing will be wanting in amplitude. The neces-
sary pressure on the spring to produce the largest am-
plitude of tracing lies between these two extremes, and
what this tension should be depends not alone on the
tension per unit of square surface, i.e., the absolute
tension of the artery, but upon this combined with the
number of units acting on the pad. In other words,
a tracing of maximum amplitude developed under a
pressure of five ounces on a small artery represents
a higher absolute tension than a tracing of maximum
tension developed under the same pressure in a large
one. Allowance must be made therefore for difference
in the size of the vessels in estimating the significance
of the amount of pressure necessary to develop a trac-
ing. The form of the tracing will, I believe, give a
far more accurate record of the absolute tension of the
vessel than the amount of pressure required to develop
it; rapid and extensive variation in tension being in-
dicative of slight resistance and low absolute tension;
slight variation in tension being indicative of great
resistance and high absolute tension. Results ob-
tained by instruments like the sphygmomanometer of
von Basch, which measure tension by indicating the
amount of pressure necessary to exert on a vessel to
prevent its pulsation being felt beyond the point of its
application, are open to three objections: (r) It is
difficult, at times impossible, to determine with any
approach to accuracy just when pulsation has ceased;
{2) the measurement of the necessary pressure is of
value only if we know also how large a surface we are
compressing; (3) the instrument measures only the
highest point of pressure existing during the cardiac
cycle and tells us nothing of its variations, which, as
will presently be demonstrated, are highly significant.
I will now present a series of tracings showing the
form of the sphygmogram in the healthy adult under
dififerent physiological conditions. From these we
will pass on to pathological variations.
I present here a tracing (No. i) taken from a healthy
young adult who had been sitting quietly for some
time previously. The ascent of the tracing is nearly
\ertical; the primary wave is slightly blunt-pointed.
I'he next most prominent wave in the tracing, the di-
crotic impulse, corresponding to the period just suc-
ceeding the closure of the aortic valves, is marked and
still more rounded. A third, known as the tidal wave,
IS indicated between these two, and is below the level
of a line drawn between the dicrotic notch and the
summit of the primary wave. One or more undula-
tions will often be manifest in the portion of the line
of descent following the dicrotic wave. There will
be variations in the appearance of the tracing accord-
ing to the instrument used; the lever of the Marey
type moving in the arc of a circle; the recording
needle of the instruments of Pond and Dudgen play-
ing to and fro in a straight line. The relation be-
tween the magnifying power of the instrument and the
rapidity of the motion of the paper must also be con-
IK
4^
sidered in contrasting the work of different instru-
ments.
The illustrations which I show are copied on the
same scale and with substantial accuracy from sphyg-
mograms taken with the same instrument and with the
paper moving with the maximum velocity of the clock-
work, so that these considerations do not concern us in
comparing them with each other.
The second tracing shows diminution of tension
after a meal in the same individual from whom the
first was taken. The primary wave has become much
more pointed, the dicrotic undulation more marked,
and the dicrotic notch, whose position in the tracing
is the best indication of post-systolic tension, occupies
a lower level.
The third tracing was taken from the radial artery
of a perfectly healthy young man immediately after
several minutes of active work on a stationary wheel
in a gymnasium. The spring pressure was two and
one-half ounces.
A tracing of the pulse at the same pressure just be-
fore the exercise showed a normal sphygmogram.
In accordance with the law explained at the begin-
ning of the paper, the pressure of two and one-half
ounces on the artery expanded during exercise repre-
sents a lower tension than the same pressure on the
artery when relatively contracted during rest. The
long pointed primary wave, the disappearance of the
tidal wave, the low position of the dicrotic notch,
the marked dicrotic impulse and great increase in
rapidity of the pulse and amplitude of the tracing, are
Fig. 4.
characteristic of low tension in a normal vascular sys-
tem due to relaxation of tlie peripheral vessels, pro-
duced in this case by a physiological cause.
The tracing (Fig. 4) taken during the actual work
shows the same characteristics, but is exceedingly ir-
regular owing to the unavoidable muscular jerking and
some irregular actfon of the ventricle.
February 24, 1900]
MEDICAL RECORD.
;i5
Fig. 5 represents a type of high tension taken from
the same subject as the preceding, during an attempt
to raise himself from the floor with one hand. The
first few waves show the same characteristics as the
Fig. 5.
preceding, but the general line of the tracing runs up
rapidly on the paper, showing increase of tension, and
the amplitude of the individual waves diminishes
greatly. The explanation is that with the effort the
glottis was closed and the muscles of the trunk rig-
idly contracted. The pressure in both thorax and
abdomen being thereby greatly raised, the entrance of
the venous blood into the great vessels of the trunk
was impeded, venous tension markedly increased, and
this acting backward through the capillaries caused a
corresponding increase of pressure in the arteries, the
peripheral vessels still remaining widely open.
The sixth tracing was taken from a case of tetanus
and shows exceedingly high tension in elastic vessels.
The line of ascent is gradual, the primary is lower in
level than tlie tidal wave, both being, in common with
the dicrotic, but faintly indicated. The dicrotic notch
is as high in the tracing as the primary wave.
The seventh, as proved by autopsy, taken from a
case of diffuse nephritis, predominantly parenchyma-
tous, in a boy, shows these same characteristics in a
less pronounced degree, the ascent being not so grad-
ual, the primary waves in common with the tidal
being more pronounced and on the same level, and
the dicrotic notch lower in the tracing.
These cases may be described as cases of continu-
ous high tension.
One rule given for the interpretation of a sphygmo-
gram is to consider every tracing as above the normal
in tension in which the tidal wave is above a line
drawn from the dicrotic notch to the summit of the
primary wave. These two tracings by this test, it will
be observed, are of decidedly high tension.
The next (eighth) sphygmogram was taken from a
woman of eighty-three years in good general health
but for the infirmities of age, whose radials were some-
what rigid and tortuous. Primary and tidal waves are
fused together in a rounded summit; the dicrotic notch
is at a slightly lower level than in the tracing No. 7,
which shows moderate high tension in elastic arteries,
and the dicrotic impulse is but slightly indicated. As
Marey has stated, the systolic portion of such a trac-
ing bears a strong resemblance to the tracing taken in
the ventricle during its contraction, and represents the
transfer of the ventricular impulse to the radial artery
through the rigid vessels with but slight modification.
Owing to the slight retractility of the great vessels the
amount of blood forced into the periphery during car-
diac diastole is less than normal, dicrotism is less,
velocity falls, but the tension does not suffer a corre-
sponding diminution because of the resistance offered
by the inelasticity of the vessels beyond the point at
which the sphygmogram is taken. The tracing may
be described as one of high systolic and relatively low
post-systolic tension, a combination which is typical
of arteries which are less than normally elastic.
In cases which we meet in practice in which dis-
eases of the vascular system and of the kidneys are
found in various combinations, we have frequently the
combined effects of inelasticity and increased periph-
eral resistance manifest in the tracing.
The following (No. 9) was taken from a stout lady,
aged fifty-two years, who suffered from considerable
dyspnaea. The tracing is of small amplitude. Its
almost flat top without indication of primary and tidal
waves indicates lack of elasticity, while the very high
position of the dicrotic notch shows very high tension
in the post-systolic portion. Moreover, it took a pres-
sure of five ounces to develop the tracing. This pulse
felt very small and weak. I would not have been able
to recognize its nature without the sphygmo2:raph.
The pressure of five ounces on a very small artery,
required to develop this tracing, was significant of
absolute high tension.
The next tracing (No. 10) shows a fiat-topped systo-
lic and rather low tension post-systolic portion indica-
tive of loss of elasticity. As the artery was large, the
pressure (five ounces) necessary for its development
was not significant of so much absolute high tension
as in the last case. It was taken from a patient suffer-
ing from a recent cerebellar hemorrhage, whose urine
presented at the time nothing abnormal. Retinal hem-
orrhage occurred at this time. Hyaline casts were
found in the urine two years later, albumin after five
years had elapsed, the quantity of urine gradually in-
creasing and the specific gravity falling. He died,
finally, from the giving out of his heart, more than
nine years after his apoplexy.
The next tracing (No. 11) was taken from a lady,
aged sixty-four years, who suffered from dyspncea and
attacks of syncope, in one of which she died a month
later. Her pulse was beating at the rate of thirty per
minute. The systolic portion shows the rounded wave
j6
MEDICAL RECORD.
[February 24, 1900
of inelasticity, and the dicrotic notch is very high on
the tracing, showing enormous peripheral resistance.
Under the influence of nitroglycerin, the following
modifications resulted:
(No. 12.) The rounded top of the systolic wave
became almost flat, recalling the types last shown, the
plateau being preceded by a small, sharp elevation.
The dicrotic notch was lower in the tracing and the
dicrotic wave more accentuated. This sharply pointed
elevation at the summit of the tracing is to be ex-
plained as being due to an oscillation of the spring of
the instrument. In inelastic vessels, especially when
the tension at the end of the systole falls below a cer-
tain point, the advancing ventricular impulse is so
sudden as to act as a water-hammer and cause a sharp
oscillation of the spring of the instrument. This is a
very frequent feature in tracings from inelastic vessels
at medium and low average tensions. In elastic ves-
sels this water-hammer oscillation occurs only in cases
of extremely low peripheral resistance with a fairly
strong ventricle.
The next tracing (No. 13) to be considered is an un-
dulation from this same sphygmogram, but in a place
where three slow beats at the rate of about forty per
minute followed others, one of which we have just ex-
amined, which were at the rate of seventy per minute.
The slower beat allows the artery more fully to empty
itself before the next systole. \Ve get greater ampli-
tude, less absolute tension, as shown by the downward
curve of the general line of the sphygmogram, and the
plateau back of the water-hammer oscillation is con-
verted into a somewliat obtuse point, all showing the
effect of a still greater lowering of tension in this same
vessel.
In the next tracing (No. 14) one of the larger units
from a very irregular sphygmogram obtained from a
man with rigid and tortuous arteries, suffering from
pneumonia, we see the result of a still greater reduc-
tion of peripheral resistance on a tracing taken from
an inelastic artery. The cardiac systole is represented
solely by a sharp point, the plateau having disappeared
entirely. The tracing still shows the inelasticity of
the artery in the relatively high position of the dicrot-
ic notch, which in the tracing of a normal, very low
tension pulse with a somewhat corresponding systolic
wave, would be near the base line and in the relatively
slight development of the dicrotism.
The next tracing (No. 15) from a case of pneumonia
in a man, aged sixty-two years, shows a still lower
tension of the same character, except that there are two
jagged water-hammer oscillations at the summit in-
stead of one, the blow being so sharp and the pulse
collapsing so suddenly that a second slight oscillation
occurred before the spring of the instrument followed
the receding wave.
Tracing No. 16 shows a water-hammer apex betray-
ing inelasticity of the artery, a slightly indicated systol-
ic elevation, a dicrotic notch midway in the tracing
and a slightly indicated dicrotic wave. The tracing
is obviously one of rather low tension in an inelastic
artery. Low tension indicates diminished velocity
and consequent diminished resistance to the blood
current, and may be produced, as in examples given
above, by arterial dilatation with a normal ventricular
output, in which case we have a large blood stream
flowing slowly. Or it may be produced by dimin-
ished ventricular output with normal or even contracted
or inelastic arteries, in which we have a small blood
stream flowing slowly. Other things being equal, the
amplitude of the tracing will be greater in low tension,
due to peripheral relaxation of the vessels, than in the
same condition due to ventricular failure, but no abso-
lute conclusions can be drawn in comparing the ampli-
tude of one tracing with that of another, because dif-
ferences in the size of individual arteries and in the
adjustment of the recording instrument are factors
having a material influence on the amplitude. In this
case, however, the radial was very large and somewhat
hard. It would be safe to infer, therefore, from the
moderate amplitude of the tracing, supposing it to be
properly taken, that the low tension was due to ven-
tricular failure. The patient in question was a man
of large frame, formerly of great physical strength but
suffering from cardiac dilatation, chronic nephritis,
and acute bronchitis. He moved about with difficulty
on account of dyspncea and weakness. The chief
point of interest for our present point of view was that
to tlie finger this pulse gave the impression of excep-
tional force, so much so that the patient, himself a
physician, remarked that there could not he anything
much the matter with his heart because his pulse Avas
so strong. The explanation was that on account of
the very great size of the artery the finger had to over-
come the resistance of a much larger surface under
tension than in the case of a vessel of normal size.
This combined with the comparatively sudden impulse
of a low' tension pulse and the resistance of a some-
what hardened artery, gave the misleading feeling of
strength and high tension to the pulse. The man's
condition proved that the sphygmogram was right and
the impressions produced upon the finger were abso-
lutely misleading.
One of the chief uses of the sphygmograph in ac-
tual practice consists in the ability it gives us to de-
tect high arterial tension in the earlier stage. This
February 24, 1900]
MEDICAL RECORD.
317
high tension in the majority of cases shows itself in
the flat-topped tracing similar to that shown in Fig.
10, and is indicative of arteriosclerosis chiefly, though
this is obviously combined in some cases, as in Fig.
9, with contracted arterioles. In many cases the
sphygmogram has given me information which I was
not able to obtain with my finger. It is hardly neces-
sary to recall the fact, long since demonstrated espe-
cially by Mahomet, that this high tension often pre-
cedes recognizable indications of lesions of the kidneys
by a long interval of time. In a case reported above
it was two years before granular and hyaline casts
were found, and five before albumin appeared in the
urine, that marked inelasticity of the vessels was de-
monstrated by the sphygmograph. The combined car-
dio-vascular and renal lesions require often not one or
two, but five, ten, or more years for their full develop-
ment.
Back of persistent high tension, back of the lesions
of heart, vessel, and kidney, are the little understood
changes in metabolism due to hygienic errors in eat-
ing and drinking, work and worry, e.xercise and recre-
ation, modified more or less by intercurrent infections,
acute and chronic. When the damage to the vascular
system and the kidneys has become so great that they
no longer are able to respond fully to even the most
restricted physiological demands, we can do but little
for our patients. In the earlier stages we can do
much.
It has often astonished me to see for how long some
patients, who are willing and able to take care of them-
selves, especially women in comfortable circumstances
and leading sheltered lives, will remain in fair general
health in spite of marked evidence of serious renal
and vascular disease. It is hardly necessary to insist
upon the great value of this early warning of coming
danger. The absence of high tension does not, how-
ever, necessarily exclude the existence of serious renal
lesions, especially those of parenchymatous nephritis
in a subacute stage. One of my records shows a nor-
mal, rather low-tension tracing in a case of parenchy-
matous nephritis apparently of malarial origin. The
patient from whom was taken the tracing showing high
tension, in a normally elastic artery (No. 7) during a
remission of the disease, later had a normal pulse.
Autopsy showed a diffuse nephritis predominantly
parenchymatous.
The effect of high arterial tension in producing car-
diac overwork has long been recognized. In a paper'
before this Academy, read last April, I presented the
reasons for believing, as demonstrated experimentally
by Romberg in 1895,= that excessive low tension such
as is present in pneumonia and other acute infectious
maladies is also a source of cardiac strain, my study
being confined to acute lobar pneumonia. Although
the resistance to be overcome at each ventricular sys-
tole is much below the normal, the increased rapidity
of the heart-beat rendered necessary in order to main-
tain a capillary tension adequate to the needs of the
body, and to secure a proper distribution of the blood
in all the organs irrespective of gravity, more than
offsets this advantage.
The records of other observers were confirmed in
demonstrating the existence of this low-tension pulse
by the use of the sphygmograph.
An interesting fact in this connection is the great
tolerance by these patients of digitalis. In a number
of cases on my service in the Harlem Hospital I
demonstrated this, using the U. S. P. infusion, not the
weaker one employed by Petresco, who has so strongly
advocated the treatment of pneumonia by large doses
of the drug The connection between this tolerance
' " The State of the Vasomotors in Acute Lobar Pneumonia."
New York Medical Journal, October 8, l8g8.
'■'Berliner klin. Wochenschrift, Nos. 51 and 52, 1895.
and the low peripheral resistance was strongly indi-
cated by the fact that the only patient who showed
marked intolerance of the drug, as evidenced by irregu-
larity of the pulse after its administration, was an old
man with rigid arteries, i.e., with one factor in periph-
eral resistance which dilatation of the arterioles
could not overcome. My expeiieiice confirms Petres-
co's records of very slow Jieart action during con-
valescence after this treatment.
My records contain cases suggesting that exces-
sively low arterial tension may be an important factor
in chronic as well as in acute diseases. The tracings in
cases of exophthalmic goitre are characterized by low
tension. In one instance the administration of ergot
and bromide of potassium, given with a view of bring-
ing up the tension, was followed by the rapid improve-
ment and recovery of the patient. One case proves
nothing, of course, but it is suggestive.
A case of rapid heart with a low-tension tracing
suggestive of both relaxed vessels and weak ventricle,
in which there was no other indication of Graves' dis-
ease, was not much affected by ten-drop doses of tinc-
ture of strophanthus, but was markedly helped by
twenty-five- and thirty-drop doses continued for a long
period.
This experience recalls the correspo- ding tolerance
of digitalis in pneumonia. Most authorities agree in
stating that digitalis is of little use in Graves' disease,
referring doubtless to the ordinarily used amounts of
the drug. This case suggests the possibility that in
Graves' disease, as in pneumonia, there may be a tol-
erance of the drug requiring a much larger dose to
produce a given effect than is necessary in cases of
average pulse tension.
A lady who had long been exposed to trying condi-
tions in life, came to me complaining of prostration
and flatulent dyspepsia. Her sphygmogram (No. 17)
showed inelastic arteries and marked post-systolic low
tension. After improving greatly under treatment she
presented the following tracing (No. 18). The con-
trast makes it not at all improbable that abnormally
low tension due to some passing auto-intoxication was
embarrassing her heart and giving rise to the feeling
of weakness complained of when she was first seen.
I had from time to time been much puzzled by com-
plaints of faintness from patients, quickly following
the administration of nitroglycerin. In these cases,
what probably happened is that owing to an overdose,
or to the more than usually rapid absorption of a dose
generally tolerated, the arterial tension was carried so
far below the middle point, at which the heart does its
work with the least effort, that it became embarrassed
in the way above indicated.
The conception of abnormal relaxation of the periph-
eral vessels as a factor in causing cardiac embarrass-
ment has received but little attention.
These cases are offered to illustrate the importance
;i8
MEDICAL RECORD.
[February 24, 1900
of more definite study of this condition in the future,
and of the value of the sphygmograph iin demonstrat-
ing its existence.
The last series of sphygmograms which we will con-
sider are those produced in cases of aortic-valve le-
sions. Leakage of the aortic valve gives rise to post-
systolic low arterial tension, which will be greater or
less according to its amount.
Tracing No. 19, taken from a boy aged eighteen
years, with marked cardiac dilatation, shows a pri-
mary wave obtusely pointed, a dicrotic notch far down
in the tracing, and slightly indicated dicrotic impulse.
The last feature in a tracing, showing, as this does, an
elastic artery, is indicative of considerable aortic leak-
age. In an elastic artery with competent aortic valves
and as low a post-systolic tension as is indicated by
the position of the aortic notch, the dicrotic wave
would be much more pronounced than it is in this
instance.
Tracing No. 20 shows a slightly high-tension sphyg-
mogram of normal type. As the dicrotic impulse is
fully developed, the murmur must have been due to a
very inconsiderable leakage. Mitral regurgitation and
great hypertrophy of the left ventricle were also
present.
The next tracing (No. 21), taken with a spring
pressure of three ounces from a subject with marked
cardiac hypertrophy but no subjective symptoms,
shows systolic high tension with rounded indications
of primary and tidal waves and marked post-systplic
low tension, with slight indication of the dicrotic im-
pulse. This shows a well-compensated leakage of
considerable extent in elastic arteries.
In the next (No. 22) the rounded summit of inelas-
ticity appears, and the post-systolic low tension is ob-
viously due to two factors, viz., rigidity of the great
vessels and aortic-valve leakage. Three months later,
this patient's pulse had increased from 80 to 126, and
his compensation had markedly failed. His sphyg-
mogram (No. 23) then presented two jagged water-
hammer oscillations at the summit, which we have al-
ready learned to associate with falling tension in rigid
arteries, and the dicrotic impulse became much more
marked. This latter circumstance would seem to show
that rigidity had a greater share than leakage in the
suppression of this impulse in the earlier sphygmo-
gram, as the effect of rigidity in suppressing dicrotism
is in a measure offset by diminished tension, as may
be seen by comparing tracings 17 and 18, in which
inelasticity existed unaccompanied by leakage. The
autopsy of this case, made some months later, showed
a flabby dilated and hypertrophied heart, smooth,
evenly contracted, and somewhat thickened aortic-valve
leaflets, and a very atheromatous and dilated aorta.
Tracing No. 24 shows a sharply pointed wave fall-
ing quickly to the base line without indication of
either dicrotic notch or impulse. In a pulse of so
extremely low tension we would hardly be justified in
concluding that the water-hammer oscillation was due
to inelasticity of the vessels, because even in elastic
vessels such an oscillation may be produced when the
tension drops excessively. The tracing falls away
with great suddenness, showing no trace of tidal wave
or dicrotic notch or impulse. A very short ventricu-
lar systole and great leakage of the aortic valves may
be inferred. It was taken twelve hours before death
from a man in whom an autopsy showed enormous left
ventricular hypertrophy and dilatation associated with
extensive fibroid changes in the heart muscle, dilata-
tion of the aortic orifice with shrunken and thickened
valve leaflets, and an aorta which was greatly dilated
and atheromatous, the roots of the great vessels being
also markedly affected.
Broadbent presents in his book on the pulse a num-
ber of tracings of varying form representing aortic re-
gurgitation, taken by different observers with different
instruments, as proof of the unreliability of the sphyg-
mograph. I have presented a still more widely vary-
ing set of tracings from patients with aortic regur-
gitation taken by the same observer with the same
instrument. I hope that the above analysis has made
it clear that these differences, instead of showing any
fault on the part of the instrument, are in reality valu-
able and easily interpreted records of the varying con-
ditions present in individual cases.
The next tracing (No. 25) was taken from a case of
marked aortic obstruction, the characteristic feature
of which is the very gradual line of ascent indicative
of the slowness with which the blood was forced past
the narrower aortic orifice into the vessels. The pulse
in this case gave a misleading impression of extreme
weakness owing to the gradual distention of the ar-
tery. The sphygmogram corrected this false impres-
sion and indicated the fact that the systolic murmur
over the base to the right of the sternum was due to
very considerable narrowing of the aortic orifice.
February 24, 1900]
MEDICAL RECORD.
319
This tracing resembles in character No. 26, which was
tai^en from the left radial of a case of aortic aneurism,
No. 17 showing the right. In this case marked dif-
ference was detected only on an occasion when the
aneurismal sac was temporarily distended by a parox-
ysm of coughing.
The utility of the sphygmograph in giving a record
of the various irregularities of the pulse associated
with myocardial disease, with or without mitral lesions
and with certain to.xaemias, may be mentioned, but ex-
emplification would hardily be profitable in this place.
The individual pulse waves show nothing characteris-
tic of these conditions, and in so far as they give evi-
dence of deviations from the normal they are to be
analyzed in accordance with principles already suffi-
ciently illustrated.
A general objection to the utility of the sphygmo-
graph has been the alleged uncertainty of its results:
that different observers working with the same or dif-
ferent instruments fail to get analogous tracing in sup-
posedly parallel cases, or even in the same case. Some
of these objections, such as that of Broadbent above
quoted, are certainly not valid, as the observed differ-
ences are based upon corresponding variations in the
factors which influence the tension of the arteries in
the successive periods of the cardiac cycle in the indi-
vidual case, as I have illustrated in a number of in-
stances. It is nevertheless true that faulty appli-
cation of the instrument may give unsatisfactory or
misleading results. In small arteries of high tension
failure in the use of sufficient pressure on the spring
results in getting a tracing of too small an amplitude
for analysis.
In many cases of medium-sized vessels and tension,
however, variations in spring pressure often produce
surprisingly uniform tracings differing only in ampli-
tude. Every degree of tension in the artery requires
a certain degree of pressure on the spring for its full-
est development in the tracing. Too feeble a spring
pressure fails to develop fully the strong portions of
the tracing and gives undue prominence to the weak.
Too strong a pressure tends to suppress more or less
completely the weaker parts of the tracing and give
undue prominence to the strong.
In tracing No. 28, taken from a case of pneumonia
with a pressure of two and one-half ounces, the systol-
ic portion is strongly marked, the dicrotic wave is
almost suppressed.
Tracing No. 29, taken from the same case, with a
pressure of one and one-half ounces, shows a less
marked systolic wave and a very well-marked dicrotic
impulse. In this case, if the rule, had been followed
to accept the tracing taken when the spring was at that
degree of pressure which gave the largest excursion of
the recording needle as the nearest representation of
the truth, it would have been an obvious error. The
only method of getting with any degree of certainty a
tracing with that medium pressure on the spring which
does not sacrifice the strong to the weak portions, or
■vice versa, is to take a series of tracings, each not nec-
essarily occupying more than a third or fourth of a
slip of the usual length, with a gradually increasing
pressure on the spring. As with each increase of pres-
/v^^^s^^Mv^^^^^Mwv^^
sure on the spring there must be a corresponding in-
crease of the tightness of the band which fastens the
instrument to the wrist, the addition of two small tour-
niquets on this, band, one on either side of the sphyg-
mograph, is of very great importance in securing accu-
rate results, as by their use the band may be tightened
or loosened without lateral displacement of the instru-
ment. The effect of too great pressure on the spring
in another type of tracing is illustrated in Figs. 30
and 31. The first (No. 30) was taken at a pressure of
three ounces. The second (No. 31), at a pressure of
four ounces, shows the suppression of the first portion
of the tracing and a diminution of amplitude in the
tracing as a whole.
I have so often proved that this peculiar nicking
out of the first portion of the tracing is an artefact that
I am sure that any sphygmogram presenting such a
peculiarity may be rejected as imperfect. It will be
observed that the water-hammer oscillation is included
in the suppressed part of the tracing. The spring had
become too stiff, relatively to the force of the pulse,
to yield to the blow.
On the other hand, in taking a series of tracings at
gradually increasing pressure the water-hammer oscil-
lation may be absent in the tracings taken with a small
amount of pressure upon the spring, and appear as the
pressure increases. The tracings in which it appears
under these circumstances will usually be found to be
of greater amplitude than those taken at a lower spring
320
MEDICAL RECORD.
[February 24, 1900
tension, and these pulses are usually of considerable
tension in inelastic arteries. The explanation of its
absence in these lower spring tension tracings is that
the spring had not yet been pressed down upon the
artery enough to get the full force of the blow.
In tracing No. 32, at a pressure of three ounces no
water-hammer oscillation is evident. In tracing No.
33, at a pressure of four and one-half ounces, it is ob-
vious.
Failure to apply the middle of the pad of the instru-
ment exactly over the artery results sometimes, espe-
cially in large vessels of low tension, in obvious dis-
tortion of the tracing. The variety which I have been
able distinctly to recognize resembles that produced
by too great tension of the spring. Apparently the in-
strument is tilted to one side as the artery rises, and
the vessel impinges on the rigid projection at the side
of the spring. As a consequence, the tracing is par-
tially suppressed.
Finally, it must be confessed that we find occasion-
ally arteries that are so small or so deeply placed that
no satisfactory tracings can be obtained. Also, when
the ventricular action becomes very feeble the varia-
tions in the tension of the artery may be too weak to
overcome the inertia of the instrument sufficiently to
give a tracing of any value. In spite, however, of these
confessed limitations and sources of error a review of
a considerable number of tracings taken by me during
the last fifteen years shows so constant a recurrence
of certain types whose readings harmonize with the
clinical history of the cases and with the post-mortem
findings, when it has been possible to obtain autop-
sies, that I have come to regard the sphygmograph as
of very considerable practical value in diagnosis, and
its sources of fallacy no greater than in many other
methods of investigation which we would not think
of discarding.
106 West One Hundhed and Twenty-second Street.
THE PHY-SICIAN AS A FACTOR IN EDU-
CATION.
By frank OVERTON, A.M.. M.D.,
PATCHOGtiR, N. V.
Dr. Holmes, in his " Autocrat " papers, says that each
individual is a trinity of three distinct personages:
First, he is what he thinks himself to be; second, he
is what others think him to be; and third, he is what
he really is. What medical science actually accom-
plishes is in marked contrast with the notions which
are often held even by educated people. This paper
deals with the second person of the doctor's trinity,
or with the opinion which the public have of medical
matters. It indicates a few of the many points in
which they might be educated by the medical profes-
sion with benefit both to the community and to the
profession itself.
A little of a man's knowledge comes from read-
ing and study; but by far the greater number of
his ideas are received from conversation with his
parents or associates. In other words, the most of
each individual's knowledge is as purely traditional
as it was in Homer's day. Fifty years ago the science
of medicine was crude in its simplicity, and could
easily be acquired through a short apprenticeship
in a doctor's shop. As in other sciences, what
were then professional secrets have now become com-
mon knowledge. But many theories which have long
since been discredited by the profession still linger
in the popular mind, and are perpetuated by tradition,
as parents tell them to their children, and ignorant
nurses to their patients. Within a generation medi-
cine has advanced so rapidly that even an educated
layman can scarcely follow a modern interpretation of
a simple disease. The laity, however, are familiar only
with the medicine of a generation ago, and they are
ready to act on their erroneous ideas.
In the treatment of every patient the physician will
be plied with questions which indicate the survival of
ancient ideas of physiology and pathology. Has he
taken cold.'' Will it lead to fits.' Would a plaster
draw out the pain? Can't you give something for his
blood? \^'ill it do to heal up the sore? Would it
not be better to wait for the abscess to open itself?
These familiar ^^uestions are relics of ancient medical
thought, which survive only by tradition. The physi-
cian in his hurry or annoyance assents to every ques-
tion, and thus unwittingly lends his sanction to erro-
neous and often untruthful impressions. While these
antiquated ideas may not directly affect the patient's
recovery, they put a conscientious physician in a
dilemma. If, for instance, he says that a patient suf-
fering with boils does not have bad blood, he loses
his reputation as a diagnostician; and if he professes
to give a blood medicine, he loses his own self-re-
spect. As long as a recent graduate thinks only of the
needs of his patient, his practice is chiefly in personal
economy; but when the struggle for existence compels
him to look chiefly after their preferences, he gains a
profitable reputation for experience in purifying the
blood, opening the pores, drawing out pain, and bring-
ing abscesses to a head. This is business, but it does
not seem quite professional that we need to deceive
the community by our words, even though our diag-
noses and prescriptions are scientifically correct.
Along with treatment, patients usually ask concern-
ing the nature of their diseases, and the reasons for
treatment. It is to our advantage to give them this
information, and especially so since it is expected.
There need be no fear that in a few moments any one
can wrest from us secrets whose acquisition cost us
months of close application. Even though some
should gain a few practical ideas, sickness will not
cease, for human nature is ever the same, and the doc-
tor himself sometimes transgresses the laws of health.
The meaningless diagnosis that the "system is run
down," and that a "tonic" will permanently restore
it, is usually satisfactory to the patient, and profitable
to the physician. This belief seems harmless, but it
is really only another phase of the fable of the foun-
tain of eternal youth. The public have outgrown
these nursery tales, and can now bear the strong meat
of science. Let us teach tiie great principle of self-
poisoning from the retention of waste products; show
their origin in errors of diet, ventilation, and exer-
cise; tell of their expulsion ordinarily through the
skin, kidneys, liver, and bowels, and in an emergency
through the stomach also; give the action of drugs on
these organs; and explain nature's remedial measures
of refusing food or of rejecting that which is already
feeding the poisons. Let us make plain the nature of
each infectious disease, and the manner o' its trans-
mission; and impress the infectious origin of all
February 24, 1900]
MEDICAL RECORD.
321
"matter" and abscesses, and the necessity of surgical
measures in their treatment. It is time that these
and similar truths should enter into popular thought.
How shall we instruct our "nervous" patients?
The more the)' know the more fearful they become, un-
til it would seem as though any instruction at all
would be unpractical. This class of patients are
usually intelligent, and talk much about their ail-
ments and the doctor's opinions. Many erroneous
impressions are fixed by the innocent deceptions
which the physician is almost compelled to practise
in order to pacify them. For instance, the popular
confidence in "something to quiet the nerves" is per-
petuated in this way. These patients are impressed
by the personality of a healer rather than by any in-
trinsic value in his therapeutic measures. Hence they
are the willing followers of Christian scientists, faith
curists, advertisers of nostrums, and of any one else
who has the self-assurance to claim unusual powers.
Of course a few are completely relieved, and their
positive testimonials outweigh the negative opinions
of the hundreds who are duped. If only for our own
interest, we should explain the scientific principles by
which these cures are effected, and that, under other
names, they are being applied constantly with but a
small percentage of failures.
Abstract physiology is taught in all public schools,
but applied physiology and the physiology of sickness
is learned only from the doctor. No matter what the
schoolbooks may teach, the doctor's opinions are be-
lieved and acted upon.- The proper administration of
a prescription presupposes a certain amount of knowl-
edge on the part of the attendant. Unless the medical
education of the people is up to the times, we will be
handicapped in our treatment. Both self-interest and
the public good demand that we should promote the
medical education of the people.
AN OPERATION FOR THE RELIEF OF AN
INCARCERATED IRIS.
By GEORGE HU.STON BELL. M.D..
Realizing the number of failures and the bad results
that very frequently accompany the operations which
are done for the relief of tlie incarcerated iris, I desire
to bring to the notice of the ophthalmic surgeon an
operation which, so far, I have never seen fail. It is
not recommended, nor can it be employed, in recent
injuries which are seen in the first forty-eight hours.
It can be used only in what one might call "an old
case of incarceration " which has had for its duration
four to six days, or longer, and in which the original
wound in the cornea has completely healed, leaving
the iris jammed between its internal lips. When the
nutrition of the cornea has been re-established, it is
then that this operation is indicated, and not before.
In this class of cases I submit this operation for con-
sideration and approval. As to whether or not a sur-
geon wishes to operate, after the lapse of several days
or more, upon an eye of this kind, must be decided by
himself, based solely upon his clinical experience, as
there is no hard-and-fast rule laid down by the text-
books on ophthalmology, although Fuchs claims that
an incarceration may afterward give rise to increase
of tension, to inflammation, and even to sympathetic
disease of the other eye. Such deplorable symptoms
are not rare, and several times came under my imme-
diate observation while a house surgeon at the New
York Eye and Ear Infirmary.
As to the operation, it can generally be done much
more satisfactorily, as a rule, under local anaesthesia.
although ether is preferred for children under ten
years of age. The great principle involved in this
operation is the cutting loose of the iris from its at-
tachment to the posterior surface of the cornea, with
one sweep of the Von Graefe cataract knife. The
technique of the operation is as follows: After the eye
has been made as aseptic as possible, either with solu-
tion of boric acid or i : 5,000 mercuric chloride, the
curved linear incision is made with the Graefe knife
after the manner employed in doing anterior sclero-
tomies. Not always cutting upward, not always cut-
ting downward, but sometimes to one side, sometimes
to the other, as the case may be, the surgeon using his
best judgment, depending entirely upon the situation
and the extent of the incarceration, the Graefe knife
is entered one-half to one millimetre outside the mar-
gin of the cornea, and the blade of the knife is passed
into the anterior chamber between the incarceration
and the centre of the pupil. The counter-puncture
is made the same distance behind the limbus if pos-
sible; then the operator cuts from within outward,
through the incarceration, on out through the sclera
and conjunctiva. It is not necessary for the counter-
puncture to be directly opposite the point of entrance
of the knife as it is in anterior sclerotomies or cataract
extractions. The great object is to make as small a
section as possible, and after one gets the point of the
knife by the incarceration, one makes the counter-punc-
ture at once, thereby reducing the size of the section
to the minimum, for obvious reasons, having always
in mind the conjunctival flap. Now the operator turns
this flap over the cornea, so that the wound may be
exposed to view; then the iris forceps is introduced
into the anterior chamber and the iris is caught, drawn
out, and excised with the scissors. The columns of
the coloboma are then replaced by means of irrigation
with a sterilized decinormal salt solution through a bulb
syringe, which little device is generally very efi:ective
and without any bad results to the lens. Of course,
when necessary we resort to the spatula to help us out
of the difficulty of freeing the pillars of the coloboma.
Too much stress cannot be laid upon this point. The
flap of the conjunctiva is then returned to position and
the wound is sealed by stroking it with the spatula;
one drop of a sixteen-grain solution of atropine is in-
stilled, and both eyes are bandaged for twenty-four
hours.
My reasons and plea for the conjunctival flap are as
follows; (i) Fuchs claims that scleral wounds are less
liable to become infected than those of the cornea, be-
cause of the slighter tendency that the sclera exhibits
toward purulent inflammation, which is certainly worthy
of consideration. (2) Another great advantage, which
must not be overlooked, is that the wound heals a great
deal faster, thereby causing a quicker restoration of the
anterior chamber, which, after all, is the desideratum.
(3) The astigmatism is not nearly so great.
This operation has been done successfully a number
of times. Dr. Peter A. Callan having performed it fre-
quently at the New York Eye and Ear Infirmary, and
always with excellent resialts. Dr. N. D. McDowell,
my successor as house surgeon, as well as myself,
has had satisfactory experiences with such cases.
54 East Twentv-fifth Street
Buboes, when suppurating, may be opened pain-
lessly by first injecting beneath the skin a three-per-
cent, solution of beta-eucaine. After evacuation a
five-per-cent. solution is poured into the wound, and
after a few minutes curetting may be performed lightly
without pain. One drachm of solution may be thus
used with safety. To obviate the prick of the hypo-
dermic needle in very sensitive subjects, first spray
with ethyl chloride. — Dalton, Therapist, December
15, 1899.
322
MEDICAL RECORD.
[February 24, 1900
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM, WOOD &. CO., 51 Fifth Avenue.
New York, February 24, 1900.
THE SIGNIFICANCE OF BOVINE TUBERCU-
LOSIS.
In order to determine this matter in an adequate man-
ner Dr. George Adami, of Montreal, says that the fol-
lowing three main questions have to be asked and an-
swered: (i) Is tuberculosis in cattle a source of danger
to other cattle so as seriously to affect their well-being
and to be a source of loss to their owners? (2) If
infectious from animal to animal, is it infectious from
animal to man, and thereby a grave source of danger
to the human race.' (3) If infectious from animal to
man, what are the commonest modes of infection, and,
as a sequel to this, how are we to diminish the dan-
ger?
The first question Dr. Adami answers with an un-
qualified affirmative, and gives a mass of statistics col-
lected from different parts of the world in support of his
contention. To the second and most important ques-
tion, while accepting an affirmative as the correct an-
swer. Dr. Adami points out that the amount of reliable
evidence of direct transmission of tuberculosis from
cattle to man is singularly slight. After drawing at-
tention to the fact that experiments undertaken with
the view of proving or disproving this theory have
been attended with more or less negative results, Dr.
Adami says we are forced, therefore, to fall back upon
evidence of another type, and presents the case thus :
"Do the bacilli gained from the human and bovine
species possess a morphological and cultural identity?
They do not. The bovine grow more freely in the or-
dinary glycerinated media; they are, I find, of greater
relative breadth, while again pathogenetically they e.x-
hibit different degrees of virulence, and this when inoc-
ulated not only into cattle, but into guinea-pigs and the
small animals of the laboratory. ... So far, however,
bacilli having all the morphological and cultural char-
acteristics of the bovine ' race' have not been isolated
from the human organism, nor do I know that, so far,
by placing protected human bacilli in the abdominal
cavity of the cow these have assumed the bovine char-
acters. It is in this last e.\periment, I believe, that
the solution of the question is to be found. For if we
can show that under favorable conditions the human
bacillus can become highly pathogenetic for cattle, the
converse would also seem to hold, that there are con-
ditions under which bovine tubercle bacilli can be
pathogenetic for man." Dr. Adami concludes that
failing experimental and bacteriological evidence of
bovine and human tuberculosis, the casuistic evidence
while not absolutely convincing is strongly in favor
of the view that tuberculosis can be conveyed through
the milk of animals extensively diseased.
With regard to the more frequent modes of infection
Dr. Adami dismisses rapidly the infectiousness of
meat, and goes on to say that with milk the problem
presents several difficulties. With the finding of the
British Royal commission, that only when the udder is
diseased does the milk become infectious, he is not in
agreement, being convinced that it is founded on im-
perfect knowledge, and states that he cannot but come
to the somewhat unsatisfactory conclusion that where-
as, in the first place, the milk of animals not suffering
from udder tuberculosis may contain bacilli, neverthe-
less such milk is not of high infective power, and that
therefore the frequency with which the bacteriologist
may by inoculation into the very susceptible guinea-
pig find the milk to be infectious is not absolute
indication of its danger when employed as a food for
man. Only when there is recognizable udder tuber-
culosis, and active tubercle bacilli are discharged into
the milk in enormous numbers in consequence of ul-
cerative changes occurring in the tubercles, is there
real danger. For practical purposes Dr. Adami agrees
with Nocard that as regards the milk supply local tu-
berculosis of the udder is what has to be most espe-
cially guarded against, and this not because the evi-
dence at our disposal affords absolute proof of the
transmission of tuberculosis from cattle to man, but
because the trend of evidence is all in that direction.
On the whole, therefore, Dr. Adami is in accord with
the chief authorities on bovine tuberculosis with re-
gard to the means of transmitting the disease to man,
that*the danger from infection from meat is so slight
as not to be worth considering; that the principal
source of danger is from infected milk, and that only
milk procured from cows with diseased udders is to
be greatly feared. The question as to what measures
should be taken to guarantee a milk supply free from
infection has been so fully dealt with in former num-
bers of the Medical Record that further discussion
of these points would be superfluous.
It is, however, satisfactory to observe that at the
meeting of the Medical Society of the County of New
York the question of a pure milk supply was treated
at length, and the president of the society was re-
quested to appoint a special committee to consider the
possibility of a commission to improve the milk supply
of New York.
THE DANGERS OF WATER GAS.
The substitution of water gas for lighting purposes in
the place of coal gas, w-hich has been carried out in
many American cities, has been a fruitful cause of
numerous fatal cases of asphyxiation. Coal gas is
comparatively harmless, containing as it does but
from three to twelve per cent, of carbon monoxide,
more often the former quantity than the latter. On
the other hand, water gas has in its composition
seldom less than twenty-five per cent, of carbon
February 24, 1900]
MEDICAL RECORD.
323
monoxide, and not infrequently as much as thirty per
cent, and over. Water gas has found favor with the
municipalities of a number of American towns for the
reasons that it gives a brighter illuminating-power
than coal gas, and because it is better adapted for an
emergency; that is to say, it can be manufactured
more quickly. But although it has these substantial
advantages on its side, it is notwithstanding a con-
stant menace to the public health. The danger of
carburetted water gas lies in the fact that it contains
so large a quantity of carbon monoxide that its inhala-
tion by human beings is always attended by serious
consequences to life. Dr. Haldane, one of the Brit-
ish departmental committee appointed to inquire into
the manufacture and use of water and other gases con-
taining a large proportion of carbon monoxide, pointed
out that in the case of Boston, where ninety per cent,
of the gas is water gas, about one in every three hun-
dred deaths is due to accidental poisoning, and the
committee resolved that they would not allow in Great
Britain more than twelve per cent, of carbonic mon-
oxide in illuminating-gas.
However, no such permissive regulations are likely
to be put into force in this country. The American
is ever somewhat careless of risks, provided that his
comfort and convenience are considered ; so that the
crux of the problem here is how to treat in the most
successful manner those who are unfortunate enough
to inhale a sufficient quantity of the gas to become
dangerously asphyxiated. Working along these lines,
experiments have recently been conducted under the
direction of Dr. N. Wiley Thomas, at the physiologi-
cal laboratory of the University of Pennsylvania, with
the object of demonstrating the most effective methods
of resuscitating animals poisoned or rather asphyxiated
by inhalations of common illuminating-gas. The gas
used in the experiments was the ordinary illuminating-
gas of Philadelphia, which is composed of hydrogen
26.25; marsh gas, 28.91; carbon monoxide, 27.12;
illuminants, 15.80; carbonic acid, trace; oxygen,
trace; nitrogen, 1.92. Dr. Darrah's theory of the ac-
tion of the gas — with which the writer on the subject
in Allbutt's "System of Medicine" agrees — is that
the asphyxia is due to the fact that the carbon monox-
ide in the gas forms a stable compound with the hemo-
globin, thus preventing the haemoglobin from carry-
ing oxygen to the tissues. Dr. Darrah goes on to say
that the compound itself has only a slight irritating
effect. When animals breathe pure oxygen and small
amounts of carbon monoxide, the carbon monoxide is
taken up by the haemoglobin in preference to the oxygen,
and forms a compound that cannot be displaced with
oxygen. The condition produced in the animals after
inhalations of the illuminating-gas resembled in most
respects those of individuals asphyxiated by identical
means, as dizziness, tottering, and inability to walk.
Later in the condition there was low temperature, with
rapid, feeble pulse. Respiration was increased in
frequency and depth. The remedies first used to re-
lieve this collapse were stimulants such as strychnine,
brandy, glonoin, digitalis, followed by inhalations of
pure oxygen, electricity, and artificial respiration, but
with few favorable results if the condition had been
profound. Nor did doses of hydrogen dioxide vary-
ing from 10 c.c. to 60 c.c. afford any but negative re-
sults. Hydrogen dioxide was next injected intrave-
nously in both small and large doses. The former
were without effect, and the latter caused oxidation of
the blood with formation of gas in the blood-vessels,
causing instant death. Injections of saline solutions
did practically no good. Lastly, resort was had to
transfusion of blood, the blood being drawn from the
carotid artery of a healthy normal dog, and allowed to
flow into the jugular vein of an animal under the in-
fluence of gas. Dr. Darrah reports that the effect of
this method of procedure was magical recovery, occur-
ring in most cases instantly; some few dogs showed
symptoms for several hours, but eventually recovered.
During the transfusion improvement was noticed in
the heart action and in breathing with the first few
ounces of blood injected.
From the foregoing experiments Dr. Darrah drew the
following conclusions: i. Small quantities of H„0,
have no effect. 2. Large quantities of H„0„ have an
oxidizing action, with death from gas accumulating
in the chambers of the heart. 3. Saline solutions are
not of much use; some animals rallied but finally
died. Life may be somewhat prolonged. 4. Trans-
fusion abolishes almost immediately the poisonous
effects of the gas, with no bad effects except in case
of septic infection. It is interesting to note that the
dogs from which blood was taken recovered in every
instance.
Although the results of the experiments at Phila-
delphia appear to have been wholly successful, yet
there are many medical authorities who prefer to put
their trust in inhalations of pure oxygen. Dr. Hare
holds that the direct transfusion of blood, even from
the same species of animal, is futile, as the corpus-
cles are destroyed and a transient haemoglobinuria
follows. He stated that in some experiments made by
himself and Dr. Martin they had found that inhala-
tion of oxygen produced extraordinary results in dogs
poisoned with coal gas. However, the fact should be
borne in mind that the experiments undertaken by Dr.
Darrah were upon animals which had inhaled much
more carbon monoxide than would be contained in
any description of coal gas.
Dr. Lorrain Smith reported in the London Lancet,
in the early part of this year, several cases of gas
poisoning which occurred in Belfast. He said that
the cases brought out for the first time on record the
extreme importance of the secondary effects of gas
poisoning. One case on analysis showed the pink
tint of carbon-monoxide haemoglobin. On analysis by
the carbon method the blood was found to be fifty-
seven per cent, saturated. The blood of one child aged
four years was very slightly tinted and not more than
five per cent, saturated. Since the child was exposed
to the same atmosphere as the adult, it is clear that
her blood was at one time at least as highly saturated
as fifty-seven per cent. Thg artificial respiration
which was applied by the medical attendant sufficed
to clear the carbon monoxide out of the blood. The
child therefore died from what may be called second-
ary effects of gas poisoning on the heart and nervous
324
MEDICAL RECORD.
[February 24, 1900
system. In Allbutt's " System of Medicine " the fol-
lowing modes of treatment are laid down: "Imme-
diate removal of the patient from the presence of the
gas, and artificial respiration persisted in for hours in
order to expel, if possible, the poisOn from the blood;
Laborde's method of rhythmic traction of the tongue;
hypodermic infections of strychnine, and the applica-
tion of the faradic current to the phrenic nerve — but
even with these measures venesection and transfusion
of blood may also be necessary. Inhalation of oxygen
in some cases is also recommended." Dr. Ransome
advises Sylvester's method of artificial respiration.
Taking into consideration the peculiarly insidious
narcotizing and fatal effects of carbon monoxide, and
the presence of it in large quantities in the gas used
in so many American towns, the importance to the
public of discovering a really effective means of re-
suscitating individuals who have fallen under its in-
fluence is one that can hardly be overestimated. Ex-
periments such as have been prosecuted at Philadelphia
will go far to elucidate these moot points, and if it can
be plainly shown that transfusion of blood is the best
method to revitalize the almost extinct spark of life in
cases of deep asphyxiation, a great boon will have
been conferred on that portion of the human race who
live in the big cities.
DIETARY STUDIES OF NEGROES.
Dr. Frissell and Miss Isabel Bevier have in connec-
tion with the United States Department of Agriculture
contributed a series of dietary studies of negroes liv-
ing in Eastern Virginia. The studies made in 1897
were conducted by Dr. P'rissell, and the investigations
on the same lines in i8g8 by Miss Isabel Bevier.
The mode of life and the quality and quantity of the
food of the colored race in the United States is a sub-
ject that has received but little attention. Some statis-
tics were collected a few years ago with regard to the
food consumption of negroes residing near Tuskegee,
Ala. These investigations showed that where negro
families had profited by the opportunities for educa-
tion provided at Tuskegee Institute, their methods of
living had undergone a considerable change, approach-
ing more closely to those of an ordinary American
family. Other families who had not come under such
influence might be regarded in the matter of diet as
representative of the uneducated negro type.
The results of the studies in Virginia coincided in
the main with those arrived at in Alabama. More
protein was found in the dietaries of negro families in
Virginia than the average amount consumed by white
persons in fairly prosperous circumstances, nearly as
large as that called for in the tentative American
standard — namely, 125 gm. per man daily. This fact,
however, is explained by the proximity of salt water
to the district in which the investigations were con-
ducted in Virginia, which made fish an important arti-
cle of diet. The average fuel value of the food con-
sumed per day by the negro families both in Alabama
and Virginia is as large or larger than that found in
dietary studies made among white families. The aver-
age fuel value found in nineteen studies in Virginia
was 3,745 calories; that found in twenty studies in
Alabama, 3,270; the average of ten white families in
New England and New York, 3,515; while the tenta-
tive standard for a man at moderate work calls for
3,500 calories per day. Perhaps the most noteworthy
feature revealed in connection with these studies was
the small cost of the food. For eleven cents the fam-
ilies in Virginia obtained food materials furnishing
more protein and more energy than were obtained for
twenty-eight cents by the families of professional men
in comfortable circumstances, and for nineteen cents
by families of well-paid mechanics. It would appear
from a consideration of the dietary studies made in
Alabama and Virginia among negro families that the
character of the food consumed by them is coarser and
less appetizing than would be tolerated by an ordinary
white family. " Hog and hominy " forms the staple
of their diet. Scarcely any meat besides pork is
eaten, but where obtainable fish is a favorite article
of food, while at certain seasons frogs, turtles, and even
snakes are eaten by some families. The cooking of
the negroes is primitive to a degree, and their drink-
ing-water is, as a rule, stagnant and brackish, often
muddy. The fact, however, stands out prominently
that notwithstanding the agricultural negro's careless,
unhygienic methods of living, he is able to do hard
manual labor and enjoys almost if not quite as good
health as his white brother placed in like circum-
stances.
TYPHOID FEVER IN PHILADELPHIA.
While the authorities are deliberating upon the best
means of providing a pure supply of water, the people
of Philadelphia are again threatened with an epidemic
of typhoid fever. The drinking-water in that city has
for some time past been filthy and most unattractive
for either bathing or drinking, but a short time ago a
number of boys in amischievous spirit interfered with
an intercepting sewer, as a result of which sewage was
made to overflow into the Schuylkill at a point not
remote from a pumping-station. The statistics tell
the rest of the story more eloquently than could any
description. For the week ending January 20th there
were reported to the Philadelphia bureau of health
thirty-five cases of typhoid and eight deaths; for the
week ending January 27th, forty-four cases and nine
deaths; for that ending February 3d, thirty-nine cases
and six deaths; for that ending February loth, fifty-
six cases and six deaths ; and for that ending February
17th, seventy-six cases and fourteen deaths. For this
last week there are also tabulated thirteen deaths from
" inflammation of the stomach and bowels." The
whole number of deaths for the city during the week
was five hundred and three — thirty-four more than for
the corresponding week of last year. As already indi-
cated, the city of Philadelphia has under consideration
the report of a commission of experts on water purifi-
cation, which it has adopted, and for putting into exe-
cution the recommendations of which it has voted the
February 24, 1900]
MEDICAL RECORD.
;25
making of a loan of many millions of dollars; but
with conventions to look after, vacant senatorships to
fill, patronage to solicit and dispense, franchises to give
away, ballot-boxes to stuff, election returns to falsify,
and other congenial occupations, office-holders and
politicians may see no need of haste in providing a
better water supply — and the people will get what they
deserve from those they selected to act as their repre-
sentatives.
Hetus of tixe 'S^cek.
A New Anti-Tuberculosis Serum — The Sei-i-Kwai
Medical Journal announces a discovery which will
doubtless have most important consequences if the
author's hopes are realized, in the following terms;
" Fleet-Surgeon T. Yabe, of the imperial Japanese
navy, who is now studying bacteriology in the Pas-
teur's Institute, Paris, discovered some method to
make human subjects immunity from the tubercular
disease with some material which he calls tuberculo-
immunitine. We heartily congratulate his success
for such great and difficult subject which was consid-
ered almost impossible to achieve at among the immi-
nent authorities in pAirope and America."
A Suit for the Value of Epidermis.— A young
woman recently sued a physician of North Adams,
Mass., for damages for having taken more skin from
her body for grafting purposes than she claims to
have authorized him to take. She had consented to
furnish the material for skin-grafting in a case in
which that operation was necessary, but after the
operation was concluded she claimed that the surgeon
had denuded her too much. The judge, however,
decided that there had been no specification as to the
amount the plaintiff was willing to give, and conse-
quently the defendant was at liberty to take all he
needed. The case has been appealed to a higher
court.
Heat in South America. — On February 5th, there
were two hundred and sixty-seven cases of sunstroke
in Buenos Ayres, and one hundred and eighty-seven
on the following day, making a total of seven hundred
and seventy-five cases in four consecutive days. The
number of fatal cases was large. In Montevideo there
were also many cases of insolation. The distress in
Argentina was increased by a strike of the grave dig-
gers for higher pay, and numbers of dead bodies were
left to decompose in the cemeteries above ground.
The intense heat destroyed the corn crop.
Contesting Chiropodists. — A suit has been brought
by the president of the Academy of Chiropody against
members of the Pedic Society for alleged discrimina-
tion against him by the society. It is alleged that the
two members of the society, who are also the State
examiners in chiropody, conduct a school, and favor
their own pupils in the examination to the detriment
of the academy, the pupils of which are thus not on an
equal footing with the other students, and the presi-
dent of which has no standing in the Pedic Society.
Lepers in New York — A physician in this city
having asserted that there are a hundred lepers, more
or less, at large in New York, the president of the
board of health is said to have called upon him for
his proofs. There are unquestionably lepers in this
city under medical treatment, but we doubt whether
there are one hundred.
A New Fasting Man is undergoing a self-imposed
forty-days' abstinence from food in Mount Vernon,
N. Y. He has already passed about thirty-five days
without food, as alleged, and is confident of complet-
ing his fast without injury.
Possible Closure of a Hospital. — The managers
of the Flushing Hospital are said to contemplate clos-
ing its doors, because under the present rate of pay-
ment made to hospitals for public patients by the
city the institution finds itself running heavily in
debt. The city allows eighty cents a day for surgical
cases and sixty cents for medical cases, and during
January the income from this source was only about
$200, while the expense of maintaining the hospital
was nearly $1,000.
The Famine in India — A despatch to the Sun
from Bombay, dated February 7th, says that the
famine in India is rapidly becoming worse, and
threatens to eclipse the last disaster of this nature,
and to outrun the government's resources. Already
four million persons are receiving relief, and a steady
increase in this number is to be expected. Deaths from
starvation are becoming frequent, especially in Raj-
putana. The advent of famine refugees to Bombay
city aggravates a situation that is already serious
owing to the prevalence of the plague, smallpox, and
other epidemic diseases.
A Board of Health for Havana. — Before leaving
Cuba last week, General Ludlow organized the Hava-
na board of health by the appointment of Drs. Emili-
ano Nunez, Charles Finlay, Benito Valdez, Carlos
Desvernin, Joaquin Jacobsen, and Manuel Delfin.
The chief surgeon of the United States troops and the
chief sanitary officer of the department will be ex-
officio members so long as the military department
exists. The mayor of the city will be ex-officio presi-
dent of the health board. The board will have re-
sponsible executive functions, exercised under the
provisions of suitable rules and regulations drafted
in accordance with modern science and practice. The
functions of the board will be exercised subject to the
orders of the military governor. Major John G. Da-
vies, the chief sanitary officer of the department, ap-
plied for transfer to the Philippines, and has already
been ordered to report at New York.
The Louisiana Leper Home. — The board of con-
trol of the leper home of Louisiana will at an early
date select a site and erect a permanent home for the
lepers of the State. The present home is situated at
a point rather inconvenient for caring for patients
to the best advantage, and it is the intention to select
a site for the new buildings nearer New Orleans where
every convenience can be obtained, and where scien-
326
MEDICAL RECORD.
[February 24, 19CX5
tific observations can be carried on. The funds for
the erection of the buildings were appropriated by the
State legislature. There are at present thirty-three
inmates of the home.
Trouble in the Harlem Hospital. — The commis-
sioner of public charities has suspended two of the
physicians of this hospital and reprimanded the female
superintendent with threat of dismissal, on account of
a quarrel which has been agitating the ofiicials of the
institution for some time past.
Smallpox at Bellevue — An orderly in the erysip-
elas ward at Bellevue Hospital was recently found to
be suffering from smallpox. He was transferred to
North Brother Island, and all those with whom he had
come in contact were revaccinated. It has not been
discovered how he acquired the disease.
State Hospitals Independent of the City.— The
New York City authorities have claimed that, under
the charter of the city, they have the right to inspect
the buildings, boilers, etc., of the Manhattan and the
Long Island State hospitals, but this claim has been
resisted by the officials of these hospitals. The dis-
pute was referred to Attorney-General Davies at
Albany, and he has decided that the city has no juris-
diction.
The Barren Island Nuisance. — The State board of
health in its last annual report claims that the garbage-
rendering establishment on Barren Island is less of a
nuisance than those living in the neighborhood hold
it to be. It asserts that " while under certain atmos-
pheric conditions the odors from this plant can be de-
tected at the places from which these complaints are
sent, it is so modified by the appliances before men-
tioned that it is scarcely noticeable, and is not in any
way injurious or detrimental to health or comfort."
Yellow Fever has reappeared in Havana at an
earlier period than usual, the city being ordinarily
comparatively free from the disease until well into the
spring. On February 14th there were eight cases un-
der treatment. The presence of the disease is attrib-
uted to the exceptionally warm weather and to the
presence of so many unacclimated Spaniards and
Americans.
Capital Punishment in New Jersey. — Two bills
have recently been introduced into the New Jersey
legislature dealing with capital punishment. The
first provides that in murder trials if a jury return a
verdict of murder in the first degree, accompanying
the finding with the phrase "without capital punish-
ment," the defendant's punishment shall be imprison-
ment for life. The second substitutes the electric
chair for the gallows in the execution of the death
sentence.
The Stickler Memorial Library. — The plans have
been accepted for the library building at Orange, N.
J., which the parents cf the late Dr. J. W. Stickler are
to erect in memory of their son. The medical library
of the deceased physician is to be placed in a room in
the new library building for the use of medical stu-
dents, and his entire laboratory apparatus has been
given by his widow to the Orange Memorial Hospital.
Mr. and Mrs. Stickler have also given $40,000 to the
Orange Young Men's Christian Association for the
erection of a new building, to be known as Stickler
Hall, and which will also be a memorial to Dr. Stick-
ler, who was the first president of the association.
Dr. Jameson, who led the Transvaal raid a few
years ago, for which he was imprisoned in England, is
in Ladysmith, and is reported to be ill of a fever, the
nature of which is not stated.
The Hospital Ship "Missouri" arrived in San
Francisco from Manila on February i6th, with two
hundred and sixty-nine wounded and invalided sol-
diers from the Philippines. Eighteen died during the
voyage.
The Inoculation of Malaria by the Mosquito. —
In the article with this title by Dr. Irving Phillips
Lyon, which appeared in the Medical Record for
February 17th, the name of the tick which carries the
germ of Texas fever should have been Boophilus
bovis, instead of Pyrosoma bigeminum, which is the
name of the organism that the tick carries.
The Sale of Drugs in Department Stores A bill
to prohibit the sale of drugs in department stores in
this city has been advanced to the third reading in
the State assembly. It was opposed on the ground
that it was too radical, as under its provisions a de-
partment store could not even sell cough drops, and
the constitutionality of the measure was also called in
question. The bill was advanced to the third reading,
however, by a vote of sixty-five to forty.
The Influenza still afflicts Europe, and the cable
brings the names of many prominent personages among
the hundreds of thousands who are suffering from it.
In Paris President Loubet and Sarah Bernhardt, and
in Berlin Ambassador White, the Empress Augusta
Victoria and two of her sons, and the burgomaster
have been among those attacked. General Krautwurst,
a surgeon in the German army, has died of the dis-
ease. In this city the number of cases diagnosed as
influenza and of respiratory affections which may be
attributed in part to this disease has been steadily in-
creasing during the past two weeks, and doubtless will
increase still more during the weeks yet to come.
Hospital Corps for South Africa — Between fifty
and sixty men constituting the " Irish- American Hos-
pital Corps " recently sailed from this port for Havre
on the way to Pretoria, where they will offer their
services to the Boers. They were not recognized by
the Red Cross Society until each man had taken an
oath that he was over twenty-one years old, that no
women were dependent upon him for their support,
that he was working for no compensation, and that he
was going within the Boer lines not as an ally, but
merely to give aid and comfort to the injured and sick.
There are six surgeons, six assistants, nurses, litter
carriers, and other attendants. The surgeons are Drs.
J. R. McNamara, Herbert McAuley, James J. Slattery,
R. L. Long, A. F. Corney, and J. B. Aderholt. They
have six assistants. The litter carriers and other at-
February 24, 1900]
MEDICAL RECORD.
327
tache's are under the command of Capt. Patrick O'Con-
nor. The men will wear a khaki uniform with the
red cross on the sleeves and on the hat. Their outfit
consists of medical supplies, surgical implements,
surgical dressings, tents, and emergency kits for field
work. A movement has been started by English-born
Americans to organize a similar hospital corps to care
for the British sick and wounded in South Africa. It
is reported from Lorenzo Marques that the Portuguese
authorities have seized two large cases of saddles
forming part of the baggage of the Russo-Dutch Red
Cross contingent that arrived at that port a short time
ago, the claim being made that saddles are contraband
of war.
The Gallaudet Home for Deaf-Mutes, near New
Hamburg, N. Y., was totally destroyed by fire on last
Sunday night. The twenty-six inmates, some of
whom are blind and others very feeble, who were all
in bed, were safely carried out of the building.
The Plague Up to February 17th there have been
forty-two cases of plague, with thirty-two deaths, in
Manila, about twenty of these being among China-
men. A hundred inspectors, thirty of whom are
Chinamen, are employed in enforcing the sanitary
regulations and ferreting out the cases of the disease,
which are often concealed by the friends of the suffer-
ers.— In Honolulu four new cases of the plague were
reported subsequent to the destruction- of the Oriental
quarter of the city, but advices dated February gth
say that no new cases had developed during the past
four days, and the health officials had granted permis-
sion for churches, schools, and places of amusement
to reopen. War has been declared on rodents, a
bounty having been offered for rats dead or alive, and
every householder having been supplied with poison
for use on his premises. — A despatch from Rio de
Janeiro states that the Brazilian government an-
nounces that Argentine and Portuguese ports are free
from the plague. — The St. Petersburg Institute of
Experimental Medicine has established a laboratory
for the study of plague and for the manufacture of
plague serum at Cronstadt. The laboratory is sur-
rounded on all sides by water. There are stalls for
twelve horses, and apartments for the medical officers
and their assistants, with a lazaretto in case infection
occurs among any of the staff.
Navy Department, Bureau of Medicine and Surgery,
Washington, D. C. — Changes in the medical corps
of the United States navy for the week ending
February 17, igoo. Medical Inspector H. H. Si-
mons commissioned medical inspector from Septem-
ber 24, 1899. Medical Inspector H. Wells com-
missioned medical inspector from January 15, 1900.
Medical Inspector M. H. Simons detached from the
naval recruiting rendezvous, New Orleans, La., and
ordered to the Philadelphia as fleet surgeon. Medi-
cal Inspector T. H. Streets detached from the Phila-
delphia as fleet surgeon on reporting of relief, and
ordered to the New York navy yard. Passed As-
sistant Surgeon J. C. Rosenbleuth ordered to the naval
recruiting station, New Orleans, La. Surgeon H. M.
T. Harris commissioned surgeon liom October 21,
1899. Assistant Surgeon Karl Ohensorg appointed
from January 27, 1900. Passed Assistant Surgeon G.
L. Barber ordered to X\\Q Kearsarge February 20, 1900.
Assistant Surgeon D. G. Beebe detached from the
Petrel and ordered to Port Isabella.
Alleged Cancer Cures. — California is prolific in
newspaper cures for tuberculosis, alcoholism, cancer,
and other ills. The latest is a telegraphic report of
the cure of a cancer of the face of twenty-five years'
standing by means of .x-rays. A " cancer " of that age
might be regarded as obstinate, but could hardly be
denominated malignant. The reporter of the case
cautiously remarks that it is uncertain what effect the
Roentgen rays may have on carcinoma of the internal
organs.
Mr. William Adams, a well-known English ortho-
pedic surgeon, has recently died. He was consulting
surgeon to the National Hospital for the Paralyzed
and Epileptic. He was known especially for his work
in operations for the relief of ankylosis of the hip.
The Late Dr. William A. Hammond.— The New
York Neurological Society desires to record its regret
at the death of Dr. William A. Hammond, one of the
founders of this society and for many years one of its
most active and distinguished members. Dr. Ham-
mond was one of the pioneers of neurology in this
country. His work was always suggestive and most
lucidly presented, and it was often original and of
permanent value. It has indissolubly linked his name
with the history and growth of neurological science.
It was before this society that many of his papers
were presented. We record our appreciation of his
work as well as of his brilliant mental gifts. These
were most helpful to this society in its beginnings, and
led to enduring results in the advancement of clinical
neurology and psychiatry and the development of
neurology in America. — Charles L. Dana, Landon
Carter Gray, George W. Jacobv.
Obituary Notes. — Dr. Woolsey Hopkins, of this
city, died on February 15th from pneumonia, at the
age of thirty-two years. He was born in Alexandria,
Va., and was graduated from the College of Physi-
cians and Surgeons, New York, in the class of 1890.
He was assistant surgeon to the Manhattan Eye and
Ear Hospital, and was a member of the American
Laryngological, Rhinological, and Otological Society.
A widow and two children survive him.
Dr. Gustave Mozart Stoeckel, of this city, died
at his country home in Norfolk, Conn., on February
15th, at the age of fifty-one years. He was a graduate
of the College of Physicians and Surgeons in the class
of 1874.
Dr. William H. Hastings died at his home in
Boston on February 16th, at the age of sixty years.
He was a graduate of the Harvard Medical School in
the class of 1868. In 1869 he became district physi-
cian of the Boston Dispensary, and was appointed
superintendent in 1876, which place he occupied con-
tinuously from then up to the date of his death.
328
MEDICAL RECORD.
[February 24, 1900
Dr. De Witt C. Green, of Florence, Ala., died in
consequence of a fall from the roof of his house on
February 14th. He was a graduate of the Jefferson
Medical College in 1882.
Dr. John D. Hillis died in West Haven, Conn.,
on February isth, at the age of forty-five years. He
was born in Poughkeepsie, N. Y., and was graduated
in medicine from a school in Cincinnati. He prac-
tised for a time there and later in Chicago, but after-
ward engaged in mercantile pursuits. A widow sur-
vives him.
Dr. Horace R. Allen, of Chicago, died in conse-
quence of a surgical operation at the Presbyterian
Hospital in that city on February 13th. He was a
graduate of the medical department of the Western
Reserve University in the class of 1857.
Dr. Edward Lorenzo Holmes, of Chicago, died
on February 12th, of pneumonia, at the age of seventy-
two years. He was born in Dedham, Mass., and was
graduated from the Harvard Medical School in the
class of 1854. He settled in Chicago soon after
graduation, and th»re devoted himself chiefly to the
study of disease of the eye and ear. He was for
many years professor of ophthalmology and otology in
the Rush Medical College, and was one of the found-
ers of the Illinois Charitable Eye and Ear Infirmary.
He was a member of the American Ophthalmological
Society and of the American Otological Society, and
was a frequent contributor to the literature of diseases
of the eye and ear.
Dr. Sa.muel R. Forman died at his home in Jersey
City, on February 19th, of Bright's disease, at the
age of sixty-four years. He was a graduate of the
College of Physicians and Surgeons, New York, in
the class of 1857.
Dr. R. a. Kennedy died at Shamokin, Pa., on Feb-
ruary 9th, in an apoplectic attack, at the age of forty-
four years. He was a graduate of Bucknell and of the
medical department of the University of Pennsylvania.
Dr. Gerald J. M. McMurray died at Philadelphia
on February loth, of meningitis, at the age of thirty
years. He was graduated from Jefferson Medical Col-
lege in 1894.
Dr. Charles B. Kennedy died of heart failure at
Hollidaysburg, Pa. He was a graduate of Bellevue
Hospital Medical College.
Dr. William ^V. Lamb died at Philadelphia on Feb-
ruary 15th, at -le age of fifty-nine years. He was a
graduate of the Long Island Medical College. He
was an assistant surgeon in the Eighth New Jersey
volunteer regiment during the Civil War, from 1872
to 1885 an inspector of drugs, from 1872 to 1890, sur-
geon to the Third Regiment Pennsylvania National
Guard, from 1890 to 1892 assistant surgeon to Bat-
tery A, and from 1871 a police surgeon. He was
further surgeon to the Methodist Home for the Aged
and to the Methodist Orphanage.
Meddlesome Probing is condemned in military sur-
gery by Dr. Senn in his " War Correspondence," the
old-fashioned probe having been entirely superseded
by dissection and the use of the .r-rays.
progress of ^cdical Science.
Aledkal News, February jj, jgoo.
Report of Bacteriological Investigations upon Yel-
low Fever. — Aristides Agramonte gives the results of
experiments in which he injected serum taken from
convalescents from uncomplicated yellow fever. The
serum is perfectly innocuous; it is more readily ab-
sorbed than the equine serum. It has never produced
any cutaneous manifestation, and within twenty -four
hours every sign of the injection has disappeared ex-
cept at the point of puncture, where a minute red spot
may be visible. No case is injected which is seen
after the fourth day of the invasion. The disease has
been distinctly modified in every instance. In these
experimental injections two facts have been empha-
sized: (i) the absence of hemorrhagic tendency; (2)
the rapidity with which patients who received the
serum went through the period of convalescence; the
fever having once left them, their reparative functions
were quickly started, and they were ready to return to
business in an unusually short period of time.
An Improved Operation for Acute Appendicitis or
for Quiescent Cases with Complications.^ — Robert F.
Weir in this method increases the intermuscular space
of McBurney. He tears off with the finger-tips, or
with the end of blunt scissors, the already denuded
fascia of the external oblique muscle from the sheath
of the rectus quite up to the median line, where it is
held retracted by an assistant. The anterior sheath
of the rectus is now divided transversely in a line con-
tinuous with the opening made in the peritoneum by
the original muscle-separation operation. The outer
edge of the external rectus is then lifted up and car-
ried by a retractor to the median line. The epigastric
vessels should be divided and ligatured. The poste-
rior sheath of the rectus and the peritoneum should be
cut in a manner similar to the outer sheath. When
blunt retractors are now passed into the peritoneal
cavity and the abdominal wall is put on the stretch,
there is a very superior exposure of the whole pelvis
and of the right iliac fossa.
Two Cases of Rupture of the Right Lobe of the
Liver; Laparotomy, Recovery. — H. Beeckman Dela-
tour says that the question of when to operate in these
cases is the all-important one and must be decided for
each case individually. In the first of these two cases,
had operation been at once resorted to, probably a
fatal issue would have resulted, while in the second
case unavoidable delay nearly cost the patient's life.
A Consideration of Acute Inflammatory Rheuma-
tism.— W. H. Neilson believes that inflammatory
rheumatism is an infectious disease; that its natural
history points to this, its complications point to it, and
the treatment found so effective proclaims it. He ap-
proves of the use of salicylic acid and its compounds.
The Bubonic Plague. ^ — Edwin Klebs declares that
the bacillus pestis bubonicai is undoubtedly the cause
of bubonic plague. The first step in combating the
spread of the plague must be by general hygienic
measures. The demonstrated cases should be at once
isolated in a plague hospital.
A Case of Post-Epileptic Amnesia. — David 'Jrum-
bull Marshall reports this case, in which the amnesic
period was ten days. There was great difficulty in
obtaining a history of epilepsy, since the family did
not wish the matrimonial prospects of the patient
blighted.
February 24, 1900]
MEDICAL RECORD.
329
Journal of the America?l Medical Ass' 11, Feb. ij, igoo.
The Hockey-Stick Incision. — Willy Meyer describes
this incision, useful in certain complicated cases
of appendicitis. He says that its chief advantage
is that it enables the operator to respect the fibres
of the external oblique muscle, and that, if properly
lengthened at its lower angle, it gives sufficient access
to the small pelvis and its contents for whatever work
may be necessary, at least as far as the adnexa of the
right side are concerned. The author calls it the
" hockey-stick " incision on account of its shape. In
most cases the incision commences at a spot about
one-half inch above and midway between McBurney's
point and the anterior superior spine, and ends about
one-half to three-quarters of an inch from Poupart's
ligament. Meyer has used this incision in ten cases
of appendicitis, gangrenous, perforative, or compli-
cated with tubal or ovarian affections, and recom-
mends it as a typical mode of entering the abdominal
cavity in such cases, as by it extensive work can be
done within the small pelvis without necessitating an
additional median incision.
Have We in Nature a Basis for a Science and
Art in Medicine ? — H. J. Herrick says it is the pur-
pose of this paper to show that the conditions with
which the physician deals have such uniformity of
phenomena and facts that the subject may be properly
termed a science, and that such conclusions may be
reached and practical results attained, as to be un-
questioned by any intelligent inquirer, and that when
those principles are applied to practical use for the
curing of disease, it may appropriately be styled an
art.
Why the Negro Does Not Suffer from Trachoma.
— -Warwick W. Cowgill says that this disease is com-
mon only among the poorer classes of whites in the
country districts. Between this class and the negro
there is a wide gulf fixed. Assuming therefore, as
the author does, that the disease is contagious, the
conclusion is reached that the negro owes his immu-
nity to his lack of contact with the source of contagion.
Bilharzia Haematobia. — Edwin Walker says that
the authors who have described this parasite all sup-
posed that Africa was its only habitat. But one other
case has been reported in this country, the patient be-
ing a resident of Sparta, 111. In the case reported by
Walker great care was taken to avoid error; the para-
site was found in the specimen of urine passed in
sterile vessels, as well as that drawn by catheter.
Mucocele in the New-Born.^ — Clark W. Hawley
reports six cases of this disease in his practice, from
observation of which he has reached the following
conclusions: i. The disease is a rare one. 2. The
indications are to establish drainage into the eye if it
is not possible to cause flow into the nose. 3. The
tumor should be opened by a very small incision. 4.
An anaesthetic should be given and probing done.
The Maddox Rod or Phorometer ? — Alvin A.
Hubbell gives results of his own experience with these
two forms of test, and says that in view of the fact that
by the rod test there is introduced no extraneous im-
pulse to muscular contraction, and as its findings are
in the great majority of cases equal to or in excess
of the phorometer, he believes the rod to be the more
precise and trustworthy guide in daily practice.
Corneal Corpuscular Activity. — In his discussion
of this subject Joseph E. Willetts says that the phe-
nomenon consists of bright moving bodies filling the
field of vision. He adds that all the evidence is in
favor of these bright bodies being the amoeboid leuco-
cytes circulating through the lymph canals of the
cornea.
Railway Hygiene and Emergency Equipment.—
W. W. Grant says that the present methods of venti-
lating cars and of cleaning their furniture are entirely
inadequate. He suggests many radical improvements,
including the equipment of every train with a hand
litter for the removal of the sick.
Operative Treatment of Chronic Glaucoma
Alexander W. Stirling discusses the usual operations for
this disease, viz. : iridectomy, sclerotomy, and sclero-
iritomy. As to the relative advantages of myotics or
operation he thinks it impossible to speak dogmati-
cally.
Eviscero-Neurotomy. — J. G. Huizing describes a
new method for evisceration of the eyeball, and claims
for it all the advantages of the Mules operation, as
well as those of enucleation, without their disadvan-
tages.
Convergent Strabismus. — William B. Meany re-
ports this case of total apparent strabismus — conver-
gent— of 62", in order to demonstrate the method used
for this individual case by Professor Landolt in his
clinic.
Eosinophilia in Dermatitis Herpetiformis (Duhr-
ing). — Mark A. Brown and George P. Dale report a
case of this disease in which a clinical examination
of the blood changes, showed a large percentage of
eosinophilia (at one time 44.3 per cent.).
The Bubonic Plague. — Edmond Souchon gives
some points of special interest to sanitarians regard-
ing this disease, which he has gathered from the writ-
ings of Kitasato, Nakagawa, Yersin, Wyman, and
Manson.
Treatment of Septic Conditions in Children. — By
Edwin Rosenthal. See Medical Record, vol. Ivi.,
page 27.
A^eiv York Medical Journal, February 77, igoo.
The Importance, both Medico-Legal and Clinical,
of the Early Recognition of Certain Organic Affec-
tions of the Nervous System, Including Paresis. —
J. Leonard Corning discusses the early symptoms of
locomotor ataxia, multiple sclerosis, paralysis agitans,
and general paresis. All these maladies play a con-
siderable part in the litigation of to-day to determine
the presence or absence of insanity. He calls atten-
tion to the care necessary in studying the symptoms
of prisoners in order to arrive at a proper diagnosis,
and shows how juries are often influenced by the lay
idea that organic disease of the nervous system neces-
sarily entails insanity.
A Plea for the More Extended Use of Antitoxin
for Immunizing Purposes in Diphtheria. — From
statistical tables compiled from New York City
Health Reports, J. S. Billings claims that the in-
creased number of cases of diphtheria in the city for
1899 was due in part (in the author's view) to a neg-
lect of immunization by antitoxin. He believes that
300 units should be used in children and 500 units in
adults.
Four Cases of Diabetes Mellitus of Apparent
Bacterial Origin, and their Successful Treatment.
— J. P. Sheridan states his belief in the bacterial
origin of this disease, though he gives no proofs to
330
MEDICAL RECORD.
[February 24, 1900
sustain his position. He finds the ideal remed)' for
the malady in a combination of the bromides of gold
and arsenic.
Overstudy. — L. M. Yale is sceptical as to the fact
of overstudy being the cause of physical ailments, but
believes that physical ailments underlie difficulty in
school work. The pjiysician should never accept
"overstudy" as a cause for deranged health until he
has carefully sought for and failed to find a physical
reason.
Digitalis and Aconite ; their Physiological and
Therapeutic Value. — F. O. Hawley makes a study of
the peculiarities of these drugs and condemns the
loose methods of assay so frequently practised. To
the resulting unreliable preparations we owe much of
the uncertain effects so often seen in administration.
The Therapeutic Value of Alcoholic Stimulants.
— F. A. Castle maintains that it is the volatile ethers
which give to wines and spirits their chief therapeu-
tic value.
The General Treatment of Phthisis Pulmonalis.
■ — G. A. Evans discusses the general therapeutics of
the disease, and gives tables referring to diet and
mode of living.
Skin Manifestations of Influenza Observed in
the Present Epidemic. — J. E. Herman has seen erup-
tions resembling respectively measles, scarlatina, and
herpes.
Studies on Internal Antisepsis. — By E. Klebs. A
continued article.
Philadelphia Medical Journal, February ij, igoo.
The Pleural Friction Sound. — Albert Abrams de-
scribes several manoeuvres of value in eliciting this
sound, (i) Respiration is suspended, and then the
arm on the affected side is raised while in extension,
the suspected area being auscultated in the mean
while. (2) The patient lies on the affected side for
a minute or two and then rises suddenly, suspending
respiration. The affected area is now auscultated
while the patient takes a deep breath. (3) Pressure
in an intercostal space with the buttoned rod of the
phonendoscope screwed to a piece of tin, which is
fitted over the hard-rubber bell of the stethoscope.
The phonendoscope itself cannot well be used, for when
pressure is exerted with the buttoned rod in the inter-
costal space the patient's breathing gives rise to ad-
ventitious sounds which are confusing.
Gangrenous Stomatitis Treated with Antistrep-
tococcus Serum. — W. C. Cahall reports a case of
noma in a child seven years old suffering from
typhoid fever. The disease was treated first by cau-
terization, then by the curette, and finally by an ex-
tensive cutting operation, but each time the gangrene
reappeared. Then an injection of 10 c.c. of antistrep-
tococcic serum was made, and within twelve hours a
line of demarcation formed, and within twenty-four
hours the gangrenous part had disappeared, leaving a
healthy-looking wound.
The Earliest Recorded Autopsies, in America. —
Francis R. Packard says the earliest mention of an
autopsy in America is to be found in " An Account of
Two Voyages to New England," published in London
by John Josselyn in 1674. Four other post-mortem
examinations were made in New England during the
remainder of the seventeenth century.
An Unusual Case of MoUuscum Fibrosum
Daniel H. Williams report the removal of a tumor of
this character weighing twelve and one-half pounds
and measuring fifteen by eighteen and one-half inches.
The State Care of Consumptives.— Charles E.
Nammack enters a plea for the fresh-air treatment of
tuberculosis and for the establishment of State sana-
toria for the poor.
Position Symptoms in Joint Disease. — By Harry
M. Sherman. See Medical Record, vol. Ivi., p.
494.
Boston Medical and Surgical Journal, February ij, igoo.
The Clinical Value of Oliver's Hasmocytometer.—
David D. Scannell describes this instrument in detail
and extols it as being time-saving and accurate as com-
pared with the Thoma-Zeiss procedure.
A Case of a Man who Swallowed his Suspen-
ders Maurice H. Richardson by external cesopha-
gotomy extracted the ingested wearing apparel, and
the patient, a previous inmate of an insane asylum,
made a good recovery.
A System of Clinical Instruction A. H. Went-
worth describes the method which he employs for the
simultaneous instruction in small sections of a large
number of students.
Diffuse Peritonitis from Acute Appendicitis — J.
Coplin Stinson reports a case in a young girl in which
operation was followed by recovery.
Medical' Fress and Circular, Jan. JT and Feb. ", rgoo.
The Correlation of Sexual Function with Insanity
and Crime. — H. Macnaughton-Jones concludes his
paper, taking up climacteric insanity, which occurs
chiefly in women but also in men. The correlation of
insanity and disordered sexual functions arising out
of affections of the generative organs is,a factor to be
taken seriously into consideration. A careful exami-
nation should be made when there is suspected a con-
dition of the generative organs which might produce
or aggravate the mental affection. Due weight should
be given irregularities in investigating criminal acts
in women, especially during the menopause, etc. The
special dangers of the climacteric period (climacteric
mania) must be remembered. Pelvic examination
should be made when moroseness, depression, hys-
teria, hallucinations, unfounded suspicions, and ap-
prehension are leading symptoms. There is greater
predisposition to mental disturbances after operations
on the generative than other organs. Those previous-
ly insane are predisposed to relapse under such oper-
ations. Suicidal impulse and crime at the climacteric
should be anticipated by operation if gross lesions are
detected.
A Rare Form of Ulceration of the Female Ure-
thra.— Richard Dancer Purefoy says the external
female genitals furnish some of the best illustrations
of chronic syphilitic disease being confounded with
malignancy. In a case observed there was upon the
inner surface of the left nympha a circular excavation
with sharp cut overhanging edges, the base being white
cicatricial tissue. The entrance to the vagina was
closed by a morbid growth with red nodular surface
hanging from an enormously dilated urethra. Dr.
West had seen six similar instances — mostly in wom-
en giving a history of syphilis or venereal disease.
The writer has seen it as an independent affection
and also associated with condylomata. The lower
wall of the urethra is often like cartilage and the
aperture is permanently patulous. Sometimes the
February 24, 1900]
MEDICAL RECORD.
331
urethra will admit one or even two fingers through its
whole extent. Strong nitric acid may produce enough
contraction to control the urine. This rare affection
is similar to, if not identical with, Huguier's lupus
hypertrophicus.
A Case of Posterior (Congenital) Luxation of
the Shoulder Joint. — G. Burbridge White says poste-
rior luxation is the most unusual form which congen-
ital dislocation of the shoulder assumes. He relates
an instance in which, when examined, there was total
inability to move the arm or forearm, to pronate or
supinate or to flex or extend the hand. The forearm
was turned in so that the dorsum of the hand rested on
the loin. Treatment consisted in careful massage
until motion in the arm independent of that of the
scapula took place. When slight active motion was
possible, dumbbells and an American elastic exerciser
rendered improvement more rapid. After twelve
months there was considerable use of the arm possible.
The -v-ray confirmed the diagnosis of luxation of the
acromial end of the clavicle and atrophy of the head
of the humerus.
Five Cases of Angina Pectoris. — Dr. Salomon re-
ports five similar cases. There were no asthmatical
symptoms. In a few w-eeks the pain began to radiate
to the left arm. The pain was often started by slight
movements, as in undressing. The duration of the at-
tack was from ten minutes to several hours. Three
patients died, and two recovered. Two had had syph-
ilis, one influenza. The writer does not believe that
iodides are of benefit in genuine ordinary angina. Pa-
tients with coronary angina die ; those with neuras-
thenic angina get better. Iodides along with hygieno-
dietetic treatment must always occupy the first place.
The Dilatations and Diverticula of the (Esopha-
gus.— John Knott divides these rare abnormalities
into congenital and acquired, each being arranged,
according to Rokitansky, under three heads : ( i ) The
cylindrical or fusiform, in which a great part of the
length of the tube is enlarged; (2) the sacciform, in
which one or more pouches are found, which involve
all the coats of the oesophagus; (3) the hernial, in
which the mucous membrane alone expands, and this
coat, protruding through the muscular layers, forms
diverticula or herniae. Illustrations are given, and
the subject is to be continued.
Some Remarks on the Operative Treatment of
Uterine Fibroids. — W. Gow supports the view that, of
all radical operations for fibroids, abdominal hysterec-
tomy with subperitoneal treatment of the stump is the
best and safest procedure, and that this operation may
confidently in the future be looked upon as giving a
mortality of not more than one or two per cent. He
relates four cases in which single or double pyosal-
pinx existed, and gives a table of forty-seven patients
treated in this way with a mortality of just over two
per cent. There were thirty-nine consecutive cases of
recovery.
Acute Chorea Treated with Large Doses of
Arsenic. — Murrell carried out the treatment recom-
mended by William Murray, but somewhat modified.
Instead of giving fifteen drops of liquor arsenicalis
three times a day for a week, he gave smaller doses
over a longer period, b'ut vomiting was a distressing
symptom, and the drug was discontinued. He finds
that the duration of the attack is immensely shortened
by giving arsenic.
Some Remarks on the Oils of Cajeput and Cu-
bebs and their Use in Inhalation Robert J. Lee
finds that these oils may be vaporized without diffi-
culty, and as their properties are well understood it is
unnecessary to point out the class of cases in which
they may be inhaled with benefit.
Ambrose Par6 and his Times.— J. Grant Andrews
gives an entertaining account of Pare''s life.
Bj-itish Medical Journal, February 10, igoo.
An Undescribed Form of Plague Pneumonia
W. C. Hossack reports five cases of an indefinite and
obscure form of plague, differing in character and
general symptoms from the classical form of plague
pneumonia in that its onset is not fulminant but in-
sidious, and the symptoms are slight. The most strik-
ing characteristic of the disease is the pulse, which
presents grave characters quite out of harmony with
the brief duration of the illness and the limited amount
of lung mischief. Every case the writer has heard
of, including the five coming under his immediate
notice, have ended quite unexpectedly in death on the
fifth to the tenth day. In answer to the probable ob-
jection that these cases were not plague at all, but
simple broncho-pneumonia, the writer evidences their
clear connection with the plague, their occurrence in
series with indisputable plague cases, and their ap-
parently inexplicable fatality.
Preventive Inoculation against Bubonic Plague.
— A. Lustig and G. Galeotti assert that preventive
inoculation is the only means by which this disease
may be rationally combated when it has manifested
itself in epidemic form. They give the results of ex-
periments on animals by means of a nucleo-proteid
which they have succeeded in extracting from the
plague bacilli. The authors claim that this product
is free from the drawbacks of Haffkine's vaccine, and
that its advantages may be summed up as follows:
(i) Its efficacy has been proved from the experiments
made on various animals; (2) the substance is in-
nocuous in the case of man; (3) if the cultural
liquids possess an immunizing power they owe it to
the nucleo-proteid which the writers have isolated;
(4) the advantages of using an active substance iso-
lated and pure instead of cultures which contain it
mixed with heterogeneous elements are evident.
A Case of Malignant Malarial Fever with Cere-
bral Symptoms Terminating Fatally, in England.
■ — D. C. Rees reports tliis case, and says that he has
never seen such an enormous number of parasites in
the peripheral circulation in any case of malignant
malaria. It is noteworthy that the patient was only
five days in a malarial country. The writer points
out the importance of blood examinations in such a
case as this. The patient was unconscious; no relia-
ble history could be obtained; he had practically no
pyrexia, no rigors, no sweating; without the blood
examination the diagnosis of malaria would hardly
have been justifiable.
The Serum Diagnosis of Mediterranean Fever. —
T. Zammit says in every case of fever the method of
serum reaction should be used in diagnosis. He sub-
mits the following facts gathered during the past year :
(i) The micrococcus of Bruce can be grown success-
fully from a culture seven months old;. (2) cultures
of the micrococcus two years old give a clear serum
reaction; (3) the micrococcus does not grow on sea
water solidified with agar, not even when the water was
taken from a sewage outfall ; (4) the micrococcus
grows on an agared solution of normal human faeces.
A Case of <*Beef Worm" (Dermatobia Noxialis)
in the Orbit.— This case is reported by Frederick T.
Keyt. He says the " beef worm " is commonly found
332
MEDICAL RECORD.
[February 24, 1900
in British Honduras and Central America, in dogs
and cattle, and often in human bejngs. The natives
treat it by applying tobacco leaf over the swelling and
occluding the orifice; the worm is narcotized or
killed, and its expulsion is easily effected by squeez-
ing. Occasionally it gives rise to serious inflamma-
tion of the subcutaneous tissues, demanding liberal
incision and free drainage.
Cinnamon in the Treatment of Tropical Diar-
rhcea. — A. Norris Wilkinson reports good results
from the use of cinnamon in teaspoonful doses, mixed
with milk to mould it into the shape of a bolus, and
chewed night and morning. In all cases ranging from
ordinary diarrhoea to severe cases of dysentery the
author relies upon this mixture given in conjunction
with a mixture of quinine sulphate, potassium bro-
mide, and antifebrin.
Poisoning by Castor-Oil Seeds. — In this case, re-
ported by \V. P. Meldrum, the patient, a dock laborer
in good health, ate a couple of castor-oil seeds. No
medical assistance was sought for three days. There
were then incessant purging and vomiting with cold
extremities and weak pulse. Under treatment the
purging stopped, but the vomiting persisted, and the
patient expired from exhaustion.
Some Researches into the Nature and Action of
Snake Venom. — In his account of these researches
Robert Henry Elliot describes his method of collect-
ing and storing venom, bile, etc. ; he gives the stand-
ardization of solution and mode of administration,
describes the preparation of the animal, witli the cal-
culation of dose based on idiosyncrasy, and notes the
variations in lethal dose for different animals.
A Case of Vesical Calculus in Sierra Leone —
In this case reported by \V. Renner recovery followed
lithotomy. The author says the case is of interest
from the fact of the rare occurrence in this colony of
a case of stone in the bladder, so rare in fact that
there was not in the colony a single instrument for
the operation of lithotomy, and one had to be sent from
London.
The Epidemiology and Prophylaxis of Malaria
in the Light of Recent Researches In this article
A. (Jelli traces the life cycle of the malarial organ-
ism in man and the mosquito, discusses the habits
of Anopheles, and deduces therefrom certain prophy-
lactic measures which experience has also shown to
be of service.
A Note on Species of Anopheles Found among
Mosquitos Sent from Shanghai and Java.— George
Thin pictures two specimens of mosquitos sent to him
for examination from Batavia and Shanghai. They
were both probably A. pictus, as appeared from a
comparison with specimens of A. pictus and A.
claviger caught in Spain.
The Saline Treatment of Dysentery. — W. J.
Buchanan gives notes of five hundred and fifty-five
consecutive cases of dysentery treated by a saturated
solution of sulphate of magnesium, with only six
deaths.
The Lancet, February jo, igoo.
Further Observations on Pernicious Anaemia ; A
Chronic Infective Disease In this final article of
the series, W. Hunter calls attention to the relation
between this affection and infection from the mouth
and stomach. The nature of the infection is a mixed
one, as it occurs in all classes irrespective of surround-
ings and as there is an abundant presence of organ-
isms of coccal and short streptococcal nature forming
zoogloea-like masses amid the catarrhal and inflam-
matory exudation contained in the vomit. Treatment
must include hygiene of the mouth and teeth, local
treatment of the stomach and intestine, arsenic, and
serum injections. The nature of the serum to be used
is still to be determined.
Prognosis in Appendicitis — From a series of two
hundred cases H. A. Caley discusses prognosis as to
recovery and as to recurrence. Under the former, he
studies the pathological basis of prognosis from the
nature and extent of peritoneal infection and the na-
ture and course of the appendix lesion; the clinical
basis requires the consideration of local symptoms,
general symptoms, local signs and progress of the case.
Consanguineous Marriage and Deaf-Mutism. — A.
H. Huth gives elaborate statistical tables, from which
he concludes that when there is a family taint of deaf-
mutism, more deaf-mutes are liable to be born in fam-
ilies in which theie is a double inheritance through the
relationship of the parents than when this is not the
case.
A New and More Permanent Method of Mount-
ing Amyloid Sections Stained with Iodine. — A. B.
Green recommends the employment of Weigert's io-
dine, liquid paraffin, and xylol, with iodine crystals.
Each is to be used on the section in the order named.
A cover-slip smeared with vaseline is then placed over
the section.
The Present Position of Aural Surgery. — ^^W. B.
Dalby thinks that the advance in aural surgery has
greatly dispelled quackery, and calls attention to the
vast amount of study which is now being given to the
subject of chronic suppurative discharge.
Eighty Successive Cases of Stacke's Operation.
— Full tables are given with an analysis of symptoms.
Only three deaths resulted, and all these cases did not
come under observation until a very advanced stage
of pysemic poisoning had been established.
A Case of Complete Inversio and Prolapsus
Uteri. — F. L. Pochin records this case occurring in a
primipara aged twenty years. Reposition was suc-
cessful, and the puerperium was without special inci-
dent.
Fetichism in Surgery. — E. Stanmore Bishop thinks
that the modern surgeon is especially liable to fetich-
ism in two directions: undue importance attached to
certain details in technique, and a desire to operate
with a rapidity which is injurious to the patient.
Successful Case of Enterectomy for Gangrenous
Hernia. — A. H. Burgess removed four inches of gut
from a boy aged fifteen years. Healing occurred with-
out suppuration, and the patient was up in three weeks.
Mental Dissolution. — A clinical lecture by G. H.
Savage, in which lie calls attention to the physical
and mental peculiarities seen in persons passing into
a condition of mental weakness.
Deutsche me J. Wochenschrift, Jan. 2 J ami Feb. I, I goo.
The Saliva and its Influence on Gastric Digestion.
■ — Martin Cohn says the alkalinity of the saliva varies
in different individuals and in the same individuals at
different periods of the day. The average corresponds
to a 0.0154-per-cent. solution of caustic soda. He
never found an acid reaction, such as was noted by
Sticker in the interval between breakfast and dinner.
It has been suggested that retained products of nietab-
February 24, 1900]
MEDICAL RECORD.
333
olism may be got rid of by increasing the salivary se-
cretion, but the author was unable to discover any
evidences of such vicarious elimination in cases of
renal disease. The digestive activity of the saliva
does not cease with deglutition, but is continued for a
time in the stomach. As has been shown by Van der
Velden, there are two stages of stomach digestion. In
the first the acidity is not sufficient to inhibit the sac-
charifacient action of the saliva (amylolytic stage),
but in the second this action is arrested by the in-
creased secretion of hydrochloric acid (proteolytic
stage). It has been asserted|by Sticker that the saliva
has an influence also in the aige^tion of albumin, but
Cohn does not think \he experiments offered in proof
of this assertion are conclusive. His investigations
led him to the conclusion that the presence of saliva
in the stomach is beneficial, but he was unable to de-
termine that its presence was of extreme importance
in digestion or that its absence impaired the process
very materially. ^
A Case of Pneumathsemia. — Paul Bernhardt re-
ports the case of an idiot, fifty-four years of age, who
died after a brief illness marked chiefly by diarrhoea,
anuria, and extreme restlessness. At autopsy the
blood was found to be fluid and of a peculiar crimson
tint. The heart, especially the left auricle and coro-
nary veins, was swollen, and when opened under water
its contained blood was found to be mixed with air.
Incision of the inferior vena cava gave exit to a
bloody foam. The liver was enlarged, its surface was
covered with little vesicles, and on section a thin,
bright-red foam exuded; the hepatic veins, when cut,
gave exit to more air than blood. Examination of
cover-glass preparations of the liver fluid showed the
presence, in almost pure culture, of thick rods with
rounded extremities, i ,a thick and from 3 to 5 //. in
length; there seemed to be an indistinct capsule; they
did not form chains; they were stained by gentian
violet, carbol fuchsin, and after Gram's method. The
writer thinks it was probably the bacillus aerogenes
capsulatus, which has been so carefully studied and
described at the Johns Hopkins laboratory.
Clinical and Experimental Studies of Dural In-
fusion.— Paul Jacob gives an account of his experience
with the injection of-various fluids into the subarach-
noid space after the removal of an equal quantity of
cerebrospinal fluid through a lumbar puncture. The
fluid must be injected very slowly (fifteen to twenty
minutes being required for the passage of 25 c.c);
otherwise the most alarming pressure symptoms might
be produced. Animal experiments with methylene-
blue solutions showed that the fluid injected into the
lower part of the subarachnoid space very quickly
re.iched the brain, that it was eliminated very slowly,
and that within a very short time it permeated the
cerebrospinal substance. The writer reports a case of
tetanus cured after dural infusions of antitoxin, and
three cases of cerebrospinal syphilis treated most suc-
cessfully by dural infusions of sodium-iodide solution.
He believes there are great therapeutic possibilities in
the treatment of many diseases of the central nervous
system by this method of bringing the curative agent
into direct contact with the diseased foci.
Employment of a Heart-Supporting Apparatus in
Cardiac Affections, Especially in Cardiac Dyspnoea.
— Abe'e, observing that patients with heart disease
often instinctively make pressure with the hand over
the cardiac region, was led to devise a mechanical sup-
port in which a pad should take the place of the pa-
tient's hand. He reports two cases of various cardiac
affections in which the subjective symptoms, especially
pain and dyspncea, were markedly relieved, and the
patients were able to take moderate exercise when
previously they had been unable to walk without the
greatest distress. The writer has studied the physical
effects of the pad and finds that it elevates the heart
as much at times as 2 to 3 cm. and causes an axial
turning of the organ, as shown by the altered apex
beat; the pulse is slowed by as much as ten beats in
the minute; and finally the limits of lung expansion
anteriorly on the right side are increased 1.5 to 2 cm.
All these changes are constant, and occur within two
or three minutes after the adjustment of the pad.
Treatment of Circumscribed Abscess of the Ab-
dominal Cavity. — Sonnenburg cautions against rashly
opening into the peritoneal cavity in suppurative ap-
pendicitis. A free and rapid opening of the abscess
cavity is permissible only when the general symptoms
are threatening and septic symptoms are present. In
all other cases when it is a question of operating
upon a circumscribed purulent collection, one should
not immediately open the peritoneum, but should first
seek for the abscess and evacuate it, and often the ap-
pendix will be found in the cavity. Greatcare should
be taken not to break up the protecting adhesions.
A Specific Immunizing Serum against Sperma-
tozoa.— Moxter injected guinea-pigs with the sperma-
tozoa of rams, and found that the injected organisms
gradually acquired a more potent spermatozoicide
property. This power resided in the body of the
guinea-pig, for the blood serum removed from the ves-
sels did not possess it. The anti-body resulting from
these spermatozoa injections is also hsematolytic in
relation to the red corpuscles of sheep.
Ileocolic Ijivagination Lewerenz reports a case of
intussusception of the ileum into the colon through the
ileocecal valve occurring in a boy twelve years of age.
The abdomen was opened, and the invagination was
reduced with some difficulty. The patient made a
good recovery.
Berliner klinische WocJicnscJiriJt, January 2g, jgoo.
Simultaneous [Gunshot Wounds of the Thoracic
and Abdominal Cavities. — F. Koenig concludes a
lengthy article by a brief summary of the various
pathological processes which follow injuries of this
nature in the regions indicated. He calls attention
to the fact that in addition to the injuries sustained
along the course of the wound there may be severe
lesions at a distance caused by the explosive force of
the missile. Bacterial infection may arise not alone
from the outside, but from the migration of germs from
their natural habitat in the intestinal and biliary tracts.
Products of inflammation may be removed by punc-
ture. This failing, opening of the cavities is indi-
cated.
The Surgery of Cancer of the Stomach. — H.
Lindner discusses the question of possibly more radi-
cal intervention in the future. The removal of in-
fected glands suggests itself and is to be attempted.
On the other hand, recurrence in' the glands is com-
paratively rare. In cases in which a radical operation
is impossible, gastro-enterostomy is to be commended.
In the latter class of cases it has been suggested that
jejunostomy is the preferable procedure, but the author
is not disposed to grant this point.
Therapeutic Employment of Moist Heat — H.
Davidson describes and figures an apparatus devised
by him for this purpose. It consists essentially of a
coil arrangement shaped to the human frame and sup-
plied with a cover-lid. The coil is supplied with hot
water from a reservoir to which is applied a spirit
lamp.
Chronic Villous Polyarthritis and Arthritis De-
formans By M. Schueller. A continued article.
334
MEDICAL RECORD.
[February 24, 1900
Wiener kUnische Rundschau, January 28, igoo.
Two Cases of Tuberculosis of the Serous Mem-
branes in Man, with the Macroscopical as well as
the Microscopical Appearance of Bovine Tubercu-
losis.— Josef Pelnar draws these conclusions from his
observations on this subject. There exists in man
a tuberculous affection of the pericardium and peri-
toneum which is characterized by small connective-
tissue tumors with pedicles. Sometimes these are the
only signs, then again there are besides these tumors
other small tuberculous growths. These little swell-
ings are both macroscopically and microscopically
like the nodules in bovine tuberculosis. In these
nodules tubercle bacilli are sparingly found, and
show the morphological peculiarity that they almost
always appear in little masses which are like those
seen in actinomycosis. Cholangitis and pericholan-
gitis tuberculosa hepatiscan be seen as solitary thick-
walled cysts of the size of a walnut, without other
demonstrable tuberculous changes in the liver.
A Simple Method for the Application of Carbon
Dioxide. — Rudolf Hatschek states that a good method
of applying carbon dioxide is to take gr. Ix. of sodium
bicarbonate mixed with a Uttle warm water, and with
this mixture rub the patient. Carbon dioxide is
evolved.
Wiener klinische Wochcnschrift, February i, igoo.
Air Emboli in Placenta Praevia.— Hugo Hiiblsays
that diagnosis of this affection should be made: (i)
By the exclusion of other possible diagnoses such as
ruptures of the cervix and uterus, death ffom ansemia
or from chloroform, and thrombus emboli. (2) If
there is present over the heart a clucking murmur, and
if in that region there is a tympanitic or dulled tym-
panitic percussion sound, then the clinical diagnosis
of air emboli is certain. Hiibl gives two conditions
which make possible the entrance of air into the veins :
((?) Pressure in the abdominal-uterine vessels is sud-
denly diminished, and so air is sucked into the open
vessels, {b') Pressure in the interior of the uterus is
increased, and in this way air within the uterus is
pressed into the gaping vessels.
The Limitation of Laparotomy in Favor of
Vaginal Coeliotomy.— F. Schauta believes that the
improved technique of vaginal cceliotomy is one of the
most valuable advances in modern operative gynaecol-
ogy. Its mortality is about half that of the abdominal
method. The course of healing is painless and un-
complicated, while there is an absence of suppuration
and hernia, resulting from the operation, so common
in the other method. As to the objections raised
about "operating in the dark," he lays special stress
on the fact that the technique should be so skilfully
managed that the operation is under careful observa-
tion from beginning to end.
Ovariotomy per Anum Hubert Peters cites the
history of a Russian woman, thirty-seven years old,
who had from early youth suffered from constipation.
For years she had noticed a rectal prolapse on defeca-
tion. On examination, a cystic tumor was also dis-
covered, corresponding in position to the left ovary.
In order to shorten the operation as much as possible
on account of the precarious condition of the patient,
ovariotomy was performed at the same time with the
rectal operation by means of the anal method, instead
of the usual abdominal or vaginal cceliotomy or the
p.srineal or sacral method. The ovarian tumor proved
to be a serous cystadenoma.
Bacilli of the Stools of Nurslings Colored by
Gram. — Ernst Moro has isolated a bacillus from the
stools of infants which he calls bacillus acidophilus
because it flourishes in acid media. Tissier has also
isolated a bacillus from the same source by means of
anaerobic culture methods. Both are stained by Gram's
method.
Miinchener medicinische Wochenschrift, Jan. jo, igoo.
Contribution to the Question of the Causes of
Death in Burns by Fire and by Scalding.— E.
Scholz gives the results of two series of experiments
made for the purpose of ^:ertaining the influence of
the skin in the formation of toxins in the living body.
First, he compares equally extensive burns, by fire, of
the skin and peritoneum. Next, he compares burns of
the skin — in the-first place, skin with the circulating
blood, then in a bloodless condition. He concludes
that in scalding the skin changes do not play a chem-
ical roWbut that the chemical changes result from the
infiuenre of heat on the blood. In peritoneal burns a
great number of blood corpuscles are changed. The
burn of the skin, because of the protecting covering it
affords, is not so destructive as the same injury of the
peritoneum. Scalding of bloodless skin, which would,
if the blood were present, cause death, is followed by
no suck effect in the anaemic part. This shows that the
fofis^on of toxic substances is not concerned with
the skinX Neither do the blood changes occur through
the absoraMon of toxic materials, but death by fire or
scaldiitgis due to the combined influence of the phys-
ical and chemical waste products of the blood result-
ing from the effect of heat.
Psychiatry in Relation to the Question of School
Physicians. — \V. Weygandt declares that the use of
the school physician for the psychical observation of
the students is still in the experimental stage. Psy-
chology and pyschiatry are chiefly useful in the build-
ing up of this theory. The physician with psycholog-
ical and psychiatrical education has the best foundation
for the position of school physician in the higher
schools of learning. In the public schools the stu-
dents should be sifted and the weak-minded separated
from the others and put in classes by themselves.
A Case of Acute Perichondritis and Periostitis
of the Nasal Septum of Dental Origin. — Gustav
Killian reports the case of a man thirty years old.
Pain was severe, and foul-smelling pus escaped from
the left nostril. The left second incisor ached. The
mucous membrane of the nasal septum was opened
and dressed. Six months later the patient again ap-
peared, the tooth was extracted, and a cyst was dis-
closed. This was excised, and recovery followed.
A Case of Perityphlitis in a Hernial Sac : Resec-
tion of the Caecum and Vermiform Appendix C.
Goschel, after giving a history of this case, speaks of
the literature on this subject. Diagnosis between in-
carceration and perityphlitis in a hernial sac cannot be
made Before operation. Happily this has little influ-
ence on the treatment of the affection. Operation is
always indicated.
Severe Opium Poisoning of an Atrophic Child of
Ten Weeks ; Ten Hours' Faradization of the Phrenic ;
Recovery. — August Model reports the case of a young
child to whom its nurse gave an overdose of the tinc-
ture of opium. He applied faradization to both phre-
nic nerves with the happiest results. After this treat-
ment the infant, who had been very feeble, improved
greatly in general health.
Experiments Concerning the Influence of New
Antiseptics on Infected Corneal Wounds. — Wilhelm
Hauenschild has experimented with protargol, sil-
February 24, 1900]
MEDICAL RECORD.
335
ver nitrate, and oxycyanide of mercury of different
strengths on infected corneal wounds, and finds the
vitality of the micro-organisms in no way affected by
the antiseptics. So far, mercury oxycyanide applied
under high pressure has had the best results.
Absorption and Fat-Splitting in the Stomach.—
By F. Riegel. A continued article.
La Rifortna Medica, January 20 and 2J, igoo.
The Action of the Halogens on the Cells of the
Central Nervous System. — O. Modica and U. Alessi
conclude from a series of experiments on guinea-pigs
that the halogen salts, more especially bromides and
iodides, profoundly affect the central nervous system.
Changes in the chromatin constitute the first symptom,
shortly followed by degeneration and necrosis of the
cells. These grave lesions existed in animals which
had apparently normally working nervous systems.
The action of these salts does not differ from that of
many other substances.
Acute Fibrinous Bronchitis Camillo Vittorio
Pick reports a case noteworthy because of the rapidity
of its onset and disappearance.
The Tetany of Influenza. — R. Gomez describes a
case of tetan)' due to influenza in a child aged seven
years.
Bulletin de r Academic de Mcdecine,/an. 2J and jo, igoo.
Respiratory Reflex and Lingual Tractions J. V.
Laborde, describing his method of treating apparent
death, says that the respiratory reflex is the first phe-
nomenon of life in a newly born infant, and the first
to be exhibited in the resuscitation of asphyxiated in-
fants; so should it be the first in cases of suspended
animation, or apparent death. The sensory nerves
governing this function are the pneumogastric through
the superior laryngeal, and the glosso-pharyngeal (as
lately determined by the author). Rhythmical trac-
tions of the tongue, by stimulating these nerves, excite
them to renewed activity. The method is so simple,
of such easy application by any bystander,jthat in cases
of apparent suffocation, etc., it should invariably be
tried. Laborde holds that after apparent death there
is a latent period of life which lasts about three hours,
and that it is during this time that rhythmical tractions
of the tongue will often re-establish the respiratory
function and restore the patient to life. Failure to
obtain this result proves that death is real, not merely
apparent. He urges the use of this procedure in every
case of death for three, six, or twelve hours, either by
means of the hand alone, or by the use of apparatus
devised by him for the purpose.
Congenital Lacrymal Tumor.— M. Gueniot de-
scribes a case in a new-born infant. When pus formed,
the lacrymal sac was emptied and cleansed, and two
drops of a coUyrium of 10 cgm. silver nitrate to 15
gm. distilled water was used morning and evening. A
cure followed.
Abscess of the Liver ^Lucas-Championniere de-
scribes a case in which the radiograph was of use in
determining the presence of a tumor. Exploratory
puncture confirmed the diagnosis, and a curative oper-
ation followed.
The Chigre — M. R. Blanchard discusses Clair and
Joly's report of the recent appearance of the chigre or
burrowing flea in Madagascar.
Dystocia — M. Porak discusses a case reported by
Narich concerning the diagnosis and prognosis of dys-
tocia from foetal hydrocephalus in breech presentation.
French Journals.
Invasion of the Lymphatic System in Cancer of
the Stomach. — E. Cuneo makes a practical study of
this subject, long one of theoretical interest. Anatomo-
pathological data point out operative indications of
great importance: (i) The frequent, almost constant,
existence of submucous changes at 2 cm. beyond the
apparent limits of the neoplasm, showing the necessity
of cutting well beyond this limit. (2) The advance of
the neoplasm along the lymphatic channels of the
lesser curvature necessitates a wide resection of this
region. (3) The habitual integrity of the duodenum
permits of not including in the resection more than
1.5 or 2 cm. of this portion of the intestine. (4) The
ganglia of the coronary chain and of the gastro-epi-
ploic chain on the right side should be completely
extirpated, so far as possible, at the same time as the
tumor. (5) Pylorectomy is the best of the palliative
operations in adenopathies at a distance, on condition
of being easy and rapidly executed. — Gazette des Hbpi-
taux, February i, igoo.
Some Ocular Disturbances in Typhoid Fever
Edmond Koenig discusses optic neuritis and other eye
affections in the course of typhoid which, like other
severe infectious processes, may determine ocular
changes. Optic neuritis is one of the accidents which
may lead to atrophy and blindness. In doubtful cases
we are no longer justified in admitting a meningitis
in an exclusive sense, when such a lesion of the optic
nerves is found. This ocular accident, occurring at
times in the early period of convalescence, should
make a reserve progiiosis necessary from the double
standpoint of general and local condition. Optic neu-
ritis of microbic origin is possible without the inter-
vention of other physiological or pathological mechan-
ism.— Le IVogrcs Medical, February 3, igoo.
Osteo-Hypertrophic Varicose Naevus. — Klippel
and Trenaunay relate an observation of congenital
deformity in a man aged twenty-eight years, impli-
cating the thigh, leg, foot, and portion of the trunk,
consisting in a varicose nsevus with elongation and
enlargement of bones, causing slight limping. The
condition had not changed essentially from a very
early period. The literature is given, and the origin
of such conditions is thought due to intra-uterine in-
fection the effects of which persist after birth during the
whole period of development. — Journal des Fraticiens,
February 3, igoo.
Primary Epithelial Tumors of the Bronchi •
Charles G. Nicolas finds that up to 1886 only eighty-
six instances of primary epithelioma of the lung had
been reported, and Pick in iSgi had found but fifteen
cases of primary cancer of the trachea. The writer
now collects thirty-five instances of neoplasms sup-
posed by their observers to be primary cancer of the
bronchus. He studies the whole question. The evo-
lution is quite rapid and treatment is only palliative.
— Gazette Hcbdomadaire de JSIedccine et de Chirurgie,
February 4, igoo.
Hydatid Cyst of the Pleura. — Gibert and Jean-
brau put on record the case of a man aged thirty-two
years, operated upon by Professor Forgue by resection
of the eighth, ninth, and tenth ribs, evacuation of the
pleural cavity, and cure, in hydatid disease originating
in the liver. These cases are usually mistaken for
simple pleurisy or tuberculosis. Ample thoracotomy
at once is the best treatment to avoid lasting bronchial
fistula and gangrene of the lung. — Gazette des Hbpi-
taux, January 25, igoo.
Experimental Typhoid Fever. — Paul Remlinger
reviews the history, modes of inoculation, conditions
336
MEDICAL RECORD.
[February 24, 1900
which favor infection of animals, symptomatology, and
pathology, and concludes that there exists in animals
a true experimental typhoid, which is closely con-
nected with typhoid of man, and that it presents in
particular analogies with typhoid in infancy. — Gazette
lies H bpitaiix, January 27, 1900.
Joiiy. of IS! e IT. and Mental Disease, /an. and Feb., igoo.
Progressive Ankylotic Rigidity of the Spine
B. Sachs and J. Frankel report several cases belong-
ing to what they call the Striimpell-Marie type, which
has an apparent resemblance to ordinary rheumatic
affections, but differs from them in that the vertebral
joints are affected; hereditary predisposition has not
been established; the disease is progressive, has been
noticed chiefly in men, and shows no tendency to im-
provement. The morbid changes causing this affec-
tion appear to differ in degree and localization, not in
kind, from those found in extreme forms of articular
rheumatism and arthritis deformans; but from a clin-
ical standpoint " spondylose rhyzomd lique " merits fur-
ther study.
Trauma of the Cervical Region of the Spinal
Cord, Simulating Syringomyelia. — James Hendrie
Lloyd reports a case in which the anatomical findings
were extensive destruction of the gray matter of the
cord, and of the direct cerebellar and Gowers' tracts,
with comparative exemption of the posterior columns.
Correlating this with the clinical phenomena in the
case, he thinks the inference warranted that the tracts
for heat, cold, and pain pass up by way of the gray
matter, eventually passing from the gray matter into
Gowers' tract, while tactile or common sensation is
conveyed by the fibres in the posterior columns.
Meralgia Paraesthetica. — John Herr Musser de-
scribes ten cases of this disease, which he defines as a
disturbance of sensation on the external surface of the
thigh, characterized by various forms of parsesthesia,
associated with dissociation and more or less diminu-
tion of sensation. In statistics collected in regard to
99 cases, the affection occurred 75 times in males.
The duration cannot well be determined. As to etiol-
ogy, injury was mentioned 19 times, syphilis 10, alco-
holism 8, typhoid 8, other infectious processes 8, preg-
nancy 6, gout and rheumatism 13, other nervous
conditions 1 1.
A Case of Tumor at the Base of the Brain in
the Pontine Region. — By James Hendrie Lloyd.
See Medical Record, vol. Ivi., p. 138.
The Unity of the Acute Psychoses By Philip
Coombs Knapp. See Memicai, Record, vol. Ivi., p.
137-
Two Cases of Muscular Dystrophy with Necropsy.
— By William G. Spiller. See Medical Record, vol.
Ivi., p. 140.
Anniversary Address By Wharton Sinkler. See
Medical Record, vol. Ivi., p. 141.
The Nervous Equivalent of Fever. — By Henry S.
Upson. See Medical Record, vol. Ivi., p. 137.
Landry's Paralysis. — By Philip Coombs Knapp.
See Medical Record, vol. Ivi., p. 142.
A Case of Haematomyelia. — By James Hendrie
Lloyd. See Medical Record, vol. Ivi., p. 141.
Annals of Surge?y, February, rgoo.
Pathology of the Lymphatics of the Peritoneum.
— From observations based on over five hundred ab-
dominal post-mortems, Byron Robinson concludes that
there are in the adult certain localities of peritonitis
which are practically constant; peritonitis over the
right psoas muscle is found in seventy-five per cent.
of the cases involving appendix, caecum, and distal
end of the ileum ; over the left psoas involving the
meso-sigmoid in eighty per cent. Lymphangitis over
the levator ani in women involves about the same
number. Examination of pieces from the areas of
local lymphangitis show-s nearly complete occlusion
of the lymph-vessels. White connective tissue prolif
erates and constricts them. Means to transport infec-
tious material is thereby wanting, and hence repeated
lymphangitis becomes less and less dangerous.
Further Observations on Depression of the Neck
of the Femur in Early Life , Including Fracture of
the Neck of the Femur, Separation f^f the Epiphysis,
and Simple Coxa Vara — R. VVhit:r.,.n places on rec-
ord another case of separation of the epiphysis in ado-
lescence, and points out the essential differences be-
tween this class of cases and those of true fracture of
the neck of the femur. Depression of the neck, either
simple or traumatic, predisposes to progressive deform
ity, and may indicate operative treatment at an early
stage as a preventive measure. Since forty-eight cases
of this depression have come within the author's ob-
servation within a comparatively short time, he is
inclined to believe that this deformity is more com-
mon than is generally believed.
Traumatic R\ipture of the Bile Duct — R. W Gar-
rett records the case of a young farmer suffering from
this injury as the result of a fall. Abdominal section
revealed the rent at the back of the upper part of the
common duct as it passes downward and to the left
between the two layers of the lesser omentum. The
patient recovered. Reference is made to other re-
corded cases.
Actinomycosis in Man, with Special Reference to
the Cases which Have Been Observed in America.
— J. Ruhriih reports seven cases, in addition to those
previously published by him in the Annals These
additions make the total of American cases seventy
two. The author believes that there are still addi-
tional unreported cases, and urges that the records be
made complete with reference to this affection.
Inter-Scapulo Thoracic Amputation.— From the
study of a large number of cases R. S. Fowler con-
cludes that sarcoma of the humerus offers slight chance
of ultimate cure by any but the most radical procedure,
and that the operation of choice for sarcoma of any
part of the humerus is primary inter-scapulo thoracic
amputation.
The Technique of the Positive and Negative Di-
agnosis of Ureteral and Renal Calculi by the Aid
of the Roentgen Rays. — C. L. Leonard makes a plea
for the employment of this means of differential diag
nosis, which he believes is perfectly reliable and in
the light of our present knowledge an absolute clinical
necessity.
intestinal Obstruction due to Intussusception •
J. F. Erdman analyzes the histories of nine cases seen
by him within a few years. Results of treatment were
as follows: three operative recoveries, one enema re-
covery, four operative deaths, one non-operative death.
American J our?ial oj tlte Medical Sciences, Feb., igoo.
Some Cases of Dilatation of the Stomach —John
H. Musser and J. Button Steele conclude from their
observation of these cases that: (i) The symptoms
upon which most reliance can be placed in deterniin-
February 24, 1900]
MEDICAL RECORD.
337
ing the presence of gastric motor insufficiency are : (a)
Tlie presence of fluid and food in the stomach fasting
over-night; {/•) the ready entrance of fluid through the
tube and difficulty in the return flow, (() the absence
of visible gastric peristalsis, (t/) evidences of fermen-
tation and intoxication by the products thereof; (e)
thirst; and (/) scanty and concentrated urine. (2)
In determining the position and size of the stomach,
by far the most certain method has been inflation with
air through the stomach-tube. (3) The condition
does not seem uncommon in students. The etio-
logical factor is myasthenia caused by chronic gas-
tritis from the abuse of alcohol and tobacco, from de-
ficient innervation, probably of congenital origin, and
occurring in the course of acute disease.
Narcolepsy : A Contribution to the Pathology of
Sleep. — D. J. McCarthy has found nothing in his
studies of sleep and its disturbances to support the idea
that the condition known as narcolepsy is a distinct
neurosis or disease. In the only autopsy report out
of eighteen cases collected by S. Weir Mitchell there
was simply " no lesion." In Mitchell's case he found
" starch corpuscles in those portions of the gray matter
submitted to examination." McCarthy feels certain
that a microscopical examination of the brain in such
cases of prolonged sleep as that lately reported by
Skerrit and Stewart, when the patient recovered from
a sleep of fifty days with inco-ordination and other
symptoms of brain lesion, would reveal cellular
changes. He cites several interesting cases.
The Increasing Prevalence of Cancer as Shown
in the Mortality Statistics of American Cities. —
G. Betton Massey declares that the conviction is war-
ranted that there is a widespread increase in the
causes of this affection or the liability to acquire it,
throughout the country. The greatest increase appears
to have occurred in San Francisco. He gives nine
charts representing the mortality rates of cancer in
New Orleans, Philadelphia, Boston, New York City,
San Francisco, St. Louis, Baltimore, Fngland, and
Wales, and one showing the combined cancer mortal-
ity of seven American cities. Aside from operations
in private and in ordinary hospitals, the attention paid
to this trouble may be said to be comprehended en-
tirely in the establishment of one State laboratory of
research and one special cancer hospital, the latter not
confining its attention to cancerous diseases.
A Critical Summary of Literature on the Influ-
ence of Heredity on Deafness. — W. Scheppegrell
states that there is a lack of unanimity of the views
on this subject. In cases in which deaf-mutism can-
not be traced to heredity or to consanguineous mar-
riages, it may be the expression of an abnormal
condition in the parent. It is a phase of physical
degeneration which may appear in families suffering
from scrofula, tuberculosis, mental or nervous diseases,
syphilis, or alcoholism. Social environment is also of
importance in this connection, as has been advocated
by Me'niere. Many nervous aftections have been no-
ticed in the families of deaf-mutes. Boys appear to be
more frequently affected than girls.
A Case of " Family Periodic Paralysis." — James
J. Putnam, in reporting this case, inclines to the view
that in this curious disease we have to do with a
subtle disorder of the physiological co-ordinations of
health rather than with a general poison.
The Surgical Treatment of Acute Puerperal Sep-
sis, with Special Reference to Hysterectomy. — By
Hiram N. Vineberg. See Medical Record, vol. Iv.,
p. 796.
7'/te Practitioner, February, igoo.
On the Relation of Pneumonia to Pulmonary
Tuberculosis. — R. W. Philip says such terms as tuber-
culous pneumonia and pneumonic phthisis should be
dropped to avoid confusion. He is inclined to think
that the concomitance of pneumonia and pulmonary
tuberculosis in the same subject is commoner than is
sometimes stated. His experience is that the super-
vention of pneumonia during the course of pulmonary
tuberculosis is by no means uncommon, the already
damaged lung falling more easily a prey \o further
attack. In this mixed affection there is a tendency of
the pneumococcus to loiter, and he has found it pres-
ent many months after the acute attack. As to the
possibility of pneumonia determining the establish-
ment of pulmonary tuberculosis, many authors are
quoted. Some years ago the writer analyzed one
thousand cases of pulmonary tuberculosis, and con-
cluded that in only one-half per cent, was a close se-
quence of tuberculosis or croupous pneumonia to be
made out. It is not a common precedent factor and is
rarely found in immediately determinant relationship.
In some supposed cases of croupous pneumonia the
condition is really one of acute exacerbation of the
tuberculosis.
The Surgical Aspects of Pneumonia A. Pearce
Gould considers the surgical treatment of certain se-
quels, empyema, pulmonary abscess, gangrene of the
lung, and briefly mentions the conditions under which
pneumonia occurs in surgical practice. The surgical
diagnosis of empyema is made with the aid of an ex-
ploring syringe. Every case of pneumococcus empy-
ema should be submitted to operation as soon as the
condition is diagnosticated. The surgical treatment
of pulmonary abscess and gangrene consists in making
a direct opening into the diseased area of the lung and
evacuating the pus or removing the sphacelated tissue.
The sign especially relied upon is the presence of
moist rales. Pneumonia as a sequel to surgical opera-
tions may be due to too great exposure of the chest,
but it must be remembered that the operation may take
place just as an attack is developing. Broncho-pneu-
monia is a more frequent sequel to operation, due at
times to aspiration of blood. Traumatic pneumonia
is of limited area without tendency to spread unless
infective organisms are carried into the injured lung.
On Some Methods of Treatment of Pneumonia.
— Sir Hermann Weber confines his remarks to lobar,
acute, or croupous pneumonia, comparing the treat-
ment by blood abstraction, tartar emetic, opium, and
salicylate of sodium, and the mortality of cases treated
in Bonn and in London. In Bonn it was somewhat
higher than in London (fourteen to seventeen percent,
as against twelve to fourteen per cent.). Epidemic
pneumonia is more fatal than sporadic. He thinks
an abortive treatment may be found by means of anti-
toxic serum. It is a possibility that different forms of
pneumonic fever may be caused by different microbes.
The prejudice against small doses of antimony and
against bleeding in moderation in suitable cases is
entirely unfounded, and both may be eminently bene-
ficial.
On the Treatment of Pneumonia.— Sir Samuel
Wilks says those who examine all patients thoroughly
are the least likely to mistakes in diagnosis, confound-
ing pneumonia with inflammation of the brain, deli-
rium tremens, etc. If pneumonia reaches the stage of
complete albuminization it is inevitably fatal. He
doubts whether digitalis has a capability of lowering
the pulse except given in doses which are probably
injurious. None of the products of the laboratory can
be compared with opium for long-continued use. He
338.
MEDICAL RECORD.
[February 24, 1900
is satisfied when he sees a patient with pneumonia
taking a dose of saline and five grains of Dover's pow-
der every four hours. Cold to the chest and blisters
are harmful. Pathology and therapeutics must go
hand-in-hand.
American Jourtial of Insanity, January, igoo.
Case of Multiple Cerebro-Spinal Sclerosis of a
Special Anatomical Form, with a History of Pro-
nounced Family Defect. — I. H. Neff and T. Kling-
mann give a complete history of the case with post-
mortem findings. The interesting features are: (i)
The distribution of the sclerosis, it being largely
limited to the motor tract; (2) an absence of marked
changes in the vascular system ; (3) a pronounced
secondary descending degeneration in the pyramidal
tract and complete atrophy of the ganglion cells; (4)
the reaction of degeneration and muscular atrophy.
Differential Diagnosis of Paretic and Pseudo-
Paretic States.^ — A. W. Hurd makes special mention
of cerebral syphilis and insanity of alcoholic origin.
These are the cases which are most likely to develop
paresis. Diagnosis is most difficult in the melan-
cholic and demented types.
Common Features in Neurasthenia and Insanity ;
their Common Basis and Common Treatment.^ —
G. W. Foster collates the results of other observers
along this line, and makes a plea for the more general
employment of hydrotherapy in cases of this nature.
Cortical Functions and Psychology. — H. Nicho-
las believes that much is to be expected from the
psychologists in regard to determining the functions
of the cortex of the brain, two-thirds of which is still
a functional terra incognita.
A Differential Count of White Blood Corpuscles
in a Few Cases of General Paralysis. — F. H. Jenks
gives figures from nine cases, and thinks that they
show an increased percentage of large lymphocytes at
the times of a paretic seizure.
What the Chronic Insane can Accomplish under
Proper Directions. — J. VV. T. Rowe describes the
work done at Central Islip, Long Island, and shows
how beneficial out-door work is to this class of pa-
tients.
The Colony System of Caring for the Insane. ^ —
H. Ostrander warmly commends this system and de-
scribes an institution of this kind recently established
by the trustees of the Michigan asylum.
General Pathology of Mental Diseases. — By H.
J. Berkley; from advance sheets of "A Treatise on
Mtntal Diseases," based upon the lecture course at the
John Hopkins University, 1899.
Transitory Alienation following Intense Pain. —
H. J. Berkley narrates a case in which the onset of
symptoms was dependent upon the menstrual epoch.
Bulletin of the Johns Hopkins Hospital, January, /goo.
Contributions to the Surgery of the Bile Pas-
sages, Especially of the Common Bile Duct. — VV. S.
Halsted writes that he is much impressed with the
splendid results of operations for gall stones in the
common duct. He reviews eight of his recent cases,
pointing out interesting facts in connection with
them. In one case were conditions suggesting hepa-
tico-cholecystostcholecystenterostomy as a possible
operation. Remarkable toxic (?) renal colic resem-
bling closely intestinal colic, associated with anuria;
colic and anuria entirely relieved by salt infusion.
In another case renal pains resembling intestinal
colic (third observation of the kind within eighteen
months). Halsted believes, if no contraindication
exists, that adhesions should be separated if possible,
as not infrequently to adhesions alone are due the
symptoms which persist after the calculi have been
removed or have escaped.
Medical Commission to the Philippines. — Lewellys
F. Barker writes that at present the observations con-
cerning the causation of dysentery — one of the most
important results of the expedition to the Philippines
being the isolation by Dr. Flexner, from the dejecta
of patients, of a bacillus which is almost certainly the
cause of the acute dysentery studied — the dift'erentia-
tion of the fevers of the region, the relative prevalence
of typhoid fever and malaria, the studies of the varie-
ties of the malarial parasite there found, and the in-
vestigations of beri-beri, may be specified as among
the more important scientific results of the expedition.
Early Exploratory Operations in Tuberculosis of
the Hip.- — Joseph C. Bloodgood states that the chief
object in the early operation for tuberculosis of the
hip is to take the disease in its early stage, to relieve
the tension of the distended capsule, to check and
cure the tuberculous synovitis by disinfection and
drainage, to explore the bone with the hope of finding
the tuberculous osteomyelitis, in which case it can be
partially or completely excised ; trusting also to dis-
infection, drainage, and the healing-process to check
and later cure the disease of the bone without injury
to its continuity.
A Reconstruction of a Glomerulus of the Human
Kidney. — William B. Johnston has made a wax model
of a glomerulus of the kidney of a child three months
old. When the child was dead but a few hours, the
kidney was injected in situ through the abdominal
aorta until the Berlin blue appeared in the renal vein.
Gunshot Injuries by Weapons of Reduced Calibre.
^L. A. Lagarde declares that upon the whole, in the
later Cuban war, the gunshot injuries by the Mauser,
the reduced-calibre rifle of the Spaniards, were in
keeping with those humane effects so confidently pre-
dicted by experimenters generally.
An Apparatus to Aid the Introduction of a
Catheter or Bougie.— George Walker describes, with
cut, an instrument whose object is to distend the ure-
thral canal, and in this way to enlarge the narrowed
portion, so that an instrument will pass through.
Archives <f Pediatrics, February, /goo.
A Study of Lesions of the Liver in Young Chil-
dren.— Rowland Godfrey Freeman gives a summary ■
of his observations on hepatic lesions in young children.
Fatty livers are frequent. The condition of nutrition
apparently has no connection with this lesion. Fatty
livers occur rarely in marasmus, malnutrition, rachitis,
and syphilis, unless such condition be complicated by
an acute disease; and with tuberculosis not more often
than with other conditions. They occur most often
with the acute infectious diseases and gastro-intestinal
disorders. The two cases of cirrhosis of the 'liver
examined by the writer ran a comparately acute
course. The livers on section showed a marked
hyperplasia of the so-called new-formed bile ducts.
Focal necrosis of the liver may be a lesion of mea-
sles.
February 24, 1900]
MEDICAL RECORD.
339
The Mortality and Treatment of Acute Intus-
susception.— Fred. Kammerer believes that after one
failure of an attempt at reduction laparotomy is indi-
cated. The causes of the high rate of mortality in
irreducible cases are generally tlie septic condition of
the intussusceptum, and the necessity of extended sur-
gical interference. The mortality in reducible cases
is less than half that in irreducible cases.
The Necessary Factors in the Successful Treat-
ment of Intussusception. — C. L. Gibson thinks that
the main feature of expected success in relieving in-
tussusception depends, first, on the intussusceptum
being found in a reducible condition and free from
septic changes, and, second, that such a favorable con-
dition can ordinarily be met only by a very early inter-
ference. That is, the prognosis depends absolutely on
the promptness of relief.
Report of Two Cases of Sarcoma of the Lower
Jaw. — W. H. Hudson states as particular points of
interest: In Case I., the successful removal of the
tumor and the uneventful recovery of the patient after
the first operation. The necessity is also shown for
the very early and thorough extirpation of sarcomatous
growths if permanent relief is to be hoped for. In
Case II. is the proof that a sarcoma may develop from
a tooth follicle in a person eighteen years of age.
Bulletin of Cleveland General Hospital, October, j8gg.
A Report of Several Cases of Typhoid Fever
with Interesting Complications I. Friedman, in
summing up the interesting points in five cases of
typhoid fever, says that in Case I. the pus from the
suppurated parotid did not contain typhoid bacilli,
but a pure culture of the pneumococcus. Case II.,
complicated by intermittent malarial fever, further
proves the possibility of double infection. In Case
III., at the time of perforation, tlie temperature did
not show the usual sudden drop. Case IV. tends to
show that low enemas do not produce the desired
result in securing free evacuation of the bowels and
so prevent the serious complication of auto-infection;
further, it shows that the use of decinormal saline solu-
tion has little effect on the conditions resulting from
this complication. Case V. shows the not uncommon
difficulty in making a differential diagnosis between
miliary tuberculosis and typhoid fever. Tub baths
produced a decided and prompt amelioration of many
of the serious symptoms in these cases.
Osteomyelitis of Fibula with Spontaneous Cast-
ing Off . of the Entire Bone, Empyema, Pyaemic
Abscesses ; and Recovery, with a Useful Limb. — J.
C. Steuer gives the history of this case with the final
results of his treatment. The leg was incised and
the pus evacuated. The pleura was incised and
drained and the various abscesses were opened. All
the wounds were dressed with bichloride gauze and
irrigated with i : 2,000 bichloride solution. Digitalis,
nux vomica, and brandy were prescribed. The child
recovered with very little trace of her severe illness.
Kryofin in Neuralgia. — Charles J. Aldrich's ex-
perience with this drug shows it to be safe in com-
parison with acetanilid, although it is as active. It
is also safer than phenacetin. The purely neuralgic
cases seem to be its field, and when used judiciously
it rarely disappoints. It is often given in doses of gr.
xv-xx., with excellent results.
A Case of Puerperal Mania with Albuminuria.
— C. F. Button, reporting this case, believes that both
ihfe nephritis and mania were due to autotoxsmia.
Whether the poison had its origin in the alimentary
canal, in the liver, or in the more general metabolism
of the body does not appear.
A Case of Appendicitis. — George VV. Crile reports
the substance of this case as follows- Rupture of gan-
grenous appendix; general peritonitis, incision and
drainage; fecal fistula; resection with end-to-end
anastomosis, ventral hernia, herniotomy, recovery.
Treatment of Stone in the Bladder — C. B. Par-
ker states that the successful treatment of stone in
the bladder is always surgical. The two approved
methods are: i, litholapaxy , 2, lithotomy.
Guaiacol in Orchitis and Epididymitis. — William
Huss notes the remarkable effects of guaiacol in these
painful affections. It was first used on suggestion of
Dr. Aldrich.
Report of a Case of Persistent Priapism W. J.
Scott thinks that in this case the condition must be a
reflex to the constrictor penis.
Tie Medical Chronicle, February, jgoo.
Peripheral Neuritis following Chorea Treated
with Arsenic. — J, C. Railton reports four cases which
show that there is a risk of disastrous results follow-
ing the treatment of chorea with arsenic, if that remedy
is given in doses which amount in the aggregate to as
much as six grains of arsenious acid. The results >
may give no warning of their approach during the ad*
ministration of the drug, but make their appearance
afterward with an interval varying from a week to a
fortnight subsequent to its discontinuance.
Statistics on Lactation — G. F. Blacker found that
out of one thousand women of the lower classes in
London, only twenty-four never suckled their children
on account of an entire absence of milk, and of these
only eleven were multiparae.
T/ie Edinburgh Medical Journal, February, igoo.
Vaginal Cffiliotomy J A. C. Kynoch claims the
following advantages for the vaginal over the abdom-
inal route: Shorter convalescence, no abdominal
cicatrix, consequently no risk of hernia or formation
of intestinal or omental adhesions, less shock, drain-
age, if necessary, carried out through the posterior for-
nix. Cases suitable for the vaginal route (other means
of treatment failing) he believes to be: Mobile retro-
flexion, causing symptoms at about the menopause;
chronic ovaritis with adhesions, prolapse of the ovary
with .fixation; ovarian cysts if small; pelvic hemato-
cele; unilateral, mobile, tubal swellings. Cases un-
suitable are large tumors, old standing tubal disease
with dense adhesions.
Sprue Lauder Brunton uses dilute solution of bi-
carbonate of soda to lessen the soreness of the mouth,
and treats the sore anus with an ointment of bismuth
and lanolin. The diet should be an entirely milk
one.
The Treatment of Hypertrophied Prostate by
Vasectomy. — T. Vincent Jackson says that this opera
tion has never been followed by any kind or degree of
harm, and that it has seldom failed to relieve the pa-
tient.
Pyosalpinx Removed by Laparotomy in the
Early Puerperium. — R. Milne Murray successfully
performed this operation on a patient two days after
delivery. There was a good recovery.
340
MEDICAL RECORD.
[February 24, 1900
Injuries and Diseases of the Conjunctiva. — A.
Maitland Ramsay describes the various accidents and
diseases which may affect the eye, and gives the treat-
ment therefor.
Papilloma of the Tongue. — J. Grant Andrews re-
ports a case in which many features suggested carci-
nomatous change. After removal there was a recur-
rence in the submaxillary lymphatic glands.
Sudden Death following Labor G, W. Simla
Paterson reports a case in which unsuspected cardiac
lesions and suddenly superadded pneumonia caused
death twenty-four hours after labor.
Effects of the Roentgen Rays J. Hall Edwards
reports three cases of lupus in which the use of the
.a:-rays gave fairly satisfactory results.
Tlie British Journal of Dermatology, February, igoo.
A Clinical Study of Some Winter and Summer
Recurring Eruptions. — H. Radcliffe Crocker first
considers acrodermatitis pustulosa hiemalis, a papulo-
pustular winter eruption of the hands, probably a
variety of folliclis. The winter diseases /lar excel-
lence are chilblains, Raynaud's disease, pruritus hie-
malis, and dermatitis hiemalis (Corlett). Three cases
are given which agree fairly well with others de-
scribed under a variety of names, including the one
employed, folliclis. He says, in a foot-note, that since
his paper was written he has read of a case described
.by C. W. Allen under the name necrotizing chilblain
lesions, which seems closely analogous to his own,
coming on only with the advent of cold weather. He
described a recurrent pustular eruption of the hands
similar to Corlett's dermatitis, a recurrent winter ery-
thema causing red blotches upon the cheeks and about
the mouth ; an acneiform eruption limited to the nose;
and a diffuse finely papular eruption. The recurrent
tumor eruptions are vesico-pustular ; vesicular, erythe-
matous, and urticarial, numerous cases being cited,
all except the acrodermatitis being of angioneurotic
origin.
The Primary Lesion of Psoriasis.— William J.
Munro points out as the result of studies in Sabou-
raud's laboratory that the initial lesion in psoriasis is
a dry abscess in the superficial part of the horny layer
of the- skin; the vice of keratinization being second-
ary.
Dublin Journal of Medical Science, February, /goo.
Tropical Diarrhoea.— A. A. Gore discusses this
question in the light of his military experience in
India. During enforced residence in that country
everything tending to lowered vitality should be
avoided; habits should be regular, exercise moderate,
diet unstimulating, and stimulants used only in
moderate quantities. Flannel clothing must be con-
stantly worn. On the supervention of diarrhcea, we
may give a castor-oil purge guarded by a little opium.
After that a most careful dietary is prescribed Later
remedies include nitro-muriatic acid, lead, chloroform,
bismuth, and carminatives.
A Contribution to Renal Surgery T. I\Iyles dis-
cusses the question of bleeding in floating kidney, and
gives the details of the method which he prefers for
the fixation of this organ.
Dublin Fever.— H. Fitzgibbon studies a group of
febrile symptoms which he attributes to unsanitary
conditions in the city of Dublin. He considers the
disease as an enteric influenza.
The Position of Murphy's Button in Modern
Surgery.— By J. S. McArdle. A continued article.
// Folicli7iico, January i , igoo.
The Action upon the Renal Function of Hyp-
notics Associated with Diuretics. — T. Pirocchi con-
cludes from experimentation that chloral increases the
diuretic action of cafl:eine and arbutin, occasionally
that of diuretin and potassium nitrate, but that it has
no effect upon sodium nitrate. The sulphate of du-
boisine increases the diuretic action of caffeine, sodium
nitrate, diuretin, and arbutin, and sometimes of potas-
sium nitrate. The most useful combinations are ■
chloral and caffeine; chloral and arbutin; sulphate of
duboisine and diuretin; sulphate of duboisine and the
nitrate of sodium; sulphate of duboisine and arbutin.
Influence Exercised by Diphtheritic and Typhoid
Toxins on Nutritive Exchange. — Domenico Pace
concludes that a large but non-lethal dose of toxin
causes a consumption of albumin, but exercises such
an influence upon the delicate mechanism of nitrog-
enous exchanges that a second larger dose of the poison
is felt only as a lesser dose which tends to economize
the body albumin. This is what occurs when, in the
study of the- organic, exchanges in an organism, re-
peated doses of toxin create a condition of opposition
to infection, or what Charrin calls " the nutritive type
of immunity."
Metabolism in Ankylostoma Anaemia.— Giuseppe
Vannini gives the detailed results of observations in
six cases.
Albuminuria in Diabetes and Renal Diabetes —
By Ferruccio Shupfer. A continued article.
Lo Spcrime)italc,^'o!. Itii., I\o. 4, i8gg.
Hemorrhagic and Necrobiotic Infarcts in the Cir-
rhotic Liver. — A. Bonome holds that these are not
due to the formation of connective tissue, although
related to the obliterating endarteritis of the small
branches of the hepatic artery and to the disappear-
ance of the branches of the portal vein. The impeded
circulation in the liver due to cardiac lesions or even
to functional insufficiency of the heart facilitates the
production of these infarcts. It also favors the action
of the tubercle bacillus and its toxins and the devel-
opment of connective tissue.
Typhoid Infection Without Intestinal Localiza-
tion.— L. Picchi reports a number of cases in which
there were no intestinal lesions, but in which the path-
ological and bacteriological researches gave unmistak-
able evidence of typhoid fever. As to the method of
entrance of Eberth's bacillus into the .system, that is
as yet unknown.
The Spinal Accessory Nerve is a Mixed Nerve.
— Gaetano Pieraccini states that recent macroscopical
and microscopical researches have proved beyond a
doubt that the eleventh nerve is a mixed nerve.
Results Obtained by Specific Serum Therapy in
Malignant Pustule. — Achille Sclavo gives the statis-
tics relating to one hundred cases. All but two re-
sulted in recovery.
Norsk Magazinfor Licgevidenskaben, January, igoo
The Temperature in Psychopathic States and its
Importance in a Diagnostic Sense. — Harald Holm
says that the body temperature is normally slightlv
higher in the evening than in the morning, and in the
rectum than in the axilla. Any notable departure
from this rule in either direction — that is to say, if the
morning temperature equals or surpasses the evening,
or the axillary the rectal, or if the evening and rectal
temperature are two or three degrees Fahrenheit
higher than the morning and axillary respectively — tn-
February 24, 1900]
MEDICAL RECORD.
341
dicates a pathological condition. The author presents
the results of a special study of temperature abnormal-
ities in the hysterical and insane.
Hysterectomy in a Case of Fibroid Tumor. —O.
Senib reports the case of a woman, forty-four years
old, who had excessive losses with severe pain at the
menstrual periods. Examination showed the presence
of a submucous fibroid the size of a goose egg; the
uterus was hypertrophied and completely inverted;
there was no prolapse of the vagina. The uterus was
extirpated and the patient made an excellent recovery.
Specialism and Massage — Chr. Bergh argues in
favor of the performance of massage only by specially
trained experts, and reports a number of cases of vari-
ous affections in which this mode of treatment ren-
dered signal service.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, Fchniary zj, jgoo.
William H. Thomson, M.D., President.
Report by Drs. Roswell Park and Gaylord upon
their Researches on the Etiology of Cancer at the
State Laboratory, Buffalo, N. Y. — Dr. Roswell
Park, who read the first paper, dealt with the clinical
portion, or border line of the subject. He said that
Arnold had called attention to the comparative fre-
quency of what he called " fragmentation " of cancer-
ous tumors, but others had claimed that this was a
post-mortem change. Leucocytic aggregation and in-
filtration must be regarded as a reaction against some
form of irritation. Leucocytic infiltration or phago-
cytosis was practically always the reaction against ex-
traneous forces. The mechanism of lymphatic en-
largement had not been made so clear yet as it should
be. To his mind, every metastasis had the force and
significance of an inoculation experiment. Secondary
nodules in the involuntary muscles at a distance were
very rare. Diffusion of cancer along the nerve trunks
was very interesting, and was more frequent than was
commonly supposed. Involvement of surfaces con-
stantly in contact had been known to furnish numer-
ous instances of the spread of cancer. That imme-
diate contact was not necessary, was shown by cancer
of the lip and tongue. Cancerous elements, when in-
troduced into the serous fluids, seemed to find very
favorable conditions for their development. A num-
ber of observers had succeeded in transmitting tumors
from one animal to another of the same species.
Syphilitic lesions, or their resulting scars, might be
points of departure for cancerous formations. Fistu-
lous tracts, especially those leading inward from the
skin, with a gradual downward extension of the epi-
thelium of the skin, had often been the starting-point
of cancer. Scars were particularly prone to undergo
cancerous change, and this tendency was the more
marked in proportion as the nutrition of the scar tis-
sue was lowered. For this reason, cancer was liable
to attack scars following extensive burns. About the
vulva, as well as about the tongue, slight but pro-
longed irritation or traumatism was a common source
of cancer. One observer had reported no less than
six cases, in which cancer of the uterus had been ap-
parently the result of traumatism, inflicted by the use
of a pessary. Of forty-eight cases of cancer of the
liver reported by one observer, forty-one gave a his-
tory of gall stones. The speaker said that he had
recently seen a marked case of multiple sarcoma,
originating in what had been apparently an innocent
naevus. In the mucous membrane of the alimentary
canal similar changes were noted. Uterine adenoma
certainly predisposed to cancer of the uterus. Dr.
Park did not believe in the heredity of cancer, al-
though he expressed his belief in a hereditary
transmission of a soil favorable to the growth of can-
cer. He carefully distinguished between the cancer-
ous dyscrasia, the forerunner of cancer, and the
cancerous cachexia, the result of cancer. Apparently,
cancerous cachexia was a complex product of numer-
ous factors, though characterized in general by toxic
phenomena. In this connection one should not lose
sight of the effect of frequent and exhausting hemor-
rhages, and the common association with renal disease.
Dr. Gaylord made some remarks on the pathology
of cancer, illustrating them with lantern slides. He
said that the most prominent school in this line of re-
cent research was the Italian school. He character-
ized Bras as an ignoramus, and his work as being in
the hands of a charlatan. He had exhibited to the
speaker some of his peculiar organisms, and these had
been at once recognized as nothing more than com-
mon contaminations. Russell, of Edinburgh, eight
or nine years ago had described what was now known
as "Russell's fuchsin bodies." They occurred with
sufficient constancy in cases of cancer to make Rus-
sell describe them as having an etiological relation to
cancer. It had been soon found, however, that many
other bodies having no pathological significance what-
ever also stained readily with fuchsin. Dr. Gaylord
said that, from our present knowledge, it was not at all
improbable that these so-called fuchsin bodies might,
after all, have some definite relation to cancer.
Shortly after Russell had come Walker and Plimmer.
The latter investigator had stained twelve hundred
carcinomata, and had found in these a certain organ-
ism, which could be injected into animals, and c*ould
be recovered from the tissues of these animals. Plim-
mer had not, however, succeeded in reproducing the
phenomena of cancer by such inoculations. He had
demonstrated that this organism was a species of
yeast, and that it gave rise to certain well-marked
pathological changes. The speaker then discussed
pathogenic yeasts, and their bearing upon this subject.
He stated that it had been only comparatively recently
that a pathogenic yeast had been known to exist. Bot-
anists had not yet definitely determined whether the
yeast represented a definite form, or only a transition
stage of a higher organism. It was probable that it
existed in two forms, one being a pathogenic fungus.
The most exhaustive research showed that it was so
far impossible to classify yeasts morphologically.
He had employed Plimmer's technique recently in
twenty-five cases of carcinoma, and in every instance
had found Plimmer's bodies therein. These organisms
had been occasionally cultivated, and hence it was not
probable that these bodies were degeneration products.
Concerning the work at the State cancer laboratory in
Buffalo, the speaker said that those working there had
exhausted all the classical methods of investigating
the nature of cancer. They had once succeeded in
producing carcipoma by inoculation with the organ-
ism referred to. Their recent experiments had em-
braced prolonged and thorough drying of infected
lymph nodes, proved by the microscope to contain
Russell's bodies, and the injection of the powdered
product into animals. In each instance the animal
had died within three or four weeks, and the lymph
nodes had been found generally enlarged, and had
been shown by the microscope to contain large num-
bers of Russell's bodies. He thought it probable that
if these bodies bore an etiological relation to the
tumors, it was a very broad one, and probably would
be found related to all forms of rapidly growing tu-
mors.
342
MEDICAL RECORD.
[February 24, 1900
THE PRACTITIONERS' SOCIETY.
One Hundred and Fifty-Second Regular Meeting, Held
on Friday, January j, igoo.
A. Alexander Smith, M.D., President, in the
Chair.
A Case of Recurrent Retinal Hemorrhages. — This
was presented by Dr. E. G. Janeway. The patient
was a man, thirty-eight years old, who had suffered from
four attacks of hemorrhage into the retina. In the
first attack, which occurred about four years ago, there
was a hemorrhage into the retina of both e)'es; in the
two subsequent attacks only the left eye was involved,
and in the last attack the right eye. Dr. Janeway said
the case was interesting on account of the location of
the hemorrhages, and because no adequate reason could
be assigned for them. They occurred when the patient
was fatigued or while he was suffering from a cold or
coryza. The man's heart was a little enlarged, and
there was a faint systolic murmur on one e.xamination.
His urine was generally loaded with urates. There
had been no hemorrhages elsewhere, and nothing of
the nature of purpura. The sight of both eyes was
much impaired, particularly the right. He had had
rheumatism in earlier life, and diphtheria some nine
years ago.
Dr. Charles Stedman Bull, after examining the
patient's eyes with the ophthalmoscope, said he re-
garded the case as one of chorio-retinitis disseminata,
the inflammatory process being primarily in the cho-
roid, with resulting hemorrhages. In one eye an ex-
tensive hemorrhage involving the macula had been
followed by a large atrophic patch, leaving nothing
but ^he sclera. The right eye w-as the more seriously
involved. The lesions were more numerous at the
periphery than in the centre of the field in the left
eye. The blood-vessel walls did not show any oph-
thalmoscopic evidence of disease, and the speaker
said he thought the cause of the trouble was in the
blood rather than in the vessel wall. In the left eye
the nerve was still perfectly healthy, well nourished,
and normal in appearance, but around the optic discs
in both eyes there were marked degenerative changes
in both retina and choroid. Dr. Bull said he thought
the original cause of the trouble was some blood dis-
order, possibly rheumatic, producing an ophthalmo-
scopic picture totally different from that observed in
cases in which the vascular walls were diseased,
A Case of Primary Intrathoracic Growth of the
Left Lung. — This case was reported by Dk, Janeway.
The patient was a man, forty-seven years old, wiio had
been in good health until last September, when he be-
gan to complain of shortness of breath. His previous
history, as well as that of his family, was negative;
he had never had syphilis nor met with an accident.
When Dr. Janeway first saw him, about three weeks
ago, the dyspnoea was very pronounced. There was
swelling of the neck and lower part of the face, and
the patient complained of a throbbing in his head.
Examination showed an intrathoracic growth which
had replaced the upper lobe of the left lung. The
veins of the neck were swollen and congested, and a
superficial vein about as large as a lead pencil, begin-
ning about the sixth rib, ran down the left side of the
chest to the level of the umbilicus, with its current of
blood downward. The speaker said he attributed this
fo interference with the current of blood in the vena
azj'gos, internal mammary, and some of the intercostal
veins, causing a reflux of the blood. Dr. Janeway
said he regarded the intrathoracic grow'th in this case
as a sarcoma or carcinoma, probably originating in
the mediastinum, on account of its rapid growth and
the marked pressure symptoms it had given rise to.
The man was now scarcely able to walk across the floor.
Intrathoracic growths, Dr. Janeway said, were more
common than was usually believed. During the past
year, four such cases had come under his observation.
In one, which he saw about three weeks ago, death
occurred suddenly as the man was turning over in bed.
That patient had been under treatment for months for
severe intercostal neuralgia. He then developed some
pleurisy and subsequently symptoms which indicated
the presence ofran intrathoracic growth, which proved
fatal. In another case which he saw last spring, the
patient, a lady, was supposed to be suffering from pul-
monary tuberculosis. Over the left lung there was
marked flatness, with loss of vocal fremitus, and par-
alysis of the left recurrent nerve. There were no fever
and no special distress; there was very little displace-
ment of the heart. Subsequently, the disease affected
the other lung, and pleurisy with effusion developed.
The patient died of suffocation within five days.
Dr. Janeway also reported the case of a woman whose
cousin had died of sarcoma of the pleura. Two years
before her death she had an attack of pericarditis in
the course of slight rheumatism. From this she made
a complete recovery, and the examination of the lungs
showed no evidence of disease. About a year before
her death she began to complain, and an examination
showed a progressive solidification of the left upper
lobe w ith dulness and bronchial breathing. Gradually
fluid took the place of the lower lobe, while the side
of the chest did not enlarge nor did the heart become
displaced; neither v^'as there any fever present. Some
of the fluid in the lower part of the left chest removed
for diagnosis was of low specific gravity, without
blood or diagnostic cell contents. From these factors
the diagnosis of carcinoma of the left lung with re-
traction was made. Toward the end of life a nodule
made its appearance in the left breast, which had pre-
viously been free. At the autopsy the left lung had
the appearance of a chronic pneumonia. The lung
was of a grayish color, retracted, and a clear fluid
filled the rest of the pleural space. Two secondary
cancerous nodules were found in the right lung, two
in the liver, and one in the left breast. The reasons
for the diagnosis of cancer before death were given
above. Even at autopsy this case might have been
mistaken for chronic pneumonia.
Dr. Robert F. Weir said the subject of intratho-
racic growths was interesting from a surgical stand-
point, particularly those occupying the mediastinum.
Growths in this region were of more common occur-
rence than w^as generally supposed. Of the malignant
neoplasms, carcinoma was the most frequently ob-
served, and in such cases surgical interference was
of very little avail, but when the anterior or posterior
mediastinum was the seat of a benign tumor, due per-
haps to enlargement of the glands in that region, the
possibility of surgical relief from such pressure effects
should be borne in mind. A certain amount of suc-
cess had already been achieved by operating in these
regions. Posterior incisions, through which the oesoph-
agus and growths in the posterior mediastinum may be
reached, were known to all the members. Anteriorly,
Milton, of Cairo, had shown that much could be done
by splitting the sternum nearly its whole length and
retracting the two sections of the bone for a distance of
from one to two inches, thus obtaining free access to the
anterior mediastinum. Others, with the same object
in view, proposed division or ablation of the sternum
high up. Dr. Weir had in one instance been able to
reach behind the sternum to a distance of nearly one
and a half inches below its notch.
Dr. George L. Peabody related a case of primary
carcinoma of the lung which came under his observa-
tion on the autopsy table sonxe years ago. The pa-
tient was a man whose only symptoms of pulmonary
February 24, 1900]
MEDICAL RECORD.
343
trouble made out during life were those of a bron-
chitis. His most prominent symptoms, for which he
had been treated for man)' weeks, were of spinal ori-
gin. There was evidence of pressure on the cord in
the dorsal region, with intense pain, ultimately paral-
ysis, and death from exhaustion. The autopsy showed
a diiTuse development of carcinoma in both lungs,
with a secondary large growth involving the dorsal
vertebrae and the muscles of the back. The disease
had undoubtedly originated in the lungs, yet the symp-
toms referable to those organs were very trifiing.
Treatment of Hernia of the Sigmoid Flexure. —
This paper was read by Dr. Robert F. Weir (see page
309)-
Dr. Joseph D. Bryant said that his experience
with hernia in the region described by Dr. Weir was
not very extensive; he had seen two cases of cffical
hernia and one of sigmoid. In his first case of cffical
hernia he was prompted to suspect that he had to deal
with this condition — or at least with some form of
hernia which was not properly provided with a sac —
because there was no history of any definite periods
of reduction, such as commonly occurred in a hernia
which was provided with a proper sac. Then again,
the outline of this hernia, wfiich was not strangulated,
was different from that frequently observed. An inci-
sion was made in the usual way, but lower down, and
after exposing the intestine and liberating the connec-
tive-tissue adhesions lying between it and the adjoin-
ing structures, the hernia was quite easily pushed back.
No gangrene or other unfavorable symptoms resulted.
The man was discharged from the hospital and lost
sight of, so it was impossible to say whether a recur-
rence took place or not. In the second case of caecal
hernia, which was strangulated, the operation proved
more difficult. Reduction was accomplished only after
free separation of the tissues, with division of the
restraining bands on either side, including the perito-
neum. The patient made a good recovery. In the
case of sigmoid hernia, Dr. Bryant said he did not
suspect this condition of affairs until the time of oper-
ation. Reduction was comparatively easy because of
the fact that the intestines were better provided with
peritoneum than was usually the case. In operating
on this class of cases, the speaker said, care should
be taken not to employ too great force, and interfer-
ence with the vascular supply should also be avoided.
In the next case which might chance to come under
his observation, Dr. Bryant said he would resort to the
method described by Dr. Weir.
Dr. Charles McBurney said he had seen four cases
of hernia of the sigmoid flexure possessing the peculi-
arities which Dr. Weir spoke of. He had never rec-
ognized the condition prior to the time of operation,
the external signs having been those of ordinary left
inguinal hernia. Aside from the confusion arising
from failing to find the usual hernial sac. Dr. Mc-
Burney said he experienced no special difficulty in
dealing with the cases. In each instance the mass
was returned to the abdominal cavity by means of
blunt dissection and gentle manipulation, and then
the wound in the abdominal wall was closed in the
usual way. The cases did well, and recurrence had
not taken place when they were last heard from. Dr.
McBurney said he did not think the danger of im-
pairing the vascular supply of the intestine deserved
much consideration, unless the dissection was carried
too close to the intestine. As soon as the true
condition of affairs was recognized care should be
taken to make the dissection as far away from the
intestine as possible, so as not to interfere with the
plexus of vessels running into the gut. Of course,
if the dissection was made very close to the wall
of the gut, every stroke of the knife divided so many
supplying vessels. Dr. Weir mentioned several cases
of intestinal fistula resulting from defective vascu-
lar supply of the gut, but in connection with such
a statement the kind of wound healing which followed
the operations should also be known. If clean, asep-
tic healing was obtained, the speaker said he would
feel absolutely safe about the nutrition of the gut, but
if suppuration occurred he would feel afraid that the
vascular supply of the gut might suffer. The method
of peritoneal covering described by Dr. Weir, the
speaker said, he had never seen employed; from the
description, it appeared to be an attractive method of
dealing with such cases.
Dr. Weir, in closing, said that the cases which he
had collected from the French literature did not al-
ways give the details of the operation. He was there-
fore unable to say how much dissection was done, but
he was inclined to believe that a good deal of force
had been employed in replacing the bowel. He said
that two classes of this form of hernia were met with;
in one class the gut was comparatively loosely attached
and could be pushed back without much trouble and
retained there, but there were other cases in which,
because of inflammation, or long residence in situ, or
slight traumatism, the connective tissue became dense
and a certain amount of dissection was required. Of
course, it was better to cut widely, but the most impor-
tant factor to remember was to employ no force in
manipulating the gut. As regards the healing of the
wounds in the cases he had quoted, Dr. Weir said the
operations had been done by well-known surgeons,
and he was inclined to believe that they worked with
proper antiseptic precautions.
Dr. Bryant said he had recently operated on a
woman for recurrent appendicitis, and found that the
appendix arose from a posterior fibrinous band of the
ascending colon, at the junction of its upper and mid-
dle third. The speaker said he had never seen or
read of. anything of the kind before. The patient
made an uneventful recovery.
Dr. Charles Stedman Bull said that at the pre-
vious meeting of the society Dr. Kinnicutt had reported
a case of acromegaly, and the patient had subsequently
had an ophthalmoscopic examination. This had
proved absolutely negative, as far as any pathological
conditions of the optic nerve were considered, much
to Dr. Bull's surprise. The speaker said that well-
marked cases of acromegaly generally showed ad-
vanced signs of atrophy of the optic nerve.
Chorea and Taenia. — Dr. Andrew H. Smith re-
ported the case of a boy, twelve years old, who suf-
fered from chorea, and had a distinct cardiac lesion.
He was treated for a long time without much benefit.
Recently, the nurse discovered some flakes of tape-
worm in the stools, and upon the expulsion of the
worm the chorea readily yielded to treatment. It dis-
appeared within a week after the tape-worm was ex-
pelled.
Dr. a. Alexander Smith said it was not uncom-
mon to see choreic manifestations in children suffer-
ing from tape-worm.
Dr. Beverley Robinson said he was recently called
to see a woman who was suffering from what was ap-
parently a severe attack of bronchial asthma, with
marked cardiac depression, cold extremities, and a
condition bordering on collapse. Her symptoms, it
appeared, had been induced by some tablets' which
her husband had given her for the relief of a "cold."
The tablets were made by a patent-medicine concern,
and Dr. Robinson said he was unable to learn their
composition.
Typhoid Bacilli and the Gall Bladder.— Dr.
Weir said he was recently called to operate on
a woman who, about a month before, had recovered
from an attack of typhoid fever. Recently she had
been seized with a severe pain in the region of the
344
MEDICAL RECORD,
[February 24, 1900
upper abdomen, and on the right side a tumor was
made out, which was recognized as a distended gall
bladder. This was opened, and about six or eight
ounces of a tolerably clear glairy fluid and some pus
were evacuated. This was sent to the pathologist for
examination, who reported that it contained large
numbers of typhoid bacilli. The gall passages, it was
supposed, had become temporarily blocked by a ca-
tarrhal swelling. Though a number of such cases
had already been reported, yet they were comparative-
ly rare and obscure. Dr. Weir asked whether any
of the members present had observed similar cases.
Dr. Andrew H. Smith said he recently saw a
young woman convalescing from typhoid fever; her
temperature was normal, when she was seized with
what was apparently an attack of hepatic colic; there
was tenderness over the region of the gall bladder,
and an ill-defined tumor could be made out.
Dr. Walter B. James mentioned the case of a boy,
aged twelve years, who very early in the course of
typhoid fever developed jaundice, with severe pain
over the gall bladder, and some enlargement of that
sac. His symptoms were regarded as the result of a
catarrhal condition of the gall ducts. The patient
went on through a mild attack of typhoid fever, from
which he made an uneventful recovery.
Dr. Weir said that certain German observers re-
garded the mucous secretions of the gall bladder as a
very good medium for the cultivation of the typhoid
bacilli.
Dr. Janewav said this subject was now being studied
at the Johns Hopkins laboratory.
Dr. Peabody said the fact had been recognized that
the gall bladder could be infected by the typhoid
bacilli. In the case referred to by Dr. Weir, there
had been a previous attack of biliary colic some years
ago.
Dr. Janewav said the fact that in Dr. Weir's case
a light glairy fluid was evacuated, indicated a stop-
page of the cystic duct. The speaker said he had
recently seen a woman who was quite indignant be-
cause an operation for gall stones had not saved her
from a recurrence of the same trouble. She had had
four attacks of gall-stone colic dicing the past six
weeks, three months after the operation, and in three
of them she passed gall stones. Another patient, a
man, was operated on by Dr. Bull, who removed a
stone from the common duct by opening the duode-
num. A year later, at a second operation, another
stone was removed. The patient now wished to know
whether he could get rid of his gall stones by other
than surgical means.
Dr. McBurnev said it had never been claimed that
these operations prevented the formation of gall
stones. If, after the operation, nothing was done to
prevent the formation of the stones, recurrent attacks
were apt to occur.
Dr. J. W. Brannan said that it had been suggested
that the bacilli in the gall bladder might be the direct
agent in causing relapses in typhoid fever. So long
as the bacilli remained m the bladder, they apparent-
ly did no harm, except perhaps locally. It was prob-
able, also, that they might be discharged into the
bowel without reinfecting *he patient, provided this
did not occur until after ne had become immune
against a second attack of the disease. If, however,
this occurred before immunity had been acquired, the
patient was liable to suffer a relapse. This view
enabled us to account for the relapses which so often
followed upon indiscretions in diet before conva-
lescence had been thoroughly established. The more
liberal diet stimulated the liver, and caused an in-
creased flow of the bacteria-laden bile into the intes-
tine, at a time when the patient was not protected
against infection. In support of the opinion that
typhoid bacilli were an etiological factor in the forma-
tion of gall stones, Keen in his " Surgical Complica-
tions of Typhoid Fever" stated that typhoid bacilli
had been found by several observers in the gall stones
themselves, and in some cases apparently serving as a
nucleus.
Dr. Robinson reported the case of a boy, who was
treated at St. Luke's Hospital for typhoid fever. He
apparently made a good recovery, and as he had been
without any fever for at least eight days, he was
allowed to go home. For some days previous to his
discharge, his diet had been practically unrestricted.
On the night of his arrival home, he had a high fever,
and when Dr. Robinson saw him the next morning his
temperature was 102.5° F- He was sent back to St.
Luke's Hospital with a relapse which had lasted for
several weeks. Dr. Robinson said he could explain
the relapse only upon the basis that reinfection had
occurred through the gall bladder.
Dr. James said he had seen a relapse occur as long
as twenty-eight days after an attack of typhoid fever.
Dr. Peabody mentioned a case in which a relapse
had occurred after three weeks.
CCorrespondencc.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondent. )
Writing as I do at the beginning of the second week
in February, I have no new information to transmit to
you from the seat of operations, as matters have been
for "the past ten days at a complete standstill. At
Modder River the camp is healthy, and there have
been no casualties. The stories that the Boers in the
trenches just ahead of Lord Methuen are suffering se-
verely from typhoid fever and smallpox are all per-
fectly untrue. With General Frencii's column a few
casualties have occurred, but there has been no actual
engagement on the Free State frontier; and while the
present lovely weather lasts in South Africa the med-
ical department of the forces is not likely to have
much to do unless as a direct result of fighting. From
Ladysmith the cheering account comes of a better state
of health ; the spread of typhoid fever has apparently
ceased, and with this cessation the urgency to relieve
the city has disappeared. Sir Redvers Buller has
probably come to an understanding with Lord Roberts
that he will not attack again till Lord Roberts is ready
to move up also, a policy which the better public health
of Ladysmith now renders practicable.
The Irish Hospital. — Lord Iveagh's hospital equip-
ment, which is known as "the Irish Hospital," left
Dublin for the Transvaal on February 3d, and had by
far the most enthusiastic and popular send-off that has
been accorded to any of tlie numerous bodies of men
who have left Dublin for the seat of war. In Ireland
the feeling among the lower orders, which it must be
remembered is reflected by the members of Parliament,
is more pronouncedly in favor of the Boers than it is
in any other part of the kingdom. Many English and
Scotch regret the war most sincerely, but all, whether
they think the situation to have been inevitable or to
have been brought about by faulty diplomacy, greedy
capitalists, or ambitious politicians, hold that, being
in the quarrel. Great Britain must bear herself as one
that eventually intends to win. When the war is over,
let the recriminations come. Not so many of the Irish
people; so sincere is their hatred of England that they
desire the Boers to win, although the most determined
soldiers in the arniy that is fighting against the Boers
February 24, 1900]
MEDICAL RECORD.
345
are Irish by birth and recruited in Dublin. The
" Irish Hospital," however, came in for no expression
of ill-will; on the contrary, the aims of its generous
donor and its staff were recognized in the heartiest
way by the citizens. The hospital corps was played
out of barracks by the band of the Royal Irish Con-
stabulary, and marched through densely crowded
streets to the North Wall. The whole line of the
quays was a mass of cheering men and women, who
made it sufficiently clear that all good wishes went to
South Africa with the departing hospital and its
officers. Dr. George Stoker was in command, Sir
William Thomson, ex-president of the Royal College
of Surgeons of Ireland and chief surgeon to the hos-
pital, having previously started for the seat of war.
The Imperial Yeomanry Hospital Staff — When
the superior mobility of the Boers to the British — not
to say the absolute uselessness of infantry attacks de-
livered point-blank against an ambushed enemy — had
been demonstrated by three or four serious reverses,
the British government decided to send out to the
Transvaal ten thousand mounted volunteers. These,
the Imperial Veomanry, required to be supplied with
a complete hospital equipment, and the personnel of
the medical staff to accompany the hospital has now
been announced. It is as follows: Lieutenant-Col-
onel A. T. Sloggett, R.A.M.C., military commandant
of the Imperial Yeomanry Hospital and principal
medical officer; Mr. Alfred Downing Fripp, assistant
surgeon to Guy's Hospital, chief civilian medical
officer; Dr. John VVichenford Washbourn, physician to
Guy's Hospital; Mr. Raymond Johnson, assistant sur-
geon to University College Hospital; Mr. F. New-
land Pedley, dental surgeon to Guy's Hospital ; Mr.
L. Vernon Cargill; Mr. Hamilton A. Bailance; Mr.
William Turner; Mr. John F. Hall Edwards, surgeon-
radiographer and photographer; Mr. Wallace C. G.
Ashdowne; Mr. J. S. Christopherson ; Dr. Andrew
Elliot; Dr. H. W. Saunders; Mr. L. E. C. Handson;
Dr. H. W. Bruce; Mr. A. P. Parker; Mr. G, E. Rich-
mond; Mr. R. T. Fitzhugh, and Mr. Barclay Black.
The Excellence of the Medical Arrangements at
the Seat of War. — On all hands it has been allowed
that the medical arrangements in the Transvaal have
been excellent. Correspondents with Buller's column
and with Methuen's column alike have said that the
Royal Army Medical Corps have discharged their
duties both in the front and at the base, on the march
and under fire, with calm and deliberate attention.
There has been no sacrifice to display and no hurry.
The wounded have been quickly collected, rapidly
dressed, and comfortably transported to hospital.
There has been but one voice dissenting to this view,
a view that has been adopted upon the authority not
only of special correspondents of all nations and of the
medical press, but upon the direct reports of Lord
Roberts, Sir Redvers Buller, and Sir Willam MacCor-
mac. But an anonymous correspondent of The Times.
writing late in January, sent back a message to Eng-
land to the effect that the arrangements of one of the
big base hospitals at Wynberg were bad, and that
there was disagreement between the R.A.M.C. and the
Red Cross organization. The Tnncs' correspondent
was quite inaccurate, and telegrams from the highest
authorities at the Cape gave his assertions direct con-
tradiction, and people are wondering how J'he Times
came to print the insinuations and why the government
does not print the rebutting telegrams.
IDENTITY OF DIPHTHERIA AND MEMBRA-
NOUS CROUP (?)— A COUNTRY PROTEST.
Sir : It is taught and supposedly believed by the pro-
fession that these diseases are one and the same. I
cannot think so, and I wish to state some of the rea-
sons why I cannot. There is, I know, a diphtheria of
the larynx, contagious and capable of reproducing itself
in larynx or pharynx, nares, and elsewhere; but there
is also another disease of the larynx, which we country
practitioners call membranous croup, not specific in
character, whose origin is much the same as that of
pneumonia, and which is no more contagious than
pneumonia. It originates sporadically and does not
propagate itself. The desolating track of diphtheria
by a little investigation may always be traced before
and after, while in my observation this croup blew
where it listed, and no man knew whence it came or
whither it went. In many cases I have seen it have
every opportunity of contagion, yet contagious it has
not been in a single instance. Time and again have
I seen it in the same house, in the same log cabin, in
the same room, in the same bed with other children,
yet no contagion. Often have I seen other children
tucked under the same coverlet ere the "light that
failed" dimmed in the eyes of the sick one; yet no
contagion. I have seen little brothers and sisters kiss
the dying forehead and mouth; yet no contagion. I
have seen mothers hold the stertorous mouth of their
gasping three-year-old to their breasts for hours, and
then with unwashed hands, with unchanged dress,
nurse their infants through garments sodden with the
sick one's breath; yet no contagion.
Further, observation has given me some hope in the
treatment of diphtheria, but this croup ever brings its
rope and black cap, and I stand by its bedside as help-
less as a mother by the gallows of her law-doomed
child. I am compelled, therefore, to believe that, if
these diseases are the same, " it is a sameness with a
difference," both as to contagiousness and fatality, and
different I assuredly believe them to be. I am aware
that my limited experience entitles my opinion to lit-
tle weight, yet I am convinced that if country practi-
tioners will lay aside their fear of being accused of
bucolic ignorance, and, like Sairey Gamp, "speak as
they find," their aggregate voice will give my opinion
substantial approval.
S. M. WORTHINGTON, M.D.
Versailles, Kv.
Coxalgia with Abscess — Iodoform in ether is pain-
ful as an injection; camphorated naphihol is toxic.
Under camphorated menthol healing takes place in
seventy-five per cent, of cases. — Menard.
GUARDING AGAINST THE PLAGUE IN
JAPAN.
(From our Special Correspondent.)
ToKio, January 12, 1900.
Preparations on a very extensive scale are being
made to meet the epidemic of the pest, which it is
feared will break out in the spring. The total num-
ber of cases up to the present time is fifty-five; name-
ly, twenty-seven in Osaka, twenty-three in Hyogo, and
one each in Fukuoka, Nagasaki, Wakayama, and Shiz-
noka. Of these forty-five patients have died, and it is
doubtful if some of the remaining ten will survive.
Yersin's serum has been tried, but has not yet given
evidence of a satisfactory nature as to its real value
in the present appearance of the disease, which attacks
and destroys the victim so quickly as to leave little
time following its discovery for any measures what-
ever. It is said that the serum would doubtless prove
useful as a preventive, if those exposed to contagion
always made use of it. Three physicians have
already contracted the disease while engaged in in-
spection, and died; while the wives of all three have
likewise become infected, and may not survive. The
346
MEDICAL RECORD.
[February 24, 1900
infection is supposed to have been important from
New-chwang, China, or Formosa, in which latter place
it has existed for over a year, but in a far more malig-
nant type than that of the disease now existing in
Japan.
High fever, acute pneumonic symptoms, dyspnoea,
and heart failure characterize the present appearance
of the disease, which, it is thought by some, is carried
in the air like influenza, an epidemic of which is
now in progress.
Extensive and thorough sanitary measures are now
being carried out, by which the examination of dwell-
ings and the persons of the inhabitants of the lower
class in cities threatened, and the complete isolation
of patients suffering from the disease, or suspected of
having it, are being accomplished; while special pre-
cautions are being taken upon all lines of travel for
the inspection and detention when necessary of all
suspects. These measures are being conducted under
the supervision of Drs. Kitasato, Ogata, Nakahama,
Shiga, and others, while Drs. Eldridge, Wheeler, and
Koch, of Yokohama, are acting as an advisory com-
mittee in that port, where most of the foreign travel
concentrates.
Dr. Eldridge, who as United States medical in-
spector has charge of the inspection of passengers
proceeding on vessels to the United States, regards the
outlook as serious, and considers most rigorous quar-
antine of new cases absolutely necessary, including
the destruction of the buildings by fire when circum-
stances will permit.
In Tokyd a wholesale cleansing has been going on
for several weeks, including the taking up of floors
and sweeping the ground underneath, as well as ceil-
ings, when practicable. A price, 5 sen apiece (2^
cents), has been set upon rats and mice by the muni-
cipal authorities, and it is hoped that a general de-
struction of this kind of vermin will ensue.
The writer has driven rats out of his own house for
a time by the use of a formaldehyde generator, placed
between ceiling and floor, and phosphorus paste has
also proved successful here, although neither of these
means is applicable to the dwellings of the lower class
in Tokyo and other large cities in Japan.
THE APPENDICITIS QUESTION.
Sir: In the Medical Record for January 27, 1900,
Dr. Morris asks if I know of any responsible surgeon
who will operate for removal of the normal appendix.
I do not, and I hope I never shall; but the logic of
Dr. Morris' position must inevitably carry him to that
very thing. It is only a step from operating on a very
mild case because it is liable to become severe, to
operating on a normal appendix because it is liable
to become infected. If the doctor will divest himself
of the glamour of hospital statistics, and put himself
in touch with the sentiment of general practitioners
and conservative surgeons, he will find that the ap-
pendicitis question is not an unending controversy,
but that the great majority have practically settled
the question of management in general, as follows:
"Operate as a rule in recurring cases. Operate in
primary cases when circumstances arise which, in the
opinion of the physician, make it justifiable."
There it is in a nutshell, as it were. Physicians
might well wish it otherwise. What a weight of re-
sponsibility and care would be lifted from them, and
how gladly would they adopt the exclusively surgical
plan of operating on every case, if they could do so
with justice and safety to their patients! Then it
would simply be a matter of diagnosis, operation, and
either recovery or leaving it to the surgeon to explain
to the family how it happened; no worry, no respon-
sibility, no drawing on the utmost resources of one's
mind, that the best interests of his patients may be
conserved. Yes, we would gladly adopt the surgical
method, if we could honestly.
But again, if we would adopt the exclusively surgi-
cal plan, there is a practical obstacle to operating on
very mild cases that would have to be overcome, that
one in Dr. Morris' position is apt to lose sight of. A
physician on reading the '"Treatment of Appendicitis
from a Surgical Standpoint " decides to follow it in
his next case. He is called to see a patient supposed
to be suffering from indigestion — belly-ache, or some
kindred ill — and finds on careful examination that
the patient has appendicitis. Although everything is
apparently favorable for a mild attack, with every
prospect of recovery, he calls the family and friends
together, and tells them that the patient must immedi-
ately be cut open, and his appendix removed. They
at once say to him, " Do you think he will die with-
out operation?'' and the physician, if honest, will
answer, "No; the chances are ninety-nine out of one
hundred that he will recover." "Then why do you
advise operation?" they ask. He replies that some-
thing might come up in a few days that might alter
the patient's condition, and make an operation advis-
able. Then he is met with the question, " Do you
think there will anything arise?" and again, if he is
honest, he will say, "There is a possibility that there
may, but the chances are that there will not"; upon
which they naturally wonder why it would not be ad-
visable under the circumstances to wait until- there
was some sign of something unfavorable liable to set
in in the case, before subjecting him to a serious
operation. Then what will the physician do — insist
upon an operation, and, if it is refused, retire from
the case, because some surgeon high in the profession
has said that every case, even if it were very mild,
should be operated on? Or will he go on and treat
the case in the manner which his judgment, based
upon experience, and observation, and the accumu-
lated experience of almost the entire medical profes-
sion, tells him to do?
There has as yet been no reason of sufficient impor-
tance presented to the profession why such a case
should be operated on. " Sufficient unto the day is
the evil thereof" is just as sound logic to-day as it
ever was.
Dr. Morris says he has published letters from pa-
tients approving his method of treatment, and insists
that we should be impressed by them : I am sure if
the doctor would consider for a moment the thou-
sands of letters published from patients testifying to
the superiority of certain methods of treatment from
cancers cured without knife or pain, to cases of loco-
motor ataxia cured almost while you wait, he would
not lay so much stress on published letters.
Another point that Dr. Morris lays too much stress
upon is the difference in the prognosis of cases treated
medically and those surgically treated. He says we
must tell the patient at the commencement of each
case whether it is to be a mild or severe attack, or
own up that the nature of each case is determined
afterward. That saying would apply with equal force
also in typhoid fever, pneumonia, scarlet fever, and
many other diseases of which, of course, the. positive
outcome can be determined only afterward; but it is
necessary for the successful physician to be able to
make a prognosis beforehand, and it is certainly a
matter of common knowledge that in any of the above
diseases the physician will be asked immediately
upon his diagnosis for a prognosis; and there area
certain group of symptoms taken together by which the
physician is enabled to tell the patient's family, of
February 24, 1900]
MEDICAL RECORD.
347
course not positively, but very nearly so, that such
and such a patient will recover unless complications
set in; that another patient's chances are against him,
and if it be appendicitis the experienced physician
will be able to say with reasonable correctness that
he will recover, or perhaps that his condition shows
tliat an operation would give him a better show, or
may be that he will probably die, but an operation
niav possibly save him, the prognosis depending upon
the case and the circumstances. Now let us see what
the surgeon would say. If it be a mild case and cir-
cumstances warrant, he can say that "an operation
will probably result in recovery." I do not under-
stand that Dr. Morris or any other responsible surgeon
guarantees recovery in every case, even in operations on
the mildest. If it be a primary case and complicated
before the surgeon sees it, he will probably give a
prognosis that is indicated by the gravity of' the case.
Therefore we see that the e.xact outcome can be de-
termined only afterward in surgical as well as medical
cases; as neither the physician nor the surgeon can
guarantee recovery in a mild case, the relative value
of their respective prognoses can be determined only
by the results of similar cases in the past. In addi-
tion let us remember that the physician who has diag-
nosed a case of appendicitis, and has been enabled
from the conditions to give a favorable prognosis, has
in reserve the knife as a sheet-anchor, providing some-
thing does turn up to alter his first opinion.
Dr. Morris admits that he draws his conclusions
from a careful comparison between the results of sur-
gical and the medical treatment, as shown by hospital
statistics. To siiow how unreliable and worthless to
the profession such conclusions must be, we need only
remind the doctor that the general practitioner does
not employ the exclusively medical treatment, but also
that hospital medical statistics show an immensely
heavier rate of mortality than physicians find in their
private practice. The uselessness of hospital medical
statistics to the profession at large has already been
published.
That Dr. Morris will never see the mode of treat-
ment he upholds accepted by the profession at large I
am confident, not only on account of any unsoundness
which may exist therein, but also because it is essen-
tiallv impracticable.
J. S. Horner, M.D.
NVest Pawi.ft, \'t., February 3, 1900.
OSTEOPATHY AND THE LAW.
Sir : Your editorial in the Medical Record of Janu-
ary 20th, on "The Set- Back for Osteopathy in Ken-
tucky," ought to be a source of satisfaction to every
one who has at heart the welfare of his fellow-citizens,
not to mention the interests of the medical fraternity.
That osteopathy unrestrained is not a harmless form
of charlatanism, but a real menace to the life of many
a poor patient, I have long been satisfied, and I wish
to relate a case in point that a few weeks since drove
conviction home to me more strongly than ever.
Called in great haste one morning to see a sick per-
son in my neighborhood, I found a young woman
dying in collapse — pulseless at the wrist; shallow,
rapid respiration ; ashen pallor, blue lips, pinched nose,
clammy sweat; heart sounds feeble and very rapid,
and temperature subnormal — but withal clear-minded.
There was no pain, but profound weakness. She had
had intense abdominal pain, especially in the right
iliac region, since ten o'clock the previous day, but it
had suddenly left her at about one o'clock in the
night. " Examination showed the abdomen moderately
distended, tympanitic, quite rigid, and very sensitive,
with marked resistance over the McBurney region.
My diagnosis was ruptured abdominal abscess, prob-
ably appendical. In about five minutes after my ar-
rival she lapsed into unconsciousness, and in ten min-
utes more was dead. Shortly before she died, another
physician, summoned from a distance earlier in the
day, arrived.
On inquiry of the friends as to the previous history
of the case, I learned that she had for some days past
complained of indefinite abdominal pains coming on
at intervals, but had not taken to bed till the morning
previous, and, indeed, had prepared breakfast for the
family that day. Seized with severe pains about the
middle of the morning, she went to bed, and had suf-
fered intensely, vomiting several times, till the small
hours of the following morning, when the pain sud-
denly subsided as I have said. I asked who was at-
tending her, and was told she had had no physician,
which I thought very strange, as they seemed intelli-
gent people and were able to have one, and certainly
her symptoms must have been alarming.
Returning to my office, I left affairs in the hands of
the physician first called, as he was a friend of the
family, and a little later was surprised to receive a
call from him in company with the undertaker to get
my signature on the death certificate. I did not see
why he did not sign it himself, as he was quite as well
qualified to do so as I, but he urged it, and I did so,
and the body was immediately shipped out of town.
The undertaker reported a discharge of pus through
his needle when he inserted it to inject the peritoneal
cavity, a confirmation of my diagnosis.
Later in the day I accidentally learned that the peo-
ple in the flat where the young woman died were nearly
all students of osteopathy, her own brother — who, by
the way, is totally blind — being one of them, and that
the president of the " college " had been called as soon
as she had taken to her bed the day before. He had
given her three "treatments" that day, and was in
attendance upon her the morning of her death, and it
was then at his suggestion that the physician had been
sent for. I also learned that said physician — a grad-
uate of Rush Medical College — is a teacher in the
local "college of osteopathy" and is not infrequently
called upon by osteopaths under similar circumstances
(an osteopath cannot sign a death certificate here).
Also, that upon being reproached one time by a former
classmate for disgracing his profession by associating
himself with charlatans, he replied in words to the
effect that the profession might be , that he was
out for money.
Being naturally indignant at the part I had been led
to play in the affair, I resolved to find out if possible
what diagnosis had been made, and what sort of treat-
ment had been given, and accordingly called next
morning on the president of the " college." He was
nervous and fidgety when I mentioned the case, and
spent some time assuring me that he would tell me
exactly the conditions as he had found them. When
he finally got down to business he stated that he found
the patient had for some time been troubled with a
little "stomach derangement" and "constipation,"
that the condition was somewhat exaggerated that day,
but that she had presented "no alarming symptoms
whatever," and he had assured the friends there was
not the slightest cause for anxiety. Being asked what
his diagnosis had been, he said he regarded her symp-
toms as due to a "posterior condition of the spine! "
but did not deign to explain what that meant. Nothing
could be learned about treatment, except that he had
" treated " the lower end of the spine. Continuing, he
said that when he visited her that morning he saw that
" it was not a case for us to treat" — which meant he
realized then that she was dying and that he might get
MEDICAL RECORD.
[February 24, 1900
into trouble, not being able to sign the death certifi-
cate— and so he had at once sent for the doctor before
mentioned.
Since this episode I have taken the trouble to inform
myself as fully as I could on osteopathy and osteo-
paths, visiting their "college," talking with devotees,
reading their literature, and >joking up their legal
status here in Wisconsin. I have before me a copy of
the Wisavisin Osteopath, a semi-occasional publication
(price, %\ a year) which occupies the proud position of
otticial organ to the "Wisconsin College of Osteopa-
thy,'' and which at irregular intervals is left on our
front doorsteps or tossed into our hallways. I quote
briefly a part of the " farrago " of the osteopathic creed
relative to the " spinal origin of disease," as set forth
in its pages:
" Anatomists have discovered along the spine cen-
tres which control the various organs of the body, and
in the development of osteopathy the whole system
revolves to a certain extent ai)out these centres, open-
ing up great possibilities to the osteopath in overcom-
ing disease. As before said, the nerves escape from
the spinal cord through openings between bones, liga-
ments, and muscles with only a limited amount of
space. The encroachment upon this space by the con-
traction of a muscle or the slipping of a bone may
cause a disturbance in the organs of the body to which
tiiese nerves, with their sympathetic communications,
pass. Upon these nerves the osteopathist must play,
as upon the keyboard of a piano, removing any press-
ure or obstruction which would cause discord in the
nerves, or in the functions of the organs which they
supply. It is upon the spine, for this reason, that the
osteopathist does the major portion of his work."
Could anything be more cunningly devised to catch
the attention and appeal to the reason (?) of the
average patient, who always wants to know the why
and the how? That it does catch them is evident
from the fact that the school has a large following
both here in the city and all over the State, and it does
a riourishing business in the turning out of new D.
O.'s — Diplomates in Osteopathy — to catch the shekels
of the unwary.
What is more surprising is that this official organ,
distributed from house to house, contains in its refer-
ence column the names of some of our best-known
citizens as indorsing osteopathy. They may have
been benefited by their treatment — we all know that
massage (or manipulation, as they prefer to call it)
has a field of usefulness — but that they should be will-
ing to have their names distributed about the town to
advertise somebody else's business, is indeed astonish-
ing. That is putting themselves in the same class as
those who testify in the daily papers to the merits of
"Lydia Pinkhapi," "Dr. Pierce," "Peru-na," etc.
To sum up the results of my investigations in brief :
I find that the osteopathic principle of treatment is
based on a substantial truth well recognized as valua-
ble in certain conditions and long practised by the
members of the regular profession, viz., digital manip-
ulation of the body regions; that about this kernel of
therapeutic truth they have constructed their " science,"
which to the laity appears most plausible, but to the
enlightened is a meaningless mass of nonsense; that
tlieir etiology is mere fiction, their pathology a myth,
di rgnosis is a conjecture, and all are carefully planned
to harmonize with and support their one uniform line
of treatment. In other words, it is a made-to-order
science. Their course of study in no way fits one for
the intelligent care of the sick.
Now I am not opposed to specialties. We have
specialists in all branches of our art, and if any one
wishes to specialize in the treatment of proper cases
by manipulation, well and good; but first make him
comply with certain requirements of preparation, as
all legitimate specialists are made to do, so that he
will be presumably capable of selecting cases amen-
able to treatment by his methods — and then when he
is found manipulating an appendical abscess or stick-
ing his finger into a diphtheritic throat, let him feel
the strong hand of the law, the same as any other mal-
practitioner. As matters stand now in most of oi:r
States, the osteopathists openly boast of treating any-
thing and everything, advertise themselves as doctors,
and yet are not amenable to law, because, forsooth,
they do not give medicines, and so are not recognized
and regulated. Is not this most unjust to the rest of
us, as well as a menace to the public welfare?
Philip F. Rogers, M.D.
SERO-THERAPY IN PNEUMONIA.
To THE Editor of the Medical Recokd.
Sir : Referring to the letter of Dr. Fanoni in the
Medical Record of January 27th, if Dr. Fanoni will
consult the sixteenth volume of the "Twentieth Cen-
tury Practice of Medicine," at pp. 122-129, he will be
" really surprised " to find that I have discussed at
considerable length the claims of sero-therapy in pneu-
monia. Andrew H. Smith, M.D.
18 East Forty-sixth Strebt,
THE USE OF KOLA IN SEASICKNESS.
To THE Editor of the Medical Recokd.
Sir : Some of your readers may be interested in my
experience in the use of the kola nut for the ameliora-
tion of seasickness during the past fortnight in a voy-
age from Yokohama to San Francisco. The first five
days of the trip were rough, the third being marked by
a westerly gale. I am an indifferent sailor, and in
such weather commonly find no little difficulty in do-
ing my part in the care of a family of four small chil-
dren. By keeping a piece of the dried nut in my
pocket and frequently biting off a morsel to chew-
slowly I found myself free in the main from the swim-
ming head and the sour stomach which would otherwise
have attended the washing and dressing, the feeding,
and other attentions necessarily rendered the little
ones, who shared but slightly in my indisposition. If
I waited till stomach symptoms appeared, no effect
seemed to result from the use of the nut; probably be-
cause nausea and vomiting followed so rapidly as to
forestall absorption. But when taken with a clear
head and a sound stomach, as upon waking in the
morning after a refreshing sleep, the effect seemed
almost specific in preventing the severer symptoms of
mal-de-mer. The effects are not immediate, but result
in about twenty minutes or half an hour, and seem
mainly to lie in the stimulation of the nervous system
and the general toning up of relaxed tissues which are
known to be the proper physiological effects of the
drug. More especially did I note the freedom from
bile among the stomach contents, even when the
roughness of the sea and confinement to close cabins
brought on fits of vomiting. The latter was mild in
degree and accompanied by no retching or bitter taste.
Moreover, at a later period of the voyage, with a much
smoother sea, circumstances otherwise similar brought
on repeated vomiting with deep retching and with the
raising of bile and even of blood, soreness of the
hypochondrium, lightness of the head, burning pain
in the oculomotors, and all the other aggravating
symptoms of seasickness.
I conclude that kola nut does not cure but decidedly
ameliorates seasickness, if taken in time, through its
familiar action as a cerebral stimulant.
C. C. Vinton, M.D.
F"ebruary 24, 1900]
MEDICAL RECORD.
349
SUCCUS CINERARIvt: MARITIME IN CATA-
RACT.
To THE Editor of the Medical Record.
Sir: I read in the Medical Record of January 27th,
p. 165, that the editor of Experience says: "The use
of SUCCUS cinerariiE maritima:, for the absorption of
cataract, when dropped into the eye daily, two or three
drops at a sitting, acts in many instances with results
nothing short of miraculous."
Dr. Lewis F. Read, surgeon-general Pennsylvania
National Guard, and myself used this remedy, as sug-
gested, on the eyes of my mother, aged seventy-six
years, a resident of Norristown, Pa., for eighteen
months without any result whatever, except to give her
needless pain.
Albert S. Ashjiead, M.D.
New York.
OUR LONDON LETTER.
(Fr
ijur Special Correspondent.)
WAR INTESTINAL RESECTIONS MASTOID OPERATIONS
SATURDAY HOSPITAL FUND — INFLUENZA — RECENT
DEATHS.
London, February 2, igoo.
The medical world pursues its course amid the clash
of arms, as in the times of peace. Every hour we are
reminded that we are at war. Amid the curses, loud
if not deep, which are being heaped on the War Office,
it is cheering to find that even the " man in the
Street " has become aware that the doctors, at any rate,
have not failed. Lord Methuen has said in a despatch
that he was glad to have been slightly wounded, as in
no other way could he have learned the care taken of
the wounded, and how the medical officers never tired
in their endeavors to alleviate the suffering. We may
take this testimonial as a set-off against the spite of
Lord Wolseley, who is now likely to have enough to
do to defend himself against the charge of neglecting
his obvious duty. The meeting of Parliament has
already put the government and their experts on their
defence. News from the front is continually coming
to hand. Even the medical journals boast of their
special correspondents in the field and at the several
hospitals. Letters, too, are coming from Sir W. Mac-
Cormac and the other civil surgeons sent out by the
War Office to disguise their own insufficient arrange-
ments. But their letters can only describe the work
of the army medical officers, to whom they give un-
stinted praise, and mention a few remarkable cases.
It is too soon to expect much, but later on we may
gather some valuable surgical lessons from the horri-
ble conflict. I turn from it to the peaceful work we
are engaged in at home.
At the Clinical Society on the 26th inst. Mr. Hutchin-
son, Jr., related two cases of resection of gangrenous
intestine in cases of hernia. One was that of a wo-
man with femoral hernia, five inches of intestine being
removed, and the patient was found in good health six
years afterward. The other was that of a man with
strangulated inguinal hernia ; ten inches were removed,
and the patient recovered. He died three years after-
ward from ulcerative colitis, and Mr. Hutchinson ob-
tained the specimens which he showed at the meeting.
At the seat of resection, there was not the least nar-
rowing. In both these operations suturing only was
employed, and in reference to the relative safety of
this plan and the use of Murphy's button, Mr. Hutchin-
son said he had collected from hospital statistics fif-
teen cases of primary resection for gangrenous intes-
tine with the button and sixteen without. Of those
with the button, only one patient recovered, or seven
per cent. ; of those without, six recovered, or forty per
cent. Further, in the fatal cases sutured alone, the
patients survived on an average twicg as long as in the
others. Three of the ten fatal cases simply sutured
might have resulted in recovery but for complications
— multiple strictures, obstruction by band, and phthi-
sis. The post-mortem records showed, moreover, better
union after simple suture. The longer time required
for accurate suturing did not seem of great impor-
tance against the disadvantages of the button. It was
necessary to excise enough to secure the sutures being
inserted in healthy tissue, and it was generally advis-
able to do it through a median abdominal incision.
If the intestine could be emptied and made to con-
tract, this would favor union, and prevent infection of
the stitch apertures by the contents. Possibly an
aperient directly after the operation would improve
results.
Mr. Barker preferred to dispense with the button,
and insisted that the amount of intestine removed did
not matter much; the one element of success was to
place the sutures in healthy tissue, the walls of which
had not been damaged by distention.
Mr. Marsh also insisted that no untrustworthy part
should be included in the sutures.
Mr. Charters Symons was also against the button,
and thought the great difficulty was to empty the
bowel in order to prevent a continuance of the symp-
toms from its paralysis.
At the same meeting Mr. Gould read an account of
the case of a man aged twenty years, who was acci-
dentally shot in the abdomen with a small revolver.
Seen an hour later, when he was partly under the
influence of a morphine injection, the respiration was
easy, and the pulse 96. There was still pain. The
wound was found to extend into the peritoneal ca\-
ity; it was freely opened, and blood flowed out, but
no gas or bowel contents. Four wounds were found
in tiie jejunum, three perforating. They were closed
with Halsted's sutures of sterilized silk. Two
wounds of the mesentery close by were also sutured.
The peritoneal cavity was cleansed, the bowel re-
turned, and the abdominal wound closed. The man
recovered. The bullet was located in the left buttock
and was let alone. Mr. Gould approved the injection
of morphine, as it relieved pain and shock and in-
testinal movements, thus lessening the chance of foul-
ing the peritoneum. He thought the case showed the
value of careful exploration in perforating wounds of
the abdomen.
Other speakers concurred in the value of morphine,
which some thought too much neglected at the pres-
ent time. It was also agreed that exploration was
desirable, when it could be done under favorable cir-
cumstances; if the patient was not seen until after the
lapse of a long time it might be doubtful, and a re-
cently reported case was referred to in which a bullet
passed through the abdomen, and the man recovered
though nothing was done. Saline injections were
mentioned as useful for overcoming shock in some of
these cases.
Three communications in one evening on such a
subject as the mastoid operation make a full dose for
even so grave and staid a society as the Royal Medi-
cal and Chirurgical, and not unnaturally led to an ad-
journment of the discussion to which the contribu-
tions are expected to give rise. Such was th^ course
of events at the last meeting (January 23d).
Mr. Ballance opened the evening with an account
of twenty cases on which he had operated, and six of
his patients were shown. He advocated the treatment
of intractable otorrhcea by two distinct operations.
The first of these is the complete mastoid operation
to get rid of the disease; the second is directed to the
healing of the wound by epithelial grafting of the raw
bone cavity. He noticed the difficulty of selecting
550
MEDICAL RECORD.
[February 24, 1900
cases for the mastoid operation, and thought clinical
experience a safer guide than rigid rules. But the
cases being suitable, he would certainly follow on
with the grafting.
Sir William Dalby followed with a paper dealing
chiefly with the selection of cases for operation. He
said it was necessary (i) when septicaemia had begun;
(2) when there was carious bone in the tympanic
cavity, with ominous symptoms often recurring; (3)
when there was evidently mastoid disease. On the
other hand the question of operatiori was often one of
doubt, even when dead bone was present, but with-
out ominous symptoms. Cases also occurred in which
a less complete operation might be done. It should
not be forgotten that many persons went through long
lives with perforations which at times discharged
slightly, but at other times were dry and apparently
healed, and that, too, without experiencing discomfort
enough to make them desire active treatment. They
could hear pretty well, and transact the ordinary
business of life, and only of late had it been suggested
to adopt severe measures in such cases.
The third communication was by Mr. Cumberbatch,
who thought it was easier now than formerly to decide
on the cases suitable for operation. First he specified
three groups of cases, in which, speaking generally,
he did not adviseo peration; i.e., (i) when the whole
or the greater part of the membrana tympani was de-
stroyed, and the mucous lining of the cavity hypertro-
phied, but without bone disease; (2) when there was
frequent discharge for a time, but easily arrested, the
perforation being permanent or else closing on the
cessation of each discharge; (3) when both ears were
discharging, but the hearing remained good, and there
were no symptoms calling for interference except the
discharge. On the other hand, he specified four
groups of cases in which the complete mastoid opera-
tion was advisable, viz.: (i) In recurrent discharges
when every onset was preceded by malaise, headache,
and rise of temperature with sometimes mastoid ten-
derness; (2) in "spoilt ears," which, after giving no
trouble for years, suddenly developed symptoms of
labyrinthine vertigo, showing that inflammation was
involving the labyrinth, or some accumulation was
causing pressure; (3) intermittent discharges with
masses of sodden epidermis, often hiding small
granulations, and when syringing constantly removed
white shreddy patches, the usual treatment having
failed; (4) periodical attacks of mastoid pain after
active mischief had ceased in the ear, and when neu-
ralgia could be excluded.
The Hospital Saturday Fund decided last week to
distribute ^17,013 13^'. 8(/. among the hospitals, dis-
pensaries, convalescent homes, and auxiliary organi-
zations, such as ambulance, surgical appliance socie-
ties, and institutions for the gratuitous nursing of the
sick poor in their own homes. The gross income of
the fund for 1899 was ^20,023 ^s. 3^.
Influenza is still decreasing. The deaths registered
last week from this disease numbered one hundred and
fifty-two as against two hundred and eight in the pre-
vious week. The average death rate in England and
Wales was 22.6, as against 24.9, 29.1, and 30.9 in the
preceding weeks, a steady fall chiefly due to the de-
cline of the epidemic. Turning to the provinces, Bir-
mingham is suffering from influenza and typhoid. At
the same time whooping-cough and measles are so
prevalent that the work of the schools is much in-
terfered with. No less than one hundred and eighty-
seven fresh cases of measles and seventy of whooping-
cough were reported among the children attending the
board schools last week. In most of the other great
towns which have been attacked by influenza, there
is an abatement of the disease, varying in degree
with the date of its appearance.
Mr. Bernard Brodhurst died on the 30th ult., in his
seventy-eighth year. He was for many years surgeon
to St. George's and the Royal Orthopeedic hospitals
and published lectures on orthopedic surgery and other
works.
Sir William Miller, J. P., M.D., of Londonderry,
died on the 28th ult., aged seventy-three years. For
more than forty years he held a most prominent social
and professional position in his native city, where his
father had had a similar position, being M.D. mid
J. P., and dying at the great age of ninety-tviJO years.
One of Sir William's sons is also in the profession.
Dr. T. J. Dyke, J. P., died on the 20th ult., aged
eighty-four years. He was for over thirty-six years
medical officer of health for Merthyr.
Another J. P. and M.O.H. was Dr. H. H. Vernon, of
Southport, where he settled some thirty years ago.
He died on the i6th ult., aged sixty-nine years.
Surgeon-Major A. C. A. Alexander of the Cold-
stream Guards died on the 23d. He served with his
regiment in the Sudan, and last year had a sunstroke
at Gibraltar, and regretted not to be able to go to
South Africa.
^cui Instruments.
A RECTO-GENITAL IRRIGATING TUBE.
Bv RAMON GUITERAS, M.D,
The tube under consideration is called the " recto-
genital irrigating tube," because it is one which,
although inserted in the rectum, is intended for the
treatment of diseases of the internal genitals, and not
for those of the rectum proper. The diseases of the
internal genitals for which it is used are those of the
prostate gland and seminal vesicles, and embrace acute
and chronic seminal vesiculitis, acute and chronic
prostatitis, prostatic abscess, acute inflammatorv at-
tacks occurring in cases of prostatic hypertrophy and
certain functional disorders, as jJrostatorrhcea, sper-
matorrhaa, and atonic impotence.
Description of the tube : The tube is six inches
long and one-half an inch in diameter. It is slightly
curved at the end for insertion, thus presenting a con-
vex and a concave surface, the latter better accommo-
dating itself to the internal genitals, particularly the
prostate. There are three openings near the end of
the tube, one in the concavity and one on either side
of the straight part of the shank. At the other end,
the one which may be called the proximal, there is a
shield with two pipes protruding from it, one of which
connects by means of a piece of piping with a reser-
voir on the wall, and the other, or waste pipe, connect-
ing with a receptacle upon the floor. The tube is so
constructed that it is double throughout its entirety.
The irrigating fluid comes down from the receptacle,
generally a douche bag hung on the wall, enters tl.e
tube by means of a piece of tubing, and passes along
the upper compartment, escaping through the opening
in its concavity, and bathing the parts to be treated,
the seminal vesicles or prostate. It then again
enters the tube through the two openings in the sides
and escapes by means of the attached tubing into a
receptacle on the floor.
The opening in the concavity by which the fluid en-
ters the intestine is smaller than the side openings
through which it escapes, thus rendering the outtlow
more than twice as great as the inflow, and in this «ay
overcoming the great difficulty which is usually en-
countered in rectal douches, namely, the o\er-acci!iiu-
lation of the fluid in the gut. The opening in ihe
February 24, 1900]
MEDICAL RECORD.
351
concavity also presents a decided advantage over one
in the end, where it is usually situated, as the tube,
being smooth at the extremity, enters more freely, and
also because the fluid is discharged directly against
the internal genitals instead of shooting by them up
the rectum.
The material used for making the tube is generally
hard-rubber or metal; the former is more liable to be
injured and is not so easy to clean and sterilize as the
latter.
Description of fluids : The fluids used are generally
hot salt solution, or flaxseed tea. The former is made
by adding a teaspoonful of salt to a quart of water,
the latter by adding a tablespoonful of flaxseed meal
to a quart of water, boiling and straining. Plain hot
water seems to dry the parts, and is much inferior in
its effects. The temperature of the fluid is generally
from 105'^ to 120° F., a good rule being to use the
water at the temperature which gives the most relief
and produces the best results.
The technique of a rectal irrigation is as follows:
The patient should assume a reclining position with
the legs elevated. If he lies in the bath tub with his
feet elevated on its sides, or if he reclines in a chair
with his legs up, he is in a good position to receive an
irrigation. The douche bag should be hung so that
its bottom is just above the head of the patient, which
will admit of an easy refilling if necessary, although
it should be placed still higher in case the pressure of
the fluid is not sufficient to allow it to make the circuit
freely.
The tube should be lubricated, and inserted with a
rotary movement. If the case be a prostatic one, two
and three-fourths inches is sufficiently far, while if it
be a disease of the seminal vesicles it should be pushed
up from three and one-half to four inches. From one
to four quarts of fluid should be used at each sitting.
The best time for taking the irrigations is just before
retiring. If the fluid is not escaping freely, and too
much has accumulated in the intestine, the inflow
tubing should be compressed until some of the fluid
already in the gut has escaped. If the fluid does not
escape freely, the tube should be moved about in the
rectum until a better flow is established.
The diseases for which this method of treatment is
generally used have already been enumerated. The
benefit is derived from the effect of moist heat. In the
case of acute prostatitis it gives great relief to the pain
and at the same time diminishes the inflammation. In
cases of prostatic abscess it stimulates the circulation
in the gland, thus hastening either absorption or sup-
puration. In diseases of the seminal vesicles it also
reduces the inflammation by the action of the heat, as
is evident by the diminution of the pain and tender-
ness at each rectal examination. In prostatorrhcea it
relieves any deep irritation of the genitals, upon which
the relaxation may depend. In cases of atonic impo-
tence the cause is often a chronic inflammation of the
vesicles, which is benefited by the irrigation.
In almost all these cases amelioration is hastened
by gentle massage of the internal genitals per rectum
every four or five days. This not only tends to cause
absorption of any inflammatory exudate, but it breaks
up adhesions and strengthens the function of the pros-
tate or vesicles.
When the inflammation has left the part, as is evi-
denced by the absence of tenderness on rectal pressure,
then hot irrigations are of no further use, and can be
discontinued, or if the parts are relaxed the tone may
often be better restored by general tonics, the use of
cold water by means of the recto-genital psychrophore,
or by electricity administered through a rectal elec-
trode. A recto-genital psychrophore is of the same
shape and size as the tube under consideration,
although it has no opening in its shank. The cold
water simply circulates through the tube, thus apply-
ing constant cold to the parts.
63 West FiFTv-rouKTH Stkeet,
IP^cdical Jtcms.
The Influence on Health of Chemical Preserva-
tives in Food. — As a result of an experimental in-
vestigation, Foulerton (Lancet, December g, 1899) ex-
presses the opinion that it is extremely improbable
that boric acid or formic aldehyde, used in small pro-
portions for the preservation of milk, would cause any
injurious effect whatever to the average adult taking
the ordinary amount of milk with his daily food; but
because of certain possible injurious effects that might
result, the use of such preserved milk for invalids and
young children taking large quantities is to be con-
demned. So far as these injurious effects are con-
cerned, it appears unlikely that the digestive processes
would be materially affected — or, indeed, affected at
all — by the boric acid, but that toxic effects in a more
general way might be produced by this preservative.
Formic aldehyde, on the other hand, would probably
have no injurious general effect in small proportions,
but would tend to lessen somewhat the digestibility of
the milk. The necessity for legislation on this subject
lies in the fact that these preservatives are, in small
proportions, tasteless and so cannot be detected by the
consumer. Such legislation should provide that no
preservative should be used that is not sanctioned by
the proper authority, and that the proportion should
not exceed a certain maximum amount to be fixed
officially; that the nature of the milk should be de-
clared by the vender, and that it should be sold only
as " preserved milk." The penalties for infringement
of the law should be sufficiently heavy to render un-
352
MEDICAL RECORD.
[February 24, 1900
profitable the sale of "preserved milk" as fresh milk.
There is no good reason for the presence of salicylic
acid or other special preservative in such articles of
food as jam, cheese, and pickles, while the use of cer-
tain preservatives as substitutes for alcohol is a matter
of fraud pure and simple. The use of a tasteless pre-
servative in butter must also be regarded as fraudulent
unless the fact is declared. The use of boric acid for
salting bacon and ham may or may not cause injury to
the consumer, but such articles should not be sold with
concealment of the fact.
Erythromelalgia. — Rosen {Bi-riiner klinische Wo-
cliensc/uijt, December 4, 1899, p. 1081) reports a case
of erythromelalgia in a demented individual, and from
a study of the literature expresses the opinion that in
the majority of cases of this disease the symptoms are
dependent upon a lesion of the central nervous system.
.\ number are in fact attended with symptoms of such
lesions, and upon which the erythromelalgia may be
considered as dependent. In another group of cases,
however, there is no manifest organic lesion of the
central nervous system, but in these also the disease,
in its localization, in its course, in its association with
various sensory and trophic disturbances, and in its
combination with certain general manifestations, is
suggestive of a disorder of the central nervous system.
Acute Acquired Internal (Idiopathic: Hydroceph-
alus.— Heidenhain {Berliner klhiische IVodiense/uiJ/,
December 4, 1899, p. 1078), upon the basis of four
cases carefully studied and from an analysis of the
literature, expresses the opinion that acquired idio-
pathic internal hydrocephalus is a disease stii geiu-ris.
It may set in abruptly (serous apoplexy), or it may
develop insidiously. Under the conditions first named,
recovery may take place, while under the latter the
disorder is probably incurable. The insidious variety
either pursues an even course or is interrupted by ex-
acerbations. These are characterized by sadden de-
pression of temperature and of pulse far below the
normal, with increasing restlessness. Death occurs
with gradual perversion of consciousness in conse-
quence of asthenia or intercurrent disease ( pneumonia,
severe digestive disturbances, etc.). With regard to
the etiology, direct injury to the brain is not essential
to the development of acquired idiopathic internal
hydrocephalus. The disease is caused by cold, and
must be considered a vasomotor reflex neurosis. With
regard to the acute exacerbations these may be ex-
plained by the limitation of the serous effusion by the
resistance of the elastic brain. If this subsides in the
course of clays or hours, a new effusion takes place,
and this again is restricted by the limits of compres-
sibility of the brain. The assumption that the brain
first undergoes atrophy and that the effusion occurs at
the same time in consequence of the rarefaction, is ab-
solutely incorrect. The high degree of pressure under
which the exudate exists is opposed to this view. In
one of the cases recovery was observed in the sequence
of subcutaneous injections of morphine, which not only
induced rest and sleep, but allayed the vasomotor
spasm. In the insidious cases persistent treatment
with subcutaneous injections of morphine or supposi-
tories of codeine may be recommended.
An Electric Danger for Horses Herr Rusterholz,
writing to the Sc/nceizer Archh and reported in The
]'cteriiiary Journa!, relates a somewhat startling story
which may put veterinary surgeons on their guard in
these days when electricity is used everywhere. He
says that two carriage horses got into the habit of re-
fusing to take their oats. They both appeared to be
in perfect health, ate hay with appetite, and took their
oats easily; but at a given moment after they had con-
sumed a part of their ration, they tried to take up the
oats at the bottom of their iron manger and suddenly
recoiled, making curious movements with their heads.
The animals did their work well and seemed to be in
good spirits, but the same strange conduct was repeated
at each meal. When Rusterholz was called in he be-
gan by examining all the food, especially their oats.
All was found to be of excellent quality. Wishing io
see if the oats lying in the manger had not undergone
some deterioration which might explain the symptoms,
he thrust his hand into the oats, which were now some-
what moist by admixture with saliva and water. Each
time he did this he felt a curious tingling, such as is
produced by an electric current. The stable beir;g
lighted by electricity, Rusterholz caused the wires to
be examined, and this brought about the discovery
that over the horses' heads the wire had become de-
nuded of its insulating cover; the current was trans-
mitted by the coat of paint, which had become an
excellent conductor by reason of a slight coating of
moisture deposited on its surface through the conden-
sation of vapor, and this current reached the iron
manger. It did not cause the animals Sny trouble so
long as the oats were dry; but as soon as they became
damp by the saliva and condensed vapor from the
horses' breath it took effect, and the animals were
subjected to it every time they took a mouthful of oats.
Health Reports. — The following cases- of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended February 16,
1900 :
Cases. Deaths.
x-Un
States.
o loth
Alabama. Mobile February 3
FloriHa, Jacksonviile February 2d to mth
Georgia, Brunswick February 5th
Indiana, Evansville February 2d to 10th
Kentucky, Atchison January 27th to February loth.
Mound Valley. . .November 3d to February 8th. .
Louisiana, New Orleans ... . February 3d to 10th
Shreveport February 3d to loth
Mississippi, St. Louis January 22d to February 3d , . .
Ohio, Cincinnati February 2d to gth
Cleveland February 3d to loth
Voungstown February 3d to 10th
^^outh Carolina, Greenville . . . February 3d to 10th
Tennessee, Nashville . . February 3d to loth
LUah, Salt Lake City February 3d to loth ,
Virginia, Portsmouth February 3d to 10th ,
Smai-ltox-Fokeign.
■.\ustria. Prague January 13th to 2oth
IJelgium, Antwerp January 13th to 27th
Ghent January 27th to Februarj ^d . . .
China. Hong Kong December i6th to 23d
Colombia, Barranquilla January 2:;d to 27th
Knglaiid. Leeds .. .January 27th to February 3d. . .
Liverpool January 22d to 27th
London January 22d to 27th
Southampton January 13th to 27th
France. Paris January 22d to 27th
< lermany, Konigsberg January 13th to 2oth
Greece, Athens January 22d to 27th
1 ndia, Bombay January 2d to i6th
Calcutta I)ecem6cr 22d to January 6th . .
Japan, Formosa, Tamsui October ist to 31st ...
-Mexico, Chihuahua January 27th to February 3d . .
Mexico December 24th to January 28th.
Vera Cruz January 27th to February 3d, . .
Russia. Moscow January 13th to 20th
Odessa January 13th to 27th
St. Petersburg January 13th to 20th
Warsaw , January 13th to 20th
Spain, Corunna January 22d to 27th
Madrid January 20th to 27th
Turkey, Smyrna January 7th to 21st
Straits Settlements. Singapore, Decern ber 1 3th to 30th
Switzerland, Geneva January 4th to 13th
Vei.i.ow Fever.
Cuba, Havana January 31st to FVbruary 6th.. .
Plague— Ukiteu States.
December 12th to January 23d.. 52
Pla
-Foreign.
India,
Japan,
Hong Kong December 8th to 23d 5
Bombay January 2d to i6th
Calcutta December 22d to January 6th , . , .
Kurrachee January 1st to r4th. 13
Formosa ... October ist to November 30th. . 40
Kobe November nth to DecemMr 23d 21
Osaka January 7th 41
Medical Record
A Jl'cckly yoiiyiial of Medicine and Siiygeiy
Vol. 57, No. 9.
Whole No. 1540.
New York, March 3, 1900.
$5.00 Per Annum.
Single Copies, loc.
Q^rigiual AvticU-s.
SPINAL FRACTURE— PARAPLEGIA."
By KOBERT abbe, M.]).,
The subject on which I have been asked to make
some remarks to-night is one that interests not only
the surgeon but the physician, because of the certainty
that every physician may, sooner or later, be brought
face to face with this distressing accident of a broken
neck, or of a broken back, in the person of patient or
friend.
One sees children fall in climbing trees, or from
swings, or over banisters; youths suffer broken necks
in diving, workmen falling from scaffolding, elevator
accidents, falling from cars or out of carriages, horse-
back falls; and in all cases the sudden, horrible, and
instantaneous paralysis of the body faces the physi-
cian, and it is of the greatest moment to him that he
should be able to say to the distressed family what the
probable future will be, and what can be done at the
moment or in the future. Life-long paralysis will
inevitably follow the accident in perhaps the great
majority of cases in spite of all care, because the acci-
dent, as we shall see presently, produces a fracture of
the bodies of one or two vertebra;, with instant dislo-
cation and crushing pressure upon the soft spinal cord.
In many cases, after the damage, the displacement
is spontaneously corrected in part by the rebound of
the body to its natural position, so that after being
damaged the cord is not compressed within the canal,
but in most cases the sharp angular deformity within
the canal produced by the impaction of the fractured
vertebra; holds the spinal cord tightly squeezed against
the posterior lamins. In these cases there is less
chance for restoration of the damaged cord after nature
has absorbed the temporary hemorrhagic pressure.
It is from a rather large experience in cases of
broken neck and broken back, including two gunshot
paraplegias also, tiiat I venture to speak of the follow-
ing points.
Let us group the cases one sees according to symp-
toms with which the physician should be familiar, and
note the correspondence between the early symptoms
of damaged cord and the intensity of the damage. Be-
fore studying these let us note one condition allied to
and simulating broken neck which stands out in bold
relief and should be ever present in the mind of the
physician; that is, "dislocation of the neck."
I am able to show to-night a good radiograph illus-
trating for the first time the real deformity (Fig. i).
It has been supposed, heretofore, in the absence of
post-mortem opportunities, because the cases are al-
most never fatal, that the characteristic deformity of
dislocated neck is due to the displacement of one ar-
ticular facet backward into the notch on the upper side
of the vertebra below, thus giving the peculiar cock of
the head and slight rotation of the face to the affected
side.
' Read before the Practitioners' Society, l,>ecember 5, iSijg.
The case in which this radiograph was taken is of
a boy aged nine years, who fell down one flight of stairs
last July, and instantly his head was fixed immovably in
the characteristic position; there were little pain and
no paralysis. The radiograph shows a dislocation of
the axis upon the alas of one side.
The deformity has usually been imagined to exist
between the middle cervical vertebr;i-, but in both lat-
eral and front views of this case these vertebra; are
clearly seen to be in their normal relations.
It is of interest in this case that the reduction was
spontaneously accomplished during sleep the second
night after the accident; the boy awakening to find
his neck perfectly supple and correct. The explana-
tion is readily seen : the muscular relaxation during
sleep, with the leverage afforded by the patient's rest-
less movement on the pillow, accomplished what would
have been done under ether and by surgical manipu-
lation.
To grasp more easily the relations between the dam-
age in broken-neck cases and the group of symptoms
following, let me illustrate this large and varied class
of accidents by three cases of broken neck from div-
ing, which have come under my observation this last
year.
Case I. — A man, aged twenty-eight years, was diving
in shallow water, sandy bottom ; he suffered instanta-
taneous paralysis below the neck; he was rescued
quickly and found to be unable to move the muscles
of tiie body, but on examination directly after it was
found that there was slight voluntary motion of the
limbs and only partial loss of sensation. Soon after
the accident the predominant symptom was increasing
and incessant jactitation of all the limbs, which did
not subside for some days. After the third day better
voluntary action ensued, numbness diminished, and
in three weeks the patient had excellent control of all
his muscles.
Case II. — Boy, aged nineteen years: he was diving
in shallow water with sandy bottom and struck his
forehead; he instantly realized inability to move any-
thing below his neck. Consciousness was perfect.
He noticed a Happing motion of the limbs in the w'ater,
and held his breath until rescued. He was absolutely
paralyzed below his neck for three days. Sensation
was almost entirely lost, but he could feel pin-pricks
at some points ; the arms also had a prickling sensation
as if asleep. After two days he could move the tips
of the fingers and draw up the left leg, and could bear
his weight on one leg in two weeks, and in three
weeks could walk. He made a rapid convalescence.
Six months from the accident, there remains some
wrist-drop of the right hand, feeble grasp still improv-
ing, but otherwise nearly normal. The case might
well have been regarded as one of hemorrhage only,
within the vertebral canal, with very slight damage of
the cord; no deformity of the spine could be discerned
either in the pharynx or by external palpation. It
remained, however, for the radiograph, which I show
here, to show a most perfect comminuted fracture of
the body of the fifth cervical, which is clearly shown
to be crushed into a wedge instead of a square shape.
The displacement forward of the upper segment is less
than usual in these cases, and explains graphically
554
MEDICAL RECORD.
[Mj
1900
why the cord was contused rather than crushed, and
hence the transient paralytic symptoms.
Case III.— A young athlete and skilful swimmer
was diving in three feet of water ; his forehead struck the
sand, the head being thrown forward with chin upon
the sternum. Immediately instant paralysis ensued.
Consciousness was retained. He held his breath un-
til rescued. He was seen by me two hours afterward.
I found motor paralysis absolute below the neck, except
for the fifth root group of the shoulder, viz., deltoid,
brachialis anticus, and triceps, giving the arms the
characteristic position, elbows held out from the sides,
hands resting on pectorals. Respiration was entirely
by the diaphragm. To my surprise the skin was sensitive
over most of the body, even down to the feet, and the
patient had made voluntary flexion of two middle toes
of the right foot. The head, neck, and chest were en-
cased in a plaster-of-Paris support, traction of the spine
being maintained during hardening to correct the de-
formity as much as possible. Two unusual features
in this case justified a shade of hope in an otherwise
unpromising outlook, viz., the apparent, slight, volun-
tary action in the right foot, and the retained sense of
touch over the body ; both arguing an incomplete de-
struction of the cord. A successful radiograph was
taken promptly, showing a comminuted fracture of
the body of the fifth vertebra. The posterior bony
wall of the canal, marked by the lamina;, was appar-
ently nearly flat. The alignment of the spinous proc-
esses also seemed nearly normal, from which it ap-
peared that the cord remained under pressure, which
the removal of the posterior wall (laminae and spine)
would relieve. The patient urgently desired an oper-
ation at the earliest possible moment; but it was not
until the fifth week that any interference could be tol-
erated. Meanwhile, evidences of local myelitis and
meningitis ensued — namely, a severe girdle pain at
the limit of anesthesia, jactitation of the lowest unaf-
fected muscles, and loss of any muscle action below.
Cutaneous sensation with thermal sense was care-
fully noted by Dr. Pearce Bailey from day to day, who
found but little change. After the second day, how-
ever, acute pulmonary oedema with rusty expectoration
and hypostatic pneumonia (temperature, 104° F.) pre-
vented any operative interference.
The temperature during five weeks after the acci-
dent varied from 101° to 103° F., with exacerbations
due apparently, in some instances at least, to intesti-
nal putrefactive changes relieved promptly by calomel
purge. The patient wasted much during his confine-
ment.
Operation six weeks after accident: cutaneous and
deep muscular anasthesia by cocaine (fifteen drops
two-per-cent. solution) was resorted to, general anes-
thesia being impossible on account of diaphragmatic
respiration. The lamina; of the fifth vertebra were
found fractured, close to the transverse processes on
either side, and removed with the greater portion of
the lamina of the sixth also, and the spinous processes
all but the tips. The underlying dura was found of a
deep mahogany red and exquisitely sensitive to the
pressure of a sponge, and rounded up into a full, soft
swelling immediately upon removal of the flat bony
pressure. The acute sensitiveness of the dura to the
slightest touch was most interesting evidence of the
local meningitis, and corroborates what I have noticed
before in serous membranes, that, when uninflamed,
there is no pain sense, but when inflammation sets in
the pain on handling is very acute.
Owing to the opportunities afforded by cocaine op-
erations, one may occasionally compare the uninflamed
dura mater, knee joint serous surfaces, and peritoneum
with the same membranes when inflamed, and find that
these membranes are absolutely free from pain-sense
when handled in the uninflamed condition, but that
the slightest touch in the inflamed condition elicits
a cry of pain from the patient.
The cord being thus relieved of all posterior press-
ure, the wound was closed, and the patient felt no ill
effects from the operative procedure.
On the third day after operation the temperature
declined to nearly normal for the first time since the
accident, and continued until in another week it was
running normal morning and evening. The girdle
pains progressively diminished and soon entirely dis-
appeared. The general cutaneous circulation contin-
ued to improve, so that the nurses volunteered the
statement that pressure points required less care to
maintain good circulation. General nutrition improved
and the extremities seemed warmer. The patient soon
became entirely free from muscular jerkings of the
arm and chest muscles. Frequent rigors, to which the
patient. had been subject, and which were independent
of much temperature elevation, but which always called
for blanketing and hot bottles, now ceased. The pos-
terior splint upon the neck was removed eight weeks
from the time of accident, the bony spine being then
well united. He soon regained full and painless use
of his neck.
Twelve weeks from the time of accident the patient
w-as allowed to sit up in bed, and one week later was
allowed exercise in a wheel-chair in the upright
posture.
At the end of the sixth month from the accident the
patient's condition is as follows: Sensation is almost
complete over the entire body, being restored in some
anesthetic areas which were present after the accident
upon the lower extremities. Sensation in the left lit-
tle finger, absent after the accident, returned after four
months. No voluntary motion has yet returned in the
paralyzed muscles. The power of motion in the upper
extremities has steadily increased, so that the patient
can now raise his hands to his face and forehead. This
seems rather due to better voluntary control and co-
ordination of the lowest group of unparalyzed muscles.
Dr. Pearce Bailey, examining the patient at the ex-
piration of six months, reports: "The improvement in
his condition is most gratifying. With the exception
of the anterior tibial groups, all the muscles respond
to faradism. This is true not only for those in which
voluntary motor power has returned, but also for those
which are still totally paralyzed. This persistence of
faradic irritability is a reliable indication that muscles
which are now partially useful will become more so.
March 3, 1900]
MEDICAL RECORD.
355
and that there will ultimately be some return of power
to those which are still powerless. Thus, I think we
have strong reason to hope that in the upper extremity
the deltoid, the biceps, and the extensors of the wrist
and fingers will get steadily stronger, and that in time
the triceps, the flexors of the wrist and fingers, and the
intrinsic muscles of the hand will undergo some
restoration of function. The same holds good for the
muscles of the thigh. The anterior tibial group of
muscles do not respond to the faradic current, the
current, when applied to this region, passing through
and causing a contraction of the posterior groups.
While this cannot be construed as a positive indica-
tion that these muscles will remain totally and per-
manently paralyzed, it is certain that if power returns
to them it will be at a much later date than to those
which respond to faradism."
The patient's general health is otherwise restored.
The temperature has been continuously normal. The
diaphragm has accustomed itself to the perfect man-
agement of respiration. Nutrition is good, so that he
has reached almost normal weight. The digestive
functions are perfect. The patient sleeps regularly
and without pain; he sits upright in a wheel-chair
two to four hours daily, having perfect control of his
head, and using his neck naturally without apparatus.
We see in this case a more hopeful condition than
when the complete crushing of the cord is shown by
symptoms of complete sensory and motor antesthesia
and absence of knee jerk. In the latter case there is
usually a sequel of symptoms which tend to exhaust
the patient and end life within a few weeks, viz., pain,
distributed on the border line of anJESthesia and at the
site of fracture, requiring morphine sooner or later in
considerable dcses; cellular oedema of the extremities,
bed sores, and cystitis; pulmonary engorgements and
intestinal disturbances.
The combination of symptoms, sensory and motor
paralysis with loss of knee jerk, is not necessarily a
hopeless one, as is shown by the following interesting
case:
Case IV. — E. M , a stout muscular man, aged
thirty-five years, war correspondent in Cuba, was shot
by a Spanish Mauser bullet over the second left sacral
vertebra and was instantly paralyzed below the hips.
Two months afterward he came under my care, still
suffering complete sensory and motor paralysis of both
extremities and loss of knee jerk. An .v-ray photo-
graph showed the bullet at the site of the right renal
vessels; to have traversed this course it must have
ascended alongside the lumbar vertebrse and deflected
across the first lumbar. Examination by Dr. Pearce
Bailey established the lower segment of the cord as
the part injured. I operated, removing the lamina; of
the last dorsal and two lumbar vertebrte, the middle
portion of this section showing a crushed-in lamina.
The patient began to recover sensation and motion
within two weeks, and one month later had all the
muscles restored excepting those supplying the left
foot and ankle, which portion also remained without
sensation subsequently. He was able to go about on
crutches, but he demanded amputation of the left foot
a year later on account of its dragging, so that he
might use an artificial foot.
Operation in Cases of Fractured Spine.— Since
1875, when I had the opportunity of caring for my
first case of broken neck luider the guidance of Dr.
Sabine, the attending surgeon at St. Luke's Hospital,
I have watched the course of many victims of spinal
fracture which were refused operative treatment; but
ten years ago, under the stimulus of Thorburn's writ-
ings, I felt that these cases might have some little
hope of relief held out to them; I now feel justified
in saying that the operation presents little danger to
the patient, and gives sufficient improvement to justify
the time given to the operation. This improvement
may not often be seen in the restored power of motion,
but in minor evidences of the removal of the persist-
ent meningeal irritation from pressure ; relief of girdle
pains, improved vasomotor conditions of paralyzed
parts, and muscular twitchings. No surgeon would
refuse operation for depressed fracture of the skull,
leaving bone pressure to irritate the brain. I think
it equally logical that the spinal cord should also be
treated with the same care.
I have on several occasions in late operations upon
spinal fracture found complete occlusion of the canal
by adhesion of the meninges at the site of pressure,
preventing the flow of cerebro-spinal fluid from above
downward. I would repeat here, in brief, the method
of operation for laminectomy devised by me, and which
is the most simple and bloodless of all and gives per-
fect access to the cord.
Method: A straight incision, six inches long, is
made a little to one side of the spinous processes, the
knife passing between the muscle and the spines di-
rectly down to the laminse; the muscles are then easily
separated by blunt dissection from the lamina on
one side, and the tips of the spinous processes, with the
interspinous ligament unbroken, are separated by cut-
ting-pliers. These, with the opposite side muscle, are
then easily dissected in the opposite direction, the
muscles being very loosely attached to the laminae,
and the method comparatively bloodless. A rongeur
is now used to gnaw away the base of the spines and
as many laminae as are required to expose the cord.
Summary of Observations. — The immediate signs
and symptoms of fracture paraplegia give fairly accu-
rate data for prognosis.
If loss of sensation and motion below the injured
part is complete and instantaneous, and the patella re-
flex (knee jerk) is lokt, the outlook for recovery is al-
most hopeless. Yet knee jerk, sensation, and motion
may be absent, as in one case just reported (E. M- ),
and recovery takes place after operation.
Partial loss of sensation or motion gives hope that
a large degree of recovery may be looked for, the cause
in such cases being hemorrhage within the central
canal or in the cord substance and meninges. Dis-
tribution and absorption of blood-clot take place
usually within ten days or a fortnight, and returning
sensation follows.
;56
MEDICAL RECORD.
[March 3, 1900
Return of motion in complete paraplegia cases does
not always go on to perfect restoration. Wrist-drop of
one hand, or dragging of one foot, may still remain two
or three years after.
In cervical-fracture paraplegia the fifth vertebral
body is most often injured, hence the phrenic nerve
derived from the third and fourth branches of the cer-
vical plexus gives the only supply to a respiratory mus-
cle, to wit, the diaphragm.
The labored respiration by diaphragm only usually
results in pulmonary csdenia and hypostatic pneumo-
nia a few days after the accident. This may be over-
come by nitroglycerin internally and frequent change
of posture.
Intestinal fermentation with temperature disturb-
ance easily occurs in high paraplegias, and is speedily
relieved by calomel.
Regeneration of a pulpified cord is impossible.
Restored function is probably always due to absorp-
tion of blood, or of the secondary inflammatory depos-
its which prolong the pressure symptoms.
The persistence of bone pressure at the site of in-
jury justifies operation as much as in depressed frac-
ture of the skull, because through pressure an injured
cord must be further degenerated.
Laminectomy should be done as promptly as pos-
sible. If the subject be favorable, it may be done by
expert use of cocaine. It will be less painful if done
before local meningitis sets in.
An .r-ray view of the fracture can be readily taken
in these cases by from ten to fifteen minutes' exposure,
and greatly aids the surgeon.
lowed the employment during a number of years of a
similar method in reduction of dorsal dislocations of
the hip. It has now been tried in about ten succes-
AN EASY METHOD OF REDUCING DISLO-
CATIONS OF THE SHOULDER AND HIP.
By lewis a. STIMSON, M.D.,
SURGEON TO THE NEW YORK AND HUDSON STREET HOSPITALS ; PROFESSOR
During the last three months the following method of
reducing anterior dislocations of the shoulder has
been employed exclusively at the Hudson Street Hos-
-Reduction of Anterior Dislo
1 of the Shoulde:
pital, and has proved so effectual and easy that I
think it has earned the right to be more widely
known.
I was led to devise it by the success that had fol-
h'lG. 2. — Reduction of Dorsal LMslocation ut uic my. ii-'iMui;aiiuii w^s
present in either of the patients photographed for these illustrations. )
(Dislocation was not
sive recent cases; it has failed in none, and has never
required more than six minutes to effect reduction.
The principle is that of steady moderate traction
upon the arm in abduction, and the procedure is as
follows :
A round hole about six inches in diameter is made
in the middle of the canvas of a cot, about eighteen
inches from one end. The patient is placed upon the
cot with the injured arm hanging down through the
hole, as shown in the illustration. The cot is raised
upon blocks so that it will be at a sufficient height
from the floor, and a ten-pound sand-bag is made fast
to the wrist of the dependent arm. After a wait of a
few minutes reduction is found to have taken place.
None of the patients has complained that the pro-
cedure is painful. I recommend it as an effectual,
easy, expeditious, and apparently safe method.
Theoretically it would be better to attach the weight
to the arm close above the elbow, but in practice the
wrist has proved to be the better place, for some of
the patients would grasp the legs of the cot with the
free hand, and thus interfere with the action of the
weight. Possibly, lacking a cot, two tables might be
used, placed end to end, the head resting on one, the
body on the other, with the arm hanging down be-
tween. But the lack of snug support of the shoulder
might induce a muscular effort, which would defeat
or at least delay success.
The same method could be employed in dislocation
of the elbow whenever the joint can be freely extended
without the aid of anesthesia, but under such circum-
stances traction by the hands alone is usually suffi-
cient.
In dorsal dislocations of the hip the method is ap-
plied as follows: The patient is placed prone upon a
table in such a way that his thighs extend beyond its
end. The uninjured thigh is held horizontal by an
assistant, to prevent tilting of the pelvis, and the in-
jured one is allowed to hang vertically, vvhile the sur-
geon, grasping the ankle, holds the leg horizontal
March 3, 1900]
MEDICAL RECORD.
357
(right-angle flexion at the knee) and gently moves it
from side to side. If relaxation of the muscles is
slow to appear, a sand-bag — five or ten pounds — is
placed on the leg close behind the knee, or pressure
is made there with the hand. This has succeeded in
more than four-fifths of the cases in which I have em-
ployed it, and often without the aid of anesthesia.
In the two cases in which it failed, reduction was
accomplished by traction in a line midway between
right-angle flexion and full extension. I presume
they were cases in which the bone had left the socket
at a higher point than usual, probably dislocations
"above the tendon," so called.
THE RELATIVE MERITS OF OPERATIONS
FOR THE EXTRACTION OF VESICAL
STONE IN THE MALE; WITH OBSERVA-
TION ON THE SUPRAPUBIC AND LEFT
LATERAL PERINEAL METHODS.'
By SCHUYLER COLFAX GRAVES, M.D.,
VISITING SURGEON TO THE U. B. A. HOSPITAL, GRAND RAl-IDS, I\nCH.
Mr. President and Gentlemen : The index of merit
associated with the performance of any surgical oper-
ation is the mortality rate. Where the figure is low,
success is frequent; where the figure is high, failure
comes far too often. Eyes beaming with gratitude are
the handmaid of the former; and sighs and sobs the
mournful accompaniment of the latter. That the joy
of the world may increase, and the grief decrease, is
the ever-present desire of the medical profession. We
all know this, and are doing what we can to multiply
the comforts of life and eliminate the woes by a con-
stant endeavor to minimize mortality percentages.
Trusting that the thoughts contained in this paper
may be productive of good along this line, the same
is respectfully presented.
Let us turn, first of all, to the mortality tables bear-
ing upon this subject as prepared by J. William White
for Dennis' " System of Surgery." These tables are
arranged to cover the three operations done during
three different epochs of life, viz., " (a) Infancy to
puberty; {/>) puberty to middle age; (<■) middle age
to old age," and are as follows:
ii. Suprapubic, i
2. Perineal,
3. Litholapaxy,
( Suprapubic, :
< Perineal,
( Litholapaxy,
( Suprapubic, iS^
< Perineal, 19
( Litholapa.xy, 7
It will thus be noted that the Bigelow operation
bears the lowest rate in each instance, and this fact is
evidently due to the greater dangers at present con-
nected with the cutting operations.
I now invite your attention, briefly, to a schematic
exposition of the general merits and demerits of these
three operations:
1. The Bigelow (litholapaxy): A, Advantages — (i)
Avoidance of cutting; (2) abbreviated convalescence.
£, Disadvantages — (i) Danger of damage to the
bladder wall; (2) liability of laceration from incar-
cerated fragments; (3) Greater possibility of recur-
rence from failure to extract all particles; (4) poor
drainage; (5) amount of time required; (6) ineffi-
ciency in case of very large calculi.
2. The suprapubic: A, Advantages — (i) Adapta-
bility in case of large or impacted stones; (2) Ocular
inspection and digital touch ; (3) avoidance of hyper-
trophied prostate and tortuous prostatic urethra in the
aged; (4) possibility of drainage. B, Disadvantages
• — ^(i) Danger of opening the abdominal cavity; (2)
danger of sepsis from urinary infiltration ; (3) Exces-
sive detail in technique.
' A paper read before the Calhoun County Medical Association,
at Battle Creek. Mich., December 5, 1S99.
3. The perineal: ^, Advantages — (i) Rapidity of
accomplishment; (2) digital touch; (3) drainage.
£, Disadvantages — (i) Hemorrhage: (<?) artery of
bulb; (l>) internal pudic; (c) prostatic venous plexus.
(2) Opening of pelvic connective-tissue planes, with
sepsis from urinary infiltration ; (3) section of ejacu-
latory duct; (4) rupture of entire urethra.
The operation of litholapaxy requires a very delicate
and highly educated touch for its proper performance,
and this means that many patients must suffer to enable
the surgeon to develop that touch. It also often con-
sumes considerably more time, even with the most
skilled of operators, than prudence will permit, and
furnishes real danger in the gui.se of laceration, infec-
tion, and the risk of recurrence. However, it must be
admitted that when vesical calculus is very common,
and under the old regime, this procedure, in the
hands of the few, has given the best results; but in
the hands of the many, and in localities where stone
is not often seen, it is my sincere belief that the
suprapubic or perineal methods, modified as will be
observed later, will yield results in percentage rates
fully as good as, and better than, those following
litholapaxy in the same hands.
These modifications I shall now proceed to epito-
mize, and then discuss.
.,4, Improvements on the suprapubic method: (i)
Horizontal incision; (2) Bristow's modification; (3)
Harrington's modification; (4) Senn's modification;
(s) writer's modification.
B, Improvement of the left lateral perineal method:
Dilatation of the prostatic urethra, as well as the
vesical neck, instead of section. Advantages: (i)
Maintenance of prostatic and vesical integrity; (2)
diminution in amovmt of traumatism; (3) avoidance
of hemorrhage from prostatic plexus; (4) avoidance
of damage to the ejaculatory duct ; (5) avoidance of
urinary infiltration; (6) avoidance of separation of
bladder from urethra; (7) avoidance of much filthi-
ness in surroundings; (8) more or less urinary con-
trol; (9) ease of drainage in cases requiring it; (10)
rapid convalescence.
A (i) I cannot recall the reference; but some time
ago my attention was drawn to an article by a Western
surgeon advocating a transverse incision in cases re-
quiring the high operation. This suggestion is a
valuable one, and has been employed by the writer on
several occasions since then with much satisfaction.
The cases have not been lithotomies, for I have pre-
ferred the low operation in the stone patients who
have come to me; but were cystotomies for (a) uri-
nary distention from a hypertrophied prostate, and
(/') urinary infiltration from a urethral tear made dur-
ing the passage of a sound for stricture dilatation.
The principle, however, is the same. The incision is
made along the upper border of the pubis, and, in
connection with other details, best exposes the space
of Retzius (cavum Retzii), thus avoiding as much as
possible the prevesical peritoneal fold. The tendons
of the recti may be snipped or not as the case de-
mands.
(2) Bristow, of Brooklyn, has developed an impor-
tant modification of the high operation, and I would
respectfully refer you to his original article." His
idea is to distend the bladder with air instead of water
in the effort to render accessible the cavum Retzii.
The doing away with the nuisance of stuffing the rec-
tum with a water-bag, the diminished danger of vesi-
cal rupture from hydrostatic pressure, and the lightness,
elasticity, and compressibility of air are advantageous
points fully developed in his essay. Bristow origi-
nally inflated the bladder directly from his lungs,
' Bristow, A. T.: "The Use of Air to Dilate the Bladder in
Suprapubic Cystotomy." Annals of Surgery, 1893, vol. xvii.,
p. 667.
558
MEDICAL RECORD.
[March 3, 1900
although now he recommends a bicycle pump (a sug-
gestion of F. Tilden Brown), used after the initial
incision is made, in order to permit of inspection dur-
ing the process: and he claims that by his method the
peritoneum can be lifted from two to three inches
above the symphysis without the use of a rectal bag,
while the vesical injection of ten ounces of water will
lift it only about one-half an inch under the same
conditions. He also states that the injection of four
ounces of water has caused vesical rupture.
Some criticism was offered as to the applicability of
this plan in actual practice, Bristow having based his
statements on cadaver experiments without reference
to bladders altered by disease; but as higli an author-
ity as Professor Pilcher, of Brooklyn, came to the
rescue by a practical substantiation of its claims, even
in bladders softened by advanced disease and exten-
sive ulceration,' and since then Bristow himself has
had abundant opportunity to prove the practical value
of his suggestion. There can be no doubt, however,
that in cases in which the bladder has undergone great
inflammatory thickening and contraction, this proced-
ure will, at least occasionally, be found inefficient if
not actually dangerous. Such cases are not suitable
for the suprapubic operation.
(3) In 1893 Harrington, of Boston, published an
article" recommending intraperitoneal cystotomy in
selected cases. This theme has been discussed, and
several additional cases have been added to the record,
by Richardson, also of Boston.' From a perusal of
these papers it seems that this procedure is at times both
justifiable and successful. Richardson's cases were
lithotomies, and in neither of them was any prevesical
space present or even obtainable, because of small or
chronically contracted bladders. In one he managed
to stitch the summit of the bladder to the abdominal
wall, thus partially shutting off the general peritoneal
cavity, opening the bladder through its anterior
aspect; in the other this could not be done, and the
bovvels had to be protected solely by sterile gauze.
In both cases the vesical cavities were packed witii
aseptic mull for several days, for purposes of drain-
age, and both patients recovered.
When the suprapubic route seems preferable in an)'
case, and the cavum Retzii is found to be absent, the
Harrington plan should be adopted. As a matter of
fact, however, such a condition of affairs is not often
observed, and the inherent dangers associated with the
intra-abdominal section of a calculous bladder are
suflficient to deter many operators from its perform-
ance.
(4) In an article published for Senn by the Mniical
News* in 1893 (later than the Bristow essay), the
Chicago man recommends a truly life-saving innova-
tion in the performance of this operation, viz., division
into two stages. He cuts to the bladder, then packs
with iodoform gauze, and waits five days for the ap-
pearance of the ■■ cobble-stone " granulations. In this
way microbic infection and the absorption of pto-
mains from urine, often exceedingly q^ensive and
poisonous, are almost entirely obviated.
(5) It occurred to the writer that he could contract
Senn's five days into five minutes, by the use of the
cautery, actual or chemical, or by some protective
powder, as the stearate of zinc, and later this was suc-
cessfully done in a cystotomy for urinary retention, the
wound being thoroughly treated with the "solid stick"
(AgNOj). By this suggestion it may become pos-
'" Tuberculosis of the Bladder; Suprapubic Cystotomy."
Annals of Surgery, 1894, vol. xIn.. p. 370.
* " On the Feasibility of Intraperitoneal Cystotomy, with a re-
port of a Case." .•\nnals of .Surgery, vol. xviii., p. 408.
^ " Two Cases of Intraperitoneal Suprapubic Cystotomy for
Stone." Annals of Surgery, vol. .\xiii.. p. 132.
■■"Suprapubic Cystotomy in Two Stages." Medical News,
July I, 1893.
sible to cut to and open the bladder at the same sit-
ting, and thus save days of pain and delay and danger
to the patient.
B. When about to do a lithotomy on a boy aged
seven years (February 5, 1896), the knowledge that
so great an operator as Sir William Ferguson had, in
a similar case, completely severed the bladder from
the urethra in his endeavor to dilate the parts with
his finger, the accident naturally resulting in the
boy's death, caused the writer to think of the advan-
tage of instrumental over digital dilatation: and so,
in this case, after severing the fibres of the compressor
urethra;, an ordinary grooved director was slipped into
the bladder, tiie staff was withdrawn, and the tips of a
double uterine dilator were passed along the director's
groove into the vesical cavity. The parts were then
easily dilated so that the finger could readily be
passed into the bladder, and at this juncture, with a
Longyear forceps, the calculus, which was about the
size of the terminal phalanx of the little finger, was
withdrawn. The wound was packed and the bladder
drained for eight hours, after which no urine came
through the incision, micturition being accomplished
normally. The convalescence was very rapid, as is
the case generally with children.
If tiie parts can be dilated in the child, they ought
to be dilatable in the adult, and it was not long before
the opportunity to decide the matter came. A young
adult, twenty-seven years old, had stone, of four
months' standing, complicating a vesical tuberculosis.
The bladder was very much inflamed, hemorrhages
were frequent, and the urine was purulent and exceed-
ingly foul. After some preliminary treatment he was
placed on the table (March 5, 1896), and the deep
tissues were exposed by the usual lateral incision.
The membranous urethra alone was cut, the dilator
being used as in the case of the boy, and the parts
were readily stretched. Inasmuch, however, as the
stone was a large one, and the patient was quite weak
and also the subject of organic disease of the heart, I
deemed it advisable to crush the calculus in order to
save time. This young man acted as did the boy.
His urinary control was almost perfect. He held his
water, and, when the impulse came, voided it, the
stream passing through both wound and penis, as in
the case of perineal section external to the compressor
urethnt. There was very little incontinence, and in
spite of a delay of eight days from hemorrhage caused
by the ravages of tuberculosis, as a result of which,
upon the expulsion of clots, it was deemed necessary
to institute siphon drainage, the wound closed the
sixteenth day, the urine being voided thereafter
through the normal passage until about the thirtieth
day, when after considerable straining some urine
forced its way through the site of the incision. From
tliat time on a tuberculous fistula persisted.
The question naturally arises: Was the outcome in
these two cases exceptional or the result of prostatic
and vesical integrity, purposely maintained? I think
the latter, particularly in the case of the adult.
Although the idea of dilatation was original with
the writer, he has since learned, by reference to the
history of litliotomy, that it has been practised by
medi.x'val and later operators, although not in the
same way. Two methods are described:
Forcible dilatation, the so-called Marian operation,
named from Marianus Sanctus, a pupil of the cele-
brated De Romanis, an Italian operator of the six-
teenth century. This plan consisted in forcibly
dilating the parts until they ruptured, the idea being
that cutting was more dangerous than tearing. The
results, however, must have been equally disastrous.
2. Gradual dilatation, the method of James Arnott,
an Englishman of the earlier portion of the present
century. He recommended gradual dilatation, ex-
March 3, 1900]
MEDICAL RECORD.
359
tending over hours or days, by hydrostatic force ap-
plied through the proper placing of a dilatable bag at
the neck of the bladder. The method has never been
much used.
Turning to the dicta of modern operators let me
quote: The section of both prostate and bladder is
to-day recommended by White (Dennis' "System");
Thomas Bryant ("American Text-Book of Surgery"),
VVyeth, Moullin, Jacobson, and Treves. Roberts cuts
the prostate alone. Joseph Bryant cuts the prostate and
dilates the vesical neck, and so do Morrow and Keyes,
the latter t^vo also recommending section of bladder
neck in the case of children. All recommend section
of the prostate, and almost all section of the vesical
neck as well.
The prostatic urethra and neck of the bladder can
be readily dilated. Leidy' states, in reference to the
prostatic urethra, that " it is the widest and most di-
latable portion of the canal," and Roberts^ speaks of
"dilatation of the prostatic urethra and vesical ex-
ploration."
No modern author, as far as my observation goes,
recommends the innovation which the writer offers,
and no author, of any age, recommends the same pro-
cedure.
A word in possible explanation of the evidence of
more or less urinary control following the modified
operation. In doing the operation on the old plan it
will be noticed that there are occasionally two sepa-
rate gushes of urine, one when the fibres of the com-
pressor urethras are severed, and the other upon the
division of the prostate and vesical neck.
Henry Morris,' in discussing the prostate, says:
"The organ itself is composed of muscular and glan-
dular tissue. The muscular element represents about
three-fourths of the entire mass, and consists princi-
pally of unstriped fibres, continuous above with the
vesical sphincter, and forming in the upper third of
the organ a ring of great firmness and strength, lying
above the urethral orifices of the ejaculatory ducts,
and discharging in all probability the function of in-
tercepting the backward flow of semen and prostatic
fluid into the bladder during sexual congress."
Again, in reference to the presence and nature of
the vesical sphincter, I quote from Leidy:' "At the
neck of the bladder the internal (muscular) stratum is
thicker, and thence extends upon the urethra, where it
forms the circular vesical sphincter."
Associated with these unstriped fibres is more or
less elastic tissue, adding strength and solidity to the
compound. The phenomenon of double gush during
the lateral lithotomy incision is thus explicable.
Now, if the prostatic sphincter can prevent the back-
ward flow of semen, it can at least assist materially in
preventing the outward flow of urine, and thus it can
be seen that, after the operation described above, the
muscle, itself unimpaired, together with a tonic
sphincter vesicas, can account for post-operative uri-
nary control.
Gentlemen, I cannot consider it bad surgery, even
with the evidence of litholapaxy statistics, to recom-
mend for the aged, for those who have enlarged, in-
flamed, and lobulated prostates, the modified sectio
alta, and for the middle-aged and the young the
modified sectio lateralis.
THE APPLICATION OF THE ELECTRO-
STATIC WAVE CURRENT.
Bv WILLIAM BENHAM SNOW, M.D..
Bleeding of the Gums after Extraction of Teeth.
—In five severe cases J. Munk {Aerztlkher Ceiitral-
Anzeiger, 1899, No. 27) has seen almost immediate
cessation of the hemorrhage follow the placing of a
stypticin tablet upon the previously cleansed gum.
' " Human Anatomy." second edition, p. 641.
^ " Modern Surgery," p. 690.
' " Human Anatomy," p. 1037.
^ " Human Anatomy," second edition, p. 631.
Since the introduction of this new contribution to
electrotherapeutics by Dr. W, J, Morton, those famil-
iar with it have had reason to congratulate themselves
on the possession of a more potent agent than any of
the older electric currents. The writer's familiarity
with the current, having used it now for more than a
year in private practice and in the electrotherapeutic
clinic at the New York Post-Graduate Medical School
and Hospital, furnishes material for the following
observations.
During the summer of 1898, a patient under two
months' treatment for a condition of general decline
due to advanced age, receiving treatment of one-half
hour's duration three times each week, made such
marked improvement that it became evident that this
current was an agent of no mean value. In this case
a spinal electrode of sheet lead one and one-half
inches in width, and ten or twelve inches long, was
applied over the spinal column in close contact with
the skin. The patient became stronger, and all his
functions resumed their normal tone and activity,
while he was receiving no other treatment, and this
during the depressing humidity of that summer in
town. Realizing that one case would not establish a
precedent, but confident that to it much was due, I
began to use the new current in all cases of malnutri-
tion, neurasthenia, insomnia, and migraine, and in
every instance was reassured and gratified witli the
result. In these cases I employed a block-tin elec-
trode about one inch in width and sixteen to twenty
inches in length, applied next to the skin over the
vertebral column.
In patients whose secretions were inactive, marked
improvement took place in every case. A patient who
would barely perspire under the plate at the first sit-
ting would perspire sensibly over the whole surface
after the third or fourth application, and the feeling
of exhilaration that followed each treatment for a few
hours would become longer, until a sense of well-be-
ing became constant, with improvement in appetite
and all other functions. This will be true in cases
in which no serious organic disease exists, and even
these will receive proportionate benefit. When such
cases are treated and muscular contractions do not
interfere (as they may when the patients are spare,
with muscles well developed) a spark gap at least
four inches in length should be allowed to discharge
between the balls of the prime conductors, after the
first tingling sensation disappears, which will be when
the surface becomes moist between the surface of the
body and the plate electrode.
These treatments should not be for less than twenty
minutes, and daily for the first week or more, as the
case may require.
In cases of headache or neurasthenia, the point
electrode, having a good ground connection, should
be placed over the head or on a level with the knees
in front, and in either case at a distance just far
enough to allow the spark gap to discharge uninter-
ruptedly.
Patients of a congestive type and full habit are usu-
ally benefited by placing the point in front of the knees,
causing the main drift of the current to flow in that
direction, while weak or anajmic patients feel greater
relief when it is placed over the head.
The anodyne effects of the current were not realized
until the writer, after failing to give relief in an acute
case of tic douloureux with the friction spark and
short sparks, when treated for upward of half an hour,
36o
MEDICAL RECORD.
[March 3, 1900
succeeded on the following day, after fifteen minutes'
application of the " wave current," in completely re-
lieving the pain for fifteen hours, when it returned
with much less severity. No other anodyne had given
so much relief with one administration for so long a
time before, and when followed up for five days it
effected a complete cure. Other cases of severe neu-
ritis, as sciatica and brachial neuritis, have been com-
pletely relieved and cured in my practice without re-
course to other measures, which establishes beyond
question the claim. Attacks of neuralgia, when not
due to pressure or necrosis, are without exception
promptly relieved by the same method.
The next surprise was received when the writer
sought to relieve a timid patient who came to his
office suffering from a swollen and painful knee joint
(rheumatoid arthrftis), without recourse to sparks.
The joint was put up in a bandage of block tin, and
the current, with a four-inch spark gap discharging,
was continued for twenty minutes. The relief was so
complete that the patient left without limping, after
having suffered and grown worse for seven weeks. In
a few weeks this patient, the first case of joint disease
treated by the " wave current," was completely re-
lieved, and has remained cured for one year. Since
then many similar cases, as well as sprained joints,
have been greatly benefited or cured by the same
treatment.
Dr. Gibson, of Birmingham, Ala., reported at the
meeting of the National Association of Electrothera-
peutists, held in Washington in September last, a case
of acute rheumatism in which a complete cure was
caused by one treatment.
The treatment of paralyses by this wave current is
far more satisfactory in our hands than by any other
current. I find, however, in some forms that com-
bining it with sparks gives best results.
This current is administered without the least un-
pleasant sensation as soon as the skin once becomes
moist beneath the metal electrode, unless it is given
strong enough to cause muscular contractions. It
may be administered in any of the cavities or canals
of the body without discomfort if metal electrodes are
used without insulation. The results as far as known
are most satisfactory, excelling and fully succeeding the
sinusoidal and faradic currents whenever this treatment
has been adopted. New fields for the use of this cur-
rent will suggest themselves as time goes on, and the
greatest of electric currents for therapeutic use will
find new friends who must concur in the above state-
ments, which are not at all extravagant. Before con-
demning it, every detail of tiie technique must be un-
derstood and practised, and those who ridicule the
electrotherapeutist because the subject is too technical
for their investigation will realize, after all, that he
has at least one agent potent to relieve human suffer-
ing.
That there may be no misunderstanding, by those
who have machines, in properly managing the current,
I will briefly add the essential features:
1. Ground one pole of the machine to a gas or water
pipe. A good ground is imperative, and the matter
of polarity, so far as known, is immaterial.
2. Always treat the patient on the insulated plat-
form.
3. Always employ metal electrodes (lead or block
tin are best because pliable), and see that no mate-
rial is between the electrode and the patient's skin.
4. Connect the patient by one rheophore, or more if
several joints or parts are being treated at one time, to
the side of the machine not grounded.
5. Close or nearly close the prime conductors, and
start the machine.
6. Gradually separate the prime conductors until
there is commencing discomfort from muscular con-
traction, or a burning sensation, which will disappear
as soon as the skin becomes moist, or pain if applied
over a neuritis. After short intervals the spark gap
may be increased from time to time to get the best
results.
7. In treating a neuritis do not make the electrode
too large, or the current will be too much diffused to
produce the best result.
8. Allow no object that would draw off the current
to come near the platform, and be careful that no one
touches the patient, for obvious reasons.
There are very many lesser details, but the above
I believe sufficient for practical application; but
every one isessential.
©linical gepai^tmetit.
ONE RESULT OF ATTEMPTED ABORTION
IN THE EARLY WEEKS OF GESTATION.
Dr. L. S. Alexander, of St. Augustine, Fla., writes
that in many cases of tubal pregnancy he has, on close
questioning, obtained a history of attempted abortion
by drugs. The attempt is made almost immediately
upon the non-appearance of the desired menstrual flow,
conception being feared, to establish the catamenia by
the use of oxytocic drugs. The action of this sub-
stance in contracting the circular muscular fibres pre-
vents the descent of the fructified ovum, and tubal
pregnancy, followed by rupture, "results. In the South
a favorite combination for this purpose is a mixture
of cotton root and ergot.
PEANUT IN THE AIR PASSAGES.
Bv R. C. SHULTZ, M.D.,
LOS ANGELES, CAL.
This case is of interest only as adding to the statistics
of results of foreign bodies in the air passages without
operative interference. A girl, fourteen years of age,
while buggy-riding with another miss, got some pea-
nuts, which she was eating, into the air passages, and
coughed most violently. She continued having attacks
of coughing, and a whistling sound was audible part
of the time to people in the room. A few days later a
general practitioner made examination and expressed
the opinion that the foreign body was in the right
bronchus. An intended railway journey of some days
was postponed, but was carried out without untoward
incident between September 27th and October 6th.
On the latter date I made a casual examination of the
chest and distinctly heard a prolonged whistling,
moaning, uncanny sound, onlj' on expiration, all over
the chest, but loudest a little above the right nipple
and at the same level behind. At some subsequent
examinations the sound was audible on inspiration, or
on both inspiration and expiration, and with varying
intensity, being occasionally heard, after coughing, at
a distance from the patient.
On October 8th, after exposure, she had a severe
nasal catarrh and enlargement of the tonsils. This
had about subsided when, on October i6th, she had a
most severe coughing spell, and coughed up profusely
(which she had not done before); she felt some
peculiar body reach the upper air-passages, which after
a moment was expelled forcibly on the floor. The moth-
er and the patient said the body was of the size and
shape of a complete peanut kernel, hardest within, and
which crumbled when picked with a pin. They felt
sure it was the offending peanut. The patient ex-
March 3, 1900]
MEDICAL RECORD.
361
perienced immediate relief and soon quite ceased to
cough.
The same evening I was able to hear only a few
coarse rales over the lower right lung; the wliistling
sound had disappeared; the breathing was deep and
free over the entire chest. The patient's risibilities
are very excitable, and I have cautioned her, as I think
all ought to be, against uncontrollable laughter during
eating.
VACCINELLA.
By E. V. MOCK, M.D.,
CAMBRIDGE, ILL.
Reading the account in the Medical Record of the
patient with tertiary syphilis who after vaccination
developed "vaccinella" brings to mind a case of
which I kept a record while house surgeon of the
workhouse hospital, Blackwell's Island. The patient
was a woman, aged thirty-five years, admitted to the
medical ward of the prison hospital with a severe at-
tack of lobar pneumonia. She had fallen asleep in
the street, drunk, during a cold rain, and was arrested
and sent to the workhouse. Besides the pneumonia
she had an extensive ulcer above the knee, which I
diagnosed as specific after obtaining a history of syph-
ilis of five years' standing. By the tenth day her tem-
perature was running at 99° F., and she seemed in a
fair way to recover, when she suddenly grew worse
and the temperature rose to 104° F. Within a few
hours an eruption appeared on lier breast, spreading to
her arms, abdomen, and legs. The eruption progressed
from macular to papular, to pustular, and resembled so
closely a smallpox eruption that I asked an attending
surgeon to see the case. He advised isolation, and
the sending for a dermatologist from the health board,
which I did. After the pustular stage was well devel-
oped, the health board dismissed the case as one of
tertiary syphilis. During the last stage pulmonary
gangrene developed, and the patient died on the twen-
tieth day after admission to the ward. The similarity
of the two cases was such that I thought a comparison
might be of interest.
SURGICAL ODDS AND ENDS.
By WILLIAM ANDERSON PAYNE, M.D.,
PATHOLOGIC
At St. Mary's Hospital, Hoboken, N. J., I met with
the following cases that I hope will be of interest to
the profession, not so much on account of their prac-
tical bearing, as for the lesson they teach one to be pre-
pared at all times for all things. The conditions here
presented are rare, if I may be allowed to judge from
the statistics at hand.
Case I. — Fracture of the mandible at both angles.
This case I saw in consultation with Dr. Stack. The
patient, eighteen years of age, was hit by a thrown
brick on the side of the lower jaw, while walking
through an ill-lit park. Nothing presented to make
him think of fracture, and he thought the jaw merely
out of place, until on examination the next day we as-
sured him of the true condition. He could make
himself well understood, and in articulating moved the
symphysis considerably. He could eat food that re-
quired no chewing, and complained of nothing save
slight pain, greatly increased on moving or manipu-
lating the maimed member, and deformity. On in-
spection there was much swelling at both angles of
the jaw, not unlike a double parotitis, and had I not
observed the deviation of the chin to the left, I would
surely have thought of that condition. The mouth
was open and he could not close it. The manual ex-
amination showed free motion of the symphysis down-
ward and upward, as well as from side to side, yet in
this latter attempt I failed to bring the chin to the
middle line. Grasping the molar teeth with two fin-
gers, I found that 1 could move the ramus of one side
with my other hand, and this procedure and result I
demonstrated on the other side as well. The mucous
membrane was untorn. So easily did I obtain the
false points of motion and crepitus that from these
signs alone I was warranted in making the diagnosis.
The deformity and position left no room for doubt.
With my thumbs in the mouth and fingers grasping
the lower border of the bone, I reduced the fracture,
and maintained the jaw in its proper place by a plaster
splint, moulded snugly, and so broad as to embrace
the angles thoroughly. The line of fracture on both
sides was quite the same, extending from behind the
last molar teeth to the angles.
A fracture at this point is not common, and when it
occurs on both sides and with such manifest symmetry
it becomes rare indeed. The mild type of symptoms
should also be noted, and it would really appear as
though a double fracture of this nature would be
preferable to the usual single and compound fractures
of the symphysis. These fractures, besides being sim-
ple, were unaccompanied by injury to the contents of
the inferior dental canal. The attachment of the
masseter muscle to the fragments of both sides must
be given credit for the mildness of the subjective and
objective symptoms, for it bound the pieces together
and constituted a natural splint and at the same time
lent its action to either fragment. After four weeks
the patient was quite well and without deformity.
Case II. — Rupture of the internal lateral ligament
of the knee, with gunstock deformity of the leg. This
patient was a strong, robust man, aged thirty-one years.
He fell from a scaffold twelve feet high, and landing
on his outstretched feet was thrown forcibly to his
right. He was unable to arise, and was brought to the
hospital in the ambulance. On examination I found
his leg occupying an angle of 135' with his thigh.
With little force this angle could be made more acute,
but all efiforts to reduce the deformity failed. The
inner hamstrings were quite taut, but none of them was
ruptured. The inner portion of the capsular ligament
had been torn across, and the ruptured ends of the in-
ternal lateral ligament could be felt in their retracted
positions. In this rent I could thrust my finger tips
Ijetween the intact head of the tibia and the inner con-
dyle of the femur, and in this intervening space I could
feel what I believed to be the dislocated internal
semilunar fibro-cartilage. To its detached presence
between these articular surfaces I attributed my failure
to bend the leg inward to its normal position. It
greatly hampered, furthermore, the movements of flex-
ion and extension, and only through a very small arc
and with great difificulty could I accomplish this-
movement.
By manipulation with the fingers of my right hand
in the situation described, and by vigorously moving
the malplaced leg with my right hand, I was suddenly
conscious of a click, and the leg once more occu-
pied its normal position. This click was produced by
the slipping of the cartilage into its proper site. The
inflammatory reaction was great, but after several days
spent in combating it the whole limb was encased in
plaster. At the end of six weeks this was removed,
but so weak was the joint that a reapplication of plas-
ter was deemed necessary. It, however, bade fair fin-
ally to regain its strength. At this point I lost sight
of the case.
Case III. — Inward dislocation of the foot, without
fracture. This man, aged thirty-three years, stepped
on tlie end of a plank; the other end went up, and he
362
MEDICAL RECORD.
[March 3, 1900
was thrown forcibly on his left side. He managed to
get to a car and from the car walked unaided into the
hospital. His right foot was dislocated inward. If
it had been outward instead, one would, after inspec-
tion, have diagnosed it as a Pott's fracture with the ac-
companying deformity. The sole of the foot, however,
was parallel to the floor. The foot was pushed inward,
and the internal malleolus rested on the middle of the
trochlear surface of the astragalus. This malleolus
being intact, I was curious (and am yet) to know how
the inner articular surface of the astragalus passed
under it and to its inner side. Surely it could not
have passed directly inward, for the projecting malle-
olus and the capsular ligament offered a formidable
barrier, to say nothing of the adjacent prohibitory
structures. To go around the malleolus would have
been easier, and I am forced to conclude that this is
what happened. Considering the articular surface of
the astragalus as a segment of a wedge with its base
forward, we must regard the route pursued by this in
freeing itself of the malleoli on either side as a for-
ward one. When it had passed sufficiently far ante-
riorly the inner malleolus slipped outward on its pos-
terior surface, and from this situation'the malleolus
passed forward, by the flexing of the foot in walking.
So we find the tip of this process resting firmly against
the centre of the trochlear surface, probably indenting
it, and maintained in this position by the strong up-
ward pull of the adjacent ligaments and tendons. The
external lateral ligament was ruptured ; the internal one
was not and could be felt as a taut band running from
the malleolus almost horizontally inward to the dis-
placed astragalus. On the outer side the malleolus
had nearly penetrated the skin and was felt beneath it
as a sharp projection. At one point I could pass my
finger between the outer surface of the astragalus and
the inner surface of the malleolus. With the patient
under chloroform I succeeded by repeated efforts in
forcibly replacing the foot. The patient remained tive
weeks in the hospital, and was left without deformity
and with a leg of normal usefulness.
Case IV. — Fracture of the fourth metatarsal bone.
How a force of any kind could act on one of the inner
metatarsal bones alone is rather remarkable, unless it
be from some pointed object. This case, however,
presents further interest, in that the man with foot
strongly extended had the anterior part of the sole and
toes come in contact with the pavement. I shall not
attempt to disclose the selective action of this partic-
ular pavement. There was swelling over the outer
part of the foot. A tap on each of the toes elicited
pain only when the fourth toe was struck. I could get
fremitus and a false point of motion, and these com-
bined with the signs above brought me to the diag-
nosis as recorded.
Case V. — Incised wovmd of the ischio-rectal fossa
produced by breaking of a chamber vessel. These trips
to Chinatown are not infrequent, and I do not mention
it on account of its oddity, but rather to show the beau-
tiful effects of saline infusions in the treatment of
hemorrhage.
This heavy old woman produced by her great weight
breaking of the night-glass beneath her, and incurred
thereby a wound four inches long, extending deeply
into the ischio-rectal space. When she reached the
hospital it was quite evident that a severe hemorrhage
had occurred. All the symptoms of hemorrhage were
present, but the absence of the radial pulse alone
sufficed to indicate that our patient was on the verge
of death.
Besides the usual remedies we started the flow of
saline solution into the buttocks and beneath the
breast. Gradually the pulse increased in strength,
and the patient before long was placed on a fair basis
of life. By far the greater part of this improvement
was directly traceable to the salt solution. I could
feel the pulse come up as the liuid filled the vessels.
Unfortunately the patient died of hypostatic pneumonia
two weeks later. The danger of such accidents im-
presses upon one the fact that beneath the bed there
often lurks the enemy of womankind.
HYPODERMOCLYSIS IN TYPHOID FEVER.
Bv O. O. BURGESS, M.D.,
SAN FRAN-CISCO, CAL.
In typhoid fever several important factors are regu-
larly or occasionally at work to reduce the quantity of
circulatory fluids in the body. Among these may be
mentioned the increased consumption of fluids inci-
dental to febrile movement ; the lessened absorptive
activity of the stomach and intestines, hemorrhage,
colliquative diarrhoea and sweating, etc.
In view of the fact that solutions sufficiently salt to
provoke increased endosmosis cannot, consistently, be
introduced into the stomach and by way of the stomach
into the intestines, why should it not be good practice
to use the decinormal salt solution, upon occasion re-
quiring it, by way of high rectal injection if practi-
cable, or by hypodermoclysis, or in emergency by the
intravenous method? In addition to the usual advan-
tages of hypodennoclysis, we should thus secure the
introduction into the blood-vessels of a pure liquid,
uncontarainated by the bacilli and ptomain products
which liquids by way of the stomach and intestines
are pretty sure to pick up, and the probability of de-
creased exosmosis should not be lost sight of.
Indications for the use of the decinormal salt solu-
tion should not be limited to hemorrhagic cases, but
the method should be resorted to in all cases in which
the usual methods of treatment fail to accomplish the
desired result. It seems highly improbable that any
harm could come of it.
THE AUDITORY CANAL AS AN INCUBATOR.
By a. J. HOLMQUIST, M.D.,
R. B , male, aged seventeen years, presented him-
self for treatment late in the afternoon of August 14th,
with the following history: While out on a fishing
trip, a fly, supposedly a blue-bottle, had entered the
left auditory canal. From the irritation produced and
the consequent buzzing he supposed the offending ob-
ject still present. A speculum was introduced, but
examination revealed only a mass of cerumen impacted
against the drum. As this was easily accountable for
the buzzing I naturally discredited the patient's state-
ment concerning the fly in liis ear, especially as exam-
ination revealed no trace of it. Hence my first treat-
ment was directed toward clearing the canal of its
accumulated cerumen. A softening mixture of gly-
cerin and water with sodium carbonate was prescribed
for use at home, and a pipetteful of pure hydrogen
peroxide was instilled into tlie canal. This was fol-
lowed by syringing, which resulted in bringing away
only a few small flakes of wax. The patient here
stated that his mother had introduced some warm lard
into his ear to allay the irritation. This having united
with the cerumen probably accounted for the syringing
being so ineffectual. On the patient's return the next
afternoon he complained of intolerable buzzing and
acute pain. A few drops of blood also had oozed
from the canal. Examination, as before, was negative
except revealing the mass impacted against the drum.
Hydrogen peroxide was again employed in full
March 3, 1900]
MEDICAL RECORD.
363
strength, followed by syringing, which failed to dis-
lodge the wax. Two hours later the patient returned
with a living maggot, which had wriggled out of his
ear. A mixture of alcohol and turpentine, equal parts,
was prepared, and between fifteen and twenty drops
introduced into the canal, the patient's head being
held so that the full effect of the medicament could be
e.xerted against the drum. He complained of excru-
ciating pain and increased buzzing. As soon as the
latter ceased the head was inverted and irrigation
with warm water from a fountain syringe was em-
ployed. This resulted in the expulsion of a dirty
mass of detritus containing two dead maggots. A
quarter grain of morphine sulphate dissolved in warm
vaseline followed the irrigation, to allay the pain caused
by the turpentine, and no further trouble was reported.
A week or two afterward the patient, on being ques-
tioned, remembered that before applying for treatment
he had removed from his ear between twenty and thirty
white, elongated objects Avhich resembled the larvae of
an insect. This would account for the small number
(three) of maggots being found, as the detritus from
the last irrigation revealed no larvse. What seems a
remarkable feature is the short time required for the
incubation of the larvae, as only twenty hours elapsed
from the time the fly entered the ear until bleeding
from the canal occurred. However, the medium of the
warm lard and the normal body temperature must have
proved favoring factors to rapid incubation.
FLOATING KIDNEY MISTAKEN FOR AN
APPENDICITIS AND OVARIAN TUMOR-
OPERATION AND RECOVERY.
By H. T. miller, M.D.,
SURGEON TO MITCHELL-THOMAS HOSPITAL, SPRINGFlELn, OHIO.
In a recent issue of the Medical Record, there was
reported a case of " nephrorrhaphy and stripping of the
appendix through lumbar incision for floating kidney
and painful appendix." Though the case I am about
to relate is not a parallel one, yet it suggests the pos-
sibility of mistaking a right floating kidney for an
appendicitis, or, in a woman, for an ovarian tumor.
Mrs. R , aged forty-four years, occupation do-
mestic, entered the hospital on March 29, 1899,
suffering from pain in the right iliac fossa, about
one inch below McBurney's point. This pain had
commenced about one year previous to the above
date, and had continued up to the time of operation.
During this period an enlargement made its appear-
ance in the right iliac region. A few days previous
to the operation an examination could not determine
anything distinctly characteristic in the outlines of
this tumor to prompt an absolutely positive diagnosis,
nor did the subjective examination determine anything
further than that the patient was incapacitated for
about a year by almost constant suffering from pain in
the right iliac fossa. At infrequent intervals there
was a slight rise of temperature.
The outlines of this tumor were not at all distinct,
and because of its location it could easily be mistaken
for either an appendicitis or an ovarian tumor; then,
moreover, the subjective examination could not deter-
mine whether the enlargement had appeared gradually
or suddenly, whether it was preceded or followed by
pain, or whether the fever was short or long in dura-
tion; in fact, the history of the case was nil. How-
ever, the opinion seemed to favor the possibility of the
tumor being ovarian, so it was not a little of a surprise
when, upon exploration by median incision, a right
floating kidney was discovered.
In order to complete the history of the case, I would
add that the median incision was at once closed, and
a lumbar incision was made, commencing at the twelfth
rib to the crest of the ilium. In order to get hold of
the kidney and bring it to the margin of the incision,
a pair of vulsellum forceps was used, and the organ
was secured to the posterior abdominal wall by three
large-sized interrupted catgut sutures, no drainage
being used. The patient left the hospital on the sixth
of May following, cured.
A recent examination showed the kidney still se-
curely anchored.
CONGENITAL HERNIA OF THE UMBILICAL
CORD.
By GEORGE KESSEL, M.D.,
In the Medical Record for November 4, 1899, is an
article on " Congenital Hernia of the Umbilical Cord,"
with a history of two cases. I want to add the history
of a case.
On August 2, 1899, I delivered a healthy woman in
her first confinement of a healthy girl baby. The la-
bor was normal. But I was astonished when I took
my first look at the child and saw the large hernia of
the cord. The coils of intestine and the liver could
be seen clearly through the transparent membranes of
the cord. Apparently all the abdominal viscera were
in the tumor, which was as large as the child's head.
These contents could be easily reduced. Being afraid
to leave the tumor over night as it was, I immediately
performed the operation of stitching the freshened
edges of the incomplete umbilical ring together with
silk. But the child died during the night. Death
seemed to me to be due to the pressure of the abdom-
inal contents within the abdomen, for every time I
reduced the contents the pulse weakened and failed,
and upon relaxing the pressure it grew strong again.
If I ever see another case of the kind I shall wait a
day or two before I operate.
A CASE OF TETANUS IN WHICH THE
MOUTH WAS THE PROBABLE SOURCE OF
INFECTION.
By E. K. LOVELAND, Ph.G., M.D.,
WATERTOWN, CONN.
During the night of September 19th, I received a
hurried call to see a child. The messenger said the
little patient had just had a severe convulsion, and he
wished me to get there as soon as possible. On
arriving at the house about an hour later, I found a
healthy-looking, well-nourished, plump, and exception-
ally bright-appearing, twenty-months-old girl sitting
in the lap of an anxious mother. On inquiring into
the history of the case, I found that the child had been
unusually healthy during her entire life up to the
present sickness, which commenced two days before,
when it was noticed that she awoke from her afternoon
nap with a sudden start, crying. Her parents thought
nothing in particular of this at the time, as the child
had played exceptionally hard before her nap and
continued to do' so during the rest of the day. That
night the child awoke once or twice with a sudden
start, crying for a second or two as if in severe pain,
but dropped off to sleep again very soon, and the
parents attributed it to her having become over-tired
the day before. The following day she seemed well
and had a good appetite, but during the night that
followed, she had a repetition of the symptoms of the
night before, except that the spasms of crying and
sudden awakening seemed to be more severe; but in
the morning she seemed quite bright again and also
through the day, eating well ; but they noticed that
564
MEDICAL RECORD.
[March 3, 1900
she acted as if her throat were a little sore. The
next night (September igth),the little one awoke sud-
denly out of a sound sleep, and crying out as before
went into a convulsion, upon which they sent for me.
At this time when I reached there, as I have already
stated, she was very bright, sitting in her mother's
lap, but had a temperature of 100° F. with a tense,
rapid pulse. She dropped to sleep repeatedly while
in her mother's lap, as often as once in five minutes,
and each time awoke with a terrible jump and a con-
traction of the muscles of the back of the neck and
throat, which lasted but a few seconds and then passed
off, and the child again dropped off to sleep. On
trying to open her mouth to examine her throat, I
found that I could not separate her jaws, which were
tightly closed, and although she was a bashful child,
and generally cried when strangers were present, yet
she did not do so now. The parents said that they had
also tried once or twice that day to see her throat,
but could not get her mouth open. I left her some
bromide, also some aconite to reduce the fever and
tension of the pulse.
I called the following morning and found that she
had had no more convulsions nor much sleep since
the night before, owing to the fact that she could
sleep but a few minutes before she would be awakened
by a sudden contraction of the muscles, followed by a
peculiar cry, probably due to pain ; but she would not
weep, nor did she from now on, during her entire sick-
ness. The muscular contraction and cry during the
past twelve hours had not seemed to be quite so severe,
probably due to the bromides; her temperature was
now 99° F. and the pulse was not quite so full and
snappy as it had been the night before. When even-
ing came I found her with a pulse more rapid and
fuller, with a temperature of loi 'j° F., and she had
had two spasms during the day; the jaws were tightly
locked, and in trying to open them they were strongly
forced together and closed so firmly upon the spoon
handle that it was really with difficulty that I could
remove it, and on doing so I found the print of her
teeth upon the spoon; the patient immediately went
into a spasm, probably due to the irritation, in which
the opisthotonos was very marked and there was a
marked sardonic grin. I then felt confident that I
had a case of tetanus to deal with, and, although the
parents had told me two days before that there were
no scratches, cuts, or sores of any kind on the child,
yet I examined her carefully myself to see if I could
find any kind of flesh wound. On the calf of her leg
I found where there had been a slight scratch, said to
have been three weeks old; it was about a half inch
long and the scab had already dropped off; there was
no inflammatory action present, it being entirely
healed and well. There was only one other mark
anywhere on the child's skin, and that a very small
scar, over the left eye, which was due to a dog having
bitten her five months before, but there was no inflam-
mation here nor did any develop during her sickness,
and the dog is still living and well. There seemed
to be considerable trouble somewhere in the throat,
as there was a large amount of ropy mucus, mixed
with pus and blood, with a powerful odor, which was
constantly discharged from both nose and mouth, and
her neck was swollen over the tonsils; but as yet 1
had been unable to get her mouth open enough to ex-
amine her throat. I left instructions with the nurse
to increase the dose of bromides and give three grains
of chloral each three liours. The next morning (the
2 1 St) she had slept more, and yet had had two or
three spasms during the night. She was still taking
some nourishment from her nursing bottle, she her-
self folding the rubber nipple and crowding the same
between her teeth at such times as she was able to get
her teetli apart, the opening probably amounting, at
the most, to something less than a quarter of an inch.
I wished for counsel, and Dr. E. C. French, of Water-
town, met me with the patient that afternoon. We con-
sidered the antitoxin treatment, but it was not thought
favorably of by the family and we did not press it. We
now felt that she was getting neither the nourishment
nor the stimulant by the mouth that she needed, so we
commenced giving her pre-digested food with stimu-
lants by enema; also the chloral and bromides with a
very little morphine were given by the rectum, and
pushed almost to the extreme of tolerance during the
night, as the spasms and opisthotonos had been re-
peated at intervals of a very few minutes all day, and
the risus sardonicus was now almost constant. The
child had worked at her nose almost constantly dur-
ing her sickness, crowding her little fingers into her
nostrils as far as she could. I examined her nostrils
as far back as possible, using my head mirror. As
far back as I could see there w-as considerable inflam-
mation, and at this time there was an increase of the
flow from the nostrils of a sero-sanguineous pus, which
had an extremely sticky consistency, and this continued
to increase up to the child's death four days later.
The next day the temperature went down to normal,
where it remained. The pulse was short and snappy,
but was readily softened by the use of veratrum viride.
The following day the jaws relaxed fully three-quar-
ters of an inch, and the spasms were not so intense
(probably due to the use of anodynes), and, on exam-
ining the posterior nasal pharynx with a head mirror,
I found quite a large sore on the back of the mouth
surrounded by a boggy, honeycomb tissue which in-
volved uvula, tonsils, base of the tongue, and particu-
larly the palate, and this was, I believe, the original
site of the infection. I then asked if the child had
at any time been putting things into her mouth while
at play from which she could have received any in-
jury. The parents recalled that, two or three days be-
fore she was taken sick, she was playing in the attic
with a kit of old cobbler's tools, belonging to her
father, and they thought that she put some of the tools
in her mouth, and said that she might have got
scratched in that way, although they did not remem-
ber hearing her complain. My belief is that she,
while playing with the rusty nails, awls, etc., to which
more or less earth was adherent, put them in her
mouth, and from these received a slight scratch on
her palate, and this was the source of tetanus infection.
AN UNPRECEDENTED CASE OF PROLONGED
ANESTHESIA WITH NITROUS OXIDE AND
OXYGEN.
By S. ORMOND GOLDAN, M.D.,
Seldom if ever can the efficacy of any an<Esthetic be
more severely tested than in the following case:
Mrs. J , aged seventy-six years; general condi-
tion fair; type of patient antemic though stout; previ-
ous narcosis, none ; respiratory system normal, though
respiration was slightly increased in frequency, being
24; circulatory system normal; slight arteritis con-
sidering the age of the patient, arterial tension slightly
increased; pulse, 8,) ; urine analysis negative. The
anaesthetic used was nitrous oxide and oxygen through-
out. The operation was for extirpation of both breasts
with axillary contents, the narcosis lasting two hours
and forty minutes.
Dr. Hewitt's apparatus was used with Earth's ar-
rangement of cylinders, the precaution having been
taken to turn the stopcock at right angles to the face
piece, which I have found by experience, in using this
apparatus with the patient in the recumbent position,
March 3, 1900]
MEDICAL RECORD.
365
insures more perfect working of the valves, which is
of the greatest importance when using the mixed gases.
The jjercentage of oxygen during the first half of
the anaesthesia varied according to this apparatus be-
tween six and eight per cent., during which the pa-
tient's pulse averaged about 70; respiration about 20;
the pupils were normal, or moderately dilated. Cy-
anosis was entirely eliminated; in fact, the patient's
color was better than before the administration was
commenced. There was some slight venous oozing
during this part of the operation. During the second
part of the operation I found the patient stood ten per
cent, of oxygen, and only at twelve per cent, or more
did she evince signs of returning consciousness. There
■was no venous oozing during this part of the oper-
ation. I found no stimulation necessary before,
during, or after anaesthesia, nor did any untoward
symptoms develop. Consciousness was regained imme-
diately upon removal of the inhaler, and no excitement
developed, which is not infrequent after the use of
nitrous oxide and oxygen. Following the removal
of the inhaler the patient objected in vigorous tones
against the application of dressings and tight bandages,
which shows the transitory effect of this anesthetic
when compared with ether and chloroform. There was
slight temporary nausea, but no vomiting following
the anaesthesia.
The rapid convalescence of the patient shows that
the anesthetic shock was entirely prevented, for it is
extremely doubtful whether this patient could have
stood ether or chloroform for this length of time.
The case demonstrates the importance of reducing
or entirely eliminating the aneesthetic factor.
The surgeon. Dr. H. J. Boldt, informed me that the
tirine analysis was negative in its results during con-
valescence. There was also, I am told, a circum-
scribed area of dulness in the right lung posteriorly.
I might also say that during the operation upon the left
side tiie pleura was perforated. Neither occurrence
had apparently any effect upon the patient's convales-
cence, for the temperature and pulse were hardly ever
much above the normal. At this writing only ten days
have elapsed, and the patient was up the day following
operation. Dr. Boldt tells me that this is his usual
custom whenever practicable after any operation or
anaesthetic, to avoid secondary pulmonary complica-
tions, and I must say it is a most commendable one.
While a mixture of gas and oxygen is the safest of
all anaisthetics, eliminating the unpleasant features of
the gas when used alone, it is, however, the most ex-
pensive. In this patient the nitrous oxide used was
fifty-five ounces by weight, two hundred and twenty
gallons by volume. The oxygen was ele\en ounces by
weight, sixty gallons by volume; making a total cost
of the gases used $7.40. Nitrous oxide is two and
oxygen five cents per gallon, as supplied by the dental
companies of this city.
As far as I have been able to learn after careful in-
vestigation, this is by far the longest period of time
in which surgical anesthesia was ever maintained with
nitrous oxide and oxygen. When we consider the age
of the patient, the nature and duration of the opera-
tion, and the rapid convalescence, the case is certainly
remarkable and leaves nothing to be desired.
Mild Types of Typhoid Fever. — George Murray
Waters questions whether cases of typhoid fever, in
which all the symptoms are lacking, can really be
called typhoid at all, although conceding that two
or three of the symptoms can be absent without inval-
idating the diagnosis. — Columbus Medical Journal,
January 5, 1900.
The Laryngoscopic Image — R. Forns makes a
diagrammatic study of the elementary action of each
group of the laryngeal muscles (intrinsic). He finds in
the special innervation of the crico-thyroid the key to
the various clinical appearances found. — Aniiales des
Maladies de F Oreille, etc., December, 1899.
Abdoininal Extravasation of Bile. — B. Poulton
reports a case in which the symptoms were so urgent
that a laparotomy was performed. The muscles and
fascias were loaded with bile, and on opening the
peritoneum seven ounces of bile were collected. The
gall bladder was distended and very large. Continu-
ous irrigation with hot saline solution was carried out,
and through incisions made in the right loin and over
the pubis large tubes were carried into the lumbar re-
gion and the pelvis. No lesion was found in the gall
bladder. The author thinks it was a case of perforating
ulcer of the common duct, due to impaction of stone. —
The Australasian Medical Gazette, December 20, 1899.
Excretion of Urinary Water and Urea by Di-
minished Kidney Weight. — John B. Nash, from a
study of three cases and laboratory experiments, con-
cludes that if one kidney be removed, three years later
the healthy kidney will excrete more urine than the
average excreted by two normal kidneys, and the aver-
age amount of urea produced by two healthy kidneys.
The same results follow as regards urine if one-half
of a kidney be removed, but the urea will be unaf-
fected. After removal of one kidney, the urine ex-
creted during the immediately succeeding seven weeks
will be below the average daily amount. The urea
will be less than the average for two healthy kidneys.
— The Aicstralasiati Medical Gazette, December 20,
1899.
Immediate and Remote Effects of Nasal Obstruc-
tion.— F. R. Reynolds states that by the successful
treatment and permanent relief of nasal stenosis, many
diseases are prevented, relieved, or cured. Among
these are anemia, marasmus, hay-fever, asthma, and
laryngismus stridulus. Reflex cough may be due to
hypertrophic rhinitis. Also gastralgia, cardiac palpi-
tation, neuralgia of the trigeminus, scotoma, migraine,
cephalalgia, ciliary neuralgia, vertigo, photophobia,
neurasthenia, spasmodic cough, spasm of the glottis,
frontal and supra-orbital headache may all have their
origin in an exciting nasal focus. Emphysema and
bronchitis often accompany nasal stenosis. Nasal
stenosis not rarely has a deleterious effect on the ears.
— The Medical Age, January 25, 1900.
Remarkable Tolerance of the Young Child for
Opiates. — Borde relates his experience in the use of
opiates for young children which seems to be at vari-
ance with the generally accepted views on the subject.
He gives a summary of his treatment of sixty-four
cases, the patients ranging in age from one month to
twenty-five months. He declares that he has never
observed signs of intoxication from opium — that is,
coma, contraction of tlie pupils, cessation of urine,
anorexia, arrhythmical respiration, flushed face, con-
vulsions, etc. Borde uses opiates most frequently in
fetid diarrhoea. His successful experience has been
too wide to be called accidental. He has used four
different preparations: first, the syrup of diacodium,
which he uses no longer on account of its feebler
activity; second, laudanum, which he has now ceased
to use because its activity can be modified by its age;
third, syrup of thebaine; fourth, syrup of morphine,
which he prefers because it contains only one alkaloid,
and because its standard does not vary. He believes
that the child has a much greater tolerance for opiates
than the adult. — Journal de Medecine de Bordeaux, De-
cember 31, 1899.
366
MEDICAL RECORD.
[March 3, 1900
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Pl-blisheks
WM. WOOD &. CO:, 51 Fifth Avenue
New York, March 3, 1900.
REGULATION OF THE PRACTICE OF MID-
WIFERY AND PROVISION FOR THE LI-
CENSING OF MIDWIVES IN NEW YORK
CITY.
An assembly bill has recently been introduced with
the above object in view. The bill in question seems
to present several objectionable features, and could be
greatly improved by much judicious revision. Prob-
ably were a vote of the members of the medical pro-
fession throughout the State taken as to the necessity
or desirability of licensing midwives, the consensus of
opinion would be against such a course.
A very large number of physicians think that the
licensing of midwives would be by no means a step in
the right direction, but rather hold that a parturient
woman is likely to receive more beneficial treatment
at the hands of a skilled medical practitioner than if
placed in the charge of a midwife. If, however, a bill
of this description is to come into force, at any rate it
will be well to have as satisfactory a one as is pos-
sible. The bill in its present form does not fulfil
these conditions. Exception may be taken to its first
section, in which it is provided that the mayor of the
city of New York shall appoint the examining-board.
Surely such an appointment should be left to the dis-
cretion of the Medical Society of the County of New
York. Another provision of the bill which will de-
cidedly meet with the disapprobation of the medical
profession is that a board of examiners should be ap-
pointed to serve without compensation. Physicians
already perform more than their fair share of gratui-
tous work, and why they should be required to fill
posts of this nature for " love and good-will " alone is
a thing, in the words of the immortal Lord Dundreary,
"no feller can understand." Again, grave objections
must be brought against that portion of the bill which
provides for a board of examiners for New York City
only. Physicians in all parts of the State should in-
sist upon this clause being struck out or altered. The
Medical Society of the State of New York has always
strongly opposed bills to create examining-boards for
midwives in separate cities and counties, and has
insisted, and rightly so, that if midwives are to be
licensed the practice should include the whole State.
If this provision were allowed to become law, an ex-
tremely awkward precedent would be established:
other cities in the State would probably follow suit,
and would in the long run bring about a state of
chaos. •
There has been but little convincing testimony forth-
coming that the midwives bill is called for. On the
contrary, the mass of evidence tends to point in the
opposite direction. Doubtless the services of a mid-
wife who has undergone an examination testifying that
she possesses a certain amount of experience and skill
would be preferable to those of one who has been put
to no such test. But, on the other hand, the fact must
be plain to the veriest tyro that even a licensed mid-
wife cannot be expected to grapple with all the com-
plications which may occur, with the confidence of a
qualified medical practitioner. In the end it will as-
suredly be found cheaper to employ skilled attendance,
and when the public has grasped this truth the pres-
ent class of ignorant midwives will in the natural
course of things pass away.
The duty of medical journals is to bring the minds
of the community at large to a realization of this fact.
MANAGERS AND PHYSICIANS.
It is proposed to establish a hospital for the care of
indigent crippled and deformed children who may
have resided in this State for a period of not less than
a year, and for that purpose a bill has been introduced
into the House of Assembly. The aforesaid hospital
is to be located within a reasonable distance of the
city of New York.
The object is most meritorious, and will without
doubt prove a great boon to the many unfortunate lit-
tle ones who by reason of their infirmities are a bur-
den on their people, and who live in too many in-
stances a life of the utmost misery amidst the dirt Zf\A
vice of this great city. At the same time the bill
contains certain clauses which are deserving of sharp
criticism. Section 3, after detailing the duties of the
managers, reads as follows: "They shall not receive
any compensation for their services, but shall receive
actual and necessary travelling and other expenses."
Section 5 commences thus: "All the surgical and
medical officers of the hospital shall render their
services gratuitously," and ends with these words:
" For the first two years the attending surgical and
medical officers shall provide their own surgical operat-
ing-instruments "
Now there can be no particular objection to the
managers receiving actual and necessary travelling and
other expenses, but why should the surgical and med-
ical officers be expected not only to give their services,
but should also be required for the first two years to
provide their own surgical operating-instruments? Is
it because the duties of the managers are so much
more onerous than those of the medical staff that this
seemingly unfair discrimination is made? Impartial,
unprejudiced persons, who are familiar witli the man-
ner in which hospitals in this State are conducted, arc
of the opinion that the contrary is the case. This is
without doubt the fact, and it is the fault of the mem-
bers of the medical profession themselves that they do
March 3, 1900]
MEDICAL RECORD.
367
not receive adequate compensation for the work they
perform. If the physicians and surgeons of this
State were one and all to insist — barring very excep-
tional circumstances — upon being paid for services
rendered, the cause of charity would not suiTer, and an
excellent example would be set to their professional
brethren in all parts of the country. The medical
profession throughout the world might with advantage
take to heart and act upon the good old Bible precept,
" The laborer is worthy of his hire."
STATUS EPILEPTICUS.
The symptomatology and pathology of status epilep-
ticus are deservedly receiving much attention at the
hands of neurologists. The status in epilepsy is
fairly well recognized now to be the acme or climax
of the disease; that is, given the greatest number of
contributing causes, the epileptic is foredoomed to die
of the status as the maximum development of the dis-
ease. Certainly chance plays no part in the produc-
tion of status.
Throughout all the present-day definitions of status
epilepticus, we find that the constant factors of rapidly
repeated seizures and the progressive deepening coma
are always included as the essentials of the condition.
There is also a marked elevation in the fever, pulse,
and respiratory curves. Some still hold that status is
seen only in certain kinds of epilepsy ; but by far the
greater number of authorities maintain the more
logical ground that the condition may occur in all
epilepsies. An interesting point isdisclosed by recent
investigations, as there appears to be a necessity for
reviving the old theory of cortical heat centres (Eulen-
burg and Landois) to explain the high temperature in
status epilepticus composed entirely of psychic at-
tacks. The fever curve of status still remains mysteri-
ous, although it is generally in direct ratio with the
severity and number of epileptic convulsions. Inas-
much as this rule is not always true, there are evidently
latent factors in heat production in the epileptic par-
oxysms, which are not referable to the muscular con-
vulsions. The understanding of the anomalous fever
curves in status will probably rest for ultimate solu-
tion upon its etiological pathology. After all, the
enigma of the fever curve is not more difficult of solu-
tion than the loss of consciousness in isolated convul-
sionsiof epilepsy proper. The length of time after the
disease of epilepsy begins and the time when status
will occur is a point of great practical importance to
all physicians. Recent statistics seem to prove that
epilepsies developed in later life have status in a
shorter period of time than when the epilepsy is con-
tracted in early life. However this may be, it is cer-
tain that the disease of epilepsy in the majority of
cases must be very well established before status will
supervene. Epileptics may never have more than one
status period, or may have six or seven, although the
latter number is quite rare. Cases are not unknown
in which patients have recovered from status and also
from the epilepsy proper; although it is now generally
conceded that status is the severest manifestation of
epilepsy, and but few patients ever recover from their
disease when status has once occurred.
The influence of menstruation and pregnancies upon
the production of status in epileptic women is nil. It
is as infrequent a clinical experience to see true status
develop from the menstrual period as it is common to
see serial attacks of major hysteria at such epochs.
This fact alone aids one much in the differential
diagnosis. :I
The immediate cause of status is still as indefinite
as that of epilepsy proper, and the solution of the
problem probably rests upon the discovery of the
pathology of the affection and the modifying agencies
of the individual's resistance to the progress of the
disease. Its pathology, beyond a vascular and cellu-
lar degeneration of tke cortex, is still obscure. Often-
times the vascular and cellular degeneration is really
a result rather than a cause of the status. The actual
onset of status does not differ from the beginning of
serial attacks, and serial periods, without status, are
frequently termed aborted or pseudo-status. Careful
attention to these periods frequently delays the pres-
ence of true status epilepticus in the individual pa-
tient. The gradual, step-like advance of the grave
symptoms is the cardinal factor in forming a prog-
nosis of status.
The advance of our knowledge of treatment of status
is not great. A significant fact of the futility of me-
dicinal treatment is seen in that all plans of medication
are of service in isolated cases. The percentage of
recoveries remains about sixty or seventy in spite of
improved methods of treatment. In the medication
of status it should alwajs be borne in mind that that
which is indicated for the convulsive stage is contra-
indicated for the stuporous stage, and that the admin-
istration of large doses of chloral, uncombined with
other drugs, has come to be considered as dangerous
medication, in the light of depressing effects obtained
from chloral upon weak hearts. Notwithstanding the
frequent abscess formations from hypodermic bromide
medication, this line of treatment is steadily growing
in favor in the severest cases of status. Good general
nursing is nowhere more needed than in giving proper
care to epileptics suffering from status, either in their
own homes or in special hospitals for this disease.
SCIENTIFIC PREFERMENT IN CUBA.
Complaint is made in the February number of the
Archivos de la Policlinv-a of Havana, concerning the
manner in which medical appointments are made un-
der the present regime. Formerly (that is, under
Spanish rule), our esteemed contemporary says, scien-
tific merit was the means by which posts of honor and
profit were obtained, and medical men were thereby
stimulated to study and to conduct original investiga-
tions. Under this stimulus the laboratory of the
Cronica Medico-Qiiiri'ii-gica and the Free School of
Medicine were established, the attendance at the meet-
ings of medical societies was large and enthusiastic,
368
MEDICAL RECORD.
[March 3, 1900
and the first insular medical congress was held.
Now, however, desirable positions are obtained
through personal friendships, and there is no neces-
sity for superior knowledge nor any reward for study.
At first, the Archivos says, these appointments were
made for political merit, and to this no objection is
made, since the country owes its existence to the army,
but now, it complains, not the most fit among the po-
litically deserving, but the most friendly to the new
powers are selected. And recently, indeed, even po-
litical merit no longer counts, but only personal favor.
Influence is now the sole recommendation to prefer-
ment. We trust the condition is not universally so
bad as that, and that one or two specific instances
have led our esteemed contemporary to a generaliza-
tion. But there should not be even one such instance,
and certainly the present military governor of the
island, who is himself a scientifically trained medical
man and no friend of place hunters, does not counte-
nance such abuses. The medical men of Havana
should take their complaints to General Wood, for he
will heed them.
|lcius of the "^J^celi.
Philadelphia County Medical Society — At a stated
meeting held February 14th Dr. Thomas J. Mays ex-
hibited a number of patients with phthisis treated with
injections of silver nitrate. Dr. B. Franklin Stahl
presented a communication entitled " Copy the Formula
on the Label." Dr. John H. Gibbon presented a com-
munication entitled " Rupture of the Plantaris (Lawn
tennis Leg)."
College of Physicians of Philadelphia : Section on
General Medicine. — A stated meeting was held Feb-
ruary 1 2th, when Dr. Frederick A. Packard read a
paper entitled " Diet in Typhoid Fever." He pointed
out that the most important cause of death in typhoid
fever is the intoxication or the asthenia, and he ana-
lyzes the suggestions that have been made by various
clinicians to enlarge the customary diet employed in
this disease with the object of averting the dangers
arising from these conditions. While he has hmiself
not gone beyond the conventional diet as yet, he pro
posed to do so as soon as a suitable opportunity
offered. He laid emphasis upon the administration
of water in generous amounts. Dr. John H. Musser
read a paper entitled "The Use of Stimulants in
Typhoid Fever." He pointed out that alcohol is not
required in the sthenic cases, and is needed in the
asthenic cases only when the tongue becomes dry, the
secretions are diminished, the urine is deficient, and
muttering delirium, with picking at the bed-clothes, is
present, and the pulse is soft and feeble, and the sounds
of the heart are weak. Dr. James IVL Anders read a
paper entitled "The Use of Intestinal Antiseptics in
Typhoid Fever." He pointed out that in accordance
with present conceptions of the disease little can be
hoped for from the administration of antiseptics in the
treatment of typhoid fever. It is his custom when the
diarrhoea is not present to administer calomel at the
outset, and when meteorism is present and the char-
acter of the intestinal evacuations furnishes the indi-
cation, to administer salol in doses of gr. iii. at vary-
ing intervals, and occasionally to make antiseptic
injections into the bowels. Hydrochloric acid is use-
ful both as an antiseptic and as an aid to digestion.
Dr. James Tyson said that as milk contains all of the
necessary elements of food, and that, as in the case of
infants, it seems designed by nature as a suitable
article of diet, it appeared to him the most available
form of food in cases of typhoid fever. So many of
the unpleasant symptoms previously observed have
disappeared since the more general adoption of the
Brand method of treatment that the need for stimulants
has been greatly diminished. So, too, a better appre-
ciation of the nature of typhoid lever has removed the
indication for intestinal antiseptics. Dr. Judson Da-
land stated that it is his custom to supply fluid to the
body by means of rectal injections of salt solution.
He pays especial attention to the condition of the
mouth. Dr. B. F. Stahl stated that milk can be made
more available as a food in the management of febrile
conditions if more attention is given to variations in
its preparation; for instance, by greater dilution the
dangers from the formation of large Curds is easily
obviated. Dr. H. A. Hare stated from personal expe-
rience that he felt it desirable to feed typhoid-fever
patients more liberally than has been the custom in
the past. In his own practice patients are permitted
to have from two to four eggs, soft boiled, daily, and
with the approach of defervescence also corn starch
and tenderly boiled rice. Strychnine should not be
given for too long a time, as it is a cardiac stimulant
and may cause abnormal cardiac activity.
Antirabic Inoculations in Berlin. — Three hundred
and eighty-four persons bitten by mad dogs and cats
were treated during the past year in Berlin by means
of antirabic inoculations. Three hundred and seventy-
eight of these recovered, and three of the six who died
were already suffering from rabies when treatment was
begun.
Philadelphia Pediatric Society.— At a stated meet-
ing held February i4tli. Dr. \. A. Eshner presented a
case of mitral obstruction and pulmonary obstruction,
occurring in a girl nine years old. Dr. J. P. Crozer-
Griffith presented a case of congenital heart-disease,
with great cyanosis and clubbing of the fingers, in a
boy of about six years. Dr. G. G. Davis presented a
case of double congenital dislocation of the hips in
a girl five years old, in whom permanent reduction had
been effected upon one side at the age of three and
one-half years, and after other measures had failed an
artificial acetabulum was created at the age of four
years on the other side, with retention of the head of
the femur in the new socket. The previously marked
lordosis had quite disappeared, and there was but lit-
tle shortening on the side operated on. Dr. J, P.
Crozer-Grifiith presented a case of cerebral diplegia
with choreiform movements, and also a case of stenosis
of the larynx in the course of typhoid fever. Dr. A.
March 3, 1900]
MEDICAL RECORD.
369
M. Seabrook read the report of a case of hemorrhagic
purpura in a new-born infant. Although the umbil-
ical wound had healed smoothly, hemorrhage occurred
from the umbilicus on the fifth day, requiring the
application of hare-lip needle ligatures. At the same
time large oval ecchymotic spots appeared in numer-
ous situations. The needles were kept in place for
sixty hours; the ligatures came away in a week, and
recovery ensued. Dr. F. A. Packard read a paper en-
tilted "A Brief Note on Kernig's Sign in Infants,"
relating cases of meningitis in children, in which
extension of the leg upon the flexed thigh could be
effected with the patient in the sitting posture.
A State Hospital for Inebriates — It is stated that
a bill will be introduced into the New York legisla-
ture during the present session to establish an institu-
tion for the treatment of the victims of alcohol and
drug addiction. The bill provides for the appoint-
ment by the governor of a board of managers who will
receive compensation during the time they are engaged
in making plans for the institution. After it is ready
for the reception of inmates, the managers are to serve
without pay, each for a term of three years. The in-
stitution is to have accommodations for three hundred
inmates. Incurables will not be admitted. Inebri-
ates may be committed for terms of five years, but it
is purposed to have a parole system similar tq the one
now in use at the Elmira reformatory. Commitments
will be made by magistrates, although persons seeking
to enter for treatment will be accepted when there is
room for them. The cost of maintenance of inmates
committed by magistrates will be charged against the
counties from which they have come.
Limiting the Output of Doctors in Russia. — The
Russian government has grappled with the question of
the over-production of medical practitioners in a dras-
tic manner peculiarly its own. By a recent decree of
the minister of education the admission of first-year
students by the several medical faculties throughout
the empire is restricted to a fixed number. The Uni
versify of Moscow is limited to 250, Kieff to 200,
Charkow to 175, Dorpat to 150, Warsaw to 100, Tomsk
to 120, and Kasan to 100. The total number of first-
year medical students in the dominions of the Czar
must, therefore, not exceed 1,095. This number does
not include the students of the St. Petersburg Medico-
Military Academy, which is allowed to admit 250 first-
year students. — British Aledical Journal.
Prevention of Venereal Disease in Norway. — Dr.
C. R. Drysdale writes to the British Medical Jour-
nal regarding a bill recently introduced into the Nor-
wegian Storthing. This bill was drawn up by a com-
mittee of statesmen and physicians, and was presented
for discussion to the members of the Brussels Con-
gress. Many of its sections, the writer says, are quite
urisuited to a country so little accustomed to paternal
government as the United Kingdom, and we ni.iy add
the United States, but he thinks the following sections
might serve as suggestions for some future bill to be
drawn up for the United Kingdom: "Section XI. —
Every practitioner who examines a person affected
with a venereal disease is required to inform his patient
of the contagious nature of his disease; and at the
same time must seriously explain to the patient his
legal and moral responsibilities, in case he shall com-
municate the disease to another person, or expose
others to contract it from him. The practitioner must,
above all, call the attention of the patient to the dan-
ger of contagious relapses of his malady; and of the
consequences of it to his children, and at the same time
inform him that he should frequently have himself ex-
amined in case such a relapse may occur. [The prac-
titioner must also tell the patient what means he
should employ to prevent such contagion to others.]
The Minister of Public Health may cause printed in-
structions to be drawn up, and given by the practi-
tioner to his venereal patients. Section XIV. — Every
practitioner who treats a venereal patient and who
knows that the patient by his conduct is exposing oth-
ers to contagion, must immediately make this known
to the president of the health commission."
Corresponding Members of the Academy of Med-
icine of Paris. — At the session of the Paris Academy
of Medicine, held January 30th, Drs. Kaposi, of Vienna,
Erb, of Heidelberg, and Hansen, of Bergen, were
elected foreign correspondents.
An International Congress of Medical Electrology
and Radiology will be held in Paris the week previ-
ous to the meeting of the International Medical Con-
gress, from July 27th to August ist. Those desiring
to take part in this congress are requested to com-
municate with Dr. E. Doumer, secretary-general, 57
Rue Nicholas-Leblanc, Lille.
Tuberculosis in Denver. — According to the annual
report of the Denver board of health, there were 536
deaths from tuberculosis in that city during 1899. In
1898 there were 505 deaths from this disease, and in
1897 489. Only 58 of the deaths in 1899 were of
persons who had contracted the disease in Colorado,
this comparing favorably with the 99 fatal cases of tu-
berculosis acquired in the State in 1898, and 88 in
1897.
Dissatisfied Homoeopaths. — The members of the
homceopathic and eclectic State medical examining-
boards of Pennsylvania are dissatisfied with the distri-
bution of fees under the act of assembly providing for
the examination of applicants for license to practise
medicine. Each applicant pays a fee of ^25, and the
fees, less expenses, are distributed among the three
boards. As many applicants appear before the regu-
lar board, representing the Medical Society of the
State of Pennsylvania, and comparatively few before
the other two boards, the former have not complained
of their remuneration, while the latter are correspond-
ingly unhappy.
The Paris Congress. — The Compagnie Gene'rale
Transatlantique announces a reduction of ten per cent,
on tickets from New York to Paris to members of the
International Medical Congress. The French railway
lines offer a round-trip ticket for a single fare. The
secretary-general of the congress. Dr. A. Chauffard, 21
370
MEDtCAL RECORD.
[March 3, 1900
Rue de I'Ecole de Medecine, Paris, has arranged to pro-
vide early applicants with lodgings at the rate of 5
francs a day. This includes light and service, but not
meals.
The American Medico-Psychological Association.
— The meeting of this society in Richmond, Va., will
be held May 8th, 9th, loth, nth — not May ist, 2d,
3d, 4th, as heretofore announced. The change in
date is made to enable members to attend the Congress
of American Physicians and Surgeons in Washington,
May I St to 4th.
Vinegar as an Antidote to Carbolic Acid Dr.
Edmund Carleton of this city requests that proper
credit be given to him for the discovery that vinegar
will relieve both internal and external burns from car-
bolic acid. We give it to him with pleasure, but must
add that the same fact was noted in The Lavcet four
years ago (p. 255, i., 1896).
" The Medical Examiner," a journal hitherto de-
voted to the interests of medical examiners for life in-
surance and others, and ably edited by Dr. George W.
Wells, is to enlarge its field of usefulness. The
editor says that, as every part of medicine bears upon
the duration of life, he will henceforth admit to his
columns articles upon any medical subject, and the
title of the journal is accordingly enlarged to The
Medical Examiner and Geneial Practitioner.
A Mysterious Dog Malady in England A cor-
respondent of The Medical Press and Circular suggests
that the plague may be existent at present in England.
This surmise is based upon the fact that some six or
eight months ago there appeared at Southampton a
disease which attacked dogs, and proved so fatal and
infectious that in a short space of time the town was
practically cleared of its canine population. Since
then the disease, which appears to be of a highly spe-
cific nature, has spread slowly but surely over many
parts of the United Kingdom. Deaths from this epi-
demic are occurring at the present time in London,
and veterinary surgeons are now everywhere alert as
to its occurrence. The points suggestive of plague
are the invasion of a seaport town, where dogs might
easily become infected through ship rats, and the fatal
nature and the high degree of infectiousness of the
malady. On the other hand, as our contemporary
remarks, it is hardly likely that, if plague had really
attacked so widely domesticated an animal, the conta-
gion would not quickly have been communicated to
man.
Medical Expert Testimony. — .\ good story is re-
published in Law Notes from the reports of the su-
preme court of California. A woman named Doolin
brought an action against the Omnibus Cable Com-
pany for damages for injuries alleged to have been
received by her in the derailment of one of the defend-
ant's cable cars. Some months before the trial an ex-
amination of Mrs. Doolin was made by six physicians,
three appearing in her behalf and three for the defend-
ant, for the purpose of ascertaining her physical con-
dition. At the trial several of these physicians testi-
fied that they had ascertained during the examination
that she was suffering from a tumor, either ovarian or
uterine, and of about the size of a cocoanut; but they
differed as to its precise location. As to the existence
of the tumor there seemed to be no dissent. The fam-
ily physician of the plaintiff testified that the tumor'
had increased in size until it had become about four
times as large as when the examination was made.
The defendant contended that plaintiff's ailments were
caused by the tumor and not by the accident of the
cable car. On the other hand, the plaintiff sought to
show that the tumor was the result of the accident.
Ten days after the trial Mrs. Doolin «gave birth to a
child at full terai. On the appeal each side admitted
that such was the fact, and that she had not been suf-
fering from a tumor at all.
Christian Science and Life Insurance. — There is
a case now before the supreme court of Connecticut
in which the question is to be decided whether a life
insurance company can be compelled to pay a claim
when a Christian Science policy holder dies after hav-
ing refused all medical treatment.
A Privat-Docent Expelled from the University
of Berlin. — Dr. L. Arons, a privat-docent in electric-
ity at the University of Berlin, has been expelled by
the State authorities because he is a member of the
Social-Democratic party. The senatus of the Uni-
versity was requested to do this some months ago, but
refused, so the government has taken upon itself to
expel him.
The Gonococcus as a Therapeutic Agent. — A cor-
respondent of lite Medical Press and Circular says that
one of the best remedies with which he is acquainted
for habitual excessive indulgence -in alcoholic bever-
ages is the gonococcus. Over and over again, he saj-s,
he has failed to induce patients with this particular
weakness to control their appetite for alcohol. Prom-
ises of reform were made only to be broken. Then
they contracted gonorrhoea, and forthwith, without any
pressure, for three long months at least, they forewent
their tipple, and recovered the strength of will which
they had lost. He says he could point to a number of
cases in which the drunkard's progress has been sum-
marily arrested by an intercurrent attack of gonorrhoea
with the most satisfactory results in respect of his
after life, and he thinks it is really open to question
whether in refractory cases this treatment might not
offer an alternative to seclusion in a home for inebri-
ates.
The Long Island Hospital The board of man-
agers of the Long Island State Hospital recently
adopted resolutions of protest against the failure of
Governor Roosevelt to reappoint Dr. Truman ]. Backus
as a member of the board. After a preamble express-
ing regret that the governor did not reappoint Dr.
Backus according to promise, the board resolved:
"That the method of procedure through which Dr.
Backus was retired from the office of manager of this
board is a disappointment and discouragement to its
members, and should be to all honorable and manly
State officials, who gave their time and energies in
March 3, igoo]
MEDICAL RECORD.
37^
furthering the philanthropic obligations of the State
to its wards, without reward of any kind whatever,
except that which comes through the pleasure of per-
sonal identification with good works and the prompt-
ings of a right conscience. Against the continuance
of such methods this board respectfully and earnestly
protests." Copies of the resolutions were sent to
Governor Roosevelt, to the Commission in Lunacy,
and to Dr. Backus.
The Medical Census of Great Britain The re-
cently issued Medical Directory contains the nam.es
of 35,651 qualified medical practitioners, an increase
of 534 over the number of last year. In the London
list, however, there is a falling off of 15 names. The
number of surgeons in the army, navy, and Indian
medical service is larger by 177 than it was a year
ago, despite the vigorous protests against unfair treat-
ment of army surgeons by the line officers.
A Judicial Opinion on Medical Honesty. — During
the trial of a case of assault before one of the New
York police magistrates recently, a certificate from a
physician was presented to the effect that one of the
parties to the case was unable to appear in court.
Then, " Oh, these doctors' certificates don't amount
to anything," the magistrate is reported to have ex-
claimed. " You can get them for ten cents over in
the Essex Market district, and I guess it is just as
easy to get them over here. I won't recognize any
certificates except those from hospitals or hospital
doctors."
A New Harlem Hospital. — The department of char-
ities has determined to build, as soon as possible, a
new Harlem hospital, and ground will be broken for
it in the spring. It is thought a site will be purchased
in Lenox Avenue, between One Hundred and Thirty-
fifth and One Hundred and Thirty-sixth streets, em-
bracing twenty-six city lots. The hospital, when com-
pleted, will cost, inclusive of the plot, in the
neighborhood of $500,000, and will be one of the
most attractive public hospitals in the city. At first
it is probable that only one section will be built. An
effort is being made to induce the department to put
a part of the new hospital in charge of homeopathic
physicians.
Damages Claimed for Antenatal Injuries.— The
supreme court of Illinois has recently handed down
a decision in a peculiar case. It was that of an in-
fant who claimed damages for a deformity alleged to
have resulted from injury to the mother before its
birth. The mother, while pregnant, was injured in
an elevator accident at St. Luke's Hospital, Chicago,
her left leg being caught and crushed. When the
child was born, his left leg was deformed. The hos-
pital authorities settled with the woman for her inju-
ries, and then she brought suit in the child's name for
$50,000 damages for the deformity, which it was
claimed was due to the same accident. The court
dismissed the suit on the ground that at the time of
the accident the child could not be credited as a sepa-
rate being, capable of sustaining an action independent
of the mother.
Filtering Croton Water — A resolution was intro-
duced at a recent meeting of the New York board
of aldermen, requesting the board of public improve-
ments to inform for Municipal Assembly whether a
filter could not be arranged in the Croton aqueduct
which would prevent the water from getting dirty and
muddy.
Dr. Henry E. Muhlenberg has been elected mayor
of the city of Lancaster, Pa.
Philadelphia Polyclinic Dr. Jay F. Schamberg
has been elected professsor of diseases of the skin in
succession to Dr. J. A. Cantrell, resigned.
Munificent Bequest.— By the death of the widow
of the late Benjamin D. Maxham the sum of $100,000
will revert to the New Jersey Training-School for
Feeble-Minded Children at Vineland.
Yellow-Fever Ships — Several vessels have recently
arrived here from Santos infected with yellow fever.
What with the plague and the yellow fever it is be-
coming the rule for coffee ships from Santos to be
kept in quarantine on their arrival at this port.
Measles on Randall's Island. — The Infants' Hos-
pital on Randall's Island has been quarantined on
account of an epidemic of measles that threatened the
children. Ten cases of the disease have been discov-
ered, but all have been isolated, and the epidemic is
now apparently under control. Foundlings will be
sent to the New York Foundling Asylum until 'he
measles have disappeared.
Opposition to a Pest-House. — Smallpox having re-
cently broken out in New Rochelle, the health author-
ities took measures for the erection of a pest-house on
the outskirts of the city. Farmers in the neighbor-
hood, however, opposed the placing of the hospital
near their homes, and when they found that their pro-
tests were unavailing they organized a band an(J drove
away the builders with threats of violence.
Defeat of the Barber Licensing Bill The Bren-
nan bill, providing for the appointment by the gover-
nor of a State barbers' e-xamining-board, also requir-
ing the examination and licensing of barbers and the
inspection of the sanitary condition of their shops, was
killed in the Assembly last week when it came up on
the order of second reading. It was moved to strike
out the enacting clause, which motion was carried by
a vote of 70 to 42.
A Crowded Hospital — Bellevue Hospital has had
so many calls on it of late that its facilities have been
taxed to the utmost. A large number of patients were
transferred one day last week to the City Hospital on
Blackwell's Island. Before the transfer there were
eight hundred and twenty-eight patients at Bellevue.
The hospital accommodates eight hundred and fifty
persons, but sixty of the cots are for insane or alco-
holic patients. The congestion was due to the many
cases sent from other hospitals to Bellevue.
Liberal Bequests.— By the will of Elizabeth W.
Baker, who died recently at Philadelphia, two bequests
of $5,000 each are made to such hospitals as her exec-
372
MEDICAL RECORD.
[March 3, 1900
utor, Dr. George Fales Baker, shall select, her own
preference being in favor of the Pennsylvania or
Presbyterian for the one, and the University Hospital
for the other, for the endowment in perpetuity of five
free beds.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
February 24, 1900. February i6th. — Pharmacist R.
Waggener granted sick leave for four months. Feb-
ruary 17th.— Assistant Surgeon J. R. Murphy appointed
assistant surgeon. February 19th. — Assistant Sur-
geon Karl Ohnesorg ordered to temporary duty at the
Naval Academy. February 21st. — Medical Director
W. G. Farwell commissioned medical director from
January 22, 1900. Medical Inspector D. N. Berto-
lette commissioned medical inspector from January
22, 1900.
The Plague is thought to have been overcome in
Honolulu; at least there had been no cases reported
for ten days prior to February i6th, the date of the
latest advices. The disease has appeared elsewhere
in the islands, however, news of seven deaths in Ka-
hului, on the island of Maui, and of one at Hilo, on
the island of Hawaii, having reached Honolulu. The
same energetic measures were instituted at Kahului
that had been successful at Honolulu. Chinatown,
which was found to be in a fearful sanitary state, was
burned to the ground, and two hundred and fifty Ori-
entals were put in the detention camp. The sheriff
organized a posse to search all persons who had been
in Chinatown within the period of infection, and on
the plantations a regular system of inspection was
adopted.- — A despatch from Aden, under date of Feb-
ruary 23d, states that six cases of the plague and one
death have occurred there. Drastic measures have
been taken to prevent a spread of the disease. The
infected districts have been isolated. — Another case
of the plague has been discovered in Sydney, N.S.W.,
and many persons who had been in more or less inti-
mate contact with the victim have been quarantined.
The Author of the << Gold-Cure" Treatment
Dead — Dr. Leslie E. Keeley, who won fame of a cer-
tain kind and a large fortune through the exploitation
of the "gold cure" treatment of inebriety, died of
heart disease at Los Angeles, Cal., on February 21st.
He was born in St. Lawrence County, N. Y., about
sixty-eight years ago, and was graduated from the
Rush Medical College, Chicago, in 1864. He en-
tered the army as acting asi' itant surgeon upon gradu-
ation and served until the close of the war. He then
settled in Dwight, HI., where he practised medicine
for many years in a conventional way. A few years
ago he announced that he had discovered a remedy for
the cure of alcoholic addiction, and opened a sanato-
rium for the reception of patients with this habit.
Later he closed this institution, saying his treatment
was not perfect, and he wanted to discover something
to counteract the influence of the bichloride of gold
on the system. After two years he resumed his treat-
ment, and though his claims were disputed and his
theories ridiculed, he prospered financially, and soon
a company was formed for the establishment of "gold-
cure" institutes in various parts of the county. He
owned a half interest in this company, and is credited
with having made more than a million dollars while
the gold-cure boom lasted.
Health Reports — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended February 24,
1900 :
-Un
Cases. Deaths.
Alabama, Jefferson Co February 5th 86
Mobile February loth to 17th 3
Florida, Jacksonville February loth to 17th 3
Illinois, Aurora February loth to 17th 6
Danville February 3d to loth i
Idaho, Eastern towns February 9th Prevalent.
Indiana, Evansville February loth to ijtfa 3
Kansas, Wichita December 30th to February lotli. 15
Kentucky, Louisville February 15th 2
Louisiana, New Orleans . . . February icth to 17th 62
Shreveport January 27th to February 3d 14
Minnesota, Minneapolis ... .January 27th to February 17th. . 4Q
Mississippi. Greenwood January 27th to February loth.. 216
Montana, Butte February 7th 150
Oregon, Eastern towns Prevalent.
New York, New York February icth to i7lh 1
Ohio, Cincinnati February 9th to 16th 4
Cleveland February loth to 17th 27
Youn^town February loth to 17th . i
Tennessee, Nashville February 10th to 17th i
Utah, Salt Lake City February loth to 17th 3
Virginia, Martinsville February 7th 1
Portsmouth February loth to 17th 6
Richmond January 1st to 31st 21
Washington, Spokane February loth to 17th 6
Smallpox— Foreign.
.\ustria. Prague January 20th to 27th 1
Belgium, Antwerp January 27th to February 3d. . . . 7
Brazil. Kio de Janeiro December i5lh to January uth. .. k
Canada, Amherstburg February loth to 17th i
Quebec February 3d to 9th 4
Egypt, Cairo January 16th to 21st 4
England, Leeds February 3d to loth
London January 20th to February 3d . . 45
France, Lyons February 20th to 27th
Nice January 20th to February 3d . . . 5
Paris January 27th to February 3d
Germany, Konigsberg January 20th to 27th 3
Gibraltar January 22d to 28th 2
Greece, Athens January 27th to February 3d ... . 2
India, Calcutta January 6th to 13th
Kurrachee January i6th to 21st 12
Madras January 13th to 19th
New Brunswick February 10th Prevalent.
Nova Scotia February loth to 17th Prevalent.
Mexico Ciudad Porfirio Diaz. February icth to 17th 5
Vera Cruz February ifth to 17th
Russia. Moscow January 20th to 27th . 2
Odessa January 27th to February 3d, ... 10
St, Petersburg January 20th to 27th 26
Warsaw January 25th to February ist
Spain, Corunna December 9th to February 3d. . . 5
Straits Settlements, Singa-
pore December 31st to January 6th . . . ,
Switzerland, (ieneva. ., , , January 21st to 28th 6
Turkey, Smyrna January 29th to February 4th .. .,
Yellow Fever,
Brazil, Rio de Janeiro December i^th to Tanuary 12th . 25 ■
Cuba, Havana Febru.iry 7th to 14th 2
Mexico, Vera Cruz February loth to 17th
Cura^oa February 3d to 10th i
Cholera.
India, Calcutta January 6th to 13th 3
Brazil, Rio de Janeiro January 20th
Sao Pan lo Jan uary 20th
India, Calcutta January 6th to 13th .
Kurrachee January 16th to 21st.
Obituary Notes. — Dr. Ernest Brewster Sangree,
late professor of bacteriology and pathology in the
department of medicine at Vanderbilt University,
Nashville, Tenn., died at the home of his father, in
Harrisburg, Pa., on February 23d. Dr. Sangree was
also bacteriologist of the State of Tennessee prior to
relinquishing the professorship of Vanderbilt Univer-
sity to accept a similar place in the University of Illi-
nois. He was thirty-six years old, and was a graduate
of the Medico-Chirurgical College of Philadelphia in
March 3, 1900]
MEDICAL RECORD.
373
Dr. Joseph M. Creamer died of pneumonia at his
home in Broolclyn, N. Y., on February 23d, at the age
of forty-nine years. He was a graduate of the medi-
cal department of the New York University in 1873.
He served a term as coroner in 1892.
Dr. Henry B. Moore died at Colorado Springs on
February 21st, of pneumonia. He was born in Maine,
and was graduated from the Jefferson Medical College
in 1886. He served a term as interne at the Blockley
Almshouse in Philadelphia, and practised for a while
in this city, but was obliged to remove to Colorado on
account of his health.
Dr. Andrew^ R. Wright, a prominent homaopathic
physician of Buffalo, N. Y., died in Chicago on Feb-
ruary 25th, at the age of seventy-four years. He was
born at Crawford, N. Y., and studied at the Buffalo
Medical College and in Paris, but obtained his degree
from the Homoeopathic Hospital College in Cleve-
land, O., in 1858. In 1898 he was president of the
American Institute of Homoeopathy.
Dr. James L. Watson died in Brooklyn on Febru-
ary 22d, of cardiac disease following influenza. He
■was born in 1830 and was graduated in medicine in
1857. He was the last surviving member of the old
City Guard of Brooklyn, which was merged into the
Twenty-third Regiment. He served as surgeon in
the civil war, and was for some time surgeon-general
of the Grand Army of the Republic.
Dr. William Edward Walmslev died at his home
in Brooklyn on February 25th, at the age of forty-five
years. He was born in Rochester, N. Y., and was
graduated from the medical department of the New
York University in 1877.
Dr. I. B. Lathrop died at Springville, Pa., on Feb-
ruary 20th. He had been engaged in the practice of
medicine in Susquehanna County for nearly fifty
years.
Dr. I. F. ScHMiNKEY died at Gratz, Pa., on Febru-
ary 19th, at the age of sixty-seven years. He was at
one time a member of the State legislature.
Vibration as a Hypnotic and Anassthetic. — B. F.
Ward advances the theory that narcosis and anassthe-
sia may be produced by vibratory force, and that the
vibration, in order to exert its specific effect upon the
nerve centres, must be uniform and rhythmic, and to
reach its greatest intensity the vibratory wave must
gradually and steadily increase in force. The writer
says it would be impossible to devise any appliance
which would so fully meet these indications as the re-
lations that exist between a steel rail and a revolving
car wheel, because the vibratory thrill will begin to be
faintly delivered while the train is still many miles
away, and with every revolution there will be a uni-
form and perfectly rhythmic increase in the force of
the vibratory wave. He suggests that it would be
possible to mechanical skill to devise a metallic ope-
rating-table with wheels run by electricity against rails
attached to the under surface that would impart to the
table and the subject thereon a vibratory force exactly
similar to that which the rail receives from the revolv-
ing wheel and equally potent, and that a perfect anaes-
thesia might thus be secured as free from danger as
natural sleep. — Journal cj the Mississippi State Mcdi-
£al Association, February, 1900.
progress of l^ctlical Science.
Journal of the Amcr. Alcd. Association, Feb. 24, igoo.
Treatment of Typhoid Fever. — Frank Billings
says that at present the specific treatment of typhoid
fever is on trial, although the success so far attained
gives us hope of still better results. He sums up the
methods of treatment under the heads of efficient
nursing, a proper diet, and the elimination of the toxins,
and concludes that for the latter purpose hydrotherapy
is best.
Treatment of Typhoid Fever in Private Prac-
tice.— William E. Quine discusses this subject under
the heads of prevention, general management, diet,
water, medicines, and hydrotherapy. The writer says
that although it be admitted that the Brand treatment
effects a saving of life in hospital practice amounting
to six or seven per cent., its use in private practice
must necessarily be of slow growth.
Treatment of Medical Complications of Typhoid
Fever. — George W. Webster discusses the treatment
of thrombosis, of respiratory complications, and of
pain as among the possible problems for the physi-
cian in typhoid fever. He says that most important
of all is the support of the right heart. As soon as
this begins to Hag, we i.iust make use of strychnine,
digitalis, ammonia, oxygen, camphor, or caffeine.
Tobacco Amblyopia — Francis Dowling gives the
results of some recent examinations made to determine
the influence of tobacco on vision among the em-
ployees of the tobacco factories of Cincinnati. He
thinks that a tobacco-laden atmosphere is not enough
to produce poisoning so far as the eyes are concerned,
but that these symptoms are the result of smoking or
chewing.
Electro-Cautery in Affections of the Lids and of
the Cornea. — Flavel B. Tiffany enumerates the many
affections of the lids and cornea in the treatment of
which he has found the electro-cautery a valuable
agent. Among these affections may be mentioned ul-
cers and fistula of the cornea, phlyctenular keratitis,
pannus crassus, trachoma, keratoconus, staphyloma,
ectropion, entropion, distichiasis, and trichiasis.
Craniectomy for Epileptiform Seizures and Grave
Mental Disturbances following Head Injury with-
out Apparent Fracture H. Reineking reports this
case as illustrating what violent disturbances may
follow comparatively slight traumatisms of the head.
Operation was followed by immediate recovery.
Silver Catgut and How to Tie it.— Eduard Boeck-
mann says that although several improvements must
be made before we can speak of ideal catgut, still the
catgut impregnated with metallic silver is sp nearly
perfect that it can successfully take the place of all
other kinds of material for sutures and ligatures.
A Sulpho-Salt of the Aliphatic Creosote-Esters
and its Therapeutic Usefulness. — Heinrich Stern
reports cases of diabetes insipidus, diabetes mellitus,
and chronic ulcerative phthisis in which eosolate of
calcium was employed with varying results.
Scarlatina and Scarlatinous Sore Throat. — W. J.
Class reports in detail three cases in which cultures
from the secretion of the throat and the blood showed
the presence of the micro-organism described in the
Medical Record, vol. Ivi., pages 330 and 513.
374
MEDICAL RECORD.
[March 3, 1900
Cremation. — Robert Marsena Stone thinks that very
soon cremation will be adopted by the educated class
in all communities, and argues for the aesthstic as well
as the hygienic \irtues of this method.
Food and Drink. — In this article Elmer Lee dis-
closes the secret of long and healthy life, namely two
meals a day and profuse water drinking.
Philadelphia Medical Journal, February 24, igoo.
The Etiology of Sydenham's Chorea. — Joseph Col-
lins and I. Abrahamson analyze one hundred cases.
No disease except rheumatism seems to be an etio-
logical factor. The exciting cause is psychical trauma
or physical exhaustion, very seldom gastro-enteric irri-
tation or eye-strain. Mental symptoms were noted in
fifty-four of the cases studied.
Subhyoid Pharyngotomy for the Removal of a
Malignant Growth of the Larynx. — F. J. Lutz re-
ports this operation in a man, aged seventy-three
years. The patient survived a month, the dyspnoea
and dysphagia from which he had suffered being en-
tirely relieved.
Certain Effects of Benzoic Acid upon the Urine.
— William W. Ashhurst finds benzoic acid has an
inconstant diuretic action, diminishes the acidity of
the urine slightly, retards or prevents alkaline fermen-
tation, and inhibits the growth of micro-organisms.
Inter- Scapulo-Thoracic Amputation. — Willianv D.
Hamilton reports a case of sarcoma of the shoulder
following repeated injuries in a man, thirty-two years
old. Amputation of the upper extremity with clavicle
and scapula was successfully performed.
The Resuscitation of Apparently Dead New-born
by Laborde's Method Francis Eustace Fronczak
reports four cases of resuscitation of asphyxiated in-
fants by rhythmical traction of the tongue.
A Case of Successful Symphyseotomy. — Joseph
B. De Lee reports a case in a secundipara, about
thirty -one years old.
New York Medical Journal, February 24, igoo.
The Benefits of Balneotherapy in the Treatment
of Chronic Rheumatism and Gout. — H. H. Schroeder
prefers the spa with its change of climate and other
stimulating environments to the average hydropathic
institute with its sick and grumbling inmates, and de-
scribes a place in the Rocky Mountains which in his
judgment offers ideal advantages. The author then
discusses the details of treatment, stating that it is
well to warn the patient that an increase of joint pains
is liable to occur during treatment, but that as a rule
the pain soon ceases.
The Treatment for Hypertrophy of the Inferior
Turbinated Bone. — E. Harrison Griffin precedes op-
eration by the use of bromide and quinine internally
for some days before operation. He believes that this
course diminishes the hemorrhage during operation
and lessens the tendency to chills and fever afterward.
Removal of the offending tissue is made with the saw
under the bone, the line of section being from below
upward and inward. For after-plugging, he prefers
absorbent cotton to iodoform gauze.
The Surgery of the Superior Cervical Sympathetic
Ganglion. — G. F. Suker finds that in the resection of
one or both of these ganglia for glaucoma, simple op-
tic atrophy, Basedow's disease, and perhaps epilepsy,
we have a definite surgical intervention yielding posi-
tive results, so far as we now know, in selected cases
in which heretofore we were at a loss what to do in
like cases.
The Determination of Sex at WilL — According
to J. G. Davis, the "great law of vibrations" is the
only thing which will throw any light on this subject.
When male issue is desired, sexual congress should
not take place until ten days after the cessation of
menstruation. Congress within two days after the
cessation or within three days of an expected menstru-
ation will result in female issue.
Studies on Internal Antisepsis. — E. Klebs narrates
the results of his experiments on rabbits with inocula-
tion of staphylococcus and nosophen. He considers
that this remedy and antinosin (considered in the first
instalment of the paper) of great importance in septic
infections caused by streptococci and staphylococci.
An Operation for Divergent Strabismus. — D. Web-
ster describes an operation consisting in division of
the tendon of the excernus and advancement of that of
the internus, which gave extremely satisfactory results
in a case of divergent squint.
The Treatment of Iritis by the General Practi-
tioner.— N. B. Jenkins advises hot foot baths, salts,
and small doses of calomel. The local treatment con-
sists in atropine, darkness, hot applications, and punc-
ture of the cornea.
Albuminate of Mercury (Sapodermin) in the
Treatment of Parasitic and Fungoid Diseases G.
J. Bucknall commends the use of this agent in scabies
and reports some cases in which it was employed.
Medical Ne7C'S, February 24, jgoo.
Experimental Researches on the Effects of In-
creased Barometric Pressure and of Foreign Bodies
in the Pharynx, (Esophagus, Trachea, and Larynx.
— George \V. Crile still further confirms the results of
other experimenters that animals under chloroform an-
aesthesia are decidedly more liable to respiratory fail-
ure than animals under ether anjesthesia. There is
also greater tendency toward reflex inhibitory phenom-
ena in chloroform anaesthesia. -On the other hand,
the patient may be more quietly and readily reduced
under chloroform than under ether, and the tendency
to the secretion of mucus is less. In every case where
it is possible, local rather than general anaesthesia
should be employed. Cocaine is preferable to eucaine.
A foreign body lodging in the trachea and' not dis-
lodged during coughing can produce only the effect
indirectly produced by the powerful respiratory altera-
tions in the act of coughing. If the tube is completely
obstructed symptoms of asphyxia will appear. If the
foreign body is in the larynx attacks of cyanosis will
be likely to occur.
Some of the European Sanatoria for Consump-
tives, and the Final Aims of Phthisiotherapy.— W.
Freudenthal believes that all patients with incipient
phthisis should be occupied in some rational muscular
work, such as gardening, snow shovelling, light carpen-
tering, and agricultural work of various kinds. Every
sanatorium should be provided with facilities to teach
these occupations. All this work should go under the
supervision of physicians. Sanatoria for the rich and
for the poor should be under one financial manage-
ment, though not necessarily in the same place. A
society should be formed by the people most affected
by it, viz., the lodges, in order to send the patients to
a milder climate, where they can work constantly in
March 3, 1900]
MEDICAL RECORD.
375
the open air; for example, certain parts of Arizona and
New Mexico.
A Clinical Contribution to Thyroid Therapy. —
Charles E. Hirsch speaks of an affection designated
by Jeulain as thyroid chlorosis, which represents the
symptoms of ordinary chlorosis together with those of
exophthalmic goitre, in which the administration of
iodothyrin produced a remarkahly rapid and decided
improvement. He also reports the happy effect of
this treatment in cases of obesity.
Notes on Plague.— By H. E. Deane. A continued
article.
Eoston Medical and Surgical Journal, February 22, igoo.
On the Advisability of a More or Less General Ex-
ploration of the Abdomen when it Has Been Opened for
an Operation. — John Romans says that it has several
times happened to him to discover conditions and dis-
eases different from the one for which he had opened
the abdomen. Three times he removed gall stones
whose presence was unsuspected, and whose removal
did more for the patient's recovery than the removal of
the tumor for which the abdomen was opened. There-
fore he advises general exploration in the course of
operations without lengthening the original incision.
A Clinical Study of Heroin. — James R. L. Daly
considers that this drug possesses many advantages
over morphine as a respiratory sedative. It is not a
hypnotic.
A Case of Old Shoulder Dislocation. — Frank E.
Peckham describes a case of twenty-two months' dura-
tion, upon which he operated successfully.
The Unity of the Acute Psychoses.— By Philip
Coombs Knapp. See Medical Record, vol. hi., p.
137-
Psychology and Heredity — By Robert MacDou-
gall. A contiijued article.
Wiener klinisclie Rundschau, February 4, igoo.
Bacterio-Therapy of Leg Ulcer. — Ivan Honl de-
scribes his method of treating ulcers of the leg. It
consists in the application of substances extracted
from the bacillus pyocyaneus. The bacterial flora of
leg ulcers presents no specific characteristic elements.
Pathogenic as well as saprophytic micro-organisms are
present. As to the patient, he is to lay the affected
leg in tepid water from time to time. The protein is
applied twice daily, while sterilized absorbent gauze
thoroughly saturated with the protein is laid on the
ulcer, covered with wadding, and fixed by a bandage.
Honl declares that this protein cures leg ulcers with-
out exception and in a shorter lime than other meth-
ods. He also recommends its simplicity and comfort.
An Hour-Glass Stomach Resulting from the
Corrosion of Hydrochloric Acid ; Gastro-duodenos-
tomy. — Emil Klein reports this case, giving a dia-
gram of the stomach as well as four others represent-
ing dried specimens in the pathologico-anatomical
museum of the Vienna University. This condition
may be either congenital or acquired. As causes of
the acquired may be mentioned scar contractures fol-
lowing round ulcer, carcinoma, syphilis, corrosions.
In the present instance the patient, a man, drank fum-
ing hydrochloric acid into which matches had been
thrown. Two months later gastro-duodenostomy was
performed with the happiest results.
Berliner klinische Wochenschrijt, February 2, igoo.
Syphilitic Goitre.— E. Werraan records the case
of a man aged twenty-four years, who passed through
a severe stage of specific infection lasting over several
years, during which time he was regularly treated.
Tertiary symptoms developed as evidenced by cerebral
pressure, irritability, loss of palate, etc., and finally an
enlargement of the thyroid body. This enlargement
diminished under treatment, but recurred upon its ces-
sation. The author calls attention to the fact that en-
largement of the thyroid has also been observed after
influenza and measles, and he notes the danger of
initial changes in the early stages of syphilis, which
may be so slight as to escape notice, but which may
lay the foundation for serious trouble later.
The Mechanical Distribution of Bony Growths
H. Maass points out the effects which such conditions
may produce in the development of the bony skeleton,
especially when the growths occur before the final
union of epiphysis and diaphysis.
Cerebral Pressure Symptoms in Typhus Fever.
— H. Salamon reports five cases in which the pressure
symptoms were due, he thought, to an intra-meningeal
exudate excited by the toxins of the disease.
Epidemiology and Prophylaxis of Malaria from
the Most Recent Etiological Standpoint.^ By A.
Celli. A continued article.
Chronic Villous Polyarthritis and Arthritis De-
formans.— By Max Schueiler. A continued article.
Vratcli, January ij and 22, igoo.
Corporal Punishment in Russia on the Eve of
the Twentieth Century.— D. N. Zhbankoff reviews
the various opinions expressed by physicians and oth-
ers regarding whipping as a punishment for crime,
and argues forcibly against its continuance. He says
it was the hope of many that the new century would
see no more of this barbarous punishment in Russia,
but we are already on the eve of the twentieth century
and there is no sign of its abolishment. He cites with
astonishment and reprobation a statement in an Eng-
lish journal that the New York Medico-Legal Society
had advocated public whipping as a punishment for
certain crimes, but says that the existence of such
views in a country where lynch law prevails is quite
comprehensible. All physicians, he argues, should
protest energetically against the continuance in Rus-
sia of what he calls this epidemic of legalized trau-
matic lesions which exerts so malign a psychical
influence over the entire nation.
Post-Partum Sloughing of the Uterus. — Under
this title V. G. Bekman describes puerperal gangrene
of the uterus. The disease may vary in extent from
a small area of the uterine wall to the entire organ,
and perforation may or may not occur The affection
is much more frequent, the author believes, than is
usually supposed, constituting a very appreciable pro-
portion of puerperal affections of the uterus, but it is
thought to be rare because many cases pass undiag-
nosed. This is owing partly to the want of a lucid
description of the disease in the text-books — a want
which the writer meets in his article. He reports
twelve cases occurring in his own practice, five of
which have never before been published.
Treatment of St. Vitus' Dance with Large Doses
of Arsenic. — V. E. Chernoff reports several cases of
chorea in children from eight to twelve years of age, in
which he employed arsenious acid in the average daily
376
MEDICAL RECORD.
[March 3, igoo
dose of one-third of a grain, which is larger than that
usually allowed for adults. . The results of this treat-
ment were excellent, but the author calls attention to
its obvious dangers, and sa3's a child taking such large
quantities of arsenic should be seen b)' the physician
at least twice a day. The treatment is therefore more
feasible in hospital than in private practice.
Bathing of the New-Born. — G. O. Kovarski reviews
the arguments for and against the bathing of new-born
infants, and concludes that there are no convincing
arguments or scientific facts in proof of any injurious
effects of baths upon children in the first days of life,
and consequently that this old custom may profitably
be continued.
Epidemic of Plague in the Village of Kola-
bovka, Astrakhan Government. — M. I. Arnstamofif
gives the histories of the twenty-four cases of plague
which occurred at this place in the summer of 1899,
the epidemic of which was also described by Levin
in the issue of December 4, 1899, of this same jour-
nal. See Medical Record, vol. Ivii., p. 29.
The Bitter Lakes of Batalpashinski V. A. Po-
poff describes two lakes in the Kuban district of the
Caucasus, the waters of which contain a large propor-
tion of magnesium sulphate, iron, and aluminium.
The Value of Widal's Serum Diagnosis of Ty-
phoid Fever. — By Th. A. Dombrovski. A continued
article.
Progressive Spinal Paralysis. — By L. R. Krever.
A continued article.
La Rijonna Medica, January 2g and Februaiy 6, igoo^
The Resistence of the Red Corpuscles in Some
Diseases of the Skin. — Francesco Cenci, from nu-
merous e.xperiments, found that the blood of patients
suffering from purpura hemorrhagica was no more re-
sistant than normal blood. There was an increase in
leucocytes. Under the action of FeCy^K^ the red
cells are less changed than those of normal blood.
The blood of a syphilitic patient treated with NaCl
and FeCy^K, behaved exactly like normal blood.
Treated with pepsin it became darker than normal
blood, and the cells changed more quickly. Pancrea-
tin caused no different changes in healthy and abnor-
mal blood. Lactic acid gave the same results in both.
The serum of horse's blood (tuberculized) retarded the
solvent effects of solution of pepsin, pancreatin, and
lactic acid.
Rudimentary Anomalous and Complicated Forms
of Mitral Stenosis.— G. Rummo describes cases of
pui ^ congenital or foetal mitral stenosis, of extrafcetal
or rheumatic stenosis of a truly inflammatory nature,
and of stenosis combined with insufficiency, and gives
directions for their diagnosis.
French Journals.
Experimental Tuberculous Meningitis. — A. Sicard
concludes that it is possible to produce disseminated
tuberculous meningitis either through the blood or by
inoculating the cephalo-rachidian fluid directly. The
lymphatic system plays no role. In the majority of
instances there is a diffuse process, but a meningitis
en plaques may at times occur. The toxins of the ba-
cillus play an important part in the process. The
cerebro-spinal fluid is an essential factor in the dis-
semination of bacilli and their toxins. Exudations
and granulations situated in the region of the pia
mater are not the result of a polymicrobic infection, but
the Koch bacillus or its toxins are alone capable of
creating these granulations. — La Presse Medkalc, Feb-
ruary 7, 1900.
Acute Traumatic Arthrites of the Kuee in Chil-
dren.— A. Proca, basing his remarks on a case de-
scribed, concludes that treatment by arthrotomy is
superior to resection of suppurating arthritides of the
knee in children, whatever their origin may be. The
anterior incision sometimes recommended along the
border of the patella should not be practised, but
a long incision should be made on either side at the
posterior part of the lateral surfaces of the knee, with
a large transverse drain under the knee cap. He
rarely has occasion to employ lavage. — La I'ressc Me-
dkak, February 7, igoo.
Alimentation in Typhoid Fever.— H. Vaquez con-
siders whether typhoid patients are properly and suffi-
ciently fed by present methods; whether there is dan-
ger in giving more food and in a different manner;
and what would be the advantages of other methods.
The gravity has been diminished by balneotherapy,
and the writer believes that to the iBrand method can
be wisely added that of superalimentation by giving
in addition to milk the yellow of eggs, somatose, fari-
naceous soups, etc. — La Presse Alcdicale, February 10,
1900.
Localization, Elimination, and Origin of Arsenic
in Animals. — A. Gautier has shown that certain or-
gans normally contain arsenic. He now studies the
origin in alimentary sources and finds minute traces of
arsenic in various substances. He also finds that per-
fect health is incompatible with complete disappear-
ance of arsenic from the system, and points out the
medico-legal aspects of detection of minute traces of
arsenic in the secretions and organs. (See Medical
Record, vol. Ivii., p. 29.) — Le Bulletin Medical, Feb-
ruary 7, igoo.
Cancer of the Large Intestine.— FT. Lardennois
studies the question in all its bearings. Out of two
hundred and fifty-five observations collected of total
ablation, the mortality was 32.9 per c^nt. In thirty-
two cancers of the colon observed by Brahman the
radical operation was performed fourteen times. Six
patients succumbed and eight were cured. When the
radical operation is possible, it should be attempted.
In complications a palliative operation (entero-anas-
tomosis, exclusion, artificial anus) may be done. — Ga-
zette des Hbpitaux, February 10, 1900.
Appendicular Colic. — Ch. Talamon studies the prog-
nostic value of colic in the region of the appendix —
seven observations. Two lessons are drawn : First,
at the onset of colic a purgative should never be given,
as one is too much tempted to do; second, the patient
should be immediately and strictly immobilized until
all pain in the iliac fossa has completely ceased
for several days. — /<? Midecine iModcrne, February 10,
1900.
Two Cases of Nerve Elongation. — R. de Bovis
gives two observations. In one of Raynaud's disease,
or local syncope of the extremities, nerve elongation
resulted in disappearance of the trophic troubles, but
with persistence of a certain degree of paresthesia.
The second case was one of gangrene of the foot due
to syphilis and arteriosclerosis. The tibial nerves
were elongated with negative result. — Gazette des L/o-
fitaux, February 8, igoo.
Pylorectomy by Billroth's Method.— Guillot, in
an article to be continued, finds that pylorectomy by
the Billroth operation is preferable to that of Kocher,
which in some instances is more difficult, increases the
March 3, 1900]
MEDICAL RECORD.
\n
chances of infection, and prolongs unnecessarily the thyroid, he should be inclined to recommend it in the
intervention. — C;<?c^//<? des Hcpitaux, February 13, early stages of those cases which are likely to result
'9°°- in the so-called chronic catarrh of the middle ear.
The Remote Results of Brushing in the Treat-
ment of Granular Ophthalmia. — Felix Lagrange re-
views the technique, and out of one hundred and twelve
eyes treated finds seventy-eight per cent, of cures, 4.5
per cent, of improvements, and 17.5 per cent, of fail-
ures.— Lc Bulletin Medical, February 7, 1900.
Treatment of Exophthalmic Goitre by Stabile
Voltaization — L. R. Regnier gives five ob.servations
in which good results were obtained, and thinks electric
treatment should be tried before surgical procedures.
— Le Progres Medical, February 10, 1900.
Archives of Otology, Vol, x.xviii., Nos. j and 6, i8gg.
A Case of Influenza followed by Mastoid Abscess,
Sinus Thrombosis, Meningitis, and Death ; Au-
topsy. ^F. Allport gives the history of a man aged
seventy-six years, who contracted influenza in January,
1899, The attack was severe and accompanied with
delirium. During the attack he had abscess of the
left ear followed by a swollen and painful mastoid for
several weeks. The ear was simply syringed by the
attendant. The patient was first seen by Dr. Allport
six months later. Soreness of the mastoid on pressure
was found, with fistula of the lower posterior bony
meatus emitting copious foul pus. The nienibrana
tympani was intact. The operation was done in the
usual manner. The bony covering of the lateral sinus
was necrosed and the sinus exposed, but was appar-
ently healthy. Recovery from the operation was good,
but on the fifteenth day symptoms of meningitis de-
veloped, and death resulted fourteen days later. Cere-
br.il abscess had been suspected, and the patient was
trephined, but no pus cavity was found. The dura
w.ij completely adherent to the skull by old adhesions.
There was also a slight puriform thrombus in the left
lateral sinus. The author observes that a subnormal
temperature as shown in this case does not always in-
dicate a cerebral abscess (none was found on autopsy),
and may exist with an acute intense meningitis.
Tinnitus Aurium. — R. Pause concludes a careful
study of this phenomenon as follows: Almost all
sounds should be designated by their pitch. The
pure conduction sounds arise from the diminished out-
let of sound, due to rigidity of the conducting appa-
ratus. Inasmuch as the motility of the latter is re-
quired for hearing only low notes, its fixation is an
obstacle to the outlet of these notes alone. Pure con-
duction sounds are mainly placed between sixteen and
two hundred and fifty-six vibrations. The higher
pitched sounds are due to processes in the inner ear.
They may be produced (a) by reflex from the external
meatus, middle ear, and many different parts of the
body; (h) by changes in the inner ear or the nerve
itself. In rare cases, however, low sounds may, per-
haps, also originate in the inner ear. Hearing of
complex sounds, like melodies, etc., is not prima-facie
proof of a cerebral affection. In respect to treatment
he gives the rule not to perform any grave operations
upon the conducting apparatus when the sounds heard
are high pitched, and especially not to attempt removal
of the stapes.
On the Thyroid Treatment of Chronic Deafness.
— A. Bruck collates the experience of the profession
along this therapeutic line, but has not personally
seen a single case of positive improvement in the
hearing. The translator of the original article, J. A.
Spalding, adds that, from his limited experience with
Occidental Medical Times, February, igoo.
Leucopathia Unguium.— W. A. Briggs gives the
details of a case to which he assigns a neuropathic
origin. He also describes a disease of the nails at-
tributed to a mycotic source, and presenting a separa-
tion of the distal part of the nail from its bed.
The New Materia Medica and Modern Doctors.
— H. D. Powers condemns the multiplication of new
and useless remedies, and thinks that students should
be taught more thoroughly about the old and reliable
ones.
Report of a Case of Sub-Glottic Tumor G H.
Powers reports a case of epithelioma. Tracheotomy
was done, but the growth extended below the bottom
of the tube, and the patient died during the operation.
Report of a Case of General Tuberculosis.
Dextro-Cardia, Meningitis ; Lumbar Puncture. — S.
J. Hunkin reports a case of this nature in a child aged
six years. A fatal result followed the operation.
Large Solitary Tubercle of the Heart. — A. vv.
Hoisholt describes the case of an asylum patient
whose heart showed on autopsy a tuberculous growth
from the lining of the left ventricle.
Hydrocephalus ; Cranial Paracentesis ; Lumbar
Puncture. — VV. N. Sullivan reports a successful case
of this description.
Illinois Medical Journal, February, igoo.
The Treatment of Goitre. — A. I. Bouffieur com-
mends the internal use of iodine or thyroid extract or
the intra-parenchymatous injection of iodoform or
carbolic acid These failing, enucleation or partial
thyroidectomy is indicated. Cysts should be evacu-
ated and injected with iodoform emulsion , this fail-
ing, enucleation should be done.
Fatal Perforation of a Uterus Partially Atro-
phied Post Partum ; a Medico-Legal Case C. S.
Bacon and M. Herzog record the case, and give a
resutne of the legal points brought out on the trial of
the physician who curetted the uterus twelve hours
before the patient's death. The physician was ac-
quitted.
The Prevalence of Alcoholism and its Influence
on Mortality. — G. W. Webster discusses the points
of heredity, inebriate heredity in crime, suicide, in-
san''.j, special senses, healing of wounds, sunstroke,
tub :culosis, and heart affections.
Nervous Complications and Medico-Legal Rela-
tions of Alcoholic Insanity. — D. E. Brower considers
some of the nervous diseases set up by alcoholic ex-
cess, and considers that the jurisprudence of inebriety
needs to be rewritten.
A Sociological View of Criminal Abortion. — W.
J. Fernald studies this question from the standpoint
of modern sociology, believing that many of the ills
of modern society follow from making marriage a civil
contract instead of a religious vow.
Traumatic Rupture of the Urethra.— E. J. Senn
gives a general description of the condition, and
records the clinical history of a case.
378
MEDICAL RECORD.
[March 3, 1900
Abstract on Pulmonary Tuberculosis. — T. H.
Stettler commends the employment of large doses of
carbonate of guaiacol.
General Uveitis. — Description of a case by J. W.
Smith, with some observations on the subject in gen-
eral.
Operative Treatment of Exophthalmic Goitre. —
A historical and statistical study by Karl Doepfoner.
The Laryngoscope, January and February, igoo.
Appropriate Treatment of Certain Varieties of
Nasal Deflections and Redundancy. — D. Braden
Kyle considers the following classification of septal
deformities: split septum with bilateral bulging, dis-
location of the columnar cartilage, simple deflection
with thinning, letter-S deflection, deflection with in-
volvement of the bony septum, split cartilage with
unilateral bulging, and finally deflection with redun-
dancy of tissue overlapping the septum and extending
close to the nasal floor. Deflections may be congeni-
tal, from disease, and from trauma. The condition
does not always demand surgical intervention. Most
of the surgical methods are but modifications of the
original Adams operation. Details are given of the
various devices which in Kyle's experience have
given most satisfaction in the different forms of devia-
tion. He strongly advocates the employment for re-
tention apparatus of malleable tubes which can be
moulded to fit each individual case. He has followed
the plans advocated in thirty-seven cases, and has had
failures in six. For post-operative irrigation he pre-
fers a weak solution of boric acid in sterilized water.
Cases must be carefully watched, and the calibre of
the tube altered if necessary to prevent undue pressure.
The Principles of Stuttering ; Therapeutics R.
Coen advocates the methodical continuance of breath-
ing-exercises, enumerating, as the principal ones,
deep continued inspiration, short expiratory move-
ment of the breath, gradual prolonged expiration, and
the holding of the breath. In addition the vocal and
speech-producing organs must be regulated. All dis-
turbances which lead to altered innervation must be
controlled, the will-power of the patient strengthened,
and the general system toned up.
Papillomatous Growth of the Tonsil Payson
Clark reports the case of a boy aged eight years in
whom an irregular mammillated mass occupied the
site of the right tonsil. Removal was effected with
the cold snare without any special bleeding. Ex-
amination of the growth showed that the central part
was composed of more or less dense connective tissue
with vessels, etc. The peripheral lobulated parts were
made up of lymphadenoid tissue and of cellular con-
nective tissue covered with mucosa.
77/1? Therapeutic Gazette, Fe/>>uary, igoo.
Some Points of Interest in Connection with
Chronic Urethritis.— Orville Horwitz says chronic
gonorrhoea is a very grave disease. Besides the long
list of dangers to the subject himself there are those
to the wife. In follicular urethritis the best results
are obtained by steel bougies anointed with Finger's
ointment and left in situ for five minutes. Congested
patches are best treated by protargol, one per cent,
gradually increased to two. Granular patches should
be treated with solutions of iodine, silver, or copper
through an endoscope. Erosions and ulcerations
should be treated in much the same way. In pro.static
irritability the Winternitz psychrophore often gives
good results. When local remedies have been long
employed without benefit, they should be discontinued
and constitutional treatment given.
Santonin in the Treatment of Epilepsy G.
Frank Lydston believes santonin quite as efficient, as
a palliative, as the bromides, and it may be proven to
be quite as curative. He has employed the drug for
nearly twenty years and has seen no mention of it in
literature. He finds that santonin has a large field of
usefulness in convulsive affections of infancy. It is
found to act well in cases of epileptics who do not do
well under the bromides. It is free from injurious
effects. In the adult gr. ii.-v. is the initial dose, and
this is increased up to the point of tolerance. Some
patients take gr. xx. three times daily for weeks.
Characteristic twitchings about the mouth do not oc-
cur in the adult. Idiosyncrasies must be looked out
for.
The Therapy of Femoral Hernia in the Adult.—
T. H. Manley divides treatment into prophylactic,
palliative, and radical. An illustrated case is pre-
sented and the therapy of femoral strangulation is
given, together with the relative mortality and a long
table of cases from journal reports. There were 166
cases with 59 deaths (thirty-five per cent.), 150 fe-
males with 52 deaths (thirty-four per cent.), 16 males
with 7 deaths (forty-three per cent.). In 89 cases of
umbilical hernia there were 27 deaths (thirty per
cent.); in 83 females, 26 deaths (thirty-one percent.);
and in 6 males, i death (sixteen per cent.). A bibli-
ography is added.
A New Surgical Dressing. — T. A. Dewar calls at-
tention to chloretone as a dressing possessing remark-
able properties. It is antiseptic, a local anaesthetic,
and harmless. In aqueous solution it can be used to
prepare wounds, burns, etc., for subsequent treatment.
Crystals may be sprinkled over an open surface and
chloretone gauze used as a dressing. The writer has
amputated fingers on three occasions under the effect
of the drug as a local anesthetic. In operations upon
the urethra or the passage of sounds it may also be
used.
The Relation between Posterior Urethritis and
Prostatic Abscess, and the Treatment of Each. —
Ramon Guiteras says prostatic abscess is usually an
extension of urethritis along the prostatic ducts. Ab-
scesses usually open into the urethra or the rectum, but
at times through the perineum, in the inguinal region,
or the ischio-rectal fossa. When surface redness shows,
the swelling should be poulticed and opened. The
importance of hot rectal douching in the active stages
is emphasized, and of combining douches with rectal
massage in the later stages.
Treatment of Appendicitis and its Great Mortal-
ity.— Mordecai Price believes that a more uniform
system of surgical treatment should be adopted in ap-
pendicitis. It is rare that there is more than one best
way. United experience should point out this way.
Mistakes should be more fully reported. Statistics of
four hospitals are quoted to corroborate his views re-
garding the high mortality, and to show that they are
not exaggerated. Catarrhal appendicitis he finds four
times as prevalent as the genuine appendicitis which
it simulates.
Pediatrics, Feliruary /j, igoo.
Blood Diseases in Children. — J. M. Taylor gives
clinical contributions upon purpura, scurvy, Hodg-
kin's disease, and arthritis deformans. In a fatal case
of hemorrhagic purpura in a girl aged thirteen years,
March 3, 1900]
MEDICAL RECORD.
379
with good history, and nothing to be found in the in-
ternal organs, there were hemorrhages from the mucous
membranes after spots and ecchymoses had appeared
on the skin. There was pain in the head. Coma en-
sued, followed by death. Calcium chloride, hydras-
tinine hydrochlorate, ergot, turpentine, and many
blood reconstructives were used in vain. In a case of
scurvy resembling syphilitic hemiplegia there were
complete paralysis of the right arm and leg, and great
oedema and severe pain on manipulation. Syphilis
was suspected from a flat eruption on the buttocks and
a longitudinal ulcer on the raphe of the perineum.
Under iodide of potassium recovery took place. A
case of Hodgkin's disease in a boy aged seven years
was first thought to be one of glandular fever. This,
as well as the preceding cases, was very imperfectly
studied. Arthritis deformans in a boy aged nine
years, seen in Weii^ Mitchell's clinic, is reported, and
the pathogenesis, after Riesman, is reviewed. For a
year there were progressive swelling of the joints and
diminished power of locomotion. There was no evi-
dence of rickets. Anti-rheumatic remedies made no
impression. The case passed from observation.
Fractures.— T. Halsted Myers reports fracture of
the neck of the femur in an infant aged six and a half
months, with photograph. The tumor suggested sepa-
ration of the epiphysis or neoplasm. An .r-ray picture
shows a case of fracture of the tibia and fibula simulat-
ing anterior curvature of syphilitic origin, in a child
aged eighteen months.
Imperfect Development of the Right Pectoralis
Major and Right Scapula. — H. L. Taylor gives with
illustrations a case of one-sided flat chest in a girl
aged six years. The right scapula was smaller than
the left.
Report on the Cause and Prevention of Infantile
Mortality. — By Ernest W'ende. A continued article.
S/. Louis Couiirr of A'ledichie, January, igoo.
Sanatoria for Consumptives. — Beverley Robinson
believes that for the cure of consumption and preven-
tion of contagion, laws regulating personal and house
hygiene would be more effective than the isolation of
a few patients in sanatoria.
Results of Eighteen Tests Made for Rendering
the Hands Aseptic before Operation N. B. Carson
has had great success with Weir's method, by which
Labarraque's solution is developed by sodium carbo-
nate and calcium chloride in the presence of water.
The Relative Value of Antisepsis and of Im-
provement in Technique as Regards the Actual
Results in Operative Gynaecology. — By L. Gustave
Richelot. See Medical Record, vol. Ivi., p. 420.
Torpor of the Retina due to Exposure in the
Klondike. — J. Ellis Jennings describes a case of par-
tial snow-blindness, cured by strychnine sulphate, gr.
Tf'jj- t.i.d., dark glasses, and instillations of atropine.
Typhoid Fever Complicated with Chorea and
Diabetes Insipidus. — Carl Orth reports a case of this
imusual complication of troubles. The patient made
a good recovery.
Functional Derangements of Ocular Muscles.—
Edward R. Wright discusses eye strain and its treat-
ment by muscle training, prism wearing, and operation.
Removal of One Hundred and Seven Polypi at
One Sitting. — H. W. Loeb accomplished this feat
with an electro-cautery snare of his devising.
International Medical Magazine, February, igoo.
The Symptomatology, Complications, and Sequels
of Gastric Ulcer.— Boardman Reed says that the three
most prominent symptoms of gastric ulcer are pain,
hemorrhage, and circumscribed tender spots. Vomit-
ing after taking food is another rather frequent symp-
tom. It is very exceptional in cases of ulcer to find
the stomach contents deficient in hydrochloric acid.
The appetite is generally good — often excessive. The
complexion varies. According to Welch the largest
proportion of cases occurs between the ages of twenty
and thirty years. Nearly two-thirds of the cases are of
women. A tumor can sometimes be felt. The most
important complications are: (i) rapid and possibly
fatal collapse; (2) partial perforation with patches of
local plastic peritonitis ; (3) perforation with escape of
gastric contents into the peritoneal cavity and result-
ing peritonitis; (4) subphrenic abscess. The sequels
may be a contraction or closure of the cardiac or py-
loric orifice; prostration, ansemia, and cachexia, or
gastric ulcer may be followed by cancer.
The Diagnosis of Some Ocular Maladies by* the
General Practitioner.— J. A. Patterson quotes Risley
on the location of pain in ocular maladies : '" In optic
nerve diseases, there is in many cases pain in the front
of the head, on top, but it is not a vertex pain. The
pain, when associated with eye affections, occurs in
the brow, occiput, back of the eyes, and in the temples,
in point of frequency in the order named. Simple eye
strain, particularly in children, will usually give rise
to brow pain. If associated with some abnormality of
the ocular balance, there will usually be occipital pain
also." The diagnosis of muscular disabilities is as
intricate as it is important, and requires very careful
testing for the perception of all the minute features.
In making pupillary examinations the physician
should notice whether the pupil reacts to light stimu-
lus promptly, sluggishly, or not at all. The ophthal-
moscope is an invaluable adjunct in the diagnosis of
ocular maladies.
Stricture of the Urethra. — J. D. Thomas favors
the following method of treatment in this affection :
After passing the filiform, pass over this as a guide a
small tunnelled divulsor, and, opening this up, divulse
to about No. 20 F. After the removal of the divulsor
and filiform, a No. 20 F. metallic sound is passed,
which enables the patient to urinate freely; the blad-
der is relieved, and the patient is in good condition
for treatment by gradual dilatation.
The Importance of the Early Recognition and
Treatment of Gonorrhoea in the Female. — Edward
E. Montgomery declares that syphilis is not nearly so
baneful in its influence upon the future health of the
woman as gonorrhoea. For when the latter affection
has once invaded the deeper structures of the genital
tract, it is beyond the physician's control and produces
changes in structure and relation which can be relieved
only by a sacrificial operation.
Importance of Thorough Urinary Examinations.
The Needed Preparations, Apparatus, etc. — A. Robin
believes that uranalysis is often incomplete. Appa-
ratus should be cleaned as soon as the work is finished.
Printed blanks are valuable. A most useful preserva-
tive is formalin.
Some Practical Points in Infant Feeding.— How-
ard S. Kinne emphasizes the importance of regular
feeding: the child should remain at the breast for fif-
teen to twenty minutes, but not longer. Night nursing
should be avoided.
38o
MEDICAL RECORD.
[March 3, 1900
Franklinic Electricity and Methods of Application.
— By Margaret A. Cleaves. A continued article.
The Century of Surgery. — By W. Wayne Babcock.
Deutsche Acrzte-Zeitimg, February i, igoo.
Treatment of Erysipelas with Antibactericidal
Remedies. — Max Helm mentions a variety of drugs —
iodoform, alcohol, carbolic acid, turpentine, etc. —
which have been used with more or less favorable
results. The antistreptococic serum (Marmorek) is
useless. In migrating cases, the application of equal
parts of ichthyol and vaseline, together with Riedel's
method of multiple scarification and washing wl ^
bichloride solution (i : i,ooo), often brings the disease
to a close. Four successful instances are recorded.
Present Status of Treatment of Hypertrophic Rhi-
nitis L. Rethi concludes that in large diffuse hyper-
trophies energetic treatment with trichloracetic or
chromic acid, nitrate of silver, or galvano-cautery is
indicated. In polypoid hypertrophies the galvano-
ca«tery, snare, or cutting is indicated. The methods
applied are carefully described. Hypertrophies of the
septum are best removed with the snare.
Observations on the Use of Heroin. — Jacob Wils-
ner used the muriate internally and subcutaneously,
four hundred and eighty-one times in sixty-five cases,
irrespective of age and sex. Only narcotic, analgesic,
and sedative effects were tried, with the result that it
bids fair to replace morphine and codeine for these
purposes. Smaller doses are necessary and the after-
effects are less than with morphine.
Observations upon the General Deficiency of Al-
bumen in Nourishment. — Ludwig Hellwig takes issue
with Finkler, who says that most people do not take
sufficient albumen with their food. Quotations from
Finkler and Pfliiger are freely discussed.
Giornalc Medico del Regio Esercito, December 3 1, iHgg.
The Mosquito-Malaria Theory.— Claudio Sforza
takes up the question of the prevention of malaria
among soldiers, and, basing his remarks on the theory
of the connection between the disease and certain va-
rieties of mosquito, urges that greater care be exercised
in the selection of localities for the encampment and
drilling of soldiers. The latter are exposed both day
and night to the punctures of these insects. He also
recommends the wearing of the hoods and gloves recom-
mended by Professor Celli for railway employees, the
use of mosquito netting when practicable, and of va-
rious substances supposed to be obnoxious to mosquitos.
Aneurism of the Innominate Artery. — Luigi Rugai
reports and describes a case. The tumor is of small
size, and the pressure symptoms are very slight. Rest,
careful dieting, and potassium iodide will be the treat-
ment given, unless more alarming symptoms should
call for ligature of the carotid and subclavian arteries.
Archives Gtntrales de Medectne, February, igoo.
The Self-Help of the Organism in Certain Cases
of Angina Pectoris. — Joseph Pauniski studies the va-
rious compensatory influences in cases of heart disease
causing stenocardia, and concludes that hypertrophy is
the chief one. Improvement in the general nutrition
of the patient favors this hypertrophy, but this does
not mean superabundant nutrition which might oxer-
tax the myocardium. The greater the amount of heemo-
globin in the blood, the slower is the circulation and the
longer the diastole, an essential condition to nutrition
of the heart, since it fills only during diastole. Hemo-
globin may be obtained by increasing the albuminates
or by diminishing the water in the organism.
Clinical Study of the Contraindications to the
High-Altitude Treatment. — L. Murat considers ca-
chexia a contraindication in most cases; laryngeal
phthisis is usually aggravated by mountain air; em-
physema, erethism, acute phthisis, or acute attacks in
the course of chronic phthisis are all contraindications.
Haemoptysis, on the other hand, is usually benefited
by high altitude. Kidney disease, rheumatism, and
white swelling are rendered more painful, and phthis-
ical patients suffering from these complications should
r '; be sent to an altitude as great as forty-six hundred
feet.
Ganglional Tuberculous Cavity Opening into the
Aorta, Left Bronchus, and CEsophagus. — L. Brodier
and P. Lecene describe this condition in a patient who
was not suffering from pulmonary tuberculosis.
Botryomycosis Occurring in Man. — By Antonin
Poncet and Louis Dor. A continued article.
Various Forms of Purpura and Visceral Affec-
tions.— By C. Oddo and Olmer. A continued article.
// Foliclinico, /auuary 75, igoo.
The Consequences of the Escape of Urine into
the Peritoneum L. Rizzo, as a result of experi-
mentation on animals, concludes that small amounts
of urine in the peritoneum have neither local nor gen-
eral action; doses up to one-thirteenth of the animal's
weight have no local action, but cause a grave uremic
condition. Higher doses cause death. The presence
of urine in the peritoneum renders this serous mem-
brane most vulnerable to the infections. The peri-
tonitis which by organization closes wounds of the in-
traperitoneal tract of the urinary passages is not due
to the action of urine, but to the fact that a bloody sur-
face is in contact with the peritoneum.
Bacteriological Researches in Normal and Dis-
eased Fallopian Tubes Guiseppe Bel lei found that
healthy tubes are not free from germs; that the micro-
organism most frequently causing purulent salpingitis
was the staphylococcus pyogenes albus, but other germs
may also cause the process. He at no time found any
association of pathogenic microbes in purulent salpin-
gitis, and only rarely found a pathogenic germ with
one or more saprophytes. In chronic salpingitis he
found no micro-organisms. The saprophytes found in
the tubes are either special to this organ, or have as-
su-ned special characteristics due to their environment.
The Genesis of Lipoma. — Eriberto Aievoli gives
a number of reasons for believing that in the future
lipomata will not be included with neoplasms, in the
strict meaning of the term, but will be considered as
belonging to the class of trophic lesions. As to the
reasons for the disturbance of equilibrium in the
physiological deposition and removal of fat, the au-
thor holds that in the distribution and function of
elastic tissues, or their influence upon the distribution
of nutritive fluids, will be found the solution of the
problem.
Fibrous and Muscular Abnormalities of the Fas-
cia Transversalis (luglielmo Romiti describes some
peculiar conditions found in the course of autopsies,
and upon living subjects.
Deviations and Contractures of the Spinal Col-
umn of Neurotic Origin, Especially Hysterical Sco-
liosis.— Frasmo de Paoli describes several cases of
this aff'ection.
March 3, 1900]
MEDICAL RECORD.
^cxiicxos and Notices.
State Board of Massachusetts, Thirtieth Annual
Report, 1899. 8vo, pp. 878.
This rather bulky volume contains, among other useful docu-
ments on the public health of Massachusetts, an e-xcellcnt
and exhaustive report on the water supply and sewerage of
towns.
Lea's Series of Pocket Text-Books. Diseases of
Children : A Manual for Students and Practitioners. By
George M. Tuttle, M.D. Edited by Bern. B. Gal-
LAUDET, M.D.
This new manual has just appeared. It describes a series
of infants' disorders, and gives the management of the same
without going into extensive details. It is well adapted for
the purpose of the author. We take exception to the other-
wise good monochrome — but ask the author to credit the
same to Dr. Flindt, New York Medical Record, October
21, 1899. The book is well written, and has some very
good illustrations.
Transactions of the Medical Society of the State
OF North Carolina. Forty-sixth annual meeting,
held at Asheville, N. C.
After the address of the president and the annual oration,
this volume is divided into the various branches of practice
of medicine, obstetrics, pathology and microscopy, medical
jurisprudence, anatomy and surgery, materia medica, and
therapeutics. A code of medical ethics, covering fifteen
pages, proves a source of great instruction.
The Transactions of the Medical Society of the
State of California. Twenty-ninth annual session,
Monterey, April, 1899.
Unlike the reports of most society meetings, this volume
offers numerous interesting and instructive articles as its
main contents, giving only secondary importance to constitu-
tion and by-laws, committee reports, member lists, etc.
Transactions of the Vermont State Medical So-
ciety, 1898.
This little volume contains the transactions of the eighty-
fifth annual meeting held at Brattleboro. It presents a num-
ber of interesting papers, with their general discussion, a
list of members and past presidents, and the by-laws and
constitution.
Mt. Sinai Hospital Reports. Volume I., for 1898.
Edited for the Medical Board by Paul F. Munde, M.D.,
LL.D.
The hospital and editor are to be congratulated upon the
very excellent and practical manner in which this maiden re-
port has been presented. Each department has contributed
its share, in a way which carries conviction and instruction
with it, so that in all the volume proves a very valuable
source of information.
Transactions of the Medical Society of the State
OF West Virginia. Held at Weston, May 17, 18, and
19, 1899.
This volume, though covering but a hundred pages, con-
tains reading-matter whose value is in inverse proportion to
its quantity. The article on the " Present Status of Appendi-
dicitis," by Hupp, would repay careful study, as it is clearly
and thoroughly presented. The Transactions have many
other short and instructive contributions.
The Retrospect of Medicine. A half-yearly journal.
Edited by James Braithwaite, M.D., and E. F. Tre-
velyan, M.D. Vol. 119. July, 1899. London; Simp-
kin, JMarshall, Hamilton, Kent & Co., Limited.
It is largely a matter of choice with medical readers whether
they require or desire their scientific pabulum served up
weekly, bi-weekly, monthlv, quarterly, half-yearly, or in an
out-and-out year book. The market supplies medical liter-
ature of current nature in all these and many other forms,
Recent reviews of the publication before us appearing in
journals interested in the success of other and newer ven-
tures would make it appear that " Braithwaite " has outlived
its usefulness. It is the same half-yearly journal it was half
a century ago, giving abstracts and short articles from medi-
cal journals, and showing the most important indications of
treatment, published by different writers during the half-year,
arranged alphabetically under general headings of practical
medicine, surgery, obstetrics, and gynecology, these being
subdivided to cover the field. The "Retrospect" has al-
ways been a welcome visitor to the IMedical Record's
table, and is still ; and we could advise no old or recent
subscriber to give it up in an attempt to get better food more
promptly served for the same outlay.
Practice of Medicine : A Manual for Students and
Practitioners. By George E. Malsbary, M.D., As-
sisf'nt to the Chair of Practice, Medical College of Ohio,
I 'n-"ersity of Cincinnati; Assistant to the Lectureship of
Clinical Medicine, Good Samaritan Hospital, Cincinnati.
Philadelphia and New York : Lea Brothers & Co.
This is one of the series of pocket text-books issued by this
publishing house, and edited by Dr. Gallaudet. While it is
*rue that the manual has the advantage over a deep treatise
that it can be published quickly and include the latest fash-
ions in medicine, still there is always the possibility that the
work has been too hastily done in these smaller works. A
soldier is no better than his feet ; a chain is no stronger than
its weakest link, and a book is no better than its worst page.
The work before us has one weak if not worst page. In de-
fining the pox, the author says : ' ' Two or three months later, "
(after the primary lesion) "the secondary lesions develop."
'- The third stage of the disease develops after a period of three
or more years, with falling of the hair, etc." Under treat-
ment we read: "Some advise excision of the primary sore,
since it is a focus of infection. When this is done, medici-
nal treatment is begun at once ; but usually active treatment
is deferred until the second stage." We cannot regard the
postponement of active treatment for " two or three months "
as the best teaching of the day. Differential diagnosis and
treatment, which should be the strongest features of such a
book, are noticeably weak.
A Text-Book of Materia Medica, Therapeutics,
AND Pharmacology. By George Frank Butler,
Ph.G. , M.D., Professor of Materia Medica and Clinical
Medicine in the College of Physicians and Surgeons, Medi-
cal Department of the University of Illinois, etc. Third
edition, thoroughly revised. Philadelphia : W. B. Saun-
ders. 1899.
Nothing has been omitted by the author which, in his
judgment, would add to the completeness of the text, and
the student or general reader is given the benefit of latest
advices bearing upon the value of drugs and remedies con-
sidered. What has seemed detail of no great importance
has been excluded to make place for weightier matter. In
its new form, this volume of eight hundred and seventy-five
pages must be regarded as a thoroughly up-to-date aid in
instruction in the branches covered. There is at the end a
clinical index, making the matter available in a very practical
way.
The Logic of Figures ; or. Comparative Results of
Homoeopathic and Other Treatments. Edited by
Thomas Lindsley Bradford, M.D. Philadelphia:
Boericke & Tafel. 1900.
Drawn from various sources, statistics are here offered by
the writer and compiler to show by the "logic of figures"
the superiority of his school of teaching and practice.
Though not exhaustive the attempt has been made to in-
clude all important statistics for the past fifty years cover-
ing death rates in the hospitals, asylums, etc., under the
dil'.'erent schools. There is a bibliography of statistical
books and articles.
Bee-Line Therapia and Repertory. By Stacy
Jones, M.D. Second edition. Philadelphia: Boericke
& Tafel. 1899.
The author of this little, soft-covered pocket-book of three
hundred and thirty-three pages thinks that "if we can get
three legs to the stool of affiliation we will have a pretty
sure base for a successful prescription." He therefore ad-
vises the physician who uses this work to consult especially
^82
MEDICAL RECORD.
[March 3, 1900
sections on "Cause," " Aggravation," and "Amelioration.."
New features of this edition are chapters on "Person" as
distinguishing the peculiar physique of the patient ; and on
the various kinds and uses of suppositories. The title ■ ' Bee-
Line " has been chosen because of the specific indications
for remedies as set forth.
A Practical Treatise ox Materia Medic a and
Therapeutics. By Roberts Bartholow, M.A.,
M.D., LL.D. Tenth edition, revised and enlarged.
New York : D. Appleton and Company. 1 899.
To the student of twenty or more years ago who prepared
■for his examinations from the first edition of "Bartholow,"
the present volume will indicate the many advances .scored
in the matter of drug medication. There will also be dis-
covered such changes as increased space, omission of
references now deemed unnecessary in order not unduly to
increase the number of pages, a brief account of the newest
remedies, and a special article on prescription writing. The
student or practitioner who now becomes acquainted with
this iustly popular work for the first time will find within
its pages, attractively presented, all that is reasonably re-
quired to be known' about drugs and their action, in con-
formity with the only official standard, the United States
Pharmacopoeia.
Warner's Pocket Medical Dictionary of To-
day, comprising Pronunciation and Definition of Ten
Thousand Essential Words and Terms used in Medicine
and Associated Sciences, and Tables of Arteries, Nerves,
Muscles, etc. Arranged for convenient reference by
William R. Warner. Pp. 374- Philadelphia: Wil-
liam R. Warner & Co. 1898.
This is a most handy little volume of the right size as a
pocket cornpanion and especially adapted to medical students
who are being introduced to many new terms. Many of the
very common words have been omitted. This is the second
edition and has been revised to date.
The Medical News Visiting List for 1900. Weekly
(dated, for 30 patients); Monthly (undated, for 120 pa-
tients per month); Perpetual (undated, for 30 patients
weekly per year) ; and Perpetual (undated, for 60 patients
weekly per year). The first three styles contain 32 pages
of data and 160 pages of blanks. The 60-patient Perpet-
ual consists of 256 pages of blanks. Each style in one
wallet-shaped book, with pocket, pencil, and rubber.
Philadelphia and New York : I-ea Brothers & Co.
This little book is most admirably arranged, and contains
many useful tables and references. The printed contents
consist of articles on Urine Analysis, Important Incompat-
ibles. Artificial Respiration. Table of Eruptive Fevers. Poison
Antidotes, etc. The blanks are arranged for daily record of
visits, general memoranda, obstetric engagements, vaccina-
tions, death register, addresses of patients and nurses, and
cash account. It should suit excellently the needs of the
general practitioner.
Clinical Lectures on Neurasthenia. By Thomas
D. Savill, M.D., Physician to the West End Hospital
for Diseases of the Nervous System, London, etc.
The English edition of this well-known book was reviewed
in our columns on July 15th last. We are in receipt of an
American edition of the work, in every way the equal of the
original, just published by arrangement with the author by
Messrs. William Wood & Company, New York. (Muslin,
S1.50 net.)
Clinical Society's Transactions. Vol. XX.XII.
London : Longmans, ( "ireen, & Co. 1 899.
It is with deep interest that one reads the last volume of the
Transactions of the London Clinical Society, not only because
of the intrinsic worth of the papers read and the clinical value
of the cases that were presented, but also because the work of
this society illustrates how much can be accomplished for clin-
ical medicine when the proper spirit pervades the members
of the association. It is indeed no wonder that the meetings
of this society are well attended, for each member strives to
present briefly and yet minutely the very best clinical mate-
rial. To review either the papers that were read or the
cases that were presented would hardly be possible in the
space that can be devoted to this notice of the society's
Transactions, and the volume can only be recommended to
the entire rank and file of the profession, as containing most
interesting and unique material. The book is excellently
printed, the illustrations are particularly good, and the con-
tributors, editors, and publishers are all to be heartily con-
gratulated upon the manner in which their work has been
accomplished.
Obstipation. By Thomas C. Martin, Ph.D., M.D.,
of Cleveland, Ohio. Philadelphia: Medical Publishing
Company. 1 899.
The author stvles the book " a practical monograph on the
disorders and diseases of the rectal valve," and devotes the
first portion to a critical review of the literature bearing upon
the existence of this anatomical structure. He then details
his method of rectal examination. This he makes a com-
plicated procedure, and for its perfection he has devised a
special table and quite an array of instruments; whereas,
with a patient in the knee-chest position, a direct ocular in-
spection of the interior of the rectum, when it is distended
with air, is quite simple and easy. The last half of the book
deals with the importance of abnormal conditions of the rec-
tal valve in producing obstipation. In infancy the deficient
muscular development of tlie lower segment of the bowel,
and the greater length and mobility of the sigmoid flexure,
are certainly far more important factors than the rectal valve
in causing obstipation ; and in adult life, with the exception
of those rare cases of congenital membranous septa which
obstruct the lumen of the bowel, it is not the rectal valves
which cause the obstipation, but the inflammatory processes
and new growths, which affect the bowel at the site of these
structures , and it is to the pathological condition that our
treatment must be directed, and not to the rectal valve.
Bacteria, Especially as They are Related to the
Economy of Nature, lo Industrial Processes,
AND to the Public Health. By George Newman,
M.D., F.R.S. Edin., D.P. H. Camb., etc.; Demonstrator
of Bacteriology in King's College, London. Illustrated.
Pp. 348. New York : G. P. Putnam's Sons. London :
John Murray. 1899.
This volume is the sixth in the " Science Series " edited by
Prof. J. McKeen Catteil and F. E. Beddard, and is fully as
interesting and instructive as its predecessors. The author
does not claim to put forward the results of his own original
work nor to give a complete technical guide to the labora-
tory. His purpose has been lo deal with the subject in a
popular way, and in this attempt he has most happily suc-
ceeded. There has been a great need for just such an ex-
position of the life histories of bacteria, and Dr. Newman
has taken pains to describe the advantageous uses as well as
the disease-producing activities of our friends the enemy.
The book is divided into various chapters on the biology of
bacteria — bacteria in water, in air, in the soil, in milk, milk
products, and other foods, the relation of bacteria to fer-
mentation, the question of immunity, and antitoxins and
their relation to disease. The publishers have produced a
well-printed volume, well bound, and of neat appearance,
while the illustrations are sufllcient and to the point.
The Veil as a Cause of Erythema of the Nose
and Cheeks.— 0. Rosenbach (BtiUncr klin. Wochen-
sc/iri/f, October i, 1899) calls attention to the fre-
quency with which women who wear veils in winter
suffer from redness of the tip of the nose and the
cheeks. This is not due to any draught of cold air;
on the contrary, the heavier the veil, the worse the
condition. He attributes it {a) to the roughness of
the threads of the veil, and (/') to abstraction of warmth
by the veil from those parts of the face with which it
comes immediately in contact — "acting like a cata-
plasm.'' The blood is thus drawn to these parts, and
the capillaries become over-distended. On the cheeks
the area of redness is limited to the points of separa-
tion of the veil from the skin. The condition is natu-
rally increased upon entering a warm room.
March 3, 1900]
MEDICAL RECORD.
383
Jlxcra^jcutic gtitxts.
Treatment of Simple Appendicitis D'Arcy Power
{^British Medical Journal, Ho\'^vViQ^x 25th) writes as
follows regarding this subject: Medical treatment
may be adopted so long as the patient seems fairly
well, his pulse is regular, firm, and not too rapid; if
his respiration is full and painless, his belly is but
little distended, and if the stools are normal, or there
is only slight constipation. It is better not to use
opium in any form, because it hides the tenderness
and masks the facial changes, which are the only safe
indications of the course which the disease is running.
As a routine treatment of a straightforward and
simple case of appendicitis I have seen the best re-
sults follow the method to, which Mr. Maylard has
recently drawn renewed attention. It consists in the
immediate administration of a copious enema of warm
soap and water, followed by teaspoonful doses of
magnesium sulphate in two wineglassfuls of warm water
given hourly, the dose being repeated six or eight
times until the bowels begin to act. A hot boric-
acid fomentation or an ice-bag is applied to the right
iliac region, the choice being determined by the re-
lief which the patient obtains, though the surgeon pre-
fers the ice-bag. The patient must be kept in bed
until the swelling and all the tenderness have left the
right iliac region, and he must be fed upon food which
ia easily digested, that neither constipates nor forms
ma.ssive stools.
Boric-Acid Poisoning — ^Dr. Grumpelt {Sem. Medi-
cale. No. 15, 1899) reports a case of severe intoxica-
tion following the employment as an enema of about
a pint of a one-per-cent. solution of boric acid. The
toxic manifestations consisted of erythematous, papu-
lar, and bullous lesions on the hands, marked dry-
ness of the skin, high fever, nausea, and headache.
The Therapeutics of Acute Pneumonia. — Dr.
Thomas G. Mays {Merck's Archives, May, 1S99) be-
lieves that cold is paramount to everything else in the
treatment of acute pneumonia. He applies ice in large,
flat rubber bags to the head and chest. This measure
reduces the fever, lessens the tendency to convul-
sions in children, and allays the irritability of the
nervous system in adults; it limits and checks the ex-
tension of the pneumonia process by contracting the
pulmonary capillaries; it promotes resolution, and
disperses the products of exudation ; it acts as a pro-
found sedative to the circulatory and respiratory cen-
tres; it supports the function of the heart; it allevi-
ates the difficulty of breathing; it abates pain in the
chest, and it gives general rest and comfort to the
patient.
Preventive Treatment of Impending Diabetic
Coma. — -Upon the appearance of the aceto-acetic acid
reaction in the urine place the patient on a strict milk
diet. Administer internally 30 gm. sodium sulphate
and 20 gm. sodium bicarbonate. Give cardiac stimu-
lants, digitalis, caffeine, etc. To combat the ferment
action, give ammonium fluoride gr. -^ in water, after
each cup of milk. Inject twice daily i gm. of a twenty-
five-per-cent. solution of sodium glycero-phosphate,
and begin oxygen inhalations. — Robin.
The Medical Treatment of Puerperal Infection.
— Dr. Howard W. Longyear {Medical Times, Decem-
ber) summarizes the treatment as follows: Local
Treatment — Early recognition and destruction of
pseudo-membrane by topical applications is of great
importance. The iodine, carbolic acid, and chloral
mixture is a safe and efficient application for this pur-
pose. The intra-uterine douche, frequently applied,
is of most value in the forms of infection unattended
by the formation of a pseudo-membrane, but is useful
also in connection with local applications. Peroxide
of hydrogen per vaginam is useful in all forms of in-
fection. Frequent packing of the vagina, previously
dried, with iodoform gauze, is especially useful in
cases attended with pseudo-membrane. Inspect in-
fected cases daily with the speculum. Some uncom-
fortable surprises may thus be avoided, and the local
treatment will be most intelligently carried out. Gen-
eral Medication — Quinine in large doses twice daily;
whiskey and strychnine to support the heart, if indi-
cated; nuclein and protonuclein in all cases; mer-
curial and saline cathartics at first in all cases, then
as indicated. Serum therapy to be applied in all
cases when the Klebs-Loeffier bacillus or the strepto-
coccus can be demonstrated by bacteriological exami-
nation, and also in all other cases when such examina-
tion has not been made, but in which these specific
varieties of infection are probably present. Strepto-
coccus antitoxic serum is to be used persistently to
prevent pus formation and symptoms of systemic in-
fection, even if local symptoms and high temperature
persist.
Asthmatic Attacks. — Subcutaneous injections of
atropine in do.ses of Ji-i mgm. are followed by prompt
relief; the earlier the administration during an at-
tack, the better. — Riegel {Deutsch. med. Wochenschr.,
1899, No. 41).
Contraindications to Carbonic-Acid Baths in Cir-
culatory Diseases. — Carbonic - acid baths in gen-
eral cause increase of blood-pressure; occasionally a
diminution is noted. Diminution in the heart's dul-
ness or percussion and increase in urine excreted are
observable in some cases. The baths are therefore
contraindicated when apoplexy is threatening, or when
the heart is just compensating and cannot respond to
greater demands.
The Effect of Codeine on Coughs. — In epidemic
bronchitis codeine is a valuable remedy for the relief
of the harassing pain of the cough, and when com-
bined with one of the coal-tar antipyretics the an-
algesic effects become more pronounced. It is a
favorite drug in the cough of phthisis and chronic
bronchitis, and its sedative influence is highly satis-
factory, clinical data having shown it to be the best
succedaneum for opium. Another advantage of co- ■
deine over morphine, one of special value in bronchial
catarrh, is that the patients not only cough less but
also expectorate more easily than after morphine.
The cough-dispelling power of codeine is such as to
make it indispensable in phthisical patients, and a point
of great importance in these cases is that it does not
impair the appetite or digestion, and can therefore be
used uninterruptedly for months. — George J. Loch-
BOEHLER, Journal of the American Medical Associaliott,
December 2d.
The Nutritive Value of Albumose Peptone -It is
impossible to maintain life upon peptone alone, as it is
upon all other strictly nitrogenous foods. Upon the
addition of a small amount of carbohydrate, the nitro-
genous loss from the body, with the same amount of
albuminous food, is very much retarded. Peptone
must be regarded as not only able to replace native
albumin as a means of checking nitrogenous loss, but
also as a means of increasing albuminous tissue. For
a period of forty-five consecutive days, at least, pep-
tone causes no diarrhcea or disturbance of the stom-
ach.— A. E. Austin, Bos/on Medical and Surgical
Journal, November 30, 1899.
384
MEDICAL RECORD.
[March 3, 1900
Creamy Thrush. — For this frequent form of stoma-
titis in infancy to arise the saccharom3'ces albicans
must be introduced from without, and must find a
peculiar condition of the digestive tube favoring the
growth of this fungus. On this are based the rational
treatment and care necessary to prevent its spread.
Cure the gastro-entritis which has preceded it. Ery-
thematous stomatitis, which also precedes it, as a rule,
may be prevented by good hygiene. Wash the mouth
several times daily with Vichy water, or five-per-cent.
bicarbonate of sodium solution, or apply:
IJ Bora.x 5
Glycerin 20
Wash out the stomach also with Vichy water. In re-
bellious cases antiseptics should be used with care
and chiefly by the physician himself. Carbolic solu-
tions are not to be used. Internally a teaspoonful of
a half or one per cent of resorcin solution should be
given every two hours.
IJ Saccharin i
.Spt. vini rect. (60 per cent.) 50
S. .A. teaspoonful in a glass of water as a mouth wash five
times daily.
— Ladbe, La Presse Med., December 13, 1899.
For Coughs. —
If Heroin gr- tV
Amnion, hypophos gr. iij.
Hyoscyami gr. i.
Pin. alb. cort gr. iiiss.
Bals. tolutan gr. \
Glycerini puri J i.
M. .S. B'or dose.
—Ex.
Balsamic Pills. —
1^ Terpin 0.05 cgm.
Sodii ben^oat o.io "
Picis veg q.s.
M. For one pill. Make forty. .S. Take ten daily.
— Delesquelle.
Psoriasis
i^ Acidi salicylici,
Acidi pyrogallici.
Amnion, sulph. ichthyol aa gr. xlvi.
01. oliv 3 iiss.
Adipis lanoe 5 '^ ■
M, S. Apply twice daily.
This produces no irritation nor discoloration of the
skin. — Unna.
Local Asphyxia of the Extremities. — In a certain
number of cases sulphate of quinine has given incon-
testable results.
If Quin. sulphat. ,
Ergotin aa 0.05 cgm.
Pulv. digitalis fol 0.005 nigm.
Ext. beIladonn:e o. 001
M. For one pill. S. Give two tn four before each meal
— Plicque, La Frcsse Med., No. 92, 1899.
Phthisis. —
If Ichthyol.,
Aquoe p. jeq.
M. .S. One to two drops in tablespoonful of water after
meals, gradually increased to ten drops t.i.d.
VfERTHEI.MER.
Phtheirius Pubis. —
R Hydrargyri bichloridi 0.25 cgm.
Spt. terebinth 30 gm.
Glycerini 40 "
Spt. lavandulse 175 "
M. S. Apply.
— Gaz. des Hop.
Treatment of Corns. — Dr. E. L. Wood, of Dans-
ville, N. Y., writes: "A radical cure for corns con-
sists in paring the callosity as closely as possible with-
out causing any hemorrhage ; then placing in the centre
of the corn a very small drop of croton oil, and ban-
daging for twelve hours. Then remove the bandage
and paint the corn with reliable cantharidal collo-
dion; a pustular bleb will result, in the formation of
which the entire callosity, nucleus and all, will be
raised without very much pain from the tissues be-
neath and can be easily removed. The process should
be conducted under the care of a surgeon to insure
prompt sterilization of the part after the callus is re-
moved. Healing has always been rapid, not requiring
more than three or four days, with no liability to re-
currence unless the foot is afterward abused. I have
treated active, working patients without a loss to them
of more than a half day of time."
Hepatic Colic. — Avoid the hypodermic use of mor-
phine by giving:
V, Ext. ballad.,
Ext. opii aa o. 20 cgm.
01. theobromatis q.s.
M. For one suppository— make four such. S. One repeat
in half an hour, then every hour.
Apply over the liver region a flax-seed poultice made
with laudanum. Give internally;
If Sodii bicarbon 4 gm.
Aq. destil " 100 "
Syr. simp 30 "
M. S. A teaspoonful every half-hour, alternating with:
If Ac. citric 4 gm.
Aq. destil 100 "
Syr. limonis 30 '
A teaspoonful on the quarter hour.
— Bacaloghi.
Tender Feet, especially among soldiers. Harden
the epidermis and destroy bacteria with salicylic solu-
tions five per cent. ; remove offensive odors with
formic-aldehyde solutions two per cent., or apply tan-
noform powder (formaldehyde added to an aqueous
solution of tannin and precipitated with hydrochloric
acid).
JSperminum is said to act as a 'ferment in textural
respiration, oxidizing the products of regressive meta-
morphosis. To it is ascribed the property of preserv-
ing the system from auto-intoxication. Its use is in-
dicated when it is necessary to raise the tone; when
there is diminished intra-organic oxidation, in anaa-
mia, gout, rheumatism, phthisis, neurasthenia, etc. It
seems contraindicated in mania and epilepsy. —
"Notes on New Remedies," December, 1899.
Carbolic Acid in Tetanus. — Ten minims of a ten-
per-cent. carbolic solution were injected hypoder-
matically, and after fifteen minutes twenty minims in
addition, in a boy of twelve with general symptoms of
tetanus, dyspnoea, and opisthotonos ten days after in-
jury to the foot. After the third day there was im-
provement, and he gradually recovered. — Woods, iVVw
York Medical Journal, September, 1899.
Honey-Bee Therapy. — The source from which the
honey is gathered will influence very greatly its value
in medicine. — L. O. Howard.
Most of the honey served to guests in Swiss hotels
is said to be merely glucose flavored with honey.
Apis mel has been successfully used in dropsy,
possessing decided diuretic and diaphoretic proper-
ties.— Miller.
Overworked and feeble individuals are saved work
for their digestive machinery by eating honey instead
of cane sugar. — Professor Cook.
Creosotal. — Two and a half grams four times daily
in emulsion of hot milk are said by Cassoute to be
tolerated by adults in acute broncho-pulmonary affec-
tions, while children up to one year of age can be
given from 0.25 cgm. to i gm. daily in four doses;
children from four to six years of age can take 3 gm.
to 4gm. daily. The dose given in Coblentz's "Newer
Remedies" is Til iii.-v.
March 3, 1900]
MEDICAL RECORD.
385
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, January 10, igoo.
T. Mitchell Prudden, M.D., President.
A Case of Congenital Renal Malposition with
Anomalous Arterial Supply — Dr. Harlow Brooks
presented a specimen taken from a negress, twenty-
eight years of age, who had been healthy previously,
and had borne one child at full term without any
uraimic or other complications. About one year later
she had again become pregnant. When supposed to
be about three months pregnant she had entered the
Harlem Hospital complaining of cramp-like pains in
the region of the appendix. She had no fever, and
palpation at McBurney's point did not give the char-
acteristic tenderness or sensation to be expected in
appendicitis. The urine had not been examined until
rather late in the case, and then had been found to
contain a small quantity of albumin, and some blood
corpuscles. There had been at this time still no eleva-
tion of temperature. Pelvic examination by the house
surgeon had shown the woman to be pregnant, and had
revealed the presence on the right side of a masj sup-
posed at the time to be a cystic ovary or a pyosalpinx.
The woman had been rather irritable, but had gradu-
ally passed "into a comatose condition, when a diag-
nosis of uraniia had been made. The autopsy had
revealed a twin pregnancy at about the third month.
One umbilical cord was tied in a hard knot. The
uterus was in the normal position. The left kidney
had been about the normal size, but exhibited an acute
hemorrhagic nephritis. The right kidney had been
found below the brim of the true pelvis, and the en-
larging uterus had jammed it up against the bones of
the pelvis. The tissue of this kidney was extremely
anaemic. There were two renal arteries on this side,
one given off just above the bifurcation of the abdom-
inal aorta into the common iliacs; the other branch
had been derived from the sacra media. The enlarg-
ing uterus had compressed and rotated the kidney, cut-
ting off the blood supply from the sacra media, and
also from the upper renal artery, which was given off
slightly above the sacra media. It was this that had
caused the anaimia of the kidney and probable loss of
function. This sudden increase of function explained
the pain and the rather sudden onset of the acute
nephritis on the other side. This position of the kid-
ney in the pelvis was not particularly rare, and it was
not extremely rare for the sacra media to become the
renal artery, but in all such non-functionating cases
found in the literature the kidney had been apparently
deprived of its function. In none of these other cases,
moreover, had any symptoms been produced. In the
case just reported the malposition of the kidney had
probably caused death. In her first pregnancy the
uterus had risen out of the true pelvis before it had
been large enough to compress the kidney; in the last
pregnancy, however, twins being present, the uterus
had enlarged sufficiently to compress the kidney before
it rose from the true pelvic cavity. The only other
interesting feature of the case was the general small-
ness of the arteries of the body.
Dr. Hodenpyl asked if the entire blood supply had
been cut off from the kidneys.
Dr. Brooks replied that he thought it had been, for
the reason that the pelvic blood-vessels had been pretty
well filled, and the renal vessels apparently bloodless.
The reason that gangrene had not taken place was that
the nipping of the kidney had apparently taken place
only about three days before death, i.e., at the time she
had complained of the cramps.
Some Unusual Cases of Leukaemia, with Demon-
stration of Stained Specimens of the Blood. — Dr.
Theodore Janeway reported live cases of lymphatic
leukffiinia, four of which had been seen in his father's
consulting practice. The fifth had been seen recently
in dispensary practice, and he had been able to obtain
a partial autopsy. Two of the cases should be classi-
fied as acute leukaemia. The first case occurred in a
man aged thirty-eight years, who had had severe mal-
aria two years before the onset. There had been a
prodromal period of two weeks, during which he had
felt tired. The onset had been marked by severe pain
in the left side, and during the first week there had
been uncontrollable epistaxis. Later on petechial
spots had appeared on various parts of the body.
There had been some rise of temperature. When seen,
four weeks after the commencement, there had been
marked pallor; an enlargement of the spleen down to
the umbilicus; slight enlargement of the cervical
and inguinal lymph nodes, and slight enlargement of
the liver. The blood count showed 840,000 red cells
and 77,000 white cells. In the stained specimens it
was evident that fully ninety per cent, of the white
cells were mononuclear cells without granulations.
There were a few myelocytes, megaloblasts, and nor-
moblasts. No mast cells had been found. Death had
occurred about two weeks afterward, the total duration
of illness having been six weeks and a half. The sec-
ond case was that of a child aged four and a half years,
who had been seen in the University clinic. There
had been diphtheria and scarlet fever two years be-
fore, and these had been followed by suppurative otitis.
As the child had been on Long Island it had been
treated at first for malaria. Six weeks before death
there had been enlargement of the abdomen with con-
siderable tenderness of the left side. Two weeks later
there had been a hemorrhage from the nose and bowel.
The blood count had not been made. When seen by
the speaker there had been marked pallor of the skin
and mucous membrane, with a lemon tint to the skin.
The temperature was 101° F., and the pulse was very
rapid. The spleen was enlarged down to the umbi-
licus, and extended well around into the flank. The
liver was one finger's breadth beneath the free border
of the ribs. The cervical and inguinal lymph nodes
on the left side had been very slightly enlarged. The
ophthalmoscope had shown a -pale retina with numer-
ous large, red-blotched hemorrhages. The blood ex-
amination showed very many large red cells present,
but scarcely any poikilocytosis. The proportion of
white cells was about one in twenty. There was a
total of ninety-seven per cent, of lymphocytes. There
was a little over two per cent, of multinuclear cells.
There were also a few myelocytes, megaloblasts, and
normoblasts. One week before death there had been
persistent vomiting and bleeding from the gums and
from the nose. At this time the abdomen diminished
markedly in size. The child had died four months
from the beginning of the attack, and six weeks after
the onset of acute symptoms. The abdominal organs
had been removed the day after death. The spleen
reached only to the free border of the ribs, and had
shrunk more than one-half in the last week of life.
Both the liver and the kidneys were extremely pale, and
the surface of the latter was covered with numerous
hemorrhages. The marrow of the rib was pink. He
had been unable to obtain the shaft of one of the long
bones. Peyer's patches in the intestine were swollen
and ecchymotic. The mesenteric glands were some-
what enlarged. The next case had been that of a man,
seventy-two years of age. The first sign had been
enlargement of the spleen, and this had steadily in-
creased up to the time of death. Four months after
386
MEDICAL RECORD.
[March 3, 1900
enlargement of the spleen the cervical, submaxillary,
and inguinal lymph nodes had enlarged. At the time
of coming under observation the spleen had reached
two inches below the umbilicus. The liver reached
four inches below the free border of the ribs. There
had been no fever, and no heart murmurs. Two or
three blood counts had been made. The haanoglobin
had been about si.xty-five per cent, and the red cells
had never been below 4,500,000. There was over
nine per cent, of large uninuclear cells. It had been
noted that the cells took up Ehrlich's nuclear stain
with great difficulty. Death occurred nine months
after the first symptoms, from pneumonia. The next
case had been that of a man between fifty and si.xty
years of age, who had gradually emaciated for nearly
a year before his death. The spleen had been very
markedly enlarged, and the inguinal, abdominal, and
axillary lymph nodes had also been enlarged. The
blood showed the ratio of at least one white to five red
cells, and of the white cells over ninety per cent, were
small lymphocytes. There were no mast cells, myelo-
cytes, or eosinophiles. Death had occurred in a little
over one year. The fifth case had been that of a man
fifty-seven years of age, who had had the grippe three
years before, followed by slight enlargement of the
cervical and axillary glands. Nineteen months be-
fore death the lymph nodes on each side of the neck
had begun to increase in size, and at the same time
blood clots had been passed in the urine. The latter
was explained by an ulcer in the urethra. Several
times bacilli resembling tubercle bacilli in appearance
had been found in the sediment from the urine, which
had not been decolorized by remaining twenty-four
hours in alcohol. The enlargement of the neck had
been so great that the neck had measured nineteen and
one-half inches in circumference. The spleen had
reached to three fingers' breadth below the ribs. The
liver had been only slightly enlarged. The haemoglo-
bin was thirty-five per cent.; red cells 2,000,000, and
white cells 418,000. The white cells were over ninety
per cent., almost all being of the small variety. The
duration of the illness was seven months. The speaker
said that the most interesting feature of these cases
was that the count of the white cells had apparently
run parallel with the duration of the disease, the cases
having the highest count of white cells having lasted
the longest.
Dr. E. Libm.'\x said that he had seen five cases of
acute leukaemia, and they had been of a verj' different
type from the chronic ones. The term " acute lympho-
cythaemia" seemed to him a much better one. In the
cases that he had seen, the white cells had consisted,
for the most part, of uninuclear cells, which ranged
from the size of the red corpuscle to twice that size.
There was but little protoplasm, about the nucleus, and
the nucleus stained poorly and was poor in chromatin.
The multinuclears were relatively, and sometimes ab-
solutely, diminished in number, and the eosinophiles
were very few. Frankel had described such cases.
The first case that he had seen had been that of a child
who had been admitted to the Mount Sinai Hospital
after an illness of a few weeks. At that time there
had been moderate enlargement of all the lymphatic
glands, a very large spleen, and hemorrhages all over
the body. He had been impressed at that time with
the fact that the red cells showed the characteristic
picture of pernicious anemia. Otherwise the picture
was that of an acute leukasmia. Many of the white
cells appeared to be degenerating. Two days later the
white cells had decreased very markedly. Corre-
sponding to this, the spleen and the lymphatic glands
had been reduced almost to the normal. Before death,
the white cells numbered only 2,200, and the blood-
picture was that of a pernicious ana;mia. There had
been a pneumonia present to which was attributed the
regiession of the leukasmic symptoms, as it was known
that under the influence of acute infectious processes
leukasmic changes ware apt to diminish. Another of the
cases he had seen had resembled typhoid fever. In a
third case, there had been two small abscesses, and,
the contents of these consisted almost entirely of
uninuclear cells. The fourth case had been that of
a woman who had entered Mt. Sinai Hospital suffer-
ing from pneumonia. She had the color of pernicious
anemia, and had hemorrhages in the skin and from the
gums. The white cells had not been increased greatly,
but had been of the type described. It was considered
that the patient was suffering from an acute leukaemia
which was regressing because of the pneumonia, and
an unfavorable prognosis was made. The pneumonia
resolved entirely, but the patient died some days later.
Dr. Libman said that he had reason to believe that the
symptoms and blood changes in an acute leukaemia
could regress without the presence of an infectious
process, and that such regression would have to be
explained theoretically by an exhaustion of the bone
marrow, clue to the hemorrhages.
Dr. James Ewing said he could accept three of the
cases as rather typical, but the eivdence in the first
two cases of acute lymphatic leuksemia seemed incom-
plete. In the first there had been a moderate number
of myelocytes and megaloblasts. The ansmia had been
severe, and there had been no autopsy. Moreover, the
lymphatic enlargement had been very slight. Such
evidence seemed to him insufficient to establish the
diagnosis. Myelocytes were almost unheard of in
lymphatic leukitmia — it was a diagnostic point. The
megaloblasts were usually very scarce; from the mild
stages of the chronic cases up to the termination of
the disease the absence of megaloblasts was quite char-
acteristic. The lymph nodes were usually the chief
seat of the lesion, and were very prominent, yet in
this case they had been but very slightly affected.
While, therefore, he would not say that it was not a
case of acute lymphatic leukaemia, there was good
ground for hesitating to accept that diagnosis. In the
second case, megaloblasts had been present; the
spleen had Ijeen extremely small, as had also been
the intestinal lymph nodes. The absence of any dis-
tinct indication of hyperplasia of the lymphatic struc-
tures was a strong point against acute lymphatic
leukaemia. He understood that there had been a con-
siderable enlargement of the liver during life — even
more marked than that of the spleen — while the blood
had shown the white cells to be not small lymphocytes,
but large uninuclear cells. He would not, therefore,
classify the case as one of acute lymphatic leukaemia,
but rather as one of von Jaksch's anaemia. He had
seen over one hundred thousand leucocytes in a case
of diphtheria in a child, over ninety percent, of which
had been small lymphocytes. He would not make a
diagnosis of acute lymphatic leukaemia unless the
lymphatic structures were very much enlarged, or the
blood changes very distinct, or until he had made a*
microscopical examination of the bone marrow. It
was beginning to be recognized that the separate types '
of leucocytes had nothing to do with one another. In
typical cases of lymphatic leukfemia the small
lymphocytes were the ones specially increased, yet on
examining the slide presented it seemed to him that
the small lymphocytes were hardly increased at all.
Dr. Libm.vn said tliat from the examination of the
blood slide from the second case, he thought there
could be no doubt that it was a case of acute leu-
kaeniiu. These cases were entirely different from lym-
phatic leuka-inia. The term "acute leuka'mia'' was
introduced to describe cases in which there existed
fever, hemorrhages, enlargement of the spleen and
lymphatic glands, involvement of the bone marrow;
and Frankel had shown, in 1895, that the blood
March 3, 1900]
MEDICAL RECORD.
587
changes found were such as appeared in the specimen
under the microscope, and that all these changes could
disappear to a large extent before death. He had
himself seen two cases in which the phenomena had
almost entirely disappeared before death, yet the bone
marrow presented typical changes at the autopsy. The
slide, together with the history, made it clear that the
case was one of acute leukasmia, according to the de-
scription given by Friinkel.
Dr. Janeway, in closing, said that in the first case
the spleen had decreased from one-half to three-fourths
during the last few days of life. By comparing the
size of the mesenteric lymph nodes as found at autopsy
with the clinical record it seemed evident that the
lymph nodes had diminished in size in proportion to
the diminution in the size of the spleen. It had
been recently suggested by Minkowski to make three
classes of leukaemia, viz.: (i) Ordinary chronic leu-
ksemia, beginning rather acutely, remaining stationary
for some time, and having a considerable duration;
{2) acute leukaemia, having the primary lesion in the
bone marrow, just as in the first class, but associated
with enlargement of the spleen and of the lymph nodes
and lymphatic apparatus elsewhere, and running a very
rapid course, sometimes only a few days, and associ-
ated with fever and hemorrhages; and (3) the chronic
lymphajmias — the class specially referred to by Dr.
Evvfing. The classification of von Jaksch's anremia
had seemed to him specially indefinite. A number of
cases had been recorded of transition from von
Jaksch's anemia to acute leukaemia. There was one
case on record of transition from pernicious anaemia
to acute leukasmia. In his fifth case, which Dr.
Ewing did not question, the cells had not all been of
the small lymphocyte type. The presence of megalo-
blasts in the acute cases had been thought to go hand-
in-hand with the acute anamia.
Demonstration of Specimen Showing the Growth
of the Tubercle Bacillus on Hesse's Medium. — Dr.
Robert J. Wilson said that Hesse's medium was sup-
posed to be peculiarly favorable for the growth of
tubercle bacilli, and depended for its efficacy upon a
special food-stuff. It was claimed that the tubercle
bacilli would grow on this in a few hours, so that their
vitality could be proved or disproved very quickly.
The medium was also useful in cases in which the
growth of the bacilli was not very characteristic.
Dr. Wilson said that he had made a series of seventeen
plates, and growths had been obtained on nine of these.
Trials had been made on blood serum and on ordinary
agar-agar, and with the e.\ception of one there had been
no growth at the end of forty-eight hoiu's. In the ex-
ceptional case there had been a small growtlr limited
to the borders of the cell. He had observed that the
growth in the plates seemed to start in some of the
material carried on to the plate at the time the culture
was made. This led him to think that it was highly
probable that the growth always first started in such
material, and then, finding the medium favorable,
further growth was able to develop on it. The mate-
rial transferred to this plate was necessary for the
starting of the growth, in very much the same way as
blood was necessary for starting cultures of the influ-
enza bacillus. Hesse thought it probable that the tu-
bercle bacillus divided in its longitudinal axis, which
was, of course, contrary to the general belief, yet a
.itudy of these plates which he had prepared afforded
some ground for such belief.
Dr. Hiss said that he had had experience in only
four cases in the growth of bacilli from sputum on
Hesse's medium. In all of these he had obtained a
growth which had continued for from twelve to four-
teen days, after which. the colonies had developed very
slowly. One plate had been under observation for two
months. He had seen nothing to make him think
that longitudinal division occurred. The organisms
were pressed out of the advancing line along the line
of least resistance. It might be that material carried
over had something to do with the starting of the
growth. The medium might be of service in the rapid
differential diagnosis of organisms presenting the
same staining characteristics.
Dr. L. a. Conner asked whether the tubercle
bacilli grew very much more rapidly on Hesse's me-
dium than the other bacilli found in the sputum.
Dr. Hiss replied that the contaminating organisms
from the sputum did not seem to grow so well on
Hesse's medium as did the tubercle bacilli. This
was one of the chief advantages of the medium.
Dr. Wilson explained that his work had been done
with pure cultures from guinea-pigs, so that he had
had no contaminating organisms.
Dr. Hiss said that the specimens that he had had
under observation for two months had not been over-
run in this way. and in the others the colonies were
still discrete. Hesse had taken great pains to secure
bacilli from material as free as possible from contam-
ination.
Dr. Harlow Brook.s said that he had seen four
plates by Dr. Hesse from sputum which contained a
good many streptococci and staphylococci. The con-
taminating organisms had been found comparatively
common in the smear, while the tubercle bacilli had
not been very numerous. About forty-eight hours
afterward the colonies of tubercle bacilli were strik-
ingly evident, while the growth of the contaminating
colonies had not been very marked. Two or three
days later the contaminating colonies had overrun the
tubercle growths.
A Case of Intestinal Tuberculosis in a Child. —
Dr. D. Bovaird reported the case of a boy aged three
years who had been returned to the New York Found-
ling Hospital last August in accordance with the rules
of that institution. He had then been sent to the
home at Spuyten Duyvil and had remained in fair
health until October 24th. At this time, during an
epidemic of measles, he had developed this disease,
and it had run the usual course. For a whole month
the temperature had been very irregular, and the
symptoms had indicated a severe bronchitis or bron-
cho-pneumonia, although the physical examination
failed to show pulmonary consolidation. During this
time there had been a severe stomatitis, though this
had improved slowly. At the end of November the
evening temperature had been 100° to loi' F. After
about two weeks more of this irregular fever the child
had developed the first enteric symptoms. About
December 15th the condition of the mouth had again
become worse, and had soon changed into a true can-
crum oris. It was in this condition that the child
had been returned to the Foundling Hospital. Death
.had occurred from the exhaustion incident to this. On
December 20th the child had died, and the autopsy
had been made on the following day. The pharynx,
trachea, and bronchi w ere normal. Both pleural cavi-
ties, except anteriorly, had been obliterated by ad-
hesions. The bronchial nodes contained a few minute
caseous foci. The lungs themselves were normal.
The peritoneal cavity had been obliterated by adhe-
sions, and the intestine and all the other viscera were
matted together by adhesions. The peritoneum was
thickly studded with miliary tubercles. The perito-
neal surface of the liver was covered wiih miliary
tubercles, but only a few were found in the hepatic
tissue. The same condition was found in the spleen.
The kidneys, suprarenals, pancreas, and stomach were
normal. Peyer's patches were swollen and contained
numerous ulcers which reached to the peritoneal coat.
In the upper part of the large intestine were a few
caseous nodules. The solitary follicles were enlarged
MEDICAL RECORD.
[March 3, 1900
throughout and somewhat ulcerated. The bladder
was normal except for slight congestion. The mesen-
teric nodes were enlarged, and some of them showed
caseous foci. Among the records of the Foundling
Hospital were those of two hundred autopsies on
cases of tuberculosis in children, yet in only three was
there a fair presumption that the intestine had been
the primary seat of the infection. For this reason
the case just presented was of special interest. Fur-
thermore, when tuberculosis had developed immedi-
ately after measles he had usually assumed that it was
nothing more than a lighting up of a previously re-
ceived tuberculous infection, but in the present in-
stance the dilTusion of the lesions through the small
intestine, taken in conjunction with the history of the
case, made it not improbable that the tuberculous in-
fection had developed subsequently to the measles.
Dr. Ewing thought the development of tuberculosis
after measles was too common to make it probable that
the tuberculous infection always occurred after the
measles. Regarding the condition of the Peyer's
patches it should be borne in mind that these were real-
ly excretory organs, and might possibly, under certain
circumstances, suffer from the excretion of tubercle
bacilli. He had recently seen for the first time cases
of intestinal tuberculosis limited entirely to Peyer's
patches. He had formerly supposed that tuberculous
ulcers were almost invariably irregular, and that their
long axes were in the transverse diameter of the intes-
tine. In some recent cases the ulcers had been con-
fined to Peyer's patches, which had been deeply
excavated. It seemed possible that the bacilli might
sometimes be deposited here by the blood current or
by the lymph current, instead of from the intestinal
contents.
Dr. Bovaird said that the child had been fed on
milk obtained from an excellent source. Up to the
very last the child had had a diarrha?a, yet the stools
had never contained blood, only mucus and undi-
gested food.
Dr. Martha Wollstein said that autopsies had
been held at the Babies' Hospital on some hundreds
of cases. Probably fifteen per cent, had been on tu-
berculous infants, yet in few of these children during
life had bloody stools been present, so that they had
come to look upon this as a rare symptom in young
infants. At that hospital they had never met with a
single case in which it seemed at all clear that the
infection had been primary in the intestine, even in
infants fed on bad milk. In the case under discus-
sion it seemed impossible to prove that the tuberculo-
sis had not been primary in the bronchial nodes. Its
rapid extension along the intestinal tract was pos-
sibly due to the condition of that tract (a previous
catarrhal condition of tiie intestine), thus furnishing a
line of least resistance, and explaining the localiza-
tion.
A Case of Acute Tuberculous Broncho-Pneu-
monia.— Dr. E. Hodeni'vl presented specimens from
a case of acute tuberculous broncho-pneumonia in
which death had occurred on the twelfth day of the
disease. The symptoms and physical signs had re-
sembled very closely those of acute lobar pneumonia.
The gross lesions of the lung could hardly be distin-
guished from those of a simple case of bronchopneu-
monia. The short duration of the disease was very
remarkable. The shortest recorded case of pulmo-
nary tuberculosis of which the speaker was aware was
eleven days. The subject was a colored woman, who
had been taken sick with pain in the left chest, cough,
prostration, and fever. After remaining in bed five
days she had been removed to the hospital, and exam-
ination had shown apparently an ordinary pneumonia
involving the whole lung. The temperature fell
rapidly in two or three days from 105° to 96" F., and
in a few hours rose again to 105°. At this time evi-
dence of consolidation had been discovered on the
opposite side. She died on the twelfth day. At the
autopsy, the left lung, which was free from pleurisy,
was studded with larger and smaller pneumonic
patches arranged about the bronchi. These were so
numerous as to cause the lung to appear almost solid.
The pneumonic patches except in one or two instances
failed to show any cheesy degeneration. The right
lung presented the same lesions as tlie left, though
developed to a less degree. Stained smears from the
pneumonic exudate showed tubercle bacilli in enor-
mous numbers.
Dr. Prudden asked if there was any clew as to the
possible source of the infection.
Dr. Hodenpyl replied that he could find none.
Evidently this was a case of aspiration tuberculosis
from the bronchi. No old tuberculous focus had been
made out.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meeting, February 12, igoo.
Charles N. Dowd, M.D., Chairman.
False Joint after Old Fracture and Dislocation of the
Elbow. — Dr. Forbes Hawkes presented a boy aged
thirteen years who, when eight months old, had fallen
and injured his left elbow. At that time it had been
treated for a time with plaster of Paris, but shortly
after the removal of the dressing he had hurt the arm
again. This second injury had not been treated.
The arm was now strong and useful, but there-was a
slight deformity over the inner condyle. Examina-
tion showed the left upper extremity to be slightly
shorter than the right. In the extended position the
internal condyle could be felt projecting, and there
was a movable bony mass above and attached to the
head of the radius. Flexion and extension were pos-
sible to practically the normal limits. Apparently a
new joint had been formed between the outer frag-
ment and the humerus itself. The case was of inter-
est because of the unusually good functional result,
considering the nature of the original injury. The
condition of the joint was shown by radiographs. No
operation was advised.
Dr. T. H. Manley was inclined to believe that the
olecranon was in its proper position in this case, that
the protrusion above was due to the enlargement of
bone, and that the olecranon moved on the proper
articular surface of the humerus. He had seen a
number of similar cases in which there had not been
really a false joint, and he did not believe that the
.r-rays gave much assistance in such a case.
Dr. Reginald H. Savre thought if an .r-ray photo-
graph should be taken in the antero-posterior direc-
tion, with the arm in an extended position, it would
clear up the point raised by the last speaker.
Dr. Hawkes replied that one of the radiographs
had been taken with the arm perfectly extended, and
this seemed to him to demonstrate the existence of a
false joint. Regarding the interpretation of A--ray
photograpiis he would say that he had recently had a
case of CoUes' fracture with typical deformity, which,
after its reduction, had failed to show in an .r-ray
photograph any evidence of fracture.
Round - Celled Sarcoma of the Testicle — Dr.
Pfister presented a man, twenty-five years of age, from
whom he had removed a large round-celled sarcoma of
the testicle. One testicle had not descended, but in
this instance it was the descended testicle that had
become malignant.
March 3, 1900]
MEDICAL RECORD.
389
Dr. John B. Walker said that, of a number of
ectopic testicles reported in the literature, a consider-
able percentage had developed sarcomatous change.
This was one of the reasons for urging operation on
the undescended testis.
Acute Intestinal Obstruction ; its Diagnosis and
Treatment. — Dr. Parker Syms read a paper with
this title. He said that there were two main classes
of this disorder, (i) in which there was not only an
occlusion of the intestinal canal, but a condition of
strangulation, and (2) those in which the fecal flow
only was arrested. The vast majority of cases of
acute intestinal obstruction belonged to the first class,
or, in other words, were attended by acute intesti-
nal strangulation. Acute intestinal obstruction and
strangulation, as in the case of a strangulated hernia,
must be looked upon as absolutely fatal, unless
promptly relieved by operation. This condition was
due either to intussusception, volvulus, constriction
by bands, escape of a loop of intestine through some
normal or abnormal aperture, pressure by a tumor or
displaced organ, or impaction of some foreign body.
Of course, any case of chronic intestinal obstruction
might become suddenly one of acute obstruction. For
most practical purposes it was proper to assume that
the strangulation was associated with acute obstruc-
tion of the bowel. Strangulation meant that a great
injury had been inflicted upon the nerves of the solar
plexus. This gave rise to abdominal shock — a condi-
tion which stamped these cases early and most emphati-
cally. This fact should enable the general practitioner
to differentiate early between true intestinal obstruc-
tion and mere constipation. The more important
symptoms were pain, vomiting, constipation, tympa-
nites, scanty urine, and the train of symptoms vi'hich
went to make up the picture of abdominal shock, i.e.,
small, rapid pulse, drawn and anxious face, perspira-
tion, and a peculiar mental condition of combined
fear and braggadocio. The vomited matter at first
would be the contents of the stomach; later, it would
be gastric mucus mixed with bile, and still later there
would be stercoraceous matter vomited. The consti-
pation would be absolute, and the tympanites would
increase. Hiccough might come on at any time. As
to treatment, the condition being a mechanical one, it
could be removed only by mechanical means. Ca-
thartics should never be employed, because they could
not relieve the condition, and might seriously augment
the pressure and even cause rupture of the bowel at
the weakened point. High enemata might be given,
but operation should not be postponed any great
length of time. The incision should be in the
median line, and the distended intestine should be
systematically inspected in the search for the site of
the obstruction. This having been found, it must be
dealt with according to the conditions found to be
present. In some cases the exhausted state of the
patient would allow of only a palliative operation,
such as the hasty establishment of an artificial anus.
When the vomiting was almost constant and projec-
tile in character, there was always danger from using
a general anesthetic. The use of opium in these
cases was most dangerous until operation was about
to be done, but at that time it was useful, as it was an
excellent abdominal stimulant. The author's conclu-
sions were: (i) Acute intestinal obstruction was a
fatal condition, if not promptly and properly relieved;
(2) acute intestinal obstruction should rarely be fatal
if promptly recognized and treated; (3) acute intes-
tinal obstruction was a mechanical condition, and
could be relieved only mechanically; (4") the symp-
toms of acute intestinal obstruction were absolutely
characteristic and distinct, and the diagnosis could
always be made, unless the clinical picture had been
obscured by the administration of opium; (5) an
early laparotomy, properly performed, was the only
plan of treatment which should be relied upon in this
class of cases.
Dr. a. a. Berg called attention to one pathological
condition coming on after the second or third day in
these obstructed cases, viz., an intense and rapidly
progressive emaciation. He had at first supposed
this to be due to the shock arising from the involve-
ment of the sympathetic plexus, but he was now in-
clined to think that the intense pathogenicity of the
imprisoned micro-organisms was the cause. The
question had often occurred to him, whether it was
wise to proceed to a resection of the bowel, even
granting that the patient's condition was good. Such
resection, together with an intestinal anastomosis,
would mean that the bowel must be kept at rest for
two or three days afterward. This would mean that
the organisms in the proximal loop of the intestine
would be draining the system constantly. He was of
the opinion that our statistics would be far better if,
under such circumstances, the artificial anus was made
at the time of the first operation, and a large tube was
introduced into the proximal and distal loops of the
bowel, and the latter washed out with saline solution.
A rather early secondary operation could be under-
taken for the relief of the artificial anus. This plan
seemed to him better than immediate resection and
approximation. He had had very good results from
infusing the patients every hour with saline solution.
He had seen patients pulseless at the time of making
an artificial anus kept alive for several days by these
repeated infusions, so that it seemed possible*that life
might be saved by the same treatment.
Dr. Manley said that he had never seen a case of
acute intestinal obstruction in which the patient sur-
vived twenty-four hours, if not operated upon. He
called attention to the fact that practically the same
symptoms would be observed in a case of perforation
of the bowel as in one of acute intestinal obstruction.
The chief difference would be in the absence of he-
patic dulness in cases of perforation, because of the
diffusion of gas upward. A case was mentioned in
which, though the symptoms had been very acute and
had lasted only a few hours, the use of a high enema
had resulted in the escape of the fluid through the
gangrenous portion of the bowel into the general peri-
toneal cavity.
Dr. H. J. BoLDT narrated the case of a child aged
twelve years who had been operated upon for perfora-
tive appendicitis and a general peritonitis. The
operation had been done last July. The girl had re-
covered with a fecal fistula, which had healed spon-
taneously in a few weeks, and had remained so up to
a few days ago. When she had been seen on Febru-
ary 5th there had been vomiting and abdominal pain,
a pulse of no, and a temperature of 101,4° F. A
high enema had been given at once, but with no relief.
On tli,e following day most of the symptoms had abated,
and the general condition had been better. It was as-
sumed that the intestinal obstruction was due to a band
from the previous peritonitis, and owing to the excel-
lent general condition and the absence of tenderness
to the left of the umbilicus and on a level with it, de-
lay had seemed justifiable. On the next day the pulse
had been normal, and tiie temperature nearly so, but
there had been a suspicious point of resistance, and a
little stercoraceous mattei had been vomited. Ab-
dominal section was therefore done promptly, and, to
his surprise, considerable peritonitis was already
present. The obstruction was found to be due to a
band. About eight inches of tJie bowel had been re-
sected and an anastomosis established. So far, the
child had done well. He had operated upon another
case early that morning — that of a child aged seven
years. The history had been absolutely typical of an
39°
MEDICAL RECORD.
[March 3, 1900
acute intestinal intussusception, but on examination he
had found a large swelling in the epigastrium, which
had led him to doubt the correctness of this diagnosis.
Owing to the great urgency of the symptoms he had
hastily made an exploratory incision, but had found
nothing but a very greatly enlarged liver. That child
had died within a few hours, but he had been unable
to explain the symptoms of intestinal obstruction.
One speaker had referred to the necessity for keeping
the bowel quiet for a few days after these intestinal
operations, and this led him to say that he had not
made it a practice to do so, and had seen no reason to
regret having adopted this course.
Dr. a. Ernest Gallant mentioned a case of vol-
vulus in which he had relieved the early bilious
vomiting by the use of plain water and nitroglycerin.
He had desired to operate, but several consultants
had advised against it. Death had finally occurred,
and the autopsy had shown the cause to have been a
volvulus. According to his experience most patients
in cases of acute intestinal obstruction did not die
under five or six days. In post-operative cases of in-
testinal obstruction, relief might often be afforded by
masgage of the bowel, and when this did not succeed
he felt that immediate operation was imperative.
Dr. Willy Meyer said that the gut should always
be opened above the seat of obstruction at the time of
operation, and the contents of this portion should
never be allowed to pass on downward. The evacua-
tion of the matter contained in this portion could be
readily effected by making either a transverse or a
longitudinal incision into the bowel. This should be
the rule with every surgeon before attempting to re-
duce the intestine into the abdominal cavity.
Dr. Syms said, in closing, that he had endeavored
to show in his paper the possibility of making an
early diagnosis, and the probability of securing a
good result from early operative interference. It was
most important, therefore, to throw into the back-
ground the exceptional cases, which served chietly to
obscure the diagnosis and encourage fatal hesitancy.
He was disposed to follow Dr. Boldt's advice to move
the bowel early, even after resection and anastomosis.
The Hockey-Stick Incision — a Typical Mode of
Entering the Abdominal Cavity in Certain Compli-
cated Cases of Appendicitis Dr. Willy Meyer
read a paper with this title. He said that at the
present time in interval cases of appendicitis every
surgeon tried to get along with as small an incision
as possible. The effort should be made to restore the
abdominal wall to its former condition. It was differ-
ent in cases of acute appendicitis, in which very free
access to the abdominal cavity was often essential.
The incision parallel to the outer side of the rectus mus-
cle was now rarely employed ; the majority of surgeons
when operating for acute appendicitis preferred to
make the incision very near the anterior superior iliac
spine, where the abdominal muscles were the thickest.
The trouble here was to decide upon the best mode of
enlarging such an incision should it become neces-
sary. Many surgeons would abandon the first in-
cision, and make a second one in the median line;
others would make a more oblique incision without
regard to the direction of the fibres of tiie external
oblique muscle. The speaker said that, in the course-
of his operative work in appendicitis, he had found a
very useful incision^the one described in the title of
this paper. He had discovered that an incision in
the direction of the fascia of the external oblique
should begin exactly midway between McBurney's
point and the anterior superior spine, and then con-
tinue in a straight line downward to a point at which
the femoral artery was found pulsating under Pou-
part's ligament. In ninety-five per cent, of the cases
such an incision would correspond with the direction
of the fibres of the fascia of the external oblique. In
most cases of acute appendicitis he began the inci-
sion half an inch above and midway from McBurney's
point and the anterior superior spine of the ilium, and
ended it from half to three-fourths of an inch from
Poupart's ligament. He first ascertained where the
femoral artery was pulsating under Poupart's liga-
ment, and then cut toward this point. His practice
was to enter the peritoneal cavity at the lower end,
and, with his finger inside as a guide to the position
of the epigastric artery, enlarge the incision down-
ward and inward in a curved direction. This gave
to the whole incision the shape of a hockey-stick;
hence the name. The incision was exceedingly use-
ful in intrapelvic operations. Even the left Fallopian
tube and ovary could be palpated by two fingers passed
through this incision. The upper or straight portion
of the incision might be closed with tier sutures, and
the lower portion left for drainage, although some-
times it was desirable to insert one or two sutures in
the extreme lower angle of the curved incision.
Dr. John F. Erdmann said that some years ago
he had employed an incision having a similar curve,
and had found it exceedingly useful for exploring the
pelvis. It seemed to him that it should not be neces-
sary to cut through the conjoined tendon; it should
be possible to separate this structure.
Dr. Joseph Wiener said that he could not quite
agree with Dr. Meyer that most surgeons, in cases of
appendicitis, cut through the thickest portion of the
abdominal muscles; the majority, he believed, now
avoided dividing the muscles as had been done eight
o.r ten years ago, preferring to use Kammerer's inci-
sion through the rectus muscle. One point in favor of
this incision was thai one did not know, even in in-
terval cases, just where the appendix would be found.
An incision along the border of the rectus muscle,
which could be enlarged upward or downward ad
libiium, seemed to him the most valuable for the great
majority of cases.
Dr. Meyer said that by means of an incision near
the anterior superior iliac spine it was possible, in
almost every instance, to reach the appendix, no mat-
ter where the latter was situated. In cases of acute
appendicitis he was particularly opposed to the inci-
sion at the border of the rectus, not only because such
an incision did not give the freest access to the ap-
pendix, but because it involved the division of the
nervous supply of the rectus, and therefore caused
paresis of this muscle.
Strangulated Omental Tumor.— Dr. C. H. Peck
exhibited a tumor made up of the entire omentum.
This had been found rolled up in a vertical direction,
and filling the right side of the abdomen from the
umbilicus down to the pelvis. It projected behind
the uterus and to the right, and pressed well into the
anterior fornix of tlie vagina. The woman gave a his-
tory of having been in her usual health up to four or
five days prior to admission to the French Hospital.
She had then been attacked suddenly with abdominal
pain and vomiting, associated with a moderate rise of
temperature. On admission the temperature had been
100.5° F., and a mass could be m;ide out indistinctly
in the abdomen. On performing abdominal section,
this solid tumor had been found. About two inches
below the transverse colon a very tightly twisted
pedicle had been discovered. This had proved to be
the entire upper portion of the omentum twisted
around the vertical axis. The symptoms had evident-
ly begun when the strangulation of this portion had
been produced by the twisting.
'« The Journal of the Medico-Chirurgical College "
of Philadelphia is the title of a new monthly journal,
under the editorial charge of Dr. John A. McKenna.
March 3, 1900]
MEDICAL RECORD.
391
CTofvespciiuIence.
OUR LONDON LETTER.
(Fn
I Our Special Corresponclenl.)
MILITARY MEDICAL SERVICES — THE EPIDEMIC THE
REGISTRAR-GENERAL — SALOL IN' SMALLPOX — GLAU-
CO.MA CAUSED BY MYDRIATICS — EPIDEMIC DIARRHiXA
MIDWIVES BILL — INCREASE OF PROFESSION —
DEATHS OF SIR T. G, STEWART, DR. TURNER, AND
MR. ADAMS.
, London, February y, 1900.
The rude awakening of the public to. the inefficiency
and criminal blundering of the War Office may
perhaps lead to an improvement of the medical depart-
ment. Already there is some anxiety as to the defi-
cient number of the Royal Army Medical Corps mani-
fest at Aldershot. A correspondent there says it is a
very grave question where the details of this corps are
to come from for the thirteen thousand men leaving
our shores for active service by Monday next. All
that are at present left at Aldershot are the details for
the eighth division and less than fifty men outside
the recruits under training. A reinforcement of the
corps by at least one hundred officers is urgently
needed to meet the necessities of the service, but the
military authorities go on groping in their purblind
way of routine. A "competitive" examination has
been advertised for thirty vacancies, and only twenty-
five candidates are ready to compete! Competition
indeed!
On Tuesday the War Office notified that men of the
Volunteer Medical Staff Corps and bearer companies
of the volunteers who joined the Royal Army Medical
Corps would receive the same pay, allowances, and
other gratuities or privileges of the R.A.M.C.
The condition of the militia is also causing anxiety.
As this force has been neglected in nearly every other
department, it is not to be wondered at that the medi-
cal has got near the vanishing-point. On the part of
the authorities it is asserted that twenty-four medical
officers are still serving with the militia. These must
be fast nearing the age of retirement, and are those
who have survived of the two hundred and fifty at-
tached to this force before the change from the regi-
mental system. Some forty years ago the army medical
officers with those of the militia were nearly fourteen
hundred in number. Now they do not muster nine
hundred. Everything connected with the defence of
the country is now occupying public attention, and the
indignation expressed as toother negligences is likely
to be extended to that concerned with the sick and
wounded.
Inliuenza continues to decline steadily, as seen in
the mortality returns. In the last week the number
of deaths registered from the epidemic fell to one
hundred. It was a contributory cause in fifteen other
deaths, but in this class the fall is just as marked.
The death rate of London from all causes fell last
week to 19.6, and in this total rate the decline has
been steady. For the preceding three weeks the figures
were 33.3, 26.9, and 22.2. In the thirty-three great
towns the rate averaged 21.2, the highest being 35.4
at Sunderland, the lowest 12.6 at Derby. At Notting-
ham, which I mentioned a month ago as having
reached 44.9, it has declined to 18.3.
Speaking of registration reminds me that a new
registrar-general has been appointed in place of the
retiring one. There were a certain number of people
who thought that in the fitness of things the authori-
ties would appoint a medical man to the office. They
counted their chickens too soon. What matters that
medical knowledge is the proper qualification for ap-
preciating the many questions that arise in the regis-
tration of deaths? What matters the lessened scien-
tific importance of the statistics.' The berth was too
good to be given to a mere doctor, when a hundred
greedy hands were stretched out to every one who ha<l
any voice in the selection or recommendation of a
candidate.
The salicylates at one time were employed, perhaps,
on a more extended scale than of late. In all sorts
of fevers some of them were tried. Pridaux treated
eighty-eight cases of confluent smallpox by salicylates
without one death. That was in 1878. Since then I
have heard of no such success, though perhaps the
treatment is still employed in some places. Dr.
Charles Begg last month communicated to one of the
Edinburgh medical societies his experience in China,
where he treated the disease with salol, acting on in-
ferences he drew from observation in patients taking
the drug for other conditions. A patient with cystitis
took a drachm daily, and though he had hundreds of
mosquito bites they gave him no trouble; there was
no swelling, redness, or irritation. Vet before taking
the salol the man suffered much from the mosquitos.
Dr. Begg inferred an anaisthetic effect on the skin, and
proceeded to try salol in smallpox. He admits that
there was some mental depression, but not enough to
account for the freedom from skin irritation. In
smallpox, he says, salol almost always prevented the
vesicles from becoming pustules, and when it was used
early no pocking occurred. The patients had no de-
sire to scratch the skin, so the danger to the eyes was
greatly lessened. The freedom from cutaneous irrita-
tion also allowed the patients to sleep and so pre-
vented exhaustion. No ill effects were noticed when
doses of a drachm daily were continued for long
periods.
Dr. Begg attributes to the drug an anaesthetic effect
during elimination by the skin, but we have no evi-
dence that elimination through this channel takes
place; it is certainly not the usual course. He says,
too, that the foul odor of variolous patients was masked
by a fruity odor, which he infers is due to the elimina-
tion of the salol by the skin. The observation is in-
teresting, whether the inference be correct or not.
Dr. Norman Walker said his experience with salicin
in skin diseases supported Dr. Begg's observations
with salol.
Glaucoma may follow a single instillation of hom-
atropine. Mr. Shears reported sucii a case to the Oph-
thalmological Society. It occurred to a woman aged
fifty-two years, who at the Liverpool Elye and Ear In-
firmary had one or two drops of a solution, four grains
to the ounce, put into her right eye, and a week later
returned with all the signs of acute glaucoma, render-
ing iridectomy necessary. Mr. Shears said he thought
no mydriatic should be used in patients over the
age of thirty without very careful consideration. If
homatropine were used it would be well to instill
eserine before the patient left the hospital; cocaine
followed by eserine was usually sufficient for ophthal-
moscopic examinations, or euphthalmin, the new
dilator, would be satisfactory.
Only a few cases have been reported by specialists,
but it is of importance to the general practitioner,
who often uses mydriatics, to remember the possibility
of this untoward effect.
The Royal College of Physicians has adopted the
recommendation of its committee appointed last sum-
mer on the certification of deaths from diarrhoea. It
appeared that a number of different terms were em-
ployed by practitioners to designate epidemic diar-
rhoea, leading to confusion in the registration returns,
and perhaps confirming the public in the notion that
diarrhoea is not dangerous. The college, therefore,
recommends that the term "epidemic enteritis " should
392
MEDICAL RECORD.
[March 3, 1900
be uniformly employed, to the exclusion of gastro-
enteritis, muco-enteritis, gastric catarrh, etc.
We are again to be troubled with a midvvives bill.
It has been put down for the 28th. Happily the
miners' eight-hours bill has the first place for that
day, so perhaps the midwives may be lost for want of
time.
The subscribers to the Medical Directory have re-
ceived their copies. The issue was delayed by a fire
at the printing-office. From the statement of the
editors the number of names included is 35,651, be-
ing an increase of 534 on last year's numbers; and
that is an increase of 6,127 '" t'i<^ ^^^^ ts" years. An
overcrowded profession — but the numbers still rising!
You will regret — doctors in all countries will regret
— to hear that Sir Thomas Grainger Stewart has suc-
cumbed to the illness to which I have more than once
referred. He died on Saturday last, February 3d, in
his sixty-third year. The end was rather une.xpected
by many, though it was generally known that it might
occur at any time, although he had not long before
been able to drive out. In youth he had had rheu-
matic fever with cardiac complication, and in 1882 he
was again attacked, pericarditis being severe. He re-
turned to work, and in 1891 had influenza, which left
the weakened heart much worse. Last year a pleuritic
attack necessitated paracentesis. The valvular dis-
ease proceeded, now better, now worse, as usual, and
at length the heart quite failed. It is as a great
clinical teacher that Sir Thomas Grainger will be
first thought of by his pupils scattered all over the
world, for he succeeded Professor Laycock in the chair
of Physic of Edinburgh University as long agp as
1873, having previously been connected with the
Royal Infirmary and the extra-mural school. He was
born and brought up in Edinburgh, but after graduat-
ing he spent some time in study on the continent.
Soon after returning he became pathologist and assist-
ant physician to the Infirmary. For some time he
lectured on pathology at the Royal College of Surgeons,
where his remarkable teaching ability had full play.
Those who have heard him speak in later years will
readily understand that his eloquence, commanding
figure, and profound learning, combined with a gift of
humor, must have been most attractive to students,
who found that he could make the dryest subject in-
teresting. Once a man so gifted begins to teach, his
steady rise in the estimation of colleagues and stud-
ents may be safely predicted, and Edinburgh soon
became proud of her professor. Other universities
recognized his merits and gave him their degrees,
and the College of Physicians made him president.
Learned societies in various countries enrolled him
in their membership. He was appointed physician
to the Queen, and in 1894 was knighted. He was
deputy-lieutenant of the city and county of Edinburgh.
Sir Thomas Grainger's chief medical treatise was
that on " Bright's Diseases of the Kidney," which at
once placed him in the front rank of renal pathol-
ogists, and the second edition of which appeared in
187 r. In 1884 he published " An Introduction to Dis-
eases of the Nervous System," and he had previously
made several contributions to this class of diseases.
Somewhat later came two " Clinical Lectures on Im-
portant Symptoms," issued separately. No. i was on
"Giddiness" and No. 2 on "Albuminuria." But a
man of Sir Thomas Grainger Stewart's breadth of
mind and literary power would not be confined to
medical work, and some two years ago he ventured to
publish a drama in blank verse, "The Good Regent,"
and so he is numbered with the doctors who have
dallied with the muse.
The death of Dr. Charlewood Turner will come as
a surprise to many who looked to him for further con-
tributions to pathology, for he was comparatively
young and had certainly not reached the height to
which he seemed destined. He graduated at Cam-
bridge in 1874, joined the London College of Phy-
sicians the next year, and was elected a fellow in 1881.
He was physician to the London Hospital, where for
some time he taught pathology. To the International
Congress of 1S81 he contributed a paper on " Fibroid
Degeneration of the Heart." He had previously read
important communications at the Pathological and
other societies, and at their meetings he was always
listened to with the respect due to his extensive
knowledge of pathology.
Last week I recorded the death of an aged ortho-
paedic surgeon, Mr. Brodhurst. I have now to an-
nounce another still older, Mr. William Adams, who
died on Saturday last, the eightieth anniversary of his
birth, of bronchitis and pulmonary congestion. He
took his diploma of M.R.C.S. in 1842, and the fel-
lowship of the college in 1851. He won the Jack-
sonian prize in 1864, the subject that year being club-
foot, though his lectures on orthopedic surgery and
on subcutaneous surgery were much earlier; in fact
he was a frequent contributor to the press and societies
from the fifties to the time of his retirement, for you
will find an article of his on " Wry-neck " in the Trans-
actions of the American Orthopedic Association for
1896. He was an ex-president of the Medical Society
of London.
LETTER FROM NEW ZEALAND.
CFrom our Special Correspondent.)
Auckland, January 17, 1900.
There are only three topics that occupy public at-
tention here at present: First, the war; second, the
influenza, and third, the appearance of the bubonic
plague in South Australia, the Sandwich Islands, and
New Caledonia.
The last is the most recent sensation. " Proximus
ardet Ucalegon," and finding the fire so near us and
in places with which we have constant communication,
we have naturally taken the alarm. The sanitary
authorities have ordered the inspection of all premises
and the removal of filth. Of course this is rather late
in the day, but better late than never. The death
rate here is small, about eleven per thousand annually,
and the people live well, and for the most part are
temperate as to drink. It is probable that there will
not be nearly so large a mortality from plague as there
has been from influenza.
Influenza has been prevailing in every part of the
colony during the last two or three months. The
curious thing is that instead of commencing at one
centre and spreading gradually to the rest of the
colony, it broke out simultaneously in every part.
This I cannot but attribute to the occurrence of elec-
tion meetings. We are not plagued with many elec-
tions. \^'e do not elect our judges or magistrates or
local officials. We have only the municipal elections,
and the general election for the House of Representa-
tives. I don't know who the people are who take
any interest in municipal elections. The general
election, which takes place once in three years, does
arouse some public interest, more, however, on account
of the prohibition question than for any other reason.
We have local option here to the fullest extent, and
the vote is taken at the same time and place as that
for the House of Representatives. Our upper house
is nominated by the governor.
Very many crowded and enthusiastic meetings w-ere
held in every part of the colony during the three or
four weeks preceding the election. These meetings
were held in halls always badly ventilated, and, if
ventilated at all, by open windows. Persons just re-
March 3, 1900]
MEDICAL RECORD.
393
covering from influenza were there, poisoning the air.
The people came out (it was our summer) bathed in
perspiration, exposed themselves to the night air, for
these meetings are always held at night, caught cold,
and the cold took the form of influenza, with the
usual characteristics. There was the sudden attack,
the high fever, the complete anorexia, the cough, slight
bronchitis, or in some cases gastro-intestinal catarrh,
and above all the intense nervous prostration. This
is sooutof all proportion to the short but severe febrile
stage, and lasts so long unless specially treated, that
it forms the most important feature of the disease.
Practically, in this relaxing and debilitating climate
of Auckland, unless people can get away for at least
a short time after an attack of influenza, the weakness
will last for months. I have known cases in which
the patient has complained, a year after the primary
attack, of never having felt well since it occurred.
The disease is not fatal under proper treatment,
but by careful selection of your doctor you may kill
off speedily and without scandal an aged relative from
whom you have expectations. I have found a treat-
ment by small doses of liquid extract of cinchona, two
to three minims every four hours of liq. strychnina;
(P.B.), and whiskey, invariably successful. I have not
yet lost a case. The whiskey I find very popular with
prohibitionists.
The war absorbs about four-fifths of the public at-
tention. We have already sent one contingent, and
before this letter is posted a second one will have
left. Our men have already undergone the baptism
of fire, and three have been killed. We could send
thousands, if they were not so mighty particular about
the medical examination. It is very absurd to be so
strict, as the men are engaged for only a year, and are
mounted infantry. Now any man in fair health with
a good constitution, and accustomed to an outdoor life
mostly on horseback, may be taken as good for a
twelvemonth, to do the same as he has been doing
before. If he is a good rider and a fair shot, he is
certainly good enough for the Boers to make a target
of. I remember in the Crimean campaign having a
lad aged eighteen years under my care, who had been
only three months in the service, and who was
wounded in four places before he had ever fired off
his own rifle. And this grieved him. So he died.
It will give you some idea of the spirit that is ani-
mating our people to mention that it is more than
hinted that political influence is brought to bear on
the examining doctors, to induce them to reject some
and admit others. I believe half our young men would
go, for the mere love of a iight, if they could get the
chance.
LETTER FROM SYRIA.
(From our Special Correspondent.)
Eevrout, Svria, January, lono.
In speaking of our climate, we cannot say a word
against the time that came between our summer and
our winter. The months passed on the even tenor of
their way. It was never cold, and — except, perhaps,
of a sultry evening — only moderately hot. The famous
mosquito came, carrying with him, no doubt, as every-
body knows, his more famous parasite. But the
weather did its duty, and the too-familiar insect took
itself off before a storm, carrying its sucklings with
it — and thus malarial types of fevers have been in
abeyance.
These autumnal days of ours, too, they did the best
of all ; besides their action on the pests we mentioned,
they cleared with a whirligig of purifying tempest —
albeit, they nearly cleared us, too, off this promontory
of ours — they cleared and cleaned the dens and lanes
of filth and rubbish in many forms, and flushed the
drains, and did such wonders with the rains from
heaven that old men tell us here that never in their
memory has this town been so empty, swept and gar-
nished. It may have been the thunder and the light-
ning and the rain that did it. At any rate there was
not a speck of mud nor the least small cloud of dust
for at least three days.
So we woke up one morning to find our streets clean.
And then for a time again there was nothing but dust
and sunlight with mellow nights between, and with a
drizzle or two old winter came on at last, letting the
hardier ones of us off from the necessity of lighting
fires in our houses to warm ourselves. From October
till now, inside our homes the temperature has ranged
from 64° to 62° F., with a minimum temperature of 52°
F. outside. One night, however, we must admit the ther-
mometer did drop to 56° F. in the house. The next
morning there was a general complaint against the
bleakness of the season, and many caught colds. It
was a good thing for the profession here, as Beyrout
had been previously presuming (as I heard it put by
some one) to be so healthy that it might be necessary
for medical men to raise their fees.
Be that as it may, this Eastern race, though subtle
in instinct, is of a cool and calculating judgment, and
they tell me that there is no need for either the Peculiar
People or the Christian Scientists (so called) to come
among them. These abnormalities would have small
shrift in this Eastern town of ours, so the doctors are
not likely to suffer from their invasion.
Healthy and all as we are here, there are two dis-
eases abroad among us, and " we cannot wash them
out": tuberculosis and typhoid. Strange that the
former should exist in a land of sunlight and fresh
air! We have the sunlight; but the fresh air is kept
back from us. We speak only of the town. The
mountains and the villages thereon, though not looked
after well, are so situated as to be able to look after
themselves in a manner.
But there is always the mauvais cerde — the constant
current — ranging round some fixed point, or flowing
onward. We miss them sometimes, but they find them
(these two) at home among the snow, having climbed
the mountains, and then they wander, maybe hand-in-
hand (it seems so), down the valleys, and they are in
our midst again.
They go as men go, these little, vicious rods made
to scourge us, and they come again with the men that
carry them to scourge us once more. Let them — they
and all that are their bearers — abide each in his own
place. We do not presume to say that segregation is
a necessity ; merely do we suggest that judicious super-
vision is in all cases advisable should we all be placed
in a position to render each other's lives long and
spent to best advantage.
Whether drawing their inferences from the instruc-
tions of physicians, or from book lore, or from what
not, the people among whom we dwell have arrived at
a sound judgment of the disease which it is best to
avoid — with one exception. A wife is not driven from
her husband on account of his suffering from typhoid
fever. His friends and relations are sure to get under
cover or get out of range; once the disease is diag-
nosed the word goes forth. Once the dread word
" sill " (the meaning whereof is tuberculosis) is whis-
pered, good-by to family and friends and wife together;
and there are nursing and tending by strangers.
And then comes what one would look upon as the
irony of it all! Diagnose a case of the disease that
made Jenner justly famous, and you are as unto the
man that used to make the silver shrines for Diana of
the Ephesians — your craft is gone. They know that
people have been, or ought to have been, vaccinated
(the Turk adopted the method long before the Euro-
pean), and having a firm belief in the efficacy of the
394
MEDICAL RECORD.
[March 3, 1900
method as proved so many times among them, they
wait and trust, and good-by to the medical attendant.
Prevention can hardly be taugjit to people like this.
It seems it cannot be to people who, as the world goes,
are more enlightened. In France, in one year, they
say, nearly a quarter of a million fall from what we
call preventable diseases. In London, a month's out-
break of influenza raised the average death rate to
what might be called fabulous figures. It is a stale
phrase, maybe, but the words are good — prevention is
better than cure.
There is a great war raging in the Transvaal just
now, and though the Boers and their allies have been
trying their game of " fool's mate " against the English,
the latter seem, at any rate, to have been playing a
steady game against the intrigues of disease among
their soldiers — disease is more destructive than war in
the killing of men.
A MODEL DAIRY FARM.
To THE Editor of the Medical Record.
Sir : I was very sorry not to have been able to be at
the New York County Medical Society at its last
meeting, for I very much wanted to hear and to take
part in the discussion of the milk question. Having
read the paper and the remarks of those who spoke on
the subject I cannot refrain from supplementing them
by giving a little of my observation regarding the
handling of milk.
The reader of the paper is correct in assuming that
the proper way to have clean milk is by care at the
dairy farm.
It was once my pleasure and very great privilege to
visit a properly conducted milk farm. The stable
itself was situated on a hill. The building was well
lighted and ventilated. One set of men, who had
nothing else to do, kept the stable in a state of perfect
and perpetual cleanliness. They wore a clean uni-
form of brown, and themselves were clean and healthy.
The udders of the cows were washed immediately
before milking, each time, by a set of men who bore
the same general description, save that they wore a
uniform of blue. The cows were milked by a set of
men who were if possible more cleanly than the others,
and who wore uniforms of the purest white. Pails
used for milking were provided by a man who did not
go near the cows. These pails had been sterilized in
a steam sterilizer for two hours before being used and
then were locked, the milk entering through a strainer
as it left the cow. Once in the pail it could not be
taken out until the lid was unlocked. This duty was
attended to by the man who cared for the pails at the
entrance to the stable. He received the full pails
from the milkers, unlocked them, put the milk in a
forty-quart can that had also been sterilized, and when
this can was full sent it off by an elevated wire to the
milk-house, a quarter of a mile away — where it was
received by a man in attendance, who himself was
clean, and who put the milk into a large copper hop-
per, which had been within the last half-hour released
from its steam bath, but was now surrounded by cold
water in a sealed vat.
From this tank or hopper the milk ran down over a
copper cooler, one side of which was in contact with
iced water, and which had recently been steamed.
From this cooler the milk flowed into another vat for
bottling, which was accomplished without handling.
This last vat, like all the receptacles into which the
milk goes, is regularly sterilized by steam, as are the
bottles into which it finally goes. These bottles re-
ceive the most careful washing with a soda solution
and then are steamed while upside down for two and
one-half hours, and without handling of any kind re-
ceive the milk and then are sealed by hands that are
aseptic.
There was nothing I could think of that was likely
to contaminate the milk in any way, and it was thor-
oughly aerated and was cooled in a very few moments
after leaving the cow, and put on ice.
This milk will keep for a very long time if on ice.
It lias been sent to Europe and back remaining per-
fectly sweet and good. How long it will keep when
thus treated no one knows; but I think I had some
once two months old, perfectly sweet and good. Just
as much care is used in the care, feeding, and selec-
tion of cows as in the handling of the milk.
Four physicians and two veterinarians are employed
to examine the cows, and look after and certify regu-
larly to the healthfulness of both the cows and the
milk.
Surely this is near the ideal condition; and since it
has been very profitable to this man it undoubtedly
would be so to others; and I wish this description of
a successful and thoroughly satisfactory milk farm
could have gone with the discussion of the subject at
the County Medical Society.
WicKES Washburn, M.D.
February lo, jgoo.
ODOR RECORDS.
To THE Editor of thk Medical Record.
Sir: In your London Letter of December 29, 1899,
there is a remark concerning which I have thought
much. It says: "But in most zymotic diseases we
are still searching for clear, easily applied diagnostic
tests." A short time ago I had a case of obscure ru-
beola accompanied with typhoid symptoms. The
eruption did not indicate the disease and was very
slight. Now the thought occurred, if one could have
a sensitive plate which would record a photograph of
either the odor or emanation of the various eruptive
fevers it would be of great value in either an early or
difficult diagnosis. Say, to have the patient breathe
upon the plate and to be able to make a photograph of
various emanations from different fevers. For those
who have the time the above suggestions might lead
to interesting and useful experimentation. Our
knowledge of odors is quite limited, and I would like
to offer the above as a possible way to increase such
knowledge. W. G. Cotton, M.D.
THE MEDICAL ASPECTS OF THE WAR IN
SOUTH AFRICA.
( Kroin our Special Correspondent.)
The Numbers of the British Troops The begin-
ning of the third week in February brings no successes
to British arms, and the story of each battle, whether
a genuine engagement or only a " reconnoissance in
force," is the same. The Boers, having taken ample
advantage of the opportunities given them wiiile num-
bers were on their side, and having used well their
knowledge of the country and their peculiar aptitude
for a certain class of warfare, have taken Up impreg-
nable situations between the British forces and the
towns to be relieved. Numbers, overwhelming num-
bers, of soldiers will have to be employed by the Brit-
ish in the attacks, so that, like a sea, they may flow
round the Boer positions; otherwise success is hardly
to be expected for them. This is now realized by the
British government. Only a month ago I gave you
the exact figures of the British troops as 70,000 all
told, the medical officers numbering 160. By the be-
March 3, 1900]
MEDICAL RECORD.
395
ginning of February the total of British troops in
South Africa amounted to 179,000, made up as fol-
lows: Regular army, 128,000; navy, 1,000; militia,
9,000; yeomanry, 5,000; volunteers, 10,000; and
colonials, 26,000. Of the colonial troops, 20,000 were
raised in South Africa, and 6,000 have been sent from
Canada, Australia, and other dependencies. The
medical staff has been augmented in proportion, and
there are now in South Africa, or there will be in the
course of a few days, 368 officers of the Royal Army
Medical Corps and 133 civil surgeons. The propor-
tion of medical officers to the total number of troops
is worth noting. As the war has been characterized
by heavy fighting, and as the British medical arrange-
ments have been on all sides considered adequate, it
may be held that this proportion is as high as is neces-
sary.
The Attempts to Relieve Ladysmith have so far
been unfortunate. The second attempt, which resulted
in the capture and subsequent abandonment of Spion
Kop, was attended by considerable loss of life, but the
third, which was rather a reconnoissance than a delib-
erate forward movement, brought no casualties in its
train. The capture of Spion Kop cost the British 34
killed and 61 wounded officers, 217 killed and 1,115
wounded men, making 1,744 in all. (I include in
these figures the casualties attending the accompany-
ing' or preceding movements at Venterspruit and Pot-
gieter's Drift.) It will be seen that the death rate
among the officers was very high, testifying to the good
marksmanship of the Boers. If ten per cent, of the
total of 1,176 wounded die — which is rather above
than below the average at present shown by medical
statistics of the war — the total deaths will amount to
368, so that the advance was a costly one. Two-thirds
of the wounded will, however, probably be fit to serve
again in three weeks' time. This, again, is based
upon medical statistics. From which figures it will
be seen that while modern warfare calls for many men
because of the heavy slaughter that may occur at one
point, it also allows the same men to be used many times,
because the wounds from the Lee-Metford and Mauser
rifles tend to heal so rapidly. The third attempt to
relieve Ladysmith was attended by no fighting. Its
failure places the beleaguered city in a sad plight, but
the garrison is not only in good spirits, but in far bet-
ter health than it was, the attacks of typhoid fever be-
ing much less numerous.
The St. John Ambulance Association, which is
entrusted by the Central British Red Cross Committee
with the reception and forwarding of material for the
sick and wounded to the seat of war, has sent to South
Africa 5,855 suits of pajamas, 9,293 shirts, 23,603
handkerchiefs, 2,319 pillows, 6,409 pairs of socks and
stockings, 6,210 pairs of slippers and shoes, 1,471
knitted caps, 1,080 knitted jackets or cardigan vests,
4,735 knitted mufflers, and 694 cushions — not to ex-
haust the list. These things have been sent at the
instance of medical officers and other competent judges
at the front — Colonel Young, the secretary of the Red
Cross committee, for example — and the choice of arti-
cles shows well where the kit of the English soldier,
which I have already detailed to you, is deficient.
Light, warm, durable things will be the costume of the
future soldier all over the world, and smart regimentals
will become as obsolete as the greaves, visors, and
breastplates of the Crusaders. The opposing forces
on the veldts are fortunate in the weather which they
are experiencing, but the drenching showers and heavy
dews, no less than the hot sunshine of midday during
what is the South African summer, taken together mean
that the clothing of the soldiers must be woollen. As
proving the great variations of temperature in the sum-
mer months in Cape Colony, the most recently pub-
lished observations of the government meteorologist
show that in January, 1898, the maximum tempera-
ture at Graaf Reinet was 108° F. and the minimum for
the same month was 40 F. At Kenilworth, just out-
side Kimberley, where the next British advance in
force will be made, the maximum black bulb in the
sun was 159.8° F., the highest shade temperature being
94.7° F. ; the minimum black bulb on the grass was
39.1° F., the lowest shade temperature being 44° F.
For such a country wool is the only wear.
Military Medical Attaches. — Two German mili-
tary attache's, Stabsarzt Dr. Krumacher and Stabsarzt
Dr. Schmidt, have been up to the front at Modder
River, and on their return to Cape Town expressed their
satisfaction with all that they saw. As the casualties
with Lord Methuen's column were extraordinarily
heavy at Magersfontein, the fact that critics of another
nation were complimentary has been received by the
Royal Army Medical Corps with particular pleasure,
for it proves that the corps is as good in an emergency
as it is with lots of time before it and lots of money to
spend. These attaches from the German army are the
only foreign military medical men who have yet made
their appearance at the seat of war. Sir William
MacCormac, who has seen other campaigns in a vol-
unteer capacity, considers that the move is a very wise
one on the part of Germany. The care of the sick and
wounded is becoming much better understood among
civilized nations, and if accredited representatives of
military surgery from other countries fall generally
into the way of accompanying belligerent forces the
result can only be an increase of knowledge that will
be of the highest service to humanity.
The Hospital Ship <' Maine." — This hospital ship,
the splendid gift of American ladies to the British
government, had in the second week in February one
hundred and forty patients on board her, half of whom
were wounded during the attack on Spion Kop, the
other seventy including sixteen cases of dysentery,
fourteen of rheumatism, four of ague, and three of
typhoid fever. The Maine lies at Durban.
The Utility of Hospital Ships has been called in
question by some of the medical men serving in South
Africa, but it is not their employment at Durban or
Capetown to which exception is taken, but their use as
transports. There are many large transports available
from Capetown to Southampton, and those in charge
of the base hospitals say that the accommodations
offered by them to the sick and wounded is ample, in-
asmuch as no one is sent back until his plight has
ceased to be urgent. This being so, the necessity of
using to take the sick and wounded to England slow,
small ships, expensively equipped with operating-the-
atres and .T-ray chambers, is certainly not very obvious.
But to bring the sick and wounded, while still suffer-
ing acutely, trom Durban round to the base hospitals
near VVynberg these ships are of the most splendid
utility. They have saved the lives of many, and have
eased the pains incident upon travelling of thousands
of poor fellows. In addition to these hospital ships
which I have already mentioned to you, a new one, the
Niibict, has just been equipped. Like the Lismorc Cas-
fk, she has been transformed from the ordinary passen-
ger steamer of the Peninsular and Oriental Steam
Navigation Company to a hospital ship by the rapid
work of the plumbers, carpenters, and painters of Dur-
ban. She makes the sixth hospital ship.
A Scottish Hospital in South Africa. — Scotland,
in emulation of Ireland, is sending out a hospital to
the seat of war, but, like Lord Iveagh's Irish Hospital,
there will be no national or regimental distinctions
made in the selection of patients to be relieved.
The American Field Hospital. — Mr. Van Alen, an
American gentleman, has presented the English gov-
ernment with a complete hospital of twenty-five beds.
This is one of the most princely contributions yet re-
396
MEDICAL RECORD.
[March 3, 1900
reived by the government. Dr. E. G. Powell is to be
medical officer, and the secretary-superintendent is
Mr. Murray Gutlirie, the newly elected member of Par-
liament for an East London constituency.
STATIC INDUCED CURRENT AND DR.
MORTON.
'to the Editor cf thk Medical Recokd.
Sir: The witticisms and personalities indulged in by
Dr. Morton in his reply, not to my "gratuitous at-
tacks," but to my just accusations, have nothing
to do with the case in hand; nor do they alter the
facts. He says that he is still waiting to hear from
me, and that "practically no one disputes his humble
claims." Has he so soon forgotten Professor Pupin's
vigorous handling of some of his extraordinary claims?
Let me refer him and any others interested to his own
article and Professor Pupin's reply in Electricity, Feb-
ruary 19, 1896.
And now, in the first place, although not specially
germane to the central idea of the subject of discus-
sion, let me call Dr. Morton's attention to tiie fact
that Reiss' singing telephone was also a microphone
with two platinum points in contact by gravity.
There was no adjustment screw and none was needed.
Therefore the turn of one-millionth of an inch in or-
der to transform it into a speaking telephone is a dream
of his own. If Reiss had had carbon instead of plat-
inum, he would have had the telephone of the present
day.
The accompanying illustration and description from
Tibbett's " Handbook of Medical I^lectricity " (Lon-
don, 1873) shows clearly enough with what accuracy
Dr. Morton has reproduced the ideas of others as his
own. The author of the work ends his description of
the machine by saying: "The two exciters A" and J,
representing the charge of the outer and inner coating
of the jar, can discharge it through any muscle. The
intensity of the charge is regulated by the distance
apart of the balls E\J."
Dr. Morton has simply copied in its essential de-
tails this illustration, or some similar one, from the
earlier French or English issues — Mauduyt, Imison,
Adams, or Ca\allo — and given to the current that
these old fellows knew of and used the name "static
induced." That long before his time this current not
only "could be," but was utilized, is evidenced by the
second illustration.
Fig. 2, taken from Mauduyt, 1784, represents an ap-
plication to a very sensitive part by what they called
shocks (they called almost everything shocks), but
shocks regulated by so fine a graduation of the spark
gap as to merge them into a veritable current. These
men of a former time had everything but the name.
Dr. Morton says truly, that the old writers describe
their administration and discoveries with the minutest
detail, and no one knows better than he how often al-
lusions can be found to the electric manifestation called
the static induced current. I quote from one of them,
'■ Cavallo on Electricity," vol. ii., page 123 (London,
1786). .\fter describing an arrangement substantially
the same as the one above given, he says: "Thus any
number of shocks precisely of the same strength may
be given without altering any part of the apparatus
. . . and when the strength of the shock is required
to be diminished or increased, it is only necessarj' to
diminish or augment the distance between the balls
B, C." These balls correspond to the balls £ , J , of
our first illustration. In a work on electricity by
Adams, published in London, 1792, page 514, he de-
scribes his seventh method of application thus: "By
a sensation between a shock and the spark which does
not communicate that disagreeable feeling attending
the common shock. . . . The effect of this species of
shock., ij it may be c<ii/cd line, (italics mine] is to pro-
duce a great vibration in the muscular fibre without
inducing the pungent sensation which the shock ef-
fects." These are nothing more nor less, could be
nothing more nor less, than what Dr. Morton claims
as his wonderful discovery of the static induced cur-
rent and physiological tetanus. In Cavallo, again,
page 157, we find the statement that small shocks, i.e.,
one-twentieth of an inch, may be sent through the pel-
vis. With this slight separation the result could be
nothing else than the static induced current, and it
is useless for Dr. Morton to flippantly say they "could
but they didn't." But why multiply examples which
are so readily verified by reference to the original
sources that I have mentioned.'
•As for Dr. Morton's article on " Electrostatic Cyr-
rents and the Cure of Locomotor Ataxia," etc., it
seems to me that the title alone is enough to con-
demn it.
Speaking from an experience quite equal to his own,
possibly, in the treatment of gross organic diseases by
the very same as well as by other electrical methods, I
know well enough how unsubstantial are the claims he
makes and evidently wishes to be inferred. So far as
I am concerned, this discussion is closed. Each one
who has been sufficiently interested to read what has
been written, and will consult these old works, will
form his own opinion as to the measure of Dr. Mor-
ton's originality and the value of his therapeutic
claims. I began the discussion not because I do not
thoroughly believe in the value of electricity as a
therapeutic agent, but because I believe in it so much
that I regret to see it discredited in the minds of the
conservative, thoughtful members of the profession,
by asking of it so much more than it is capable of
doing. A. D. Rockwell, M.D.
Medical Record
A IVeekly yoiirnal of Medicine luid Surgery
Vol. 57, No. 10.
Whole No. 1531.
New York, March 10, 1900.
$5.00 Per Annum.
Single Copies, loc.
@ri0mat Articles.
PROGRESS AND DRIFT IN PATHOLOGY.'
By T. MITCHELL PRUUDEN. M.D., LL.D.,
The closing years of the century have inspired so
many summaries of progress and such a diligent cast-
ing of horoscopes that one should not lightly indulge
in another inventory or invite to new outlooks in medi-
cine. But there are, it seems to me, some border-lands
between the purlieus of the practitioner and of the
pathologist wirich we may profitably survey. I have in
mind not so much a summary of facts as a glance at
tendencies, an estimate or realization of the point of
view to which we have more or less purposefully won
our way, or toward which we mayhap have only drift-
ed, during the past two decades.
It is, I think, unfortunate that the practitioner often
forgets that he is still a pathologist; that the clinical
studies which largely command his time and mental
resources are studies in pathological physiology. That
which we are wont to call pathology is really those
phases of the etiology and morphology of disease which
can be more easily, and often more completely, studied
at the autopsy table and in the laboratory than at the
bedside. Using the word in this sense, the pathology
of twenty-five years or so ago was in this country pur-
sued almost exclusively by practitioners of medicine,
and it was avowedly an adjunct of medical and surgi-
cal practice. The most distinctive function of the
physician-pathologist was the making of autopsies
and the naming of tumors. These things he did,
either to increase his knowledge, or for the skill and
experience which were useful stepping-stones to prac-
tice; or because he wished the material for demonstra-
tion to students; or because this work held out the
promise of interesting themes for study and a paper.
Finally there appeared upon the horizon in this
country a few anomalous individuals who cherished
the notion that the science of disease, even in its etio-
logical and morphological aspects alone, was broad
and deep enough to command the exclusive attention
of its devotees.
Twenty years ago, the most obvious aim of the spe-
cial pathologist, apart from his material service to the
practitioner along the old lines, was to discover some
new lesion or to give greater precision to the morphol-
ogy of an old one ; to gather statistics ; to exploit or-
gans of exaggerated size; and in general to celebrate
the monstrous and the strange. Nomenclature and
classification were his cherished fetiches. His battles
royal raged about the origin of pus, the nature of cell
stimulation, the relative importance of the various
phenomena of inflammation, and the possibility of the
successful transplantation of tumors. The experi-
mental method was in vogue, the doctrines of the cel-
lular pathology were dominant, and there was year by
year a steady gain in facts.
It was the facts, in truth, which were troublesome
' Read before the Practitioners' Society of New York, February
2, 1900.
from their rapid and prodigious accumulation. For
the correlation of the facts was at that time diflScult or
in many cases impossible. So description and cata-
loguing, not explanation, was the business of the hour.
The blind devotion to minute objective description of
lesions in man of which no one knew the origin, the
significance, or the relationship, was as praiseworthy
as it was pathetic.
I would not underrate the achievements of those
years in the seventies, nor the sound scientific spirit
which underlay thein. But it was in truth e'en stand-
ing water between the cellular pathology of Virchow
and his early followers, and the cellular pathology
which was to be reincarnate by correlation with and
illumination by other phases of science, from which
medicine had long held aloof; and by a fresh stimu-
lus to research through new light on the infectious
diseases.
The conception of the cell was no longer as at first
that of a membranous bag containing active substance,
but of a lump of protoplasm. The intimate structure of
the cell had no particular significance, except that one
had learned to recognize a granular appearance in the
body, a stainable object in the interior called the nu-
cleus, which in its turn often revealed one or more
darker spots within. The cell did wonderful things
indeed, and, as the doctrine of the conservation of
force became current, was looked upon by those who
had enjoyed some training in physics and chemistry
as a centre of physical and chemical activities in
which occurred those transformations of energy re-
quired in the dynamics of life. So prominent in
those days were the chemical aspects of the cell, that
the manifestations of life, assimilation, growth, and
reproduction were looked upon, and justly too, with the
knowledge then at command, as properties of the not
very complex chemical organic compound, protoplasm.
And speculations involving a chemical theory of life
seemed not so very unreasonable. The cell studies in
pathology of those days, a quarter of a century ago,
were largely limited to changes in the shape, size, and
position of the cell ; to its degenerations, and to the
cruder destructive processes to which it is subject.
But the studies of the past few years, especially
upon the lower and simpler cell forms, have wrought
a complete revolution in our conception of these ele-
mentary organisms. The cell is no longer a lump of
living matter of rather simple chemical composition
which transforms energy, and whose intimate structure
we need not worry about. It is a most complex ma-
chine whose varied structural features are of the utmost
significance. The nucleus harbors the special struc-
tures closely involved in reproduction and heredity,
and is deeply concerned in the processes of cell nutri-
tion. The chemical substances of which the cell is
composed are numerous, and the physical comparison
of protoplasm with a lump of jelly is no longer ade-
quate. Already, while we as yet are only upon the
threshold of this new cytology, cell structure demands
an extended nomenclature of its own, and whole trea-
tises are written upon the performances of its varied
mechanisms. Into this field pathology has barely
entered, halting still behind the students of normal
and lowly cells.
398
MEDICAL RECORD.
[March lo, 1900
Moreover, we are admonished by these brilliant
discoveries that the secrets of cell structure and cell
function are hardly to be won by the study of higher
forms alone. In our extremely diiYerentiated and in-
timately co-ordinated cells, many features fundamen-
tally simple are veiled or modified; so that we can
understand them only when we interpret them in the
light of less advanced forms.
Thus it has come to pass that while the pathologist
of a couple of decades ago found his morphological
studies of the cell ended when he had made a few
crude observations on its size and shape and texture,
the pathologist of to-day counts all these as but
glimpses on the threshold of a domain in which his
problems demand the most accurate technique; the
most minute observation; a recognition of the domin-
ion in his own fields of universal physical and chem-
ical laws, of the doctrine of organic evolution, and of
the potency in single cells and in cell communities
of hereditary traits and tendencies. We can, it is true,
with the cruder superficial observations on the form
and grouping and texture of cells, still make the mor-
phological observations which the exigencies of prac-
tical diagnosis require, but this is done in the con-
sciousness always that clews to unknown phases of
disease are eluding our grasp, and that it is not thus
that the more subtle maladies are to be comprehended.
Curiously enough, it is in the nervous system, which
so long occupied a mysterious little pathological baili-
wick of its own, that the new phases of cell study in
pathology have been most diligently pursued. Not
yet, it is true, in such fashion and to such extent as to
have secured unanimity of interpretation, but suffi-
ciently to suggest high promise, here and elsewhere,
for the future.
Let us now turn to another phase of progress in
pathology and briefly consider its promise, its drift,
and its disappointments. We can all recall the vague
conception of the causes and nature of the infectious
diseases with which most of us entered upon our
active careers in medicine. The lesions which we
found after death were often indefinite and unsatisfac-
tory, and preventive measures, dealing as they did
with the unknown, were for the most part halting and
futile. We had grown weary of the personification of
disease, of the conception, and the treatment too,
of morbid processes as if they were things, and of the
persistence, in nomenclature at least, of ideas about
the causes of disease which belonged in the era of
barbarism, superstition, and personal devils. While
we knew that disease was really a process and not a
thing, we got, or 'thought we did, some help by calling
certain of the infectious diseases " specific." But this
comfort was meagre and short-lived.
The word " specific," as we all have frequent oc-
casion to deplore, is used in varied senses and often
with no sense at all. To some, it is that which per-
tains to a species, as of animals or plants. To
others, it connotes a disreputable trio of venereal
diseases. As applied to cells and other structures of
the body, it signifies something typical and character-
istic in the structure, the metabolism, or the per-
formance— as a specific secretion of a gland. It .is
applied to the action of poisons, which vary among
themselves in their effects upon the same structure,
and which vary as individuals in their action upon
different structures. On the other hand, the term
"specific" came to be applied long ago to certain in-
fectious diseases which were so peculiar, so character-
istic in their clinical manifestations that an enumera-
tion of their symptoms served for their identification,
as species were identified among plants and animals.
Thus the infectious diseases became personified, be-
came species, things, entities, and their specificity was
expressed in the description of symptoms. But after
a while it was more clearly seen that disease as a
process involved the action of the living body cells on
the one hand and some then unknown inciting factor
on the other. Then it dawned upon the medical world
that, after all, the actually characteristic thing, the
really " specific," was not to be sought in the symp-
tomatic manifestation of disease, but in the underly-
ing agencies whicT: determined its occurrence. And
so the light failed in which we had tried to find com-
fort, and we realized that to call the infectious dis-
eases specific didn't really make them any more com-
prehensible.
All at once the mystery seemed to be swept away.
In the place of vague speculation on the causes of the
infectious diseases, we had definite, tangible, visible,
living things to deal with, in some cases certainly and
by fair inference in all. The term " specific infec-
tious disease " promised at least to mean something
precise, and the most "specific," characteristic, essen-
tial, determinative thing about it appeared to be the
particular germ species which, as it seemed, alone and
always caused it.
It is of great significance that while the most strik-
ing contribution of Koch to the science of that day
was the formulation of a very simple technical pro-
cedure in bacterial culture and study, he went beyond
that and threw the whole weight of a strong and con-
vincing personality and the commanding power of an
excellent teacher into the enforcement of so positive
and detailed a conception of the nature of the infec-
tious diseases, of the characters of the things which,
as he assumed, " caused " them, and the practical
measures necessary for their control, that he fairly
forced upon the medical world a new school of thought
and practice.
Everything conspired in these days to fix the atten-
tion of the medical world so sharply upon the microbe
that the man side of the matter was largely ignored,
and Virchow, with the cell lore which he had gathered
or inspired, sat glowering and protesting in the shadow
as the procession swept jauntily past. No young
pathologist was so ill provided with utensils and none
so busy that he did not hasten to lay some new microbe
at the newly risen shrine. The older pathologists
were for the most part too dazed and confused by the
new shibboleths and the clamor to join either in pro-
test or acclaim, but held aloof babbling softly of cells
and stimuli and tumors and heredities. The average
practitioner was mildly interested, judiciously incred-
ulous, took it all apparently as a part of the passing
show, and went on doing good and earning his living.
The poor old fellows struggling along in the dark
before the eighties spent many nights in vigil and
many days in toil in the vain task of deciding whether
phthisis was always tuberculous. The pitiful mor-
phologists had struggled through many a claim and
many a renunciation without clear light upon the rela-
tionship of the different pneumonias. Diphtheria or
croup had stimulated many a hot encounter. But now
that you could put your finger upon the " specific
cause " so easily and so surely, the road seemed plain.
If the tubercle bacillus were there, the disease was
tuberculosis. It needed no jury if the pneumococcus
were lurking in the lungs. Diphtheria or angina? —
send a swab to the laboratory.
But let us see what the words " cause " and " dis-
ease " really mean which in these days under cover of
the microbe we had begun to juggle with so blithely.
The devotees to medicine are so largely absorbed in
the practical aims which are at once their glory and
their undoing, that no one seemed to realize at first
that in using the word " cause " to express the rela-
tionship between these newly exploited germs and the
diseases with which they had been found to be so
closely associated, they were plunging headlong into a
March lo, 1900]
MEDICAL RECORD.
399
mistiness of conception in which the human mind liad
long floundered. For it was not until the ph)sicists
had taken the matter in hand that clearness of expres-
sion about causes was secured in dealing with forms
of energy. Now it seems to me that without risking
an excursion among the pitfalls of metaphysics, we
might secure a practical advantage if we were to cease
to speak of microbes — at least without a mental reser-
vation— as the cause of disease. For to do so is
fundamentally or in a dynamic sense as inexact as to
speak of the spark which starts the train of chemical
decomposition in gunpowder as the cause of the ex-
plosion. The microbes may be, indeed they are,
absolutely essential factors in certain diseases without
having that quantitative relationship to the effect
which, in the physical sense, true causes must always
bear.
Hueppe has rendered a great service to medical
science by calTing attention again and again to this
erroneous conception, and by reminding us that in the
end we must recognize the doctrines which the physi-
cists have laid down in studying the forms of energy,
which in all their subtleties and intricacies apply just
as absolutely to the manifestations of energy in the _
human body as in the domain of inorganic nature.
The fire which burns in my grate is not caused, I
think, by the lighted match, but by the molecular po-
tencies in coal and air which the match has set astir.
Nor is the play of forces which it has evoked a thing.
The coal, the air, the ashes — these are things, these
are entities; but the molecular activities, the transfor-
mations of potential into actual energy, the burning —
these are not things ; they are processes. And so it
is with disease; it is a process, not a thing. Indiges-
tion is no more a thing than is digestion ; both are
processes; both are, at bottom, transformations of
energy. Their difiEerences are due to differences in
the conditions under which the forces are brought into
play.
The normal processes are what they are because of
the conditions under which the cells have been slowly
evolved and are at the moment placed. The abnormal
processes involve no new forces, but are what they are
because the manifestations of energy of the normal
state are modified by new conditions. This transfor-
mation of energy occurs, indeed, in both cases tlirough
a definite mechanism, and this mechanism may suffer
modification under changed conditions so that we may
have lesions of disease. But the lesion is no more the
disease than the ash or the coal or the air is the burn-
ing of the fire.
The cause of physiological performances is the po-
tential energy, the capacity for doing work which the
organism possesses, drawn from the universal store-
house whose total stock never wanes. The true causes
of disease are the same dynamic forces acting under
modified conditions. Under these modified conditions,
the potential energy of the living organism may be set
free in a variety of ways. But diverse as these ways
may be, they involve only the liberation and not in any
marked degree the supply of energy. They belong
among what the physicists are wont to call " liberating
impulses," or sometimes "secondary causes," and are
the analogues of the spark which with a minimal
amount of impulse makes possible the transformation
of potential into kinetic or actual energy. I think,
therefore, that it would be wise if we were to cherish
the conception of the microbes which are regularly
involved in the infectious diseases, not as causes, but
as inciting factors.
That which the physicist calls a secondary cause is
designated by the physiologist as a stimulus. Simi-
larly, we might perhaps wisely call these liberating
impulses the stimuli or excitants of disease.
Of course the word " cause " is commonly and not
improperly used in a less limited sense than that here
urged, and this ordinarily does no harm. But in this
case the unrestricted use of the word does, as it seems
to me, do harm, because it constantly diverts our at-
tention from a fundamental to a subsidiary though not
unimportant thing.
The manifestations of the infectious diseases are
expressions of processes of the body cells and not of
the micro-organisms, which only aft'ord one of the nec-
essary conditions. Of course you cannot have tuber-
culosis, for example, without the tubercle bacillus.
Nor, on the other hand, will the tubercle bacillus incite
tuberculosis in an oak plank. If the tubercle itself
were essentially a heap of tubercle bacilli; if the va-
rious and significant subsidiary phases of tuberculosis,
the fever, the malnutrition, etc., were expressions of
perverted life processes of the bacillus and not of the
man, then I grant that one might be justified in con-
sidering the tubercle bacillus as the cause of tubercu-
losis, and man simply as an indispensable condition.
The requirements of sanitary science and preven-
tive medicine may perhaps be more easily met by the
use of the word "cause" in treating of the microbes
as inciting factors in infectious diseases. But our
own conceptions must be clear as to what are real and
what only apparent causes, if we are to avoid in the
future the pitfalls which have marked the advance of
the medical and other sciences.
Such considerations as these are, as it seems to me,
not unimportant. The science of medicine has suf-
fered greatly in the past, and still suffers, from the
tendency, almost universal among its devotees, to con-
sider the human body as a thing by itself; an object
which can be studied and treated without regard to
the close relationship in every cell and fibre with
forms of life which are its prototypes; and without re-
gard to the identity of the forces w^hich sway alike the
molecules of the cell and the molecules of the air, the
drop, or the crystal. It may be that in such consider-
ations we gain no hint which will reveal a clearer
symptom, a safer method, or a better pill. And if the
horizon be for any limited, by necessity or by choice,
to these outlooks, then he may slumber while we prate
of causes and entities and dynamics. But if we are
going to talk of causes, let us know, if we can, what
the word signifies. If we mean processes, let us not
say things.
The trouble w'ith the point of view which was so
early formulated and so successfully urged by Koch
was that what he conceived to be the causes of the
infectious diseases are really only the inciting factors.
The result was that the lines of study led away from
the body to the germ. The beautiful simplicity, the
precision of conception, the technical ease, with which
discoveries were made were all due to the fact that we
were ignoring the real complexities of the situation,
entering with an easy enthusiasm upon new fields
■which of right belonged to the botanist. So long as
the study was one of cultivation, description, and
species-making, the pursuit of bacteriology seemed a
succession of simple tasks. But complexities soon
began to reveal themselves.
Koch was especially insistent upon the definiteness
and permanence of specific forms, as indeed it was nec-
essary to be, if the so-called causative relationship was
to be maintained between specific bacteria and specific
diseases. But the matter has proven not to be so sim-
ple after all. For although there is, so far as I know,
no evidence that one well-defined species ever changes
into another, there is a certain lability, especially in
the physiological characters of many bacteria under
variations in environment, which renders species-
making and classification in these organisms a parlous
job.
When the establishment of bacterial species was
400
MEDICAL RECORD.
[March lo, 1900
fairly under way, it became evident that although we
had the advantage of other species-makers in higher
plants and animals, in that our subjects went through
their life cycles very rapidly, so that we could gather
the available facts in a few days, or at most weeks,
we were yet seriously embarrassed because we had to
depend for specific characteristics largely upon physio-
logical data, the available morphological differences
being very few and limited in scope.
Let me illustrate what I mean by lability in the
physiological characters upon which species determi-
nation among the bacteria largely depends. At an early
day the bacteria were divided into three great classes:
the zymogenic or fermentation-inciting, the chromo-
genic or pigment-forming, and the pathogenic or dis-
ease-producing. These characters were believed to be
sufficiently precise to justify this great group division.
' But it soon appeared that each of these activities is
variable. Chromogenes can grow without their color.
Zymogenes may be swayed by artificial means up and
down the scale of activities. Pathogenes may be ren-
dered innocuous. But more than this, it was presently
discovered that chromogenes and zymogenes might be
pathogenic; that zymogenes might produce color and
chromogenes cause fermentation. Form, too, is sub-
ject to considerable change, and spore producers may
be made asporogenous. Those germs which naturally
require oxygen for growth may be made to do without
it, while anaerobics may have an aerobic existence
forced upon them.
As the stability of these characters grew unsatis-
factory as a basis of classification, it became more
clear that the alterations in capacity of these organisms
were due to changes in the conditions of life, such as
temperature, light, food supply, the presence of dele-
terious substance at the seat of growth, etc. Thus the
development of qualities and capacities which at first
were deemed specific to the germ were found to depend
quite as much upon external as upon internal condi-
tions. This was an old story in science, but it was
new in bacteriology. We have, in fact, owing to the
wide range of variation which some bacteria display
under different conditions in their environment, been
finally compelled to establish certain groups which
seem to belong to what we are pleased to call the same
genus, but which are so variable in form and physio-
logical manifestation that we are unwilling longer to
incur the peril which belongs to the attachment of a
specific name. When one hears nowadays, therefore,
of the coli group, or the diphtheria group, or the tu-
bercle-bacillus group of bacteria, he should realize that
this indicates just a refuge by the way in which bac-
teriologists have sought shelter and safety from the
fury and risk of species-making, until new light dawns.
These complexities in bacteriology when applied to
the conception of the relationship of micro-organisms
to disease were further deepened by the realization
that not all animals are affected alike by the so-called
pathogenic germs; a fact which now needs no illustra-
tion.
The notion of bacteria as disease entities was fur-
ther shaken by the revelation that the same germ may
incite more than one disease. Suppuration may be
induced by the typhoid bacillus, the tubercle bacillus,
the pneumococcus, and the anthrax bacillus, as well
as by those germs which were at first caW&A par excel-
lence pyogenic. The pneumococcus is the inciting
factor in only one phase of pneumonia, and it may be
responsible for meningitis, endocarditis, and so on.
In a word, it soon became clear that the action of a
given germ in the living body depends only in part
upon its intrinsic capacities — which in themselves are
very variable — but also and in marked degree upon the
capacities, also variable, which exist at the moment in
the body cells among which the lot of the germ is cast.
Thus the conception of bacteria as the " specific en-
tities" of disease lost much of its keenness; the body
cells came quickly to the front, and Virchow smiled
again.
We now realize that disease is, as Hueppe has hap-
pily expressed it, like an endless chain, from which if
any link be missing the closing of the chain is im-
possible and the disease cannot occur.
When once attention was turned from the microbe
aspect to the cell aspect of infectious disease, facts of
the utmost importance began to accumulate about
natural or artificial predisposition, immunity, acquired
tolerance to poisons, etc., to which the scope of this
paper permits me only briefly to refer.
The tendency to a one-sided interpretation of facts,
which, as I have tried to show, characterized our
earlier knowledge of bacteria as inciters of disease,
was again manifested when attention was directed to
the effects of poisons, bacterial and other, in the body.
And here, too, a group of investigators came presently
to think that it was the toxic agents, in which the
"specific essence," the "primary cause," of most of
the infectious and many other diseases was to be found.
And it really seemed at one time, as Martins has
pointed out, as if, apart from traumatic and certain
strictly mechanical disturbances, pathology were in a
fair way of becoming merged in toxicology. Auto-
intoxication loomed big upon the horizon, not simply
as a most significant factor in pathogenesis, as it un-
questionably is, but as the very essence of disease.
AH organ ic»diseases which depend upon destruction
of the parenchyma, most proven or alleged microbic
diseases, and many less readily characterized diseases
such as leukaemia, were to be considered as funda-
mentally auto-intoxications. And these diseases were
to be classified on toxicological principles. The con-
siderations which I have urged against partial views
in speaking of the bacteria are pertinent here also,
and have already fostered wiser and saner conceptions.
I have touched in a somewhat critical vein upon
some early phases of drift in bacteriology, because
since we are yet only upon the threshold of knowledge
in this domain it is of great importance to have a clear
vision of our aims, and because a good deal of unnec-
essary complexity in problems of the hour is still due
to narrow views of the relationship of micro-organisms
to disease.
I wish that it were practicable for me to devote a
few moments to a survey of our drift and progress in
fields which concern immunity. For I think that this
subject has been unnecessarily cumbered with conjec-
ture and hypothesis not based upon a clear conception
of the actual relationship between variable inciting fac-
tors on the one hand, and the variable mechanisms on
the other, through which the dynamics of life are man-
ifested. So much has been written about immunity,
and such multitudes of half-apprehended and wholly
inco-ordinated facts are lugged into the discussion,
that, in reading on this theme, one is reminded of a
saying of Montaigne, that "there is more ado to inter-
pret interpretations than to interpret the things them-
selves."
We are apt to forget, in our thought of immunity
and tolerance and health and disease, that the life of
the cells of the body, like the life of the microbes, is
a continuous adjustment between the properties of the
organism and those of its environment; that the nice
balance which we name health may be swayed now
this way and now that by a thousand subtle agencies
from within the body and from without; that the body
cells as well as the bacteria are organisms capable of
considerable variation both in form and function whT
the conditions of their existence change.
U'hen we talk of immunity and antitoxins, we are
apt to forget that natural or acquired cell tolerance to
March lo, 1900]
MEDICAL RECORD.
401
poisons may be, and in many cases certainly is, a mat-
ter of cell education. So that, as Hueppe has pointed
out, we do not need to assume, in the presence of an
acquired tolerance to alcohol or morphine or arsenic,
the presence in the body of a " specific " anti-alcoholin
or anti-morphine or anti-arsenicin. There is no doubt
a condition, capable of being artificially induced,
which we may properly call, if we utter some sotto voce
exorcism as we name the words, " specific immunity."
But the balance of cell metabolism is so subtle, and
the introduction of new substances into the body can
modify in such marked degree the responses of the
cells to various poisons, bacterial or other, that the
phrase "specific immunity '' should not be lightly con-
jured with. The pathologist has never realized so
keenly as he does to-day how dependent he is upon
the ministrations of the chemist not only for his con-
ceptions of the ways in which the life energies are
stored and poised, but also as he faces those protean
aspects of disturbed metabolism which lie at the heart
of so many of his problems.
The substantial gains in all these years of research
into the nature and mode of diagnosis and treatment
of the infectious diseases — I could easily contrive a
wearisome hour of inventory — it is not my purpose to
review. But I cannot leave this phase of my subject
without a protest against a too hasty inference of doubt
or of failure because the new interpretation of facts in
these rapidly growing fields of science may seem for
a moment, now and then, to denote a backward drift.
The technical difficulties which we have encountered
and the really only superficial changes in bacterial
nomenclature which the hour demands may well be
puzzling and discouraging to the harried practitioner
who is forced to read as he runs. Bacillus coli com-
munis may not slip so trippingly as at first from the
tongue. The bacteriologist may not enter so jauntily
as was his wont upon the capture of a stray typhoid germ
in the water of a suspected well. The swab from the
throat may not always unlock, so surely as was hoped,
the secrets of diphtheria. We may, as seems likely at
the moment, even be compelled to call the tubercle germ
not a bacillus but a fungus. But these changes to
which I have referred do not, in fact, involve the re-
linquishment of one jot of the solid practical vantage-
ground which the earlier studies won.
In the light of our new knowledge of tuberculosis,
attention was at first directed almost wholly to the tu-
bercle bacillus, while the body aspects were largely
ignored. There had been substantial agreement that
in the prevention of this disease the destruction of the
sputum and an intelligent cleanliness were of supreme
importance. Now that we are looking to the man side
and realize that predisposition is also of great impor-
tance, we are beginning to hear deprecation of serious
efforts to destroy the infectious agent, and are coun-
selled to lay the greatest stress upon improving the
health and thus, as it is assumed, strengthening the
resistance capacities of the individual. This it is
entirely propsr and wise to do. But we should not
forget that we do not as yet know at all definitely what
the factors are which make one predisposed to tuber-
culosis and another not. So that we are compelled
to fall back upon rather vague suggestions. On the
other hand, those measures which have approved them-
selves, in the care of the sputum, and the sequestra-
tion, when it is practicable, of the sick, are positive
and proven and should not be lightly relinquished.
I believe that the conclusion to which the surgeons
have come, in regard to the relative or even absolute
harmlessness of aerial micro-organisms which may
enter fresh wounds at operations, are sustained both
by practice and by the knowledge of the varying viru-
lence of germs which has been gained since surgery
emerged from the illuminating incubus of Listerism.
But I think that the conclusion afifords no justification
for a lack of attention on the part of practising physi-
cians to the risks which their patients who are seri-
ously ill are subject from secondary infection, due to
the inspiration of dusty air. For the sick man who is
breathing germ-laden air is largely deprived of those
natural safeguards against infection which at the por-
tal of entry in the surgical case are usually in full
activity. The exposure of the sick man is not mo-
mentary, but continuous. The nasal filter is often
thrown out of function by mouth breathing; the buc-
cal secretions are scanty or altered; the cilia of the
air passage share in the disabilities of the body at
large, so that access is relatively easy to the recesses
of the lungs; while finally the internal protective
agencies are often feeble or ineffective. I have not
time to pursue this subject, but I think that the meth-
ods of cleaning in hospital wards and in sick-rooms
might well claim a more careful consideration than is
common from practitioners of medicine.
I now turn, in illustration of new outlooks, to the
subject of inflammation. When most of us were serv-
ing our novitiate in pathology, the study of inflamma-
tion was largely limited to a bare description of visible
phenomena and a cataloguing and classification of
lesions. Like other diseases, inflammation was re-
garded with more or less complacency as an entity, a
thing. We were engaged in studying the ways in
which the blood cells, especially the leucocytes, got
out of the blood-vessels in the exudative phases of in-
flammation; and the more inquisitive among us were
much exercised to find out whether it was the emi-
grated leucocytes or the fixed connective-tissue cells
which were most concerned in the formation of new
tissues. So earnest were the advocates of each of
these views that the social amenities sometimes suf-
fered. Thus it was my hap to be banished from
Strieker's laboratory in Vienna when it became known
to that champion of the connective-tissue cell that I
had been under the baleful influence of Cohnheim
and Arnold.
This question of the origin of new connective tis-
sue, the minute alterations in the walls of the blood-
vessels which permitted emigration and diapedesis,
and whether the leucocytes crawled out or were
squeezed out, bounded in this field our extremest hori-
zon. I do not remember that it ever occurred to us to
inquire what, if anything, inflammation meant. It
was enough for us to fight the battles of the hour; to
remember if we could the phenomena and the lesions;
and to keep the classifications from getting mixed.
But the formulation of the new bacteriological tech-
nique and the deeper study of the infectious diseases
in which inflammation is frequently a prominent fea-
ture, brought new light and fresh impulse into the
study just then drifting rather aimlessly in the eddies.
I think, too, that we shall not readily overrate the im-
portance as a stimulus, here as elsewhere in pathology,
of the practical awakening of the medical world at this
time to the fact that, superior as in some ways he is,
and occasionally enjoying a bank account, the man
physical is pretty closely linked from the cradle to the
grave with lower life forms in ways which could not
longer be ignored. And the hospitalities which we
were forced to accord to the bacteria and to protozoa
in our scientific housekeeping did much, I think, to
foster the wider outlooks and the more intelligent and
practical recognition of fundamental laws which chem-
istry and physics had long since formulated, and the
study of organic evolution had revealed, when these
were at last seen to bear not remotely but directly
upon the more subtle problems with which we now
stood face to face.
There is an interesting story in the drift of events
at this period which I have not time to tell. Cut the
402
MEDICAL RECORD.
[March lo, 1900
fresh point of view led away for the moment from our
descriptions and our catalogues of inflammation as it
occurs in man, down to the study of analogous phe-
nomena in lower and simpler forms of living things.
That trusty old pal of the physiologist, Araceba,
was lured from his seclusion and injured in a variety
of ways which resemble the injuries known to initiate
most often the inflammatory processes in man. He
was prodded, bruised, cut — actually vivisected, I shud-
der to say. He was supplied with strange, barbarous
diet; microbes were set upon his trail. And when
Amceba didn't succumb, the ways in which he held his
own and the processes by which he responded to in-
juries were carefully noted. In the word injuries I
include those toxic injuries which micro-organisms
can inflict, and which are en the whole more frequent
and important than the cruder pliysical injuries to
which man and his lowly brother are alike subject.
Then other simple forms of living things were
brought upon the stage and the conditions which deter-
mine amoeboid movement were investigated. It was
found that while the range of stimuli is limited in
response to which under normal conditions aniceboid
movements occur, in abnormal conditions a similar
response is elicited by the most varied agencies which
for better or worse can lure or repel the elementary
organism. So chemotaxis began to figure in our
books along with phagocytosis and emigration.
It thus had not been necessary to extend this new-
line of study beyond a few elementary living organisms,
which had been submitted to chemical and physical
injuries, before we had a suggestive clew to the expla-
nation of one of the most significant phenomena of
exudative inflammation. This clew, if formulated,
would be something like this. The physiological ca-
pacities of simple cells acting as independent organ-
isms are capable under abnormal conditions of re-
sponding in an altered or exaggerated manner to
unusual stimuli in ways which protect the organism
against diverse forms of injury. Thus amoeba, for
example, by means of its digestive processes can pro-
tect itself against pathogenic microbes. In this
protective response to an actual or impending injury,
amceba no more makes use of newly acquired capabil-
ities than does a man who kicks a predatory dog in-
dulging or threatening some sinister raid upon his
shins.
Then the study turned upward, and bits of old lore,
which had been gleaned and catalogued and stored
away and forgotten, because at the moment their mean-
ing was not clear, were dug up again and patched into
the new mosaic. To be brief about it, I may say that
it was found that as we rise in the scale of being,
from those organisms which consist of a single cell to
multicellular forms and then on up through the series
in which the structural differentiation of cells and
organs keeps pace with the physiological division of
labor, until we reach the very highest, w^e find that
there still remain — and here is the heart of the matter
from our present standpoint — there still remain some
cells which have shared but little in the changes in-
volved in the physiological division of labor. These
have retained such simple and varied capacities as
belong to lower independent organisms. Such cells,
as you know, are the connective-tissue cells, including
endothelium and especially the leucocytes. It was not
long before it had been shown that under similar con-
ditions these undifferentiated cells of the higher beings
respond to injuries physical and chemical very much
as cells do which are wholly independent organisms.
Now assuming that the success of these lowly cells in
the body in resisting injury and in destroying injuri-
ous material — for such, in common with amoeba, ap-
pears to be one of their capacities — tends to foster the
welfare of the body at large ; we seem to have won at
last a reasonable basis for an hypothesis around which
to group facts at least, if not to explain the phenomena
of suppurative inflammation.
I cannot permit myself to go further in this direc-
tion, nor to suggest ways in which other elements of
the exudate than the leucocytes may contribute in
their new forms and situations to the welfare of the
individual. Nor is there time even to enter upon
those phases of inflammation which directly contrib-
ute to permanent and extensive repair.
I am not quite certain that we know enough yet to
define inflammation concisely; there are so many
phases of it and of the life of the body at large which
may modify its manifestations and about which we
are almost wholly ignorant. But I think that we shall
gain some definiteness of conception, some clearness
as to most urgent lines of research, possibly — although
I have not for the moment that much at heart — some
immediately practical hints, if we fall in with Adami's
suggestion, and characterize inflammation as " the
series of changes constituting the local manifestation
of the attempt at repair of injury," or briefly " the local
attempt at repair of injurv.'"
This far-reaching conception of inflammation as a
conservative process in which the body cells adapt
their physiological capacities to changed conditions,
does not at all supersede, but does co-ordinate, the old
catalogues and classes of phenomena and lesions.
We may keep our exudative, hemorrhagic, necrotic,
croupous inflammation, if we like. We can even
drag out the dear old tumor, rubor, calor, and dolor and
reverently dust them off if we be so inclined. These
things may be still of practical as well as academic
value. But the clew which we have won to the mean-
ing of it all is that which, as it seems to me, particu-
larly marks the drift and purpose of pathology .in this
field to-day.
Of course, it may not strike the surgeon as a happy
conception that one of the phases of disease of which
he stands most in dread, and the suppression of which
in these later days it is one of his greatest triumphs to
have achieved, should be at bottom conservative in its
nature. Nor will the physician perhaps find it easy to
think of tubercle as in truth a triumph of conservatism.
But after all we must not forget that this new concep-
tion of inflammatory processes and lesions does not
imply the belief that the body always, or even ever,
succeeds in obtaining the best conceivable results in
these conservative responses to injury. But when we
reflect that its achievements in this direction are only
the result of emergency measures, in which the body
adapts as best it can machineries and powers main-
tained for other uses; if we remember that excessive
stimuli may incite excessive response; that especially
unfavorable conditions may turn its powers and mech-
anisms awry — we shall, I think, find it possible to
admit that we cannot justly count the failures as legit-
imate ground for total dissent from the point of view
to which I have directed your attention. There are
many other phases, which I have not time to consider,
of this which Welch has happily called adaptation in
pathological processes.
If I am not making too large a claim upon your time
and patience, I should like to call attention to one
other theme, namely, the inciting factors in tumors.
It would certainly seem at first glance, that in con-
sidering tumors we shall not need to be warned against
the traditional error into which medical men as well
as others have so often fallen, that of conceiving of
disease as a thing. For surely our fundamental no-
tions of tumors and even our very definitions imply
that they are things, circumscribed tangible structures;
objects which we can cut away. But here again the
tumor ''s not the disease; it is only one of the results
of the disease, just as pus is not inflammation but only
March lo, 1900]
MEDICAL RECORD.
40:
one of its typical products. Disease is here, as always,
a process, and although in this case the morbid process
which leads to the formation of the tumor is masked
by the tangible result, it must not be ignored in such
a point of view as we are now striving to attain. And
thus it is that when we speak of the alleged causes of
tumors we do not really mean causes at all, but the
inciting factors of the processes from which the tumor
results.
This distinction, fine and possibly finical as it may
seem, is not unimportant, because, as it appears to me,
there is no field in pathology in which the alleged
causes of disease, which are solemnly arrayed in trea-
tises and lectures under the heading of etiology, fall
so wide of the mark as just here among the tumors.
From bumble-bee stings to clay pipes; from aberrant
cells to postulated parasites, we lay these motley things
and circumstances in a row before our pupils with a
complacent smile; as who should say the veriest
dunce cannot fail to see that since tumors occasion-
ally, or frequently, follow these local visitants, here be
veritable causes.
One may have a more or he might have a less profit-
able employment than speculating upon the reason why
the cells of the human body do not go on growing in-
definitely in size, instead of stopping as they always
do when they have reached certain moderate dimen-
sions. And if one had for a moment no better busi-
ness than this inquiry, he might learn that others also
had been engaged at various times in the same occu-
pation. He might learn, further, that a clew to the
answer had been reached. That clew is to this effect:
cells being supplied with nutriment from without by
absorption through their surfaces, a certain proportion
must be maintained between the bulk of the material
to be nourished and the absorbing surfaces. But as
bodies increase in size the sliperficial area does not
keep pace with the mass, so that in the case of cells
the nutritive balance is disturbed and growth ceases.
Of course, this may occur sooner in some cells than in
others, but it occurs so early in all the body cells that
these rarely get beyond the microscopic limit. And
that appears to be one reason at least why cells don't
grow as big as grapes or pumpkins.
If, on the other hand, we consider a more complex
organism as a whole, one made up of many and of di-
verse cells and cell groups, we fail to find in this sim-
ple nutritive factor any reason why a mouse, for ex-
ample, should not grow to be as big as a man, or a
man as big as an elephant; since we cannot give any
reason, so far as I know, why the kidney, for example,
could not have a liundred times as many cells as it
has. If asked to account for this, we naturally and
properly fall back upon the inherited capacities and
limitations of the species, and either dismiss the in-
quiry so, or, like the learned judge in "Nathan the
Wise," summon our interlocutors to appear again in a
thousand thousand years, when there will be more
likelihood of an answer.
But — and now mark well how familiarity breedeth
contempt — when all of a sudden some. part of the body,
with its inherited limitations like all the rest, begins
to grow and keeps piling cell on cell until the new
production, a tumor, is sometimes so massive in pro-
portion to the tissue from which it sprang that an ele-
phantine man would be but a petty wonder in compar-
ison— well, under these conditions we come at the
solution of the identical problem which we had so
dexterously shirked or so ruthlessly handed to poster-
ity with a club or a sting, with an ulcerated tooth or
the butt of a clay pipe.
When we prate of hereditary predisposition as the
cause of tumors, we simply beg the question. When
we urge local excesses in cell nutrition we are reckon-
ine: without the host.
In truth, without pursuing this quarry to cover, we
are not, I think, likely to apprehend the real cause of
tumors until we approach the subject from the stand-
point of the cell itself — until we know much more
than we do to-day of the subtle influences which deter-
mine the vigor or the feebleness of its nutrition and
its growth; the inexorable sway of its heredities; the
factors which control its proliferations and its degen-
erations; and, perhaps more than all, that interdepen-
dence of closely or remotely related cells which makes
the living body an organism and not a simple conge-
ries of autonomous units.
The cell capacities, complex and varied as they are,
have been very firmly fixed by untold generations of
environmental influences, and are extremely tenacious
of their birthrights. They are doubtless to-day, as
they have always been, and as all other living things
are, subject to sway and variational drift. But these
influences become evident only after long periods.
How then can we conceive of a fundamental altera-
tion in cell capabilities as the result of a momentary
trauma ?
Of course what we mean when we cite our hodge-
podge of traumatic agencies as causes of iumors is,
that a long-continued slight local injisry or a more
acute or positive damage may in some way alter the
local conditions of cell life and growth so that the
proliferative capacities of the cells can come into play,
in a fashion determined by their antecedents.
The new cell lore has, indeed, widened our outlooks
in the possibility of profitable study of the minute
morphology and physiology of tumor cells, though we
can hardly surmise to-day whither it will lead. But
until we gain clearer vision in the normal fields, which
are hardly yet opened, we cannot, I think, reasonably
expect to fathom the subtleties of the abnormal. So
I hold one offer open to all comers: If any one will
tell me by what arrangement of cell mechanism, by
what disposition of cell impulse, under what direction
of heredity or environment, the various cells of the
normal body go on growing, multiplying, taking on
new forms and functions, framing new tissues, from
the time the original cell ceases to be an egg and be-
comes an individual, until full maturity of the body is
attained — if any one will tell me this, I say, and then
tell me why at maturity this tissue growth ceases, why
these new adventures in organ-forming stop, and from
maturity until the worn-out body is ready for the grave
only those growths and replacements occur which are
demanded by the exigencies of nutrition or by acci-
dental emergencies, I will agree to hand him back his
lore as a fair clew to, if not an exhaustive exposition
of; the origin of tumors.
I cannot think of tumors as a superior sort of inflam-
mation. I cannot understand to-day cell and tissue
formation in response to the presence of microbes, ex-
cept as a protective effort against an injury. And so,
finally, I fail to conceive how the development of a
complex and elaborate structure, almost organoid in
character, such as we have in adenoma and carcinoma,
for example, should be required, if protection against
a microbic injury be the outcome of the process.
Certainly I recall no analogy for this conception in
the varied responses to such injury with which we are
already familiar.
It is possible that in some inflammatory growths
now grouped among the sarcomata microbes may be
found which are capable of setting the cell impulses
astir. This has not yet been done. Nor are there, in
my opinion, any sufficient or even promising data at
hand for the belief that microbes of any kind are the
inciting factors in any honest tumor. I do not say
this cannot be ; but only that we have to-day no proof.
I look upon this notion as one of the numerous chalk
eggs whose shaping an uncritical estimate of the bac-
404
MEDICAL RECORD.
[March lo, 1900
teriological era has encouraged, and on which the
spirit of discovery will, I fear, brood for a long time
without quickening.
It was the uneas)- consciousness of the futility of the
commonly urged so-called causes of tumors which led
to Cohnheim's hypothesis of aberrant embryonal cells
or cell masses. But it soon became clear to the criti-
cal that this did not help the matter much, if at all,
because, admitting his postulated cell strays, you are
no nearer to the reasons for their sudden growth after
various periods of dormancy.
Virchow always, if you will permit the crudeness of
the implication, had a choice assortment of conceiv-
able cell stimuli up his sleeve, nutritive, functional,
and formative. So that it was not very difficult for
him, when he came up against pathological new for-
mations, to mix, in theory, a judicious quantity of
nutritive and formative stimulus with the body, to
which the cells would, in theory, dutifully respond.
This did well enough for simple tissue growths. But
when he came to account for such complex affairs as
cancers, he was forced either to brew a particularly
choice thing in stimuli, which he was fain to call
"specific" in consonance with the specific growth
which it was to determine; or to assume specific qual-
ities in the tissues themselves, which he called "pre-
disposition." He concluded — clever Virchow! — that
for his part he felt safer to keep a string on both pos-
sibilities.
In later times, Hanseman has based a rather inge-
nious hypothesis of the origin of tumors on alleged
irregularities in mitosis — a standpoint difficult to share
for those who keep in mind the ancestral traits which
hold every living cell of the human body in most rig-
orous restraint.
The most common attitude to assume — and perhaps
this is at once the most imposing and the easiest — is
to say that the reason why tumors occur is because the
proliferative capacities of the cells are increased; and
then refrain from further fruitless prying.
More subtle conceptions of the origin of tumors are,
however, much in evidence in the thought of the day
in pathology. Ribbert, of Zurich, has perhaps more
definitely than any other framed a working hypothesis
which is clever and suggestive; though, like any hy-
pothesis which essays to bridge abysmal ignorance,
it is likely to lead to Omar's plaint that we " evermore
come out by the same door wherein we went." Rib-
bert lays great stress, in his conception of the origin
of tumors, upon the intimate associations of the cells
as parts of an organism, and believes that their varied
capacities are normally held in some fashion under
mutual restraint in subservience to their common wel-
fare. This mutual relationship however once de-
stroyed, for example by the separation of cells or cell
groups from their organic associations, their physio-
logical capacities are no longer held in leash, and if
the nutritive and other conditions be favorable may
express themselves in exaggerated fashion witliout the
actual acquirement of new capacities for the transfor-
mation of energy. This restrained state of the cells
under ordinary conditions Ribbert calls tissue-tension
(" Gewebsspannung"). As I understand it, the state
of affairs is in Ribbert's conception something like
that of a lot of active, healthy boys in a schoolroom
who have a great deal more energy than can for the
welfare of the whole school be safely released. Turn
some of them out of doors, and they do not develop
any more capabilities for roaring, shrieking, fighting,
and making themselves generally offensive than they
had before; only these now find expression. What
Ribbert would call the schoolroom tension is relaxed.
In neither the cells nor the boys do we need to as-
sume new or exaggerated capabilities to account for
the result of organic disassociation.
Ribbert goes further than this, and explains in a
rather convincing fashion the way in which he con-
ceives the process of cell disassociation and release
from restraint to occur. Since he does not admit an
increase in the inherent proliferative capabilities of
the cells, he cannot assume, as is commonly done, that
the process is initiated, in carcinoma for example, by
the epithelial cells. He assumes and adduces very
striking evidence for his assumption that the process
starts in the connective tissue, which, as we know, is
very liable to increase in amount in response to a va-
riety of infiuences, notably those which involve trauma,
or simple inflammation, or replacement hyperplasia.
In the starting of carcinoma of the stomach or intes-
tine, for example. Ribbert shows that, in many cases
at least, the new-formed connective tissue cuts off cells
or cell groups from their organic connections, and
claims that in this way alone we may account for the
required release from the restraints of his " tissue-
tension."
Numerous objections have been urged to these con-
ceptions of Ribbert. But they are highly suggestive
at least, and I call your attention to them here because
they illustrate the tendency in modern pathology to
seek for explanations of abnormal phenomena in
more subtle agencies than we have hitherto been wont
to recognize. In our eft'orts to comprehend such ob-
scure abnormalities as lie at the bottom of the origin
of tumors, as of other diseases, I think that it would
be wise if we were at least to hold in mind the possi-
bility that a vague group of physiological factors
which we dimly conceive of through the so-called iti-
ternal secretions may be of significant influence even
in local manifestations of disease.
Notwithstanding these new outlooks to which I
have called your attention as illustrations of the gen-
eral drift, pathology in its immediately practical
phases still moves on in the beaten paths. Many of
the most significant diseases still await competent
study along the old objective lines and do not as yet
admit of adequate hypotheses. We have caught
glimpses here and there of important physiological
capacities which we as yet hardly venture to name,
much less understand. The inciting factors in many
of the most dreaded and serious infectious diseases
are wholly unknown. So the pathologist will continue
his search for pathogenic micro-organisms; he will go
on making autopsies for the practitioner, and simple
diagnosis will mostly be his not altogether inspiring
aim. He still will veil as best he can his grief when
the inexorable exposures of the autopsy fail to confirm
the convictions of the bedside. He will still strive to
evince a subdued if not enthralling interest in tacking
names to tumors removed from persons whose past or
present he knows not, and whose future he will never
learn. This he will do, not so much because there is
any scientific interest to him, as a rule, in his per-
formance, as because so only can he gain material for
study or for academic purposes.
One great practical result of this busy quarter of a
century in pathology is the getting together into use-
ful form of a series of tests and methods by which the
practitioner can secure greater accuracy in diagnosis
and greater precision in treatment than was possible
in the earlier days. These new methods in diagnosis,
requiring considerable technical facility and some
experience, now form a compact discipline which has
been called " clinical microscopy.'" " Clinical pathol-
ogy " would, I think, be a better term. Although
strictly a practical adjunct to the work of the practi-
tioner, clinical pathology still largely remains in the
hands of the pathologist. This condition of affairs
may be wise, and certainly must be convenient — for
the practitioner. But it involves the pathologist in a
series of the least interesting and most time-consum-
March lo, 1900]
MEDICAL RECORD.
405
ing tasks, diverting him from lines of work along
which lie his most cherished outlooks. To ask the
professional pathologist to continue the practical ad-
ministration of these diagnostic tests is, to borrow an
example, somewhat as if one who should seek for ad-
vice about his diet from his physician were then to
request the doctor to digest his food.
I think that this matter is of the utmost importance
in hospitals which have an officer called a pathologist,
who is, however, at present usually almost wholly oc-
cupied in assisting the practitioner in diagnosis. This
is useful work, indeed, but the pathologist is in conse-
quence almost wholly debarred from pursuing those
lines of research which it is the privilege and duty of
hospitals to encourage and maintain. It seems to me
that physicians, who constitute the medical boards of
hospitals, might wisely urge the creation of an office
which may be called an interneship in clinical pathol-
ogy, whose incumbent could, under the direction of
the pathologist perhaps, be responsible for much of the
routine work in laboratory diagnosis.
If I have succeeded in my purpose in these glimpses
here and there in pathology, you will realize, as indeed
you may all have done long ago, for I have not aimed
to present new things to you, that pathology has set
for itself in these later days problems which involve
far more subtle conceptions of the cause and meaning
of disease than were possible when we entered upon
its study a couple of decades or so ago.
We have seen that the cell is not a mere lump of
jelly with curious chemical proclivities, but a most
complex machine. The microbe has set the door ajar
to a vast arena of beneficent study. But it no longer
claims an exclusive role in the drama of infectious
disease. It is indeed often the sinister and necessary
villain on whose capacities and deeds the plot hinges,
but it is by no means the star performer and is as cer-
tainly not the play.
Bacteriology, the foster child of medicine, has grown
so lusty and exacting that we are eagerly acquiescent
in its partition among those who love it for its own
sake, those who cherish it for the light which it casts
into other fields of science, and those who prize its
economic aspects; reserving for ourselves only those
relatively limited, though highly important, phases
which bear upon the metabolism of the body and the
incitement of disease.
We have begun to realize in a practical way that
molecular constitution, the laws of osmosis and the
diffusion of gases, gravitation, elasticity, and pressure
are all physical factors in the structure and work of
the body which we must reckon with in disease as well
as in health. We have learned to perceive in inflam-
mation something more than a vexatious episode in
the life of man or an exhaustless stimulus to descrip-
tions and catalogues. We find ourselves forced to
look for light on the etiology of tumors past the crude
incitements with which the academic juggler has been
wont to toy, to those deeper phases of cell life and
impulse which it remains for future workers to unveil.
We realize clearly to-day that the man with whom
we deal does not stand for himself alone, but is the
outcome of ages of adaptation to changing environ-
ment, whose record we may spell out not only in his
normal state, but in the stress of disease, when capac-
ities and vulnerabilities, which do but rehearse the
story of his slow evolvement, stand out now with sin-
ister and again with beneficent import.
Pathology is now passing out of the stage in the
development of a science which is marked by the sim-
ple accumulation of facts. We are " grouping whole
series of phenomena as diverse manifestations of iden-
tical forces due to diverse conditions of environment."
We are even gaining courage with Schleich to describe
disease as "a form of the struggle for existence against
those injurious influences to which man is not yet
adapted."
If one were asked to summarize the most important
change in outlook and purpose which has woven itself
into pathology during the past half-century, I think
that he might wisely say of disease as Conn has re-
cently said of animals and plants, namely, that fifty
years ago they were objects to be classified; to the
student of to-day they are objects to be explained.
Of course, medicine has had explanations a plenty
which for exhaustiveness and finality left little to be
desired; ranging as they have from black-bile to Beel-
zebub. But there is just one fundamental difference
in our attitude to-day which lends assurance to the
hope that we are in the right way at last. That is,
that we are no longer trying to conduct alone our
search for light, but have called in our sister sciences.
We have at last linked our conceptions of the forces
which sustain and sway the human organism with
forces wliich are universal. And when we get concep-
tions which fit in with tlie laws of the conservation
and transformation of energy, with the doctrines of
organic evolution, and the formulas of molecular
physics, it is, I think, a good deal more than an even
chance that we are on the right trail.
When I recall the severely objective and intensely
practical character of the meetings of this society in
which it has been my privilege to share, I am more
than a little dubious as to the pertinency of my theme.
So I shall not think it strange if you regard this essay
as less an exercise in scientific exposition than an in-
dulgence in the gentle art of babbling.
CYSTITIS DUE TO THE TYPHOID BACILLUS
INTRODUCED BY CATHETER IN A PA-
TIENT NOT HAVING TYPHOID FEVER.
Bv THOMAS R. BROWN, M.D.,
From the discovery of the bacillus typhosus by Eberth '
up to within a comparatively recent period, a rather
limited role has been assigned to this micro-organism
by the great majority of medical men. Nevertheless
isolated observations made from time to time presaged
our modern views of this bacillus, and now we know
that it plays a much larger part and has a much wider
significance in bacteriological investigations than was
formerly supposed. Many cases of a true general in-
fection with this bacillus have been described, while
numerous observations have been made of its presence
in the spleen, in the rose spots of the typhoid erup-
tion, in the lymph glands, in abscesses and periosteal
swellings, and in many hitherto unexpected locations.
Among the most interesting and, from the hygienic
point of view, most important places in which it has
been found is the urine. Even shortly after Eberth 's
discovery of the bacillus a few cases of the finding of
the micro-organism in the urine were reported. Bou-
chard " in twenty-one of sixty-six cases of typhoid
fever examined found albumin associated with bacteria,
which he assumed to be typhoid bacilli ; Hueppe' in one
of eighteen cases; Seltz' in two of seven cases, in both
of these associated with albumin and in one also with
casts; Konjajeff ■' in three of twenty cases, calling es-
pecial attention to the fact that they appeared during the
later stages of the fever and were always in large num-
bers, if present at all, and regarding the presence of
J Virchow's Archiv, vol. Ix.-cxi., iS8o, and vol. Ix.xxiii. . iSSi.
'Rev. de Med.. iSSi, t. 671.
^Fortschr. der Med., 1886, iv. , 44S.
* " Rakter. .Studien zur Typhus-Aetiologie," Munich, 1S86.
^Ref. in Cent, f, Balvt., iSSg, vi., 672.
4o6
MEDICAL RECORD.
[March lo, 1900
the bacilli in the urine as evidence of typhoid lympho-
mata in the kidney.
Karlinski ' in forty-four cases of typhoid found the
bacilli present in the urine of twenty-one, always asso-
ciated with albumin and always in pure culture; Neu-
mann" in forty-eight cases found the bacilli eleven
times, and was the first to call attention to the danger
of the urine in the spread of the disease, especially as
the bacilli remained in the urine in many cases for a
long period of time after the cessation of the fever,
and that they could be present in a urine otherwise
normal, i.e., without casts or albumin.
Melchior' reports a case (Case IX., 1S92) which
developed all the typical symptoms of cystitis fourteen
days after the cessation of typhoid fever, from the
urine of which he cultivated the typhoid bacilli in pure
culture; in this case the condition cleared up entirely
in twenty-two days without treatment. He also re-
ports a case of post-typhoid cystitis due to the bacil-
lus coli communis and one of typhoid with associated
nephritis, in which Eberth's bacillus was found in the
urine.
Borges^ found the bacilli in three of ten cases, but
in three others found albumin, thus showing that the
finding of the latter was no evidence of the presence
of the former; Blumer' found the typhoid bacillus in
only two of sixty cases examined, while Baart de la
Faille" found the bacillus four times each in twenty-
seven cases examined, Blumer suggesting that the
bacilli might possibly reach the bladder from the in-
testinal tract by penetrating the recto-vesical wall.
Krogius' found the bacillus in a case of post-typhoid
cystitis; Wright' in six of seven cases, and Besson"
in six of thirty-three cases, in five of which albumin
was present in considerable amount.
Rovsing'" reports a case (Case LV. of his series) of
cystitis with swollen and reddened vesical mucosa,
following nephrolithiasis and typhoid fever, double
*jppurative nephritis, and right pyonephrosis, in which
Eberth's bacillus was found in pure culture; the case
had never been catheterized. All the above cases
were reported previous to the time of the Widal reac-
tion, and as this reaction seems to be the only abso-
lutely certain means of determining whether or not a
micro-organism is the typhoid bacillus, in many of
the earlier cases the micro-organism present and re-
garded as the typhoid bacillus was probably the colon
bacillus, although this chance of error is much less in
the cases reported between 1895 and 1898, due to the
use of the differential media of Eisner, Capaldi, Hiss,
and others. In the cases reported since 1898 differen-
tiation has been rendered comparatively easy by the
application of the VVidal reaction, and it is largely
from these cases that we must derive our views con-
cerning the prevalence of typhoid bacilli in the urine.
Richardson" studied the urine of thirty-eight typhoid
patients with extreme care and for a considerable pe-
riod of time; of these, nine cases showed the typhoid
bacillus in pure culture, while in eight of the remain-
ing twenty-nine other micro-organisms (in six the
colon bacillus) were found; in all the nine cases in
which the typhoid bacilli were found there was slight
albuminuria, but this also occurred in fifteen of the
remaining twenty-nine cases; thus showing that the
presence of albuminuria is in no wise indicative of
' Trag. med. Woch., 1S90, xv., 437. 452.
'Berlin, klin. Woch., iSyo, xxvii.. 121.
'" Cystitis und Urininfektion," Berlin, 1897.
' Inaug. Diss., WUrzburg. 1894.
* Johns Hopkins Hospital Bulletin, 1895, v., 327.
'' Inaug. Diss., Utrecht, 1895.
' Annales Gt'nito-urin. , 1894, May, 370.
■■ Lancet. 1S95, ii., 196.
•Rev. de Med., 1897, xvii., 405.
° " Infektiose Krankheiten der Harnorgane." Berlin, 1898.
' Journal of Experimental Medicine, 189S, iii., 349.
the presence of the typhoid bacillus; its absence, how-
ever, usually pointing to the absence of this micro-
organism. The bacilli usually appeared quite late in
the disease and generally persisted for a long while un-
less appropriate treatment was carried out; this treat-
ment Richardson' considers to be the administration of
urotropin, which he thinks is almost a specific in this
condition.
Petruschky" found the micro-organism in three of
fifty cases examined, and Horton-Smith ' in three of
seven cases, the latter calling especial attention to the
fact that the faeces were particulaly dangerous as a
disseminator of the disease in the early, the urine in
the later stages — often, in fact, long after the entire
subsidence of fever.
Gwyn^ reports seven cases in which the typhoid ba-
cilli were present in the urine, usually associated with
pyuria and signs of bladder irritation, while Schich-
bold " found the bacilli in five of seventeen cases ex-
amined, the latter observer concluding from the find-
ings of the two of these five cases that came to autopsy
that the presence of Eberth's bacillus in the urine is
evidence that the case is one of nephro-typhus.
Two cases of especial interest are those of Young
(personally communicated) and Houston,'' both cases
of chronic cystitis due to the bacillus typhosus, the case
of the former being the first one of this nature of
which I have any knowledge. In Young's case (to be
reported in full subsequently), one of a chronic cystitis
of five years' duration immediately following an attack
of typhoid fever, typhoid bacilli were found in large
quantities in the urine in pure culture, the micro-
organisms not only showing all the characteristic cul-
tural peculiarities, but agglutinating positively with
typhoid serum; while, on the other hand, the patient's
serum gave a positive reaction with the laboratory cul-
tures of the typhoid bacillus. The patient was not
cured at the time, and now, two years later, has reap-
peared, still showing large numbers of typhoid bacilli
in the urine. The patient had never been catheter-
ized. In Houston's case, the cystitis was of three
years' duration and directly followed an attack of
what was probably typhoid fever. A bacillus was ob-
tained in pure culture from the urine, which culturally
resembled the typhoid bacillus in every respect and
also agglutinated with the patient's own seium in dilu-
tion of I : 100, while the same serum agglutinated the
stock typhoid bacilli, but not colon bacilli. At the
time when the case was reported, Houston had been
unable to cure the condition.
The case I wish to report is a unique one in many
ways; in fact, as far as its etiology is concerned, I
have been unable to find one like it in the literature.
The patient, Mrs. S , entered the service of Dr. H.
A. Keely, who kindly permitted me to study the case
bacteriologically ; she was operated upon for a large
myomatous uterus on January 20, 1899. The only
thing of interest to us in her past history was the fact
that thirty-five years previously she had had an attack
of typhoid fever; since that time, however, there had
been no illness in the least suggesting a reinfection
with typhoid, nor had there been any manifestations
of the presence of the micro-organisms in bone lesions,
periosteal swellings, or osteo-myeliiic abscesses; there
had never been at any time painful or difficult mictu-
rition. The operation, performed on January 20, 1899,
was a difficult one, and there was considerable inevit-
able handling of the bladder and possibly some slight
trauma of that organ. The urine, examined on the
' Journal of Experimental Medicine, 1899, iv., ig.
= Cent. f. Bakt.. 189S. No. 28.
^ Lancet, 1S99, i., 1346.
■* Johns Hopkins Hospital Bulletin, 1S99. x., June.
' Deutsch. -Vrch. f. klin. Med., Ixiv.
'British .Medical Journal, 1S99, i. , p. 78.
March lo, 1900J
MEDICAL RECORD.
407
day of operation, was absolutely normal, of acid reac-
tion, of specific gravity 1.02 i, with no trace of albumin
or sugar, and showing under the microscope only a
number of bladder epithelial cells, but no pus cells,
casts, or bacteria. For eight days after the operation
the temperature was practically normal, and the con-
valescence uneventful ; on the ninth day, January
28th, the temperature rose to 100.4° F-j and for the
ten days following showed a daily rise to about 100"
F., gradually declining after that time. On the day
preceding the rise of temperature, the patient had
complained of intense pain in the bladder, and the
urine showed a dense sediment consisting of almost
pure pus, with considerable albumin; the reaction
was distinctly acid, and the specimen was of course
obtained by catheter. Two days before this the urine
had been examined, and had been found to contain a
trace of albumin, with a few pus cells and a large
amount of amorphous urates in the sediment. A cys-
toscopic examination made a few days later showed a
universally congested vesical mucous membrane with
no areas of ulceration.
The usual symptoms of acute cystitis, tenesmus,
frequent and painful micturition, vesical pain, etc.,
were present in a marked degree for the first ten days
after the development of the cystitis, after which most
of the symptoms abated markedly except the frequency
of urination, which continued up to the time when the
condition was cured. The urine showed large quanti-
ties of pus, however, for a period of twenty-eight days,
after which it disappeared quite rapidly, as will be
described shortly.
On January 27th a specimen of urine was obtained
under strict aseptic precautions, the method used being
as follows: theexternal urethral orifice being carefully
cleansed with bichloride-of-mercury solution, followed
by sterile water, a sterilized glass catheter whose ex-
ternal end was covered by a sterile rubber cuff extend-
ing several centimetres beyond the end of the catheter
was introduced, the fingers of the operator being al-
lowed to touch only the distal end of the rubber cuff;
the urine was allow ed to flow for a short space of time,
when the rubber cuff was pulled off by traction on its
distal end and a small amount of urine was collected
in a sterile test-tube, the cotton plug of which was of
course immediately reinserted after the urine had been
collected. A large series of control experiments with
normal urines has shown that this method is absolutely
reliable. An examination of the specimen thus ob-
tained showed that, besides large numbers of pus cells,
a few red blood cells, and many bladder epithelial
cells, it contained large numbers of an actively motile,
rather short, rod-shaped bacillus. Plate cultures on
agar were then made, when it was found that the micro-
organism was present in pure culture. Transplanta-
tions were then made on the various media, gelatin,
potato, glucose-agar, litmus, milk, peptone, and bouil-
lon. On gelatin the growth was white and fine, both
along the line of stab and on the surface, while there
was no liquefaction of the medium; there was no gas
production in glucose-agar; milk was neither coagu-
lated nor acidified; in peptone there was clouding but
no indol production; on potato a very faint, whitish,
almost invisible growth was to be made out, while the
study of the bouillon culture, which was much clouded,
showed that the micro-organism was markedly motile
after forty-eight and even after seventy-two hours. A
second culture made from a specimen of urine, obtained
on February i6th in the same way as before, demon-
strated the presence of the same bacillus in pure cul-
ture with identically the same cultural peculiarities,
but in smaller quantity.
As the micro-organism so definitely resembled the
typhoid bacillus in all its properties, the final test
was made, i.e., to see whether or not it would agglu-
tinate with typhoid serum. The person from whom
the serum was obtained was a patient at the Johns
Hopkins Hospital who had an absolutely typical case
of typhoid fever, w'ith palpable spleen, typical roseola,
characteristic temperature, etc., and her serum gave an
unquestionably positive reaction with the stock labora-
tory cultures of the bacillus typhosus. Both cultures
in my case, that of January 27th and that of February
i5th, reacted with this serum in the most typical man-
ner; in dilutions of 1:20 clumping was marked in five
minutes and complete in twenty minutes, while in
dilutions of 1:80 clumping was noted in ten minutes,
positive in thirty minutes, and complete in sixty
minutes.
The patient was treated at first by bladder irriga-
tions of borax and sodium bicarbonate solution, but
although showing improvement under this treatment
as evidenced by the decrease in the amount of pus,
the quantity of albumin, and the number of micro-
organisms, this improvement was so slow that uro-
tropin, gr. v. by mouth three times a day, was given,
and under this treatment the urine rapidly cleared up.
Seven days after the inauguration of this last treat-
ment, on March 4th, the urine, obtained in the same
way as before, was found to be sterile, although there
were still some pus cells present, and even a few on
the day of the patient's discharge, four days later.
The urine was acid throughout the whole course of
the disease and was markedly turbid during the height
of the infection.
As to the mode of infection in this case there are
two possibilities: first, that the bacilli had lain dor-
mant somewhere in the system since the attack of
typhoid fever thirty-five years before; and second,
that the bacilli had been freshly introduced.
Many reports have been made to show the great
periods of time in which the bacillus may remain in
various parts of the body in a latent condition, yet
capable of starting up a reinfection if the circumstances
are favorable. Flexner' has demonstrated living
typhoid bacilli in an abscess between six and seven
years after the occurrence of the original infection;
Orlon^ found the typhoid bacilli in an osteomyelitic
swelling six and one-half months after the fever; while
in periosteal abscesses the living bacilli were found
by Melchior' ten and one-half months, by Chante-
messe' fifteen months; byBuschka' seven years; and
by Hiibener'' four and one-half years after all the
symptoms of the disease had disappeared. Miller'
has reported a case in which the living bacilli were
found in the gall bladder seven years after the original
infection.
Notwithstanding these examples of the marked
ability of this micro-organism to remain latent for a
long time, it is highly improbable, in fact almost
impossible, to explain the present case on the sup-
position that the micro-organisms had lain dormant
somewhere since the original infection. In the first
place, the attack of typhoid fever had occurred thirty-
five years before, and there had been no illness sug-
gesting in the least a recurrence of the disease in the
interim; in the second place, there were absolutely
no evidences of any nidus in the body in which the
micro-organisms could have remained latent; in the
third place, there had never been any evidences of
cystitis at any time previous to the present attack;
and in the fourth place, the urine, carefully examined
previous to the operation, was found to be absolutely
normal. It is, therefore, highly probable that the
' Journal of Path, and Bact., iii., 202.
* Baumgarten's Jahresbericht, 1S87, ig7.
*" Der Typhusbacillus als Eitererreger, " Copenhagen, 1892.
■".Sera, med., iSgr, p. 415.
* Fort, der Med., 1894, Nos. 15 and 16.
" " -Mittheil. a. d. Grenzgeb. d. Med. u. Chir. ," ii.. part 5
'Johns Hopkins Hospital Bulletin, May, 1899.
4o8
MEDICAL RECORD.
[March lo, 1900
bacillus was introduced into the bladder from outside,
prer imably by catheterization, the inevitable vesical
trauma in such a difficult pelvic operation undoubtedly
rendering the dangers of infection much greater. As
far as I could learn, none of the nurses that came in
contact with the case had recently been nursing typhoid
patients. Nevertheless, when we consider the number
of cases of cystitis produced by catheterization, rela-
tively a small percentage perhaps, but absolutely quite
a large number, and the variety of micro-organisms
found as the provocative cause, it is not at all improb-
able that very occasionally Eberth's bacillus may be
this cause, since it is a micro-organism of quite wide
distribution and of undoubted pyogenic properties,
and I have no doubt that with a complete bacterio-
logical examination of all cases of cystitis, a few of
this nature would be found. Perhaps, in this case,
the fact that the patient had already had typhoid fever
and was presumably more resistant to the infection,
perhaps a diminished virulence on the part of the
micro-organism, caused the infection to be so localized
and prevented its spreading.
This case— a unique one so far as I know — adds
but another to the ever-increasing list of pathological
conditions which may be produced by the bacillus
typhosus, and once more calls attention to the neces-
sity of applying modern bacteriological, chemical, and
microscopical methods to the study of conditions
whose etiology has hither been unrecognized, for it
must be mainly through these channels that light will
be thrown upon many of the "dark continents" still
remaining in clinical pathology.
A MliANS OF ACCOUNTING FOR GAUZE
LAPAROTOMY PADS.
By victor cox PEDERSEN, A.M., M.D.,
NEW YORK,
HOUSR SURGEON, SECOND SURGICAL DIVISION, NEW YORK HOSIMTAL.
The final responsibility for instruments, sponges,
gauze-pads, and dressings used in or about the body
/ ..
3~
n
Uh^
T'if / ^
/ ^
/ B
cavities legally rests with the operator. Although
nothing will compensate for a very careful search of
tlie field just before the wound is closed, any simple
procedure which will secure their more reliable ac-
counting must be valuable. Perhaps the article most
frequently overlooked is the laparotomy sponge, or its
substitute, the gauze-pad. The following means and
method have very recently been devised by the writer,
and used in the New York
Hospital sufficiently to demon-
strate that they are capable of
furnishing accurate verification
of the number of pads used in or
about a laparotomy wound.
I. Of the means: a. The
usual gauze laparotomy pads,
with a tape from twelve to four-
teen inches long securel}" sewed
to a corner or an edge ; /',
" tally snaps," or their substi-
tutes, namely, "tally rings,"
"tally checks," or artery
clamps; c, "keepers," of either
continuous or divided ring,
continuous or divided oval, or
fenestrated bar form.
II. Of the "tally": Fig. i
gives the details and the dimensions of the "tally
snap"; side view. A; edge view of the jaw side, B;
interlocking of jaws, C. They are made of one-eighth
inch diameter bright spring-steel wire, nickelled and
burnished, bent as shown to avoid all joints, and can
J«/. 3.
be very readily and thoroughly cleaned. The snap
open for cleaning is shown in the dotted line. Fig. i,
A, a. Rigidity against opening laterally is gained by
the overlapping elbow in each jaw (Fig. i, C, a), and
by the specially firm interlock of the jaws, Fig. 1, C.
The bevelled edges, a, of the male and female parts
aid rapid locking, while the straight sides, /^ of the
tongue and socket hinder lateral displacement. Fig.
2 shows the measurements of the "tally ring." Fig. 3
'a-
suggests a form of "tally check," which is like a
trunk check, burnished nickel finish, with a hole in
each end. One hole receives the tape and the other
the keeper.
If desired, any form of tally may be stamped with
a number as shown on the check above. The objec-
March lo, 1900]
MEDICAL RECORD.
409
tion to this is that it is almost impracticable to hand
anything in series during an operation.
III. Of the "keeper"; Fig. 4 shows the features of
the divided ring " keeper," Fig. 5 those of the divided
'/■
'//
■
^.--.
Ja,
_
_
J
J-ig. 6-
oval '■ keeper," Fig. 6 those of the bar-form '" keeper."
The continuous ring and the continuous oval " keeper "
are of the same size as those divided. Otherwise no de-
scription of them is needed. The material is nickelled
and burnished bright spring-steel wire, three-sixteenths
or a quarter of an inch in diameter. The clasp of the
divided keepers may consist of two spheres, five-
eighths of an inch in diameter, one countersunk
deeply to seat the other. A better lock is illustrated
in Fig. 7. An olive-form button drilled through its
long diameter is screwed for half its length on one
end (i) of the wire. A slot is then cut from one
side into the remainder of the central hole and its
edges are bevelled to facil itate rapid seating. Into this
slot the other end (2) of the wire is received. I'his
form of lock can be managed with one hand by com-
pressing the end 2 away from i as indicated by 3, and
then letting it spring back. The two-sphere type of
lock usually needs both hands for rapid working.
Fig. 6 states full particulars as to the fenestrated bar-
form " keeper."'^ It has the advantage of maintain-
ing the tapes separate and spread out, not massed
as occurs w-ith the rings and the ovals.
The divided ring and the divided oval "keep-
ers "are suitable for the tally rings, the tally
checks, or the artery clamps. It may here be stated
that the clamps are put upon the keepers by either
of their handle finger-loops. The tally snaps may
be used with any form of keeper.
IV. Of the method: i. The number of pads and of
tally snaps are known and recorded before the opera-
tion. 2. Two keepers are needed, one for each margin
of the wound. 3. Each pad is handed to the operator
with the tally snap securely tied to its tape. 4. While
the operator is packing the pad away the assistant
catches the tally on the keeper. If the bar-form
keeper is used the first and second snaps must be put
at its opposite ends to keep it horizontal. The sub-
sequent tally snaps may be hooked into any conven
lent fenestra. Tapes twelve to fourteen inches long
permit the keepers to hang well out of the opera-
tor's reach on the sides of the patient. 5. When a
pad is removed from the field the tape is cut close to
the tally snap. 6. The tally snap remains on the
keeper till after the operation. 7. At this time the
soiled pads and the tallies on the keepers are counted.
The number of each should agree with that of the
other. This identity in the number of snaps and pads
is the first verification. 8. The second verification is
the one usually made. The pads still clean are
counted and their number is added to that of the soiled
ones to obtain the total before the operation; so like-
wise with the tally snaps.
For instance : pads and snaps before operation 36
each; after operation, soiled pads 25, tally snaps on
one keeper 10, on the other keeper 15, total 25.
Hence all pads used in or about the operation are
correctly accounted for — or the first verification is
had. Clean pads 1 1 ; unused snaps 11 ; added to 25
each used, makes 36 each, the total of each before
Fig. 8.— n, a'. Tapes, attached to pads and leading to snaps; i, i', tally snaps, each securely tied to a tape : c, c'. tally snaps, with cut tape-ends at-
tached, belonging to pads removed from the field, hence left on the keepers: </, continuous-ring keeper (drawn a little too large); .-, continuous-oval keepei
(drawn a little too large); /, bar-form fenestrated keeper. (The snaps on the ring-keeper should have been drawn massed close together, which is one obiec
tion to this type of keeper," as compared with the separation of them on the fenestrated bar.)
4IO
MEDICAL RECORD.
[March lo, 1900
the operation. Hence the second verification is had.
A careful negative search of the field will now make
closing of the wound safe.
Fig. 8 and its explanatory notes will make plain
an operation field with pads, tape% snaps, and keep-
ers.
No system is perfect. No means will make a final
examination of the cavity unnecessary before closing
it. The above plan is not perfect; but in actual prac-
tice it has been shown to furnish an accurate check on
the number of pads used in or about the wound. It
puts upon the operator's assistant the responsibility of
attaching each snap to the keeper. This is easier
than watching many tapes without keepers and with
only artery clamps attached to prevent the tapes from
being dragged into the wound, which clamps may
themselves be used in error to clamp vessels. The
keeper makes it impossible for pad tape and snap to
get into the wound as has occasionally happened with
loose artery forceps. The plan does not add any time
to that of the operation, because the assistant can
snap the tally on the keeper or cut the tape more
rapidly than the operator can pack or extricate the
pad, as the case may be. The great essentials are,
first, that after a body cavity is open no pads be
within the operator's reach except such as have tapes
and snaps attached, and second, that each snap be
promptly affixed to its keeper.
It is advisable to adopt a distinctive tally, some-
thing which can be used for nothing else, as can the
artery clamp for haemostasis in a hurry. The advan-
tage of the tally ring and tally check over the tally
snaps is that only the lock on each keejjer needs at-
tention as compared with the lock on each snap.
The general plan can be carried out fully by adopt-
ing any one of the above designs. It is hoped that
service and security will be realized as fully as pos-
sible by it.
.\'hw \\>HK Hosi.rrAL,.Deccmber i, iSgc..
Author's Note: Any one desirous of trying this
method with very little outlay can buy several dozen
large horse-blanket safety pins to use as tally snaps
and make for himself any pattern of keeper he likes.
Strips of galvanized, square mesh, railroad wire-fenc-
ing with meshes one by one inch will make excellent
bar-form keepers. Ordinary large-sized safety pins are
almost too small for safe use as tally snaps.
HISTORICAL NOTES ON THE SANATORIUM
TREATMENT OF ALCOHOLISM.
Kv CII.VRLES J. DOUGLAS, M.I)..
HUSTON', MASS.
Apparently there is a notion prevailing in some quar-
ters that the medical treatment of drug addictions —
particularly alcoholism — is an idea that was originated
within a decade or two by quacks and venders of secret
nostrums. This supposition is far from correct. It is
true, however, that during the last ten or fifteen years
these exploiters of commercialism, with their secret
and infallible ■■ cures" for drunkenness, have made
more noise than all the regular practitioners combined.
Similarly, it may be said that Lydia Pinkham's face is
more familiar to the general public tiian are the faces
of the most learned and skilful specialists in diseases of
women. But we are not justified in concluding from
this fact that gynecology is a specialty that originated
with quacks, and that they only are now engaged in it.
While the recognition of alcoholism as a disease
requiring sanatorium treatment by medical means is a
modern idea, yet it long antedates the secret "cures."
The honor of being the pioneer in this movement be-
longs to J. Edward Turner, M.D. His brain conceived
and his zeal and industry established the first sanato-
rium in the world for the treatment and cure of alco-
holism. His position was well stated by his lifelong
friend and disciple, Dr. Valentine Mott, who in 1847
said: '"In my professional life of over forty years I
have accumulated facts enough to prove beyond all
doubt that inebriety is a disease, affecting every mem-
brane, tissue, and nerve of the human mechanism,
producing in its victim a compound fracture from the
crown of his head to the sole of his foot, as well as a
mental and moral dislocation." As a result of the
discussion aroused in the medical profession by the
earnest and self-sacrificing labors of Dr. Turner, a pe-
tition was sent to the New York legislature in 1857
for the establishment of a State institution in accord-
ance with his plans for the treatment of alcoholism.
This petition was signed by over one thousand physi-
cians. In it they said: "\\'ithout such an institution
the physician has been compelled to turn from his pa-
tient, discouraged, disheartened, and defeated ; and
the victims of this painful malady — be they rich or
poor, high or low, educated or uneducated — alike must
find a drunkard's death and a drunkard's grave. With
this institution we can save hundreds who are now
crowding our insane asylums, inundating our courts,
and perishing in our streets.'*
In the same year the Onondaga Medical Society ad-
dressed a memorial to the New York legislature on this
subject, in which they said: "From a long experi-
ence in the duties of that profession which has brought
us in daily contact with the victims of a diseased ap-
petite, -we have been forced to the conclusion that an
institution in which the patient could be medically
and morally treated would prove to be of greater ben-
efit socially, politically, and charitably than any other
institution of its nature in our land."
LTp to that time there had never been in this coun-
try, or in any other, an institution for the medical
treatment of alcoholism. In September, 1858, at
Binghamton, N. Y., the corner-stone was laid of the
first building ever used for this purpose. The cere-
monies were conducted by a group of brilliant and
famous men, and letters were received from the Presi-
dent of the United States and members of his Cabinet,
as well as from many other distinguished officials.
Edward Everett, then at the zenith of his fame, deliv-
ered an eloquent address on this occasion, in the
course of which he predicted that the work begun by
Dr. Turner would be taken up in other States and
countries, until the principles here established would
be utilized as a blessing to all mankind. His closing
words were; "And believe me, many years will not
pass away before it will appear that what you have just
done for your own community, you have done for the
civilized world."
This institution was operated with success for about
three years, when it fell into the hands of the political
Philistines, was wrested from Dr. Turner's manage-
ment, and soon diverted to other uses. Nevertheless,
the prediction of Edward Everett has proven true, that
the medical treatment of alcoholism so ably and zeal-
ously advocated by Dr. Turner would prove a world-
wide blessing. The pathological nature, of inebriety
is now universally recognized, and the profession is
to-day giving more attention to its treatment than it
did ever before in the history of medicine.
Like all pioneers who have blessed the world by
forcing a new idea upon its attention, Dr. Turner's
whole life was dominated by this one great object. No
man has ever yet left a lasting impress on human his-
tory without exemplifying in his life the motto of the
apostle to the Gentiles: "This one thing I do." Dr.
Turner was animated by this apostolic spirit. From
early manhood to the close of life all that he had or
March lo, 1900]
MEDICAL RECORD.
411
was or hoped to be — all liis powers of inind and bod)^
— were laid, willingly and gladly, upon the altar of
this one noble purpose. To teach mankind that alco-
holism is a disease, and a curable one, was the object
of his life. For this cause came he into the world;
for this he lived, and for this he prematurely died.
To-day he sleeps in an unmarked and forgotten grave,
but the sons who build sepulchres lo the prophets whom
their fathers have killed will yet do him justice, and
the day is coming when the world will crown him as
one of the benefactors of the race.
The effect of Dr. Turner's work was immediately
felt in many ways. Governor Andrew, in his annual
address lo the Massachusetts legislature in 1863, said:
" Drunkenness is a disease as well as a sin. VVe have
long since legislated for its punishment; let us no
longer neglect to legislate for its cure. By every mo-
tive of humanity and reason, by every law of duty, it
challenges our consideration."
In 1868, the Massachusetts legislature appointed a
joint special committee, consisting of five members
from the Senate and nine from the House, " to consider
the matter of inebriety as a disease." These gentle-
men brought in a long and able report, in the course
of which they said ;
•' The position taken by those who have given this
subject a special investigation in the light of all the
facts which bear upon it, is that the continued use of
alcoholic drinks produces a disease peculiar and dis-
tinct from all other diseases, having a distinct pathol-
ogy, and presenting post-mortem appearances unlike
those of any other disease, being as characteristic as
those of typhoid fever or pneumonia. . . . The fact
that inebriation is a disease, a mania, and that it is
both acquired and hereditary, being conceded, the next
practical question is. Have such cases heretofore been
properly treated, and if not, what is the correct treat-
ment? We know they cannot be successfully treated
at home , they ought not to be associated with crim-
inals nor with the insane; neither should they be
neglected."
In 1870, Dr. N. S. Davis, one of our most distin-
guished medical men, who has since been called to
preside over the International Congress of Physicians,
said in a published address:
" If the inebriate is the victim of a positive disease
induced by the action of an alluring and deceptive
physical agent, alcohol, will any number of moral
lessons addressed to his intellect, or any amount of
denunciation hurled at his degradation and his vices,
cure or reform him? Or will his arrest, arraignment
in a police court, and extortion of the few dollars he
has left, as a fine, eradicate the disease that is preying
upon the most delicate parts of his organization?
Abundant experience throughout the civilized world
answp.rs these questions in the negative. The treat-
ment demanded by the nature of inebriation and the
interests of humanity is the same in kind as that
awarded to the sick and insane."*
The many private sanatoria for the treatment of al-
coholism now found throughout the country testify
that the seed sown by Dr. Turner has taken root and
is now bearing a beneficent harvest. I, of course, do
not here refer to those widely advertised institutions
where secret nostrums are used in a routine way, and
where usually the attending doctor does not know the
composition of the remedies he is employing — these
having been sent to him from " headquarters," where
they are secretly prepared. No self-respecting practi-
tioner can countenance such a concern. But I have
reference lo those ethically conducted sanatoria where
alcoholism is carefully treated by specialists in this
disease, and where the physicians are concentrating
their thought and study upon the best methods that
scientific research can devise for its cure. To such a
place a physician may take his alcoholics and be cor-
dially welcomed as a consultant, and get any informa-
tion he desires regarding the remedies employed in
the treatment of his patients.
The secret " cures " referred to above are, however,
rapidly disappearing. The most widely known of
these had, a few years ago, three or four establish-
ments in Massachusetts, tach one doing an immense
business. Now all of them are closed, with one mel-
ancholy exception, and that has but a small fraction
of the patients it formerly treated. So far as I know,
all similar concerns that were organized to exploit
secret nostrums are either dead or dying.
On the other hand, it is gratifying to note that the
professional and scientific sanatoria devoted to this
specialty have greatly increased, both in number and
efficiency, during the last few years. More patients
suffering from alcoholism and other drug addictions
are being thus ethically treated and cured than ever
before. There are few chronic diseases more preva-
lent than these, and few that are more curable, and I
predict that their treatment will soon be rated among
the most important specialties in the medical profes-
©Xiuical gcpHXtmciit.
AN INTERESTING CASE OF LABOR COM-
PLICATED BY UTERO-ABDOMINAL FIXA-
TION.
Bv JOSEPH M. RECTOR, M.D..
E. A , forty years of age, was the mother of six
children, the first five of whom were born into the
world after a normal labor, while the birth of the last
was instrumental. The menstrual history was good.
There were no indications of pelvic trouble or uterine
disease either past or present, except as hereafter
stated.
In January, 1897, the patient first came under my
observation complaining of the usual indefinite train
of pelvic and vaginal symptoms. I made an examina-
tion and found a lacerated and everted cervix, with
complete procidentia of the uterus, relaxed vagina, and
lacerated perineum. I advised operation as being the
means of affording the speediest relief, but the request
was refused, whereupon I replaced the uterus and in-
serted a large inflated rubber-ring pessary, supplement-
ing it with the usual office treatment. The patient
improved somewhat, and after a short time ceased
visiting my office. I had no further trace of her until
after the lapse of about six months, when she again
called to see me, in the mean while having subjected
herself to the operation as I before had advised.
In March of the present year she became pregnant.
In April I was first called to see her, and found her
suffering from continuous vomiting and at times severe
abdominal pains of an intermittent, contractile type.
Creosote and opium mitigated her sufferings, but she
was compelled to use the same until the sixth month
of her pregnancy. She was averse to being examined,
and thus I was ignorant of her exact condition as re-
gards what operation or operations had been per-
formed, until the time of her labor, which occurred on
Thursday, December 14, 1899. The contractions of
the uterus began in the morning about eight o'clock
and continued throughout the day. The expulsive
efforts followed each other in rapid succession, and at
six o'clock in the evening of the same day I was
called in attendance.
Examination of the abdomen showed the scar of a
412
MEDICAL RECORD.
[March lo, 1900
median abdominal incision midway between the sym-
physis pubis and the umbilicus, while stretching
downward from the upper extremity of the scar was a
broad, tense band of tissue which could be easily felt
beneath the skin, marking the adhesion between the
fundus of the uterus and the abdominal wall. Dur-
ing the contractions of the uterus, the over-developed
posterior wall could be recognized, while the normal
fundus and anterior wall below the adhesion were
poorly developed and flabby, making no attempts at
contraction or expulsion, but on the contrary forming
a pouch into which a portion of the foetus was forced
and which rested upon and lay in front of the sym-
physis pubis. Vaginal examination was unsatisfactory
until an anesthetic was given. Nothing could be felt
with the first and second fingers in the vagina. Upon
insertion of the entire hand, an opening was felt at
the vault marking the orifice of the cervical canal,
the entire vaginal portion of the cervix had evidently
been amputated. The opening in the canal with difii-
culty admitted the index finger, although pains had
been continuous for the past ten hours. The internal
03 uteri was drawn upward with the vagina, resting
about two inches above the sacral promontory and
pointing directly backward. The occiput was pre-
senting in the fourth position, and between the right
parietal bone and the symphysis pubis could be
felt the feet of the child. Passing the hand upward
along the legs I found them flexed at the knees and
resting upon the symphysis, while the thighs and
pelvis were contained within the pouch above described
and resting in front of the symphysis.
The anesthesia was pushed to the full surgical de-
gree. Complete dilatation of the remaining cervical
canal was accomplished with the hand, and the mem-
branes were ruptured. I deemed it inexpedient to
deliver the child by the presenting part because of its
failure to have already engaged the inlet, the existing
complications, and the dangers to the child of a high
instrumental delivery with an unmoulded head; there-
fore, after pushing the head upward and the lower
trunk from within the pouch, I performed podalic ver-
sion, and a living child was brought into the world.
Confining my attention to the mother, 1 gave the par-
tially asphyxiated child to Dr. Imnianuel Pyle for
resuscitation.
The hemorrhage following the delivery of the
placenta was enormous. The uterus contracted but
feebly; that portion above the adhesion contracted
slowly, while the lower anterior portion did not con-
tract at all. Hot diluted acetic acid was thrown into
the uterus, while continuous manipulation was made
from without; the upper posterior portion responded,
but the lower anterior did not. Ice was then passed
up into the pouch, and it at once contracted, thus
causing the hemorrhage to cease.
After half an hour's continuous efforts Dr. Pyle suc-
ceeded in resuscitating the child. My attention was
called by Dr. Pyle to the peculiar cry of the baby,
and an examination revealed to us a deep depression
in the skull over the right frontal region and a corre-
sponding condition in the left occipito-parietal region.
These depressions marked the points of compression
in nature's attempt at natural delivery.
It has seemed best to me to report this interesting
case, thus adding another proof in evidence of the
disturbances wliich may arise from the formation of
adhesions between the uterus and abdominal wall in
child-bearing women. Such patients' suffering from
symptoms referable to retroflexed, retroverted, or pro-
lapsed uteri certainly call for some means of cure or
relief, but when to accomplish that end we are obliged
to jeopardize and endanger their future lives, and that
of their unborn children, it becomes our duty to con-
sider carefully before we act. The operations of Goff,
Alexander, Mann, Edebohls, Wylie, Dudley, Kelly,
and many others are far preferable, and in the end
may save many lives for some more useful purpose.
A REMARKABLE CASE OF CHLORAL
POISONING.
By PHILIP F. ROGERS, M.D ,
I WAS called a short time ago to the bedside of a
middle-aged man, and found him suffering from the
effects of prolonged worry and pretty hard driiiking
He was restless and sleepless, and in a mental state
bordering on melancholia, having repeatedly threat-
ened suicide. He begged me to give him sleep, and
along with gradual withdrawal of whiskey and substi-
tution therefor of strychnine and tincture of cap.sicum
I prescribed a two-ounce mixture containing chloral
hydrate gr. x. and potassium bromide gr. xv. to the
drachm, instructing the attendants to give him a tea-
spoonful every three hours with a double dose at bed-
time if he was still restless, but no more. This was
on Thursday. I was not sent for again till the fol-
lowing Monday, when the man's peculiar actions
alarmed his friends. I found the patient curled up
in bed with knees and chin approximated; his ex-
tremities were cold, and he was jerking and rolling
fitfully about now and then to assume a new position.
Breathing was slow and stertorous with frequent pro-
longed, loud, grunting expirations; the pulse was slow
and soft, but full; the face was ashen gray with
parched mouth and lips and swollen tongue, and there
was almost complete stupor. On inquiry I found that
since I had last seen him he had had the bottle of
sedative mixture refilled four times, and had been
drinking the stuff by the half whiskey-glassful. He
had slept and been wakeful by turns, but was withal
in a happy mood and invited those about him to drink
with him, saying it was "great stuff." Sunday night
he had been in a state of happy delirium nearly all
night, jumping out of bed and wandering unsteadily
from room to room, but toward morning he lapsed into
the stupid condition in which I found him. During
all this time he had eaten heartily, but had taken little
or no alcohol and scarcely any of the strychnine
mixture.
On Sunday his hand had been so unsteady that he
spilled considerable of the medicine on attempting to
take it, and the amount so lost was about one bottleful
(two ounces). During the three days, then, Friday,
Saturday and Sunday, he had taken no less than eight
ounces of the mixture, or six hundred and forty grains
of chloral and nine hundred and sixty grains of potas-
sium bromide! The treatment consisted in the ap-
plication of heat and a hypodermic injection of strych-
nine gr. -j'tj. In a few hours the man was sitting up
and chatting pleasantly, saying he did not know when
he had had such a good time, although he could re-
member distinctly nothing of what had happened.
Being upbraided for disobeying orders, he said I did
not understand his constitution; that he required large
doses to obtain any effect from medicines, and that
what I had ordered was entirely inadequate. He
praised my medicine highly and thanked me warmly
for what I had done for him; but the next day and for
several days thereafter he had for his companions
"devils'" of a deeper indigo hue than he had ever
known before.
In view of the enormous quantity of the drug taken
I regard his escape from death as little short of mir-
aculous, and attribute it to the fact that he had
taken food freely and had frequent movements of the
bowels.
March lo, 1900]
MEDICAL RECORD.
413
Medical Record:
A ll't'ckly Journal of Medicine and Surgery.
GEORGE E. SHRADY, A.M., M.D., Editor.
rUKLISIIERS
WM. WOOD & CO., 51 Fifth Avenue.
New York, March 10, 1900.
BOARD OF CHARITIES OF THE STATE OF
NEW YORK.
The thirty-third annual report of the board of chari-
ties contains much interesting matter. Never before
has such activity in charitable legislation been wit-
nessed in this State. No less than one hundred bills
were introduced during the four months of the legis-
lative session. The legislation recommended by the
board to the legislature of 1900 is as follows: i. The
extension of the territory from which the New York
Institution for the Blind shall receive State pupils;
2. An amendment to Section 698 of the Penal Code
to prevent the sending of short-term offenders to the
houses of refuge and reformatories for women. Much
of the report is devoted to a history of the board's
legal proceedings against the New York Society for
the Prevention of Cruelty to Children.
The board reports the number and classification of
beneficiaries in institutions subject to its supervision,
October 1, 1899, to be as follows: Aged and friendless
persons, 7,392 ; almshouse institution inmates, 11,251 ;
blind in almshouses, 341 ; blind in other institutions,
414; deaf in almshouses, 94; deaf in other institu-
tions, 1,548; dependent children, 31,218; disabled
soldiers and sailors, 1,611; epileptics in almshouses,
316; epileptics in Craig Colony, 378; hospital pa-
tients, 8,223 ; idiotic and feeble-minded in almshouses,
1,153; idiotic and feeble-minded in State institutions,
1,303; juvenile offenders, 3,501 ; reformatory inmates
(women and girls), 1,868; making a total of 70,611.
The board calls attention to the urgent need of further
provision for the feeble-minded and idiotic. The re-
moval of the House of Refuge at Randall's Island
from its present situation to one in the country is ear-
nestly recommended by the board.
With regard to the Craig Colony for epileptics the
report says : " The experience of the past three years
is sufficient to encourage the belief that this greatest
custodial effort of the State of New York will meet the
anticipations of its founders. Time for gradual and
carefully studied development is necessary, and it can-
not consistently be expected that the complete organi-
zation and establishment of so extended an experiment
can readily be effected. For success in this as in all
similar enterprises a scrupulous attention to details
of development and painstaking economy are essen-
tial. The number of dependent epileptics in the State
reported to the board at the time the recent" census was
taken is 785, and the Colony expects to be able to re-
ceive 270 of this number within a comparatively short
time."
The other institutions inspected were, on the whole,
in a highly satisfactory condition, and it is gratifying
to note that by removing children from Randall's Isl-
and and placing them at board in families the mor-
tality has been reduced to a point far below that of
the previous years.
ADULTERATION OF FOOD.
This is a matter which has within the past few years
assumed a somewhat alarming phase. While granting
that in many instances the dangers arising from this
cause have been greatly exaggerated, and that for the
most part the chemicals used in the adulteration have
little harmful effect, yet at the same time this line of
reasoning does not in any way justify the practice.
No sane person will be found to assert that the so-
called preservatives are beneficial to health; on the
contrary it is certain that they are all harmful in a
greater or less degree. The truth undoubtedly is that
foreign substances are added for the purpose of gain-
ing a larger profit than would be possible if the article
offered for sale were what it is labelled. An individ-
ual has a right when he buys a food commodity to
obtain exactly that which he requires, and this right
should be protected by law. It is said, and there
would seem to be no cause to doubt the truth of the
statement, that the adulteration of food is carried on
to a greater extent in the United States than in any
country in the world. The various States are unable
by their own police regulations effectually to protect
their citizens from such practice. Therefore the only
course to be pursued is, in the words of the memorial
from the National Pure Food and Drug Congress, held
in March, 1898, "to secure suitable legislation of a
national character to prevent the adulteration of food,
drinks, and drugs, and to secure the enforcement of
such laws."
AN INQUIRY INTO THE LOCAL GOVERN-
MENT OF THE CITY OF NEW YORK.
A BILL has been introduced into the Assembly for the
purpose of authorizing the appointment of a commis-
sion to inquire into the local government of the city
of New York and the charter thereof, and to suggest
legislation thereon. The proposed commission, con-
sisting of fifteen persons, is to be appointed by the
governor thirty days after the bill takes effect. The
powers to be placed in the hands of the commission-
ers will be considerable, and the result of their inves-
tigations should be for the public weal. Nothing is
mentioned in the provisions of the bill as to the con-
stitution of the commission, but the suggestion has
been made that at least one physician should be in-
cluded among its members. A consideration of the
charter must necessarily embrace many matters con-
414
MEDICAL RECORD.
[March lo,. 1900
nected with the public health, and it would therefore
appear fitting that the medical profession should be
adequately represented. There would be no necessity
to make this a provision of the bill, but in the event
of its becoming law the governor should be urged to
appoint one or more members of the commission from
among the physicians of this city. We are of the
opinion that this suggestion should be acted upon both
in the interests of the population of New York City
at large and of the medical profession.
THE SOLUTION OF AN ECONOMIC PROB-
LEM.
We live in an age of fragmentary knowledge. Every--
body is developing some independent line of thought,
discovery, or action, but as a people we do not know
what our contemporaries are doing for us until the
fact-fragments are collected and digested.
One of the first books of the year will doubtless be
one of the most useful and practical in the coming
century, for the reason that it is the summing up of
methods and theories, with a practical solution of a
medico-social problem. " The Care and Treatment
of Epileptics,'' by William Pryor Letchworth, LL.D.,
is a unique work. It contains a critical summary of
the various methods that have been adopted for the sup-
port and the amelioration of this class of dependents.
Mr. Letchworth traces the first charitable attempts
made over a century ago to relieve epileptics, down to
the more efficacious and modern methods adopted in
France and Germany. The Bethel colony near Biele-
feld in Westphalia he describes as the most far-reaching
and beneficent in its results. The colonization system
for epileptics, as put into working practice there, has
become the accepted model for philanthropic work
among them to-day. And it was this system, as exam-
ined by Dr. Peterson, and worked up by such able
men on the State Charity Commission as the late
Oscar Craig and Mr. William Letchworth himself,
that brought about, in New York State, the establish-
ment of Craig Colony.
It is not the extolling of a philanthropic scheme
that makes this book valuable; it is the practical dis-
cussion of site, labor, buildings,- restrictions, diet,
training, supervision, economics, nursing, and treat-
ment of epileptics that illustrates what has been done
in this beautiful Genesee village, with its farm lands
and orchards, to make the epileptic a useful, happy
member of the community, in spite of his fits. He
contrasts the greater benefits of the village life as
against the institution life, such as is very ably car-
ried out in the Ohio Hospital for Epileptics at Galli-
polis. He shows the practical proof of the statement
so often made by Dr. Spratling, medical superintend-
ent of Craig Colony, that " out-door work is the key-
stone in the arch of treatment of epilepsy." He shows
how this very out-door work provides the vegetables
and dairy produce which are recognized as the best
diet for such patients, and how the tonic of fresh air,
combined with the soporific effect of tired muscles,
induces sleep and renders the long-established bro-
mides unnecessary.
Five States in the Union, including Massachusetts,
New Jersey, and Te.xas, have made some provision for
this dependent class of unfortunates, the provisions of
which Mr. Letchworth has discussde in detail. There
are also many private institutions, but none seems to
give such help to the individual nor renders him cap-
able of as much self-support as the methods adopted
by Craig Colony.
The chief value of Mr. Letchworth's historical
sketches and descriptions of methods of work is that
it is now possible for every State in the Union to es-
tablish just such a colony without the labor of break-
ing the ground of new ideas and untried philanthropy,
and of slowly bringing public opinion and charity
commissions to the sticking-point.
THE SIEGE OF LADYSMITH.
The siege of Ladysmith adds yet another page to the
already long list in the history of beleaguered towns.
The condition of the garrison and inhabitants of the
place when relief came affords further evidence of the
capacity of the human body to withstand the attacks
of famine and disease, if buoyed up and stimulated by
a sense of duty. In brief, here is one more instance
of the influence of mind over matter.
The state of the survivors in Ladysmith is said to
have been pitiable ; they were reduced to eating horse
and mule flesh, and the water of the Klip River, whence
they derived their supply, was so contaminated by the
Boers as to be almost undrinkable. The putrid water
was undoubtedly the cause of the greater part of the
sickness, and the question is being asked whether the
shut-in force was sufficiently supplied with filters, or,
if so, whether their use was strictly enforced. The
contention has been put forward by many experts that
water, however much it may be infected, if passed
through a reliable filter will have no injurious effect
upon the consumer. This is a point that up to the
present has not been made altogether clear, and
requires additional proof before being accepted as
an undeniable fact. The campaign in South Africa
should go far toward solving the problem. Probably
the efficacy of even the best of filters has been over-
estimated, or it may be that under the " stress and
storm " of siege, and owing to the well-known careless-
ness of soldiers, it was found impossible to insist
upon the general use of this method of purifying
water. At any rate irrefutable figures show that dur-
ing the enforced occupation of Ladysmith by British
troops, eight thousand, or more than two-thirds of the
total number, passed through hospital, a goodly pro-
portion of which we may take it were suffering from
the consumption of polluted water.
The war in South Africa viewed from a medical
standpoint has taught and will teach many useful les-
sons, not the least of which is the need of keeping up
the army medical service to its proper strength. The
task of making " bricks from straw " is extremely diffi-
cult, and this country as well as Great Britain has
recently learned the absolute folly of a policy of un-
preparedness.
March lo, 1900]
MEDICAL RECORD.
415
g:cxus of the "emcdi.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
March 2, 1900. February 26th. — Passed Assistant
Surgeon F. W. Olcott detached from the naval recruit-
ing rendezvous, Detroit, Mich., and ordered home and
to wait orders. Assistant Surgeon J. A. Murphy or-
dered to the Pensacola navy yard. February 27th. —
Passed Assistant Surgeon W. F. Arnold detached from
the Pensacola navy yard and ordered to the naval hos-
pital, Norfolk, Va., for treatment. Assistant Surgeon
D. H. Morgan ordered home from the Asiatic station
and to wait orders.
Vital Statistics of Havana.— We have received
from Major John G. Davis, surgeon U.S.V., and
chief sanitary officer of Havana, some interesting
statistics in regard to births, marriages, and deaths
in that city during the ten years ended December 31,
1899. In that period there were 40,509 births, 9,596
marriages, and 101,932 deaths, an apparent excess of
61,423 deaths over births. The death rate was heav-
iest during 1898, 1897, and 1896 in the order named.
Of the total number of deaths during the decade 5,413
were from yellow fever, and 96,519 from other causes.
Of the 40,509 births during the ten years covered
by the report, 34,498 were whites, 2,248 negroes, and
3,763 mulattoes. Of the births 26,489 were legiti-
mate and 14,020 were illegitimate. Of the marriages
during the same period 9,068 were whites, 394 mulat-
toes, and 134 negroes.
Dr. Andrew J. McCosh, who has been suffering
from septic poisoning resulting from a cut on the arm
while performing an operation, is now happily con-
valescent.
A Leper Refused Admittance. — A young man from
Barbados was recently detained by the immigration
office and ordered to be returned to Bridgetown. He
was the son of an official there, and himself had held
a clerkship in one of the colonial government offices.
A few months ago he became afflicted with a malady
which several physicians who examined and treated
him said required cool weather for its cure. He in-
tended going from here to Canada.
To Abolish the Office of Coroner Dr. Henry has
introduced in the Assembly a bill to obtain more ac-
curate determination of the causes of death in cases
of those who have died suddenly or under conditions
which warrant the suspicion of crime. The bill will
confer on boards of health certain duties and powers
in the investigation of such deaths, and abolishes the
office of coroner.
Surgeons in South Africa It was announced re-
cently in Parliament that three hundred and sixty-
eight regular army surgeons and one hundred and
thirty-three civilian surgeons were now with the Brit-
ish army in South Africa, and that twenty-eight more
civilians were under orders to go to the Cape. Of the
other regular surgeons, three hundred and. seventy-
seven were at colonial stations and one hundred arwi
eleven at home stations, in addition to one hundred
and twelve retired officers who were temporarily em-
ployed on home duty. The organization of the med-
ical staff in this war has been praised by every one
competent to speak or cognizant of the facts. Even
such a fuzzy old fossil as the Duke of Cambridge,,
who did all in his power when commander-in-chief of
the army to degrade and humiliate the medical offi-
cers, has been forced to the confession that one of the
few bright things of the war has been the magnificent
work done by the army medical department under
Surgeon-General Jameson.
Smallpox among Students. — According to a press
despatch nine students of the Detroit College of Med-
icine are confined in the pest hospital with smallpox,
and two others are at their homes in the country with
what is believed to be the same disease. About two
weeks ago the students dissected a negro's cadaver,
shipped from the South, and among those present were
the eleven now ill. The cases are all mild, as all
those affected had been vaccinated in infancy. A
freshman at the Sheffield Scientific School at Yale
University was recently attacked with smallpox. All
his associates who had been in his company recently
have been revaccinated and isolated.
A New Public Hospital for Crippled Children
The Ways and Means Committee of the Assembly has
reported favorably the bill appropriating $10,000 for
the establishment in New York City of the " New
York State Hospital for the Care of Crippled and
Deformed Children." There is to be a board of five
managers, appointed by the governor.
Casualties at Ladysmith.— The following were the
total casualties among the British troops during the
siege of Ladysmith: Killed or died of wounds, 24 offi-
cers and 236 men; died of disease, 6 officers and 340
men; wounded, 70 officers and 520 men, exclusive of
white civilians and natives.
Disinfection of the Urine in Typhoid Fever
The Nev^ York City board of health has issued a bul-
letin calling attention to the fact of the frequent pres
ence of typhoid bacilli in the urine of persons suffer-
ing from this disease, and urging upon practitioners
and those in attendance upon the sick the importance
of the disinfection of the urine in such cases. The
best disinfectant for this purpose is carbolic acid, it
is effectual, cheap, and easily obtained. Urine to
which has been added one-third of its volume of a
1 : 20 solution of carbolic acid is thoroughly disin-
fected in a few minutes. The best method is to keep
the urinal or bedpan partly filled with the disinfecting
solution at all times. In this way any germs present
in the urine are almost instantly destroyed. It is
believed that careful disinfection of the urine and
faeces in typhoid fever would eventually produce a
sensible diminution in the number of cases of this
disea.se occurring in New York City, and a corre-
sponding reduction in the death rate from it.
4i6
MEDICAL RECORD.
[March lo, 1900
To Shorten the Medical Course In response to
an appeal by college presidents to admit to the sec-
ond year of tiie medical course graduates qualified in
the branches taught in the first year of the course, the
Pennsylvania State Medical Council adopted the fol-
lowing resolution :
" J?esoh't'd, Tha.t in the judgment of the council,
when the medical course of a literary college, as
proven by the examination of the student by the med-
ical college, covers the entire work of the first year of
actual medical study, such course may be accredited
by the medical college as the first year of medical
study required by law."
The Plague is not yet entirely stamped out in Hon-
olulu, three fatal cases having occurred there on Feb-
"■uary 19th. The victims were Chinese, two men and
one woman. — It is reported from Texas that there
have been several cases of bubonic plague on the inl-
and of Cozumel, off the coast of Yucatan.
Pennsylvania State Medical Examinations. — The
next examinations by the Pennsylvania State board of
medical examiners will be held from June 26th to
29th for graduates of regular medical colleges at Pitts-
burg and Philadelphia, for graduates of homoeopathic
colleges at Philadelphia, and for graduates of the Ec-
lectic College at Harrisburg.
Fraud in Medical Examinations. — In a report
presented by a committee of the Pennsylvania State
medical examining-board, appointed for the purpose
of investigating charges that graduates of medical col-
leges had obtained in advance the lists of questions
used in recent examinations for the license to practise
medicine, it is admitted that the questions were in the
possession of some of the candidates prior to the
examination in June, 1899, and the office of the pub-
lic printer is suggested as the point of leakage. It is
added that the percentage of candidates having prior
possession of the questions was comparatively small,
and that of those having the questions almost all
would have passed the State examination.
The Hahnemann Monument. — A joint resolution
introduced by Representative Dalzell, granting per-
mission for the erection of a monument in honor of
Samuel Hahnemann, the founder of homoeopathy, has
passed both houses of Congress and has been signed
by the President. The committee on the library, to
which this bill was referred, reported it back to the
House favorably, and recommended that the chief of
engineers, United States army, the chairman of the
joint committee on the library, and the cliairman of
the monument committee select a site to build the
foundation. The monument will be of gray granite
with statue and bas-reliefs of bronze. It will be an
elliptical exedra with a sitting statue of Hahnemann
on a pedestal in the centre. It is expected that the
corner-stone will be laid on April nth, the one hun-
dred and forty-fifth anniversary of Hahnemann's birth.
Tenement-House Reform. — A joint bill has been
introduced into the New York Senate and Assembly
to effect a reform in the laws governing tenement
houses. The bill authorizes the governor to appoint
a commission to inquire into the New York City tene-
ment question, and to report to the next legislature a
code of tenement-house laws.
Philadelphia County Medical Society. — At a stated
meeting held on February 28th, Dr. Andrew J. Downes
read a paper entitled " Siphonage of the Partitioned
Bladder," with the demonstration of a new instrument
designated " the separate urine siphon." Dr. J. Madi-
son Taylor presented the report of the committee to
secure a pay hospital for contagious diseases, and a
resolution was adopted favoring the establishment of
such an institution. Dr. George C. Stout read a paper
on " Some Diseases in Children."
A New French Hospital.— The board of managers
of the French Benevolent Society has decided to erect
a new hospital building. The present hospital of the
society was established in 1881. It contains seventy
beds and twelve private rooms. The capacity of the
building which it is proposed to erect will be one
hundred and fifty beds and twenty-five private rooms,
besides sun parlors for convalescents and the inev-
itable and unneeded dispensary.
The New Orleans Polyclinic. — A report being in
circulation that this school has been closed on ac-
count of the prevalence of smallpox in New Orleans,
Dr. Isadore Dyer writes that the smallpox situation
in the city has at no time justified the apprehensions
of any intending visitors. He says that the Poly-
clinic will not close until the end of the regular term
in May.
Hospital Corps of the National Guard of the
State of New York. — Assemblyman Cotton has in-
troduced a bill into the legislature amending the
military code by providing that there shall be at-
tached to each regiment in the National Guard a
pharmacist who is to rank as first lieutenant; two hos-
pital stewards instead of one, and three if the regi-
ment consists of more than ten companies. The bill
also increases the number of members of a regi-
mental hospital corps from thirteen to twenty-five.
Obituary Notes. — Dr. Christopher Prince died
on March 4th, at his home in Irvington-on-Hudson,
from pneumonia. He was born in Brooklyn in 1823.
He studied medicine under Dr. Willard Parker, and
was graduated from the College of Physicians and
Surgeons in this city in the class of 1845. For some
years he lived at Fort Hamilton. He subsequently
moved to New York, where in 1872 he was appointed
police surgeon, which place he resigned to accept the
surgeonship of the fire department. A few years later
he moved to Irvington. He was a member of the
Academy of Medicine, the County Medical Society,
and the Pathological Society, and was for some years
chairman of the obstetrical section of the Academy.
Dr. Clarence Edwin Beere, a well-known homce-
opathic practitioner of this city, died March ist. He
was a graduate in arts of Yale and in medicine of the
medical department of the New York University in
the class of 1873. He was assistant surgeon of the
Seventh Regiment Veteran Corps.
March lo, 1900]
MEDICAL RECORD.
417
progress of l^ctUcitl J^cicucc.
Medical News, March j, njoo.
A' New and Improved Method of Entering the
Abdominal Cavity in the Ileocaecal Region, with
Special Reference to the Removal of the Vermi-
form Appendix. — George R. Fowler states that the
incision in all cases of appendicitis should be so
planned as to include removal of the appendix ; thus
there must be free access to the base of that organ.
Attempts to fix arbitrarily the exact location of the
base of the appendix in its relation to tiie anterior
abdominal wall have proved futile on account of the
varying anatomical relations in different individuals.
Fowler's favorite incision is so planned that its centre
strikes a point corresponding to the intersection of a
line extending from one anterior superior spinous
process of the ilium to the other, with a vertical line
drawn half-way between the median line and the right
anterior superior spine. He then describes his method
of procedure in detail, summing up its advantages as
follows: Ready access to the ileocEecal region and
ample room for manipulation; weakening of the ab-
dominal wall and liability to surgical hernia are re-
duced to a minimum by {a) incising the necessary
structures so that an immediate, firm, and permanent
union is secured, and (/') avoiding injury to the ves-
sels and nerves of the involved parts.
Notes on Plague. — H. E. Deane draws the follow-
ing lessons from Indian experience of the plague:
The fact is emphasized that compulsory measures have
failed to have the desired repressive effect on the dis-
ease, because the populace have been dead against
them and the authorities. The people distrust the
possible stringencies that might be imposed on them
in an epidemic of more formidable proportions. Oc-
cidentals dislike to have their sick removed to hospi-
tals and their homes disturbed. They suppress in-
formation concerning the disease as far as possible.
Even the medical practitioners atTord little or no help
in this way, for fear of losing practice. The whole
question is a medico-political one in which medicine
lias to be subservient to policy. Deane believes that
hygienic precautionary measures will do more to
stamp out the plague than all the bayonets of the
British army.
Status of Medical Practice in Puerto Rico
George G. Groff gives the essential points in the order
regulating the practice of medicine, pharmacy, and
dentistry in Puerto Rico. An examining committee
of three physicians, two pharmacists, and one dentist
is appointed to conduct examinations under rules
made by the superior board of health. The members
of this committee must all be of ten years' standing
and recognized professional ability, and must speak
English. The superior board of health appoints the
president and secretary of this committee. The ex-
aminations are all written and the papers submitted to
the board of health, by whom licenses are issued to
the successful candidates. Examination fees are:
For physicians and surgeons, ^25; pharmacists, $25;
dentists, 5125 ; practicantes, $15 ; professional nurses,
Sio; midwives, $5. Persons who violate the order
may be punished by both fine and imprisonment.
The Xiphopages, Rosalina and Maria.^j— Alvaro
Ramos describes his ojjeration which he undertook to
separate these wonderful twins. All possible precau-
tions were taken in order that if the desired result
could not be attained there should be no disastrous
effect. Unfortunately the parenchyma of the two livers
was continuous, and further steps in the separation
were abandoned. The twins made a good recovery.
A Case of Salivary Calculus from the Submax-
illary Gland. — .S. H. Dessau reports this case in
which the condition suggested some slight suspicion
of Ludwig's angina. Suppuration and spontaneous
rupture occurred, followed by recovery. The calculus
was passed from Wharton's duct and measured eleven-
sixteenths by twelve-sixteenths of an inch.
Again the Question of Cancer. — ByRoswell Park.
See Medical Record, vol. Ivii., p. 212.
Journal 0/ the Amer. Med. Association, March j, igoo.
Chancre of the Lip in a Child Seven Months
Old. — L. Duncan Pulkley says that while extragenital
chancres innocently acquired are not so very rare, in-
stances of their occurrence at the early age of seven
months are seldom seen, this being the youngest
subject in whom he has seen it among nearly two hun-
dred cases of extragenital chancre coming under his
observation. Careful questioning of the mother failed
to reveal any source of the infection. The parents,
however, were from Finland, where syphilis is very
common, and the child was bottle-fed. It is more
than probable, therefore, the writer thinks, that some
friend while caring for the child infected the nipple
of the bottle when testing the food. This is a trick
common among nurses, who then place the nipple in
the child's mouth without washing it.
Legislative Problems in the Regulation of Mar-
riages.— C. W. Parker considers the obstacles in the
way of legislation regulating marriage. He then sug-
gests as a partial remedy, until education shall have
blazed a path for more stringent measures, a bill
which, while calling for the examination of men, shall
exempt women, thus doing away with what he calls
" the sentimental objection," which bill shall also be
drawn so as only to include those with tuberculosis
when actually developed, dipsomania when positively
proved, and syphilis in all its stages, together with
actual imbecility.
Can the State Suppress Genito-Urinary Diseases ?
• — Ferd. C. Valentine answers this question by the fol-
lowing summary: (i) Illegitimate relations between
sexes have always existed; (2) moralists, theological
or lay, could never induce the suppression of vice; (3)
physicians know that men who have sufifered most in-
tensely from genito-urinary disease will expose them-
selves to new infection even long before they are
cured. The writer sees the only remedy in the proper
enlightenment of humanity, especially the frank edu-
cation of the young in these matters.
Restriction of Marriage for the Prevention of
Communicable Diseases. — Albert H. Burr instances
the Creed bill, passed by the senate of South Dakota,
as being a step in the right direction. He says that
similar bills have been presented or are ready for
presentation in several other States, and he confidently
expects to see State after State follow this lead, as the
public become sufficiently educated to realize its im-
portance.
Restrictive Marriage Legislation from the Stand-
point of the Wife, Mother, and Home.— Mrs. Alice
Lee Moque asks : " May it not be that surgical science
shall be the means of giving humanity the panacea
for the crime committed against progeny by the crimi-
nal and degenerate classes? The writer refers to a
method for effecting the sterilization of women as
practised by Professor Spenelli, of Turin.
4i8
MEDICAL RECORD.
[March lo, 1900
The Legal Restriction of Marriage for the Pre-
vention of Pauperism, Crime, and Mental Diseases.
— Albert H. Eurr thinks that the time is not yet ripe
for legislation in this matter, and will not be until the
laity have been educated by the medical profession up
to the point of demanding for themselves the neces-
sary enactments.
Simple Device for Rapid Hypodermoclysis in
Combating Shock. — Evan O'Xeill Kane says the ob-
jection to hypodermoclysis has been that it is too slow
in action. To obviate this he has devised an apparatus
with which four or more needles may furnish fluid to
the tissues at the same time, from a single receptacle.
Two Practical Points in the Care of the Tuber-
culous.— William Porter urges the importance of two
indications in tuberculosis — relief of heart weakness
and of constipation. He believes these conditions to
be a part of the direct progress of the disease, and
complications of no little gravity.
A Clinical Study of Four Hundred and Fifty
Cases of Scarlet Fever — Annie .Sturges Daniel pre-
sents a detailed study of scarlet fever occurring in
children under twelve years old in the tenement houses
of the East Side in New York City.
Ureteral Calculus. — Howard A. Kelly reports a
case of ureteral calculus in which the diagnosis was
made by means of the wax-tipped bougie. The cal-
culus escaped per vias naturales after forcible dilata-
tion of the ureteral orifice.
Value of Formaldehyde in the Disinfection of
Buildings, Rooms, and Cars. — John E. Owens re-
ports gratifying results from experiments made with
the German forty-per-cent. solution of formaldehyde.
Two Hundred and Twenty Cases of Hemor-
rhoids.— These cases, reported by Joseph B. Bacon,
were all successfully operated on by the ligature
method, with only one complication.
Ne7C' York Medical Joiinial, Marrk j, igoo.
Rheumatic Gout B. C. Loveland considers this
affection worthy of being called a painless rheumatism,
and studies the clinical aspects of the disease. Illus-
trations and radiographs are given of cases which have
come under his own observation. Treatment is com-
prised under the headings of dietary, hygiene, and
hydrotherapy, and medicinal. He finds the most useful
remedies to be the salicylate and benzoate of sodium
and the iodide of potassium. It may be necessary to
study each individual case for some time before find-
ing the alkali which will give the best effects.
A Case of Ossification of the Uterus. — C. Jeff
Miller reports the case occurring in a girl aged sixteen
years, with absence of the vagina, and in the space
normally the site of the uterus and appendages was a
mass which was removed by abdominal incision, and
which proved to be composed of true compact bone.
No trace of ovarian or tubal structure could be found.
Typhoid Fever — C. E. Page gives some general
observations on the subject and describes what he con-
siders to be the physiological treatment including
physiological diet. He advocates the Brand bath,
temporary fasting for diarrhoea, and free use of water
internally. He considers that college teaching is
very imperfect in the matter of fever therapy.
Another Accommodation of the Eye. — N. B. Jen-
kins calls attention to the power manifested by the
eye in " adapting itself to badly fitting glasses." This
" other accommodation " of the eye is the chief stock
in trade of the wandering spectacle expert, and is the
sheet anchor of unscientific refraction methods.
A Partial Study of a Child Presenting Multiple
Deformities. — G. R. Elliott gives illustrations of a
case occurring in the practice of J. Fraenkel and B.
Onuf. The deformities were double drop-wrist, douSle
drop-foot, subluxation of the left hip joint, and a for-
ward dislocation of the right radius.
Thirty-two Cases of Typhoid Fever without a
Death. — J. C. Crist advocates in his treatment of the
disease bathing, milk with lime-water (but if this dis-
agrees, he substitutes soft-boiled eggs, meat broths,
and soups), and carbonate of guaiacol for the intesti-
nal symptoms.
F>rimary Hemorrhage following Amygdalotomy»
— A case in a woman aged twenty-six years is reported
by G. B. Hope. Bleeding was finally checked by ap-
plication of the galvano-cautery after the failure of
cocaine, antipyrin, cold, and hydrogen peroxide.
Some Therapeutic Notes Philip Zenner com-
mends the use of apomorphine in tachycardia and
cacodylic acid in ana;mia.
Boston Medical and Surgical Journal, March 7, igoo.
Psychology and Heredity. — Robert MacDougall,
in concluding his article from the previous number,
compares the Spencerian and VVeismannian theories,
and says that the moral problem is absolutely differ-
ent according as we hold to one or the other. Accord-
ing to the first the effects of use and disuse are inher-
ited, and the cumulative results of right thinking and
right living in the end convert bad stock into good
stock. Restraint, discipline, the confoimance to a
higher life are fundamentally hopeful. Under the
Weissman concept there is no hope — the bad stock is
no more got rid of by discipline and culture than are
the impurities of a river by filtration of the water on
the part of those living below the source of pollution.
The Relative Humidity of Our Houses in Win-
ter.— Robert DeC. \\'ard says that the present means
of heating our houses are wretchedly inadequate from
the point of view of supplying sufficient moisture.
The relative humidity of the air coming from an ordi-
nary furnace may be somewhat increased by increas-
ing the size or the number of the evaporating pans in
the furnace, or 'by placing pans of water on, or better
still within, the registers. Dr. H. J. Barnes has found
that with a relative humidity raised from thirty-one
per cent, to fifty-three per cent., his office is comfort-
able at a temperature of about 65°, whereas before a
temperature of 70' to 71° was required.
Vivisection in Harvard Medical School.— James
J. Putnam writes a strong paper in denial of charges
brought against physiological investigations, meeting
the various accusations and successfully disposing of
them, showing that they are made in ignorance of
what is really done in vivisections, of the actions
of drugs used, and of the value of results obtained.
He pleads with investigators, physicians and laymen,
to oppose the bill to restrict experimentation on liv-
ing animals, since the object of vivisection is to di-
minish pain in both human beings and animals by
increasing our knowledge of the conditions which
underli^health and disease.
Stricture of the Urete"r a Possible Result of Lac-
eration of the Cervix Uteri, and Uretero- Vaginal
Fistula a Result of Trachelorrhaphy.— E. C. Dud-
ley describes an interesting case.
March lo, 1900]
MEDICAL RECORD.
419
Perinephritic Abscess Involving the Appendix
Hugh Williams describes a case in which the appen-
dix was probably secondarily involved. Recovery
followed operation.
Philadelphia Medical Journal, March j, igoo.
Cultivation of the Typhoid Bacillus from Rose
Spots. — Mark W. Richardson reports the results of
six cases in which a bacteriological culture examina-
tion was made of the exantheni in typhoid fever. In
five of these cases the bacilli were found from two to
twelve days (average about six) before the Widal re-
action was obtained. The writer believes, therefore,
that the method may be of diagnostic service.
Exploratory Laparotomy under Local Anassthe-
sia for Acute Abdominal Symptoms Occurring in
the Course of Typhoid Fever. — Harvey Gushing re-
ports five cases of this description, in one of which
recovery occurred, and discusses the advantage of
cocaine anaesthesia in such operations.
Typhoid Fever in New Orleans P. E. Archinard
discusses the causes of the prevalence of the disease
in this city, and gives a summary of twenty-two cases
occurring in the practice of several physicians. Like
all other germ-diseases in New Orleans, he says, tj-
phoid fever is there of a decidedly benign type.
Monocular Diplopia in Typhoid Fever Edward
B. Heckel reports a case of typhoid fever in whicli the
diagnosis was not made because of the irregularity of
the symptoms, one of which was a monocular diplopia
lasting two days. Subsequently the patient relapsed
into a typical typhoid condition.
Three Cases of General Convulsions in Typhoid
Fever. — Thomas Ash Clayton reports three cases of
this rare complication, two of which appeared to be
due to the action of the toxins on the nervous centres,
the other possibly being a case of intracranial throm-
bosis or hemorrhage.
The Therapeutic Use of Water. — George P.
Sprague discourages a resort to hydrotherapy by those
unable to judge of its value by its physiological ef-
fects. Eut when its physiological effects are kept in
mind the scientific application of water is a valuable
means of combating disease.
Brand Treatment.— -J. C. Wilson and J. L. Salinger
present a summary of 1,904 cases of typhoid fever
treated during the past ten years by systematic cold
bathing combined with the administration of drugs as
indicated. The mortality was 7.5 per cent.
The Nervous System in Typhoid Fever.— Ed-
ward E. Mayer reports several cases in which the ner-
vous symptoms were especially marked. He says that
typhoid fever is as much an infectious disease of the
nervous system as of the abdominal organs.
A Case of Suspected Typhoid Fever Shown to
be Acute Catarrhal Otitis Media without Pain. —
Charles H. Burnett reports a case in which paracente-
sis of the drum membrane was followed by a speedy
subsidence of the fever and delirium.
The Diagnosis of Perforation in Typhoid Fever.
— Alexander McPhedran says this accident often oc-
curs unaccompanied by strong symptoms. Persistent
pain is perhaps the most constant sign in these marked
cases.
Surgical Sequelae of Typhoid Fever. — Under this
head Martin B. Tinker reports cases of oesophageal
stricture, hip-joint ankylosis, costal osteomyelitis, and
spondylo-arthritis.
Typhoid Fever Complicated by Meningitis H.
M. Fischer reports a case in which the bacillus typho-
sis was found in cultures made from beneath the cere-
bellar meninges.
Water-Borne Diseases.— E. G. Matson advocates
sand filtration of a city water supply as the only prac-
tical method of purification which has stood the test
of experience.
The Treatment of Typhoid Fever Frank Bil-
lings advocates the cold bath with friction, the effect
of which is to increase enormously the elimination of
toxins.
The Ocular Complications of Typhoid Fever. —
G. E. de Schweinitz discusses affections of tlie eye
which may occur during or after an attack of this dis-
ease.
Observations on the Gruber-Widal Reaction in
Typhoid Fever — By Aloysius O. J. Kelly and Alex-
ander A. Uhle. See Medical Record, vol. Ivii., p.
193-
The Duty of the Physician in Preventing the
Dissemination of Typhoid Fever By Thomas G.
Ashton. See Medical Record, vol. Ivii., p. 193,
The Value of Clinical Laboratory Methods in the
Diagnosis of Typhoid Fever By J. H. Musser.
See Medical Record, vol. Ivii., p. 193.
Preventive Inoculation and Serum Therapy of
Typhoid Fever. — By Joseph McFarland. See Medi-
cal Record, vol. Ivii., p. 193.
The Examination of Urine for Typhoid Bacilli.
— By Norman B. Gwyn. See Medical Record, vol.
Ivii., p. 193.
British Medical Journal, February ij and 24, igoo.
A Modification of the Operation of Inguinal Co-
lotomy. — In this operation, described by R. Cozens
Bailey, after the abdomen had been opened and a loop
of sigmoid flexure drawn out in the usual way, the
proximal arm of the U-shaped sigmoid loop was then
stitched all round to the edges of the incision in the
external oblique muscle by a row of sutures which
penetrated the external coats of the bowel only. A
second incision a little over one inch in length was
then made, parallel with the first and about two inches
below it. This, which was placed just above Pou-
part's ligament, exposed the surface of the external
oblique. The band of skin and subcutaneous tissue
between the two incisions was next freed from the sub-
jacent structures with the handle of the scalpel, and
the loop of intestine drawn out through the lower
wound, where it was subsequently kept in positicn by
a glass rod passed through the mesentery. The upper
skin wound was closed. The object of the operation
as described was to allow the pad to make pressure
upon a portion of the length of the wall of the viscus
as well as upon the opening itself, and thus to obtain
more efficient control, as in Frank's method of per-
forming gastrostomy.
Notes on Some Cases of Gunshot Wounds from
South Africa. — These cases, reported by William
Dick, include wounds of the head, neck, and chest,
and abdomen. They were mostly caused by Mauser
bullets, and none of them received any operative in-
terference. The author says it must be concluded
420
MEDICAL RECORD.
[March lo, 1900
from these cases that Mauser bullets do not carry with
them septic infective material. The manner in which
these wounds heal is held to be matter for future in-
vestigation— possibly, the wounds being small, extrav-
asation is prevented by contraction, this contraction
being rapidly followed by plastic effusion, resulting
in permanent occlusion of the openings. Perforations
of the bones seem to be accompanied by little or no
fissuring, and heal as rapidly as wounds of the soft
parts. Perforations of the lungs also heal quickly and
give rise to very few acute symptoms.
A Case of Bullet Wounds of the Chest F. A.
Saw reports a case of wound by a Mauser bullet.
From careful measurements of the wounds of entrance
and exit it was found that both lungs must have been
traversed by the bullet, though its exact course and
how the large structures in front of the vertebral col-
umn escaped could not be explained. The symptoms
— temporary sensations of paralysis of the limbs, fol-
lowed by retention of urine — would suggest that the
bullet grazed the body of a vertebra. Considerable
pain was suffered at the point of the right shoulder,
which is generally associated with some lesion of the
liver. The patient made a rapid recovery, was up in
two weeks, and now, a month from the date of injury,
is practically well save for a little dyspnoea on exer-
tion and slight pain on taking a deep inspiration.
Twin Pregnancy with Central Placenta Praevia.
— This case occurred in the practice of H. Oliphant
Nicholson. The patient was successfully delivered
and appeared to be rallying, when, on making a move-
ment to turn in bed, she suddenly expired, about six
hours after the termination of the labor. The author
points out that the risk to the mother must be much
more grave when this condition exists with a twin preg-
nancy, because it would not always be possible to sep-
arate the placenta entirely, thus giving the patient
time to react from the effects of hemorrhage before
emptying the uterus.
An Analytical Account of Fifty-seven Cases of
Puerperal Infection. — In giving an account of these
cases the author, W. Edgar Macharg, has not attempted
classification, simply arranging them according to
result, as fatal or non-fatal. The writer has at-
tempted to bring into relation and prominence the
chief points of interest in the total number of cases,
at the same time giving particular attention to sucii as
came to post-mortem examination. He hopes that the
results may be found of value as being founded on a
consecutive series in the practice of one observer.
A Case of Placenta Praevia and Rupture of the
Uterus. — This case, reported by James Pearse, is intur-
esting as having ended ih recovery with practicall_\' no
treatment. In order that union might not be disturbed
the bowels were kept locked for a week, and during
this time douching was avoided for the same reason.
The author says that while laparotomy is undoubtedly
the ideal treatment for this complication, such cases
as the above serve to prove that even when this is im-
possible the outlook is by no means hopeless.
On the Use of Antistreptococcus Serum in Puer-
peral Septicaemia and Erysipelas.— Alex J. Ander-
son reports three cases, one of puerperal septica;mia
and two of erysipelas, in which, after trying the older
methods for a time, he used the serum as a last re-
source with exctllcnt results. The author thinks the
effects of the serum should be watched from hour to
hour, clay and night, on account of its depressing effect
on the circulation, which lasts several days after the
injections have been stopped.
Frequent Dislocation of the Right Shoulder. — P.
O'Connell reports the case of a stout, well-built man,
with large, powerful shoulder muscles, who constantly
dislocates the right shoulder-joint. If he throws his
hand above his head, or if he receives a slight blow on
the shoulder, the head of the humerus slips, sometimes
into the axilla, sometimes under the pectoral muscles.
In one instance after the patient had flung his arm
about in drunken sleep, spontaneous reduction took
place.
Report on Three Cases of Gunshot Wound. — A.
P. Blenkinsop reports that these three cases of self-
inflicted gunshot wounds demonstrate the effects of
small-calibre bullets and cordite ammunition, which
effects are markedly different from those produced by
the older form of rifle. Their chief interest from a
medico-legal point of view rests in the fact that there
was no scorching or tattooing of the tissues, although
in each case the rifle must have been held ver}' close
to, if not touching, the skin.
Penetrating Wound of the Bladder and Rectum
from the Buttock. — In this case, reported by J. R.
Dodd, the wound of tiie buttock was opened up into
the rectum as in the operation for fistula ; the catheter
was tied into the bladder, and the usual measures were
taken for checking hemorrhage, which, however, con-
tinued for several days. W'itli the exception of a se-
vere attack of epididymitis in the left testicle, the
patient made an uninterrupted recovery.
A Case of Exploratory Operation for Dilatation
of the Stomach.— Ernest A. T. Steele thinks that
the patient in this case would have recovered if the
operation could have been undertaken before she was
worn out with the constant retching. As it was, the
retching ceased after the operation, and there was no
pain, but a slight diarrhcea occurred and seemed to
turn the scale, and the patient died suddenly with
symptoms of cardiac failure.
The Bromide Sleep.— In this case, reported by
Frank C. Ford, an epileptic lad, aged sixteen years,
took nearly two ounces of potassium bromide in forty-
eight hours. Although the stupor was marked, the
writer was impressed with the comparatively slight
effect of so large a dose, and he infers that manifes-
tation of bromism depends rather on individual idio-
syncrasy than on the quantity of drug taken.
A Case in which a Pulmonary Abscess was
Successfully Drained. — Charles A. Morton reports
a case in which the patient was expectorating about
half a pint of fetid pus a day. There was an area of
dulness at the right base posteriorly, and the exploring
needle revealed the presence of pus. An incision was
made and a drainage tube inserted into the suppurating
cavity. The man made a good recovery.
Double Monster ; Thoracopagus, Single Heart.—
De Vere Condon describes this monster, which had
two complete male bodies joined laterally from axilla
to hip. An interesting point about the case is that
the riglit child was extremely thin and emaciated,
while the left child was plump. The latter is said to
have lived for half an hour and the other to have iieen
born dead.
When is Cancer Cured ?— W. H. Jalland notes this
case as throwing an interesting light upon what is
called the " time limit." The writer removed a scir-
rhous growth from the axilla of a patient. Nine years
and two months after he operated again, removing a
lump from the site of the old cicatrix, together with
the breast to which it was attached.
March lo, 1900]
MEDICAL RECORD.
421
Fracture of Both Clavicles. — Another case of this
rare accident is reported by Thomas Milne. In this
case a shunter was caught by the shoulders between
the buflfers of two gently colliding wagons, the force
.seeming just sufficient to snap the clavicles, and noth-
ing more.
Foreign Body in the Male Urethra. — Horace Wil-
son tells of a lady's bonnet pin passed by a drunken
sailor up liis urethra. Under an anesthetic the object
was recaptured, when the patient immediately rejoined
his ship, feeling no subsequent inconvenience.
An Address on Medical Practice in European
Countries. — Thomas Kilner Clarke summarizes the
requirements for medical practice in different coun-
tries on the continent.
A Case, of Puerperal Septicasmia. — In this case,
reported by H. W. \\'ebber, a favorable result was ob-
tained from one injection of antistreptococcus serum.
Organization of Aseptic Operations and Some of
the Causes of Failure.— An address delivered before
the Leamington Medical Society, by C. B. Lockwood.
The Anatomy and Pathology of the Rarer Forms
of Hernia. — By B. G. A. Moynihan. See Medical
Record, vol. Ivii., page 421.
Recent Legislation in Relation to the Medical
Profession. — An address by Fletcher Beach.
The Role of the Municipality in Public Hygiene.
— An address by Sir Charles A. Cameron.
The Lancet^ February ij and 24^ igoo.
On the Restoration of Co-ordinated Movements
after Nerve Section. — R. Kennedy concludes as the
result of experiments that after section and immediate
coaptation of a nerve, restoration of conductivity and
of voluntary function ma}' be effected in a few days.
This may be the result of regeneration of young nerve-
fibres in the peripheral segment. Voluntary co-
ordinated movements are regained, whether the two
ends of the divided nerve are united as accurately as
possible, or twisted so that non-corresponding ends of
the nerve-fibres are brought into contact. In the lat-
ter case it is doubtful whether the restoration of func-
tion is due to the re-establishment of the old paths by
decussation in the nerve cicatrix or to the reunion of
ends of nerve-fibres which do not correspond but
which happen to be brought into apposition. In sutur-
ing a divided nerve, therefore, the simple approxima-
tion of the two ends, no matter in what relationship, is
all that is required.
A Case of Interstitial Fibroid Tumor Sloughing
*' en Masse," and Some Other Cases of Fibroid
Tumors of the Uterus. — Arthur H. N. Lewers reports
the following cases: suppurating ovarian tumor and
uterine fibroids (ovariotomy was done and the fibroid
markedly diminished in size); a case of abdominal
hysterectomy with intraperitoneal treatment of stump;
large abdominal tumor composed of subperitoneal
fibroids (one of the latter had undergone cystic de-
generation with formation of puriform fluid); sub-
peritoneal fibroid complicating pregnancy — expectant
treatment, normal labor; submucous fibroid causing
hemorrhages — dilatation, enucleation, recovery (two
cases); subperitoneal fibroid with adhesion to gut, left
hydrosalpinx — removal of both; also the case named
in the title.
A Brief Review of Our Knowledge Concerning
Backward Displacements of the Pelvic Organs F.
H. W'iggin believes that these conditions are largely
unnecessary and due to preventable causes. Growing
girls should be properly instructed by their mothers
about mode of life, use of suitable clothing, passing
urine at proper intervals, dangers of falls and of lift-
ing heavy weights. Damage at parturition requires
immediate repair. A modified rest cure should be in-
stituted immediately after confinement, and the patient
should in all cases visit the physician three months
after confinement for further examination.
Measles in a Patient Aged Eighteen Years Com-
plicated with Meningitis and Spinal Myelitis ; Re-
covery A case is related by E. F. Eliot. The patient
on the fourth day after appearance of the rash sud-
denly developed convulsions, epileptiform in charac-
ter, which were referred either to toxic poisoning from
measles, or to cessation of the menses, or to a general
neurotic condition. The subsequent course of the
case led to the diagnosis named in the title. The
entire duration of the sickness was two months.
An Anomalous Case of Continued Fever with
Abscesses of the Liver. — J. G. McNaught describes
the history of a gunner in the artillery service, a man
aged twenty-four years, who for a period of sixteen
days gave symptoms of enteric fever with bowel hem-
orrhages. Five abscesses were found in the liver.
Cultures from the spleen gave a bacillus somewhat
resembling the bacillus coli and a coccus which was
probably the streptococcus pyogenes.
A Successful Case of Cceliotomy for Intestinal
Obstruction due to Persistent Meckel's Diverticu-
lum.— A case occurring in a girl aged nine years is
reported by C. A. Morton. The symptoms of onset
suggested appendicitis. A portion of the small gut
was found distended, but on tracing an enipty coil of
the bowel it was found that the constricting ring into
which the gut had slipped was formed by a persistent
Meckel's diverticulum.
Ocular Phenomena Associated with Cheyne-
Stokes Respiration. — G. Y. Eales noticed in a man,
aged sixty-one years, with cardiac valvular trouble,
Cheyne-Stokes respiration, observing that during the
interval of the series of respirations both pupils re-
mained stationary and somewhat contracted, but as a
new cycle came on they both gradually became widely
dilated and so remained during the height of the cycle.
A Hepatic Mucoid Cyst W. C. McDonnell re-
ports such a case in a man aged fifty-three years, suf-
fering for some time with intermittent attacks of sud-
den epigastric pain. The cyst was located on the
upper mid-surface of the liver, and contained a jelly-
like mass of apple-green color, specific gravity 1.029,
composed chiefly of mucin.
Topographical Relations of the Brain, the Fron-
tal and Maxillary Sinuses, and the Venous Si-
nuses of the Dura Mater to the Walls of the
Skull. — P. Regnier and J. Glover give an account of
their researches, in which radiographic methods were
applied to the investigation of the anatomy of the
skull and face.
Epistaxis from the Ethmoidal Veins. — Four cases
are reported by A. Brown Kelly. Epistaxis from the
anterior ethmoidal vessels is controlled by firm pack-
ing between the septum and' the anterior half of the
middle turbinate, the strip of gauze reaching as near
as possible to the roof of the nose.
The Anatomy and Pathology of the Rarer Forms
of Hernia. — B. G. A. Moynihan discusses, in the first
422
MEDICAL RECORD.
[March lo, 1900
of the Arris and Gale lectures delivered before the
Royal College of Surgeons, the anatomy and pathol-
ogy of bilocular hernia, including inguinc- and cruro-
properitoneal and intestinal hernia.
Hemiatrophy of the Tongue. — The case related by
L. A. Parry was that of a man aged fifty years. The
condition was referred to injury (possibly due to a
previous fracture at the base of the skull) of the hypo-
glossal nerve in its passage through the anterior
condyloid foramen.
Large Doses of Carbolic Acid in Equine Teta-
nus F. E. Place has injected in this disease as
much as a drachm dose of the acid (B. P.), and has
so used thirty-six drachms in eighty-four hours. The
neighborhood of the neck and shoulders is chosen as
the site of injection.
Two Cases of Pulsus Paradoxus. — John Hay de-
scribes with tracings two cases of the condition occur-
ring in dyspnoea from bronchitis in a child, and in
pleurisy and pericarditis (both with effusion) in an
adult.
Diphtheria of the Conjunctiva. — S. Stevenson re-
lates a case. He believes that a bacteriological exam-
ination will show the true diphtheritic nature of about
two per cent, of all cases of ophthalmia.
Tuberculous Disease of the Kidney ; its Etiol-
ogy, Pathology, and Surgical Treatment.— By D.
Newman. A continued article.
The Anatomy and Pathology of the Eye. — By
E. Treacher Collins. The Erasmus Wilson lectures.
Medical Press and Cimilar, Feb. 14. attd 2T, igoo.
The Risks of Unoperated Uterine Fibromata —
E. Stanmore Bishop says the dangers may be divided
into two classes: those directly due to the presence
of the growth itself; secondly, those which render
dangerous an operation undertaken late. All these
are avoidable and unnecessary if surgical aid is ob-
tained sufficiently early. There are five inherent dan-
gers : Death from hemorrhage, from sepsis, from pres-
sure upon important organs, death during or after
pregnancy, death from cardiac degeneration owing to
persistent loss of blood. The operation for fibroid
has the advantage over that for malignant disease,
that there is no recurrence for the patient to fear.
There should be less waiting for the menopause.
A Case of Inward Displacement of the Lower
Epiphysis of the Humerus D'.Vrcy Power describes
a case of this injury in which the arm was in a
state of cubitus varus, the long axis being directed
inward at the elbow. The case belongs to a very ob-
scure class, becoming better known by application of
the Roentgen rays, which showed that separation of
the lower epiphysis of the humerus liad been subperi-
osteal. The external condyle had lost its cartilag-
inous covering, and the epiphysis seemed fixed in its
new position by ossification of the periosteum.
Note on a Case of Loose Body in the Knee-
joint. — R. G. Patteson reports a synovitis with lock-
ing of the joint, preceded by occasional pains for six
weeks and the feeling of something loose in the joint.
A loose body was located and cut down upon, and
when extracted appeared to consist of equal propor-
tions of bone and cartilage. It was supposed to be
derived from an outgrowth in the course of chronic
rheumatic arthritis.
Chronic Total Inversion of the Uterus. ^F. W.
Ramsay reports a completely inverted uterus covered
with phosphates. The base of the bladder was com-
pletely gone, exposing the fundus, the edges being
composed of dense cicatricial tissue. The womb was
removed and an operation done to close the fistula.
The patient was able to do all her work and retain her
urine for three hours.
Uterine Myoma Associated with Temporary Gly-
cosuria and Umbilical Hernia. — Arthur E. Giles re-
ports a case in which subperitoneal hysterectomy was
done in a woman whose glycosuria was functional and
due to nervous apprehension of the operation. Sugar
persisted after the operation for a week. Cure of both
conditions resulted.
Distended Pyosalpinx F. A. Purcell records a
case of distended pyosalpinx of the right side, the
opposite tube being distended and thickened. The
uterus was removed by the subperitoneal method, with
recovery.
Instruction in Obstetrics and Gynaecology. — Ab-
stract of presidential address of W. J. Smyly delivered
before the British Gynaecological Society, February 8,
1900.
The Dilatations and Diverticula of the (Esoph-
agus.— A continued article by John Knott.
Treatment of Pleurisy. — A clinical lecture by
Prof. G. Debove. >•
Ber/hicr kUnische Woehenschrijt, February 12, igoo.
Epidemiology and Prophylaxis of Malaria from
Most Recent Etiological Standpoints. — A. Celli be-
lieves that cases of malaria should be isolated in the
same manner as are infectious diseases. He believes
in tlie mosquito theory of causation, and advises the
immediate removal of the patient from the place in
which he contracted the disease. He does not think
that we possess at the present time any means which
can prevent the ravages of this insect, and the ideal
place for the patient is a sanatorium on high ground
with plenty of fresh air. The patient is not to be
allowed to revisit the place of infection until examina-
tion of his blood and spleen shows absence of malarial
organisms.
Polyarthritis Chronica Villosa and Arthritis De-
formans.— M. Schueller concludes a lengthy article
upon this subject. Arthritis develops often spontane-
ously without any preceding joint inflammations. The
possibility of a bacterial origin is still uncertain.
More likely a disturbance of nutrition lies at the bot-
tom of the malady. Most of the patients suffer from
constipation and flatulence, and an interference with
the elimination of lime salts from the body. An es-
sential point in treatment is to provide a dietary which
is poor in this particular chemical element, and to pay
special attention to the action of the bodily emunc-
tories.
The Origin of Dermoid Cysts. — S. W. Handler re-
gards these structures as due to the development in
abnormal situations of certain embryonal cells and
organs, which in this new situation elaborate them-
selves in exactly the same way as if they were nor-
mally situated. Such abnormal development begins
at a time when the loss of cell elements from their
normal site is made good by the development of other
similar cells at the original site. Hence, in spite of
the abnormal development, we have the bodily organ-
ism coming to full maturity.
Experimental Researches on Bleeding in Urae-
mia.— P. F. Richter finds that in rabbits slow and
gradually progressive renal insufficiency from increas-
March lo, 1900]
MEDICAL RECORD.
423
ing doses of renal poison is not changed by bleeding.
There is no essential lessening of osmotic pressure in
cases of sudden increased -concentration of the blood
through bleeding either with or without saline infusion.
He would not, however, deny that clinical observation
in man emphasizes the fact that bleeding in urasmic
states is of benefit.
Nature's Methods of Protecting the Organism
against Infection By P. Baumgarten. A continued
article.
Auto-Intoxication. — By C. A. Ewald. A continued
article.
Wiener klinische Wochenschrift, February 8, igoo.
The Influence of Thyroid Extract on the Circu-
lation and Respiration, besides an Addition Con-
cerning the Relations between lodothyrin and So-
dium Iodide, or Atropine — Be'la v. P'eryvessy, from
his experiments on rabbits, says that the influence of
thyroid extract on respiration was not uniform. Often
the intravenous injections were followed by no changes.
Sometimes an acceleration resulted. The characteris-
tic influence on circulation was a lowering of blood
pressure. From his observations he cannot confirm
the statements respecting the antagonistic influence of
iodothyrin to sodium iodide or atropine. He thinks
that the apparently positive results in regard to this
have been deceptive on account of the transitory influ-
ence of sodium iodide and atropine.
Opinions of the Medical Faculty in Vienna.
Murder Committed by an Intoxicated, Ethically
Depraved Individual ; Alleged Acute Intoxication
and Somnolence. — V. Wagner relates this case and
gives the questions asked by the court: Did this man
commit this deed while entirely robbed of his reason,
or was it during a period of insanity which alternated
with a normal mental state? The answer was that he
was ethically defective as well as being intoxicated at
the time. The criminal was condemned for man-
slaughter and sentenced to eight years' imprisonment.
Disturbances of the Vasomotor Function and
Sensibility after Peripheral Traumatic Facial Pa-
ralysis.— Carl Biehl reports a case and considers that
it proves what Frankl-Hochwart has maintained, that
the facial nerve contains also both sensory and vaso-
motor fibres.
Miitiilicner viedicinische Wochenschrift, Feb. 6, igoo.
The Reaction of Leucocytes to the Tincture of
Guaiac. — Kurt Brandenburg believes that the reaction
of pus to tincture of guaiac deserves a more extensive
use as a convenient reagent for pus in the urine and
other excreta. It is often advisable to filter the urine
and use the filter for the reaction on account of the
many reducing substances in the urine which hinder
the appearance of the blue coloration. In like man-
ner, by filtering ofl; a few drops of blood dissolved in
water, in cases of leukaemia, the reaction of the filter
with guaiac tincture produces a blue color. The prop-
erty of pus to color guaiac tincture blue depends in
all probability on the influence of nucleo-proteids — this
is seen even in extreme dilution. Nucleo-proteids ex-
tracted from various tissues do not give this reaction
— only the nucleo-proteids derived from the leucocyte
group (bone-marrow cells). Tissue abounding in
lymphocytes, e.g., adenoid, does not give this reaction.
Absorption and Fat-Splitting in the Stomach.—
Franz Volhard concludes from his work on this sub-
ject that an extensive splitting of finely emulsified egg
and milk fat takes place in the stomach. He believes
Mering's method, in which the Soxhlet apparatus is
used and the fatty fluid is spread over clay and dried
with dry sodium sulphate, is the simplest and most
convenient.
A Preliminary Communication on a New Stain-
ing Method for the Determination of the Finer
Structure of Bacteria — K. Nakarishi describes a new
method of staining with methylene blue which has
met with successful results. He has tried many ani-
line colors, and considers methylene blue best suited
to this work.
Two Cases of Beri-Beri ( Panneuritis Endemica
Balz) on Board a German Steamer. — P. Schmidt,
after submitting these reports, states that much micro-
scopical work has been done to elucidate the etiology
of this disease. But the work of both European and
Japanese physicians has yielded no valuable results.
Some Remarks on the Basophilic Granules in
the Red Blood Discs. — Martin Cohn thinks it most
probable these granules are the result of protoplasmic
degenerations which depend to a certain extent on the
chemical alteration of the blood serum, since they are
always present in anaemia.
Ischiadic Scoliosis. — Krecke is of the opinion that
the bowing is not caused by functional incapacity nor
by paralysis or contracture of the sacro-lumbalis, but
conies from the patient's tendency to shift all the bur-
den of effort on to the side that is not painful.
The Application of Gelatin for Checking Cholae-
mic Hemorrhages after Operations on the Biliary
System, besides Remarks on Poppert's Waterproof
Drainage of the Gall Bladder.— By Hans Kehr. A
continued article.
Reports of Cases of Skull and Brain Injuries.—
Carl Frohlich reports two cases of this nature, the first
of which ended in recovery, while the latter developed
traumatic encephalitis after a year and resulted fatally.
Deutsche wed. Woehenscltrift, February 8, igoo.
The Diagnosis of Incipient Tuberculosis from
the Sputum. — L. Brieger -and F. Neufeld hold that
( I ) the sputum should be examined not only for tuber-
cle bacilli but also for other bacteria, especially for
those of the so-called mixed infections; (2) the exam-
ination should be repeated at intervals if no tubercle
bacilli are found at first; (3) in any case the clinical
symptoms must be carefully studied, for it is only by
a comparison of the clinical and bacteriological find-
ings that one can arrive at any satisfactory diagnostic
and prognostic conclusions; {4) whenever repeated
examinations leave the diagnosis uncertain, recourse
should be had to the tuberculin test, which is positive
and at the same time free from danger.
Turners' Palsy. — E. Lehrwald describes, under the
title " Klimmzuglahnumg," a form of paralysis in-
duced by the strain of raising the body by the arms,
the hands grasping a horizontal bar. In a reported
case the trouble appeared quite suddenly and involved
the deltoid chiefly, but also the biceps and in less de-
gree the brachialis internus and supinator longus.
The paresis was accompanied by atrophy of the af-
fected muscles. In another case the paralysis was
much more extensive. The author believes this af-
fection is not very uncommon among weak and unskil-
ful gymnasts, and says such persons should be warned
424
MEDICAL RECORD.
[March lo, 1900
against persisting in tiie offending exercises when they
cause pain or excessive fatigue in the arms.
Treatment of Ulcerative Stricture of the Rec-
tum.— Julius Wolff reports a case of stricture of the
rectum following ulcer in which, after unsuccessful
attempts to cure by less heroic measures, an extensive
resection of the wall of the rectum was made. Heal-
ing did not take place, the stitches gave way, and the
final result was an enormous opening at the anus, with
consequent prolapse of the rectum. A resort was now
had, many months after the primary operation, to a
plastic operation, whereby the posterior wall of the
rectum was re-formed with a skin flap, and the divided
ends of the sphincter were freshened and reunited.
The operation was a complete success.
Spondylitis Rhizomelica — M. L. H. S. Menko re-
ports a case of this affection, described first by Eech-
terew as chronic ankylosing inflammation of the spine
and large joints, and later called by JNIarie " spondy-
lose rhizome'lique."
French Journals.
Experimental Study upon the Parasitism of Tu-
mors.— VV. Podwyssotski, basing his experiments upon
the classical study by Woronin of the excrescences
found upon the roots of plants — especially the cab-
bage— and taking the plasmodiophora brassica; as the
type of productive agent in parasitic tumors in the
vegetable kingdom, studies the effect of such parasites
upon animal tissues. He inoculated rabbits and
guinea-pigs with small masses of the root of diseased
cabbage containing the parasites in the stage of sporu-
lation. Round or oval tumors formed, showing masses
of cells much like those in leprous granuloma or
large-celled sarcoma. The infiltration began in the
perivascular lymphatic spaces. The cells of the tumor
were filled with round corpuscles, of red blood corpus-
cle size, surrounded by a very thin membrane and
containing very fine fat granules. The parasite pro-
duced an irritation of the cell nucleus, which en-
larged, and to the presence of the parasite were attrib-
uted the hypertrophy and cellular proliferation. A
number of illustrations show the microscopic appear-
ances of what the experimenter believes are parasitic
tumors or myxomycetic granulomas of mesodermic ori-
gin, produced in animals by the plasmodiaphora. In
reference to the great question of cancer, he thinks his
results show that a cellular inclusion of undoubted
parasitic nature may be almost invisible in the proto-
plasm of the tumor cell, and that scepticism should
not go to too great lengths because of the difficulty of
discovering parasites. ^ — La Presse Medicate, February
14, 1900.
Pulmonary Embolus in Phlebitis M. de Trei-
gny considers the various causes for this sudden acci-
dent in the course of phlebitis when nothing indicates
the imminence of the danger. Instances are cited.
Curative treatment is purely symptomatic. He men-
tions the success obtained by Oeder by means of injec-
tions of camphorated oil every five minutes until 2.4
gm. were administered in an hour. Isch-Nall resected
the veins as a prophylactic measure after a series of
slight embolic attacks. Extirpation of suppurating
phlebitis of the cord is also mentioned. Immobiliza-
tion is a necessity, and before permitting a patient to
get up or to receive massage after pregnancy, pelvic
tumor, abdominal operations, convalescence from ty-
phoid and other severe fevers, as well as fractures, we
should assure ourselves by methodical exploration of
the venous system that there is no sign of deep-seated
coagulation. — Journal des Praticiens, February lo,
1900.
Treatment of Vaginismus Dr. Verchere says
the first advice to give a woman suffering from vagin-
ismus is to suppress all genital excitation, since abso-
lute and prolonged rest of the organ may of itself
alone bring about a cure. Iodoform is recommended
as a dressing, being anaesthetic as well as antiseptic,
and is usually efficacious. Various methods of treat-
ment, from cold sitz baths to divulsion and cutting
operations, are passed in review. The Sims method
is in a general way regarded as too radical. Two suc-
cesses are reported from subcutaneous section of the
anal sphincter. Medical treatment is of great impor-
tance. Much attention must be paid to subjects pre-
disposed to hereditary insanity. Antispasmodic and
tonic treatment is usually indicated, while hydrother-
apy and arsenical treatment are not to be forgotten. —
La Medecine AloJer?ie, February 14, igoo.
Renal Function in Chronic Nephritis L. Bernard
finds that renal permeability is not uniform in all
nephritis; there is a nephritis with permeable and a
nephritis with impermeable kidney. There is no nec-
essary- relation between the existence of ura-mic phe-
nomena and those of renal impermeability. The term
parenchymatous and interstitial as applied to nephri-
tis are considered unfortunate. The evolution of each
is different. The evolution in two periods of the
nephritis termed parenchymatous is not a transforma-
tion into interstitial nephritis. We should say that
at a given moment it becomes complicated with scle-
rous lesions which carry with them renal impermea-
bility and its attending symptoms. — La Presse Mkdi-
cale, February 17, 1900.
Reflections upon Muco-Membranous Colitis and
Appendicitis Produced in the Course of this Dis-
ease.— Louis Beurnier says that authors are agreed
that subjects of muco-membranous colitis are neuro-
paths. He has found this to be the case in all his pa-
tients. In a case reported, the symptoms led to an
operation for appendicitis. The appendix w-as found
healthy in appearance and under the microscope. The
whole trouble was due to absolute fusion of the epi-
ploon with the large intestine, the cementing process
extending to the upper limits of the ascending colon.
— Journal des L'raticicns, February 10, 1900.
Jl Policlinico, February /, IQOO.
Albuminuria in Diabetes and Renal Diabetes
In an article concluded from the preceding number,
Ferruccio Schupfer states, among the many conclu-
sions drawn from his cases and experiments, that the
albuminuria in diabetes may be due to (i) over-func-
tioning of the kidneys; (2) diabetic coma; (3) cysti-
tis and pyelitis; (4) the excessive ingestion of eggs;
(5) nervous influences; (6) the passage of microbe
toxins through the kidneys; (7) stasis; (8) renal hy-
pera;niia; (9) parenchymatous nephritis; (10) shrink-
age of the kidney. Cases published under the name
of renal diabetes w^ere merely ordinary cases of dia-
betes, in which the glycosuria disappeared or was
diminished when a nephritic developed after the
diabetes.
The Disappearance of the Red Corpuscles Stain-
able by Methylene Blue in the Blood in Grave
Anaemia. — Vittorio Belli says that the presence of
these corpuscles is not constant, but varies at differ-
ent times of the day. The gravity of ana?mia is shown
rather by the frequency of the appearance of these
cells than by their number or the depth of their color-
March lo, 1900]
MEDICAL RECORD.
425
ing. Their absence shows improvement and cure of
antemia only when confirmed by repeated examina-
tions during the course of the day.
Influence of Diphtheritic and Typhoid Toxins on
Nutritive Exchange Domenico Pace concludes his
article from a previous number, already abstracted in
these columns, with tables illustrating the conclusions
reached.
Chorea. — Angelo Ruffini calls attention to the fact
that in 1892 he claimed that chronic chorea was due
to slow and progressive atrophy of the ganglia of the
motor zone of the cerebral cortex.
Journal of Tiopica! Medicine, February, igoo.
Notes from Lagos, West Africa. — Henry Strachan
notes that the greatest prevalence of malarial fever in
the tropics occurs siiortly after the cessation of the
rains, and that there are few cases during the rains
unless these have been interrupted by short periods of
dry, hot days. In other words, the malarial curve pai-
allels that of the rise of subsoil water, and follows by
some days that of the rainfall. When the ground is
saturated, surface puddles which afford breeding-places
for Anopheles are more readily formed and last longer.
The same writer records his belief that blackwater
fever is possibly a disease distinct from malaria. He
says, in support of this opinion, that hcemoglobinuria
occurs all through the year independently of the vary-
ing prevalence of malaria, and that the salicylates are
more curative than quinine.
An Undescribed Form of Plague Pneumonia. —
William C. Hossack reports fi\'e cases of an indefinite
form of plague, which is especially important because
of the danger of its escaping recognition. It is a pul-
monary form, beginning insidiously, the general symp-
toms at the end of five or ten days being perhaps no
more severe than they would be in a case of simple
bronchitis, while the local lung symptoms are very
vague. As a rule, there are no enlarged glands.
Death occurs suddenly and unexpectedly from the fifth
to the tenth day. The most striking feature is the
pulse, which is weak and rapid, out of all proportion
to the apparent local or general condition.
Typhoid or Malarial Fever. — W. E. de Korte dis-
cusses the diagnosis between adynamic remittent ma-
larial fever and typhoid fever as observed in South
Africa. There is a fever there which the public calls
"slepende" or dragging fever, and for whicii no med-
ical advice is sought; but when it suddenly becomes
acute, with rise of temperature, the physician steps in
and calls it typhoid. In such cases the writer has
found the plasmodium malaria;. He does not deny
the existence of typhoid fever in South Africa, but
contends that many fevers so called are really mala-
rial.
Plague in Siberia and Mongolia and the Tar-
bagan. — Frank G. Clemow reviews accounts in Rus-
sian journals of an endemic disease in several places
in Siberia and eastern Mongolia, which has many
points of superficial resemblance to the bubonic plague,
although proof of identity of the two affections is
wanting. The disease in Siberia seems to be connect-
ed with an endemic affection of the tarbagan (Arcto-
mys bobac), a rodent of the nature of a marmot.
A Contribution to the Diagnosis and Treatment
of jEstivo-Autumnal Malaria. — J. Preston Maxwell
says this form of fever is much more refractory to the
action of quinine than benign malaria, yet the prompt
use of quinine by subcutaneous injection at the begin-
ning of an asstivo-autumnal attack may avert the
threatening paroxysm. He reports a case in support
of this conclusion.
Clinical Report of Four Cases of Suspected Yaws
or Framboesia. — W. S. Griffith reports these cases oc-
curring in a Kaffir woman and three of her children.
The diagnosis rested betw'een syphilis and yaws, and
the writer inclined to the latter.
Monatsschriftfiir Gebiirts. und Gyiidl;., February, igoo.
Puerperal Tetanus Hans Kentmann says that
although puerperal tetanus is the most frightful com-
plication of the puerperium, it is also the most infre-
quent. This affection is rare in the northern zones,
but comparatively frequent in the south. In a series
of forty-three cases, the first symptoms of the disease
appeared on the average nine days after confine-
ment, the longest period being nineteen days and the
shortest four. As to treatment, the severe cases do not
seem to be influenced by antitoxin. It is important
to eliminate the original focus of the disease, but irri-
gation, curetting, and even total extirpation of the uter-
us have not yielded the desired results. The progno-
sis is unfavorable. Kentmann relates the history of a
case, and then speaks of the colossal power of resist-
ance of the tetanus spore.
The Application of Hot Steam in Gynaecology
R. v. Steinbiichel speaks of some of the affections in
which the local employment of hot air and steam was
followed by good results — dysmenorrhoea, endometritis
with hemorrhages or with copious discharge, subacute
or chronic uterine gonorrhcta, subinvolution of the
uterus, myoma if the uterine cavity is not irregular in
contour, carcinoma with hemorrhage and fetid secre-
tion, hemorrhages after abortions, putrid endometritis.
In order to obtain obliteration of the uterine cavity,
the application of a temperature of 1 10° to 115° F. for
a period of two minutes is necessary. When obliter-
ation is not the aim, the steam is applied for only
seven to ten seconds. Although the results from the
short applications are less certain, still in this method
stenoses and unintentional obliteration do not follow.
Can the Place of the Appearance of the Contrac-
tion Phenomenon be Determined in a Purely Ana-
tomical Way without Objection ? — Otto v. Herff con-
cludes from his work on the living woman that, in
order to designate any one place as the point in the
uterine wall where the contraction phenomenon origi-
nates, this particular point must be proved never to
shift. This result has not yet been attained.
Fibrinous Placental Polypi.— W. Langhans believes
that dependent on every conception there occur certain
polyp-like masses in the uterus, consisting of blood
clot; these masses are pedicled, and situated generally
in the fundus, hanging down either into the expanded
uterine cavity or the expanded cervical cavity. They
are capable of no further organization, and they have
no relation to new growths.
Two Cases of Fibrosarcoma in the Broad Liga-
ment.— Axel R. Limnel, in speaking of these two cases
which he has treated, believes that the most probable
origin of the fibrosarcoma was in the broad ligament,
for it was not in the uterus, ovary, parovarium, or Gart-
ner's canal. The diagnosis is difficult and the condi-
tion is often mistaken for ovarian tumor.
Dystocia Caused by the Contraction Ring. — J.
Veit-Leiden, in discussing this subject, concludes that
426
MEDICAL RECORD.
[March 10, 1900
there is no proof of the isolated condition of contrac-
tion of Bandl's ring without simultaneous contraction
of the whole muscle surface of the uterine cavity.
Revue tie Chirurgie, February lO, igoo.
Radical Cure of Large Umbilical Hernia. — M. K.
Sapiejko describes the case of a woman, four months
pregnant, with an enormous umbilical hernia. After
making an incision, which extended from the xiphoid
appendage to the symphysis pubis, he separated the
skin from the aponeurosis the whole length of the
incision, at a breadth of six inches at the umbilicus,
narrowing above and below. He then fixed the left
border of the aponeurosis to the right peritoneal sur-
face by a continuous suture, and the right border to
the left side. By this means the anterior part of the
abdomen, formed of peritoneum, muscles, and aponeu-
rosis, was made up of a double layer of these tissues.
The skin was then sutured, after removal of two ellip-
tical flaps.
The Treatment of Cancroids without Extirpation.
— Charles J. Rossauder reports cases in which the in-
jection of a one- to one-half-per-cent. solution of potas-
sium hydrate into cancerous tumors has given good
results. He believes that these injections, although
not sufficiently strong to have a cauterizing effect, do
provoke an irritation of the connective tissue around
the tumor and in the capillaries, leading to coagula-
tion of the blood and obstruction of the blood-vessels.
Necrosis of the tumor is not produced, but its vitality
is diminished and new growth inhibited.
The Treatment of Fractures of the Clavicle — L.
Gratschofif, after reduction of the fracture, uses an im-
mobilizing apparatus, the essential features of which
are a shoulder cap, an iron rod placed so that one end
corresponds to the apex of the acromion process, and
the other to a point one and three-fifths inches below
the nipple of the normal side, with a four-part bandage
going over the unaffected shoulder, around the hip of
each side, and across the front." All start from the in-
ferior end of the iron rod. Supplementarj' bandages
support elbow and forearm. Two cuts illustrate the
description.
Iliac Colostomy by Double Ligature — Michel
Gongolphe describes sixteen cases in which his ope-
ration has been perfectly successful and satisfactory.
After making an abdominal incision, he draws out a
loop of the ileo-colon and strangles it with a double-
chain ligature. He fixes it to the wall, cutting it oft'
from the peritoneal cavity, and forty-eight hours later
removes it by the therrao-cautery without ana;sthesia.
The inferior end is left open in the iliac wound.
Metatarsalgia — Niccolas Giannettasio reports a
case, giving the radiographic and histological find-
ings. The cartilage was found to be much diminished
in thickness, and the cartilage cells were dispersed in
elongated capsules.
Total Splenectomy. — Andres F. Llobet describes
an operation performed in a case of displacement and
hypertrophy of the spleen, with primar}- cancer of the
pedicle.
Tumors of the Biliary Ducts. — By K. Terrier and
M. Auvray. A continued article.
Jour, lies Maladies Ciitanees ct Sypliilitiqncs,Jati., /goo.
Blennorrhagic Infection and Marriage. — Ignacio
Callari concludes an essay with the suggestions that
popular instruction should be given upon the perils of
the disease in order that they may be lessened. Young
people should be warned against a poisoned union
and compromised posterity. They should be deterred
from marriage while diseased by appealing to their
honesty, reason, and interest, and they should be
taught especially the necessity of thorough cure.
Transmission of Ecthyma by Direct Contagion
from Animal to Man.— Le Calve and H. Malherbe
present an observation with bacteriological control
experiments, in which a lady contracted the disease
from a pet dog. Inoculation of another animal with
the germ resulted in typical ecthymatous lesions and a
general infection ending in death.
A>i?i. lies Mai. lies Organes Geiiito-Urinaires, Feb., igoo.
Bacteruria. — A. Gassmann gives notes of a case of
bacteruria with remarks upon the diagnosis of pros-
tatitis. The number of published cases of bacteruria
according to Krogius' definition is still restricted.
The present case originated in seminal vesiculitis.
Urotropin and salol in ordinary doses are not capable
to preventing development of cocci. The best results
are obtained by instillations of silver nitrate.
Hypertrophy and Epithelial Neoplasms of the
Prostate. — J. Abarrau and N. Halle give fifteen ob-
servations in a continued article.
Atiii. lie Dermatologie et tie Syphiligraphie, Jan., igoo.
Impetigo. ^ — R. Sabourand presents his first memoir
upon the clinical and bacteriological study of im-
petigo. He distinctly separates, in this the clinical
portion, impetigo contagiosa of Tilbury Fox, from' the
superficial pustular impetigo of Bockhart developing
about a hair.
The Question of Eczemas. — Brocq gives sixty-one
pages of a continued article. Circinate seborrhceal
eczema is set apart as an affection of probable para-
sitic nature. The opinions of various observers as to
the varieties of so-called seborrhceal eczema are pre-
sented.
Norsk Magazin for Liegei'ltleHskabeii, February, igoo.
A House Epidemic of Diphtheria. — C. M. F. Sind-
ing-Larsen describes an epidemic of diphtheria occur-
ring "in the Seashore Hospital for Scrofulous Children
at Fredriksvnern. The epidemic began with two cases
at the end of December, 189S, and. in spite of repeat-
ed examination of all the children, and isolation not
only of those presenting actual symptoms, but also of
those in whom bacilli were found in the throat and
nose (latent diphtheria), and disinfection of the wards,
the end of the visitation was not until October 12th of
the same year. During the epidemic there were sev-
enteen clinical cases and twent3'-seven latent cases.
Gelatin in the Treatment of Aneurism of the
Abdominal Aorta. — J. Buchholz reports a case of ab-
dominal aortic aneurism in a woman aged thirty-five
years. The treatment consisted in rest, the applica-
tion of an ice-bag day and night, and the internal ad-
ministration of six ounces daily of a five-per-cent. so-
lution of gelatin. At the end of three months of this
treatment the patient was cured.
The Parasite of Cancer. — B. ^'edeler describes the
results of a careful parasitological examination of an
adeno-carcinoma of the ovary, in which he found a
micro-organism (pictured in the colored plates accom-
panying the article), which he believed to be patho-
genic, though the proof of cultivation was wanting.
March lo, 1900]
MEDICAL RECORD.
427
(S'Ovvespantlcncc.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From Our Special Correspondent.)
During the 14th and 15 th of February, as every one
knows, Lord Roberts made a curving advance upon
Kimberley, which had the result of relieving the town
and of forcing General Cronje to retreat from his en-
trenched positions toward Bloemfontein. The sani-
tary condition of Kimberley was found fairly good,
although the mortality among the children had been
terrible. In forty-eight hours railway connection was
established between Cape Town and Kimberley, and
trains full of supplies were running northward, while
hospital trains were carrying the sick down to the
base hospitals. The inhabitants of Kimberley were
beginning to suffer from scarcity of food, especially
of vegetables and milk, and the supply trains were the
most efficient medical aid tiiat they could have re-
ceived. The New South Wales medical corps, the
medical staff corps organized and equipped by Aus-
tralia, distinguished itself in the relief operations.
The ambulances, drawn by excellent Australian horses,
'^ept pace with General French's flying cavalry col-
umn and picked up the wounded. The corps received
many compliments for its excellent work.
General Hospital No. 4 — The first three general
hospitals are, as I have said, situated near Cape Town,
but General Hospital No. 4 is in Natal on the Mooi
River, a tributary stream running northward into the
Tugela River. It is constructed to accommodate five
hundred sick and wounded, which should amply suffice
for the wants of General Buller's force, for it must be
remembered that this force has behind it a big hospi-
tal of one thousand beds at Pietermaritzburg as well
as a stationary hospital at Estcourt. To this hospital
Mr. Frederick Treves, certainly the operating surgeon
of the widest repute in England at the present mo-
ment, has been attached, and did excellent operative
work after the unfortunate attempts to relieve Lady-
smith. But I learn by telegram that on February 20th
he was prostrated with dysentery and had to go down
to the coast to recover. There has been a good deal
of dysentery and enteric fever among both officers and
men of Buller's force. The routine treatment for
dysentery at the Pietermaritzburg hospital is purga-
tive doses of sulphate of magnesia, and, though the
treatment is painful, Mr. Treves considers it to be on
the whole successful, more successful than the exactly
opposite treatment by opium. General Hospital No.
4 was made at its start the subject of severe criticism
by the Times 0/ Natal, a paper of some standing in the
colony. The Times of JSatal said that the adminis-
trative authorities had failed, that stimulants and med-
icine were forthcoming only after long delay, that the
nursing was inadequate, that the food supply was defi-
cient, and that while tons of stores lay at Durban
undistributed, the hospital depended upon charity for
such necessaries as pajamas and pillows. The accu-
sations of the Times of Natal were founded upon com-
pletely incorrect information, as was at once pointed
out to the editor, but they have provoked a feeling in
Durban and Pietermaritzburg that, while so much has
been done for the base hospitals at Cape Town, not
enough has been done for similar institutions in Na-
tal. The Mooi hospital is, as a matter of fact, well
found and excellently managed ; but it is quite pos-
sible that there was at first some disorder among the
administrators in Natal, for it must be remembered
that all the preparations were originally made in Eng-
land under the idea that the chief fighting would be
first in Cape Town, but that when the army arrived at
Cape Town most of it had to go on at once to Durban
to attempt the relief of Ladysmith. The change of
programme may at first have led to some confusion,
but for many weeks matters have been running quite
smoothly. One thing, and as yet one thing only, can
be fairly alleged against the medical administration
in this war — i.i., not enough female nurses have been
provided, too much reliance having been placed upon
the administrations of orderlies, better fitted to act as
porters than as assistants in the dressing of wounds.
Two More Voluntary Hospitals are proceeding to
the Cape, the Princess Christian Hospital and the
Welsh Hospital. That there should be a Welsh hos-
pital set on foot, as soon as a Scotch hospital and an
Irish hospital were announced as starting for the seat
of war, was a foregone conclusion; for Wales is very
tenacious of its right to be considered a separate na-
tion. ' A provisional committee has been formed in
London for raising the money to equip a Welsh hos-
pital, the following well-known medical men being
responsible for the movement; Sir John Williams,
physician accoucheur to University College Hospi-
tal; Dr. Frederick Roberts, physician to the same
hospital; Mr. Edmund Owen, surgeon to St. Mary's
Hospital ; Mr. Thomas Jones, professor of surgery in
Manchester; and Prof. Alfred Hughes, professor of
anatomy in King's College, London. The Princess
Christian Hospital, which will sail from Southamp-
ton at the end of February, has been presented to the
government by Mr. Alfred Mosely, a native of Bristol.
It is a completely equipped hospital of one hundred
beds. Mr. Paul Bush, surgeon to the Bristol Royal
Infirmary and lecturer on operative surgery at Univer-
sity College, Bristol, goes out as chief surgeon, and
Major Mathias, R.A.M.C., is the government medical
officer. The hospital has been called " Princess Chris-
tian " in recognition of the work done by Her Royal
Highness Princess- Christian of Schleswig-Holstein
in the nursing-world, and possibly in compliment to
her eldest son. Prince Christian Victor, who is at the
front, and distinguishing himself as a major in the
Sixtieth Rifles.
OUR LONDON LETTER.
(From our Special Correspondent.)
STORMS INFLUENZA — MORTALITY RETURNS ■ — MOS-
QUITOS' — AMYLOID DISEASE — CHOLERA TOXINS —
CHOREA — H/EMOPNEU.MOTHORAX — DUODENAL ULCER
— PRINCE OF wales' HOSPITAL FUND SIR M.
FOSTER ELECTED M.P. — THE LATE DR. HYDE^ — THE
WAR — THE ARMY SURGEONS — MORTALITY RETURNS
WEATHER THE MIDWIVES BILL AND THE GYN.-E-
COLOGICAL SOCIETY — A PLEBISCITE OF THE PRO-
FESSION MASTOID DISEASE — CLINICAL EXHIBITION
OF THE MEDICAL SOCIETY.
LON
s, Febn
Frost, snow, blizzard! a long chapter of accidents
with corresponding pressure in the receiving-wards of
the various hospitals; these have been the distrac-
tions of the last few days, and so immediately affect-
ing us as to hold attention above everything, unless it
be the more serious subject of the war. To-day, how-
ever, a change of wind and clearer sky make us more
cheerful with the promise of less discomfort.
The effect on the mortality returns will not be per-
ceived for a week or more. The London death rate
for last week was 20.4. In the thirty-three principal
towns of England and Wales it was 23.8. There w^as
a sudden rise in the north of England. It marked
32.3 in Blackburn, 31.8 in Liverpool, 35.1 in Preston,
34.2 in Salford, 28.4 in Leeds, and 28 in Manchester.
428
MEDICAL RECORD.
[March lo, 1900
InHuenza is responsible for a considerable share in
these high rates, as the epidemic has passed north-
ward, where so many workmen are kept at home that
the collieries and factories are very greatly inconven-
ienced, some of them being brought nearly to a stand-
still.
In London the epidemic continues to decrease.
The deaths from it last week fell to sixty-three. In
the first two weeks of the year the numbers were three
hundred and sixteen and three hundred and forty-nine.
This was the highest point reached. A substantial
drop followed, the succeeding weeks showing two hun-
dred and eight, one hundred and fifty two, and one
hundred and nine. Now with thisw'eek's fall to sixty-
three we may consider the epidemic practically over.
Ireland has also suffered from influenza, which is one
of the causes of the abnormally high mortality in
Dublin, Cork, and other cities. The rate in both these
passed fifty in December, and in Cork was fifty-eight
in January, but in both there has since been a fall.
Typhoid and measles have contributed to their mor-
tality.
Mr. Pearce Gould, senior surgical \ice-president of
the Pathological Society, has been requested by the
council to act as president during Mr. Cheyne's ab-
sence in South Africa. Accordingly he presided at
the last meeting, when he paid an appropriate tribute
to Dr. Charlewood Turner, whose death I mentioned
in my last. Dr. Nuttall then demonstrated a number
of microscopic lantern-projections illustrating recent
discoveries as to the part played by insects in spread-
ing infective diseases, particularly that of mosquitos.
An account of experiments made by Dr. A. Green
to test Krakow's statements on the production of amy-
loid disease was then given by Mr. S. Pigg. The ex-
periments were made with cultures of staphylococcus
pyogenes aureus injected subcutaneously in rabbits
and fowls. The results were mostly negative, but in
the case of one hen Dr. Green obtained the mahogany
stain with iodine. No definite amylaceous change
could be found in the twenty rabbits experimented
on.
Dr. VV. Myers reported his researches on the neu-
tralization of cobra venom by Calmette's antitoxin.
The venom seemed to contain two toxins, one hemoly-
tic, the other a nerve toxin. The former is destroyed
before the latter when venom is gradually heated. In
a concentrated form the venom retains its strength,
but a dilution of one per cent, loses strength by keep-
ing.
Dr. Bertram Abrahams then showed lantern slides
and microscopic specimens illustrating the changes in
the parietal cortex of a woman aged twenty-eight years
who died on the thirty-seventh day of an attack of
chorea gravidarum. These changes were similar,
though less in degree, to those described by Dr. F.
W. Mott in cases of status epilepticus, and as in them
it was thought that tlie alterations in the cells de-
pended on modifications in the chemical condition of
their lymph environment. Moreover, their nature and
extent were obviously compatible with complete recov-
ery.
Haemopneumothorax presents puzzling problems to
the physician. There were two cases related at the
Clinical Society and others mentioned by subsequent
speakers. Dr. Rolleston related one in a man aged
twenty-one years who after two days of diarrhoea was
seized with pain in the right hypochondrium radiating
to the umbilicus and right shoulder. He seemed mori-
bund on admission, but rallied, and next day had signs
of right pneumothorax with displacement of the heart.
Paracentesis brought out blood and air at considera-
ble pressure. Death occurred eight days after. The
right pleura contained si-xty ounces of blood but no
air. No explanation was found. There were no signs
of tubercle, pleurisy, haemophilia, scurvy, cirrhosis of
the liver, aneurism, or traumatism.
The other case was related by Dr. Newton Pitt. It
was of a man aged eighteen years, who had sore throat
and diarrhoea for three days ar.d was then seized with
pain and collapse. Six or seven hours after there was
evidence of acute pneumothorax, with dulness over the
right base and displacement of the heart, the impulse
being two inches to the left of the nipple line. To
relieve the pressure a Southey's tube was inserted in
the sixth interspace in the axilla, and blood flowed,
to the surprise of the doctors. Another puncture had
the same effect, and as no relief followed it was con-
cluded that hemorrhage was continuing. He died that
evening. At the post-mortem eight pints of fluid blood
besides clots filling the hand three times were found.
The heart, aorta, and pleura were normal. There was
no tubercle or necrotic change in the lung, but there was
one emphysematous bulla about half an inch in size,
torn open at the apex and attached to this a ruptured
adhesion, the size of a knitting-needle, from which
perhaps the blood may have come, but no aneurismal
pouch or patent vessel was discovered. This case
seems rare, if not unique.
Dr. Hingston Fox referred to the case of a man aged
forty-four years who was taken with pleurisy and was
tapped on the tenth day, when fourteen ounces of dark
blood came away. Three days later signs of pneumo-
thorax came on and the operation was repeated, forty-
five ounces of blood coming with much air. The pa-
tient recovered.
Sir D. Duckworth thought that in these cases rup-
ture of the lung with pneumothorax was followed by
the hemorrhage, and behind all was tuberculosis.
Dr. S. West mentioned a case of pyopneumothorax
in which pus was evacuated, and this was followed by
haemoptysis. At the post-mortem an old tuberculous
cavity into which an aneurism had burst was found.
As the cavity communicated with- the pleura blood
escaped both w^ays.
Sir D. Powell (president) said the precedence of
hiemo- and pneumothorax wanted clearing up. In an
experiment he could not pump more than six or seven
pints of fluid into the pleura. He thought St curious
for the blood to remain fluid in the presence of air.
Dr. Pott in replying mentioned that in looking up
the literature he found cases in which eleven and
twelve pints were said to have been removed.
Drs. Perkins and Wallace related a case of per-
fora.ing duodenal ulcer on which they had operated
with success, convalescence being uninterrupted. The
whole abdomen was irrigated, the intestines being
turned out for the purpose.
Mr. Barker took exception to this, as he did with
regard to gastric ulcer in a discussion I lately noticed.
He thinks the less the abdomen is meddled with the
better, as the peritoneum can dispose of much septic
matter.
Mr. Gould doubted the septic state of the contents
of the stomach, though they are very irritating.
Mr. C. Symonds rather agreed with Mr. Barker as to
the risk of evisceration, and recommended a medium
plan, viz., flushing and then mopping with gauze.
Dr. Poynton thought duodenal ulcer more frequent
than is generally supposed. In two years' necropsies
at St. Mary's Hospital he had seen eight such lesions
and met other cases in the wards. All were chronic
with thickened, raised edges, and had formed adhe-
sions. Prolonged dyspepsia with severe pain was
present in some of the cases for five to ten years. Fx-
treme severity of the pain was suspicious.
Sir Michael Foster has been duly elected member
of Parliament for the University of London. He made
a short speech to those present, remarking that this
is the first time the graduates had elected one of them-
March lo, 1900]
MEDICAL RECORD.
429
selves. He took it that his fellow-graduates did not
send him to Parliament simply to add one more unit
to either political party, but that he should place at the
disposal of the House his special experience in science
and learning. He would take his seat at first among
supporters of the government. The old cry of civil
and religious liberty made him prick up hisears. He
was born in the same town as Oliver Cromwell, and
his forefathers harbored John Bunyan when he
preached outlaw sermons in the wilds of Hertford-
shire.
The Prince of Wales presided at the annual meet-
ing of the council of his hospital fund. The receipts
for 1899 exceeded ^48,500, showing an increase of
about ;£,g,ooo on the amount for 1898.
I regret to record the death of Dr. Samuel Hyde, of
Buxton, at the early age of fifty years. A native of
the town, he settled there soon after qualifying. He
was chairman of council of the Balneological and
Climatological Association, and editor of its journal.
He wrote many contributions on the effect of waters,
especially those of Buxton. His " Buxton, its Baths
and Climate," reached a fourth edition in 1898. His
treatise on "Rheumatoid Arthritis" appeared in i8g6.
Many other articles from his pen on allied subjects
have been published. Last summer his active life
was interrupted by obstruction of the bowels, for which
colotomy had to be done. He rallied well, and was
able to absent himself from home for some time so as
to gain rest, but complete recovery was not to be, and
he sank and died on the 8th instant.
February 2-^, igoo.
The war makes such demands on our attention that
other subjects seem to be of minor importance.
Nevertheless we pursue our usual routine of work, and
engage with some interest in professional conversa-
tions and discussions. Newspapers, of course, are
full of the war, and the medical journals are occupying
themselves with it more than ever before. The civil
surgeons at the front send letters giving their impres-
sions of the hospitals and cases. We read them with
some interest, but an increasing conviction that they
are of no use out there except to assure the public of
the excellence of the military surgeons and of the
arrangements of the army medical department. The
fact that so far this branch has made no blunders is
making a strong impression on the public. At length
the Duke of Cambridge has found words of praise for
the Royal Army Medical Corps and its work. At a
critical inspection of the Langman Hospital on Wed-
nesday His Royal Highness warmly congratulated the
generous donor and all concerned. Then he expressed
his gratification that every class in the empire had
shown splendid spirit and done its best. Then he
added "No class has done more in the work of the
campaign than the medical men." This from the late
commander-in-chief is praise indeed. In office he
never did justice to the medical officers, and always
opposed any redress of their grievances. The stress
of war seems to have converted him. Will his suc-
cessor now make the amende honorable and indorse the
praise of His Royal Highness?
Rapid variations in the weather, disastrous floods
succeeding the snow and storms, with the usual con-
sequences to the public health — these are the charac-
teristics of the week, though one day seemed to bring
promise of spring.
The mortality returns are not yet satisfactory, though
the epidemic of influenza is nearly over. In the
thirty-three great towns the average death rate was
25.8. This is an advance, but it must be remembered
that it shows the deaths registered, not those taking
place in the week. The rates of the three preceding
weeks were 22.6, 21.2, and 22.7. In London the rate
was 22.9; Birmingham, 33.4; Manchester, 37.2. There
is a very remarkable return for Preston, 54.8. If some
error or misprint has not crept in, this calls for inves-
tigation.
Midwives, no doubt, will always be with us in some
form or other, but why, oh why, must a midwives bill
be forever troubling us.' And why should the ques-
tions involved stir up more passion than reason.'
Here we are threatened with a possible second reading
next week of a most obnoxious measure promoted by
a set of interested persons who play on the feelings of
the public. Their proceedings and object may be
judged by the fact that they have not hesitated to issue
an advertisement in the daily press urging that " all
married people should agitate to secure the passage of
the bill," telling them it "will practically abolish the
system of man-midwifery by creating a class of prop-
erly trained, qualified, and registered midwives who
will be employed with perfect confidence in all cases."
And the very people who resort to such methods of
agitation declare privately that their scheme cannot
injure the profession, and they pretend, too, that their
clients will attend only normal cases. Those who
look forward as well as backward tell us that once
certified and registered these gossips can no more be
restrained from practice on all the women and chil-
dren they can reach, than the old apothecaries could
be hindered from becoming full practitioners as soon
as they were properly educated and licensed. And a
number of consulting obstetricians who are assisting
the agitation are declaring that they do so out of pure
benevolence and pity for women laboring with child.
Their opponents sneer at this, and say they only want
to be called in to help the midwives. If such be their
motive they can hardly expect ever to be consulted by
the men whose bread they would take away to bestow
it on the women who would practically be their part-
ners. It is certainly a fact that there is qualified aid
at the disposal of all parturient women in England,
and that being- so the only women allowed to compete
should be fully qualified too — and not mere midwives
or nurses. Women can enter the profession , an in-
creasing number are doing so. Their interest is to
resist the encroachment of the midwives and support
the present law of the land that every registered prac-
titioner must be qualified in our three branches —
medicine, surgery, and midwifery.
Amid the din of controversy that has been provoked
on the question the voice of Dr. W. J. Smyly, of Dub-
lin, has been heard and deserves an acknowledgment
of his tolerant attitude. Dr. Smyly has been elected
president of the British Gynaecological Society, and
came over to deliver his inaugural address on the
8th inst. He is a past master of the Rotunda,
which some think the first obstetric school in the
world, and his experience extends to midwives, for
they are taught at the Rotunda, and Dr. Smyly con-
siders with benefit to the public. He, however, ob-
jects to the proposed bill because it does not apply to
Ireland. This is certainly a new grievance from the
Emerald Isle, and withal a little inconsistent with the
proposition that the Rotunda has worked so well for
one hundred years. The opposition of the general
practitioners in England is more significant, as they
constitute the corpus rile on which the experiment is
to be tried. If successful, happy Ireland would soon
claim her share of the benefit. Dr. Smyly touched on
the threat once made to charge the Rotunda officers
before the Medical Council. That was foolish, as the
Rotunda has the authority of a royal charter. Very
different is the position of the Obstetrical Society of
London, which has not a vestige of authority for grant-
ing its diplomas, in which it does a profitable busi-
ness. Even the general medical council — the slowest
43°
MEDICAL RECORD.
[March lo, i^oo
of all slow bodies to mo^-e — condemned the Obstetri-
cal Society's trade and threatened to prosecute its
managers, but to the disgust of all reformers it soon
after climbed down, and there is still a brisk demand
for the sham diplomas. With the holders of these
competing for practice, no wonder the English general
practitioners object to an inferior grade of partially
qualified persons being shoved upon them.
Dr. Smyly told the society that in Ireland no dis-
tinction is made between monthly nurses and midwives,
and he thought it unfortunate that in England the
same plan is not followed. A midwife who met with
a complication in Ireland at once sent for a doctor
and remained as nurse with the patient.
At the conclusion of the address, Dr. Macnaughton
Jones (the retiring president) proposed the vote of
thanks. In doing so he said the society took a mod-
erate view and was practically in accord with the
medical council. He remarked too that every regis-
tered practitioner was a midwife, and he objected to
anything which would impair the traditions and pres-
tige of the obstetric art.
The vote was seconded by the venerable Dr. Routh,
who contrasted the present teaching with that when he
was young. He said we must have midwives, but they
should be kept in their proper places.
In view of the possibility of the bill coming on in
the House, The Lancet has issued a post-card plebis-
cite asking for a plain yes or no to questions put in
order to show \\ hether the profession is for or against
the«bill, and, further, for or against any legislation on
the matter.
The adjourned discussion on mastoid disease at the
Medico-Chirurgical Society took place on the i3lh
inst., but it cannot be said to have added to our
knowledge of the subject. It gave indeed an oppor-
tunity for some surgeons to express an opinion on the
operations which have been performed, and for others
to repeat or supplement their former statements. The
subject is one for specialists, and Mr. Barker said
naively that "this department of surgery was in one
sense a legitimate specialty," a grudging admission
quite characteristic of general surgeons. These gen-
tlemen praise Mr. Ballance because he is a general
surgeon of a very high position, but as he lias been a
diligent worker in "this department of surgery" for
some fifteen or sixteen years, and is aural surgeon at
St. Thomas' Hospital, the aurists naturally look upon
him as one of themselves. His position, training,
and experience combine to make him an ideal aural
surgeon, and otology is unquestionably a surgical spe-
cialty. His treatment described at the former meeting
is, as I told you, a twofold operation, the first for the
cure of chronic purulent otorrhoea, the second, for
healing up the wound by epithelial grafting of the raw
bone cavity. The disadvantage, or, as one speaker
called it, the defect, of the proceeding is the double
operation and the possibility of having to resort to a
third reopening for the removal of the gold-leaf which
Mr. Ballance employs. He. however, has not had to
do this. Indeed, he said the patient was quite un-
conscious of tlie removal of the gold-leaf, and though it
might possibly be unnecessary, he did not at present
see his wav to dispense with it. Further, he did not
consider his technique perfect, and therefore his sug-
gestion might be further improved upon.
The diflficulty and responsibility of deciding whether
to operate were dul}'- discussed, but no new indications
were arrived at. With every improvement the ten-
dency is to increase the number of operations, and
the constant danger of intracranial extension points in
the same direction. On the other hand, such exten-
sion is rare, for most practitioners know of cases in
which otorrhcea has lasted for years without inconven-
ience. I have known it to last forty years without any
serious symptom. Nevertheless, a complete operation
is a protection from the risk such a patient is always
running, and Mr. Ballance's plan seems a distinct
advance.
The exhibition of cases at the Medical Society on
the clinical evenings is usually very interesting — much
more so than many papers — though only a few lend
themselves to reporting. At the last meeting there
was a resection of intestine in a boy aged seven years;
a case of urticaria pigmentosa in a boy aged fifteen
months; cyanosis in a girl aged eighteen years, proba-
bly congenital, but without cardiac murmur. It was
suggested as to this that perhaps the opening was too
large to produce a murmur and the valves were normal,
another suggestion being that the aorta arose on the
left-hand side. The right ventricle seemed dilated.
There was shown the heart of a boy aged fourteen
years, who was brought to a former meeting, and who
died suddenly eight days later. The left ventricle was
hypertrophied and the aortic opening reduced to a slit.
Another heart case was in a man aged twenty-two
years, the heart-beat being on the right side in the
sixth space, the stomach and the liver being also
transposed. Two rather rare cases of rheumatism were
present; one of osteo-arthritis in a girl aged eight
years after several attacks of acute rheumatism ; the
other in a girl who had chorea followed by cardiac
disease and embolism. A somewhat obscure case of
tumor of the femur in a man aged twenty-nine years
was thought to be osteitis deformans involving only
one bone. Three cases of hernia due to or associated
with abnormal descent of the testis elicited the men-
tion of some other cases more or less similar.
Besides patients, appliances w-ere shown, viz.. a
tourniquet to compress the artery in amputation of the
hip-joint, but which has also been used in other opera-
tions; two jackets for aiding respiration in emphy-
sema; one applies pressure continuously, the other in-
termittently. Both had been tried and improvement
followed. The rival inventors can discuss their rela-
tive value.
AX APPENDICITIS OPERATION IN 1867.
To THE F.l.ITOK OF THE MeDICAL ReCOKD.
Sir : In his excellent historical essay on appendicitis
recently published. Dr. Edebohls says: "In his first
case of operation (1867) for perityphlitic abscess re-
sulting from perforation of appendix. Dr. \\"eber con-
tented himself with cutting down as far as the fascia
transversalis, allowing the abscess to open spontane-
ously through the wound thus made."
The case of L. H , referred to, was the second
operated on in this city by what was then known as the
Willard-Parker method, and there was a feature in the
progress of the operation which was of considerable
interest to me and otiiers at that time, and may be of
interest even now, because the procedure then employed
by force majeure, or accident, if you please, might be
followed with advantage in suitable cases as a modifi-
cation of the method usually employed in modern
times.
In making the incision I was advised by one of the
surgeons present to make it much nearer to Poupart's
ligament than it had been my intention to do. Very
soon I came down upon the large vessels and could
feel and see the iliac artery pulsate. In fact, I had
proceeded very much as if I had intended to tie the
iliac artery. \\"hen I had gone so far and found that
I was below the abscess and behind the peritoneum, I
thought I had gone far enough ; the gentlemen pres-
ent were of the same opinion, and a drain was laid to
the bottom of the wound ; the greater part of it was left
open. It was, indeed, to my great satisfaction and the
patient's welfare that the pressuie of the pus collected
March lo, 1900]
MEDICAL RECORD.
431
worked in the direction of the least resistance, and the
abscess discharged within forty-eight hours after the
incision through the wound made.
In all my other cases of appendicular abscess oper-
ated in the old way, I cut down through the abdomi-
nal muscles direct into the abscess cavity, but have
often thought that my first experience had pointed a
way to get at the appendix by a different route from
the one in vogue, and have the advantage of avoiding
the division of the abdominal muscular structures.
It is long since I have practised surgery, but it seems
to me it might be worth trying whether it be practica-
ble and safe to cut down as far, tying the common iliac,
and remove the appendix that way. Abdominal her-
nia, infection of abdominal muscles, etc., would then
be readily avoided. With these few words on an ever
interesting and important subject I leave the consider-
ation of my proposition to the surgical confreres.
Leonard Weber, M.D.
25 West Forty-sixth Street.
ANTIPNEUMONIC SERUM.
To the Editor of the Medical Record.
Sir: In your issue of February 24th, Dr. A. H. Smith,
in replying to my letter which appeared in the Medi-
cal Record of January 27th, refers me to his article
in the "Twentieth Century Practice," vol. xvi., p.
122, wherein he "has discussed at length the claims
of antipneumonic serum therapy." I am sorry that
Dr. Smith's answer only implies that I had no knowl-
edge of the existence of this article, and also that, in
his opinion, antipneumonic serum is a remedy of such
doubtful efficacy that he considered it not worth men-
tioning in his recent paper.
In justice to myself, I wish to slate that at the time
of writing the letter to which Dr. Smith now replies,
I had read the aforesaid article in the "Twentieth
Century Practice." In this article Dr. Smith gives an
excellent historical sketch of the attempt at antipneu-
monic serum therapy, beginning with Netler(i888)
and ending with De Renzi and Pane. He mentions
as the latest achievements in this field the first thirty-
two cases of De Renzi and the first five cases of Mara-
gliano — all of which, by the way, are quoted from my
first article on the subject (jVctc York Medical Jour-
>ial, May 7, 1898).
My surprise, therefore, was caused by the fact that
Dr. Smith does not take into consideration in his re-
cent paper the advances which have taken place in
this field since the publication of the ficst successes of
De Renzi and Maragliano.
As a matter of fact, however, a large number of suc-
cessful cases with Pane's serum have been reported
since then by Massolongo (Milan), by Cantieri
(Siena), by Maragliano (Genoa), by De Renzi and
Pane (Naples), and by many other clinicians. All
the reported cases were of the gravest character, and
the percentage of cures is enormously in excess of that
obtained with the old empiric methods.
Professor Maragliano, in the closing lecture of the
session of 1898, said to his students: "Taking the re-
sults of the past- year and those of the year before, I
am becoming more and more convinced of the anti-
toxic power of Pane's serum, and of its efficient thera-
peutic action in pneumonia. All the cases treated
with the serum were most severe."
Professor De Renzi, at the Congress of Internal
Medicine held at Turin in 1898, said: "A case of
pneumonia, no matter how grave, treated in time with
a sufficient amount of serum, must surely recover."
For my part, I do not think that we can aflford to
ignore the testimony of these observers.
Antonio Fanoni, M.D.
66 West Tenth Street.
OUR VIENNA LETTER.
(From our Special Correspondent.)
Vienna, February 13, igoo.
Professor Schauta has been using some new instru-
ments in his clinic this week. One, a needle devised
by Joannesdu, of Budapest, for carrying wire, is large
and hollow, curved like an aneurism needle, and in a
case of ventral hernia in a stout woman with very
thick abdominal walls seemed to be very successful.
Another is a double hook for craniotomy, designed by
Zweifel, of Leipsic. It looks like two of the Braun
hooks fastened together, side by side, and is supposed
to be so adjusted in the tissues; then the two handles
are turned apart, thus turning the hooks at the other
end from each other. Professor Schauta thinks that
it would be of advantage were it not for the fact that
the hand mij^t be removed before swinging the hooks,
thus leaving one in doubt as to whether the maternal
tissues are not being lacerated; and for this reason he
is not prepared to indorse it fully, although it is quick
and effective.
The professor has sacrificed his beard to the cause
of asepsis, but neither he nor any of his assistants wears
gloves while operating. They scrub thoroughly with
soap and water, then with alcohol and bichloride. He
uses Schleich's method of anrfsthesia — ether, chloro-
form, and petroleum — and says that in the two years
he has employed it in his clinic he has never had an
accident; the patient comes out of the narcosis much
more readily, and the after-effects are not to be com-
pared with those following the use of any other anaes-
thetic.
They are treating all the chronic retroversions by
the so-called " Belastungstherapie," a method intro-
duced here by Dr. Josef Halban, one of Professor
Schauta's assistants. -After emptying the bladder the
patient is placed on a table in the dorsal position, and
a colpeurynter smeared with vaseline is introduced into
the posterior cul-de-sac and filled with o.j kgm. of
quicksilver. This is left in the vagina for one-half
hour, unless it causes pain, in which case a shorter
time is allowed. This treatment is continued daily,
gradually extending the time and the amount of the
quicksilver until the patient tolerates i kgm. of mer-
cury one hour. In thirty-five cases recently followed
up by Dr. Halban the results have been excellent. In
the chronic cases of para- or perimetritis, he uses it in
connection with abdominal massage, or makes coun-
ter-compression with shot on the abdominal wall after
Freund's suggestions. The advantages of using quick-
silver in the vagina in place of shot, which Freund
used, would seem to be that the mercury much more
readily assumes the shape of the cul-de-sac and causes
less pain — acting really much more like massage.
The Wertheim operation, of shortening the round
ligaments by going through the anterior vaginal wall,
is done in place of the Alexander whenever possible.
At a recent meeting of the Dermatological Society,
Dr. Rudolf Metzenauer, first assistant to Professor
Neumann, read a report of some interesting investiga-
tions he has been carrying on in cases of hospital gan-
grene, whereby he has succeeded in isolating a bacte-
rium which they are not prepared to classify, but which
he believes to be the bacillus of hospital gangrene.
It is a large bacillus, about one and one-half times
larger than the tubercle bacillus, stains readily with
the Weigert stain, and is found not only in the gan-
grenous tissue where the staphylococci, etc., exist, but
is plainly visible in the deeper tissues in which no
other bacteria can be demonstrated. In a set of three
hundred and fifty slides he lias never failed to find it.
He has not yet succeeded in growing a culture, but he
believes it to be anaerobic.
Medically there is little of interest, influenza playing
the most important part in the wards at present.
432
MEDICAL RECORD.
[March lo, 1900
THE APPENDICITIS QUESTION.
To THE Editor of the Medical Record.
Sir: Dr. J. S. Horner's interesting article in the Med-
ical Record for February 241!], under the above cap-
tion, calls for further response on my part as a sort of
spokesman. He says that " it is only a step from
operating on a mild case because it is likely to be-
come severe, to operating on a normal appendix be-
cause it is liable to become infected." What is a mild
case of appendicitis.'' Is it one in which the round
slough is about to cause a perforation, without pre-
monitory symptoms enough to keep the patient in bed ;
or is it a case of safely ulcerating mucosa with such
spasm of the muscularis of the bowel that the patient
is screaming with pain? Will he please define for us
"a mild case." I know only the patholagy of appen-
dicitis, and do not know a mild case from a dangerous
one. The doctor says that we are to "operate in pri-
mary cases when circumstances arise which in the
opinion of the physician make it justifiable." In the
opinion of which physician? Does Dr. Horner not
know physicians whose opinion he would not trust?
I have been present at consultations in cases in which
concretions and pus had already escaped through the
wall of the appendix, and some of the consultants
thought that they could still cure the patient with
sweet oil or opium or salts.
We are to be guided by our knowledge of the pa-
thology of appendicitis and not by the opinion of any
one who has not looked at the lesion in any given
case. The doctor draws a picture of a case " with
everything apparently favorable for a mild attack,"
and quotes the conversation between the physician and
members of the family, including the statement that if
the physician is honest he will answer concerning
operation : " No! The chances are ninety-nine out of
one hundred that he will recover." I will give one
thousand dollars to the West Pawlet school fund if
such percentage statement is correct for appendicitis
cases in that town. If such percentage statement is
not correct, then Dr. Horner should be careful about
going on record, for we have some pretty correct data
for guidance.
I made a similar ofter two years ago, when Dr.
Terry, in the New York Midical Titnes, stated that he
had cured forty-nine cases of appendicitis out of fifty-
one by medical treatment. I offered to give the above-
named sum to a public institution if Dr. Terry would
simply state that he personally knew what had become
of the cured cases, and if some of them had not since
died of appendicitis or had not been operated upon.
In answer to my offer a great deal was said about the
bad taste of betting in order to settle scientific ques-
tions, but nothing was said about the bad taste of pub-
lishing misleading statistics for the guidance of physi-
cians who were dealing directly with human life and
human happiness. Dr. Terry finally admitted that he
knew little about tiie outcome of some of the cases
with which I happened to be familiar. I did not ac-
cuse him of dishonesty, but of untrained observation
and of unscientific method. Dr. Horner says : "There
has as yet been no reason of sufficient importance pre-
sented to the profession why a mild case should be
operated upon." What text-books does the doctor pos-
sess upon the subject? It seems to me that several
authorities have given explicit reasons.
The doctor refers to my published letters from a se-
ries of appendicitis patients, all of whom stated that
they suffered less under surgical treatment than under
any sort of medical treatment, and he likens these let-
ters to the testimonies from irresponsible patients in
the public press. Has he actually read the letters in
question? They are published in the Medical Rec-
ord for May 21, 1898, and are republished in the
third edition of my book on the subject. These let-
ters are worth reading in a genuinely critical way.
Dr. Horner quotes me properly as saying that physi-
cians must either tell the patient at the beginning of
an attack of appendicitis whether it will probably be
a mild or a severe attack, or else they must confess
that it can only be told afterward; but he says that the
same thing is true of typhoid fever, pneumonia, and
scarlet fever. Very well! If a case of typhoid fever,
pneumonia, or scarlet fever began at a localized focus
of infection, which could be readily picked up between
the thumb and finger and put into a bottle, most of us
would come to our senses in a few years about the
proper method of procedure in the treatment of these
cases. Dr. Horner says that hospital medical statis-
tics show an immensely heavier rate of mortality than
physicians find in their private practice. Where are
these private practice statistics? As a matter of fact,
physicians are apt to speak out of memory, and hospi-
tal statistics are in black and white. That is the
chief explanation for the difference. Not long ago I
stated, out of memory, that I had not lost a case of
general septic peritonitis in which the patients were
treated by fiushing out the peritoneal cavity with hot
saline solution, and by intravenous saline infusion.
My statement was honest in intention, as I believe the
statements of most physicians to be; but on going over
records later, I found that two patients had died after
recovery from the acute symptoms, because the func-
tion of the bowel could not be restored.
Dr. Horner says that my rule of operating in acute
appendicitis as soon as the diagnosis has been made
is impracticable. That depends upon the locality. It
certainly is impracticable in localities where the sur-
geons have not proven their ability to make the suffer-
ing rate, the loss-of-tinie rate, and the death rate in
appendicitis less under surgical treatment than under
medical treatment of any sort. It is practicable, and
is practised by many physicians in localities in which
the environment of the patient enables him to benefit
by the progress that has been made in our comprehen-
sion of the whole subject of appendicitis.
Robert T. Morris, M.D.
5S West Fiftv-sixth Street.
Cholelithiasis. — In a recent address before the Not-
tingham Medico-Chirurgical Society upon "The Dan-
gers of Delay," Dr. A. W. Mayo Robinson expressed
his opinions upon treatment of cholelithiasis as fol-
lows: (i) Seeding that statistics from various countries
and by many observers agree in showing the frequent
association of gall stones and primary cancer of the
gall bladder and liver, it is desirable that cases of
cholelithiasis should be submitted to surgical treat-
ment at an earlier stage than has hitherto been the
custom. (2) In all cases of tumor of the gall blad
der, even if unaccompanied by symptoms, an opera
tion should be advised, and the obstruction, usually a
calculus, should be removed. (3) If these rules were
followed, primary cancer of the gall bladder and ex-
tension to the li\er would probably be less frequent.
(4) If early operation in cases of tumor of the gall
bladder was followed out, even if cancer had com-
menced, it could be caught in an incipient stage,
when a cure by cholecystectomy, or even partial hepa-
tectomy, might be reasonably hoped for. (5) An
exploratory operation, even in a patitnt seriously ill,
with a localized tumor in the gall-bladder region, is
worth advocating, though malignant disease be feared,
in the hope that the disease may be inflammatory, and
so capable of relief. (6) If there are any secondary
nodules in the liver, or if adjoining viscera are in-
vaded, the operation had better be terminated as a
simple exploratory one. — British Medical Jourtial.
March lo, 1900]
MEDICAL RECORD.
433
NEW YORK ACADEMY OF MEDICINE.
SECTION ON MEDICINE.
Stated Meeting, February 20, igoo.
John H. Huddleston, M.D., Chairman.
Some Observations in Counting Blood Cells. — Dr.
A. H. Gardner presented some results of such obser-
vations. The technique followed by him had been the
use of a smear from the finger, hardened in alcohol and
ether, stained, and then examined with an oil-immer-
sion lens. In nearly every instance he had counted
tiie number of leucocytes in a cubic millimetre, and
had endeavored to make the observation about midday.
Restated that the generally accepted proportion of the
various cells were: multinuclear, sixty-five to seventy
per cent. ; lymphocytes, twenty-five per cent. ; eosino-
philes, 0.5 per cent, .\bout one-fifth of the lympho-
cytes were usually of the large variety. The most in-
teresting part of his work had been in connection with
typhoid fever, eleven cases having been studied. In
a case of typhoid fever reported in detail by the
speaker, the largest number of lymphocytes noted had
been sixty-five per cent., and this had been on the tenth
day, while the smallest number had been thirty-one
per cent., occurring on the twenty-first day of the dis-
ease. In another case, in which four counts had been
made after the occurrence of a relapse, the highest
number had been sixty-four per cent., and the lowest
forty per cent. On one occasion he had counted sixty
eosinophiles. It was noticeable in all these cases that
by far the larger number of lymphocytes were of the
small variety. Similar results had been observed in
the other typhoid cases. In two of the cases there had
been slight leucocytosis, and these were the ones in
wliich the Widal reaction had been absent. In a case
of Hodgkin's disease there were twenty-nine per cent,
of lymphocytes, twenty-seven of which had been of the
small variety. In a case of sarcoma of the pleura
there was twenty-two percent, of lymphocytes, of which
eighteen had been small. In a case of eestivo-autum-
nal malaria there was forty-nine per cent, of lympho-
cytes, tliirty-five of which were small, and three eosino-
philes had also been found. In a case of tumor of the
brain there were twenty-nine lymphocytes, twenty-eight
being small, and there were also four eosinophiles.
An interesting case was referred to — one of chronic
alcoholism with ascites and pleuritic effusion, in which
examination of the latter showed 4.3 per cent, of multi-
nuclear cells, 1.2 per cent, large multinuclear cells,
I 5.4 per cent, small multinuclear lymphocytes, and
eighty per cent, eosinophiles. The blood of this man
showed thirty-seven per cent, of multinuclear lympho-
cytes, eleven per cent, being large, thirteen per cent,
small, and there was also thirty-nine per cent, of
eosinophiles.
Dr. I. Adler said that he was of the opinion that
much could be done by studies of this kind toward elu-
cidating many interesting clinical and pathological
problems. It was still a moot question as to how the
multinuclear lymphocyte was formed, and studies of
this nature would help to solve this^and similar prob-
lems. It also seemed to him quite probable that these
studies would make it necessary to give up very largely
the attractive but mechanical notion of phagocytosis.
It was probable that leucocytosis, when present, was
not so much the effect of phagocytosis and the elimi-
nation from the system of germs and effete matter, but
rather a renewed activity of the blood-making appara-
tus.
Membranous Colitis — Dr. William H. Thomson
read a paper on this subject. He began with the state-
ment that it was to be hoped that but few physicians
would be called upon to treat a case of membranous
colitis at the outset of their professional career, for it
would under such circumstances prove most discourag-
ing to the youthful physician. These patients were
apt to develop a train of vague nervous symptoms in
addition to their abdominal misery. In no other com-
plaint was the morbid self-consciousness of abdominal
affections more marked. Many writers had been led
to look upon the disease as primarily a neurosis.
Chronic bronchorrhoea or a chronic gleet was never a
neurosis. The neurotic theory of the etiology of
membranous colitis was most unfoitunate, as it led the
physician in the wrong direction in regard to treat-
ment. Microscopical examination of the membranes
discharged from the bowel showed a structureless ma-
terial, wholly devoid of clots, leucocytes, or other in-
gredients of an infiammatory exudate. The clinical
symptoms were utterly unlike those of ulcerative coli-
tis. For example, constipation usually preceded and
followed membranous colitis, while diarrhoea was one
of the characteristics of ulcerative colitis. Hajmaturia
and albuminuria were not uncommon as temporary
symptoms in membranous colitis. He ascribed these
renal symptoms to the entrance of the bacillus coli
into the blood through the diseased intestinal wall.
/\11 the sections of the colon were characterized by
abdominal distress, with tenesmus or pain before and
during defecation. One of the important etiological
factors was direct irritation of the rectum ; e.g., by horse-
back and bicycle riding, and pressure from uterine
fibroids. Perhaps the most potent factor was the ha-
bitual and prolonged retention of hard scybalous
masses of fceces in the rectum. The first indication
for treatment was to relieve the colonic symptoms prop-
er. Nothing was so soothing to the tenesmus and the
general abdominal distress as irrigation of the colon
with decinornvil saline solution at a temperature of
1 10^ F. This irrigating fluid should contain five
drops of oil of peppermint to the pint of water. The
irrigation should be given with the Kemp rectal irri-
gator, and several gallons of the saline solution should
be used. This irrigation might be used as often as
once in twelve hours. Unfortunately such treatment
was not curative. He believed that in small or altera-
tive doses of castor oil the physician possessed a rem-
edy which was distinctly curative in this affection. It
was proper to give the castor oil in an emulsion, each
tablespoonful of which would contain half a drachm
of the oil. It should be given half an hour before, or
more than one hour after, meals, and should be con-
tinued for months at a time. Another useful remedy
was nitrate of silver, given in doses of gr. Y^ of the
silver salt, combined with gr. ix. of turpentine, in cap-
sules, three times daily. After a course of this medi-
cation for six weeks, sulphate of copper should be sub-
stituted for the silver salt, and should be given in
doses of gr. y^. Abdominal massage and outdoor
e.xercise were useful adjuncts. As these patients were
very apt to reduce the dietary unwarrantably, he ad-
vised that they should be told simply to exclude beans,
corn, spinach, and the woody vegetables.
Mucous Colitis. — Dr. Walter Mendelson read a
paper on this topic. He stated that there were three
prominent symptoms in mucous colitis, viz., (i) neu-
rasthenia, (2) the passage of mucus in various forms
from the bowel, and (3) the existence of abdominal
pain. These, were the history of long duration, made
up the clinical picture of mucous colitis. The three
symptoms usually coexist, but any one might be pres-
ent or might largely predominate. Tractically all
cases gave a history of neurasthenia, and, although it
was not always marked, it was invariably present.
434
MEDICAL RECORD.
[March lo, 1900
The intensity of the pain was variable in degree. It
was very common for the pain and the desire to go to
stool to come on very early in the morning. Not all
of the patients had loose passages ; some passed hard
masses of faeces. The mucus was always separated
from the fecal matter, and not mingled with it as in
catarrhal processes of the bowel. The essentially ner-
vous nature of this disease should be kept in the fore-
ground. The cause of this disorder was to be found
in those occupations which overstrained the nervous
system, and hence it was far more common in women
than in men, and was a disease of brain-workers as
distinguished from other occupations. The disease
was most common between the twentieth and forty-fifth
year, but childhood and old age were not entirely ex-
empt. Mucous colitis he would attribute to a pervert-
ed action of the intestinal glands, the result of a dis-
turbed metabolism brought about by abnormal inner-
vation. In the treatment the rule should be not to
treat the bowel trouble as such, but to treat the indi-
vidual. It was of the highest importance to improve
the general nutrition by the combined use of rest and
food. Some clinicians advised the use of unbolted
flour, small fruits with seeds, and other irritating arti-
cles of diet, with the idea of thus stimulating the
intestine to do its work better. In administering
enemata he had rarely found it necessary to use the
long rectal tube, and had ordinarily employed either
drugs or decinormal saline solution. One or two quarts
should be given daily at the same time each day. It
should be retained for about fifteen minutes. Drugs
played a very subordinate part in the treatment of this
disease. Unless the patients were willing to give the
necessary time to the proper treatment — usually sever-
al weeks — very little could be expected. The neu-
rotic woman was usually cured, while the hysterical
woman broke otf treatment and relapsed again and
again, and rarely recovered'completely.
Report on Three Cases of Amoebic Colitis.—DR.
H. R. A. Grakser reported these cases. The first of
these was that of a man who had never lived outside
of New York City. In his stools the amceba; had
been found at every examination. At first no Widal
reaction had been obtained, but about one week later
this reaction had been present, and there had been
abundant evidence that this man had also become in-
fected with typhoid. He died one week later, but no
autopsy could be ODtained. The second case was that
of a young woman who had eight or nine stools daily.
At every examination of the stools, after the first one,
amceboe had been present. The patient had improved
rapidly, and had left the hospital before being regu-
larly discharged. The third case was that of a man,
who had from eight to twenty stools daily. His blood
contained no plasmodia, and the Widal reaction was
negative. The first examination of his f^ces showed
many very active amcebs, and many Charcot-Leyden
crystals. At no subsequent examination were the
latter present. The treatment with calomel inter-
nally and quinine locally seemed to have given the
best results. The faeces to be examined for the
amtebai should be received in a warm vessel, and
immediately examined on a warm stage in order to
find the live amoebee. The amoeba; in these cases
very often contained red blood cells. In the formed
freces these amceba; were most abundant in the mucus
on the surface of the fecal masses. In every case
of obstinate or chronic diarrhoea the stools should
be examined for living amcebas or other intestinal par-
asites.
Examination in Cases of Amoebic Colitis. — Dr.
Harlow Brooks presented a brief summary of the
eight cases of amoebic colitis occurring in the fourth
division of Bellevue Hospital since December, 1897.
He had also observed four other cases in private
practice of other physicians. Four of the patients
had certainly been infected outside of this city. One
symptom, not previously mentioned, was the very se-
vere, cramp-like pain in the skeletal muscles, especial-
ly in the muscles of the calves. The cases had been
benefited chiefly by the use of enemas, and a solution
of quinine, i : 5,000, or a solution of nitrate of silver
of the same strength. None of the cases, so far as
known, had relapsed. The stools for examination
should be received in a warm bed-pan, and if acid
should be at once neutralized by the addition of so-
dium bicarbonate. A portion of the stool should be
then poured into a warm, wide-mouthed bottle, corked,
and sent at once to the laboratory for examination
under the microscope, preferably on a warm stage. It
was important to take the precautions mentioned, and
to make the examination as soon as possible after the
stool had been passed. In such specimens many of
the amcebag would be found in an active state. If the
stools became acid or cooled, the amoebic movement
would be destroyed. Unless the movement of the
amoebae could be seen, it was often most difficult to
make a correct diagnosis. He had not found stained
specimens very satisfactory. The specimens could be
fixed as were blood specimens, preferably by heat fixa-
tion. They could then be stained by the ordinary
Loefller stain. The nucleus did not readily stain,
while the foreign bodies adhering to or within the
amoeba stained readily, thus obscuring the amceba
itself. Generally the number of amoebce present cor-
responded to the severity of the symptoms. Amoebse
from the stools discharged shortly after having taken
a quinine enema were usually motionless.
Duration and Prognosis of the Various Forms
of Chronic Colitis. — Dr. James K. Crook read this
paper. He asserted that nature paid no heed to the
artificial divisions of the intestinal canal so carefully
drawn by the anatomists, one or more parts, or even
the whole intestinal canal, being sometimes involved
at once in the disease process. In chronic inflamma-
tory states of the large intestine, with recognizable
symptoms, the prognosis was naturally quite serious.
The various types of colitis had been sufficiently de-
scribed by the foregoing speakers.
Dr. Robert T. Morris said that he wished to say
a word in support of the theory that some of these
cases of membranous colitis and mucous colitis repre-
sented a functional neurosis. Surgeons considered
some of these cases coming to them quite curable.
This was probably because of the special nature of the
cases which they saw — namely, those having a recog-
nizable and definite source of peripheral irritation.
As he was speaking from memory and not from accu-
rate clinical records, he could not state just what pro-
portion such cases bore to the total. A common sur-
gical cause was a loose kidney. He recalled one such
case, occurring in a hysterical woman, in which after
fixing the kidneys most of the symptoms had disap-
peared, and she had gained somewhat in weight. He
felt sure that many cases of membranous or mucous
colitis could be relieved or cured by attention to an
enteroptosis as the underlying cause.
Dr. Spencer Franklin said that he had treated a
good many cases of tropical or amoebic dysentery, and,
finding almost no result from internal treatment, he
had abandoned it in favor of enemas given with the
long rectal tube. His plan had been to flush out
the colon with saline solution, and then throw into the
bowel, almost daily for a week, four ounces of a solu-
tion of nitrate of silver having the strength of ten
or twenty-five grains to the ounce. This treatment
seemed to physicians here very heroic, and while he
would advise giving, as a preliminary, a hypodermic
injection of morphine, he felt that such extreme meas-
ures were perfectly justifiable in the severe cases met
March lo, 1900]
MEDICAL RECORD.
435
with in the tropics. Since he had adopted this meth-
od he had not lost a single case.
Dr. Adler said that in the German Hospital, of
this city, it was the practice to examine every diar-
rhceal stool microscopically, and by this method it had
been found that ama-bic and protozoic or infusorial
diarrhea was very much more common than was ordi-
narily supposed. The zoology of the human bowel
had been by no means exhausted, and the subject was
much more extensive than was usually believed. He
had seen many cases of amcebic colitis, and was thor-
oughly convinced that the tropical colitis was the re-
sult of an entirely different species of amceba. His
experience would not lead him to be anything like so
sanguine as was Dr. Brooks. He could not recall
having permanently cured any one of his patients.
Sometimes there would be a cessation for several
months, or even for a year or two, yet even Dr. Graeser
had shown that microscopical examination of the mu-
cus of the bowel would reveal the presence of the liv-
ing amrebffi. He had seen no real benefits in these
cases from the internal use of salol or tannalbin, but
calomel, given in large doses or in small doses, inva-
riably killed the amceba; and checked the diarrhcea.
This good effect would last for a certain fixed time —
perhaps a week or two — after the administration of the
calomel.
Dr. William B. Graves exhibited a colon taken
from a case of chronic mucous colitis. The man had
been under his observation for fifteen years, and had
died with some ursemic condition. The colon was very
much swollen and narrowed in its diameter, and was
adherent at the splenic junction. Its lumen was al-
most obliterated.
Dr. Harlow Brooks said that he had examined
two caess of mucous colitis post mortem, with an en-
tirely negative result.
Dr. VVilliam H. Thomson said that the changes
found in this colon were quite characteristic of cases
of chronic nephritis aifecting the colon, and the ante-
cedent condition might have been very different. It
seemed to him that the mucous colitis described by
Dr. Mendelson was identical with his own cases of
membranous colitis. Every patient with membranous
colitis would in time become neurasthenic. From
careful notes he could say most positively that some of
his patients had presented not the slightest evidence
of neurasthenia until they had been sufferers for some
time from membranous colitis.
Dr. Mendelson replied that the results of treat-
ment had convinced him that the nervous element was
the prominent though not the only one, and if it could
be eliminated the intestinal affection could be cured.
Many of the cases coming to him had lasted for
a number of years, and the intestine had previously
received assiduous attention, yet with little or no
benefit.
NEW YORK COUNTY MEDICAL ASSOCIA-
TION.
Stated Meeting, February ig, igoo.
Frederick Holme Wiggin, M.D., President.
Report of a Case of Rupture of the Perineum in
Coitus. — Dr. R. Abrahams made this report. He
stated that, according to a recently published article,
medical literature contained only twenty-two recorded
cases of a similar nature. His patient was a woman
of twenty-six, who married in the latter part of De-
cember, 1899. Her previous health- had been good,
and she had never suffered from prolapse of the rec-
tum, hemorrhoids, ischio-rectal abscess, or any inflam-
matory process in the perineum. At the first sexual
intercourse the hymen had been ruptured, and a little
blood had escaped. During the first six weeks of
their married life, the couple cohabited six or eight
times, and on the last of these occasions there had
been a little pain and considerable bleeding attendant
upon the act. These were regarded, as she had ex-
pressed it, as "the finishing touch to virginity," but
the following morning she had been astounded to ob-
serve that fatces escaped not only from the anus but
from another opening higher up. This had led to her
consulting Dr. Abrahams. On examination, the ex-
ternal genitalia, the vagina, and the uterus had been
found well developed and perfectly normal, but there
was a complete rupture of the perineum as if it had
been designedly made with a surgical instrument.
Two fingers could be readily passed through the wound
into the rectum, but careful examination had failed
to reveal any recto-vaginal or recto-vulvar communica-
tion— only what might be called a recto-perineal fistula.
The patient had become alarmed at the prospect of an
operation for the repair of the rupture, and had disap-
peared from observation.
Dr. Edwin Gaillard Mason said that he had seen
one similar case during his experience in St. Mary's
Hospital. The patient was a young woman who had
been married a few months, and the rupture had oc-
curred during the first attempt at coitus. The hymen
was exceedingly thick, and he had cut it away. The
laceration had extended through the recto-vaginal
fold. Between the time of the occurrence of the lacer-
ation and the operation for its repair sexual intercourse
had taken place through the rupture.
Exhibition of New Devices for the Administra-
tion of Anaesthetics. — Dr. S. Ormond Goldan ex-
hibited a bag fitted with a valve obturator, and also a
simple apparatus for the administration of nitrous-
oxide gas in conjunction with ether. It was devoid
of valves, and it was possible lo induce a perfectly
normal nitrous-oxide ana;sthesia w ithout the admission
of air. He also showed a device for administering
the chloroform through a tracheotomy tube, and also
a triple tenaculum which he had found very useful for
preventing the tongue from dropping back while per-
forming artificial respiration without proper assistance.
Dr. J. W. Draper Maury exhibited a modification
of the S. S. White apparatus.
Discussion on Ansesthetics This was the special
topic for the evening's discussion.
Selection of the Anaesthetic in Surgery. — Dr.
John A. Wyeth opened the discussion by a considera-
tion of the selection of the anaesthetic, considering,
however, only the use of chloroform and ether un-
mi.xed. He said that during the first few years of his
practice he had employed ether almost exclusively,
and during this time had not failed to note the great
irritation sometimes caused by this ara-sthetic agent,
and the great difficulty of inducing complete narcosis
in alcoholic subjects without producing asphyxia. He
had, therefore, been led gradually to make more and
more frequent use of chloroform. At present, in about
seventy-five per cent, of his operations he employed
chloroform, either wholly or in some stage of the nar-
cosis. In using chloroform he invariebly injected be-
neath the skin one-fourth of a grain of morphine and
y-|-[f of a grain of atropine about fifteen minutes before
commencing the anesthesia. These agents stimulated
the heart, and allayed to a considerable extent the
anxiety of the patient. He believed chloroform was
dangerous chiefly to the heart, and that it was during
the early stage of its administration that this di-inger
was imminent. The depression of the heart, when
observed at all, occurred almost invariably prior to the
induction of complete narcosis.
Administration of Chloroform. — Chloroform should
be administered with very great care, and only by an
436
MEDICAL RECORD.
[March lo, 1900
expert. In giving chloroform, he preferred to use the
ordinary Esmarch's screen, keeping his finger on the
pulse and watching the pupil for any sudden dilata-
tion. If the patient gradually gave way to the anes-
thetic and the pulse showed no interruption in its
rhythm, he felt satisfied that the chloroform was hav-
ing no unfavorable effect. The pulse might be rapid
— 120 or more a minute — or it might be as slow as 50
or 60 beats per minute, but these variations were not
suggestive of serious danger so long as the heart beat
regularly and rhythmically. If, however, a beat was
lost here and there, or if two successive beats fell oft"
in fulness, and then rose again in volume, it was al-
ways to him a signal which was to be respected, and
he promptly withdrew the chloroform for a moment to
note the effect. Should sudden pallor of the face
occur, especially about the lips, on resuming the
chloroform, he stopped the anesthetic, and lowered
the patient's head, preferably placing him in the
Trendelenburg position. If the heart still showed re-
sentment to chloroform, ether was at once substituted.
If there had been no alarming symptoms from the first
use of chloroform, he returned to it after having ad-
ministered the ether for a short time. Another alarm-
ing symptom of the too profound effect of chloroform
was the sudden and wide dilatation of the pupil.
When this occurred, he always desisted from the use
of chloroform anesthesia. In his opinion, it was not
proper to endeavor to bring the patient rapidly under
the influence of chloroform. The free admixture of
air was essential to safety. The average time for
complete narcosis with chloroform was from fifteen to
twenty minutes.
Ether Narcosis. — When ether was employed, he
always used it with the Ormsby inhaler, or some form
of inhaler which did not allow of the passage of the
atmosphere directly over the inhaler and into the ap-
paratus. The Allis instrument, or any similar form
of open inhaler, seemed to him extremely objectiona-
ble because the passage of the atmosphere over the
inhaler lowered the temperature within the inhaler
and carried a chilled vapor into the respiratory pas-
sages, often exciting inflammation in this way. The
introduction of a warm, moist anaesthetic vapor facili-
tated and modified the anaesthesia satisfactorily. In a
series of administrations at operations in the Mt.
Sinai Hospital he had proved that with the Ormsby
inhaler the patient could be anesthetized with ether
and maintained under narcosis, and would come out
of the anesthetic more rapidly and with less irritation
of the kidneys or other organs than by any other
method of administration. It was well known that
the elimination of the ether vapor by the kidneys was
the cause of very considerable irritation of these
organs. Of course, the greater the volume of ether in
the blood, the greater was the volume that must be
eliminated by the kidneys. Just here was observed
one of the advantages of the closed .inhaler — />., the
diminution in the quantity of the anesthetic necessary
for a given period of narcosis.
Ether and Chloroform Contrasted. — In the hands
of a tyro ether was safer than chloroform, and this
without regard to the condition of the patient, but in
the hands of an experienced anesthetist, and one who
had studied his case carefully and had satisfied him-
self that the use of chloroform was justified, this agent
was practically without danger. He preferred chloro-
form in all cases in which there were pathological
changes in the kidneys, and in which heart lesions
were absent. When the lungs were seriously involved,
as by tuberculosis, gummatous tumors, or inflammatory
changes, or when there was a moderate pleuritic effu-
sion, chloroform was preferable. When, however, in
any way the heart had become crippled, ether was the
safer anesthetic. For operations in the abdominal
cavity, chloroform was preferable for the reason that
vomiting was less likely to occur during and after th*
operation. He was especially afraid of chloroform in
patients who had had repeated attacks of rheumatism,
and in whom the action of the heart was weakened
by serious valvular lesion, atheroma, or fatty met-
amorphosis. In alcoholic subjects chloroform was
preferable because of the difficulties met with in se-
curing profound narcosis from ether.
Chloroform Unsafe for Children. — In children,
ether was, in general, the safer anesthetic. He had
been taught that chloroform was the better anesthetic
in this class of cases, but he had learned that in chil-
dren under twelve years of age chloroform was not so
safe as ether. He had seen death occur in a child of
ten years, without a single danger signal, and when
not more than one drachm of chloroform had been ad-
ministered by an expert. Chloroform was especially
dangerous in children who were poorly nourished or
weakened by any dyscrasia. Particular care was nec-
essary when the child struggled and made deep and
rapid inspirations. Over the age of twelve years, in
healthy subjects, he believed chloroform to be as safe
as ether.
The Amount of the Anaesthetic Dr. Thomas L.
Bennett took up this topic. He stated that in his
opinion many of the symptoms of prostration noticed
after operation, and attributed to hemorrhage or shock,
were really due to overstimulation from the use of an
excessive amount of the anesthetic. Many factors
entered into the production of nausea and vomiting
after operation, yet he was sure that there was a direct
relation between these symptoms and the quantity of
the anesthetic employed. Asphyxia might result from
an overdose of the anesthetic agent, or from foreign
bodies in the air passages. Syncope was invariably
due to an overdose. Mucus, saliva, vomited matter,
or blood might flow into the pharynx, and be carried
into the trachea. Here it acted as an obstruction to
respiration, and, as a result, the inspiratory efforts
were greater, and these substances were drawn deeper
and deeper into the lungs. Acute pulmonary cedema,
in his experience, had been a rare complication of
anesthesia. The influence of anesthetics upon the
kidneys had received much attention, and all observ-
ers agreed that the chief factor was the quantity of
the anesthetic enlployed. The necessary amount of
the given anesthetic would depend upon : (i) The re-
quirements of the individual patient; (2) the require-
ments of the particular operation; (3) the method of
administration; (4) the administrator. Large, strong,
energetic, wiry, neurotic, and intemperate patients, as
a rule, required more than the average amount of the
anesthetic, while small, weak, lethargic, phlegmatic,
and temperate people required less than the average
amount. Many children about the age of puberty
required an unusually large quantity of the anesthetic.
The amount would vary according to the nature, sever-
ity, location, and duration of the operation. Opera-
tions on the rectum, perineum, bladder, the eye and
ear, and abdominal operations requiring severe and
deep manipulations, all required a very deep narcosis.
As to the method, lie would say that when he had ex-
perienced great difficulty in securing ether narcosis
by the open method h^ had succeeded quite rapidly
when he resorted to the closed inhaler. There were
two ways in which ether might be administered with
a given inhaler, viz.. (i) using a small quantity at
short intervals, and (2) using a larger quantity at
longer intervals. His personal preference was for the
first method, just as he favored the drop-by-drop
method of administering chloroform. On an average,
about four ounces of ether would be required for the
first hour, if the closed method was used, and about
two ounces for the next hour.
March lo, 1900]
MEDICAL RECORD.
437
Nitrous Oxide and its Modifications for Prolonged
Surgical Operations. — Dr. S. Ormond Goldan read
this paper. He said that in the use of nitrous-oxide
gas for prolonged operations, the following precautions
should be observed: (i) A sufficient quantity of gas
should be at hand; (2) a hot cloth should be wrapped
around the valve if the apparatus became covered with
frost; (3) the patient's face should be turned on the
side. Operations of delicate dissection, or where
venous engorgement was undesirable, contraindicated
the use of nitrous-oxide gas. The use of this gas was
not contraindicated in abdominal operations, but it
had been found necessary to flex the legs and thighs
well in order to secure the proper relaxation. This
was a point which had served him well, though he did
not recollect having seen it mentioned in the books.
It was undesirable to carry the anaesthesia to the pro-
duction of clonic spasm. The time required for the
induction of ancesthesia by nitrous oxide varied from
thirty seconds to two minutes. About four gallons of
gas was required in the average case to produce anes-
thesia. Nitrous-oxide gas was an asphyxiating agent,
although it also had anaesthetic properties, as was
proved by its use with oxygen. When administered
in conjunction with carbonic dioxide the patients often
complained afterward of headache. To obviate this
the inhaler should be opened occasionally, and then
filled with fresh gas. For the administration of nitrous
oxide and oxygen Dr. Hewitt's apparatus was gener-
ally employed. The effort was to give each patient as
much oxygen as he or she would tolerate. The per-
centage of oxygen must be varied from time to time
throughout the narcosis, depending upon the effect.
The mask was kept constantly supplied, and the inhala-
tion was continued uninterruptedly. This mode of an-
sesthetization required the greatest skill. As much
oxygen as possible should be administered without
interfering with the anesthesia. Consciousness was
almost immediately regained after nitrous-oxide anes-
thesia. Sometimes there* was intense headache for
hours after its.administration. Nausea and vomiting
were also occasionally persistent for some hours.
Hysterical attacks occurred at times after this an-
aesthetic. Anesthetization with nitrous-oxide gas and
oxygen was the most expensive of all the methods.
In one operation lasting two hours, in which these
gases had been administered in minimum quantity,
the cost of the anesthetic agents alone amounted to
seven dollars.
Experience with Ethyl Chloride in General An-
aesthesia.— -Dr. James P. Tuttle read this paper,
which was based on some experiments that he had
made during the past three months with kelene, or
pure ethyl chloride, as an adjunct to anesthesia with
ether. The first experiment had been made on No-
vember 15, 1899. The patient was a strong man aged
forty-five years, having a fatty tumor on the border
of the scapula. Insensibility to pain had been in-
duced in four minutes, but the muscles had notrelaxed
promptly, and supposing that this could not be readily
induced by kelene, the anesthetist had been directed
to change to ether. Complete narcosis had been in-
duced so rapidly then that he had been at first alarmed.
His next experiment had been on a case of hemor-
rhoids. For three minutes and a half kelene had been
administered, and then, the cornea having become in-
sensitive, ether had been given with the Ormsby in-
haler, and complete anesthesia had been induced in
two minutes more. Since then he had adopted the
following method: The kelene is sprayed upon the
under surface of an Esmarch inhaler, and the spray-
ing is repeated from time to time. As soon as the
cornea became insensitive, ether was given by the
Ormsby inhaler In forty cases of which he had
notes, the time required to induce anesthesia had
never exceeded seven minutes. As a rule, conscious-
ness seemed to be retained up to the time of changing
to ether. There was sometimes momentary spasm of
the glottis at the time of beginning the use of the
ether. The shortest time required for inducing anes-
thesia had been three minutes and a half, and the
longest seven minutes. Occasionally there had been
a little struggling, but ordinarily the patient was con-
scious, and a reassuring word or two, explaining to
him that there might be a momentary spasm or chok-
ing, was sufficient to prevent any struggling. He had
asked a number of patients whether they had any rec-
ollection of the application of the ether cone, and in
each instance had received a negative reply. In four
cases the use of the ethyl chloride had proved unsat-
isfactory. In one of these it had been found exceed-
ingly difficult to anesthetize the patient with ether.
None of these four persons was at all the worse for the
kelene, and he felt sure that in none of these instances
had the induction of ether narcosis been rendered
more tedious or difficult by the preliminary use of the
kelene. The average quantity of kelene employed
had been between 10 and 20 c.c. He considered it
important that the kelene should be kept in a closed
graduated tube. He had seen no deleterious effects
from this use of ethyl chloride.
Closed Inhalers Dangerous Dr. Hobart A.
Hare, of Philadelphia, opened the general discussion.
He stated that the physicians and surgeons in Phila-
delphia believed the best form of inhaler for both ether
and chloroform to be the simplest one imaginable —
the ordinary towel cone with a piece of absorbent cot-
ton in the fop of it, or an Allis inhaler for ether, and
the folded towel for chloroform. Personally, he was
very much opposed to the various forms of cumber-
some apparatus that had been shown this evening.
He was opposed to them because of their cumber-
someness, and because he believed much the same
objections applied to tubes and bags in connection
with inhalers that applied to tubes in infants' nursing-
bottles. He believed a good many pulmonary acci-
dents had occurred from the use of these bags and
tubes in connection with inhalers. We were told, of
course, that these things could be boiled and sterilized,
but how often in private practice was this neglected
when the physician or surgeon returned home tired
out after a long and trying operation ? He had seen
a gynecologist in Philadelphia use one of these bag
inhalers, and had always been impressed with the idea
that his patients were being anesthetized primarily by
the anesthetic and secondarily by carbon dioxide, and
thirdly, perhaps, anesthetized or benumbed by taking
into the system the effete material which it was known
the breath was continually giving off. Physiological
experiment had proved most positively that, after all,
it was not the carbonic-acid gas which was given off
from the lungs which acted so deleteriously in crowded
rooms — as in the historical Black Hole of Calcutta — •
as the effete material expired. For these reasons he
was of the opinion that an anesthetic agent should be
selected and used by itself without having its effect
obscured and rendered more complex by the use of
these closed inhalers.
Comparative Safety of Chloroform and Ether in
Children. — He had been particularly interested in the
title of Dr. Wyeth's paper because he believed it was
a common fault to resort to the routine use of both
ether and chloroform without carefully selecting the
anesthetic to suit the needs of the individual case.
He had been greatly surprised to hear the statement
by Dr. Wyeth that the use of chloroform in children
was more dangerous than in adults, for he felt sure
that medical literature would not support this assertion
— indeed, it seemed reasonable to suppose that what
might be called "the fresh heart" of the child could
438
MEDICAL RECORD.
[March lo, 1900
stand chloroform better than the heart of an older per-
son. Again, ether seemed to him particularly objec-
tionable in children because the delicate mucous mem-
brane in the respiratory passages of the child was so
much more apt to become inflamed as a result of the
irritation set up by the ether.
Effect of Chloroform on the Heart. — He would
also take issue with Dr. Wyeth in regard to the effect
of chloroform on the heart. He did not believe that
chloroform exercised primarily any very distinct de-
pressing influence upon the left heart of an healthy
individual. The explanation of the sudden circula-
tory failure which took place frequently during chloro-
form anaesthesia he believed was to be found, not in
the heart, but in the vasomotor system. It was per-
fectly possible for a man to bleed to death into his
own arteries. These deaths from chloroform, then, he
would ascribe to vasomotor paralysis. A very large
proportion of deaths from chloroform had occurred in
the hands of dentists who had administered the drug
to patients semi-recumbent or sitting up in a chair.
In confirmation of this view, the speaker referred to
a case seen by him in a private hospital of a col-
league. The patient had suddenly become utterly
pulseless, and the apex beat of the heart could not be
felt over the precordium ; indeed, a hasty auscultation
had hardly revealed the heart sounds. Dr. Hare said
that he had suggested in this emergency that the oper-
ator grasp the abdominal aorta. This had been done
immediately, and at once the heart had begun to beat
more naturally. This case seemed to him convincing
evidence of the very important part played by the vaso-
motor system. When vasomotor failure did not occur,
and still chloroform produced death, it did so, in his
opinion, by paralyzing the sister centre of the vaso-
motor centre, i.e., the respiratory centre. Dr. Hare
said that he had studied this matter very carefully on
animals for the Hyderabad commission, and had be-
come thoroughly convinced that the primary effect of
chloroform on the circulatory apparatus was to lower
the blood pressure.
Atropine before Anaesthesia. — Again, surgeons in-
numerable had found that the use of atropine just prior
to the administration of chloroform gave a more satis-
factory anesthesia. This was because atropine was
one of the best vasomotor stimulants. The atropine
more than the morphine was responsible for Dr.
Wyeth's good results when these two drugs had been
given prior to anaesthesia. The foregoing facts should
impress another lesson, viz., that before anaesthesia is
induced, or an operation performed, the limbs should
be bandaged in a feeble patient. In urgent cases an
abdominal compress should be applied with the same
object in view.
Shock following Anaesthetization. — It had often
seemed to him that the amount of the antesthetic
agent employed depended more upon the anaesthetizer
than upon the antesthetic agent or upon the patient.
Some anaesthetists seemed to know almost instinc-
tively when to add more of the anaesthetic, and when
to stay their hand. The profession at large seemed
to pay too little attention to the question of the shock
produced upon the patient by the administration of an
anaesthetic. This was a matter which could not fail
to impress itself upon physicians rather than upon
surgeons. He had repeatedly seen persons subjected
to operations and recover apparently satisfactorily
from them, and yet for many months afterward they
had carried with them a distinct stigma resulting from
the operation or the anaesthetic. Many women after
such an experience do well for a short time, and then
become vaguely nervous and out of health, and ulti-
mately have to take the " rest cure."
Position of the Head and the Use of Tongue
Forceps. — When one wished to be sure that air passed
freely into the lungs, the head should be thrown for-
ward in the position which it occupies in a trained
runner. If the anaesthetic was properly given, the
head maintained in this position, and the jaw prop-
erly manipulated, there would be seldom any occasion
for the anaesthetizer to make use of the tongue forceps
which so commonly decks the coat of the young hos-
pital interne whose duty it is to administer the anses-
thetic.
Avoidance of Nausea — He believed in many cases
the preliminary use of morphine increased the ten-
dency to nausea and vomiting. He had discovered
that if it was desired to avoid this nausea, whether due
to the anaesthetic or to the morphine itself, it could
be ordinarily accomplished by combining nitroglyc-
erin with it.
Influence of Athletics and Fright.^He was of
the opinion that nitrous-oxide gas should be used very
carefully in any case in which there was atheroma,
because this anresthetic greatly increased the blood
pressure. In the presence of valvular disease of the
heart he would employ ether in preference to chloro-
form, and also in cases of fatty degeneration of this
organ. On general principles, ether seemed to be a
safer anesthetic in young athletes than chloroform,
because statistics showed very clearly that these per-
sons were specially prone to accidents with chloroform.
When engaged in laboratory work it had been recog-
nized as a fact that strong, well-built dogs were very
prone to die under chloroform, and that the better bred
the dog the more susceptible was he to the lethal in-
fluence of this anesthetic. Dr. Hare mentioned this
amusing fact, he said, to emphasize the influence of
fright, the highly bred dog exhibiting great fright be-
fore the anesthetic had been administered.
The Effects of Different Anaesthetics Compared.
— Dr. R. Coleman Kemp continued the discussion,
speaking of the effect of anesthesia on the kidneys.
He stated that, other conditions being the same, the
secretion of the kidney varied with the quantity of
blood flowing through the kidney, and by conditions
affecting the general arterial pressure. Ether and
nitrous oxide could be taken as the types of the vaso-
constrictor anesthetics; nevertheless, with ether the
constriction of the renal vessels was entirely out of
proportion to the constriction of the other vessels in
the body — in other words, ether seemed to exert a
selective action on the kidney. Moreover, in experi-
ments on animals with these anesthetics, the percen-
tage of albumin was large with ether as compared with
chloroform, and persisted for a long time. With the
A. C. E. mixture the chloroform depression was noted
and the typical effect of ether on the kidneys. The
main objection to the Schleich mixtures, when given
with the closed inhaler, was the occurrence of the
chloroform heart and the ether kidney. Anesthol
contains chloride of ethyl, ether, and chloroform. The
chloride of ethyl exerts a certain depressant effect
upon the heart and upon the circulation. Nitrous-
oxide gas and oxygen should be considered tlie safest
anesthetic, provided the patient was not atheroma-
tous, and when kidney lesions were suspected or were
known to exist. Chloroform, as regards the kidneys,
occupied a close second position to nitrous-oxide gas.
The mixtures possessed no advantages, since they
combined the bad effects on the heart and on the kid-
neys, and one was ignorant of the actual amount of the
various constituents taken into the system.
Dr. Ferdinand Haserouck spoke from his per-
sonal experience as a dentist who had been adminis-
tering nitrous-oxide gas constantly for over thirty
years. He had administered the gas to nearly ninety-
five thousand people, and had not yet lost a patient.
He thought he was familiar with the case referred to
by Dr. Hare, and believed it was one case out of one
March lo, 1900]
MEDICAL RECORD.
439
hundred and twenty thousand. (To this Dr. Hare as-
sented.) Regarding the apparatLis that had been ex-
hibited, he said that it was very defective. The cali-
bre of the tube was much too small to prevent the
unpleasant suffocative sensation complained of by so
many persons. He could administer nitrous-oxide
gas to adults or children almost imperceptibly. As
a rule, the sensations were pleasurable rather than
disagreeable. He ascribed his good results to the
use of a very large tube, and the old-fashioned John-
son inhaler. He had administered the gas for opera-
tions of one or two hours' duration — probably five
hundred times for operations lasting one or more hours
— and had never experienced any very great difficulty
with it. He called attention to the fact that the valve
in the iron cylinder containing nitrous-oxide gas might
be broken without the knowledge of the anaesthetist,
and thus leave him in a very unpleasant position.
A Large Mortality from Ether Anaesthesia. — Dr.
R. H. M. Dawbarn called attention to the change of
opinion which had taken place in New York City in
recent years in favor of the more general use of chloro-
form as an anjESthetic. He believed that almost in-
variably when a man died under chloroform it was
due to the ignorance of the anaesthetist. He made the
statement that Dr. R. Coleman Kemp and Dr. Wil-
liam H. Thomson had records proving most conclu-
sively that in the hospitals of this city about one
patient in nineteen dies from ether anaesthesia. The
speaker said that in the last ten years he had not had
a single death from suppression of urine or from ether
pneumonia after ether anaesthesia, and he attributed
this largely to the use of a simple modification of the
Clover inhaler. The breathing over and over again
of the same ether in such an inhaler prevented chilling
and undue irritation of the respiratory passages. Un-
doubtedly it produced a carbonic-acid ancesthesia, but
so eminent an authority as Dr. H. C. Wood, of Phila-
delphia, had expressed his conviction that such ana,'s-
thesia was not injurious. The modified Clover inhaler
to which he had referred could be cleansed in a mo-
ment— -certainly in much less time than was required
for cleaning the AUis inhaler. For the last ten years
he had almost always given prior to anaesthesia gr.
.j-^ij of atropine and gr. '5 of morphine, with a little
whiskey. This medication reduced the quantity of
the anesthetic required, and certainly reduced, and
sometimes annihilated, the element of fear.
Ether Gelatinizes Acid Urine. — Dr. J. A. Bodine
referred to the observation, made some years ago by
Dr. Andrew H. Smith, of this city, to the effect that
when acid urine was mixed with ether in the labora-
tory it would gelatinize after a time, but that this did
not occur when the urine was alkaline. This sug-
gested the possibility, which seemed worthy of further
study, that if the precaution was taken to have the
urine acid before giving ether, the effect on the kid-
ney might be less dangerous.
Fright an Important and Dangerous Factor.—
The speaker laid great stress on the element of fright
and apprehension concerning the administration of the
anaesthetic, and referred to a case occurring in the
practice of a surgeon in New York City, in which
death had occurred just before the administration of
the anesthetic had been begun. In this person the
autopsy revealed all the vital organs in a normal state.
Because of this fright before anaesthesia, he favored the
administration of a moderate dose of morphine. The
reason that chloroform was relatively safer in obstetric
practice was that the woman looked upon parturition
as a natural process, and welcomed the anesthetic as a
relief from the pain. Future research regarding anes-
thesia should be directed toward studying the effect of
the anesthetic upon the blood, as the field of pure clin-
ical study of anesthetics had been nearly exhausted.
A Simple Home-Made Ether Inhaler — Dr. A.
Ernest Gallant spoke of the important and responsi-
ble position of the skilled anesthetist, and contrasted
the usual fee which he received with that demanded
and received by the operating surgeon. He advocated
allowing the patient to hold the ether cone; the addi-
tional time required would be more than compensated
for by the diminution of fright. His method of using
the Allis inhaler was to remove the bandage from the
frame, to cover the lower portion of the frame with a
layer of absorbent cotton retained by slipping a rub-
ber elastic band over the frame, and then loosely to
fill the frame with gauze. The ether cone used and
recommended by him could be readily made by any
one at home, the frame being made from a piece of
ordinary stove-pipe, tin, or galvanized iron leader pipe,
three inches in diameter, and three and a half inches
long, or even from a heavy piece of cardboard. If the
latter was used, it should be wetted on one side to
make it flexible, and then bent to an oval shape. The
gauze was to be adjusted over the end, and a newspaper,
folded eight inches wide and wrapped in a towel, was
wound tightly around the frame, both ends being left
open. The loose gauze having been put into the
frame, the inhaler is ready for use.
Effect of Chloroform after Nitrous Oxide. — Dr.
J. W. Draper Maury said that he understood that in
Germany the custom was not to give chloroform by the
drop method, as had been stated, but by saturating the
mask with the chloroform. If nitrous oxide was
followed by chloroform it almost always induced vom-
iting, and not infrequently the effect of chloroform on
the heart after the use of gas was deleterious.
Schleich's Mixtures Commended. — Dr. M. L.
Maduro spoke favorably of the Schleich mixtures,
and in this connection cited the experimental work of
Dr. S. J. Meltzer. This investigator claimed that the
petroleum ether was the dangerous constituent, though
Schleich denied this. The work of Drs. Kemp and
Thomson was interesting, but was more than offset by
the results of experience, as abundantly proved by the
statements that had been made in this discussion.
Dr. Parker Syms spoke with great earnestness in
favor of the growing tendency to turn over the admin-
istration of anesthetics to those specially trained for
this work.
Dr. EiiiL Mayer brought up the question as to
when consciousness ceased, and the important bearing
which it had upon the conduct and conversation of
those present in the anesthetizing-room.
Dr. Hare emphasized the fact that the dose of the
anesthetic which the patient got was not that quantity
which was put upon the towel or mask, or which was
breathed, but the amount which was absorbed. For
this reason, if the patient breathed in one ounce of
ether in a closed inhaler, and breathed it over again
ten times, there was very little difference in the effect
upon that patient, as regarded the quantity of the
anesthetic, from giving a good many ounces of ether
on an open inhaler. In his opinion, the reason that
the parturient woman could take chloroform so much
more safely than others was because the pain stimu-
lated the abdominal vasomotor centres. In conclu-
sion, he advised that a careful selection of the anes-
thetic should be made for each case.
Dr. Goldan, in closing, said that he always made
it a practice to sterilize thoroughly his bag inhaler
each time. Regarding the physiological experiments
of Drs. Kemp and Thomson, he would say that their
results were decidedly at variance with clinical expe-
rience, for certainly it was rare to find bloody urine or
suppression of the renal secretion after etherization.
Chloroform should never be given immediately after
nitrous-oxide gas; if it must be given, ether should
be used as an intermediate agent.
440
MEDICAL RECORD.
[March lo, 1900
ptetlical Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending March 3, 1900:
Tuberculosis
Typhoid fever
Scarlet fever 1 60 23
Measles SiS 33
Diphtheria 262
Laryngeal diphtheria (croup)
Cerebro-spinal meningitis
Chicken-pox
A Resected Coil of Small Intestine Twice Per-
forated by a fragment of bone 4 cm. long by 1.5 cm.
wide was demonstrated by Biidinger at a meeting of
the Gesellschaft der Aerzte in Vienna on October 20,
1899. The patient had presented himself on account
of a painful swelling in the right inguinal region,
which upon operation proved to be a collection of foul-
smelling pus. — Klinisch-therap. Wochenschrijt, 1899,
No. 43.
Precocious Dentition. — Heard {^British Medkaljonr-
nal, December 2, 1899, p. 1543) reports the case of a
girl, born at seven and a half months, labor being in-
duced prematurely on account of a justo-minor pelvis.
The infant was perfectly normal and healthy in every
way, but the two lower central incisor teeth were vis-
ible under the gum. These cut through within a few
days after birth, the right on about the fourth and the
left on the fifth day. In a few days an abscess began
to form, and the teeth to loosen. It was decided to
extract the teeth, and a distinct effort was required in
the operation. They were typical milk-teeth of a
whitish color. For some time after the lateral inci-
sors appeared there was a gap, but this subsequently
closed.
A Story of Sir William MacCormac. — Here is a
story of Sir William MacCormac, which strikingly il-
lustrates his well-known kindliness of disposition and
willingness to assist in any emergency. On the night
of the terrible explosion which occurred some years
ago at Shoeburyness, when Colonel Fox Strangeways
and eight others lost their lives. Sir William was tele-
graphed for at a late hour and hurried off to Fen-
church Street, where, after no little difficulty, he was
provided with a special train. By a stroke of luck a
well-known journalist had also "caught wind" of the
catastrophe, but on reaching the station he discovered
that the train had gone. Seeing the preparations that
were being made for the " special," he boldly ap-
proached Sir William, and was invited, to his astonish-
ment, to share the saloon. At the station a brougham
was waiting for the famous specialist, and recognizing
that unless he continued to stick close to his fellow-
traveller he would have all his journey for nothing,
the reporter hit upon another expedient. With a
glance at the doctor he took possession of the two
cases of surgical instruments, and with one in each
hand he mounted the box and sat beside the coach-
man. At the station hospital his entree was unchal-
lenged, as he was assumed to be the great surgeon's
servant. Having written a hurried account of the dis-
aster and secured a list of the killed and injured, he
promptly roused the telegraph clerk from his bed and
was thus able to send his office in London a full and
exclusive description of the whole affair. Naturally
he still retains the liveliest recollection of the services
rendered him by the man who is now at the Cape.
Health Reports The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended March 2,
19.00 :
Cases. Deaths.
Smallpox — United States.
Alabama. Mobile February 17th to 24th 3
Florida, Jacksonville February 17th to 24th 2
Illinois, Rockford February i6th to 17th 2
Indiana, Evansville February 17th to 24th 3
Indianapolis February i7lh to 24th 2
Kentucky, Louisville February 15th to 2xd 4
Louisiana, New Orleans February 17th to 24th 55 aj
Mississippi, Greenwood February loth to 17th 87
New York, New York February T7tht024th. 2
Ohio, Cincinnati February 17th to23d 1
Cleveland February 17th to 24th 20
Youngstown February 17th to 24th 1
Utah, Salt Lake City February \^^\ to 24th 1
Virginia, Portsmouth February 17th to 24th 6 2
Washington, Spokane February 17th to 24th 9
Tacoma February loth to 17th 9
Smallpox — Foreign.
Brazil, Rio de Janeiro January 12th to 19th 29
Canada, New Brunswick: Rest-
igouche County January i6th to February 3d . . 73
Gloucester County January 25th to February 8th.. 39
Northumberland County. .February ist i
Westmoreland County January iSth to February 3d. .. 3
Ontario, Amherstburg ... February 2d to 24th i
Quebec, Gaspe Basin February 6th to 15th 4
France, Lyons January 27th to February 3d 2
Paris February 3d to loth 4
Germany, Konigsberg January 27th to February' 3d. . . i
Gibraltar February 1 ith to iBth 3
Mexico, Mexico January 28th to February nth . 24 19
Spain, Corunna February 3d to 10th 3 i
Madrid January 20th to February 3d 21
Straits Settlements, Singapore, January 6th to 13th 1
Yei,i:Ow Fever.
Brazil, Rio de Janeiro Januarj' 12th to 19th 16 6
* Generally prevalent and spreading.
Plague.
.Madagascar, Tamatave December 16th to 23d i
Plagi'e.— Insular Pos-^essions United States.
Hawaii, Honolulu Jautiary 23d to February 19th. . . 6
While the MEDICAL RECORD is pleased to receive all new pub-
lications which may be sent to it, and an acknowledgment will be
promptly made of their receipt under this heading, it must be with
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it which in the judgment of its editor will not be
of interest to its readers.
Transactions of the Mississippi Valley Medical Asso-
CIATION, 25th annual session, held at Chicago, III., October 3,
4, and 5, 1899. Vol. I., 8vo, 474 pages.
A .System of Medicine, by many writers. Edited by Thomas
Clifford Allbutt, M.D. 8vo, 998 pages. Vol. IX. The Mac-
millan Company, New York.
A Manual of Surgery. By Charles Stonham. 8vo, 3 vols.
Illustrated. Vol. I.. General Surgerj'. Vol. II., Injuries.
Vol. III., Regional .Surgery. The Macmillan Company, New
York.
Gynecology. By Montgomery A. Crockett, M.D. 8vo,
368 pages. Illustrated. Lea Brothers & Co. , Philadelphia and
New York.
Nervous and Mental Diseases. By Charles S. Potts.
M.D. Svo, 455 pages. Illustrated. Lea Brothers & Co.,
Philadelphia and New York.
Healthy Exercise. By Robert H. Greene, M.D. i2mo,
165 pages. Illustrated. Harper & Bros., New York and
London.
Trait6 Pratique des Maladies des Pays Chauds et
Tropicaux. Par le Docteur J. Brault. Svo, 528 pages. Il-
lustrated. Librairie J. B. Bailliire et Fils.
The American Year-Book of Medicine and Surgery.
Edited by George M. Gould, M.D. Two vols., Svo. Illus-
trated. W. B. Saunders, Philadelphia.
International Clinics. Edited by Judson Daland, M.D.
Vol. IV. Svo, 337 pages. J. B. Lippincott Company, Phila-
delphia.
Medical Record
A IVeekly yoiiriial of Medicine and Surgery
Vol. 57, No. II.
Whole No. 1532.
New York, March 17, 1900.
$5.00 Per Annum.
Single Copies, loc.
©riginat Jtrticlcs.
SOME POINTS IN THERAPEUTICS OF HEART
DISEASES.'
By W. II. THOMSON, M.D., I.L.D.,
In diseases of no other organ do the indications for
treatment differ so widely as they often do between
different conditions in both the acute and in the
chronic affections of the heart. In the limits of this
paper I can only point out the salient features in
these contrasts, with the reasons why the heart in its
disorders at one time calls for one class of remedial
measures, and for a wholly different class at another,
so that this organ should be regarded as the last in
the body whose disorders can allow of any routine
fashion of treatment.
First, as to the acute disorders. The great major-
ity of them are of an inflammatory character. But it
is a serious mistake to regard them as always or pre-
dominantly so. In many instances, as in diphtheria,
the danger to the patient is not from inflammation,
but from a parenchymatous myocardial degeneration.
A similar danger often arises in the hearts of children
during attacks of the exanthemata, in pertussis, and in
pneumonia, in which the deaths are due primarily to the
involvement of the heart, which may be fatally weak-
ened by the toxins of these infections without giving
any auscultatory signs of a carditis. Even in the car-
ditis of rheumatism, a specific softening and conse-
quent distensibility of the myocardium generally take
place, which may be revealed on physical examination
only by percussion; while on the other hand there
may be evidences of general failure in the circulation
whose gravity should be fully appreciated, though the
auscultatory signs be relatively little marked. Over-
strain also may produce an acute condition of dilata-
tion with its symptoms and indications for treatment
differing from any of those above mentioned, and this
may occur not only in healthy hearts from undue mus-
cular stress, but also from injudicious exertion in
convalescents from a prolonged fever.
First, then, I will allude to the acute inflamma-
tory states. The condition, then, is one of great ex-
citement of the viscus. Our chief complication on
that account arises from the fact that normally this
organ rests the least of any other in the body. The
two layers of the pericardium rub against each other
in health seventy times and more in a minute, in peri-
carditis a hundred and twenty times and more. Could
the slightest inflammation in any other part of the
body get well readily if it was moved as often.' Nev-
ertheless rest is one of the most imperative indications
in all inflammations, and none the less so in the case
of the heart. Rest from over-action must invariably
be the first aim in acute carditis of every form. This
truth cannot be emphasized too strongly. When the
heart is beginning to fail in acute cardiac inflamma-
tions, as the pulse, dyspnoea, and other signs of cir-
' Paper read before the Jersey City Practitioners' Club, Feb-
ruary 13, 1900.
culatory embarrassment develop it is from an over-
fatigue which in the majority of cases will only" be
aggravated by administering heart stimulants. The
recognition of the exact indications for treatment is
then of the supremest importance, and I would define
them thus :
With a febrile temperature, cardiac pain either sen-
sible to the patient or elicited by pressing upward
during expiration under the left costal arch, with hur-
ried breathing, rapidly rising pulse, and, on ausculta-
tion, disturbed rhythm with or without murmurs, the
treatment should be as follows: Leeches to the pre-
cordium, afterward constant poultices of flaxseed meal
made with extract of hamamelis, and laudanum poured
on just as the cataplasm is applied, and then covered
with oiled silk and that part carefully so covered with-
out a single exposure night and day. This is not a
mere minor detail, for I have seen an acute pericarditis
fatally aggravated by a medical teacher baring the chest
of the patient in a cold ward for upward of an hour
while a large class of students listened to the interest-
ing friction sound. While there is no vascular con-
nection between the circulation of the skin and the
blood-vessels of internal viscera, there is the most
intimate vasomotor association between the nerves
which control the blood-vessels of the viscera and
the cutaneous nerves of the corresponding skin areas
above them. Cold applied suddenly to the skin of the
abdomen will check a post-partum hemorrhage, not
by the cold striking in, but by the same blood-vessel
constriction occurring within, through reflex vascular
action, which the cold causes in the blood-vessels on
the surface. In disease this mutual sensitiveness be-
comes heightened in two ways. The internal irrita-
tion causes a hypera;sthesia of the cutaneous nerves,
which reacts all the more upon the vasomotor nerves
of the internal viscera. Let a cold hand be suddenly
laid on the precordium in health and it will cause the
heart to bound. In a carditis the heart is all the more
sensitive to such an impression. So with a phthisical
localized pleurisy at one lung apex, the application of
a cold hand will cause the patient to give a cough, ,1^
while the same application to the chest over the sound
lung will not. I have used this fact for diagnosis in
physical examination. Owing, therefore, to this rela-
tion between the skin and the heart, I always am par-
ticular to use vascular sedatives to the precordium as a
preventive as well as a remedial measure when acute
carditis is impending or present; and besides what I
have recommended by the protection of moist heat, I
would add that no vascular sedative is so potent in
acute inflammation as topical blood-letting. This is
wholly through the surface nerve impression of the
bleeding, and this fact is illustrated in a great variety
of other conditions. A leech applied at the sternal
notch will often surprisingly relieve the agonizing
dyspnoea of a thoracic aneurism; a few leeches to the
epigastrium will as surely check the vomiting of acute
gastritis; leeches on the mastoid will also likewise
relieve the pain of meningitis, etc. — all of which exam-
ples can be explained in no other way than that of the
production of reflex nerve sedatjon. In acute rheu-
matism, which is so common a cause of cardiac inflam-
mations, the tendency to sweating and consequent easy
442
MEDICAL RECORD.
[March 17, igoo
surface chill should be guarded against from the be-
ginning by discarding sheets and directing the patient
to have only underwear of flannel, and to lie between
blankets throughout his illness.
One medicine takes the lead of all others in acute
inflammations of the heart, and that is aconite. It is
the ideal heart sedative in all such conditions on ac-
count of its prompt alleviation of cardiac pain and
consequent irritation, and secondly on account of its
specihc action of slowing the heart beats. While the
salicylates have proved invaluable in diminishing the
pains of the acute arthritis, it must be confessed that
they have wholly failed as preventives of rheumatic
carditis. In fact I am certain that the old treatment
with alkalies showed better results, as far as involve-
ment of the heart is concerned, than does our experi-
ence to-day with the salicylic salts. But a steady em-
ployment of aconite pushed to producing its specific
effects upon the pulse will often change marvellously
for the better the whole clinical aspect of the case.
This is shown very strikingly in some of the acute
exacerbations of chronic heart disease. We repeatedly
see cases admitted to our hospital wards with the worst
conditions of general ana;mia and intense dyspnoea,
and then find the patients greatly improve without any
medicine, evidently simply from rest in bed. Now,
this common experience is explicable only by assum-
ing that the dropsy and the pulmonary engorgement
with hydrothorax are largely due to the heart failing
from fatigue, and then recovering measurably from this
weakening fatigue by rest in bed. But on the same
principle I have again and again in these chronic cases
stopped the administration of heart stimulants and sub-
stituted aconite, with an immediate change for the
better in the gasping for breath and in the progressive
increase in the pulmonary cedema. The indications
here for giving aconite rather than digitalis, etc., are a
strong laboring heart impulse and a rapid pulse. The
same recommendation for aconite may be given in all
cases of rapid pulse with distinct cardiac pains — in
other words, when the evidence is plain of an irritable
heart on account of causes directly traceable to intrinsic
cardiac irritation, whether from the eff^ects of previous
inflammation or from over-strain. On the other hand,
a quick pulse with high tension is not uncommonly the
beginning of chronic heart disease from primary kid-
ney disease. In this case veratrum viride is much
better than aconite, owing to its specific dilatation of
the arterioles, as well as to its slowing effect upon the
heart.
Very different from the indications furnished by
acute carditis (including in this term its three forms
of endo-, myo-, and pericarditis) are the conditions pre-
sented by acute parenchymatous degeneration. Thus
the toxin of diphtheria is one of the most powerful
proteolytic poisons known. It digests and dissolves
living muscular tissue more powerfully than pepsin
dissolves the muscular elements of food. Thus the
living heart begins to fall to pieces under its influ-
ence, and to this is added a like degeneration of the
heart's great adjuvant in the circulation, namely, the
muscular layer of the arteries. A very striking fall
in blood pressure, therefore, takes place, which goes
on progressively increasing till death, as has been
conclusively established in experiments with this toxin
on animals, as well as clinically in tiie human subject.
In striking contrast, therefore, with the flush of acute
rheumatic carditis, a surface pallor is the character-
istic hue of these patients, quite different also in its
way from the bluish pallor of carbonic-acid poisoning.
We often note the same pallor, with its accompanying
rapid, small, and irregular pulse, to result from other
toxins of the exanthemata. Now, there is one drug
often mistakenly administered in these conditions of
heart weakness which is extremely mischievous, and
that is digitalis. It is frequently prescribed with the
idea that it is a heart-muscle tonic, and that, therefore,
whenever we have a weak heart, we at once should
give digitalis. But this term "tonic" is one of the
vaguest terms current in our therapeutics, and that is
saying a great deal. Thus we read of arsenic being a
tonic, also iron, cod-liver oil, electricity, a cold bath,
and a sea voyage. Anything, in short, that does good
is called a tonic, the original conception evidently
being derived from "tone" in music, as when the
relaxed strings of a violin or of a piano are tightened
or toned up. But vague terms lead to the loosest kind
of practice, and what we need is to form very definite
ideas about the specific action which we are aiming for
under the term tonic. , -Now, the action of digitalis
upon the heart is to t^ow its walls into an irregular
kind of cramp. The heart, under its influence, has
a mottled or nutmeg-like appearance, from the white,
anaemic, contracted bundles compared with the more
red, non -contracted neighboring strands. The general
effect of its action, however, is to diminish the size of
the heart's cavities. The drug, therefore, is of the
greatest service when the heart walls are over-dilated
and too much residual blood remains after each systole
from inability of the dilated cavities to contract
strongly enough to expel their contents. Cramp the
heart walls to one-half the abnormal width and the
heart systole then will work to much greater advan-
tage, on an easily understood mechanical principle.
But here comes the important fact about digitalis,
that in order to produce its contractile effect it must
have a more or less normal muscle fibre to work upon.
It is utterly powerless with degenerated heart muscle,
whether it be in fatty degeneration or in the parenchy-
matous degeneration of diphtheria, or by the weaken-
ing of the fever toxins as in typhoid fever. Not only
is it then powerless, but it is actually harmful from its
cramping rather than stimulating effect upon the heart's
action. I have seen the utmost distress caused by it
in diphtheria, especially in a case which I shall never
forget. But to illustrate my meaning I shall cite only
one case, and that in an adult. He is a copper-mine
magnate. After thirty years' active life spent in work-
ing copper mines which are situated at an average
level of six thousand feet above the sea, he began to
be very short-breathed. After some two years of in-
creasing dyspncsa, accompanied by a cough ascribed
to bronchitis, he had a sudden attack of pulmonary
congestion which nearly terminated his life. He
came on East and was seen by several medical con-
sultants, who all agreed as to the diagnosis of great
cardiac dilatation, without either valvular disease or
general endarteritis. Again and again digitalis had
been prescribed for his heart dilatation, and each time
his symptoms were so much aggravated after taking it
that he came to know digitalis by its effects in bring-
ing on cardiac distress. When called to see him, I
asked him if there was not a good deal of arsenic
given off in the fumes of his snielting-works, among
which works he was accustomed to be constantly going
about on his daily rounds of inspection. "Oh! " said
he, " arsenic lies around there like hoar frost! " Now,
percussion showed the heart to be enormously dilated;
no heart impulse was anywhere palpable. The pulse
was extremely irregular, but there was no valvular
leakage, and not a trace of oedema anwyhere. Arseni-
cal fatty degeneration of the heart, with passive dila-
tation favored by high altitude (with some similar
degeneration of the liver), was my diagnosis of the
etiology of his cardiac condition; all digitalis was
stopped and other remedies were prescribed, with the
result that not only has he been able to lie down and
sleep for eight hours as he had not done for two years,
and also to attend copper-mine speculations in Wall
Street, but he had a fall on the icy pavement five weeks
March 17, 1900]
MEDICAL RECORD.
443
ago in which he was knocked senseless and broke two
ribs, without any more serious results following than
if he had a normal heart.
In the heart weakness of diphtheria, instead of digi-
talis or its congener strophanthus, we ought to push
the administration of alcohol to its utmost limits, with
strychnine, caffeine, and, above all, the hypodermic
injection of camphor in sterilized oil, in dose of gr.
viii. of camphor to TTl, xx. of sterilized oil, repeated
p.r.n. These remedies are also indicated in rheu-
matic conditions when the heart is beginning to fail.
When, therefore, to stop aconite and the use of the
other sedatives above mentioned as so valuable in
acute carditis, and change to the stimulant class in-
stead, is a proper question, and the answer is, when
the heart is beating feebly instead of strongly, and
when the feet are beginning to be no longer hot but
cold.
The chronic sequelae of acute endocarditis form too
extensive a subject to permit me to do more than allude
to some of their aspects. In the first place, after the be-
ginning of convalescence from a severe rheumatic at-
tack it would be greatly to the future advantage of the
patient if he should be kept in bed for at least two
months, especially in the case of children. When we
consider that the rows of small vegetations along the
edges of the valvular flaps act as so many irritating
foreign bodies, like the granulations on the eyelids in
trachoma, we have the explanation of the progressive
involvement of the valves which we find a year after-
ward, with increased incompetence or constriction
from the increasing fibrosis due to chronic inflamma-
tion. Prolonged rest and continued administration of
aconite afford the greatest safeguards against the su-
pervention of an irremediably damaged heart. The
sequelie of acute pericarditis, on the other hand, may
be either wholly unimportant or the most distressing
of all results of a cardiac inflammation. This last
condition is when in addition to pericarditis we have
peri-pericarditis as it may be termed, in which the
inflammation extends beyond the pericardium so as to
leave it finally attached to the sternum, ribs, and pleura.
These consecutive adhesions prevent the heart from
contracting fully in systole, and the most terrible dysp-
noea may follow, with general valvular incompetence
and dropsy. Inspection shows this state of things by
actual recession occurring between the ribs during the
systole. I speak of this condition mainly to empha-
size the great relief which follows on the firmest strap-
ping of the left chest, which approximates the ribs and
lower end of the sternum to the laboring heart and
prevents their undue external pull upon its walls. In
all such cases for the frequent cardiac pains (which
ps-ins also often torment patients for months after
acute endocarditis before good compensation is estab-
lished), belladonna is of much service from its specific
action in all disturbed conditions of rhythmically act-
ing muscular fibre, by allaying spasm and restoring
normal rhythm. Belladonna is thus often very bene-
ficial in mitral stenosis.
The greatest contrasts of cardiac therapeutics, how-
ever, meet us in the treatment of chronic diseases of
the heart which begin later in life than most instances
of acute carditis. We may take for illustration such
a case as the following: A man who has led an active,
though meanwhile physically sedentary, business life,
consults us for a shortness of breath, which he has no-
ticed more or less for many months, but which lately
is growing much worse. His complexion is quite sig-
nificant; face full and irregularly mottled, with a de-
cided yellowish paleness underlying a superficial red-
dish coloration of the cheeks. The forehead is often
greasy. While he is speaking to us we notice that he
has to take one or more inspirations before he finishes
a sentence. He then may complain of nothing else
about his breatliing, but his mind has become slug,
gish or forgetful, and he is much troubled with gastro-
intestinal flatulence and with disturbed sleep. We
examine his heart and find that the cardiac impulse is
very feeble or scarcely to be felt at all. There are no
valvular murmurs, but the first sound at the apex is
often a prolonged rumbling, while the second sound at
the base may be too clear. His pulse is weak or ill
sustained, and sometimes on exertion it intermits a
beat or two. This man may die suddenly, and his
autopsy may show no valvular disease whatever, but
the aorta may be lined with atheromatous patches and
the coronary arteries be found narrowed by a similar
condition in them, while the heart walls prove to be
the seat of extensive myocardial degeneration. Now
this form of heart disease is by no means uncommon.
My experience tells me that myocardial degeneration
is one of the commonest and most efficient of all
causes of failure of compensation in the heart diseases
of patients after middle life, and that it precedes val-
vular incompetence in a large proportion of them. We
meet them afterward with general anasarca, pulmonary
oedema, mitral and tricuspid murmurs, etc., and put
them down as cases of chronic valvular disease, when
in reality the valvular incompetence and the arrhyth-
mia and general dilatation are all secondary to a pri-
mary slowly developing change in the nutrition of the
heart walls themselves, long unrecognized because
there were no murmurs present. The first question
which I ask myself, therefore, in such cases is, hew
long this patient's heart has been weak in its stroke,
and not how long has he had valvular trouble of this'
kind or that, and the first question then to elicit from
the patient is, when did shortness of breath first at-
tract his attention on going upstairs or while walking
against a wind? Then should follow a careful exam-
ination of his arteries and of the skin, such as whether
the skin of the abdomen is chalky white and cannot
be reddened by friction or by drawing the finger-nail
upon it.
In the treatment of such cases of chronic heart dis-
ease I may mention the following points: First,
every organ of the body which has to do with nutrition
must be called upon to do its share to help the labor-
ing heart, and if any of them are out of order they
must be set to rights as a special part of the treatment
of the heart disease; for every influence or condition
which affects these injuriously constitutes by so much
a factor of the cardiac trouble. In other words, we
must not think only of the heart now. In this connec-
tion come, first, the effects of portal stasis. Gastric
and intestinal flatus alone, without and still more with
ascites, greatly embarrasses the heart, both mechani-
cally and through its nervous relations. This flatus is
due to fermentation in the alimentary canal, owing to
readily understood causes. Gr. x. of sodium benzoate
t.i.d. are helpful against this complication. Sodium
phosphate, 3 ii., dissolved in a tumblerful of quite hot
water and sipped slowly, shouldbe taken every morning.
A blue pill, once every four nights, with half an ounce of
the sodium phosphate the next morning, is a remedy I
would not like to do without in such cases, and I have
kept up this mercurial laxative for months together with
the most striking benefit. VVhen the kidneys are slvg-
gish, whether albuminuria be present or not, there is no
diuretic which will equal daily flushing of the bowtls
with three or four gallons of decinormal saline solu-
tion, at 110° F., by means of Kemp's rectal irrigator.
It is now that digitalis is of such inestimable service
in cases of dilatation subsequent to hypertrophy, with
mitral regurgitation, ascites, hydrothorax, etc., but no
clinical fact I think is better established than that in
these conditions mercurial laxatives are the most effec-
tive adjuvants to this drug. I prefer in a new case to
begin with full doses of a half ounce of the infusion of
444
MEDICAL RECORD.
[March 17, 1900
digitalis every three or four hours for the first two or
three days, and then substitute for it afterward thirty
drops of a mixture of equal parts of the tinctures of
digitalis, strophanthus, and nux vomica. Always with
each dose of digitalis nitroglycerin should be given to
obviate the arteriole constriction which digitalis causes,
and as soon as the digitalis beigns to disagree with
the stomach its administration should be promptly in-
termitted. When neither digitalis nor strophanthus is
well borne, a very good pill may be given instead, of
sparteine sulphate gr. i., powdered squills gr. ss., caf-
feine citrate gr. iss., and strychnine gr. ^\. In quite
a number of these cases, which at first sight might
seem to indicate clearly the administration of digitalis,
this drug fails altogether, or, after being apparently
useful for a while, it loses its effect and causes mucli
gastric disturbance instead. There can be little doubt
that in such instances the myocardial degeneration has
advanced too far for digitalis to be of any service, but
fortunately we are not by any means left without other
remedies.
The most important part of my subject, however, I
have left to the close of this paper, and it is this, that
the physician should not forget that all nervine medi-
cines such as digitalis, strophanthus, nitroglycerin,
strychnine, caffeine, sparteine, and the rest can never
be other than temporary makeshifts. All that they can
do is to relieve symptoms, and that only for a while.
They may be of great service in warding off immediate
dangers, and as adjuvants to the real remedies which
act upon nutrition; but if a progressive degenerative
process is going on, they are powerless to cure it. I
am sure that one of the chief reasons for ultimate fail-
ure in the treatment of many chronic heart diseases is
to be found in too great a reliance on such drugs. Per-
manent improvement is to come from other agents and
measures which restore nutrition rather than stimulate
function.
The first of these which I would mention is fresh air.
If we are to have sanatoria for treating tuberculosis by
fresh air supplied continuously night and day, I would
advocate a similar aim, still more demonstrably ap-
plicable, for the prevention and cure of chronic heart
failure. Throughout the whole animal kingdom mus-
cular power invariably is found to be directly in pro-
portion to tJie activity of the respiration, that is, to the
amount of oxygen consumed. If we could breathe
from every part of the body as insects do, instead of
by one localized breathing apparatus, the muscular
pow'er of a man might be like that of a flea, and, as
Huxley calculated, one man then could move Newgate
prison across the street. Every muscular function in
the human body is weakened by sedentary modes of
life, because in such life breathing is lessened. But
whereas surgeons deal chiefly with the skeletal or so-
called voluntary muscles, we physicians should remem-
ber that for us general muscular weakness means, to
begin with, weakened bronchial muscles; and there-
fore fresh air, or open air in summer, is one of the best
things for chronic bronchitis and emphysema. Muscu-
lar weakness also means gastric and intestinal atony;
witness how chronic constipation ceases after two
weeks' camping in the woods. Muscular weakness
means atony throughout all the pelvic viscera, and
weakened portal circulation. Woe to our gynecolo-
gists if our ladies should take to the modes of the Bed-
ouin or Tartar women, for their offices would be empty.
I have known an old gentleman, who had been spend-
ing three years of catheter life, empty his bladder nat-
urally after a month's open-air breathing at Palm
Beach, Fla. But last, and by no means least, general
muscular weakness means weakness in the whole cir-
cuit of the circulation from the heart to the remotest
arterial twig and back again, for here muscular func-
tion is everywhere the dominant element.
Let fresh air be systematically and continuously
provided to enter the lungs without effort on the part
of the patient with failing heart, and a great train of
serious symptoms will finally vanish, and that not tem-
porarily as too often with drugs. We have also for our
encouragement here the physiological fact that no one
of the higher tissues has such recuperative powers as
muscular tissue, as may be witnessed in the rapid re-
covery from the remarkable muscular wasting of ty-
phoid fever.
Among drugs, on this account alone, I never fail to
administer iron as soon as I can, and keep it up con-
tinuously in chronic heart disease, because the one
business of iron in our blood is to help us breathe.
There are other drugs, such as mercury, the iodides,
and arsenic, which are slow acting and constitutional,
and not functional in their effects, whose modes of
operation we do not know, but which I feel assured are
often of great service in chronic cardiac disease. The
bichloride of mercury, given in doses of gr. ^'^ three
times a day for a week, has been for long a favorite
remedy with me for chronic endarteritis. It may then
be left off for two weeks and afterward resumed as be-
fore. Among the iodides the sodium is much to be
preferred to the potassium salt, because potassium in
any combination is weakening to the heart. I have
prescribed it in doses of gr. v. three times a day for
weeks and months, and in many cases with such un-
doubted advantage that I rarely fail to administer it
sooner or later in chronic enlargement of the heart,
accompanied by arterial disease. Dr. Balfour in his
work on the senile heart praises a combination of the
liq. arsen. hydrochlor. with the liq. strych. hydro-
chlor., equal parts, as the only liquid preparation of
the two drugs which will make a clear solution. The
dose is from four to six drops. I have frequently used
it, and in some cases in old people with benefit.
Finally we have the completest contrast to the rec-
ommendations for absolute rest in bed and heart seda-
tives in acute carditis, in Oertel's mountain climbing
for heart disease, and in the various forms of resistant
muscular exercise, massage, and Schott's saline and
carbonic bath courses. These are all excellent in
principle and frequently in effects, but they may also
be fatal in cases not adapted to them. The salient
fact demonstrated by these measures, each in its sepa-
rate way, is that muscles ought to be made to breathe
as well as to contract, and that unused muscles fail in
nutrition because disuse lowers their consumption of
oxygen. The muscles use up more oxygen than all the
other tissues put together, and when by massage and
by passive exercise, and lastly by gradu.ited resistant
exercises, every accessible muscle is made to call for
more arterial blood, the whole muscular apparatus, in-
cluding that of the heart and blood-vessels, shares in a
reinvigoration which may long be beneficially felt in
an enfeebled heart wall. Meantime the cutaneous
stimulation of the carbonic and saline baths reopens
vast tracts of closed arterioles and by so much "lessens
the tired heart's work, for high arterial tension always
implies undue cardiac labor. In the appropriate cases
the benefit following upon these modern methods is
sometimes marvellous, but an irremediably diseased
aorta or arteries, permanently rigid throughout the
body, cannot safely be subjected to the strain of these
measures.
Pneumatocele. — A sonorous tumor formed above
the ear in a man, aged forty years, whenever he blew
his nose. Under pressure it would disappear with a
whistling noise. The patient, who has a discharge
from the ear on this side, hears better when the tumor
is distended with air. Treatment was by wide incision
and osteoplastic closure of the orifice. — Berger, Za
Mid. Mod., December 16, 1899.
March 17, igoo]
MEDICAL RECORD.
445
THE INOCULATION WOUND OF LUKS.
Bv CHARLES WARRENXE ALLEN, >LD.,
CONSULTING SURGEON (GENITO-U
The diagnosis of lues in its earliest stages is as im-
portant as it is often difficult. Perhaps too much
stress has been laid upon the typical Hunterian
chancre and a sore with classically indurated base as
necessary features of the initial lesion before a diag-
nosis can be ventured. It is my intention in this
brief communication to speak of some typical lesions
upon various portions of the body which have in my
experience marked the site of luetic infection. Con-
trary to the teachings of most writers I have insisted
upon the great desirability, if not an absolute ne-
cessity, of beginning treatment both local and con-
stitutional at the earliest possible moment, if it is ex-
pected to get the best results in this affection. It is
also of the utmost importance from the side of prophy-
laxis that the dangers be early appreciated by the
patient, so that necessary precautions may be taken to
limit its spread to others in accidental ways. To be
sure, a very large proportion of unusual sites for the
inoculation wound, and of wounds acting in unusual
ways, is found in patients who present themselves with
secondary evidences so well marked that the primary
manifestation is carefully sought for.
Such was the case in a young man seen by me for
the first time several weeks ago. A typical maculo-
papular eruption occupied the face, trunk, and penis,
forming erosive lesions about the moist glans penis
and prepuce. Upon the left side of the neck and
about the angle of the jaw was a pronounced and very
hard swelling made up of a mass of lymph nodes.
There had been no preceding lesion upon the virile
member nor within the oral cavity. The scalp and
post-auricular region on the left side were the seat of
a marked seborrhoeal eczema of long standing. The
appearances about the ear were peculiar and at once
attracted attention. The eczematous infiltration was
more marked than is usual; the color was duskier,
and a few outlying papules were rather coppery in
when it began to do badly, although the description
is not that of a typical chancre. A physician was
visited, who ordered an ointment.
When first seen at the clinic, the external ear was
deformed — chiefly from the surrounding infiltration;
the concha bulged forward and the lumen of the canal
was almost occluded. It was chiefly upon the color
and induration of the eczematous patch behind the
ear, and the enormously enlarged and indurated nodes,
..'V..,
hue. The skin of the whole region behind the ear
was firmer to the touch than one would expect from an
uncomplicated eczema. The history given was that
on November 3d last in an election fight his oppo-
nent had bitten through th; external ear. A simple
dressing had been applied without stitches, and the
wound appeared to do well for about three weeks,
that the diagnosis was made. Under inunctions of
blue ointment the whole picture has already changed
and the seborrhctal eczema as well is rapidly disap-
pearing.
In chancres about the face and head, as in the case
just related, swelling of the lymph nodes is almost in-
variably excessive, and is a point to be remembered
in differentiation from sycosis, ordinary wounds, cold
sores upon the lips, etc.
Infection due to bites is not unknown in literature,
and many extra-genital chancres undoubtedly have
this origin, in which no definite history of such injury
is acknowledged by the subject. I have in my notes
of cases three or four in which injury with the teeth
was acknowledged, and I have seen others in which I
strongly suspected it. Fist blows are sometimes as
dangerous as injury by the teeth. On November 22,
1886, M. P came to me with a chancre upon the
bridge of the nose which had followed an injury in-
flicted in this way by her husband two months before.
She had been to a "black-eye artist" and had the
ecchyraotic area painted. The possibility jf an in-
fection at the hands of the artist, perhaps through
moistening the brush in his mouth, could never be
excluded.
Slight injuries are not infrequently the starting-
point of infecting sores, and it is oftentimes an im-
possibility to discover whether the object inflicting
the wound has been itself infected, or whether the
solution of continuity has afi^orded the opportunity for
subsequent entrance of virus derived from an entirely
different source.
A gentleman came to me some years ago for an
opinion as to the nature of a round ulcerating sore
hidden by the mustache (Fig. i ). He stated that in
curling the ends of the mustache the barber had burned
the lip some weeks before. There was not much in-
duration at the base, and, while stating my strong suspi-
cions, I advised temporizing. Confirmatory signs soon
appeared. Here the possibility of an infecting kiss
after the injury has to be considered. I have many
times seen chancre of the lip which followed upon a
very clear history of fever sore, but there was likewise
often a clear history of suspicious kissing before the
herpes had healed.
446
MEDICAL RECORD.
[March 17, 1900
While I believe it to be among the great rarities of
practice that acquired lues should exist without an
initial lesion, I have seen the primary wound so in-
significant from start to finish, and the signs of in-
duration in an infecting ulcer so slight, that I can
readily believe that the point of inoculation often has
so little to show for itself that it escapes detection.
Twice recently I have observed upon the finger in
physicians papular indurations, which, though they
marked the point of entrance of the poison, never
reached more than a pea-size development. Then,
too, in women we must remember that by the time the
wound is looked for upon the cervix or vagina it has
perhaps healed.
Acquired lues without chancre may exist if we are
to understand by the term chancre an induration even
approximating that of typical lesions. As to the
location of accidentally acquired infecting wounds and
their relative frequency, I shall speak now simply
from my own experience, and I must premise with the
statement that I have recently been impressed with the
relatively large n'anber of accidental infections which
have fallen under my eye. In one hundred consecu-
tive histories of lues of all stages and varieties taken
from my private record book, a lesion upon which a
diagnosis could be made was either present, or there
was a clear history and scar evidence of extra-genital
infection, in fifteen instances. The lip was involved
eight times, the finger four times, the hand once, the
Fig. 3.
nasal septum once, and the cheek once. In twenty-
eight subsequent histories there were ten instances of
primary lesion occurring upon what are generally
considered unusual situations. In this series the lip
was implicated twice, the cheek twice, the finger three
times, the nipple once, the eyelid once (Fig. 3), and
the arm once.
Believing these figures to show a much larger per-
centage of accidental infection than holds true when
large series of cases are studied, I have turned to pub-
lic practice for a comparison. In a series of two
hundred consecutive cases of lues at the Good Samari-
tan I!)ispensary I find twenty records of extra-genital
chancre being present, or good evidence was shown of
such having been present. The lip was the site of
lesions seen by me personally in eight instances. In
one case there was a doulile chancre involving both
lips resulting from a bite. In two instances a man
and wife came together for treatment, both showing
typical indurations. Once the husband's sore was on
the right lower lip, while that of his wife was upon the
left upper one (Fig. 2). This case is almost identical
with one I published in 1885 in the March number of
\.h& Journal of Ciita?icflus and Venerea/ Diseases. At the
time I did not know that there was any connection
between the two patients, but after publishing the
paper I learned that the woman who had left her hus-
band and burned her lip with creosote had become
most intimate with my young male patient. Their lip
lesions were here also rights and lefts. The dangers
to other members of a family arising from lip lesions,
whether primary or secondary, has become pretty gen-
erally known, but is seldom brought home more forci-
bly than in two succeeding cases in this list: a young
woman, A. H , was treated for a chancre of the lip,
and despite instructions as to precautions necessary
the next extra-genital chancre seen was one of the
tonsil in her sister.
Next to the lip comes the cheek with four instances
to its credit, the nipple with two, and one each for the
nose, ear, chin, tonsil, rectum, and back.
Statistics must vary of necessity according to the
line of practice in which the lesions are seen. The
gynaicologist undoubtedly finds a large proportion
located on or about the cervix, while those observed
by the laryngologist would make tonsillar lesions
seem more frequent.
Reviewing then this series of cases we find in less
than four hundred consecutive records of lues there
were no less than forty-six non-genital inoculations.
This is probably a larger proportion than will be found
reported elsewhere, and, like all statistical data, is sub-
ject to error. I simply give the records for what they
are worth, not as proving anything, but rather once
more and in another way to direct attention to an un-
fortunate prevalence of non-licentious lues.
126 East Sixtieth Street.
CHORION EPITHELIUM AND DECIDUA IN
TUBAL GESTATION.'
I5v B. S. TALMEV, M.D.,
Physiologists are not as yet agreed on the question
regarding the origin of the chorionic epithelium,
although many observers have for years attempted its
definitive solution. Even the number of layers of the
villous epithelium is as yet a matter of controversy.
While most of the writers describe a double epithelial
layer, there are yet some opposing this opinion.
Moreover, the believers in a double layer attribute
the different layers to a different origin.
Turner found two layers in the epithelium of the
chorion, and considers the lower layer as the proper
chorionic epithelium, which atrophies at the end of
pregnancy; the upper, more persistent layer being of
maternal origin. He found that in the whole series
of placenta; there is interposed between the vascular
chorion of the fcetus and the maternal blood-vessels a
layer of cells, which is in close relation to the mater-
nal blood-vessels. They constitute, or are derived
from, the epithelium of the uterine mucous membrane
and belong to the maternal part of the placenta. Ka-
meneflf considers the lower layer as the proper chori-
onic epithelium, but believes it to be persistent, and
contrary to Turner he found the upper layer only at
some points of the villi, and only in immature pla-
centa. Langhans considers the upper layer as the
only proper epithelium, the lower being a formation
of the connective tissue of the membrana granulosa.
Kastschenko finds the epithelium of the chorion in the
human jilacenta to consist of two layers: the upper,
" protoplasmatic," forms the main mass surrounding
the chorion and villi like a continuous multinuclear
Plasmodium, the lower being derived from a prolifera-
tion of the single cells of the upper layer. Both layers
are accordingly of fcttal origin. Kupffer also finds a
double epithelial investment of the chorion, but he
does not believe that the villi stand in any relation to
the uterine glands. Minot believes also in tiie exist-
ence of two layers. In regard to their origin, he
agrees with Kastschenko that the external covering is
foetal ectoderm. Hofmeier, on the other hand, claims
' From Professor Ribbert's pathological laboratory, University
of Zurich, Switzerland.
March 17, 1900]
MEDICAL RECORD.
447
never to have found a double epithelial covering in
specimens of placenta; of later months, and declares the
contrary findings of others to be an optical delusion.
Keibel found a double epithelial lining of the villi, but
he could not see the pretended intrusion of the villi
into the crypts of the uterine glands. Klein found a
double epithelial covering of the villi even in the tubal
placenta:. They are intimately surrounded by the de-
cidua; otherwise there is little difference between the
uterine and the tubal decidua. According to Seleuka,
the villi of the chorion invade the uterine glands, and
in advancing further receive the flattened glandular
epithelium as a second layer for their investment.
Thus most of the authors describe a double layer of
the epithelium of the chorionic villi, and many of
them believe one layer to be a derivative of the ma-
ternal uterine glands. The disputed question could,
therefore, be answered by a comparison with the pla-
centa in tubal gestation, where the villi are embedded
in a glandless mucosa. Inasmuch as few authors only
have been fortunate enough to examine a tubal pla-
centa in situ, and especially a full-grown placenta as
in the following case, I thought this case not an unsuit-
able one to contribute somewhat to the solution of the
question at issue.
In January, 1899, Professor Ribbert, the director of
the Pathological Institute of the University of Zurich,
received a woman's internal genital tract, obtained by
laparotomy. The operation was performed for a full-
time tubal gestation. A living child was removed.
The macroscopical inspection of the preparation, har-
dened in alcohol, shows the uterus and right adnexa
to be quite normal. The left Fallopian tube, 4 cm.
away from the uterine opening, is dilated into a sac,
the length of which is 20 cm., the circumference 35
cm. The placental site covers almost the entire pos-
terior wall of the sac. The diameter of the placenta is
12 cm., the greatest thickness 5 cm., and the rest of the
placenta, as yet adherent to the tubal wall, 1-2 cm.
The thickness of the anterior wall of the sac is 2 mm.
Nearing the placental site the wall of the sac becomes
gradually thicker, ending in an elevation around a pit
in which the placenta is situated. The thickness of
this edge is 7 mm. The wall of the tube arching over
the placenta is greatly thinned out, being at some
points less than 0.5 mm. in thickness. The tubal
canal leading from the uterine cavity into the sac does
not admit a probe. Of the left ovary nothing is dis-
tinguishable.
Five months later Professor Ribbert delivered to me
this specimen for microscopical examination. I took
out small pieces from several points and cut them
partly in paraffin, partly in celloidin. The structure
of the anterior wall consists mostly of connective-tis-
sue fibres of the usual type. Of the muscular coat
only isolated fibres are seen scattered between the
connective-tissue fibres. Nowhere could I find a con-
tinuous muscular coat. There is cellular infiltration
of lymphocytes as well as leucocytes through the
whole tissue. Fibres of red blood cells are lying in
spaces between the connective-tissue fibres. These
spaces have no endothelial lining. The blood-vessels,
especially the veins, appear to be enlarged. All traces
of the tubal mucosa have disappeared. The entire ex-
ternal surface of the tube is covered with an exudate
consisting of fibrinous material, and fibrinous-looking
connective-tissue strands hang down from the wall.
At the placental site the wall of the tube is greatly
thinned, consisting at some points of the thickened
serosa only, which is surrounded by a thick layer of
fibrin. The serosa consists of a layer of thick con-
nective-tissue fibres. Here and there separated mus-
cular fibres can be seen. The next layer toward the
inner surface of the sac consists of more loose connec-
tive tissue containing less lymphocytes and red blood
cells. In this part isolated villi scattered between
delicate connective-tissue fibres can already be noticed.
Gradually the connective tissue disappears, and the
villi are seen in all directions close to each other and
separated only by fibrinous material, leucocytes, and
islets of red blood cells.
In the placenta proper the villi graft themselves on
a fibrinous layer, which does not contain any cellular
elements. The nuclei' have almost entirely disap-
peared. There is no recognizable intervillous sinus
system. The villi consist of a homogeneous-looking
fibrinous connective tissue. In some villi degenerated
nuclei or granules are embedded. The stroma of the
villus, staining a bright pink by hajmalaun and Van
Gieson, is surrounded by a ring of fibrinous material
of dark yellow color, which is distinctly differentiated
from the surrounding tissue. But even in this margin,
which I hold to represent the degenerated ectoderm of
the villus, cells and nuclei have entirely disappeared.
Nearer the tubal wall the villi impinge upon a fibrin-
ous stroma of an alveolar structure, which contains num-
bers of cells which are in no way different from the
common lymphocytes. Sometimes they resemble rather
the inflammatory elements in salpingitis. At some
points the nuclei have a narrow margin of protoplasm
and resemble the cellular elements of dysmenor-
rhoea membranacea. These enlarged connective-tis-
sue cells, which sometimes take an ovoid form, could,
superficially seen, be mistaken for decidual cells. But
on examining the preparations more closely we see
that they present different characters from the real
large vesicular decidual cells. They are different in
form as well as in size, and the typical stratification
of the true decidual cells is also missing here. The
fibrinous intervillous stroma has at some points a close
resemblance to young granulation tissue. At times it
resembles a fibrinous exudate, like that in diphtheritic
membranes. The cellular elements of the villi have
disappeared even in this richly cellular tissue. In
the stratum next the sac's cavity, the nuclei of the in-
tervillous substance are becoming more sparse, and
later on in the placenta proper disappear entirely.
Where normally the intervillous spaces are found,
slits filled with a partly homogeneous, bluish-red,
partly filamentous, scarcely staining mass are seen,
through which small, round degenerated cells without
nuclei, of the size of soaked red blood corpuscles, are
scattered. At the advanced stage of this pregnancy it
is entirely out of question that this mass could repre-
sent, as Gussener thinks of his case, a kind of uterine
milk for the nutrition of the embryo.
The structural modifications in our case afford us
four points of interest:
1. The hyperplasia of the Fallopian tube in tubal
gestation consists only of a proliferation of the con-
nective tissue and not of the hypertrophic muscular
coat. The muscular part, on the contrary, has almost
entirely disappeared by the direct destructive action
of the growing connective tissue.
2. The tube, at the placental site, is thinner than
normal, consisting only of thickened serosa and a layer
of fibrin without any muscular elements. The grow-
ing placenta had the same effect upon the lube as a
malignant growth.
3. Decidual cells are entirely absent in this full-
time tubal gestation.
4. The stroma of the chorionic villi, as well as their
covering, have entirely lost their cellular elements.
These histological modifications, I am inclined to
think, may serve to contribute to the solution of the
question about the origin of the chorionic epithelium,
and how far the maternal tissue contributes to the
formation of the placenta by furnishing decidual tis-
sue. Is the development of the fcetal part of the pla-
centa in the Fallopian tube the same as in the uterus?
448
MEDICAL RECORD.
[March 17, 1900
But before analyzing this question at length, I wish
to cast a rapid glance at the strange atrophy of the
tubal muscular coat in our case. In spite of the im-
mense thickness of the posterior wall of the sac, the
muscular coat has almost entirely disappeared. At the
placental site especially no circular fibres could be
found, and through the entire wall of the sac I failed
to see a continuous muscular layer. These findings
are at variance with the accounts given by other ob-
servers, who found hypertrophy of the muscularis.
Although Aschoff, who in a case of tubal gestation of
two to three weeks' duration found also an atrophy
of the tubal muscularis, remarks that most of the re-
ported cases of hypertrophy of the muscular elements
in tubal gestation have not been microscopically ex-
amined, yet even if the recorded hypertrophy really
belonged to the muscular layers and was not mistaken
for the proliferated connective tissue our observation
could easily be explained. The described histological-
ly e.xamined cases of tubal pregnancies concerned young
ova between three and twenty weeks. I searched in vain
through the whole current literature to find a micro-
scopically examined case of a full-time tubal pregnancy.
My interpretation would, therefore, be that at the out-
set, when the whole tubal wall begins to hypertrophy,
the muscular coat is also participating in this hyper-
trophy, but later on the proliferation of tlie connective
tissue predominates. This proliferation bursts first
the muscular fascicles and later on destroys them en-
tirely. Fueth, it is true, already found in a very young
ovum a cuneiform bundle of villi pushing forward
and in close attachment to the tubal wall, and sur-
rounded by cells similar to the elements of the cell-
columns derived from the tips of the villi. The bun-
dle was invading the muscular fascicles and dislodging
them. The ovum was splitting the tubal muscularis,
lifting off the submucous layer, and in its advance de-
stroying almost entirely the circular layer. Fueth also
mentions a preparation from the women's hospital of
the University of Kiel, in which the ovum was lodged
very near the open end of the fimbria. He emphasizes
the extraordinary shrinking of the tube at the site of
the ovum, contrasting with the greatly thickened neigh-
boring wall. At the site of the ovum the wall was
scarcely i mm. thick, and consisted only of peritoneum
and delicate connective-tissue fibres. Muret, in whose
case the ovum was also inserted at the open ostium
abdominale, noticed the wall at that point to be greatly
thinned; mucosa and muscularis had entirely disap-
peared, and the wall consisted only of peritoneum.
Prochownik describes, in an ovum situated near the
ampulla, intact chorionic villi with fresh budding
closely beneath the serosa. Excepting the serosa and
a very thin layer of connective tissue nothing of the
tubal wall was left. Leopold found in a case of tubal
gestation of eight weeks' duration, in which the ovum
was inserted at the abdominal end, the muscular coat
greatly diminished and at some points distorted and
displaced. Thus even in very young ova a loss of the
tubal muscular tissue was observed.
Now a few words will suffice about the strange phe-
nomenon of the chorionic villi having entirely lost
their cellular elements. According to Turner, the
lower layer, which he considers the only chorionic
epithelium, atrophies at the end of pregnancy, while
Kameneff considers the lower layer to be persistent,
and finds, on the contrary, the upper layer covering
only some points of the villi, and even this only in
immature placentae. Eckard noticed at the cell layer
of the villous epithelium a different development at
different times of the formation of the placenta. Very
early, certainly from the twelfth week, the cells can-
not be found everywhere. According to Langhans,
there is only at the tips of the villi a fast and durable
attachment between the cell layer and the maternal
tissue; at the other parts of the villus this layer be-
comes thinner and cannot be seen in the last three
months of pregnancy. Thus the opinion of most
of the authors is that one of the two layers of the
villous epithelium, even in uterine full-grown pla-
centas, is doomed to atrophy. We could, therefore,
assign the entire loss of both layers in our case of
tubal gestation to the unfavorable conditions under
which the placenta reached its full development.
But the question immediately presents itself, why
the nuclei in the stroma of the villi disappeared. In
about twenty full-time uterine placenta which I have
examined for comparison's sake, I always found deeply
stained nuclei in the villous stroma as well as in the
ectoderm. I would not try to give a definite answer
to this question. But the histological modifications
of the villous covering would allow the following in-
terpretation :
The cell — Dr. Langhans' layer — is, according to
the opinion of the discoverer himself, finally bound to
atrophy, and the villous covering consists then of the
"protoplasmic" layer or syncytium only. The syn-
cytium is declared, as above alluded to, by many ob-
servers to take its origin from the flattened and[changed
epithelium of the uterine glands. The mucosa of the
Fallopian tube, not containing any glands, could not,
therefore, furnish to the villi of the tubal placenta any
cell material for its syncytium. The villous covering
accordingly consisted from the very start of one layer
of Langhans' cell layer only. When this layer atro-
phies later on, the villi are entirely denuded of their
epithelial covering. The accounts given by those who
describe a double epithelial covering in early stages of
tubal gestation are surely difficult to reconcile with
my interpretation. But I have no doubt in assigning
a purely optical delusion to such findings, as Hofmeier
does to the assertion about the later stages of uterine
pregnancy.
The entire disappearance of decidual structure in
our case is in conformity with the observations of Vir-
chow, who claims the absence of a decidua in tubal
gestation. Lately Aschoff came to the conclusion, from
the cases he examined, that a real decidual develop-
ment"does not take place in tubal gestation, not even
at the placental site. Otherwise he finds no dift'erence
between the structure of the uterine and that of tubal
placenta. The cell proliferations of the fcetal epithe-
lium at the tips of the villi lead to the development of
columns of cells, which in coalescing form a large
sucking-plate. This plate invades the tubal wall, de-
stroys mercilessly mucosa and muscularis, and opens
the blood-vessels for the placental blood circulation.
Prochownik also emphasizes the slight development of
the decidua tubaria. Kossmann speaks also of a
spotty appearance only of decidua around the blood-
vessels in tubal gestation. Berry Hart says that in
extra-uterine placenta we begin to see the serious dam-
age caused to the placenta! structure by its development
in connective tissue. The villi are less perfect in con-
tour, blood extravasation is present, blood crystals are
in abundance, while the decidual cells are few and less
perfect. We may say, he continues, that the develop-
ment of the extra-uterine placenta is a destructive one,
reducing the placenta practically to compressed villi,
while the serotina is destroyed and replaced by blood
crystals and organizing blood clot. Giilland found
that the decidual cells become more and more degen-
erated and are replaced ultimately by a fibrinous layer,
which contains immense numbers of leucocytes, most
of which are also degenerated.
Contrary to these authors, others have seen a per-
fectly developed decidua. Orthmann found in eight
of liis ten cases of tubal pregnancies all stages of the
changes of the mucosa to decidua. Zedal finds cer-
tain cells in the tubal serotina having the same shape
March 17, 1900]
MEDICAL RECORD.
449
and quality as the well-known decidual cells in the
uterine mucosa. Yet he mostly observed a consider-
able proliferation of the intercellular substance. The
outline of the cells is often more or less blurred, and
finally the nuclei of the cells are destroyed in the more
changed parts. In place of decidual tissue a homo-
geneous-looking fibrinous mass could be seen, which
at some points has a striated appearance. He attrib
utes the degeneration of the decidua to mechanical
causes. In our case a full-time child was removed,
and the pressure in the tube was consequently immense.
The disappearance of the decidua could, therefore, be
attributed to mechanical causes. VValther finds a del-
icate connective-tissue stratum bordering the epithe-
lium, in which large connective-tissue cells are to be
seen in large aggregates. These piles of cells can
be traced even within the intermuscular connective
tissue, and here again near the perivascular tissue.
Thus the tubal wall is, in fact, filled with nests of de-
cidual cells as if invaded by the cells of a malignant
growth. In our case the tubal wall is also filled with
nests of cells, but they resemble in no way true decid-
ual cells. Webster, Goebel, and Mandel found a
partly developed decidua even in the other non-preg-
nant tube. In our case no traces are found even at
the placental site. This phenomenon cannot be easily
interpreted, but I incline to accept Aschoff's view and
that of the other writers, that in our case also a devel-
opment of a decidua never existed.
The fact that our fcetus reached its full development
would surely suggest the idea that this tube furnished
to the embryo a better lodgment by the development
of a true decidua. But, on the other hand, we find the
villi advanced to the tubal serosa. This phenomenon
refutes the last assumption; for if the proliferating
foetal cell-masses had found in the decidua a cushion,
rich with blood-vessels, to furnish enough blood to the
intervillous spaces for the nourishment of the embryo,
the villi would not have penetrated so far in search of
a highly vascularized tissue. They never do this in
uterine pregnancies except in deciduoma malignum.
The fact that the villi advanced here through the mu-
cosa and muscularis to reach the well-vascularized
serosa makes the view acceptable that no decidua was
ever developed here.
As to the possibility of tiie fa-tus reaching its full-
timed development, although the wall is gradually be-
coming thinner as the size of the fcetus increases,
there cannot be any other interpretation than that
the menacing rupture of the tube by the contractions
of the hypertrophied muscular fibres in the early
months of the pregnancy was prevented by the im-
mense proliferation of the peritoneum over the thinned
part. In the later months, when the muscles have
already atrophied, considerable contractions cease to
occur, and the danger of a rupture or a tubal abortion
is greatly diminished.
I would not try to give a definite answer to the ques-
tion why a decidual development had not occurred
here. According to Strahl, the uterine epithelium
changes into a syncytium, or simple protoplasmatic
mass with deeply staining nuclei. This layer is lo-
cated between the stroma of the uterus and the con-
nective-tissue groundwork of the chorion and villi. It
would, therefore, seem that in the tube the mucosa has
a different destination. Here, as Frommel, VVyder,
and Abel claim, the mucosa is doomed to atrophic
changes by the great pressure within the amniotic
sac. On the other hand, if the decidual cells origi-
nate, as Hennig and Abel claim, from the leucocytes,
immigrated from the blood, or, as Aschoff thinks, that
the decidua takes its origin from the proliferated foetal
epithelium at the tips of the villi, it is hard to explain
why a decidua should not develop in tubal gestation
as well. Langhans, Orthmann, and Dobbet claim
that the origin of the decidual cells is from the
spindle-shaped cells of the uterine mucosa. Now the
tubal mucosa, having normally only one function,
namely, to forward the ovum into the uterus, would not
have the faculty of furnishing a decidual proliferation
even under changed conditions. But if the decidua
was a product of the villous epithelium, nothing would
prevent its development in extra-uterine pregnancies
as well.
Anyhow, the main difficulty of embryonic histologi-
cal researches is and remains yet, as Marchand appro-
priately remarks, our defective knowledge of the gen-
etic meaning of the epithelial covering of the chorionic
villi.
BIBLIOGRAPHY.
Aschoff: Beitrage zur path. Anat.. vol. x.xv.
Fueth : Monatsschr. fiir Geb. u. Gyn.. vol. viii.
Goebel : Archiv fiir Gyn., vol. Iv., 1S9S.
Gulland . Reports from the Laboratory of the Royal College of
Physicians, Edinburgh, 1S02, vol. .\1.
Gussener : Centralblatt fiir allgeraeine Pathol, u. path. Anat.,
No. 6, i8t)i.
Hart: Edinb. Med. Journ., iSSg, No. 412.
Hofmeier : Die menschliche Placenta. Wiesbaden, 1890.
Kastschenko : Archiv fiir Anat. u. Entwickelungsgesch., 1S55.
Keibel : Archiv fiir Anat. u. Entwickelungsgesch., 1890.
Klein : Festschrift fiir Gyn. u. Geburtsh., vol. xx., 1890.
Kupffer : Miinchener klin. Wochensch., No. 31, 1888.
Langhans : Beitrage zur Anat. u. Embryologie. Festschrift
fiir Henle, 1S82.
Minot : Uterus and Embryo, Boston, iSBg.
Mandel : Monatschr. fiir Geb. u. Gyn., vol. v.
Orthmann : Festschrift fiir Geb. u. Gyn., vol. xx.
lYochownik : Archiv fiir Gyn., vol. xlix.
Seleuka : Biologisches Centralblatt, vol. x. , No. 24.
Turner: Journ. of Anat. and Physiol., vol. xi.. 1876.
Walther : Festschrift fiir Geb. u. Gyn. , vol. xxxiii.
Zedel : Festschrift fiir Geb. u. Gvn , vol. xxvi.
SOME REMARKS ON WHOOPING-COUGH
AS SEEN IN DISPENSARY PRACTICE.
By WALTER A. DUNCKEL, M.D.
SCHOOL OF
The cases forming a basis for these remarks were
taken from my service at the New York Dispensary
between November, 1894, and February, 1900. Ex-
cept those whose parents speak only Italian, all' chil-
dren up to the age of fifteen years are referred to on the
occasion of their first visit to this class.
Two hundred and sixty-one cases of whooping-cough
are recorded among 22,666 new cases of all diseases.
This probably does not accurately represent the rela-
tive frequency of the disease, as the diagnosis was en-
tered in the books only when the history was definite
or a paroxysm occurred during examination.
Aside from these there were other cases in appar-
ently incipient stages that had not declared them-
selves. It is almost needless to state that a paper of
this sort is necessarily lacking in scope. Many of the
patients did not return after a diagnosis was made,
for a dispensary clientele possesses unbounded faith
that the disease will hold its course regardless of an
array of drugs. A mild case is not likely to return
unless some complication arises, making the child
worse. Although provision is made for visiting all
patients with severe illness at their residences, some of
these passed from observation. An accurate estimate
of the duration of the disease, efficacy of treatment,
and mortality cannot therefore be obtained. It is
with these limitations in view that the paper is pre-
sented. Thus recorded, the relative frequency of
whooping-cough to that of other diseases is a fraction
over Ciie per cent. The percentages by years are as
follows :
450
MEDICAL RECORD.
[March 17, 1900
Twenty-nine per cent, during 1895 ; twenty per cent.
during 1896; thirteen per cent, during 1897; fifteen
per cent, during 1898; sixteen per cent, during 1899.
For the three months of November and December,
1894, and January, 1900, there were seven per cent,
of the cases. Fifty-five per cent, were seen in the
summer months and during September and January.
In point of frequency of sex sixty per cent, were
females and forty per cent, males. Sixt)^-seven per
cent, of cases occurred between the ages of six months
and five years. The percentages fell to one per cent,
for the eighth, and the same for the ninth year.
There were but two cases at three months and none
later than ten years. As the age was entered at the
first visit there is a slight source of error equivalent
to the length of time the disease had existed before
advice was sought. In about one-half of the cases in
which notes were made of the duration of the disease
before coming for treatment, the characteristic cough
had been observed from two to three weeks and was
then very pronounced. The eighth and twelfth weeks
furnished the next largest number of patients — periods
when severe complications or relapses are rife.
Complications — The number of cases in which
complications were noted at the time of the first visit
or subsequently is sixty-seven — or 25.6 per cent.
Sixty-one per cent, were females, .showing no in-
creased liability of sex. In speaking of complica-
tions it may be well to state that bronchitis has been
included in this category. While the lesion is so
common as to be a part of the disease in nearly every
instance, there were many cases without physical signs.
Only those are included in which signs were present.
The complications naturally arrange themselves in
two groups: (<?) Those dependent upon the violence
and strain of the paroxysm ; (/>) those due to lesions
associated with the disease.
Of the first group there were: Hemoptyses, 6; epis-
taxis, 2 ; subconjunctival hemorrhage of both eyes, 1 ;
umbilical hernia, 2 ; ulcer beneath the tongue, 2.
Of the second group there were : Mild bronchitis,
2; bronchitis of moderate severity, 25 ; severe general
bronchitis with involvement of the small bronchi, 8;
broncho-pneumonia, 19; tuberculous meningitis, i;
adenitis of the anterior cervical glands, i ; pericar-
ditis (plastic stage), i; malnutrition and wasting, 8.
Four of these cases terminated fatally — three with
broncho-pneumonia and one with meningitis. As some
had more than one complication, the total number of
cases under this heading does not equal the number
of complications. Aside from the sixty-seven cases
presenting complications, measles coexisted in two
and scarlatina in one. Forty-six per cent, of the com-
plications occurred during the months of January,
July, and August; 13.5 per cent, in January; 13.5 per
cent, in July; 19.5 per cent, in August. As only
thirty-two per cent, of the whole number of cases were
seen during these months, and the complications ex-
ceed them by so much as fourteen per cent., it seems
fair to assume, even from .so small a number of cases,
an increased liability to complicating disorders dur-
ing these months. Gastritis did not occur as a com-
plication, although vomiting with the paroxysms was
a frequent manifestation. Gastro-intestinal disturb-
ance existed in the wasted babies, but was not directly
assignable to the infectious disease. Diarrlict-a in
those not artificially fed or suffering from malnutri-
tion did not add a serious phase to the malady. It
was observed almost entirely during the hot season.
Wasting is used merely as a descriptive term and does
not refer to essential infantile atrophy. There were
eight of these cases — three of them under one year,
two between one and two years, and three at three,
four, and five years. Two of those under two years
were artificially fed, and one was insufficiently nour-
ished at the breast. The two at three and four years
had broncho-pneumonia, and the one at five developed
tuberculous meningitis. In looking over the statistics
to inquire if possible into the relation shown between
the frequency of the disease at stated ages and the
occurrence of complications, there seems to be an in-
creased liability to those of the graver sort in the very
young, but no increased liability to complications in
general. Thus fifty-eight per cent, of all the cases of
whooping-cough were observed between the ages of six
months and four years, while fifty-nine per cent, of the
complications— fourteen being cases of broncho-pneu-
monia— occurred during the same period. There is a
falling off between the third and fourth years as shown
by sixteen per cent, of the cases having only six per
cent, of the complications. Between the fourth and
fifth years the ratio is increased to fifteen per cent, of
the complications for ten per cent, of the cases. Only
one patient had con\ ulsions, and these were due to the
onset of a broncho-pneumonia. Cerebral hemorrhage
can be excluded, as the patient was under observation
for nearly three months. Broncho-pneumonia was a
late complication, occurring as a rule about the eighth
week, although one case was seen in the third week.
Relapses of whooping-cough were noted in five
cases (possibly recrudescences would be a better
term). These came for treatment after having gone
through the period of characteristic cough, followed
by a short period of immunity from it, and this in
turn succeeded by a revival of the whooping. Four
of the cases had persisted three months and one for
two months.
The two cases of ulcer at the junction of the frjenum
of the tongue with the mucous membrane on the floor
of the mouth were observed after the disease had ex-
isted for three months in one and seven weeks in
the other. One child was fourteen months and the
other two years old, and as they were seen for the first
time there was no saying when the ulcer first ap-
peared. The ulcers were about one-sixteenth of an
inch in diameter, superficial, grayish, not associated
with stomatitis, and not painful.
Loss of control of the sphincter ani during the par-
oxysm was not a troublesome affection except in one
child three years old.
The average duration of the disease cannot be
given with any exactness owing to insufficient data.
The longest case recorded was four and one-half
months and the shortest two weeks, the latter includ-
ing the paroxysmal stages only.
Before concluding, a few facts may be gathered
from three interesting cases accidentally left out of
the foregoing enumeration.
The first was that of a boy, eighteen months, breast-
fed, who came for the first time with an empyema of
the left pleural sac. Operation was done by incision
and gauze drainage, as the child was too weak for
more elaborate surgical measures. The paroxysmal
cough was frequent and severe, but seemed to favor
expansion of the lung. Recovery was rapid and com-
plete. Three years later he was strong and healthy,
and but for the scar there were no physic.il signs.
The second was a girl, breast-fed, extremely wasted
and having diarrha*a. The whooping persisted four
months, and in the later stages the chest was never
free from fine moist rales. Tuberculous involvement
seemed highly probable, but recovery was complete.
Two years later the child was well nourished, and a
physical examination gave a hyper-resonant note over
a chest that was deep and emphysematous in type.
There were no changes in the breath sounds, and the
heart was normal. The third case was that of a boy
who acquired whooping-cough at twenty months, which
ran its course in eighteen weeks. He was in good
flesh two years later, the chest emphysematous in
March i 7, 1900]
MEDICAL RECORD.
451
shape, the resonance somewhat high pitched, and the
breath sounds were normal. There was no abnormal
cardiac condition.
It is only surprising that emphysematous changes
are not more common. Tuberculosis would seem to
have an inviting field for operation in whooping-cough.
It is difficult to understand why it should not be of
more frequent occurrence. When it makes its appear-
ance it is far more likely to be late than early. With-
out wishing to advance on untenable ground, it may
be that the organism is somewhat protected against a
secure lodgment of the bacilli by the very violence and
frequency of the cougli. This is, to a certain degree,
borne out by the occurrence of broncho-pneumonia
after the spasmodic feature has become less promi-
nent. The fatality of these pulmonary complications,
even as shown in these inadequate records, is sugges-
tive of their tuberculous causation. The one case of
tuberculous meningitis occurred in the ninth week, and
was fatal in five days. That prognosis, when consoli-
dation appears, must not be invariably bad was clearly
shown in one case —that of a girl of three years with
well-marked emaciation, and broncho-pneumonia late
in the disease, who recovered. Two years later she
was well nourished and the physical signs were nor-
mal. Evidence that pulmonarj' tuberculosis is not a
common complication or sequela of whooping-cough
is also forthcoming from the fact that very few cases
of the disease are seen in the service. It is of inter-
est as well that in but one of the cases of meningitis
was whooping-cough a factor. Only one case of
adenitis was observed, and this was not sufficiently
characteristic to be considered tuberculous. There
were no cases with bone or joint lesions.
Atelectasis was never regarded as a positive condi-
tion. There were cases in which slight dulness and
changes in the breath sounds over small areas were
suggestive of this condition. If these signs were
transient some degree of assurance was felt in con-
sidering them to have been due to collapse or defec-
tive aeration.
A word or two here in a negative way at least as to
the relation between cardiac disease and whooping-
cough. The great strain of the paroxysm might prop-
erly be regarded as an etiological factor. Not one of
these cases, while under observation, had an endocar-
dial complication, nor was it possible to be satisfied
that there was cardiac enlargement. Moreover, there
have been no cases of cardiac disease on my records
in which the etiology was clearly related to whooping-
cough. The one case in which there was a pericardial
triction sound passed from observation.
It is obvious that careful records of urinary anal-
yses could not be made, and the presence of albumi-
nuria or nephritis as a complication definitely noted.
In so far as the external evidence of nephritis is
concerned, there was none to indicate any severe
forms of this disorder.
Speaking of treatment, belladonna, when indicated
by the severity of the paroxysms, was preferred above
other drugs on account of safety, tolerance, and expe-
diency. Given in increasing doses it occasionally
ameliorated the severity of the seizures. In addition
to this a supporting treatment of cod-liver oil and
malt preparations was prescribed. That the mothers
had faith in the latter was shown by the regularity of
their return for the "thick medicine." They cared
little for other medication. Antipyrin was prescribed
for several cases, in doses of gr. ii. combined with
potassium bromide gr. iv., but was discontinued, as
these moderate doses were ineffectual. The drug
being a depressant it did not seem safe to prescribe
it in large doses unless the patient could be kept un-
der the most careful supervision. While there are
instances when the disease is exceptionally severe,
and vigorous measures may be demanded, it does not
seem good therapy in the cases of average severity to
attempt to substitute a drug danger for the danger
lurking in the disease, unless the former can be proved
the less harmful measure. Bromoform has not been
prescribed during my service. My predecessor, Dr.
John H. Huddleston, made use of it in several cases,
and to him I am indebted for the following: "In some
an improvement in the severity of the paroxysms with-
out any change in their frequency was reported. Too
much reliance could not be placed in these statements,
and whatever improvement there might have been did
not compensate for the danger of unequal dosage when
given in a mixture. On this account its use was dis-
continued."
If anything is to be learned as to prognosis it should
be Ijprne in mind that as a rule the hygienic surround-
ings in which these children were reared were as poor
as can be found in the city. Even so the outlook was
not a grave one unless broncho-pneumonia set in.
The latter is a complication that can be very largely
avoided where better conditions prevail. Such crude
methods of treatment as could be adopted afford a
great deal of encouragement for the successful man-
agement of cases when every detail of diet and hygiene
can be carried out in a suitable climate.
SIX NEPHRECTOMIES.
By F. V. CANTWEl.L, M.D..
LATE SURGEON TO ST. FRANCIS HOSPITAL, TRENTON, N. J.
The group of symptoms which accompanied each of
the following cases was sufficient for me to make out
the condition found at the operation. In my limited
experience careful clinical study and frequent exami-
nations are sufficient to clear up the diagnosis in sur-
gical disease of the kidney, in the majority of cases,
without the use of instruments to explore the ureter or
pelvis of the kidney. I believe that in the hands of
men unaccustomed to their use, the latter will do more
harm than a clean incision down to the kidney for the
purpose of ascertaining its condition. If a disease of
the kidney exists which demands surgical interven-
tion and one is not sure of the character of the lesion,
he should cut down and see what it is and proceed
according to the finding. If one is in doubt as to the
presence or condition of the other kidney, he should
do as Edebohls advises — look at it. Then one who
has experience and common sense will know how to
proceed. A man whose sense of touch is at all culti-
vated can with a finger in the female bladder feel the
weak spurt of urine from the mouth of the ureter, and
so get some evidence that there is a kidney above.
I have seen but one case in an adult, and that on
the post-mortem table, in which but a single kidney
existed. This kidney was almost twice the size of a
normal one. I have examined the bodies of several
new-born or prematurely born babes in which no
other cause of death could be found than that one
kidney had become entirely cystic from some acci-
dent to or defect in the development of the ureter,
while the other kidney was normal. I believe that
sometimes such cases go on to adult life, and the cys-
tic kidney is entirely absorbed, while the good kidney
grows larger in order to keep up with its work. A
patient suffers little or no inconvenience from the
removal of a kidney that has been disabled for some
time, for the reason that the healthy kidney has been
in training. As the diseased kidney has slowly fallen
off in its capacity for work, the good kidney has taken
it up and has been undergoing a compensatory hyper-
452
MEDICAL RECORD.
[March 17, 1900
trophy; so that when the grand crisis of nephrectomy
comes, the healthy organ takes upon itself the entire
burden, and the patient is better off than he was before
the operation.
The incision I prefer is one that parallels the last
rib; and if the wound thus made binds the hand or
interferes with free manipulation, it should be enlarged
in whatever direction the surgeon sees fit.
My cases have been as follows:
Case I. — Man, aged thirty-five years, in previous
good health. While running across the mill-yard he
fell into a shallow ditch. He felt something give
way, and immediately there was a sense of fulness in
the bladder with a desire to urinate. He was taken
home, and four hours afterward was examined by Dr.
E. H. Rogers, who found great tenderness over the
right kidney and a marked fulness over the bladder.
The urine was passed frequently and in small quanti-
ties, deeply stained with blood. He was kept quiet;
ice-bags were applied to the back, and ergot, gallic
acid, etc., administered. This was kept up for three
weeks. The patient grew steadily worse, and no
symptom was relieved. When I saw him the man was
in a state of collapse from bleeding. I advised an
exploratory incision and nephrectomy if necessary.
The incision was made parallel to the spinal muscles
and the kidney brought out. No break in the kidney
capsule was found, but the organ had a bluish, bruised
look, with some distention of its pelvis. As I was
confident that this was the source of bleeding, I re-
moved it. In addition to a looped ligature I put a
large catch forceps on the stump to insure against
bleeding. I would not do this again, as it made the
patient very uncomfortable. This man died after
twenty-four hours. Upon slitting open the kidney I
found a tear in the substance of the organ, from which
came the loss of blood. Its pelvis was filled with
old grumous-looking clots as well as fresh blood. A
post-mortem examination showed the left kidney to
be normal. The bladder was over-distended with
blood clots, which I would have removed if the man
had lived. This man died of a stillicidium of blood
from the torn kidney. The bladder no doubt filled
with blood at the time of the accident, and the back
pressure must have been great enough to stop any
large flow, and so allow^ed the man to die by inches.
His symptoms were by no means severe enough at first
to suggest even an exploration of the kidney. The
absence of any tumor, due to the peculiar character
of the injury — a wound of the kidney without any
break in the capsule — was evidence against any seri-
ous lesion. There was nothing to do but wait during
the first week after the accident. The lesson taught
by this case is, that when a man after an injury of
this kind continues to pass bloody urine for four or
five days, and there is other evidence that he is still
losing blood, an incision should be made at once and
the bleeding controlled.
Case II. — Man, farmer, aged thirty-four years. He
was sent to St. Francis' Hospital, Trenton, N. J., by
Dr. Van Neste, of Hopewell, N. J. He had for sev-
eral years suffered from the passing of stones from the
kidney, with all the classical symptoms. During the
previous six months he had been passing quantities
of blood with his urine. This loss had reduced him
to a thin, waxen, listless wreck, completely bedridden.
He was dying because he was losing more blood than
he could make.
Ten weeks before I saw him, a surgeon had opened
his bladder above the pubes in a vain search for the
source of bleeding, and a fistula still remained. His
pain was always referred to the right kidney, and
there was a great deal of tenderness in that region.
The kidney could not be felt. I advised exploration.
An incision alongside the last rib gave easy access to
a kidney that externally looked normal. Palpation
disclosed a very suspicious lump in the parenchyma
of the organ. Under the circumstances I thought re-
moval the best course — this was in 1894. On cutting
into this lump, a sac, an inch and a half in diameter,
was opened. This was packed with hundreds of
stones, each the size of a millet seed. The wound
was closed without drainage, and the man made a
quick and perfect recovery. He is still well and at-
tending to business. I have sometimes felt a twinge
in my surgical conscience for the removal of this kid-
ney, but have come to the conclusion that it was the
proper thing to do. I might have cut into the sac
and removed the stones, but this would involve danger
from several causes: First, the danger of not remov-
ing all the stones; they were very small, and a few
might easily have been left; second, of not removing
the cause of bleeding, which was fast killing the man;
third, of leaving a fistula; fourth, of an abscess of the
kidney. The man would not have lived for a second-
ary nephrectomy. Above all, " Finis coioiiat opus : " the
man has been well since the operation.
Case III. — Woman, aged twenty-eight years. She
had been sick for a year or more, complaining of great
pain in the region of the left kidney and below. Her
body showed that she was a big-boned and had been
a muscular woman. She was then very thin, pale, and
bedridden. The urine was loaded with pus. No bac-
teriological examination was made. A large fluctuat-
ing tumor was found in the left flank and back, extend-
ing to the iliac crest. A diagnosis of perinephric
abscess due to rupture of a kidney abscess was reached
and operation was advised. Owing to the fluctuating
mass a longitudinal incision was first made. This
gave vent to about a quart of thin, ichorous pus. The
kidney was bound firmly down by old adhesions,' and
as the first incision did not allow of ready access a
second one was made along the border of the last rib.
This made removal of the organ much easier. A great
deal of force was used to break up the adhesions, but
the kidney was finally brought out. It was found to
be tuberculous, enlarged, and nodulated. An incision
was made into a nodule, and cheesy pus found. The
ureter was isolated and tied off separately, and the
kidney remoxed. The wound and pus sac were irri-
gated and packed with gauze, and the wound was
loosely sutured. For a few days only the urine was
blood-stained and contained some pus. This cleared
up very quickly. She recovered well from the opera-
tion, but a discharging sinus remained. In the course
of about two months this discharge grew so copious
that it began to tf 11 on the health of the woman. She
was again etherized and about three inches of the ure-
ter was excised. The sac and sinus were well scraped,
and the wound was packed and left open. After three
weeks this had entirely closed and she left the hospi-
tal in good health. She is now working hard as a
domestic, and does not miss her kidney.
Case IV. — Man, aged twenty-five years; a strong,
sturdy Italian. About an hour and a half before he
came to St. Francis' Hospital, he had fallen a distance
of three feet on to the end of a railroad tie. He
struck on his back in the region of the right kidney.
He was brought to the hospital in a carriage, but
walked upstairs to the ward alone. He was put to
bed, and in a few minutes the resident physician no-
ticed that he grew pale, restless, yawning, thirsty, and
had a rapid, small pulse, as if a sudden severe liemor-
rhage had occurred. I happened to be in the iiospital
at the time, and was called. I found a vague, ill-
defined, compressible tumor in the right lumbar re-
gion, with great tenderness. His urine was drawn
and found to be bloody. A diagnosis of ruptured
kidney was made. The man was quickly prepared and
sent to the operating-room. An incision along the
March i 7, 1900]
MEDICAL RECORD.
453
last rib was made. Before the kidney was reached at
least a quart of loose blood clot was turned out.
Loose lying in this mass was the lower end of the kid-
ney stripped of its capsule. The remainder of the
kidney was brought out as rapidly as possible; it was
still attached to its blood-vessels, and bleeding. The
pedicle was tied with a looped ligature including
everything, and the kidney was removed. The cavity
made by removal of the kidney and blood clot was
dried and the wound closed, leaving a small piece of
gauze for drainage. The kidney looked as if there
had been an explosion from the inside, it was so torn.
Besides the piece that was completely separated there
were two large rents from which blood had been pour-
ing. Embedded in the cortex immediately beneath the
capsule was a stone about the size of a small cherry.
This man made an uninterrupted recovery, and when
I last heard of him was working hard in a grocery
store.
Case V. — Child, male, aged two years. He was
brought to my office, supposed to be suffering from
worms. The child was of normal size and appeared
to be well nourished, with no cachexia. A tumor
could be felt on the right side, extending from the
lower border of the ribs to the anterior superior spi-
nous process of the ilium. It was freely movable and
not at all sensitive. The child suffered no pain, and
was brought to me because the parents had noticed a
slight failing. The urine contained no blood but a
quantity of albumin. A diagnosis of sarcoma of the
kidney was reached, and nephrectomy advised. The
operation was done August 10, 1898. An incision
was made one-half inch from the lower border of the
last rib, commencing at the lumbar muscles. This
incision had to be carried almost to the umbilicus
before the tumor could be delivered. Of course the
peritoneal cavity had to be entered, and the kidney
was found to be as distinctly an intraperitoneal organ
as is the ovary. Its pedicle was formed of a meso-
nephron surrounding ureter, artery, etc. There were
a few adhesions, which were easily broken down.
There were no glands noticeably involved. The ped-
icle was secured by a crossed ligature including
everything, and the kidney was removed by a few
snips of the scissors. There was practically no bleed-
ing. The peritoneum, muscles, and skin were closed
in layers. A strip of gauze was left behind the peri-
toneum for drainage. This was a mistake, as it left
a small sinus difficult to heal. The albumin dis-
appeared from the urine, and the child left the hospi-
tal in three weeks after an uninterrupted recovery from
the operation. The tumor weighed little short of three
pounds, and was a sarcoma which had destroyed al-
most all the kidney. When I left Trenton in Decem-
ber, 1898, the child was well to all external appear-
ances and felt well. I have since heard that in March,
1899, it died either of an abscess caused by the pedi-
cle ligature or of a return of the growth; very likely
the latter. In spite of this I would adv.ise removal
of sarcoma of the kidney, no matter at what age it
occurred.
Case VI. — Man, aged thirty-one years. This man
came to me first in 1887. He had suffered pain dur-
ing urination " since he was born." He had often to
stand on his neck and shoulders with his feet and
pelvis elevated before he could pass water. I found
a large stone in his bladder, which I removed by lat-
eral lithotomy in October, 1887. The stone was ham-
shaped. This relief made a new man of him, and for
eight years he worked comfortably at his trade of dish-
making. He then began to have attacks of heavy
pain in the region of the right kidney. These attacks
sometimes lasted for days. They would always com-
mence while he was on his back in bed. During
these times it was impossible for him to have a stool.
owing to the severe lumbar pain it gave him to strain.
This pain no doubt was caused by the dense adhe-
sions found during the operation. He often brought
me a sand that he passed with stool. This was uric
acid. His urine always contained pus, and after an
attack of pain he would pass clear pus. The kidney
could be felt at times, and there was a small spot of
extreme tenderness at its lower border. This condi-
tion continued until life once more became unbear-
able to him. I sent him to St. Francis' Hospital for
a week, during which time a careful study of his
symptoms was made and a diagnosis of pus kidney
reached. A nephrectomy was advised and consented
to. An incision was made parallel to the last rib,
and, as the occasion demanded, extended down two
inches at a right angle from its outer end. The kidney
w-as reached easily, but a great deal of care had to be
taken in enucleating it on account of dense adhesions
at its lower border. Several of these had to be tied
and cut. During these manipulations the intestine
could be seen beneath the thin peritoneum. The ure-
ter was isolated ; the vessels were tied with a single
ligature after being stripped of all superfluous tissue,
and the kidney was removed. A quantity of pus
oozed up from the cut ureter, but a probe passed
through it into the bladder disclosed no obstruction.
It was then fastened to the lower angle of the wound
with the idea of flushing it out through the bladder and
urethra during convalescence. The lumbar muscles,
which were cut partly across, were united, and the
cavity of the wound was wiped dry. The wound was
then loosely closed and a small piece of gauze left in
for drainage. The kidney removed was a fan-shaped
collection of abscesses emptying into the pelvis, a
typical surgical kidney. He recovered well from the
operation, but at last account the open mouth of the
ureter was still leaking pus. The chances are that a
ureterectomy will have to be done before he is well.
This condition occurred after the lateral lithotomy,
but not as a consequence of it. I am inclined to be-
lieve that a concurrent specific urethritis was the cause
of the pyonephrosis. After the bladder stone was
removed he gained in health and strength for several
years before he had symptoms of any trouble with his
kidney. I could never fathom the significance of the
intestinal " sand " found in this case. I have seen
the same " sand " in a case in which adhesions had
formed between the gall bladder and adjacent intes-
tines.
A Case of Cerebro-Spinal Meningitis due to the
Coli Bacillus. — Orazio d'AUocco reports a case in
which the spinal fluid removed by Quincke's method
was found to contain the coli bacillus. — La R if or ma
Medica, February 14, 1900.
The Night Air of New England in the Treatment
of Consumption. — C. S. Millet reports on several
cases of tuberculosis treated by sleeping in the open
air. The patient takes his own temperature at 9 a.m.,
I, 4, and 8 p.m. The rule is, rest in bed during the
day long enough to keep the temperature below 99.5°
F., or better 99°. The patient keeps a record of the
hours spent in the house, and must give a good reason
for this time. He is to eat all he can at the three
ordinary meals, avoiding pastry and confectionery. A
cold sponge bath in the morning and another bath at
about 90° F. at bed-time are advised. The nose and
throat are carefully looked after and any necessary
treatment is given. The patient sleeps in the open air,
the one caution being to keep warm. During the
cooler months some woollen nightgowns and sheets
should be used. Almost the only medicines taken are
nux vomica and an occasional laxative. — Maryland
Medical Journal, January, 1900.
454
MEDICAL RECORD.
[March 17, 1900
Medical Record:
A Weekly Jouriial of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 51 Fifth Avenue.
New York, March 17, 1900.
CARE OF THE INSANE.
The measures taken for the care of the pauper insane
in New York State, although far more humane and ra-
tional since the enactment of the " State Care Act " of
1889, are nevertheless susceptible of still greater im-
provement. In accordance with the provisions of the
above-mentioned act, the care of the dependent insane
devolves upon the State of New York, and in order to
simplify arrangements tending to reach this end in the
most satisfactory manner possible, the State was di-
vided into eleven districts, in each of which was
placed a State hospital for the reception of patients.
The object of this plan is both obvious and excellent,
viz., that the inmates may be easily kept in touch with
their friends, who are naturally desirous to receive
from time to time information as to their condition.
With the exception of a somewhat serious drawback
this arrangement is said to work admirably. No
fault can be found with the care and treatment of the
patients when located in the hospitals.
The weak spot in the system is pointed out in the
Albany Medical Annals for December, 1899, which de-
scribes the situation thus: "No statutory requirement
exists as to the management of the patient during the
process of commitment, and pending transfer to the
hospital. In some counties, notably New York, Kings,
and Erie, the local authorities have provided so-called
' detention ' or ' reception ' buildings or wards in con-
nection with existing general hospitals, where the pa-
tient's claims as an invalid receive full consideration.
Throughout the rest of the State the insane patient is
cared for by friends as best they can, or placed in a
jail or some convenient receptacle. The hardship of
this is at once apparent, and in the more active cases
where exhaustion is rapid, consignment to a jail or
other ' lock-up ' results not only to the detriment of the
patient's recovery, but even of his life."
All this is very true, and attention is further drawn
to the fact that in those general hospitals in which
such reception wards have been established the results
have been highly instructive. This has been espe-
cially the case at Bellevue Hospital in New York
City, where in many instances patients have received
so much benefit that they have been discharged as
practically cured. The authorities of Albany Hospi-
tal, fully recognizing the desirability of introducing
reception wards for the insane in general hospitals
throughout the State, resolved if possible to cause to
be erected a pavilion for the insane in connection
with their own institution. The matter was placed
before the board of supervisors of Albany County, and
in the February number of the Annals the announcement
was made that the board had declared its willingness
to meet the wishes of the projectors of the movement.
An appropriation of $i8,ooo has been set aside for the
erection of the pavilion, and plans are now under con-
sideration.
There are undoubtedly many mild cases of insanity
for which the treatment provided in the State institu-
tions is unnecessary. A clearer discrimination is
needed between acute and chronic cases. If reception
wards were established for the insane in general hos-
pitals it would be a comparatively easy matter to de-
termine quickly which patients required a lengthy
course of treatment, and the fact of thus being enabled
to distinguish between the different degrees of mad-
ness, and to treat accordingly, would be at once an act
of humanity, and doubtless in the long run a saving to
the general public. The partial irresponsibility of
those given over to the alcohol or drug habit is now
generally allowed, and the necessity of prompt emer-
gency treatment for this unfortunate class cannot be
ignored. Drug or alcohol habitues refuse to enter a
hospital for the insane, but the majority of them
would gladly avail themselves of the opportunity
afforded of temporary treatment and care in a special
ward of a general hospital. On the whole, therefore,
the public-spirited plan about to be inaugurated at Al-
bany Hospital will commend itself as one worthy of
imitation by similar institutions not only in New York
State but in all parts of the civilized world.
MEDICAL EDUCATION IN THE UNITED
STATES.
So far as the number of schools of medicine is con-
cerned, the United States will compare favorably with
any country in the world. Excluding graduate schools
there are, according to a monograph on professional
education written by Mr. James Russell Parsons, Jr.,
156 schools of medicine, 5,735 instructors, and 24,119
students. A foreigner reading this statement, and
unacquainted with the facts of the case, would come
to the conclusion that medical education in this coun-
try was in a particularly healthy condition. If, how-
ever, he were of a curious disposition, and were to
dive more deeply into the matter, his opinions would
assuredly undergo a radical change. In saying this
there is no intention to disparage the efforts made in
the country generally to improve the standard of
medical education, or even to assert that these efforts
have not been attended with a fair measure of success.
The defect in the present system is the apparently
needless multiplication of standards, and until effect
five means have been introduced to bring about some
sort of uniformity in the standards, medical education
will stand on no solid foundation. Mr. Parsons is of
the opinion that a uniform standard for admission to
March 17, 1900]
MEDICAL RECORD.
455
practice throughout the United States is impracticable
at present, owing to varying conditions as to density
of population, educational advantages, and general
development, and recommends that, instead of the
adoption of a separate standard for almost each politi-
cal division, two, or at most three, standards should
answer for all.
The existing easy-going methods of granting degrees
in medicine prevailing in many States has the effect
of flooding the market with medical men, with corre-
spondingly disastrous competitive results. For ex-
ample, quoting again from Mr. Parsons' monograph,
the ratio of physicians to population is one to less
than six hundred in the United States, while in foreign
countries it varies from one to about eleven hundred
in the British Isles to one to about eighty-five hundred
in Russia. We are said to have in proportion to our
population four times as many physicians as France,
five times as many as Germany, and six times as
many as Italy. There are more medical schools in the
United States alone than in countries whose total
population is six times as great, and yet few of these
medical schools in the United States have endowments
corresponding to those so lavishly made to other edu-
cational institutions or in any way proportioned to
their needs. Fortunately a change would now seem
to be indicated in the attitude of philanthropists
toward medical schools. In New York the advanced
requirements for license have been accompanied by
extraordinary growth in the property of medical
schools, especially in Greater New York. Indeed,
without wishing to exalt unduly the accomplishments
of the regents of the University of the State of New
York, the fact must be recorded that owing to the fore-
sight of this body professional education in New York
State now stands on a higher plane than in any other
State in the Union, and emphasizes the need of simi-
lar councils of education in the other political di-
visions.
FLEAS OF R.\TS AND MICE AS CONVEY-
ERS OF PLAGUE INFECTION TO MAN.
While evidence is rapidly accumulating to show that
rats are the chief factors in the importation of plague
into a country, opinions are at variance as to the dan-
ger to be apprehended to man from the fieas of rats and
mice. Much has been written in support of the theory
that it is possible for a human being to become in-
fected by the plague germ through the agency of fleas
which may have infested these vermin, but no satis-
factory proofs on this point have been as yet produced.
The fact has been demonstrated that fleas taken from
a plague-stricken rat are capable of inoculating healthy
rats or mice with the plague bacilli, but it must be
borne in mind that there is a distinct difference be-
tween the flea of a man and that met with on rats and
mice. Dr. Bruno Galli-Valerio, of Lausanne, in an
article first published in the Centmlblatt fiir Bakterio-
logie, etc., and reproduced in the " Public Health Re-
ports " of the United States Marine-Hospital service
of February 16, 1900, distinguishes these fleas as fol-
lows: ''The flea of man (Pulex irritans) has an ovoid
body, reddish-brown in color, and is without a comb
upon the head or prothorax. The flea which most
commonly infests rats (Typhlopsylla musculi) has a
Ihin body, is yellowish in color, with spines upon each
side of the inferior border of the head, and a comb
upon the prothorax. Upon the mouse and marmot we
also find the Pulex pasciatus, but it presents upon the
prothorax a comb of eighteen points and has only been
found, as I remember, in Holland and in Halle, and I
myself have found it once in Milan." Therefore Dr.
Galli-Valerio does not consider it as proven that the
fleas of rats and mice may transmit the plague to man.
PURE FOOD LEGISLATION.
At the present moment there are two bills before
Congress whose aim is to prevent the adulteration of
food products. The first of these is H. R. 4,618, in-
troduced December 18, 1899, by Mr. Babcock, and the
second is H. R. 6,246, introduced January 15, 1900,
by Mr. Brosius.
Mr. Babcock's bill provides for the appointment of
a food commissioner within the Department- of Agri-
culture. The food commissioner shall, with the ap-
proval of the Secretary of Agriculture, appoint a chief
chemist, who on his own responsibility shall appoint
such chemists and other employees as shall be needed.
The food commissioner shall make the requisite rules
and regulations for the proper conduct of his bureau.
The bill further defines the term " food," and indi-
cates in a general way what shall be considered as
adulterations. Section 8 provides "That the food
commissioner may call upon the Association of Offi-
cial Agricultural Chemists to determine the standard
of any food products within the meaning of this act,
and when so determined, such shall remain the stand-
ard before all courts." This is a curious provision,
throwing much responsibility on a body which, though
called "official," is simply a private association of
persons holding official positions in different States. It
apparently gives this body the power to determine the
wholesomeness or otherwise of certain food products,
a function that in no proper sense is within the prov-
ince of a chemist. The clinical physician alone is
competent to judge of matters of this kind, and it is
to be regretted that chemists so often overstep the
proper confines of their science and presume to offer
opinions on subjects beyond their proper scope. We
cannot too strongly commend to their attention the old
saying: " Ne sutor supra crepidam." Section 11 per-
mits manufacturers, etc., of "compound mixed or
imitation foods " to " certify, under oath," that they
are " not deleterious or injurious to health," and on
further payment of §10 permits the same to be regis-
tered by the Secretary of Agriculture. This is cer-
tainly an extraordinary provision. The other sections
of the act relate to regulations necessary to its proper
administration, and appear to us to be wise and judi-
cious. The last. section of the bill provides that the
expenditures necessary to the carrying out of the act
shall not exceed $100,000 in any one year.
456
MEDICAL RECORD.
[March 17, 1900
We believe that the passage of this act with the
omission of Sections 8 and 11 will be the beginning
of a movement that in time will secure to the Ameri-
can public a reasonable guarantee as to the quality of
the foods they consume. It must be remembered that
Congress has power to legislate only in connection
with interstate and foreign commerce, and that the
various State governments must enact supplementary
measures before the people will be properly safe-
guarded. We will consider the second or "Brosius"
bill later.
THE STATUS OF THE ACTING ASSISTANT
SURGEONS OF THE UNITED STATES
ARMY.
The civil surgeons whose aid it was found necessary
to enlist during our war with Spain would appear to
be extremely dissatisfied with the manner in which
they have been treated, and are, moreover, bent upon
ventilating their wrongs, with the view of having re-
moved the disabilities from which this somewhat anom-
alous class of army doctors suffer. A mass-meeting
of acting assistant surgeons was held at the armory of
the Seventh Regiment in New York on December's,
1899, at which one hundred and fifty of these gentle-
men were represented in person, by proxy, or by letter.
At this meeting a permanent organization was formed
and a constitution and by-laws were adopted. The
constitution reads as follows: "The object of the
association shall be to maintain the patriotic and
professional esprit de corps and camaraderie of the men
who during the war between the United States and
Spain held the position of acting assistant surgeon in
the United States army, and to secure their rights and
to protect their interests of every kind, especially
those requiring legislation by the Congress of the
United States?'
The grievances under which the acting assistant
surgeon now labors, in the opinion of the members of
the organization, are that although an acting assistant
surgeon is expected to fulfil in every respect the
duties incumbent on the regular army surgeon, yet he
is debarred from sharing in the privileges and emolu-
ments accorded to the latter. He does not rank as an
officer. When an acting assistant surgeon is wounded
or killed in action or stricken down by disease while
on duty, no provision is made for his care or support
in tlie event of such occurrences. If sick while on
duty, his pay is immediately stopped, and no provision
is made for feeding him, for sheltering him, for giving
him medical attention, or for bestowing on his dead
body any of the care accorded to the military dead;
and lastly, an acting assistant surgeon is not eligible
to receive a medal for "conspicuous bravery in the
field."
It is also statec' that there is a lamentable lack of
harmonious feeling between the regular army surgeon
and the contract surgeon. The lines therefore of the
civil surgeon who volunteers his services in the time
of war do not seem to be cast in pleasant places, and
the inducements offered are not sufficiently attractive
to render his position one to be ardently desired. The
old contract system might be with advantage, if not
entirely abolished, at Ifeast considerably modified. It
would appear but reasonable that during the time that
an acting assistant surgeon serves in the army, per-
forming to the best of his ability all the duties re-
quired of a regular army surgeon, he should be entitled
as far as is possible to the same privileges and emolu-
ments. If perchance this country should be suddenly
plunged into a large vi-ar, the services of civil surgeons
would necessarily be again requisitioned. Would it
not be better policy to place the status of these men
on a satisfactory footing than to continue an out-of-
date and unpopular system?
Crowded Professions in Cuba. — The Cuban cabi-
net has decided to adopt the recommendations of
Senor Barreiro, secretary of public instruction, for the
reorganization of the School of Engineers, in order
that young men may be able to adopt some other pro-
fession than law and medicine, both of which are over-
crowded. The Spaniards founded an engineering
school, out when they found that the graduates were
competing with Spanish engineers the school was
neglected to such an extent that it became valueless.
It will now be raised to a high standard of efficiency.
A French Institute for the Study of Tubercu-
losis.— The Societe Lyonnaise des Tuberculeux Indi-
gents has undertaken to build an institute for the
study of phthisio-therapy, which it proposes to make an
annex of the free sanatorium which it is about to open
at Hauteville. It is now suggested that the under-
taking be made a national one, and with .this end in
view a bill has been introduced into the French Senate
making an annual grant of 15,000 francs to further
the work of tlie institute.
The Anglo-American Nursing-Home in Rome
Efforts have been making for some time to establish
in Rome a nursing-home, in which persons of British
or American nationality who have the misfortune to fall
ill in the Eternal City can be received. The scheme
met with opposition in certain quarters, but The
British Medicaljournal announces that all difficulties
have now been successfully overcome. A villino
excellently adapted for the purpose was found in the
Via Nomentana, a little way outside the Porta Pia.
The building is charmingly situated, standing well
back from the road, in about half an acre of ground.
Round about it are pretty villas, each isolated in its
own ample garden, and there is no fear of the sur-
rounding open spaces being built over. The house
has twenty-seven rooms, and can conveniently accom-
modate six or eight patients, who have the use of sev-
eral comfortable day-rooms. The walls and ceilings
are artistically painted, and all the rooms have a
cheerful outlook. On the roof is a terrace command-
ing an extensive view of the Campagna, with the whole
ransre of the Alban and Sabine hills in the distance.
March 17, 1900]
MEDICAL RECORD.
457
Ordinary patients pay an inclusive charge of twenty
francs a day, but two beds are set apart for patients
who cannot afford more than half the usual rate, and
two are entirely free. The home, which was opened
in the early part of January, is at present pai in-
dependent on subscriptions, but it is hoped that it will
soon be self-supporting. Miss Gibbons, who was
formerly matron of the Tewkesbury Cottage Hospital,
has accepted the post of directress, without salary.
Patients can be sent in by any medical practitioner in
Rome, and remain under his charge while in the home.
Transactions of the International Medical Con-
gress.— The secretary-general of the Thirteenth Inter-
national Medical Congress writes to Dr. Jacobs, secre-
tary of the American National Committee, that, as
there has been some misunderstanding about the sec-
tional arrangements, it .should be known that every
member may join as many sections as he pleases for a
single subscription, but that the expense will prevent
every member receiving a copy of the whole twenty-
four volumes of the Transactions of the Congress, as it
is intended to issue a volume of the work of each sec-
tion. Each member of the Congress will receive
therefore (i) a volume containing a general summary
of the work of the Congress, (2) a volume containing
a full report of the general sessions of the Congress,
(3) a volume containing the work of the section to
which he chooses to affiliate himself. If a member
has joined several sections he will receive the Trans-
actions of the section which he has placed first on his
form of application for membership. Members of the
Congress who wish to receive the whole set of trans-
actions should communicate with M. Masson, the pub-
lisher, 120 Boulevard St. Germain, Paris. The greater
the number of volumes ordered by any congressist the
less will be the price of each volume.
The Samuel D. Gross Prize of the Philadelphia
Academy of Surgery. — The conditions annexed by
the testator are that this prize of $1,000 "shall be
awarded every five years to the writer of the best orig-
inal essay, not exceeding one hundred and fifty printed
pages, octavo, in length, illustrative of some subject
in surgical pathology or surgical practice, founded
upon original investigations, the candidates for the
prize to be American citizens." It is expressly stipu-
lated that the competitor who receives the prize shall
publish his essay in book form, and that he shall de-
posit one copy of the work in the Samuel D. Gross
library of the Philadelphia Academy of Surgery, and
that on the title-page it shall be stated that to the es-
say was awarded the Samuel D. Gross prize of the
Philadelphia Academy of Surgery. The essays, which
must be written by a single author, in the English lan-
guage, should be sent to the " Trustees of the Samuel
D. Gross prize of the Philadelphia .Xcademy of Sur-
gery, care of the College of Physicians, 219 South
Thirteenth Street, Philadelphia," on or before Octo-
ber I, 1901. Each essay must be distinguished by a
motto, and accompanied by a sealed envelope bearing
the same motto, and containing the name and address
of the writer. No envelope will be opened except
that which accompanies the successful essay. None
of the essays received on January 1, 1900, was deemed
by the trustees worthy of the prize.
The American Academy of Medicine. — The twenty-
fifth annual meeting of this society will be held at
The Shelburne, Atlantic City, on Saturday, June 2d,
and Monday, June 4th, just preceding the meeting of
the American Medical Association. The president is
Dr. G. Iludson Makuen, of Philadelphia. The sub-
ject o*^ the annual symposium is "The Medical As-
pects of the Home."
Philadelphia Neurological Society. — At a stated
meeting held February 26th, Dr. A. P. Francine pre-
sented two cases of tabes dorsalis in negroes — husband
and wife. The symptoms had appeared first in the
husband, who admitted a history of syphilis, and in
whom there was a remote admixture of white blood,
while the wife presented evidences of considerable
admixture. Dr. C. W. Burr presented a case of lesion
of the spinal cord following injury to the neck. The
patient was a woman presenting right hemiplegia, with
a tendency to contractures and easily induced and
persistent patellar clonus, and impaired thermal sen-
sibility. The symptoms had developed in the se-
quence of a fall. Dr. Wharton Sinkler presented two
cases of paralysis agitans. In one the tremor was
violent and confined to the right hand, while the face
was mobile. The other was of long standing, the
symptoms developing many months after an injury.
The patient exhibited marked propulsion and retro-
pulsion, and was able to walk better over obstacles
than upon the level. He could perform few move-
ments deliberately, but upon sudden impulse and un-
der emotional strain he was able to do much better.
A deformity of the spine had been discovered and an
operation had been performed, the statement being
made that a fracture of a transverse process of the
second lumbar vertebra had been found. The patient
thought the symptoms had been stationary subsequent
to the operation, but the evidence pointed to the fact
that they had progressed. Dr. Joseph Sailer presented
a case of paralysis of the left upper extremity with
astereognosis. The patient had had several convul-
sive seizures, with transitory loss of consciousness,
and he presented physical evidence of valvular dis-
ease of the heart. The lesion was thought to be situ-
ated in the arm centre in the right cerebral hemi-
sphere, and to be of vascular origin, but the discovery
of bilateral neuro-retinitis raised the question of a new
growth. Dr. Henry J. Berkley read a paper on " The
Pathological Findings in a Case of General Cutaneous
and Sensory Ancestiiesia." The patient was a middle-
aged woman who had been under observation for some
ten years, and presented not only widespread cutaneous
anesthesia, but also abolition of all of the special
senses. Post-mortem examination disclosed intense
thickening of the vessels generally, with diminution
in calibre, and slight degeneration in various parts of
the nervous system. Dr. Berkley exhibited a speci-
men of false porencephaly in a rather unusual loca-
tion. The patient had been a medium-grade imbe-
458
MEDICAL RECORD.
[March 17, 1900
cile, without symptoms of focal disease; but upon
post-mortem examination a deficiency in the brain
structure was found on the median and inferior aspect
of one hemisphere. More careful investigation showed
this to be due to an extravasation of blood from a rup-
tured vessel. Dr. C. W. Burr presented a case of gen-
eral cutaneous anaesthesia, with partial loss of painful
sensibility. The patient was a man of low intelli-
gence, who presented, besides, symptoms suggestive of
hysteria. Dr. W. G. Spiller made a brief report of a
case m which there was bilateral optic neuritis, with
abolition of the function of the remaining cerebral
nerves upon one side.
University of Pennsylvania, Class of '75. — An ef-
fort is being made to secure a reunion of the Univer-
sity of Pennsylvania, medical class of '75, at the coming
commencement in June. Every member of this class
is requested to send his address and a brief account
of his doings since graduation to Dr. Charles W.
Dulles, 4101 Walnut Street, Philadelphia.
College of Physicians of Philadelphia. — A stated
meeting was held on March 7th. Dr. Frederick A.
Packard read a report of a case of ostitis deformans
(Paget's disease). Dr. John H. Musser read a paper
entitled "The Antitoxin Treatment of Diphtheria," in
which he reported a series of cases treated by this
means without a death, and some of which it was
thought would have terminated fatally if other meas-
ures had been used instead. Dr. Edward P. Davis
read a paper entitled " The Differential Diagnosis of
Ectopic Gestation, with a Report of Cases." Dr. W.
VV. Keen exhibited a new kind of material for sutures
and ligatures made of celluloid, and which commends
itself on account of its-cheapness and its susceptibility
of sterilization by all of the easily employed methods.
Dr. Keen also exhibited the specimen from a case of
ligation of the abdominal aorta. The vessel was tied
just below the diaphragm with several strands of silk,
and the patient survived for forty-eight days, death
resulting from hemorrhage due to cutting through of
the ligatures. On post-mortem examination the con-
dition was found to be a false aneurism.
Pathological Society of Philadelphia At a stated
meeting, held March 8th, Dr. A. O. J. Kelly read a
communication on "Tumors of the Vermiform Appen-
dix," and exhibited sections of endothelioma and
carcinoma of this organ. He related that among nearly
eight hundred vermiform appendages examined sys-
tematically following operation, in four only were new
growths found, and none of these had been suspected
during life. Three were carcinomatous and one was
an endothelioma. Dr. C. H. Frazier presented a com-
munication entitled " Vermiform Appendix Containing
Oxyures Vermiculares." The patient had presented
symptoms of appendicitis, and after removal the ap-
pendix was found to contain a considerable number of
living seat-worms. Dr. G. G. Davis reported a case
in which a segment of tape-worm was found, in a
removed appendix. Drs. De F. Willard and W. G.
Spiller reported a case of cyst of the inguinal region,
and presented numerous foreign bodies removed there-
from. Some doubt existed as to the nature of the cyst,
but it was thought to represent a collection of so-called
free bodies, such as form in cavities lined by endothe-
lium, although the possibility of its being a dermoid
cyst was considered. Drs. Blackwood and Dr. W. G.
Spiller reported a case of cerebro-spinal syphilis, and
presented the specimens, which exhibited a marked
degree of arteritis and cavities in the substance of the
brain. Dr. D. J. McCarthy presented the brain from
a case of adiposis dolorosa, exhibiting a tumor of the
pituitary body obstructing the orifices of the'\'entricles
and causing considerable internal hydrocephalus.
The patient had presented no symptoms of acromegaly.
The Medical Club of Philadelphia tendered a re-
ception on March 8th to Dr. Charles G. Stockton, of
Buffalo.
The Boer Army Surgeons. — It is stated that two-
thirds of the surgeons in the Boer army are either
Germans, or Afrikanders educated in Germany. Two
of the Germans, Drs. Hohls and Coster, have been
killed while assisting the wounded on the battlefield.
An Example for Philanthropists to Follow.— A
philanthropist of Palermo, Signor Jgnazio Florio, re-
cently founded a dispensary for diseases of the eye, in
which all the poor are treated without cost. But this
is done at the expense of the institution and not of the
attending ophthalmologists, each of whom receives
regular fees for the cases treated at the same rate as if
they were cases in private practice.
An Epidemic of Typhoid Fever is prevailing at
Milton, Pa., over one hundred cases being believed to
exist, and the physicians are unable to check the
spread of the disease. Among the deaths are those of
Dr. Clark and Dr. Sticker. The epidemic is attributed
to the city's water supply, which is derived from the
Susquehanna River.
Faith Cure and Keeley Cure. — Our attention has
been called to a palpable error of statement made by
a correspondent (Medical Record, December 23,
1899, p. 949) referring to cases of insanity following
the so-styled Keeley cure for alcoholism. It should
read "faith cure" instead of "Keeley cure." We say
this in justice to the alleged claims of the latter, al-
though we are free to confess that neither mention is
entitled to any scientific consideration.
The New York Medical League. — The report of
the committee on charities and legislation of the Man-
hattan section of this society was presented at the last
annual meeting. We learn from this that the League
was active in securing the passage of the dispensary
law by the legislature. It was also instrumental in
preventing the grant of a certificate of incorporation
of the Home for Patients with Incurable Cancer and
of the Emanuel Hospital.
Mania a Sero. — A severe epidemic of a new form
of insanity appears to be setting in. With mrr/iia- a
potu medical practitioners are already sufficiently
familiar; now we are beginning to make acquaintance
with mania a scro. This remarkable affection does
March 17, igoo]
MEDICAL RECORD.
459
not attack the patient but the physician, and the symp-
toms are particularly severe in those who themselves
make the serum. The victims of seromania suffer
from extraordinary delusions, under the influence of
which they appear bereft of the power of judgment,
and mistake their own fancies for facts. It is only
on this hypothesis that one can explain the amazing
statements made in all good faith by men whose
scientific training should have made them capable of
seeing things as they really are. — The Practitioner.
Typhoid Fever at Ladysmith. — Mr. Treves reports
that he entered Ladysmith on March 2d and found the
health conditions in the town most deplorable, the
number of cases of typhoid fever being eight hundred.
" Bibliographia Medica." — This is the title of a
successor to the Index Medicus, published in Paris
under the direction of Drs. Potain and Richet and the
editorial management of Dr. Marcel Baudouin. The
work will appear the isth of each month, and the sub-
scription price is 60 francs ($12) outside of France.
Gratitude was shown in a substantial manner to
Dr. Linder, the house surgeon of the Society of the
Hebrew Orphan Asylum of Brooklyn, at a recent meet-
ing. A purse was voted him as a testimonial of faith-
ful work during a recent epidemic of diphtheria. That
his work was probably also efficient would appear from
the fact that though twenty-three cases were treated,
there were no deaths,
The Louisiana State Medical Society. — The twenty-
first annual meeting of this society will be held at the
Tulane University Medical School, New Orleans, on
April 19th, 20th, and 21st, under the presidency of Dr.
W. G. Owen, of White Castle. The work of the meet-
ing will be distributed over fifteen sections. In the
section on diseases of children the subject for discus-
sion will be " Measles and Smallpox in Children."
The Orange Practitionerc' Society was organized
on March 2d, at Orange, N. J., with a membership of
twenty. A constitution and by-laws were adopted and
the following oflicers were elected : President, M. Her-
bert Simmons; Vice-President, Edgar Calvin Seibert;
Secretary and Treasurer, Walter M. Dodge ; Executive
Committee, Arthur W. Bingham, Francis E. Knowles,
and Thomas N. Gray. The society will meet on the
first Friday in each month at the residences of its
members.
A Sicilian Sanatorium for Consumptives. — Signor
Ignazio Florio, a wealthy merchant of Palermo, has
recently built a sanatorium for consumptives which is
said to be a model of sanitary perfection. It is on
the shore to the north of Palermo, and faces south,
Monte Pellegrino protecting it at the back from the
north winds. The building is constructed of fireproof
material, with iron and concrete flooring. The corners
of the rooms are rounded, there are no mouldings and
no projecting decorations, and the walls are smooth
and painted. The patients' rooms all face the sea, and
each has its own bathroom and toilet arrangements.
The laundry and disinfecting-plant and the chemical
and bacteriological laboratories are housed in separate
buildings. The drainage system has been constructed
with particular care, and excrementitious matter is
sterilized before being discharged into the sea. The
sanatorium is under the medical direction of Dr. Vin-
cenzo Cervello, of Palermo, who has a staff of assis-
tants. The sanatorium is for those who can afford to
pay for luxury, but seventy-five per cent, of the net
profits will be devoted to the maintenance of other
sanatoria for the poor.
A Medical Society Dispensary — The Society of
Russian Physicians in Moscow manages a dispensary
in which 26,240 patients were treated in 1899.
A History that Repeats Itself Four-year-old
Matilda Neiman contracted diphtheria. A Christian
scientist visited her. The house was not placarded.
People came and went. Matilda died. Coroner Loyd
investigated. Verdict, neglect. There are other cases
in that neighborhood now. — The Stylus.
Miitter Lectureship of the College of Physicians
of Philadelphia. — The next course of ten lectures
instituted by the late Prof. Thomas Dent Miitter,
M.D., LL.D., on some point or points in surgical
pathology, will be delivered in the winter of 1902-
1903 before the College of Physicians of Philadel-
phia. The compensation is $600. The appointment
is open to the profession at large. Applications, stat-
ing in full subjects of proposed lectures, must be made
before October i, 1900, to the committee on the Miit-
ter Museum, John H. Brinton, M.D., chairman, north-
east corner of Thirteenth and Locust streets, Phila-
delphia, Pa.
The Plague It is curious to note the senseless
panic that seems to seize even physicians whenever
plague is mentioned. Last week in San Francisco a
Chinaman died, and somebody suggested that the cause
of his death might have been pest. Immediately a
cordon was placed around Chinatown, and a quaran-
tine was maintained for several days until the health
authorities found that the case was probably not one
of plague. In the mean time cooks and other servants
in hotels and private houses were kept from their
work, and the community was duly scared. — ^A Japanese
steamer is held in quarantine at the Diamond Head
station near Port Townsend, about seventy miles from
Vancouver, because of a death from plague which
occurred on board during the voyage. It is said that
several cases of alleged beri-beri on Pacific steamers
have been found to be of the plague. — Reports from
Honolulu, dated March 2d, state that sporadic cases
of plague continue to occur there and on other islands
of the group. The executive council in Hawaii has
been authorized to expend $300,000 in furthering the
effort to stamp out the plague there.^ — In Calcutta the
disease is increasing, there having been four hundred
and eleven deaths from the disease there during the
first week in March. — From Cape Town a dispatch
states that a case of plague occurred on a vessel
arrived there from Rosario and Buenos Ayres. From
the latter city a telegram, dated March 7th, announced
that a number of cases of what is supposed to be the
460
MEDICAL RECORD.
[March 17, 1900
bubonic plague have beer officially reported. Urgent
measures are being adopted to prevent the spread of
the disease. — Three new cases of the plague were
reported in Sydney, N. S, W., on March nth.
Navy Department, Bureau of Medicine and Sur.
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
March 10, 1900. March 2d. — Medical Director J. C.
Wise commissioned medical director from February 7,
1900. Medical Inspector E. Z. Dorr commissioned
medical inspector from February 7, 1900. Surgeon
R. P. Crandall commissioned surgeon from September
24, 1899. Assistant Surgeon J. T. Kennedy appointed
assistant surgeon. March 7th. — Medical Inspector
G. E. H. Harmon detached from the Baltimore and
ordered to the Oregon. Surgeon F. B. Stephenson
detached from the Oregon and ordered to the Balti-
more. Assistant Surgeon W. B. Grove detached from
the Brooklyn and ordered to the Baltimore. Assistant
Surgeon H. H. Haas detached from the Brooklyn and
ordered to such other duty as the commander-in-chief
of the Asiatic station may assign. March 8th. —
Passed Assistant Surgeon J. C. Rosenbleuth detached
from the naval recruiting rendezvous, New Orleans,
La., and ordered home and to wait orders. Assistant
Surgeon F. E. McCullogh detached from the Nero
when put out of commission and ordered to temporary
duty on the Independence. Pharmacist I. N. Hurd
ordered to additional duty on the Massasoit, Key
West, Fla.
Obituary Notes. — Dr. Frederick William Hecker
died at Spring City, Pa., on March 3d, at the age of
seventy-one years. He was graduated from the medi-
cal department of the University of Pennsylvania in
1849. He was commissioned assistant surgeon in the
Fifth Pennsylvania Cavalry in 1862, and in a little
while was made surgeon in charge of the One Hundred
and Sixty-fifth Pennsylvania Infantry.
Dr. William L. Smith died suddenly at York, Pa.,
on March 4th, at the age of sixty-four years. He was
a graduate of the medical department of the University
of Pennsylvania, and he served through the civil war,
having charge of the division hospitals of Generals
Kearney and Geary during the campaign of the Penin-
sula of Virginia.
Dr. Oliver Payson Hubbard died at his home in
this city on March 9th, at the age of ninety-one years.
He was born at Pomfret, Conn., and studied at Ham-
ilton College and at Yale. He was graduated in arts
from Yale College in 1828, and became the assistant
of the elder Professor Sillinian. He received his
medical degree from the Medical College of the State
of South Carolina in 1837. He was for many years
professor of chemistry and pharmacy at Dartmouth
College, and was retired as professor emeritus in 1883.
He was for many years corresponding sc^cretary of the
New York Academy of Sciences.
Dr. Aaron Edgerton Peck died at his home in
Brooklyn on March 8th, at the age of sixty-five years.
He was a graduate of the College of Physicians and
Surgeons in this city in the class of 1855.
Dr. William Glatzmayer died at his home in
Newark, N. J., on March 6th, at the age of forty-two
years. He was born in Brooklyn, and was graduated
from the medical department of the University of New
York in 1885. He was an alderman in Newark, hav-
ing been elected in 1898.
Dr. Israel Prior died at his home in North Stam-
ford, Conn., on March 6th, after a prolonged illness,
at the age of fifty-eight years. He was graduated from
the Bellevue Hospital Medical College in 1865, and
began practice in Illinois, but later removed to North
Stamford.
progress 0f ^cjctical J^cicnce.
Medical News, March 10, igoo.
Milk Inspection by the New York Board of
Health. — Herman Betz makes a brief statement of the
routine milk inspection in New York City. The milk
inspector is appointed from the head of the list after
passing a successful civil-service examination. He is
on duty technically all the time, for he may be called
upon at any hour, Sundays included. The relations
between milk dealer and milk inspector are far more
cordial than would be supposed, for the department of
health is always fair. The inspector spends from 9
a.m. to 4 P.M. in actual inspections, after which a
carefully detailed report is written out and handed in
promptly to the chief inspector. The inspector carries
with him a satchel containing suitable instruments
and utensils. The samples of milk are taken to the
laboratory of the department and examined. The
analysis consists of the following factors: Water, per
cent.; total solids, per cent.; fat, per cent.; solids,
not fat, per cent.; per cent, low in solids; per cent,
low in fat; borax, present or absent; salicylic acid,
present or absent; formaldehyde, present or absent;
reaction, acid or alkaline. Since 1896 the department
has required every niilk-dealer to take out a permit.
There is an arrangement by means of which informa-
tion from the various boards of health of the States
from which milk is shipped to New York is sent to
the New York board, concerning any contagious or
infectious disease in those sections from which the
milk comes. This is often of the greatest service in
preventing the spread of disease.
A Case of Brain Tumor, with Exhibition of Speci-
men.— Hugh T. I'atrick reports this case. The pa-
tient was a man thirty-five years old. He had several
apoplectoid attacks which were followed by impair-
ment of the use of the right arm. He had most of the
mental symptoms of general paresis. His pupils
were equal and normal in every respect. On account
of the distinctly focal character of the paresis of the
right arm, particularly, the author believed this a case
other than general paresis. Active syphilitic treat-
ment improved the patient considerably, especially as
to his mental condition. The diagnosis lay between
general paresis and brain syphilis. The former was
excluded because he grew no worse, and because the
symptoms of paresis had cleared up considerably
under specific treatment. After his death, the brain
was examined, revealing a growth of the nature of a
glioma which was most intimately associated with the
brain substance itself.
Observations on a Spirillum Occurring in False
Membrane on the Tonsil. — Charles F. Craig, before
describing the case that he reports, enumerates the
March 17, 1 900]
MEDICAL RECORD.
461
spirilla which have been found associated with man.
They are: Spirillum cholera; Asiatica;; spirillum
Obermeieri; spirillum of Finkler and Prior; spirillum
sputigeneum of Miller; spirillum dentium of Arnt;
spirillum or vibrio nasale of VVeibel; spirillum of
Miller. The case which Craig reports is that of a
young man who complained of difficulty in swallow-
ing and soreness of the throat on the right side. On
examination the right tonsil was seen to be enlarged,
slightly reddened, and covered with a thick, dirty
white membrane occupying the posterior part and ex-
tending to the surrounding mucous membrane of the
fauces. Cultures were taken from the membrane and
a spirillum was obtained, the chief points of which
werfc its large size, extreme activity, decolorization
by Gram, and its occurrence in almost pure cultures
in a false membrane of which it formed a consideiable
part, and in the crypts of the diseased tonsil. The
case is of further interest because of the resemblance
of the false membrane to that of diphtheria, and as
showing the value of a microscopical examination of
the exudate in all tonsillar affections.
Surgery of the Epiphyses. — Charles L. Scudder
declares that many of the epiphyseal separations are
mistaken for fractures in the neighborhood of the
epiphyses. The Roentgen ray is revealing with a
great degree of accuracy the lesions after traumatism
to joints. The author gives great praise to John
Poland's book upon the traumatic separation of the
epiphyses, published in 1898. In conclusion, he
reports four cases of surgery of the epiphyses.
Recent Methods in Cardiac Therapeutics by Baths
and Exercises. — By Thomas E. Satterthwaite. See
Medical Record, vol. Ivii., p. 255.
A Unique Case in Obstetrics. — By Frederick H.
Parker. See Medical Record, vol. Ivii., p. 212.
Boston Medical a>id Surgical Journal, March 8, igoo.
The Gastro-Intestinal Tract in Nervous Diseases. —
E. Savary Pearce holds that there are three classes of
disease in which the nervous system is more or less
intimately influenced by gastro-intestinal disorder and
usually of a toxic nature: i. (a) Neurasthenic states,
general or in localized areas of distribution; {l>)
when organic changes are present in the nerve cells.
2. Cases when long-continued gastro-enteritis causes
organic change in the mucosa and gastro-intestinal
glands. 3. A mixed class of cases in which neu-
rasthenia or organic nervous diseases are associated
pari passu with disorders of digestion of a functional
or organic nature.
A Method of Determining the Digestive Power of
Gastric Juice as well as the Absorptive Power of
the Stomach A. E. Austin describes his method and
submits a table of experiments, by which we find these
peculiar combinations ; We may have good absorption,
good digestive power, and deficient motility, or we
may have another combination of poor absorption, fair
digestive power, and deficient motility. These three
factors once determined, in connection with the deter-
mination of the amount of rennin, make up an analysis
which apparently alifords us about all that chemical
examination offers in the analysis of the stomach con-
tents.
Remarks on the Influence of Technique upon the
Results of Closure of Wounds of the Abdominal
Wall. — Charles P. Noble prefers tier sutures to
through-and-through sutures, and uses silkworm gut
of a light weight as a buried suture, observing rigid
asepsis, tying the sutures without tei.sion, making the
knot with three ties and cutting the ends off short.
He describes his method of closing wounds, washing
the wound repeatedly with salt solutions as layer after
layer is closed. He uses the permanganate of po-
tassium and oxalic acid method of disinfecting the
hands, and wears rubber gloves.
Two Cases of Thomsen's Disease, and One of
Transient Myotonia, Occurring in One Family S.
A. Lord reports these cases from the neurological de-
partment of the Massachusetts General Hospital.
Abstract of Paper on '< Further Experience of the
Operative Treatment of Anteflexion." — VV. L. Bur-
rage reviews his notes of ninety-two cases of operation
performed for anteflexion.
Journal oj American Med. Association, March lO, igoo.
Some Points in the Diagnosis of Traumatic In-
juries of the Central Nervous System — J. T. Esk-
ridge calls attention to the fact that damages are
sometimes recovered from corporations for the effects
of disease existing many years before the occurrence
of the accident on which suit is brought. For this
reason the railroad surgeon should make systematic
examination of the injured as soon after the accident
as possible. Persons who are severely injured are
anxious for treatment and communicative, and a care-
fully gleaned history will often reveal that the subject
had been hysterical, neurasthenic, or a sufl^erer from
intrapelvic trouble prior to the injury. It must be
borne in mind that the presence of one positive sign
of organic trouble is of more importance for diagnosis
of an organic lesion, than the presence of many symp-
toms, functional in character, in justifying us in ex-
cluding organic disease.
Treatment in Compound, Compound Comminuted,
and Non-Union or Ununited Fractures. — C. D.
Evans describes a contrivance for the treatment of
fractures, especially ununited fracture. He reports a
case of fracture of the lower third of the leg success-
fully treated by this means. The only material used
by the writer to secure bony apposition is catgut No.
3, and the splint is formed from what is known as
"band iron," which can be found at any tinshop and
easily bent and moulded. Great stress is laid upon
aseptic dressing of the wounds.
Treatment of Minor Traumatisms R. Harvey
Reed insists upon the importance of handling the
smallest minor injury with the same precaution as
though it were a major one. He sums up the rules
for the successful treatment of this class of trauma-
tisms as follows: (i) Strict observance of surgical
cleanliness; (2) preservation of normal blood supply;
{3) perfect coaptation when possible; (4) simplicity
and efficiency of dressings; (5) the use of chemicals
which will destroy infective germs but will not irritate
or disturb cell reproduction.
A Contribution to the Surgery of the Common
Bile Duct. — John E. Summers reports a case of chole-
dochenterostoniy. The patient, a young woman aged
eighteen years, reports herself as being in perfect
health, having gained eleven and one-half pounds
since the operation. The author says that, so far as
he has been able to discover, this is the only reported
American case of an anastomosis between the common
bile duct and the bowel, although some of the latest
text-books mention that such an operation may be
done.
Hysterical Lethargy, with Report of Cases.— G.
W. McCaskey says that after eliminating chronic auto-
462
MEDICAL RECORD.
[March 17, 1900
toxcBmic processes in cases of somnolence or stupor,
there still remain a large number which, so far as we
know, are not toxic in their origin. Their nature is
often obscure, although they can for the most part be
regarded as either hysterical or epileptic in character.
The writer reports several cases of hysterical origin.
The treatment of these cases, aside from electricity
and other forms of stimulation to the hysterogenic
zone, is that of the hysterical state which forms its
background.
Nervous Depression as a Sequel of Influenza. —
B. J. Byrne calls attention especially to two features
of this depression which he does not think are found
associated with any other disease — namely, the sub-
normal temperature and the reduced pulse rate. In
the cases of which he has kept records the tempera-
ture ran from 97° to 95° F., and the pulse from 60
to 48, for weeks and months. The medical treatment,
consisting of strychnine in full doses (gr. ^\ of the
sulphate three times a day), was somewhat unsatis-
factory. The best results were derived from absolute
rest.
Treatment of a Common Cold. — Frank Woodbury
thinks that the " neurotic element " in a common cold
has been too largely ignored in the plans of treatment
usually followed. With the view of acting directly
on this neurotic element he has for the last two years
used the following combination : Pulv. morphinai
comp., gr. XX. ; acetanilidi, gr. vi. ; sodii bromidi, gr. x.
This is divided into twelve capsules, of which one is'
taken every half-hour for two hours, then one every
two hours. The writer has found that this will usu-
ally break up a cold in a few hours.
Dangerous Pulmonary Hemorrhage in Tuberculo-
sis and its Management. — Norman Bridge says that
in a severe hemorrhage the measures to be resorted to
should have for their purpose the immediate lessening
of the blood pressure. To this end the patient should
keep as still as possible and avoid taking deep breaths.
The bowels should be kept open and the clothing be
loose. Of all measures, the writer thinks that mor-
phine, preferably with a proportionate admixture of
atropine, administered hypodermically, gives the most
valuable results.
Insanity and the Turkish Bath. — Charles H.
Shepard thinks that among the constitutional agenci*es
in the treatment of the insane the bath should stand
high, and that of all baths the Turkish bath is pre-
eminent. The author says that while few asylums in
this country have Turkish baths, much has been done
in this way in Great Britain and Ireland to the great
improvement in the statistics of cures, and also in the
death rate.
An Intestinal Anastomosis in a Case of Tuber-
culous Fecal Fistula of Twenty Years' Standing. —
In this case, reported by Jacob Frank, the anastomo-
sis was performed with a one-inch Frank's decalcified
bone coupler. In spite of an extremely severe condi-
tion very good union took place within a compara-
tively short time.
Description of a Case of Oral Surgery. — G. V. I.
Brown reports this case, and submits photographs
showing the extreme degree of disfigurement resulting
from a burn, as also the extraordinary cosmetic im-
provement following operative interference.
Hygiene of Public Schools.— C. F. Ulrich con-
siders this subject under the heads of ventilation,
light, water supply, playgrounds, and prophylactic
measures against contagious and infectious diseases.
JVe7c York Medical Journal, March 10, igoo.
Results of Hot-Air Treatment in Rheumatism
and Gout. — L. A. Coffin describes the apparatus most
commonly used in this country. It has been employed
in the various forms of chronic rheumatism, tubercu-
lous joint inflammations, sprains, synovitis, tendo-
synovitis, neuralgia, and club-foot. Various clinical
histories from the experience of others are given, and
the author cites two personal cases. He thinks that
the superheated air acts by producing a profuse
sweating of the part, carrying oft" immediately many
waste products resulting from increased activity about
the joint. It also increases cell activity and second-
arily stimulates the general system.
The Direct Examination of the Larynx in Chil-
dren.— Thorner figures various forms of lingual de-
pressors which have been devised for this purpose.
Difficulty in examination may arise from subjective
causes due to the age of the patient, or may be due
to the anatomical conditions present in the infan-
tile larynx. He does not think that any of the in-
struments or methods described can be considered
perfect, but they are an advance over our previous
helplessness v.ith this class of patient's. The paper
considered as a wiiole is an interesting resiune of the
history of this special procedure in laryngology.
Some Home-Made and Homely Appliances. — J.
Leverett commends the use of large manila-paper en-
velopes for the reception of all infected dressings, etc.
The whole can then be burned. As a substitute for
the Kelly obstetric pad he employs a circular tube of
canvas containing the inner tube of a bicycle tire
which can be inflated with the ordinary pump. To
the canvas can be attached by a hook-and-eye device
an ordinary rubber sheet. The whole can be deflated
after use and packed in a small pocket.
Perineal Lacerations in Country Practice. — H.
H. Wilson commends double episeotomy and the im-
mediate repair of slight lacerations. Deep complete
lacerations should wait for the secondary operation.
Six Cases of Chronic Heart Disease Successfully
Treated by the Schott Method — Histories of the
cases are given by V. Neesen, who includes a descrip-
tion of the method and a diagrammatic plan of the
Schott exercises.
Report of a Case of Double or Twin Uvula
The case occurred in the practice of L. S. Somers, the
patient being a woman aged twenty-five years. The
author adds some remarks upon abnormalities of the
uvula and their relation to other lesions of the upper
air tract and to the system at large.
Shock and its Surgical Significance — By J. H.
Rishmiller. A continued article.
Philadelphia Medical Journal, March 10, igoo.
Arteriosclerosis. — Joseph Eichberg gives the etiol-
ogy, symptomatology, and treatment of this affection.
The main causes mentioned are physical overwork,
mental strain, poisons — lead, tobacco, and possibly
alcohol — and overeating combined with a sedentary
life. The treatment consists in the removal of the
cause as far as may be possible, the application of
the Schott method, and the administration as needed
of the nitrites and iodide of sodium.
A Case of Gastrotomy for a Foreign Body in the
Stomach. — George G. Hopkins describes the case of
a dime-museum performer from whose stomach he re-
moved a collection of miscellaneous metal articles.
See Medical Record, vol. Ivii., p. 109.
March 17, 1900]
MEDICAL RECORD.
465
The Surgical Use of Celluloid Thread — W". w.
Keen and Randle C. Rosenberger describe a number
of experiments demonstrating the value of this suture
and ligature material devised by Pagenstecher.
Double Fracture of the Clavicle. Gunshot Wound
of the Lower Portion of the Spine, Producing Paral-
ysis of the Area Supplied by the Fifth Sacral
Nerve. — W. H. Hudson reports cases of these injuries.
A New and Simple Breast Binder for Post-
partum Use Joseph Brown Cooke describes and
pictures an improvement on the Murphy binder.
Some Old Certificates of Proficiency in Medicine.
— Francis R. Packard makes a contribution to the his-
tory of medicine in North America.
Selection from the Lane Lectures A portion of
a lecture on diseases of the arteries, by T. Clifford
AUbutt at Cooper College in i8g8.
The Lancet, March j, igoo.
The Treatment of Some Forms of Appendicitis
at Plombieres without Operation. — Skene Keith states
that at the spa mentioned, chronic appendicitis is
treated by daily baths, the patient lying covered to the
neck in water at 35^ C. Baths last for forty minutes.
After the first few baths and for the last ten minutes
of the later ones, a feather-like douche of warmer
water is applied to the region of the appendix. Care
must be taken to regulate the force of this douche.
After the bath the patient rests for half an hour or so.
The cases of appendicitis best adapted to the treatment
are those due in part at least to some general con-
dition.
On the Relation of Blood to the Lymphatic Ves-
sels.— C. H. Leaf illustrates by diagrams the various
ways a vein can communicate with a lymphatic.
These communications allow malignant cells to pass
from one set of vessels to the other in either direction.
Hence in sarcoma and carcinoma alike the veins
should be looked upon as possible channels of con-
tagion.
A Case of Suppression of Urine of Sixty Hours'
Duration Treated by Operation. — The patient seen
by F. Jaffrey was a man, aged fifty-three years, sup-
posed to be suffering from hydronephrosis. Operation
showed the pelvis of the kidney full of blood clot.
Secretion of urine began two hours after the operation
was finished.
A Case of Leprosy.— The case described by J. D.
Gimlette occurred in an Eurasian, aged twenty-seven
years. The symptoms were obscure at the outset, the
case being confounded with infective rheumatism,
peripheral neuritis, and finally tertiary syphilis. Ba-
cilli of leprosy were finally found.
Hallux Valgus and Hallux Varus.— J. Jackson
Clarke defines these terms and gives their anatomical
relations. For the former he advises complete exsec-
tion of the head of the metatarsal bone. He believes
that every case is curable.
A Contribution to the Surgery of the Kidney —
L. W. Bickle gives histories of nephrectomy during the
third month of pregnancy with recovery, followed by
delivery at full term, and of nephro-lithotomy.
The Anatomy and Pathology of the Rarer Forms
of Hernia By B. G. A. Moynihan. The third of the
Arris and Gale lectures.
Tuberculous Disease of the Kidney ; its Etiology,
Pathology, and Surgical Treatment — By D. New-
man. A continued article.
Rabies. — By J. R. Bradford; a lecture delivered at
the University of London.
The Medical Press and Circular, Fehriiary 28, igoo.
Antral Catarrh and Suppuration.— J. G. Turner
says the causes of antral suppuration are to be found
in extension from neighboring sinuses and the nose.
Third molars, acting as foreign bodies, may start antral
suppuration. For transillumination the lamp must be
placed centrally in the mouth and both sides compared
as to (i) illumination of pupil; (2) appreciation of
light by the patient; (3) amount of light coming
through around the lower margin of the orbit; (4)
amount coming through the cheek. Chronic cases are
difficult of cure.
Radical Cure of Hernia — P. G. Lodge records a
case of epiplocele of six years' duration. An eight-
inch incision was made over the tumor. A pound of
adherent omentum was removed. The free edge was
hemmed with catgut. An undescended testicle was at
the same time removed. The muscular structures
were stitched to Poupart's ligament. The limb was
immobilized by poro-plastic felt down the front of
the body and thigh. A complete cure resulted.
Tuberculous Trochanteric Disease — J. Basil Hall
bases a paper upon four cases reported. The deposit
of tubercle is inside the line of junction between the
trochanter and the bone, in the base of the neck of the
femur rather than in the trochanter. In each case
there seems to have been an ostitis round an old tuber-
culous sequestrum.
Vaginal Pessary in Uterine Erosion. — Alexander
Duke presents a note on the use of the pessary as a
help in the treatment of uterine erosion, and finds it
an important factor of speedy cure.
Chronic Prostatitis. — H. Delagrammatica gives
clinical notes of four cases of chronic prostatitis, each
presenting points of interest.
The Dilatations and Diverticula of the (Esopha-
gus By John Knott; a continued article.
Deutsche mcil. Wochenschrijt, Feb. 75 and 22, igoo.
Cancer of the Large Intestine. — I. Boas discusses
under this title the symptomatology and treatment of
malignant disease of the colon. As regards subjective
symptoms the cases fall into four classes: (i) those
in which local signs are absent for a long time or
throughout, the progressive cachexia being the only
thing to arouse suspicion ; (2) those in which the local
symptoms are indefinite; (3) those of deep-seated
stenosing carcinoma in which colicky pains are ac-
companied by tenesmus and strangury, as frequently
seen in cases of rectal cancer; (4) cases in which
symptoms of ileus appear in the midst of apparent
health or after prodromes of not alarming character.
Of greater value than the subjective symptoms is the
presence of a palpable tumor. Contrary to the teach-
ing of the text-books the tumor is not always movable.
A movable tumor may temporarily escape the most
careful palpation, and repeated examinations are there-
fore necessary. The occurrence of stricture is a symp-
tom of the greatest value. Vomiting, ha-matemesis,
constipation, diarrhoea, the shape of the formed dejec-
tions, and the presence of blood and pus in the stools,
are signs, taken alone, of little positive value. The
464
MEDICAL RECORD.
[March i 7, 1900
results of operative treatment have hitherto not been
particularly encouraging, but with the possibility of
earlier diagnosis will come that of earlier operation,
and the prognosis will then be improved.
The Surgical Treatment of Renal Tuberculosis.
— F. Konig says that two forms of renal tuberculosis
must be recognized: (1) tuberculosis of the gland sub-
stance not communicating with the pelvis, and (2) the
pyelitic form. The diagnosis of the first form is often
impossible, but that of the second is usually quite
easy even without the demonstration of tubercle ba-
cilli. It is, however, not always possible to assure
ourselves of the soundness of the other kidney. Re-
section of the kidney is scarcely ever to be thought of,
and cystotomy also very seldom, in cases of renal
tuberculosis, extirpation of the diseased organ being
the only certain operation for the relief of this condi-
tion. This operation is indicated as a life-prolonging
measure in a number of cases even when the other
kidney is slightly affected and when the bladder, pros-
tate, and testes are likewise diseased.
A Case of Sharply Circumscribed Cancer of the
Stomach. — Herhold reports tiie case of a man who
consulted him for the relief of severe gastric symp-
toms. Palpation revealed the presence of a hard mov-
able tumor of the stomach. On operation this was
found to be attached by a broad base to the mucous
membrane of the stomach. The stomach was mark-
edly contracted owing to the nominal quantity of food
the man had taken for months previously. The
growth was removed and the man made a good recov-
ery, having gained remarkably in weight and strength
in the four months which had elapsed between the
operation and the date of the report. The tumor was
confined to the mucous membrane, the muscular and
serous tunics being absolutely free.
The Oliver-Cardarelli Symptom in Cases of
Mediastinal Tumor. — Ma.x Auerbach reports two
cases of tumor of the mediastinum, one of enlarged
mediastinal glands due to metastasis from gastric
carcinoma, the other of cancer of the lung with metas-
tases of the bronchial glands. In both of these
tracheal tugging, a symptom alleged to be patho-
gnomonic of aneurism of the arch of the aorta, was
present.
Vaccination Technique. — Flachs covers the place
of vaccination with sterilized gauze fixed by means of
adhesive plaster, and covers all with a bandage. The
child is bathed every day, and the bandage is changed
after the bath. At the end of a week the gauze is re-
newed, being then spread with boric-acid ointment.
By this method the production of a conspicuous scar
is usually prevented.
Absorption and Elimination of the Iron of Iron
Somatose in the Animal Organism. — W. Nathan
describes the results of a number of experiments made
by feeding this substance to mice, from which he con-
cludes that it is actually absorbed when introduced
into the intestinal canal.
Actual Dilatation of the Heart. By Hans Herz.
A continued article.
Berliner kliniscJie Wocliensihrift, February jg, igoo.
Auto-Intoxication. — C. A. Ewald discusses the
question in the light of recent literature and clinical
experience, devoting especial attention to the poison-
ous effects of the urine. He is inclined to think that
the matter has been carried to too great a refinement
of discussion in these later days, and that the modes of
actual auto-intoxication are far fewer than is generally
supposed. Many instances adduced as causative of
disease are really the result of the latter.
Caesarean Section.— According to H. Freund, per-
foration of the head of a living child is an unjusti-
fiable procedure when there is no danger to the life
of the mother, and when the surroundings are in the
general sense favorable for the successful issue of a
grave surgical operation. He does not consider the
dangers of the operation greater than those of a
complicated delivery, an ovariotomy, or an abdominal
section with removal of the adnexa.
Observations on the Paper of H. Salomon on Brain-
Pressure Symptoms in Typhus. — E. Stadelmann dif-
fers from Salomon, whose paper was published in No.
6 of the current volume of the Wochenschrijt, and
states that he does not approve of lumbar puncture in
the condition named, his clinical experience having
convinced him of its futility.
The Care of the Navel of the Newly Born. — A.
Martin advises the application of a ligature of steri-
lized silk and then section of the cord with any form
of a hot wire or similar device. Bleeding is thus per-
manently checked. The eschar is covered with anti-
septic gauze and the cord dressed in the usual manner.
Nature's Methods of Protection against Infec-
tion.— By P. Baumgarten. A continued article.
Miinchciicr medicinische Wochenschrift, Feb. ij, igoo.
The Application of Gelatin for Checking Cholaemic
Hemorrhages after Operations on the Biliary Sys-
tem, besides Remarks on Poppert's Waterproof
Drainage of the Gall Bladder. — Hans Kehr has had
excellent results from the use of gelatin in several cases
of* cholsmic hemorrhage. The technique is very
simple. Into 500 c.c. of a seven-per-cent. solution of
sodium chloride he puts 10 gm. of white gelatin. The
mixture is sterilized, and 200 c.c. at 38 t'. is injected
subcutaneously into the patient. He is positive that
cystectomy combined with cysticotomy and drainage
of the hepatic duct will prove superior to cystotomy
with its numerous modifications, and also to water-
proof drainage proposed by Poppert and two years pre-
viously by the author himself. This drainage con-
sists in the insertion of a long rubber tube into the
incised gall bladder, the tube being wrapped about
with a great deal of gauze in order to protect the
abdominal cavity from infection by the bile which has
passed througli the tube. The tube is snugly fastened
into the incision by suturing the wound right up to
the tube. This method is also applied to the drainage
of the hepatic duct. Kehr believes that in order to
obtain a permanent cure for the patient the surgeon,
in the majority of cases, should not only drain or
excise the gall bladder, but also lay great stress on the
careful palpation and sounding of the bile ducts.
Critical Remarks on the Rosin Method for the
Determination of the Reducing Power of Urine,
etc. — L. Spiegel and (]. Peritz criticise adxersely tlie
method devised by Rosin, which consists in pouring
into an Krlenmeyer flask of 100 c.c. capacity 25 c.c. of
urine diluted five times but still havirg a slight yellow
tint. To the urine is added i c.c. of officinal caustic
potash. Then liquid paraflnn is poured over the mix-
ture till three times its depth, and the whole is care-
fully heated almost to boiling. Care must be taken to
exclude the air, and to hinder boiling, by means of
which bubbles would rise to the surface and establish
a communication with the outside air. Into the heated
March i 7, 1900]
MEDICAL RECORD.
465
liquid there is poured through a burette whose tube is
long enough to reach below the paraffin layer, i c.c.
of methylene blue solution, i : 3,000, and the fluid is
further heated over a wire net. After some seconds
the blue color entirely disappears. Then by means of
another burette there is added to the liquid, which is
still being heated, but not boiled, sufficient i : 100
normal permanganate solution to cause the blue color
to return, that is, till the fluid assumes a bluish-green
shimmer.
Epileptiform Attacks in Convalescence from Ab-
dominal Typhoid — F. Miihlig gives the history of a
patient, a man aged twenty-three years. He speaks of
the following points as noteworthy: the rapid succes-
sion of the attacks, the long duration of each, and the
fact that the convulsions occurred only in one day and
then never returned.
Hydrorrhoea Ovarialis Intermittens.— By
Nassauer. A continued article.
Max
A Contribution to the Etiology and Therapy of
Episcleritis Periodica Fugax W. Stoltzing cites a
case of this kind, and speaks later of the therapy and
etiology of the affection. Fuchs says the therapy is
for the most part without results, although quinine and
sodium salicylate are the most effective. The author
himself- in the reported case has found potassium
iodide to exert a very favorable influence. He also
believes that there is no foundation for believing in a
syphilitic etiology of the disease from the results of
the iodide therapy, since all other symptoms of this
affection fail, and since when the iodide is stopped
the episcleritis always recurs soon. Syphilitic phe-
nomena, if dispersed by potassium iodide so per-
fectly and quickly, are not accustomed to return in this
manner.
Studies on the Inflammation of Serous Mem-
branes.— R. Heinz states that his researches have led
to the same results as those reached by Graser as well
as those of some recent work done under Ziegler's
direction. F.ndothelium prevents serous membranes
from adhering together. Adhesion occurs when the
endothelium is lost from any cause. This fact is not
surprising. It is well known that when layers of
uncovered connective tissue are laid together, they
very soon grow together. In order that this may not
happen, the serous cavities, the lymph spaces, the
brain and spinal-cord cavities are covered with en-
dothelium. Whenever the endothelium is destroyed
by an injurious agent, the connective-tissue layers
lying underneath adhere together.
On Intermittent Claudication — Erb speaks of
Grassmann's article on this subject in Ziemssen's
Festscluift^ in which the author gives an account of an
interesting case observed by himself. Erb then calls
attention to the fact that he himself, almost a year and
a half ago, published a rather comprehensive article
on the same subject in the DeutSiJte Zeitschrijt Jiir
Nei-'enhfilkundc, Band xiii. He makes this note in
order that it may not be thought that no attention had
been paid to this subject before the appearance of
Grassmann's article.
On Total Stenosis of the Pylorus after Corrosion
by Lye. — A. Hadenfeldt reports a case of this kind in
a child six and three-quarter 3'ears old, and thinks that
whenever corrosive poisons are swallowed, a stomach
lesion should be thought of as well as the oesophageal
trouble, and in case of intestinal disturbances that can-
not be explained by the existence of the stricture of
the (Psophagus alone, stenosis of the pylorus should be
considered. Relief should be afforded as soon as pos-
bible. to save the patient's strength.
An Improvement on the Intra-Uterine Dilating
Sound of Doleris. — E. Toff describes his new instru-
ment, which has the advantage of being separable into
parts and so admits of being thoroughly cleaned and
sterilized. Its arms are curved at a more obtuse
angle than is the instrument of Doleris, which also is
advantageous in its cleansing.
Wiener klmische Wochenschrijt, February ij, igoo.
On Malta Fever. — Alfred Brunner, in giving a care-
ful description of this disease, says that according to
Hughes the most striking characteristic of this disease
is the long duration of the fever. Among three hun-
dred and seventy-two cases, the fever lasted in the
great majority from forty to seventy days, although
Hughes had two cases in which the fever lasted over
two years. The same author speaks of four principal
types of the disease : (i) The malignant type, in which
hyperpyrexia obtains, the temperature always rising
above 41" C, and death following in a few days; (2)
the indolent type; (3) the intermittent type; (4) the
irregular type. Prognosis as to life is very good. As
to the diagnosis, if the case presents absence of diar-
rhoea, a clear sensorium, absence of roseola and
epistaxis, a moderate splenic tumor, and no or little
headache, then it is easily differentiated from typhoid.
It must also be diagnosticated from malaria. Serum
diagnosis is valuable in this disease. The therapy
of Malta fever is very limited. Symptomatic treat-
ment is in order.
Landry's Paralysis with Especial Reference to its
Bacteriology and Histology. — Julius Kapper carefully
reviews a case of Landrj 's paralysis in which a bac-
teriological examination of urine and blood made in
life, as well as the autopsy four hours after death, and
the pathologico-histological examination of the central
nervous system and peripheral nerves, gave a perfectly
negative result. An auto-intoxication must be regarded
as an etiological factor in this disease. This apparently
originates in the intestine and would be accounted for
by an increased putrefactive process. Thus would it
be explained, if, on the one hand, in spite of apoplec-
tiform clinical symptoms the post-mortem findings
were negative, or, on the other hand, if we find patho-
logico-histologically a polyneuritis or myelitis which
we regard as being of toxic origin. In the case cited,
the presence of the products of intestinal putrefaction
in the urine and the transitory improvement after
copious alvine evacuation are in favor of the existence
of an auto-intoxication. In view of this conception
anti-fermentative measures would be indicated.
On Salivary Calculi — Friedrich Hanszel notes
three cases. The first calculus was caused by chronic
inflammation of the glandular substance itself with
consequent stagnation and inspissation of the secre-
tion; 't was not till later that this stone reached the
duct through the salivary stream. The second calcu-
lus waSi^aMsed by micro-organisms and was formed in
Wharton's duct itself. The third was formed in
Wharton's duct and resulted from the long-continued
injury of the left sublingual by the mouthpiece of a
tobacco pipe.
Viatch, January 2g and February j, igoo.
Glioma of the Retina. — Y. V. Zelenkovski reports
a case of this affection in which he made a very care-
ful histological study of the lesion, as a result of
which he formulates the following conclusions: i.
466
MEDICAL RECORD.
[March 17, 1900
The cylindrical arrangement of a glioma is not for-
tuitous, but is very probably dependent upon the
spherical shape of the retina and pressure exerted by
the original cell-nests both upon the normal parts of
the retina and one upon another. 2. Glioma of the
retina may develop simultaneously from four layers —
that of the nerve fibres, the ganglionic, the internal
and the external granular. 3. Retinal glioma con-
sists of spider cells with many offshoots, identical with
the cells of the neuroglia and the spider cells of the
retina and optic nerve, and of ganglion cells of va-
rious sizes in the midst of which are others resem-
bling embryonal retinal cells. 4. The possibility of a
glioma originating from the layers in which spider
cells are ordinarily not encountered, and the presence
of these embryonal nerve cells render very probable
the view of Greef that a glioma of the retina is devel-
oped from neuroglic and ganglionic elements which
may remain for a certain time quiescent in any layer
of the retina and then take on growth when favorable
conditions arise.
Transitory Spinal Paralysis. — L. R. Krever re-
ports two cases of this affection occurring in appar-
ently healthy women. There began quite suddenly,
■without any apparent cause, a paraplegia of the lower
extremities accompanied with painless cramps of the
legs, increased patellar reflexes, and disordered vesical
and rectal functions. In one case sensation in all its
forms disappeared and did not return for a long time,
in the other it was pre.served from the beginning to
the end of the disease.. There were no trophic dis-
turbances, and all the severe symptoms disappeared as
rapidly as they came on. From the first signs of the
affection to complete recovery not more than two
months elapsed.
The Origin of So-Called Acute Cataracts.— I. I.
Maslennikoff reports a case of cataract occurring sud-
denly in a woman, twenty-seven years of age, of sound
physical condition but suffering from an hysterical
attack, and discusses tlie cases of sudden clouding of
the crystalline during convulsions from other causes,
a clouding attributed by some to spasm of the ocular
muscles.
A Defence of Osteoplasty in Amputations S. I.
Spasokukotski refers to a former article in which he
advocated osteoplastic methods in amputation of the
leg, as recommended also by Kocher, and returns to
the subject in order to answer sundry objections which
had been advanced against this procedure. He reports
five cases of amputation illustrative of the advantages
of osteoplasty.
The Value of Widal's Serum Diagnosis of Ty-
phoid Fever Th. A. Dombrovski reviews at length
the literature of this subject and reports several cases
in which the test was applied, and concludes that it
furnishes one of the most certain of all the evidences
of typhoid fever, although it is not strictly patho-
gnomonic.
A Nasal Speculum for Pediatric Practice.— J. I.
Katz describes and pictures an instrument to<fccilitate
inspection of the nasal passages in children.
The High Operation for Stone.— By V. I. Lisiav-
ski. A continued article.
Endothelial Neoplasms of the Gastrc-Enteric
Tract.— By L. V. Soboleff. A continued article.
French Journals.
Milky Ascites with Leucocytes of Lymphatic
Origin. — Femand VVidal and Prosper Merklen present
the case of an alcoholic, aged fifty years, showing
lactescent ascites. This is usually of chylous origin.
It may exist without chyle, but the distinction pre-
sents great difficulties. A precise study of the leuco-
cytes found in tlie fluid may show the lymphatic origin,
as in the case presented, and give more valuable infor-
mation than is furnished by the amount of fat present.
— La Presse Medicalc, February 24, 1900.
Botryomycosis. — Charles Lenormant describes a
case of botryomycosis situated upon the dorsal surface
of the right ring finger in a woman, aged thirty-one
years, who had worked in straw in the family of a
butcher. The raspberry-like appearance of the tumor,
and possible indirect contact with animals, were suffi-
cient for the diagnosis, which was confirmed by finding
botryomyces in formative stages. — Gazette hebdovia-
daire de Medccine et de Chirurgie, February 21, igoo.
Observations on Cacodylic Medication Paul
Dalche gives his personal results of treatment. He
prefers pills of cacodylate of sodium, each containing
25 mgm. Various tabulated resuUs are presented.
He concludes that the drug is destined to render real
service in tuberculosis when conditions of hygiene and
therapeusis are favorable. He began with one pill at
a dose and gradually increased to two and then three.
— Le Bulletin Medical, February 24, 1900.
Tuberculous Stricture of the Small Intestine
Th. Tuffier studies the hypertrophic form of stricture
in tuberculous subjects. There are three varieties of
stricture, the purely cicatricial, the primarily fibrous,
and the hypertrophic. A case of the latter is given
with illustrations. Surgical treatment has given
thirty-seven operative cures out of forty-five cases. —
La Presse Medicate, February 21, 1900.
Annals of Surgery, March, igoo.
A New Method of Suture in Operations for In-
guinal and Other Forms of Hernia. — L. Freeman
exposes the internal ring, ligates and cuts off the sac,
which is knotted on itself. The cord being held out of
the way, a loop of silkworm gut is passed from without
inward through the muscular tissue on the umbilical
side of the ring, then carried through Poupart's liga-
ment from within outward. Another loop is similarly
inserted near the pubic limits of the opening. A
piece of stiff silvered wire long enough to reach the
entire length of the inguinal canal is run through the
loops, which are pulled tight enough to hold it in
place. Another wire is laid along Poupart's ligament
between the free ends of the loops, which are firmly
tied over it, thus approximating the wires and bunch-
ing a quantity of muscular tissue against the ligament.
The wires are bent upward at their pubic extremities
so as to protrude through the external incision, thus
facilitating their removal. The ends of the wires far-
thest from the pubes must be so placed that they leave
the new internal ring neither too large nor too small.
The cord is now dropped in place over the line of
union, and the aponeurosis of the external oblique
united above it, the upturned ends of the wires passing
through the external ring. In uniting the skin, the
free ends of the loops and the ends of the wires are
brought out through the incision between the stitches.
In from ten days to two weeks, which are long enough
to procure reasonably firm union, ihe wires are re-
moved by pulling on their protruding ends. This frees
the loops, which are likewise readily extracted.
Fracture of the Neck of the Humerus with Dis-
location of the Upper Fragment, with a Report of
Three Cases Treated by Operation B. F. Curtis
discusses the literature of this injury, and describes
March i 7, 1900]
MEDICAL RECORD.
467
one personal case in which simple resection was done
and two other cases in which he followed the method
of reduction by open arthrectomy. He believes that
when attempts at simple reduction under anaesthesia
have failed, operative measures should be resorted to
unless contraindicated by the patient's condition.
Resection of the h^ad of the bone should be reserved
for those cases in which reduction is impossible or
would extensively damage the parts. Resection will
probably give a better result in fracture of the ana-
tomical neck than of the surgical, but reduction is to
be preferred in both. Motion should be begun as soon
as the wound has healed.
A Case of Acute Osteomyelitis of the Femur
•with General Systemic Staphylococcus Aureus In-
fection, Terminating in Recovery A. A. Berg gives
a detailed history of the case. Antistreptococcus
serum was used, and there was an absence of any
metastatic focus of infection. The organism was
eliminated by the kidneys, causing acute degeneration
of these organs as well as toxin poisoning of other
viscera, but the patient finally recovered.
Prolapsus of the Rectum in Children C. G.
Cumston states that in acute prolapse and invagina-
tion of the colon which are irreducible and at the
same time present incarceration, gangrene, or intes-
tinal obstruction, immediate resection should be done.
Operation at a time of election should also be done
in chronic cases which cannot in a reasonably short
time be cured by milder therapeutic measures.
Effects of Intracerebral and Subcutaneous Ad-
ministration of Tetanic Antitoxin in Tetanus, as
Observed in Nine Cases. — R. Abbe narrates histories
of two mild and seven severe cases. Of the seven
seen this last summer, live were subjected to trephin-
ing. Three patients lived and two died. Good
effects from the serum were noted in five of the nine
cases, and four of the five patients recovered.
Report of a Case of Recovery after Gastrectomy
for Carcinoma. — J. B. Harvie reports the case of a
woman aged forty-six years, the stomach being resected
and the oesophagus attached to the duodenum. The
patient left the hospital in six weeks in good condi-
tion. A detailed report is given of the pathological
condition found in the stomach.
Two Cases of Cicatricial Stricture of the (Esoph-
agus Treated by Gastrostomy, the "String"
Method, and Permanent Dilatation by Elastic
Tubes. — B. F. Curtis reports the cases, one of a boy
aged t\\'o and one of a girl aged nine years. H. prefers
the method first described in 1894 by Stamm. The re-
sults in both cases were most satisfactory.
Report of Results Obtained in the Treatment of
Ununited Fractures with the Parkhill Clamp. —
A. L. Bennett reports nine cases of perfect union out
of fourteen cases operated upon. The clamp was de-
scribed in the A7inah of Surgery for May, 1898.
Coccygeal Dermoid Fistula. — By R. T. Morris.
See Medical Record, vol.lvi., p. 531.
Treatment, February 8 and 2J, igoo.
On Some Cardiac Affections due to Influenza. —
J. L. Bunch has found as sequelai of influenza in-
creased frequency of cardiac rhythm, the " irritable
heart " of Da Costa, the pulsus bigeminus, arrhythmia,
and acute cardiac dilatation. Treatment must consist
first of all in rest, absolute for a time, and then in the
avoidance of any exertion which can throw a strain
upon the heart. Later, carefully graded exercises
may be used to assist the heart to return to its former
condition of functional activity. A diminished intake
and an increased output of fluid are recommended.
Quinine and strychnine are usually of value.
On the Uses of the Stomach Tube Hampson Simp-
son would employ the stomach tube for diagnostic
purposes; for the removal of the contents for clinical
examination ; for inflating the stomach, and for the
detection of stricture at the cardiac orifice, for loca-
tion and measuring, for transillumination, to ascertain
the elasticity of the walls, to investigate the motor
function, and" \vith the ;c-rays to determine the size,
form, and position of the stomach. As a therapeutic
measure it is useful in cases of poisoning; for forced
feeding, lavage, to apply electric treatment, for intra-
gastric douching, for "internal massage," and for spas-
modic stricture of the cesophagus.
A New Eyelid Forceps, with a Spring Lock
that Can be Used on Both Sides O. Neustatter
describes an instrument which he has found useful in
practice.
Foreign Body, Chisel, Embedded in the Naso-
pharynx and Posterior Pharyngeal Wall. — By Cary
B. Gamble, Jr., and L. M. Tiffany. See Medical
Record, vol. Ivii., p. 67.
Locating Foreign Bodies in the Eye. — William
M. Sweet reports the results of two years' work with
the Roentgen rays.
Bu/ktin of the Johns Hopkins Hospital, February, igoo.
Report upon an Expedition Sent by the Johns
Hopkins University to Investigate the Prevalent
Diseases in the Philippines. — Simon Flexner and
Lewellys F. Barker, in writing of this expedition,
speak first of the value of their visit to Japan before
proceeding to Manila. Here, they studied beri-beri,
dysentery, and the bubonic plague. They first con-
sider the diseases in the Philippines which affect the
natives: (a) Skin diseases. Of the skin diseases pre-
vailing ajnong the natives, aside from smallpox and
other specific exanthemata, are (i) diseases of the
scalp, which are very frequent; (2) dhobie itch; (3)
an affection probably identical with Aleppo boil, (b)
Smallpox, {c) Leprosy; a definite focus of this dis-
ease exists in Luzon, (d) Tuberculosis; accurate
statistics of this affection could not be obtained, {e)
Venereal diseases; syphilis does not prevail unduly;
chancroids and gonorrhoea are very common. (_/")
Beri-beri.
The chief causes of disability among American
land forces are the enteric diseases: {a) Dysentery
is responsible for the greatest amount of invalidation
and the highest mortality. (/') Typhoid fever, (c)
Malarial fevers. {d) Tuberculosis. {e) Dengue.
(/) Tropical ulcers, (g) Wound infection. The
writers conclude with a note on climatological and
hygienic conditions existing in the islands.
A Case of Multiple Gangrene in Malarial Fever.
• — William Osier reports this rare and remarkable case.
The patient, a man aged twenty-three years, was ad-
mitted to the Johns Hopkins Hospital in November,
complaining of sores. Both hands, both feet, the left
buttock, and the occiput showed gangrenous areas.
Though the history did not suggest malaria, as in the
routine examination of the abdomen the spleen was
found to be considerably enlarged, the blood was ex-
amined, and very large numbers of ajstivo-autumnal
organisms were found. Large numbers of crescents
were present. Cultures taken from the blood proved
negative. The eosinophiles were only two per cent.
MEDICAL RECORD.
[March 17, 1900
The patient was given quinine in full doses and began
to improve rapidly. The larger sloughs were treated
with linseed poultices made with bichloride solution.
Haemophilia in the Negro. — Walter R. Steiner in
reviewing this case states that in the literature only
one well-defined case of haemophilia is mentioned.
This patient, a girl aged fourteen years, will conse-
quently make the second on record. Treatment con-
sisted in calcium chloride (gr. xv. t.i.d.) given in
Wright's prescription. It is interesting to note that
both the cases of ha;mophilia were not -in patients of
pure negro blood. In the family of the second, con-
trary to the usual statement, both the males and the
females seem to have been bleeders, but only one (a
male) died from the effects of hemorrhages.
Benjamin Jesty : A Pre-Jennerian Vaccinator.—
Thomas McCrae declares that there can be no doubt
of Jesty having performed vaccination in 1774. The
date of Jenner's first vaccination was 1796, although
for many years before he had been making observa-
tions regarding it. Jesty was born at Yetminster in
Dorset, and was a farmer.
Pediatrics, March I , igoo.
Report on the Cause and Prevention of Infant
Mortality — Ernst Wende concludes his article, giv-
ing milk tests, adulterations, and grounds for condem-
nation of milk, with prosecution and penalties. He
discusses preservatives of milk, condensation, etc.,
and concludes that the municipality should continue
supervision upon tk^ lines of: (i) Continuation of
the license system; (2) milk should comply with State
standards; (3) sanitary, non-absorbent milk-rooms
should be constructed with reference to hygienic rules;
(4) wagons should be protected from summer heat;
(5 ) intercourse with houses containing contagious dis-
eases should be prohibited ; (6) obligatory cleaning of
utensils should follow uniform method; (7) special
supervision or abolishment of sale of milk in groceries,
etc., is advised; (8) until State and city act in unison
milk from unsatisfactory dairies should be interdicted
or destroyed at the city line; (9) systematic reports
should be mutually made.
Alcoholic Cirrhosis of the Liver in a Baby. — R.
Abrahams gives the following case- A girl sixteen
months old had been ill for two months with greatly
distended belly and general an.Tmic condition. The
ascites interfered with walking. Diagnosis by exclu-
sion. The baby had been accustomed to take beer,
being allowed a glass a day from early infancy to im-
prove nutrition. Paracentesis gave relief and per-
mitted an enlarged and hard liver to be made out.
Rickets. — Charles Ailing Tuttle presents a si ort
paper. He finds the most plausible theory of causa-
tion is the so-called inflammatory theory, making the
cause primarily a chronic inflammatory condition be-
ginning in the bone-forming tissues. Under proper
treatment the prognosis is good. Treatment is pro-
phylactic, medicinal, mechanical, and operative.
Vaccination. — James W. Guest discusses the use rf
points versus glycerinized lymph, since the re-intro-
duction of which a revolution, he says, has taken place
in its favor. The quantity of lymph in the tube is too
large for most people, especially children. The ad-
vantages are: Greater percentage in taking; it can be
kept pure much longer, and one is more apt to get a
pure article from the store.
The Thomas Knee Splint — Henry L. Taylor says
this is in efiEect an ischiatic crutch transmitting the
weight of the body to the ground. An illustration
shows its adaptability to stages of osteitis of the knee,
ankle, and tarsus.
American Journal oj the Medical Sciences, March, igoo.
Conclusions Based on Sixty Cases of Fatal Gastro-
intestinal Hemorrhage due to Cirrhosis of the
Liver. — R. B. Preble states that fatal gastro-intestinal
hemorrhage is an infrequent but not rare complication
of cirrhosis of the liver. The cirrhosis is generally
atrophic, although it may be hypertrophic. In one-
third of the cases the hemorrhage is fatal; in the
others, they continue at intervals for varying periods-
of time — even eleven years. In one-third of the cases,
diagnosis can be made at or before the time of the
first hemorrhage; in the others, only after months or
years. CEsophageal varices are present in eighty per
cent, of the cases, and in many of them are seen
macroscopical ruptures. Fatal hemorrhages in cases
showing no resophageal varices are probably due to
the simultaneous rupture of capillaries of the gastro-
intestinal mucous membrane. In only six per cent, of
the cases showing oesophageal varices was the cir-
rhosis typical.
A Case of Traumatic Varix of the Orbit in which
Ligation of the Left Common Carotid Artery was
Successfully Performed. — Charles A. Oliver reports
this case of a man twenty-seven years old. The
patient had received a crush of the head at four years
of age, and this probably was the beginning of either
an aneurismal varix between the petrous and the
cavernous portions of the internal carotid artery and-
the corresponding cavernous sinus, or a varicose aneu-
rism with an intervening sac between the two vascular
channels. The situation was well protected in any
case, and the growth very slow. A second blow on
the same eye produced such painful symptoms that
the patient presented himself for treatment. The left
common carotid artery was tied. In five months the
condition of an absolute secondary glaucoma was
present. The fellow-eye continued normal.
The Histology and Histological Diagnosis of
Adenomyomata of the Uterus. — John Cooke Hirst
describes a case with this uterine tumor. In the uterus
were found embryonal epithelial inclusions from the
mucous membrane of Miiller's duct. These were
situated in the peripheral subserous layer of the
myometrium. Adenomata with glands and cysts in
scattered arrangement are to be considered as from
the mucous membrane as soon as they are provided
with cytogenic tissue sheaths around the glands. The
formation of subserous adenomyomata from incorpo-
rated glands of the uterine mucous membrane is pos-
sible.
The Ehrlich Diazo Reaction. — James R. Ameill
declares the results of his observations to confirm in
most particulars the statements of Ehrlich. To be of
value Erhlich's test must be made in accordance with
his directions. The pink foam is an important factor.
The statistics in cases in which the test has been cor-
rectly performed are overwhelmingly convincing as to
the value of this reaction in the diagnosis and prog-
nosis of typhoid fever, and the prognosis of diseases
such as pneumonia, diphtheria, septicaemia, and espe-
cially tuberculosis.
A Case of Tricuspid and Mitral Stenosis with
Adherent Pericardium — T. L. Chadbourne describes
this case. The patient was a woman thirty-six years
of age when first seen in 1894. She was an epileptic.
March i 7, /900]
MEDICAL RECORD.
469
The necropsy, held May 2, 1898, showed both the
mitral and tricuspid orifices to be so narrow as to
admit only the tip of the index finger. There was
complete obliterating chronic pericarditis. The prob-
ability of a double mitral lesion was entertained from
the first examination of the patient, but the true state
of the case was not discovered till the post-mortem.
Gangrenous Dermatitis Complicating Typhoid
Fever. — B. Franklin Stahl writes that bacteriological
examination of this affection showed cultures of staphy-
lococcus pyogenes albus and aureus, no other bacteria
being found. In the reported cases, the trunk was the
most frequent seat of the disease. Three of the ten
cases resulted fatally.
A Critical Summary of the Literature on Retro-
Peritoneal Sarcoma. — By J. Button Steele. See
Medical Record, vol. Ivii., p. 281.
T/ie Practitioner, Marcli, igoo.
The Pathology of Pneumonia and Pneumococcal
Infections. — J. W. VVashbourn says lobular pneumonia
may be caused by several kinds of organisms; the
most frequent are the pneumococcus, the streptococcus
pyogenes, and the influenza bacillus. We should dis-
tinguish pneumonias by the cause and not by the
anatomical effect, but imperfect methods make such
classification impossible. Pneumococcal affections
are here alone discussed. In lobar pneumonia the
pneumococcus enters by inhalation. In severe cases
they gain access to the circulation. Pneumonia is
therefore a septicsmia, the lung infiammation being a
local attempt to shut in the cocci from the circulation.
In lobar pneumonia the cocci, probably by means of
the lymphatics, pass through the whole of the lobe;
in lobular they are localized to individual lobules.
The discovery of large numbers of capsulated dip-
lococci in the sputum is almost pathognomonic of
pneumonia. More frequent bacteriological examina-
tion and classification of the different types of pneu-
mococcal infections together will mark an advance.
The Treatment of Acute Pneumonia. — R. \V. Philip
says that the key is to be found in the recognition of
pneumonia as a continued fever, and he prefers the
name " pneumonic fever." The local lesions are an-
alogous to the intestinal lesions of typhoid. The heart
and circulation should be guarded. The diplococcus
has yielded a rational basis for treatment, but the mor-
tality has not yet been materially reduced. Attempts
to destroy the organism have not been successful. At-
tempts to neutralize the toxic products are more
promising. First of all, an abundant supply of fresh
air and sunshine should be given and the strength
husbanded. In most cases after the first two or three
days alcohol will be useful. Cardiac tonics are called
for when the circulation shows signs of embarrassment.
Pain should be relieved quickly by poultices, fomen-
tations, or morphine. Oxygen should not be ordered
when the sick-chamber has become vitiated and sti-
fling. Antipyretics are rarely needed. Open air meas-
ures are to be adopted early in convalescence. Pro-
phylaxis should follow the same lines as laid down for
tuberculosis.
TheSo-Called " Ether Pneumonia."— J. Frederick
W. Silk says the term is misleading and to some extent
incorrect. There is no evidence that lobar or croupous
pneumonia occurs after ether with greater frequency
than might be expected from the normal rate of inci-
dence of the disease. Other potent causes are at work,
and it must be looked upon as a coincidence. Pneu-
monia after ether inhalation does not differ from the
ordinary type. On tiie other hand, catarrhal pulmo-
nary affections are prone to follow ether inhalations.
Prophylaxis is important, and care should be exercised
in administering ether to those with marked tendency
to pulmonary complaints.
The Treatment of Pneumonia. — Julius Dreschfeld
discusses croupous pneumonia in the adult. Weak
and elderly persons should avoid the sick-room. The
serum treatment is quoted from Washbourn. Older
methods are reviewed. The object should be to enable
the body to resist the toxic effects and to guard againsi
threatening symptoms. We must guard from the onset
against heart failure. If a diabetic develops pneu-
monia, the diabetic diet must be stopped and large
doses of aH<alies given. If a patient develops pleural
effusion, one may wait till the pneumonia has sub-
sided before paracentesis, unless there is much fluid
or much dyspncea.
Dust Pneumonia. — Alfred Hillier says that since
pneumococci are constant in the sputum of normal
individuals it is not improbable that the dust storms
of sub-tropical countries may be capable of exciting
inflammation, and act as a contributory cause, just as
do exposure, alcoholism, trauma, etc. Osier speaks of
chronic interstitial pneumonia due to the dust of cer-
tain occupations. Pneumococci may be inhaled with
the dust.
"The Diplococcus Pneumoniae. — J. W. H. Eyre
studies the morphology, biology, and pathogenesis of
the diplococcus, with staining-methods, conditions of
growth, action of germicides, media, vitality in cul-
tures, resistant forms, rate of growth, pathogenic
effects on animals, virulent types, post-mortem appear-
ances, inoculation methods, etc. A table gives the
susceptibility of animals.
Medicine, March, igoo. ■
The Operative Treatment of Fracture of the
Patella ; A Clinical Lecture Delivered October 20,
1899 Charles Greene Cumston states that the first
step in the operation for fracture of the patella is the
opening of the joint and freeing the fragments of
bone. There are various methods of making the
cutaneous incision, certain conditions, however, being
necessary for a proper incision. It should give plenty
of space and freely expose the joint. The flap should
be well supplied with blood at its base, and the latter
should be broad in proportion to the flap's height.
The cutaneous incision should be as far away as pos-
sible from the cicatrix in the bone in old fractures.
He believes the proper course in case of a recently
fractured patella is to wire it subcutaneously. Asepsis
should be perfect.
The Nature of Neurasthenia : A Study of the
Recent Literature. — Rosalie M. Ladova concludes
from her researches on this subject that nerve exhaus-
• tion, fatigue, primarily a simple detention of reflex
tonus, becomes only secondarily a chemical phenome-
non— defective nutrition. Any purely mechanical
stimulation of any of the peripheral nerves determines
first increased tension of the general tone, an increase
in energy, heightened intensity in the activity of all
the organs, and later on augmentation in the combus-
tion process. The nature of fatigue is primarily
dynamic, and the primary source of vital energy is not
in the nutrition, but in the centripetal nerve irrita-
bility.
The Intestinal Neuroses. — William J. Rothwell,
after reviewing those neuroses which are functional
disturbances, touches on their treatment. For peri-
47°
MEDICAL RECORD.
[March 17, 1900
staltic restlessness, in addition to general treatment,
arsenic and methylene blue are especially valuable.
In enterospasm sedatives and antispasmodics musftake
the place of purgatives; opium or codeine by the
mouth ; warm cataplasms on the abdomen, and soothing
enemata at intervals. In obstinate cases, injections
of warm oil are excellent. Enteralgia is amenable to
treatment by anodynes.
A Laryngo-Hyoidectomy for Carcinoma, with the
Report of a Case. — Jacob Frank states that the chief
indication for complete or partial excision of the
larynx has been carcinoma. In this case, which he
reports, as soon as carcinoma was diagnosticated he
advised laryngectomy. The patient was at date of
writing — a few months after the operation — able to
take solids and liquids by the mouth. The speech is
intelligible, but a hoarse monotone. ^Recurrence is,
l.owever, likely.
A Case of Oculomotor Paresis following Indirect
Violence — C. A. Veasy reports the case of a man
mirty years old. From the symptoms there was a
paresis of the right oculomotor nerve following an
injury to the left temple, and affecting those muscles
supplied by the inferior division of the nerve to a
greater extent than those supplied by the superior
division, as some movement of the lid and of the
superior rectus remained at the time of the first exami-
nation.
Prevention of Tuberculosis Charles J. VMialen
believes the best means of prevention of tuberculosis
to be the destruction of the sputum and the removal
of those affected who are too poor to receive the neces-
sary care at home to an isolation hospital which should
be provided by the State.
A Case of Ulcerative Endocarditis, with Aneurism
of a Sinus of Valsalva ; and a Case Simulating
Ulcerative Endocarditis. — By Augustus A. Eshner.
See Medical Record, vol. Ivi., p. 525.
Deutsche Aerzte-Zeitung, February /j, igoo.
Vaporization of the Uterus. — H. Fuchs reviews
the literature of the subject, giving SnegiurefT the
credit of being the first to show the hEEmostatic effect
of vaporization. Later this was applied to uterine
hemorrhages, particularly those of the climacteric.
The observations and methods of Pincus, Pawlik,
Pet'ha, Baruch, von Weiss, Diihrssen, and Flatau are
related at length.
Upon the Disinfecting Power of Aluminum Ace-
tate.— Aufrecht tabulates his experiments with the
antiseptic properties of alsol, liquor Burow, and car-
bolic acid upon anthrax bacilli, streptococcus pyo-
genes, staphylococcus aureus, gonococci, tubercle and
diphtheria bacilli. He concludes that the antiseptic
effect of aluminum acetate is enhanced by the addi-
tion of tartaric acid.
Resorption of Medicines. — Gustav VVendt states
that the method of administration witli various drugs
hasagreat influence upon their usefulness to the econ-
omy.
Upon the Occurrence of Inguinal Hernia — By
Graser. A continued article.
Zeit.fiir kliii. Med., I^os. j a/11/4, Vol. xxxix., I goo.
Observations upon Alimentary, "Spontaneous,"
and Diabetic Glycosuria, with Special Reference
to the Carbohydrate Variations of Febrile and Al-
coholic Patients. — J Strauss states that there is a
difference between the alimentary glycosuria produced
by the ingestion of sugars in predisposed individuals
and the glycosuria due to the consumption of starchy
foodstuffs. Numerous tables and many series of ex-
perimental cases are given upon the subject. He
concludes that the alimentary glycosuria e saccharo
is to be classified with the diabetic metabolic disturb-
ances. The differences between the glycosuria e' sac-
charo and ex amylo are apparently of a gradual nature.
Disturbances of a mild character give rise, under
otherwise favorable circumstances, to alimentary sac-
charine glycosuria, and disturbances of a severer
nature diminish the tolerance for carbohydrates.
Chronic Articular Rheumatism and Arthritis
Deformans in Childhood. — Axel Johannessen gives
at great length the literature upon this subject from
1484 to the present time. Thi'ee instances are related
with histories, photographs, treatment, macrosccpical
and microscopical examinations, etc. There are a
number of excellent .v-ray pictures. The first patient
presented a chronic history, with pain and swelling
in the ankle joint, and a good family history; atro-
phy set in later, then crepitation on movement. The
second case gave a gouty family history, and the dis-
ease began acutely as in articular rheumatism; atro-
phy of muscles and bones occurred later. In the third
instance the onset was chronic, atrophy was marked,
and the joints were thickened.
Lymphaemia without Swelling of the Lymphatic
Glands. — A. Pappenheim narrates an instance in which
during an acute leukasmia the blood showed the ordi-
nary typical lymphocytes in large numbers, although,
as in all cases of chronic lymphsmia in contradistinc-
tion to lymphocytosis, large lymphocytes were not
absent. In this case, the mild lymphatic enlargement
could not be the primary source of the disease, but
was rather the expression of the general infection.
The second instance was a pure specimen of lymphas-
mia without lymphatic enlargements.
The Alkalinity of the Blood in Certain Patho-
logical Conditions. — Burmin experimented with
Tscherbakoff's modification of Landois' method of
titration. The modification consists of dissolving the
tartaric acid in a sulphate-of-sodium solution. The
technique, with a tabulation of the various diseases,
chronic gastritis, catarrhal icterus, cirrhosis, pneu-
monia, bronchial asthma, etc., and their results, are
given.
Physiological Chemistry of Pentose and Methyl-
pentose. — Suleiman Bey says that xylose and arabinose
form lactose with the alkaline earthy oxides. Experi-
ments are described showing the separation of pentose
as barium dipentosate, and a new method of separating
pentose from methyl pentose (rhamnose).
Determination of the Alkalinity of Small
Amounts of Blood. — J. Hladik mentions a simple
method of determining for clinical purposes the blood
alkalinity. ,Vs little as 0.1 c.c. of blood may be used.
Experiments with fourteen diseases are tabulated.
Analysis of the Irregular Pulse — K. F. Wencke-
bach discusses allorliythmia, pulsus paradoxus, pulsus
bigeminus, and pulsus ahernans.
J'luska Liikari'siillskapets Haihllingar, January, igoo.
Statistics of Venereal Diseases in Finland V.
Leontjeff presents numerous statistical tables showing
the prevalence of venereal diseases in Finland. The
statistics are more accurate than they would be in
most countries, for tl)e people have an unusual dread
March 17, 1900]
MEDICAL "RECORD.
471
of syphilis, and any one even suspected to have this
disease is forced by the neighbors to undergo treat-
ment or to secure a certificate of health from a physi-
cian. The writer states that syphilis is diminishing
in that country and is also growing more benign, but
the number of cases of gonorrhoea, on the other hand,
is increasing.
Dystocia from Stricture of Bandl's Ring.— C.
Hahl reports a case in a woman aged twenty-four
years. The os admitted three fingers, but 10 cm.
above this was an opening 2 cm. in diameter with
thin edges but hard as if ossified. The opening was
enlarged as niuch as possible by means of Tarnier's
dcarteur, and the foetus was extracted after cephalo-
tripsy. The woman recovered.
A Fifth Series of a Hundred Laparotomies. — G.
Heinricius reports briefly on the fifth hundred lapa-
rotomies performed at the gynaecological clinic in Hel-
singfors. The mortality was four per cent.
C5o vr espoti d en cc.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
CFroin our Special Correspondent.)
The relief of Kimberley has been followed since my
last communication by two events of the first impor-
tance in the progress of the war, the capitulation ot
Cronje's army and the relief of Ladysmith. Each
event has enormous medical significance because of
the strain that has been thrown thereby upon the hos-
pital accommodation along all the lines of communi-
cation down to both bases, Durban and Cape Town.
The Physical Condition of the Boers, who capitu-
lated at Paardeberg under Gen. Piet Cronje, after a
struggle in which they displayed extraordinary resolu-
tion and gameness, was on the whole good, the num-
ber of sick and wounded being smaller than was ex-
pected. The total number of prisoners was just short
of five thousand, forty-one hundred being taken in the
bed of the Modder liiver, and six hundred (other ac-
counts give eight hundred) being captured in odd
parties during the many attempts to relieve the main
force. Two hundred severely wounded were found in
the Modder River laager, some of them being in a
shocking condition for want of surgical aid. These
were carried across the drift by the English bearers, and
are by this time in one of the hospitals on the line of
communication. At least two hundred more of the
prisoners required medical attention, for during the
last forty-eight hours of resistance Cronje's army was
placed in sore straits. Their laager was in a terribly
insanitary condition ; dead horses and cattle in various
states of decomposition were lying close to the tents,
the food supply was mainly putrid, and the insecure
shelter was made doubly trying by the cold, wet
weather at night-time. There was practically no
medical contingent with the force. The prisoners,
when they reach the base, will be placed on board
ship at Simmonstown — those of them, that is, who do
not require hospital attention ; and it is the experience
of every one throughout this campaign that once a
proper hygienic environment is provided health re-
turns, so pure and clean is. the air and so bahry the
daily temperature.
The Base Hospitals Near Cape Town, /.<-., the
three general hospitals at Wynberg and the sani-
tarium at Claremont, were becoming full again by the
beginning of March, and it is fortunate that the previ-
ous lull in hostilities, due to the English having to
wait for reinforcements, had emptied them before the
stress of Lord Roberts' movements was felt in them.
Sir Redvers Buller's second attempt to relieve Lady-
smith, the march that culminated in the futile seizure
of Spion Kop, cost the English one thousand and
twenty in wounded, and five hundred of these, officers
and men, were brought round from Durban to Cape
Town by the hospital ships Spartan and Lismore Castle ;
but except for their patients and the sufferers from
enteric fever contracted at the Modder River camp,
the Cape Town hospitals were fairly empty by the
time Roberts' casualties after the relief of Kimberley
began to arrive. On the whole, the relief of Kimber-
ley and the capture of Cronje's army did not cost the
English many lives, but the list of casualties was a
long one, and the Royal Army Medical Corps have to
work at top pressure to keep level with what is re-
quired of them. Roberts had fifty thousand men with
him when he entered the Orange Free State, and a
large proportion of them were under fire for a week as
well as making forced marches, so that it was well
that the big base hospitals were ready to receive sev-
eral hundreds of patients, and it was particularly well
that all the arrangements for transport of the sick,
which I have already described, were complete.
The Relief of Ladysmith was effected on the even-
ing of Wednesday, February 28th, by Buller's force on
the fourth attempt. No doubt the surrender of Cronje
the day before had led to the withdrawal of seme
f the Boer troops, and possibly to the desertion oE
others, but enough remained to dispute with the Eng-
lish every foot of the way. The Dublin Fusileers and
the Inniskillings, two Irish regiments, made some
magnificent charges, and lost heavily, but when the
relief was actually effected it was done without any
severe casualties. But altogether, in his four attempts
to join hands with Sir George White, Buller had some
three thousand of his men wounded or too ill to fight.
This means that an enormous strain has been thrown
upon the hospitals in Natal. Even before the relief of
Ladysmith this strain was shown by the fact that after
the attack on Spion Kop a proportion of the wounded
had been conveyed round from Durban to Cape Town.
Since then there have been one week's continuous
fighting and one week's desultory skirmishing, every
day of which added to the total of wounded, while
now the sick of Ladysmith have to be cared for. The
succor of Ladysmith did not come one moment too
soon. The rations of the beleaguered had been re-
duced to half a pound of meal a day, and the horses
and mules were being used to supplement the meat
supply. There were many cases of typhoid fever and
many more of extreme weakness from emaciation.
The whole of Sir George White's fine force, still num-
bering about nine thousand men, will require some
days' rest and feeding before they vv'ill be able to assist
in any forward movement, and the brigade of cavalry
are rendered temporarily useless by the condition of
their horses. Enormous preparations were fortunately
made both at the fourth general hospital at Mooi
River, the big hospital at Pietermaritzburg, the Dur-
ban hospitals, and in many private houses to receive
the sick from Ladysmith whenever Buller should get
there, so that the garrison, so long inactive, will soon
be on the aggressive again.
Casualties in the Royal Army Medical Corps. —
The deaths of two more officers of the R.A.M.C. are
reported. Captain R. H. E. Holt, who entered the
medical service of the army eight years ago, died of
wounds received in one of the February engagements.
Captain G. S. Walker, who was of the same seniority,
died of typhoid fever in Ladysmith a week before the
siege was raised. Lieutenant Mackenzie, who was
wounded at Koodoosberg, having already distin-
guished himself at Magersfontein, had only joined the
R.A.M.C. a few weeks before war broke out.
472
MEDICAL RECORD.
[March 17, 1900
The Hospital Ship "Princess of Wales" arrived
at Southampton, England, on February 25th, and on
February 26th was visited by H. R. H. the Princess
of Wales. The sick brought back expressed them-
selves grateful for a pleasant and uneventful passage.
Most of them went to Netley Hospital on landing,
where they and the other patients were visited by the
Queen on the following day. Her Majesty brought
to Netley the information of Cronje's surrender, which
before her arrival was unknown to the men.
Lieutenant-Colonel Sloggett, R.A.M.C, and Mr. A.
D. Fripp, respectively military superintendent and
chief civil surgeon to the Imperial Yeomanry Hospi-
tal, arrived at Cape Town on February 28th. The
Imperial Yeomanry Hospital is, I learn, to be placed
at Deelfontein, a place some thirty miles south of De
Aar Junction. Now that the English are sure of their
lines of communication, the tendency there shown to
establish hospitals rather nearer the fighting forces
will be maintained, and the immensely long trans-
ports of the wounded avoided.
A Brave Medical Officer. — I send you a story of
how an officer of the R.A.M.C. with Buller's force
was wounded :
Captain , R.A.M.C, was wounded on Janu-
ary 23d near Colenso at a distance of one hundred
yards while he was bending over in the act of dressing
a wounded man. The wound of entrance was through
the right rectus abdominis muscle, one inch below the
costal margin and one and a half inches from the median
line. The wound of exit was one inch above and one
inch behind the centre of the right iliac crest. The
symptoms were nil throughout, although it was difficult
to suppose that the ascending colon escaped perfora-
tion. This officer watched himself carefully for
symptoms which he believed must inevitably arise.
He knew where the entrance wound was almost di-
rectly, but did not localize the position of the exit
wound for two hours afterward. He tried to finish the
dressing of the wounded man, but became giddy and
had to lie down. He then remained perfectly still on
his back for twelve hours, suffering much from the
constrained position but nothing from his wound, and
refused to take some water offered to him by the Boers.
Two other men close by, who were also shot through
the abdomen, did drink, although strongly advised by
him not to do so, and soon began to suffer very much,
one vomiting constantly. The captain had eaten only
■ a little porridge for breakfast ten hours before, and
took nothing by the mouth for forty-eight hours after-
ward. On the 31st he was convalescent, and he had
no abdominal symptoms throughout.
The pluck which led a man in the agony of an ab-
dominal wound to attempt completing his ministration
upon another wounded man cannot be too highly com-
mended. It will also be noted that the medical
knowledge of Captain probably saved his life,"
for had he moved much, or been made to vomit by
drinking unwholesome water, the risks of peritonitis
would have been incalculably increased.
THE CLIMATE OF NASSAU, N. P.
To THE Editor of the Medical Record.
Sir : Nassau, the capital of the Bahamas, situated on
the island of New Providence, has received of late
very little notice, either in regard to the health-giving
qualities of its wonderful climate or the opportunities
one can enjoy for sport and recreation. I have been
impressed more especially with the facility with which
invalids recover from grippe and bronchial troubles,
contracted in northern latitudes. Patients have come
here suffering from colds and laryngitis, recovering
from some of the more severe lung affections, like
pneumonia, pleurisy, etc., and, after resting for a
few days in rooms where the temperature is always
from 70° to 73° F., their coughs leave them, the secre-
tions are lessened, and they begin to enjoy sitting out
of doors in the soft, balmy air, and, with proper pre-
cautions toward evening, gain rapidly in health and
strength.
There is some humidity at all times, but clothes do
not feel damp, and I have yet to see mould gather on
boots or books, as it does at some of the Northern sea-
side resorts.
No rain falls through the winter months, and each
day is a repetition of the one just passed — balmy
breezes and cloud-flecked skies.
Tuberculous cases, either of lungs or larynx, and
of an advanced type, do not seem to improve very rap-
idly, and I should not advise patients with the disease
far advanced to come here. I consider it an idea)
place for early nephritic disease; the skin is kept by
gentle exercise in a moist condition, so helpful to im-
paired kidneys, and by care and a complete change of
clothing on coming in from wheeling or golf, one
avoids driving the blood back upon the internal or-
gans, and obtains all the benefits of summer in home
latitudes.
The changes of temperature are not sudden ; the
lowest point reached during my stay here thus far has
been in January, when it was 62° F. at 6 a.m., and at
that time New York was suffering from a cold storm
and a temperature of 12° above zero. The usual
daily range is from 70° to 73°, the highest having
been 78.°
Judging from a visit here some years ago and my
stay this winter, I feel no hesitancy in saying that
Nassau combines all the qualities that go to make up
an ideal resort for those who wish to escape the rigors
of our northern winter, and also for convalescents who
desire a climate which admits of constant out-of-door
life. William E. Bullard, M.D.
Nassau, N. P., Bahamas, February 20, 1900.
CHLORAL AS A RELAXANT.
To the Editor of the Medical Record.
Sir: The treatment of strangulated hernia in your
number of February 17th recalls some memories.
While I believe in the operative treatment of hernia
under favorable conditions, whether strangulated or
not, there are times when it will be agreeable to
patient and physician alike to avoid operation, if
practicable. At such times chloral may be useful.
In the interior of Montana, twenty odd years ago, I
was sole medical attendant with a detachment of
troops in the field. A lieutenant of the line was rup-
tured. I failed to reduce the hernia by taxis under
chloroform. I decided to try the effect of a large dose
of chloral before undertaking operation with such as-
sistance as the lieutenant's brother officers might ren-
der. I placed the officer on his back upon a cot, hips
elevated, and gave as much chloral as I considered
safe, and went about preparations for operation.
Under the profound sleep induced the hernia was
spontaneously reduced.
Many years later, at a remote frontier post, a civil-
ian was brought to the hospital with a strangulated
inguinal hernia. I failed to reduce it under chloro-
form, and proposed immediate operation. The patient
begged for further time and trial. As night was ap-
proaching, and the symptoms were not yet alarming,
I consented to postponement until the following morn-
ing. I treated the case in the same way as that of the
lieutenant. I visited the patient before retiring for
March 17, 1900]
MEDICAL RECORD.
47;
the night, and found him asleep in the position I had
left him, and the hernia was reduced.
Having no failures to offset these cases, they seem
to me suggestive. S. S. Turner,
Acting Assistant Surgeon, U.S.A.
THE WORK DONE BY THE MARINE-HOSPI-
TAL CORPS IN HAVANA.
Sir: a recent visit to Havana gave me the oppor-
tunity of inspecting the excellent sanitary work that is
being done by Drs. Guite'ras, Dudley, and their asso-
ciate of the Marine-Hospital corps. These gentlemen
deserve the greatest praise for tlieir energetic methods
and their efforts not only to check and uproot disease,
but to protect the United States, and their ceaseless
and successful labor is fully in accord with the spirit
of reform inaugurated by the American authorities in
the island of Cuba. Handicapped as they were and
are by the criminal neglect of the Spaniards and the
carelessness of the Cubans, they work with a rare will
and intelligence that bid fair to reduce greatly the
danger at our very doors that has menaced us for so
long. The results already attained by this little body
■of medical men in a few months form a strong argu-
ment for placing every American port under the con-
trol of this branch of the national government, and will
insure the uniform harmony of action which has be-
come a necessity.
I may be pardoned for referring to the plan followed
by the Marine-Hospital corps:
1. This branch of the service has the inspection of
incoming vessels from foreign ports and from such
home ports as are known to be infected. Two medical
•officers are assigned to this duty. The vessel enters
the port flying the quarantine flag, and is immediately
boarded by the medical officer, who makes a careful
inspection of the ship, its crew, and passengers. The
condition of the baggage is also carefully inspected,
and if there has been or is a case of sickness of a con-
tagious or infectious nature, the vessel is kept in
quarantine at the Mariel quarantine station, ten miles
distant. There the passengers are landed, and the
vessel returns for disinfection of everything. Since
the appearance of plague in Portugal and Spain, espe-
cially precautionary measures have been taken with
the inspection of these vessels, and the entire crew
and passengers pass through the hands of three differ-
ent medical officers, who work independently of each
other. Of course all of the necessary guards are
placed on board to watch baggage and prevent people
from leaving the vessel, or people from shore boarding
the vessel.
2. Vessels leaving Havana for ports in the United
States, or for other ports in Cuba, are invariably in-
spected by the medical officer in the same careful way,
and he gives the vessel its necessary bill of health.
It must be readily seen that in a harbor of this size,
where the shipping commerce is so active, quite a large
corps of medical officers is necessary, with quite a
number of boats. There are at present five boats for
the use of these officers.
3. The third department at this station is devcLed
exclusively to the inspection of passengers leaving
here for the United States, and for certain ports in the
island of Cuba. This inspection is carried out at this
office by Dr. Menocal. A passenger going to any port
in the United States is advised to present himself at
this office for a certificate of health. He is examined
for vaccination. If he has been successfully vacci-
nated and is in good health, a certificate is issued. If
not, he or she is vaccinated and then allowed to pro-
ceed. In 1897 and 1898, when smallpox was wide-
spread in tiie city, the officers were obliged to be much
more exacting in regard to immunity to smallpox.
Then a passenger was required to show recent and suc-
cessful marks of vaccination. The vaccination marks
that proved to be over four years old were considered
insufficient, and at that time they vaccinated the pas-
senger and held him for five days. He then presented
himself at the local office, and if the operation was
unsuccessful, he was revaccinated and then allowed
to proceed. This year there has really been no small-
pox, and it has been unnecessary to enforce so severe
a regulation. The great value of the inspection of
passengers by the service is manifest during the quar-
antine months from April ist to November ist. As is
known, the different southern States have different
regulations regarding non-immunes to yellow fever,
and the Marine corps, while carrying out its own regu-
lations, tries to co-operate with the various State boards
of health. Passenger traffic between Havana and
Florida demands the greatest vigilance on its part.
During this quarantine period non-immunes to yellow
fever are not allowed to go from Havana direct to
Florida. The voyage from Havana to Florida ports is
very short, and an individual who has been exposed to
yellow fever could arrive in Florida two or three days
before the completion of the period of incubation of
the disease. Such passengers as are allowed to go are
obliged to prove to us their immunity. A proof of
having had a previous attack of the disease or proof
to the effect that the individual has resided in an
infected focus continuously for ten years is accepted.
The greatest care has to be exercised in the considera-
tion of various certificates of immunity presented by
passengers. There is at the Havana office a record of
thousands of names of people who are registered there
as immunes to yellow fever. All baggage for the
States is carefully inspected and disinfected by this
service. Baggage for the southern States is disin-
fected on the barge Protector, and then sent on board
the vessel. Baggage for ports north of the southern
boundary line of Maryland is disinfected by the shore
plant.
4. The disinfection of vessels for ports in the United
States during quarantine period by the barge Frotector,
which is equipped with hot chamber, steam boilers,
apparatus for bichloride spraying and formaldehyde
disinfection. In the southern States disinfection and
detention are required of all vessels. It has been pos-
sible to help the shipping interests a great deal, and
time and a large outlay of money have been saved by
disinfecting these vessels in Havana, when bound for
southern ports in the United States. A vessel is dis-
infected by the Frotector, and immediately on comple-
tion of disinfection, that is, after the sulphur has been
in the hold for the required period, the vessel is given
her bill of health and allowed to proceed, and she
makes up her detention time on the voyage. A vessel
going from Havana to a certain port can save one to
three days' detention time. For instance, a vessel
arriving at her destination three days out of Havana
simply has to be detained two days at her port of arri-
val; whereas if she had gone directly to the port, and
had been disinfected at the port of arrival, she would
be detained five days after her disinfection.
5. Under this heading conies the inspection oi
cargoes (this is especially important during the quar-
antine period) ; character of cargoes inspected ; method
of packing; and certain prohibited material is of
course not allowed.
6. Inspection of ballast. Vessels carrying ballast
from Havana are required to carry either water ballast
taken outside the harbor, or to carry rock ballast of a
474
MEDICAL RECORD.
[March 17, 1900
hard and flinty character, which must be non-porous,
so that disinfection can easily be carried out.
7. The inspection of all express matter, and the
disinfection of such express packages as require it.
8. Under this heading comes the general sanitary
supervision of the harbor; and the Marine-Hospital
corps keep themselves informed as to the sanitary con-
dition of vessels while in port, the different wharves,
and, in fact, the entire bay.
9. Medical assistance given to American merchant
vessels while in port. While this department has no
hospital in Havana, the American masters invariably
call on this service for medical assistance, and it has
always furnished medical aid.
In addition to all this work it must be understood
that there is a large amount of baggage to be handled
during the year, and a regular baggage system has been
established not unlike that of the railroads, with a
baggage master, clerks, and checking system.
Allan McLane Hamilton, M.D.
^itroical 5'itODCstions.
A Saponic Lubricant for catheters, etc. :
If White castile soap, powdered 5 i.
Water tl | iij.
Mucilage of chondrus crispus fl | iij.
Formalin (forty per cent.) ill x.
Thymol gr. v.
Oil of thyme m v.
Alcohol TTL XV.
Mode of preparation : Heat the soap and water, and
stir until a homogeneous slime is formed; then add
the three ounces of mucilage (made of the strength of
one ounce of chondrus crispus to the pint of water).
When cool, pour in the formalin, then the thymol and oil
of thyme mixed with the alcohol; stir, strain, and keep
in a covered vessel until all air bubbles have vanished.
The result is an opalescent, slimy substance, of the
consistence of honey, which should be put up at once
in two-ounce collapsible tubes and sterilized. — Gou-
LEY, A^etv York Medical Journal, November 4th.
Hot Vapor as a Haemostatic Among the disad-
vantages is the possibility of sloughing being pro-
duced. In parenchymatous bleeding the method is
of surprising efficacy. Vapor under pressure has,
however, little effect when the bleeding vessels have
a decided calibre. Benefit is also secured from the
asepsis and heat. — Teccherelli and Bonfanti.
Erosions of the Cervix Uteri. — It will be recog-
nized from what I have said that I do not consider
erosions the innocent or simple aftairs which many I
am sure do. I believe that the}' have a marked intlu-
ence upon the nervous system of delicate women, and
that something should be done for their relief. In
order to attain better results than I can by applications,
and in many cases by attention to the general health,
I am more and more inclined to treat these cases by
operation. — F. H. Davenport, Boston Medical and
Surgical Joiirjial, October 12th.
Epistaxis — If the bleeding is from far back and of
a persistent character, plugging will be required. lor
this I use long strips of iodoform gauze which have
been soaked in a mixture of peroxide of hydrogen and
an antiseptic oil (containing menthol, eucalyptus,
thymol, and camphor in liquid vaseline). The oil is
somewhat hjemostatic. and prevents the gauze from
sticking to the parts and setting up bleeding again
when it is removed a day or so later. By putting the
oil and peroxide in a small wineglass and soaking the
gauze therein, the mixture is readily effected. To in-
troduce take the nasal forceps and, carrying one end
of the gauze far back, gradually fill the entire nostril.
— George L. Richards, Jnternational Journal oj Sur-
gery, October.
Hip-Joint Tuberculosis. — It is a rare thing now-
adays to have a fatal septic arthritis follow resection,
the former bugbear of the operation, the mortality
having changed from sixty per cent, to less than three
per cent. — Mc-Vrthur.
The treatment of hip disease is practically a purely
mechanical problem; operative treatment is not de-
manded by more than one per cent, of cases that are
subjected to even moderately effective mechanical
treatment. We are of the opinion that operative treat-
ment should be resorted to only as a life-saving meas-
ure, because the best results of operative treatment are
inferior to the poorest results of mechanical treatment.
• — John Ridlon.
Treatment of Fractures of the Patella. — Dr. Will
H. Means {Co/umfius Medical Journal, July 5th) offers
the following conclusions to an interesting article:
(i) The results of the non-operative treatment are
unsatisfactory both as to long confinement and func-
tional disability. (2) The methods of maintaining
apposition of the fragments by external appliances
are unsatisfactory and unscientific. (3) In open
arthrotomy the fragments can be carefully approxi-
mated and sutured in such a manner as will maintain
apposition and, ultimately, bony union. (4) The oper-
ative method saves months of confinement, and gives
permanent results. (5) The buried suture material
should be absorbable, such as catgut or kangaroo ten-
don. (6) The field of operation should be continu-
ously irrigated with a hot salt solution during the
manipulation, and the incision closed without drain-
age. (7) The massage treatment begun at an early
date is an important factor in restoring functional
activity of the joint.
First-Aid Packages. — In a paper read by Dr. N.
Senn at the American Surgical Association meeting
held June 7, 1899, the following conclusions are
formulated: (i) P"irst-aid packages are indispensable
on the battlefield in modern warfare. (2) The first-
aid dressing must be sufficiently compact and light to
be carried in the skirt of the uniform, or on the inner
surface of the cartridge or sword belt, to be of no in-
convenience to the soldier or in conflict with military
regulations. (3) The Esmarch triangular bandage is
of great value in the school of instruction, but in the
first-aid package it is inferior to the gauze bandage.
(4) The first-aid package must contain in a waxed
aseptic envelope an antiseptic powder, such as boro-
salicylic powder, two sterilized safety pins wrapped
in tinfoil, and between this package and the outside
impermeable cover, two strips of adhesive plaster one
inch wide and eight inches long. (5) The first-aid
dressing must be applied as soon as possible after the
receipt of the injury, a part of the field-service which
can be safely entrusted to competent hospital-corps
men. (6) The first-aid dressing, if emploj-ed behind
the firing line, should be applied without removal of
the clothing over the injured part and fastened to the
surface of the skin with strips of rubber adhesive
plaster, the bandage being applied over and not under
the clothing. (7) The first-aid dressing must be dry
and should remain so by dispensing with an imper-
meable cover over it, so as not to interfere with free
evaporation of the wound-secretion. (8) The first-aid
dressing should not be disturbed unnecessarily, but
any defects should be corrected at the first dressing-
station.
March 17, 1900]
MEDICAL RECORD.
475
^cxn %nstvn\mnta.
A MIRROR-TEST FOR SIMULATED BLIND-
NESS.
By PERCY FRIDENBERG, M.D.,
One might paraphrase a well-known epigram to indi-
cate that we are able to detect some frauds all of the
time, and all frauds some of the time, but not all frauds
all the time, and it is rather to supplement than to sup-
plant the various methods for the determination of vis-
ual acuity in cases of alleged blindness that a new and
simple apparatus is presented.
In a recent publication' the writer took occasion to
point out that in almost all instances of simulation
the claim of monocular amblyopia only is made, as
this condition is so much more easily feigned than
loss or deterioration of vision in both eyes. The great
majority of detection tests aim to secure an admission
of binocular vision or else to induce a physiological
act inseparable from it, such as accommodation,
convergence, or fixation ; the former without the
subject's knowledge, the latter independent of
his will. The theoretical basis of such tests is
that we are unaware of, or rather habitually over-
look, the fact that we .receive a double sensory
impression from each object in our field of
vision, which, falling on corresponding points
of- either retina, are translated by the cerebral
centres into their real significance and are seen
as one image.
The principle upon which the writer has pro-
ceeded is the corollary of this fact, for it is true,
conversely, that when the image of an object
falls on the retina of one eye only, as by reflec-
tion from a mirorr, we do not detect the absence
of binocular vision, and fail to refer our sensory
impression to its proper source so as to rec-
ognize which eye is being used. An instrument
was devised to present the mirrored image of a test-
card to ;he subject of examination in such a way that
it jrm be seen by one eye only at a time, allowing a
quantitative determination to be made of the vision of
either eye without giving any clew as to which eye is
being tested.
The test-cards are attached, one at each temple, to a
spectacle frame in which, if necessary, glasses can be
placed for the correction of ametropia, facing a small
mirror which slides on a horizontal arm so as to allow
its distance from the oye to be regulated. The mirror,
which has ; lateral adjustment to correspond with the
inter-pupillary distance, is mounted on a short bar,
hinging n the slide, and can be presented to either
eyo in succession by revolving the carrier through an
arc . f 180 . Tiie lateral tilt of the mirror is indicated
by a pointer on . horizontal scale. When the pointer
is :»t 90° the mirror is at right angles to the line of
vision of ihe corresponding eye, so that the latter sees
its own reflected image. The test-card on this side,
however, is not normal to the plane of the mirror, and
its image is reflected only into the opposite eye, which
the subject presumes to be unconcerned in the visual
act, as this eye is nowhere in evidence. A slight tilt-
ing of the mirror to the temporal side, bringing the
pointer to 95' or 100°, is sufficient to reverse the opti-
cal conditions, so that the test-card is approximately
normal to the mirror, and its image is now reflected
int'. the ey^ of the same side only.
By switching the mirror-carrier over to the opposite
side of ihe frame a similar double test can be applied
to the other eye; or this can be accomplished without
'Ophthalmic Record, January, iSgg.
bringing the mirror over, by giving it a nasal tilt,
bringing the pointer to 70'^ and to 60-65*^ respectively;
so that in all eight variations can be rapidly obtained.
The following table indicates the various possible
com.binations;
Mirror before O. D. :
1. At 95 degrees right card is seen by right eye.
2. " go " left
3. " 70 " left " right "
4. " Co " left
Mirror before O.S. :
1. At 95 degrees left card is seen by left eye.
2. " 90 " " " right "
3. " 70 " right " " " " left
4- " <■>" right ■'
In practice, the test is made with the mirror before
the admittedly sound eye, but in the second position.
If the card is read at this angle, it must be by calling
into play the other eye which the malingerer does not
even see, but whose action is demonstrated by having
him close it. He will then be convinced, by seeing
nothing, that the sound eye which he believed he was
using was in no way concerned in vision. As a con-
trol test, the mirror is brought before the simulating
eye, again in the second position, so that the card and
this eye are seen by the subject, who naturally thinks
that the mirrored eye is the one which receives the
visual impression, whereas, in fact, it is seen by the
sound eye which is nowhere visible. If it is now
stated, as will most probably be the case, that the im-
age cannot be seen, deliberate falsehood at least is
made evident. The test is simple, rapid, and accurate,
offers no clew to the simulant, and enables us to make
a quantitative determination of vision. Another ad-
vantage lies in the fact that the instrument demon-
strates itself and can be handed around to the mem-
bers of a class, commission, or jury to prove the
conditions found, without the necessity of going into
any theoretical explanation of the optical principles
involved.
Note. — As the mirror gives a reversed image, the
characters must be printed backward, or face both
ways, as A, O, V, V, T, etc.; or the "illiterate" type
is used. It should be remembered that the actual test-
ing distance is twice the distance of the mirror from
the eye. When the mirror is twelve inches off, the
characters subtend a visual angle corresponding to a
distance of twenty-four inches. The instrument may
be used for distant vision by placing the patient with
his back toward a test-card twenty feet away, and hav-
ing him read in the mirror as before. For this test
the apparatus should be firmly fastened to a suitable
stand.
Periosteal flaps should be secured, if for no other
reason, to prevent the disagreeable complication of
skin-puckering in the stump.
476
MEDICAL RECORD.
[March 17, 1900
THE PRACTITIONERS' SOCIETY.
One Hundred and Fifty-third Meeting, Held Friday,
February 2, igoo.
A. Alexander Smith, M.D., President, in the
Chair.
A Case of Partial Laryngeal Paralysis — This case
was presented by Dr. Beverley Robinson. E. J.
H , male, twenty-nine years old, single, Ameri-
can, an electrician, came under observation Novem-
ber 24, 1899. He had tonsillitis three years ago,
with a membranous exudate on the tonsils. His ill-
ness at that time was slight; he was not confined to
his bed and was about in a few days. Hoarseness
began four months later. During two and a half
years it was not continuous. During a period of two
months, for example, he had a good voice, and then,
without apparent cause, he would lose his voice in
about two months and regain it without obvious
reason. Since last spring the patient had been con-
tinuously hoarse. During the past few weeks, oc-
casionally and for a short time, the voice was much
improved, but was never entirely natural. Until the
patient came under Dr. Robinson's care he had had no
general or local treatment. On October 31, 1899, he
went to Saranac Lake. He stayed there one month,
walking, skating, shooting, etc. His general health
was good until last spring; since last spring he had
been tired from overwork. He lost ten pounds in weight
in six months. There were no fever, no cough, and
very little sputa; no hemorrhage, no soreness of throat,
no dysphagia, no dyspnoea. The patient was not ner-
vous. He had had no syphilis. There was no local-
ized swelling in the neck. On November 24, 1899,
a physical examination of the chest showed doubtful
signs of phthisis at the right apex. The larynx showed
congestion and slight general infiltration. The right
vocal cord moved well in phonation. The left vocal
cord was covered by the epiglottis which inclined
toward the right. No growth could be seen. The
urine was normal. The blood examination showed
a slight secondary anasniia, probably, which might,
however, be a simple anemia or chlorosis. Careful
examination of the sputum on two occasions showed no
tubercle bacilli. Treatment consisted of emulsion of
cod-liver oil and creosote internally, with the use of
a perforated zinc inhaler with creosote and alcohol.
Local applications were made to the larynx of gly-
cerite of borax and later of tincture of chloride of
iron and glycerin, with a stimulating liniment to the
neck. His present condition was as follows: The
larynx showed very slight congestion in parts; the
epiglottis was rather anaemic than otherwise; it had
returned to the median line. The left vocal cord
could now be seen. During phonation it approxi-
mated the median line, although sluggishly. The
abduction of the left vocal cord w^as less active than
the right. Physical examination of the chest showed
little or nothing abnormal. The diagnosis at present
was partial paralysis of the adductors and abductors
of the left vocal cord. The causation was obscure.
If it was a post-diphtheritic paralysis it should not
be, probably, unilateral, and would not affect the ab-
ductor muscles of the larynx. If it was due to thora-
cic growth, without other signs, it should cause paraly-
sis of the abductor muscles and not affect the adductor
muscles. No doubt later a positive diagnosis as to
causation might be made. The patient's general
health was now thoroughly good.
The case reported might possibly be one of primary
tuberculosis of the larynx, which was now in its in-
cipient stage. The paralysis of the muscles on the left
side might be explained rationally, in part by so-
called functional disturbance, in part by tuberculous
infiltration. If ulceration should occur bacilli might
be found.
In connection with the above case. Dr. Robinson
read the following letter from Dr. Frederic E. Sondern
concerning the new culture method for the rapid growth
of tubercle bacilli :
"Dr. W. Hesse published the method in the Zf/A
schrift fi'tr Hygiene, etc., in the fall of last year (1899).
The essential element in the agar-agar culture medium
is Nahrstoff Heyden, an albuminoid product. The
claims for the method are a rapid growth of tubercle
bacilli in from five to six hours or more, and a re-
tarded growth of many if not most of the contaminat-
ing bacteria contained in the specimens of sputum,
etc., under examination. In this way he claims that
a decided increase in the number of tubercle bacilli
can be demonstrated when a specimen of tuberculous
sputum is planted, which on usual microscopical exami-
nation shows but very few isolated bacilli. He re-
cords some failures when the sputum contains many
contaminating organisms which at times overgrow the
small colonies of tubercle bacilli in a very short time.
" For somewhat more than two months I have been
applying the Hesse culture method to every specimen
of sputum, urine, or other fluid sent to me for exami-
nation, which might possibly contain tubercle bacilli,
and have for the present arrived at the following con-
clusions: (i) As yet the culture method has never re-
vealed tubercle bacilli in specimens inwhich they could
not be found by some other method of examination^
excluding animal inoculation. (2) Not infrequentl)-
the rapid growth of contaminating bacteria ruined the
culture attempt. This applies alike to sputum, urine,
and other fiuids. (3) Numerous specimens were en-
countered, however, especially of urine and tubercu-
lous serous fluids, in which the usual examination
revealed so few bacilli not always absolutely charac-
teristic, while the Hesse culture method produced
pictures justifying an undoubted diagnosis.
"Continued use of the method will demonstrate its
practicability as well as its limitations much more
firmly."
Dr. J. \V. Brannan asked Dr. Robinson if he had
tried the tuberculin test.
Dr. Robinson said he had not. He thought the
suggestion a good one.
Dr. Brannan said that his experience with paraly-
sis of the vocal cords was principally confined to cases
in which the disability followed intubation, and in
which the tube had been left in for weeks or months.
In those cases the paralysis was probably the result
of pressure; the abductors were usually affected.
Dr. F. p. ICiNNicuTT said he thought the tuberculin
test would prove decisive, so far as the presence of
tuberculosis was concerned. The occurrence of tuber-
culous laryngitis without previous implication of the
lungs was exceedingly rare, and in such instances the
lungs became involved sooner or later. Dr. Kinni-
cutt said that during the past ten years he had seen
tw'o or three casts in which the tuberculous process in
the larynx preceded the lung trouble, so far as the ab-
sence of physical signs permitted one to judge; in two
of the cases the laryngeal symptoms preceded the pul-
monary symptoms by several months.
Dr. Robinson, in reply to a question, said that no
temperature elevation had ever been found. The man
had lost about ten pounds in weight during the past
six months.
Dr. Andrew H. Smith, after an examination of
the man's larynx, said he did not think the picture
presented was one of laryngeal phthisis, although the
March i 7, 1900]
MEDICAL RECORD.
477
general appearance of the patient, together with his
loss of weight, pointed to a tuberculous trouble some-
where in the body.
Dr. Kinnicutt said it was entirely possible to have
tuberculosis of the larynx without any elevation of
temperature. The speaker said he had noted this fact
even in cases in which the tuberculous process in the
larynx was well advanced.
Dr. V. P. GiBNEY asked whether, in a case of tu-
berculosis of the larynx followed by pulmonary tuber-
culosis, the process extended by continuity or by gen-
eral infection.
Dr. Kinnicutt thought that the most rational expla-
nation was in an extension to the lungs through an
inhalation infection.
Dr. T. Mitchell Prudden said he thought the ex-
planation by Dr. Kinnicutt was probably the correct
one. When these cases came to autopsy it was very
difficult to make out how the infection had spread.
Dr. Gibney inquired whether the possibility of pul-
monary infection could be averted by any surgical
measures.
Dr. Kinnicutt replied that abroad a very radical
method had been employed of scooping out these le-
sions in the larynx.
Dr. Robinson said that cases of primary laryngeal
-tuberculosis were so rare that the question of the mode
of extension of the process to the lungs was still un-
settled. In regard to treatment, tracheotomy had been
tried in some cases, in order to help such a diseased
larynx by putting it at rest. The method referred to
by Dr. Kinnicutt, namely, scooping out the lesions,
could not, in the speaker's opinion, be done thoroughly
enough to bring about a cure. Personally, he relied
upon local applications to relieve these patients. The
most severe symptom of which they complained was
pain on deglutition ; this came on only after the epi-
glottis had become affected, and fortunately it was
rare. After its onset, feeding was best accomplished
through a nasal tube, into which the food could be
introduced through a funnel.
Dr. Gibney said that in tuberculous foci in bones
the tuberculous tissues had been found as far as one-
quarter of an incii from the surface, and often very
extensive excavations were necessary to eradicate the
disease.
Exhibition of a Pair of Cystic Kidneys and a
Cystic Liver. — These were shown by Dr. George L.
Peabody, with the following history: The patient
from whose body these kidneys were removed was a
woman, forty-four years of age, a dressmaker by occu-
pation. She entered the New York Hospital on De-
cember 26, 1899. She had had in early life scarlet
fever, measles, and whooping-cough. Six years ago
she had malaria. There was no history of other ill-
ness except that she had an attack of bronchitis two
years ago. She used coffee and red wine in modera-
tion, but no other form of alcohol. She said that
she was easily fatigued all last summer, and that
this sense of fatigue had gradually become a con-
tinuing condition of great weakness. There had
been no headache or vertigo, and she had noticed no
oedema. For several weeks past she had had cough
and moderate dyspnoea. There had been no change
in the quantity of her urine, but it had a bad odor, and
she thought her kidneys were diseased. Her appetite
was poor; her bowels were constipated, and her weak-
ness was extreme. She was unable to stand. On ad-
mission to the hospital her respiration was 32; pulse,
106; temperature normal. She was fairly well nour-
ished, but her color was bad. She presented a sub-
icteric hue in her skin and conjunctiva;. Her tongue
was dry, cracked, and coated. The apex beat of the
heart was a little farther out than normal. The liver
and spleen seemed both increased in size. There was
a little cedema of both legs. Ophthalmoscopic exami-
nation revealed an absence of retinitis. She lived
only a day and a half after entering the hospital.
During that time her urine was twice examined. It
was acid; specific gravity, i.oii; it contained from
0.75 to I gm. of albumin to the litre; no sugar; a
thick sediment of pus, and no casts. She passed an
average of twenty-two ounces a day. She was restless
and very weak, unable to take other food than milk,
of which she took between three and four pints a day.
She died exhausted, in spite of active stimulation,
early in the morning of December 28th.
The autopsy was made by Drs. G. P. Biggs and L.
A. Conner, the pathologists to the hospital. The kid-
neys were both enlarged, weighing 468 and 472 gm.
respectively. The kidneys preserved their usual shape,
but owing to many projecting cysts they presented
somewhat the appearance of bunches of grapes. On
section both organs were seen to be composed of a
multitude of cysts which varied in diameter from i
mm. to 2.5 cm. These were most abundant in the
peripheral parts. The usual topography of the kid-
neys was entirely lost, and in only a few places could
anything resembling kidney tissue be recognized by the
naked eye. Several of the larger cyst ca\ities con-
tained thick, grumous pus. Some contained tiiick.
brown, gelatinous material, which was coagulated by
formalin six percent. Some contained grayish-white,
thin translucent material, which was not much changed
by formalin. The pelves were small and somewhat
compressed by cystic kidney tissue. The ureters and
blood-vessels were normal. The liver showed numer-
ous cysts varying in size from 2 mm. to i cm. These
were seen on the surface and deep in the liver tissue.
The weight of the liver was 1,770 gm. The heart
showed slight hypertrophy of both ventricles. The
lungs showed emphysema. Microscopical examina-
tion showed many microscopic cysts in the cortex and
medulla of the kidneys, and very advanced interstitial
changes with numerous microscopic abscesses. The
small cysts in the sections were all lined by epithe-
lium of the tubes, which had undergone a varying
amount of change. Numerous microscopic cysts were
seen in liver sections, all lined by epithelium of the
gall ducts, which had also undergone a varying amount
of change in form. The liver also contained micro-
scopic abscesses; but in general its structure was not
abnormal.
Dr. Peabody called attention to the fact of the pos-
sibility of a woman attaining middle life with a fair
degree of health in spite of the fact that her kidneys
must have been congenitally cysUc to an extent prob-
ably unusual.
Dr. Prudden said that a similar lesion in the hu-
man kidney and in the kidney of the pig had been
shown at the New York Pathological Society some
years ago. The condition of the liver in the case re-
ported by Dr. Peabody was certainly a rare one, and
was especially interesting in its association with the
kidney lesion.
Dr. Andrew H. Smith inquired what the woman's
condition of health had been earlier in life.
Dr. Peabody replied that she had had all the dis-
eases of childhood — scarlet fever, measles, etc. Six
years ago she had malaria and two years ago bron-
chitis. During the summer preceding her death she
was easily fatigued, and this symptom grew more pro-
nounced in the autumn and winter.
Dr. Smith asked whether such a condition of good
health in early life would be consistent with the idea
that the condition of the liver and kidneys was con-
genital.
Dr. Peabody, in reply to Dr. Smith, said the mi-
croscope showed that in spite of the extensive degen-
eration there was still a good deal of kidney tissue left
4/8
MEDICAL RECORD..
[March 1 7, 1 900
which was able to functionate, and this was proved by
the fact that she passed considerable quantities of
urine. The theory was that this condition of cystic
degeneration was present at birth and increased as
time went on.
Dr. Prudden said he thought such a condition of
the kidneys might exist in spite of tlie absence of
symptoms.
Dr. Brannan asked Dr. Peabody whether he re-
garded the presence of these degenerative conditions
in the liver as well as the kidneys as associated with
one another, or merely accidental.
Dr. Peabody replied that to him the condition was
quite an unusual one. Certain degrees of cystic de-
generation of the kidney were quite common, but he had
never before seen the liver similarly affected. Prob-
ably in the case he had reported the condition of the
liver and kidneys was dependent upon the same un-
known cause.
Some Lines of Progress and Drift in Pathology.
— This paper was read by Dr. T. jSIitchell Prudden
(see p. 397).
Dr. Brannan said the general practitioners of the
present day appreciated very much what the patholo-
gists were doing for them in clinical microscopy.
That branch of medical science had advanced to such
a degree that men who were engaged in general work
could hardly keep pace with it.
Dr. Charles McBurxey said he had been ex-
tremely interested in listening to Dr. Prudden's paper,
which contained a resume of what had recently been
achieved in the field of pathology. The agreeable
manner in which the scientific facts were set forth did
not detract from their interest, and the speaker ex-
pressed the hope that Dr. Prudden would some day
find the time to elaborate further many of the points
which he had merely touched upon in his paper.
Dr. Robinson said that in view of the rapid strides
made in pathology and chemical analysis during recent
years, it was hardly possible for a man who was en-
gaged at clinical work to become sufficiently expert in
the use of the microscope, the various staining-fluids,
etc., so that he could rely solely upon his own opin-
ion in the diagnosis of an important case in which such
examinations were necessary. The speaker said he
thought that in cases in which a microscopical exami-
nation was deemed important, the aid of a skilled path-
ologist should be called in, and in all hospitals this
work should be delegated to a competent man.
Dr. Andrew H. Smith said he had greatly enjoyed
the poetic flow of Dr. Prudden's words. To follow
in the same strain, Uie speaker said that, in his opin-
ion, the "chalkiest of all the '"chalk eggs" upon
which pathology was " brooding " was the conception
of an intermediate process between the noxa and its
action upon the tissues, a process termed " inflamma-
tion." The speaker said that whenever he found an
egg on which a name was pencilled ending in '" itis"
he was inclined to look upon it as "chalk," and to
throw it out of the nest. It seemed to him tiiat the
cause which produced disease grappled directly with
the tissues, and not through a more or less imaginary
process called inflammation. Conditions which were
utterly different had been forced into seeming rela-
tionship by including them under this common desig-
nation, as, for example, keratitis and peritonitis. It
was time that we addressed ourselves to the study of
the morbific agent on the one hand and the reparative
process on the other, without mixing them up with a
hypothetical teriium ijiiid, which was only a sickly sur-
vival of what was rapidly becoming obsolete.
A Case of Trichinosis in which the Diagnosis was
Suggested by Examination of the Blood. — This case
was reported by Dr. F. P. KiNNictTT, and confirmed
by the discovery of the parasite in the muscle.
Dr. Brannan asked if the faeces were examined.
Dr. Kinnicutt replied that they were not; that it
was not considered necessary, as the diagnosis was
confirmed on the day following the patient's admis-
sion to hospital. The patient was an American. He
had been in the habit of eating pork, always cooked,
two or three times weekly. Dr. Kinnicutt said it had
been shown that living trichinae might exist in par-
tially cooked pork; it was not necessary that it should
be raw. In reply to a question by Dr. McBurney, as
to what finally became of the trichina; in the tissues,
Dr. Kinnicutt said that they became encapsulated and
gave rise to no further trouble. A man might enjoy
very good health, in spite of the fact that his muscles
contained many of these encapsulated parasites.
Dr. Peabody said he had seen these parasites in
the muscles in the course of dissection.
Dr. W. Gilman Thompson said the case reported
by Dr. Kinnicutt emphasized the value of a differen-
tial blood-count at the bedside as an aid to diagnosis.
This subject was still in its infancy, but from the
present outlook much might be expected from it in
tlie future. The mere existence of a leucocytosis
might be sometimes misleading, but a careful blood-
count, although a very laborious procesS; certainly
ought to be made in cases of this nature. Dr. Thomp-
son said that another interesting point was the relation
of cause and effect. Why should the eosinophilic
cells be so increased by this irritant in the system,
and should the production of these cells be regarded
as a pathological process? The speaker said he was
under the impression that the eosinophiles were also
increased in the presence of certain other intestinal
parasites.
Dr. Kinnicutt said that an increase in the eosino-
philic cells had been noted in various pathological
conditions. Chief among these were bronchial asthma,
spleno-myelogenous leukaemia, and certain affections
of the skin, pemphigus, psoriasis, prurigo, and chronic
eczema. Concerning the nature of the eosinophilic
granules and the origin of the cells containing them,
varied views were held. The view most generally
held was that they were developed from the polymor-
phonuclear neutrophiles by a kind of ripening process.
Brown was led to believe, from his study of cases of
trichinosis, that the transformation occurred in the
muscles.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, March j, igoo.
William H. Thomson, M.D., President.
The discussion on cancer, begun at the last meeting
was continued at the present one.
Cancer of the Larynx. — Dr. D. Bryson Delavan
took up the consideration of this topic. He said that
the most common, as well as the most dangerous, form
of cancer of the larynx was epithelioma. The consid-
eration of the surgical management of carcinoma
would include all that could be said about the radical
treatment of excision of the larynx in general. The
responsibility of determining the possible malignity
of a given case might fall upon any practitioner, and
hence the great importance of tiiis subject. During
the past ten years much attention had been devoted
to laryngeal carcinoma, though it must be confessed
that little progress had resulted, except as to its surgi-
cal treatment. Thus far no successful system of toxic
treatment had been suggested for carcinoma of the
larynx. The attempted cure of these cases by endo-
laryngeal methods had been practically conceded to
be a failure, notwithstanding the few comparatively
March 17, 1900]
MEDICAL RECORD.
479
successful cases of Fraenkel and others to the con-
trary. No one should attempt the radical operation
for laryngeal cancer until one had thoroughly mas-
tered the subject.
Diagnosis. — The beginnings of intra-laryngeal car-
cinoma were usually too trifling to attract attention.
A small area of infiltration first developed, and this
might become diffuse, or more commonly the site of a
small outgrowth, often papillomatous in appearance.
Soon, too, highly suggestive signs were liable to pre-
sent themselves, viz., (i) sudden, Sharp pain, and (2)
distinct loss of motion on the affected side of the
larynx. The pain was distinct from that observed in
other affections of the larynx, or in ordinary sore
throat. The loss of motion of the affected side was
due to infiltration of the muscles controlling the ary-
tenoid cartilages. In a doubtful case care should be
taken at once to exclude tuberculosis by exhaustive
examinations of the lungs and of the patient's sputa,
and syphilis should be excluded by the therapeutic
test. It had been generally recommended that as
soon as the growth became sufficiently developed to
admit of a fragment being removed, this should be
done, and the diagnosis established by microscopical
examination; but instances innumerable were on rec-
ord in which, with every sign of malignity clinically,
the result of the microscopical examination had been
negative, or directly misleading. A notable example
of this was the result of \'irchow's examination in the
case of the late Emperor Frederick. If there was one
principle which had long been established with regard
to epithelioma, it was that irritation of such a tumor
tended to accelerate its growth, and was, therefore,
directly harmful. This was particularly true of epithe-
lioma of the larynx, and hence the wisdom of not being
too eager to remove a fragment of a suspected growth
for microscopical examination. One could rely fairly
on three signs, viz., (i) continued hoarseness without
other obvious cause; (2) a characteristically sharp
and sudden pain, and (3) loss of motion on the af-
fected side. Removal of a fragment of the growth
was difficult of accomplishment, and was painful and
harmful to the patient.
Treatment. — While a fair number of cases of extir-
pation of the larynx had resulted in prolonging life
in comparative comfort, it was universally conceded
that the best results had been obtained in cases in
which an early diagnosis had allowed of the removal
of a moderate portion of the larynx, and, at the same
time, total excision of the disease.
Dr. Delavan then presented a gentleman upon whom
Dr. Curtis had successfully operated some time pre-
viously.
Dr. B. Farquhar Curtis said that this man had
been operated upon by him three years ago next June.
The packing had been removed very soon after opera-
tion, and the patient had been allowed to swallow
within twenty-four hours, this having been accom-
plished by placing him in such a position that his
head hung far back. His voice had begun to return
about one year ago, and was now fairly good.
Cancer of the Gastro-Intestinal Tract ; Diagnosis
and Treatment Dr. B. Farquhar Curtis read this
paper which will appear in a future issue.
Cancer of the Stomach. — He said that some re-
cent statistics showed that over twenty per cent, of
all cancers occurred in the stomach. Among men
suffering from cancer, nearly one-third had cancer of
the stomach; in women, only about thirteen per cent,
were similarly affected. In 1896 a large number of
cases of operations on the stomach by expert German
surgeons had been collected, and the mortality from
one hundred and seventy-three of these had been thir-
ty-one per cent., as against seventy to eighty per cent,
at the time when the operation had been first intro-
duced. Three of the cases had been followed for four
years, and had been well up to that time; four cases
had remained well for over five years, and at least
three cases had remained well for eight years. This
showed the ability of the operation to cure cancer
radically. About two-thirds of the cases could be car-
ried through the severe operations with success. The
reduction in mortality was partly due to the improve-
ment in technique, and partly to the earlier diagnosis
of these cases. The chief gain in the future would
probably arise from the diagnosis being made still
earlier. This same factor should increase the num-
ber of cures. All cases of cancer could be divided
into two classes — (i) cases with a perceptible tumor,
and (2) cases without any perceptible tumor. Quite
a number of cases of cancer of the stomach came to
the surgeon simply with a tumor, and with an entire
absence of all symptoms. Not uncommonly the tumor
was detected accidentally. The points of importance
to the surgeon were the size of the tumor, its mobil-
ity, its location, and the previous history. The very
large tumors had been formerly considered to be inop-
erable, but as patients had survived two years or more
after the extirpation of these large tumors, this opin-
ion could no longer be held. The location of the
tumor was usually at the pylorus, though it might be
farther to the left. There were some cases on record
in which a supposed tumor of the cai^cum had proved
to be a tumor of the pylorus displaced in that direc-
tion. It was quite important in making the diagnosis
in these cases to exclude gall stones. Probably the
majority of patients presented themselves either with
a tumor which was adherent under the liver or ribs,
so that it was practically concealed, or with a very
small tumor. The symptoms formerly laid down- —
vomiting, h<ematemesis, and pain — should be set aside
as of no value in making the diagnosis of cancer.
Perceptible distention of the stomach was not very
common in malignant disease; hence a true dilata-
tion of the stomacli would be a point in favor of a
benign stenosis of the pylorus.
Chemical Diagnostic Tests. — The chemical exam-
ination of the stomach contents had become the mod-
ern means of making the diagnosis. Authorities were
not yet agreed concerning the value of some of these
points, and yet, in most cases, reliance must be placed
on them. The first thing was tc give a test-meal, and
determine the presence or absence of hydrochloric
acid. About all that could be said about the absence
of hydrochloric acid from the stomach was that it
raised suspicions of the presence of cancer. The
presence of lactic acid had also been noted, and it
had been maintained by some observers as absolutely
diagnostic of cancer of the stomach. An important
element in this diagnostic study was the digestion of
albumin. Owing to the great atrophy of the gastric
glands in these cases the digestion of albumin was
usually quite defective. The study of the motor in-
sufficiency of the stomach was also of significance.
In most cases there was great motor insufficiency of
the stomach, this organ not emptying itself even though
there was no stenosis of the pylorus, and the cancer
was situated on the anterior or posterior wall. It
should be remembered that hyperacidity of the gas-
tric juice was the rule in cases of benign stenosis of
the pylorus. If there was no stenosis and the hydro-
chloric acid was diminished it would be necessary to
study the motility of the stomach. The advantages of
studying the washings from the stomach had been em-
phasized by many physicians. Microscopical exami-
nation of the stomach contents included a search for
a certain bacillus resembling a baseball-bat in appear-
ance. This organism probably belonged to the fer-
mentation forms, and was said to be a positive sign
of the presence of cancer of the stomach. Hemmeter
48o
MEDICAL RECORD.
[March i 7, 1900
maintained tliat it was proper to operate in a case in
which there were rapid emaciation, absence of hydro-
chloric acid, presence of lactic acid, reduction of al-
bumin digestion, and the presence of the bacillus just
mentioned, even in the absence of tumor, provided no
benefit followed appropriate medical treatment for a
period of several weeks.
Indications for Operation. —The first indication
for operation. Dr. Curtis said, was the presence of a
tumor. The second indication would be obstinate
vomiting. A third would be a dilated stomach. In
nine-tenths of the cases the dilatation would be the
result of stenosis of the pylorus, and in the remaining
ones it would be due to enteroptosis. He was in-
clined to think the repeated vomiting of blood should
be considered as an indication for operative interven-
tion. Severe and frequently recurring pain in the
stomach, resisting lavage and appropriate diet, would
seem to warrant an exploratory incision, although
doubtless some of these cases were dependent upon
a neurosis. Even here, however, the operation had
been known to effect a cure. At the present day, the
surgeon was able to say not merely that an exploratory
operation would do no harm, but that it would prob-
ably do good, even in the event of there being no
malignant disease present.
Gastric Ulcer Predisposes to Cancer. — Dr. Curtis
said that he believed there was very considerable
danger of gastric ulcers being converted into cancer.
A very large number of cases of carcinoma of the
stomach gave a history of prolonged stomach difficulty,
probably dependent upon ulcer.
Selection of the Operation. — It was not true, at the
present time, that a tumor should not be removed
simply because of its large size; nor should adhe-
sions limit the operation, because these adhesions
were often inflammatory, and portions of organs in-
volved in these adhesions had often been removed
successfully. A fairly long survival had been known
to follow the removal of glands found to be cancerous
at the time of their extirpation. Of course, very large
and extensive involvement of the glands contraindi-
cated the removal of the tumor, but here a gastro-
enterostomy could be done. It should not be at-
tempted, however, unless there was decided stenosis.
Gastro-enterostomy, done for the relief of the pain of
carcinoma of the stomach, was an illusion, as it only
cleaned the stomach and supplied proper drainage,
whereas the pain was really due to involvement of the
retroperitoneal glands. The longest survival after
gastro-enterostomy recorded had been two years and
a quarter; the average time was less than six months.
This operation was capable, however, of giving very
marked relief from the distressing vomiting when ste-
nosis was present.
Intestinal Carcinoma. — The speaker said that car-
cinoma of the intestine was generally annular in form
and spread very slowly. Both of these facts could be
explained by the arrangement of the lymphatics in the
bowel.
Arrangement of the Lymphatics. — The lymphat-
ics were in two groups, submucous and subserous.
These two systems did not connect, but both passed
through the lymphatic glands at the mesenteric attach-
ment, and then passed into the second tier of these
glands — the ones usually spoken of as the mesenteric
glands. The lymphatics next passed into the retro-
peritoneal glands. In this way the body was protected
by three lines of defences. From these considerations
it followed that even after carcinoma had lasted for
years and a tumor of considerable size had been
formed, there was a chance for a cure. A specimen
was exhibited showing very beautifully this arrange-
ment of the lymphatic glands.
Pathology. — Carcinoma of the intestine usuaU> be-
gan its growth in the mucous membrane, and spread
circularly around the bowel. As soon as this had
occurred, fibrous tissue began to form at the base, and
then contracting, choked off the blood supply, and led
to the formation of an ulcer in the centre. On the
edges the process spread slowly, but not along the line
of the lymphatics. This resulted in a stricture, which,
although in reality fibrous, had its origin in carci-
noma. The tendency to produce metastases or glan-
dular invasion was very slow, so that the process
might go on for years without giving any symptoms
except those merely the result of mechanical obstruc-
tion of the bowel. In these cases often no special
difficulty was experienced until a seed or other sub-
stance suddenly blocked up the already narrowed lu-
men of the bowel, thus giving rise to what appeared
to be an attack of acute intestinal obstruction.
Symptoms. — These patients were usually consti-
pated, and suffered at times from attacks of subacute
intestinal obstruction. Sometimes there would be
" ribbon stools " or pill-like stools, like the discharges
from the bowel of a goat.
Prognosis. — In eighteen cases at Czerny's clinic
the mortality from operation had been fifty per cent.
Of the recoveries, one patient had remained well for
ten years; four were known to have remained well for
periods varying from one to three years and a half
after operation. The mortality was high because
many of the cases had been operated upon during the
period of acute obstruction, and also because, in some
instances, tumors had been very large, necessitating
very severe and prolonged operations.
Treatment. — The palliative operations were colos-
tomy and anastomosis. The latter consisted in mail-
ing a communication between the bowel above and
below the stricture, leaving the tumor in place. It
was, however, a most useful operation in suitable cases
because it established, so to speak, an internal anus.
The operation of "exclusion'" of the intestine had
been lately introduced. This consisted in uniting the
ends of the healthy bowel, and closing one end of the
loop in which the tumor existed and opening the other
upon the skin. This admitted of the discharge of the
contents later on without causing any obstruction.
Colostomy was of the greatest value when the cancer
had caused obstruction. He favored resort to this
operation earlier tiian was commonly done.
Treatment of Inoperable Cancerous Tumors. — Dr.
William B. Colev read this paper. He said that
during the last few years several methods of treatment
for inoperable cancer had been advocated. He had
tried the method of administering thyroid extract in
a few cases, but with negative results. The treatment
by injections of alcohol gave little chance of success.
The same was true, he thought, of cataphoresis. The
results of his treatment by the use of the mixed toxins
of erysipelas and of the bacillus prodigiosus still con-
tinued to be satisfactory. He preferred to make use
of the mixed unfiltered toxins made from cultures in
the same medium, and sterilized by heat. The injec-
tions should be made directly into the tumor when-
ever possible. The initial dose should be rarely more
than half a minim. When the injections were given
at a point remote from the tumor much larger doses
could be tolerated. If no improvement was observed
after three or four weeks of this treatment it was sel-
dom advantageous to continue it. If improvement
occurred, the use of the toxins should be persisted in
until the tumor had entirely disappeared, or until it
was evident that the toxins had lost their controlling
influence. The question of harm from long-continued
injections was a very important one. It had been
proved that moderate doses could be administered
twice a week for a period of two years and a half
without doing harm. In another of his cases the treat-
March 17, 1900]
MEDICAL RECORD.
481
ment had been continued for four years, and the pa-
tient, a physician, was now in perfect health, at the
end of six years from beginning the treatment. The
action of the toxins, he thought, could be explained
only on •^he parasitic theory of the origin of cancer.
In the majority of his cases both the clinical and the
microscopical diagnosis had been confirmed by expert
pathologists and clinicians.
Results. — Of the total number of cases treated,
eighty-four were round-celled sarcoma, twenty-one
spindle-celled, and nine melanotic sarcoma. Of the
round-celled variety forty, or less than half, showed
more or less improvement, and in three the treatment
had been successful. On the other hand, of the twen-
ty-one spindle-celled sarcomata, ten had disappeared
entirely, and all of the remainder had shown marked
improvement.
Risks — He believed that under proper precautions
the risk from this treatment was very slight. He had
employed it in upward of two hundred and thirty
cases, with only two deaths, and these latter had oc-
curred about four years ago. It should not be forgot-
ten that this method was recommended only for inop-
erable cases. He recommended that it be used as an
adjunct to operative measures, the toxins being ad-
ministered immediately after operation instead of
waiting for a recurrence.
Dr. R. H. M. Sell referred to a case which had
come under his care in 1873. Eighteen other physi-
cians had seen this case, and all of them had made a
diagnosis of cancer of the stomach, but to this he had
taken exception. The patient had been almost exsan-
guinated at the time. The post-mortem had revealed
the presence of cicatrices and fresh ulcerations in the
oesophagus, and the same condition in the duodenum.
Dr. Thomas H. Manley asked Dr. Delavan if it
was not true that life was as much prolonged and as
much relief was afforded by tracheotomy alone as by the
removal of a part or all of the larynx in carcinoma of
this organ. He also called attention to the frequency
with which haematemesis in young persons was due to
gastric ulcer, and maintained that tumors in the pos-
terior wall of the stomach near the cardiac end were
absolutely inoperable.
THE MEDICAL SOCIETY OF THE COUNTY
OF NEW YORK.
Stated Meeting, February 26, igoo.
George B. Fowler, M.D., President.
The Physiological Properties of the Suprarenal Ex-
tract.— Dr. B. Moore, professor of physiology at
Yale, discussed the physiological properties of the
suprarenal extract. He said that Addison, by most
painstaking post-mortem examinations of the supra-
renal gland, had found that, in the disease bearing
his name, there were certain constant changes in this
gland. He found nervous and muscular changes
associated with a very low blood pressure. This low-
ering of the blood pressure was all the more remark-
able when viewed in connection with experiments on
injecting the suprarenal extract into animals. In
1855, Brown-Se'quard had begun a series of experi-
ments on the removal of one or both glands in animals.
He found that the removal of one gland often proved
fatal, and that the extirpation of both glands was
rapidly followed by death in every instance. These
results had been very much disputed, and his experi-
ments had been repeated by dozens of experimenters.
Schaffer had suggested that the cases in which other
experimenters had not observed death after the removal
of both suprarenal glands could be explained by sup-
posing that there had been present accessory glands
in those instances. About ten or more years ago
some experiments had been conducted on the effect of
injecting the suprarenal extract subcutaneously. With
large doses there had been profound disturbances of
the nervous system — tremors, clonic spasms, and
paralysis of the extremities. The results from admin-
istering the gland by the mouth had been vague and,
for the most part, negative. Dr. Oliver, who had been
using suprarenal extract clinically in persons having
a low arterial pressure, had suggested to Professor
Schaffer to try the intravenous injection of the gland.
The speaker said that he had been in Professor
Schaffer's laboratory at the time these experiments had
been made, and had noted that the intravenous admin-
istration of even a fraction of a milligram was suffi-
cient to double or treble the blood pressure. It should
be remembered that there were comparatively few sub-
stances which had any very marked effect on the blood
pressure. If the vagi nerves were intact, there would
be, accompanying this augmented blood pressure, a
hyperactivity of the vagi nerves. If these nerves had
been cut, the blood pressure would rise still more
markedly, and the heart action would be more power-
ful. Of course, such a rise of blood pressure might
be produced in three ways, viz., (i) by the action on
the heart muscle; (2) by stimulation of the vasomotor
system, whereby all the arterioles of the body would
be constricted; and (3) by direct action of the supra-
renal extract on the coats of the arterioles. Experi-
ment had shown that it was by this direct stimulation
that the suprarenal extract acted, and it was this direct
peripheral action that made this drug so valuable a
haemostatic.
The Active Principle. — The speaker said that he'
had investigated the chemical nature of the substances
contained in this gland, which gave rise to the effects
just noted. The active principle was a substance
which was not changed even by a ten-per-cent. solu-
tion of sulphuric acid, but minute traces of alkalies
destroyed it very rapidly. At one time he had thought
it might be a reduced pyridin, as nicotine and various
other substances reduced from pyridin produced an
effect very similar to that observed from the supra-
renal extract, except that the action was not on the
muscular coat of the arterioles, but upon certain gan-
glion cells. The characteristic odor of pyridin could
be obtained by heating the suprarenal extract with
alkalies. The most active form was obtained by
throwing down all the proteids. With this substance
he had secured distinct effects from one milligram per
kilogram of body weight. In a great many cases after
both glands had been removed from animals, the latter
had died very quickly, apparently from surgical shock. •
An attempt had been made to eliminate this possible
source of error by injecting bacilli, and causing a slow
degeneration of the gland — an artificial Addison's
disease, so to speak.
Mode of Action. — Two theories had been put for
ward as to the mode of action of the suprarenal gland.
One of these was, that the gland formed a substance
having a useful function in the human system, i.e.,
altering the tonicity of the arterioles and of the mus-
cular tissue all over the body. The other theory was,
that the effects noted after removal of the gland were
the result of auto-intoxication, a substance of a poison-
ous nature being normally removed by the suprarenal
gland. In support of this view it was urged that the
blood from the animals from which the suprarenal
gland had been removed possessed unusual toxicity.
Note on the Preservation of Aqueous Solutions of
the Extract of the Suprarenal Capsule — Dr. Lucien
Howe, of Buffalo, sent a communication with this title.
He said that great variations were noted in the differ-
ent preparations found on the market. His plan was
482
MEDICAL RECORD.
[March 17, 1900
to rub half a drachm of *^he extract with sufficient dis-
tilled water to make a paste. This was placed in a
capsule and heated at 160° F. for fifteen or twenty
minutes, and the amount of water lost by evaporation
was replaced by sterilized water, so that the resulting
product still measured one fluid ounce. A little boric
acid was then added to this solution. Under ordinary
conditions, this solution kept well for several weeks
in well-corked bottles. Three other methods of preser-
vation were mentioned. The first of these was by
putting up the extract in the form of the so-called
ophthalmic discs. The powder was rubbed up into a
paste with water, and then sufficient mucilage was
added to make the mass cohere into small wafers.
Solutions of the extract could also be preserved by
formalin, in the strength of one in ten thousand parts.
Both of these preparations had the disadvantage of
being more or less irritating. The extract also kept
apparently indefinitely in a thirty-five-per-cent. gly-
cerin solution, but this preparation was also somewhat
irritating.
Suprarenal Therapy. — Dr. W. H. Bates began his
paper on this subject with the assertion that in spite
of the almost infinitesimal dose needed to produce a
recognizable physiological effect, suprarenal extract
was not poisonous, its effect was not cumulative, and it
had no direct effect on the nervous system. It was not
an anaesthetic. Out of the two thousand cases in
which the suprarenal extract had been seen to con-
strict the blood-vessels, in not a single instance had
the expected subsequent dilatation of the blood-vessels
been observed. All inflamed tissues were benefited by
the application of this extract. The effects obtained
by the local use of the extract could be obtained,
though to a less degree, by the internal administration
of this remedy. He had seen congestion of the eye,
ear, and throat, larynx, and thyroid gland become
decidedly less within three minutes after swallowing
five grains of the suprarenal extract. He had con-
trolled nasal hemorrhage in a "bleeder" by syringing
the nose with a solution of suprarenal extract, after
peroxide of hydrogen, tampons, and other means had
failed to check the bleeding. This extract was not an
objectionable heemostatic like iron. Secondary hem-
orrhage was lessened by the suprarenal extract. The
haemostatic effect was temporary, and it miglit be
necessary, therefore, to use it every two hours for a
number of hours. The preparation used must have
been freshly prepared to be efficient. He had known
the aqueous extract to spoil in one hour.
Effect on the Heart. — It was not uncommon for
enough of the suprarenal extract, when instilled into
the eye, to be absorbed to increase perceptibly the
tonicity of the heart in persons affected with cardiac
disease. A number of sphygmographic tracings were
shown in this connection. The internal administra-
tion of the suprarenal extract did not affect the normal
heart or the normal blood pressure, but an intermit-
tent pulse would become regular, and a weak pulse
stronger. The author's conclusions were: (i) The
aqueous extract of the suprarenal gland, when used
locally, was the most powerful astringent and hremo-
static known; (2) congestions of other organs besides
the eye were relieved by the internal administration of
the extract; (3) it was useful in all forms of inflam-
mation and in all parts of the body; and (4) it was
the strongest known stimulant of the heart.
The Treatment of Diseases of the Nose and Throat
■with the Suprarenal Extract. — Dr. H. L. Swain, of
New Haven, read this paper. He said that the extract
would not noticeably affect the vessels in which there
was not a well-developed muscular coat, or the pal-
sied vessels inet with in long-standing and extreme
inflammation. On the other hand, the suprarenal ex-
tract would always contract the turbinal swellings, and
open up the nasal passages. The blood-vessels in
these bodies were surrounded by extremely well-devel-
oped muscular coats. When cocaine was used, either
before or after the suprarenal extract, the greatest pos-
sible contraction of the mucous membrane was made
possible. Perhaps the most valuable property of the
extract in nose and throat work was that it could be
used freely, and could be swallowed by the patient
without harm. Tolerance was not established, and no
drug habit was induced. In hay fever and hypertro-
phic rhinitis this remedy proved of signal value, when
used locally, but he had not been able to observe from
the internal administration of the extract the results
reported by some other observers. Patients with
hypersesthetic rhinitis were made very comfortable by
a thorough spraying once daily with the suprarenal
extract. It had also proved quite useful in certain
asthmatic attacks arising from nasal pressure. It was
useful in conjunction with other measures in aborting
or controlling an acute cold in the head. But perhaps
the most important field for this remedy was as a
heemostatic in nasal surgery. Whenever there was any
removal of tissue, he always made use of it. He had
often employed the suprarenal extract and cocaine at
the same time, or in immediate succession. Even in
the most bloody operations the result was excellent.
He could not say conscientiously that he had observed
secondary hemorrhage more frequently since using the
suprarenal extract than before. For most purposes
the freshly made aqueous solution was sufficiently
aseptic, but it would be very convenient if some enter-
prising drug firm would undertake to supply the pro-
fession with hermetically sealed glass tubes containing
an absolutely sterile solution of the suprarenal extract.
He had been disappointed with his results from the
internal administration of the suprarenal extract in
cases of hay fever. He had used it with the greatest
satisfaction in all forms of tonsillitis, and had been
able in this way in some instances not only to give
patients with quinsy sore throat much comfort, but to
enable them to take more nourishment. In acute dry
congestions of the naso-pharynx which followed a cold
in certain states of the system the suprarenal extract
seemed to be especially grateful to the patient. Acute
cedema of the glottis reacts most favorably to this agent.
Treatment of Asthma with the Suprarenal Ex-
tract.— Dr. Solomon Solis Cohen, of Philadelphia,
read a paper on this subject. At the outset he ex-
pressed the opinion that asthma was a morbid condi-
tion, symptomatic in its nature, and associated with
varying and various pathological processes and physi-
cal states. It was a distinctly paroxysmal disorder. In
certain cases the paroxysm was often the direct result
of spasm of the bronchi, both muscular and vasomotor.
Abnormal states of the upper respiratory passages and
underlying diathetic conditions were responsible in
many cases. He had not found the suprarenal exract
uniformly beneficial in asthma, as might be antici-
pated from the varied pathology of this disorder. This
remedy had been most serviceable in cases of asthma
exhibiting vasomotor ataxia of the relaxing variety,
and in those subjects liable to develop urticaria or
known to be extremely sensitive to slight changes in
climate. The remedy had been chiefly useful in
averting the paroxysms and preventing their recur-
rence. It had rarely cut short the attack, but had
proved serviceable by virtue of its ability to remove
from the patient the fear and apprehension of the
occurrence of the paroxysm. When given internally,
it acted well, but the dose must be pushed until some
physiological effect is observed. He wished to state
emphatically that suprarenal extract was not a specific
for asthma.
The Treatment of Hay Fever with the Suprarenal
Extract. — Dr. H. Beawan Douglass, who read this
March i 7, 1 900]
MEDICAL RECORD.
483
paper, was more enthusiastic than the last speaker
regarding the effect of this extract in hay fever, declar-
ing that, in his opinion, one was justified in speaking
of it as a specific in this disorder. Under the con-
tinued administration of this remedy the patient would
be in comparative comfort during the remainder of the
attack. The cases yielding to it had been benefited
equally well by the local and by the internal use of
the extract. Some individuals, when taking this sub-
stance by the mouth, experienced vertigo or nervous
excitement, and observed an increased action of the
heart. Naturally, the best results had been achieved
in the simple cases, in which the symptoms had been
those of nasal and laryngeal inflammation, together
with conjunctival involvement. In the cases in which
asthma had occurred later as a coitiplication, the asth-
matic tendency was certainly diminished or wholly
checked by the use of the suprarenal extract. In nasal
cases, not accompanied by much congestion, not so
much benefit was observed. Cases dependent upon
gouty or rheumatic diatheses seemed to be benefited,
but in the cases in which the elasticity of the blood-
vessels had been diminished by atheroma or by inter-
stitial nephritis, the extract had had little or no effect.
The speaker recommended a combination of local and
internal treatment. The local administration was best
carried out by spraying the parts with a freshly pre-
pared aqueous solution of the extract. Internally it
should be given in doses of gr. v. at first, at intervals
of two hours, the interval being gradually lengthened,
but the remedy should be kept up throughout the
entire hay-fever season. No other remedy alone was
as useful as the suprarenal extract.
The Use of Suprarenal Extract in Laryngitis
Dr. H. Holbrook Curtis read this paper. He said
/hat he had made extensive local use of the suprarenal
extract. His practice had been to spray the larynx
with a freshly prepared solution of the extract, of a
strength of thirty grains to the ounce. In a recent
case he had secured a most gratifying result in the
oedematous stage of a tuberculous laryngitis from
insufflations of the powdered extract. In relaxed con-
ditions of the vocal cords the use of the extract seemed
to be as beneficial as in the more acute congestions of
this part. A practical point, worth remembering, was
tha-t peroxide of hydrogen rendered the suprarenal
extract inert.
The Treatment of Diseases of the Urethra with
the Suprarenal Extract — Dr. J. A. Moore read a
paper on this subject, based on an experience extend-
ing over three years, and comprising two hundred
cases. The blanching of the urethra produced by this
remedy, he said, could be readily observed with the
endoscope. In his experience the thick, unfiltered
solution had acted much better than the filtered solu-
tion of the extract more commonly used. He had also
found it more potent when allowed to stand for two
hours after its preparation, before using it. He ordi-
narily employed a ten-per-cent. solution, injecting it
with a syringe. In the gradual dilatation of strictures
the extract was very useful, as it relieved the mus-
cular spasm. The effect of the remedy was quite
transient, so that if more than two sounds were to be
passed at one sitting, another application of the extract
should be made. By its action on muscular tissue the
extract would sometimes sensibly increase the calibre
of a stricture. In several cases of meatotomy l.e had
administered a twelve-percent, solution of the filtered
extract, injecting it into the tissues. In four cases of
acute gonorrhoea in which there was severe smarting
at urination, the injection of the unfiltered solution
gave immediate and decided relief. The unfiltered
solution had also proved to be a grateful application
in most cases of inflammation of the urethra and when
there were ulcers in this canal.
General Discussion.— Dr. E. Larue Vansant, of
Philadelphia, opened the general discussion. His ex-
perience had taught him that the suprarenal extract,
when used in diseases of the nose, throat, and ear,
acted as a harmless and most potent non-irritating as-
tringent and haimostatic, and also enhanced the action
of the local anaesthetics usually employed. It was well
to remember, however, that the relief was local and
temporary, and that other treatment must also be em-
ployed. A granular condition of the vault of the
pharynx, most often seen in people with wide nostrils,
proved especially amenable to the local application of
the suprarenal extract, followed by some other astrin-
gent, such as one of the salts of silver. There could
be no doubt about the efficiency of this remedy in
cases of hay fever, but its local administration was
greatly superior to its internal administration. He
did not approve of using the drug by means of a spray,
because of the tendency of portions of the solution to
be retained in the accessory sinuses, and elsewhere, to
undergo decomposition and so lead to sepsis. This
form of sepsis might occur even though the solution
of the extract had been perfectly fresh and sterile at
the time of making the application.
Dr. R. H. Cunningham said that at one time he
had made some experiments with various ductless
glands, including the suprarenal. After experiment-
ing upon twenty or more dogs, he had at last succeeded
in completely removing the right suprarenal gland
and partly isolating and ligating the other gland,
though not in removing it from the body. He had
kept this dog alive for two years, and had then killed
him and examined with the microscope the tiny por-
tion of the gland that had been allowed to remain.
He had been unable to find any suprarenal gland
tissue. From this experiment he had been led to be
rather sceptical concerning the inability of dogs at
least to live without a suprarenal gland. He had at
one time administered a large quantity of the supra-
renal extract to an anaesthetized dog, and had kept a
manometer in place for a number of hours, but had
been unable to observe the slightest effect on the cir-
culation from this enormous dose. This result was in
keeping w'ith the statement that had been made here
this evening, to the effect that the remedy did not
show its effect on the heart of a normal person or
animal.
Dr. R. C. Myles said that he had used this remedy
quite extensively, and while the results had been ex-
traordinary, he had not yet been able to formulate defi-
nitively in his own mind the standing and value of the
extract. He had used the powder in the nose for
nearly two years, and did not think he had succeeded
in tracing any sepsis to its use. The action on the
turbinal tissues was definite, though it did not have
any special action on hypertrophies. The effect
appeared to be more upon the artery, in contradistinc-
tion to the effect of cocaine, which was more particu-
larly on the vein. He had had two quite bad hemor-
rhages following the use of the suprarenal extract,
but, on the other hand, he had been able, with this
remedy, to do an almost bloodless operation on the
nose in persons who were considered to be "bleeders."
Use in Intratympanic Operations.— Dr. Wendell
C. Phillips looked upon the extract as a desirable
addition to the materia medica of the nose and throat
specialist. He had had some experience with it in
cases of suppuration of the middle ear, accompanied
with necrosis of the ossicles and a good deal of granu-
lation tissue in the tympanum and attic. In these
operations the hemorrhage was ordinarily very free and
troublesome. During the part six months he had done
a number of such operations after having instilled a
solution of the suprarenal extract into the ear, and
with a surprisingly small amount of hemorrhage. The
484
MEDICAL RECORD.
[March 17, igoo
operations had been thereby greatly simplified and
shortened, thus diminishing their danger.
Secondary Hemorrhage More Frequent after the
Extract. — Dr. F. E. Hopkins, of Springfield, Mass.,
said that, in his experience, troublesome hemorrhage
had occurred far more frequently after the use of
suprarenal extract than after cocaine. It was also
well to remember that this hemorrhage was apt to
occur several hours afterward, and at a time when the
patient might be many miles away, and far from
medical aid. It had seemed to him that there had
been fewer cases of prostration since using the supra-
renal extract in conjunction with cocaine.
^cdical Items.
The Normal Tympanic Cavity is Germ-Free. —
The investigations of Zaufal, which taught that the
healthy tympanic cavity of rabbits contained the same
germs as the oral and nasal cavities, were disproved
as far as human beings are concerned by Preysing
{Ceniralblatt Jiir Bakti:riologie,tXc., Nos. 18, 19, 1899),
who experimented with the contents of the cavity in
recent corpses, and who arrived at the following re-
sults: (t) That the healthy human tympanic cavity
is absolutely germ-free. (2) Even the cavities (which
are filled with mucus) of the newly born are germ-
free. (3) The serous exudates which depend on gen-
eral dropsy are likewise free of germs. (4) The germs
of typhus can be the direct cause of an otitis media.
Simultaneous Occurrence of Extra- and Intra-
uterine Pregnancy. — Mand {Miincheuer meet. Wocheii-
schrift, 1899, No. 37) describes a case of extreme
interest. A diagnosis of ruptured extra-uterine preg-
nancy having been made, the case was operated upon
and the diagnosis thus substantiated. The uterus was
found to be enlarged and gravid in the third month,
and five months later a living child was born. Mand
also gives a resume of similar cases which have been
published. Apart from the interest which attaches
itself to these cases, they go to point out a danger
which may result from the introduction of a uterine
sound in examination for extra-uterine gestation.
Electrical Treatment of Gout. — Th. (juilloz rec-
ommends the use of gahanism on the gouty parts, as
it increases the nourishment of the diseased tissues
and at the same time makes it possible to bring urate-
dissolving substances to the affected joints, by means
of cataphoresis. He places the gouty joint in a solu-
tion of two-per-cent. lithium (carbonate.'), in which
the positive pole is placed while a broad negative elec-
trode is applied to the back or breast. After five to
twenty sittings, in which he used a current of 120-200
milliamperes, he noticed not only a cessation of pain
and swelling and a certain resumption of movement,
but also with simultaneous use of a high-tension alter-
nating current a pronounced improvement in all the
bodily functions.
The Permeability of the Skin in Warm-Blooded
Animals. — Vogel {Vinlwiv's Arcliiv, Bd. 156, 1899,
p. 566) gives an interesting and important description
regarding the power of certain substances in difTerent
solutions to permeate the healthy skin. The results
varied much. Thus the skin was found not to absorb
a one-per-cent. w-atery solution of potassium cyanide
even if the solution were acidified ; neither did it al-
low to pass through it the following: Illuminating
gas, alcoholic and watery solutions of chloral hydrate,
vapor of ether at 18° C, vapor of chloroform at the
temperature of room, watery solution of strychnine
nitrate, watery solution of physostigmine salicylate.
On the other hand it was permeable to prussian blue,
sulphuretted hydrogen, ethyl ether, chloral hydrate in
ether, ether vapors at high temperature, chloroform,
vapor of chloroform at high temperatures, strychnine
hydrate in chloroform, physostigmine salicylate in
chloroform, and salicylic acid in ointment with water
and ether.
Pain. — Pain of a neuralgic or drawing character in
the neighborhood of the heart is found as the result of
several causes, as a rule, in the following order of fre-
quency: (1) Pain with palpitation of the heart from
the accumulation of flatus in the transverse colon just
as it turns to descend. Many patients who go to the
physician complaining of heart disease suffer only
from this condition,' due to fermentation in the large
bowel. Again, the pain due to gastralgia, or, as it
has been called, cardialgia, may be referred to the
heart by the patient. ('2) Intercostal neuralgia due to
debility. In these cases tender spots will often be
found, one in the prajcordium, another in the outer
edge of the scapula, and a third on the vertebral col-
umn. These are sometimes called " spots of Valleix."
In other cases the pain will be due to spinal trouble,
anamia, or tight lacing of corsets. (3) Pseudo-an-
gina. (4) True angina. (5) Locomotor ataxia. — H.
A. Hare, "Practical Diagnosis," page 559.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended March 10,
igoo :
allpox-Uni-
States.
Arkansas, Searcy December 25th to February 27th. 40
Ulinois, Aurora February 17th to March sd 4
Chicago February 24th to March 3d 1
Kentucky, Covington February 24th to March j;d 5
Louisiana, New Orleans . . February J4th to March 3d 6t
Michigan, Detroit February 17th to March 3d 12
Ohio, Cleveland February 24th to March 3d .... . 26
Pennsylvania, Philadelphia . February 24th to March 3d 3
Tennessee, Nashville February 24th to March 3d i
Te.xas, State February 21st to 28th 142
Utah, Salt Lake City February 24th to March 3d j
Virginia, Portsmouth February 24th to March 3d 3
Roanoke February ist to 28th 7
Washington, Tacoma February 18th to 24th 13
West Virginia, Puckhannon.. February gth Present.
Calhoun County February qth Present.
Camden on the Oauley. . February' 9th Present.
Fayette County February 9th Present.
Oilmer County February 9th Present.
Lewis County February 9th Present
Harrison County February 9th Present.
ALLPOX — Foreign.
-\ustria, Prague
Belgium, Antwerp
Chent
Canada, .Amherstburg ,
Quebec
F.ngland, London
".ibralti
Gr.
Me
Athens .
, Bombay .
Calcutta.
^ladras ..
Russi
, Moscow
Odessa
St. Petersburg
Warsaw
Spain, Corunna
Straits Settlements, Singa-
pore
Turkey, Constantinople
. February
. February
. February
. February
. February
. February
. February
.February
.January i
.January 2
. rebruary
. February
. February
.January ;
.January 2
February
5d to loth
3d to 10th
3d to 10th
24th to March 3d
15th to azd
5;d to 17th ,
'4th to iiih
3d to loth ,
5th to ^oih ,
:^th tozoth ,
ytli to February 2d ... ,
17th to 24th
3d to loth
3d to loih - . ,
i7th to February 17th.
!7th to February loth.
ioth to 17th
January 13th I
February 3th 1
Vei-1 ow Fever.
Brazil, Santos January zgth Increasing.
San Paulo Increasing.
Cuba, Havana February loth to 17th 9
Matanzas February 10th to 17th
Mexico, Vera Cruz F'ebruary 17th to 24th •. ..
India, Bombay January 23d to 30th
Calcutta January 13th to 20th
Plagl-e— United States.
Hawaii, Honolulu February loth to 19th
Kahului February 13th 3
Philippine Islands, Manila . .January 13th to 20th 4
Total to date 16
, Rombay January 16th to 3olh .
Calcutta January 13th to 20th
Medical Record
A II 'cckly Jonnuxl of Medicine and Siirgciy ,
Vol. 57, No. 12.
Whole No. 1533.
New York, March 24, 1900.
$5.00 Per Annum.
Single Copies, loc.
@ri0iual Articles.
NON-MALIGNANT GASTRIC AND DUODENAL
ULCERS: WITH ILLUSTRATIVE CASES.
];v THOMAS E. SATTERTHWAITE, M.l).,
The widespread interest that has recently been shown
in the matter of gastric ulcer, and especially in its
treatment, has made it appear to me opportune to
publish this article at this time.
Clinically speaking, the relation between gastric
and duodenal ulcers is so close, as to their causation,
symptomatology, and treatment, that it is proper to
consider them together.
Ulcers of the stomach are comparatively rare in this
country. While Brinton' believed they were found in
five per cent, of all autopsies, and his belief was con-
firmed by the results of 32,052 autopsies made in
Prague, Berlin, Erlangen, and Kiel," where, as in
Brinton's cases, gastric scars and open ulcers were
very properly classed together, these percentages ap-
pear not to apply in theLInited States, certainly not in
this vicinity; for Welch found them in only six cases
out of about eight hundred in New York City, and I
in not more than five out of seven hundred and fifty-
two, according to my private records taken from St.
Luke's and the Presbyterian hospitals, between the
years 1872 and 1888. Da (Josta' also holds to the
view that gastric ulcers are less common in this
country than in England. And Ewald ' has shown
that the liability to this disease appears in some
degree to be governed by locality, for in northern
Europe and Denmark he found that gastric ulcers
were comparatively frequent, the percentage rising to
thirteen in (Copenhagen, while they were infrequent
in parts of Russia and Southern Europe. Indeed,
Nolte' found the percentage in Munich to be as low as
r.23 per cent. It may, however, turn out in the
future that a close search for small scars will show that
gastric ulcers are more common than these figures
indicate. Gruenfeldt' has sustained this idea by hav-
ing found ninety-two, or twenty per cent., of gastric
scars in four hundred and fifty autopsies at Copen-
hagen; but he examined closely for gastric lesions.
Ulceration of the stomach is sometimes divided into
the acute and the chronic; a division, however, that
lias more pathological than clinical value, because we
can never distinguish the two during lifetime, except
when the ulcer is felt through the abdominal wall by
palpation — a rare occurrence — or exposed in the course
of a laparotomy. For the same reason we are usually
ignorant as to the size, shape, and special characters
of the ulcers, though it is common to call them round,
' Brinton : " Diseases of the Stomach," 1859, p. 155.
' Welch : " American System of Medicine," vol. ii. , p. 4S2.
^ Da Costa: "Medical Diagnosis," eighth edition, Philadel-
phia, 18S1, p. 576.
■* Ewald : " Diseases of the Stomach," pp. 391, 392.
^ Gruenfeldt ; Hosoitalstid., ix., p. 765 (Ewald).
eroding, corrosive, etc. But these ulcers are not
always round. They may be oval. They erode, but
so do cancerous ulcers. The term corrosive applies
to a corrosive liquid, but corrosive liquids as a rule
produce erosions that heal readily without leaving any
scar. Howevev, it is true that a large number of gas-
tric ulcers have a rounded contour with sharp-cut
edges surrounded by a zone of tough fibrous tissue, a
puckering of the gastric walls about them, and bands
of fibrous tissue radiating outward. This variety has
been called the acute; as a rule, however, it is merely
a form of the chronic variety. On the other hand, the
ulcer which has greatly infiltrated walls and ragged
shelving edges forming a sort of in\erted cone, the
apex being at the peritoneal covering of the stomach,
is always a chronic variety. There can hardly be
much mistaking such an ulcer, when it is exposed to
the eye, though it might be taken for a cancer or sar
coma. Indeed, in microscopic section it might be
mistaken for a round-celled sarcoma, because in both
sarcoma and gastric ulcer there is a great similarity in
the character of the round cells. But if the non-
malignant ulcer iS brought into view, the peculiar ex-
cavated centra should indicate its true character.
In taking up the etiology of gastric ulcers we naturally
consider the question of age and sex. Brinton in two
hundred and thirty-four cases found that one bundled
and sixty were females and seventy-four males, and
that the average age in women was twenty-seven years,
while in men it was forty-two. These points have
some practical value from a diagnostic point of view,
for while Goodhart ' has described a gastric ulcer in a
child thirty hours old, and one is related by Eppinger''
in a man over one hundred years of age, the plain fact
remains that in gastric ulcer the disease is one of
middle life. The periods of greatest frequency have
been regarded as between the ages of twenty and forty,
and forty and sixty, with some preponderance in favor
of the first-named period. But as these views were
derived from post-mortem data, they might be some-
what inaccurate, so far as fixing the date of inception
of the ulcer, for this point is obviously not determin
able by post-mortem evidences. The ulcer may have
existed for many years — ten, fifteen, twenty, or perhaps
thirty, or even more before its discoveiy; that is, if
we rely on clinical evidence. But we have nothing
better, or as good. In this connection, however, it is
important for us to know that both the clinical and
pathological data fix the period of greatest frequency
of ulcer at from twenty to thirty years of age.
Among the causes that have been assigned are:-
mechanical compressions, as by corsets, tight belts,
pressure against the stomach by the shoemaker's last;
injuries to the stomach, wounds of the organ, as by
instruments, or in fact injuries of any kind. Gat trie
ulceration is a common circumstance in tuberculosis.
It is also found in anaemia and menstrual disorders, and
disturbances of the circulation such as endocarditis and
atheroma. The fact that gastritis, scurvy, diabetes,
intermittent fever, burns, typhoid fever, septic proc-
esses, etc., and the other conditions named, have been
assigned as causes of gastric ulceration, only illustrates
'Goodhart: Trans. Lond. I'ath. Soc, vol. x.\.Nii.. pp. 79-81.
" Eppinger : Prager. Vierteljahrschr. , Bd. iiO, p. 130.
486
MEDICAL RECORD.
[March 24, 1900
how obscure the causative factors are in medical
minds. For this reason it is instructive to consider
the diseases with which gastric ulcers are actually as-
sociated. It is now admitted that miliary tuberculosis
of the walls of the stomach is generally believed to be
rare, though hemorrhages from these ulcers have been
fatal. In one of my cases, in which the patient died
of hemorrhage by the bowel, I believe the source of the
trouble was a tuberculous ulcer. In another case, also
seen by the writer in consultation, in which the patient
died of inanition, numerous ulcers supposed to be
tuberculous were found in the stomach. This experi-
ence, therefore, confirms that of Brinton' as derived
from the statistics of Jaksch, Dittrich, and Engel, who
have held that tuberculosis carries off the patient in
from nineteen to twenty per cent, of gastric ulcers. But
it has been customary of late to reject all cases from
our statistical tables if tubercle bacilli were not
found in the ulcers. Naturally this course of action
invalidates the older statistics; however, Herman
IJurck " has actually found tubercle bacilli in four out
of nine hundred autopsies in Munich, the bacilli being
in the gastric ulcers. And Letulle' has found one
tuberculous ulcer in one hundred and eight autopsies
in tuberculous subjects. In these cases cheesy changes,
giant cells, and bacilli should be expected in the
earlier stages. In fact, evidence that tuberculosis is
a cause of gastric ulcer is accumulating rapidly. In-
deed, I am inclined to think that if special attention
is paid to the matter, it will be found that the stomach
is very more often the seat of tuberculous ulcer than
we now think; and I am satisfied that the aniemia
described in these cases is often due to tuberculosis.
But it is quite likely that anamia alone, or chlorosis,
or even a sluggish circulation may be of etiological
importance, and that the liability to ulcer is increased
by tight lacing or mechanical pressure on the organ.
Such conditions could cause a localized necrosis event-
uating in ulcer.
But there are other prominent causes. Lang^ found
a syphilitic history in twenty per cent, of gastric ulcers,
Engel ' in ten per cent. ; and Chiari ° has described two
forms of syphilis occurring in the stomach, the local-
ized or gummatous, and the diffuse. In my first five
cases, as recorded in my case books, there was some
reason to believe that three of the patients were syphi-
litics. Typhoid may produce ulcers of the stomach,
duodenum, and cesophagus. In one of my cases the
patient had suffered from typhoid fever fifteen years
before, and it is possible that this ulcer had never
healed. Septic or an}' form of bacterial infection is
competent to produce infarcts in the stomach. It is
in this way that ulcers of the stomach sometimes fol-
low burns, the causation beirg similar to that of the
duodenal ulcer; the septic matter in both cases being
carried from the sloughs of dead tissue. The theory
that ulcers may be due to circulatory disturbances is
based on sound theoretical principles, in so far as such
disturbances are competent to produce embolism,
thrombosis, or even hemorrhage anywhere in the body,
but as a matter of fact it does not appear that the
stomach suffers much from this condition of tiie circu-
lation, probably on account of its excellent collateral
circulation. However, Berthold,' of Berlin, has re-
ported that of two hundred and ninety-four cases of
gastric ulcer, in one hundred and seventy, or fifty-
eight per cent., there were disorders of the circulation.
' Brinton, 1859, p. 1S2.
' Durck, quoted by Hemmeter in " Diseases of tlie Stomach."
P 554-
•'Letulle: Centralbl. f. Path., Bd. iv., p 760.
* Lang Wien. med Presse, 1885, p. 11.
■■■Engel: Hemmeter, " Diseases of the .Stomach." p. 55S.
"Chiari . Prag. med. Woch., 1885, p. 47.
^ Berthold, quoted by Welch, loc. cit. , p. 487.
chiefly endocarditis and atheroma, and Steiner' found
even a larger percentage (seventy-one out of one hun-
dred and ten, or sixty-four per cent.). For the reasons
given above, however, it is not likely that tiiese views
will be sustained by future investigations. In this
connection it should be remembered that simple
erosions are probably of frequent occurrence, being
often caused by the ingestion of foreign substances or
improper food, abuse of the stomach tube, etc. In
fact, it has been abundantly shown that foreign bodies,
such as knives, bits of glass, broken china, etc., may
be swallowed with comparative impunity, and if they
make wounds they heal readily and usually without
scars. But the most important agent in the develop-
ment of the ulcer is the gastric juice itself. This being
heavily charged with hydrochloric acid is a corrosive
liquid competent under appropriate conditions to
destroy all albuminous substances with which it comes
in contact. How, then, can it be secreted as it is with
impunity in the human stomach.' This is a questioh
still to be answered, but Pavy has offered a possible
solution by suggesting that this acid is neutralized by
the blood current, which is strongly alkaline during
gastric digestion. But even in ordinary health, if
there has been any considerable destruction of the gas-
tric tissues below the level of the epithelial cells, the
tissue does not appear to be able to withstand the cor-
rosive action of its own juices. And there are periods
when the danger is extremely great, and when the
epithelial tissues are themselves acted upon by these
same juices. It is when the circulation is very feeble,
as during the crises in fevers or in periods of profound
inanition during the last hours of life, or after death.
There is now no blood current, or it is extremely
feeble, and there is therefore no alkaline current suffi-
cient to neutralize the hydrochloric acid of the gastric
juice. It is then that gastromalacia, or the auto-diges-
tion of the stomach by the gastric juices, takes place.
Another theory is that the acid is resisted by the
protoplasm of the gastric cells themselves. Gastro-
malacia is a rapid process and may extend in a few
hours from the stomach to the adjacent organs. I
have seen a considerable part of the entire stomach
destroyed, precisely as if it had been dipped in a cor-
rosive liquid. In infants, this process is especially
frequent, and has been attributed in part to the decom-
position of the undigested milk. It is a phenomenon
of wasting diseases such as tuberculous meningitis.
The gastric ulcer varies in size from the head of a pin
upward, but the dimensions are usually between one-
half an inch and one and a half inches. I have seen
it, however, much larger. Ulcers the size of one's
hand have been described. But it is easy to be mis-
taken on this point. In removing the stomach post
mortem, or in separating it from its attachments in the
• course of an operation, the ulcer may be torn, and fre-
quently has been torn so as to appear larger than it
really is, or the inexperienced operator may mistake
gastromalacia for an ulcer. Of course we should ex-
pect that these errors would not be made by persons
of experience, but they do occur. The margin of gas-
tric ulcers is almost always somewhat thickened, and
the walls are apt to be perpendicular or sharply out-
lined. The mucous coat in the so-called chronic
ulcer, whose base is turned upward, is the most
affected. As the ulcer advances in age, there is
usually a progressive thickening of the walls caused
by fibroid infiltration and by its subsequent contrac-
tion, with which there is to a less degree some hyper-
trophy or at least some contraction of the muscular
coat. It was formerly held that most of the gastric
ulcers are either on the posterior surface of the organ
or on the lesser curvature. Brinton found in one
hundred cases that the ulcer was on the posterior sur-
' Steiner . Pepper's ".System," vol ii. , p. 4S7.
March 24, 1900]
MEDICAL RECORD.
487
face or lesser curvature or pylorus in eighty-six per
cent.; Welch in 77.9 per cent, from a study of seven
hundred and ninety-three cases. Nolte in forty-one
cases, however, found the disease located in the
greater curvature, anterior wall, or pylorus, in thirty-
eight, or ninety-one per cent. If this last percentage
is shown to be even measurably correct, it ise.xtremely
important from a surgical point of view, opening up
great possibilities to the operator.
The ordinary symptoms of ulcer in the stomach are
localized pain after eating, vomiting, hamatemesis or
melaina, or both. There may be also gastric irrita-
bility. We should look for all of these symptoms of
gastric ulcer; but they may not occur. There may
also be the signs of the disease with which gastric
ulcer is often associated. Tuberculosis may be pres-
ent but have no lesion from which we can get the
tubercle bacilli. However, in such cases we should
expect anaemia and a low count of the red blood cells,
or a reduction in the hcemoglobin, even in cases in
which there has been no apparent hemorrhage. As
syphilis holds an important place among the probable
causes, we should look closely for the signs of the
disease. Pain is a most prominent symptom of gastric
ulcer. There are two places where the pain is apt to
be located; one is the epigastrium, and the other is in
the back — a later sign. The point of pain is usually
well localized, and will vary from an area of one-half
inch to one and a half inches in diameter. The pain-
ful spot in the back is usually to the left of the spine
and over the tenth, eleventh, or twelfth lumbar or first
dorsal vertebra. Sometimes it is as high as the
eighth vertebra. Another sign is hyperacidity of the
stomach, caused perhaps by an irritation of the gastric
nerves, producing an excessive secretion of hydro-
chloric acid. If, however, an ulcer has once formed,
or there is the direct stimulus to the formation of
hydrochloric acid, and if the motility of the organ is
so interfered with that the food is unduly retained,
there will be hypersecretion of the gastric juices.
And yet, on the other hand, after ulcers have become
chronic, the glands may become so exhausted by
hypersecretion that they will excrete a diminished
amount of hydrochloric acid and pepsin, and so it
happens that there may be hypo- instead of hyper-
secretion of the acid. As a rule, however, subacidity
or hypochlorhydria or hyposecretion, whatever name
is given it, is a neurosis. The points of pain are
aggravated by eating, but are present at all times in
the same spot. At first it might be classed as simply
epigastric distress, but it is often of a boring character,
going through to the back. When the stomach is
empty there is little if any actual pain, but after eating
there is apt to be some immediate distress, due to the
solid food producing irritation ; after a couple of hours
the pain will be due to the movements of the stomach
and the increased acidity due to the pouring out of
hydrochloric acid. If the pain does not occur within
an hour after eating, the ulcer is probably either in or
near the pylorus or the duodenum. Relief comes
through vomiting or after the food has been expelled
through the pylorus. As a rule, in gastric ulcer pain
is to be expected as early as half an hour after eating.
Tiiirst is another symptom. Vomiting is frequent, but
may be absent. Hsmatemesis is usually the first sign
of gastric ulcer, but it is very inconstant, occurring in
from twenty-five percent, to eighty-five per cent, of the
cases. The amount of blood vomited varies; it does
not depend on the size of the ulcer but on the size of
the vessel. When there is hasmatemesis, there is pretty
sure to be mela-na later, but when the ulcer is near the
pylorus we may have mela?na without hajmatemesis.
Flatulence is a symptom that is not uncommon. It is
due to some one of the causes connected with indiges-
tion. It is one of the exciting causes of perforation.
If the vomited matter has the appearance ol coffee
grounds, the indications are that the ulcer is small.
If much blood is lost the ulcer is probably large, but
we should not be deceived; a small amount may be
vomited and a larger amount pass off by the bowels.
The cause of the hemorriiage is apt to be some unusual
exertion. The appetite is usually good during the
early history of the disease. The bowels are apt to be
constipated. Diarrhoea is not a common symptom.
There may be merely the symptoms of dyspepsia, but
chronic catarrhal gastritis usually accompanies the
gastric ulcer. I saw such a case in the practice of the
late Dr. Thurman, of this city. His patient had been
fairly well till within a few days of his death, when
signs of perforation appeared from which he did not
rally. At the autopsy it was found that he had a large
chronic ulcer on the anterior aspect of the organ under
the parasternal line. The ulcer had perforated the
organ probably some time ago, through the medium of
a subphrenic abscess, and there had been a discharge
through the anterior abdominal wall in the left groin;
but the sinus had never closed. It was surrounded by
a fibrous cord, impervious at the upper end, but in the
lower portion lined with a smooth membrane, excret-
ing a serous fluid and capable of admitting a urethral
bougie for from eight to ten inches. '1 he patient had
been under the care of one of our most distinguished
surgeons, but it did not appear that an operation had
ever been proposed, although in this particular case it
would have been comparatively easy to follow up the
sinus, excise the ulcer, and sew up the wound. But it
was before the era of laparotomy. In such instances,
however, operations have been done by Billroth,
Hoffmeister, and Mikulicz, and these three have been
successful, according to Weir.'
In a great majority of cases ulcer of the stomach
involves adjacent organs. Brinton found this to be
the case in seventy per cent. It is probable, however,
that large ulcers such as have been described can
never be cured without an operation. In our diag-
nosis, we are called upon to discriminate chiefly from
gastric catarrh, cancer of the stomach, nervous dys-
pepsia, hyperacidity, sarcoma, duodenal ulcer, diseases
of the pancreas,^ and the subphrenic abscess that is
independent of gastric ulcer. In gastric catarrh there
is diffuse pain after eating; tenderness and pain are
diffused at first; later as improvement sets in there are
more limited areas of tenderness. In gastric ulcer the
pain is more distinctly localized; but these statements
have, after all, comparatively little value, because in
ulcer there is usually more or less chronic gastritis
and the pain is not always localized. Hfematemesis
is a marked symptom; in catarrh it is usually absent,
and is never profuse. In gastric catarrh, if chronic,
there is usually dilatation, and it may be extreme.
There is little dilatation in gastric ulcer. The vomit
in catarrh is mostly mucous. In nervous dyspepsia
the pain is relieved by pressure. It is sharp and
shooting, and usually occurs when the stomach is
empty. The pain is relieved by stimulants, while in
gastric ulcer it is increased by stimulants. This gas-
tralgia is seen in hysteria, melancholia, and other
nervous affections. There is no hsmatemesis or
nielaina in nervous dyspepsia.
In this country carcinoma of the stomach is much
more common than the malignant ulcer. It is usually
a disease of middle age or above it. There are \ omit-
ing and sometimes hsmatemesis. The vomited matter
is apt to be offensive. There is usually some emacia-
tion, though not always, but the distinctive sign is a
' Medical News, May 2, 1896, p. 4SS.
■' A case of hemorrhagic pancreatitis has been mistaken for gas-
tric ulcer C Maurice H. Richardson : Philadelphia Medical Jour-
nal. February 2, I900) . Laparotomy was done, 'and the patient
recovered.
488
MEDICAL RECORD.
[March 24, 1900
tumor that can be felt. When recognized positively
by palpation, it may be confidently said that the
patient will not live more than six months. Cancer is
a progressive disease without intermission. It is
sometimes said that gall stone may be mistaken for
gastric ulcer. It is more correct to say that abscess
of the liver, due to cholecystitis, may be hard to dif-
ferentiate from subphrenic abscess caused by perfora-
tion of the stomach. The history of the case is most
important. In gall stone, the pain is violent and brief
and distinctly localized. It is apt to be accompanied
or followed by an attack of jaundice, and the liver
will be tender and swollen. Sarcoma of the stomach
is rare, but a number of cases have been reported. It
may be primary or secondary, nodular or diffuse. The
onset is usually insidious. There may be anorexia,
haematemesis, or melsna. As yet, however, we have
no clinical signs that will permit us to dififerentiate
this neoplasm from other conditions. However, if a
tumor can be felt, and the spleen is enlarged, the dis-
ease is probably sarcoma, more especially if a sarcoma
has been removed by surgical operation. Carcinomas
and sarcomas do not, in my experience, ever occur
contemporaneously in the same subject.
The prognosis as to eventual cicatrization is doubt-
ful, notwithstanding the favorable opinions of some
eminent writers. Brinton says that perforation did
not occur in eighty per cent, of his cases. That ulcers
will heal is shown lay the scars found at post-mortem.
Thus, in 11,888 bodies, 164, or 1.04'per cent., had
open ulcers, and 373, or 3.01 per cent., had scars,
which would make at least sixty-nine per cent, of
cures. According to the consolidated statistics of
Dittrich, Jaksch, Welling, and Dahlerub,' in 303 cases
of healed and unhealed ulcers, there were 147 scars
and 156 open sores, so that at least in fifty per cent,
cicatrization had been accomplished. According to
Debove and Remond, cures may be found in fifty per
cent., the causes of death being tuberculosis twenty
.percent., perforation and peritonitis thirteen percent.,
hasmatemesis five per cent., inanition five per cent.,
complications seven per cent. ; a total of fifty per cent.
Welch puts the danger of perforation at 6.5 per cent.
Patients will sometimes get well without treatment.
Treatment. — In so far as treatment is concerned,
two things should be prominent in one's mind: first,
to relieve immediate symptoms; second, to cure the
ulcer. In haematemesis one cannot insist too strongly
on rest in bed, and that the patient must not get up for
any reason whatever. No food should be taken by the
mouth, and in fact no liquid should enter the oesopha-
gus. The lips may be bathed in water. If hemorrhage
continues, some preparation of ergot should be used,
perhaps followed by morphine in gr. ^^ doses. An
ice or cold-water bag should be applied to the stomachy
In case of collapse, transfusion should be made with
decinormal salt solution. During this period the
patient should be fed by the bowel. Six ounces of
peptonized milk should be given every three or four
hours. At the end of three days a little liquid may be
given by the mouth, i.e., milk, lime water, beef tea, or
the peptonoid. At the end of the week the patient
should be put on a regular diet, and kept in bed. The
bowels should be moved by laxatives, such as Apenta
water. Warm applications should be made continu-
ously to the epigastrium. After two weeks the patient
may be allowed to get up, but food likely to distend
the stomach should be avoided. The stomacii should
never be washed out or the tube used in gastric ulcer;
profuse hemorrhage may occur with all its attendant
dangers. There is, I am sure, much harm done some-
times by unskilful washing out of the stomach. Large
pieces of mucous membrane may be caught in the eye
of the tube and torn out. Bits of mucous membrane
Brinton, p. 163.
are so frequently found in the wash-water as to lead to
the supposition that they were torn off by the tube.
In fact, at postmortem examination I have seen in a
single case numerous erosions of the stomach caused
by lavage. Operative measures have been frequently
resorted to, and especially during the last few years.
But, as will be seen, it is difficult to make a fair
comparison between the medical and surgical results
that have been reported thus far. When Weir and
Foote published their paper,' there appeared to be no
reason to prefer surgical to medical methods, for the
surgical mortality in their seventy-eight collected cases
was set at 71.51 per cent. Apparently the surgical
outlook is now better, for. Tinker" reports that one
hundred and thirty-one cases he has collected since
the former date show a surgical mortality of only
35.71 per cent., while individual surgeons are now
known to have reported still better results. Thus,
Haberkant's show a surgical mortality in gastro-
enterostomies of only twenty-five per cent.' Further,
of Tinker's cases thirty-seven operated on during the
first twelve hours showed a mortality of only sixteen
per cent.; in pyloroplasty of 13.2 per cent.' The
French surgeon. Doyen, in his book ^ puts his mor-
tality after gastro-enterostomies at ten per cent., while
W. S. Mayo, of Minnesota, reports that he had only
one death in fifteen gastro-enterostomies, a mortality
of 6.6 per cent.'^ Accepting these statistics it is plain
that the dangers from surgical interference are be-
coming gradually less and less in certain classes
of operations, so that the counsel of the surgeon
may be well invoked by the medical practitioner in
these cases. In fact, in suspected cases of gastric
ulcer the physician and surgeon should work together,
mutually aiding one another in diagnosis and in
deciding the question as to whether an operation is
advisable or not.
For on the medical side of the case it must be
recognized that the mortality from medical treatment
is probably quite small. Weir and Foote once put it
at twenty per cent.' On the other hand, a recent
writer' puts it at only five per cent.; while Leube, of
stomach fame, has stated publicly' that in five hundred
and fifty-six of his cases he has lost only twenty-two
per cent, by death, and four per cent, represents his
failure to cure.
It would not be proper to let the opportunity pass of
emphasizing the statement, that a surgical operation
is the only possible resort in some cases, if life is to
be saved.
But all is said and done, and although, therefore,
surgery seems likely to gain new laurels in the treat-
ment of gastric ulcer, especially in complicated cases,
or if tile operations be done very early, medical prac-
titioners will still be content in uncomplicated cases
to employ established medical methods, and will have
a good share of success.
The most dangerous complication is peritonitis,
and it is extremely important to be able to recognize
this condition at the earliest possible moment. Pal-
pation ought to show' a little tenderness over the ulcer.
Peritonitis sets in with a chill, a rise of temperature
to 100° or 102 F. The patient lies with the knees
drawn up, and has the characteristic facies. The
pulse is rapid and small. It is now that surgical
relief is to be sought at the earliest possible moment.
' Medical News, April 25 and May 21, 1896.
- Philadelphia Medical Journal, February 3, 1900,
■• Weir : Lv. at.
■•Seniaine Med., 1897, p. 142.
^ " Traitement chirurgicale des afTections d'estomac," 1S95, p.
392.
' Philadelphia Medical Journal, Februarx- 3, 1900.
'Medical News, May 2, 1896.
'Robert Saundby : Brit. Med. Journ., January 20, I900,
'Semaine Med., 1897, p. 142.
March 24, 1900]
MEDICAL RECORD.
489
Subphrenic abscess is another complication that is
also very important from a surgical point of view. It
may be dependent on or independent of gastric or
duodenal ulcer, but it is most frequentiv caused by
perforating ulcer of the stomach or duodenum. Other
causes are ulcerated appendix, abscess of the liver or
kidneys, or various intraperitoneal troubles; it may
also be due to extraperitoneal influences. 1 have de-
scribed such a case as a sequel to empyema.' Sub-
phrenic abscesses are apt to be so large as to push
down the stomach and the spleen on the left side and
the liver on the right, raising the diaphragm up to the
level of the third or fourth rib; they may even per-
forate the diaphragm, causing empyema, or burst
through the lungs into a bronchus and so discharge
their contents. In a laige number of cases these
abscesses contain gas, owing in part to communication
with the stomach, or to the decomposition of their
contents. At first the signs will be gas in a sac con-
taining liquid associated with a perforated ulcer of the
stomach or duodenum, together with pain in tlie epi-
gastrium, possibly a gastric tumor, and the signs of
local peritonitis. The differential diagnosis must be
made from empyema, simple abscess of the liver or
spleen, or pneumothorax. Theoretically the upper
level of the diaphragm should in subphrenic abscess
be concave, with the concavity upward so that the
upper limit of the abscess should correspond to this
upward curve of the diaphragm. On the other hand,
in simple empyema the curve of the diaphragm should
be downward." In these cases of subphrenic abscess,
according to Penrose and Dickson,' including the
thirty-four cases collected by Weir with fifteen cures,
Nowak estimates his cures at fifty-five per cent. The
treatment should be incision with or without exsection
of the rib and drainage. I should be disposed from
my experience to recommend through drainage as
originally recommended by Chassaignac' If the
diagnosis of a subphrenic abscess is made, a surgical
operation should be considered at once.
There is no ditTerence in anatomical characters
between the ulcer of the stomach and the duodenum;
in fact, the non-malignant ulcer that has been de-
scribed, with its sharply cut edges and rounded con-
tour, may be found as well in the duodenum and
oesophagus as in the stomach ; for the gastric juices
can under appropriate conditions act in all these
localities. In fact, the causes of the one ulcer are
equally well those of the other, except perhaps that
burns have a special tendency to be associated with
duodenal ulcers (in from twelve per cent, to four per
cent, of burns). As in the stomach, these ulcers are
usually found in a middle period of life, but there is
this difference, that in men they are three times as
frequent as in women. Duodenal ulcers are usually
found near the pylorus on the inner or posterior walls
of the bowel. In a large number of cases there will
be no symptoms; in about 12.5 per cent, ulcers of the
duodenum and stomach will be associated together.
In one hundred and fifty-one cases of duodenal ulcer
collected by Perry and Shaw" there were no noticeable
symptoms. So far, however, as we are able to decide,
symptoms of pain come on later than in gastric ulcer.
If it occurs in from four to five hours after eating,
duodenal ulcer is probable. There is also more or
less pain to be expected over the right lower border of
the liver. This pain radiates and may go through to
the back. There is no tumor, but there may be a pain-
ful spot. If the patient takes no solid food, the pain
' Medical Kecukd, November 17, iSSS, p. 5S2.
■Curtis : " Twentieth Century Practice of Medicine."
^Trans. Clin. Soc, London. 1893. vol- xxxvi., p. 72. I,ey-
den ; " Ueber Pyopneumothorax," Zeitsch. f. klin. Med., 1S80,
Bd. i., p. 320
^Chassaignac : " Traite de la Suppuration." vol. ii., p. 341.
* Guy's Hospital Reports, i3g2, vol. i.
may stop. As in gastric ulcer, hemorrhage is an
important sign. If the food is first vomited without
blood, and blood follows, the indications are that tlie
difficulty is below the pylorus. There will also be
obscure dyspeptic symptoms. The prognosis is more
unfavorable than in gastric ulcer, because the disease
is less easy of reacii.
The following are some illustrative cases taken
from my hospital and private records:
Case I. — Probably syphilis of lungs and liver; ulcer
of stomach; death following hxmatemesis. L. St.
R , aged forty-two years, admitted September 18,
1882. The patient had some chronic sore throat.
The hair had fallen out in large quantities. She had
been tapped for ascites. Eleven days after admission
to hospital she had mehtnn, followed by haematemesis.
Hypodermics of- ergot were given without avail, the
patient dying of collapse. At the autopsy, the whole
gastro-intestinal tract was found congested, while the
sigmoid flexure and rectum were found thickened. At
one point in the stomach there was a superficial ulcera-
tion. This case illustrates the fact that a very small
ulcer may be the seat of a fatal hemorrhage. It was
probably syphilitic.
Case II. — Chronic tuberculous ulcers of the bowels;
catarrhal gastritis. A. R , aged thirty-six yea's,
admitted to hospital October 14, 1886. For the past
five years the patient had suffered from pain over the
pylorus and vomiting after eaiing. The pain had not
been constant, but was marked after taking food. The
order of symptoms had been, after a meal, pain,
nausea, and vomiting. Tiiere never was any ha;ma-
temesis. The patient was taken with se\ere epigastric
pain and also vomiting, with severe intestinal cramps
and abdominal soreness. A second attack occurred
three months later. Two months ago, he had another
attack. The pain he described as if the intestines
were twisted or knotted. The stomach would retain
nothing, not even ice water. Constipation and flatu-
lence were present. Rectal injections could not be
retained. The mouth and throat were swollen ; vom-
iting of greenish matter occurred. The patient became
delirious, collapse ensued, and he died on the third
day after admission. No history cf tuberculosis or
syphilis had been obtained from him. At the post-
mortem the lungs were found infiltrated with tubercles,
and the mesenteric glands were cheesy. Tuberculous
ulcers were present from the duodenum downward
through the entire length of tlie intestine. In this
case the patient died of ulcerative enteritis, while the
stomach was merely in a condition of catarrhal gas-
tritis. This case is especially interesting as showing
the difficulty of distinguishing enteric from gastric
ulcer. It was never suspected that his disease was
anything but gastric ulcer, until the autopsy showed
the error.
Case III. — Tuberculous phthisis; duodenal ulcera-
tion, etc. G. H— , aged twenty years, porter, ad-
mitted to the hospital May 6. 18S0, was found on
examination to be emaciated and in the third stage of
phthisis. He had hectic and night sweats, with
chronic diarrhoea. The patient died of exhaustion
fourteen months after admission. The bowel was
studded with ulcers from duodenum to ca-cum, as
shown by post-mortem examination. This case and
the preceding one show that tuberculosis plays an
important part in ulcer of the duodenum.
The two following clinical cases from my practice
are sufficiently interesting to be detailed:
Case IV. — Ulcer of the stomach and intestine;
typhoid fever; tuberculosis; membranous enteritis.
The patient was put under my care by a physician
April 12, 1898. The history was as follows: A.
K , aged nineteen years, iiad been delicate all lier
life. She had "enteric fever" in August, 1897, which
490
MEDICAL RECORD.
[March 24, 1900
lasted four weeks. A month later she had intestinal
colic. Still a month later she began to cough, and
diagnosis of acute tuberculosis was made. She had a
daily rise of temperature, with night sweats, loss of
appetite and flesh. Throughout her sickness a good
deal of pain occurred in her stomach, coming shortly
after meals. Iron, bismuth, silver, etc., did not relieve
her. Menstruation was suspended for eight months.
There was no vomiting. On examination it was stated
that she had lost twenty pounds during the year. She
complained of pain in the epigastrium after eating,
with occasional flatulence. There was no movement
without medicine, but Hamburgtea relieved her consti-
pation effectually. She vomited food; there was pain
on pressure over the centre of the stomach. Physical
examination showed consolidations of both apices, as
also scattered areas in both lungs. ' The pulse was
weak and intermittent. The temperature was 99.8^ F.
Small doses of calomel stopped vomiting. Complete
mental and physical rest was ordered, with some such
nutrient as marrow, the prepared infant foods, and
malt preparations, of which maltzyme was especially
satisfactory. Carefully selected and nutritious foods
were also prescribed at intervals of two hours, so that
she took something six times a day. Starchy food
was excluded as far as possible. Gradually, as her
strength came to her, she was allowed to take short
walks. This treatment was kept up for twelve months,
at the end of which time she was gradually permitted
to return to the regular diet of a woman in health.
She had gained sixteen pounds. She now (January
30, 1900) has the general appearance of healtli, rides
her wheel, and is constantly gaining flesh. Kpigastric
pain is only occasional, and this is caused by gaseous
distention.
Case V. — Gastro-intestinal ulceration ; chronic gas
tritis, endocarditis; lateral curvature. In April of
1898 I saw in consultation a lady who had been under
treatment for several years and had consulted many
eminent practitioners both at home and abroad.
Several summers earlier she had suffered from what
was called acute gastritis. She then vomited blood.
A diagnosis of cancer of the stomach was made, and
a surgical operation was proposed. She had been
suffering from mitral endocarditis and interstitial
nephritis, but during a recent trip in Europe had
gained some ten to fifteen pounds. After her return
an attack of influenza ensued, and exposure to cold
brought on a fresh exacerbation of nephritis. I found
her much emaciated and suffering from gastric and
abdominal pain increased by pressure. The liver was
not enlarged. There was no thickening over the
pylorus. Owing to emaciation the stomach could be
accurately mapped out. From the duration of the
disease and the absence of tumor, I excluded cancer.
The heart's action was tumultuous. Her hands and
feet were cold. The pulse at the wrist was almost
imperceptible. The heart apex was carried to the
left. There was much food undigested. Relief was
given by kneading the bowels and continued applica-
tion of warm compresses. Some improvement followed
the use of the subgallate of bismuth and the tincture
of adc^nis vernalis in doses of ni i., together with
calomel followed by codeine. The sarcopeptones were
retained. Stimulants were also given freely. The
patient was greatly improved, when an accident hap-
pened on the third day after I first saw her; though
admonished to keep perfectly quiet and not to rise
from her bed for any reason, she insisted on rising,
and during the exertion a large quantity of blood
escaped from the bowels. Death followed at once.
Case VI. — Disseminated tuberculosis with tubercu-
lous ulcers of stomach. I had the opportunity of see-
ing another interesting case at Bedford Mills, N. Y., in
the practice of Dr. J. F. Chapman, of Katonah, N. Y.
Miss M , aged fifteen years, I found confined to
her bed with all the symptoms of acute general tuber-
culosis. The case was beyond the reach of medical
skill. The diagnosis was confirmed by the autopsy,
the peculiarity being in this case that while the family
give no ex'idence of tuberculous taint, the daughter was
an extreme example of tuberculous infection, with
numerous tuberculous foci in the stomach, in addition
to those of the mesentery and peritoneum.
I should add that in these cases classed as tubercu-
lous no bacilli were found, because at that time the
tests for bacilli were unknown, but there was no
doubt in my mind that they were tuberculous.
7 East Eightieth Street-
ON THE TREATMENT OF FATTY HEART.
By PKOKESSOR TH. SCHOTT. M.H..
In attempting to give the treatment of fatty heart I
shall relate my own experience and also the changes
which have occurred in the therapy of chronic heart
disease in the course of the past century. We shall
see that different theories have led to different modes
of treatment.
Three varieties of fatty heart are generally recog-
nized, viz., (1) that in which the fat lies as an over-
growth or penetrates between the muscular fibres, so
that large quantities of fat are found covering the
pericardium or underlying it, quite enveloping the
heart. This condition may be observed at the apex,
in the sulci of the large cardiac vessels, especially at
the sulcus transversus and the base of the heart. The
fat may even penetrate between the muscular fibres as
deep as the endocardium. (2) Fatty degeneration of
the muscle, in which more or less numerous globules
of fat are intermixed with the muscular tissue and
the action of the cardiac muscle is thus weakened.
(3) When the fat tissue fills up, as it were, the lacuna;
of the muscular substance; this is to be seen in hearts
the muscular walls of which are quite enfeebled, and
in which, as a consequence, the fat penetrates into the
muscular substance, or in hearts which have become
atrophied by myocarditic processes, and in which the
fat is found in the lacuna; of the fibrous tissue. These
globules of fat appear to the eye like yellow spots of
various sizes. In this condition the fatty tissue is only
accidental and has nothing to do with the original dis-
ease process.
That which w'e usually understand by a "fatty
heart" is either an overgrowth or intermixture of fat,
or it is a condition of fatty degeneration of the heart
muscle. Not infrequently we find these two condi-
tions coexisting and in a state of transition, so that it
is difficult to distinguish one form from the other.
I shall now endeavor to consider fatty heart, prop-
erly so-called, viz., the first-named variety, with its
transition to the second.
As we have no unequivocal symptoms of fatty heart,
we are obliged to arrive at a diagnosis by a combina-
tion of conditions, by general observations, and by
especial heart symptoms. Thus, a fatty heart may be
diagnosed if the following conditions are detected:
an easily induced sensation of fatigue in a person
having an abundant deposition of fat over the body in
general, or more especially upon the chest and bowels,
with difficult breathing, amounting at first only to a
slight oppression and ending in dyspmta, with small
feeble, frecjuent, and easily compressed pulse, with
final dilatation of the heart, and when through weak-
ness of that organ, or owing to the effect of an ac-
cumulation of fat around it or in its walls, the ictus
cordis begins to disappear; further, a condition of
March 24, 1900]
MEDICAL RECORD.
general plethora, or fulness of the skin, and a sense
of straining in the bowels, etc. But all these symp-
toms cannot be regarded as absolutely unmistakable
signs, for I have met with many cases in which these
symptoms were due to weakness of the heart caused
by chlorosis or anamia, overexertion, mental excite-
ment, coitus nimius, or to the abuse of coffee, tea,
alcohol, etc., all of which excesses it is known ei-
ther weaken the cardiac muscle or affect the nerves of
the heart. Only long experience will enable the prac-
titioner to avoid erroneous conclusions, but in general
we may say that the diagnosis of fatty heart is made
rather too frequently. He who has patients under his
observation for a certain length of time will be less
liable to make a serious mistake in this respect.
The prognosis depends chiefly upon the state of the
cardiac muscle, the duration of the disease and its
symptoms, and, further, upon the etiology, age of the
patient, etc. The stronger the heart muscle, the less
advanced the state of degeneration, the younger the
patient, the more normal the blood, the better will be
our chance of curing the evil. The graver the symp-
toms, the more may we expect their temporary amelio-
ration to be followed by relapses, and these are espe-
cially to be feared in old people suffering from a fatty
heart and in whom other disorders are present. With
.the improvement of the system of treatment of chronic
diseases of the heart, the prognosis of these cases has
become much more favorable than formerly.
The prophylaxis plays an important part with such
patients. In those cases in which, owing to heredity
or to individual disposition, there exists a tendency to
obesity, early attention should be given to physical
exercise and to moderate mental activity, with such
regulation of the diet as to prevent additional accumu-
lation of fat. Whenever the physician has reason to
diagnose the first stage of fatty heart, he should forbid
the patient doing anything which might prove injuri-
ous to or weaken the heart, lest some degeneration of
the heart muscle may already be present or about to
occur. As all these precautionary measures will have
to be spoken of in the general treatment of fatty heart,
I need not dwell upon them at present.
Therapy". — It will not be uninteresting to recall,
for a moment, the systems of treatment which have
formerly prevailed. Before all others the means de-
pended upon were of a pharmacological nature, espe-
cially such drugs as caused either nausea or vomiting;
at a later period, bleeding was relied upon. Notwith-
standing that these measures and remedies not infre-
quently resulted in collapse and weakness of the
heart, or in prolonged periods of anaemia and chloro-
sis, yet they continued to be resorted to for a long
time until they were supplanted by drastic purgatives;
but these also were attended by so many dangers that
they fell into disuse and gave place to the use of pur-
gatives of a milder nature, which in their turn yielded
to the employment of the modest mineral waters. The
enumeration of remedies formerly resorted to would
be imperfect, did I not mention the preparations of
iodine, the use of which had many adherents. Al-
though these preparations are still advocated by a
certain number of practitioners, I must not fail to
mention that all the salts of iodine are apt to destroy
the albuminates, and by their irritant action upon the
mucous membrane of the stomach and intestines so
impair the appetite that their administration, if relied
upon at all, should be reduced to a minimum. An-
other drawback to their use is the fact that they are
more likely to reduce the general obesity than the
fatty condition of the heart. The same objections
apply to the lately recommended preparations of thy-
roidin. Doubtless in a certain percentage of cases
their use has resulted in a more or less satisfactory
decrease of fat, but this result, as I have of late had
repeated occasion to demonstrate, is accompanied, in
patients suffering from fatty hearts, with considerable
danger, for the effect upon the cardiac muscle and
upon the nervous system is such that death may re-
sult. Thus there may occur tachycardic attacks, dila-
tation of the heart muscle, insomnia, and nervous
excitement amounting at times to mania. As regards
oophorin Jn tabloids, which during the past year has
been recommended for the treatment of obesity in
females and also for cases of fatty heart at the cli-
macteric years, I must defer giving an opinion, at
least for the present. A quarter of a century ago the
principal role in the treatment was played by the min-
eral waters, and chiefly such as contained sulphate of
sodium, like those of Marienbad, Karlsbad, Tarasp, etc.
Especially were the springs of Marienbad relied upon,
and they are still visited by many in the treatment of
general obesity with a fatty heart. But even at these
springs we no longer see, as formerly, that avidity in
the use of the waters in order to obtain in the least
possible time the greatest decrease in weight. The
dangers of such a course of the waters vi'ere not infre-
quently such as even to threaten life, for patients have
come to me from these springs, when in a course of
four to six weeks such a loss of weight in proportion
to the bulk of the body had been caused, that a rapid
and marked diminution of the strength had resulted.
One of my patients, who had previously been sent by
her physician to Marienbad, was seized during her
second week of treatment at that place with an acute
attack of oedema of the lungs, and had to be sent home
in a most critical state. The mineral-water treatment
brings dangers to the heart which will be spoken of
hereafter, but general debility, chlorosis, and anaz^mia,
etc., are not infrequently caused by such prolonged
purgative measures. There is a still further draw-
back in that if other modes of treatment are added to
prevent a further accumulation of fat, the patient upon
his return home is sure to have a return of the obesity.
The injurious effect of such forced cures by the use of
mineral waters containing sulphate of sodium caused
many to abandon their use, and to turn for relief to
such saline waters as those of Kissingen, Kreuznach,
Nauheim, etc. But even these waters have been used
in too large quantities. Formerly, I frequently met
with patients for whom seven to nine glasses daily had
been prescribed, each glass containing eight ounces
of a one-and-a-half-percent. solution of salt. While it
was not to be feared that such daily quantities of these
waters would cause an immoderate reduction of weight,
their use not infrequently brought about a gastric ca-
tarrh to which obstinate constipation was often added,
requiring the active interference of the attending
physician. To the late Beneke is due the credit of
having been the first to draw attention to the fallacy
of such severe procedures.
In the last half-century the method of treatment of
fatty heart has been revolutionized. Entirely new
procedures have replaced the old ones. The two
names I must first mention are Stokes and Banting,
or, more correctly stated, Harvey-Banting. To the
first we owe the mechanical and to the latter the die-
tetic treatment. Both systems now not only form the
basis of the therapy, but have been further developed
in different directions and supplemented and made
more efficacious by new methods. First, as to the di-
etetic therapy : The fundamental idea of the Harvey-
Banting system was to inhibit further accumulation of
fat in the body by means of abstinence from carbo-
hydrates and from fatty food, and to impede the
transformation into fat by the use of increased quan-
tities of albuminates. Bearing in mind the perfectly
reliable investigations of Pettenkofer and Yoit, I
feel thoroughly convinced that the total food supply
prescribed by the originators of this system is insufii-
492
MEDICAL RECORD.
[March 24, 1900
cient in nitrogen to maintain the normal quantity of
that element in the body, or, in other words, that the
excessive supply of albuminates certainly leads to a
decrease of fat, but causes at the same time a danger-
ous reduction of the albuminates of the body. The
injurious effects of such a Harvey-lJanting cure be-
came but too soon evident in the supervention of gen-
eral nervousness and debilit}', by insomnia, etc., and a
baneful influence was produced on the functions of the
heart by a weakening of the cardiac muscle. Further-
more, the excessive ingestion of albuminates may
cause disturbances of digestion, and the predomi-
nance of nitrogen in the food has in some cases re-
sulted in symptoms of a toxic nature; not infre-
quently gouty affections are thereby either evoked or
increased in severity. It is not to be wondered at,
therefore, if at the present time the Banting cure is
but rarely recommended by a prudent practitioner.
The modification suggested by Ebstein, who instead
of albuminates increases the quantity of fat taken by
the patient, may be called a system of insufficient
feeding with all its dangers, and has therefore but
few advocates. It is hardly necessary to mention the
old ideas of Schroth, who prescribed dry bread exclu-
sively, or those of Tarnier, who allowed nothing but
milk, for they amounted in reality to forms of starva-
tion with all their fatal consequences.
Among all these dietetic formulre those of Oertel
are most in harmony with the physiological statements
of Pettenkofer and Voit, but unfortunately he com-
bined with them a severe reduction of liquids, an idea
first advanced by Dancil, and the well-known climb-
ing system, which I shall discuss later. Oertel ap-
plied his system to cases of heart disease with or
without obesity. However rational his system of
treatment may at first appear, experience has shown
that it is not without danger to the patient, the more
so because he failed to differentiate between the use
of alcoholics, effervescent beverages, and plain water.
He, moreover, frequently reduced the fluids to such
an extent — as low as twenty ounces pro die — that an
injurious effect was sure to result. His view, too,
that he could thus diminish at will the volume of
the blood has proved erroneous. I shall state later
what cases may be benefited by the use of the Oertel
cure, but it may be mentioned here that I and many
others have distinctly learned that the very condition
which Oertf I strove to prevent, an insufficiency cf the
heart-muscle, has certainly resulted from a pursuance
of his treatment, and has been accompanied by dysp-
noea, dyspepsia, insomnia, and in some cases by ne-
phritis. Hence the Oertel cure has lost many of its
adherents. Of all the systems of reduced diet in the
treatment of obesity and of special heart diseases
which have been proposed of late years, it may be
said that they are dangerous. Many are apt to forget
that a fatty heart is a heart weakened by muscular
insufficiency. From what precedes we may conclude
that no diet cure hitherto proposed is of itself suffi-
cient either to prevent the development of a fatty
heart or to benefit one without injuring the patient in
other respects. In all cases of reduction of the fatty
tissues we run the danger of at the same time dimin-
ishing the albuminates, whereby the muscular and ner-
vous systems are sure to suffer. It is not a matter of
indifference which organs are deprived of the albumi-
nates, for the loss of a few grams of the cardiac muscles
may do more harm than the reduction of as many
pounds of albumin in some other part of the body, as,
for example, in the extremities.
With our present knowledge we cannot, after a re-
duction of the albumin of the body has been brought
about, state whence that constituent has been taken,
nor do we know of any remedy to prevent a loss of a
part of the muscular substance of the heart. Experi-
ments upon animals have taught us that by starvation
it is difficult to diminish the fat in or about the heart.
VVe learn that the fat and the muscles of the body may
be largely reduced without any appreciable diminution
of the heart fat. Be it therefore understood that we
cannot altogether dispense with dietetic measures, but
they must be combined with other therapeutic pro-
cedures, of which the first to be mentioned is the
Mechanical Treatment This mode was first in-
troduced by Stokes. He had noticed that people
with fatty hearts suffered when climbing mountains,
at first from dyspnoea, but that later, as he so well ex-
pressed it, " they got their second wind," and were then
able to attain their object without being harmed there-
by. But this mountain-climbing as a sole method of
treatment soon fell into disuse and was abandoned on
account of injurious effects which often resulted, and
because of the violent opposition to it by scientific men.
Many physicians then went to the other extreme and
advised their patients to indulge in excessive rest,
until about fifteen years ago, Oertel, having tried the
Stokes system on his own person, endeavored to sys-
tematize mountain climbing by organizing in different
places certain climbing excursions, better known under
the name of "Terrain Kuren " (climbing cures).
These consisted in various paths whereby the patient
was at liberty to choose in gradation those of a level
nature and others with more or less of a rise, while
the character of still others was quite steep. Even
this method was found to be followed in many cases by
injurious consequences, giving rise to violent opposi-
tion— the reasons for which I shall speak of later — so
that the number of those who prescribe the climbing
according to Oertel's method has rapidly decreased.
Of late years a large number of apparatuses have
been invented, having in view the diminution of
fat by an increase of the muscular functions, and
thereby a strengthening of the cardiac muscle. I will
merely mention that of Gaertner, the rowing-machine,
the contrivances of Nicander, the different chest exer-
cises, etc. ; but all these expedients were unable to
rival the machines invented by Zander. I do not
purpose to discuss their value here, having done so
in previous publications in which I have called atten-
tion to their shortcomings; whether the apparatus
lately invented by Herz can overcome the defects of
the Zander machines remains yet to be seen.
The gymnastic treatment, first brought into notice
as a therapeutical measure by my brother, the late
August Schott, and by myself, consisting, as the read-
ers of this journal know,' of exercises with resistance
or self-resistance, can unhesitatingly and safely be
resorted to in all the different forms of fatty heart.
Provided the degenerative process is not too far ad-
vanced, and there are no other complications, and the
age of the patient is not too far advanced, we begin at
once with a resistance of middling strength, increas-
ing rapidly to a vigorous resistance. The long rest
generally taken after these exercises is not so requi-
site in the treatment of fatty heart. Of course such
patients must take abundant exercise in the open air,
but the climbing of mountains should not be allowed
until the heart shows increased muscular strength and
a more normal functional activity. As my brother
and I have always declared, the climbing of moun-
tains mav form the ending but never the beginning oi
the cure, as only thus do we avoid the danger of over-
straining and further weakening of the heart. On the
other hand, we have to guard against too much rest;
' Vide Theodor Schott; " Balneo-Therapeutics and Mechano-
Therapeutics in the Treatment of Chronic Heart Disease," New
York MF.DirAi, Record, February 14, iSgi; "Treatment of
Chronic Diseases of the Heart in the Light of Roentgen Rays,"
New York Medical Record, March 26, i8qS ; "On the
Treatment of Cardiac Neuroses," New York Medical Record,
March 11, iSqq.
March 24, 1900]
MEDICAL RECORD.
493
it is well known that all stout people incline to physi-
cal laziness, especially after meals. In order to bring
about a diminution of weight and of fat, rest should
never be indulged in after eating. If there be need
of repose, the patient should lie down for a while be-
fore the meal and take a walk after it. This proce-
dure alone will benefit
those suffering from obes-
ity and especially persons
afflicted with a fatty heart. >.
In combination with these J
physical exercises, mas-
sage will prove an effi-
cient expedient for pro-
moting the absorption of
fat, but without exercise massage is unavailable for
this purpose, and the reasons therefor I hope to de-
monstrate to my readers in a future paper.
Balneological Treatment. — In this field during the
last decennium the application of the balneological
and hydrotherapeutical treatment has been found to
be of the greatest value. Hydrotherapy is preferably
resorted to in the form of potations or douches, but
with patients suffering from fatty heart extremes of
temperature, high or low, may prove dangerous and
should be avoided. The readers of this journal are
doubtless familiar with the balneological method in-
troduced by my brother and myself, and I will there-
fore merely state that when the degenerative process
is not far advanced we can without fear proceed with
baths of gradually increased concentrations of salt, as
well as with baths with increased quantities of car-
bonic acid gas, and it is especially with fatty-heart
cases that we can have early recourse to the use of
Sprudel- and Sprudel-Strombiider (effervescent run-
ning-baths). Unless there are contraindications there-
to, such as chlorosis and anaamia, rheumatic or arthri-
tic complaints, or advanced age, all of which require
a warmer temperature, we may with better advantage
begin with the baths of low temperature. I generally
order at first a temperature of 88° to 86° F., and grad-
ually get down to baths of 77° to 76° F. The dura-
tion of the bath at the commencement of the course is
usually ten minutes, and the bath is at first intermitted
on the second day, and afterward every third or fourth
day. The duration of the bath is gradually increased
up to twenty minutes. I have rarely seen good results
from a longer duration. Those cases of fatty heart
associated with chlorosis and anaemia are especially
and very rapidly benefited by various effervescent
baths which I have mentioned.
The balneological-gymnastic method in combina-
tion with the dietetic treatment is undoubtedly the
agent which to-day is most relied upon in the thera-
peutics of fatty heart, and the question arises, Have
we better and more successful results by their use and
application? Judging from my large experience in
this field it is without hesitation that I can answer
time the muscular substance is not only spared but is
frequently augmented, and the volume of the blood is
increased. Thus, it may happen that the patients gain
in weight, although a decrease of the panniculus adi-
posus and of the abdominal masses of fat may be clearly
demonstrated. I have repeatedly described such cases
^..Jv-KJVJV
Fic. 2.— After Twenty Minutes' E
vith Resistance.
Fig. I. — Before Treatment,
this question in the affirmative, so that I may say that
the prognosis of fatty heart has now become much
more favorable.
While with all the older methods of treatment which
I have mentioned a diminution of the albuminates of
the bodv was brought about simultaneously with the
reduction of fat, we are now able to cause the fat of
the body to be gradually consumed, while at the same
in my writings, and among them have called especial
attention to a patient suffering with kyphoscoliosis—
a case exactly similar to that which Oertel enlarged
upon with so much enthusiasm — who lost his fatty
heart and all the symptoms connected therewith, with-
out any loss of the weight of his body. But I must
here energetically warn against a rapid loss of weight,
especially one out of proportion to the bulk of the
body. The relief produced by such a rapid decrease
in weight is but too often of a delusive nature, for
while the patient and his respiratory function are ren-
dered temporarily more comfortable by the disappear-
ance of fat from the bowels and thorax, general debil-
ity is sure to supervene very soon, and often violent
dyspncea as a result of the loss which the heart mus-
cle sustains simultaneously with the reduction of the
fat; various disturbances of the circulation occur, and
the fatty degeneration with a rise of temperature is
often followed by myocarditis with all its serious con-
sequences. Such a picture is one which was formerly
but too often seen, and even to-day is not infrequently
met with. What a marked difference is seen as the
result of a dietetic-balneological-gymnastic treatment
correctly carried out! It certainly requires more time,
but the risk is so much less and the success so much
greater. Had I space I might relate a long series of
such cases. Many of them have been published either
by myself or by physicians who have familiarized
themselves with our method of treatment in Nauheim.
By this method of treatment we soon notice a
marked change for the better in the patient, and I
have often had occasion to point out this improvement
to my colleagues. As indicative of the favorable effect
of the treatment we find that the small pulse becomes
of fuller volume, the arrhythmia disappears, and the
elevations of the pulse diagram, showing the elasticity
of the arterial wall, become more visible and frequent;
the pressure of the pulse gets stronger; a tachycardia
disappears, while not unfrequently we see a brady-
cardia give way to a normal frequency; the pale or
yellowish complexion of the patient becomes of a rud-
dier hue; the sounds of the heart become louder; the
dilatation, which is always present in cases of advanced
fatty heart, gradually dis-
appears ; the ictus cor-
dis, which could scarcely
be felt, becomes more
perceptible, the respira-
tion freer and deeper, and
the capability for physi-
cal exercise increases
day by day, so that final-
ly the patient can walk for hours without trouble,
and even ascend slight elevations, and now it is
when this amount of improvement has been achieved
that he may safely be allowed to make somewhat
longer excursions in the mountains. It does not fol-
low that because, by assiduous attention and constant
care, and with the aid given by the frequent use of the
thermometer, we have brought about such a favorable
494
MEDICAL RECORD.
[March 24, l goo-
condition in our patient, the treatment can then be
abandoned ; on the contrary, we must impress upon
Fig. 3. — After an Effervescent Eath (Sprudelbad) of Spring No. VII., of 86** F. and ten minutes' duaration
him the necessity of his continuing for many months
the same regimen of diet and exercise, and if he be of
middle or of advanced age the danger of a relapse
should not be lost sight of; in a younger person this
danger is by no means so probable. I therefore gen-
erally advise the patient on his return home to con-
tinue for quite a while his gymnastics with resistance,
for by so doing I am sure that most striking and en-
during results are accomplished. One ought never to
forget that in cases of
fatty heart our chief aim
should be to strengthen
the cardiac muscle and
to maintain its vigor.
The latest researches in
this field all go to prove
the correctness of our
views. The increased
bulk of the heart is only due to its being covered by
or partially made up of fat, while its muscular sub-
stance is inferior in quantity to that of a normal
organ, as has been fully confirmed by the latest inves-
tigations of C. Hirsch; the quantity of the muscle of
the heart is always in a direct proportion to that of
the whole body. Hence the more we increase the
muscular strength of the individual in toto, the more
we strengthen his cardiac muscle. That such a satis-
factory result may be readily obtained by our balneo-
logical and gymnastic method, I have already attested
in my published cases. Of these many were cases of
fatty heart under my care at Nauheim, and their daily
improvement and ultimate recovery I was able to de-
monstrate to a large number of physicians stopping in
that town, some for study and some for their health.
As an ocular demonstration of the beneficial effect
of bathing and of gymnastic exercise I give here with-
out further details the diagrams of the pulse and
measurements of its pressure, taken from two patients.
Figs. I to 3 refer to a wine merchant, thirty-three years
of age, whose height was 1.70 metres, but who weighed
two hundred and twenty German pounds. He suffered
greatly from fatigue and from dyspnoea even in a state
of rest. Frequency of the pulse after a long repose,
no; pressure of pulse, 95 mm. Hg. ; respiration, 26.
Fig. 2 shows the effects of gymnastic exercises of
twenty minutes' duration resorted to immediately after
mm. Hg. Its frequency went down to 94. After a
treatment of six weeks the patient, although he had
lost only six pounds in
weight, was perfectly free
from all his complaints.
Fig. 4 is taken from
a lady from New York,
Mrs. S ■, forty-seven
years of age, of middling
stature; weight one hun-
dred and eighty-two
pounds. Pulsus insequalis; frequency, 132; pressure
of pulse, 95 mm. Hg. The patient took a cure of five
weeks' duration in Nauheim, when in order to avoid
the season of extreme summer heat she spent an inter-
val of two weeks among the mountains, and then re-
sumed the course of treatment in Nauheim for another
three weeks. She took altogether thirty four baths,
and once or twice daily went through with the gymnas-
tic movements with moderate resistance. The reduc-
FiG. 5.— After Treatment.
tion of the patient's weight amounted to only four
pounds, but while before treatment her breathing had
been short she could now walk for hours without trou-
ble. The anzemia had left her, and she felt perfectly
sound and well.
Fig. 5 shown clearly the change of the pulse; fre-
quency, 72 ; pressure of the pulse, 130 mm. Hg.
Fig. 4. — Before Treatment.
the first medical examination. The patient felt relief
in breathing. The pulse was fuller and much less
compressible; frequency reduced to 100-98; pressure,
no mm. Hg. ; respiration, 21.
Fig. 3 shows the effect of an effervescent bath (Spru-
delbad) of spring No. VH., of 86° F. temperature and
ten minutes' duration, which was taken immediately
after the above-mentioned exercises. The respiration
was lowered to 18; pressure of the pulse rose to 115
ROUND ULCER OF THE DUODENUM.
Bv PERCIVAL R. BOLTON, M.D.,
INSTRUCTOR IN SURGERY, CORNELL UNIVERSITY.
The great rarity' of ulcer of the duodenum, in New
York at least, has led me to think that a review of this
subject and the report of several cases which have
been admitted to the Hudson Street Hospital, four of
them in the care of Dr. L. A. Stimson and one in my
own, would not be without interest.
Case I. — Man, aged thirty-live years, a United
States mail agent, a hard drinker. Eight hours before
admission he developed very severe abdominal pain.
There w-as no vomiting. On admission, the abdom-
inal wall was tense; there was no distention; there
was tenderness over the region of the gall bladder.
The temperature was normal ; the pulse 90. The tem-
perature rose, and the tenderness became general;
there was no distention.
The liver dulness disap-
peared. The probable
diagnosis was appendici-
tis. Twenty hours after
the first symptom the ab-
domen was opened over
the appendix, and a large
amount of greenish-brown
fluid was evacuated. The appendix wa:) normal. There
was a well-marked peritonitis. The patient's general
condition prevented any further search for the focus of
infection. He did not rally, and died some hours later.
The autopsy record has been lost, but Dr. Fielding
Taylor, who was house surgeon at the time, says that
there was a well-developed peritonitis, and that a
round ulcer of the posterior wall of the first part of the
' Kinnicutt, 0.4 per cent, among thirty thousand autopsies.
March 24, 1900]
MEDICAL RECORD.
495
duodenum was found about two inches from the pylo-
rus. Its base presented a minute perforation.
Case II. — ^Man, aged twenty -eight years, sailor; a
hard drinker. No previous diseases of significance
were noted. Two days before admission, without as-
signable cause very severe abdominal pain developed.
It was not, so far as could be learned, referred to any
particular region of the abdomen, but was accompa-
nied by vomiting. There is no note of the character
of the vomitus. The same condition continued the
next day, and on the third he was admitted to the hos-
pital. At this time there were general distention
and tenderness of the abdomen; but no localized
tenderness and no loss of liver dulness. The tem-
perature was 103" F. ; respiration, 20; pulse, 120.
No further diagnosis was possible than peritonitis of
unknown origin. The abdomen was opened by a lib-
eral median incision. The intestinal coils were every-
where matted by recent fibrin. There was little or no
fluid free in the peritoneal cavity. The patient's con-
dition did not warrant a protracted search for the
source of infection, and after rapid irrigation and the
introduction of drains he was returned to his bed.
Death followed on the third day, or the sixth from the
time of the initial pain.
The autopsy showed a general peritonitis. In the
posterior wall of the third part of the duodenum there
was a sharply lined ulcer 2.5 x 0.75 cm. in dimensions,
perforating the gut and exposing the pancreas, which
at this point was necrotic and infiltrated by pus, as
was the subperitoneal tissue about the duodenum as far
as the jejunum, from which region the peritonitis was
judged to start. The mucous membrane of the duode-
num and ileum was pigmented, and the solitary folli-
cles of the latter were very prominent.
Case III. — Man, aged thirty-five years, brakeman;
a hard drinker. He is said to have had a similar at-
tack thirteen years ago, and typhoid fever three years
ago. A short time prior to admission he developed
severe, not localized abdominal pain, accompanied
by vomiting. On admission, the abdominal wall was
rigid ; there was no distention, but very great, though
not localized, tenderness. Temperature, 102° F.
The symptoms gradually improved until the fourth
day, when there developed the symptoms of a rapidly
spreading peritonitis, which seemed most probably to
have originated in the appendix. The abdomen was
opened over the appendix in the usual way, and a
quantity of yellowish, not offensive fluid evacuated.
The appendix was found to be normal. A well-
marked peritonitis was present. At this time the pa-
tient's general condition became such that no further
investigation could be safely carried out, and after
placing drains he was returned to bed. He did not
rally, and died some hours afterward.
At the autopsy the peritoneal cavity was found to
contain some ounces of sero-purulent fluid. The peri-
toneal surfaces were everywhere congested and covered
with a thin layer of fibrin. The first portion of the
duodenum was adherent to the under surface of the
liver to left of the gall-bladder by recent fibrin, and
presented a perforation 2 mm. in diameter. The supe-
rior wall just beyond the pylorus contained an ulcer
with indurated walls, whose base was perforated as
above described. There was a second old but super-
ficial ulcer in the posterior wall just beyond the
pylorus.
Case IV. — Man, aged twenty years, an Assyrian,
single; a tailor. There was no note of alcoholism.
Seven months ago he had an attack of illness charac-
terized by pain in the region of the liver and vomit-
ing, lasting two weeks. A few hours before admis-
sion he developed severe pain referred to the right
side of the abdomen, and accompanied by vomiting.
On admission, the abdominal walls were found to be
rigid; there was general tenderness, perhaps a little
more marked in the region of the appendix. There
was no tumor. The temperature was 102° F. ; respira-
tion, 48; pulse, 118. The probable diagnosis was ap-
pendicitis. Twenty hours after the beginning of the
attack the abdomen was opened by an incision over
the appendix, and a quantity of watery fluid and
odorless gas evacuated. An active peritonitis was
present. The patient's general condition failed rap-
idly and compelled the abandonment of further pro-
cedures. Death followed in twenty-four hours.
On autopsy, the abdominal cavity contained several
ounces of thin, offensive pus. There was a general
peritonitis associated with considerable exudation of
lymph. Immediately beyond the pylorus in the ante-
rior wall of the duodenum was a round ulcer r cm. in
diameter, whose edges were thickened and whose base
presented a small perforation.
Case V.- — Man, aged forty-five years, German,
married; clerk. The family history was good. He
was a moderate drinker. A similar attack is said to
have occurred four years ago. Personal history other-
wise was negative. The patient was perfectly well
until six hours before admission, when he was seized
with severe pain referred to the right iliac region,
which gradually increased in severity, becoming gen-
eral, but most intense in the right side of the ab-
domen. On admission, the abdominal wall was tense;
there was no distention; tenderness was well marked
over the appendix; there was no tumor; liver dulness
was present. The temperature was 100° F. ; respira-
tion,32; pulse, 104. At the time of operation, twenty-
two hours after the onset of pain, the symptoms were
the same except that distention was beginning to de-
velop. The probable diagnosis was appendicitis.
The abdomen was opened over the appendix, evacuating
a considerable amount of turbid serum. A well-
marked peritonitis with fibrinous exudate was present
in the right half of the abdomen and iliac fossa, but
the appendix, except for its peritoneal coat, was nor-
mal. Following up the ascending colon and its hepatic
flexure the region of most intense peritonitis was found
beneath the liver and about the duodenum, but no per-
foration of this part of the intestine could be recog-
nized, though it was assumed to exist. Accordingly
a large iodoform-gauze drain was carried from the re-
gion of the duodenum out through the abdominal
wound, which had been extended up to the margin of
the costal cartilages. The whole abdomen was re-
peatedly flushed, particularly the pelvis, where a large
amount of fluid exudate was found, and ample drain-
age provided for. The patient rallied well and did
fairly for several days; then he became septic, dying
on the seventh day after operation.
The autopsy showed the following: In the regions
of the wounds and in the iliac fossa the parietal peri-
toneum was adherent to the subjacent coils of intes-
tine which were also adherent to one another. There
was a moderate amount of puro-fibrinous exudate in
the right iliac fossa and along the ascending colon.
The omentum covered most of the coils of small in-
testine, and these showed only slight congestion and
injection of the peritoneal coat. The pelvis and ab-
domen generally were perfectly free from fluid of any
sort. There was no ulceration of the slightly thick-
ened mucous membrane of the stomach. The pylorus
was normal.
Immediately below the pylorus on the antero-supe-
rior surface of the duodenum was an old oval ulcer 1.5
cm. in length, its long axis being transverse, whose
edges were thickened and rounded. The base of the
ulcer was composed of peritoneum and presented a
perforation 8 mm. in width. A depressed scar i cm.
in diameter was located 2 cm. to the right of this ulcer.
The rest of the duodenum was normal. The mucous
496
MEDICAL RECORD.
[March 24, 1900
membrane of the caecum and ascending colon pre-
sented a number o£ grayish irregular patches of necrotic
false membrane.
Lesions. — These cases illustrate fairly well some of
the pathological features of the disease under discus-
sion. In four of them the ulcer occurred in the first
part of the duodenum within two inches of the pylorus,
twice in the anterior wall, once in the posterior, and
once in the superior. In one case the posterior wall
of the third portion was the site of ulceration. In
three of the cases the ulcers were single; in the other
two there was in one the cicatrix of a previously healed
ulcer in the anterior wall of the first part, and in the
other superficial ulceration of the posterior wall of the
first part.
The ulcers averaged a little more than i cm. in
width, and perforation had occurred in all; three times
into the general cavity, once behind the peritoneum,
once toward the under surface of the liver to which
the duodenum was adherent. In all five a spreading
or a generalized peritoritis was present.
Of Collin's' group of 262 cases, in 242, or 92.3 per
cent., the ulcer was found within 4 cm. of the pylorus,
in 10 in the descending portion within 10 cm. of the
pylorus, and in 6 cases in the third portion. Of 119
cases in which the ulcer occurred in the first portion of
the duodenum, in 68 the anterior wall was the site, in
3 the anterior superior, in 39 the posterior, in 6 the
posterior superior, in 2 the posterior inferior, in 10
the superior, in i the inferior; of 8 ulcers of the sec-
i^nd part 5 occurred in the internal wall, 2 in the pos-
terior, and I in the external; of 4 ulcers of the third
part, in 3 the anterior superior wall was affected, in i
the posterior.
In number there is considerable variation. Among
233 cases, in 195 it was single, in 38 there were two
or more. There is considerable variation in size and
outline, but usually the ulcer is not large, involving
but a small portion of the circumference of the gut;
the base may be formed by the submucous, muscular,
or peritoneal coats, and occasionally by the tissues of
neighboring structures to which the duodenum may
have become adherent. The margins and base of the
ulcer are commonly very tough and dense, and show
but feeble attempts at repair.
Perforation is stated by Collin to have occurred in
69 per cent, of his group of 262 cases, with a circum-
scribed or general peritonitis in 125 cases; in 38 per-
foration is said to have been prevented by adhesions
to the pancreas, liver, or gall bladder, but the percent-
age of perforations is placed at a lower figure by other
writers, e.g., as low as 42.8 per cent, by Chvostek.'
This discrepancy depends, no doubt, upon the great
uncertainty that must always practically attend the
diagnosis of duodenal ulcer.
The circumscribed peritonitis which sometimes fol-
lows perforation may result in accumulations of pus
b.-neath the diaphragm, subphrenic abscess (Maydl),
or in fistulas between the duodenum and the surface
of the abdominal wall, the colon, or gall bladder; or
fatal erosion of contiguous vessels may occur."
As the effects of cicatrization Collin notes, among
thirty-nine cases, dilatation of the stomach or duode-
num, stenosis of the duodenum, obliteration or dilata-
tion of the common bile duct, stenosis of the orifice
common to the common bile and pancreatic ducts.
Etiology. — By most pathologists round ulcers of the
duodenum are regarded as identical with those of the
stomach in general characters, and are supposed to be
due to the action of gastric juice upon the mucous mem-
brane, one or other, or both, being abnormal. This ex-
planation depends for its basis upon the fact that the
' Collin : These de Paris, 1894.
■■'Wien. med. Jahrb., 1885.
^ Boas : " Darmkrankheiten, " p. 307.
vast majority of duodenal ulcers are found in the first
and second portions, above the entrance of the pancre-
atic duct, and therefore where the mucous membrane
is exposed to the acid gastric contents prior to their
neutralization by the alkaline pancreatic juice and bile.
Sex, for some reason, seems to be an important
etiological factor. Collin states that 79 per cent, of
the cases of duodenal ulcer occur in males; the greater
frequency in males being due to the more habitual use
of alcohol by that sex.'
As to the influence of age, Collin arranges 297 cases
as follows :
Between birth and 10 years 42
II " 20 " 24
2> " 30 " 43
31 " 40 " 52
" 41 " 50 " 46
51 " 60 " 41
61 " 70 " 18
71 " So " 10
" 81 " 90 " 2
" 91 " 100 " I
In this table aie included 38 ulcers following burns
and 3 following erysipelas, etc.
Symptoms. — It is indicative of the difficulty of
diagnosticating the presence of duodenal ulcer that in
the great majority of cases the lesion has not been rec-
ognized before perforation. Indeed it has been stated
that diagnosis is impossible ; but Boas" denies this and
narrates the histories of several cases in which he was
able to recognize the presence of the ulcer. He groups
the symptoms under the following heads: i. Sensitive
points — correspond to seat of pain in parasternal line,
2 cm. below the gall bladder. There are numerous
exceptions. 2. Vomiting. Vomiting, probably re-
flex, occurs after prolonged and severe pain ; it is
present in 17 per cent, of the cases. 3. Intestinal
hemorrhage and haematemesis are present in one-third
of the cases in marked degree. The loss of blood may
be so great as to cause symptoms of collapse or even
to be fatal. Repeated intestinal hemorrhages along
with the other symptoms of the ulcer are characteristic.
4. Composition of the stomach contents. Observa-
tions have differed so much that at present no value
is to be attached to hyper- or subacidity. 5. Urine,
negative. 6. Jaundice is not significant.
Perforation of the duodenum at the site of ulcera-
tion, however, marks the beginning of a sequence of
symptoms of severe character which vary somewhat,
depending upon the seat of the perforation, the rapid-
ity of the escape of intestinal contents, and develop-
ment of adhesions. The first symptom noted has usu-
ally been severe pain referred at times to the region of
the duodenum, to the upper part of the abdomen, or
not localized at all. Vomiting usually promptly fol-
lows the onset of pain.
In some of the reported cases shock was said to
have been present at first,'' but in none of the Hudson
Street cases was this at all conspicuous, and in the
patient who was admitted very soon after the begin-
ning of his symptoms none was present.
The next symptoms to appear are those of peritoni-
tis. These are usually those of the severe and rapidly
spreading type, and directly controvert the theory that
infection by the contents of the upper parts of the in-
testine is less serious than by that lower down. Less
often the peritonitis is circumscribed. In either case
the inflammation begins in the right side of the abdo-
men. It thus simulates with great exactness the peri-
tonitis which originates in appendicitis. Indeed the
whole picture is that of appendicitis, and in many of
the cases operated upon the probable diagnosis was
appendicitis.
' Boas : Loc. cit., p. 297.
* Boas : Loc cit., p. 300.
' Perry and Shaw : Guy's Hospital Reports, 1893, P- 266.
March 24, 1900]
MEDICAL RECORD.
497
There are other lesions giving rise to peritonitis,
with which it is readily possible to confound perforat-
ing ulcer of the duodenum, and of these ulcer of the
stomach, pancreatitis, suppurations of the liver and
biliary ducts occur to the mind at once. About the
symptoms of the peritonitis itself there is nothing that
is diagnostic, and the only really significant symptom,
which may be but is not always present in intestinal
perforations of whatever kind, is loss of liver dul-
ness. When present, this is a symptom of great value,
but its absence is by no means conclusive.
Course ; Prognosis. — What proportion of ulcers of
the duodenum cicatrize spontaneously is difficult to
say; a considerable number do so, as the tables of
Collin' show, where the effects of thirty-nine cicatrized
ulcers are recorded. It would seem equally difficult
to estimate the duration of the ulceration, and I know
of no figures that furnish any information on this
point, and I question the value of attempting any com-
putation in this direction through the close relation
this ulcer bears to that of the stomach. It is proba-
ble that a given ulcer will perforate the wall of the in-
testine sooner or later, and in that event the prognosis
is always most grave; the peritonitis so produced is
most likely to become a generalized one and terminate
fatally; a circumscribed peritonitis with rupture of
the abscess into a neighboring viscus or through the
abdominal wall is the rarest event, and is never to be
counted upon. Nor have any considerable proportion
of patients submitted to operation after perforation
has occurred survived. Of twenty cases of perforation
treated by operative measures collected by Darras,"
seventeen patients died and three only recovered.
But here again, as in almost all cases of perforative
peritonitis, the result of operative interference depends
in no small measiire upon the period at which it is
undertaken.
Treatment. — Ulcer of the duodenum is not likely
to come into the hands of the surgeon for treatment
before perforation has occurred, and it is, therefore,
this phase of the lesion that will be considered here.
In rare instances the shock consequent upon perfora-
tion may be very severe, and even fatal,' but, as a
rule, it is not very conspicuous, as might be inferred
from the slow escape of intestinal contents through a
minute opening. If at all marked or severe, it goes
without saying that shock must be energetically com-
bated before any extensive operative procedure may
be undertaken. Nevertheless interference must not
be too long delayed, and I think no one will dispute
the statement that in the presence of a spreading peri-
tonitis there is far less danger to life in incision of
the abdominal wall than in delay. Hence I believe
that the earliest possible moment is the time for opera-
tion.
The problem presented resolves itself into two fac-
tors: (i) the treatment of the duodenal ulcer; (2) the
treatment of the peritonitis.
In a certain proportion of cases circumstances, not-
ably a rapid decline in the patient's general condition,
or failure to discover the perforation, may render any
direct attack upon the ulcerated duodenum impossible,
and make drainage by carrying a gauze tampon from
the site of perforation out through the abdominal wall
the only plan available. But this should be regarded
as only tentative, and a more rational scheme carried
out as soon as may be.
Various operative procedures have been practised
at times upon the ulcerated and perforated wall of the
duodenum. Closure of the perforation by sero-serous
sutures seems hardly sufficient to achieve more than
obliteration of the perforation; the ulcer itself per-
1 Loc. cit.
'' Darras ; These de Paris, 1897.
' Perry and Shaw : Loc. cit.
sists, and even if cicatrization occurs there is no pro-
vision against the consequent distortion or narrowing
of the gut. Resection of the segment of the duodenum
which bears the ulcer is objectionable also. It is ap-
plicable only in the first part of the duodenum and in
the presence of a single ulcer or at least multiple ulcers
over only a very limited longitudinal extent of intes-
tine, and finally it seems unnecessary except when a
great part of the circumference of the duodenal mucous
membrane is involved. Gastro-enterostomy, except to
supplement excision of so much of the duodenum that
enterorrhaphy cannot be practised, has nothing to rec-
ommend it.
The most eligible plan of treatment consists in ex-
cision of the ulcer. This may be done in almost any
part of the duodenum except the entrance of the pan-
creatic duct, and is not at all difficult in the first por-
tions of the duodenum where ulceration is most apt to
occur. The excision need not go very wide of the
ulcer, but must be closed by Czerny-Lembert sutures,
as in pyloroplasty, so that the suture line lies at right
angles to the long axis of the gut.
The second factor in the problem, the treatment of
the peritonitis, will depend in a measure upon whether
the inflammation is localized, spreading, or general.
For a peritonitis well circumscribed by adhesions noth-
ing is necessary beyond sponging out the pus present
and supplying adequate gauze drainage. For a more
extensive peritonitis, and one that is spreading, it is
doubtful how much and how little had best be done.
It is the practice of some surgeons to expose the in-
flamed areas of peritoneum by eviscerating the patient,
and to remove all of the adherent flakes of lymph, to
sluice the peritoneum with salt solution, and then to
return the intestine. Others do not allow the intes-
tine to prolapse at all, but repeatedly flood the peri-
toneum with salt solution. Afterward in either plan
the peritoneal cavity is sponged dry or left full of salt
solution.
Again, by many operators the freest possible drain-
age is provided by carrying gauze or tubes to all of
the conventional drainage areas of the peritoneum,
making additional incisions through the abdominal
wall if they are needed. On the other hand, the free
use of drains is sometimes regarded as dangerous and
as likely to afford routes of infection that in the ab-
sence of drains would not exist.
Patients recover at times from septic* peritonitis
treated in any of these ways, so that at present no very
definite rules can be formulated.
I myself am inclined at present to the opinion that
no great advantage is gained in the treatment of peri-
tonitis by eviscerating the patient and submitting the
already inflamed peritoneum to the prolonged expos-
ure of manipulation necessary to remove adherent
flakes of fibrinous exudate. On the contrary, I feel
confident that by this proceeding shock is substantially
increased without any compensating advantage, for
the same removal of fibrin may be as well accom-
plished bypassing the intestine beneath the wound;
and it is certain that so far as the removal of fluid
exudate is concerned this can be just as thoroughly
done by carrying large quantities of salt solution
through the Chamberlain tube to all parts of the peri-
toneal cavity ; nor should one hesitate to break down
adhesions for this purpose. Such irrigation, however,
must be carried on until the overflowing fluid returns
clear. Many times in the course of irrigations made
in this way I have noted that marked improvement in
the pulse occurred. After this irrigation the peri-
toneum should be sponged fairly dry; there is perhaps
some advantage in leaving a quantity of salt solu-
tion, but an excess quickly finds its way out into the
dressings.
As to the use of drains, no doubt a strip of gauze
498
MEDICAL RECORD.
[March 24, 1900
should lead down to the point of infection, and I habit-
ually also drain in this way areas of peritoneum in-
flamed to the degree of producing a fibrinous exudate,
but I have not found it necessary to drain regions
which have simply been the repositories of turbid
serum and which have not advanced beyond the ap-
pearance of pretty active injection.
THE PROPHYLAXIS AND TREATMENT OF
GONORRHOEA BY METHYLENE BLUE.
By JOSEPH ALAN O'NEILL, U.I).,
NEW YORK.
METHVLE>fE blue administered internally will cure
gonorrhoea in from four to seven days. To the diplo-
coccus, which is the specifiocause of this disease, it is
especially fatal. The pyogenic bacteria that make
gonorrhoea a mixed infection succumb very promptly
to this germicide.
It is best given in gelatin capsules in one-grain
doses three or four times a day. After the fourth day
the dose may be reduced to twice a day. Given alone
it sometimes causes irritation of the neck of the blad-
der, but when combined with oil of nutmeg there is no
trouble of this kind. Oil of sandalwood is a desir-
able adjuvant because of its diuretic action and also on
account of its sedative effect upon inflamed mucous
membrane.
For several years methylene blue has been used in
solutions varying in strength from i : 1,000 to i : 100
for direct irrigation of the urethra in acute gonorrhoea.
But conservative practitioners are so opposed to this
method of treatment, and the staining-properties of the
methylene blue are so pronounced, that for use in this
way it has not become very popular. Recent observa-
tions show that, when given internally, it reappears
unchanged in the urine within two hours. This, of
course, simplifies the problem of cleanly and complete
urethral irrigation. ]!y giving four one-grain doses
of methylene blue daily there is always enough of it
in the urine to kill all the germs it comes in contact
with. This is irrigation "from above," irrigation not
of the urethra alone, but of the entire urinary tract.
By this method of irrigation there is no danger of forc-
ing the infection into remote recesses of the genito-
urinary orgtins. The urine impregnated with the
methylene blue not only kills the germ, but also car-
ries away its corpse.
Methylene blue is a coal-tar product, one of the ani-
line colors, and, like the other derivatives of the
series, it lowers the blood pressure, diminishes the
sensibility of the sensory nerves, and is, therefore, an
antipyretic and an analgesic. In large or long-contin-
ued doses it causes vomiting, vesical tenesmus, and
diarrhcea. Piotrowski reports ephemeral albuminuria,
cephalalgia, nausea, and malaise from the exhibition
of from one to three grains. These results are not con-
firmed by other observers; hence it is believed that he
used impure drugs, possibly methyl blue.
I have seen troublesome gastric symptoms follow
the administration of the methylene blue of the shops,
but with the following formula put up for me in elas-
tic capsules I have had uniformly satisfactory results:
5 Methylene blue, gr. i. ; oil of nutmeg, gtt. i. ; oil
of sandalwood, gtt. ii. I never continue the use of the
above formula for more than ten days without inter-
mission, and while giving it I instruct the patient to
drink freely of water.
The recent widespread interest in methylene blue
as a cure for gonorrhoea probably had its beginning
in the address of Prof. Austin Flint, delivered before
the New York State Medical Association in May,
1895, when he as president opened the eleventh annual
meeting of that body. In the course of his remarks
Dr. Flint said:
"In a few cases of gonorrhoea that were incidental
to other diseases in the medical wards of Bellevue
Hospital, I used methylene blue alone internally with
great success. ... In two of my recorded cases the
results were truly remarkable. The first case was that
of a man, thirty-five years of age, with moderate but
characteristic discharge, which had existed for two or
three days. He was put upon methylene blue, gr. iss.
three times daily, and had no other treatment. The
next day the discharge was very much diminished and
the ardor urinaj had disappeared. I saw the patient
again on the ninth day, and he was perfectly well.
He stated that the discharge had ceased on the fourth
day.
"The second case was that of a man, fifty years of
age, with his first attack, who was seen by me the first
day. In this case the gonococcus was discovered in
the discharge. The patient took gr. ii. of methylene
blue three times daily for three days, and twice daily
for four days. There was a great diminution of the
discharge on the first da)', and on the seventh the pa-
tient was entirely well."
My results with this agent, while not so brilliant as
those reported by Dr. Flint, have nevertheless been
very satisfactory. In no case have I found it neces-
sary to continue treatment for more than ten days. I
have seen the thick, purulent discharge reduced in
twenty-four hours to a thin, colorless mucus. This
serous exudate would seem tome a necessary aftermath
of any acute ulceration. Denude mucous membrane
in the urethra or anywhere else, and there is bound to
be some oozing of serum until the abrasion is healed.
The mission of the methylene blue is accomplished
when it has destroyed the bacteria of suppuration.
This it does within a remarkably short time. It seems
to have a specially deadly effect upon the gonococcus;
and this leads me again to quote Dr. Flint, who, in
closing his address, said:
" It is a reasonable scientific proposition that methy-
lene blue would probably act as a prophylactic against
gonorrhceal infection in impure intercourse."
For obvious reasons positive results from such pre-
ventive treatment are not obtainable; still it is so
logical that it seems the proper treatment to advise for
any patient who may need it. The physician who by
this advice prevents the development of a single case
of gonorrhoea really deserves his title^ — doctor.
Against such doctrine the moralist may rise in his
wrath and charge collusion against social purity; but
after discussing this theme at length with a number of
tiie best and ablest physicians in New York, I am sat-
isfied that the profession is ready and willing to meet
the charge. Gonorrhoea is a social vulture that preys
upon trusting women and innocent babes, and the phy-
sician who with a full knowledge of its remote results
fails to give prophylactic counsel is indeed a colleague
of the sinner, a party to a sin that menaces society.
Contrast the distorted dream of the social purist
with the increasing list of hysterectomies, ovarioto-
mies, and other mutilating operations made necessary
by ignorance of simple prophylactic principles. Wit-
ness the anguish of the young mother who sees her
babe blinded for life by ophthalmia neonatorum— and
then dare to tell the father that it might have been pre-
vented, not by instilling a silver solution into the eye,
but by giving him a little golden advice about his
gonorrhoea.
The prevention of gonorrhcea is as legitimate and
laudable as the prevention of smallpox. To tell a
man who has been exposed that methylene blue may
forestall the penalty of his impurity can no more be
regarded as aiding immorality than could the state-
March 24, 1900]
MEDICAL RECORD.
499
ment that vaccination will prevent smallpox. To
withhold this information will not in the least tend to
clear the social atmosphere nor to advance the interests
of morality.
202 West Eighty-second Street.
^linxCitX gcpat:tiixeut.
URETERO-VAGINAL FISTULA; OPERATION;
CURE.
at the base of the bladder. On examining the pa-
tient when she was etherized for the operation, Janu-
ary II, 1900, I found the fistula was in the lateral wall
of the ureter. An oval denudation in the vaginal
walls and in the ureteral walls around the opening
was made similar to the denudation for a vesico-
vaginal fistula. The sides of the denudation were
brought together by means of interrupted silver-wire
sutures.
February 20, 1900: The operation was a success,
and there has been no leakage of urine since it was
done, and what is better, there is no evidence of a
return of the adeno-carcinoma.
By F. W. JOHNSON, M.D.
VISITING GYN/ECO
L. H. N single, thirty-five years of age, presented
herself January 31, 189S, with the following history:
She had been flowing slightly every day for the past
three months without pain. Previous to this she men-
struated every four weeks. She has lost five pounds
in weight. The liowing has been most profuse during
the afternoon and night. Menstruation began at the
age of twelve years, and was perfectly regular every
four weeks until three months ago. She flows from
five to seven days, and saturates eight to ten napkins.
She has scarcely any pain. She has no leucorrhoea,
no vesical symptoms, and no constipation. Her
mother died at the age of seventy, of cancer. Her
father died, aged forty years, of some " liver trouble."
She has always been strong and well, working in a
factory since she was eighteen years old.
Physical examination revealed a small fibroid on
the posterior wall of the uterus. On February 5, 1898,
the uterus was curetted in order to get a specimen for
microscopical examination. The pathologist reported
that a microscopical examination of the scrapings
showed marked proliferation of atypical glands in
places invading the muscular tissue; also numerous
small areas of degenerated and proliferated epithe-
lial cells. The diagnosis was adeno-carcinoma.
On February 8, 1898, a complete suprapubic hyster-
ectomy was done. Before opening the abdomen the
cervical canal was thoroughly cauterized and the cav-
ity packed with sterile gauze, and the cervix separated
from the vagina at the vault anteriorly, laterally, and
posteriorly, with the cautery. The uterus with tubes
and ovaries was sent to the pathologist, who reported
as follows : " The uterus show's one or more characier-
stic intramural fibroids of small size, and near the
internal os two cauliflower excrescences, the size of
an English walnut. A microscopic examination shows
adeno-carcinoma of the uterus, involving principally
the fundus, but showing no evidence of 'disease of
tubes or ovaries."
On the separation of the slough made by the cautery,
part of the urine began to run away through the va-
gina; the other part was passed naturally. Except
for the leakage, the convalescence was perfect. On
making an examination I found what appeared to be
a uretero-vaginal fistula.
After waiting nearly two years without any improve-
ment in the leakage, she consented to an operation
which I had proposed long ago. Having seen the fis-
tula a great many times, I had made up my mind that
the ureter had been divided throughout its whole di-
ameter just where it entered the bladder. When the
patient was lying down or sitting no urine escaped
into the vagina. Her general health had not appre-
ciably suffered, and owing to her scrupulous cleanli-
ness the vagina was in a healthy condition.
I had made up my mind to do the operation de-
scribed by Dr. Howard A. Kelly for ureteral fistula
EPILEPTIFORM CONVULSIONS, FOLLOWING
THE INTRANASAL APPLICATION OF CO-
CAINE.
By SAMUEL KOHN, M.D.,
Although the varied manifestations of the toxicity
of cocaine have become fairly familiar to the medical
profession, cases just like the one about to be described
are so rare as to deserve more than passing notice.
C. R , aged forty-six years, a man of strong
physique, weighing about one hundred and eighty
pounds, commenced to bleed from the nose at 4 p.m.,
April 29, 1899; at 5 :30 p.m. I was called. Blood was
flowing freely from both nostrils, particularly from the
left; considerable blood had found its way through
the posterior nares, pharynx, and oesophagus into the
stomach, as was evidenced by the vomiting.
The patient sat with his head inclined forward, his
face looking into a wash-basin containing consider-
able blood; the countenance was pale, and the man
was nervous and trembling. Leaving the question of
diagnosis for later consideration, I applied my method
for checking nosebleed, which is described in No. 23,
vol. xlv., of the Medical Record. The patient was
placed in a chair, in an upright position; all con-
stricting bands about the neck, body, and limbs were
loosened, and he was instructed to breathe through the
widely opened mouth, as deeply and as rapidly as
possible. The principle upon which this simple method
depends for its efiicacy is the enforced stoppage of all
currents of air, voluntary and involuntary, through
the nostrils, until the bleeding ceases. The object
achieved is complete rest for the interior of the nose,
which favors coagulation at the bleeding point; of
course, blowing the nose is strictly interdicted.
Whatever blood drips from the nares is to be gently
touched off with the absorbent cotton ; the head is to
be inclined forward somewhat to prevent the escape
of bJood into the pharynx, which causes continuous
hawking and spitting, and sometimes vomiting. In
this case the bleeding ceased within a few minutes, and
I submitted the patient, whom I have known for years,
to a closer examination, with the following result.-
There were no growths or hypertrophies in either nos-
tril; there was an erosion on the floor of the left nostril
about the size of a small lentil, due probably to the
patient's habit of picking the nose; the profuse bleed-
ing from this slight trauma was explained by the full-
blooded habit of the patient. The man had never
been sick with any serious ailment, although he was a
sufferer from rheumatic twinges now and then; he had
been for years a steady but moderate imbiber of al-
coholic stimulants; the heart sounds are unusually
strong; no valvular lesions are apparent, so far as I
could make out. The urine is free from albumin and
sugar. These particulars are all thus detailed, because
of the extraordinary effect upon the patient of a small
quantity of cocaine applied externally, to be described
500
MEDICAL RECORD.
[March 24, 1900
presently. The cardiac hypertrophy and evident be-
ginning arteriosclerosis were the predisposing causes
of the profuse bleeding from the insignificant trauma.
At 8 P.M. I was again hurriedly summoned. The
patient, finding that the bleeding had ceased for over
an hour, had, contrary to my orders, washed out his
nose with cold water, and, as is the habit of such
patients, had violently blown his nose, to clear out all
the clots; I found the hemorrhage as free as at first.
The method just described was again employed, and,
although it required more time, was again successful
in checking the bleeding.
Having another important case to see at the time, I
asked my friend. Dr. M. S. Kakels, to remain with the
patient until my return. At 10 p.m., on my return, the
bleeding was effectually checked. On consulting with
Dr. Kakels, however, we came to the' conclusion, in
view of the tendency to recurrence of the bleeding, to
plug the nostrils loosely, in order to insure the patient
against a fresh bleeding during the night. The intro-
duction of Fraenkel's speculum, and the gentlest pos-
sible manipulation with the probe, started up a slight
bleeding, to control which I determined to apply a ten-
per-cent. solution of cocaine to the bleeding point in
the floor of the left nostril. By means of an absorbent
cotton applicator the cocaine solution was applied first
to the left and then to the right nostril; in a minute
or two a second application was made to the left nos-
tril, whereupon the patient became deathly pale, some-
what cyanosed, the facial muscles commenced to
twitch, general muscular relaxation set in, and he fell
to the floor completely comatose; he was then seized
with convulsions of the most marked epileptiform
character, being thrown from one side to the other by
the powerful clonic muscular contractions. The con-
vulsive movements involved the right half of the body
more than the left, and also the muscles of the face.
There was some foaming at the mouth; the pupils
were equally dilated. The pulse was feeble, 100,
but perfectly regular, which feature encouraged us
greatly. The convulsions continued for some five
minutes without any sign of abatement, but they slowly
became less marked, and at the end of about ten min-
utes ceased altogether.
The bleeding from the nose had ceased with the
onset of the convulsions, and did not recur at any
time. The patient remained very weak. The cause
of this unusual effect of cocaine upon a powerful man,
who had previously never had any illness worth men-
tioning, is undoubtedly the excitant effect of the drug
on the nerve centres; although the cerebral anaemia,
caused by the very considerable loss of blood and the
patient's prolonged upright posture, may have con-
tributed largely to the untoward effect.
Convulsions as a result of cocaine poisoning have
been reported by Curgenven' after the ingestion of ten
grains of the salt by the mouth. Garland '' reports a
death, in convulsions, forty minutes after the ingestion
of fifteen grains of the salt. The smallest lethal dose
thus far recorded is gr. | by the mouth. So small a
dose as gr. ^f,-^, hypodermically, has produced faint-
ness, pallor, tinnitus, etc. The instillation into the
conjunctival sac of a four-per-cent. solution of cocaine,
and applications to the gums, pharynx, larynx, and
urethra, have caused similar symptoms. But the writer
has been unable to find in the literature a single case
reported of convulsions in an adult produced by the
application of cocaine to the nasal mucous membrane
by means of an applicator. Had a spray been em-
ployed it might have been said that a large quantity
of cocaine had been absorbed by the nasal mucous
membrane.
GUNSHOT WOUND OF THE KIDNEY.
By WILLIAM F. BARRY, M.D.,
WOONSOCKET, R. I.
On July 25th, Mrs. B , while engaged at her
household duties, was shot by her husband. Two
shots were fired, both taking effect — one in the right
lumbar region, the other in the abdominal wall. The
perpetrator of the deed continued his work, firing two
shots into his wife's mother, and two more into his
own head. The husband and mother-in-law died in
a very short time. The wife fled from the room to the
street, where she was picked up and brought to a
reighbor's house. Dr. W. W. Browne, of Blackstone,
Mass., was summoned, and immediately sent for the
writer in consultation. On arrival I found the pa-
tient pale and profoundly shocked. The wound in the
abdominal wall was giving little trouble, but the
wound in the back was bleeding profusely. This was
tightly packed with iodoform gauze until the hemor-
rhage ceased. Copious subcutaneous and rectal injec-
tions of saline solution with hypodermic use of strych-
nine, brandy, and nitroglycerin served to relieve the
shock considerably. Fortunately the wound in the
abdominal wall was only muscle deep, and the bullet
was easily located at the opposite side. This canal
was then irrigated and a wick of gauze placed in each
end for drainage. It was decided to await events be-
fore more was done with the wound in the back. The
following day the patient had rallied considerably,
and was submitted to an .v-ray examination. The bul-
let was located in the ilium of the right side.
Upon removing the bandages the following morn-
ing the dressings on the back were saturated with
urine. There were, however, no signs of blood in the
urine passed by the usual channel. It became neces-
sary to change the dressings five and six times daily,
and after the first day the urine passing through the
bullet wound was not mixed with blood.
The patient was maintained in a well-nourished
condition, and the sinus was kept well open to allow
of free drainage of urine. It was evidently a case in
which either the pelvis of the kidney or the ureter was
injured. There were no symptoms pointing to injury
of the intestine. The case was a very interesting one,
as the patient continued to improve, and was very
carefully watched by Dr. Browne and myself. There
seemed to be about half the normal quantity excreted
by the false passage and the remainder by the normal
passage. Gradually the amount discharged upon the
dressings diminished, while that passed from the
bladder increased, until after about six weeks had
elapsed the sinus closed entirely and has never giveti
any concern to the patient since that time.
815 Madison Av
' Quarterly Med. Journ., January, i8q6.
'Lancet, November 2, 1895.
Mitral Stenosis.— Rummo says that (i) silent steno-
sis signifies a very slight lesion; (2) stenosis with pre-
systolic murmur signifies a slight lesion; (3) stenosis
with diasto-presystolic murmur signifies a serious le-
sion ; (4) silent systolic stenosis signifies an extremely
grave lesion, hyper-constriction, and very weak myo-
cardium.-— Za Rijorma M(dica, February 7, 1900.
The Biological Action of the Essence of Bitter
Orange Peel. — Francesco Valerio concludes from ex-
perimentation that this essence in heterodermatous
animals produces paralysis by diminishing and finally
abolishing the conductibility and tlie reflex powers of
the spinal cord. In guinea-pigs, rabbits, dogs, and
pigeons it produces convulsions by stimulation of the
cortical motor centres of the brain, the bulbar centre
being probably also involved. — Gioniak Inkriiazionale
delk Sciettze Mcdichc, December 31, 1899.
March 24, 1900]
MEDICAL RECORD.
501
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO, 51 Fifth Avenue.
New York, March 24, 1900.
PURE-FOOD LEGISLATION.
The second pure-food bill to which we alluded last
week, known as the " Brosius bill," provides in Sec-
tion I that " the Secretary of Agriculture shall organ-
ize the chemical division of the Department of Agri-
culture into a bureau of chemistry," which, besides
other duties, " shall also be charged with the inspec-
tion of food and drug products, as hereinafter provided
in the act. The Secretary of Agriculture shall make
necessary rules and regulations for carrying out the
provisions of this act, under which the director of the
bureau of chemistry," etc. There are several very
serious objections to this first section, namely: it vir-
tually places the responsibility of carrying out the act
on a "bureau " instead of on the shoulders of one man
who can be held accountable for the proper perform-
ance of his duties; second, it permits other executive
departments to call on this "bureau" for such chemi-
cal work as may be required by them. Surely we be-
lieve a food bureau will have business enough of its
own without undertaking any outside work. Third, it
would appear to trespass on the present domain of the
Treasury Department, so far as the inspection of for-
eign drugs is concerned; fourth, neither this section
nor any portion of the proposed act states by whom
this "director of the bureau of chemistry" shall be
appointed. This is certainly a curious omission.
Sections 2, 3, and 4 are administrative and appear to
be right and proper. Section 5 reads " that the term
'drug' as used in this act shall include all medicines
recognized in the United States Pharmacopoeia and
National Formulary, for internal or external use, and
cosmetics," etc. We fail to understand why the
"National Formulary," a work that we believe is sim-
ply a private business venture, is thus given such an
authoritative position. And "cosmetics" too — surely
that "bureau" will have its hands full. Section 6, if
all reference to the "National Formulary" be omitted,
is eminently satisfactorj', with the single exception of
the words "provided further, that no dealer shall be
convicted under the provisions of this act when he is
able to prove a written guarantee of purity," etc. We
very much question the advisability of this provision ;
who is to guarantee the guarantor? Section 8 reads
in part (italics our own), "That it shall be the duty of
the Secretary of Agriculture to fix standards of food
products when advisable, and to determine the whole-
somcness or unwiiolesomeness oj p?-eservatives and other
substajices 7s.'hich are or may be added to foods, and to
aid him in reaching just decisions in such matters he
is authorized to call upon the director or the bureau of
chemistry and the chairman oJ committee on Jood standards
oJ the Association oJ Official Agricultural Chemists, and
such physicians, not less than five, as the President of
the United States shall select from the medical de-
partment of the army, the navy, and the United States
Marine Hospital, and not less than five experts, to be
selected by the Secretary of Agriculture by reason of
their attainments in physiological cheinistry and hy-
giene, to consider jointly the standards of all food
products (within the meaning of this act), and to study
the effect of preservatives and other substances added to
fod products on the health oJ the consumer," etc.
Referring more particularly to the portions of the
section we have placed in italics, we earnestly inquire
what there is in the education of a chemist or any ex-
pert in "physiological chemistry and hygiene " that
qualifies him in any manner to judge of the whole-
someness or otherwise of " preservatives." If a per-
son suffers in consequence of taking preservatives, he
seeks relief not of the chemist but of the physician.
The true test of the effect of "preservatives" is clini-
cal experience. The chemist at best has but negative
evidence, as the positive evidence when it exists would
come only to the knowledge of the practising physi-
cian. An advertisement of one of the most commonly
used preservatives reads as follows: "The preserving
of meat demands modern methods. Wisdom is shown
by selecting a Preservative Reliable and also abso-
lutely Harmless." The use of this very preservative
(in dairy products), however, is forbidden by State law
and by ordinances of the health department of this
city. Yet we have known a professor of physiological
chemistry to state positively before one of the senate
committees of this State that the preservative in ques-
tion is absolutely harmless. He based his conclu-
sions on some experiments he had made on dogs. If
he had consulted the columns of this and other medi-
cal journals and well-known works of reference, he
would perhaps have believed otherwise. We admire
the assurance of the chemists, but we must protest
against their acceptance as authorities on questions
of this nature. The province of the chemist is to de-
termine the nature and composition of bodies, not their
effects for good or ill on the human system.
Section 13 provides that the expenses necessary to
the carrying out of the various provisions of the act
shall not exceed $100,000.
Comparing the " Babcock " and the " Brosius " bills,
we unhesitatingly give preference to the former, if
modified as suggested in our last issue. The Brosius
bill, on the other hand, contains so much that is ob-
jectionable that it should be entirely recast if it seeks
to carry out its ostensible purpose effectively.
The Utah State Medical Society.— The next an-
nual meeting of this society will be held at Salt Lake
City, on October 2 and 3, 1900.
502
MEDICAL RECORD.
[March 24, 1900
THE SURGERY OF MALIGNANT
PLASMS OF THE LIVER.
NEO-
It is only within the last twelve years that any serious
and systematic attempts to operate upon malignant
growths in the liver have been made, and the earlier
cases were attacked in a rather tentative and hesitating
way. The removal of a tumor in the liver has almost
always been attempted in connection with operation
for some condition of the gall bladder or ducts, and
not as a primary operation. Three of the earliest cases
(Bruns, Garre, 1888, Hochenegg, 18S9) were of this
character, and in two of them certainly the operative
work consisted in the removal of a carcinomatous mass
secondary to malignant disease in the gall bladder.
Since these cases, the reported attempts to remove
growths from the liver have rapidly increased in num-
ber, and we are gradually becoming able to arrange
our knowledge and lay down certain rules of proce-
dure.
The kinds of growth with which we must be pre-
pared to deal are, pathologically considered, adenoma,
carcinoma, and sarcoma, the last very rare if primary,
and hopeless if secondary, and the other two very lit-
tle better under the latter circumstances. Adenoma of
the liver, though not essentially malignant, behaves
like a malignant tumor, and as a primary growth is
commoner than carcinoma, to which it is closely re-
lated, and with which it may be described. Carci-
noma is very commonly secondary to growths in the
stomach, pancreas, gall bladder, or more distant struc-
tures, and its prognosis is proportional to the site and
extent of the primary growth. Of course cases are
almost always seen too late to be in the least suitable
for surgical intervention, though if the tumor was orig-
inally in the gall bladder there might occasionally be
a chance for its removal with the secondary hepatic
deposit. We shall therefore be safe in saying that the
only malignant tumors of the liver which are ever
likely to be considered as at all operable are some
adenomata and a very few secondary carcinomatous
deposits, with very rarely a primary carcinoma, in all
of which a diagnosis of probability at least is made
early. If the tumor is a secondary carcinoma, it is
important that the secondary quality is not metastatic,
but depends upon continuity of tissue. In the case of
true metastasis there must have been wide dissemina-
tion of the infection, and deposits will not be limited
to the immediate region of the primary mass, so that
operative attack is obviously useless. Primary carci-
noma of the liver is a rare disease, but may sometimes
be amenable to operative treatment.
Keen has recently (1899) added to the literature of
the subject the history of a very interesting case in
which a fortunate combination of circumstances as to
site and conformation made the extirpation of a large
tumor a brilliant success. The operation was under-
taken with the diagnosis somewhat in doubt, and it
was only after opening the abdomen that the growth
was seen to be a nodular mass involving practically
the whole of the left lobe of the liver. There had
been no jaundice, no intestinal symptoms, and, in
fact, no reason except that of locality for suspecting
the liver as the seat of the trouble. The whole mass
was removed, partly by ligature and partly by slow
cauterization with the Paquelin instrument, and it is
stated that the hemorrhage was never alarming. The
size of the wound in the liver was reduced as much as
possible by drawing over the peritoneum, and packing
was introduced down to the rest of the surface neces-
sarily left raw. Recovery was rapid. Examination
of the tumor showed it to be one of the forms of car-
cinoma, with many areas of necrosis in it, and the case
seems to have been one of true primary carcinoma of
the liver which came to operation before the lymphat-
ics were involved, since these were reported uninfected
at the time of the removal of the growth.
It is only in such cases in which there is distinct
delimitation of the disease that we can hope to do any-
thing of a radical nature, and it is also evident that
as disease approaches the hilus it becomes more dan-
gerous and less suitable to any operative treatment.
The method of operation is really the only element in
the question about which we can make any definite
rules, for as regards diagnosis, local involvement, site
of tumor, and prognosis, each case is a law to itself,
and it is only when we have come to some sort of a
decision upon all these points, either before or after
the beginning of the operation, that we reach a stage
where we can lay down general rules. Experience has
shown pretty conclusively that the cautery and ligature
alone or combined are the safest and quickest means
of controlling bleeding from hepatic tissue, and that
pressure with packing is a useful adjuvant. The cau-
terized wound in the liver should be treated by pack-
ing, and the abdominal cavity protected from contami-
nation by tlie same means. All means of combating
the effects of hemorrhage should be ready for imme-
diate use, for it is never certain that we can avoid
serious trouble in this regard. Widening experience
will probably show that the adenoma is the most
favorable for operation, and secondary carcinoma the
least so; in fact, that the latter is practically never
operable except in a very few cases in which the growth
has started in the gall bladder or ducts and has ex-
tended to the liver by continuity of tissue. Further-
more, there is no prospect that any but growths in the
superficial portions of the liver can be attacked suc-
cessfully, even supposing that it were possible to make
a diagnosis with reasonable certainty when the tumor
lies very deep.
Bile from healthy liver tissue will not hurt the peri-
toneum, but from inflamed and infected gall ducts it
will cause peritonitis.
The Mission of Gen. Leonard Wood. — In an ap-
preciative note of the work of General Wood in San-
tiago, The Lancet ventures the prediction that " General
Wood will regenerate Cuba in the same manner as
the British have regenerated Jamaica, and that in the
course of time yellow fever will be exterminated in the
former island." We believe this is a safe prediction,
if only the politicians will leave him in Cuba and not
drag him away in order to make him a vice-presidential
candidate this summer.
March 24, 1900]
MEDICAL RECORD.
503
|lcius of tTie 'SJEccTi.
Measles at Yale. — Many cases of measles have been
reported among the Yale students since smallpox at-
tacked a freshman at the Sheffield Scientific School.
Nearly all these students have gone to their homes.
The Western Ophthalmologic and Otolaryngologic
Association will hold its annual meeting in St. Louis
on April 5, 6, and 7, 1900, under the presidency of Dr.
W. Scheppegrell, of New Orleans.
The Association of American Physicians. — The
fifteenth annual meeting of this society will be held in
Washington, in connection with the triennial congress,
on May ist, 2d, and 3d, under the presidency of Dr.
E. G. Janeway, of New York.
Quarantine against Bovine Tuberculosis. — Gover-
nor Stanly, of Kansas, has issued a proclamation de-
claring a quarantine which practically prohibits the
importation of dairy cattle into that State. The quar-
antine was established at the request of the Live Stock
Sanitary Commission in order to prevent the further
introduction of tuberculosis into Kansas herds.
Dismissal of a Hospital Ship Captain. — The master
of the hospital ship Alissoitri has been dismissed from
the army transport service as a result of an investiga-
tion of charges made against him by the surgeon in
charge of the vessel. The main charges were that the
captain refused to recognize that the surgeon, who had
the rank of major in the regular service, ranked him
on the vessel, and that he talked with others against
the latter during the voyage from New York to Manila.
A New Hospital in Brooklyn. — The old Kent man-
sion, at Second Avenue and Sixtieth Street, Brooklyn,
will soon be occupied by the new Bay Ridge Hospital,
Dispensary, and Training-School for Nurses. The
building has been given by Mr. John Beet for use as
a hospital for five years, provided a sufficient sum is
raised to cover the cost of equipment and part of the
operating-expenses for the first year. It is expected
that the hospital will be opened in June.
College of Physicians of Philadelphia. — At a
stated meeting of the section on general medicine,
held March 12th, Dr. Alfred Stengel presented a com-
munication entitled "The Importance of Glycosuria
as a Symptom." He pointed out that the urine nor-
mally contained traces of sugar, but that clinical sig-
nificance was attached only to such amounts as were
demonstrable by means of the ordinary tests. Glyco-
suria might occur apart from diabetes and might result
from the ingestion of sugar or of starch in excessive
amount. When, however, it was a symptom of dia-
betes it occurred independently of the quality and
quantity of the food. Dr. David L. Edsall presented
a communication entitled "The Relations of Diet to
Diabetes." He pointed out the importance of deter-
mining in every case of diabetes the amount of carbo-
hydrates that could be ingested without the develop-
ment of glycosuria, as this constituted an important
guide in treatment, for it had been shown that patients
did worse when carbohydrates were wholly excluded
from the diet than when they were permitted to have
as much as they were capable of assimilating. When
sugar appeared in the urine independently of the
character of the food, the diet should, for a time at
least, be restricted to fats and proteids. Dr. James
Tyson read a paper entitled " The Treatment of Dia-
betes and its Complications." He attached first
importance to the dietetic treatment and secondary
consideration to the use of drugs. Among the latter
arsenic and opiates were most useful, and particularly
codeine and morphine. Alkaline mineral waters might
be taken with advantage. For diabetic coma subcuta-
neous infusion of saline solution was indicated.
Philadelphia Hospital. — Dr. James M. Barton has
resigned from the surgical staff and Dr. Samuel Wolfe
from the medical staff. A third ophthalmologist has
been added to the medical board, and Dr. Howard
Forde Hansell has been elected to fill the vacancy.
Fiftieth Anniversary.— Dr. William B. Ulrich, of
Chester, Pa., celebrated on March 15th the fiftieth an-
niversary of his entrance on medical practice. The
event was commemorated by a reception to the Dela-
ware County Medical Society.
Smallpox at Yale. — There have been four cases of
smallpox among students of the Sheffield Scientific
School during the past two weeks. None of the cases
is serious. There has been a great exodus of students
from New Haven, and those who remain of the asso-
ciates of the sick men have been quarantined.
The Plague. — Major Taylor, surgeon in charge of
the military hospital at Honolulu, reports under date
of March ist, that since the first outbreak in that city
there have been sixty-four cases of plague with fifty-
five deaths. He believes that the epidemic is over,
though there may still be sporadic cases from time to
time.
A Hospital for Contagious Eye Diseases. — A bill
has been introduced into the State legislature provid-
ing for the establishment by the city of New York of
a hospital for the treatment of contagious eye diseases.
The institution is to be located in the borough of
Manhattan, north of Fifty-ninth Street. The board of
managers is to consist of Drs. John C. Lester, of
Brooklyn, and John L. Adams, Peter A. Callan, and
Thomas R. Pooley of New York, together with three
physicians to be named by the mayor. The health
department of the city is to furnish all food, medicines,
and supplies.
Philadelphia County Medical Society At a
stated meeting held March 14th, Dr. E. W. Holmes
read a paper entitled " The Anatomy of Hanging," in
which he made a comparison between hanging and
strangulation, giving a description of the anatomical
lesions produced by hanging, together with a consid-
eration of the methods of judicial hangings and an
analysis of the sensations of those hanged and resus-
citated. Dr. S. Solis-Cohen, the retiring president,
delivered an address entitled " Progress in Therapeu-
504
MEDICAL RECORD.
[March 24, 1900
tics." He dwelt upon the fact that disease and recov-
ery represented a continuous process, and that the
intervention of the therapeutist should be addressed
to aiding and directing nature in her efforts to bring
about the desired end.
A Congress for the Study of Tuberculosis will be
held in Naples on April 25th-28th.
Dr. A. G. Wippen has been elected vice-president
and treasurer, and Dr. William L. Ballenger professor
of otology, rhinology, and laryngology in the Chicago
Eye, Ear, Nose, and Throat College.
The State Sanatorium for Tuberculosis. — The
Senate finance committee has reported favorably Sen-
ator G. A. Davis' bill appropriating ^150,000 for the
establishment of a State hospital in the Adirondacks
for the cure of incipient tuberculosis.
South African War — Sir Thomas Naghten Fitz-
Gerald, the senior surgeon to the general hospital at
Melbourne, Australia, has been appointed to an ad-
visory post as surgeon with the British South African
forces, and has left for the seat of war. Mr. Treves
is returning to England, and Sir William MacCormac
left Durban on March 10th for home.
Philadelphia Pediatric Society. — Dr. Miller pre-
sented a case of profound secondary anaemia in a girl
two years old with symptoms also of rachitis. Dr.
J. M. Swan reported a case of chronic valvular endo-
carditis following chorea. The patient was a girl,
about ten years old, who had presented symptoms of
arthritis, followed by an attack of chorea, and subse-
quently to which symptoms of endocarditis developed.
Dr. J. H. McKee reported a case of a large sarcoma of
the kidney, with operation and operative recovery.
The child remained well for several weeks after the
operation, but symptoms of recurrence soon appeared
and finally terminated fatally several months after the
operative interference. Dr. Alfred Hand, Jr., exhib-
ited a sarcomatous kidney removed from a child, two
years old, in which also temporary improvement fol-
lowed the operation, although death resulted a short
time later.
Alleged Hypnotism in the Courts — A man has
recently been convicted of murder in a Nebraska court,
the principal witness against him being the wife of one
of his victims, in order to be free to marry whom he is
said to have killed his wife and the witness' husband.
The case will be appealed on the ground that the ac-
cused was not permitted to enjoy his constitutional
right to be confronted by his accusers, in that the
principal witness, when testifying, was not required to
face the accused, and that the court erred in per-
mitting the witness to wear a heavy cloak and colored
eyeglasses, purposely preventing the defendant look-
ing her in the eye and thus forcing her to tell the
truth. The attorney's defence to this plea will be
that the allegations are true, and that while the con-
stitutional right of the accused may have been vio-
lated technically, the step was necessary, as three
physicians asserted that the woman was under the
hypnotic influence of the prisoner to such an e.xtent
that she could not testify while facing him. This
will afford a grand opportunity for the production of
contradictory medical expert testimony.
A Twin-Bearing Family. — A circumstantial ac-
count is given in the New York Times of a remarkable
occurrence in a New Jersey village recently. Three
sisters living in the village gave birth on the same day
to six children, three sets of twins, two pairs being
boys and one girls. All were born between eight
o'clock and midnight.
The Jefferson Medical College and Princeton. —
A report has been current for some time that the Jeffer-
son Medical College, of Philadelphia, was soon to
become the medical department of Princeton Univer-
sity, but President Patton, of Princeton, has recently
denied emphatically that any such union was contem-
plated.
A City Hospital for Tuberculosis — Dr. Nelson H.
Henry has introduced into the State Assembly a bill
appropriating $350,000 for the purchase of a site and
erection of a hospital for the treatment of pulmonary
tuberculosis. Upon the completion of the hospital the
New York City board of health is to have jurisdiction
over it, and will prescribe the rules and regulations to
govern the institution.
Seaside Hospital of the Brooklyn Children's Aid
Society.— The Children's Aid Society of Brooklyn
has received a gift of $10,000 from two women for the
building of an infants' hospital and a beach pavilion
as an extension to its other buildings used in the sum-
mer at Coney Island. The hospital will be reserved
for cases of critical illness. The main floor will be
divided into a number of rooms, so as to permit mothers
to be with their sick children. The buildings will be
completed in time for the summer season.
Improved Health Conditions in the Philippines.—
Surgeon-General Sternberg has received a cablegram
from Colonel Greenleaf, chief surgeon in the Philip-
pines, saying that the total number of cases in the
military hospitals in and around Manila March 12th
was twelve hundred and eighty-seven. There has been
a steady reduction in the number of cases under treat-
ment at the hospitals since January 20th last, when
they numbered twenty-five hundred and forty. The
report, however, does not cover the sick in the hospi-
tals of northern Luzon and at Iloilo. Reports received
by mail from Manila are that the hospitals are in ex-
cellent condition, and that the bubonic plague has been
fully checked, if not conquered.
Medical Courts of Honor in Prussia. — The insti-
tution of professional courts of honor is not a new one
in Prussia. The army has its courts of honor and so
has the legal profession, and on April ist, the British
Medial/ Journni szys, "similar courts for the medical
profession are to come into existence. The plan of
organization is simple. In each district where there
is an Aerzickammer (representative body of doctors) a
court is to be established; it will consist of the presi-
dent of that body, three of its members, and, in addi-
tion, a judge of one of the local courts. A central
March 24, 1900]
MEDICAL RECORD.
505
supreme court will act as court of appeal, and is to
consist of (i) the director of the Prussian ministerial
medical department, (2) four members of the central
committee of the Aerztekanwieni, (3) two medical men
specially elected by the king of Prussia. The courts
are to exercise jurisdiction over all certified practi-
tioners excepting medical officers of the army and navy
and others for whom a state disciplinary board already
exists. The scope of jurisdiction is defined by the
new law as follows: ' Every medical man is bound to
exercise his profession conscientiously, and by his be-
havior— both in his professional and in his private
life — to show himself worthy of the respect which his
profession demands. A medical practitioner who fails
in the duties incumbent on him is subject to the inflic-
tion of a penalty by the court of honor. Political,
scientific, and religious opinions or actions of a prac-
titioner as such can never form the subject of proceed-
ings in a court of honor.' The penalties which the
court may inflict are: (i) Warning; (2) reprimand;
(3) fine, not exceeding 3,000 marks (^150) ; (4) tem-
porary or permanent withdrawal of the right to elect
members of the Aerztekammer or to be elected a mem-
ber."
A Medical Club Swindle. — A man has been arrested
in Chicago for running a fake hospital association.
He collected money from the members of the associa-
tion, guaranteeing free hospital treatment for any who
were sick. The dues were regularly collected, but
when any member fell ill there was none but the pub-
lic hospital to receive him.
Lucrative Divine Healing. — A man was recently
arrested in Boston on a charge of fraudulent use of the
mails, whose occupation was that of a " divine healer "
by letter. He constituted in himself a faith-cure asso-
ciation which practised therapy by correspondence. It
is stated that he employed forty girls in sorting and
■writing letters, giving what he called his "absent
treatment," charging his distant patients ^5 a month.
Ic is alleged that his business has recently brought
him in ji3o,ooo a month.
Militant Advocates of Vaccination. — A Christian
Scientist lectured recently in Victoria, B. C, on the
"Failure and Iniquity of Vaccination," and his re-
marks were so outrageously slanderous and false that
they aroused the ire of the anti-faith-healers in the
audience, and a general mele'e ensued. When order
•was finally restored most of the men present bore
marks of the fight, and several of the "scientists" ac-
quired a sudden "belief" in epistaxis.
Another "Human Ostrich" has come to grief and
the knife of the surgeon in Baltimore. According to
the newspaper report of the operation, conducted at
the Johns Hopkins Hospital, the following junk was
removed from the man's stomach: Ninety-one nails,
iron and wire, measuring from one to four inches in
length; one pocketknife, seven knife blades, one about
three-quarters of an inch wide; nine horseshoe nails,
four inches long; eight screws, two and one-half inches
long; eleven small pins, ordinary size; two screw-
eyes ; forty-nine tacks, some with very large heads ; one
small staple, twenty-five grains of ground glass, four
brass watchchains, with catches and stays, and twelve
and one-half feet of three-eighths-inch iron chain.
Mortality of Michigan during February. — In the
Michigan Monthly Bulletin oj Vital Statistics for Feb-
ruary the secretary of State reports that 2,673 deaths
occurred in Michigan during the month. This is 37
deaths more than during the preceding month, but
over 1,100 less than during the same month of the
preceding year. The death rate for the month was
14.5 per 1,000 of population, showing a considerable
increase over January, whose rate was 13.0. There
were 445 deaths of infants under one year of age, 210
deaths of children aged from one to four, inclusive,
and 772 of persons aged sixty-five and over.
The Medical Society of the State of North Caro-
lina will meet in Tarboro, Tuesday, May 22d, under
the presidency of Dr. George W. Long, of Statesville.
The board of medical examiners will meet Wednesday,
May i6th, and will make their report before the ad-
journment of the society. The annual discussion will
be held on the afternoon of the second day, Wednes-
day, May 23d, the subject being "The Continued
Fevers of North Carolina," led by Dr. James M. Par-
rot, of Kingston. On Wednesday evening. May 23d,
the annual essay will be read by Dr. R. H. Whitehead,
of Chapel Hill, and the annual oration will be deliv-
ered by Dr. T. S. McMullen, of Hertford.
The Obligation of Caring for Sick Children. — A
child of Christian Science parents died not long since
in Detroit of diphtheria. Its only treatment consisted
in assertions by healers that nothing was the matter.
When some of the sane neighbors, realizing the danger
to the community and cruelty to the child of neglecting
a case of contagious but usually curable disease, sought
to make an example of the guilty parents, they were
rebuffed by the prosecuting attorney. This legal light,
according to the newspaper accounts, said that there
was nothing to be done, since no doctor had failed of
his duty in reporting the case, and the relatives and
healers, not being physicians, could not be charged
with knowing and concealing the nature of the disease.
An Epidemic of Pneumonia.— A strange story of
the practical extinction of a family by pneumonia is
reported in the New York Times of March 17th. On
Thursday of last week, it says, a farmer residing near
Deckerstown, N. J., died of pneumonia. He was ninety
years of age. Two hours after the funeral, on the fol-
lowing Saturday, an unmarried daughter, aged sixty-five
years, died of the same disease. Another daughter lay
seriously ill with pneumonia in an adjoining room,
and she died last evening. A married daughter came
to her father's home to care for the afflicted ones, and
she is now ill with pneumonia, and has slight chances
of recovery. A son, who has conducted the farm for
several years, and his wife are both afllicted with the
same malady at the family homestead.
Dr. William McNeill Whistler, a brother of the
celebrated painter, died in London on February 27th,
at the age of sixty-three years. He was a graduate of
5o6
MEDICAL RECORD.
[March 24, 1900
the medical department of the University of Pennsyl-
vania in the class of i860, and served during the civil
war as surgeon in the Confederate Army. At the close
of the war he went abroad and took the diplomas of
M.R.C.S. and M.R.C.P. He practised in London,
and was physician to the London Throat Hospital.
Dr. Otto Leichtenstern, of Cologne, died on Feb-
ruary 28th, of influenzal pneumonia. He was born in
1845 at Ingolstadt. After teaching for a few years,
subsequent to graduation in medicine, at the Univer-
sities of Munich and Tubingen, he went in 1879 to
Cologne, where he succeeded Riegel as director of the
medical division of the Biirger hospital. Dr. Leich-
tenstern was a well-known medical author, but the
work which brought him his greatest renown was the
discovery of the ankylostoma as a cause of anaemia in
brick-makers.
Obituary Notes. — Dr. Benjamin S. Lewis, of Cam-
den, N. J., died at Plainfield on March loth, at the
age of forty-three years. He had been a member of
Camden city council and was a member of the board
of health.
Dr. Orlando Fegley died at Allentown, Pa., on
March loth, at the age of sixty years. He was a grad-
uate of the medical department of the University of
Pennsylvania.
Dr. JusTt;s Lessey died at Philadelphia on March
14th, at the age of eighty years, from angina pectoris.
He was a graduate of Jefferson Medical College, but
for a number of years has been incapacitated by loss
of vision from the pursuit of his profession.
Dr. Samuel Hayes died at his home in Newark, N.
J., on March 14th, of apoplexy, at the age of ninety-
three years. He was a graduate in arts from Princeton
in 1825, and for two years had enjoyed the distinction
of being the oldest living graduate of that college.
He was graduated in medciine from the Geneva Medi-
cal College in 1829. In 1895 he received the degree
of LL.D. from Princeton. He was a corresponding
member of the Munich Medical Society and of the
Botanical Society of Ratisbon. He retired from prac-
tice many years ago, but was a trustee of Princeton
University and president of a bank in Newark.
Dr. Albert B. Strong, of Chicago, died in the
State Hospital at Kankakee on March 17th. Death
was due to exhaustion, brought about by maniacal ex-
citement, the attack being an acute recurrence of three
similar afflictions. His mental collapse resulted from
losses involved in the failure of a bank. Dr. Strong
was born at Galesburg, O., and was a graduate in arts
of Kenyon College. He served during the civil war
in the Eighty-fifth Volunteer Infantry, and afterward
took up the study of medicine, being graduated from
the Rush Medical College in 1872. He was a mem-
ber of the Chicago Medical Society, the Illinois State
Medical Society, and the American Medical Asso-
ciation.
Dr. Adolph Callison died at his home in this city
on March i6th, on his eighty-second birthday. He
was born in Copenhagen, and was the son of Dr. Adolph
Callison, a court physician to the king of Denmark.
He studied at the universities of Copenhagen and Kiel
and in Vienna, Berlin, and Paris. He came to this-
.country about fifty years ago and established a private
school. He had not practised medicine for many
years.
Dr. Tho.mas B. Hood died at his home in Washing-
ton on March 15th, at the age of seventy-one years.
He was born in Fairview, Ohio, and was graduated
from the Medical Department of the Western Reserve
University in the class of 1861. He began practice
in Columbus, but soon after the beginning of the civil
war he entered the army and served as a surgeon.
Subsequently for eleven years he was medical referee
of the Pension Office, and since 1885 had practised in
Washington. He was a professor of diseases of the
nervous system in the medical departmeht of Howard
University, and was also dean of the faculty.
Dr. Hans R. Hoffmann died at his home in Unioa
Hill, N. J., on March 18th, of pneumonia, at the age
of thirty-five years. He was a graduate in medicine
of the University of Leipsic in 1889.
'^xaQvcss of pXccXical Science.
Boston Medical and Surgical Journal, March 75, igoo.
Steam in the Treatment of Chronic, Hyperplas-
tic, and Senile Endometritis, Putrid Abortion, and
Puerperal Sepsis. — F. W. Johnson reports thirty-one
cases in which steam was used instead of curetting.
It is introduced into the uterus, after dilatation of the
cervix, by means of an ordinary steam throat atomizer,
to which a hard-rubber tube, eight inches long, coni-
cally pointed at one end, is connected by soft-rubber
tubing. The steam as it leaves the boiler is at 212°
F., and is allowed to enter the uterus for thirty sec-
onds, and for another thirty seconds after the remov-
al of the uterine speculum. Excellent results are
claimed.
Injuries about the Shoulder at Birth.— J. S. Stone
says that true congenital dislocation of the shoulder —
that is, defective development of the scapula and head
of the humerus — is of extremely rare occurrence. True
traumatic dislocation of the shoulder at birth or ir»
early infancy is also of very rare occurrence. Obstet-
rical paralysis is due, probably almost invariabl)-, to a
stretching and in some cases a rupture of the two up-
per roots of the brachial plexus. It is usually recov-
ered from entirely in the course of a few weeks or a
few months. In persistent cases surgical intervention
may be of value.
Instruction in Co-ordination in Tabes. — J. J. Put-
nam has a patient who has been taught to stand and
walk and do various exercises, and, considering the
difficulties to be overcome, has made good progress.
Muscular Dystrophy. — J. J. Putnam reports a case
in which the disease began at the age of thirteen
years, and has progressed ever since, the patient be-
ing now thirty years old.
Acromegaly. — G. L. Walton describes a typical
case. He believes that there is a relation between
this disease and lesion of the pituitary body, if the
secretion of this gland is increased.
Rupture of Quadriceps Extensor Tendon — J. C.
Warren reports two cases, in both of which operation
March 24, 1900]
MEDICAL RECORD.
507
gave excellent recoveries, with perfect functioning of
the extensor muscles of the thigh.
Fresh Fractured Patella Sutured with Catgut
through the Periosteum. — J. C. Warren operated
one hour after the injury. The patient walked alone,
without crutches, in six weeks.
W A Second Case of Chronic Cyanosis without As-
signable Cause. — Richard C. Cabot reports a case,
probably due to venous congestion, the cause of which
is unknown.
Resection of a Portion of the Liver for Adeno-
carcinoma of the Cystic Duct. — J. C. Warren per-
formed this operation with good results.
Idiopathic Dilatation of the Colon.— R. H. Fitz
reports a case in a child, aged two years, evidently
due to obstinate constipation.
Poliencephalitis, Superior and Inferior, with
Acute Anterior Poliomyelitis. — ^E. W. Taylor reports
such a case in a man, aged twenty-seven years.
Journal of American Med. Association, March ij, igoo.
The Physician as a Witness in Court.— William J.
Herdman proposes the adoption of the following sug-
gestions as a means to secure much-needed reform in
the matter of expert testimony: (i) Experts should be
appointed by the trial judge. (2) Their compensation
should be a part of the court expenses. (3) They
should have abundant opportunity to investigate the
facts of the case, so far as they bear on the opinion
they are expected to deliver. (4) That opinion should
be given to the court in writing, signed and sworn to.
(5) Any dissenting expert opinion must also be in writ-
ing, and state the grounds on which dissent is based.
(6j Experts may be sworn as witnesses and cross-
examined, but the cross-examination is not to extend
beyond the limits of the subjects embodied in the
opinion they have been asked to express.
The Nutritive Function of the Bronchial Arteries
in Growth ; Disease and Repair of Pulmonary Tis-
sue D. Lichty says it is the bronchial artery circulat-
ing in the intercellular spaces of the lungs, apart from
the vessels involved in the pneumonic process, that
prevents a sweeping destruction of the lung tissue
when injured or diseased. Post-mortem evidences
show us that the lung far exceeds any other tissue in
the body — not excepting the peritoneum — in its ability
to overcome the effects of tuberculous inoculation.
The author concludes that we must admit this is
largely due to the systemic circuit of the obscure bron-
chial artery and its nutritional activity.
Some Points in Treatment of Severe Crush In-
juries of the Extremities. — John Prentiss Lord dep-
recates the tendency to over-conservatism in these
cases, in the dictation of a watching and w-aiting
course, and emphasizes a general need for a more uni-
versal application of the principles of drainage. To
these principles he says must be added the application
of the best surgical metliods for carrying off and main-
taining the wound products aseptic. This may be
accomplished by an abundant hygroscopic dressing,
though in more severe cases the moist antiseptic dress-
ing is more efficient.
Symptomatology, Diagnosis, and Treatment of
Neoplasms of the Kidney. — Under the head of symp-
tomatology, L. I. Mc Arthur includes: (i) Tumor in the
renal region; (2) htematuria; (3) pain; (4) cachexia.
As aids in determining diagnosis he gives: (i) Study
of the history; (2) examination of the urine; (3) pal-
pation; (4) cystoscopy, ureteral catheterization, and
exploration by sounds; (5) direct exploratory incision.
For treatment he gives: (_i) Puncture; (2) nephroto-
my, or (3) nephrectomy, according to the indications.
Infantile Diseases from the Standpoint of Biolo-
gy.— Joseph Clements, in summarizing, says that we
may accept the dicta that disease is abnormal vital
activity, and the cause may be from without or may
arise independently within ; that the cause does not
necessarily determine the nature of the disease, but
the response of the vital activities to the contact rela-
tion of the irritant or cause, whatever it be.
May Not Gonorrhoeal Vulvo-Vaginitis be Acquired
by Children Indirectly? — Charles O'Donovan con-
cludes from observation of cases after admission to
the hospital wards that it is quite possible for the in-
fection to be carried from one child to another by
means of toys or otherwise. In uncleanly families the
infection may follow the use of towels or the transfer-
ring of clothing from an infected to an uninfected
child.
Renal Calculi. — M. L. Harris says that practically
all kidney stones may be considered of bacterial ori-
gin. So far as medical treatment is concerned, he
knows of none except it be symptomatic. When the
diagnosis is made the stone should be removed, and
there is at present no way to do this except by opera-
tion. The author states the mortality for stone in the
aseptic kidney as a little over three per cent.; in sep-
tic kidney, over ten per cent.
Pathology of Renal Neoplasms. — Daniel N. Eisen-
drath says that during the past ten years great progress
has been made in the pathology of renal growths, al-
though much still remains to be investigated in this
field. To this end every tumor should be carefully
described and subjected to microscopical examinatien.
Case of Hepatic Abscess Presenting Some Points
of Interest. — In this case, reported by Hermann B.
Gessner, the writer thinks the suppurative hepatitis
may be traced back to a dysentery occurring six years
earlier. As to treatment, analgesia was successfully
produced by means of a ten-per-cent. solution of eu-
caine-B.
Gastrectomy. — W. S. Thome reports one more case
in which this rare operation was performed. The pa-
tient survived the operation forty hours, dying from
shock.
Professional Education and Ethics. — This is a
plea by A. E. Baldwin for the better ethical instruction
of students in dentistry.
Treatment of Gunshot Wounds of the Abdomen ;
Some New Statistics. — By H. H. Grant. See Medi-
cal Record, vol. Ivi., page 906.
The Grippe Exanthemata.^By Harriet E. Garri-
son. See Medical Record, vol. Ivi., page 28.
New York Medical Journal, Aiarcli ij, igoo.
Shock and its Surgical Significance.— J. H. Rish-
miller holds that sensory-nerve irritation sufficiently
powerful to produce exhaustion of the vasomotor cen-
tre causes a reflex paralysis, and consequently a dila-
tation of the vascular mechanism. There are two
forms of shock, according as hebetude or excitement
predominates. Shock may to a large degree be pre-
vented by counter-irritation applied to the extremities.
Brandy per os and morphine subcutaneously before
operating are prophylactic. Treatment consists in
stimulating the vascular system and the application of
5o8
MEDICAL RECORD.
[March 24, igoo
artificial heat to the body. In cases of profuse hemor-
rhage an infusion of decinormal saline solution is in-
dicated.
Apomorphine as a Hypnotic. — C. J. Douglas ad-
vises tlie hypodermic administration of doses of gr.
■j'^, to be given when the patient is in bed and ready
for sleep. Restful slumber comes on in from five
to twenty-five minutes. Cumulative effect is denied,
and the remedy can be regularly used. Both as a
hypnotic and emetic the remedy is thoroughly neu-
tralized when dissolved in a saturated solution of bo-
ric acid — a fact which the author has never seen men-
tioned in literature.
The So-Called X-Ray Burn.— J. Rudis-Jicinsky
divides the injuries from the A-ray into superficial
dermatitis, spasmodic vascular contraction followed by
immediate relaxation and renewed nutrition of the cells
following upon the preceding mortification, and sequelae
of an acute attack with more extensive tissue destruc-
tion. He believes that the future perfection of appar-
atus and shortened time of exposure will diminish the
untoward effects of the rays.
Varicose Spinal Veins — C. E. Coon relates the his-
tory of a man, aged fifty-eight years, who died of tuber-
culosis, and who had suffered during life from excru-
ciating pains in the lower extremities. Autopsy
showed at the junction of the dorsal and lumbar verte-
bra an extensive varicose condition of the spinal
veins, which was thought to have been the cause of the
pains.
Extensive Thrombosis of the Lateral Sinus and
Internal Jugular Vein following Acute Suppurative
Otitis Media. — M. D. Lederman describes a case of
this nature occurring in a girl aged nineteen. He in-
dorses liberal incisions of the soft parts in surgery of
the mastoid. In this case the internal jugular vein
was ligated in its lower portion. Secondary periphle-
bitis occurred, but the patient finally recovered.
Tinea Favosa. — C. A. Kinch gives the history of
the literature of this affection, with a general state-
ment concerning its pathology, characteristics, and
treatment.
The Sheldon Murder Trial ; Resume of the Ex-
pert Testimony for the State. — By W. S. Cheesman
and A. H. Hamilton. A continued article.
The Administration of General Anaesthetics. — By
C. A. Temple. A continued article.
Aledical Nfios, March 77, igoo.
Instruments and Apparatus Used in the Diagno-
sis and Treatment of Gastric and Intestinal Dis-
eases.— H. W. Lincoln enumerates, with a brief de-
scription of each, these instruments: Stomach tube,
stomach bucket, oesophageal probe, gastrodiaphane,
intragastric bag fitted with intestinal intubator, gas-
trograph,gastroscope;.v-rays, photography, intragastric
spray, intragastric electrode, gyromele, and powder-
blower. He adds that each instrument has its field in
the diagnosis and treatment of gastric and intestinal
diseases, but many gastrologists depend largely for
therapeutic results upon the stomach tube and lavage
apparatus. There is, however, no question that the
spray, electrode, and powder-blower are productive of
some of the very best results.
Case of Pulmonary Tuberculosis Successfully
Treated by Drainage and Iodoform, with Apparent
Recovery. — Alexander Hugh Ferguson describes a
case of this nature in a colored man, twenty-seven
years old. In inserting the dry iodoform powder into
the diseased lung tissue, no pain whatever was felt;
but as soon as sound tissue was encroached upon, pain
and uncontrollable coughing occurred. The emulsion
also caused pain and coughing.
The After-Treatment of Fractures and Disloca-
tions.— D. N. Eisendrath emphasizes the advantages*
of hinged splints, especially for elbow, shoulder, and
foot, believing in the efficacy of active motion by the
patient himself. He approves of massage in disloca-
tions and fractures after the dressings are removed.
He also speaks of gymnastic apparatus for ankylosis
of the elbow and shoulder.
Tympano-Mastoiditis. — Emdon Fritz defines this
affection as an inflammatory process which involves
the tympanic cavity and the mastoid portion of the
temporal bone. He cites three instructive cases.
The Significance of Earache in Children. — By T.
H. Halsted. See Medical Record, vol. Ivii., p. 207.
Philadelphia Medical Journal, March ly, igoo.
The Spontaneous Disappearance of Senile Cata-
ract.— Walter L. Pyle divides cases of this sort into
those due to (i) absorption after rupture of the cap-
sule; (2) dislocation of the lens; (3) intracapsular
resorption of the cortex and sinking of the nucleus
below the axis of vision after degenerative changes of
the Morganian type; (4) complete resorption of nucleus
and cortex without history of rupture, dislocation,
or degenerative changes; and (5) disappearance of
incipient cataract without degenerative changes or
marked difference in the refraction. He reports ai
case in class 4.
Connective-Tissue Tumors of the Abdominal
Wall. — Albert L. Stavely discusses the fibroid and
sarcomatous neoplasms of the abdominal wall, and
reports a case of removal of a small fibromyxoma from
the inguinal region.
Gangrene of the Tonsil Alexander C. Howe re-
ports a case of this nature in a man, twenty-six years
old. A cure was obtained by cutting away the dead
tissue and applying peroxide of hydrogen and nitric
acid.
Hairpin Removed from the Bladder through a
No. 12 Kelly Cystoscope. — Hiram N. Vineberg re-
ports this case. The hairpin had slipped in, according
to the account of the patient, a young woman, during
an effort to extract a retroversion pessary.
Peroneal Type of Progressive Muscular Atrophy.—
Theodore Diller reports two cases of this condition
occurring in a brother and sister, twenty and twenty-
five years old respectively.
A Case of Tetanus Treated by Subdural Injec-
tions of Antitoxin, and Hypodermic Injections of
Carbolic Acid. — By Ernest Laplace. See Medical
Record, vol. Ivii., p. 192.
Selections from the Lane Lectures. — A portion of
a lecture on diseases of the arteries, delivered by T.
Clifford Allbutt at Cooper College in 1898.
Glosso-Labio-Laryngeal Paralysis. — Francis P.
Morgan reports a case of bulbar paralysis in a man
forty-seven years old.
British Medical Journal, March 3 and 10, igoo.
Myasthenia Gravis Pseudo-Paralytica.— Thomas
Buzzard gives the histories of two patients affected
with this disease, a man and a/'woman. In these
March 24, 1900]
MEDICAL RECORD.
509
cases the results obtained by electrical examination
were of great interest and importance, and the term
"myasthenic reaction" has been applied to the re-
markable behavior of the muscles under electrical
stimuli. This " myasthenic reaction " should be suffi-
cient to prevent the mistaking of these cases for
hysteria, an error of diagnosis often made, and a very
serious one, as the prognosis in this disease is very
grave and deatii often occurs rapidly. As to treat-
ment the best results seem to be obtained by rest,
removal from disturbing surroundings, and good food.
Feeding by tube, which is often of service in bulbar
paralysis of the ordinary type, should be avoided.
The Causes and Treatment of Movable Kidney.
— C. Mansell Moullin says that the width of the lum-
bar recesses is one of the penalties which have followed
the assumption of the erect attitude, and that taking
that width into consideration the wonder is not that
movable kidney occurs, but that it does not occur more
often. It accounts completely for the peculiar clinical
distribution of movable kidney. It is hereditary and
common; present in women much more often than it
is in men; and in women who have borne children
more often than in those who have not. As to the
treatment the author says the choice lies between wear-
ing an abdominal belt and nephrorrhaphy, the former
expedient, in his experience, only succeeding in the
milder cases, when combined with massage and mus-
cle-strengthening exercises.
The Eye Symptoms of Locomotor Ataxia — C. O.
Hawthorne concludes from a record of thirty cases:
(i) That an optic-nerve atrophy, an ocular paralysis,
or an Argyll -Robertson pupil may exist as an isolated
symptom for a long time; (2) that any two may be
associated, with an increased presumption that the
process causing them is of the locomotor-ataxia order;
(3) that any one of the three or a combination of two
or all of them may exist in conjunction with more or
less pronounced evidences of spinal disease; (4) that
occasionally a case which commences with purely
ocular symptoms may be seen to develop with com-
parative rapidity characteristic symptoms of the spinal
lesion of locomotor ataxia.
A Case of Complete Inertia and Prolapsus Uteri.
— A case reported by F. L. Pochin, who says that the
accident is extremely rare and has been ascribed to
traction on the cord, either by the midwife or as a re-
sult of the funis being twisted round the child's neck.
In this case the patient had been very anaimic for a
long time before delivery; there had been some trou-
ble with the afterbirth, and the midwife had "pulled
the cord a little." The writer detached the placenta,
bathed the uterus with hot boiled water, and returned
it to its normal position. The patient quickly im-
proved under stimulating treatment, and the puer-
perium was comparatively uneventful.
Perforating Gastric Ulcer, with Notes of Two
Successful Cases after Operation. — P. Rhys Grif-
fiths reports these cases, and says that the operation
for perforating ulcer may be very easy or may be very
difficult, requiring great care and patience to render
the holes water-tight. The openings in the anterior
wall are generally fairly easy to close, but the open-
ings in the posterior wall, which fortunately rarely
occur, often present serious difficulties. Absolute
cleanliness is the keynote of success. In one of the
cases reported recovery was uninterrupted, the other
developed a subphrenic abscess.
A Contribution to the Surgery of Perforated
Gastric Ulcer A. B. Mitchell considers this subject
with special reference to the results of operations in
Ulster, where the total number of cases operated on
have been fourteen, with seven recoveries. The author
draws the deduction that a few cases of true perforat-
ing ulcers result in recovery without surgical aid, but
that the chief factors in successful treatment are early
diagnosis and early operation. When once the phy-
sician suspects symptoms of perforation there is not a
moment to be lost.
A Contribution to the Study of the Pituitary
Body. — In this preliminary communication, VV. A.
Osborne and Swale Vincent say that their investiga-
tions have been performed, as were those of other
observers, with ox material, but that they used dogs
and rabbits for the experiment animals. In the main
their results have been confirmatory of those obtained
by others, with the addition of some facts in regard to
the histological, chemical, and comparative physio-
logical aspects of the question.
Maniacal Excitement during an Attack of Influ-
enza.— John H. Spitzly reports this case, in which the
patient, a man twenty-five years old, suffered delirium
of so violent nature that the employment of a male
nurse was necessary to keep him from throwing him-
self from the window. This excitement continued for
nearly a week in spite of narcotics, the application of
ice to the neck and head, and frequent doses of gray
powder. There was perfect recovery from all symp-
toms in three weeks.
Suicide in Scotland. — Sir John Sibbald concludes
after an examination of the statistics on this subject
that the alleged increase of suicide must be regarded
as not proven. We must keep in mind, he holds, that
a great change has taken place in public feeling in
regard to this matter of late years; the belief that the
act of suicide necessarily involves disgrace has much
diminished, and efforts to conceal its occurrence have
therefore decreased. The degree of efficiency of the
registering machinery must also be kept in view.
Diphtheria, Parturition, Retained Membranes,
and Influenza in the Mother ; Diphtheria in the
Infant. — R. H. Steen reports this case as being of
interest owing to the association of confinement with
diphtheria and influenza. Both mother and child
made good recoveries after the administration of large
doses of antitoxin. The child received a dose of 350
units when five days old, and 1,000 units the following
day, but exhibited no ill effects.
Case of Tabes Dorsalis with Bulbar Symptoms
George E. Rennie reports this case, which he considers
exceptional because of the severity of the laryngeal pa-
ralysis and the involvement of the other bulbar centres.
The involvement of the pharyngeal muscles was so
extensive that nasal feeding became a necessity, and
the dyspnoea was so great that tracheotomy had to be
performed and a tube worn, until the patient finally
died of a lobar pneumonia.
Experiments to Determine the Efficacy of the
Different Constituents of Haffkine's Plague Prophy-
lactic— C. Balfour Stewart gives the results of experi-
ments with rabbits. Haffkine, on theoretical grounds,
thought that the addition of the supernatant fluid
reduced the case mortality, and the results obtained
by Stewart show experimental confirmation of this
theory.
Gastro-Jejunostomy for Gastric Ulcer. — In this
case, reported by W. Jones Greer, the patient had suf
fered for nearly ten years from symptoms of gastric
ulcer. Scientific dieting and rectal feeding failed to
efl:ect more than transient amelioration of the symp-
5IO
MEDICAL RECORD.
[March 24, 1900
toms. Operation was followed by a complete return
to health, the patient having gained twenty-seven
pounds in four months.
Retention of the Placenta for Nine Days — Grif-
fith Griffiths reports this case. Douches of sublimate
solution (i : i,ooo) and the administration of ergot and
quinine (the latter for the malarious condition) resulted
in a gradually subsiding temperature, followed by per-
fect recovery.
A Case of Tetanus. — W. Murray reports a case of
well-marked tetanus in a boy ten years old, who had
been wounded in the foot by a stone, in which recovery
followed treatment by antitetanic serum, in conjunc-
tion with chloral and bromide of potassium.
Supernumerary Nipple. — E. G. Salt reports a case
in which there was a supernumerary nipple on the
under surface of the right breast which was large
enough for the child to suckle, and from which milk
flowed freely.
Practical Observations on Cancer of the Breast.
— The first of the Lettsomian lectures, by Sir William
Banks. See Medical Record, vol. Ivii., p. 510.
The Surgery of the Stomach. — Abstract of the
first Hunterian lecture, by A. W. Mayo Robson. See
Medical Record, vol. Ivii., p. 510.
The Anatomy and Pathology of the Rarer Forms
of Hernia. — By B. G. A. Moynihan. The second of
the Arris and Gale lectures.
The Lancet, March 10, igoo.
Tuberculosis of the Kidney ; its Etiology, Pathol-
ogy, and Surgical Treatment. — D. Newman ton-
eludes a lengthy article. He finds the process more
virulent in some parts of the genito-urinary tract than
in others, the bladder, prostate, and epididymis being
more resistant than the kidney. He has been able to
collect statistics of 135 cases of operation for tuber-
culous kidney done during the last ten years as fol-
lows : Deatks, one month or less after operation : ex-
haustion, 2 cases; e.xtension of tuberculosis, 2 cases;
urjemia (42 per cent.), 11 cases; various accidents, 12
cases; deaths, total immediate, 27 cases. Operative
mortality, 27 out of 135, or twenty per cent. Remote
results: of 19 cases no record; of the remaining 89
cases, died in two to three months, 6 cases; died in four
to nine months 7 cases — total, 13; immediate deaths,
27 ; number of deaths within nine months, 40. General
mortality after operation, 40 out of 135, or 29.63 per
cent. Survived one to eight years, 45 cases, or33y3
per cent. Prognosis good or improvement great in
patients alive one to nine months after operation, 31.
Total survivors and promising cases, 31 plus 45, mak-
ing 76, or 76 out of 135, or 56.3 per cent.
The Surgery of the Stomach. — A. Mayo Robson
discusses the operative treatment of gastric ulcer and
of hemorrhage due thereto. From the statistics on
the subject and from his personal experience he con-
cludes that operative treatment in acute hemorrhage
gives such a high rate of mortality — 64.2 per cent, as
compared with from five per cent, to ten per cent, in
cases treated medically — that it is better in such cases
to rely solely on medical means. But in repeated
chronic hemorrhages the operation of gastro-enteros-
tomy affords a reliable method of treatment, since it
gives rest to the stomach and removes the hyperacidity
of the gastric juice. When the ulceration is at the
pylorus, where it so frequently leads to hypertrophy
and stenosis, the operation relieves the symptoms and
•cures the disease.
Practical Observations on Cancer of the Breast.
— W. M. Banks discusses the question of the increase
in cancerous diseases with its accompanying death
rate. The prevalence of the affection has increased
more among men than among women. He is disposed
to lay great stress on the "flesh-eating" theory as the
cause of the increase, for the disease is not so preva-
lent among vegetable and rice eaters. Most of the
sufferers are persons who are likely to eat and drink
too abundantly and do not take enough exercise, per-
sons who live well and do not work off their spare
products. He indorses the statement that " cancer is
eminently a disease of persons whose previous life has
been healthy and whose nutritive vigor gives fhem
otherwise a prospect of a long life."
Complete Ossiculectomy (Removal of Remains
of Drumhead, Larger Ossicles, and External Attic
Wall) in Chronic Otitis Media. — R. Lake analyzes
fifty cases. Both sexes were alike affected. Forty-
two patients were cured, while three had temporary
relapses. Improvement in the hearing-power was
noted in twenty-one. The right ear was affected in
twenty-nine and the left ear in twenty-one. The aver-
age age of the patients was 22.4 years, and the average
duration of the disease was thirteen years.
A Suggestion for a Method of Opening the Peri-
cardial Sac, Founded on a Case of Purulent Peri-
carditis.— C. Ogle and H. AUingham advocate a
three-inch incision from the costo-xiphoid angle out-
ward along the lower edge of the seventh left cartilage
through which access is had to the pericardial sac,
which can then be opened at its lowest part in front.
The procedure has been demonstrated on the cadaver,
but has not yet been tried on the living subject.
A Case of Gunshot Wound of the Abdomen with
Injury to the Intestine ; Recovery without Opera-
tion The patient was one of the soldiers engaged
at the battle of Elandslaagte in South Africa, and
came under the care of C. Reissman, a civil surgeon
at Cape Town.
A Case of Rupture of the Brachial Plexus — P.
Stewart and M. Collier report the case, which occurred
as the result of a fall in a man aged thirty-three years.
The subsequent history showed that the patient had
probably fallen during an epileptic fit.
On the Application of Electricity in Medical and
Surgical Practice H. L. Jones describes the various
forms of apparatus for electrical application.
The Sanitary Condition of the Irish National
Schools. — By A. Roche.
Deutsche mcd. IVocheiischri/t, March i and 8, jgoo.
Active Dilatation of the Heart. — Hans Herz dis-
cusses in its various aspects the dilatation of the heart
resulting from an active alteration (not diminution)
of tone of tlie cardiac muscle — hyperdiastole, described
by O. Rosenbach in 1897. The condition occurs
physiologically during active exercise, through the
action of hot batlis, sometimes in pregnancy, and
during digestion. Pathologically it is seen in extreme
nervous states, as a result of sexual excess, and in
certain morbid conditions. It is very common in
young persons of the working classes, say between
fourteen and nineteen years of age, and is induced
by rapid growth, physical labor, and the disturbances
due to puberty. In later life the two conditions in
which active dilatation of the heart most commonly oc-
curs are obesity and abdominal plethora. The prog-
nosis is usually favorable if the condition is recognized,
March 24, 1900]
MEDICAL RECORD.
5"
but depends upon a prompt removal of the cause, in the
effort to accomplish which the proper treatment con-
sists.
A Piece of Bone in the Lung for Four Years. —
Gustav Killian reports the case of a man, forty-two*
years old, who inhaled a splinter of bone. He suffered
from a very severe and long-continued attack of
coughing with bloody expectoration and a sticking
pain in the chest. After this signs of pulmonary
trouble appeared and continued with varying intensity
for four years, during which time he consulted ten
general practitioners, six specialists, and sought relief
in seven hospitals and clinics in vain. The writer
finally succeeded in extracting the foreign body by
means of the bronchoscope and a tracheal forceps.
The chip of bone measured 15 mm. in length, 11 mm.
in width, and from i to 4 mm. in thickness (three-
fifths, two-fifths, and one-twenty-fifth to one-sixth
inch).
Simultaneous Extra- and Intra-Uterine Preg-
nancy.— Hermes reports the case of a woman, thirty
years old, who had had three children born at term and
five miscarriages. She had menstruated last in July.
In September she was operated upon for extra-uterine
pregnancy, the product being the size of an orange
and connected with the left tube. The uterus was
slightly enlarged and antefiexed. The woman made
a good recovery, but as the uterus was apparently
growing larger she was instructed to report regularly
after leaving the hospital. This proved to be a nor-
mal pregnancy, and the woman was delivered of a full-
term child in April.
Ophthalmoscopic Findings in Leprosy E. v. Diir-
ing and Trantas report ten cases of leprosy in which
they found chorio-retinitic changes of a specific char-
acter, but in several instances these were very slightly
pronounced. It is probable that these changes were
present in some other cases in which a clouding of the
media prevented a view of the fundus. These changes
were associated very frequently with other lesions,
such as iritis, cyclitis, and sclero-corneal lepromata.
These lesions of the fundus are never seen in syrin-
gomyelia, and their presence is therefore of value in
the diagnosis between this affection and leprosy.
A New Method in Physical Examination. — Eduard
Weisz has noted a bulging of the intercostal spaces
during phonation (counting), which he attributes to the
pressing outward of the lung tissue. The bulging is
not present over the spleen and liver, so that the lung
marks out its own limits. The sign is absent also over a
large pleural effusion. The patient is best examined
while lying down, the chest being illuminated by day-
light admitted from one side. Such words as " cat,"
"kilt," and "day" are among the best for phonation
for this purpose.
Splitting of the Kidney. — Egbert Braatz reports
the case of a woman, thirty years old, who suffered
severe pain in the right kidney. An exploratory
incision was made into the kidney but nothing abnor-
mal was found. The pain disappeared for three years,
then returned in great severity. The kidney was how
extirpated, and examination showed a cheesy tubercu-
lous abscess at the upper pole of the organ, and a
healed tuberculous focus at the lower pole. Doubtless
the latter had been the cause of the original trouble,
and had healed as a result of the incision into the
kidney.
The Early Diagnosis of Pulmonary Tubercu-
losis.— -Ernst Levy and Hugo Bruns insist upon taking
the entire amount of sputum for the twenty-four hours
for examination, as the bacilli are not always present,
and repeated examinations at not too long intervals
must be made. In case of a negative result from spu-
tum examination, resort should be had to animal inocu-
lations. The authors also use the original tuberculin
for diagnostic purposes, and believe that with care in
its employment no harm can come from it.
Pathology and Treatment of Lamellar Cataract
Biihr reports on 153 cases of lamellar cataract operated
upon in Hirschberg's clinic. Of these 92 were in
male, and 61 in female subjects. In 7 the cataract
was single, in all the others double. In 136 cases there
were symptoms of rickets. The treatment that gives
the best results in children is discission.
Severe Nervous Symptoms Caused by the Pres-
ence of Intestinal Worms. — Max Heim reports two
cases of severe nervous symptoms and nutritional dis-
turbances in infants under one year of age which were
caused by the presence of lumbricoid worms. These
symptoms disappeared at once upon the expulsion of
the parasites from the intestine.
Orthopedic Treatment of Malpositions of the
Uterus. — By G. Zepler; a continued article.
A New Instrument for Vibration Massage. — A.
Eulenberg describes a new instrument of his device.
Miinchencr med. Woche7ischrift, Feb. 20 and 2J, igoo.
Contribution to the Knowledge of Alexins, as re-
gards their Specifically Bactericidal and Haemolytic
Influences H. Buchner says there is no doubt that
Leber has positively proved by his experiments the
important fact of histolysis and proteolysis through
the agency of the leucocytes, this being in perfect
agreement with their general function as absorption
cells. He says further that the idea of the existence
of specifically bactericidal material must, as far as he
is concerned, be definitely laid aside. He believes
that bactericidal properties and specificity belong to
different kinds of substances, viz., alexins and anti-
toxins, respectively. The bactericidal and hemolytic
properties of alexins possess nothing of the character
of specificity. Everything of specific nature belongs
to the antitoxins.
Clinical Contribution to the Symptomatology of
Pancreatitis Acuta. — Hans Doerfler reports a case of
acute suppurative pancreatitis and necrosis of the pan-
creatic tissue. There were severe lumbar pains from
the beginning to near the end of the disease. Since
section offered no other explanation, there can be no
doubt that these pains were caused either by the pres-
sure of the pancreas, enlarged by inflammation, on the
solar plexus and the semilunar ganglion, or by an ex-
tension of this inffammation to these structures. Os-
ier and Hughes have in acute pancreatitis found
round-celled infiltration in the ganglia and inflamma-
tory changes in the nerve cells. Also a striking fea-
ture was the great distention of the ascending and
transverse colon and their sharp limitation from the
entire descending colon.
Hydrorrhoea Ovarialis Intermittens : A Contribu-
tion to the Knowledge of Tubo-Ovarian Cysts —
Max Nassauer, in reviewing this subject, says that in
all probability there occurs in all cases an antecedent
gonorrhoea causing the tubo-ovarian cyst, which con-
stitutes the origin of the hydrorrhoea. First, there is
a gonorrhoeal inflammation of the tube, which extends
to the ovary and the pelvic peritoneum on the same
side. Here the cyst is formed, and when it bursts the
adherent tube drops into it, the fimbriated extremity
of the tube adhering to the edges of the rent in the
512
MEDICAL RECORD.
[March 24, 1900
cyst wall, and in this way the cystic fluid gains access
to the tube. The evacuation of the fluid takes place
periodically.
On the Occurrence of "Riding-Pain" in the Pa-
tella.— J. A. Rosenberger speaks of three cases of this^
kind. The prognosis is absolutely good; for when
the cause, i.e., pressure, is eliminated, the pain is re-
lieved. Severe pain disappears in the first days.
Therapeutically, relief from pressure and absolute rest
are indicated. Recovery will always follow. Rub-
bing and the bath are valuable remedies. Massage in
the early treatment cannot be considered, as it in-
creases pain. On account of the absolutely negative
findings in this affection, the physician might think of
simulation or exaggeration.
The Influence of Spinal Puncture and the Con-
dition of the Spinal Fluid in Chronic Hydrocepha-
lus.— Julius A. Grober reports two cases, and says that
their clinical significance lies without doubt in the
fact that it is possible to cure chronic hydrocephalus.
Whether this is permanent or only for a time, further
observation must show. That frequent repetition of
spinal puncture has played an important, if not the
chief, role in this treatment, is apparent from the ob-
servation of other hydrocephalic children.
A Method of Treatment of Lung Tuberculosis
with Subcutaneous Injections of Oil of Camphor. —
B. .Alexander states that from the beginning he daily
injected o.i gm. camphor. For patients with fever he
daily injected 0.01-0.02 gm., or in cases of great weak-
ness 0.03 gm., of camphor for a week or a month with-
out interruption. Patients free from fever were treated
likewise, or had injected daily o.i gm. camphor for
four days; then after intervals of at least eight days
these are repeated.
Clinical Contribution to Intestinal Lipoma. — Flo-
rian Hahn states that lipomata of the digestive tract
are rare tumors. The interesting points in this case
are that the lipoma was multiple in the submucosa,
and that there was the combination of external and
internal lipoma; also that there was sclerosis of the
intestinal wall in the position of a degenerated lipoma.
It is the first case of invagination from lipoma in which
recovery took place through resection.
A Case of Self-Injury with Hysterical Basis.— J.
Eversmann relates the case of a woman on whose body
— hands and arms particularly — water blisters ap-
peared, no cause being apparent. It was finally dis-
covered that the patient herself applied cantharides
plasters when free from observation.
A Case of Friedrich's Ataxia. — C. Wickel gives
the history of this case, and in speaking of the etiology
notes phthisis in the father. The child was always
sickly. This weakness may have caused a tendency
to affections of the central nervous system. Lues was
not proved in the father.
On the After-Treatment of Severe Abdominal
Operations. — Steinthal believes in the efficacy of regu-
larly repeated intravenous infusions of physiological
salt solution, in connection with subcutaneous oil in-
jections and nutrient enemata.
Angina with Endocarditis. — Roeger speaks of the
frequency of this combination. The treatment of en-
docarditis consists in the application of an ice-bottle
to the precordia, absolute rest in bed, and avoidance
of stimulating drinks.
The Relation between Scrofula and Trachoma.—
S. Back states that there exists a certain causal con-
nection between trachoma and scrofula of the eye.
Both perhaps may be traced to the same etiological
factor.
Treatment of Suppuration of the Eyes in the
New-Born. — A. Lamhofer washes out the eyes every
hour or two with lukewarm water. If medication is
necessary, he uses weak boric or alum solution.
A Rare Case of Paralysis of the Radialis Cured
by Freely Exposing and Stretching the Nerve. —
Hans Biiiuninger reports this successfully treated case.
The patient was a youth, sixteen years old.
The Therapy of Lupus and Skin Diseases by
Means of Roentgen Rays By R. Hahn and Albers
Schonberg.
Berlinsr klinische Wochenschrijt, Feb. 26, igoo.
Clinical Significance and Experimental Production
of Granular Degeneration of the Red Blood Cells.^ —
E. Grawitz discusses the occurrence of this condition
as seen in various diseased states. He does not regard
it as an absolute or specific process occurring in the
cells, but as a simple degeneration which can arise from
many causes, and he cautions against drawing hasty
conclusions with reference to its causative relation to
any definite pathological condition. He has found
that it may be induced in white mice by subjecting
them to the prolonged influence of a moderately high
temperature.
Nature's Methods of Protecting the Organism
against Infection. — In this issue, P. Baumgarten con-
cludes a lengthy polemic (running through two pre-
vious numbers) against the views of H. Buechner. He
takes a very conservative view as to the bactericidal
properties of normal serum, claiming that some of the
theories which have been set forth in this regard are
not proven by clinical experience, and that a too
hasty transference of conclusions from laboratory
experience to the domain of actual treatment of dis-
ease has been made.
Researches on the Bacterial Contents of Brushes,
and the Possibility of Sterilizing them. — A. VVinter-
nitz finds that it is possible to sterilize brushes (no
matter how long they may have been infected) by boil-
ing them for ten minutes in a one-per-cent. soda solu-
tion, and that they may be kept sterije by preservation
in a solution of sublimate, 1 : 1,000.
Syphilis of the Lingual Tonsil. — J. Heller makes
a statistical study of the frequency of this localization
of the specific poison. He discusses the various
forms of lesion seen in this situation, paying special
attention to the so-called flat atrophy of the tongue.
Vratch, February 12, igoo.
Etiology and Treatment of Angina Pectoris — ■
Th. K. Geisler discusses that form of angina whick
occurs in consequence of vasomotor disturbances at
the menopause, and formulates the following conclu-
sions: I. Attacks of angina pectoris observed for the
first time at the menopause may be dependent upon
the changes occurring at this period, or they may acci-
dentally begin at this time from other and unassoci-
ated causes. 2. In the former case the attacks may be
purely neurasthenic or hysterical, or they n.ay be of
vasomotor origin (spasm of the coronary arteries),
giving the picture of severe organic angina pectoris.
These two forms may, of course, be combined. 3.
In the presence of angina immediately dependent
upon the approaching climacteric our first resort should
be to specific treatment with ovarian extract.
March 24, 1900]
The High Operation for Stone. — V. I. Lisianski
reports fifty cases of vesical calculus removed by the
high operation. There were two deaths from extra-
neous causes, but none attributable to the operation
itself. The stone was solitary in every case but one ; in
this one case there were two stones. The author
advises immediate suture of the bladder in moderately
young and well-nourished patients and when the urine
is healthy.
Rhinoplasty by Israel's Method. — M. M. Kuz-
netsoff reports two cases of rhinoplasty for saddle-nose
performed after the method of J. Israel. This consists
of two steps: (i) The transplantation under the skin
of the nose of a piece of bone chiselled from the tibia
to supply the bony ridge; (2) A modified Italian
rhinoplasty.
Endothelial Neoplasms of the Gastro-Enteric
Tract. — By L. V. Soboleff. A continued article.
La Rijorma Medica, Feb. /j" io March i, igoo.
The Cure of Cutaneous Epitheliomata by the
Cerny-Trunecek Method. — Cesare Casarini holds that
in applying the arsenic cure we should always have
recourse to microscopical examinations so as to ascer-
tain whether the prevalence of one histological element
over another at all affects the cure. No great impor-
tance can be attached to a cure obtained in superficial
epitheliomata, since other remedies have also given
good results. Still, arsenious acid does hasten cicatri-
zation. The application of the remedy is easy, and,
although painful, is usually well supported by the
patient.
Hydrocele. — Nicolino Ferrici says that the opera-
tion preferred in Roth's clinic is that of Hiiter, opening
at the inferior end of the tumor, emptying, making a
counter-opening above, a long closed forceps being
introduced into the sac serving as guide, and drainage.
Irrigations are made with a hot boric-acid solution.
The aseptic irritation produced by the drainage is
usually sufficient to provoke adhesion of the serous
surfaces. In rare cases when adhesion is tardy,
recourse may be had to one or two irrigations with an
iodine solution. The majority of cases result in cure
in twenty days.
Uses of the Stomach-Tube in Gastropathy, and
Indications for Gastro-Enterostomy. — E. Tricomi
says that gastro-enterostomy has already had great
triumphs, and that physicians are convinced that in
cancer of the stomach benign stenosis, simple gastric
ulcer, gastro-succorrhcea, obstinate idiopathic gas-
trectasy, and some cases of special functional disturb-
ance are best treated by this operation, either alone
or combined with resection of the stomach. In the
case of cancer there are some cures which have lasted
five, seven, and ten years.
The Influence of the Nervous System on the
Cure of Fractures. — E. Arcoleo concludes from clin-
ical observation and laboratory experiments that: (i)
Excision of the sympathetic in dogs has no influence
upon the process of recovery in fractures, which goes
on normally; {2) the nervous system has no influence
on the formation of the callus in fractures; (3) clin-
ical observations confirm laboratory experimentation.
The Action of Adonis Vernalis in Epilepsy G.
Gianni believes that this drug may have some influ-
ence in attenuating the attacks, but that it may cause
them to occur more frequently. It has no advantage
over bromide.
MEDICAL RECORD.
513
A New and Economical Thermostat C. Tauzig
describes a simple thermostat, easy of construction,
and of practical value.
French Journals.
Intoxications following the Ingestion of Mol-
luscs.— Dr. Mosny concludes his article with the
propositions: (i) The bacteriological analysis of the
organs of molluscs and of the water retained in their
shells has revealed the presence of bacteria patho-
genic for man, in particular those of typhoid fever, the
coli bacillus, and vibrios similar to those of cholera.
(2) Experiments have shown that certain pathogenic
microbes, and in particular the Eberth bacillus, the
coli bacillus, and the vibrio of cholera, artificially
placed in contact with oysters, could remain living
and virulent in the organism of these molluscs and in
the water retained between the valves of their shells,
for a longer period than usually elapses between their
being taken out of the water and sold for consumption.
— /ournal lies Fraficiens, February 24, 1900.
Contusive Pneumonia. — A. Sauques says that trau-
ma, and especially thoracic traumatism, may provoke
and localize lobar pneumonia by simple contusion.
Gamaleia was able to produce lobar pneumonia in an
animal only by injuring the lung, either in inoculating
the pneumococcus through the thoracic wall or introduc-
ing it by way of tiie trachea, after having first injected
tartar emetic. Experiment has shown that traumatism
prepared the way for infection in determining a trouble
of the vasomotor system of reflex origin. The role
and mechanism of traumatism in the development of
contusive pneumonia are solidly established. — La
Frcsse Mcdicale, March 3, 1900.
The Plague in Ancient and Modern Times, and
its Future in Europe. — Ph. Hauser completes his
serial article with a consideration of the future of the
plague. — Lm Mcdccine Moderne, March 3, 1900.
Biillefin de PAcadctnie de Med., Feb. 20 and 2^, igoo.
Attenuated Forms of Grippe and their Treat-
ment.— H. Huchard classifies these forms as the
apyretic, characterized by neuralgias, by nervous
asthenia, by general depression, by gastro-intestinal
troubles; and the febrile, shown by fever alone.
These types often lead on to more severe foims. The
author considers quinine sulphate the best possible
medicament for this affection, and from the onset
prescribes from i to 1.5 gm. the first day, and per-
haps for several days in succession. He recommends
a simple diet, and the ingestion of much milk.
Disinfection in Measles — E. Vallin says that as in
Paris deaths from measles are more frequent than from
any other infectious disease except tuberculosis —
eight hundred and fifty deaths in 1S99; two hundred
and fifty from typhoid and from diphtheria — disinfec-
tion should be more rigorously practised.
Rhinoplasty. — Paul Berger built up an entire nose
by enclosing a metallic bridge between two flaps that
were made to unite with each other by first intention.
This obviated all possibility of infection, and the result
was satisfactory.
Psoriasis. — M. Petrini reports a case cured by the
administration of thyroid gland in capsules.
Journal oj JVerrous and Mental Disease, March, igoo.
The Relation between Trigeminal Neuralgias and
Migraine. — James J. Putnam claims that recurrent
ophthalmic neuralgia stands out vividly from among
the other neuralgias of the trigeminal nerve, and that
514
MEDICAL RECORD.
[March 24, 1900
some of the characteristics that it presents strikingly
recall migraine, so that the study of either disease
throws light on our knowledge of the other. The
difference between " neuralgias " and migraine he
believes to be one of degree rather than of kind, due
partly to the fact that the centres involved in the case
of migraine are of such high functional significance
and united in such wide and close association with
other cerebral areas.
Lesions of the Optic Chiasm.— William M. Leszyn-
sky divides these lesions into four classes: (i) Asso-
ciated with intracranial growths and their concomitant
symptomatology; (2) from enlargement of the pre-
hypophysis cerebri, as occurring in acromegaly; (3)
in syphilitic basal meningitis; (4) from a circum-
scribed pathological process, which gradually produces
complete atrophy of both optic nerves, without any
cerebral symptoms whatever.
Epileptic Ambulatory Automatism. — D. J. Mc-
Carthy reports a case of that condition, in which an
individual consciously or unconsciously performs
more or less complex ambulatory acts over which he
has no control.
Dublin Medical Journal, March, jgoo.
The Position of the Murphy's Button in Modern
Surgery.— J. S. McArdle concludes in this issue a
study of the development of this device, and gives
clinical hiscories of eight cases in which he has used
it. He enumerates, as objections which have been
urged against it, contraction of the intestine at the site
of operation, sloughing from pressure, septic peri-
tonitis, retention of the button, kinking of the bowel,
faulty position of the button, difficulty of rectification
when once it has been inserted, difficulty of having
the proper size on hand, and the expense of the appli-
ance. He does not regard any of these objections as
valid. He claims that its use has reduced the mor-
tality of operation from sixty to thirty per cent.
The Role of the Municipality in Public Hygiene. —
By Sir C. A. Cameron. A presidential address to the
Leinster branch of the British Medical Association,
February 6, igoo.
Clinical Reports of the Rotunda Hospitals for One
Year, November i, 1898, to October 31, 1899 By
R. D. Purefoy, R. P. Lyie, and H. C. Lloyd.
T/ie Edinburgh Medicaljournal, March, igoo.
On the Method of Zadig in the Advancement of
Medicine — George W. Balfour, in a review of what
has been done by medical science by means of a care-
ful search for that efficient cause which must always
precede every effect, speaks of microbes which,
although always with us and around us, do us no harm,
because when in good health our natural antitoxin is
sufficient to neutralize the toxin with which they en-
deavor to flood our tissues. This is the basis of the
Nordrach treatment of phthisis, by forced feeding and
fiee exposure to sunlight and fresh air to increase the
natural antitoxin, and thus overcome the toxin of the
tubercle bacillus.
Food versus Physic. — John Haddon says that all
the nitrogen we require is just as mucii as will supply
the small amount of tissue waste that takes place, and
that when we eat much food rich in nitrogen, such as
meat, we are putting into our bodies a substance which
acts as a foreign body, and must be got rid of by the
digestive and excretory organs in the form of urea. It
is small wonder therefore, he thinks, that sooner or
later we suffer from symptoms due to the ingestion of
nitrogen. He believes in making all " gouty " sufferers
Strict vegetarians.
The Place of Protargol in Eye-Work. — Sydney
Stephenson believes that although protargol is not an
absolutely ideal agent in treating inflammatory affec-
tions of the eye, it is in some respects an important
advance upon silver nitrate.
MoUuscum Fibrosum. — G. L. Kerr Pringle reports
a case which shows both the small soft tumors and
the large pedunculated masses. The pigmentation of
the body is also disturbed.
Some Observations on Vascular Resistance. —
Harry Campbell considers the objects served by arte-
riolar resistance, and those served by the reduction of
the systemic venous resistance to the minimum.
Ulcer of the Cornea. — A. Maitland Ramsay gives a
detailed description of this affection, with its etiology,
complications, sequelx, prognosis, and treatment.
The Differential Diagnosis of Gout, Rheumatism,
and Rheumatoid Arthritis Arthur P. lAiff gives
rules for the recognition of these three conditions.
Zeilsciir. /. Didtct. und Physik. Thcrapie, Feb., igoo.
Treatment of Chronic Ulcer of the Stomach.—
August Richter says that in treating this condition the
amount of gastric mucus is the first consideration.
Only in cases in which he thinks the edges of the
ulcer clean and the wall of the stomach smooth and
free from mucus, when a certain hyperassthesia of the
sensory nerves of the stomach exists, and the amount
of hydrochloric acid is not much increased or normal,
is the solution of silver nitrate useful.
The Significance of the Hot-Air Douche in Aero-
therapy. — A. Frey, after describing the apparatus,
concludes that with it we may produce hypera;mia or
ana2mia over any given vascular area and maintain it
so that the energy of the cells may be increased or
diminished. The more extreme the temperatures the
more intense are the local results.
Value of Occupation in the Treatment of Dis-
ease.-— F. Buttersack states that there are two points
of importance in reference to the course of disease:
(i) The worry which fathers and mothers have about
the family; (2) the filling in of time during conva-
lescence.
Treatment of Diabetes at the Menopause.— E.
Heinrich Kisch states that the physician must com-
bine a psychical and physical diet in these cases.
The patient's time should be fully occupie'l and the
thoughts drawn from unpleasant things.
The Chemical Composition and Eirect of the
Inorganic Salt Solution according to the Theories
of Modern Chemistry. — R. Brasch compares and an-
alyzes Kissingen, Rakoczy, and Carlsbad Sprudel.
Several tables accompany the article.
The Blood-Purifying Diet of Galen. — Basler con-
tributes an article comparing the diet in the days of
Galen with that of modern times.
Deutsche Acrzte-Zcitung, March i, igoo.
Prophylaxis of Pulmonary Tuberculosis. — G.
Kronig takes the ground that the greater are the
natural defences against invasion the greater is the
guarantee of escape from tuberculosis. A well-built
man with healthy organs has little to fear. The early
evidences of tuberculosis of the lung apex are to be
March 2 2, 1900]
MEDICAL RECORD.
515
best secured by topographical percussion of the apex
region; a modification of Biedert's method of finding
the bacilli as given by the writer; and a careful inves-
tigation of the general condition of the patient.
Clinical Experience with Oxy-Camphor (Oxa-
phor). — Franz Meyer discusses this drug, which, like
heroin, diminishes excitability of the respiratory
centre. It was discovered by Manasse, of Munich, in
attempting to find derivatives of camphor which would
be more soluble than camphor itself. In dyspncea it
is capable of doing good work, and in daily dose of 2
to 4 gm. seems to be harmless. It has the disadvan-
tage of being still quite dear.
On the Origin of Inguinal Hernia By Graser. A
continued article.
Giornale Medico del Regio Escrcito, January ji, igoo.
Angiotripsy. — Attilio Bruni describes the process
of arresting hemorrhage by means of Cavazzani's
angiotribe. The advantages of the method are its
rapidity, and the absence of secondary hemorrhage.
For small vessels it is in itself sufficient, and in large
ones it may be used in combination with a very slender
ligature. Thumin by histological examination has
found that hasmostasis is produced, not only by retrac-
tion and constriction of the arteries, but by immediate
occlusion of the vessel from union of the endothelial
coat.
Biliary Lithiasis ; Perforation of the Gall Bladder ;
Acute Peritonitis — Pasquale Tecce reports a case
which terminated fatally, and in which examination
of the calculi showed that the two largest of the five
examined contained a foreign body. These vegetable
fragments must have come from the intestines; a fact
which upholds the latest clinical theories that calculus
is due to purely local conditions of the biliary pas-
sages, instead of to chemical changes.
A)mali di Medicina Navale, January, igoo.
The Technique of Suprapubic Cystotomy. — Fran-
cesco Rossi gives in detail the procedures to be adopted
in this operation, to avoid wounding the peritoneum,
and so to treat the wound as to prevent infiltration of
urine or to render it innocuous. These details, he
says, being a resume of the most recent procedures of
various authorities, have not as yet been described in
any work on operative surgery.
Rapidly Fatal Haematemesis from Hepatic Cir-
rhosis.— F. Antonelli reports the case of a sailor who,
feeling gastric oppression, endeavored to empty his
stomach by vomiting. Fatal haematemesis followed.
The liver was found to be cirrhotic.
Disinfection of the Hands. — Gaetano Tacchetti
describes the method in use in Bassini's clinic in
Padua, who has the greatest success in obtaining pri-
mary union after operation.
Case of Psychical Epilepsy. — R. Cesaro reports a
case in which sudden attacks of hallucination and
other psychic-sensorial disturbances, evidently epilep-
tic in their nature, replaced the typical motor attack.
Paroxysmal Bradycardia. — A. Luzzati describes
a case due to nicotine poisoning.
Corresp. /. Schweizer Aerzte, Feb. 13 and March I, igoo.
Two Cases of Tetanus Treated with Antitoxin. —
Kocher relates two instances treated at the institute for
the investigation of infectious diseases in Berne, In
the case of a man, aged thirty-two years, injured upon
the head twenty-seven days before, reco ery took place
after intracerebral injection of 10 c.c. and an intra-
venous injection of 50 c.c. of serum in the median
vein. In a child, aged five years, injured a week
before upon the eyelid, the symptoms and course were
so acute that there was little hope. An intracerebral
injection was made, but the child died the same day.
Intestinal Bacteria and Intestinal Bacterial Poison
in the Brain — Johannes Seitz discusses auto-infec-
tion or auto-intoxication, giving details of cases; and
touches upon the use of opium in peritonitis. Convul-
sions in children and unexpected death are explained
by invasion of the brain by intestinal bacteria, espe-
cially the coli bacterium, without giving rise to menin-
geal inflammation. In seven out of fifteen cases the
bacteria of the intestinal contents were thought to be
the cause of the head symptoms.
Ozsena. — F. Siebenmann discusses rhinitis atrophica
simplex and fcetida with its constantly accompanying
pharyngitis sicca. He thinks that the family phy-
sician, who sees the patient frequently and can control
him, is better constituted to obtain good results than
the specialist to whom occasional visits are paid.
Annales de Gynecologie et d' Obstetrique, Feb., igoo.
Indications for Operation in Cases of Fibroma
Complicated by Pregnancy. — H. Delage'niere believes
that when severe pain is caused by compression of the
pelvic organs, or by a tumor incarcerated in the pelvis;
when ureters, bladder, or rectum are compressed by a
tumor situated in the inferior portion of the uterus;
when hemorrhage or placental apoplexy threaten the
life of the foetus, operation should be performed.
Abortion or premature labor should never be induced,
the rate of mortality being very much greater than in
the case of radical operations.
Phlegmonous Dissecting Perivaginitis — ^Von Lin-
gen reports a case in a woman, thirty-nine years of age,
married, nullipara. The vagina, cul-de-sac, and cervix
uteri were gangrenous, and were thrown off. Abso-
lutely no cause could be found for the condition.
Right Hydrosalpingitis with Twisted Pedicle. — •
M. Hartmann reports a case complicated by adhesive
peritonitis and appendicitis. The right appendages
and the appendix were removed, and the patient made
a good recovery.
Parovarian Cyst. — E. Jeanbrau and J. Moitessier
report a case in which the cyst contained twenty-three
litres of albuminous fluid.
Archives Gencrales de Mi'decine, March, igoo.
Regeneration and Cicatrization as Related to
Embryonal Development Etienne Rabaud says that
as a result of studies in comparative embryology, it is
evident that regeneration follows the paths of em-
bryonal development. Homomorphism is the rule,
that is to say, the organ is usually regenerated in its
usual form and dimensions, but there are exceptions.
Regeneration follows the laws of ontogenetic or phylo-
genetic development; that is to say, the derivation of
the epiblast, while still in dependence upon its sur-
roundings.
Purpura and Visceral Affections. ^C. Oddo and
Olmer, concluding an article from the previous num-
ber, state that while purpura may in many cases have
no apparent connection with visceral lesions, yet it
often is related to anterior affections of the bronchi.
5i6
MEDICAL RECORD.
[March 24, 1900
lungs, tonsils, and intestines, which serve as the door
of entrance to the infective agent, causing purpura.
Sometimes the visceral affections cause purpura by
altered nutrition and auto-intoxication. Visceral af-
fections existing contemporaneously with purpura are
due to the causative toxic infection.
Botryomycosis In concluding an article begun in
the previous number, Antonin Poncet and Louis Dor
give the result of investigations into the nature of these
growths which occur in horses after castration, and
are also found on the human hand and fingers. They
have found it to be due to a special micro-organism
called the botryococcus, which has many points of
resemblance to the staphylococcus pyogenes, but is
not identical with it. There is a human botryococcus
as well as an equine.
Organic Hemichorea — M. Touche says that this
affection may be produced by a lesion of the (i)
corona radiata; (2) caudate nucleus; (3) anterior
portion of the lenticular nucleus; (4) optic thalamus,
usually of its external nucleus; (5) internal capsule;
(6) region below the optic thalamus, involving the red
nucleus; (7) superior surface of the cerebellum.
Cerebral Tumor of Psychoparalytic Form. — Brault
and Loeper report three cases. Tumors of the motor
region may be manifested only by progressive paralyses
and psychical affections. This asseciation of symp-
toms causes a suspicion of cerebral tumor; an oph-
thalmoscopic examination is necessary to decide the
matter.
Malarial Cachexia. — E. Lefas reports a case in
which there was general amyloid degeneration, but
total absence of pigmentation in the blood and viscera.
Finska Ldkaresdllskapets Handlingar, February, igoo.
Haematometra in a Rudimentary Horn of the
Uterus. — O. A. Boije reports the case of a woman,
twenty-seven years old, the mother of three children,
who had always enjoyed good health e.Ycept at the
menstrual periods, when she suffered greatly. An
oval tumor the size of a hen's egg was felt to the right
of the womb and was diagnosed as a pedunculated
fibroid. At the operation, however, its true nature was
discovered. There was no communication with the
cavity of the uterus.
The Work of the Finland Medical Society for
1899. — R. Sievers, the retiring president, states that
seventy-two communications by twenty-four individ-
uals were made to the society in the course of the year,
and forty-four original articles by thirty-three au-
thors were published in the journal of the society.
The seventeenth general congress of Finnish phy-
sicians was held on September 2ist-23d.
The Electrolytic Properties of the Blood. — Max
Oker-Blom reports a number of investigations made
to determine the electric conduction of defibrinated
blood and of blood serum, and describes a method
based upon the differences of conduction, whereby he
determines whether a given salt is taken up by the
erythrocytes or remains dissolved in the serum.
Traumatic Spondylitis with Subsequent Kypho-
sis.— H. von Bonsdorff reports two cases of this na-
ture, the first in a man aged twenty-five years, and the
second in a lad aged nineteen years.
Meditshiskoe Ohozretiie, February, igoo.
Acute Yellow Atrophy of the Liver. — E. M.
Schwalbe reports a case of this rare affection occurring
in a girl, aged sixteen years. She had been ill a week
when she first came under observation, and died a week
later. He believes the disease to be the result of
some poisonous product, elaborated in the stomach or
intestine, and carried to the liver by the blood of the
portal vein; but whether this poison is a product of
bacterial metabolism or of some abnormal fermenta-
tion in the digestive tract he does not venture to
decide.
Hereditary Syringomyelia. — S. S. Nalbandoff re-
ports the case of a man, thirty-three years of age, who
presented symptoms of syringomyelia. His father had
died of laryngeal tuberculosis, and his mother, he said,
was a sufferer from " rheumatism of the ringers." She
was fifty-five years old, and examination showed that
she too had the same disease. Authors usually deny
that heredity is an etiological factor in this affection,
although Ferrannini and Veshoogen and Vandervelde
have written upon syringomyelia as a familial disease.
Adenoids I. N. Tetereviatnikoff discusses the fre-
quency of adenoid disease, its relation to aural affec-
tions, and its influence in the causation of aprosexia
in school children. He reports three cases of un-
usually brilliant results, following the removal of
adenoid tissue from the pharynx.
Primary Sarcoma of the Gall Bladder. — P. M.
Neviadomski reports a case of this description, occur-
ring in a woman fifty-five years old, in which there
was found at autopsy a diffuse sarcomatous infiltration
of the visceral peritoneum.
Anchoring a Wandering Kidney. — P. A. Baratynski
reports a case of movable kidney in a woman, thirty-
three years of age, in which he succeeded in removing
the distressing nervous symptoms by suturing the kid-
ney in place.
Hereditary Syringomelia. — P. A. Preobrazhenski
reports three cases of syringomyelia, the first in a
man sixty-five years old, the second and third in two
of his daughters, aged thirty-two and eighteen years
respectively.
©orrjespon (Tence.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondent.)
The Boer Arrangements for their Sick are becoming
better known, and, as I have already been able to say,
have been underrated. But the Boers have availed
themselves considerably, though reluctantly, of foreign
assistance. Six foreign sanitary detachments or ambu-
lances have been admitted to the Boer lines. Two of
these were Dutch, one coming from Holland and the
other from Java; while the other four came respec-
tively from Belgium, France, Germany, and Russia.
A second Russian ambulance has been fitted out, but
it has not yet reached its destination. Professor
Korteweg, surgeon at the University Clinic in Amster-
dam, who served for two months with the Boers— />.,
from the middle of November to the middle of Janu-
ary— reports that the attitude of the Boers toward the
foreign nations desirous of helping them is not con-
ciliatory. The foreign medical men and nurses had
great difficulty in finding out where their services
would be most required, as for strategical reasons it
was never indicated where fighting was likely to take
place. This want of confidence of the Boers in all
European nations was well shown in the treatment
that Sir James Sivewright's ambulance received. Sir
March 24, 1900]
MEDICAL RECORD.
517
James Sivewright, K.C.M.G., who was for many years
general manager of South African telegraphs, and who
was knighted for his work as commissioner of crown
lands in Cape Colony, has strong Boer sympathies.
He organized and despatched from Scotland at his
own expense a South African medical corps for ambu-
lance service with the Boers. When the ambulance,
which was manned partly by Boers receiving their
medical education in Scotch universities, and partly
by British, arrived at Cape Town, the assistance offered
was refused by the Transvaal government. The ambu-
lance, however, proceeded to Delagoa Bay, where cer-
tain overtures were made to induce its members to
individually volunteer to assist the Transvaal. The
British members of the corps regarded these overtures
with suspicion and did not volunteer, for Sir James
Sivewright's intentions were humanitarian and not
dictated by any political motives; whereas, as Mr.
Allan Johnson, one of the three British members of
the corps, has publicly said, "While the Transvaal
government were quite willing to receive any number
of Afrikanders into their service, they would not look
at an ambulance corps which included Britishers, es-
pecially if these showed that they meant to stick tena-
ciously to their pledge to work for the wounded of
every sort and race." Sir James Sivewright's action
has been generally held to be unpatriotic and unnec-
essary, so that the cold and limited reception awarded
to his ambulance by the Republican States has been
a source of amusement in Cape Town.
Touch and Go at Ladysmith.— It is now known
that Ladysmith could not have held out much longer,
but that sickness and starvation would have compelled
the garrison, which included five hundred women and
children, and eight hundred persons sick with typhoid
fever, to capitulate. The day Ladysmith was relieved
the rations actually issued were (per head) a quarter
of a pound of biscuit, three ounces of meal, one pound
of meat, one-sixth of an ounce of tea, one ounce of
sugar, and pinches of salt and pepper. Blancmanges
were being made of violet powder, potatoes were 19^.
the dozen, jam and marmalade 3ii'. the pot, tomatoes
18s. the dozen, and tobacco ^12 the pound. Only
about four days' full rations remained when Buller's
fourth and furious attack dislodged the Boers and re-
lieved the place.
The Cost of the Medical Establishment of the
British Army. — The effects of the war, as might be
expected, can be traced in the estimates for the medi-
cal establishment of the army which were disclosed in
the fiscal debates in the British House of Commons at
the beginning of March. The total vote for 1899-1900
was _^305,8oo, whereas for 1900-1901 it is ^555,000.
Under the head of pay to the officers there is an in-
crease of _;({^i 20,000, which is to some extent accounted
for by the fact that the civilian surgeons serving in a
consultant capacity with the staffs are being paid at
the rate of _^'5,ooo per annum. Provision is being
made in the estimates for a large increase of officers
in the Royal Army Medical Corps. That the addition
is needed has been abundantly proved by recent
events, but the War Office will not get more men unless
they make up their minds to treat the men they already
have in a more conciliatory manner than so far has
been the custom. They say that the Royal Army
Medical Corps have reason to believe that the present
commander-in-chief. Viscount Wolseley, regards their
branch of the service with disfavor. But Lord Wolse-
ley's disfavor will not mean so much in the future as
it has in the past.
The Meat on Board the Transports — There have
been many rumors that on board some of the trans-
ports the troops were badly fed. All these stories
have now been rigorously inquired into, with the re-
sult that nearly every one has been discredited. But
in one case, viz., on board the Kildonen Castle, eighteen
hundred and forty-two pounds of salt beef was found
to be dated " 1893," and was consequently returned to
the contractors. It is to be hoped that the names of
the firms who in this or any other way have attempted
to cheat their country will be disclosed. The pun-
ishment will be sufficient, without other penalties, of
having their names published. Yet it would be ad-
visable to punish them severely in addition.
One Way to Fill the British Hospitals.— The
transports conveying troops from Great Britain to
Cape Town have recently dropped a great number of
men in the Cape Town hospitals. The medical offi-
cers of those establishments complain that more care
might be exercised in the medical examination at
home of men destined for duty at the front; cases of
hernia, for example, ought to be detected, when they
exist, prior to embarkation. Such patients take up
badly wanted accommodation in the various hospitals,
and in some instances never get farther than the wards
until placed upon a homeward-bound trooper — a de-
cidedly expensive matter for the British government.
The medical men serving with the British army con-
sider that the reserves and militia who have lately
arrived in South Africa are somewhat disappointing
from a physical point of view, which may mean only
that the inspection of their physique in England has
been carried out in a slovenly or ignorant manner, or
may mean that for the present, as far as efficient regu-
lar troops are concerned, the supply is running short.
The amount of breakdowns in the health of the re-
servists has come as a surprise to the authorities.
To the Front Again. ^ — If the good weather persists
and if there are occasional lulls in the fighting, the
hospital accommodation, all of which I have now de-
tailed to you, will suffice, in spite of the heavy de-
mands made upon it. For the slightly wounded get
back to the front quickly, while the convalescent are
regularly transported to England if they are unfit to
serve again. On March 7th there were discharged at
Durban twenty-two men from the Spartan hospital
ship, twenty-eight from the Maine, eleven from the
Lismore Castle, and thirty-eight from the Nubia, all
being reported as fit for active service again. While
the recently wounded return to the front at this rate,
there will always be a good deal of space for other
unlucky soldiers. But on March loth Lord Roberts
had rolled up ahead of him a large Boer army, of
presumably ten thousand men, so that a sanguinary
engagement may at any moment call upon the Royal
Army Medical Corps for their best services.
OUR LONDON LETTER.
(Fr<
■ Special Correspondent.)
PARLIAMENTARY — MIDWIVES, ETC. DEBATE AT THE
PATHOLOGICAL SOCIETY ON PROTEIDS IN THE URINE
THE MEDICAL SOCIETY'S ADJOURNED DISCUSSION
ON APPENDICITIS.
London, March 2, igco.
As I predicted, the midwives' bill came on too late on
Wednesday. Its fate is probably sealed for this year,
as it can be taken only at the close of public business,
but an eye must be kept on the chance of its slipping
through on some unexpected vacancy at a late hour.
Other medical matters in Parliament have been con-
nected with the army and navy services and events in
South Africa; the plague and famine in India; the
government housing bill, and the bill for the census
to be taken next year.
Another set debate has been begun at the Pathologi-
cal Society. The subject this time is " The Forms
and Significance of the Proteids Met with in the
5i8
MEDICAL RECORD,
[March 24, 1900
Urine." Professor Halliburton opened the discussion
v/ith remarks on the advantage of pathologists and
clinical observers co-operating in such debates, pass-
ing on to sa)' that our knowledge of these proteids is
still very imperfect, though each year marks some
progress. These proteids he said were of great molec-
ular weight, and their large size explained why they
do not pierce the normal renal epithelium except in
minutest traces. That which does is contained in the
mucicula, though he admitted with Morner that a trace
of serum albumin is found in normal urine. Serum
albumin was also most abundant in physiological
albuminuria; but in Bright's disease it is usually
mixed with serum globulin. Generally trie globulin
was the less abundant and its presence less serious.
There was seme evidence that the molecules of globu-
lin were the larger, which would account for the greater
abundance of the albumin. Only after damage to
the epithelial cells could the globulin pass through
them. The fibrinogen molecule was still larger, and
hence its rarity in the urine. The same reason ac-
counted for caseinogen never having been found in
cases were lactose discoverable. Having passed in
review some other rare proteids, Dr. Halliburton
turned to those with small molecules. He distin-
guished between peptonuria and albumosuria. He
would restrict the former term to those conditions,
usually of a suppurating nature, in which bacterial
digestion led to the formation of proteolytic products
which were mainly cast out by the kidneys. The
substance most frequently found was not true peptone
in Kiihne's sense, but deutero-proteose. The term
albumosuria was usually restricted to those rare cases
in which hetero-albumose was found, due to osteo-
malacia or other bone disease.
Dr. Bradshaw, of Liverpool, then dealt with mye-
lopathic albumosuria, of which only eleven cases had
been recorded. He had met with one case in a man
aged seventy years which lasted about a year. There
was extensive disease of the bones, but the chief
symptom was milky urine due to a proteid which was
frequently precipitated spontaneously. The most
characteristic reactions were a precipitate below 60°
C. (140° r.), also in the cold by nitric and hydro-
chloric acids. All precipitates were more or less solu-
ble on boiling; that produced by heat was dissolved
without apparent change by caustic-soda solution
1:1,000. The proteid was clearly an albumose, but
of a peculiar kind not found in other conditions. Its
appearance in the urine is the earliest indication of
an affection of the bones of the trunk, which has hith-
erto always been fatal.
Dr. Robert Hutchison then described a peculiar
proteid found in the urine of a man who afterward
died from multiple myeloid sarcoma. It differed from
the body described by Bence Jones in being an albu-
min, not an albumose. It differed too from all other
albumins in liaving a low coagulation point (58^ C),
in being readily denaturalized and only slowly pre-
cipitated by acetic acid and ferrocyanide of potassium.
The urine presented no visible deposit but was clear,
of lov/ specific gravity, and slightly alkaline.
Dr. Pavy could not admit that albumin in any form
occurred in normal urine. We might perhaps have
functional albuminuria that is not due to histological
change in the kidney, but then it was pathological,
not physiological. The molecule of sugar w-as very
small, so if present in the blood it would pass through
the kidneys. But although normal urine contained no
albumin it might contain a small amount of proteid
as a nucleo-albumin or mucin. This was sometimes
the origin of errors. The urine of the athlete who
walked one hundred miles in twenty-four hours Dr.
Pavy found to be loaded with albumin and casts at the
close of the exploit. The altered pressure in the
renal vessels would account for cases of cyclic albu-
minuria occurring in the morning and being absent at
night. The proportion between albumin and globulin
had not been shown to be of importance, clinically or
pathologically, nor was the total amount of proteid
significant. The gravity of the case was to be meas-
ured by the presence of casts and the amount of urine
passed.
The discussion was then adjourned to the first meet-
ing in April.
The adjourned discussion on appendicitis at the
Medical Society came off on Monday. Mr. Sheild
said the absence of induration over the CEecum need
not preclude operation. Rapid pulse was a very im-
portant sign. He was against a resort to opium unless
in very small dose, and he urged the importance of
getting the bowels to act.
Dr. Cayley would carefully distinguish mild cases
from the actually or the potentially severe ones. But
he acknowledged that when severe symptoms appeared
early in the case it was impossible to know whether
they would subside or continue their grave course.
Rapidity of pulse was significant, but should be con-
sidered in connection with other symptoms. He
thought opium beneficial. If withheld until the ques-
tion of operation was decided it could then be used
for the relief of pain as required — not continuously.
Mr. Harrison Cripps said a mild attack might be
due to some temporary cause and pass by without
operation. But recurrence implied a more permanent
condition indicating operation, which unless necessi-
tated immediately should be undertaken in the quies-
cent period. It was then almost devoid of risk. He had
not had a fatal case, and Mr. Treves had had only two
in one hundred and thirty operations. The presence of
sw-elling or its absence was not of much significance,
as it depended on the position of the appendix. But
if there should be very great induration, it might be
advisable to wait until the abscess pointed. He ob-
jected to buried sutures. He had given up the use of
abdominal supports after the operation. He pre-
ferred a free incision, and urged the importance of
dividing the aponeurosis of the external oblique.
Dr. Hunter held that the disease was always infec-
tive; consequently a mild case might at any moment
become grave. Suppuration often took place after a
mild course of seven or eight days. Therefore he ad-
vised operation after that time whenever a rise of tem-
perature occurred. Even 99° or 100° F. might be a
significant temperature. Small doses of opium com-
bined with calomel might be useful.
Mr. McAdam Eccles, who had had personal expe-
rience of the disease, said the gravity of the case was
dependent on the virulence of the microbe. The tis-
sues of the patient could sometimes deal with this, but
recurrence should always be met with excision. If
they could always remove the appendix the patient
would be cured, but this was sometimes impracticable.
Mr. Moullin favored the operation in most cases
even at the risk of performing it on patients who
might have recovered without. The patient was guar-
anteed against recurrence by the operation, and its
risk was slight. When the symptoms suddenly sub-
sided it might be due to discharge of matter into the
intestine, and it was impossible to ascertain the exact
condition. VV'henever the symptoms were progressing
at the end of thirty-six hours an exploratory incision
ought to be made.
Dr. L. Thomas, of Cardiff, had had only three deaths
in forty-one operations. One case turned out to be a
pyosalpingitis, another abscess of the ovary. He had
in one instance removed a healthy appendix for symp-
toms which afterward recurred. They yielded to Weir
Mitchell treatment. He used silk for buried sutures,
and thought this plan best.
March 24, 1900]
MEDICAL RECORD.
519
Mr. J. Berry also preferred buried silk sutures, and
had never had hernia afterward. The incision should
be free and septic matter removed by sponging. He
protested against washing out the peritoneum. He
had observed that when a surgeon was taken with ap-
pendicitis he almost always sent for a physician.
Dr. T. Roberts (president) thought the poor in hos-
pitals had the best chances, as the expense of opera-
tions often caused them to be delayed. Physicians
were very careful what they did. He was in favor of
consultations between physician, surgeon, and family
attendant. He thought calomel and opium useful.
Dr. Allchin adhered to the opinion that a great pro-
portion of patients recovered without operation, and
one good result of the debate would be that surgeons
would no longer oppose the moderate use of opiates.
Mr. Lockwood in reply said rules could not be laid
down, for the lesion varied from day to day. A ca-
tarrhal mild case to-day might be gangrenous or per-
forative to-morrow. Several speakers had referred to
appendicular abscess. This was almost impossible to
diagnose. Why not then make sure by an exploratory
incision ?
THE TREATMENT OF APPENDICITIS.
To THE Editor of the Medical Record.
Sir: Dr. Morris either wilfully or thoughtlessly per-
sists in comparing the surgical plan of operating in
every case with the exclusively medical method of not
operating in any case, and would have us believe that
the conclusions reached from a comparison of their
respective results as shown by statistics have some
bearing on the question now at issue. If he would
only pause a moment and consider the matter without
prejudice, he would see at once that statistics giving
results of the exclusively medical treatment have no
more bearing on the methods which we respectively
uphold than would statistics of smallpox or scarlet
fever. For purposes of arriving at the right mode of
procedure, namely, that which will save the greatest
number of lives, the statistics up to date are prac-
tically valueless for numerous reasons, the most im-
portant being that physicians do not practise the
exclusively medical treatment which Dr. Morris tries
to make out that I am upholding. Between the
extremes of the exclusively surgical and the exclusively
medical treatment, though each is advocated by a
small coterie of radical surgeons or honest but mis-
taken physicians, and although there is little to praise
and a great deal to condemn in them both, the surgical
plan is much preferable, because, as Dr. Morris has
well said, the loss of time is less, the death-rate is
less, and there is less suffering than under the exclu-
sively medical plan. But we do not accept either of
these radical extremes. The vast majority of general
practitioners and conservative surgeons have selected
the best there is of both the extreme methods, and
evolved a plan of management that will cause less
suffering, less loss of life, and withal be more prac-
tical than either. This plan is to operate on recurring
cases as a rule, and to operate on primary cases when
circumstances arise which in the opinion of the phy-
sician make it justifiable. Dr. Morris asks if I do
not know of physicians whom I would not trust to
determine the time when operation was justifiable in
a given case. I regret to say that possibly there are
such, but their number is growing gratifyingly less,
and it is not of those I write when I say physicians.
I have seen a surgeon operate for appendicitis and
remove a handful of stones from a distended gall blad-
der, but I am not inclined to blame Dr. Morris or
surgeons generally on that account. To return to
statistics, I wish to admit that I have seen none from
Dr. Morris, nor am I able to find that there are any,
hospital or any other kind, giving the correct results
of the exclusively surgical treatment as compared with
the treatment I am obliged to favor. Such statistics
in order to be of any scientific value must consist on
the surgeons' side only of operation on primary cases.
Recurring cases in which the operation is done in the
interval belong as much to the general practitioners'
side as to the surgical. Again, cases which were mild
and treated medically at first until the physician (I
mean competent physician) advised operation, and
were operated on, whether the operations were success-
ful or not, should be charged to the general practi-
tioners' side; also operations on recurring cases which
were treated medically at a previous attack should be
credited to our account, if successful, or put on the
debit side, if unsuccessful. In other words, the statis-
tics should be made up about as follows:
Surgical.
Dr.
Impracticability.
Deaths from operations.
Sequelae.
Recoveries from operations on
primary cases.
Amount of time saved.
Medico-Surgical.
Dr. Cr.
Deaths from operations ad- Recovery of every case, even
vised by the physician. the mildest.
Deaths from operations nee- Recoveries from interval oper-
cesitated by recurrence after ations.
apparent recovery.
Sequela;. Practicability.
Until Dr. Morris can show statistics on the general
plan outlined above, he will do well to drop statistical
comparisons which are as unscientific as they are
valueless. I believe that a one-per-cent. rate of mor-
tality in cases treated by the medico-surgical plan is
none too low when all cases, even the mildest, are
included, and unless Dr. Morris can show by statistics
carefully arranged, on a plan somewhat like that out-
lined above, that a one per cent, or one-half per cent.
is not a low estimate, it would be well for him to sus-
pend judgment. In order that he may not persist in
misunderstanding my position, I will say that the
method of management which has commended itself
to the profession in general is very concisely outlined
in an editorial in the Medical Record of December
30, 1899. Dr. Morris says that he does not know the
difference between a mild and a dangerous case of ap-
pendicitis, and asks me to define a " mild case." He
does not do himself justice in seeking to obscure the
real issue by introducing an element entirely foreign
to the subject. Every mild case is certainly a danger-
ous case if it be operated on, and of course has danger-
ous possibilities if not operated on, but if managed
medico-surgically the danger will be reduced to a
minimum. Dr. Morris says he does know the pathol-
ogy of appendicitis. Will he kindly tell us by what
term he designates the large number of recorded cases
wherein the inflammation was confined to the right
iliac region, recovery taking place without formation
of pus and no recurrence, and also enlighten us as to
the pathology thereof? Dr. Morris asks also if I have
actually read those published letters. I most certainly
have, and in my opinion they show all the earmarks of
a regulation testimonial, as witness letter from patient
number six: "No comparison between medical and
surgical treatment; the former is torture, the latter
painless and blissful results."
Dr. Morris' offer of $1,000 to charity might just as
well have been a million as to its results on the treat-
ment he advocates. If he is right the profession will
surely find it out, and if his plan is wrong, ten millions
of dollars will not blind the eyes of the profession to
its shortcomings.
J. S. Horner, M.D.
West Pawlet, Vt.
520
MEDICAL RECORD.
[March 24, 1900
THE STATIC INDUCED CURRENT.
To THE Editor of the Medical Record.
Sir: In his last communication, Dr. Rockwell brings
forward no new fact; he merely reiterates pictorially
as well as verbally his familiar refrain that, using the
apparatus pictured, " the result could be nothing else
than the static induced current." Again I repeat, if
the result were a current, why did not the ancients say
so, and why do they invariably speak of and describe
the individual shock which was the purpose for which
the apparatus was explicitly constructed.' Using gal-
lon Leyden jars with a spark gap of one-twentieth of
an inch gives a very painful single shock. And again
I repeat that Dr. Rockwell has not yet brought for-
ward the first word to prove that the ancients ever used
a series of rapidly passing sparks, thus producing a
current, nor has he adduced the least allusion to any
sort of a current, whatever its name, nor again allusion
to physiological effects upon the muscles such as
would be produced by any sort of a current. His
entire argument is one of surmise — they might have
done so and so.
I reaffirm the title of my article and its contents as
true, and no doubt in good time my critic will also be
obliged to come to the same conclusion.
Mere captiousness will not down the modern rush
of progress in electrotherapeutics or in anything else.
Is it, then, indeed so strange to say that one can cure
(arrest) locomotor ataxia and arthritis deformans? Is
it not to-day common talk and fact to cure phthisis,
and yet ten years ago how few would have believed it
possible?
But why thresh out old straw any longer; " Le jai ne
vaut pas la chandelk." My one consolation is that it
is, after all, no doubt, better to put forth new facts, if
done sincerely, even if it does excite a little criticism.
William J. Morton.
March 3, igoo.
gletiicurs and IJotices.
Le Diabete et son Traitement. Par R. Lepine,
Professeur de Clinique i rUniversite de Lyon. Paris: J.
B. Bailliere et Fils. 1899.
This book is one of the little booklets of " Les Actualites
Medicates " series. All new researches are passed in review.
There is a chapter on regimen, and opotherapy is considered.
Les Autointoxications de la Grossesse. Par G.
BouFFE DE Saint Blaise, Accoucheur des Hopitaux de
Paris.
This is another of the above series, showing how the
healthy human organism is a poison factory, the integrity of
whose machinery alone prevents the system from being con-
tinually injured. During pregnancy the author believes that
women run an especial risk of self-intoxication.
Transactions of the Medical Association of the
State of Missouri, Fortv-second Annual Ses-
sion. Held at Sedalia, Mo., May 16, 17, and 18, 1899.
Kansas City, Mo. : The Burd & Fletcher Printing Com-
pany. 1899.
This is a neaUy bound volume of papers, many of which
are of unusual interest and some of decidedly scientific im-
portance. Dr. Ohmann-Dumesnil contributes a paper on
ichthyosis nigricans, showing much literary research.
Handbook of Optics for Students of Ophthalmol-
ogy. By William Norwood Suter, B.A., M.D.,
Professor of Ophthalmology, National University, Wash-
ington, D. C. New York: The Macmillan Company.
1899.
This work is simplified down to the requirements of the stu-
dent beginning this branch of science. For those not famil-
iar with trigonometrical ratios, a brief synopsis is given in the
appendix. Optic:, is considered only as it bears directly upon
ophthahnology. Heath's "Geometrical Optics" has been
made the basis for demonstrating refraction by prisms and
spherical surfaces.
Massachusetts Volunteer Aid Association.
This is a report of the work of the association during the
war with Spain, when a hospital ship, the Bay State, was
fitted out and sent to the front. It is interestingly and in-
structively illustrated. It is compiled by Edward C. Mans-
field.
Opinions of Over One Hundred Physicians on the
Use of Opium in China. Compiled by William H.
Park, M.D. Shanghai: American Presbyterian Mission
Press. 1899.
This is a set of questions and answers as to the value of
opium and the opium curse, put out in the interests of the
anti-opium cause.
Enlargement of the Prostate: its Treatment and
Radical Cure. By C. Mansell Moullin, M.D.,
F. R.C.S. Second edition. London: H. K. Lewis.
Philadelphia: P. Blakiston's Son & Co. 1899.
Purely historic considerations have been eliminated, but
otherwise there is little change in the present edition. The
work is well worth reading by all who have prostatic cases
to manage.
Etudes de Gvnecologie Opi£ratoire. By Dr. Pho-
CAS. Paris: A. Maloine. 1899.
This paper-covered volume of two hundred and seven pages
goes over the ground of operative gynaecology from curettage
to total abdominal castration, including clinical observations.
Cure Prompte et Radicale de la Syphilis. Par j;
F. Larrien. Third edition. Paris: Societe d'£ditions
Scientifiques. 1899.
This treatise upon syphilis and mercury, with the author's
personal experience w'ith minute doses, has met with a suffi-
cient warmth of reception to necessitate a third hearing. It
contains much of interest.
Dermato-histologische Technik. By Max Joseph,
of Berlin, and Georg Loewenbach, of Vienna. Ber-
lin: Louis Marcus. 1900.
This is an excellent litde work of one hundred and ten pages
and nineteen chapters, on the best means of staining, etc.,
for skin work.
A Manual of Modern Gastric Methods, Chemical,
Physical, and Therapeutical. By A. Lockhart
Gillespie, M.D. With a Chapter upon the Mechanical
Method Used in Young Children, by John Thomson,
M.D. New York : William Wood & Co. 1899.
The present work of Dr. Gillespie, who is well known as a
specialist for digestive disorders, contains in a succinct form
all the methods — diagnostic and therapeutic — used in this
branch of medicine. Einhorn, of New York, and Turck, of
Chicago, are frequently referred to. The manual is well
written and complete, and will be of use to the practitioner.
La Tuberculose est Curable. By Dr. Elis£e Ri-
bard; with a preface by Dr. Maurice Letulle. Pp.
170. Illustrated. Paris. 1900.
A book such as this one will always be of considerable in-
terest to the physician, and of positive value to the lay pub-
lic. In the opening chapter the author shows that tubercu-
losis in its early stages is curable. The following two
chapters — the one devoted to the means and manner of in-
fection, and the other to the early manifestations of the dis-
ease— are especially intended for the study of lay people.
Under prophylaxis the author indicates the importance of
legislative action in preventing the wide spreading of the
disease, and in the final chapter on treatment sound and
rational procedures are formulated. Altogether the book
will repay reading by physicians, legislators, and the general
public.
March 24, 1900]
MEDICAL RECORD.
521
^itffltcaX Sitggestions.
Dysmenorrhoea. — VVhenever the pain in dysmenor-
rhcea is entirely or mostly on the right side, especially
if it is quite high, it is well to suspect the presence of
an appendicitis in connection with the disturbance
of the ovary and tube. — A. J. Ochsner.
Lubrichondrin. — When at a distance from the office,
or when a careful, surgically clean assistant is at hand,
Professor Bangs' lubrichondrin in collapsible tubes is
convenient. But, as the tubes will occasionally " suck
back" a little of the lubricant that has been exposed,
the whole contents of the tube may become infected. — ■
Ferd. C. Valentine.
Cancer. — In anatomically impossible cases I do not
think it is justifiable to refuse to operate in some
fashion, if, after knowing the truth as to the hopeless-
ness of the condition, a patient demands that an opera-
tion be done. In these cases the psychical effect of
even an imperfect, partial removal of the offensive
cancer sometimes is very beneficial, and puts off for
months the inevitable morphine syringe which we are
compelled to use during the last weeks.- — A. C. Ber-
NAYS, Pliiladelphia Mediuil Jounial, November i8th.
Fractures of the Bones of the Leg. — Of 232 frac-
tures of the bones of the leg, 41 were simple fractures
of the tibia, 53 were simple fractures of both bones of
the leg, 24 were simple fractures of the fibula, 14 were
Pott's fracture of the fibula, 17 were compound frac-
tures of the tibia, 7 were compound fractures of the
fibula, 71 were compound fractures of both bones, 2
were simple fractures of both bones of both legs, and
3 were compound fractures of both bones of both legs.
— W. L. Estes.
To Avoid the Harmful Effects of the X-Ray from
either a static machine or a coil as an exciter one
should never have the tube near the patient; it should
be two or three feet «vay when using the fluorescent
screen, and should be three feet or more from the plate
when taking .v-ray photographs. Between the patient
and the Crookes tube there should always be placed a
thin screen of aluminum, which should be grounded
by connecting it to the gas-pipe with a proper wire. —
F. H. Williams.
Sequelae to Herniotomy.— (i) The wound may not
unite by first intention, and if the sac has been very
adherent the disturbance of the cellular tissue may
cause some sloughing. In such cases the wound
should be reopened and stuffed with iodoform gauze.
(2) Diffuse general peritonitis may set in; this is
known by the persistence of the vomiting, the continu-
ance of the pain, distention, and tenderness of the ab-
domen, with elevation of temperature. This may be
due to leakage from a perforation, to a gangrenous
condition of the gut, or to the introduction of septic
matter from without at the time of operation, as in
any other abdominal section. Immediate laparotomy
should be done. (3) The reduced gut, which has
been returned as suspicious, may become gangrenous
and obstruction of the bowel may still continue. If
this condition be suspected, the abdomen should be
opened and the gangrenous bowel sought for, and
either resected or incised, and kept outside the abdo-
men with the object of forming an artificial anus. (4)
The bowel may not be gangrenous, yet be so injured
that it may not be able to resume its proper functions,
and the patient may die in consequence if not relieved
by a laparotomy. (5) The bowel may be temporarily
paralyzed by local inflammation so as not to be able
immediately to resume its functions, though after some
days it may recover completely its normal condition.
In such cases there is obstinate constipation, without
vomiting or other signs of peritonitis. (6) Cases of
acute mania have followed the operation for strangu-
lated hernia, some of which have proved fatal. — Shep-
herd, " American Text-Book of Surgery."
Hemorrhage from the Diploe The use of a ten-
per-cent. solution of olive oil and beeswax, sterilized,
to control the hemorrhage from the diploe, has proved
most satisfactory. The wax is pressed into the bleed-
ing surface and allowed to remain. — George W. Crile.
Intestinal Perforation in Typhoid. — Operate unless
the patient is moribund or not likely to stand the shock.
Suture by the insertion of a series of fine silk sutures,
after Lembert's method; free the peritoneum of all
contamination; close partially, leaving in a gauze
drain down to the region of sutures. — Waring.
Intubation is Unsuitable for the following condi-
tions : Obstruction caused by the presence of a foreign
body; active ulceration (whether syphilitic or tuber-
culous) of the larynx; obstruction caused by new
growths, whether simple or malignant; obstruction due
to pressure by goitre or other tumor of the neck; ob-
struction by post-pharyngeal abscess.— Bernard Pitts.
Surgical Hints. — Never use morphine before
AN/ESTHESiA in patients who are in a state of stupor or
traumatic shock. In these the drug has a distinct ten-
dency to increase these conditions. — Never have any
MORE assistants at an operation than are absolutely
necessary. They are apt to get into each other's way,
and the more people help you, the greater the difficulty
of securing asepsis. — Excepting in emergency cases,
every patient about to be operated on is entitled to as
careful an examination as if he were applying for life
insurance, and to treatment before the operation for
any complicating condition. — There are certain
patients in whom it is very desirable that they shall
make no violent movements while they are being
anaesthetized, as for instance in certain fractures. In
these cases a full dose of morphine an hour before the
anajsthesia will contribute a great deal to secure a
quiet etherization. — When using cocaine hypoder-
mically, it is seldom necessary to use a solution
stronger than one per cent., and then always have the
patient in a recumbent position. The danger of co-
caine lies in the possibility of syncope from failure of
the heart's action, and lying down is the best prevent-
ive.— When operating, never put too many instru-
ments in one tray, as it becomes more difficult to find
just what you want. It is best to have several small
trays, and to put the cutting instruments in one, the
artery forceps in another, and the special instruments
required in the particular operation you are doing in
a third. — During the removal of tumors having
many attachments, it is a good principle to free first
all the points that are easily detached, and to pedicu-
late the tumor, as it were, where it is most difficult to
free it. This will usually result in the largest vessels
being included in the pedicle, so that with your liga-
ture or clamp you may safely secure the most danger-
ous region, and cut above it without danger. — In old
ovarian lesions, it is often a fact that the patients
show a decided insufficiency in the secretion of urea.
It is well to subject such patients to preliminary treat-
ment for this condition, for two reasons: The first is
that if the proper treatment increases the excretion of
urea the patient will have a better chance of recover-
ing from the operation, and the second is that if the
patient's urine shows no improvement, the prognosis is
rendered more serious, and forewarned is forearmed.
— International Journal 0/ Surgery, November.
522
MEDICAL RECORD.
[March 24, 1900
Societal '^cpatts.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Seated Meeting, March 12, igoo.
Charles N. Dowd, M.D., Chairman.
Round Ulcer of the Duodenum. — Dr. Percy Bol-
ton read this paper (see page 494).
Dr. Alexander B. Johnson said that his personal
experience had been limited, and so far as he knew
there had been but three cases of perforating ulcer of
tlie duodenum which had been subjected to operation
in Roosevelt Hospital. In one of these, operated
upon by Dr. McBurney two weeks ago, the diagnosis
was made of an abscess probably originating in the
appendix, and evidently an abscess of a good many
days' duration. The individual was an elderly man.
Unfortunately there was no previous history, and no
distinct causation of the disease could be obtained.
When admitted to the hospital he was perfectly septic.
There was a considerable-sized mass on the right side
of the abdomen, situated a little higher than usual for
an appendicular abscess, and was evidently localized.
The history he gave was that he had been suddenly
seized some days previous to admission to the hospital
with general abdominal pain. An operation was per-
formed, and a large abscess was found containing a
considerable quantity of foul-smelling pus. Further
exploration showed the existence of a perforating ulcer
of the descending portion of the duodenum and coils
of intestines adherent to one another. There was
some difficulty in getting to the ulcer, and the condi-
tion of the patient put further treatment out of the
question. The individual lived five days and died
septic. In the second case, operated upon last sum-
mer, the symptoms also began without warning on the
right side; there was a distinct alcoholic history.
This case gave pretty much the same history as re-
ferred to as occurring in the Hudson Street Hospital.
There was more or less localized tenderness found.
The ulcer was a solitary' one and situated in the first
portion of the duodenum. It was sutured, but the pa-
tient did not survive. In a third case, operated upon
last April by him, the individual was a healthy, vigor-
ous man, thirty-one years of age. He gave a history
of having been upon a prolonged alcoholic debauch
for several weeks. He had continued at his work.
Three days before his admission to the hospital he was
suddenly seized with a moderate pain in the epigas-
trium, but this did not interfere with his work. He
continued to work during the next forty-eight hours,
although he was conscious of a certain degree of dis-
comfort. At one o'clock of the morning of the day he
was admitted he was awakened from sleep by intense
pain in the right side. He then was given an emetic
of mustard" and water, and vomited. \Vhen he entered
tiie hospital his condition was good; there was no
fever; he had general abdominal rigidity, more or
less marked upon the right side. There was one point
of extreme tenderness, situated about three inches
above the umbilicus, one and a half inches to the right
of the median line. That tender point persisted until
the time of operation. The speaker saw him about
ten o'clock. The temperature had risen to 101° F. or
more, the pulse was almost of normal frequency. The
abdominal rigidity and local tenderness were marked.
He felt certain that there was present some intra-ab-
dominal lesion, although there was no distention or
liver dulness. An incision was made on the right side
of the abdomen. The appendix was found to be nor-
mal. There was a peculiar appearance of the perito-
neal exudate and the contents of the gut. There was
considerable amount of fluid, which was bile stained,
and contained flocculi of grayish lymph. The diagno-
sis of a probable perforation of tiie duodenum was
made, and the duodenum was examined. In the ante-
rior portion of the descending part, about where the
duodenum disappeared between the transverse colon
layers, there was an oval perforation about one-half an
inch long and one-quarter of an inch wide. There
were no adhesions. From this hole in the gut there
was escaping a considerable quantity of dark bile and
digested blood. The ulcer was plugged and the entire
abdomen washed thoroughly with saline solution; into
it was poured hot water in great quantities. The pa-
tient suffered absolutely no shock, and he went from the
table in as good a condition apparently as he came on.
The speaker objected greatly to the evisceration of the
abdominal contents, which added so much to the shock.
The abdomen was dried and the ulcer v.'as sutured by
means of a purse-string suture ; this was reinforced by
four or five Lembert sutures. The patient recovered
without any special complication except a moderate
superficial infection in the skin wound. Thirty-eight
days after the operation the patient was presented to
the Surgical Society. The diagnosis of this condition
Dr. Johnson considered very difficult, and one that was
very rarely made. He was unaware whether any sur-
geon in New York had ever made a positive diagnosis
or not.
Dr. Robert T. Morris said the subject of suppura-
tive peritonitis was a very important one. Regarding
the treatment of the ulcer, it seemed to him that if the
ulcer was a small one, without a great amount of serous
infiltration of the walls of the bowel, the method em-
ployed by Dr. Johnson should be successful. But if
the ulcer was a large one, the longitudinal suture, or
angulation of the bowel, should be the method of
choice. Regarding the matter of general suppurative
peritonitis, he believed it was a physical impossibility
to remove any large quantities of adherent lymph or
serous exudate by washing and stripping the bowels;
that procedure he considered to be wrong. In the ear-
lier days the subject of hyperleucocytosis was not un-
derstood. If a number of very small incisions were
made, if we did not handle the bowel much, if we did
not draw the bowel out from the abdominal cavity,
then we avoided shocking the patient. If we used
long glass tubes, carrying them through various small
incisions into the various cavities, and washed out the
abdomen with saline solution, so getting rid of the
chief toxin-bearing fluid, then we did what was best for
the patient. This treatment should be supplemented
by distention of the circulatory system with saline so-
lution, using one or two quarts by the intravenous
method. Theoretically this caused an evacuation of
the fluid by the emunctories, carrying with it the tox-
ins. Distention of the blood-vessels caused a high
tension in such cases when there was no liemorrhage,
and the evacuation of the fluid certainly appeared to
carry off the toxins from the circulation rapidly. The
speaker had had several apparently dying patients who
had recovered by means of this combined method of
treatment. He had two patients in the hospital with
flooding of pus from the pelvis to the liver, with pulses
of 144 and temperatures of 104° F. at the moment of
operation; after operation their pulses fell to 120 and
their temperatures to 101° F., and remained there
since; he was sure they would get well. He advised
that more statistics should be obtained. It was wrong
for one man to teach evisceration; wrong to teach fill-
ing the abdominal cavity with saline solution, etc.,
unless statistics proved it to be the better method.
The plan of multiple incisions and large intravenous
injections should not be advised unless it could be
March 24, 1900]
MEDICAL RECORD.
523
shown to be the best plan of treatment to-day. It was
a life-and-death matter to the patient.
Dr. Alex.'^nder B. Johnson said he was firmly per-
suaded that the method of Dr Morris of refraining
from eviscerating tiie cavity, and washing out by
means of Chamberlain's tubes, was a good method of
treating extensive purulent peritonitis. Next winter
he intended reporting a good many such cases — twelve
in number — in which there was quite extensive puru-
lent peritonitis following perforation of the appendix;
they were \ery extensive cases. Several had processes
of different types. The treatment employed was pre-
cisely the same, i.e.. Chamberlain's tubes through
small incisions and gallons after gallons of hot steril-
ized solution thrown into the cavity until the fluid re-
turned clear. Out of this number of patients only two
were lost. One died of pysniia about four or five
weeks after the operation. The pyaemia resulted from
an abscess situated in a mass of lymphatic glands
which lay just above the kidney. T'he second died
of sepsis in spite of irrigation. . In most of the
cases that resulted in recovery it was strange that the
temperature fell almost to normal and did not again
rise. The speaker referred to a patient who had a le-
sion of the intestine which required suturing. About
five days after the operation the patient continued
vomiting, and was in such a weakened condition that
he thought there was probably a necrosis of the intes-
tine taking place at the site of suture. The abdomen
was opened and inspected. In suturing there were
pulled out about one and a half feet of small intestine.
These one and a half feet of small intestine were as
distinctly different from the rest as two things could
be; that part which had been outside was dark red
and did not react, and was probably paralyzed. The
part tliat was not removed was apparently healthy.
The impression made upon the speaker was so strong
that he decided he would avoid any extensive handling
of the intestines in the future.
Laryngectomy for Carcinoma.— Dr. A. T. Brls-
Tow presented this case. The patient was a man,
thirty-seven years of age, who first came under obser-
vation October, 1899; he then complained of hoarse-
ness which had existed for two years. The growth was
intrinsic, and a total extirpation was advised. There
was no glandular infection. He was offered the choice
between the palliative treatment by tracheotomy, or
the possibly curative treatment by extirpation ; he
chose the latter. Early in 1900 he complained of
dyspnoea, a symptom which he had not complained of
previously. He was removed to the Long Island Hos-
pital, and a tracheotomy under cocaine antesthesia was
performed. He was then placed in bed and prepared
for operation. The teeth were scrubbed every three
hours to prevent pneumonia. Nitrous-oxide gas was
administered. The speaker considered this the best
aniiisthetic for the following reasons: It was much
less depressing than chloroform, and in a great meas-
ure eliminated the danger of sudden death upon the
table. It avoided tlie irritating effects upon the throat
and the refrigerating effect upon the lung tissue itself.
Again, if the patient showed signs of collapse, the an-
aesthetic could be at once stopped and the patient was
conscious in a very few seconds. This gas prevented
vomiting. The technique of the operation was the one
described by Keen. The ana;sthetic was given through
the tracheotomy tube. The larynx was removed entire-
ly with the epiglottis. He noticed that when strong
lateral traction was made upon the larynx there was a
tendency in the patient to stop breathing. Seventeen
days after operation the patient was shown to a medi-
cal society. He believed that many cases of cancer of
the larynx could be cured by excision if performed
early. Glandular infection occurred quite late in these
cases.
Dk. D. Brvson Delava.n was pleased at the excel
lent condition of the patient at this early date. He
was particularly interested in the views the speaker
held regarding the choice of an ana;sthetic. It was
very desirable that the disease should be recognized
early, and early submitted to operation. Partial lar-
yngectomy did not show any more valuable statistics
than the complete operation, and the result of the
complete extirpation was so much better that there
could be no choice between the operations unless the
disease was so far advanced that it did not admit any
choice. He regretted the failure of many operators
to report their cases.
Dr. George E. Brewer said the mortality of this
operation was something like fifty per cent., although
he thought it would be higher than that if every case
was reported. One surgeon had recently stated that if
all cases were reported the mortality would be over
ninety per cent. ; this was probably due to the fact that
one was not permitted to operate until the oesophagus
and surrounding tissues had become involved. If one
could operate upon these patients when the disease
was confined to the larvnx, the mortality would be
much less. Regarding an ana'Sthetic, he referred to
the use of chloroform and oxygen : chloroform was
preferred to ether on account of the fact that ether
affected the bronchial mucous membrane. This com-
bination had resulted very satisfactorily. He referred
to one case of malignant growth; its malignancy was
made manifest by the fact that the growth recurred
three times in three months; since the last operation
the patient was apparently well. He said it was very
important in the technique that the areolar tissue sur-
rounding the superior laryngeal folds should be re-
moved, because this removed the lymph channels and
so prevented infection.
Extraperitoneal Rupture of the Bladder — Dr. A.
T. Bristow also reported this case, which was a \ ery
unusual one. The patient, a woman, aged twenty-four
years, fell down-stairs. Forty-eight hours afterward
she came under observation. She could pass no urine
and was tormented with the desire to urinate. Exami-
nation showed a bruise upon the abdomen, and some
muscular spasm was present. There were no signs of
peritonitis. The house surgeon catheterized her and
drew off about two ounces of urine. Six ounces of
sterile saline solution was then introduced, and the
same amount was recovered. An examination of the
urine failed to show the presence of albumin or urea.
On the following morning the condition of the patient
was about the same; it was not possible to get more
than two ounces of urine by means of the catheter.
The abdomen was opened in tlie median line, but no
intraperitoneal rupture was found. The peritoneum
was closed, and the space of Retz, or retropubic space,
was examined, and here urine was found which dis-
tended the area between the peritoneum and pelvic
cavity. Trendelenburg's transverse incision was made,
which gave an excellent exposure of the parts. Air
was pumped into the bladder, and a rent in the
bladder was found in its antero-lateral wall ; the walls
were much bruised and ecchymotic. This patient had
an extraperitoneal, but not an intraperitoneal, rupture.
Sucii an accident usually occurred in older persons.
In a series of ninety cases reported only three existed
without fracture of the pelvic bones.
Sarcoma of the Tibia. — Dr. John B. Walker pre-
sented this specimen. The patient was a woman, aged
fifty-five years, who eighteen months ago slipped and
sprained her knee; her physician recognized the con-
dition as one of synovitis, from which she recovered.
A few months later, while walking she again slipped
and received an injury which also was diagnosed by
her physician as a synovitis. The swelling refused to
go down. Three months later she was seen by a well
524
MEDICAL RECORD.
[March 24, 1900
known man, who diagnosed the condition as (Jharcot's
joint. A plaster-of-Paris splint was applied with ex-
tension, which relieved the pain, but the swelling still
persisted. An .v-ray photograph was shown. A diag-
nosis was made of sarcoma, and amputation was per-
formed.
^ciu instruments.
NEW AX.iSTHETIC APPARATUS.
By THOMAS L. BENNETT, M.I) ,
AN/ESTHETIST TO NEW YORK HOSPITAL, ROOSEVELT HOsf ITAL, ETC,
The accompanying illustrations represent inhalers for
the administration of ether, nitrous o.\ide, or these
agents in combination or succession. They have
been devised by the writer after more than ten years
of extensive experience in the administration of anaes-
thetics, during which time many different forms of in-
halers have been employed and the principles involved
carefully investigated. They have been so construct-
ed as to meet the requirements which have been found
essential to the most exact and satisfactory plan of ad-
ministering the agents in question, and their use in a
large number of cases has demonstrated their practi-
cability.
The ether inhaler, Fig. i, consists of three parts —
the face piece, the ether chamber, and the bag. The
face piece is cone-shaped; its base is oval and is
notched at the nasal end. The apex is open and is
threaded to screw into place on the ether chamber.
It is of metal, and its free edge is provided with an
inflatable rubber cushion, which may be removed at
offering little or nu resistance to respiration. The
cage also prevents the gauze packing from protruding
through the openings /' and opposite, and thus inter-
fering with the rotation of the inner chamber. On the
closed end of the inner box is placed a revolving disc,
presenting a small circular opening at one point near
its periphery; this opening is surmounted by a short
funnel-shaped chimney, and may be brought opposite
any one of three openings in the end of the box. By
this arrangement it is possible, when the patient's
head is turned on the side, to pour ether upon the
gauze without removing the inhaler from the face — a
matter of great practical advantage under certain cir-
cumstances.' The outer box presents two large and
opposite openings in its sides, and each of these is
surmounted by a chimney, one of which is threaded to
receive the face piece, the other being smooth and bev-
elled to receive the bag. On one side of the free
edge of this box is a slot, which, in connection with a
pin and pointer on the inner chamber, limits the rota-
tion of the latter and indicates whether "air" or
"ethe-r" is being breathed. When the two parts of
the ether chamber have been put together, they are
held in place by the thumb-screw shown in the draw-
ing, and this serves the further purpose of a handle for
revolving the inner cylinder.
By referring to the sectional view of the ether cham-
ber, it will be seen that a tube traverses the centre of
the inner cylinder, its upper opening being marked /.
Now if the two parts are put together in the positions
they occupy in the cut, it is evident that the openings
of the tube / will correspond with those marked i and
/of the outer cylinder; and if breathing should take
place through the inhaler so arranged, the air would
pass directly through the tube / without entering the
A, Kther Inhaler; K. Sectional Vi
will. On the side of the face piece is an air tap, A,
which may be opened or closed to any degree. When
fully open, this tap has a large capacity — a desirable
feature in a bag inhaler.'
The face piece is made in three sizes — small, me-
dium, and large. The medium size will be found suit-
able for all ordinary cases, but small children and
large men require special sizes.
The ether chamber, shown in the "sectional view,"
consists of two cylindrical metallic boxes, one fitting
accurately within the other. The inner box presents
four openings in its sides, two of which, k and oppo-
site, are of large size; the other two, /and opposite,
are smaller and are connected by a tube which passes
through the centre of the box. This part of the ether
chamber is provided w ith a cage of coarse wire netting,
to hold the gauze which receives the ether. The cage
is somewhat smaller than the box it occupies, the in-
tervening space allowing the respired air to circulate
freely around the gauze rather than through it, thus
' In this respect the Ormsby apparatus is usually inaile<niate,
the tap being too small, and in Clover's there is no air tap
ether space proper. In this position it will also be
noticed that the index pointer, seen directly below k
in the " sectional \ lew," occupies the lower end of the
slot on the outer cylinder, indicating "air." If the
inner cylinder is now rotated so that the index traverses
toward "ether," it will come to a transverse line be-
tween "air" and "ether," and in tiiis position the
openings of the tube / are just beginning to pass out
of the openings / and/, and the openings /■ and oppo-
site are beginning to enter the openings i and /.
Breathing through the inhaler in this ])osition allows
a very small percentage of air to pass through the
ether space ; further rotation increases this percentage,
till finally the tube / has passed completely away from
the openings /and _/, and full ether is on, the index
' In operations about the head or neck it is often desirable to
cover the inhaler and the hand and arm of the an.-esthetist with a
sterile towel Under these circumstances it is inconvenient to
disarrange this every time it is necessary to add ether, and it was
for this class of cases in particular that the arrangement was
added. When this plan of adding ether is to be used, the in-
haler should be so applied to the face that the revolving disc is
uppermost.
March 24, 1900]
MEDICAL RECORD.
525
pointer being at the upper limit. In this way the
ether may be turned on as slowly as desired, and any
strength of ether vapor may be administered at will
throughout the narcosis.
The ether bag, shown in Fig. i, A, is of large size, its
capacity exceeding the most exaggerated respiration.
It is attached to an elbow of metal tubing, by which
it is connected with the upper chimney of the ether
The inner box contains a T of tubing, the longer or
cross part of which traverses the centre of the chamber
and is joined in the middle by the shorter or stem part
of the T. The three ends of this T open upon the
outer surface of the sides of the box. The longer of
these tubes contains the valves mounted upon a skele-
ton tube, which may be removed at will. The valves
themselves consist o£ thin rubber flaps, fastened at one
-A, Gas Inhaler ; B, Sectional Vie
chamber when in use. In this elbow, near the attach-
ment of the bag, is a large air tap, C, which may be
opened to any degree.
The use of the ether inhaler may bfi briefly described
as follows:' The wire cage is packed firmly with dry
gauze, upon which one-half ounce or more of ether is
poured; the index is now turned to "air," the taps A
and C are closed, several expirations are caught to dis-
tend the bag, and the face piece is then kept applied;
the index is now turned to the line between " air " and
" ether '' and is moved forward slowly toward the latter,
an occasional breath of air being given by removing
the face piece. Complete anaesthesia is present in
from two to five minutes in average patients. The ad-
ministration now consists chiefly in the regulation of
two factors — the ether supply and the air supply.
The ether supply : In continuing the administration,
it is best to allow the index to remain at full ether and
to pour from one-half to one drachm of ether upon the
gauze every two or three minutes as necessary. This
may be done (i) through the face piece, (2) through
the chimney, or (3) through the revolving disc on the
end of the ether chamber; (i) is preferable in usual
cases; (2) or (3) is of great advantage when it is in-
convenient to remove the inhaler from the face.
The air supply: During the induction of anaesthesia
enough air should be given to prevent more than slight
cyanosis. In maintaining ana;sthesia it is rarely nec-
essary to exclude air to the extent of causing any cy-
anosis, and the air supply is to be regulated in accord-
ance with the following facts: The tap C (Fig. i)
being closed, if A is opened slightly the patient will
receive little air and much ether; if fully opened, he
will receive much air and little ether. The tap A be-
ing closed, if C is opened slightly the patient will re-
ceive little air and much ether; if fully opened, he
will receive much air and much ether.
The quantity of ether necessary in usual cases will
average about four ounces for the first hour and about
two ounces for the second hour.
The gas inhaler, shown in Fig. 2 and in the " sec-
tional view," consists of three parts — the face piece,
the valve chamber, and the gas bag. The face piece
is identical with that of the ether inhaler, and is made
in three sizes — small, medium, and large.
The valve chamber consists of two cylindrical me-
tallic boxes, one fitting accurately within the other.
' The plan of administration here described is termed the " close
method," inasmuch as more or less exclusion of air is practised.
Those who prefer the " open method " need only omit the bag.
end over fenestrated diaphragms set in an inclined po-
sition in the skeleton tube. Each rubber flap is rein-
forced by a thin piece of aluminum cemented to its
surface. This keeps the rubber flat and prevents it
being forced through the opening it guards, during vio-
lent respiration.' On each side of the opening of the
short or stem part of the T above described is placed
a similar opening communicating with the general box
cavity.
The outer box presents three openings through its
sides, two of which are provided with chimneys. One
of the latter has a thread cut upon it for the screwing
on of the face piece. The other is slightly bevelled
for the twisting on of the gas bag.
The boxes are held together by a thumb-screw,
which also serves as a handle for rotating the inner
chamber, the rotation being limited by a slot on the
outer box and a pin on the inner.
The gas bag is of pure rubber, and has a capacity
of about two gallons when just full, but will distend to
several times this capacity without bursting." It is
attached to a short metal tube, the free end of which
is ground to fit the smooth chimney of the valve cham-
ber. In this tube is placed a large air tap, shown at
£ in Fig. 2, A, which may be opened or closed by a
lever. Working in connection with this air tap is a
cut-off, placed between the air tap and the bag, and so
arranged that when the air tap is fully open the gas is
completely cut off and confined to the bag. \\'hen the
air tap is closed the bag is opened into the tube. At
the opposite end of the gas bag is a hard-rubber stop-
cock, through which the gas is admitted to the bag.
By referring to the sectional view of the gas inhaler,
it is apparent that if the two boxes are pushed together
in the positions they occupy in the cut, the face piece
screwed on at <?, and the inhaler breathed through,
during inspiration the valve at d will close, so that the
air must enter through the chimney r, pass through
the valve at the opening //, and down through the
opening/ into the face piece. During expiration the
valve at h will close and the air must pass into the T
' These valves may be replaced when necessary by culling
pieces of rubber bandage into proper shape and cementing the
aluminum forms to them.
-' .\ very practical point in view of the fact that such over-dis-
tention is common from inability or failure to turn off the gas in
time, or from unexpected rushes of gas from the cylinder. Under
these circumstances bags made from non-elastic material must
burst, and this is a matter of alarm from the loud report, failure
of the narcosis from inability to proceed, and expense from hav-
ing to replace the bag.
526
MEDICAL RECORD.
[March 24, 1900
and out through d and b, which are now together.
The inhaler is used in this position in the ordinary
administration of nitrous oxide. By revolving the in-
ner box so that d is depressed and h elevated to the
limit allowed by the pin and slot above referred to,
the opening b will be closed and e and g will come to-
gether with a and c respectively. Breathing now takes
Fig. 3. -Inhaler for Gas and Ether.
place through the box cavity, the valves are out of ac-
tion, and both inspiration and expiration pass through
the opening c. This position is used for a short time
during the administration of "gas and ether."
The use of the gas inhaler may be briefly described
as follows: The tap E being fully opened, the bag is
filled moderately full of gas from the cylinder through
the rubber tube supplied with the inhaler. The aper-
ture D should be fully open. The face piece must fit
the face perfectly. Inspiration will now enter at E and
expiration escape at D. Upon closing the tap E, gas
will be drawn from the bag on inspiration and escape
at D on expiration. As soon as the inhalation begins,
a flow of gas sufficient to keep the bag moderately full
should be turned on from the cylinder. The inhala-
tion should be conducted according to the principles
of gas administration. Air in any quantity may be
admitted through the tap E.
For " gas and ether " the inhalers are combined as
shown in Fig. 3, and are used as follows: The ether
inhaler is charged with ether, the index turned to
" air," and the tap A closed. The gas inhaler is firmly
attached to the upper chimney of the ether inhaler, the
apertures Z> and E being wide open. The bag is filled
with gas and disconnected from the tube
at F. The face piece is accurately applied
to the face, and E is closed. Gas is now
breathed through the valves, and when the
bag has been about three-fourths emptied
D is to be closed. Gas is now breathed
back and forth, and at this time the pa-
tient will be unconscious or nearly so.
Ether should now be turned on gradually,
though somewhat faster than when it is
given without gas. The patient is now
breathing gas and ether, and in about one
minute from the beginning of the admin-
istration will show signs of complete gas anaesthesia
if the face piece has been tightly applied.' It is un-
necessary, however, to push the gas beyond the ap-
proach of these signs, upon which air should be ad-
mitted at E for two or three respirations. After a few
more respirations of gas and ether, the gas inhaler and
bag are removed, the ether bag is substituted, and ether
is pushed to complete ansesthesia. This is accom-
plished in from two to five minutes as a rule, and usual-
' The signs that accompany complete gas anjesthesia are cya-
nosis, jerky, snoring respiration, twitching movements in the ex-
tremities, and loss of relle.xes.
ly without the least struggle or excitement, the patient
having no knowledge of the ether.
These inhalers have been made as small and as
simple as possible, in view of what they have to ac-
complish. They can be taken completely apart with
great ease, and are capable of being thoroughly
cleaned and sterilized. The only part of the inhalers
that should not be boiled is the tube carrying the
valves of the gas inhaler, which may be sterilized by
soaking in carbolic solution. Before boiling the face
piece and bags, they should be removed from the metal
parts and the hard-rubber stopcocks taken out.
Fresh gauze packing should be used for every case.
The inhalers should be handled carefully.
The successful working of these inhalers depends
upon the accuracy with which many details of con-
struction have been carried out, and while this has
been well done by the makers, it has been found that
from a practical clinical standpoint individual inhal-
ers are apt to require certain corrections before they
are perfect. For this reason the writer has arranged
to examine each inhaler as soon as it is made, and
when it is found perfect will issue a certificate to that
effect. These will accompany the inhalers, each of
which is designated by the number stamped upon it.
A MODIFIED
EINHORN
TRODE.
GASTRIC ELEC-
Bv GEORGE ROE I.OCKWOOD. M.D.,
The passage of the original Einhorn electrode into the
stomach has, in my experience, proved an unpleasant
if not impossible task for the great majority of pa-
tients. The large size of the capsule renders difficult
the primary attempt at deglutition, and even after the
capsule has actually entered the oesophagus the neces-
sity of its dragging a long tail after it naturally im-
pedes its progress.
To obviate these difficulties the following modifica-
tion has been devised: The capsule (<?) has been re-
duced in size to that of an ordinary five-grain gelatin
capsule, as is shown by the cut. To the metal point
(b) within the capsule is attached a spiral of flat steel
(r), the flexibility of which corresponds to that of an
ordinary stomach tube. This spiral is covered by thin
rubber tubing (</), and is tipped by a binding pin {^e)
for connection with the battery. The spiral with its
rubber slieatli is of the diameter shown in the cut.
Such an electrode can be easily introduced, into the
stomach without discomfort. The small size of the
capsule allows of its ready passage, while the spiral
attachment is sufficiently resistant to enable the oper-
ator to push the capsule along, just as a stomach tube
is introduced. The result of such modifications has
been so satisfactory that no further excuse is offered
for the presentation of the instrument.
The patient is the only one who will not trust you
when you say you " don't know."
March 24, icoo]
MEDICAL RECORD.
527
A NEW, SIMPLE OPHTHALMOSCOPE.
By CHARLES H. MAY. M.D.
The features of this ophthalmoscope (Figs, i and 2)
are simplicity, compactness, excellent mechanical and
optical construction, including accurate stops, perfect
lenses, proper balancing, and reasonable cost; an im-
portant improvement consists in the regulation of size
of the various openings, so that there is a minimum of
annoying reflex from .this source.
The instrument consists of two superimposed plates
— the front disc, 43 mm. in diameter, holding the con-
vex; the rear disc, 41 mm. in diameter, containing the
concave lenses. There are fourteen lenses in each
set, the weaker ones being separated by half-diopters,
as follows^ 0.50 D., I D., 1.50 D., 2 D., 2.50 1)., 3 D.,
4 1)., s I)., 6 1)., 8 I)., [oD., 12 D., IS D., and 20 D., +
and — respectively. A greater variety of lenses can be
obtained by combinations, but it is not intended that
they be employed in this manner, the number when used
singly being sufficient for all purposes. . The convex
lenses are numbered in white, the concave in red, as in'
most instruments of American manufacture. The
strength of the lens in use is shown in an opening in
the rear plate.
The two discs can be moved independently of each
other, with ease and certainty, through the following
arrangement: The disc holding the convex lenses is
slightly larger than its fellow, placed in front, and
only its extreme edge is milled; the d'sc containing
the concave lenses is slightly smaller, placed behind,
its margins are thickened, and the milling of its edge
is carried a short distance over the posterior aspect.
The index finder should be applied to the lower part
of the milled edges, thu.s avoiding contact with the
face of the patient. The linger is placed upon the
projecting front disc edge, or more posteriorly upon
the rear disc edge, according to whether + or —
lenses are desired.
The tilting mirror, concave, of the usual focal dis-
tance, is made of very thin glass, and has a 2.5 nmi.
aperture, the margins of which have been
thoroughly blackened; it is supported upon
a metal plate with a central defect of 7 mm.
. The opening of the back plate (sight-
hole) is 4.5 mm. in diameter, bevelled 2 mm.,
so as to present a sharp edge. The lenses
are 6 mm. in diameter and accurately cen-
tred. The opening in the front plate is 6.5
mm. in diameter, with a 2 mm. bevel. Thus
all the openings are larger than those of the
mirror and sight-hole — an arrangement which
reduces to a minimum the annoying cloud-
like reflex so frequently found in ophthal-
moscopes.
The handle of the instrument is octagon,
and the joint is square, on section, instead
of round; both of these modifications con-
tribute to easier and firmer grasp. By the
introduction of the requisite amount of metal,
concealed in the handle, the ophthalmoscope
is properly balanced and not top-heavy; its
entire weight is two ounces.
The instrument is supplied in the usual
leather box with a biconvex lens of good
size, or merely with a soft leather case for
protecting the upper part. It is manufac-
tured by W. T. Georgen.
The writer desires to express his apprecia-
tion of the manufacturer's courtesy during
much experimental work and his painstak-
ing execution of successive models.
Leprotis Fever is essential and due to the
bacillus or its toxins. It is always intermit-
tent, if uncomplicated. It may occur at any
period including the prodromal. It probably
occurs in all forms in varying degree. When
fever of a continued type is observed, it is due to
the presence of other toxins acting either with or en-
tirely apart from those of the bacillus leprae. The es-
sential fever simply shows that the disease is active
and progressive. — Alex. Lewers, British Journal of
Dermatology, October, 1899.
Scoliosis and Nervous Affections — H. Oppenheim
says that scoliosis is most common in syringomyelia
and sciatica; lateral curvature is also observed in
dystrophy and acute anterior poliomyelitis. Spastic
conditions of a primary or reflex nature (pain) may
also cause it; hysteria and traumatic neurosis may
also give rise to the condition. Spastic infantile
hemiplegia, diplegia cerebralis, congenital athetosis,
and chorea occasionally produce it. Hemiplegia spi-
nalis may give rise to it, and paralysis agitans rarely
causes a severe grade of scoliosis. One theory of its
causation is based upon a trophic disturbance of the
osseous and ligamentous structure of the vertebral
column, the other upon a paralysis and atrophy of the
muscles of the back. Scoliosis of a severe degree
may, by purely mechanical means, cause a neuralgia.
Scoliosis may be congenital or acquired very early in
life ; in fact it may be transmitted from one generation
to (he other. — DnitsJie Acrzte-Zfitiing, January 15,
1900.
528
MEDICAL RECORD.
TMarch 24, 1900
l^tXctUcal Items.
Red Gill is reported to have attacked the bivalves
of Chesapeake Bay. Red or " bloody " oysters, while
they are not supposed to be especially harmful, are
scarcely marketable. The red color is thought to be
due to iron or other mineral in the water. Southern
oysters are reported to be unusually scarce this season.
Regarding the Production of Uric Acid. — J. Weiss
(Zt'itsc/ir. /. physiolog. Clieniie, xxvii., 3, p. 216)
contributes the results of his continued experiments
with cinchonic acid as a factor in the production of
uric acid. He proves that tiie ingestion of cinchonic
acid, even in those cases in which special feeding was
resorted to in order to increase the excretion of uric
acid, was always succeeded by a decreased production
of the latter. He concludes that the only way in which
the uric-acid production can be increased is b\ proper
feeding (such as with thymus, pancreas, etc.). Neither
drugs nor the ingestion of uric acid itself or its proto-
type glycocol will produce the same result.
The Treatment of Leprosy with Antivenene. —
Woodson i^Philaiklphia Medical Journal, December 23,
1899, p. 1231) has reported a case of leprosy in a
woman, thirty-six years old, the diagnosis being con-
firmed by microscopical examination, in which marked
improvement followed employment of the antivenene
of Calmette. The serum was injected subcutaneously,
as a rule in the interscapular region, in the loose
tissues below the margin of the ribs, and in other
selected regions. The dose varied from 2>?> c.c. at
first to 20 c.c. at the close of the treatment. Jtesides,
large doses of hoang-nan were administered. During
the three months covered by the treatment, 500 c.c. of
serum were administered in forty-seven injections.
As a result of the treatment the patient was much
improved, having lost her leprous expression and the
infiltration in various parts of the body disappearing.
The bluish color of the face changed to a healthy red.
Some ulceration that was present disappeared, together
with a number of tubercles. Anesthesia that was pres-
ent subsided, and the skin became softer and fairer.
The patient gained fourteen pounds in weight
The Diagnosis of Adrenal Growths. — In Henry
Morris' article on primary tumors of the suprarenals
and their removal by operation {British iMciliail Jour-
nal, November 11, 1899), the author has the following
to say about diagnosis : Granted that in any given case
there is the following group of symptoms, the diagno-
sis of a primary adrenal new growth should be made,
and will most probably be correct; i. A tumor in the
suprarenal or renal region with a kidney-shaped prom-
inence on the surface of the tumor. 2. An unusual
degree of motility of the tumor, so that it falls away
from the loin on the patient rising or turning on to the
opposite side. 3. Rapidity of growth of the tumor,
and secondary growths in the skin, liver, or the tem-
poral region. 4. Marked emaciation and rapid loss
of strength. 5. .Absence of any change in the urine,
and of any alteration of the normal temperature. 6.
The presence of some pigmentation of the skin, or of
marked or rapid growth of hair over the body. 7.
Some gastro-intestinal symptom, such as nausea, vom-
iting, diarrhcea, or constipation. 8. Pain, deep seated
in some part of the abdomen; or an ill-defined, unex-
plained pain in some joint or distant part of the body.
It is, however, the exception to find the whole, or even
the majority, of these symptoms present in any given
case. If several of them are absent, and most espe-
cially if there is no tumor, a positive diagnosis is quite
impossible.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended March 17,
1900 :
Cases. Deaths.
Smallpox — tjNiTHD States.
-Alabama, Mobile February 24th to March 10th ... 11
I'lorida, Jacksonville March 3d to loth a
Indiana, Evansvillc March 3d to loth 5
Kentucky, Covington .March 3d to loth 6
Louisiana, New Orleans .... March 3d to loth 79 22
Michigan, Detroit March 5th 12
Grand Rapids. . . .March 3d to lotli i
Minnesota, Minneapolis ....February 25th to March 3d 10 2
Missouri, St. Louis , February 17th to March loth ... 8
Nebraska, Omaha Maix-h 3d to loth i
Oliio, Cincinnati Pebruary 26th to March oth 17
Cleveland March 2d to loth 15 2
Tennessee, Nashville March 3d to 10th i
Utah, Salt Lake City March 3d to loth 4
Virginia, Portsmouth March 3d to 10th 3
Washington, Centralia February 26th 150
Seattle February loth to 17th i
Tacoma February 24th to March 3d 4 1
Walla Walla. . February 21st 2
X — Foreign.
.Argentina, Bu
.De.
;ist .
. 17th .
) 17th .
1 24th..
, Pra.eue February loth t
, Antwerp February loth 1
Ghent P'ebruary 17th t
Brazil, Rio de Janeiro February igth to 26th
British Columbia February 8th to 28th
Canada, Quebec, (iaspe
Basin March 2d to 9th
Ceylon January 13th to 27th
Fgypt. Cairo January 21st to February 4th. . .
England. London February 10th to 24th
France, l-yons February loth to i7lh
Nice February 14th to 2ist
India, Bombay January 31st to February 6th. . .
Calcutta January 20th to February -d . . .
Kurrachee January 21st to February 4lh . . .
Madras February 3d to 7th
Mexico, Chihuahua February 24th to March 3d
Ciudad Porlirio
Diaz March ist to 7th
.Mexico February i ith to 18th
Vera Cruz February 26th to March 3d
Russia, Moscow February 3d to 10th
Odessa , February loth to 17th
Riga December ist to 31st
Brazil. Rahia February 3d to loth
Rio de Jant ! >■ January 19th to 26th
Santo.s January iglh to February qth.
Colombia, i^anama . l-^bruary 27th to March 6th . .
Cuba, Havana i Vbruary 24th to March 3d . . .
Mexico, Vera Cruz February 24th to March 3d. . .
, Bombay January 31st to February 6th.
Calcutta January 20th to February 3d .
Plague— United States,
Insul
California, San Francisco ... March 6th
Hawaii, Honolulu February 17th to 24tli 4
Kehei February 21st to March 17th i ♦
Philippine Islands, Manila ..January 20th to February 3d . . . 10
• Suspect.
Plagi'e— Foreign.
Argentina, Buenos Ayres March icth Present.
Australia. Adelaide February 28th v Present.
Brazil, Santos February 4th *
India, Bombay January 31st to February 6th
Calcutta January 20lh to February 3d
Kurrachee January 21st to February 4th ... 38
Paraguay. Asuncion January 8th to 15th
*l.ast case discharged.
I^ooTjs glcccitictX.
While the Medical Record is pleased to receive all new pub-
lications which may lie sent to it, and an acknowledgment will he
promptly made of their receipt under this heading, it must tie with
the distinct understanding tjiat its necessities are such that it can-
not be considered under obligation to notice or review anv publica-
tion received by it which in the judgment 0/ its editor will not be
0/ interest to its readers.
The Crlminai., a Scicntilit .'^ttuly. liy August Diahiiis. Svo,
402 pages. The Macmillan Company, New York.
The Nose and Throat. Edited by G. P. Head. M.D.,
and .\lbert II. Andrews, M.I). Svo, 274 pages.
.Mentally-Deficient Children, By (!. E. Shuttleworth,
M.D. i2mo, 173 pages. Illustrated. I'. Blakiston's Son St.
Co. , Philadelphia.
I, A I'KsiE ET SON Microbe. By le Dr. Netter. i2nio, I2i
pages. Illustrated. Georges Carre et C. Naud, Editeurs, Paris,
1-' ranee.
Medical Record
A IVeekly youriial of Medicine a7td Sttrgery
Vol. 57, No. 13.
Whole No. 1534.
New York, March 31, 1900.
$5.00 Per Annum.
Single Copies, loc.
©rijginat ^rtictcs.
MUSCULAR RHEUMATISM.
By I. ABLER, M.D.,
PROFESSOR OF CLINICAL PATHOLOGY, NEW YORK POLYCLINIC ; VISITING
PHYSICIAN TO THK GERMAN HOSPITAL ; CONSULTING PHYSICIAN TO THE
MONTEFIORE HOME FOR CHRONIC INVALIDS.
Perhaps there are few subjects in medicine on
which more has been written than on rheumatism.
Many endeavors have been made to reach an under-
standing of the morbid processes involved in this class
of diseases, by clinical analysis, by anatomical and
even experimental investigation, but as yet without
complete success. It has not yet been possible to
formulate either anatomically or clinically sharply
defined types, nor has any one of the theories pro-
pounded succeeded in obtaining universal assent. In-
deed, rheumatism, and especially muscular rheuma-
tism, is still more or less a sort of diagnostic scrap
bag, into which one is accustomed to throw promis-
cuously all those ailments accompanied by pain and
which cannot conveniently be otherwise classified.
Authorities still differ widely as to what is meant by
muscular rheumatism, and what is the nature of the
lesions which underlie its manifestations. In the first
half of this century earnest efforts were made, espe-
cially in France, to arrive at an anatomical under-
standing of the rheumatic affections, and with that
object even experimentation upon animals was resorted
to, especially by Gendrin. In this manner the theory
of rheumatic inflammation of muscles was gradually
evolved, though, of course, curiously interwoven with
the reigning humoral dogmas. On this basis Froriep
finally elaborated the whole subject in his often-
quoted book, " Die rheumatische Muskelschwiele."
There is no doubt that Froriep describes as rheumatic
inflammation and induration many conditions which
to-day are known to depend upon altogether different
lesions and to belong to quite different groups of dis-
eases. But the book contains nevertheless much that
is well worthy of attention even in our time. In 1847
Virchow finally gave a detailed and exhaustive ana-
tomical and histological description of rheumatic in-
flammation of the muscular tissue, which, with some
modifications, remains in full force to-day. On the
other hand, the majority of clinicians and practitioners
has at all times looked upon rheumatism less from
the anatomical than from the etiological point of view,
subject to the dominant theories of the time. Besides
all sorts of morbid humors and diatheses, exposure to
cold and draughts, the influence of weather, chill and
damp, were held responsible and dominated the whole
subject of rheumatism perhaps to a greater extent than
any other department in the whole field of medicine.
Even to this day opinion differs as to whether muscular
rheumatism is dependent upon structural lesions or is
.merely functional. The very latest writer on this
subject, Lorenz, in Nothnagel's " Handbook," defines
muscular rheumatism, or, as he prefers to name it,
"myalgia rheumatica," as follows: "Those diseases
in which muscular pain is the prominent symptom, and
as a consequence of the pain functional disturbances
and even obstinate contractions are brought about, but
which depend upon no structural lesions, and during
life, with the exceptions of the contractions, offer no
palpable objective symptoms, and which are due etio-
logically to cold [Erkdltung).'''' This view of mus-
cular rheumatism is probably at the present moment
the one that is most generally accepted, though there
are some notable authorities who differ in several
essential points. It is not my intention to give a
detailed and critical review of the literature on this
subject. I propose merely to summarize in brief the
convictions which have impressed themselves ufion me
in the course of years as the result of a careful study
of the literature and abundant observation, in part on
my own body. It will be noticed that the conclusions
arrived at are in every point the exact opposite of those
formulated by Lorenz.
It may be summarily stated at the very outset that
the anatomical lesion underlying every case of mus-
cular rheumatism, acute or chronic, is an inflammation,
not necessarily altogether confined to the muscle, as
will be shown later, but as far as the latter is con-
cerned an interstitial inflammation. Muscular rheu-
matism may therefore quite generally be designated
pathologically as a m'yositis interstitialis. This is
the view held by many of the older authors, and espe-
cially urged by Virchow, and, it is believed, is entirely
corroborated by all modern experience and investiga-
tion. I cannot here present any anatomical material.
It is obvious that tlie difficulties of procuring proper
anatomical material for adequate histological research
are very great. People do not die of muscular rheu-
matism, and while it will subsequently be shown that
it is very easy to demonstrate the myositic patches in
the living, it is indeed wellnigh impossible to find
such patches in the corpse. It is no doubt owing to
this difficulty that our knowledge of these forms of
myositis, especially of the finer histological detail,
is still extremely and embarrassingly imperfect and
incomplete. Without that, however, thanks to occa-
sional excisions of diseased muscles in the living sub-
ject, and to opportune and lucky finds in the corpse,
enough material has from time to time been available
to enable us to arrive at some idea of the actual
pathological conditions on which these muscular
lesions are based. It is, moreover, possible to ap-
proach the subject experimentally. It is not difficult
to produce in animals parenchymatous as well as in-
terstitial muscular inflammation. The study of these
lesions lends valuable assistance in the interpretation
of the clinical observations. Lastly, it is permissible,
with due precaution, to bring to bear upon our subject
the result of histological work done upon other forms
of myositis, which, while in many respects closely
analogous to rheumatic inflammations, are more easily
accessible and have therefore been more minutely
studied. I refer particularly to the septic form of
myositis, and to syphilitic interstitial myositis, espe-
cially as occurring in the heart.
Guided by these lights we may conceive the rheu-
matic process in muscles as follows: In one or more
places of the muscular system hyperaemia with dilata-
tion of the smaller vessels and capillaries, sometimes
even accompanied by small hemorrhages, takes place.
53°
MEDICAL RECORD.
[March 31, 1900
This is at once followed by a more or less copious
emigration of cells into the interstitial tissues, the
leucocytes crowding between the bundles of fibres and
even between the single fibrils. Very soon active
proliferation of the interstitial connective tissue takes
place, and thus in a comparatively very short time
after the beginning of this process an infiltration of
the muscle is brought about, which varies in extent
and density according to the intensity of the process.
During all this time the muscle fibres themselves are
not very materially affected; they are pushed apart to
some extent, but do not greatly suffer. In the milder
type of cases the process ends here. In due time,
usually after but a very few days, absorption of the
infiltrating material takes place. The muscle returns
to a condition practically, though perhaps never quite,
normal. If, however, the inflammatory activity attains
a higher grade of intensity, the process does not end
with the mere cellular infiltration and at most a very
slight degree of connective-tissue proliferation. More
extensive new formation of fibrous tissue is inaugu-
rated, sometimes to quite a considerable degree. The
interstitial connective tissue proliferates vigorously;
the muscle bundles and fibrils have been forced apart
and compressed. They also begin to degenerate and
are destroyed, exactly in the manner described for
interstitial myocarditis. The result of this is a fibrous
induration of the muscle. It is evident that when
this stage of fibrous induration has been reached,
spontaneous restitutio ad integrum is no longer pos-
sible. If left to itself, the induration will remain,
impeding function, causing pain, and facilitating the
recurrence of other acute attacks, thus leading over
from acute to chronic muscular rheumatism.
In rare cases the indurative proliferation proceeds
still further. Hard fibrous tissue is formed to a con-
siderable amount. The muscular tissue is extensively
destroyed. There results from this a white, hard,
cicatricial mass of tissue in which the microscope can
detect only occasional solitary remnants of degenerate
muscular fibres, and which, in its general structure,
closely resembles tendinous tissue. This is the genu-
ine " Muskelschwiele." Before proceeding further it
is well to emphasize the fact that what is usually
termed muscular rheumatism is not necessarily con-
fined to muscular tissue alone. It is of common occur-
rence that in cases of articular rheumatism the muscles
in the immediate vicinity of the joint are also affect-
ed, and vice versa, that in muscular rheumatism the
nearest joints also suffer, though usually bu^ very
slightly. But aside from articular affections it is a
fact easily verified that the inflammatory process is, as
a rule, not limited to the muscle, but involves the
adjacent tissues as well : the fasciiE, tendons, the sub-
cutaneous, fatty, and cellular tissue, and particularly —
and this is perhaps not sufficiently recognized — the
nerves. A typical rheumatic neuritis (sciatic, median,
radial, etc.) has long been recognized, in which inter-
stitial inflammatory processes, similar to those de-
scribed in the muscles, are at work in the neurilemma.
But aside from this typical neuritis of the larger nerve
trunks which occurs ?-s an independent rheumatic
affection, it is safe to say that in most cases of rheu-
matic myositis more or less numerous larger and
smaller nerves of the immediate neighborhood are also
involved in the process of interstitial inflammation.
It will be seen that not a few of the clinical symptoms
associated with muscular rheumatism find their expla-
nation in this affection of the nerve supply.
If the foregoing anatomical statements are based
upon facts, if muscular rheumatism is in truth a local-
ized inflammation associated with infiltration and
swelling of the tissues involved, we might justly ex-
pect to be enabled to recognize these infiltrations by
clinical examination, that is to say, by palpation.
This is indeed true for every case. Scattered com-
munications by various authors here and there
(Opoltzer, Ewer, Lacquer, etc.) have repeatedly called
attention to circumscribed patches of swelling and
infiltration that could at times be felt in rheumatic
muscles. These statements, however, have either
been simply put aside as based upon error, or else
the swellings have been accepted as an exceptional
and unexplained occurrence, or else interpreted as the
expression of partial muscular contraction. It is a
particular merit of the masseurs (Metzger and his
pupils, Helleday, Nostroem, Schreiber, and others) to
have zealously directed attention to these conditions,
though perhaps without adequate anatomical substan-
tiation. But notwithstanding all that has been said
and written about these things, notwithstanding the
universally lauded success of Metzger in the treatment
of these muscular affections, the great majority of
practitioners have kept entirely aloof and have persis-
tently ignored all advance in this direction. With
some practice in palpating muscles, and after attention
has once been directed to these muscular lesions, it is
not very difficult to convince one's self of the existenee
of these infiltrations, indurations, and swellings in
every case of muscular rheumatism. It must be borne
in mind, however, that the infiltration is not neces-
sarily found in the spot to which the patient refers his
pain, and recalling what w'as said above with regard to
the participation of the nerves in this process, this
will not appear surprising. Take, for example, one of
the most common forms of muscular rheumatism, the
so-called lumbago. In some cases this is strictly
localized, and the pain is referred to the precise spot
where on examination the muscular infiltration is
found. In other cases it is said by the patient that
the pain is "all across the back,'' or radiates into the
abdominal wall down to the groin. A superficial
examination of the dorsal and abdominal muscles will
in such cases fail to detect any lesion. Indeed, all
these muscles are probably entirely sound, and it is
no doubt that from such cases and from such exaifiina-
tions the conception of "myalgia without anatomical
lesion " has been derived. Nevertheless a more care-
ful palpation will without fail demonstrate in some
one muscle or in several at the back, perhaps the
gluteus, perhaps the quadratus or the spinalis longus,
one or more, sometimes quite small areas of infiltra-
tion which are extremely sensitive to pressure, and from
which the pain radiates in all directions along the
track of larger and smaller nerves, and is referred, as
is the case with every nerve pain, to the periphery of
the nerve affected. The infiltration varies greatly in
size, shape, and consistency according to the extent
and intensity of the inflammatory process. It is im-
possible in very acute cases, on account of the intense
pain produced by the slightest touch, to palpate the
diseased muscle with exactness. After subsidence of
this acute and violent stage, the infiltrations may be
recognized by careful palpation in various forms of
configuration. They may be round, fusiform, or flat.
The surface may be smooth or somewhat broken and
uneven. They may be quite hard and firm, or rather
soft and doughy. It is to be noted also that, while
normal muscles react upon a certain vigorous grip
with a contraction of the part touched, the diseased
muscular tissue will either not react thus at all, or
with plainly diminished vigor. The diseased parts of
the muscles appear besides distinctly less elastic than
the normal. After the acute inflammatory stage has
passed, the muscle, as a rule, resumes its functions
without pain or any subjective inconvenience. Never-'
theless, palpation of the diseased and infiltrated area
even then is without exception quite painful, and this
sensitiveness to touch is of great service in detecting
the foci of the lesion. When examining for these
March 31, 1900]
MEDICAL RECORD.
531
muscular lesions it is necessary to compare the sus-
pected area with the corresponding place on the other
side. Aside from differences in consistency, elas-
ticity, size, etc., it will be found in every case that the
diseased portion is sensitive to a degree of pressure
which is not at all painful at normal places. A
thorough appreciation of these facts and a sense of
touch developed and educated by practice will enablte
us to demonstrate muscular infiltration or induration
in every case of muscular rheumatism without excep-
tion. More than that, it will very often be possible
by the detection of such diseased areas in muscles and
their vicinity, to arrive at a correct interpretation of
entire groups of symptoms past and present, especially
in cases in which the acute initial stage was very
mild and has passed entirely from the recollection of
the patient, thus affording us no anamnestic data
whatsoever.
The clinical picture presented by muscular rheu-
matism varies according to the intensity arid extent of
the process, and according as it assumes an acute or
chronic character. There are cases which convey
altogether the impression of acute infectious disease
and are accompanied by fever, seldom, it is true,
above about 102° F., hut in exceptional cases rising
to 104° F. and ovef. The muscular swelling extends
in these cases over a considerable area, the cutis is
tense and shining, and the slightest motion or touch
causes almost intolerable agony. Even when the dis-
eased parts are entirely immobilized and protected
from all harmful influence, very severe spontaneous
pain is as a rule present. In these cases the disease
usually affects a number of muscles lying in more or
less close vicinity, but is, as a rule, confined to one
region alone. We rarely see this acute and intense
affection appearing simultaneously in different regions
of the body. Very often, too, the joint nearest to
or surrounded by the diseased muscle is also some-
what, though possibly but very slightly involved in
the inflammatory process. This corresponds to the
generally recognized fact that in acute articular rheu-
matism the muscles adjoining the diseased articula-
tion are also more or less inflamed. This form of
muscular inflammation which appears in the train of
acute or chronic articular rheumatism is considered
by some authors as the true and only myositis rheu-
matica. This view is entirely unfounded, inasmuch
as these forms of muscular inflammation differ in no
essential respect from the form of interstitial myosi-
tis as typical for the ordinary muscular rheumatism.
Another feature in these acute cases of muscular rheu-
matism which suggests very vividly infectious disease
is the not infrequent occurrence of endocarditis and of
cutaneous lesions, petechia, erythemata, and urticaria,
the so-called peliosis rheumatica.
Another group of cases presents an entirely different
type. I include under this heading those forms of
muscular rheumatism which are usually of short dura-
tion, more transitory in character, extending over a
very limited area of tissue, and which, while at times
appearing in various and widely distant regions of the
body simultaneously, may, on the other hand, cling
obstinately to one spot and occur again and again
always in the same place. Such affections are the
common lumbago, the rheumatic caput obstipum (vu/go
stiff neck), certain forms of intercostal pains, usually
designated as intercostal neuralgia, but in fact nothing
else than rheumatic myositis of the intercostal muscles,
and similar affections in the various muscular groups
all over the body. These. affections are so well known
and of such frequent occurrence that the mere mention
of them would appear sufficient. There are neverthe-
less some points in this connection which are not gen-
erally recognized and are of some importance. The
first is the question of fever. The general conviction
is that these mild and strictly localized cases of mus-
cular rheumatism are not associated with rise of tem-
perature, and it is undoubtedly true that in many cases
there is no fever. Nevertheless Leube's statement
that in very numerous instances, even in these mildest
cases, there is a slight rise of temperature is entirely
borne out by closer investigation. As a rule, the tem-
perature in these cases is not taken, as the patient is
about, is not conscious of any fever — the skin appears
cool, there are no objective symptoms of febrile tem-
perature. But systematic thermometric measurements
have shown- that even in these mild cases, in common
lumbago or stiff neck, slight elevations of temperature,
100°, 100.5°, 101° F., are much more frequent than is
commonly supposed. A further point that deserves
mention is the question of endocarditis in muscular
rheumatism. The occurrence of endocarditis in the
train of muscular rheumatism is altogether denied by
many observers. Now, it is beyond doubt that endo-
carditis, while of frequent and almost regular occur-
rence in acute articular rheumatism, is but rarely
observed in muscular rheumatism. But it certainly
does occur. In this respect, too, the facts bear out
entirely Leube's statement. Endocarditis is met with
not only in those severe cases associated with con-
siderable elevation of temperature as mentioned above,
but also now and then in quite mild cases of lumbago,
stiff neck, etc. Endocarditis is occasionally found in
children apparently without history of rheumatism.
Closer investigation elicits a story of transitory pains
(growing pains) here and there in the legs, the arms,
over the back. The joints are absolutely normal, but
careful palpation detects recent and painful infiltration
in one or more muscles. In the case of adults, too, it
is by no means rare to find a valvular lesion without
any satisfactory etiology to account for it.. There is
no history of articular rheumatism, pneumonia, ty-
phoid, syphilis, or other infectious diseases. Careful
palpation, however, demonstrates in various muscles
sometimes quite numerous more or less hard patches
of infiltration as the residue of former attacks of mus-
cular rheumatism, which, while not severe enough to
have dwelt in the memory of the patient, sufficiently
account for the endocarditis and resultant valvular
defect. One other point deserves mention : It is
customary to look upon lumbago, stiff neck, and other
similar very sudden myalgias as caused by trauma-
tism, as due to muscular strain or distortion. It is
indeed certain that in very many of these cases, though
by no means in all, the acute attack of pain appears
to be brought about by some sudden and abrupt motion
(stooping, lifting, rapid turning of the head, etc.).
Leube, who is of the opinion, as I am, that even these
cases of so-called myalgia must be considered as gen-
uine rheumatic infections, admits that this apparent
connection of traumatic injury with the outbreak of an
acute attack of rheumatic affection is at present entirely
unexplained. From the point of view advocated in
these pages the symptom is, however, not difficult of
solution. In all of these cases interstitial myositis
with more or less infiltration, which, as has been shown
above, may lie dormant without objective symptoms
for an indefinite time, is present and may have existed
for a long time. The myositis is in every case the
primary affection. Under these conditions a sudden
violent and abrupt motion simply lights up a renewed
and acute attack of inflammation and pain, possibly
by causing a slight intra-muscular hemorrhage, or by
rupture of bundles of already well-degenerated muscle
fibres or of infiltrated and degenerate nerve branches,
etc. All this is not mere speculation, but can easily
be proven. There are numerous persons who suffer,
sometimes for many years, from recurrent attacks of
this form of rheumatism, for instance from lumbago.
In every one of these cases it is possible in the interval
532
MEDICAL RECORD.
[March 31, 1900
between the attacks, and at times when there are abso-
lutely no subjective symptoms, to demonstrate mus-
cular infiltration in the quadratus, longissimus dorsi,
or other muscles of the trunk, and it can be shown
that in every attack the pain unfailingly takes its
origin from those spots which have been recognized as
the seat of the infiltration. Let it be stated plainly
once more, however, that numerous instances are
observed in which the attack comes about without any
traumatic influence whatsoever.
Rheumatic myositis can occur practically in almost
every part of the body where there are striated muscles.
But very few localities have thus far been found
exempt. It may perhaps be of some interest to dwell
on some of the rarer and less generally appreciated
localizations. The muscles of the head are more
often the seat of rheumatic inflammation than is com-
monly supposed. The disease occurs not only in the
muscles of mastication, the temporal, and, though
quite rarely, in the masseter, but also and very fre-
quently indeed, in the occipital and the small muscles
at the base of the occiput. In these latter localiza-
tions it is common to find the cutis, especially the
galea, and the nerves equally involved, and the pain
caused by these foci of rheumatic inflammation is
usually diagnosed as an ordinary cephalalgia or head-
ache, or as neuralgia. Palpation readily detects
patches in the muscles, the skin, and also about the
nerves. The occipital nerve, just at its exit, is a
favorite locality. Many cases of headache, occipital,
supraorbital, and otiier neuralgia, many cases of so-
called migraine, are nothing else than rheumatic
inflammations easily to be recognized by proper exami-
nation. There are, however, other localizations which
occasionally may render the proper interpretation and
diagnosis tather difficult. I wish to speak particularly
of those cases of rheumatic myositis localized in and
about the abdominal muscles, which are not generally
recognized and may be of considerable clinical impor-
tance, inasmuch as they may simulate cholecystitis,
appendicitis, and other affections of the abdominal
viscera. With reference to cholecystitis the following
case may serve as an illustration :
Mrs. H. I , forty-five years old, was very sud-
denly seized with excruciating pain. The pain was
distinctly localized in the region of the gall bladder
and radiated from there into the back and epigastrium.
The entire region was extremely sensitive to the
slightest touch, and even the ordinary respiratory
movements caused pain. The rectal temperature
ranged from 100° to 101" F.; the pulse was normal.
All the other organs were normal. The suddenness of
the attack, the strict localization in the region of the
gall bladder, the fever, suggested a possible acute
cholecystitis, perhaps with incipient peritonitis. On
the other hand, it could be urged that the woman had
never before suffered from biliary colic, while she had
at various times been subject to rheumatic affection.
The very slight pyrexia as compared with the ex-
tent and acuteness of the pain seemed to tell against
the assumption of a severe and deep-seated lesion.
Further observation seemed necessary before a positive
diagnosis could be made, though rheumatism was
thought most probable. After a few full doses of sali-
cylate of sodium the sensitiveness of the area affected
had diminished to such a degree that a thorough pal-
patory examination could be made, which demonstrated
fresh inflammatory infiltrations in the muscles just
below their insertion at the right border of the ribs.
A few months later the same patient was seized with
an entirely similar attack, the difference being merely
that the inflamed area of muscle was located in the
right quadratus lumborum.
Localization of myositic patches in the recti abdo-
minis is rather frequent and may lead occasionally to
errors in diagnosis if not carefully considered. This
is particularly true, too, of rheumatic myositis in the
obliqui, and especially when located in the internal
obliquus in the region of the right iliac fossa. It is
at times extremely difficult to distinguish between an
incipient appendicitis and a rheumatic affection of the
deep muscles and fascia;. The occurrence of this
class of cases is by no means generally appreciated,
and indeed the very possibility of rheumatic myositis
in the abdominal muscles is not taken into account by
the majority of practitioners. It may be well, there-
fore, to say a few more words on this subject, the more
so as the impression seems justified that in the pres-
ent state of nervousness concerning appendicitis which
obtains among the profession as well as among the
laity, not a few cases have been diagnosticated as
appendicitis, and not a few perfectly normal appendi-
ces have been removed, when the actual lesion was
merely abdominal rheumatic myositis. The following
observation well illustrates some of the points in
question :
Mr. S. J , forty-Seven years old, complains of
general malaise, loss of appetite, and pain, which
latter, gradually growing more severe, is located by
the patient in the right side of the abdomen. The
family physician finds rise of temperature, ranging
from 100° to 101.5° F., and a diffused sensitiveness
on pressure all over the right abdomen. No positive
diagnosis is made. Ice bag to the painful parts, mild
saline laxatives, and rest in bed, together with strict
diet, are ordered. In a few days the pain moderates,
the temperature is almost normal, and the general con-
dition much improved. The patient is then advised
to take a week's rest out of town. While away from
the city he feels comparatively well; appetite im-
proves, vigor returns, but he is never quite free from
pain. On his return I find a slow, regular pulse,
somewhat coated tongue, the viscera of the chest per-
fectly normal. There is a distinct and intense pain-
fulness on pressure over the region of the appendix.
The appendix itself cannot be distinctly made out.
There is also a slight sensitiveness just below the
right arch of the ribs about the region of the gall
bladder. The liver is not enlarged. Jarring and
percussion of the liver are not painful. Pressure over
the region of the appendix causes the pain to radiate
upward toward the epigastrium and gall bladder, and
is so painful as to predominate over all other sensa-
tions. The rectal temperature is 100° F. No albu-
min, no sugar, no phosphates, and no biliary elements
are found in the urine. A second examination next
day after the bowels have been thoroughly evacuated
led to exactly tlie same result. The conclusion seemed
obvious that the case was one of mild subacute appen-
dicitis. With a view to a possible operation a surgeon
was consulted, who in turn was disinclined to enter-
tain the diagnosis of appendicitis, but rather favored
cholecystitis. Further observation of the patient
showed the sensitive areas remaining about the same,
with this difference: On one day the pain about the
region of the gall bladder would be more severe, and
the next the pain about the region of the appendix. In
the mean while I had recollected that the same patient
had at various times suffered from rheumatic myositis
in the muscles of the neck, leg, back, etc. The some-
what uncertain and undetermined symptoms in the
present trouble suggested the possibility of a rheumatic
condition. Accordingly a careful palpation of the
muscles was made, and the infiltrations in the obliquus
externus and in the rectus, the latter under the arch of
the ribs, were readily discovered. An energetic anti-
rheumatic treatment rid him promptly and entirely of
all pain and discomfort. If the possibility of rheumatic
myositis had suggested itself to me, as it should have
done at the first, and the proper examination of the
March
1900]
MEDICAL RECORD.
5:
muscles had been made at once, the patient as well as
his physicians would have been spared much worry and
anxiety. Some time afterward the same gentleman was
seen with a new pain, but this time located distinctly
in the right quadratus.
In the following case the condition was less per-
plexing:
Mrs. E. S , twenty-nine years old, had for some
time been suffering pain in the right iliac fossa. She
was seen by a prominent gynecologist, who found the
uterus and adnexa normal, but diagnosticated incipient
appendicitis, and sent her to bed, and ordered ice-bag
and expectant treatment. Temperature, pulse, and
digestion were normal, and the appetite was good.
Pain on motion and on pressure was quite violent and
strictly localized in the right iliac fossa about the re-
gion of the appendix. This patient, too, had at various
times suffered from muscular rheumatism in various
parts. Palpation showed a firm infiltration in both
obliqui, and salicylate of sodium and massage effected
a speedy cure.
Accounts of similar cases might be multiplied almost
indefinitely. Examples might be adduced in which
myositis of the recti simulated peritonitis or intestinal
colic, when myositis of the quadratus and obliqui was
diagnosticated as renal colic, but perhaps this will
suffice to show that rheumatic myositis of the abdominal
muscles must be taken into consideration as among
the possibilities in all cases of painful abdominal
affections in which the diagnosis is at all doubtful.
It would transgress the limits of this paper to enter
into details upon the numerous questions of differen-
tial diagnosis in tiiis group of cases. It may be stated
in a general way that the absence of progressiveness
of the symptoms, the tendency to remain stationary,
characterize most of these rheumatic affections.
Moreover an attack of rheumatic myositis of the ab-
dominal muscles is rarely the first rheumatic attack.
Usually there are a history and physical evidence of
preceding or simultaneous rheumatic affection in other
parts of the body. The absence of fever or the very
slight elevation of temperature, the absence of char-
acteristic symptoms on the part of the abdominal
viscera, are in many instances valuable hints. The
main basis of the diagnosis, however, is in every case
the demonstration of the muscular infiltration or indu-
rations by palpation. This is at time extremely diffi-
cult. In very fat individuals or in hypera^sthetic and
hysterical subjects it may be practically impossible.
In every case a delicate and well-trained sense of
touch is required. The recti and quadratus are, as a
rule, more easily handled. When the patient is in the
recumbent position or on either side with flexed thighs,
it is not too difficult to grasp the rectus between the
thumb and first two fingers, or between the two hands,
and palpate all through the muscle. The obliqui,
particularly the obliquus internus, present the greatest
difficulty. Palpation here can never be properly car-
ried out while the patient is on his back. It is neces-
sary to turn him well over on either side and with
muscles thoroughly relaxed. In every case palpation
of the obliqui requires great practice and a delicate
touch.
It has already been stated above that, no matter
whether the acute initial symptoms are of considerable
intensity or so very mild as to be barely noticed,
muscle infiltrations remain in every case. These
enduring infiltrations and indurations in the inter-
stitial muscular tissue, the neurilemma, and the sub-
cutaneous and adipose tissue form the basis of chronic
muscular rheumatism. It is owing to these infiltra-
tions that more or less severe relapses take place at all
times and on the slightest provocation. But not only
periodical relapses are caused by these anatomical
lesions. Permanent disturbances of motor function,
such as pain with certain motions, contractions of cer-
tain muscles or groups of muscles, are frequent occur-
rences. If the muscles involved are numerous and the
indurations extensive and hard, really intolerable con-
ditions, seriously affecting the working-capacity and
the entire functional economy, may result. Besides
this effect on motor function, other disturbances can
be brought about by these indurative processes which
have as yet received too little attention at the hands
of the practitioner. I refer particularly to periodical
attacks of pain simulating typical neuralgia. There
are, for instance, certain forms of headache resembling
altogether typical migraine which are entirely due to
rheumatic lesions.
Soon after I had first begun to study the various
forms of rheumatic myositis, a gentleman, Mr. S ,
presented himself at my office complaining of periodic-
al seizures of very violent hemicrania with all the symp-
toms of ordinary migraine. The attacks occurred at
varying, entirely undetermined intervals, even as often
as several times in one week. The suffering caused
by the violent pain v\'as not always mitigated even by
large doses of antipyrin or phenacetin, and, moreover,
was the cause of serious disturbance in the carrying
on of his business. He had accordingly consulted
numerous nerve and other specialists without relief.
He stated that he had never been seriously ill, but
had had frequent mild attacks of rheumatic pain in
his limbs and suffered very often from lumbago. All
internal organs were found on examination perfectly
normal. In the small cervical muscles, however, in
the cucullaris, temporalis, and in the scalp numerous
rather hard infiltrations were found, as also about the
trunk of the occipital nerve, which latter was particu-
larly hard and painful. A very energetic and syste-
matic course of massage extending over several months
gave permanent relief from all unpleasant symptoms,
and the patient has since then had no recurrence of
his periodical attacks of migraine.
Since that time many similar cases with similar
results have been observed. The following case may
also be of interest:
A young widow, Mrs. P , about twenty-seven
years old, suffered for years from violent attacks of
headache which lasted for days at a time, confining
her to her room and practically keeping her from all
social duties and pleasure. The father of the lady,
it is stated, had been subject for years to similar at-
tacks, and finally died, according to the reports of
the autopsy, from hemorrhagic pachymeningitis. The
young lady., convinced that before long her father's
fate would overtake her, had fallen into a condition of
hopelessness bordering on melancholia. Careful ex-
amination showed all internal organs, including the
brain and spinal cord, to be perfectly normal. Exami-
nation of the eyes was also negative. She positively
denied ever having suffered from rheumatism or rheu-
matic pain anywhere; notwithstanding this most posi-
tive statement numerous infiltrations were found, as in
the previous case, in the muscles of the neck and head
and about some of the nerve trunks. In this case also
proper massage permanently relieved the headache and
restored the patient to a rational enjoyment of life.
Similar conditions can prevail in other regions of
the body, particularly in the extremities. There are
cases which present all the symptoms of chronic
sciatica. Indurations are found in the gluteal muscles
or in the neighborhood of the sciatic notch, and the
removal of these by massage or excision (Straus) at
once relieves all sciatic symptoms. Numerous other
instances might be cited and corroborated and illus-
trated by clinical histories. It will be proper, how-
ever, to let these few hints suffice, and proceed to a
brief consideration of the etiology of muscular rheu-
matism.
534
MEDICAL RECORD.
[March 31, 1900
It is the almost universal opinion at present, as is
manifest also in the above-quoted statement from
Lorenz, that exposure to cold is the most frequent, in
fact the sole, cause of muscular rheumatism. A dis-
cussion of the role of "cold" as an etiological factor
in disease would lead me too far. But it may be stated
in a general way that a survey of the history of medical
science demonstrates clearly the indubitable fact that
with every advance toward a more intimate knowledge
of disease, cold as an etiological factor is less fre-
quently heard of. Compared to twenty-five years ago
but very few diseases are to-day considered as in any
way attributable to cold, and it is significant that
these are such as to whose etiology but little is defi-
nitely known. Muscular rheumatism is the last
stronghold, as it were, of this once so universally
dominant etiological concept. But here, too, it has out-
lived its usefulness. Sahli has shown that articular
rheumatism is most probably caused by infection with
cocci, staphylococci, or streptococci of attenuated viru-
lence. We have seen how closely related muscular
rheumatism is to articular rheumatism. They are not
only frequently associated, but the facts that in pure
muscular rheumatism fever is often present, endocar-
ditis is not infrequently observed, and erythematous
eruptions, peliosis, are not rare, seem to suggest the
inference that muscular rheumatism must also be
classified among the infectious diseases. The old and
well-established observation of the migrator)' tendency
of rheumatism, its appearance in different regions of
the body simultaneously, or now here, now there, in
rapid succession, points in the same direction and is
best explained by the infection theory. I conclude,
therefore, in accordance with Leube, that rheumatic
myositis is an infection, caused most probably, accord-
ing to present lights, by cocci (streptococci), still less
virulent than in rheumatic arthritis. Assuming this
to be so, we have gained a uniform basis for the entire
group of infectious muscular diseases. First in order
and of least virulence would stand the rheumatic
interstitial myositis; next and more virulent those
graver forms of myositis associated with a .severe type
of articular rheumatism. Of greater virulence still
are the true septic types of myositis, those forms which
result in extensive interstitial proliferations and for-
mation of pus, 'which lead to muscle abscesses. We
must further classify under this general heading those
more specific forms of interstitial myositis which occur
so frequently in the course of infectious fevers, espe-
cially in typhoid. These are, however, no longer pure
types of interstitial inflammation, inasmuch as, prob-
ably caused by specific toxins, a primary degeneration
of the muscle fibre takes place, as a rule, simultane-
ously with the interstitial process. Syphilitic inter-
stitial myositis may possibly also belong to this group,
though to me this seems doubtful. It must be can-
didly and unreservedly confessed that this entire con-
ception as just stated has as yet not been strictly
proven, and is still more or less hypothetical in char-
acter. The cocci have not yet been demonstrated, and
even if we assume their existence we are in utter
ignorance of their mode of entrance into the system,
the conditions which influence their invasion, etc.
Nevertlveless it can safely be said that this view has
the advantage of gathering a large group of patho-
logical processes under one uniform conception, and
of affording a more logical and plausible explanation
of observed facts than the entirely inadequate theories
that are based on hypothetical effects of cold, damp,
etc. But even if we assume the above-stated views to
be correct, it cannot be denied that there remains much
that is as yet unexplained. Though we cannot admit
that colds or exposure can cause an interstitial myosi-
tis, no one can doubt the truth of the empirical obser-
vation, as old as the history of medicine, that climatic
conditions exercise to a certain degree a disposing
influence upon rheumatic affections. Just in what way
we are to explain this remains for the present an
unsolved problem. Again, it seems certain that diet
and general mode of livings may furnish a disposition
toward rheumatic muscular affections. This fact may
perhaps be not entirely inexplicable. Observation
has shown that vigorous muscular activity affords con-
siderable protection against rheumatic infection, while
indolent and sedentary habits favor a direct disposi-
tion toward this class of disease. The same can be
said of excessive and rich feeding and of even mod-
erate abuse of alcohol. Considering the extremely
abundant blood supply of muscles, their intense and
variable metabolism, and their ability to store up cer-
tain chemical substances, such as glycogen, lactic acid,
etc., it becomes quite conceivable how, under the
above-mentioned conditions, a favorable or unfavorable
breeding-ground for infective germs may result.
In conclusion, some few words must be said about
treatment. The acute cases with fever and severe pain
are treated as any ordinary case of articular rheuma
tism. The patients are kept in bed and salicylates are
administered. In a general way I am under the
impression that salol and its compounds act more satis-
factorily in muscular rheumatism than salicylate of
sodium. In most cases, too, I see better results from
the local application of cold (ice-bag) than from the hot
fomentations and hot-water bags which are so gener-
ally favored. The old notion, still widely accepted,
that acute rheumatism, whether muscular or articular,
must be treated by hot applications, and that all cold
must be carefully avoided, should at last be given up.
We have seen that every attack of muscular rheuma-
tism is essentially a proliferating interstitial m3ositis
with more or less inflammatory infiltration of the
muscles. After the subsidence of the acute stage
these infiltrations remain, undergo further changes,
and lead to recurrence of further acute attacks, to dis-
turbances of function, and to many other painful and
otherwise annoying symptoms. It should be the main
object of our therapeutics to accomplish the removal
of these infiltrated patches and reinstate normal ana-
tomical conditions in the muscle. We have essentially
local lesions which can be satisfactorily dealt with
only by local measures. The well-known hot baths
and springs, electricity, the internal administration of
iodides, gymnastics, and the host of other remedial
schemes that have been recommended, will produce no
lasting result. Though I will not deny that they may
be useful with regard to the general conditions, with
reference to circulation, excretion by skin and kidneys,
improving metabolism as a whole, etc., it is safe to say
that they w-ill scarcely touch the local lesion which is
our main objective. The rheumatic infiltrations and
indurations can be best dealt with by proper massage.
Not every so-called masseur understands this, and I
am far from indorsing tlie loose and unscientific hand-
ling that has of late years become rather too general
under the collective name of massage. For our pur-
pose the masseur must be possessed of a specially
trained tactile sense in order to find even the slightest
infiltrations, and a special technique is required in
their treatment. Quite soft and recent infiltrations
are handled differently from old and hard fibrous
indurations. In the latter the object of the massage
is the forcible breaking up of the fibrous masses and
the production of reactive hyperemia and inflamma-
tion which will gradually under persistent and judi-
cious treatment end in absorption of the fibrous indura-
tion and in new formation of muscular tissue. In the
former the. procedure is simpler and easier, though the
principle is the same. This is not the place to enter
into further details. Very few masseurs understand,
and are trained for, this special work. The well-
March 31, 1900]
MEDICAL RECORD.
535
known Dr. Metzger and his pupils have earned their
laurels principally in this field. In our city Dr.
Norstrom has devoted himself specially and success-
fully to this work. We know from careful and con-
vincing microscopical investigation that, as the inflam-
matory products are absorbed, and under the influence
of strongly stimulated blood supply, the muscle fibres
are rapidly regenerated and take the place previously
occupied by the inflammatory proliferation. It is
astonishing to see indurations almost cartilaginous in
their hardness still yield to persistent and properly
applied massage. It is evident, however, that recent
still well vascularized and cellular infiltrations will be
absorbed much more quickly and easily than old,
hard, and dense indurations. For this reason it is
■well to commence the mechanical treatment as soon as
the acute stage of fever and intense spontaneous pain
has passed. We will then be able very often to obtain
complete absorption and restitution in a very short
time. In every case the treatment requires some pluck
and energy as well as persistence on the part of the
patient, for it is obvious that this kind of massage is
necessarily quite painful, especially at the beginning
of the treatment. As the infiltrations are reduced the
painfulness of the massage rapidly diminishes. The
rare cases of genuine muscular cicatrization [Miiskel-
schwiele) can, it is obvious, derive no benefit from
massage. In these cases the fibrous cicatricial tissue
must be excised. This has repeatedly been done with
excellent result. Recently such cases have been again
reported by Strauss.
Finally, reviewing once more the entire subject, I
may briefly summarize the conclusions arrived at as
follows:
The so-called muscular rheumatism is, according
to probability and analogy, an infection with germs,
most probably streptococci, possibly staphylococci, of
attenuated virulence.
A certain degree of individual disposition toward
this class of affection is recogni'zable. This disposi-
tion is augmented by indolent and sedentary habits,
by improper nutrition, especially immoderate and rich
eating, and alcoholic beverages. It appears, further-
more, that climatic influences may also, in a manner
as yet unexplained, act favorably on the development
of rheumatic affections.
Muscular rheumatism must be designated anatom-
ically as an interstitial myositis, usually in conjunction
with inflammatory processes in the adjacent tissues,
the subcutaneous and fatty tissue, the fasciae, and espe-
cially the nerves. In the latter the process is likewise
that of interstitial neuritis.
As sequelae of the inflammatory process, cellular
infiltration, connective-tissue indurations, and some-
times even complete fibrosis of the muscles are pro-
duced. These changes in the muscular texture persist
after the abatement of the acute inflammatory condi-
tions and give rise to more or less frequent relapses
and to manifold functional disturbances.
Mere medicinal treatment is indicated in the acute,
more or less febrile stage. As soon as this stage is
over, mechanical treatment, especially proper and
adequate massage, becomes of paramount importance.
It is the object of this method to bring about the
absorption of the infiltrations and indurations and to
restore the muscle to normal conditions.
Postscript. — Since the above paper was written,
Wassermann has succeeded in isolating a streptococcus
from the blood and various viscera in the case of a
girl who died from endocarditis, nephritis, and cho-
rea following polyarticular rheumatism. Injection of
small doses of the pure culture of this streptococcus
into the blood of rabbits invariably produces typical,
usually fatal polyarthritis in the animal. The infec-
tious nature of rheumatic polyarthritis, as caused by a
specific streptococcus, can therefore be considered as
certain. It will remain an object of investigation for
the near future to determine if similar micro-organisms
cannot be found for muscular rheumatism.'
BIBLIOGRAPHY.
.\ very complete survey of the literature can be found in
Kaclcr ; Klinische Beitrage zur Aetiologie und Pathologic der sog.
primaren Muskelentziiiidungen. Grenzgebiele der Medizin und
Chirurgie, Bd. ii., Heft 2, 1897; also Lorenz ; Die Muskeler-
krankungen, i. Theil, 1S98, in Nothnagel, Spec. Pathologic und
Therapie.
A very few references of particular interest are appended here :
Kroriep : Die rheumatische Schwiele, Weimar, 1S43.
Virchow : Ueber parenchymatose Entziindung. Archiv f.
path. Anatom., etc., Bd. iv., 1S52.
Leube : Beitrage zur Pathologic des Muskelrheumatismus.
Deutsche med. Woch., 1894, No. i, p. i.
Hackenbruch : Ueber interstitielle Myositis und deren Folge-
zustand, die sog. rheumatische Muskelschwiele. Beitrage zur
klin. Chirurg., v. Bruns. vol. x. , 1893.
Lacquer ; Ueber akute intermittirende Mononij'ositis intersti-
tialis. Deutsch. med. Woch., i8g6, No. 28; also Verhand-
hingen des Congress f. innerc Med., xiv. , p. 567.
Helleday : Ueber Myositis chronica. Nord. med. Ark., viii.,
2, No. 8.
.Strauss; Lleber die sog. " rheumatische Muskelschwiele." Berl.
klin. Woch., 1898, Nos. 5 and 6.
OBSERVATIONS ON THE TREATMENT OF
CANCER.^
By a. R. ROBINSON, i\LB., L.R.C.P. and S. Edin.
fESSOk OF DERMATOLOGY
A FEW years ago I read a paper before the Toronto
Medical Society on the treatment of cutaneous malig-
nant epitheliomata, and after a full consideration of
the different forms of cutaneous cancers, and especially
of their pathological anatomy and methods of exten-
sion, endeavored to show both from a theoretical and
clinical standpoint that, in a majority of cases com-
ing under the observation of the surgeon, certain caus-
tics applied according to the principles laid down by
me, principles based on the nature of the action of the
caustic employed, the form of the epithelioma present,
and the extent and direction of the invasion of the
normal tissues, gave much more satisfactory results as
regards the complete removal of the disease and the
amount of deformity from the operation than could be
obtained by the use of the knife; that in a certain
number of cases the knife was the proper agent to em-
ploy; that in a few cases the knife, followed imme-
diately afterward by a caustic, should be used; and,
finally, that some cases were best treated by the cu-
rette, followed by a caustic.
This view I will to-day again maintain and defend,
as I firmly believe it to be in the interests of those
afflicted with this dreaded disease.
Three years ago I read a paper before this associa-
tion on the importance of early treatment in all cases
of cancer, an importance well known to the profession
in theory long before I was born, but, I am sorry to
state, strangely neglected in practice even to this day,
if I may be permitted to judge from the knowledge
which a rather large personal experience in the matter
gives me. To this lamentable neglect allow me to at-
tribute a considerable percentage of the cases of death
from cancer, for it must be admitted that many cases
of the malady which have proved fatal could have been
treated successfully, provided the proper method had
been followed at a sufficiently early stage. In that
' \'ide Westphal, Wassermann, and Malkoff : Berlin, klin.
Wochenschrift, 1S99, No. 2g, p. 63S.
'' Paper read at the annual meeting of the Canadian Medical
Association, held in Toronto, August 30, 31, and September i,
536
MEDICAL RECORD.
[March 31, 1900
paper I endeavored to shew from a pathologico-anato-
niical and etiological standpoint that treatment other
than such as would promptly and radically remove or
destroy all of the pathological tissue, generally only
injured the patient and favored a more rapid exten-
sion of the disease.
Having thus gone over the subject on previous oc-
casions, it was my intention, when I first concluded to
write a paper for this meeting, to devote the whole ar-
ticle to a report of the observations and experiments
made oy me during the last twenty years with differ-
etit drugs which had been previously lauded by others
in the medical journals, or used by myself independ-
ently in the search for a something that can control
or stop the growth of cancer wherever situated; also
to report observations made on local treatment with
different agents and methods of application, especially
as regards caustics in those cases that have shown the
mistakes I had made in the manner of using them, being
followed by unfavorable results — results that, experi-
ence has taught me, would probably have been avoided
had there been no fault in the method of treatment.
Owing, however, to the statements contained in a re-
cent article on the subject of cancer by one of the lead-
ing surgeons of England, I shall hasten over the report
of these personal observations and studies, as I wish
to join issue with some of the statement', contained in
the aforesaid article, believing it to be to the interest
of medical science in general and for the benefit of
cancer patients in particular.
As regards the effects of treatment by internal medi-
cation upon the life of a cancer, as far as my experi-
ence goes, I know of no drug or preparation, serum
or toxin, single or combined, that i-s entitled to be
regarded as a specific for cancer, or that gives hope of
being of special benefit in any form of cancer at any
stage of the disease. The use of any substance that
makes a profound and disturbing impression upon the
nutritive processes of the body usually has an inhibi-
tory action on the growth of cancer, and temporarily
there may be, as a consequence, a cessation in the
growth of the tumor, or even a marked diminution in
its size. For example, there is a case on record of
the disappearance of a mammary cancer after an at-
tack of typhoid fever. I have seen cases of superficial
epithelioma disappear when the part was the seat of
an ordinary infective dermatitis by pus organisms, and
have also known of some which disappeared sponta-
neously after lasting years, the ground condition evi-
dently having been unfavorable for a continuance of
the morbid process. Sucli a result as that noted after
typhoid fever should encourage studies in the direc-
tion of seeking an agent which would be selective in
its destruction, and which would enable us to give a
ray of hope to those cases now regarded as inoperable
no matter in what stage tiiey are observed. Personally
I have no faith in the result of efl^orts made on the
lines so successful in such diseases as diphtheria, dis-
eases of limited duration; the result of immunity ac-
quired by the tissues. Cancer is not a self-limited
disease, and I cannot understand how one could ex-
pect to obtain an anti-cancerous serum in the same
manner as anti-diphtheria toxin is produced, and
count upon its having any influence on the disease. I
might state that, as far as my studies and experiments
go, I am no believer in a microbic origin of cancer.
I shall not enumerate all the drugs I have tried, nor
give the reasons for using them, but for the present
occasion I shall state that mercury, iodide of potassium,
sulphur, sulphide of lime, turpentine, some essential
oils, arsenic, chelidoniuni, nuclein, ovarin, thyroid ex-
tract, and suprarenal extract have been tried faith-
fully, and all have failed to stop the course of the dis-
ease. A few remarks on the observations made with
some of these substances may be interesting. Although
iodide of potassium has been of marked benefit in
some of the few cases of blastomycetic dermatitis
which have been observed, I have never yet in cancer
seen the slightest beneficial action from its use,
whether the drug was given in large or in small doses.
This is, a priori, a point of some value and not to be
forgotten by those who claim a blastomycetic origin
for cancer before having the necessary scientific proof
for this view.
Dr. Sherwell, of Brooklyn, from large clinical ex-
perience believes arsenic has such a decided beneficial
action in cancer that it is wrong not to give it in every
case under treatment, but I have never yet been able
to sacisfy myself that it has any special favorable ac-
tion, even in the most superficial forms of cutaneous
epithelioma, and my experience agrees with that of al-
most all observers.
The first case treated by nuclein vi'as one of inoper-
able uterine cancer in an advanced stage, and the tem-
porary change in the patient's condition was so satis-
factory that had I not very soon placed several other
patients under the same treatment, I might have formed
a wrong opinion as to its possible value in this dis-
ease. This was at least six months before any litera-
ture had appeared reporting wonderful benefit from
both nuclein and proto-nuclein. This first patient, after
having been in bed several weeks and in consequence
of pain and general weakness having been kept under
the influence of morphine, was given nuclein, and in
less than a month was able to leave her bed and do
slight household duties. Gradually her general health
and also the local symptoms improved, and for nearly
two years she was in a comparatively comfortable con-
dition, doing her own shopping as well as some house-
work. Then the disease took on new activity, com-
menced to extend rapidly, and death soon folTowed.
During the last three or four months of her life I had
tried other drugs. Further experience convinced me
that neither in internal nor in cutaneous cancers is
the drug of any special value.
The natural history of cases of interna! cancer
especially is so variable that one is not justified in
forming even an opinion from a single instance.
I treated several cases of cutaneous cancer (inoper-
able, of course) with a dried extract of the skin of the
pig prepared for me, but did not notice any effect on
the disease. I have found the avoidance as much as
possible of meat diet, and the drinking of large quan-
tities of water, to have had decided beneficial effects
in many cases of carcinoma. I have seen a mammary
cancer diminish very much in size under a vegetable
diet and the drinking of four quarts or more of water
each day.
Thyroid extract, suprarenal extract, and ovarin
have not benefited any of my cases, either uterine,
mammary, or cutaneous, and yet I am inclined to be-
lieve that some gland extract will be the agent of the
future for cancer, just as thyroid extract is to-day for
certain diseases.
I repeat that I am not aware of any substance, whether
drug, serum, or toxin, which, given internally, by the
mouth or otherwise, can be regarded as a cure for in-
ternal or external cancers at any stage of the disease,
and the moral I would draw from these observations
is, that a physician is not justified in losing valuable
time in operable cases by prescribing drugs, either
in the hope of a possible value or because the patient
hesitates to undergo proper treatment.
Local Treatment of Cutaneous Cancers. — In the
interests of the regular medical profession and of the
subject of cutaneous cancer, I feel it my duty once
more to discuss the subject of local treatment, and to
give the reasons why, in my opinion, the majority of
cases of cutaneous cancer — and cutaneous cancers
form the majority of all cases of the disease — should
March 31, 1900]
MEDICAL RECORD.
537
be treated by caustics, or vei-y similarly acting agents,
instead of by the use of the knife.
Let us consider the argument of those who think
tlie knife should be used in all cases of the disease ad-
mitting of operation. A full discussion of the origin
and method of growth of cancer would aid in making
clear the grounds upon which I regard a caustic as
usually preferable to the knife, but because my time
is limited I shall be able to touch upon this only in a
very general way. Let me here in passing remark
that I believe a knowledge based on microscopical
studies of the normal skin and of the pathological
process in cancer is necessary for an intelligent hand-
ling of a case of cutaneous epithelioma.
In a late number of the PractUione?-, a so-called
" cancer number," there is an article on the treatment
of cancer by Mr. Watson Cheyne, in which he states
that all attempts to cure the disease by other means
than operation by the knife " are almost invariably
futile, for the reason that caustics and injections do
not attack the outlying deposits." This view, in so
far as it relates to certain caustics used by experts in
the treatment of epithelioma, I regard as quite errone-
ous and not in accordance with tlie clinical experience
of those who have had ample opportunities for study
and observation of the results by the different methods
of treatment; furthermore, I do not think it is to the
interest of those afflicted with cutaneous cancer to al-
low this statement by such a distinguished and worthy
surgeon to remain unchallenged. It may be labor in
vain to ask the knife surgeon to consider carefully the
other side of the question ; to ask him to treat forty
or fifty suitable cases of epithelioma in the manner
they should be treated when caustics are used, and to
compare notes with similar cases treated by the knife;
but if he does make such a study he will find that out-
lying deposits — not distant infected lymph glands —
can generally be attacked directly or indirectly with
much more certainty, and with decidedly less deformity
as a result, by proper caustics scientifically applied,
than by the most skilful use of the knife.'
If Mr. Cheyne referred only to internal cancers, or
to nearly every case of mammary cancer, or to can-
cers of any kind or location in which the lymphatic
glands are already affected, then his statement would
be about correct; but it is not correct for primary
cutaneous cancer, except when it is located on certain
parts of the body, to be mentioned directly.
Allow me to describe what can be accomplished
by the use of a caustic, employed in the manner and
on the principles already laid down by me in previous
articles, and then judge for yourself as to the value of
the statement made by Mr. Cheyne.
I have here a diagram in which I have represented
a cancer as occupying, according to the naked-eye ap-
pearances, the area within the circle a. We all know,
however, both from clinical experience and micro-
scopical examination, that this area is not in reality
the limit of the disease in any single case, but that
there is always pathological epithelium beyond this
line, and I have assumed that it invariably extends as
far as the circle b: the infiltration being greater the
nearer b is approached. We will also assume that
some epithelia are often outside the area enclosed by
/', but not outside the circle c. Let us further assume
that we have to deal with the usual form of a cutaneous
epithelioma of the face, a tumor usually of slow growth,
with a tendency to extension in a horizontal direc-
tion in the skin more than in a downward one, and
with very slight tendency to lymph-gland infection,
' I desire to state that some surgeons in New York City have
been convinced of the value of caustics. At present I have
three cases under treatment referred to me by a teacher of sur-
gery in that city, and I know of other teachers here who do not in
each and ever)' case use the knife.
especially in its early period of existence. My argu-
ment, however, will hold good for all the forms of
cutaneous epithelioma, and this one form is chosen
merely in order not to occupy too much of your valu-
able time, and also because it should be sufficient to
enable you to form a judgment on the soundness of
the argument I wish to make. IE the surgeon operates
with the knife in such a case, he makes the incision a
considerable distance outside of the apparent margin
at a, knowing that in reality the disease always ex-
tends beyond that margin. Suppose he make the in-
cision at b ; say, half an inch or more outside the ap-
parent limit at a, and is careful also to cut deeply
enough and has by such an operation removed all the
pathological epithelium; the operation will be a suc-
cess as far as the removal of the disease is concerned,
and the only question remaining as regards the justice
of the operation will be the consideration of the
amount of mutilation necessarily resulting from the
operation as compared with the resulting deformity
after any other method
giving complete removal
of the disease; and when
the cancer is situated
upon the face the question . 1 # \\___L_/7
is of much importance, I II J I I u
for of two operations giv- \ Y V -^ J l—C
ing similar results as re-
gards cure, the one caus-
ing least deformity should
always be chosen if at the
same time the danger from the operation is not greater.
This point will receive attention from me later on in
the address.
If pathological epithelia are present in the area be-
tween b and c, and from clinical observation we know
that unfortunately they often do exist, let us say, more
than half an inch beyond the apparent limit, as shown
by the frequent so-called recurrences (really naked-eye
reappearances and not recurrences, as the removal in
these cases had not been complete even if the surgeon
feels satisfied he has removed sufficient tissue), and
the incision is made at b, the wound being kept in an
aseptic condition, and healing by first intention, then
being uninjured, those outlying epithelia will continue
to proliferate, and in time will become visible to the
naked eye or recognizable through the sense of touch.
In other words, the disease has reappeared, and the
operation was not a successful and radical one. Such
a result will occur every time that an incision is made
at /', and there is healing by first intention, if any
pathological epithelia are outside the line of incision.
In this case the knife has not attacked all of the out-
lying epithelia, and the aseptic method of treatment of
the wound has left these epithelial cells uninjured and
still possessed of all their inherent powers of prolifer-
ation. In my opinion such a wound should immedi-
ately after the operation be soaked with a solution
that would penetrate for some distance into the open
lymph channels and injure the epithelia within them,
or destroy the microbe if the disease is a parasitic one.
I have during the last few years used various agents
with that object in view, and am still working on in
that line, as I have been encouraged by apparently
good results. It is a point I think worthy of consider-
ation, study, and experiment, especially in connection
with the treatment of cancers such as those of the
mammary gland and rectum, and also in cutaneous
cancers in which there is invasion of the lymphatic
glands. It is not necessary that the solution employed
should interfere with the healing-process.
If the incision with the knife were to be made at c
and carried sufficiently deep, the disease would cer-
tainly be completely removed, as there would be no
pathological epithelia left, and in this case we would
538
MEDICAL RECORD.
[March 31, 1900
have merely to consider the extent of the mutilation
from the operation as compared with other methods
giving as complete a removal of the disease.
You will observe that I am discussing the treatment
of a cancer of moderate size, capable of removal by the
knife and also by caustics. Other forms of epithelioma
as regards location and extent will be briefly referred
to later on.
Now as to the action of a caustic in such a case as
I have chosen for illustration; for the sake of brevity
I shall limit the description to that of the action of ar-
senious acid, as that is the caustic agent most frequently
employed in the treatment of cutaneous cancers.
Probaialy the majority of those who use this agent in
■cancer believe that it possesses above all other caus-
tics in this disease a special selective injurious action
on the pathological tissue, a special antagonism to the
epithelial structures comprising the new growth, or
possibly the organisms if it be a parasitic disease.
Hence it is preferred to the other caustics in nearly
all cases in which it can be used with safety, that is,
without danger of poisoning the patient. A paste
made by adding sufficient water to equal parts by
weight of arsenious acid and powdered gum acacia to
give it the consistency of butter, and applied over the
whole area as far as r, will cause, as a rule, within a
period of from sixteen to eighteen hours a complete
necrosis of all the tissue within a, provided the part
is in such a condition as to allow the paste to act upon
the pathological tissue, and this condition exists when
a raw surface is present and the cancer does not lie
beneath fairly normal epidermis. I state that usually
such will be the action of the paste in that length of
time, but naturally the extent of the action will vary in
any given case according to the vulnerability of the
part to which the caustic is applied, as well as to the
duration of the application. A stronger paste, such as
one made of two parts of arsenious acid and one part
of gum acacia, would cause the same amount of necrosis
in a less period of time, perhaps in from eight to ten
hours. The operator must know the amount of de-
struction required in a given case and how much has
occurred; that is, whether the desired action has been
obtained from the application — otherwise the results
will be unsatisfactory. Only experience will teach the
proper handling of the cases. Sometimes the area a
is completely necrosed in twelve hours, and in other
cases not in twenty hours, but this amount of necrosis
can and should be produced by the paste.
Permit me to emphasize the fact that the part to
which the paste is to be applied must be in a condi-
tion to allow of the action of the caustic; for in-
stance, if the epithelioma has started from a hair fol-
licle and is still a deep-seated epithelioma, the
epidermis over it is for a time in a fairly normal con-
dition, and in this case the surface; epithelium must
be destroyed by means to be described later, in order
to allow the paste to attack the pathological tissue, as
normal tissue resists the action of arsenious acid very
much longer than the cancer tissue. .Xs I have stated,
the result to be obtained, and which can always be
obtained, is complete necrosis of all the tissues within
{7. With such action there is invariably an acute in-
flammatory process extending much beyond r, and in-
creasing in intensity the nearer it is to a, since the
tissue increases in vulnerability as the latter circle is
approached. When you have obtained such a marked
action from the caustic, you have secured what is de-
manded for the proper treatment of the case. A longer
application would destroy more tissue than is essential
and cause unnecessary deformity, while less destruc-
tion would probably not kill all the cancer deposits
outside of />. That such action as I now describe as
necessary can be obtained by arsenious acid needs no
discussion here, and the statement that a caustic can-
not directly or indirectly attack '" outlying deposits,"
such as are usually present in cutaneous cancer, is not
based on fact. The truth is that many times, especially
with dispensary patients, I have destroyed much more
tissue than was necessary, owing to the impossibility
of having the patients under observation during the
whole period of application of the paste, so as to be
able to judge when the proper amount of action had
been obtained.
Let us_ consider the effect of such an action as I
have described as proper and necessary upon a cancer
which has been treated by the caustic, and compare it
with the result obtained when the knife was used.
All of the tissue within a has been destroyed, de-
prived of its vitality, and also some of the tissue be-
yond a on account of the very intense inflammatory
process there, the tissue being much more vulnerable
than normal tissue on account of the injury received
from the epithelial invasion; hence the completely
necrosed tissue always appears to embrace a larger area
than the epithelioma seemed to occupy when seen by the
naked eye. Beyond this completely necrosed area
the inflammatory process becomes less and less intense
the less the tissue is invaded by the epithelial cells,
but if the caustic has been applied for a long period
the inflammation will be sufficiently intense to destroy
all pathological epithelia as far as />, and almost with-
out exception as far asr,- that is, the disease is re-
moved as completely as if the incision by the knife
had been made at <", although the normal tissue has
been destroyed not even as far as i. Of course the
favorable action exends in depth as well as outward in
all directions from a centre. The proof that the out-
lying epithelial cells aredestroyed consists in the fact
that the disease rarely reappears after such a condition
of necrosis and inflammation has been produced.
The destruction of these outl3'ing cells depends, in
my opinion, first, upon the existence of the acute in-
flammatory process destroying the pathological tissue
quicker than it does normal tissue, according to a gen-
eral law in pathology, and especially so in this in-
stance, as the pathological epithelia lie in the lymph
spaces, and can, therefore, be vigorously acted upon
by the inflammatory lymph, thus changing quickly and
very greatly the previous condition under which they
lived; second, that arsenic has a specially selective
antagonistic action on the epithelia in this disease;
and third, that the toxins, the toxalbumins, from the
necrosed tissue act distinctly upon the epithelia, or, if
the disease is a parasitic one, upon the organisms pres-
ent.
To repeat somewhat: from the proper action of this
caustic, the same result as regards removal of the dis-
ease is obtained as if all the tissue within <■ had been
removed by the knife, although normal tissue has been
taken from a less area than that included within i> ;
that is, that the caustic is in suitable cases a much
more conservative agent than the knife, and therefore
it should be employed in all cases in which it is
an efficient one and deformity is to be avoided as
much as possible, as in all face cases, for example,
especially in cases of nose epithelioma. It must not
be forgotten also that this method of treatment enables
the surgeon to destroy the sometimes deep-lying can-
cerous tissue that cannot be excised for some reason
or other.
The after-treatment of the wound consists in appli-
cations of an antiseptic ointment. I use subiodide of
bismuth, gr. xx. to an ounce of vaseline, allowing the
dead tissue to be thrown off by the natural process and
the part to heal by granulation-tissue formation, and
we know how well nature can repair such gaps in the
tissues. The final result is the removal of the disease,
and this often with such slight deformity that the
patients themselves are astonished. It is not correct
March 31, 1900]
MEDICAL RECORD.
539
to endeavor to make the wound aseptic, for if no pus
organisms are present the inflammatory process will
be of less duration and possibly less destructive to the
epithelia, and there will also be less granulation-tissue
formation, and hence more deformity.
When we come to consider some cases of extensive
superficial epithelioma, such as this one, the photo-
graph of wliich I now show you, and which occupies the
greater part of the upper portion of the scalp, or this
case occupying the greater part of the temporal region,
or this example of the early form of epithelioma which
occupies the entire forehead, it must be evident to all
that such cases are not favorable for a knife operation,
and yet they are not very difficult to treat with caus-
tics, nor is the prognosis especially unfavorable. The
exhibition of such cases must convince you that as far
as they are concerned the knife is not the only remedy ;
in fact, that caustics ought always be used in similar
instances.
It would take up too much time to describe the dif-
ferent forms of cancer and the different seats of the
disease in which, to secure removal, a caustic is prefer-
able to the knife, or vice versa; but in general it may
be stated that when the lymph glands are involved the
knife is the proper agent; and also when the disease
is on such a part, for instance, as the scrotum, where
a large amount of tissue can be removed without caus-
ing annoying deformity. I would not think of treat-
ing an epithelioma of the scrotum with caustics.
Most cases of cancer of the penis, some cases of can-
cer of the ear, and all cases of cancer of the lip except
the very superficial ones, require the use of the knife.
A superficial epithelioma of the lip can generally
be cured by caustic applications without causing ap-
preciable deformity afterward. I have here the photo-
graph of a case in a well-known surgeon, and it will
be seen that not a trace of deformity is to be observed.
This case was treated ten years ago and was an exam-
ple of a rapidly growing papillomatous epithelioma.
A reference to Mr. Marsden's work will show equally
surprising results. In those rare cases of glandular
carcinoma of the scalp the knife should be used to re-
move the tumor mass and a caustic applied immedi-
ately to the whole of the wound to attack the outlying
epithelia. Unless these cases are operated upon early
and thoroughly the prognosis is unfavorable, as the
lymph glands are invaded early in the disease.
It may be asked, if the above statements be true,
why it is that nearly every operative surgeon of repu-
tation thinks that caustics are not to be relied >ipon in
any case of cancer, that this method is both unscien-
tific and useless. One reason is, I believe, and that
based on good grounds, that very few surgeons have
ever used caustics, although aware that the advertising
charlatan's cures are not by any means always fake
cures; and some surgeons whom I have seen using a
caustic have not applied it according to the princi-
ples of procedure I have laid down, and consequently
the result was generally a failure. The proper caustic
and the proper strength of that caustic must be used,
and the proper amount of necrosis and inflammation
produced, otherwise the result is usually injurious in-
stead of beneficial. Unless the outlying deposits are
attacked the disease will spread with greater rapidity
than if no treatment had been employed, as the circu-
latory disturbance and nutritive condition of the out-
lying parts after the injury from the caustic aid the
growth and extension (locomotion) of the outlying
epithelia. Even when the proper caustic is used expe-
rience is required to be able to recognize when the
necessary destructive action has been obtained. Mild
caustics, such as nitrate of silver, carbolic acid, etc.,
are dangerous agents to employ, and I regard the use
of them as improper and meddlesome, injuring instead
of benefiting the case, for the simple reason that with
them you cannot attack outlying epithelia. Chloride
of zinc should not be used except to remove the
papillomatous portion of an epithelioma preparatory
to the use of arsenious acid, as it produces a dry necro-
sis and destroys normal tissue unnecessarily, and the
acute inflammatory process and toxalbumin action ob-
tained from arsenious acid are absent. The danger of
reappearance is much greater after the use of this
agent, and it produces too much deformity. A small
epithelioma can be destroyed in a few minutes with
caustic potash, but a large one should not be treated in
this way unless it be a superficial one of the lip, in
which case it usually acts very well indeed. About
fifteen years ago I used tliis agent in the treatment of
a gentleman from Canada, in whom the epithelioma
occupied nearly one-half of the mucous membrane of
the lower lip; and I defy any one to recognize to-day
that he has ever had any disease of that region. With
the caustic potash you get the inflammatory process
and toxalbumin action, but it destroys normal tissue
to such an extent that it should never be used if ar-
senious acid can be employed with safety.
No reliances should be placed on methylene blue,
resorcin, salicylic acid, or pyrogallic acid, when we
have agents of decided action and virtue.
As already stated, it is useless to apply arsenious
acid to cancer covered with normal epithelium; that is
the reason why in some cases, especially the pearly
form of the disease, curettage sufficient to make a raw
surface should always be employed before the caustic
is applied. In the deep nodular form the epithelium
can be destroyed by caustic potash. Some surgeons
rely upon the use of the curette alone, but Pam abso-
lutely satisfied from a consideration of the patholog-
ical anatomy of epithelioma, as well as from clinical
experience, that it is simply an impossibility to re-
move all the pathological and leave the normal tissue
intact, or to know when the sound tissue has been
reached. The knife is far superior to such a method.
The curette can occasionally be used to remove the
mass of a large epithelioma in order that the arsenious-
acid paste can be applied near the peripheral part of
the growth.
If the surgeon has observed only cases treated in
some of the ways I have just mentioned as being
imperfect, useless, or injurious, then I can under-
stand his belief in the knife as the only proper
agent to be employed; but if he were to choose his.
cases and in the treatment of them follow precisely the
principles and methods I have just given you, he.
would recognize that the proper treatment for a given
case depends upon the kind of epithelioma, its size,
its method of extension, and its location, and that for
the majority of the cases of cutaneous cancer the caus-
tic method properly employed gives the best results
both as regards the removal of the disease and the
minimum of deformity from the operation.
It is just as important that the pathological anatomy
of the disease, the normal anatomy of the part, and the
technique of the operation be well known.by the oper-
ator as if the case were one of visceral cancer or of an
abdominal tumor. Neither the knife nor the caustic
should be blamed for the faults of the operator. There
are some cases of cutaneous cancer that are incurable
when first seen by the surgeon, the disease having
progressed too far; other cases are fatal because the
physician or surgeon has dallied with the case, rely-
ing upon ineffective or injurious agents; and finally
not a few cases have a fatal termination because the
patient is not seen often enough, nor for along enough
period after treatment has been commenced. I know
of more than one patient I have lost because I failed
to insist upon his remaining under my observation.
In this respect medical men make the worst patients,
and in the end are always dissatisfied if the disease
540
MEDICAL RECORD.
[March 31, 1900
reappears. A case should not pass out of observation
for at least one year, whether operated on by the knife
or by caustic, as there is always a possibility of reap-
pearance which demands immediate attention.
In those cases in which there is a tendency to the for-
mation of epithelioniata the complete removal of one
tumor does not prevent the formation of new ones, and
the treatment in this case is not deemed unsuccessful
on account of the recurrence. These cases require
watching as long as the patient lives.
It can be safely said that if cutaneous epithelioma
is seen early and treated properly, either by caustics
or the knife as the case demands, the disease is any-
thing but the necessarily fatal one too generally be-
lieved by the medical profession, a belief that has
been the cause of much dangerous advice to patients.
Finally, if the profession will study this subject as
I have now presented it, and the works on surgery will
represent facts as regards the results of different meth-
ods of treatment more than individual experience, the
advertising "cancer specialist " will not be treating
cases that should belong to the regular profession.
These "specialists" will, however, continue to treat
them just as long as the laity have proof that a caus-
tic has cured many a case that has already been oper-
ated upon by the knife on orthodox principles, because
the surgeon believed that '"outlying deposits could be
removed by the knife only and not by caustics."
Conclusions. — i. At present we know of no drug,
animal extract, serum, or toxin, which, given inter-
nally by any avenue of the body, can be relied upon
for the cure of cancer of any part of the system.
2. That the statement that the knife is the only re-
liable agent in the treatment of cancer is not correct.
3. That certain caustics judiciously chosen and
properly applied may attack deposits of the growth in-
accessible to the knife, and in these cases should be
employed even if the knife is necessary to prepare the
way for their use.
4. That in some cases both the knife and caustics
should be used, and in some other cases curettage,
followed by a caustic, is the proper procedure.
J. That the majority of cases of cutaneous cancer
can be removed with the greatest certainty and with
least deformity by caustics, provided the patients are
seen before the lymphatic glands are invaded.
6. That the knife should be used when the lym-
phatic glands are invaded, and also in some other cases
of external cancer.
THE CARDINAL PATHOGNOMONIC SIGN OF
FRACTURE OF THE LOWER END OF THE
RADRIS (COLLES').
By martin \V. WARE, M.D.,
The erroneous teaching of the invariable occurrence of
silver-fork deformity in Colles' fracture is still fostered
by this ever-repeated stereotyped expression in the
current text-books of surgery and special treatises on
fractures, which accord undue prominence to this sign.
In an experience of three himdred cases of fracture
of the lower end of the radius, this sign was encoun-
tered in less than ten per cent, of the cases, and for the
establishment of the diagnosis in all of these instances
reliance was placed on a far more logical and anatom-
ical sign, which a careful perusal of the literature has
convinced me is, to judge by its omission, unfamiliar
to the greater number of surgical writers.
A comparison of the outlines of what various authors
concede to be silver-fork deformities shows widely
different impressions to be gained, and this be it said
without belittling the significance of this sign when
present; yet, granting that these variations may rep-
resent different degrees of this fracture, so variable
and inconstant a factor ought not to be accepted as
paramount in the diagnosis of Colles' fracture. It
would, therefore, seem desirable to rely upon a certain
and ever-constant anatomical landmark analogous to
the Roser-Nelaton line, or to the bicondylar olecranon
relations at the elbow. That such a landmark exists,
a palpation of the topographical prominences of the
normal wrist shows. The styloid of the radius is at a
lower level than the styloid of the ulna. This is
always the case, normally differing in degree accord-
ing to the development of bones, being more marked
in males than females, less so in infancy. With the
hand in the prone position and on the same plane with
the bones of the forearm, this sign is most readily
ascertained by then impinging the thumb and index
finger against the styloids: and, projecting a line be-
tween these two points, it will take an oblique course
slanting to the radial side. This is the line I would
take advantage of in interpreting injuries about the
wrist joint. As, roughly estimated, in ninety-five per
cent, of the fractures of the radius there is impaction,
the shaft must be shortened, but this is so slight in the
majority of instances that it cannot be measured with
the tape.
It has been my experience that silver-fork deformity
is the exception /<?/• twielleiice in Colles' fracture. More
frequently many of the other signs, particularly local-
ized tenderness alone, pointed to a suspicion of a frac-
ture, but in every instance the one logical fact of the
levelling of the styloids only justified the diagnosis.
An estimate of the existence of the levelling or eleva-
tion of the radial styloid should be the first manoeuvre
in ascertaining a fracture, thus precluding any further
manipulation until reduction is performed. It would
suggest itself that this relation of the styloids ought to
be an index as to proper reduction; this is but rela-
tively so, as an absolute restoration of the normal rela-
tion of the styloids is impossible in the greater number
of instances; at the best an approach thereto can be
aimed at, since the comminution at the line of fracture
has often been so great that even when the impaction
has been broken up the subsequent absorption of bone
causes a shortening which is again apparent in the
relation of the styloids. The converse, however, may
be held, that when there is an elevation of the radial
styloid and a history of injury such as precedes frac-
ture of the wrist, even in the absence of any other de-
forming signs, a verdict of previous Colles' fracture
can be rendered. The persistence of the altered rela-
tions of the styloids is not to be interpreted as inter-
ference with the growth of the bone, for it occurs even
after the age limit at which epiphyseal junction has
taken place. Once I fell into error by crediting this
altered relation to a fracture, whereas syphilitic epiphy-
sitis was solely responsible for the condition.
I have tested this sign these past four years, and so
unfailingly has it been present that I now, in conjunc-
tion with the corroboration obtained from some older
literature, would accord it the dignity of the cardinal
pathognomonic symptom of Colles' fracture.
The only mention of this sign in any English text-
book occurs in Stimson's treatise on '* Fractures and
Dislocations." Both in the first and second editions
he says: "If the surgeon marks the positions of the
styloid processes by pressing the end of the finger into
the side of the joint below and against the end of each,
he will see that of the radius has risen so that instead
of being a quarter of an inch lower (nearer the hand)
than that of the ulna, as it usually is, it has risen to
the same level or even above it." In the text these
words are subordinated to other remarks bearing on
March 31, 1900]
MEDICAL RECORD.
541
this fracture, and in the paragraph on diagnosis this
sign is entirely neglected, and sole reliance placed
when in difficulties on localized tenderness. Recently,
however, Stimson in connection with his radiographic
studies called attention to the fact that " the promi-
nence of the ulna was due to the ascent of the radius."
Nowhere in the German literature is cognizance taken
of this phenomenon.
In the Arc/lives of Roentgen Hays (vol. iv., p. 22,
1899), Mr. J. Lynn Thomas says: "A line at right
angles to the radius and ulna should always be drawn
(when studying Roentgen photograms of old injuries
to the wrist) immediately on the hand side of llie artic-
ular surface of the ulna. This line is the only safe-
guard for rightly interpreting old healed-up fractures
of the lower end of the radius. The whole of the artic-
ular surface of the radius when in its normal position is
on a plane situated on the hand side of the diagnosti-
cating line. When the radial styloid is on a level
with that on the ulnar it is considered to be in itself
of such importance as to establish the diagnosis of a
Colles' fracture, and is known as the ' signe de Tan-
gier' in France."
Malgaigne looked upon the localized tenderness as
a pathognomonic symptom.
Gosselin ' says: "In the absence of the silver-foik
deformity, what is above else the principal element in
the diagnosis in fracture of the lower end of the ■ adius,
which I depend upon to establish the natur- of the
lesion ... I have found that in such instances the
styloid apophyses are almost on the same plane; in
other words, that they are situated on a plane forming
two right angles at the junction of a plane passing in
the line of the axis of the forearm. You know, in fact,
that in the normal state the radial apophysis is situ-
ated a little lower than the ulnar, and that a plane
joining these two is obliquely intersected by the axis
of the forearm."
Still more pertinent is the following quotation from
Richet," writing in 1882: " If you would avail your-
self of palpating on the skeleton, the bony prominences
in which the bones of the forearm terminate, viz., the
styloid apophyses, one is struck by a peculiarity which
is not mentioned by the classic authors, and which I
have repeated in my clinics for ten to twelve years.
. . . Embracing the apices of the styloid processes be-
tween the thumb and index fingers in a healthy wrist,
one notices that these prominences are not on the same
level, the radial being much lower than the ulnar. In
a fracture at the wrist, on the contrary, one can see
that the styloids are on the same level and that the
radial apophysis is even higher. This is a sign that
never fails. Moreover, since these prominences are
well marked, being superficial, it is always possible, I
should even say easy, to feel them, and consequently
to attach the importance to tbem to which I have just
alluded. I shall go even further, and I shall say that
the confirmation alone of this deformity suffices to
affirm this diagnosis."
Of still more recent date is the opinion quoted from
the " Traite de Chirurgie " ^ : " In consequence of the
penetration of the fragments the styloid apophysis of
the radius, which normally descends below that of the
ulna, ascends to the level of the latter. This is known
as the ' sign of Tangier.' It is of the greatest impor-
tance, and suffices of itself to establish the nature of
the lesion."
In estimating this sign the normal wrist must always
be taken in comparison. This sign antedates the use
of .v-rays; in addition it has stood the test of them,
and so conspicuously does this altered relation of the
' Gazette des Hopitaux, 1879, Hi., p. 697.
' La France Medicale, 1882, i. pp. 97-101.
^ Duplay et Reclus : " Traite de Chirurgie," second edition, t.
ii., p 525-
Styloids figure in skiagrams, that just herein lies the
greatest confirmation of its practical service.
Its value maybe summed up as consisting in the fa-
cility of its clinical application, wherefore A'-rays may
be dispensed wit! , and the patient spared the needless
suffering of manipulation to learn the nature of the
lesion. It rests on sound anatomical data, which
makes it a log cal sign. It is in part an index as to
what has to bf aimed at in reduction, and it is also
ever after a landmark of the site of the healed fracture.
For these reasons I accord it the dignity of " the
cardinal pathognomonic sign of Colles' fracture," in
the hope that a co isideration of the value of this sign
will further the recognition and incidentally the treat-
ment of a larger number of fractures.
LOCOMOTOR ATAXIA.'
By B. C. LOVELAND, M.D.,
Locomotor ataxia, posteiior spinal sclerosis, tabes
dorsalis — these are synonyms for a progressive degen-
eration of the spinal cord, marked by more or less of
anaesthesia, analgesia, parjesthesia, and inco-ordina-
tion, and later muscular paralysis. The only apology
I have to offer for bringing such an old and well-
s'udied subject before this society is that in its early
or pre-ataxic stage it is often o\'eriooked, while its va-
rious symptoms then presenting are treated as inde-
pendent phenomena, and what hope there is in treat-
ment depends largely on its early recognition.
It is not within the province of this paper to go into
a detailed study of the etiology of this disease, and
yet a few words as to its cause, or causes, should not
be omitted. It is pre-eminently a post- or para-toxic
degeneration. The toxic infection which has been
found to furnish the soil for the growth of this form of
degeneration in a vast majority of cases is syphilis.
So frequent is the specific history in these cases that
many authorities regard the exceptions as incomplete
histories, and not as posterior sclerosis without the
luetic infection. The percentage of cases with syphi-
litic histories varies with different authors from eighty-
seven per cent, to ninety-three per cent., and yet it is
conceded that such toxic conditions as ergotism and
pellagra may furnish the predisposing cause, and there
may possibly be others added to the list as our obser-
vation increases.
Pathology. — While the etiology of tabes dorsalis in
most cases is inseparable from syphilis, the pathology
is not the pathology of syphilis. It has a distinct
pathology of its own. As one author has graphically
expressed it, "The blackened and charred stumps and
seared grass are not fire, but they mark the track where
the fire has been." So posterior spinal sclerosis is
not syphilis, but it marks the devastation which fol-
lows in its wake. It is a true degenerative process,
beginning, according to various authors, either in the
peripheral sensory nerves or in the ganglia on the
posterior roots, which contain the trophic centres con-
trolling these nerves. The degeneration is fibrous in
character, compressing and finally obliterating the true
nerve structure. Its course is from the periphery
toward the centre of the nervous system, the degenera-
tive process following each nerve affected from its
peripheral end through its entire length, even after it
enters the cord, till it reaches the nerve cells into
which the afferent impulse is discharged, following the
order of degeneration observed by Waller after the
' Donald T. Mackintosh : " Skiagraphic Atlas of Fractures
and Dislocations," London, 1899.
' Read before the Onondaga Medical Society, March 6, 1900.
542
MEDICAL RECORD.
[March 31, 1900
section of an efferent nerve fibre. The number of
nerves at first involved ma}' be small, and it may begin
its work at the lower, the middle, or the upper or cer-
vical sections of the cord, and the early symptoms will
vary accordingly. As the disease progresses, more
and more nerve fibres are implicated, and the hardened
or sclerotic area in the cord is correspondingly in-
creased. The same degeneration may also involve the
medulla, and in certain cases it attacks brain structure,
though rarely. It may be said, however, that the
pathological change found in the brain in paretic de-
mentia is identical in character with that found in the
cord in tabes. It seldom if ever seems to attack
the various sections of the cord with equal force at the
same time. If the process is actively progressing in
one section, it will check in another. The posterior
columns of the cord are the ones affected, as the name
implies, though in some advanced cases the degenera-
tion spreads over into the lateral columns.
Symptomatology and Diagnosis.— It goes without
saying that in this disease, in which the pathological
changes are confined almost entirely to the sensory
nerves, the subjective symptoms, or the feelings de-
scribed by the patient, hold a strong place among
diagnostic signs, but should always be followed up and
verified, or set aside, by the physical signs. Among
the. most frequent symptoms complained of are a feel-
ing of general weakness, a tendency to stagger at night
when getting out of bed, a feeling of numbness in tiie
limbs, a velvety or padded sensation in the bottoms of
the feet, and sharp, shooting pains in the legs or
lower part of the abdomen. Very early in the history
of the case the patient will occasionally mention un-
usual sexual excitement; a little later, and compara-
tively early in the case, partial or complete impotence
follows, and is often referred to by the patient as a
result of his excesses, but from the pathology of the
disease it will be otherwise accounted for. There may
also occur as early signs the various crises so called,
most commonly of the stomach, which consist of sharp,
extremely painful attacks, sudden in their onset, equally
sudden in their subsidence, and baffling relief by any
of the ordinary remedies. The gastric crises are
accompanied by severe and intractable vomiting, in-
creased by anything taken into the stomach. Entire
rest to the stomach and the use of hypodermic injec-
tions of morphine may be required. The laryngeal
crisis is less frequent, but quite as distressing, by
reason of its paroxysmal and uncontrollable coughing
and dyspnoea. Occasionally hemiplegia is an early
symptom, recovering after a short time. Sometimes
also we see a paralysis of single muscles, notably those
of the eye, also transitory in nature. The pupils may
be unequal in size; may respond to accommodation,
but not to light (.\rgyll-Robertson symptom); or may
be sharply and firmly contracted. Sometimes among
the early symptoms we find a contracted visual field, a
narrowed or diminished color field, and optic neuritis
or atrophy. Muscular strength may remain good, and
the ataxic gait may not appear for a longtime, or pos-
sibly never appear in rare cases. Among the cerebral
symptoms noted early are insomnia, vertigo, depression,
more rarely melancholia, and very rarely general pare-
sis. Bearing in mind that the degenerative process
may begin in any part of the central nervous system,
the early symptoms wi'.l vary in their manifestations
according to the portion of the cord or medulla affected.
The practical identity of the pathological processes in
paresis and tabes would almost warrant the statement
that the diseases are essentially one, except that in the
former cerebral symptoms predominate, while in the
latter spinal symptoms have the lead. No one symp-
tom can be called pathognomonic, but any of the
symptoms noted should prompt investigation, and if a
fixed pupil as regards the light reflex, absence of knee
jerk, and lightning pains are present, a diagnosis may
be made witli certainty, even though the gait is not
ataxic.
Prognosis Of course in a disease based on such
fixed pathological conditions a cure, or the restoration
to normal conditions, is an impossibility, therefore we
must be satisfied with relief of distressing symptoms,
and must consider as a success any treatment which
will check the progress of the disease. The length of
time required for this disease to run its course is in
different cases from three to thirty years, and in most
cases death ensues from intercurrent affections. By
some authors it is divided into two classes, severe or
malignant, and benign. The severe cases run a more
rapid course and manifest a more persistent tendency
to progress than the benign cases. An early diagnosis
adds much to the favorableness of the prognosis, for
all that is done must be by way of preventing the
progress of the degeneration, as reorganization of the
diseased tissue cannot be accomplished.
Treatment. — Much of the treatment must be directed
toward relieving the distressing symptoms and in-
creasing the patient's general health, and may be
divided into medical and hygienic, including mechan-
ical and hydrotherapeutic.
The medical treatment at first should be directed to
the relief of the lightning pains if they exist, and for
that purpose powders containing phenacetin gr. v., cit-
rate of caffeine gr. ss., given as occasion requires, will
be found useful. Next considering the probability of
a specific history, and the possibility of effusion in the
spinal canal as a provoking cause, it is well to use
some pronounced specific treatment for a few weeks,
unless you are sure that such a course has been taken
quite recently. If good results follow, such a course
may be repeated every three months. It must be
borne in mind, however, that the general effect of heavy
doses of mercury or iodide of potassium is depress-
ing to the nutritive system and may do harm; there-
fore, if no positive good results, they are best aban-
doned. Str}'chnine and tonics generally do not hold
the strong place that they are supposed to hold in the
treatment of many of the functional nervous disorders.
Any specially troublesome symptom may require spe-
cial medication.
The hygienic treatment includes, first and most
important, rest. This should be thorough, and it is
sometimes advisable to institute a systematic "rest
cure." At all events the patient should refrain from
any exertion which would exhaust him, and also from
worry and anxiety. Next in importance, and at pres-
ent growing in popularity, is exercise. This should
be so prescribed as to get the patient to perform with
care and precision, aided by sight, those motions
which, owing to his inco-ordination, can no longer be
done automatically. It is not necessary here to give
the movements in detail which have been prescribed, as
any one with ordinary ingenuity can work out a reason-
ably useful set of exercises. Massage, for its general
effect in aiding tissue change, is often very useful, and
the same may be said of electricity. The faradic cur-
rent for general application helps to prevent the atro-
phy of muscles, while the galvanic current applied after
the manner called central galvanization, or a simple
spinal application, often helps to improve the circula-
tion in the spine. Stretching the spine has been found
to give some relief to the pains, and also, temporar-
ily at least, to increase the sexual vitality. Stretching
of the spine was at first accomplished by suspension in
the Sayre apparatus, but the same results without the
dangers can be obtained by flexing the body strongly
on itself. The modus operandi advised by Church
and Peterson is to seat the patient on the floor, and
ask him to bend forward as far as possible, keeping
the knees straight, while the physician presses down
March 31, 1900]
MEDICAL RECORD.
543
on his head, graduating the pressure according to his
judgment. This position is supposed to increase the
size of the openings between the vertebrae through
which the nerves and blood-vessels pass, thereby in-
creasing the circulation in the spine. By the method
of extension in one case I was surprised to see the
patient, who had for a long time been obliged to use
two crutches to get about at all, so far improve that he
went to work in a shop, and was able to walk back and
forth to work by the aid of one cane, sometimes two,
and the improvement remained for several months
while he was where I could observe him. The warm
or tepid bath is also of much use in relieving the
pains, and is best given as follows: A tub is filled
two-thirds full of water at 92° to 94° F. ; the patient,
disrobed, sits in the tub for twenty m.inutes. He is
then taken out, wrapped, without drying, in a fiannel
blanket, and laid on a couch, while an attendant
gently rubs the limbs through the blanket for the
space of another twenty minutes.
We are all sufficiently familiar with the disease in
its later or more pronounced development, but I shall
report for illustration one or two cases that belong to
the benign variety.
Case I. — Hon.' J. Q. A. B , October 26, 1897;
age, fifty-five years; weight, 160 pounds. The disease
had been recognized ten years before, when he began
to have the padded feeling in his feet. He had been
much depressed. He was of a constipated habit, and
his lancinating pains had been most severe and un-
yielding.
Present condition : No knee reflex was obtained ;
Argyll-Robertson pupil; the gait was not ataxic; the
Romberg symptom was not marked, but slight; there
was analgesia on the outer surfaces of both legs and
outside of both arms below the elbow; the lancinating
pains were frequent and severe. The diagnosis was
plain, although there was no sign in his walk.
Treatment; He was given proto-iodide of mercury,
gr. J, t.i.d., and a pill containing strychnine, gr. J,j, after
each meal, together with the warm sitting-bath de-
scribed above. As a result, his spirits had much
improved, and he had escaped the lancinating pains
for nearly two weeks when he left my observation.
From the fact that no systematic and prolonged treat-
ment had been pursued, I think that this case was a
benign one, and stopped its progress spontaneously.
The relief of pain following the treatment described
was, however, very marked, and may perhaps be cred-
ited to the treatment.
Case II. — Mrs. F. A. G , forty-four years old;
June 3, i8g8. Her history was as follows: She was
married and had two children, the youngest seven
years old; no miscarriages. She had had malarial
fever each spring for several years. Heredity was
good. She began to have shooting pains in her limbs
two years ago, and was treated for sciatica, and later
for neuritis. She became sleepless, greatly depressed,
and suspicious, especially of her husband. She cries
a great deal. She eats little; has lost about thirty
pounds of flesh. She still has severe pains in her legs.
Physical examination : The tongue was coated ; the
pulse and respiration were normal; the bowels were
regular. Urine, specific gravity 1.030, acid, with oxa-
lates. Blood showed hfEmoglobin eighty per cent., red
corpuscles 5,680,000. There was no knee reflex. She
had Argyll-Robertson pupil. She walked well, but
showed slight unsteadiness when the eyes were closed.
Diagnosis, tabes in the first stage.
Treatment consisted in removal from family, with
rest, massage, warm bath, and bromide and salicylate
of sodium of each gr. x., well diluted, three times a day.
Her pains improved rapidly; sleep returned, and the
depression disappeared to a large extent. Proto-iodide
of mercury gr. i before each meal, with salol gr. v.,
and phenacetin gr. iiss. when required for pain, were
substituted for the bromide and salicylate of sodium.
At the end of a year she reported as having been prac-
tically free from pain nearly the whole period. She
had continued the proto-iodide a large portion of the
year. On examination she showed a slight knee reflex,
better in her left knee, and a very slight reaction of
one eye to light. Other signs had remained the same,
except that she had gained some flesh. This case it
seems to me profited by a fairly early diagnosis, and
received much benefit from treatment, though it was
not of the worst type as regards rapidity of progress.
Caesarean Section m the Moribund. — Anton
Prokess says that in sudden death the results of sec-
tion are bad, because the foetus dies before the mother.
It has therefore been suggested not to wait for the
actual death of the mother before operating. A case
is added to the statistics of successful performance of
Cesarean section under these conditions.- — Central-
blattji'ir Gyndkologie, March 3, 1900.
The Pathogenesis of Cyclic Albuminuria Dr.
Rudolph says the centre of disturbance in this affec-
tion is still unknown, and there is no sure method of
cure. The best one can do is to spend a number of
months in Southern climates. A case is related of a
boy who showed albuminuria when active, but which
disappeared when he was in bed. Still rest did not
effect a cure. Two girls recovered without the rest
cure. The various theories of causation are reviewed.
— Ccntralblatt Jiir iiinere Aledicin, March 3, 1900.
Expanded Metal, a New Splint Material, Espe-
cially for Use in Military Surgery. — C. Hubscher
recommends a new metallic substance used in build-
ing and largely employed in the Paris Exposition
structures, for use in making splints with plaster or
cement. It can be moulded to any part, and padding
is scarcely necessary. Its advantages in field surgery
are its lightness and ease of transportation. — Ccntral-
blatt Jiir Chinirgie, March 3, 1900.
Electrolysis as a Means of Curing Chronic Gland-
ular Urethritis. — George Walker has employed the
method learned in KoUmann's clinic and found it sat-
isfactory chiefly when the glands of Littre and crypts
of Morgagni are involved. The treatment was origi-
nated by Oberlander, and consists in inserting a fine
needle into each opening. A decided urethritis is set
up by the process. Strictures have resulted, but can
be avoided by care in application. — Maryland Medical
Journal, March, 1900.
Changes in the Skin in Paralysis Agitans. —
Robert Reuling speaks of the addition to our knowl-
edge of pathology by Fraenkel's discovery of changes
in the skin in paralysis agitans. The frontalis symp-
tom recently described is best brought out by getting
the patient to look upward for two minutes and then
downward. The deep wrinkles require three or four
minutes to disappear. Fraenkel thinks it due to thick-
ening of the skin and loss of elasticity, though there
may be little change in appearance. A case is re-
ported with microscopical examination showing in-
creased connective-tissue growth in the true skin and
subcutaneous connective tissue. Skin changes were
found in four out of six cases examined, but no direct
relationship is traced between them and the tremor.
The author regards them as trophic phenomena. —
Maryland Medical Journal, March, 1900.
Surgery of the Lungs. — h.. Parozzani, referring to
operations upon wounded lungs, says that owing to their
544
MEDICAL RECORD.
[March 31, 1900
gravity in patients already weakened by traumatism,
to the action of chloroform upon respiration performed
by one lung only, and of the possible induction of
purulent pleurisy, surgical intervention should be
resorted to only in cases in which the blood comes
out in spurts, and there is forcible blowing in the
bronchi. In other cases rest in bed in a half-sitting
position, liquid diet, an ice-bag on the chest, and in-
jections of morphine and ergotin, and caffeine for
cardiac adynamia will be the best treatment. — Rhista
MeJica tiella Regia Marina, December, 1899.
Modern Surgical Treatment of Infantile Spinal
Paralysis. — A. Codivilla gives a long theoretical dis-
cussion of the methods to be adopted in the treatment
of muscles left in a condition of contracture by paral-
ysis. His work is based upon the results of forty
transplantations and plastic operations on tendons. —
II Poliilinico, February 15, 1900.
Exstrophy of the Bladder from Ulcerative De-
struction of the Scar of a Suprapubic Cystotomy. —
L. Kolipniski relates a unique case in a man after
suprapubic removal of calculi. After about four years
there was a swelling about the cicatrix due to urinary
infiltration. An incision was made, but sloughing
occurred and was followed by protrusion of the supe-
rior and posterior walls of the bladder. Death took
place on the fifth daw — Maryland Medical Journal,
March, 1900.
Movements, and Relative Change of Form and
Position in a Human Foetus of Five Months. —
Fabio Rivalta incised the thorax of a five-months
fcetus, and found the heart pulsating at the rate of
twenty-four times to the minute. The contraction of
the four heart cavities was not simultaneous but suc-
cessive. Although there was no blood current, the
movements of rotation of the heart in relation to its
longitudinal and transverse axes, the uplifting of the
apex, and the downward drawing of the apex of the
pulmonary artery and base of the aorta were exactly
the same as under physiological conditions. — Rivista
Critica de Clinica Medica, February 24, 1900.
Causes for the Weakened Virulence of Vaccine
in Hot Climates, and the Remedies Therefor. —M.
Hervieux gives the causes of the attenuation and de-
struction of the power of vaccine, as heat, especially
damp heat, winds such as the sirocco, and age. Vac-
cine, as soon as prepared, should be placed in a refrig-
erator, transported in one, or else wrapped in wet cloths,
kept moist and placed in a draught of air in the shade.
In the hot seasons it should be used as soon as possi-
ble after its reception. — Bulletin de V Acadhnie de Mide-
cinc, February 13, 1900.
Mucous Polypi of the Nasal Septum. — Oliviero
Barrago-Ciarella reports a case of this rare affection.
The left nasal fossa was completely filled with the
polypi; in the right one was an oblong tumor, about
the size of a bean, pedunculated and inserted on the
septum. It was at once removed by the use of Wilde's
snare. There was no hemorrhage. The chief symp-
toms given by the neoplasm were headache of the
right side and obstruction of the nose, sometimes to a
slight extent, sometimes total. — Giornale Internazionale
delle Siicnze Mediclie, January 15, 1900.
A Rare Complication of Progressive Locomotor
Ataxia. — P. J. de Bruine Ploos van Amstel believes,
from the literature on the subject and from personal
observations, that the following conclusions can be
drawn: (i) Progressive locomotor ataxia is not an
essential malady, but a sequel of syphilis, and may be
considered either a " nachkrankheit " or a post-syphi-
litic intoxication; (2) aneurism and insufficiency of
the aorta in the ataxic patient are not accidental
complications, but they are also caused by syphilis;
they are also the " nachkrankheiten " of syphilis. —
Lyon Medical, January 14, 1900.
Acute Rhinitis. — W. S. Fowler says that from the
notes of the last hundred cases of acute rhinitis which
have passed through his hands, seventy-six showed
clear and unmistakable constitutional symptoms as
the cause; six were due to external local irritations,
mostly occupation irritants; sixteen were recorded
tentatively as due to contagion. The author has found
that treatment addressed to the underlying cause has
given the greatest success, and thinks that many physi-
cians have fallen into a habit of treating the symptoms
only, neglecting to give proper value to temperament
and diathesis. — Southern California Practitioner, Janu-
ary, 1900.
Chyliform Ascites F. Micheli and G. Mattirolo
describe a series of experiments conducted for the pur-
pose of ascertaining to what is due the opalescence
noticed in certain ascitic effusions in which there is
but little fat. Their conclusion is to the effect that in
many cases lecithin is the cause of this milky appear-
ance.— Rivista Critica di Clinica Medica, January 27,
1900.
Total Ossification of the Choroid ; Sympathetic
Irido-Choroiditis ; Sanguineous Infiltration of the
Cornea ; Blindness. — Carlo Fruginele reports a case
in which blindness of one eye, due to corneal ulcer,
was followed eight years later by sympathetic inflam-
mation of the other eye. A slight blow received upon
the latter in its enfeebled condition must have caused
laceration of some blood-vessel, for an infiltration of
blood followed. Total blindness was the final result.
— Gazzctta Internazionale di Medicina Pratica, Febru-
ary 15, 1900.
Lumbar Puncture in Pediatric Practice. — Carlo
Giarre considers this procedure valuable for the diag-
nosis of meningeal hemorrhage, serofibrinous, purulent,
and tuberculous meningitis, the extracted fluid differ-
ing in its physical and chemical properties from that
obtained in some other conditions. With increased
knowledge of the pathogenesis of acute serous menin-
gitis and the nervous troubles known as "meningism,"
it is probable that lumbar puncture will give better
therapeutic results than any other measures known.
Quincke's operation is especially indicated in many
of the diseases observed, especially in infancy. — Riiista
Clinica di Critica Aledica, February 3 and 10, 1900.
Chorea of the Larynx. — A. Onodi says that this
affection has nothing to do with general chorea. He
briefly describes our present knowledge concerning the
latter affection, and reviews the literature which has
appeared since Ziemssen's article upon chorea of
the larynx so-called, in 1875. A special analysis is
made of the case reported by Preysz, which is the first
publication concerning the pathological alterations of
the vagus and recurrent nerves in this affection. Onodi
collates the views of several prominent laryngologists,
and believes that the term "chorea of the larynx"
should be given up, as most if not all of the cases
hitherto thus described can be included under other
clinical groupings, and because the condition is not a
true chorea. Some are cases of hysterical cough,
some are phenomena of imitation, and others are sim-
ply spasmodic habit. He would admit the designation
for some cases of " choreiform movements of the vocal
cords." A valuable bibliography is given, and also a
discussion of the paper before the Medical Society of
Budapest. — Revue Hebdomadaire de Laryngologie, etc.,.
January 13, 1900.
March 31, 1900]
MEDICAL RECORD.
545
Medical Record:
A Weekly Journcil of Medicine and Siirgety.
GEORGE F. SHRADY, A.M., M.D., Editor.
PtrELISHERS
WM. WOOD &. CO., 51 Fifth Avenue.
New York, March 31, 1900.
INTER-STATE RECIPROCITY IN MEDICAL
LICENSING.
This is a somewhat complicated subject, and is hedged
in by so many intricate points that a lucid and wholly
intelligible presentment of its "pros and cons" is a
far from easy task. Any man of ordinary intellectual
capacity can understand that until there is a uniform
standard of medical education in all the States, it
would be manifestly unfair to place the graduates of
the various schools throughout the country on a perfect-
ly equal footing. The States which maintain a high
standard of medical education have undoubtedly the
right to protect their own physicians. In fact this
course is incumbent upon them. Therefore the State
of New York, for instance, in which such a standard
is insisted upon, requires that outside physicians,
without any discrimination, who may wish to practise
within its borders, shall undergo a further examina-
tion as a proof that they possess the requisite medical
knowledge.
This decidedly just procedure is, however, a matter
for grave complaint to many regular physicians from
other States, some of whom have raised the question
as to its legality, contending that the Constitution of
the U^nited Stages by its very words protects them
from the necessity of being subjected to this further
examiijation. The provisions referred to read thus:
"Article IV., Section 1. Full faith and credit shall
be given in each State to the public acts, records, and
judicial proceedings of every other State. Section 2.
The citizens of each State shall be entitled to all
privileges and immunities of citizens in the several
States." To deal with these points in all their rami-
fications would necessitate the writing of a pamphlet,
but at the same time it is possible to indicate briefly
why these constitutional provisions do not exempt the
outside physician from the need of complying with
the particular regulations of the State to which he
goes. The "full faith and credit clause," so called,
cannot be relied on in support of the contention, as
this clause is construed only to refer to the judicial
proceedings of the several States. A physician's
license is not such a judicial proceeding as the clause
of the Constitution contemplates. Therefore there is
no need to dwell upon this phase of the matter at
greater length.
A more serious question, however, is involved in the
words included in Section 2. It Is natural for a phy-
sician duly licensed in another State to ask why the
assumed privileges and immunities as a physician of
that State do not protect him from the necessity of
passing a further examination when he comes to New
York to practise. A full comprehension of this ques-
tion in all its bearings depends upon a proper under-
standing of the history of the United States. Before
the several States adopted the Constitution of the
United States in 1789, each of these several States
was a complete independent sovereign. When the
Constitution was adopted, the national government
was thereby created with certain powers; and those
powers resulted from the surrender by the individual
States of certain features of their own sovereignty.
In order that the sovereignty of the different States
should not be altogether merged in that of the central
government, the following amendment was added to
the Constitution : " The powers are not delegated to
the United States by the Constitution, nor prohibited
by it to the States respectively or to the people."
It has thus resulted that the individual States were
in no wise divested of their sovereignty by the ado v
tion of the United States Constitution except so far as
that instrument shows an express surrender of their
sovereignty. In all other respects they have retained
it. Every State, for example, has retained unimpaired
its original power to make police regulations, included
among which is the right to make laws concerning the
regulation of the practice of medicine. This proposi-
tion has been fully determined by the supreme court
of the United States, and the courts of the individual
States have uniformly sustained the power of their
States to pass legislation of this character. Conse-
quently the State of New York is undoubtedly within
its rights in requiring physicians to pass an examina-
tion before they can be licensed or registered. When
a physician comes from another State to New York he
brings with him all the rights which he enjoyed "as
a citizen," but his right to practise medicine in an-
other State never was possessed by him merely be-
cause he was a citizen. He enjoyed that right because
he had conformed to the regulations and laws of the
State in which he lived. The fact of being a citizen
of New York confers no right to practise medicine
merely because of tiie citizenship. In a few words, if
a man goes to another State he carzies with him only
his bare rights as a citizen, and must conform to the
police laws of any State he may choose to enter.
These views have been upheld times without num-
ber by the supreme court of the United States. There
are other solid arguments in support of the contention
that every State possesses the indisputable right to
regulate the practice of medicine within its jurisdic-
tion, but these are too lengthy to be presented in a
single article. The pith of the matter has been given,
and enough has been said to exhibit the situation in a
clear light. The laws of New York State were de-
signed with the intention of excluding physicians
whose medical education did not reach the standard
required of its own citizens. Probably when some
kind of uniformity in medical education has been
reached in all or even in a majority of the States of
546
MEDICAL RECORD.
[March 31, 1900
the Union, the legislature of New York State may see
fit to revise or modify its present stringent regulations
relating to medical practice, but until that day arrives
it would be in a high degree foolish as well as unjust
to alter the existing condition of affairs.
NEW DISINFECTING STEAMER FOR
HAVANA.
The United States Marine-Hospital service is about
to despatch to Havana a new disinfecting steamer
designed under the supervision of its bureau. The
Sanator, the appropriate name of the vessel in ques-
tion, has just been completed in Philadelphia, and
would appear — from the description given of her in
Marine Engineering, March — to be up-to-date in every
particular. It is claimed for her that she is the most
complete floating disinfecting plant in the world.
The value of a floating disinfecting plant has already
been amply proved, the efficient services rendered by
the disinfecting barge Protector of the Marine-Hospi-
tal service, in disinfecting troops and troop ships re-
turning from Cuba in 1898 during our war with Spain,
being a case in point.
The disinfecting equipment of the Sanator, as a
matter of course, is of the most modern and perfect
type. There are a formaldehyde apparatus, sulphur
furnaces, and bichloride of mercury apparatus. Prob-
ably there is scarcely a harbor of the world where the
services of such a vessel as the Sanator are more ur-
gently required than that of Havana. Doubtless,
however, the efforts being put forth on land and sea
will have the effect of regenerating from a sanitary
standpoint that most unsavory town, and in wholly re-
moving the stigma which is now attached to its name.
In this good work the Sanator should play a promi-
nent part.
INTERNATIONAL ASSOCIATION FOR THE
ADVANCEMENT OF SCIENCE, ARTS, AND
EDUCATION.
The suggestion has often been made within recent
years that the formation of such an association would
greatly tend to the furtherance of science, arts, and
education, but until the meetings of the British and
French associations for the advancement of science at
Dover and Boulogne in 1899 no steps had been taken
to bring these ideas to a practical conclusion. At the
aforesaid meetings, however, the resolution was come
to that the time was ripe for action, and with this end in
view influential committees of Englishmen and French-
men were formed, the first meeting of these joint com-
mittees being held in London in October, 1899. M.
Le'on Bourgeois was elected first president, and Paris
was fittingly chosen as the seat of the inaugural meet-
ing of the association.
The association, according to a pamphlet published
on the subject, has been legally incorporated in Bri-
tain and in France; offices have been opened in Paris,
London, and Edinburgh, and in other European cities;
while Professor Geddes, secretary to the British sec-
tion, has spent upward of two months in the United
States endeavoring to enlist recruits. His labors
would appear to have been attended with a fair meas-
ure of success, as he announces that a committee has
already been formed in Chicago to carry on the work
of the association, and to co-operate with those already
existing in Paris, London, etc. Similar committees
have been organized in Boston, Philadelphia, New
York, etc. W. T. Harris, LL.D., United States com-
missioner of education, has also set the seal of his ap-
proval upon the scheme, and in a letter to Professor
Geddes signifying the same he makes use of these
pregnant words, the truth of which will strike every
unprejudiced person: "It is evident that intimate re-
lations among the educated classes lead to solid, mu-
tual benefits; while on the other hand it is a matter
of common observation that the meeting of the unedu-
cated masses of one nation with those of another na-
tion often results in misunderstanding and mutual dis-
trust."
The organization of the American group has not as
yet been decided upon. The proposal has been made
that its members should join hands with the British,
but these matters of detail will be settled later.
There can be no doubt that nothing but good can come
of an association formed upon lines so broad.
TUBERCULOSIS AMONG THE POOR.
The unhealthy conditions under which a very large
proportion of the working classes are compelled to
live is a matter too notorious to be treated lightly by
any intelligent person. The subject, especially in
these days, has been taken as the text of many a medi-
cal sermon, and the importance of both preaching and
putting into practice everywhere the gospel of cleanli-
ness has been so constantly dinned into the ears of mem-
bers of all grades of society that even the most selfish
or careless plutocrat is being forced to the conclusion
that the affairs of the poor and the need of hygienic
dwellings for them are questions not altogether outside
his sphere of interest. Municipalities and house-
owners are becoming daily more and more impressed
by the gravity of this aspect of the situation, and are
beginning, though tardily in some instances, to recog-
nize and to assume their responsibilities with regard to
the physical welfare of their fellow men.
As has been pointed out times without number, in-
sanitary houses are not only a fruitful source of danger
to those who live in them, but a standing menace to
the inhabitants of the entire neighborhood. For ex-
ample, leaving out of the question the well-known fact
that a virulently contagious disease will spread with
the greatest rapidity amid a filthy environment, the
foremost physicians and scientists hold the view that
tuberculosis is undoubtedly disseminated by the agency
of dirt and overcrowding and of unsalubrious surround-
ings generally. The extent to which supporters of this
theory carry their belief varies considerably, but all are
agreed that the proper housing of the poor will play a
conspicuous part in checking the inroads of tuberculo-
sis, and that until the methods prevailing in many large
March 31, 1900]
MEDICAL RECORD.
547
cities undergo a radical change the disease will con-
tinue to flourish. The Charity Organization Society
of New York has of late been attacking with praise-
worthy zeal the disgracefully lax manner in which the
tenement district of New York City is ordered in re-
spect to the unhygienic state both of the old buildings
and of the new. Attention has been called on several
occasions in the Medical Record to the fact that the
portion of New York in which the poor most do con-
gregate is probably more densely populated and con-
structed upon worse sanitary principles than is a simi-
lar district in any other part of the civilized world.
It is said that there are at present over forty-four thou-
sand tenement houses in the old city of New York,
and new tenement houses are being erected at the rate
of about two thousand a year.
The Charity Organization Society of New York has
recently published an address which was delivered by
Dr. S. A. Knopf before the Tenement-house Confer-
ence held in New York on February 20th ult., dealing
with the connection between the spread of tuberculosis
and the tenement house. This address is upon the
whole an able and fair presentation of the case.
The question of successfully treating incipient con-
sumptives in the poor is surrounded by many diffi-
culties, but Dr. Knopf, in his advocacy of healthy
dwellings for the toilers of the city, gives voice to the
opinion of the entire medical profession. It is by
such judicious and rational preventive measures that
the scourge of consumption can be most effectually
checked.
SLEEPLESSNESS.
Inability to sleep is merely a symptom, though of ex-
tremely varied origin. It may, however, be of such
serious import as to require especial consideration and
treatment. The first indication naturally is always to
determine the cause, but this is sometimes obscure.
In the failure to do so symptomatic measures may, for
a time at least, be required. The subject of sleepless-
ness as constituting the especial complaint for which
the patient seeks advice is discussed in an interesting
manner by Broadbent {Lancet, January 27, 1900, p.
215) in a recent clinical lecture. Opiates or sedatives
may be employed when the brain has been overtaxed
by engrossing work, or the nervous system has been
upset by a profound shock or exhausted by overwhelm-
ing anxiety or by excitement, or the habit of sleep has
been interrupted by long and anxious vigils over a
sick-bed.
Fresh air and exercise are among the most important
influences that tend to bring the nervous system into a
state favoring sound and refreshing sleep. In some
persons sleep is disturbed by exceedingly slight influ-
ences, such as a change of bed, tlie faintest noise, the
presence of light, and the like. If restlessness be
present also, chloral may be employed when the pulse
exhibits high tension, and paraldehyde or bromides, or
morphine and hyoscyamus, when the tension of the
pulse is low.
Sleep may be prevented by coldness of the feet, and
relief may be afforded by hot bottles or by enveloping
the parts in warm flannel. A little hot and strong beef
tea or hot milk on going to bed will favor sleep when
the circulation is sluggish. Sometimes vigorous local
friction may be required, possibly given after making
the patient stand in cold water. Sleeplessness may,
on the other hand, be due to a sense of heat and burning
in the feet, the patient being awakened rather than pre-
vented from going to sleep. There may be actual ob-
jective heat, as well as the subjective sensation. The
condition is sometimes associated with gout, rheu-
matism, or deforming arthritis, or other local disorder
to which treatment should be directed.
Defective elimination of the products of proteid
metabolism may cause high arterial tension and sleep-
lessness, and the indication then is to regulate the diet
and stimulate excretion. Mercurials and salines, and
drugs of this class, are useful in this connection. Low
arterial tension also may interfere with sleep in the
recumbent posture, although the patient may be unduly
drowsy in the erect position. Tonici treatment will
then be required.
Indigestion in its various forms is considered a most
common cause of sleeplessness, and flatulence, espe-
cially gaseous distention of the stomach, is looked
upon as one of the most active factors. In addition to
treatment of the fundamental conditions, a glass of hot
water at bed-time may be effectual in preventing inter-
ference with sleep. Should this not be sufficient, it
may be preceded by aromatic spirit of ammonia and
sodium carbonate, or an alkaline carminative draught
may be given. Sodium carbonate or sulpho-carbolate
with aromatic spirit of ammonia, compound tincture of
cardamom, or ether and peppermint water or camphor
water, and sometimes sodium bromide or ammonium
bromide, may be added with advantage for a time.
Friction over the abdomen or between the shoulders
may aid in dissipating flatulence. This treatment
should, however, not be persisted in longer than neces-
sary. When tea or coffee gives rise to sleeplessness,
its use should of course be abandoned.
For the sleeplessness accompanying or following
influenza, opium or morphine with hyoscyamus or atro-
pine may be required, should tonics such as arsenic,
phosphorus, strychnine, and quinine fail to bring re-
lief. Sleeplessness due to alcoholic excess requires,
in addition to withdrawal of the stimulant, the admin-
istration of strychnine or nux vomica in considerable
doses.
The Crotte Method of Treating Tuberculosis — It
was announced some time ago that this method was on
trial in the wards of St. Luke's Hospital, and some
curiosity was felt as to the result. The system was
faithfuly tried for a period of three months, and was
found to be of no value whatever. M. Crotte's attempts
to exploit his tuberculosis " cure " in this country have
not met with an unqualified success among the physi-
cians of New York or the members of the American
Medical Association. This field in the United States
has been already somewhat overworked by native — or
we might rather say, resident — talent.
548
MEDICAL RECORD.
[March 3 1, 1900
^etus of the "miccU.
For the Improvement of the Milk Supply. — At a
meeting of the Keystone Veterinary Medical Society,
held at Philadelphia on March 20th, a discussion of
questions relating to the milk supply was held. Dr.
C. J. Marshall read a paper entitled " Certified Milk."
He made a plea for a system of milk inspection that
would provide for bacteriological examination of the
milk, veterinary inspection of the cattle, and medical
supervision of the attendants at regular intervals. Dr.
F. A. Packard presented a communication detailing
" The Plans of the Philadelphia Pediatric Society with
Reference to the Milk Supply." This society has ap-
pointed a commission of hve to select a bacteriologist,
a veterinarian, and a physician for the purpose of thor-
oughly inspecting milk and noting all of the condi-
tions under which it is obtained. Any farmer or pro-
ducer of milk who permits monthly inspection of his
product is to be furnished with a certificate if the milk
comes up to a standard fixed by the society. Such
milk should command a better price than the ordinary
product. Dr. M. P. Ravenel read a paper entitled
" The Part of the Bacteriologist in the Production of
Pure Milk." He advocated the use of tuberculin in
herds in which tuberculosis is suspected. Dr. Robert
Meade Smith read a paper entitled " The Pasteuriza-
tion of Milk," Dr. George S. Woodward one on " Prac-
tical Bacteriology on the Farm," and Mr. Walter R.
Cuthbert one on "The Improvement of the Milk Sup-
ply of Philadelphia."
Erratum. — In the issue of this paper of December
23, 1899, was published an article in which charges
were made by the writer against the so-styled Keeley
cure for alcoholism, which statements we have since
found to be untrue.
For the Suppression of Rabies. — Ninety-two sheep
in the flock of a farmer near Erie, Pa., have been found
by the State veterinarian to be suffering from rabies,
and have been condemned to death. Fifteen of the
animals had been bitten by a rabid dog.
A Commendable Movement — It is stated that
efforts are being made by the borough overseers of
Sunbury, Pa., toward purchasing a poor-farm for the
maintenance of dependents. It is hoped that within
ten years the venture will pay for itself and become
self-sustaining, and eventually prove a means of lower-
ing the tax rate.
Pathological Society of Philadelphia — At a stated
meeting held March 22d, Dr. J. A. Scott presented
specimens from a case of hemorrhagic pancreatitis.
The symptoms so closely simulated those of intestinal
obstruction that abdominal section was performed, and
the patient died in the course of the operation. In
addition to the lesions of the pancreas, multiple fat
necrosis of the mesentery and the omentum was found.
Dr. Scott presented also specimens of sarcoma of the
anterior mediastinum. This had caused effusion into
the right pleural cavity and was associated with metas-
tatic neoplasms at the angle of the jaw and in the neck
and the axilla. Drs. W. S. Wadsworth and W. G.
Spiller presented a specimen of sinus thrombosis. The
layers of the falx cerebri had become separated, and
the superior longitudinal sinus, which was partly occu-
pied by a clot, was consequently greatly enlarged.
Further, a communication had been established with the
straight sinus, in which a globular thrombus had formed.
Drs. Wadsworth and Spiller presented also speci-
mens of hemorrhage into the pons Varolii. Dr. Spiller
presented a slide exhibiting malarial parasites in the
central nervous system. The organisms of the Eestivo-
autumnal variety were present in extraordinary num-
ber. Bacilli and cocci also were found, but these
were attributed to post-mortem infection. Dr. J. F.
Schamberg presented a communication on "Tubercu-
losis of the Skin of the Hand from Accidental Inocu-
lation." A nodular tumor was removed from the
thumb of a laryngologist, who had probably become
infected in the treatment of cases of laryngeal tuber-
culosis, but suffered no especial annoyance. Exami-
nation of the tissue failed to disclose the presence of
tubercle bacilli, but inoculation of guinea-pigs there-
with resulted in the development of tuberculosis.
Drs. Joseph Sailer and M. P. Ravenel presented a
specimen of aneurism in a chicken. The formation,
which involved the subclavian and the axillary artery,
was of considerable size, and was believed to be of
traumatic origin. It was not a true, but a false aneu-
rism. Dr. J. H. Jobson presented a communication
entitled " Hernia of the Vermiform Appendix," relat
ing a case in which such a condition was found. ' Di
F. A. Packard presented a specimen of malignant dis
ease of the rectum, with copious metastasis to the liver.
Smallpox is more than ordinarily prevalent through-
out the South and ^\'est, due to neglect of vaccination,
and the different local health officers are anxious and
busy accordingly. In no disease do proper precau-
tionary mea.sures more effectually pay than the one in
question. The anti-vaccination cranks have had their
day, and in the face of the object-lessons before the
public in the localities mentioned the time has arrived
for the enforcement of the other side of the argument,
and the sooner it is done the better.
Vital Statistics of Philadelphia The prevalence
of influenza and respiratory diseases is responsible for
an increase in the death rate. There were reported to
the Philadelphia bureau of health for the week ending
March 24th, 637 deaths — 57 more than for the preced-
ing week, and 106 more than for the corresponding
week of last year, and 131 more than for the corre-
sponding week of the year before. The largest num-
ber of deaths were due to the following causes: Pneu-
monia, III (congestion of the lungs, 12); pulmonary
tuberculosis, 7 ; diseases of the heart, 41 ; convulsions,
27; apoplexy, 26; old age, 22; diphtheria, 21. Eleven
deaths were attributed to influenza.
Pure-Food Congress — The A'cw i'i>rl- Froduie Re
vieic of March 2 ist, reviewing the recent congress held
in Washington, comments on pure-food legislation as
follows: "The Brosius bill, which received the sanc-
tion of the congress, is weak in its executive provisions.
March 3 1, igoo]
MEDICAL RECORD.
549
•which offer every opportunity for inaction and prac-
tical evasion of its proposed objects; also in relieving
dealers 01 responsibility for selling fraudulent goods
under certain specified conditions, which are very
likely to result in the same methods as are now prac-
tised by the oleomargarin men, who guarantee retailers
of their goods from loss by legal prosecution. Another
bill introduced in the House of Representatives by
Mr. Babcock to serve tie same purpose as the Brosius
bill overcomes these defects, and, with two or three
slight amendments, would seem to provide far more
efficient legislation in this direction."
The Canadian Medical Association. — The next
annual meeting of this association will be held on
September i2th-i4th at Ottawa. The address in sur-
gery will be delivered by Mr. Edmund Owen, of Lon-
don. The president is Dr. R. W. Powell, of Ottawa,
and the secretary Dr. F. N. G. Starr, biological de-
partment, Queens Park, Toronto.
The Tri-State Medical Society of Iowa, Illinois,
and Missouri will meet in annual session at St. Louis
on April 3d and .^th, under the presidency of Dr. O.
Beverly Campbell, of St. Joseph, Mo. The secretary
is Dr. J. C. Murphy, of St. Louis. The meetings will
be held at the Planters' Hotel, which is also the head-
quarters of the society.
A New Well at Nauheim. — Dr. Schott, of Nauheim,
■writes us that an artesian well has been sunk there, an
abundance of water being struck at a depth o^ about
six hundred and seventy feet. The water is strongly
saline and highly carbonated. The temperature is at
present 89° F., but it is thought it will rise to about
95°, as that is the temperature of the water at the bot-
tom of the boring. By this enterprise Nauheim has
now obtained an ample supply of its curative resources.
The Plague is reported to be practically at an end
in Honolulu, only one case having been found since
March 3d. In San Francisco three Chinamen are said
to have died of the disease, but there is no longer any
alarm. Many inspectors, both lay and medical, have
been appointed, and Chinatown is inspected daily. In
Bengal the disease is on the increase, 4,725 deaths
having occurred there during the week ending March
2ist, 744 of these having been in Calcutta. The num-
ber of cases of plague at Sydney, N. S. W., is reported
to have reached thirty-six on Monday last. There
have been thirteen deaths from the disease. Eight
thousand persons have submitted themselves to pre-
ventive inoculations.
Prize for a Paper on the Tropical Army Ration
To Captain E. L. Munson, assistant surgeon United
States army, has been awarded the prize offered by Dr.
L. L. Seaman through the Military Service Institution
for the best thesis on " The Ideal Ration for an Army
in the Tropics." The value of the prize is $ioo.
Smallpox Throughout the Country. — According to
a despatch to the New York Times from Chicago, a tabu-
lated list of smallpox cases throughout the various
States shows an increase for the week ending March
.23d of 1,272. The figures for the week ending March
i6th, in ihirty-s.ix States and Territories, show 3,952
cases, as against 5,224 for the succeeding week. The
State showing the largest number of cases is Louisiana,
with 2,015 cases. California is the least affected,
having only three cases. New York has eleven cases.
A Trap for Sportive Physicians. — A correspondent
requests us to warn the physicians of this city against
two men, whose plan is to call at a doctor's office to
make an appointment for a well-known jockey who is
said to have been recommended to the victim for treat-
ment of a severe disease. Just as they are leaving, one
of the jockey's alleged friends says, as if on sudden
thought, that there is to be a horse race that day which
is a pretty sure thing from inside information, and they
will help the physician place a little money — $5 or
$10. They can arrange for no more, as it is hard to
place it so late. The race proves to be one of money
rather than horses, and the innocent but would-be
sporty doctor's $10 bill goes so fast it is out of sight
in a second.
• Ptomain Poisoning. — About one hundred persons
were poisoned by chicken salad recently at an enter-
tainment given by a church missionary society at Lima,
Ohio.
A Suit for Fees that Might Have Been. — A physi-
cian in this city recently brought suit against a builder
for the loss of fees for prospective medical services.
He was spattered with mortar while passing a building
in course of construction. His coat and trousers were
ruined, and he claimed that he lost a patient and a $15
fee owing to the time lost in drying his clothes by the
boiler of the hoisting engine. The judge refused to
allow his claims for contingent fees, but gave him a
judgment for the assessed value of the ruined garments.
New State Hospital Districts A bill providing
for the division of the two State hospital districts in
this city into five has been approved by the judiciary
committee of the State senate. The Long Island State
Hospital district is divided into two, the Kings Park
and the Flatbush. The Manhattan Hospital district
is divided into three parts. The part located on
Ward's Island, known as the men's department, shall
be known as " Manhattan State Hospital East," the
part located on Ward's Island, known as the " Women's
State Hospital West," the part located at Central Islip
as " Manhattan State Hospital at Central Islip."
Contagious Diseases in School and College
There seems to be an unusual prevalence of infectious
diseases in various educational establishments through-
out the country at the present time. At Yale students
are ill with smallpox and measles; at Columbia, in
this city, a case of smallpox was recently discovered;
one of the students at the Lawrenceville School, N. J.,
was recently taken with diphtheria and was removed
to a Trenton hospital for treatment; several cases of
measles have occurred among the students at the Naval
Academy at Annapolis; the board of education has
closed the public school in Bellmore Village, L. I.,
because many of the children were suffering from
measles; and the Phillips Academy at Andover, N.
550
MEDICAL RECORD.
[March 31, 1900
H., has been closed on account of tke prevalence of
measles and diphtheria among the boys.
Epidemics of Rabies are reported in the southern
part of Richmond Borough in this city, where many
dogs and horses have been bitten, and some, which
have showed symptoms of rabies, shot; and also in the
upper part of Hunterdon County, N. J., where a num-
ber of dogs, cattle, and swine have been bitten.
Regulation of Medical Practice in Italy ^The
latest phase of the agitation in Italy against foreign
medical practitioners is the approval by the govern-
ment of a bill now before the chamber of deputies, in
which it is forbidden to any one not possessing Italian
qualifications to practise anywhere in the peninsula.
To this there are two exceptions: The law is not effec-
tive against a foreigner who may be summoned in con-
sultation in any special case, or who is in attendance
upon a family or individual travelling or temporarily
resident in the country. The second exemption is in
favor of those who confine their practice strictly to
foreign visitors, with, however, the fatal proviso that
these practitioners are citizens of countries which
accord the same privileges to Italian physicians.
Where Red Tape Worked Well The English
papers tell a funny story of how one of the younger
civilian surgeons, now serving as special consulting-
surgeon to the army in South Africa, received his
appointment. He was anxious to go to the war, and
so one of the older surgeons already appointed made
application for permission to take him as assistant at
a nominal salary. This request perturbed greatly the
fossils at the War Office, who could find no precedent
for appointing an assistant to a civilian consulting-
surgeon, and so they refused. But they didn't want to
offend the important man who had asked the favor,
and they accordingly appointed the would-be assistant
at a nominal salary a full-fledged consulting-surgeon
on a salary of $25,000 a year. Mysterious indeed are
the workings of the official cerebrum.
Changes at St. Luke's Hospital The Rev. Dr.
George S. Baker, pastor and superintendent of St.
Luke's Hospital, has resigned his charge and has been
appointed by the board of trustees pastor emeritus.
Dr. Baker has been superintendent of the hospital for
twenty-two years, having succeeded Dr. Muhlenberg,
the founder of the institution, upon the latter's death.
The cause of the retirement is stated to be ill-health
and the need of rest. Dr. Baker was an indefatigable
worker during his incumbency of nearly a quarter of a
century, and the hospital owes not a little of its pres-
ent prosperity to his labors. Mrs. Quintard, the direc-
tress of nurses in the hospital, resigned recently to talje
charge of a hospital in Cuba. The interne staff of
the hospital has been enlarged by the appointment of
a resident pathologist.
The American Medico-Psychological Association. —
The date of meeting of this society has been again
postponed, and announcement is now made that it will
be held at Richmond, Va., on May 22d, 23d, 24th,
and 25th. The change is made because the leading
hotel in Richmond has been engaged for the week of
May 7th to 12th.
The University of Hamburg — A movement is on
foot for the establishment of a new university in Ham-
burg. The medical department would enjoy excep-
tional facilities in connection with the great hospital
at Eppendorf.
"The University Medical Magazine."— The con-
trol of this journal has been acquired by the board of
trustees of the University of Pennsylvania, and from
now on, beginning with the March issue, the magazine
will be the organ of the medical department of the
university, of the recently organized University of
Pennsylvania Medical Society, and of the William
Pepper Laboratory of Clinical Medicine. A new
cover, bearing the seal of the university, has been
adopted, and a board of editors has been selected by
the trustees to conduct the journal.
The Mosquito Question In the course of a lecture
recently delivered at a meeting of the Colonial Insti-
tute in London, Dr. Manson described two experiments
which are to be carried out with the view of proving
the practicability of preventing malaria in intensely
malarial localities, and of demonstrating in an easily
understood and irrefutable manner the fact that the
mosquito carries malaria. For the first experiment a
hut would be built in a sprcially malarious part of the
Roman Campagna. This hut would be provided with
screen doors and windows, and every precaution would
be taken to maintain it mosquito-proof. Four men
would sleep there this summer from May to October,
and if they escaped, it would show that man could
easily be protected from malaria. In the second ex-
periment a number of virgin mosquitos (that is, insects
which had been raised from the egg in the laboratory,
so that they could never have got the malarial Plasmo-
dium from plants or water or earth) would be caused
to sting men suffering from benign tertian fever. They
would then be transported to London and be made to
bite men who had never had malaria or been outside
of England. If these men acquired malaria and the
Plasmodium could be found in their blood, this would
be proof positive of the possibility of the transmission
of the disease through the instrumentality of mosquitos.
Of course the experiments would be conducted with
the knowledge and consent of the subjects, and, the
disease being benign tertian fever, there would be no
danger whatever.
The Alumnae of the New York Post-Graduate
Training-School for Nurses will hold an Easter fair at
their club house, 143 East Thirty-fifth Street, on March
30th and 31st, afternoon and evening. The object of
this fair is to aid in the support of the club-house,
which has been established only about a year, and is
still something of an experiment. The club-house
furnishes a home and registry for the members of the
Post-Graduate Alumnaj Association, and is also a
meeting-place where lectures are delivered and where
business and social gatherings can occur.
Navy Department, Bureau of Medicine and Sur-
gery, March 24, 1900. — Changes in the medical corps
March 31, 1900]
MEDICAL RECORD.
551
of the United States navy for the week ending March
24, 1900. March 16th. — Surgeon J. D. Gatewood de-
tached from the Lancaster and ordered to the Bureau
of Medicine and Surger}', Navy Department. March
19th. — Pharmacist F. Wood retired from active ser-
vice, March 20, 1900. March 23d. — Assistant Surgeon
E. Thompson detached from the Celtic and ordered to
the Nashville. Assistant Surgeon M. K. Johnson de-
tached from the Nashville and ordered to the Celtic.
Assistant Surgeon H. H. Haas detached from the
Baltimore and ordered to the Don Juan de Austria.
Assistant Surgeon W. B. Grove detached from the
Brooklyn and ordered to the Scindia. Assistant Sur-
geon F. L. Benton detached from the naval hospital,
Yokohama, Japan, and ordered to the naval hospital,
Cavite, P. I. Assistant Surgeon J. S. Taylor ordered
to the Neiv Orleans.
The Late Dr. Hans Rudolph Hoffmann,— At a spe-
cial meeting of the North Hudson County Medical
Society, held at West Hoboken, N. J., March ig, 1900,
the following preamble and resolutions were unani-
mously adopted:
'■ Whereas, In this early history of our society, we
are called upon to record the death of Hans Rudolph
Hoffmann, M.D., one of our prominent, honored, and
useful members. As an expression of our sentiment
in the loss which we have sustained, be it
" Resolved, That we, the North Hudson County
Medical Society, deeply regret the death of our esteemed
colleague, and desire to express the sense of the great
loss suffered not only by the community but by the
medical profession; and be it also
" i'?(?j(5/z/ft/. That we tender to his bereaved family
our heartfelt sympathy in the great loss they have sus-
tained; and be it further
" Resolved, That a copy of these resolutions be sent
by the society to the family, and be published in the
daily papers and medical journals."
Committee, Richard Jahr, M.D. ; A. J. Walscheid,
M.D.; William Menger, M.D.
The Late Dr. John Cargill Shaw.— The New York
Neurological Society records with sorrow the death of
Dr. John Cargill Shaw, one of its members and its third
president, serving for the two years 1878-1880. Dr.
Shaw was of English stock and came to this country
at the age of seventeen years. Following his gradu-
ation from the College of Physicians and Surgeons in
1874, he served in the Long Island and St. Mary's
hospitals of Brooklyn, and for four years he filled the
office of superintendent of the Flatbush Asylum with
signal honor, and here laid the foundation of his pro-
found knowledge of psychiatry. As president of the
New York Neurological Society he was an indefati-
gable worker, and his untiring energy was of great ser-
vice in the early days of the society. His many pro-
fessional duties of late years forced upon him a less
prominent position in the affairs of this body, but his
literary work has made him known at home and abroad.
We desire to record our appreciation of his talents and
his never-failing co-operation in the interests of neu-
rology and psychiatry. Smith Ely Jelliffe, Landon
Carter Gray, B. Onuf, committee.
Obituary Notes.— Dr. Amy S. Barton died at Phil-
adelphia on March 19th, at the age of fifty-nine years.
She was a graduate of the Woman's Medical College
in 1874, and has for some time been professor of oph-
thalmology in the same institution.
Dr. Robert M. Girvin died at Philadelphia on
March 17th, at the age of sixty-five years. He was
gradated from Jefferson Medical College in 1862 and
became a surgeon in the United States army. He
was obstetrician to the Philadelphia Hospital from
1865 to 1876, and was one of the founders of the Pres-
byterian Hospital, of whose medical board he was
president at the time of his death.
Dr. William Yandell, of El Paso, Tex., killed
himself on March 24th. He had been in ill health for
several years, and. recently had become much worse
and was very despondent. He was a graduate of the
Gross Medical College, Denver, in 1868, and was State
quarantine officer at El Paso at the time of his death.
Dr. Henry B. Carpenter died suddenly at his
home in Rochester, N. Y., on March 23d. He was a
graduate of the College of Physicians and Surgeons,
New York, in the class of 1890.
Dr. I. S. Bigelow died at his home in Buncombe,
Iowa, on March 21st, of pneumonia. He was born at
North Washington, Pa., in July, 18 19, and had prac-
tised medicine for sixty years.
Dr. William Welsh Viebert died from heart dis-
ease at his home in this city on March 26th. He was
twenty-seven years old. Dr. Vibbert was a graduate in
arts of Trinity College and in medicine of the College
of Physicians and Surgeons in this city in the class of
1898.
Dr. Daniel J. Buckley, of Kingston, N. Y., died at
the State Hospital at Middletown on March 27th. He
was forty-two years old.
progress ut ^Xedical Science.
Journal oj the Afner. Medical Ass'n, March 24, igoo.
Mental Fatigue — Edward Thorndike sums up his
conclusions as follows: Mental work is not a simple
matter of mental energy, of quantity of positive or in-
hibitory nervous discharges, but of their direction as
well; mental fatigue is not like physical fatigue and
requires different treatment; its warning signs are
more complicated, less efficacious, and therefore more
often neglected; the warnings that we do have are not
measures of the degree of inability, but indefinite and
at present ill-understood signs of danger; the degree
of mental inability does not vary proportionately to
the amount of work done without sufficient rest, but in-
creases much less quickly up to a certain amount of
mental work, and then may increase much faster, so
that one straw of mental work may then break the
camel's back.
What are the Most Efficient and Practical Means
for Limiting the Prevalence and Fatality of Pul-
monary Tuberculosis.— N. S. Davis says we must
continue to take care of the infected sputum and cattle,
and provide as good sanatoriunis as possible for those
already tuberculous; but our success for the future
will depend mainly on the efficiency of our efforts to
restore and maintain in their full vigor the natural
conditions and processes of vital resistance to toxic
agents possessed by the living human body.
552
MEDICAL RECORD.
[March 31, 1900
The Frequency of Rickets in Infancy in Boston
and Vicinity. — John Lovett Morse, from an examina-
tion of four hundred children under two jears of age,
considers it is a justifiable conclusion that eighty per
cent, of the children under two years old, of the poorer
classes of Boston and the adjacent cities, have rickets.
The cause in Boston and vicinity is to be found in im-
proper hygienic surroundings rather than in race or
diet.
Thyroid Feeding in Obesity. — A. W. Sherman says
that during the past four years he has used thyroid ex-
tract in a number of cases to reduce obesity with results
satisfactory to both himself and his patients. He be-
lieves that in properly selected cases it is of great value,
and in ordinary cases, if thyroid tablets are used occa-
sionally after regular treatment has been stopped, the
weight can be kept down almost indefinitely.
Prevention of Tuberculosis. — Homer M. Thomas
considers in detail the different ways in which tuber-
culosis may be spread, and says that the most fertile
source of infection is from the sputum, which, when
dried, finds an entrance into the body. This being
the case, all patients should be taught to destroy the
sputum before it passes from their control.
Shoulder-Humero-Scapula Articulation. — Thomas
H. Manley discusses some of the complications and
sequelas attending or following reducible or irreducible
dislocations, with a brief review of the various modern
operative measures now employed for their treatment.
Philadelphia Medical Journal, March 24, jgoo.
Case of Caesarean Section. — George G. Hopkins
And Earle E. Woolworth report a case of Cesarean sec-
tion performed on a woman who had had one living
child and four still-born children. The operation was
resorted to because of the parents' desire for a living
child. The woman recovered, but the writers neglect
to say whether the child was alive or dead when ex-
tracted.
A Preliminary Report on the Etiology of Scar-
latina.— R. H. B. Gradwohl reports the results of a
bacteriological examination in seven cases of scarlet
fever. These results confirm those of Class, whose
work (published in the Medical Record, vol. Ivi., pp.
330 and 513), the writer says, inspired him to under-
take the investigation.
The Etiology and Pathology of Major Epilepsy.
• — William House regards the paro.xysms of idiopathic
epilepsy as due probably to an increase of cerebro-
spinal fluid, this being perhaps due to lymphatic
spasm or to disturbance of equilibrium between lym-
phatic and general circulatory activity.
Reflex Neuroses from Phimosis. — J. Orton Edie
reports two cases of insanity, one of emaciation and
pallor, one of retention of urine, and one of paro.xysms
of apnoea, all of which were relieved after circum-
cision, an elongated foreskin being present in each
instance.
Clinical Memoranda on Chronic Suppurative Otitis
Media John F. Oaks, in a clinical lecture on this
subject, says that the indications are to promote asep-
sis, insure drainage, and remove the etiological factor
of the chronicity.
A Medico-Legal Case in Alaska Henry B. Fitts
reports a case in which a woman was accused of having
injected a corrosive poison into a child's gullet with a
glass urethral syringe. The woman was acquitted.
A Case of Addison's Disease with Autopsy. —
William Fitch Cheney reports a case of this disease in
a man thirty-seven years old. At autopsy both ad-
renals were found enlarged and cheesy.
Radiograph of a Bullet Seen through Osseous
Tissue in the Femoral Trochlea, Two Lines from
the Surface of the Bone. — Charles Verge pictures this
case.
Parotitis Complicating Croupous Pneumonia.—
James Ely Talley reports an instance of tliis rare com-
plication occurring in a woman seventy-six years old.
New \ ork Medical Journal, March 24, igoo.
Gout and Rheumatism ; their Etiology and Die-
tetic Treatment. — \V. H. Porter attributes both cc
these affections to sub-oxidation due to the prolongeo
intake of a larger amount of nutritive pabulum than
can be perfectly oxidized; also to the action of bac-
teria on the intestinal proteid contents. Dietetic
treatment should consist in reducing the ingesta to a
point where the amount taken can be perfectly oxi-
dized. The diet should be free from an excess of the
saccharine elements and all substances tending to ex-
cite putrefactive fermentation. The best results are
obtained with plain diet largely composed of animal
food.
What Precautions shall we Take to Avoid Leaving
Foreign Bodies in the Abdomen after Operations ? —
H. A. Kelly gives histories of one or two cases which
have come under his notice, and formulates the rules
which govern his operations with reference to the
avoidance of such accidents. For keeping track of
the number of gauze pads and sponges used during an
operation he has devised a wire frame, an illustration
of which is given.
Eructation, Regurgitation, and Rumination H.
W. Lincoln suggests, for the first, suggestion with pos-
sibly a small dose of bromide; for the second, com-
pelling the patient to swallow back the food as fast as
regurgitated, proper diet, ice pellets, bromides, and
electricity; for the third, the use of foods which remain
in the .stomach as short a time as possible, a bitter at
meals, avoidance of contraction of the abdominal
muscles, internal faradization, and alkalies or hydro-
chloric acid, as suits the needs of the individual case.
A Case of Acetanilid Poisoning O. R. Summers
had as his patient a woman, aged twenty-six years,
who had taken only eight grains of the drug. The
symptoms were those of collapse with strong convul-
sive movements, partial loss of consciousness, and
great retching. .After prolonged administration of
whiskey, nitrate of strychnine, and, for two hours, arti-
ficial respiration, the patient recovered.
Cerebral Complications Caused by Extension from
the Accessory Cavities of the Nose.— R. H. Craig
finds a tendency to these complications from congenital
defective formation in the bony walls of the nares,
partial or complete closure of the normal apertures of
these cavities, and pronounced virulence of the infec-
tious material. Illustrative clinical histories of sev- .
eral cases are given.
The Administration of General Anaesthetics C.
A. Temple describes the various combinations which
have come into use during recent years, and names the
various emergencies which may arise, together with
the means of meeting them.
The Treatment of Retro-Displacements of the
Uterus. — I. L. Watkins gives a general description of
this condition, and enumerates the various plans of
treatment which have been proposed for its relief.
March 31, 1900]
MEDICAL RECORD.
553
Boston Medical and Surgical Journal, March 22, igoo.
Clinical Cases. — C. B. Porter reports the following:
Sarcoma of tonsil, which was successfully removed by
operation. — Slipping patella: An incision was made
on the inside, and an elliptical piece of internal
lateral patellar ligament one-half inch wide removed.
The joint was not opened. The patient was discharged
well fourteen days after operation. — Cysts of both
ovaries, hydatidiform mole: abdominal section, re-
moval of cysts, incision of uterus, removal of tumor;
curetting; wound of uterus was closed with animal-
tendon sutures. Good recovery. — Dislocation of in-
ternal semilunar cartilage: Removal. Distention of
the joint with fluid that was proved to be sterile, caused
a rise in temperature and in the white blood count on
the sixth day after operation. Good recovery. — Un-
united fracture of olecranon: Fragments were wired,
arm put up on straight anterior splint reaching from
finger tips to axilla, a large pad at the elbow holding
the arm slightly flexed. Good recovery. — I'loating
cartilages in both knee joints: Incision was made on
inside of left knee through capsule. Twenty-five pea-
sized, hard, irregular, slippery bodies were removed. —
Fracture of right patella: Curved incision made over
the joint, which was found to be filled with blood clots.
The joint was washed, and the fragments were wired.
Recovery. — Comminuted fracture of humerus: Bone
comminuted into four fragments. Operation resulted
successfully, with no shortening. — Fracture of surgi-
cal neck of humerus, with displacement of head of
humerus: Open section with wiring of fragments was
performed. Excellent results followed.
Intermittent Gastric Hypersecretion. — Arthur W.
Elting, in the treatment of this rather rare alTection,
uses the stomach tube and lavage with weak alkaline
solutions or 1:1,000 silver-nitrate solution. Mor-
phine hypodermically or cocaine internally is indi-
cated when the pain is very severe. Constant tonic
treatment of the nervous system is indicated during
the intervals between attacks. Strychnine, nux vom-
ica, quinine, phosphide of zinc, arsenic, etc., are indi-
cated. Over-indulgence of all kinds and psychical
excitation are to be avoided, and a carefully arranged
diet is insisted upon.
Clinical Cases. — J. C. Mumford reports the follow-
ing: Acute general peritonitis: The condition, due
to appendicitis, was cured by operation and washing
of pelvis and abdominal cavity with six gallons of hot
sterilized salt solution. Good recovery. — Chopart's
amputation, with tendon implantation and tenotomy :
A slight limp remained, but the stump was painless.
Traumatic Rupture of Echinococcus Cyst of
Liver. — C. A. Porter reports a case, relieved by opera-
tion. Incision of the right rectus muscle was fol-
lowed by escape of three quarts of bloody fluid.
X-Ray Plates of Traumatic Separation of Epi-
physis.— Charles L. Scudder showed tracings, and
advocated open treatment of closed fractures and epi-
physeal separation.
Strangulated Diaphragmatic Hernia. — S. J. Mixter
reports a case. Operation was performed, but the
patient died of shock.
Medical Nnvs, March 24, igoo.
Neurological Observations in the Hawaiian Isl-
ands.— Daniel R. Brower, in speaking of leprosy, says
that the physicians in the islands who are experts on
the subject have abandoned the hereditary etiology
and regard it as contagious. They account for its
rapid spread among the natives by their lowered resist-
ance, a consequence of the great prevalence of syphilis,
and their socialistic tendencies. They eat out of a
common vessel and smoke each other's pipes. Climate
has considerable influence over the progression of the
disease. Prophylaxis is the great problem, difficult to
meet on account of the long incubation period and
insidious onset. Zambico believes that progressive
muscular atrophy, Raynaud's disease, Morvan's dis-
ease, and syringomyelia are simply modified forms of
leprosy.
A Case of Transverse Presentation ; Double Ute-
rus A. H. Hayden reports this case. The patient
was a woman aged forty years, multipara, ninth preg-
nancy. She had been in labor thirty-six hours when
the writer first saw her. He delivered her of a dead
child. She died on the tenth day, evidently from ex-
haustion, as there was no other factor to account for
her failure to recover.
The Thrush Fungus as a Cause of Gastritis —
W. A. Bastedo cites a case of this kind in a woman
aged twenty-six years. Lavage was resorted to, which
on the fourth day showed no fungus, and the patient
improved from that time.
The Lancet, March ij, igoo.
Some Remarks upon External Urethrotomy. — R.
Harrison describes a case, and adds that he believes
the operation to be applicable, (i) in resilient and
rapidly contractile strictures in the deep urethra; (2) in
cases in which the wound made by an internal urethro-
tome is out of proportion to the natural drainage possi-
bilities of the urethra; (3) in stricture complicated
with urinary fistula; and sinuses; (4) in cases of stric-
ture with extravasation ; (5) in some rare cases of stric-
ture in which operative treatment is rapidly followed
by acute symptoms of impending death. He would
attach importance to the use of a guide, the utility of
the internal operation as immediately preliminary to
the external, and the more efficient provision for urine
and wound drainage.
The Surgery of the Stomach. — In this lecture, A.
Mayo Robson discusses perforation, gastric fistulae,
perigastritis and adhesions, hour-glass contraction,
dilatation, and congenital stenosis of the pylorus,
giving various statistical tables of the several opera-
tions which have been devised for the conditions above
enumerated. Hour-glass contraction he regards as
more common than is usually believed. He has seen
one case in which the normal viscus was divided into
three distinct compartments.
A Loose Foreign Body in a Hydrocele Sac—
J. R. Benson found in the sac a small, hard mass of
fatty tissue which he thinks may have been a detached
piece of an appendix epiploica, or may have arisen
from a clot of fibrin from a previous tapping.
Unusual Ending of a Case of Empyema — In this
case of an Arab child of three years under the care of
J. Cropper, the empyema of the right chest opened
either into the stomach or duodenum. In spite of
operation, death resulted on the sixth day.
Medical Examination of Personal-Injury Claims.
• — ^A. Benthall gives an account of his experience in
the line of claim adjuster for accident insurance, and
mentions certain principles of ethical and medico-legal
importance.
Medical Press and Circular, March 7 a7id 14, igoo.
The Causes and Treatment of Movable Kidney.
— Mansell Moullin draws a distinction between mova-
ble and floating kidney. The theory that the kidney
554
MEDICAL RECORD.
[March 31, 1900
is a fixed organ is incorrect. The normal range of
movement is from 3 to 5 cm. The failure of the kid-
ney to reascend on tranquil expiration, the patient
standing erect and first driving the kidney down
by forced inspiration, is a fair test. The anatomical
relations are considered at some length. The choice of
treatment lies between the application of an abdominal
belt and nephroirrhaphy. Only in the milder cases
does the former succeed, and then it must be combined
with massage and exercises to strengthen the abdomi-
nal m^lscles. A belt cannot press the kidney back
into place or retain it on deep inspiration in the erect
posture. Pads are useless. Nephrorrhaphy never
fails when properly carried out, if the symptoms have
not already lasted so long as to produce an indelible
impression upon the nervous system.
The Surgical Treatment of Tuberculous Kidney.
— Konig says two different conditions must be distin-
guished: isolated foci in the gland substance, and the
pyeliticform. Very different symptoms are presented.
The so-called haematogenous form is difficult of diag-
nosis, and can but rarely be controlled. Tuberculous
pyelitis can always be diagnosticated. The only pos-
sible operation is extirpation. There are no certain
means of diagnosing whether the second kidney is
healthy. According to Tuffier, we may operate when
the other kidney is diseased, and simultaneous disease
of the bladder, testicle, or prostate is not a contraindi-
cation. The author has operated eighteen times with
eleven recoveries. In many cases operation prolongs
life.
The Dilatations and Deviations of the (Esopha-
gus— John Knott concludes his article, taking up the
third or hernial class of Rokitansky's arrangement.
He calls special attention to Hoffmann's method for
oesophageal dilatation. Gastrotomy should be per-
formed some time before excision of the oesophageal
sac, so that the patient can be fed into good condition,
oesophageal rest obtained, and inflammation allowed to
subside, permitting the sac to be washed out before
the second operation is attempted. The writer looks
upon this as the most hopeful procedure in dealing
with all dilatations and diverticula of the oesophagus.
Ovarian Tumor of an Unusual Character. — T.
Jason Wood records an operation upon a large univer-
sally adherent cyst with foci containing fetid green pus.
The wall gave way in places. There was no trace
of a pedicle. The end of the alembroth gauze pack-
ing was brought out of the wound. This was removed
in forty-eight hours and a tube substituted. Good
recovery followed. The absence of pedicle was ac-
counted for by the ovary becoming detached and under-
going cystic change.
Some Surgical Cases Illustrated by Radiographs.
— Noble Smith illustrates the value of the .x-rays in a
case of old Pott's fracture, in which the w-eight of the
body was transmitted so as to impinge upon the edge
of the astragalus. Immediate relief was gi\'en by cut-
ting through the fibula, dividing the tendo Achillis,
and securing better position. .In a child supposed to
have bowed leg, a fracture of the tibia was shovi'n. In
congenital dislocation of the hip, aid has been given;
also in dislocation of cervical vertebras.
British Medical Joiinial, March ij, igoo.
The Treatment of Rheumatism, with Special Ref-
erence to Prophylaxis and to Cardiac Complica-
tions.— William Ewart states that lesions of the joints
are easily recognized, but not always the early begin-
nings of the cardiac lesions, which may develop mur-
murs only at a late stage. Cardiac lesions may accom-
pany every form of arthritis down to febris rheumatica
sine arthritide (Hawthorne), but their frequency and
their degree are not proportionate to the degree of the
joint affection nor to the intensity of the rheumatic
attack. The writer then speaks of the treatment by
vesication and serotherapy. It may be possible that
prophylaxis may demand in predisposed subjects the
application of blisters for the threatenings of an attack.
The Practical Applications of Largin in Diseases
of the Eye. — Sydney Stephenson says that the appli-
cation of largin, even when concentrated, is painless;
if prolonged beyond a few weeks, it may stain the con-
junctiva. It acts well in blepharo-conjunctivitis and
in some cases of dacryocystitis. It is an efficient sub-
stitute for silver nitrate in any of the conjuncti\'al
inflammations associated with the Koch-Weeks ba-
cillus.
Some Cases of Belladonna Poisoning George
Scott reports the cases of three lads who took some-
"horse" medicine, and afterward exhibited all the:
signs of belladonna poisoning. He administered
emetics and purgatives. To one of them, whose pulse
was very weak, he gave a mixture of ammonium car-
bonate and spiritus chloroformi. They all recovered.
Remarks on the Holmgren Wool Test ; is it Ade-
quate for the Detection of Color Blindness ? — Thomas
H. Bickerton declares that the Holmgren wool test is
by no means a certain discoverer of the lesser forms
of color blindness. To insure certain detection of all
color defects, a quantitative test for color is required in
addition.
Detachment of Corneal Epithelium (?).— J. Acworth
Menzies reports such a case of five years' standing,
caused by a blow. He scraped the part with a sharp
spoon, removing the epithelium for some little dis-
tance around the affected area, and recovery was com-
plete.
Foreign Body in the Male Urethra Arthur Haw-
ley withdrew a hatpin from a male urethra by means
of a pair of curling tongs, all other methods having
failed. This proved successful.
Wiener klin. Woche/ischri/t, Feb. 22 and March i, igoo.
Suture of the Bladder in Suprapubic Lithotomy.
— (ieorg Lotheissen declares that the time for recovery
is considerably shortened by this method. Bierstein
found this to be in the open treatment thirty-one days;
with suture, from eleven to thirteen days. There seems
no greater danger on the whole than in sectio alta.
Angerer always employs the suture and has never lost
a patient directly through the operation. In recent
literature many cases are reported with excellent re-
sults. The author finds, in one hundred and thirty-
seven cases, ninety-six healed primarily without fistula,
i.e., seventy per cent., which is even not so favorable
as some others report.
A Rare Form of Aneurism of the Descending
Thoracic Aorta. — Maximilian Weinberger and Arthur
Weiss present this case of saccular aneurism, in which
there was erosion of the upper dorsal vertebra; and the
fourth and fifth ribs, with a growing together of the
aneurismal sac with the upper lobe of the right lung,
and the rupture of the latter into a bronchial tube.
There was aspiration of blood in the right middle lobe,
with chronic endarteritis of the ascending and descend-
ing aorta and ectasy of the first, eccentric hypertrophy
of the left ventricle, and fatty degeneration of the my-
ocardium. Fatty heart and fatty infiltration of the
liver were found.
March 31, 1900]
MEDICAL RECORD,
555
Alimentary Glycosuria. — Emil Raimann states that
this condition does not depend on a local disturbance,
but on the lowered capacity of the body to assimilate
dextrose. The continued constitutional lowering of
the assimilation limit is like a sign of degeneration in
a chemical sense. Since by nvsans of simple experi-
ment on individuals a quantitative expression of glyco-
suria can be made, it will be possible from a mass of
material to formulate the laws which cause the predis-
position to this affection.
Therapeutic Studies on Sanatogen. — Eduard Ry-
biczka mentions as advantages of sanatogen the high
nutritive value of the preparation, easy assimilation,
non-irritating qualities, indifferent taste; its happy in-
fluence on the appetite in different kinds of illness, on
nervous troubles, viz., sleeplessness in neurasthenics;
its influence on the body weight and in some cases on
the hjEmoglobin; and the increase of subjective good
health in patients, resulting from its use.
Berliner kUnisclte Wocheiischrift, jWt. jo, March j, igoo.
Acute Non-Purulent Encephalitis. — H. Oppenheim
treated a boy aged seventeen years, who suffered from
cerebral symptoms following an old chronic otitis
media. High fever supervened with stupor and a
slow pulse. Later there appeared cortical epileptic
attacks and right facio-brachial monoparesis with
complete motor aphasia. The patient finally recovered
as to life, but six months after subsidence of acute
symptoms still had slight paresis of the right side of
the mouth, weakness in the right hand, and complete
motor aphasia. A diagnosis was made of acute hem-
orrhagic non-purulent encephalitis of the left frontal
lobe, more particularly of the third left frontal convo-
lution, including the base of the central convolution.
Nephritis without Albuminuria in Young Chil-
dren.— Cassel has recently seen a series of such cases,
all being under two and a half years of age. Of the
nine children, the anasarca followed varicella twice,
and digestive disturbances five times. In one no cause
could be assigned, and in one it preceded an attack of
measles, which did not, however, alter the course of
the renal symptoms. In all scarlatina could be posi-
tively excluded. Most careful uranalysis failed to dis-
cover at anytime the slightest trace of albumin or cell
elements. Reference is made to similar cases previ-
ously reported.
Miincheiicr mediciiiische Wocheiischrift, March ij, igoo.
Contribution upon the Management of Infants
Prematurely Born. — O. Rommel says that more than
one-third of all children who die in Munich in the first
months of life do so because of lack of vitality from
premature birth. A series of observations upon arti-
ficial means of nourishment and supplying the requi-
site warmth are given, with tables showing the curve
of increased weight.
A Strange Accident Dr. Peters saw a boy one
year after he had fallen, a piece of wood of lead-
pencil size having penetrated the eye, causing loss
of sight upon this side, and momentary cerebral symp-
toms. Upon examination and incision a previously
undiscovered splinter of considerable size was found
penetrating the orbit.
Oxycamphor. — Hans Neumayer describes this new
preparation (see Medical Record, vol. Ivii., p. 515)
with tests upon the respiration and pulse in health,
giving tabulated results. He finds it a trustworthy
remedy in many cases of dyspncea. The dose of gtt.
xl. of oxaphor (i gm. of oxycamphor) is recommended
with considerable water given on a fasting stomach.
(Edematous Sclerema Neonatorum in Connection
with Extensive Bleeding from the Lungs Joseph
Esser relates the interesting post-mortem appearances
in a twin whose sister showed no abnormality. Death
had occurred on the eighth day. The lungs were
hemorrhagic, and the pathology is considered at length.
A Unique Splinter Injury.— Conrad Rammstedt
relates a peculiar accident by which a splinter of wood
was driven in beneath the orbit, fixing the jaws by
being forced against the coronoid process when attempts
were made to open the mouth.
Distortion of the Ankle Joint Heinrich Krapf
directs attention to a peculiar form of injury, which
may also have as a result a painful condition caused
by lateral movements of the foot. A typical case is
related.
Vratch, Februaiy ig, igoo.
Endothelial Neoplasms of the Gastro-Enteric
Tract. — L. V. Soboleff reports the case of a woman,
twenty-eight years old, who had complained for about
a year of constipation, eructations, and pain at the pit
of the stomach, and for three months of vomiting and
loss of appetite. For a month before coming under
observation she had cedema of the face and feet. He
father, she said, had died of cancer. In the region of
the pylorus was felt a hard tumor with uneven surface,
connected apparently with a smooth, hard, easily mov-
able body deep down in the right hypochondrium. A
dense band extended downward from this body into
the right iliac fossa. The urine was turbid and con-
tained hyaline casts, many pus cells, and a few red
blood corpuscles. A diagnosis was made of cancer of
the stomach with extension to the right kidney and
ascending colon, and inflammation of the bladder and
renal pelvis. Treatment proved of no avail, and the
patient died. At autopsy a new growth was found in-
volving the stomach, duodenum, and large intestine;
other findings were fibrinous peritonitis, acute cystitis,
beginning right hydronephrosis, acute pyelitis in the
left kidney, diphtheritic ileocolitis, and brown atrophy
of the liver and heart. The gastro-intestinal new
growth was a multiple interfascicular medullary en-
dothelioma.
Phototherapy. — I. I. Makaveeff reports seven cases
treated by means of light. He used an incandescent
light of 50-candle power, with a current of 100 volts,
thrown on the part by means of a parabolic reflector.
The seances lasted from five minutes to half an hour
in different cases, but usually from ten to fifteen min-
utes. The patient's eyes were protected by shades or
dark glasses. The cases in which this method was
employed were: Lupus, 1; rheumatic joint affections,
2 ; tuberculous arthritis of the elbow, i ; hysterical
neuralgia, i ; intense pains accompanying recurrent
inoperable cancer of the left breast, i ; traumatic
orchitis and epididymitis, i. The results in every
case were most encouraging.
Schleich's Method of Local Anaesthesia.— A. I.
Osloff reports nineteen cases in which he employed
the Schleich method of local anesthesia with entire
satisfaction. The operations were of all sorts — Piro-
goff's disarticulation of the foot, removal of the thyroid,
removal of a lipoma of the shoulder, resection of the
rib, gastro-enterostomy for cancer, castration for tuber-
culous disease, etc. In order to reduce to a minimum
the pain of the first prick of the needle, the writer
makes a primary injection with an ordinary hypoder-
mic syringe, and employs the larger (ic gm.) syringe
later. Osloff says that the influence of suggestion in
most of these cases can hardly be denied.
556
MEDICAL RECORD.
[March 31, 1900
Operative Treatment of Congenital Enuresis.— S.
K. Mayer relates the case of a twelve-year-old girl
who suffered since birth from incontinence of urine.
Examination showed, with otherwise normal external
genitals, a widely open urethral orifice. The urine
was normal in character, but the bladder was con-
stantly empty. The urethra was narrowed by opera-
tion, and the bladder soon became tolerant of water so
that the child was not forced to empty it more than
once an hour or hour and a half. Three weeks after
operation there was perfect control over micturition,
and the child slept every night from ten o'clock to
seven without wetting the bed.
Consumption in the Russian Army.— N.. K. Shche-
potieff presents the statistics of pulmonary disease for
the Russian army from i8go to 1897 inclusive, and
discusses its causes and the means for its prevention.
La Riforvia Medica, March 2 to g, /goo.
The Vagus in Relation to Malignant Forms and
Complications of Measles. — Emilio Cioffi believes
that the suffocating catarrh, pulmonary collapse, cough
and pseudo-croup, vomiting, diarrhoea, nausea, and
sense of satiety, kidney symptoms, anuria, oliguria,
oedema with or without albuminuria, otitis, and men-
ingeal inflammation, all met with in some cases of
measles, are due to the effect of the specific toxins
upon the pneumogastric nerve. He has reached these
conclusions through laboratory experimentation.
Dermoid Cysts of the Anterior Fontanelle. — Emilio
Curzio reports a case of this rare affection, which is
congenital, but becomes visible a few months after
birth. Removal is the only treatment, and is best
performed when the fontanelle is diminished in size,
when the child is about a year old.
Lesions of the Central Nervous System in Poi-
soning from Sodium Salicylate. — G. Paoli says that
these lesions are easily cured upon removal of the
cause.
Urinary Toxicity. — Umberto Baccarani holds that
there is no relation between the elimination of sulphu-
ric ethers and indican and the toxicity of the urine.
French Journah.
The Histological Diagnosis of Rabies — A. Van
Gehuchten and C. Nelis present the results of their
experimental studies, which they look upon as impor-
tant and which lead them to believe that in the future
one will not have to search for an intervertebral gan-
glion. They find that the nodular ganglion of the pneu-
mogastric presents the most deeply seated lesions.
This is readily found in the upper cervical region
against the base of the skull. Here we must look for
the histological ^xzgvvoiAi.—La Presse Medicalc, March
7, 1900.
Pruritus, its Complications and Treatment. — Dr.
Du Castel, after reviewing the various forms, points
out that there are many persons affected with more or
less generalized symptoms, who are really only pru-
riginous subjects, badly cared for at the beginning.
He calls attention to two internal remedies: lactic acid
and beer yeast. The former may be given to children,
beginning with gtt. vi., gradually increased to 2 gm.
Good results have been reported from yeast. — Le Bul-
letin Medical, March 10, 1900.
Hysterical Neurasthenic Tympanites. — Henry Ber-
nard finds that neurasthenia, the same as hysteria,
provokes intestinal spasm manifest clinically by a
simple colic. The treatment is general, attacking
the nerve element, and local, but generally without
effect, the tympanites disappearing spontaneously.
Antispasmodics, especially opium and belladonna, may
be employed, but purgatives should not be given. —
Gazette Hebdomadaife ^ dc Mcdccine et de Chiniigie,
March 1 1, 1900.
Hereditary Tic Douloureux of the Face Cured by
the Continued Current of Electricity. — S. Dubois is
led by the statement of Gilles de la Tourette, that no
case of cure of true tic douloureux of the face is known,
to relate one case as cured and mention two others
apparently cured by the continuous current. In one
man, now seventy-seven years of age, there has been
no recurrence in twenty-six years. — Bulletin Ghitral
de Therapeutiqtte , March 8, 1900.
Congenital Ranula. — Xavier Delore gives with il-
lustration the history of an enormous branchial cyst of
the floor of the mouth. The distinction is not always
easy between sublingual ranula and dermoid cyst.
Among the signs in favor of the latter was that of
probable adhesion to the hyoid. Treatment consists
in complete extirpation of the membrane ; that is, of all
epithelium. — Gazette Hebdomadaire de Medecine et de
Chinirgie, March 8, igoo.
Specific for Bacterial Diseases of Man and Ani-
mals.— P:. Gaube believes that in a multiple salt dis-
covered by him, the iodobenzoyliodide of magnesium,
he presents to medicine the most powerful arm it has
ever known in the defence of man. His remedy has
always shown activity, often curative, principally in
diphtheria, though tried in rheumatism, erysipelas,
typhoid fever, pneumonia, etc. — La Medecine Moderne,
March 7, 1900.
Opotherapy. — A. Vaquez follows the historic stages
of organotherapy from antiquity through the Middle
Ages, and into the renaissance of a few years ago. He
finds that the ancients were right in believing, and the
moderns in demonstrating, that organic secretions con-
tain an infinite number of substances of remedial
value. — La Presse Mcdicale, March 10, 1900.
Some Phenomena of Excitation and Mental De-
pression in Relation with the Attack in Epilepsy.^
Maurice de Fleury relates a number of personal obser-
vations with comments from advance sheets of his work
on "Clinical Researches in Epilepsy and its Treat-
ment," which will shortly appear. — Le LVogrh Aledical,
March 10, 1900.
Hypertrophic Length of the Tongue. — C. Girod
gives with illustration notes of an enormously elon-
gated tongue in a woman, which so seriously interfered
with talking tiiat one would at first examination take
her for an idiot. — Gazette des Liopitaii.\, l\Iarch 3, 1900.
Archives of Pediatrics, March, igoo.
Analytical Study of the Clinical Phenomena Ob-
served in One Hundred and Twelve Consecutive
Cases of Chorea.— John Lindsay Steven gives a sta-
tistical repoit of these cases. Of 87 out-patient cases,
23 were males, 64 females; 43 were between the ages
of six and ten years; 60 patients had one attack, i
had six attacks; 7 had an attack of one month's dura-
tion and under; i had an attack of twelve months' dur-
ation. The etiology seems to be fittingly classed under
the heading "emotional " in many cases. History of
antecedent rheumatism was given in 26 cases. As to
condition of the urine, there seems in chorea, on the
whole, little tendency to derangement of the renal
function. The author likewise tabulates 25 cases ob-
served in the wards.
March 31, 1900]
MEDICAL RECORD.
557
Dilatation of the Colon.— F. T. Stewart and Alfred
Hand, Jr., report a case of congenital dilatation of the
colon in a boy six years old. The child was fed from
birth on condensed milk (1:5), with a few breast-feed-
ings daily. The distention was noticed first when the
child was three months old. There was no clew to the
origin of the affection. Treatment consisted of mas-
sage of the abdomen with olive oil, the application of
the galvanic current to the abdominal muscles, and
the hypodermic injection of strychnine, gr. j}^j, once
daily in the abdominal wall along the line of the colon.
Later they were given in the arm with quite as good
results. The child, however, died, and the post-mor-
tem showed a hypertrophic dilatation of the colon and
rectum.
Two Cases of Idiopathic Haematuria. — T. J. Elte-
rich, after reporting these cases, states that in the
treatment of this trouble rest in bed is essential.
Mineral and vegetable astringents, efficient in other
hemorrhagic conditions, are said to have no effect in
these cases, but they may be tried.
Ji>ur. oj Laryngology, Rhinology, and OtoL, Alarc/i, igoo.
Antiseptic Purification of the Meatus and Adja-
cent Parts both for Operations and as a Treatment
in Chronic Middle-Ear Suppuration. — Urban Pritch-
ard advocates the application of a more rigid antisep-
sis to the classes of cases named in the title. His
plan consists essentially in flushing the meatus, scrub-
bing the auricle, packing the canal with antiseptic
gauze, and covering the whole ear with an antiseptic
pad, all this being done previous to operation. When
the patient is under the anesthetic, the whole dressing
is removed, and when it is finished a fresh pad is ap-
plied. With these precautions, Pritchard finds that
granulations and purulent discharges are avoided and
that wounds heal up much more quickly. This puri-
fication treatment is adapted to those cases in which the
membrana tympani is intact and there is no suppura-
tion. Here its use renders the surfaces of the meatus
aseptic and so allows the surgeon to operate on growths
in the walls or to open into the tympanic cavity with-
out infecting the deeper parts. The plan is also of
service when suppuration exists with perforation of tiie
membrane, whether we have simply chronic otorrhoea
or polypi, granulations or necrosis requiring curetting.
Two Cases of Very Extensive Unilateral Angio-
Elephantiasis. — \^'olff reports the cases of this nature
which have appeared in literature, and gives personal
experience with those referred to in the title. One
patient died, the autopsy showing thrombo-phlebitis
of the right femoral vein with multiple embolism of
the right lung.
The Laryngoscope, March, igoo.
Report of a Case Illustrating the Importance and
Possibilities in the Early Recognition and Treat-
ment of Malignant Growths of the Larynx. — The
case is reported by W. K. Simpson, who by means of
drawings gives a very clear presentation of its inter-
esting features. The patient was a man, aged forty-
four years, who has been under observation for the last
three years and a half. Three points are brought out
by the case: (i) That all laryngeal new growths in the
adult, especially those of a recurring nature, should al-
ways be regarded with suspicion, the relation between
benignity and malignancy being often so close that the
line of demarcation is difficult to define. (2) The
difficulty attending a positive diagnosis in very early
cases, during an apparent period of transition, when
the microscopical examination admits of some doubt.
(3) The satisfactory results which may sometimes fol-
low a thorough removal of the growth and destruction
of the underlying tissues. In some cases of early
recognition and removal, even when a diagnosis of
malignancy has been substantiated, a cure may be
effected without resorting to laryngectomy.
A Case of Fatal Sphenoidal Suppuration. — The pa-
tient was a man aged thirty-one years, under the care
of S. Lodge, Jr. For six months he had constant pain
in the right side of the face and in the ear. For two
months the face was swollen and there was a con-
tinual discharge of matter (often bloody) from the
right naris. Examination showed symptoms of pus
absorption, and a sequestrum could be made out in
the region of the cribriform plate. Syphilis of nine
years' standing was present. Death from brain sepsis
resulted in about three weeks. Autopsy showed that
to the right of the sella turcica there was some necrosis
of the walls of the sphenoidal sinus. There, was a
large free opening from the latter into the nose, while
a probe passed freely from the base of the skull through
the sinus into the nose.
The Silver Salts in the Treatment of Chronic Sup-
puration of the Middle Ear E. B. Gleason com-
mends especially the use of protargol. In his cases 01
prolonged otorrhoea a hypodermic syringe full of a five-
per-cent. solution was injected by means of a Blake's
cannula as high up into the attic as possible. The
parts then were massaged with Siegle's pneumatic
speculum, in order, if possible, to force a portion of
the solution into more distant parts than could be
reached with the syringe. The ear finally was care-
fully dried by means of absorbent cotton. Before
using the protargol the middle ear had been cleansed
with the aid of Blake's cannula and dried in the usual
Archives de Neurologie, February and March, igoo.
Psychical Disturbances in Degenerative Chorea
P. Ladame says that while many patients suffering
from Huntington's chorea threaten suicide, none of
them really attempts it, the threat being merely a phase
of a fit of anger, resulting from the nervous excita-
bility of these patients. Hallucinations, delirium, and
symptoms of paranoia are merely accidental phenomena
in this disease, but irritability and a progressive weak-
ening of the intellect are characteristic of hereditary
chorea. Complete dementia may ensue, the clinical
picture being absolutely similar to that of general
paralysis, from which, however, a careful examination
of symptoms will suffice to distinguish it.
Hysterical Polyuria and Pollakiuria.— Jean Abadie
concludes that among urinary disorders due to hysteria
there is an urgent pollakiuria with or without poly-
uria. This may be the only manifestation of an hys-
terically irritable bladder. Polyuria, simple and urgent
pollakiuria may all be provoked by direct hypnotic
suggestion, and possess the same characteristics as the
spontaneous forms. Both varieties may be cured by
direct or indirect suggestion.
The Sensibility of the Blind — The popular im-
pression that the blind possess a more acute sensibility
for tactile impressions is not supported by the numer-
ous and carefully made observations of Professor Greis-
bach, of Basle. The tips of the fingers of those who
see are more sensitive than those of the blind. There
is no difference between them in regard to the senses
of smell and hearing. Those who can see can work
longer and to better effect than the blind. — Lancet.
558
MEDICAL RECORD.
[March 31, 1900
OUR LONDON LETTER.
(From our Special Correspondent.)
ARMY AND NAVY IN PARLIAMENT GENERAL MEDICAL
COUNCIL — THE WAR AND INSANITY — LORD PEEL
AND THE DRINK QUESTION PERFORATED NASAL
SEPTUM SCOLIOSIS — FALMOUTH LEICESTER — UNI-
VERSITY ILLUSTRATED JOURNAL — DR. OSLER
DEATHS OF DRS. MARCET, SCATTERGOOD, WHISTLER,
AND GUY — MIDWIVES BILL AGAIN IN PARLIAMENT
— A DIVORCE CASE — SOCIETIES ENLARGED PROS-
TATE COXA VARA PATHOLOGICAL SOCIETY'S DE-
MONSTRATIONS — MORTALITY RETURNS THE LATE
DR. MASON.
London, March g, 1900.
In Parliament ameliorations have been promised to
the naval medical service. The numbers of inspectors
and deputy-inspectors-general of hospitals and fleets
are to be increased; the instruction at Haslar Hos-
pital is to be extended and prizes awarded; study
leave is to be granted; a professor of tropical diseases
appointed; surgical instruments are to be supplied to
all ships.
The estimates for the Royal Army Medical Corps
are considerably increased, but it is by no means clear
that the establishment is sufBciently provided for.
Every available ofificer has been sent to South Africa,
and numerous civil surgeons have been engaged for
duties at home stations. It seems rather too previous
for the minister to talk of great increase when he can-
not find candidates to compete. Redress of grievances
will have to be granted and the oppression by the War
Office made to cease.
The General Medical Council seems to emulate the
War Office in blundering. Perhaps I ought to say the
law officers of the council. They have just lost another
action, being ignominiously beaten by the notorious
Alabone, who since he was removed from the Register
has been practising. He was summoned for describ-
ing himself as M,D, Bellevue Coll., and M.D. Phil,
U. S. A., and the lawyers of the council knew nothing
about the bogus diplomas, but admitted them to be
reputable documents of New York and Philadelphia.
So the magistrate dismissed the case. These are the
lawyers who muddled the case of Dr. Hunter.
Dr. Clouston, superintendent of the Edinburgh
Royal Asylum for the Insane, has presented his annual
report to the managers. As usual it is an interesting
document. The proportion of cases due to alcohol is
stated as 25.25 per cent., which is exactly the same as
for the last five years. Influenza is also said to be
responsible for many cases — more, in fact, than the
excitement consequent on the war. But in regard to
the last it is certainly too early to form any opinion,
especially from the experience of one institution. Dr.
Clouston thinks the selfish character observable to-day
may be a reason for the little insanity attributable to
the vi'ar. This seems a notion without any evidence
in its favor, and in fact in direct opposition to the
magnificent outpouring of help for the sufferers which
has been shown in all directions and in every possible
form.
The Times has published, as it has done for a num-
ber of years, the annual drink bill of the nation, the
figures being, as usual, supplied by Rev. Dr. Dawson
Burns. In 1899 there was an increased expenditure
on intoxicants of no less than ;^6, 169,455 above the
amount of the previous year. The aggregate expen-
diture of the year was /"i62,i63,474. This, Dr. Burns
calculates, is equal to £2, \<)s. \\\d. per head, or for
each family of five persons ^19 19^'. gi^/. Some
people have begun to argue that the figures prove the
prosperity of the country, but there is a darker side to
be remembered. The royal commission sitting while
this bill was being run up concluded that the " gigantic
evil '■' called for a remedy, as it had become a " national
degradation." These phrases were employed in the
report indorsed by those engaged in the trade — the
majority report, for, as you probably know, the royal
commission resulted in two reports being made. The
minority report was drawn up by Lord Peel, whose
judicious impartiality as president of the commission
had been extolled by the trade up to the last moment,
but ever since his proposals he has been denounced by
their organs in the press. Last week his lordsTiip
broke his long silence in a speech at Cambridge, when
he asked the public " to judge between the two methods
of solving the drink question " put forth in the two
reports, and warned those who fancied they could take
the good points of both as a basis for legislation that
the differences were " vital," and if not very careful
" they would fall into a trap." He said, too, " he
gloried in belonging to the minority on the commis-
sion," for its report had '" taken hold of the public
conscience and intelligence." He added that " some
extreme measures ought to be tried to make the trade
subordinate to the public interests," and this object is
" not only enjoined by Christianity and morality," but
"enforced by the merest, lowest utilitarian principles
of social and domestic expediency."
Such expressions from the man who was selected to
preside over the commission on account of the con-
spicuous impartiality and ability with which he had
filled the speaker's chair in the House of Commons
are deserving of every consideration.
Among the cases exhibited at the Clinical Society
was a young woman who had been previously shown
in 1897, with a perforation of the nasal septum' sup-
posed to be due to tuberculous disease. In 1896 a
growth the size of a filbert had been removed from the
septum. Three months later the base broke through
the septum. Active local treatment was employed and
three injections of tuberculin were given, to which she
reacted. The growth has increased in size, but other-
wise the condition has improved. Sections show giant
cells and caseation; no bacilli. Painting with iodine
and iodide of potassium had been employed, and later
guaiacol and olive oil.
There was a case of scoliosis in an infant, aged
seventeen months, probably due to rickets. Three
other children, surgical cases, were shown. One, aged
three years, had tuberculous disease of the knee treated
by dividing the patella, free exposure of the joint,
removal of the affected membrane, and swabbing with
pure carbolic acid. The child can now walk, though
the movement of the joint is limited. Another child,
aged twelve years, had necrosis of the shaft of the
humerus. The sequestrum was removed, and the arm
is gaining power. The other child, aged eleven years,
had osteitis and periosteitis, treated by cutting down
on the tibia, elevating the periosteum, and cutting a
deep groove through the epiphysis and diaphysis. The
pain has gone, and the child can stand.
Dr. Buchanan's report on last year's outbreak of
typhoid at Falmouth has now been issued. He is not
satisfied that the water supply was contaminated, but
he recommends the company to adopt certain further
precautions. He seems to think there was contam-
ination through suction into the pipes at some part.
He advises the town council to consider not only the
disposal of the sewage, but the state of the drains and
sewage, and further to provide an infectious hospital.
The Leicester Medical Society traces its pedigree
through a medical book club back for one hundred
years. On the 2 7tii ult. its centenary was celebrated
by a dinner which was attended by leading practi-
tioners from various localities, including London.
March 31, 1900]
MEDICAL RECORD.
559
The statutes recommended by the commissioners for
the reorganization of the University of London have
been laid on the table of both Houses of Parliament,
and if unopposed for forty days will become law.
A new medical journal, illustrated, came out in
February. It takes the title of The Physician and
Surgeon, and is a weekly review of the medical- w'orld.
It is illustrated and got up well, and takes a good tone.
The price is ^d. I hardly see how it can pay.
You have probably heard that there is a movement
in Edinburgh to get Professor Osier to accept the
chair of medicine in succession to the late Sir Grainger
Stewart.
We are not yet quit of influenza, though its effect on
the death rate is less obvious. In fact, the total num-
ber of deaths registered in London last week was
three hundred and thirty-four below the average for
the corresponding weeks of the last ten years. Those
due solely to influenza were fifty-two, and the number
is falling.
The death rate of Dublin still excites considerable
apprehension. After falling to 29.1 it suddenly rose
to 51. But there seems a source of fallacy about this
on account of the returns from one union having been
delayed so that two weeks of that district are included
in one.
Dr. William Marcet, F.R.S., died on the 4th inst.
in his seventy-second year. He had been in feeble
health for some time and sought winter climates. He
died in Egypt. He was at one time physician to the
Consumption Hospital, and wrote a small work on the
larynx. He had been president of the Royal Mete-
orological Society, a fact which w'ill show you one of
his favorite studies. He delivered the Croonian
Lecture for 1897, and took for his subject the "His-
tory of Respiration of Man."
Dr. Scattergood, of Leeds, died on the 22d ult., aged
seventy-four years. He was dean of the Medical
School, lecturer on forensic medicine, and consulting
surgeon to the Hospital for Women and Children. He
had been connected with the Leeds school for more
than half a century, was chairman of the building-
committee of the present school, and did great service
in the negotiation for union with the Yorkshire Col-
lege. His portrait by Sir G. Reid, subscribed for by
his colleagues and friends, is nearly finished, and will
probably be placed in the medical department of the
college.
Dr. William MacNeill Whistler died on the 27th
ult, aged sixty-three years. As a native of Pennsyl-
vania he studied at the university of his State, and
graduated there in i860. He entered in the medical
service of the Confederates. After the civil war he
came to England, took the M.R.C.S. in 1S71 and the
M.R.C.P. in 1S76. He was elected physician to the
Throat Hospital in Golden Square, and at the great
disruption of its staff went with the majority of his
colleagues to establish the London Throat Hospital.
His chief work is lectures on " Syphilis of the Larynx
— Lesions of the Secondary and Intermediate Stages."
He contributed the article on " Diseases of the Nose "
to Quain's " Dictionary." He was a brother of the
eminent painter.
The death is also announced of Inspector-General
Thomas Guy, who entered the army in 1842 and had
seen service in various countries. He retired in 1872.
He translated Esmarch's treatise on " First Dressing
on the Battle-field." He was a brother of Dr. William
A. Guy, F.R.S., the author of the " Manual of Forensic
Medicine."
London, March i6. loco.
The midwives bill is not dead — it has attained a new
lease of life by a snatch vote in the House of Com-
mons after its advocates had given up all hope and
introduced a measure into the Lords. Yet within two
hours after this had been done, the government busi-
ness in the Commons closed, one may say collapsed
unexpectedly, and the way was left clear for private
members. This bill accordingly came on for second
reading. Mr. T. P. O'Connor led the opposition to
it with skill and energy. He urged that the measure
could only aggravate the evils it pretended to remove;
that it would assuredly increase malpractices of vari-
ous kinds; that ignorant women would be registered,
and would undoubtedly carry on illegal practice, and
that The Lancet's voting papers gave 5,000 against the
bill out of 7,250 replies.
Mr. V. Gibbs stated that the General Medical Coun-
cil and the two Royal colleges were in favor of the
bill. This inaccurate assertion ought to have been
contradicted at once; but, of course, no member was
present who could do so, and the circumstance shows
the mischief these bodies have done by paltering with
the question. The Council of the College of Sur-
geons, a month ago, protested against the avoidance of
the recommendations of the General Medical Council.
Eventually the bill was read a second time and re-
ferred to the standing committee on law. It can be
defeated at a later stage only by the most strenuous
efforts, and there is a sad amount of apathy in the
profession. As many as six hundred and forty men
have not been ashamed to reply to The Lancet's query
that they are indifferent. Their names should be pub-
lished, as they are too selfish to consider their brethren.
Dr. Rentoul is again taking up arms. He proposes
that every fellow who disapproves of the action of the
Obstetrical Society in opening a back-door to practice
should resign his connection with the society unless it
immediately give up its diploma traffic. This is very
well as far as it goes, but how about the indifterents?
Will they trouble to resign even ? And will the traitors
who want to bring in an inferior order of practi-
tioners of one branch cease their efforts? A more dras-
tic measure is required to bring them into line; noth-
ing less than the refusal to meet in consultation any
man who approves of the diploma traffic. " I dissuade
every woman within my influence from consulting any
one of them." When the majority of the profession
adopt this treatment, the "desired effect" will follow.
The case of Crook 7s. Crook and Horrocks illus-
trates a danger to which medical men are specially ex-
posed. Lawyers and doctors both know how often
women have delusions as to their own chastity, and
proceed to accuse some one of improper conduct with
them. Dr. Horrocks has been subjected to the accu-
sation of adultery on a confession of Mrs. Crook, which
she afterward withdrew. She seems never to have
thought of such a thing until a woman who practised
palmistry told her she would be divorced and cause a
scandal. The liusband, himself a doctor, seems to
have been first to the palmist and told his wife about
her. The result of this palmistry has thus been most
sad. A happy marriage has been made unhappy, and
a respected, eminent physician subjected to a terrible
ordeal. There was no evidence against Dr. Horrocks
to corroborate Mrs. Crooks, and the jury dismissed
him from the suit, but they could not agree as to her
conduct. It is, therefore, possible that further pro-
ceedings maybe taken. Much sympathy is expressed
for Dr. Horrocks, and, although his costs have to be
paid by the other party, that is only taxed costs, and
the other expenses must be considerable. A subscrip-
tion, in testimony of the feeling in his favor, has al-
ready been begun.
At the annual meeting of the Medico-Chirurgical
Society I am told — for I was not present — that the
president called for cheers for the relief of Ladysmith,
of which news had arrived, and the grave and reverend
fellows of this very sedate society responded heartily.
The committee on suspended animation was requested
56o
MEDICAL RECORD.
[March 31, 1900
to continue its investigations. The climatological
committee has not completed its report on the baths
and climates of England, but hopes to do so this year.
The retiring president, Mr. Bryant, gave his address,
which, according to custom, dealt chiefly with notices
of the fellows who died during the year. These deaths
I have reported as they occurred. The new president,
Dr. Pavy, was then duly installed, and returned thanks
for the honor of being elected.
The Medical Society of London celebrated its one
hundred and twenty-seventh anniversary by a dinner
on the 7th inst., at which the presidents of the sister
societies, or, perhaps I should say, daughter societies,
of this venerable institution were present. The toast
of the visitors was responded to by the director-gen-
eral of the army medical department, Surgeon-General
Jameson, C.B., who naturally referred to the topic
which occupies us all. In the course of his speech he
remarked that the results of abdominal sections in field
hospitals were not very good, while many soldiers
wounded in the abdomen and left quiet had recovered.
He also said that it was not desirable for wounded
men to be taken too early on long railway journeys, as
their wounds were very apt to become septic during
the transit. Another point he emphasized was that
female nurses are not only useless, but a real nuisance
in field hospitals. It is desirable the public should
know this, as many women continue to imagine that
they could be of service, and are offering to go.
The male nurses, trained in the army, are the proper
persons for these positions. Female nurses should
be utilized only far from the front, and there is a sur-
plus supply of them at the Cape.
At the ordinary meeting of the society held on Mon-
day, Mr. Freyer brought forward a new method of per-
forming perineal prostatectomy. He started by ad-
mitting that the great majority of cases of enlarged
prostate only required careful, cleanly catheterism.
But in some cases an operation was advisable, and in
just a few necessary. His plan was put forward as
much less dangerous than suprapubic cystotomy. He
removed the tumor by a pararectal incision, preceded by
external urethrotomy. He described his operation in
detail, and related a case. In the discussion on this, the
perineal distance was mentioned as too great for in-
travesical growths to be reached. For these it was sug-
gested that McGill's operation was effective, though
not without risk. It was asked whether the division of
the hemorrhoidal nerves, necessarily involved, had led
to any inconvenience. Further, it was remarked that
as enlargement of the prostate took place in different
directions, operative procedures must also be varied.
Coxa vara was the subject of a subsequent paper,
the author of which said he iiad seen seven adolescent
cases, five of them being demonstrated by skiagrams,
the other two being too well marked to call for the
-v-rays as an aid to the diagnosis. He thought it
likely other cases would be met with if looked out for.
The Pathological Society held another of its labora-
tory meetings on the 6th inst. On this occasion the
laboratories of the conjoint colleges were lent for the
meeting, and interesting demonstrations took place.
I^r. Grube related some experiments he had made
which seem to confirm those of Sternberg, published a
short time ago, as to the probability of diabetic coma
being due to B-amidobutyric acid. He had injected
this into the veins of twelve cats. Coma followed
with respiration such as is seen in diabetic coma, and
tlie urine was found to contain substances met with in
diabetes, besides sugar, which last is not of much sig-
nificance, as that is often found in cats after other
operations.
Dr. Bain described a case of typical rheumatoid
arthritis, in which he analyzed the urine during seven
successive days of a fixed diet. Lactic acid was not
present. The only change was a diminution of uric
acid and phosphates.
Dr. Cadman described experiments on the rootlets
of the ninth, tenth, and eleventh cranial nerves in cats
and dogs.
Drs. Brodie and Dixon demonstrated the action of
some drugs on the pulmonary circulation and bron-
chial muscles. Suprarenal extract increased blood
pressure and led to congestion of the lungs. Muscarin
caused spasm of the bronchial muscles, and they said
pilocarpine also did this. Atropine neutralized the
effect, as they said urethan would also do, suggesting
its use in asthma. Dr. Brodie demonstrated the ac-
tions of diphtheria toxin on the spleen. The first
effect was constriction of the vessels. This was rap-
idly followed by relaxation; then by alternate relaxa-
tion and contraction; lastly by complete paralysis.
Dr. Pavy demonstrated the production of glycosuria
by exalted respiration, which he had shown some years
ago to be the effect. Further, jointly with Drs. Brodie
and Sian, he showed the effect of phlorizin in produc-
ing the same effect as an artificially perfused kidney.
It has previously been shown that injecting this drug
into the renal artery of one kidney produces this effect
in that organ, while its fellow remains unaffected until
the drug reaches it through the circulation.
The mortality returns are more favorable. The
London death rate last week fell to 18.8, the rate of
the three preceding weeks having been 22.9, 21.5, and
ig. For the thirty-three large towns the rates for the
last four weeks have been 25.8, 24.2, 21.2, and 20.4.
Dr. Mason, of Dublin, died on Saturday, aged eighty
years. This venerable gentl;man had held an impor-
tant position as a teacher of anatomy and of medicine
for about a quarter of a centjry, chiefly in connection
with the Ledwich school, of which he was one of the
founders, but also as physician to Mercer's Hospital.
I mentioned in January that his son had died. Now
the father follows.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondent.)
The Occupation of Bloemfontein. — Since my last let-
ter Bloemfontein, the capital of the Orange Free State,
which was clearly the objective of Lord Roberts'
march to the eastward, has been occupied by British
troops. The city capitulated without resistance upon
a message from the field marshal that he should com-
mence shelling in twenty-four hours, unless the inevit-
able was recognized, and submission made. Presi-
dent Steyn fled northward, and the keys of the public
offices were sent out to Lord Roberts. The occupation
of Bloemfontein marks a distinct stage in the war, and
all humane people must rejoice that its surrender did
not follow upon any protracted siege or loss of life
through stubborn fighting. There are no medical as-
pects from which to view the taking of the city; but,
as far as the British are concerned, the bloodless vic-
tory is of good medical omen. The troops under Lord
Roberts have now been engaged in six weeks' hard
marching, varied with some fierce fighting. They will
at length obtain a rest which will certainly save many
of them from hospital treatment.
Intombi Camp contained, after the relief of Lady-
smith, twenty-one hundred sick. By the second week
in March a large proportion of these were convales-
cent, while others had been deported to more sanitary
places on the lines of communication. By medical
advice Ladysmith was evacuated as soon as possible
after it was relieved.
The Casualties among the Royal Army Medical
March 31, 1900]
MEDICAL RECORD.
561
Corps. — The British military medical officers have
borne their share of fighting in carrying out their pro-
fessional duties, and have not come unscathed out of
the war. Their casualties by the beginning of March
numbered four killed, three dead from disease, and
fourteen wounded. Those killed in action were Major
Edward VV. Gray, Captain Matthew L. Hughes, and
Lieutenant Hugh B. Onraet. All three were fine offi-
cers; but Captain Hughes was something more. He
was one of the most promising scientific men in the
service, and had already made researches into certain
climatic diseases that were recognized by epidemiolo-
gists as being of great importance. Captain R. H. G.
E. Holt, the fourth officer whose death is recorded,
died from wounds received during his gallant behavior
at the front in Sir Redvers Buller's operations at the
Tugela.
The Imperial Yeomanry Hospital.— Since the in-
ception of the scheme of this hospital by Lady Geor-
giana Curzon and Lady Chesham, ^100,000 have been
subscribed for its purposes. With this money a base
hospital of five hundred and twenty beds has been
equipped (I have already described the site chosen
for its establishment to your readers); while a field
hospital of one hundred beds has also been prepared,
and a complete bearer company. Major Stonham,
senior surgeon to the Westminster Hospital, who has
gone to Africa as chief surgeon to the Imperial Yeo-
manry Hospital, has a grand hut responsible billet.
The Use of Hollow-Nosed Bullets. —There is no
longer any doubt that some of the Boers have used so-
called explosive bullets. A large number of hollow-
nosed bullets, such as are used in the pursuit of big
game, have been found upon Lord Roberts' Boer pris-
oners, while the surgeons with the British advancing
column have felt certain, from the more serious nature
of the wounds, that explosives were being used. This
probably means that other bullets are running short
with the federal troops, for the Boer generals would
not willingly risk the loss of the sympathies of Europe
by the employment of weapons that are universally
condemned by civilized nations. The Boers confi-
dently assert that in using hollow-nosed bullets they
are only following the example of the British, who
have employed Dumdum bullets. No such bullets have
been served out to the British soldiers for the cam-
paign, and the persistency of the stories in European
papers was a subject of wonder, until a Boer surgeon
explained to a Dutch paper the possible origin of the
mistake. It appears that many Lee-Mitford bullets,
the bullets used by the British, have been manufac-
tured at the Dumdum factory and issued to the troops
in cases bearing the name of that factory. These
cases have been noticed, and led to the obviously
genuine belief among the Boers that the British were
using explosives. The surgeon who suggests the e.x-
planation of the mistake says that he looked for the
effects of explosive bullets among the Boer wounded,
but had been unable to find them.
The Plight of Mafeking by the second week in
March was becoming acute. Messages had reached
telegraph stations both north and south of the belea-
guered hamlet stating that the garrison was reduced
entirely to siege soup made of horses and dogs, that
the horses' provender was being made into bread, that
the mortality among the natives was very high, and
among the few women and children still left terri-
ble. A relief column has started northward from Kim-
berley, and another has been for weeks coming south-
ward from northern Rhodesia; but whether either will
arrive in time is doubtful. The water supply of
Mafeking is said to be polluted, and the medical men
with the relief columns anticipate finding a large pro-
portion of Colonel Baden-Powell's tiny force prostrate
with typhoid fever and dysentery. Since the beginning
of the siege two hundred and ninety-two persons have
been killed and wounded or died of disease at Mafe-
king out of a total of less than two thousand.
Yet another Hospital Ship, the Avom, is now rid-
ing at Durban. As in the case of the Lismore Castle,
the transformation from a passenger steamer to a hos-
pital ship was entirely carried out by Durban artificers.
ACTING ASSISTANT SURGEONS IN THE
ARMY.
Sir: In your issue of March 17, 1900, you mention
the dissatisfaction that exists among the acting assist-
ant surgeons of the army who served in the Spanish-
American war, etc. This is not a new grievance, and
is not confined to those who served in the Spanish-
American war and the Philippine rebellion, but it has
continued to exist since the Mexican war, and no ap-
parent effort seems to be made by the medical depart-
ment of the army to remedy it, and so long as phy-
sicians can be obtained to fill this position it will
probably continue to exist.
Every person who knows the position of the acting
assistant surgeon of the army knows his grievance is
a just one; but there it seems to end. Your sugges-
tion that it would be better policy to place the status
of these men on a satisfactory footing than to continue
an out-of-date and unpopular system, ought to meet
with the approval of the medical profession.
There is a bill now pending before the United States
Senate, S. 1782, introduced by Senator Thomas C.
Piatt, which will, with a slight modification, give to
the acting assistant surgeon of the United States army
the same status, rank, etc., in the army as is now given
to the acting assistant surgeons of the United States
navy, which is that of an assistant surgeon of the
United States navy.
The injustice of depriving an acting assistant sur-
geon of the army (who has to sacrifice home comforts
and follow the army in the field and share the dangers
with the troops) of salary, if he is wounded or dis-
abled by disease contracted while in discharge of his
duty, is apparent, when a government clerk in Wash-
ington or elsewhere, who is exposed to no danger and
is not deprived of home comforts, is allowed one
month's vacation with full pay each year.
You are quite right in your statement that an acting
assistant surgeon of the army cannot receive a medal
for bravery, however distinguished his services may
have been. This is the ruling of the War Department.
I take this opportunity to commend the surgeon-gen
eral of the navy for his success in obtaining the proper
recognition of the acting assistant surgeons of the navy
in the late war, and to call the attention of the med-
ical profession to his interest in the medical staff. I
submit hii letter, which will show the benefits obtained
by the act approved May 4, 1898, for the acting as-
sistant surgeon of the navy, in the late war, compared
with his condition previously. It is an example that
the medical department of the army might follow with
advantage, and would be of benefit to the members of
the medical profession who enter the service.
"53.961-
"Washington, D. C, February 9, 1900.
"Dear Sir: Referring to your letter of February
8th, I would state that the law authorizing the appoint-
ment of acting assistant surgeons in the United States
navy during the War of the Rebellion is contained in
the act approved July 24, 1861, and in section 141 1
of the Revised Statutes, which states: 'The Secretary
of the Navy may appoint for temporary service such
acting assistant surgeons as the exigencies of the ser-
562
MEDICAL RECORD.
[March 31, 1900
vice may require, who shall receive the compensation
of assistant surgeons.'
"The volunteer medical officers during the War of
the Rebellion were not commissioned. They were ap-
pointed by the Secretary of the Navy. The law does
not mention their rank; it simply refers to their com-
pensation. They, however, wore the uniform of an
assistant surgeon and received all the consideration
shown to an assistant surgeon in the regular service.
The act approved May 4, 1898, is the only one con-
ferring rank on acting assistant surgeons. The act-
ing assistant surgeons in the United States navy, who
served during the War of the Rebellion, were not ap-
pointed by the President.
" Very truly yours,
" (Signed) W. K. Van Revpen,
" Surgeon General, United States Nary."
On February 13, 1900, General Orders were issued
from Headquarters of the Army, adjutant-general's
office, with the approval of names of the Secretary of
War, which contained a list of names of persons who
have distinguished themselves in *he Spanish- Ameri-
can war by " especially meritorious acts or conduct
in service." Among these names are several members
of the medical profession who should receive medals
of honor, and it seems to me that these medical heroes
deserve to be mentioned in every medical journal pub-
lished in the United States. I have culled the fol-
lowing from the General Orders, viz. :
1898.
June 24, and July i to 3. Dr. John Guite'ras, now out
of service (then acting assistant surgeon. United
States army) : For gallant and meritorious con-
duct in attending the sick and wounded on the
field of battle at Las Guasimas and Santiago.
June 24. Dr. Jose M. Delgado, acting assistant surgeon,
United States army: For distinguished service,
by being constantly on the firing line, exposing
himself in the most conspicuous manner to the
fire of the enemy, in the care of the wounded, in
the battle of Las Guasimas, Cuba.
June 30. Dr. Ma.ximilian Lund, then acting assistant
surgeon, United States army: For especially
meritorious conduct attending the sick and
wounded under fire, during the reconnoissance at
Tayabacoa, Cuba, and subsequently in making
extraordinary efforts to secure their embarkation
on the transports.
July I. Captain Thomas R. Marshall, assistant sur-
geon. Forty-first infantry, U. S. V. (then acting
assistant surgeon. United States army) : For gal-
lant and meritorious conduct during the battle of
Santiago, Cuba, where, under fire, he cared for
the sick and wounded.
Dr. Thomas Y. Aby, now out of service (then
acting assistant surgeon, United States army) :
For gallant conduct in attending to the wounded
on the battlefield and the sick .in the trenches,
while himself ill from fever and heat; this at the
battle of Santiago, Cuba.
Dr. Harry W. Danforth, deceased (then acting
assisting surgeon, United States army) : For
especially meritorious service rendered during
the battle of Santiago, Cuba, in caring for sick
and wounded. He was killed while at work at
the dressing station at the " Bloody Ford," on the
morning of July 2.
Dr. Francisco E. Menocal, now out of service
(then acting assistant surgeon, United States
army) : For gallant and meritorious conduct dur-
ing the battle of Santiago, Cuba, where, under
fire, he cared for the sick and wounded.
July. Major Frederick J. Combe, brigade surgeon
United States Volunteers (then acting assistant
surgeon. United States army) : For especially"
meritorious service during the Santiago campaign,
in establishing, with the aid of others, the divi-
sion hospital at the extreme front, carrying a por-
tion of the supplies for several miles on his back
during drenching rains and in deep mud.
Drs. Hamilton P. Jones and William W. Cal-
houn, acting assistant surgeons. United States
army: For especially meritorious service during
the Santiago campaign, in establishing, with the
aid of others, the division hospital at the extreme
front, carrying a large portion of the supplies for
several miles on their backs during drenching
rains and in deep mud.
Dr. G. Goodfellow, civilian and volunteer aid
to General William R. Shafter: For especially
meritorious services, professional and military,
during the campaign in Cuba.
July and August. Dr. Nicholas Senn, now out of ser-
vice (then lieutenant-colonel and chief surgeon,
United States Volunteers): For his surgical work
during the Cuban campaign, and for making a
scientific study into the causes of typhoid fever
among the troops.
August 13. Major Frank H. Titus, surgeon LTnited
States Volunteer staff (then acting assistant sur-
geon. United States army) : For establishing a
first-aid hospital in the village church, and for
the manner in which he came to the front with a
detachment of the hospital corps through a heavy
indirect fire, and the efficient manner in which he
rendered services to the wounded at the battle of
Manila, Philippine Islands.
August. Colonel Charles R. Greenleaf, assistant sur-
geon-general. United States army: For most effi-
cient and hazardous services in the medical de-
partment in Cuba and during the Puerto Rican
campaign, especially in the yellow-fever camps.
General Lawton's last act was to recognize the
bravery of Dr. E. K. Johnstone as follows:
"Army Corps, Manila, P. I. December 18, 1899.
— E. K. Johnsti • e, acting assistant surgeon. United
States Army, w^s attached to Kent's battery. His
performance of professional duty in field and barracks
had hitherto attracted the favorable attention of the
officers of this command; but the exceptional daring
and high sense of duty exhibited by him during this
expedition, particularly at the battle of Zapote River,
when he gave the immediate first aid to the wounded
along the river bank and on the bridge, deserve mate-
rial recognition.
" It is recommended that thii gallant young surgeon
be commissioned either major <»nd brigade surgeon or
major and surgeon of volunteers.
"Very respectfully,
" W. H. Lawton,
" Major- Genera/ Commanding, First Division U. S^
Volunteers."
The above just tribute of the War Department ta
the heroic deeds of the members of the medical pro-
fession who volunteered their services in the late war
ought to be sufficient to receive the gratitude of a
patriotic nation, and should obtain for the acting as-
sistant surgeons of the army the recognition they de-
serve and what they ask for from Congress, as well as
the approval of the surgeon-general of the army.
John T. Nagle, M.D.
THE MORTON-ROCKWELL DISCUSSION.
To THE EniTOIt OF THE MfDICAI. ReCORO.
Sir: I would like to refer the readers of the Morton-
Rockwell discussion to a quotation from Beck's Mur-
ray, " A System of Materia Medica and Pharmacy,"
March 31, 1900]
MEDICAL RECORD.
56-
published in 1828, vol. ii., page 240 : " Electricity is ap-
plied medicinally under the form of the stream or con-
tinued discharge of the fluid, under that of the sparks,
and under that of shock ; the first being the most gen-
tle, the second being more active, and the last being
much more powerful than either of the others. At the
introduction of electricity as a remedy, it was highly
celebrated for its efficacy in a number of diseases. It
is usually applied under the form of sparks; the spark
is communicated, etc., from the machine while the
machine is being worked. The shock is given by dis-
charging the Leyden phial." Again from " Braith-
waite's Retrospect," 1845, part xi., page 23- "The
second fact is, that if the nerves of a living animal be
submitted to the passage of the electric current, re-
newed at short intervals (static induced current),
tetanic contractions are excited."
C. L. Squire.
March 24, 1900.
PURE FOODS AND DRUGS.
To THE Editor of the Medical Record.
Sir: Apropos of your editorial upon the adulteration
of food in your issue of March loth, it is of further in-
terest to note that the Senate committee upon manu-
factures in its recent report suggested that a board be
appointed by the Department of Agriculture to have
full control of the standards of foods, drinks, and
drugs, and that the board use the " United States Phar-
macopoeia " as its guide. Thus a step has been taken
to secure legislation of a national character, as sug-
gested two years ago by the National Pure Food and
Drug Congress. The object and intent of such a board
would be to protect the right of the individual to ob-
tain in foods, drinks, and drugs, exactly what he re-
quires, not alone from the standpoint of obtaining his
money's worth, but also to protect him from injuring
his health. " Patent medicines," as well as drugs,
would, therefore, come under the control of this board,
at least to this extent: A patent medicine would have
to be harmless to any individual, and could not be sold
for more than its true valuation. Thus the sugar-and-
water preparations, as well as the "cures" containing
injurious amounts of opiates and alcohol, would no
longer be allowed on the market, unless, perhaps, a
true formula accompanied each package. Every well-
informed physician knows that it would be better for
the public to continue using pepper of which sixty
per cent, is cocoanut shells, than for one individual to
take a patent medicine. Who of us has not seen the
ruined intestinal tract from the free use of cathartics,
or does not know of the consumptive dying of cirrhosis,
or the neurasthenics — yes, and maniacs — from the em-
ployment of headache cures, ''pain killers," etc.?
If I am correct in my opinion that the jurisdiction
of this board would extend over the control of patent
medicines, would it not then be well for the various
medical societies to lend their influence to the imme-
diate passage of such a bill? I would suggest that
resolutions indorsing this committee's recommenda-
tions to the Senate be forwarded to Washington imme-
diately. John Joseph Nutt, M.D.
San Diego, Cal.
world, and his great temptation to resign his position.
It is the promised reward of house-surgecnship which
keeps the interne, and especially the ambulance sur-
geon, contented. After one month of first and second
ambulance call at Bellevue Hospital the surgeon has
had practically all there is to be gained from the ser-
vice. After that each week— each day even — may
bring to him some new experience, but he does not
learn enough to repay him by any means for his long
hours and hard work. There occur to me two ways in
which the ambulance service might be changed to ad-
vantage. One is that the hospital surgeon should do
his ambulance duty during his last six months, as you
suggest, but that he should receive a salary during that
time. Most of the surgeons would be glad of the op-
portunity to make a little money at the end of so many
years of hard study and work in the colleges and hos-
pital, and as experienced surgeons and salaried officials
they would indeed reform the ambulance system. My
other suggestion is that every hospital or dispensary
receiving any moneys whatsoever from the city should
be required to keep one or more ambulances in service
and a sufficient number of beds to care for all the
emergency cases they may receive. This would divide
the city up into such small districts for ambulance
service, that its adoption with a rule that all patients
are to be brought to the hospital, would lessen to a
minimum the dangers from a wrong diagnosis upon the
part of the surgeon.
John Joseph Nutt, B.L., M.D.,
ZaU House Surgeon, Bellevue Hospital.
San Diego, Cal., March 10, 1900.
REFORM IN THE AMBULANCE SYSTEM.
To THE Editor of the Medical Record.
Sir: In an editorial upon "Needed Reforms in Our
Ambulance System," of your issue of January 6th, you
suggest that the ambulance service be undertaken as
the closing duties of the surgeon's hospital career. A
serious objection to such a change would be the im-
patience of the surgeon to launch himself out into the
Jixtr0ical <§>uflflcsti0ixB.
Duodenal Ulcer should be treated on the lines laid
down for gastric ulcer. Operation is indicated in re-
peated and exhaustive bleeding with symptoms of acute
perforation. Perforation usually takes place in the
peritoneal cavity. The symptoms are either those of
generalized sepsis, suppuration, or perforation of the
gall-bladder, peritonitis, etc. Differential diagnosis
from ulcer of the stomach is, as a rule, impossible.
Bleeding is an almost constant symptom, the blood
appearing both in the stools and vomited matter. The
mortality is high — there were twenty-four deaths in
twenty-eight cases of perforation treated surgically.—
Paoenstecher, Deutsche Zeiisc/irift/iir Chirurgie, Bd.
52, Hft. 5,6.
Surgical Hints. — In phlegmonous conditions affect-
ing the hand or forearm, long-continued baths in mild
antiseptic solutions are of great usefulness. The
ordinary elongated fish-boiler is very convenient for
this purpose, as the whole hand and forearm may be
placed in it, and allowed to remain in it for hours at
a time. — In making plaster-of-Paris bandages, or in
using those that are ready-made, see if the plaster ap-
pears to be damp. If so it will not set well, but may
be greatly improved by placing it in the kitchen oven
for a short time. — Pain occurring symmetrically about
both shoulders in children should lead to examination
for cervical caries. In rheumatism the pain is of a
very different character, and practically never affects
both sides so evenly. — In concussion of the brain
death often takes place through paralysis of the
respiratory centres. The prompt use of artificial
respiration may tide the patient over his danger. If
the heart centres appear to be involved we must stimu-
late, and for this purpose there is nothing better than
heat applied to the precordial region, together with
564 MEDICAL RECORD. [March 31, 1900
such drugs as nitrite of amyl, nitroglycerin, strych- fine, continuous coaptation stitch of silk, may be made
nine, ammonia, etc. Alcohol and strong coffee may use of; and lastly, when there is little or no tension,
be administered in enemata. — In partial amputations and stitch marks are unimportant, the edges may be
of the foot it is essential to prevent contraction of the appoximated by means of thick or fine silk.
tendo Achillis, either by tenotomy or by the use of
splints, otherwise the foot is likely to point downward, Rigid Perineum.—
which will much interfere with the fitting of an arti- 1} Chloroform | ij.
ficial limb. The tendency of surgeons is more and Ether 3 i.
more to discard these partial amputations and cut j^j ''s "^^o^r'T 11 ■ ^'
above the malleoli, an operation giving less chance of
sepsis, a better stump for an artificial limb, and greater Indispensable and infallible.— Southworth.
facility of performance. — Always prepare packages of d„;„t„ t .-tu 4.^:1. r, ^ t j • i • • ^•
, .,.-' , ^ , ^ f %-,- ^, J Painless Lithotnty.— Rectal and vesical injections
sterilized sponges, made out of cotton, or cotton and r i- ■ 1 • 1 •,-,•. t
j"^ , » • • ti, u of antipynn lessen vesical sensibility. In a case op-
gauze, and always containing the same number, say .. j 1 ,-. ■ • { . ,
• \r, -c ,, .• • "• ■. •,, / erated upon by Guyon, crushing and evacuating the
six. 1 hen if the operation IS in a cavity, one will al- . • 1 r. °
, u ^1. u » ^ r ■ ^ 1 stone was painless after —
ways know whether he must account for six, twelve, ^
eighteen, etc. — Tnternaiional Journal of Surgery, De- ^ Antipyrin gr. xxiv.
cember, 1899. T''- °P" ?".-.='■
' '-' Aqu.Te 5 iij
The Prevention of Cancer. — Cancer of the uterus had been injected per rectum three-quarters of an hour
is preventable. If we believe, as Emmet has conclu- before the operation.— ^4;///. des Mai. ties Org. Genit.-
sively proved, that cancer of the cervix almost always Urin., No. 7, 1899.
begins in the cicatricial tissue in the angle of a lacera-
tion, then by removing the cicatricial tissue and re- Stricture — Massage in the perineo-bulbar region
pairing the laceration we would put a stop to this for five minutes daily with —
dreadful disease, at least so far as the cervix uteri is s, Potass, iod 4 gm
concerned. And this is just what has happened in Lanolin,
my own experience. I have made it a practice at the Ung. aq. ros aa 15
clinics and hospitals to repair every lacerated cervix • — Bazv.
that comes before me, with the result that out of five Excoriations on Hemorrhoids.—
thousand gynecological cases, of which there are com- 'S, Chrysarobin 0.08 cgm.
plete histories, there are at present less than twenty- Iodoform 0.02
five of marked laceration of the cervix remaining un- ,-;^'■ , u °'°'
, _, , . ., . . 1 , 01. theobrom 2 gm.
repaired. The result is most striking: instead of For one suppository. Use two or three daily.
having two or three cases a month of cancer of the — Boas.
uterus, as I had ten years ago, I now see only three or
four in a whole year. — A. Lapthorn Smith. Aneurism, suggesting pulmonary tuberculosis, was
detected by .v-ray examination. Other cases showing
The Incidence of Cancer. — Oophorectomy, either the value of .v-rays in suspected aneurism are given,
combined with removal of carcinoma of the mamma — F. H. Williams, Boston Medical a?id Surgical Jour-
ox performed subsequently in consequence of recur- nal, January i8th.
rence, or undertaken as a last resort in inoperable
cases, has sometimes produced remarkable ameliora- Suppurative Teno-Synovitis may be produced in
tion of symptoms, and often total disappearance of un- one of three ways: First, by direct septic infection
doubted cancerous tumors of the breast. The good of the synovial sheath by a wound. Second, by a sec-
effect of this operation has been attributed either to ondary infection from adjacent structures. This is
atrophy of the breast consequent upon removal of the seen frequently in the finger, where an infective cellu-
ovaries, or to suspension of some occult influence sup- litis spreads from the connective tissue about the vag-
posed to be exercised by that upon the breast. A very inal sheath into its interior. An infective process in
serious drawback to both these theories is that they do a phalanx or joint may extend in a similar manner,
not explain the undoubted benefit, marvellous indeed Third, in rare cases by a secondary process, as in py-
in some cases, which follows oophorectomy when it is aemia," scarlet fever, typhoid fever, etc. — W. Arbuth-
performed for recurrent scirrhus in the pectoral region, not Lane.
many months after all breast tissue has been removed r. • i m i_ ^ x t<-i- _ _ .^ x ^i.
{ ,. /-v 1 » J r Surgical Treatment of Fibromyomata of the
in a former operation. . . . Oophorectomy as a mode of ,,... / \ i-i ■ i . .. .. r cu
^ ,^ ■ c ' , u- J -..u ^i. Uterus. — (i) 1 he surgical treatment of fibromyomata
treatment of cancer is so frequently combined with the , , , • . • ^i • i / \ t.l li , i
,..,.. f ,, ., -J ^ ^ ^1 » ■» ■ j-£c u should consist in their removal. (2) Ihe bilateral
administration of the thyroid extract that it is difficult ^ r ., 1 , ^ . 1 l
,. ., . •• u • ■ removal of the adnexa by laparotomy has been gener-
ic apportion their respective shares in any improve- ,, , , . 1 • • i- .^ j 1 1
1'', , , , , 7^ , T n J- I ally abandoned and is indicated only as a complement
ment that takes place. — Dr. Arthur Jackson, j9////j-// ^ •' . , ^ • ci ., • .. u- 1 j
,- , , , ,\, , ,, ■' of ovariotomy when uterine fibromata exist which do
Medical Journal, November 2i;th. ^ ■' ^ 1 \ ^\, 1 r ci
•^ not cause grave symptoms. (3) 1 he removal of hbro-
Methods of Suturing Wounds. — Drs. W. Watson myomata should be made through the vagina when the
Cheyne and F. F. Burchard (" Manual of Surgical operation is easily made by that route. (4) Laparot-
Treatment," p. 159) give the following summary re- omy is preferable when vaginal hysterectomy appears
garding the method used: When there is no tension to present real difficulties. (5) Myomectomy and
on the edges of the wound, and a very small, fine scar vaginal hysterectomy should be made by anterior sim-
is required, either buried sutures may be used with no pie hemisection of the uterus or in a V-shape. (6)
sutures in the skin at all, or the finest horsehair may Large interstitial tumors are scooped out by a cutting
be employed. When very great tension is present, tube and removed by lozenge-shaped morcellation.
button sutures should be used, after undermining the (7) The removal of large pedunculated fibromata by
flaps, and, in addition to them, deep relaxation sutures laparotomy presents special indications. Abdominal
of silk wire should also be inserted, these being suffi- myomectomy is only rarely indicated. (8) The oper-
ciently numerous to separate the edges of the flap, ation of choice for large and multiple interstitial fibro-
which should be coapted by a fine, continuous button- mata is complete abdominal hysterectomy by subperi-
hole stitch. When there is only a moderate amount toneal decortication of the lower segment of the uterus,
of tension, interrupted silkworm gut, reinforced by a with closure of the pelvic peritoneum. — E. Doyen.
March 31, 1900]
MEDICAL RECORD.
565
'^evinxfs and Notices.
Treatment of Diseases of the Nervous System: A
Manual for Practitioners. By Joseph Collins, M.D.,
Professor of Nervous and Mental Diseases in the New
York Post-Graduate Medical School ; \'isiting Physician
to the New York City Hospital. Illustrated by 23 En-
gravings. New York : William \Yood & Company. 1900.
" Books cannot always please, however good.
Minds are not ever craving for their food. "
The book which Dr. Collins has written may not please all,
but many must surely be craving for the food he offers. It
will be a surprise to the general practitioner that a book of
six hundred pages should be written on the mere treatment
of nervous diseases. There is a general impression abroad
that the treatment of nervous diseases does not amount to
much ; that the diagnosis is the important matter; and that, if
it were not for the difficulty which the average practitioner
experiences in recognizing nervous diseases, the sphere of the
neurologist's usefulness \vould be distressingly limited. The
everj'-day experience of the specialist proves that there is in-
deed an art in treating nervous diseases and nervous patients,
and his fellow-neurologists will be profoundly grateful to the
author of the book we are reviewing for proving to the med-
ical public that there is mucli to be said regarding the thera-
peutics of nervous diseases.
Dr. Collins has had a grateful task before him, and has
acquitted himself well of it. His style, though not terse,
is vigorous ; his manner combative and original, and his
conclusions on every subject are almost certain to be both
interesting and suggestive. The author was fortunate
enough not to have been hampered by tradition, and though
he sets out to speak of the therapeutics mainly, it is natu-
ral that he should also have much to say about the diag-
nosis and the pathology of the various diseases which he
has considered. No fault is to be found with him for
having written a condensed general treatise on nervous dis-
eases. He has had the special privilege, moreover, and no
one could deny him the right, to say what he cared to say
and to leave much unsaid that he did not choose to dilate
upon. We have noted only one rather striking omission in
the chapter on the treatment of cerebral apoplexy. Very
properly the author considers cerebral hemorrhage and soft-
ening of the brain from embolism and thrombosis; he dis-
cusses the treatment appropriate to each condition ; but, al-
though he gives the etiology and the pathology of cerebral
hemorrhage and of embolism and thrombosis, he fails to
state the most important thing — namely, how the practitioner
who is attending at the bedside of a patient just laid low
from apoplexy can tell whether the apoplectic stroke is due
to hemorrhage, embolism, or thrombosis. A table giving
the symptoms of the various modes of onset of the apoplectic
attack would be very helpful, and we trust that in future
editions — which the book is certain to have — such a table
will be inserted. In almost every other chapter of the book
the information which the author gives regarding the diagno-
sis and pathology contains practically all that the physician
who wishes to treat a patient intelligently needs to know at
the time such treatment is projected, and this means much
as an indorsement of the extremely practical character of the
book.
The general plan of this manual is to be commended.
Part I. consists of a chapter on the " Causes and Origination
of Diseases of the Nervous System," and of a second chapter
on the "Prevention of Diseases of the Nervous System."
Both these chapters are so thoroughly characteristic of the
author's manner of writing and of thinking that we trust all
will become acquainted with their contents. Hereditary and
congenital influences, the neuropathic diathesis, the stigmata
of degeneracy, the role of infection, and the influence of
syphilis are thoroughly discussed. The author has a tilt
with those who are constantly speaking and writing of
"syphilis of the nervous system" as though it were "a dis-
ease with defined anatomical foundation and unvarying mor-
bid changes." We know of no recent writer of repute vvho
has spoken thus loosely of syphilis of the nervous system,
and we find that the author has given a very able presenta-
tion of the subject along the orthodox lines adopted by a
number of his predecessors. There is no reason to disagree
with him in his general discussion of this special question,
except that he makes syphilis responsible for certain diseases
which others of equally Targe experience would not ascribe to
it. Only one author of any note has maintained — and his
conclusions were based on insufficient evidence— that a ma-
jority of infantile cerebral palsies were due to syphilis. The
statistical evidence that has been carefully collected by previ-
ous writers points to the very opposite conclusion. iVe can
subscribe, however, to Collins' fling at the '• husscr-a/!,>"
fashion in which antisyphilitic treatment is generally con-
ducted. If he will stir up the syphilologists to greater ef-
forts in this respect, he will deserve the gratitude of the medi-
cal profession and of the laity. Chapter III. contains a very
useful list of the drugs employed in the treatment of nervous
diseases, and stamps the author as a firm believer in medic-
inal agents. In maintaining this position he is evidently
anxious to remain in good company; but he does not, by
any means, limit his therapeutic measures to the exhibilion
of drugs. In the chapters on hydrotherapy, massage, and
electrotherapy, as well as the one on exercise, rest, and
occupation, Collins shows that he has full regard for every
remedial measure calculated to benefit the patient. His re-
marks on hydrotherapy are thoroughly sane. They may
not meet with the approval of those who consider hydriatric
treatment a panacea, and his fling at "institutional" treat-
ment may arouse some opposition ; but he has unquestion-
ably done good work by showing that great benefit can be
derived from hydriatric procedures practised in the patient's
home.
After devoting one hundred and forty-four pages to
the consideration of the general methods of treatment, the
writer enters upon a detailed consideration of the treatment
of various diseases. These are discussed in practical se-
quence, and the order, although somewhat different from
that adopted in the ordinary text-book, is such as to be
hardly open to serious criticism. But we cannot quite un-
derstand why, after a chapter on the treatment of cerebral
apoplexy, there should be another near the close of the book
on hemiplegia. In the consideration of tabes, the author
gives a detailed account of recent methods for the re-educa-
tion of the ataxic extremities, with a series of serviceable il-
lustrations, which will help the practitioner unacquainted
with these methods to inaugurate them in any case that may
be under his care. While the treatment of the chronic dis-
orders of the central nervous system is considered briefly
enough, a very detailed account is given of the proper man-
ner of handling the large number of functional diseases which
come under the observation of the practitioner and the spe-
cialist. It cannot be our purpose to enter into a considera-
tion of the various forms of treatment recommended by the
author, and it will suffice to state that he is entirely in line
with the most modern ideas regarding the therapeutics of
the nervous system. He is generally conser\-ative enough.
In his partial indorsement of cerebellar operations he has per-
haps been a little less conser\'ative than others would have
been ; but individual experience is bound to leave its imprint
upon the work of every writer who does not merely copy
from others, and so we have no fault to find with Collins'
position in this matter, all the more as he is excessively care-
ful in the general consideration of the surgery of cerebral
tumors.
The general practitioner will find Dr. Collins' work all
that it claims to be; and even specialists will find it a con-
venient book of reference, if they are anxious to determine
what special methods of treatment had been advocated in any
given disease. The book deserves to be widely read and
carefully studied.
The Dispensatory of the United States of Amer-
ica. By Dr. George B. Wood and Dr. Franklin
Bache. Eighteenth edition, thoroughly revised and
largely rewritten, with illustrations, by H. C. Wood,
M.D., LL.D., Joseph P. Remington, Ph.M., F.C.S.,
and Samuel P. Sadti.er, Ph.D., F.C.S. Philadelphia:
J. B. Lippincott Company. 1899.
The advances made in drug study since 1833, when the first
edition of this standard work was issued, are in a measure
reflected in the increase in size of the volume now necessary
to cover the great number of remedial agents. Aside from
the accurate information concerning materia medica and the
medical properties of drugs and their uses, we have, first, a
glossar\- of terms employed ; an index of diseases, giving the
reference to the particular remedy mentioned ; and in Part
III. we find the subjects formerly embraced in the appendix,
with the additions of official tests and various tables, manv
566
MEDICAL RECORD.
[March 31, 1900
of which are now introduced for the first time. A feature
of value is the alphabetical table of formulae and molecular
weights. The index alone takes up just one hundred of the
two thousand pages. .A.11 who have had to do with the pro-
duction of so important a work, representing such a vast
amount of research, are subjects for congratulation.
The Cost of Living as Modified by Sanitary Sci-
ence. By Ellen H. Richards, Instructor in Sanitary
Chemistry in the Massachusetts Institute of Technolog)'.
New York : John Wiley & Sons. London : Chapman &
Hall. 1899.
This little duodecimo of one hundred and twenty pages,
without preface, starts with Chapter I. on "Standards of
Living." The author then studies the service of sanitarj'
science in increasing productive life, household expenditure,
rent, operating - expenses, food, intellectual and emotional
life, etc. A valuable and well-written book.
Recollections oe a Rebel Surgeon (and other
sketches) ; or. In the Doctor's Sappy Days. By F.
E. Daniel, M.D. Illustrated. Austin, Tex.: Von
Boeckmann, Schutze & Co.
Literary physicians keep springing up in various quarters.
Southern writers (in the South) have as yet been slow in go-
ing into non-medical work. We have, however, had in this
city two notable examples of Southerners who have recently
made a success with the pen outside of professional writing.
Dr. Daniel, of the Texas Medical Journal, gives in his pref-
ace an explanation of the reasons why the average Southerner
speaks as incorrectly as he does. He then makes the ' ' Old
Doctor" tell some "alleged" humorous, sad, and pathetic
stories, all said to be true. The literary merit is not of a
high order; the illustrations are very crude, and too much
slang is indulged in to make pleasant reading.
Consumption and Chronic Diseases: A Hygienic
Cure at Patient's Home of Incipient and Ad-
vanced Cases. A Popular Exposition of the " Open-
Air Treatment," with Latest Developments and Improve-
ments. By Emmet Densmore, M.D. London: Swan,
Sonnenschein & Co., Paternoster Square. New York:
The StiUman Publishing Company, 15 Sterling Place,
Borough of Brooklyn. Pp. 198.
The author contends most valiantly for the efficacy of the
Nordrach treatment by fresh air and overfeeding, and cites
many instances in which those living in cities who had ad-
vanced pulmonary tuberculosis have been wonderfully helped.
There is undoubted truth in his contentions, although they
are perhaps tinged too much with a sanguine enthusiasm,
leaving the reader with the impression that failure would be
exceptional. It is but another proof that the profession is
relying more and more upon hygiene to combat this scourge.
Chirurgie du Foie et des Voies Biliaires. Par J.
Pantaloni (Marseilles). Avec 348 figures dans le
texte. Paris: Institutde Bibliographie Scientifique. 1899.
To the surgeon who wishes to ha\e a complete and suc-
cinct history of the status of the surgery of the liver, the
gall bladder and its ducts, this volume cannot fail to be of
great use. The subject is taken up systematically, begin-
ning with the simplest operative procedures and progressing
to the most difficult, and there are numerous very good ex-
planatory illustrations. The author has evidently used great
care in examining the literature of his subject, and has been
successful in bringing it up to date, and we are glad to note
instances of credit due to American surgeons placed where
it belongs — something not too common in European writings.
The descriptions of operations are lucid, and the various
forms of mechanical aids are well illustrated. The volume
is a scholarly production and an excellent addition to any
library.
International Clinics. Edited by Judson Daland,
M.D., Instructor in Clinical Medicine and Lecturer on
Physical Diagnosis in the University of Pennsylvania.
Vol. III. Ninth series. Philadelphia: J. B. Lippincott
Company. 1899.
This quarterly of clinical lectures and specially prepared arti-
cles on treatment and drugs continues to receive contribu-
tions from the best men of this and other countries. This
issue contains the names, among others, of Baginsky, Bern-
hardt, Dieulafoy, Gartner, Gerhardt, Goldscheider (w'ho has
an excellent article on the method of treating tabes patients),
Graucher, Helferich, Krehl, and Robin, not to mention many
of the best-known American names. In a work intended for
practitioners, it would seem somewhat out of place to devote
so much space to definitions and generalities with which
every student is familiar, as has been done by the writer of
the last specially prepared article.
Contribution a l'Etude des Obsessions et des
Impulsions a l'Hojiicide et au Suicide. Par
Georges Carrier. Paris: Felix Alcan. 1899.
This is one of the publications issued by the Progres Medi-
cal, and deals with the tendencies to suicide and homicide in
degenerates, considered from the medico-legal standpoint.
It is a very readable little brochure.
Chirurgie du Rectum. Par E. Quenu et H. Hart-
mann. Vol. II. Paris: G. Steinheil. 1899.
The second portion of this excellent work on rectal diseases
treats of the tumors of the region, adenomas, villous, fibrous,
lipomatous, cancer, sarcoma, myxoma, enchondroma, lymph-
adenoma, dermoid cysts, and angiomata. Like the first
volume, it is superbly illustrated, having seventy-four figures
in the text and twenty-eight plates, many colored, as insets.
The authors are to be congratulated upon so successful a
presentation of their investigations and years of labor, as are
the editors upon the quality of the press-work.
A Practical Treatise on Medical Diagnosis, for
Students and Physicians. By John H. Musser,
M.D., Professor of Clinical Medicine in the University of
Pennsylvania, Physician to the Philadelphia and the Pres-
byterian Hospitals, Consulting Physician to the Woman's
Hospital of Philadelphia and to the West Philadelphia
Hospital for Women, Fellow of the College of Physicians
of Philadelphia, Member of the Association of American
Physicians, etc. Third edition, revised and enlarged.
Illustrated with 253 woodcuts and 48 colored plates. Phila-
delphia and New York : Lea Brothers & Co. Pp. 1082.
The third edition of this work is a considerable improve-
ment over its predecessors, good as they were. The
chapter on nervous diseases has been entirely rewritten,
while changes in the articles on the sputum and on the eye
are to be specially noted. Too high commendation cannot
be paid to the pictorial records of physical signs, where at one
glance the disease picture is seen and grasped in a manner
more like that which tlie clinician employs and less like that
of the text-book. It is a most complete work, richly and ex-
pensively illustrated and thoroughly modern. The first sec-
tion describes the data obtained by inquiry and observation,
and serves to point out how to ask questions and how to see;
the full description of the blood as regards diagnosis, and the
symptomatology of general morbid processes. Part II. takes
up in order the nose and larynx, lungs and pleurse, heart,
blood-vessels, and the mediastinum ; mouth, fauces, pharynx,
and oesophagus; stomach, intestines, and peritoneum; liver,
spleen, and pancreas ; kidneys and nervous system.
AN.t:MiA AND Some of the Diseases of the Blood-
forming Organs and Ductless Glands. By By-
rom Bramwell, M.D., F.R.C.P. Ed., F.R.S. Ed.,
Physician to the Royal Infirmary, Edinburgh; Lecturer on
the Principles and Practice of Medicine and on Clinical
Medicine in the School of the Royal Colleges, Edinburgh ;
etc. Philadelphia: P. Blakiston's Son it Co. 1899. Pp.
450.
When the author's well-known clinical ability and clearness
of description are remembered, this work hardly needs an in-
troduction. From start to finish it abounds in magnificent
pen pictures, logical discussions of theories, and common-
sense methods of treatment. After a short general descrip-
tion of what anasmia is, its causes, forms, general clinical
symptoms, and microscopic characteristics, lie proceeds to
treat in an exhaustive manner the subject of chlorosis. The
usual and unusual symptoms are all well described, and the
treatment of obstinate cases by very large doses of iron is
especially insisted upon. Among his many useful methods
of teaching particularly to be noted is the tabulation of eighty
cases with regard to the ages, number of red corpuscles, per-
March
1900]
MEDICAL RECORD.
567
centage of hjemoglobin, conditions of menstruation and
bowels, and specially noteworthy peculiarities in each case.
The next section is devoted to pernicious ansmia, treated in
much the same manner, and containing all the important
points in differential diagnosis. Here again he has tabulated
forty-five cases with reference to age, se.\, haemoglobin, red-
blood-corpuscle count, and the relative numbers of megalo-
cytes, microcytes, and white corpuscles ; the marked or mod-
erate showing of poikilocytosis, the presence or absence of
marked prostration, loss of weight, hemorrhages, dropsy,
V'omiting, diarrhoea, jaundice, and fever, with the character-
istics of the urine. The pathological physiology of the dis-
ease is discussed most fully and in an interesting manner.
It will be remembered that the arsenic treatment was intro-
duced by the author and has since become universal. Besides
the table just mentioned, a most interesting summary of forty-
eight cases is added, giving a succinct history of each, its dura-
tion and treatment. Leucocythsmia's varieties, etiological
factors, morbid anatomy, clinical history, diagnosis, and dif-
ferential diagnosis, prognosis, and treatment occupy the next
chapter, followed by a similar handling of Hodgkin's disease.
Under Addison's disease he analyzes twelve cases seen by
him during life, with a summary of the histoiT, course, and
treatment in each. The final chapters are devoted to myx-
oedema, of which disease he has seen forty cases ; exophthal-
mic goitre, w'ith a summary of seventy-nine cases, and acro-
megaly. Throughout the work the greatest completeness
and clearness obtain. When one has finished reading, there
seems nothing which one could desire to be added to the
text, and one feels satisfied that the pictures of the various
diseases have been impressed upon the mind in a manner not
soon to be forgotten. The stamp of the personal obser\'er
is seen from the introduction to the index, and the author has
the happy faculty of transferring that experience in a most
impressive way. It is to be regretted that pictorial illustra-
tions have not been introduced into this work, since many of
the conditions mentioned are such as can best be taught in
this manner. If the reader could have a picture of a my.x-
oedematous patient, for instance, near at hand while reading
the masterly descriptions, certainly it would be a great aid.
Also pictures of the microscopical appearance of the blood
would have added to the book's value. For every practitioner
this volume would seem a necessity, both to be perused in
continuous reading and to be sought as a reference in diag-
nosticating puzzling and atypical cases, or treating obstinate
ones. The book is essentially practical without omitting the
necessary theoretical discussions, such as tend to make us
broader practitioners and urge us to further effort to seek the
causes of disease. The theories are concisely treated, how-
ever, and could not possibly fatigue the reader if he is of
average intelligence.
Treatise on Orthopedic Surgery. By Edward H.
Bradford, M.D., Surgeon to the Children's Hospital,
etc., and Robert W. Lovett, M.D., Assistant Surgeon
to the Children's Hospital, etc. Illustrated with 621 En-
gravings. Second revised edition. New York : William
Wood & Company. 1899.
The first edition of this work, published several years ago,
soon made an enviable place for itself, and for some time it
was not thought necessary to publish a second. The time
finally has come when such a second edition seemed desir-
able, and the authors have given us what is practically a new
work. New subjects and illustrations have been added, and
old subjects have been amplified. As is natural, diseases of
the vertebral column take a large share of space, in which,
among other things, we find an interesting discussion of the
forcible reduction of spinal deformities. The conclusion is
conservative, and we are warned that great care is necessary
in the performance of the operation and in the selection of
cases. There are many illustrations showing the changes in
bones and joints due to chronic disease, which means practi-
cally a description of the tuberculous lesions of bones and
joints, and the various forms of apparatus are illustrated and
explained by photographic reproductions and diagrams. The
chapter on the subject of clubfoot is excellent and complete,
and is freely illustrated. There is a careful weighing of the
comparative value of the various methods of treatment, and
several excellent results after operation are shown by dia-
gram. The importance of over-correction of the deformity
is emphasized. The authors do not accept intra-uterine vio-
lence as the cause of the so-called congenital dislocations, but
believe that such abnormalities depend upon some sort of de-
fective nutrition and development. The hip, as it is most im-
portant in this regard, receives most attention. The deformi-
ties due to rickets and allied conditions are given considerable
space, and the choice between osteoclasis and osteotomy is
left to the individual operator, except that osteoclasis is not
thought desirable in adults. On the whole, this book is the
best work of reference upon orthopedic surger)' which is now
extant in this country, and must prove very satisfactory to the
specialist as well as to the practitioner.
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, March ij, igoo.
William H. Thomson, M.D., President.
The third meeting devoted to the discussion on cancer.
Cancer of the Breast. — Dr. Robert T. Abbe read
this paper. The question whether surgeons could
eradicate cancer of the breast was open to debate.
Light was dawning on the subject, showing a bacterial
origin, and any advances made in curing the disease
he believed to be the outcome of this knowledge.
Lymphatics and Cancer. — During the past fnfteen
years the minute anatomy of the efferent lymphatics
demonstrated that recurrences occurred along these
lines, and this pointed to the only method for eradica-
tion. In early life cancer of the breast was purely a
localized disease. Certain anatomical features of the
lymphatics were considered: (i) Tiiose that drained
the mammary gland toward the axilla; (2) those that
extended outward to the overlying skin ; (3) those in
the deep aspect of the gland draining to the deep cel-
lular tissue of the pectoral muscle; (4) those that
drained toward the sternum. Clinical observations
would determine which series would be the most in-
volved. The axilla received the greatest part of the
infection. The progress of this disease along ana-
tomical lines gave us such knowledge as was of interest
in the effacement of this disease; infiltration of con-
tiguous parts must be recognized.
The Operation of Removing Cancer of the breast ■
was now practically a bloodless one, and there was no
shock following. • Too much emphasis could not be
laid upon the fact that the infected cells should not be
squeezed into the wound. The hard scrubbing of the
skin by the nurse he regarded as instrumental in
causing recurrences in the neighborhood of the scar;
there should be less handling and friction of the skin.
Infection by escaping cells was no myth.
Statistics. — To determine the actual value of the
work done in this field in recent years one must be
able to state the length of time the patients were rid
of the disease, and what approach to eradication had
been made; this could be done only by (i) the statis-
tical method, and (2) the personal impressions of the
surgeon. Halsted's statistics were the best obtainable.
He gives an analysis of 133 operations done at the
Johns Hopkins Hospital during the preceding nine
years; forty-one percent, of the patients lived without
recurrence and without signs of metastasis; 76 patients
survived more than three years; 40 lived more than
three years without recurrence. Stiles, of Edinburgh,
emphasized the results of microscopical examination
proving the course of lymphatic absorption, namely, by
the lymph channels accompanying blood-vessels. In
thirty per cent, cancerous nodules were found on the
posterior surface of the pectoralis major. In Dr.
Abbe's personal experience, notes taken during only
the past fifteen years showed 33 cases in private and
90 in hospital practice, or 123 cases altogether.
568
MEDICAL RECORD.
[March 31, 1900
Among the ^3 cases in private practice that he had
recently heard from, i patient lived six years; i lived
five and a half years; 1 lived four years; 2 lived three
years; 5 lived two and a half years. Twenty-five per
cent, reached the three-year limit, and nearly as many
approached it. From a personal estimate of the mod-
ern operative work he found to-day that the impres-
sions of men had passed the stage of pessimism and
they were now high optimists. He thought that the
three years' immunity was within the reach of most
surgeons. Removal of the involved lymphatics gave
two advantages : the pressure in the neck was not seen,
and the cachexia, formerly so distressing, was now
rarely present. Recent experiences showed that re-
currence of cancer after operation need not discourage
the patient or the operator.
Muscular Tissue, Lymphatic Glands, and Skin. —
Dr. J. A. Franz Torek said that the question that
arose as to what we should do besides removing the
breast were three in number: (i) Should we remove
more skin than that which covers the breast, and if
so, how much? (2) Should we remove glands? (3)
Should we remove muscular tissue? Since the publi-
cation of Dr. Halsted's paper he had invariably re-
moved both pectoral muscles, and he had never had
occasion to regret such a radical measure. Among
the cases operated upon in this way there were a num-
ber of hard-working women, servant-girls, etc., and
after removal of the pectoral muscles, while they de-
clared that some power was lost, yet they were perfectly
able to move the arms. It was pretty well agreed that
the muscles should be removed. If the entire axilla,
anatomically considered, were cleared out, it would be
a good piece of work. In the hands of the earlier
surgeons, clearing out the glands from the axilla as
high up as an inch or two from the border of the
pectoral muscle was supposed to be effectual ; but they
really never entered the axilla. As Dr. Abbe stated,
in a great many cases infected glands were present be-
hind the pectoral muscles; he had repeatedly seen
them. The method of removing them by simply lifting
the border of the pectoral muscle was very unsatisfac-
tory; this fact alone gave justification for removing
the pectoral muscles. This method thoroughly ex-
posed the entire stretch of connective and fatty tissue,
which contained a considerable amount of infected
glands, from the outer border clear up to the clavicle.
One should never forget the supra-clavicular glands.
They could be more easily diagnosed before operation
than any other glands; they could be palpated with
great ease, which was not the case with the sub-pec-
toral glands; the latter could not be diagnosed unless
large. The removal of the skin was of the utmost im-
portance; it should be lavishly sacrificed. The skin
was the foremost organ for recurrences. In order to
be safe against recurrence we should sacrifice a con-
siderable amount of the skin.
Results of Operation.— Dr. Thomas H. Manley
said it appeared that cancer was more common in the
breast than in any other organ of the body. Up to
recent times genuine typical mammary cancer had
been regarded as practically incurable. He averred
that he had heard a statement made by Dr. Abbe a
few years ago to the effect that relapses were so com-
mon, and fatal consequences so general from this opera-
tion, that the late Dr. Sands had become so discouraged
as to practically decline to operate. The fundamental
question now was whether we were assured and satis-
fied beyond a doubt that the lesion was of local char-
acter, and that it was not disseminated or generalized
before it manifested itself in the mammary gland. It
should be caught at its birth and eradicated then and
there. A patient with cancer of the breast wished to
know two things before operation: What was the
danger to life, and whether it would impair the useful-
ness of the limb; also, whether the disease could be
cured or not. Some cancers relapsed at once and some
not for years. The new operation certainly guaran-
teed a non -recurrence in the breast or chest wall, for
the reason that there was nothing left in which the
cancer could return. Halsted's operation entailed a
large sacrifice of muscle and fascia. He had seen
elephantiasis result in an arm from which the lym-
phatics had been removed; he had seen cases in
which the nerves of the arm had been injured, result-
ing in more or less paralysis and numbness of the
limb; he had seen cases in which the patient had been
left with troublesome painful sores upon the thighs,
making walking impossible. He had not undertaken
the wide dissection of the parts because the simple
excision of the gland, in the majority of cases, had not
been followed by recurrences; the average period
being three years and some having passed nine years.
His experience had not been similar to Dr. Abbe's in
regard to the disease following the course of the lym-
phatics; in one instance it recurred in the larynx; in
another, in the opposite mammary gland. He was
hopeful that the new operation would do all that was
promised for it, but he believed that it was yet in the
trial stage.
Dr. William H. Thomson said that five years ago
he had a patient whose breast had been removed by
Dr. Sands ten years before for cancer, and she had
remained healthy until that year, w hen it developed in
the axilla. The original operation was simply its
removal, and no attempt had been made to follow it
up into the axilla. The growth had remained quiet
ten years before it started afresh.
Cancer of the Uterus. — Dr. Henry C. Coe read
this paper. He said that surgical treatment, in order
to be successful, should be done in time ; that was the
key-note of success. Accumulated experience empha-
sized that one point — early diagnosis and removal.
In Germany thirty per cent, of the patients were oper-
ated upon when first seen, and that was the explana-
tion of so many radical cures. In early diagnosis lay
the hope of improvement in our statistics. This im-
plied in general the recognition of certain symptoms
and the investigation of causes. An idea existed and
was firmly fixed in the minds of some physicians, that
a woman could not have cancer without pain, cachexia,
and a foul discharge. These were symptoms of ad-
vanced disease. Uterine hemorrhage was significant
of commencing carcinoma, and, in short, was the only
symptom; it was slight and atypical, and so was often
overlooked. It was universally believed that the ap-
proach to the menopause was the explanation of every
irregular discharge of blood, and that belief was
responsible for so many neglected cases. If the trouble
was within the uterus, the siiarp curette or palpation
was the only positive means of learning the nature
of the disease; some foci of disease might easily be
passed over by the curette; therefore a careful history
was very important. After a positi\e recognition of
the disease the questions arose, whether it was a suit-
able case for operation ; was it confined to the uterus
or did it involve adjacent viscera? These questions
could be determined only by an examination conducted
under an anresthetic. We should also determine to
what extent the glands were involved. He had oper
ated upon a case that day. Five years ago the woman
was examined in a New York hospital by several sur
geons, and it was supposed that the disease had
invaded the peri-uterine tissues, and she was told her
case was absolutely hopeless. The sharp spoon and
cautery were used, and the woman lived eight years
perfectly well. She was referred to him a few weeks
ago, when he found that the disease had recurred and
extended up the cervical canal. One man would oper-
ate when another man would not; some general rule
March 31,1 900]
MEDICAL RECORD.
569
should be laid down for our guidance. In general,
operable cases should be divided into those confined
to the uterus and into those in which there were limited
mobility of the uterus and induration at the base of
the broad ligament. The prediction as to the lease
of life without operation was notoriously uncertain.
It was well known that patients with inoperable can-
cers might enjoy life, free from pain,- even three years
after the death sentence had been pronounced. Dr.
Jackson, who was so opposed to hysterectomy, had
made a study of statistics, and stated that the duration
of life was longer when the cancer was treated pallia-
tively than when submitted to operation. Three times
as many women died from cancer as from childbirth.
In less than ten per cent, of operable cancers were the
patients saved by operation.
Increased knowledge of the histology of cancer con-
firmed the opinion of the older gyna;cologists that
erosions or ulceration were often exciting causes;
therefore it might be well to amputate the cervix or to
use the sharp curette in the early stages. Regarding
the question of removing the uterus by the vaginal or
abdominal route, all were agreed that the abdominal
route was indicated when the organ was too large to
be removed by the vagina. He was sure the trend of
opinion was now in favor of the abdominal method in
corporeal disease. It might be contraindicated in stout
patients or when rapid work was necessary. Among
twelve hundred and seventy-three cases collected by
thirty-eight surgeons in Europe, a mortality of 14.6 per
cent, was shown. In patients that could be traced,
the average period of e.xemption was found to be
three years and four months. Even if ten per cent, of
the lives could be prolonged two, five, or seven years,
or even permanently saved, there was decided hope for
the future. Abdominal hysterectomy for cancer of the
cervix was rapidly growing in favor; it appealed to
the modern surgeon as the only method by which ulti-
mate results could be improved. Assisted by cathe-
terization of the ureters and ligation of arteries, opera-
tors worked with a thoroughness formerly regarded as
impossible. Statistics were not now obtainable, but
soon would be, as data were now being prepared. The
speaker closed his paper by calling attention to the im-
portance of the early recognition of the disease; the
profession and laity should be instructed as to the im-
portance of hemorrhage as an early symptom. Every
suspicious case should be submitted to rigid search,
careful examination being made under ancesthesia.
A thorough removal should be made; unless incision
was made in healthy tissue the operation was palliative
rather than curative. He believed that abdominal
hysterectomy would be the method of the future.
Prognosis. — Dr. Herjian J. Boldt stated that the
prognosis must depend upon the early diagnosis. The
reason for the difference between operable cases found
in this country and those occurring elsewhere was
simply that abroad, whenever there was any abrasion
of the mucosa of the cervix, the scrapings from it were
subjected to a eyeful and scientific examination by
one who was competent to judge what was pathological
and what was histological. The prognosis depended
largely upon the seat of the disease. The gravest
cases of all were those in which the cancer was present
in the so-called cervical portion, especially in the
vaginal tract, because herfe the cancer was situated
beneath the endometrium. . When the parametrium was
involved, or tlie deeper tissues were encroached upon,
compressing the ureters, the prognosis was exceedingly
unfavorable. Certain unrecognized cases, treated in a
palliative manner, when they came to the surgeon and
were recognized, had gone beyond the vaginal portion
proper, and had encroached upon the supra-vaginal
portion and attacked the parametrium ; these were also
very unfavorable cases.
Diagnosis — One could not be too careful to inves-
tigate each and every case in which there was the slight-
est suspicion of the disease being present. A woman
between the ages of thirty and thirty-five years, who
showed signs of atypical bleeding, was the one offering
the most unfavorable prognosis. When such a con-
dition was present it was not enough merely to scrape
the mucosa of the uterine cavity with a curette, because
the part most desired to be removed v/as frequently
left. It was necessary to remove every vestige of
mucosa and submit it for examination. In the cervical
canal, when the disease started in the endometrium
microscopical examination became unnecessary, be-
cause here the disease was well marked. He did not
believe it was necessary to make a manual examina-
tion of the uterine canal ; forcible dilatation was un-
called for; curettage would do all that was needed.
In doing this an anaesthetic was absolutely necessary.
In examining under an anjesthetic a point that should
not be overlooked was that the vagino-abdominal
examination was entirely unsatisfactory; unless one
made a recto-abdominal examination the results would
never be satisfactory in revealing the amount of in-
filtration. An examiner of large experience could
determine whether the infiltration was malignant or
inflammatory.
Treatment. — Regarding igni-extirpation, if it was
shown that the cases operated upon were such bad
ones, and that twenty per cent, of the patients recov-
ered for a certain length of time, he thought that was
a favorable showing. In one of his cases there had
been no recurrence for nearly three years. The case
had been declined by one of the leading surgeons of
the city. Igni-extirpation was done, and although bad
complications arose, in that secondary to the igni-
extirpation both ureters gave way and there was a ure-
teral fistula on both sides, the result of the hot iron,
yet the patient did well. Comparing vaginal with
abdominal hysterectomy, he did not believe that the
modified operation would give better results than
vaginal hysterectomy if performed when the patients
were in a suitable condition.
Diagnosis. — Dr. W.. Evelyn Porter said that dur-
ing the past eight years he had been studying cases in
the various hospitals in the city, and had had the
assistance of various pathologists in studying sections
of uteri that had been removed; the result of his study
showed the difficulty in making a satisfactory diagnosis
except in the superficial forms of the disease. Hem-
orrhage should be considered in connection with the
age of the patient. Hemorrhage occurring in women
past forty years of age, in the large majority of
cases, was due to malignant disease. He preferred
the abdominal route in operating, and thought it
would be the choice of the future.
Educate the People.— Dr. Philander A. Harris,
of Paterson, N. J., believed that, in the haads of a
skilful operator, the vaginal operation could surely be
done without a death rate greater than five or six per
cent., when the cases were judged to be operable. Th.e
profession should be educated, and secondarily the
people should become educated, as to the importance
of operation. Another serious obstacle to proper
treatment was the erroneous impression women had
about the menopause; which caused this period to be
much neglected on their part. It was common for a
woman who menstruated ten or fifteen days each month
to say that it belonged to the change of life; she did
not consult her physician. It was also common for
them to disregard leucorrhcea at this period. Many
cases had gone on to tissue necrosis before a physician
had been consulted. As to diagnosis, if de'bris had
been submitted to a pathologist and he reported that
he could not find signs of malignant disease, that was
not conclusive, and the pathologist should not be
570
MEDICAL RECORD.
[March 31, 1900
blamed for what he did not find ; if he found evidences
of malignant trouble, it helped the physician.
Clinical Facts. — Dr. VV. Gill Wylie said there
was no doubt that cancer was a disease not prone to
attack normal or healthy tissue; it attacked only de-
generated tissue, and was much more commonly found
in such organs as the breast and uterus. Recognizing
that fact, he believed much could be done, and would
be done, in the removal of degenerated tissue to aid
these patients. Speaking of age in prognosis, he said
he had seen carcinoma occurring in persons
under twenty years of age, but had never seen
one cured. Between the ages of twenty and
thirty years the disease was rapid and very dan-
gerous, whether occurring in the breast or the
uterus. As the woman grew older it was nlore
manageable. After the menopause, hemor-
rhages might occur; if they did, it showed
that the disease was more advanced. If
women stopped menstruating for six months,
and then began again, that pointed to can-
cer; if they stopped one year, and began
again, it was more certainly cancer; if they stopped
for two years, and then went on again, it was most cer-
tainly cancer. In regard to the results of operation, he
said there was a difference between the results obtained
in foreign hospitals, and those in ours, because in our
institutions we had the poorer people, who, when they
came in, were in a bad condition; if they entered such
an institution as Bellevue, it was because they were al-
most helpless cases. In private practice it was dif-
ferent, and here the death-rate should not exceed one or
two per cent, in the hands of an expert. He believed it
was more difficult to get good results in operating upon
the breast than upon the uterus. If the uterus was
movable, he thought the vaginal operation was the
quicker one. As to suppuration, he did not know
whether it had the power of killing cancerous tissue
or not; but, in many operations in which he thought
they would fail, extensive suppurations had taken place,
big abscesses had formed, and the patients had re-
covered and still remained well. In inoperable cases
in which the radical and complete operation could not
be done he used the steel — not the copper — curette,
getting away the diseased tissues; then, with a knife
or with scissors, he cut in every direction all diseased
portions; he then applied a saturated solution of chlo-
ride of zinc; this gave better results than could be
obtained by the use of the galvano-cautery.
3. The distal as well as the proximal end of the
splint dilates equably. This is of the utmost impor-
tance, especially when the deflection is situated some-
what posteriorly.
4. Drainage being good, irrigation, with the splint
in position and proper precaution as to the forward
position of the head, instructions not to swallow dur-
ing the injection of the fluid, and by imparting a mod-
erate velocity to the inflowing medicament, can be suc-
cessfully carried out. There is no need of its daily
^jeiu liistriiineiits.
A NEW NASAL SPLINT.
By FR.VNCIS W. ALTER, .M.I).,
In presenting to the profession this dilating nasal
splint, to be used in the after-treatment of operated
•deflected septums, I wish to emphasize tlie following
favorable features of this device:
1. The drainage permitted by the outspread halves
of this instrument when in situ is maximum, and such
a thing as "clogging" never occurs, thus fostering
that much-desired element, good drainage. Besides,
the breathing through the previously stenosed nostril
is at once established, and the satisfactory effect to
the patient, as well as the surgeon, is immediately in
■evidence.
2. In the removal of the splint for the daily cleans-
ing-process, a few turns of the key converts the splint
from size b to a, as indicated in the cut, and its re-
moval and subsequent introduction are effected with-
out the usual pain accompanying this manceuvre with
the splints now generally used.
removal, and I leave the splint in position for five
days, replacing it again for a like period, and remov-
ing it entirely at the end of that time. If, in its first
introduction, too much or too little dilatation of the
splint has been effected, a few turns of the key either
way will bring about the desired effect. The daily re-
moval of the splint carries with it certain ill effects,
and the argument against the daily removal of the
dressings on a broken limb also holds good here.
5. In my experience the material of these splints,
metal instead of rubber, offers less opportunity for
sepsis. In four cases in which I have used this splint,
I had no rise of temperature, yet the opposite was of
regular occurrence with the vulcanized rubber tubes.
These splints are made by George Tiemann & Co.,
of New York, and the J. F. Hartz Co., of Detroit,
Mich., and are in three sizes. They are also made
without the perforations. The latter, in my estimation,
are of no use, serving only to increase one's labor in
cleansing splints. Instead of the side plates being-
concavo-convex, I have them also made perfectly flat;
or what seems to me still better, the septal plate
flat and the opposite plate somewhat concave on its
outer side for the reception of the opposed turbinal
body. The only objection to the latter arrangement is
that it somewhat increases the width of the collapsed
splint; this, however, is overbalanced by the more per-
fect apposition of the splint to its anatomical surround-
ings. These splints, as enumerated, are known as
Style "A," with perforations; "B," without perfora-
tions; " C," both plates flat; " D," septal plate flat,
outer plate concavo-convex. The key of the splint acts
also as introducer. The forceps grasps the splints when
in position, thus preventing any slipping or tw'isting.
It is my custom to dip them in sterilized olive oil be-
fore their introduction. This lubricates the joints in
the splint and makes them work without any per-
ceptible resistance.
Arsenic and Iron in the Chloro- Anaemias of Tu-
berculosis Dr. Martinet thinks the following con-
clusions are tenable: (i) The association of iron and
arsenic is rational and justified by clinical experi-
ence. (2) The combination is particularly indicated
in most chloro-antemias, and especially in the severe
forms approaching pernicious anamia, with rapid de-
struction of globules, in torpid and antipyretic tuber-
culosis, and in the glandular forms. (3) There should
be monthly alternation in the administration of protox-
alate of iron and of an arsenical water; the admin-
istration of tincture of iron and Fowler's solution in
equal parts; the administration of arsenate of iron. — •
La Presse Med., January 6th.
March 31, igoo]
MEDICAL RECORD.
571
A SIMPLE AND EFFICIENT RUBBER SPLINT-
SHOE.
By H. J. BOGARDUS, M.D.,
thickness of the rubber under the foot, a liberal slice
may be cut from the convex surface of the rubber and
the surface again nicely smoothed off with sandpaper,
or, better, by use of an emery wheel.
Probably most orthopaedic surgeons have had occasion
to recognize the apparent inherent merit of rubber as
an eligible material for the shoeing of their hip-splints
and other walking-apparatus. Hitherto it has always
been difficult to get rubber in a form that would satis-
factorily answer the requirements of a splint-shoe. It
is known that attempts have been made in the past to
secure this desideratum. Some twenty years ago Dr.
Taylor used a skilfully moulded rubber splint-shoe,
but either because of its expensiveness or its lack of
durability owing to its manner of manufacture at that
time it never came into general use.
Patients themselves have sometimes appreciated this
need, and have come to the dispensary with their worn-
out leather splint-shoes replaced with rubber carefully
fashioned from some piece of solid rubber taken from
the bumpers of cars or from a worn-out clothes-wringer
roller, etc.
Not long since, in a casual visit to a carriage maker's
establishment, the writer's attention was attracted by
some pieces of solid rubber tires, and the present
methods by which such tires are secured to the wheels
of ordinary vehicles for road use. The idea suggested
itself that this form of tire material might be readily
adapted for use as splint-shoes, and for the past five
or six months a practical test has been made of its
efficiency for this purpose at the New York Orthopeedic
Dispensary, with the most gratifying results.
For the first experiments children were selected who
were known to be the most destructive of apparatus,
returning at short intervals for repairs and renewal of
splint-shoes. By keeping a comparative time record
it has been found that the rubber is at least four or
five times as durable as the ordinary leather splint-shoe
as made by the cobbler.
Besides durability a number of other important ad-
vantages may be enumerated in favor of the rubber.
It does not involve the expense of special manufacture
tor this purpose. It is made for carriage wheels in
lengths of about thirteen feet, and all that is necessary
to adapt it to the uses of the orthopaedist is to cut it
in the desired lengths of about three inches. This can
readily be done with a sharp wet knife. Worn-out
shoes can thus be renewed at the office with the sim-
ple help of a screwdriver.
There are no nails, as in the leather splint-shoes, to
occasionally trip the patient, or maybe to scratch a
polished floor. A brace shod with rubber is less
noisy, less liable to slip on the icy pavement, etc.;
does not soak up so much of the moisture and dirt of
the street; and again, being more elastic, saves the
transmission of that much concussion to the patient in
walking. The rubber tire can be obtained in a variety
of sizes differing in width by one-eighth of an inch.
The rubber is fastened to the foot-piece of the splint
by means of two ordinary flat-headed machine screws
which, passing through countersunk holes in the foot-
plate, engage by their threads in a piece of flat steel
fitted in the slot that passes longitudinally through the
rubber tire. When the screws are tightened the rub-
ber is brought in secure and firm apposition to the
under surface of the foot-piece of the brace. At first a
piece of sheet brass was fitted over the foot-piece with
lips extending down each side acting as flanges to hold
the rubber more securely, but practically this has been
found to be not really necessary, as the two screws
alone hold the rubber firmly in place.
In some instances, if it is necessary to minimize the
A NEW CURETTE.
By H. F. GAU. M.D.,
This new safety curette is
intended for use in those
enlarged, softened, infected
post-puerperal uteri, in
which the use of the average
curette is liable to cause
perforation of the uterus.
The modified curette, which
I have named the " safety
curette," has an anterior and
a posterior cutting surface,
with a central perforation
varying from three-eighths
of an inch anteriorly to one-
half an inch posteriorly.
The anterior surface is
intended for curetting the
anterior, posterior, and lat-
eral surfaces of the enlarged
uterus, whereas the posterior
edge is better adapted for
use on the fundus and the
upper angles. Both anterior
and posterior edges are pro-
tected by a flattened surface,
so that perforation of the
uterus is impossible. The
instrument was presented to
the Cincinnati Obstetrical
Society at its February
meeting.
Xixcvnpfmtic gliixts.
Blennorrhagic Myositis. — Moist heat should be ap-
plied, by enveloping the limb in hot boric-acid solu-
tion covered with impermeable tissue. After the acute
period the following is to be given:
I^ Guaiacol. .
01. amygd. dulc p.x.
S. Apply to limb and cover with cotton.
— Braquehaye and Servel.
Ozaena. — A douche with a Weber siphon should be
given, changing the formula for the antiseptic from
time to time. After each douching the nose should be
sprayed with:
^ Acid, plienic. ... 2 gm.
Resorcin 3
Glycerini pur 5°
Aqu.-e 300 ' '
The ulcers should be touched with silver nitrate or
zinc chloride solution, and a general tonic treatment
given. — Joiim. des Praticicns.
After douching, a bean-sized mass of the following
should be introduced into each nostril, the patient's
head being bent back :
If Menthol 0.20 cgm.
Boric acid 2. gm.
White vaseline 30.
Essence of geranium gtt. ,\x.
— Bommier.
572
MEDICAL RECORD.
[March 31, 1900
Trional produces accidents by not being absorbed,
when given in water.
I^ Trional i gm.
01. amygd. dulc ... 20 "
Sacch 8 "
Gum. tragac. ,
Gum. arab aa o. 20 cgm.
Aq. aurant. flor 10 gm.
Aq. lauro-cerasi 2 "
M. S. To be taken in half a glass of water.
— POUCHET.
Intestinal Antisepsis in Children. —
I^ Benzo-naphthol 0.05 cgm.
Bismuthi salicylat. (basic) o. 10 "
Bismuthi bicarbonat (basic) o.io "
For one powder. Make five such, and give one every two
hours to a child of five or six months of age.
— COMBY.
Coryza
1} Pulv. menthol 0.25 cgm.
Pulv. betol 2. 50 gm.
Cocainx o. ;o cgm.
Pulv. caffeae tost 4. gm.
M. S. Use as snuff.
— All/1, lie Farvi., Milan.
Eczema of the Ear. — Internal measures shoujd not
be neglected in chronic eczema of the meatus. So
long as there is acute inflammation arsenic must not
be given, but in the scaly stage order:
If .Sodii arsenat o. 10 cgm.
Aqune lauro-cerasi 50. gm.
Aqua: destil 200. ' '
M. S. One to four teaspoonfuls daily at meals.
— Ler.movez.
Hypodermatically in Syphilis. —
If Hydrarg. benzoat 0.30
Sodii chloridi o. 10
Cocaina; o. 1 5
Aqure destill 40.
Dissolve with heat.
Inject I c.c. each day. This must be made fresli
at least every fifteen days. — Stotikowenkof.
Digestive Infections in Nursing Infants. — After
a castor-oil purge :
IB, Benzo-naphthol u ji;-u. 50 cgm.
Cretse prajpar.,
Bism. subnit aa 2 -3 gm.
Mucil. acac 30 "
F,li.\. paregoric gtt. vi.-xij.
M. Shake. S. Teaspoonful every hour — less often as im-
provement follows.
Psoriasis —
'S, Acid, salicylic 3 gm.
Ichthyol. ,
Picis .ia 10 "
Acid, pyrogallic 6 "
Lanolini seu petrolat 100 "
M. S. Apply.
— Brocq.
Urticaria. —
\\ Sodii bicarb 20 gm.
Tinct. opii (Sydenham) gtt. xx.
Aq. bul 500 gm.
M. S. Use as a rectal injection.
— De Mahis.
Alcoholic Cirrhosis of the Liver. — One of the best
diuretics is:
If Juniperi fruct 10 gm.
Infuse in
.•\q. bul 200 ' '
Add
Potass, nitrat. ,
Potass, acetat aa 2 "
Scill« oxymel 50 "
Syr. des cinq racines 30 "
M. S. To be taken in four or five doses during the day.
— Plicque.
l^ctticaX Items.
Christian Science will cure you of what you have
not got, or of what is going to get well of itself, just
as quickly as any of the 'pathies, and sometimes more
pleasantly.
One by Choice. — A Paris journal gives the number
of prostitutes registered at 5,183. Of these, 1,440 are
forced to the life by poverty, 1,255 ^'^^ orphans, having
no other way to obtain shelter; 280 are widows from
the provinces unable to obtain an hone.st living; 404
are young girls brought from the country by soldiers
and others; 289 are domestics discharged after being
ruined by their employers; 1,425 have been deserted
by faithless lovers; 89 admit adopting this life to
support the family. This leaves one to be put down
to pure depravity.
Dividends are Improving. — Up to now twenty-five'
per cent, has been about the limit of the dividend a
physician could expect from the sharper to whom lie
referred his patients. An optical company in Fulton
Street has raised the limit to fifty, and will now divide
the profits with the physician, siiare and share alike,
as the lawyers put it. These refractionists are paying
out, they say, as high as $10 a w'eek to some physicians
who send their patients for glasses. A good dis-
tributor will soon be able to make a iair income if
this sort of thing continues.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended March 24,
1900 :
Cases. Deaths.
Smallpo.x — United States.
Alabama, Mobile March loth to I7lh s
Florida. Jacksonville March nth to 17th i
Georgia, Brunswick March 12th 3
Cordele March 12th Present.
Tifton March 12th Present.
Illinois, Chicago March toth to 17th i
Fortv-Hve counties. .December, January, February, 1,000
Indiana, Evansville March loth to 17th 3
W'ichita February icth to March 17th. . . 53
Twenlv-four counties. . February 1st to 28th 437 14
Kentucky. Covington March loth to 17th 1
Louisiana, New Orleans March 10th to 17th 71 21
Michigan. Detroit March 3d to 17th 2
Minnesota, Minneapolis March 3d to 17th 52 X
Nebraska, Omaha March loth to 17th i
New York. New York March 10th to 17th 7
Ohio. Cleveland March loth to J7th 7
South Carolina, Greenville.. March loth to 17th ".. 2
Utah, Salt Lake City March loth to 17th i
Virginia, Portsmouth March loth to 17th 6 z
Washington, Spokane March lolh to 17th 5
Austria, Prague February
Belgium, .Antwerp February
(Ihent February
England, London February
Egypt, Cairo February
France, Lyons February
Gibraltar February
Greece, Athens i'chruary
India, Bombay February
Kurracnee February
Madr.is I''cbruary
Mexico, Chihuahua March 3d
Mexico February
Vera Cruz March 3d
Russia, Moscow February
(Odessa February
Warsaw February
Spain, Corunna February
Straits Settlements, Singa-
pore January
— Foreign.
17th to March 3d 7
17th to March 3d . . . 13
24th to March 3d
17th to March 3d 18
4th to iSth
•5d to loth
18th to ALirch 4th 22
17th to .March -A q
f.th toi-,th
4th to nth 22
loth to iCth
to loth
iSth to 25th 23
to loth
loth to 21st.. 9
17th to March ^d 2i
loth to 17th
3d to 24th
fitzerlaud, ('.'
February 3d.
bruary 14th to 24th ... ...
Yel
Brazil, Santos February Bth to T6th .
Cuba, Havana March 3d to 10th
India, Bombay February 6th to 13th .
Plague— Insular.
.February 24th to March 2d 3
Plague— Foreign.
India, Bombay February 6th to 13th
Japan, Formosa January 1st to February sth .
75
Medical Record
A IVeekly yournal of Medicine and Surgery
Vol. 57, No. 14.
Whole No. 1535.
New York, April 7, 1900.
$5.00 Per Annum.
Single Copies, loc.
©tigiual Jtrticlcs.
TRAUMATIC HEMORRHAGES INTO THE
SPINAL CORD.'
By PEARCE bailey, M.D.,
CONSULTING NEUROLOGIST TO THE ST.
NEUROLOGY,
No one who has to do with injuries to the nervous
system now qusstions the importance, from clinical,
pathological, and legal standpoints, of traumatic hem-
orrhages into the spinal cord. The subject was bril-
liantly introduced by Thorburn ten years ago; and the
contributions of the past few years from Russia, Ger-
many, and this country have entitled it to a distinct
place in the surgery of the spinal cord. Yet it con-
tinues to receive scant mention in the surgical and
neurological text-books, and is inadequately handled
even in recent monographs on spinal-cord injuries.
As a result, the condition often fails to be correctly
diagnosticated, and our knowledge concerning it is not
advanced so rapidly as it might be. This is to be
regretted from two points of view. First, because
traumatic hsematomyelia is a comparatively frequent
lesion ; and second, because the chances of recovery,
when the symptoms depend upon hemorrhage into the
spinal cord, are so much better than in any other
variety of spinal-cord injury that the surgeon who fails
to recognize the condition exposes himself to great
error in prognosis and, maybe, in treatment.
The subject has interested me during the last two or
three years; and I have tried to keep abreast of its
literature. At the same time a number of cases, both
clinical and pathological, have come under my observa-
tion. The following paper is based upon the results
of these studies. It must not be forgotten, however,
that the subject is still in an early stage of its develop-
ment, and that more observations must be forthcoming
before certain personal opinions can be regarded as
thoroughly established by fact.
Traumatic hemorrhages into the substance of the
spinal cord occur in two ways. First, as complications
of general cruslies and mutilations, due to fractures
and dislocations of the spine. These I have called
Secondary Hsmatomyelia. The other and more im-
portant variety I have called Primary Hsematoniyelia,
as it results from force exerted directly upon the cord
itself, without the intervention of pressure by bone or
cartilage. Thus, without any fracture or dislocation
of the spine the spinal cord may be so twisted or bent
within its case, or may sustain a shock, so that its
blood-vessels rupture and blood escapes into its sub-
stance. A force which ruptures the blood-vessels must
at the same time tear nerve fibres and more or less
injure nerve cells; and the resulting lesion conse-
quently is a laceration of the cord as well as hffima-
tomyelia. But unless the laceration is very large it
fails to be identified positively by the microscope.
For the blood is generally poured out freely and hides
minute lacerations; and even if the lacerations were
' From the Department of Pathology, College of Physicians and
Surgeons, New York.
apparent under the microscope, unless they had been
so to the naked eye at the time of the autopsy it
would be impossible to assert positively that they were
not artefacts or the results of destruction which the
blood itself had caused. Consequently, while admit-
ting that every case of traumatic haematomyelia is
associated with some direct injury to the internal parts
of the cord, and that such an injury is entirely inde-
pendent of the destructive efl"ects of bleeding, we are
none the less obliged to regard the amount of blood as
an index to the severity of the total lesion, and to
denominate the pathological condition as haema-
tomyelia, though it is more complex than simple hem-
orrhage. It is the special object of this paper to con-
sider primary traumatic hsematomyelia. But before
passing directly to the main body of the subject, brief
mention must be made of the other varieties of injury
of the spinal cord with which primary hamatomyelia
might be confused.
In the presence of an injury to the spinal cord, when
bullet and other penetrating wounds can be excluded,
three possibilities, and three only, present themselves.
These are :
I. Pressure from displaced or broken-down protect-
ing structures.
II. Pressure from blood poured out within the
spinal canal (Haematorrhachis — extra- or intra-dural
hemorrhage).
III. Primary haematomyelia.
I. Pressure from Displaced or Broken-Down Pro-
tecting Structures.— This class comprises the com-
mon fractures and dislocations of the spine. The re-
sulting mutilation of the cord is usually extensive, the
symptoms are w'idespread, and the prognosis, though
the better for life the lower the region affected, is always
gloomy for the restoration of function. The see of the
trouble in the cord can usually, though not always, be
inferred from the displacement or abnormal mobility
of the vertebra.
In such injuries hemorrhage occupies a place of
varying prominence. It may be extremely slight or
absent; or capillary extravasations in the vicinity of
the more severe lesion may be found scattered through-
out several segments above and below the affected
area; in still other cases, the blood makes its way in
the gray matter, in pencils or columns, up and down
the cord, often for long distances. It is to this latter
condition that Van Gieson has applied the name haenia-
tomyelopore. These hemorrhages take place either im-
mediately and from the same injury as caused the crush,
or are the later results of softening and myelitis. They
are important for two reasons : One is that a column of
blood may extend in the gray matter for some distance
above a transverse lesion, causing symptoms peculiar
to lesions of the gray matter and different from those
attributable to the transverse lesion. The most char-
acteristic gray-matter symptom is the "dissociation"
type of anaesthesia, i.e., sensibility to touch preserved,
but pain sense and temperature sense lost. Zones of
such dissociated anaesthesia are from time to time ob-
served, extending for some little distance above the
line of the total anjesthesia symptomatic of the trans-
verse lesion. The other reason for the importance of
these secondary hemorrhages is found in the cases in
574
MEDICAL RECORD.
[April 7, 1900
which with a fractured vertebra, the external pressure
effects upon the cord are slight; but in which the same
force which caused the fracture caused a hemorrhage
into the cord substance; so that the symptoms are the
combined results of pressure exerted by bone externally
and by blood internally. Such cases merge toward
the category of primary haematomyelia.
The vast majority of injuries to the cord resulting
from fractures and dislocations present no difficulties
of diagnosis. The history of the accident, the bone
deformity, the sudden and persistent paralysis of mo-
tion, sensation, and sphincter action leave little oppor-
tunity for error. ISut when one or more of the car-
dinal symptoms are absent — when the spine appears
intact or there is no ansesthesia, when the paralysis of
motion is limited or incomplete, or the sphincters are
not affected, the problem becomes more difficult.
Partial lesions of this class may resemble, in symptoms
and causation, primary traumatic haematomyelia; and,
indeed, it is probable that secondary hemorrhage is
responsible for part of the symptoms in such cases.
The diagnosis of partial lesions arising from external
pressure is assisted by remembering that the symptoms
are chiefly due to pressure exerted upon the outside of
the cord, I.e., upon long afferent and efferent tracts,
rather than upon the central gray matter. Conse-
quently, however slight the symptoms may be, they are
found everywhere below the lesion. Thus, in the case
of an injury in the cervical region, paralysis or im-
pairment of sensation and motion will involve both
arms and legs; in other words, evidences of the injury
will be present everywhere below it.
Since hemorrhage has a predilection for the central
parts of the cord, a small focal hemorrhage within the
cord substance produces a very different clinical
result. As will be explained further on, primary
hiEmatomyelia may cause symptoms in the upper ex-
tremities, while the lower extremities are unaffected —
i.e., no injury to long conduction tracts.
The dissociated type of anaesthesia also is, as far
as our present knowledge goes, distinctly character-
istic of a gray-jnatter or central affection.
I'inally, lesions due to compression from without
the cord are, as a rule, richer in symptoms than purely
hemorrhagic ones. There is usually impairment of
both sensation and motion in extended areas; also the
bladder rarely escapes involvement. However, it is
not to be denied that in some cases the symptoms fol-
lowing fracture or compression from the outside are
extremely slight. The following case shows this:
The patient, W. A. B , thirty-six years of age, a
previously healthy man, and always well except for
troubles directly induced by drink, fell on IJecember
9, 1898, about fifteen feet into an area way, landing
on the head. He was picked up unconscious, and
found himself in Bellevue Hospital the next morning.
The scalp was badly contused and lacerated; there
were great pain and tenderness and some swelling of
the neck. There was no paralysis, but both arms and
both legs were weak, the weakness being especially
noticed on the left side. There were tingling of the
fingers and numbness of the arms and legs. There
were no disturbances of the bladder or rectum. After
eleven days the patient was well enough to walk out
of the hospital. Since then the chief sources of annoy-
ance have been pain and stiffness in the neck and
numbness in the extremities of the right side.
Examination, January 25, 1899, Vanderbilt Clinic:
The patient (Fig. i) holds the head bent forward on
the chest and is either unwilling or unable to make
free movements with the neck. Efforts at movement
done either by him or by the examiner cause severe
pain. The seventh cervical spine is so unduly promi-
nent that, although there is no crepitus, false motion,
or other evidences of fracture, it seems certain that
there has been either fracture or dislocation in this
vicinity. The symptoms pointing to a nervous lesion
are a partial hemianesthesia on the right side, and a
contracted pupil, with some sinking in of the eyeball
and narrowed palpebral fissure on the left (cilio-spinal
centre). The hemianjEsthesia is very indistinct in its
upper boundaries. It does not involve the face and
begins at about the clavicle. In the upper extremity
it is more definite and in the leg it is pronounced. It
includes all qualities of cutaneous sensibility. There
is also anaesthesia of the index finger of the left hand.
All the muscles of the extremities seem somewhat
weak, but there is no demonstrable paralysis. There
is no localized atrophy, no fibrillation, no foot clonus.
The knee jerks are lively, especially the left one, but
not excessively exaggerated. The absence of paraly-
sis, of sphincter troubles, and of marked changes in
the tendon reflexes, shows that the injury to the cord
was extremely slight. It is unusual for such slight
injuries to be caused by a fracture or dislocation.
But that a bone lesion, causing pressure upon the out-
side of the cord, was at the bottom of the symptoms in
this case, seems probable. There were deformity and
extreme pain in the back; the motor disturbances,
slight though they were, involved all four extremities,
and the hemianaesthesia bespoke a lesion affecting the
long afferent sensory paths.
II. Pressure from Blood Poured out Within the
Spinal Cord. -The second class, hemorrhage between
the cord and the vertebrae (either extra- or intra-dural)
has received much more attention by clinicians than
it is entitled to by autopsy records. Surgeons are
constantly on the alert for it, in the belief that it is
amenable to cure by the knife. It is sometimes given
a distinct symptomatology in text-books. Yet my own
experience and a careful study of the literature have
persuaded me that this lesion is rarely if ever of clin-
ical importance. If it occurs as a distinct and isolated
pathological entity, there are no reliable means of
recognizing it during life. It is true that it is met
with from time to time in autopsies on traumatic cases,
but never, so far as I have been able to determine, as
an isolated lesion. It is invariably associated with
the far more important injuries of crushes or intra-
spinal hemorrhage, which latter conditions give the
clinical stamp to the case. It is needless to say that
April 7, 1900]
MEDICAL RECORD.
575
they would remain unaffected, in symptoms and course,
even were the external blood clot removed. This extra-
medullary hemorrhage is sometimes invoked (notably
by Kocher) in explanation of the charac-
teristic symptom complex known as " di-
plegia spinalis brachialis traumatica."
That this condition can be better ex-
plained'by hemorrhage within the cord
than without it will shortly be shown.
III. Primary Haematomyelia The
third variety of spinal-cord injury, primary
traumatic hajmatomyelia, it is the special
object of this paper to consider. The con-
dition, as already intimated, is relatively
frequent, but its special clinical impor-
tance results from its favorable prognosis.
The subject is yet too young to permit any
accurate estimate as to the ratio in which
this particular variety of lesion stands
with respect to the total number of spinal-
cord injuries. Some facts are, however,
accessible. Of twenty-one cases of spinal-
cord traumatisms examined by Thorburn,
six were interpreted as examples of primary
haematomyelia. Of seven cases of gen-
eral injury examined by Parkin, one was
primarily haematomyelia. Of Stolper's
twenty-two autopsies on various spinal-cord
injuries, two were primary haematomyelia.
Thus, autopsy records show that injury
causes hemorrhage into the substance of
the spinal cord, without demonstrable le- Im';. b.-Smu
sions of the bones, in a considerable num-
ber of cases. This percentage would undoubtedly be
much higher if more statistics could be obtained of
partial lesions; for there is good reasons to suppose
from clinical data that a large proportion of cases of
partial lesions are of hemorrhagic origin. But as the
patients in such cases are much more apt to recover
the hemorrhage is extensive, it may burst beyond the
gray matter into surrounding areas. The ventral and
the dorsal horns are the favorite sites. The gray com-
^^fi*iSfe.
^5v
,\
8? is
\
trrhage i
the Spinal Cord. No infl;
• degenerative
Fig. 2.— Small H
than to die, they are useless as far as the statistics of
pathological anatomy are concerned.
The situation of the hemorrhage is usually in the gray
matter. This is explained by the gray matter being
more highly vascularized and by its having less sup-
porting tissue than have other parts of the cord. When
missure often escapes, and it is unusual for it to be
involved in the immediate vicinity of the central canal.
The white matter is not left entirely free, if the
hemorrhage is at all extensive. It may be involved
by the blood passing the limits of the neighboring
gray, or the whole white matter may be spotted with
small extravasations. Large
hemorrhages into the white
matter are most frequently
found in the dorsal columns
just behind the gray com-
missures. The size of the
individual hemorrhages
varies within wide limits.
A single hemorrhage may
extend, in an unbroken col-
umn, through several seg-
ments. In some of the
reported cases the cord at
the affected level has been
completely hollowed out by
the blood clot. In others,
the blood, though extending
widely, has left some of the
cord free. In others, as in
Fig. 2, the hemorrhage is
extremely small and more
marked on one side than on
the other. The patient from
whose spinal cord this draw-
ing was made died ten days
after a severe general trau-
matism involving rupture of
the liver and kidneys. Be-
tween the receipt of the
injury and the time of death
he was conscious, could walk, and complained of no
symptoms to call attention to the nervous system.
But had he been carefully examined it seems probable
that the existence of the hemorrhage, small as it was,
might have been recognized. For it occurred in that
most important segment, the fi/st thoracic, which is
d, following i
general 1
576
MEDICAL RECORD.
[April 7, 1900
concerned with the cilio-spinal reflex and with the
fine movements of the fingers, and in which even very
small lesions cause symptoms recognizable by the
trained examiner.
These focal hemorrhages are usually surrounded by
some smaller extravasations which may be invisible to
B
the naked eye or may appear as minute dots. It is
usually impossible to tell without the aid of the micro-
scope whether the blood in such cases is extra- or
intravascular. When the hemorrhages are small, they
do not cause any visible inflammatory or degenerative
reaction in the cord (Fig. 3). Large hemorrhages may
be surrounded by areas of softening. In many cases of
large hemorrhages, however, the action of the hemor-
rhage seems almost entirely mechanical. The blood
pushes its way through the cord substance, and destroys
as it goes. As it disintegrates and is absorbed to-
gether with the destroyed nervous tissue, there results
a cavity in the cord. Fig. 4 shows the mechanism of
the formation, in an early stage, of such a cavity.
The spinal cord is that of a man who sustained a
fracture of the fifth cervical vertebra;, and died in five
days. There was extensive mutilation in the sixth
cervical segment with ascending and descending
columns of blood. The
ascending column went
through the posterior col-
umn just behind the
gray commissure. Figs.
4 and 5 show the condi-
tion of the fourth and
third cervical segments,
the latter segment being
the upper limit of the
hemorrhage. The blood
and destroyed nervous
tissue have not had time
to be entirely absorbed.
In Fig. 5 the disinte-
grated area dropped out
during the manipulation
of the cord for micro-
scopic purposes, leaving
a cord apparently healthy
except for the loss of
substance. This loss ap-
pears as a clearly
punched-out hole, around
the edges of which are
clinging broken-down
blood cells. When the
patient lives for some
time after the injury, it is
the tendency for such
cavities to be filled up
more or less completely
with neuroglia tissue.
Fig. 6 sliows a section
of the cord at the eighth
cervical segment of a
man who died seven
months after an extensive
primary traumatic haema-
tomyelia. At autopsy the
cord was flattened from
before backward, and the
outlines of the gray mat-
ter were lost. The cen-
tral part of the cord was
occupied by new tissue,
with cracks and slits
tliroughout. Microscopic
examination showed that
this was new connective
tissue, containing many
and variously shaped
spaces, some of which
were filled with broken-
down blood. What had
undoubtedly taken place
in this cord was hemor-
rhage into the gray matter; partial absorption of blood
and broken-down nerve elements, and outgrowth of
connective-tissue cells from the limits of the original
cavity, gradually decreasing the size of the latter. Such
hematogenous cavities have no epithelial lining and
are not ordinarily connected with the central canal.
They may resemble very closely the conditions found
in syringomelia, and the symptoms to which they give
rise are often surpri.singly like those of syringomyelia.
Some writers have gone so far as to refer to such cases
as traumatic syringomyelia. It seems to me, however,
that they should be kept distinct in name from the
\
April 7, 1900]
MEDICAL RECORD.
577
chronic progressive and probably congenital spinal
disease, as they are distinct in origin, and that they
should be designated as primary hsmatomyelia.
Localized collections of hemorrhage from injury are
found very much more frequently in the regions of the
cord subjacent to the lower cervical ver-
tebrae, i.e., in the region of the greatest
spinal movements. The corresponding
spinal cord segments are the fifth, sixth,
seventh, eighth cervical, and first and
second thoracic. It is probable also that
primary traumatic hsmatomyelia occurs
in the lower lumbar region and in the
conus meduUaris. In the majority of
the cases of hemorrhage in this region,
however, there have been serious lesions
in the bones.
Such hemorrhages as have now been
described are usually localized or focal.
The largest hemorrhage may be sur-
rounded by smaller collections of free
blood cells, but the hemorrhagic region
is limited to one region of the cord, and
beyond it the cord is normal.
In contrast to this type of hsemato-
myelia is another, the disseminated type,
in which there are extravasations through-
out the whole spinal axis. This is a
variety of ha;matomyelia which has been
much speculated upon as affording an
anatomical foundation for the traumatic neuroses. It
has been found at autopsies on infants born after pro-
longed and difficult labor. But with the exception of
a case described by me,' I have found no pathological
records of it in traumatic cases in adults.
An epitome of the case referred to is as follows:
A workman received a severe fall and died in three
hours. The autopsy showed a hemorrhage into the
middle fossa of the skull without fracture. There was
a fracture dislocation of the atlas and axis, with exten-
sive mutilation of the cord at this point. Except at
the point of compression, the cord looked in every way
normal. On section it could be seen that the blood
vessels were somewhat prominent, but the eye could
detect no free blood either at the seat of injury or at
lower levels. Sections were made of every segment of
tne thoracic, lumbar, and sacral regions and examined
the majority of them contained fewer. In some places
there were only two or three "free cells. In a few sec-
tions the blood lay in little cavities, but the most
common distribution of it was in the form of an infil-
tration of a small number of blood cells between the
A Hv<k^'
^r.
ultb of Cavity tc
place are beinj, hlled up
microscopically. The lesions found were generally
distributed up and down the cord, and consisted of
recent capillary hemorrhages. No single hemorrhage
contained over two or three hundred blood cells, and
' " Accident and Injury; their Relations to Diseases of the
Nervous System," New York, 1898.
neuroglia and nerve fibres. There was nowhere any
tubular cavity formation. The largest extravasations
were in the pia and around the nerve roots. In the
spinal cord, although occurring in the gray matter,
they were most frequent in the white matter, especially
in the posterior columns. Nearly every section con-
tained the hemorrhages, but no section contained very
many, usually not more than two or three. The situ-
ation of the hemorrhages bore little or no relation to
the location of the large blood-vessels. The blood-
vessels were prominent and filled with blood. In all
other respects the spinal cord appeared normal.
Thus, to resume briefly, a healthy man fell with
sufficient violence to break his neck and to cause an
intracranial hemorrhage without fracture of the skull.
The force was exerted chiefly on the atlas and axis, as
seen by the injury to these bones. But it was also
adequate to cause through-
out the cord punctate
hemorrhages, which were
- — ' — —^^ii., entirely unassociated
■ ■ .^ witii the severe local in-
"X:^- jury and which were prob-
>--- ably due to the general
■ ,; , violence to which the
•V;^- . V", ' , i whole spinal cord was
subjected.
Since the publication of
the foregoing, two other
similar cases have come
to my observation. Of
these, one came to me
through the courtesy of
Dr. P. R. Bolton from
the Hudson Street Hospi-
tal, the other from Dr.
. which hemorrhage had taken EugCUe Hodcnpyl's path-
'^"'^' ■ ological service at the
Roosevelt Hospital.
Case I. — An adult workman fell through a hatchway
and died in two days. An autopsy was made four
hours after death. There was a fracture of both laminae
of the sixth cervical vertebra. Otherwise the spinal
column was normal. The cord was softened and dis-
colored in the lower part of the cervical region — i.e..
578
MEDICAL RECORD.
[April 7, 1900
the region subjacent to the fracture. There was also
a similar area of softening in the lower thoracic
region.
Microscopical examination: The chief lesions in
this case were small hemorrhages throughout the whole
cord from the upper cervical to the lower lumbar
region. They were especially pronounced in the
region subjacent to the fracture and in the part of the
cord included between the seventh and tenth thoracic
segments (Fig. 7). The most serious damage was in
the eighth cervical and first thoracic segments. Here
the hemorrhages in both gray and white matter were
very numerous and comparatively large, and were asso-
ciated with a slight condition of softening, character-
ized by Gliige's corpuscles, myelin drops, and disin-
tegration of nervous elements. There were similar
appearances in the lower-lying focus of severe lesion.
In addition to these two foci of most pronounced
injury, capillary hemorrhages were present throughout
the spinal axis from the second cervical to the lower
lumbar segments. Above the second cervical and
below the lumbar enlargement they were least frequent
and prominent. The collections of blood throughout
the affected segments varied in size and number. In
some places only a few blood cells had been extrava-
sated, in others they were more numerous. The larg-
est hemorrhage was not over 3 mm. diameter, and none
could with certainty be identified with the naked eye.
In the most seriously affected regions the sections
were studded throughout with the blood collections;
in the other segments they were chiefly, though not
exclusively, confined to the gray matter. In many of
the larger hemorrhages there was degeneration in the
centre so that the outlines of the blood cells were lost.
In some of these there were fissures which, had the
patient lived, would have gone on to cavity formation.
The finer structure of the ganglion cells could not be
determined, as the cord had been put in Miiller's fluid ;
they seemed, however, except when directly involved
by the blood, to be normal in number and size. The
nerve fibres were, in general, well preserved. The
blood-vessels were prominent and filled with blood
throughout. Their coats were not thickened.
Case II. — A boy, two and a half years of age, fell
down a flight of stairs, at the foot of which he was
found unconscious. Four hours later, without regain-
ing consciousness, he died. I did the autopsy four
hours after death. The temporal and parietal bones
of the skull were fractured, and there was an extensive
subdural hemorrhage in the middle fossa, extending up
over the convexity of the brain. The spinal cord was
removed with especial care to avoid bruising. Macro-
scopically it appeared normal. Studied through all
its segments in microscopic section it appeared normal
in respect to topography and essential elements. The
blood-vessels were not thickened nor unduly prominent.
In the cervical and lower thoracic regions there were
small capillary hemorrhages situated chiefly in the
dorsal horns of the gray matter and on the dorsal
white columns. They contained only a few blood
cells, were in no apparent relation to the blood-ves-
sels, and produced no secondary consequences in the
saucture of the cord.
In reporting cases of this character I am well aware
oi the danger of error of interpretation of such lesions,
and of advancing as pathological what are in reality
artefacts due to post-mortem mutilations. But that
the free blood cells in the cases recorded here were in
reality extravasated, and that they occurred before
death as the direct results of the physical injury, I am
confident for the following reasons:
I. All the patients suffered fatal traumatisms. 2.
The cords were removed with especial care. 3. All
gross evidences of internal or external bruisings were
absent. 4. Such punctate hemorrhages are not found
in spinal cords, removed in the ordinary way, unless
there is a history of injury. 5. The wide dissemination
of the hemorrhages. If they were artefacts, they would
probably be focal. 6. The fact that in many places
the blood had degenerated is conclusive proof that it
had been poured out before death.
These cases must be accepted, therefore, as proving
that severe general injuries can cause disseminated
lesions throughout the spinal axis. Although the verte-
bral column was intact in only one of the cases, the
bone injuries were confined to one point, and the hemor-
rhages existed so far from that point that they unques-
tionably arose independently of any local effects of
compression, and would in all probability have oc-
curred even if there had been no fracture of the spine.
The clinical importance of these disseminatec'
hemorrhages will be referred to a little further on.
Clinical Considerations. — For clinical purpo.se;
primary ha-matoniyelia can best be considered undei
three heads: A. Large focal hemorrhages. B. Small
focal hemorrhages. C. Disseminated hemorrhages.
A. Large focal hemorrhages: In an article read
before the Johns Hopkins Hospital Medical Society'
I described this condition at some length. A brief
resume of certain parts of that article may make the
present one more complete.
After certain injuries by which the neck is forcibly
flexed or, perhaps, extended, there develops immedi-
ately a condition of motor paralysis, variously dis-
tributed, together with -peculiar sensory symptoms.
The paralysis of voluntary motion, with few exceptions,
ensues instantly upon receipt of the injury. The
muscles involved at the level of the injury (since the
hemorrhage is most constant in the lower cervical
region) are those of the forearm and hand, and some-
times of the upper arm; those below, of the lower
extremities. The paralysis of the upper extremities
has a different anatomical basis from that of the lower.
The first is due to the blood being poured directly into
the spinal nuclei of the brachial nerves, thus consti-
tuting a destructive lesion. From such a condition
perfect recovery is improbable, and, in fact, most of
the patients remain permanently paralyzed, though the
paralysis may be very limited in some of the muscles
of the upper extremity. The paralysis of the legs, on
the other hand, is the result of conditions often per-
mitting recovery. The most plausible explanation of
this paralysis, from which recovery may be expected,
is that the hemorrhage, although occupying the central
portions of the cord, exerts sufficient pressure, or is
followed by oedema sufficient to compress for a time
the pyramidal tracts which lie a little distance from
it, and which are carrying the long cerebral fibres
destined for the muscle nuclei situated at lower levels.
When the hemorrhage ceases, the commotion it has
caused in its vicinity subsides and the pyramidal
fibres are permitted to resume their wonted function.
The distribution of the paralysis varies with the situ-
ation and extent of the hemorrhage. If below the first
thoracic segment, an unusual situation, the arms
escape. If above the second thoracic segment, the
paralysis affects the muscles whose nuclei are below
the upper limit of the hemorrhage. If the hemorrhage
is on one side of the cord only, affects the arm chiefly
or only; if larger, but still confined to one side, there
is spinal hemiplegia.
In a large number of cases the hemorrhage is suffi-
cient to cause at first paralysis of both aims and of
both legs. When the patient is seen ininiedialely after
the accident, the paralysis is flaccid in character, the
muscles are soft and yielding, without rigidity, and
the paraplegia is complete. The knee jerks are di-
minished or lost (this does not of itself indicate a trans-
■' " Primary Focal Hctmatomyelia from Traumatism." New
York Medical Record, November 19, iSgS.
April 7, igod]
MEDICAL RECORD.
579
verse lesion, as is often maimtaine-d). When the lesion
is very small, the knee jerlos may be hypertypical or
exaggerated at once. In the lower extremities the
paralysis soon undergoes a change, and from being
flaccid it becomes spastic. The knee jerks, if they
are diminished or lost, return and become e.vaggerated,
and ankle clonus is added.
With the establishment of spasticity strength re-
turns to the legs. Some patients are able to walk a
few weeks after being completely paraplegic. The
recovery in the legs comes sooner than that in the
arms; in the arms it is also less perfect than in the
legs, there usually being left a permanent atrophic
paralysis in some of the brachial muscles.
Of these muscles the most frequently affected are
the small ones of the thumb and the interossei. Thus,
a patient recovering from this affection may present a
picture very similar to that of progressive muscular
atrophy (amyotrophic lateral sclerosis), viz., a paraly-
sis of the upper extremities of the peripheral neuron
type, with atrophy, fibrillation, and degenerative elec-
trical reactions, and of the lower extremities of central
neuron type, with rigidity, increased knee jerks, and
ankle clonus.
When distinctive sensory symptoms are added to
those of progressive muscular atrophy, the picture
changes to that of syringomyelia, and, as has often
been emphasized, primary focal hasmatomyelia from
trauma has many things in common with syringomyelia.
Tiie sensory symptoms in these cases differ materially
from the sensory symptoms observed in transverse
lesions.
From the study of syringomyelia, a disease affecting
primarily the central gray matter, and having for its
most distinctive clinical manifestation a dissociated
antesthesia, the gray matter of the spina! cord has
come to be regarded as intimately connected with the
passage brainward of the sensations of temperature
and of pain; and it is further probable that, whatever
may be the paths for the sensations of touch, they are
not in the gray matter. We expect, therefore, that in
all cases, whether chronic or acute, in which the lesion
is confined to the structures surrounding the central
canal, the ability to recognize thermic and painful
stimuli will be impaired or lost, while tactile sensi-
bility remains normal. Such is the condition in focal
ha;matomyelia. Sensibility is not affected, but there
exists thermo-anaisthesia or analgesia, or both together.
It is generally necessary to examine these functions
specifically, as the patient will say that he "feels
everything," being unaware that he cannot tell heat
from cold or feel pain. The distribution of these dis-
turbances is in general the same as that for the total
anaesthesia of transverse lesions. The Brown-Stfquard
type is often seen, viz., a motor parrlysis of one arm
and leg, with loss of pain sense and temperature sense
in the opposite side. The degree of thermo-ana;S-
thesia and analgesia is not constant. As a rule, anal-
gesia is the less of the two; in recovery also, it is the
first to improve or disappear. From personal experi-
ence I can speak only of the loss of temperature sense.
That has generally been, for the first few weeks after
tiie accident, complete, so that the patients were not
only unable to distinguish between heat and cold, but
felt no discomfort from contact with the test tube of
boiling water, although other kinds of painful stimuli
were appreciated at their true value. When the symp-
tom was incomplete at first, or when time had permitted
it to become so, it appeared as a delayed perception.
The tendency of these affections of the pain and tem-
perature sense is toward improvement, and sometimes
recovery is perfect.
The other symptoms of these large focal hemor-
rhages are those of spinal-cord injuries generally.
Thus, there may be pain, loss of sphincter control,
bedsores, priapism, cedema, cyanosis of the extremi-
ties, etc. In purely hemorrhagic conditions, however,
these are generally characterized by their short dura-
tion and by one or more of them being absent. The
chief title to distinction which these cases possess is
their relatively good prognosis. Many of the patients
recover almost entirely. It is certainly remarkable to
see a man who had been completely paralyzed in all
four extremities as the result of a severe injury, walk-
ing about again and pursuing a gainful occupation.
It has been my privilege to see this in several cases,
and there are numerous examples of it in literature.
In the earlier article I described such recoveries in
detail. Since that writing the following case has
come to my observation :
A man, thirty-one years of age, fell off a cart, strik-
ing on the right side of the head, on July 21, 1899.
He was immediately paralyzed in both arms and in
the left leg, and for three days following there was
retention of urine. On September 6th, less than eight
weeks after the accident, when examined at the Van-
derbilt Clinic, the right arm had nearly entirely re-
covered; the left arm was still weak, as was the left
leg, though the patient could walk without much diffi-
culty. There was no deformity of the vertebra;, though
the movement of the neck caused pain. Tactile sensi-
bility was everywhere normal, but there remained con-
siderable impairment of thermal and pain sensibility
in the right side of the body, />., on the side opposite
to the motor palsy, thus constituting the Brown-Sequard
type. 'I'hus, in less than eight weeks after an accident
which had caused complete paralysis in three mem-
bers, one arm had recovered almost entirely, the other
arm was useful to a certain extent, and the paralyzed
leg had regained sufficient power to make locomotion
ea.sy.
B. Small Focal Hemorrhages: It is evidently impos-
sible to distinguish sharply between large hemorrhages
and small ones; the one merges naturally and im-
perceptibly into the others. But as there are many
clinical cases of hcematomyelia of which it is possible
to say that the hemorrhage and consequent injury to
the cord are extensive — so are there others in which it
is equally possible to assert that the hemorrhage and
cord injury are minute. Under '" Large Focal Hemor-
rhages" were described the cases in which the initial
paralysis was extensive, involving three or more of the
extremities, and associated, at first at least, with many
other evidences of severe lesion. Under " Small Focal
Hemorrhages" an account will now be given of the
cases in which many of the cardinal symptoms of
injury to the spinal cord will be sought for in vain,
and in which such symptoms as are present are incom-
plete or limited in distribution. These small hemor-
rhages rarely if ever cause death, and consequently
post-mortem evidence concerning them is meagre.
But they are occasionally found after death in the
bodies of persons dead from other causes; and there
are many correlated facts which make diagnosis reason-
ably certain. Chief among these are the facts that the
symptoms point to the cervical region, and that they
indicate in their mode of origin, their individual char-
acters, and evolution, a central lesion of the cord.
It has been thoroughly demonstrated that the cervical
region is the elective seat, if not the exclusive one, of
primary focal haematomyelia. It is the region of which
our knowledge of fibre courses and cell groups is most
complete. It is here that such diseases as syringo-
myelia and progressive muscular atrophy, which have
furnished invaluable information as to spinal-cord
structure and function, have their favorite starting-
points. From the fourth cervical through the first
thoracic segment are grouped the muscle nuclei for the
upper extremities; the sensory supply, in sharply
differentiated areas, of the whole integument below the
5So
MEDICAL RECORD.
[April 7, 1900
neck; the cilio-spinal centre, and various centres of
reflex action. The functions of this region are so im-
portant and so closely packed together, and their allo-
cation is so well known, that even a slight lesion can
hardly pass undetected and unlocalized. Such a
minute lesion is exemplified in the following case:
The patient, a man forty-three years of age, with an
unimportant previous history, was injured in an ele-
vator shaft on November 11, 1898. He was packing
the cylinder, and was wedged in between it, the wall
of the elevator shaft, and a discharge pipe, when the
balance weight of another elevator came down slowly,
engaging his head on the left and back surfaces.
Being unable to extricate himself, and the weight
Fic. 8.— Diagrammatic Representation of the Anaesthesia and the Condition
Keflex Activity, in a case of primary focal haimatomyclia from injury.
continuing to descend slowly, his head was bent for-
ward and to the left on his chest, and in this position
he was pressed down to the floor. Tliis is all he
remembers of the accident. When he recovered con-
sciousness, about two hours later, he was in the New
York Hospital. His symptoms then were: Laceration
of the scalp, where the weights had pressed; severe
pain and tenderness in the neck, with limitation of
movement; tingling in the tips of the fingers of both
hands. He could move all the extremities freely,
although they felt weak; he could pass his water nor-
mally; his bowels moved regularly. He remained in
the hospital for two weeks, tiie treatment being directed
to the stiffness and pain in the neck and to the scalp
wounds. He had no bed sores. When discharged
from the hospital the pain in tlie neck was still trouble-
some, and he felt weak generally, conditions which
have been gradually improving.
Examination, January 24, 1S99, Vanderbilt Clinic:
The patient is a fairly well-nourished man. There
are no disturbances of mental capacity, no interference
with the special sense functions of sight, hearing,
smell, or taste. The pupils are normal. There are
no symptoms referable to the cranial nerves. The
neck is held somewhat forward on the chest and is very
stiff. Attempts to cause movement in it in forward,
backward, lateral or rotary directions, either on tiie part
of the patient or of the examiner, cause sharp pain.
There are, however, no demonstrable evidences of
fracture or dislocation in the vertebra;. The onlv
positive indications of destructive lesion in the ner-
vous system consist in a patch of ana;sthesia over the
right shoulder and a foot clonus on the left side. The
anaesthesia, as indicated in the diagram (Fig. 8) cor-
responds to the deltoid region. In the area marked
black on tlie chart it is profound and total, so that
touches are not felt, pin pricks cause no pain, and
temperature sense is abolished. Surrounding this
patch of total anajsthesia in front, behind, and above,
there is a narrow zone of diminished sensibility, which
merges into normally sensitive skin. I^elow, the whole
right arm is not so acutely sensitive as the left, although
there is no objective anrtsthesia. In the trunk and
legs feeling is the same on the two sides. The foot
clonus on the left side is rhythmic and fairly forcible.
It is not particularly persistent and is easily ex-
hausted. The tendon reflexes are everywhere very
lively. The left knee-jerk is more active than the
right; elsewhere there is little comparative differ-
ence between the tendon reflexes of the two sides.
The man is weak generally, but he is not conscious
of, nor was I able to demonstrate, a greater weak-
ness on one side than on the other. Fibrillary
twitchings manifest themselves upon use of the mus-
cles of the upper extremities. They seem equal on
the two sides. There is no atrophy. The measure-
ment of the limbs of the left side are somewhat less
than those of the right, but not beyond physiologi-
cal limits. There have never been rectal or vesi-
cal difficulties.
This is evidently the history of a case of spinal-
cord injury. Vet many symptoms, usually promi-
nent, were at no time present. There was no
paralysis of motion ; the sphincters acted physiologi-
cally ; there were no trophic disturbances. The
lesion therefore must be very minute. The diag-
nosis of ha-matomyelia is based upon the character
of the accident, the anaesthesia, and the condition
of the tendon reflexes. The accident caused a
forced flexion of the neck, the most fertile cause
of intramedullary bleeding; the anaesthesia, since
it involved all forms of sensibility, is best ex-
plained by a lesion in the dorsal half of the left
dorsal horn ; and a lesion there, since it would
press most severely upon the left (crossed) pyra-
midal tract, would account for the excess of knee jerk
and foot clonus on the left side. All the symptoms
can be harmonized by assuming a lesion within the
cord, and by that only. And as hemorrhage is the
chief primary intramedullary lesion from traumatism,
there can be little question that a focal point of bleed-
ing in the left posterior horn, extending not above
the fifth cervical segment, is the correct explanation
of this case.
Since a focal hemorrhage may vary greatly in situ-
ation and in extent, and since small hemorrhages may
be multiple, it is evidently impossible to create any
sharply defined syniptomatological category into which
all cases mav be gathered. The lesions being small,
there is a still further departure from the clinical
picture of a transverse lesion than in the large focal
hemorrhages. There is usually no loss of rectal con-
trol, and the bladder, if involved at all, is so only
temporarily, lied sores, as the patient is rarely con-
fined to bed for a long time, do not occur. Sensory
symptoms, with the exception of pain, may be entirely
absent. This is the case especially when other evi-
dences point to implication of the ventral horn nuclei.
Anaesthesia, if it exists, is not widespread. It may
involve all forms of sensibility as in the case just cited,
or may be of the dissociated type. The Erown-St'quard
distribution is common. Tain is generally present to
a greater or less degree. It may manifest itself simply
as pain and stiffness in the neck, or it may take the
form of "root pains," and be extremely severe. The
paralysis of voluntary motion is similar to that
April 7, 1900]
MEDICAL RECORD.
581
described under large focal heniorrli?ges, viz., a paraly-
sis with rapidly ensuing atrophy, some of which will
be permanent, of the peripheral neuron type, in one
or both upper extremities; and, if the pyramidal tracts
are encroached upon, a spastic weakness of one or
both legs. In small hemorrhages the knee jerks are
usually lively or exaggerated from the outset. This is
an important differential sign from large hemorrhages.
The symptoins referable to lesion of the cilio-spinal
centre are usually limited to a myosis, often unilateral.
Fibrillary twitchings, so constant a sign in chronic
disease of the motor nuclei, are no less frequent in
acute lesions. In some cases of injury to the back a
persistent fibrillation in one or more muscles of the
shoulder girdle is the only evidence of spinal-cord
involvement. In all cases it should be looked for.
Occurring alone, or associated witii other symptoms,
it is of great diagnostic value. It is found especially
in the pectoralis major, the triceps, and the biceps.
It is more difficult of recognition in the compactedly
placed muscles below the elbow.
The condition known as diplegia brachial is trau-
matica has usually been explained by assuming an
extra-dural hemorrhage. In the absence of post-
mortem evidence of the existence of such a lesion as
an isolated condition, and in the light of our present
knowledge of h;r;niatomyelia, it seems to me that
the clinical condition must henceforth be recognized'
as resulting from hemorrhages into the cord and not
outside it. The symptoms consist in a iiaccid paraly-
sis of both upper extremities appearing as the imme-
diate result of an injury to the neck. The legs are
not involved; there is generally no anaesthesia, and
the sphincters are implicated slightly and temporarily
or not at all. Pain may be prominent, but it may
also be slight or absent. The knee jerks may be
normal or hyperactive. The following from the Van-
derbilt Clinic is a typical illustration of this con-
dition :
A man, fifty-four years of age, was run into on the
street by a light carriage on December 2, 1899. He
was stunned for a moment or two, and is consequently
unable to give the exact details of the accident. He
thinks, however, that one of the shafts struck him in
the neck from behind, and that then the carriage ran
over him. As a result of this accident there were the
following conditions: Fracture of two ribs, scalp
wounds, and paralysis of both upper extremities. The
patient went to Roosevelt Hospital and stayed in bed
ten days. During that time he says there was com-
plete paralysis in the shoulders and in the upper arms,
and great weakness in the forearms and hands, though
he could use these to a certain extent. The right side
was more affected than the left. The neck was stiff
and painful on movement, and there was severe pain
between the shoulders and in the neck, which darted
down the arms as far as the elbows. These latter dart-
ing pains caused the patient intense suffering. At no
time was there any paralysis of the legs, of the bladder,
or of the bowels; nor was the patient himself conscious
of any impairment of cutaneous sensibility. There
were no bed sores. On January 8th, the patient came
to the Vanderbilt Clinic, when the following notes
were taken as to his condition :
The patient is well built and well nourished, and
walks naturally, though the head and neck are held rath-
er stiff. There is a slight prominence of the seventh
cervical spine, but no marked tenderness. The move-
ments of the neck are fairly free and cause no pain.
Both upper extremities are weak, and around the
shoulders there is almost total paralysis. This latter
affects the deltoid, the spinati, the rhomboids, and the
supinatores longi. These muscles are pronouncedly
atrophied, are the seats of fibrillary twitchings, and
respond sluggishly to faradism. In the other muscles
of the upper extremity the affection is weakness rather
than paralysis, and evidences of degeneration of muscle
tissue are wanting. The knee jerks are normal. It is
impossible to demonstrate positively pathological dis-
turbances of sensibility. Touch is everywhere normal.
It may be that on the inner sides of the arms and over
the chest sensibility to pain is less acute than it should
be, and that in these regions the patient is somewhat
uncertain in his recognition of heat and cold. These
disturbances, if they are regarded as such, are too
slight to warrant the terms of analgesia or thermo-
ana.'stliesia. The symptoms, therefore, were almost
purely motor and were confined to the upper extremi-
ties. It is evident that the pyramidal tracts for the
legs were not destroyed nor pressed upon. A le-
sion able to cause such symptoms must affect the
ventral horn nuclei, or the ventral nerve roots, with-
out encroaching upon sensory tracts or the pyramidal
tracts. How a hemorrhage situated without the cord
could cause such selective symptoms it is difficult to
see; neither does it seem probable that all the ventral
roots going into the formation of tiie brachial plexus
could be so seriously injured as to cause bilateral
brachial palsy, without at the same time there being
other conspicuous symptoms on the part both of the
spinal cord and of the spinal column. In contrast to
these improbable hypotheses is the one which postu-
lates that the lesion consists of hemorrhage among the
nuclei of the brachial ner\es in the fourth cervical
segment. This latter explains perfectly all the symp-
toms, and its correctness seems almost incontestable in
view of the clemonstrated frequency with which hemor-
rhage involves the gray matter of the cervical region.
As to the prognosis of these small focal hemor-
rhages, little is to be said. Life is not directly menaced
by them. The degree of ultimate disability is depend-
ent upon the situation and size of the hemorrhage.
Like the larger hemorrhages, the initial paralysis is
susceptible to a great degree of improvement. For
example, an arm which at the outset was completely
paralyzed, after a few weeks or months has regained
its function in all but a few muscles or groups of
muscles. Muscles in which atrophy sets in early and
progresses rapidly are the least likely to regain full
power. But even in them there may be considerable
return of usefulness. The paralysis is the only symp-
tom which need cause anxiety. Ana-sthesia is usually
transitory, and even if it persists it rarely causes any
serious trouble.
The treatment of both large and small hemorrhages
is to be conducted on the same lines. As the hemor-
rhages are within the cord, they are beyond the reach
of surgical aid, and operation, therefore, becomes
absurd. This will of course be granted by any one.
But until surgeons generally become more familiar
with the differential diagnosis of injuries to the spinal
cord, cases of primary htematomyelia will continue to
be operated upon. And the relatively favorable prog-
nosis inherent to them will be turned to the embellish-
ment of the fame of the operator.
Rest in bed is the first primary requisite for these
cases. When the legs are paralyzed, there is of course
no other alternative. Then a water-bed is necessary.
But even when the patient can walk, he should be kept
in bed for ten days or two weeks after the accident, or
longer if necessary. Orthopaedic appliances are not
indicated. The customary attention to bowels and
bladder should be carefully given. The pain in the
neck can often be relieved by the use of the thermo-cau-
tery, or analgesic drugs may be necessary. The iodide
of potassium in ten-grain doses may have an effect
in hastening the absorption of the blood clot. Fara-
dism to the paralyzed muscles should be given as long
as they react to it. If they fail to respond, galvanism
is to be substituted. After the immediate effects of
582
MEDICAL RECORD.
[April 7, 1900
the injury iiave passed, massage and passive motion
in the neck are useful.
Disseminated hemorrhage : There is little to be said
concerning the clinical characteristics of primary dis-
seminated hamatomyelia, for we have no means of
positively diagnosticating it during life. If, combined
with the scattered blood extravasations, there is a
point of bleeding in a functionally important region
of the cord large enough to give focal symptoms, there
will be the symptoms of focal haematomyelia plus the
evidences of a general commotion of the cord. When,
however, there is no single collection of blood cells
large enough to interfere with the function of afferent
or efferent tracts, of cell groups or of reflex arcs, in
a way to permit a clinical recognition of local inter-
ference, the diagnosis, if it be attempted, can at best
be only one of probability, depending upon the patho-
logical possibility of disseminated hemorrhages, to-
gether with the general clinical evidences of shock.
It seems to be extremely probable that many of the
vague yet persistent nervous disturbances which are
occasionally seen after severe general traumatisms are
the direct results of such hemorrhages.
4 West Fiftieth Street.
SOME REM.^RKS OiN THE TREATMENT OF
SYPHILIS.
3v CHARLES T- PROBEN, M.D.,
If comparison is invited w ith the class of ordinary in-
fectious diseases, syphilis will be found to have many
points in common. In fact, syphilis is regarded as
an infectious disease, imparting its virulence from a
local focus to the fluid tissues, producing constitu-
tional symptoms, which abate and in their wake leave
insidious constructive processes that ultimately de-
generate and take on a destructive type. Practically a
division of syphilis into primary, secondary, and ter-
tiary stages is helpful in ascertaining pathological con-
ditions and the resultant treatment, though such class-
ification may appear rather arbitrary and fanciful.
Rather a debatable question arises, why one person
should present an apparent immunity to the syphilitic
virus, while another may become severely infected by
inoculation. No doubt good general health offers a
certain check or a bulwark in counteracting the effect
of this morbid infection. Susceptibility of the indi-
vidual probably depends upon the inherent vulnerabil-
ity and the resistant power of the tissues of the healthy
body. And the better the health appears, the more
reasonable would it seem that the tissues and the cir-
culating fluids should counteract this unknown poison.
Hence no two bodies exhibit the same degree of viru-
lence, and no two bodies present the same fortifying
and repelling influences of their tissues. Whether
the disputed germ of syphilis or its resultant ptomains
are responsible for the prolific cell growth in lues
I am not prepared to state. This luxuriant cell
growth readily and vigorously attaches itself to the
walls of the lyniph- and the blood-vessels, and so in-
duces many morbid tissue changes. It is surmised
that this almost explosive cell distribution throughout
the body wages constant war against the tissues, the
cells finally implanting themselves upon some vulner-
able point, producing morbid processes extending over
a number of decades, or even over the lifetime of the
individual. Manifestations may appear at any time
without warning; in fact, in the course of time they
become more alarming and destructive, finally leav-
ing irremediable sequela;. Implantation of syphilitic
processes acts at first destructively upon the functions
of the organs, later sapping their very vitality.
The morbid tissue of syphilis is of a granulation
type and has certain characteristics to distinguish it
from other types of tissue. Granulomata are apt to
infiltrate the lymph-vessels and nodes and the walls of
the blood-vessels, being accumulative primarily, but
owing to poor vascularization they readily undergo
destructive metamorphosis. This tissue has character-
istics in common with other tissue, in that it is subject
to attacks of inflammation, suppuration, and caseation,
yet it is a notable and a characteristic fact that even
large accumulations of syphilitic granulation tissue
become entirely dissipated by vigorous antisyphilitic
medication. This capacity for complete absorption
and disappearance without leaving any marks of ul-
ceration or degeneration may be caused by various fac-
tors, but it strikes me that it is the only morbid tissue
which will positively yield to medicinal treatment.
The ravages of the disease increase with age, though
it might be supposed that the germicidal effect of the
blood plasma would be antagonistic to syphilitic in-
fection, and so wear out its virulence. There is a
constant effort of one trying to conquer the other,
health having the germicidal action of the tissues in
its favor. Our gratitude is due to the natural proc-
esses of our fluids, which are usually victorious: for
experience teaches that in years elimination of the in-
fection takes places in over two-thirds of those afflicted,
who fail to record any but primary and secondary
manifestations of this dreaded monster. In other
words, we may put it as an axiom that over sixty-five
per cent, of the afflicted escape tertiary manifestations
or sequelae, the foe being conquered by the elements
of time and good health. Prolific cell hyperplasia at
first gives rise to indurations; steady accumulations
give rise to swellings and tumors. Progressive.plastic
elements increase the thickness of the walls of the
bloodvessels, obliteration of their lumina may ensue,
with thrombosis and embolism and a cut-off blood
supply. For a vital organ like the cerebrum we see
how important and necessary a good supply is — far '
more so than for the spinal cord. As a sequela a sub-
sequent destruction of tissue takes place; the function
at this area is forever destroyed, and it would not be
feasible to suppose that this softening could ever be
completely regenerated. This is one of the destruc-
tive ra\ages of this dread disease, and while we can-
not regenerate what is completely destroyed, we may
hope to check the progress of a contiguous and similar
process which has not so far advanced. Suppose
pressure of a similar growth upon the delicate nerve
fibre produces a descending nerve degeneration with
entire disappearance of axis cylinder and replacement
of connective tissue, would we expect the connective-
tissue changes to disappear completely, after their ex-
istence for a long time has caused the nerve to cease
functionating.' No, undoubtedly not, though we are
aware of the great reparative power of nerve fibres,
especially if peripherally injured. You say. What has
all this to do with syphilis.' A great deal, I say, be-
cause many of us expect to cure all kinds of lesions if
they are syphilitic in character; we do not consider
that they are sequel*, which fail to respond to treat-
ment, though they may have been caused by syphilis.
Especially does this argument hold good in various
cerebral affections of an organic type, excluding func-
tional and nutritional diseases, in which syphilis plays
a very important role as a causative factor — in fact, the
most important, excluding heredity, worry, excitement,
alcohol, etc. Nerves are far more prone to become re-
generated, but they never can replace connective-tissue
changes; restoration is as impossible in descend-
ing degenerations as it is impossible to restore cere-
bral softening when function has once become lost.
In these lesions we must not expect too much from
treatment, though we may be able to inhibit a further
April 7, 1900]
MEDICAL RECORD.
583
extension of the disease. There is no relation be-
tween a primar)' focus of infection, which may be very
minute, and later manifestations, which may appear
\ery severe and destructive. As a rule, from the local
focus of infection we have little to fear; it is the har-
binger of an already infected system, which may be
followed by syphilodermata and a febrile movement.
The multiform eruption of the skin need give us less
apprehension than the visceral complications, which
are apt to appear later, affecting the functions seri-
ously and inducing structural lesions. U'hese remarks
apply generally, except to those cases dreaded so much,
though fortunately rare, the cases of galloping syphilis.
The mooted question, whether tentative excision of the
local infection should be practised in order to induce
a more favorable and attenuated disease, can be read-
ily dismissed with the answer that extirpation is rarely
practised, though it may appear to hold out hopes of
lessening the virulence of this noxious poison. It is
well known that the cure of the focus is a simple mat-
ter, unless a mixed infection causes much suppuration,
when radical means must be resorted to. Excision
to-day is very much discredited, as infection readily
extends and permeates the tissues with wonderful
rapidity. Enlargement of lymphatic vessels and gen-
eral adenopathy, especially inguinal, and the syphilo-
derma, usher in the second stage. If the initial le-
sion is a doubtful one, it is a much-disputed question
whether to begin treatment at once or wait for sec-
ondary manifestations. In order to give weight to our
diagnosis and to strengthen our belief, it is better to
wait until constitutional evidences arise rather than
subject the victim to tentative treatment which is pro-
ductive of nothing but leads us into error, not only
for a short time but for a number of years, wiien we
may regret to have before us an example of disease of
a questionable character. The appearance of objective
signs, taken in conjunction with an initial infection
which was of a dubious character, will give a pic-
ture tliat removes all future ambiguity as to the char-
acter of the treatment to pursue. Great injustice may
be done the patient in suspending over him a constant
cloud of condemnation, whenever a symptom arises that
cannot be explained, and that with great trepidation
will surely be ascribed to the causative influence of
syphilis. Syphilitic viius tenaciously lurks in the
organism and insidioi.i'y affects the viscera and the
osseous system, gradually producing serious lesions,
the more rebellious to treatment the longer the process
has continued.
Allusion has already been made to the resistant and
overpowering action of the healthy tissues of the econ-
omy, and the possibility of a successful combat of the
normal tissues with the specific poison, gradually at-
tenuating the virus and rendering it innocuous, till at
last they gain a decided victory over their weakened
foe, that finds no further nidus for implantation and
finally succumbs. Whatever be the character of the
poison or its composition, though not an entity, it
is apparently never dormant, always eager to prey
upon weakened tissues, and this will explain why
tissues debilitated by constitutional vices, dissipation,
and alcoholic excesses succumb readily. Hence it is
of the utmost importance in the treatment of syphilis
to have a patient in as good a physical condition as
we may possibly secure. Some of the worst cases of
tertiary syphilis we see in those who in their youth
have wilfully abused their constitutions, and who ap-
pear not well able to cope with the inroads of disease.
Medicinal treatment of syphilis by mercurial salts
has been well known for centuries. In fact, these
salts have been eminently successful in the primary
stages ; but the same cannot be said of iodide of potas-
sium, though it appears absolutely necessary in the
later stages to facilitate the melting away of plastic
material and young connective-tissue changes. With-
out mercury it is impossible thoroughly to eradicate
the disease and ultimately cure the patient. Some
observers contend that the iodides alone are curative.
This is a doubtful assertion. Mercury forms the
sheet-anchor and is the greatest foe of syphilis. Symp-
toms of the tertiary stage frequently appear of a du-
bious character, but the history of the patient and the
subsequent objective signs create important links in
the chain of our diagnosis. The etiological factor may
long have been forgotten or may have been intention-
ally kept from the practitioner; the same may be said
of tiie secondary manifestations, and no evidences
may exist save a general adenopathy. Our diagnostic
acumen is very much taxed, but the suspicion of syph-
ilis lurks everywhere about the patient, and here we
realize the necessity of the so-called unscientific thera-
peutic test. Many objections may be raised against
this fallacious argument; it is only tentative, but as an
example let us take an obscure cerebral disease, with
an organic lesion possibly located, but whose character
is unknown from its very obscurity; no history of pri-
mary infection in youth, no etiological factor to assist
us, and yet we are forced to accept syphilis as the most
probable factor of its existence, or at least we suspect
it. The family history is blank ; an examination of the
iris and cranial nerves, and an ophthalmoscopic exam-
ination of the choroid and the optic nerve, may assist.
Providing we find an absence of a definite cause and
absolutely no evidence of constitutional syphilis, the
query is, what our treatment should be and whether we
are justified in tentatively using antispecific remedies.
On the strength of past numerous successes and
the rapid amelioration of symptoms and objective
signs, though we cannot demonstrate any evidence of
syphilis, we are forced to admit the frequency of syph-
ilis as a causative factor, and our justification is well
supported by a possible recovery. I am well aware
that I am generalizing my remarks and am treading
upon somewhat foreign ground, but an admission of
ignorance is better than confident assertion of contro-
vertible statements. It is true that heroic antisyphilitic
treatment has frequently caused marked amelioration
of severe brain symptoms, supposedly due to syphilis,
but later demonstrated to be due to other causes widely
divergent and not specific in character. The truth of
this objection has especially impressed itself upon
me in cases of tuberculous meningitis of children, when
an apparent lull in symptoms, even holding out hopes
of reco\ery, was caused by the administration of large
doses of the iodides and by inunctions, which fact
tended to deceive us severely. It is difficult to account
for these phenomena, save on the theory that the ameli-
oration of symptoms could be ascribed to an increased
absorption of liquid elements by a lymphatic system,
whose activity had been markedly increased by the
stimulation of the drugs administered. This test is
not without its fallacies, and is consequently forcibly
held out as irrational by the opponents of specific
treatment in chronic cerebral disorders. Yet it must
be contended that in these obscure cases palliation
is the entire extent of our resources. The query nat-
urally arises, whether we are justified in forcing the
patient to submit to a heroic form of specific treatment
when the etiological factor is in doubt. As a rule,
very little detriment results from such a procedure, and
much may be gained in a doubtful case. Justification of
aggression by resultant cure in a single case, though it
had been merely tentative, will well repay us for a dozen
failures. While the plan seems unscientific and irra-
tional, the patient's feelings are very little influenced
by adherence to the strict rules of our science as long
as we can hold out relief and a possibility of a cure.
Especially does this apply to those young in life, when
cure signifies much for their future welfare, or, if not a
584
MEDICAL RFXORD.
[Apr
1900
cure, at least a checking of the degenerative process
and prevention of subsequent recurrence. Degenera-
tive types of disease, especially with multiple patches
of sclerosis as a basis, can be hardly expected to yield
to treatment, though it be heroic, as no drug is known
which will cause dissipation of firm scirrhous connec-
tive tissue. Though the so-called stages of syphilis are
an arbitrary division, yet they help us to understand
more thoroughly the pathological conditions and the
principles upon which a rational treatment of syphilis
is based. From our present knowledge we infer that
the proliferative cell growth of syphilis produces
accumulative lesions, which must be affected by drugs
in a way to cause dissipation or dissolution, in all
probability by a process of fatty metamorphosis.
"Syphilitic granulomata, more than any other tissue,
in fact characteristically so, completely disappear under
proper treatment, leaving no vestige of their presence.
This property of causing fatty degeneration is as-
cribed to the mercurial salts more than to any other
drug. When the deeper connective tissues are affected,
the iodides are especially useful in stimulating tlie
various lymphatics to increased absorption and in
arousing the emunctories to eliminate the products of
fatty metamorphosis. Regarding the quantities of
mercury and the iodides that effect this change, every
case is a law unto itself, except that the drugs should
be administered with firmness and heroically. Iodide
toleration is usually well marked in syphilis, though
various idiosyncrasies play an important role in its
administration. lodism, with its well-marked rhinor-
rhoea, various skin eruptions, and gastro-intestinal
irritation, are drawbacks familiar to all. Symptoms
of iodism may primarily be well marked and cause an
interdiction of iodides; again, they may readily disap-
pear by persistence in the drug. H. Wood even goes
so far as to say that if 4 gm. of iodide of potassium is
administered three times a day without producing symp-
toms of iodism, it shows that the patient is afflicted with
syphilis. This is a dogmatic assertion, for I have fre-
quently seen proof that idiosyncrasy against the drug
is overcome by energetic persistence of administration.
On the other fiand, a severe syphilitic case may not tol-
erate even minute doses of iodides without a profound
impression and aggravated constitutional disturbance
being produced. When danger is imminent and deglu-
tition is impossible, iodides may l)e administered per
rectum. Absorption is notably enhanced by dissolving
the iodide in a warm saline enema. Oral administra-
tion in the ordinary case, which calls for no particular
hurry, requires average doses of from ten to twenty
grains three times a day; when danger is imminent, as
much as one-half ounce may be administered three
times a day, and this without apparent detriment to the
patient's health; in fact, as the patient improves he
may put on flesh and fat. As a warning in some cases,
emaciation may set in and be rapid, owing to the large
doses. Careful watch should be exercised to detect
this beginning waste and check its further progress.
Iodides should always be given well diluted wdth water,
preferably after meals. In but two conditions am I
aware of the harmfulness of iodides. The first is in
some cases of optic neuritis, in which it facilitates
the atrophy and loss of function. In the second, in
cases of general or pulmonary tuberculosis, iodides
increase the rapid wasting of the tissues. The dis-
appearance or rapid amelioration of grave symptoms
under iodide treatment would lead vis to infer that the
case is specific, or at least would offer strong presump-
tive evidence of syphilis, though we may have no right
to assume this in the absence of a history to that effect.
Our materia medica teems with countless drugs, few
of which can be considered true specifics, among which
mercury occupies the foremost rank in the treatment
of syphilis. Centuries have been unable to weaken the
usefulness of this drug; rather has time tended to
strengthen our opinion regarding its effectiveness if
properly used. Besides having ascribed to it a specific
action upon the doubtful germ of infection, it is sup-
posed to act upon syphilitic granulomata, causing
them to undergo a process of fatty degeneration which
facilitates their absorption.
While the drug has innumerable advantages, it has
many disadvantages, especially in the hands of the
tyro. One of these is its marked tendency to cause
local disturbances in the buccal cavity, affecting the
gums and neighboring glands, giving rise to increased
salivation and to pain and tenderness. Notably is
the condition made worse by vulnerable spots in the
mouth, especially diseased gums and teeth, which call
for a thorough overhauling before a course of mercurial
administration is begun. Certain salts of mercury are
more prone than others to produce salivation. What-
ever salt be selected by the practitioner, this tendency
should always be kept in mind, and the method best
adapted to the case should be chosen. There is no
doubt that the economy is unable to assimilate the
amount introduced, especially if given by mouth, when
it has a marked tendency locally to affect the gastro-
intestinal tract, and if the secretions give a warning of
their lessened activity. The emunctories require
careful attention, especially if the kidneys seem to be
in a state of acute or chronic intiammation, since they
eliminate the metal and throw off quite a quantity
from the system. A marked pathological condition
of these organs may constitute a distinct contraindica-
tion to large doses of an irritating mercurial salt.
From time to time various plans of treatment with
salts of mercury have been suggested, but the three
most prominent ones are the expectant, the con-
tinuous, and the interrupted. F.ach has its advocates;
however, rules, especially if absolute, never take the
place of brains. F'rom time immemorial the expectant
plan has held sway, which consists in administering
mercury only when symptoms or objective signs appear.
After their disappearance no further treatment is
deemed necessary, unless signs of syphilis should
again present themselves. The fallacy of this plan is
that recurrence in some form usually takes place; in
fact, quite frequently an aggravated explosion takes
place after a period of quietude. The numerous hos-
pital and dispensary patients generally present them-
selves only when some manifestation of the disease ap-
pears, and receive treatment for the time being, to be
lost to view after relief. Recurrences are consequently
to be expected; in fact, it is surmised that many se-
vere ceretDral cases occurring late in life are due to the
short term of medication, w.hich allows the poison to
remain latent and to show augmented activity in later
life. The continuous plan of medication appears more
rational and has many advocates, foremost among whom
is the older Keyes. who has formulated many nice
rules. He aims at obtaining a saturation point of the
system by administering large and increasing doses,
as large as the system will tolerate — this only for a
limited time. Mild colicky pains and a serious diar-
rhoea determine this so-called saturation point. These
are supposed to show a bare excess of the amount the
system can take or tolerate, and half this quantity de-
notes the tonic dose. The toleration dose and the
tonic dose are alternated, the possibility of abdominal
symptoms being always kept in mind. After a contin-
ued administration of mercury the system seems to
adapt itself to its presence, and the doses are apt to
lose their therapeutic effect; markedly so is this the
case in syphilis. In order to prevent this, some favor
the withholding of mercury for some time, in the
interim giving tonics and trying to build up the system.
Owing to the necessity of withholding mercurial treat-
ment for a short time, the interrupted plan has found
April ;, iC)Oo]
MEDICAL RECORD.
5S5
many advocates, foremost among whom is Fournier.
It must be remembered that those persons who are
otherwise in good healtli present the best subjects for
treatment. They respond far more readily; a less
favorable nidus exists for the development of syphilitic
cells, which are alert for a vulnerable point.
Hygiene offers us an important adjunct to treatment
and is responsible for some excellent results obtained
at local bathing resorts, where the habits of life of the
individual are completely changed. Notable in such
respects is abstention from alcohol and tobacco. It
has already been indicated that oral administration
of mercury calls for watchfulness for symptoms aris-
ing from the gums and the buccal glands. Though
this is the favorite method of administration, it will be
noticed that some salts of mercury produce salivation
more readily than others, also that some are more
elTective than others. The insoluble salts of mercury
are still in vogue, though soluble ones appear to have
the preference. Green iodide, once a favorite, is weak
in its action, while the soluble bichloride is more effect-
ive, especially if given in conjunction with the iodide.
Oral administration of mercury is especially adapt-
ed to the early stages. When it cannot be thus given
and when heroic dosage is required, inunctions and
hypodermatic injections are preferable. Though the
former constitute the most simple and the usual method,
they furnish an additional way of introducing mer-
cury into the system. The elegant preparation ole-
ate of mercury has proved an almost signal failure
in severe emergencies. Inunctions of unguentum
hydrargyri, though not so cosmetic, can be depended
upon when a rapid impression is desirable. One or
two drachms should be thoroughly rubbed in for about
one-half hour daily until physiological effects are pro-
duced. Rubbings are at the same time helpful when
local lesions exist, though situated in the deeper tis-
sues or in the vicinity. Warm baths in conjunction
facilitate the absorption of the minute globules of mer-
cury. The simplicity of this method of introducing
mercury into the system has secured for it a host of
friends, who prefer it to the hypodermatic method,
which has for its bugbear pain. However, when rapidity
of action and certainty of dose are desired it can be
depended upon, especially if the soluble salt is used.
Pain in some cases is probably due to a precipitation
of the soluble salt in the blood plasma, which in turn
dissolves in the alkaline fluids assisted by sodium
chloride. Theoretically and practically, this gives us
a hint to use a saline solution for our menstruum, in
a syringe capped with a gold-plated needle. The site
selected for the injection should be the nates and the
deep intermuscular tissues. If injected into the deeper
layer of the true skin, a slough results; if into the in-
tercellular tissues, pain usually follows. It is a note-
worthy fact that injections seldom affect the gastro-
intestinal canal. Solubility of salt should be attained,
as insoluble salts must first undergo chemico-physio-
logical changes before they can become absorbed by
the lymphatics and pass the lymph nodes. Osmosis
becomes more difficult the more radically different
the salt is from the composition of the blood serum.
Hence it seems to me that oily menstrua holding these
salts in suspension are objectionable. Liquid paraffin,
almond oil, vaseline oil, etc., are as objectionable as is
unaseptic gray oil. Insoluble salts are numerous ; cal-
omel seems the most preferable, from the fact that it
can be freshly sublimed and is then in an aseptic con-
dition. These injections, of about gr. i. to gr. iss.,
should be made in a suspended form into the intermus-
cular tissue of the nates and repeated not oftener than
once a week, allowing the salt to become slowly brought
into solution. Pain may thus last a number of days,
as we have a foreign body in the tissues; and such
complications as suppuration and embolism are rather
the exception. It appears an unscientific and a risky
procedure; one failure makes us apprehensive, and is
apt to curtail its further use. On the whole, soluble
salts are preferable; but kidney complications should
always be kept in view. Intravenous injections of bi-
chloride have been used, and with success, in tropical
malarial toxaemia.
While I have but cursorily touched upon some of
these interesting points of mercurial administration,
much more could be said of a combination of drugs, of
legions of drugs, especially of vegetable origin, which
have proved signal failures in the treatment of syphilis.
The necessity of improving the patient's general health
and of placing him in the best hygienic surroundings
must be obvious to all. By our knowledge of the phy-
siological functions and of the action of drugs we as-
sist nature to resist the action of venom and successfully
to cope with disease. Through the agency of the fluid
elements of the body we introduce medicaments known
to be capable of coping with an enemy making serious
inroads by his destructive ravages — while art assists,
nature tends to heal. The deadly comrade of Venus
continues to select its victims irrespective of rank or
position. In the firmament of our materia medica
the constellations present innumerable luminous foci,
the majority of which are faint and lustreless, but
among a few one remains fixed, full of lustre and lumen,
with an indelible inscription upon it — '" hydrargyrum."
Q70 Lexingtu.\ A\enle.
TREATMENT OF RHEUMATISM AT THE NEW
YORK HOSPITAL.'
By hughes DAVTON, M.D.,
The treatment of the various forms of rheumatism at
the New York Hospital is practically the same during
the terms of service of the four attending physicians,
Drs. Peabody, Ball, Loomis, and Lambert.
I. Acute Articular Rheumatism. — In this form
rest in bed and a milk diet are naturally employed
during the presence of acute symptoms. After their
subsidence the diet is increased to fluids, and then to
" fluid and soft," as the appetite returns. As in other
forms of articular rheumatism, the bowels are care-
fully kept open, avoiding salines in weak, anaemic
subjects, and employing them in plethoric persons.
Elimination is also encouraged by the liberal use of
alkaline mineral waters. The patients are kept in bed
for several days after symptoms disappear, in order to
avoid exposure.
Treatment by alkalies has not proved satisfactory in
many acute cases. Internally, sodium salicylate is
chiefly relied upon, in doses of gr. x.-xv. every three
hours except between 9 p..m. and 5 a.m. The frequency
is reduced as the pain and temperature abate. If mild
toxic symptoms — ringing in the ears and deafness —
develop, they are controlled or diminished by the
administration of sodium bromide, gr. xxx. with each
dose of sodium salicylate, when it is deemed advisable
to push the action of the latter as far as possible
instead of diminishing the dosage. Poisoning by
salicylate of sodium has occurred at the New York
Hospital recently in two cases, in both of which only
the usual quantity for medicinal purposes had been
employed. As an instance of the small amount which
may cause this result, the following case is briefly
reported :
D. McM , fifty years of age, was admitted on
February 22, 1900, suffering from symptoms of acute
articular rheumatism. He was treated by the local
' Read before the Section on Medicine of the New York Acad-
emy of Medicine, March 20, igoo.
586
MEDICAL RECORD.
[April
1900
application of methyl salicylate to the inflamed joints,
and was also given sodium salicylate gr. xv. every
three hours, beginning at 2 p.m. After the eighth dose
the symptoms had greatly diminished, and the drug
was administered only three times a day. When two
such doses had been received, the patient became
actively delirious, insisted that he felt perfectly well,
slept only three hours at night, refused all medication,
and demanded his discharge from the hospital. His
rectal temperature had fallen from 103.4" to 100° F.
on February 24th. He was given sodium bromide
3 iiss. in divided doses of gr. xxx. and Z i-, and
although the delirium became much less severe he
went to his home on February 25th. He returned on
March 7th with no mental symptoms, and suffering
from general muscular rheumatism which had devel-
oped the day before readmission. Under phenacetin
and salol the muscular pains rapidly disappeared.
If sodium salicylate is not well borne by the stom-
ach, salol in doses of gr. v. every three hours, and
salophen gr. xv.-xx., have been satisfactorily employed.
The salicylate of sodium has also been administered
recently by rectum in a few cases for the same reason.
A dosage of gr. xxx. in water ; ii- every three hours,
and later three times a day, has been employed. No
symptoms of rectal irritation have been observed.
In nearly all cases internal medication has been
supplemented by local application of methyl salicylate,
which has invariably given excellent results in rapidly
relieving pain in the affected joints. This is renewed
daily until the local symptoms subside. Many cases
in which gastric irritability contraindicated treatment
by mouth have quickly resulted in recovery when such
local use of the drug alone was employed. Methyl
salicylate, the synthetical oil of wintergreen. is applied
upon a thin compress of gauze wrapped around the
joint and covered by gutta-percha tissue, which is held
in place by a bandage. The initial sensation of burn-
ing is soon followed by relief of local pain, and later
of that in other joints. The rapidity with which the
drug thus employed enters the general circulation is
shown by the fact that its excretion in the urine has
been found to begin within thirty minutes after appli-
cation to the unbroken skin. At the expiration of this
time the urine shows a marked reaction to ferric chlo-
ride.
If fluid persists in the joints after the other symp-
toms disappear, a cantharides blister or tincture of
iodine is applied; and if infiltration of the surround-
ing tissues or stiffness of the joints remains, it is
relieved by hot-air treatment. The anaemia accom-
panying the attack is combated with iron, arsenic,
strychnine, and cod-liver oil; the cardiac and other
complications are carefully watched for, and are treated
by the usual methods in such cases and by increase of
the salicylate.
Rheumatic hyperpyrexia is rarely met with, but when
encountered is treated by large and frequent doses of
sodium salicylate and the tub-bath at a temperature of
65° F. for ten minutes every three hours.
II. Subacute Articular Rheumatism.— In subacute
articular rheumatism the same internal medication is
employed as is used in the acute form, but it is pushed
less vigorously. Alkalies and potassium iodide are
the most favored lines of treatment, supplemented in
all cases by tonics. Locally, methyl salicylate is
employed for the relief of pain. Fluid in the joints
is treated as in the later stage of acute articular rheu-
matism; and infiltration of the tissues around the
joints by the local hot-air bath. This is applied for
one hour daily, at a temperature ranging between 200°
and 450" F., to the affected joints; and when persisted
in, has given great diminution of the peri-articular en-
largement and almost immediate alleviation of the dis-
agreeable stiffness. A fairly liberal diet is allowed.
III. Chronic Articular Rheumatism. — Sucii cases
are rarely accepted at the New York Hospital. Tiiey
are given internally potassium iodide or alkalies, Vichy
in large quantities, a liberal diet, iron, arsenic, strych-
nine, and cod-liver oil. Locally, the hot-air bath is
used persistently. The diet is as nutritious as pos-
sible.
IV. Muscular Rheumatism is combated by the ad-
ministration of sodium salicylate as in acute articular
rheumatism, or by salol and phenacetin, aa gr. v. every
three hours. Locally, methyl salicylate often gives
great relief. Belladonna ointment or plaster is fre-
quently used with the same result. In severe cases
no remedy is more efficacious or more rapid in action
than the thermocautery applied over the site of pain.
One or two applications rarely fail to give complete
relief.
V. Sciatica of rheumatic origin is often cured by
the same treatment as articular rheumatism, including
the local use of methyl salicylate. In the later stages
counter-irritation by the cautery, blister, or mustard
paste is very efficient. In obstinate cases stretching
the affected nerve has been effective and causes only
temporary increase of the pain.
VI. Tonsillitis in rheumatic subjects is amenable to
salol and catharsis, while phenacetin and the frequent
use of a very hot gargle of solution of sodium bicar-
bonate greatly diminish the distressing pain. Tinc-
ture of guaiac is employed in some cases.
VII. Peliosis Rheumatica, so called, though appa-
rently not connected etiologically or pathologicallj'
with articular rheumatism, is treated with sodium
salicylate in default of any other logical method.
To summarize what has been found at the New
York Hospital to be the best routine treatment:
1. In acute articular rheumatism: bed, cathartics,
milk diet during the acute stage, sodium salicylate by
mouth or rectum, combined with sodium bromide if
cerebral symptoms follow the administration of that
drug, and methyl salicylate locally. In the later stages
the methods employed in the subacute form are used.
2. In subacute articular rheumatism: bed if symp-
toms are severe, fairly liberal diet, alkalies or potas-
sium iodide internally, methyl salicylate locally for
the relief of pain, and the hot-air bath for stiffness or
peri-articular enlargement.
3. In chronic articular rheumatism : nutritious diet,
alkaline waters in large quantities, potassium iodide
or alkalies, and the hot-air bath.
4. In muscular rheumatism: salol and phenacetin
internally; locally, methyl salicylate, the cautery, or
belladonna.
In conclusion I would call attention chiefly to the
use of sodium bromide in combination with sodium
salicylate for combating cerebral symptoms and per-
mitting larger dosage; to the hot-air treatment in sub-
acute and chronic rheumatic conditions; and to the
value of local treatment by methyl salicylate, which
possesses the following advantages: ( i ) Rapid relief
of pain; (2) avoidance of gastric irritation.
Nrw York Hospital.
The Clinical Thermometer as a Germ Carrier. —
W. L. Conklin examined six thermometers for bac-
teria> Four had been washed but not sterilized. Mi-
cro-organisms of one or another variety were found on
each of the four. Two had been w.ashed and then
placed in a case containing bichloride solution. No
micro-organisms were found on either. The author
urges the necessity of a more thorough cleansing of
thermometers, and describes the case which he fills
with a I : 500 or i : 250 bichloride solution, in which
he keeps his thermometer. — Buffalo Medical Joitntal,
February, iqoo.
April 7, 1900]
MEDICAL RECORD.
587
SUMMARY OF CASES OF CARCINOMA AND
SARCOMA TREATED BY THE WRITER'S
METHOD OF CATAPHORIC STERILIZA-
TION, TO JANUARY 15, 1900.
By G. BETTON MASSEY, M.D.,
In the Medtcal Record for July 31, 1897, the writer
reported a number of cases of malignant growths treated
by a new method, involving the massive cataphoric
diffusion of the nascent electrolytic salts of mercury.
The interest aroused within the profession by the
claims made in that article, and in other subsequent
publications, suggests the present resume' of all cases
treated by myself, which includes the ultimate results
in quite a number of cases of from two to five years'
standing.
The process may be described briefly as a cataphoric
diffusion of nascent mercuric salts produced by the
electrolysis of metallic mercury inserted by a gold-
anode into the growth, the patient being usually under
general anesthesia, and the chemical and cataphoric
force being a direct current of 200 to 1,200 milliani-
peres continuously employed for a time varying from
fifteen minutes to two hours and a half. The im-
mediate effects are the production of an area of necro-
sis involving the most evident portions of the growth,
beyond which extends a zone of sterilization, in which
the malignant germs are killed without destruction of
the normal tissue elements. The zone of sterilization
radiates in all directions, but more especially through
cellular planes of cancerous proliferations.
Since the inception of this process of destruction
and sterilization of cancerous growths in 1893 I have
applied the method to thirty-seven cases, including
a number that afterward showed that metastases had
been present before the treatment. These cases may
be classified as follows:
Operable cases : Cured, 4; probably cured, i ; failed
to cure, 2; total operable cases, 7.
Inoperable cases: Cured, 6; probably cured, 2;
probably failed to cure, 2; failed to cure, 20; total
inoperable cases, 30.
Total cases, 37; cured. 10; uncertain, 7; failed to
cure, 22.
Of the thirty-seven patients two died under treat-
ment— one with an inoperable epithelioma of the tonsil
and the other with an inoperable sarcoma of the orbit,
the latter in a child aged five years. Of the ten
patients cured but two showed recurrences, necessi-
tating additional applications, and both patients are
now well, after considerable periods since the second
applications.
Summary of the cured cases:
Operable cases cured : i. Epithelioma of the cervix
uteri, confined in seat to the vaginal portion, in a lady
aged forty-nine years. Repeated mild applications
were made in June, 1896. The patient continues in
perfect health, three and a half years after application.
2. Acinous carcinoma of the breast in a lady aged
fifty-one years, without glandular involvement. The
growth was about two inches by one inch in extent,
situated in the lower outer quadrant of the right breast.
One strong application (475 milliamperes) was made
November 16, 1898. The patient remains in perfect
health at present, a year and two months after the ap-
plication.
3. Epitheliomatous wart on the face in a feeble
man aged seventy-nine years, was removed by a series
of mild applications in June, 1898.
4. Carcinoma of the breast, with infected axillary
gland, in a woman aged forty-four years, was treated by
one strong application, April 13, 1899 (300 to 500
milliamperes for one hour and twenty minutes). The
primary growth was in the outer quadrant of the left
breast, involving about one-quarter of the gland, the
skin being adherent and changed in texture over the
growth. There was one enlarged gland in the left
axilla which was subjected to the treatment at the
same time. The patient is well and with perfectly
healthy cicatrices at the present time, nine months
afterward, and possesses also the greater part of the
breast intact.
Inoperable cases cured: 5. Sarcoma of the soft and
hard palate in a man, aged thirty-eight years. The
patient was nearly in extremis from suffocation and
inability to swallow, the growth being the size of a
goose egg and nearly occluding the fauces. The treat-
ment was by repeated applications of the mild method
in 1894. He continues well, at the end of six years.
6. Adeno-carcinoma of the upper rectum in a lady
aged fifty years. Repeated applications of 100 to 125
milliamperes were made in 1895. The patient was
well when last heard from, some years later.
7. Sarcoma of the upper maxilla in a man aged
thirty-nine years. The growth filled the right antrum,
causing a bulging of the cheek and flattening down-
ward of the hard palate on that side, and projected
into the mouth, having displaced four teeth. On
October 11, 1897, an application was made under
ether, 300 milliamperes being employed to electrolyze
and diffuse the mercury for fourteen minutes, the result
being incomplete by reason of the instruments being
too short. Subsequent repeated mild applications
were made without ether. The man has perfect health
at present, over two years later, the distortion of the
bony plates having disappeared, and a healthy sinus
now leading into the antrum.
8. Recurrent carcinoma of the breast and axilla in
a lady aged sixty-three years. The breast and a dis-
eased gland in the right axilla had been removed by
the knife ten months before the case was seen by the
writer, December 11, 1897. The disease had recurred
in the scars at both sites and in the skin of the chest
between the breast scar and clavicle. On this date a
cataphoric application was made with 500 milliamperes
for fifteen minutes. The diseased scar in the axilla
was not disturbed until a year and a half later, August
16, 1899, when an application with 200 milliamperes
was made, lasting twenty-fi\'e minutes. The patient
is in perfect health at present, with both scars soft and
normal.
9. Inoperable carcinoma of the mouth in a woman
aged fifty-six years. The growth was sittiated beneath
the left side of the tongue, evidently developed within
the left sublingual gland, with extension along the
floor of the mouth as far back as the base of the tongue.
On December 28, 1897, an application was made with
350 to 400 milliamperes for half an hour. The result
appeared perfect for a time, but in June, 1899, there
was evidence of a similar growth in the opposite sub-
lingual gland, which received an application on June
24th, 4,000 milliamperes being employed to diffuse the
mercury for one hour. This resulted in destroying
the disease on that side, and a piece of devitalized
lower jaw subsequently came away. On November 3,
1899, it was noted that a recurrence had appeared at
the site of the first application, and a third cataphoric
diffusion of mercury was made at this date. At the
present time this has healed except for a portion of
bone sequestrum which is coming away, and the patient
appears to be free from the disease and in good health,
though the tongue is somewhat bound down and the
inner sides of the lips are contracted by healthy ad-
hesions.
10. Inoperable rodent cancer of the face in a phy-
sician aged sixty-six years. The case was of twenty
years' duration, had been operated on by the knife two
years before, and had recurred in worse form when
first seen, January 16, 1899. The disease was situated
588
MEDICAL RECORD.
[Apr
1900
on the right side of the face, extending from above the
eyebrow to the middle of the cheek, the bone of the
skull and upper maxilla being eroded, and the disease
was just reaching into the orbit. The patient was
placed on mild zinc-mercury cataphoric applications
daily, and at the end of three months the whole of the
area except a small spot had filled in with healthy
skin and flesh — not scar tissue — the skin spreading
inward from the edges. Another series of applica-
tions was made in the summer of 1899 to the remain-
ing spot, and at the present time the disease is thor-
oughly eradicated, and the face has completely healed.
Cases probably cured: i. Inoperable recurrent ade-
nocarcinoma of the neck in a lady aged fifty-seven
years, in whom the submaxillary gland of the same side
had been removed by the knife one year before. An
application was made June 23, 1899, the mercury being
diffused by 300 to 400 milliamperes for fifty minutes.
Condition, November i, 1899, well healed with healthy
scar. I have been unable to hear from the patient
since.
2. Inoperable primary carcinoma of the uterus and
vagina in a lady aged sixty-one years, in whose case
surgical interference had been declined at the Cancer
and Mt. Sinai hospitals in New York City. The
growth was a scirrhous epithelioma arising in the
cervix uteri and infiltrating the left broad ligament
and vaginal walls, a large indurated mass extending
down the recto-vaginal septum nearly to the anus.
Application was made on December 10, 1899, the
mercury being electrolyzed and diffused by a current
of 400 to 600 milliamperes for fifty minutes. On
recovering from the ether the patient noted a cessation
of pains in the back and thigh, though the soreness
from the operation was very great. .\t the date of dis-
charge, January 10, 1900, the parts were well healed,
leaving a recto-vaginal fistula, but the softness of the
newly formed tissue within the vagina, coupled with
continued absence of the cancer pains, made a cure
seem possible.
3. Inoperable recurrent carcinoma of both breasts
and both axillary regions in a lady aged forty-one
years. The right breast and diseased glands in the
right axilla had been removed by the knife in June,
1899. Three months later a second operation had
been performed for recurrence in both scars and also
for diseased glands in the left axilla. Tliree months
later, when seen first by the writer, December 8, 1899,
there were a recurrent growth about eight inches long
in the situation of the breast scar, and recurrent
growths in both axilla.-. Across the upper portion of
the left breast three nodules showed, revealing the
lymphatic-vessel route by which the disease had gained
access to the left axilla. .\n application was made
December 16, 1899, of 600 to 700 niilliampt-res for
two hours and a half, permitting the wiiole of the dis-
eased areas to be gone over with the gold-mercury
electrodes. The patient reacted well from the pro-
longed etherization, and has done well since, there
being apparent evidence of all the diseased cells being
killed in both axilla; and in the principal recurrent
area, except possibly a small spot in the latter, which
may demand a second application within a few weeks.
Analysis of the cases of failure to cure: Of the
thirty-seven cases, twenty-four have been recorded as
failures or probable failures. Deducting the two cases
in which death occurred during the application, we
have twenty-two cases of failure to arrest the disease,
without any bad consequences following the treatment
itself. The cause of failure to arrest tlie disease in
nine of these cases was the development of latent
metastases after the method had secured a local eradi-
cation of the primary growths, the metastases develop-
ing in each case without evidence of recurrence at the
primary seat, showing that they were due to the lodg-
ment of emboli from the primary growth previous to
its destruction by cataphoresis. In the remaining
thirteen cases there was failure to arrest the disease
locally in the stage in which it was found, many of
them being already recurrences after knife operations;
and these failures to arrest were due to insuflicient
diffusion of mercury for various reasons: either failure
to use anaesthesia and a strong current, or failures of
batteries to give enough current in the early applica-
tions, or the fact that the growth was so close to the
brain as to make an effective current impossible.
Prostatic Affections in Young Men. — James Ross
says that the most important causation of inflamed
prostate in young men is no doubt gonorrhoea. In the
treatment of membrano-prostatic catarrh the writer has
had good results from the topical application of nitrate
of silver, beginning with a few drops of a solution five
grains to the ounce and increasing the strength. — Mari-
time Mciliiiil AVuM', January, 1900.
Operation on the Pharyngeal Tonsil ; Haemo-
philia ; Death. — R. Sachs operated on a boy, aged
ten years, under chloroform, using a modified Gott-
stein knife. The tonsil was removed in one piece as
large as a walnut. Bleeding at the time was no more
than usual, and the child was sent home, but he began
to bleed again in a few hours. Hemorrhage recurred
at intervals; it was temporarily checked, but recurred
again, and the child died on the fourth day. Later in-
quiry revealed the fact that his maternal grandfather
had died at the age of forty-two years of hemophilia
(renal hemorrhage). The child had also manifested
in previous years evidences of the same disease. —
/<>iinia/ 0/ L(UX>igology, Vthruaiy, 1900.
The Alterations in the Venous Coats in Varices.
— Raft'aele lanni finds that in varicose veins the retro-
gressive changes in the walls are due not only to their
passive distention but also to sometimes extensive
new formations of connective tissue, chiefly in the
intima — an endophlebitis resulting in nodes or plaques.
The elastic fibres of the internal limiting membrane
become thinner, and there is new formation of these
fibres also. In the innermost layers of the media there
is apt to be a circumscribed connective-tissue new for-
mation in the vicinity of the nodes and plaques. This
endophlebitis is primary, and does not possess the
compensatory powers ascribed to it by F.pstein.—
Gazzelta Jntcruazioiiiile di Aledlciiia Pratiia, February
15, 1900.
A Type of Enteric Fever — Not Typhoid Otto
T.erch claims that there is a type of enteric fever, not
typiioid, which is probably caused by one of the varie-
ties of the bacterium coli commune. He reports a
case which he believes to come under this head, in
which, after an illness somewhat resembling an atyp-
ical typhoid, the patient suddenly died of heart failure.
In this case, the fever chart did not resemble typiioid,
not even atypical typhoid : the onset was sudden,
though prodromes seem to have preceded it; the erup-
tion was peculiar, and tremor was not present, es;-.e-
cially tremor of the tongue, a symptom to be looked
for in typhoid; the examination of the urine showed
the diazo reaction absent, and the blood count showed
an enormous increase of white blood corpuscles, never
met with in an uncomplicated case of typhoid. At the
autopsy the gall bladder was found intact, and the mes-
enteric lymph nodes were not perceptibly enhirged.
The author thinks that the foregoing summary justifies
the conclusion that the case represents a type of en-
teric fever not caused by the bacillus typhosus. — Ne^u
Or/edus Mfitiuil iiihl Sinxital Joiiyjial, February, 1900.
April 7, 1900]
MEDICAL RECORD.
5«9
Medical Record:
A Week/)' Journal of Medicine and Siiri^ery,
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 51 Fifth Avenue.
New York, April 7, 1900.
THE URIC-ACID DIATHESIS.
A PAPER on " Uric Acid and the Circulation, Some New
Methods of P^stiniating its Effects," read at the meet-
ing of the British Medical Association in August
last, by Dr. Alexander Haig, and recently published
in pamphlet form, is instructive even if regarded as
simply elucidating the well-known original views of
the author on the subject. Although Dr. Haig is de-
cidedly too prone to lay at the door of uric acid most
of the diseases to which the human race is liable, and
thus prejudices his case by the very excess of zeal
with which he fights for his cherished theory, never-
theless it must be admitted in common fairness that
his investigations have not been unfruitful of results,
and that he has done good service in insisting upon
the importance of the part played by uric acid in the
causation of certain diseases. There would at least
seem to be a solid basis for some of his reasoning.
Since the discovery by Garrod, in the middle of the
last century, that the blood and interstitial fluids of
gouty persons are surcharged with urates, pathologists
have been veering with ever-increasing steadiness to
the conviction that uric acid is the ruling factor in the
causation of gout. It is also conceded that uric acid
may probably be rightly regarded as a dominant cause
of other diseases, notably migraine. The medical pro-
fession considers that this supposition requires further
and stronger proofs before being accepted as an estab-
lished fact. As yet many links are lacking to render
the chain of argument complete.
Haig states in regard to migraine that '"the greater
the relative excess of uric acid and the greater its
absolute excretion per hour, the more severe the head-
ache." Dr. Lichty, of Pittsburg, questions the accu-
racy of the statement, in an article published last year
in X\\t Journal of the American Medical Association, Dr.
Lichty having demonstrated by careful experiments on
persons suffering from migraine that the quantity of
uric acid excreted was not increased during the most
severe part of the attack. But the particular point
upon which Dr. Haig differs most widely from other
authorities is as to the means whereby uric acid obtains
ingress into the system, asserting that it is introduced
into the body as such in certain articles of food, and he
further claims to have detected uric acid in the blood
by microscopical examination, a contention stoutly de-
nied by other workers in the same field of research.
The opponents of the first theory declare that these
conclusions have been reached by processes altogether
unsatisfactory to an organic chemist; while in regard
to the second theory Dr. Luft' says that uric acid has
never been demonstrated in the blood by the one in-
fallible test — the murexide test — and his opinion is
that it is urea in the blood which has been converted
into uric acid in the kidneys.
The writer of a review in the British Medical Journal
on the last edition of Dr. Haig's work, " Uric Acid as
a Factor in Disease," records his views as follows:
"Numerous investigations have plainly proved that
uric acid is entirely absent from the blood of a healthy
man, as also from the blood of other mammals and
birds. Dr. Haig's explanation of the causation of the
numerous diseases attributed by him to uric acid is
based upon the assumption that uric acid is deposited
in the colloid form throughout the organs and tissues
of the body." Dr. Haig in his paper thus describes
his methods of estimating the effect of uric acid on the
circulation. He first refers to the tediousness of the
ordinary tests made use of for this purpose, and goes
on to say : " I have therefore been in search of a test
which might be completed more quickly in patient
after patient without loss of time and almost without
any instruments. This test, it has long appeared to
me, I might obtain if I could measure accurately the
capillary circulation or its effects in the retina, for
instance; and an observation made by Raynaud led
me to the more generally useful measurement of the
rate of capillary circulation in the skin. Raynaud
says that when the vessels in the skin of a finger
affected by local asphyxia are emptied by pressure, as
much as thirty seconds may elapse before it regains its
color, while in the skin of a normal e.xtremity the
color returns in one or two seconds. It struck me
that if there is all this difference between the normal
return and the pathological return, and if Raynaud's
disease is, as I have suggested, due to colleemia, I
might find differences in time of return of the blood
corresponding to the physiological drug action, and
other pathological fluctuations of uric acid. ... I ac-
cordingly began to measure experimentally the times
of what I call the capillary reflux — that is, the time in
which the color returns in, say, a given area in the
back of the hand when removed by pressure. And
after a time I adopted an instrument which gives a
constant definite area of pressure, a definite and meas-
urable force, the pressure being applied for a definite
and constant time, measured by a metronome beating
half seconds, the length of time the blood and color
take to return being measured by the same instrument.
With regard to the eye, I eventually adopted the meas-
urement by the same metronome of the duration of a
certain phase of the ' after image ' produced by a con-
stant light at a constant distance, and with a constant
time of exposure." Dr. Haig says that he found that
these tests recorded in the most striking manner all
the marked fluctuations in the excretion of uric acid,
whether due to the physiology, drug action, or pathol-
ogy. The capillary reflux acts synchronously with
high blood pressure and with the disappearance of the
after or fatigue image in the retina indicating the
590
MEDICAL RECORD.
[April 7, rgoo
capillary circulation there. He therefore claims that
testing this capillary reflux is an index of the amount
of uric acid in the blood and urine, and that capillary
circulation is controlled by uric acid.
If, as asserted by Dr. Haig, high blood pressure and
defective capillary circulation are constant concomi-
tants of the headache and mental depression due to
uric acid, and if uric acid can be introduced into the
body by means of food, and if it is present in the
blood of a healthy man, then the tests devised by Dr.
Haig to estimate its effects on the circulation would
certainly be in a high degree useful. But the fact
must be borne in mind that there is no absolute proof
that migraine is caused by an excess of uric acid,
although the observations of Dr. Haig in his own case,
and his successful treatment of those who have been
guided by his advice, would seem, so far as that dis-
ease is concerned, to point that way. In regard to the
other two theories, they are, as we have said before,
judging by the mass of evidence brought against them,
entirely hypothetical.
WOMEN AS ARMY NURSES.
In* the treatment of the sick and wounded in war-time
careful and tender nursing is almost as important as is
skilful surgical and medical attention. The surgeon,
especially after a great battle, cannot give much time
to each patient, and must depend upon the nursing
corps for the minute carrying out of his directions.
It is therefore a matter of the first moment that this
necessary branch of the medical department of an army
in the field should be thoroughly well trained and or-
ganized. Military nursing differs in so many respects
from ordinary hospital nursing, that a special course
of instruction is requisite in order to gain a competent
knowledge of the duties which may devolve upon an
army nurse when a campaign is in progress. The
question was raised in our war with Spain and is again
being brought into prominence in the South African
war, as to whether men or women are better fitted to
fill the position of army nurses. So far as the nursing
itself is concerned, there can be little doubt that wo-
men are superior to men. Sir William MacCormac
considers women better fitted both physically and
morally for the charge of the sick. He has put it on
record that in his opinion no male nursing can be com-
pared with a woman's, although no one insists more
than he upon the necessity of training.
In the Crimean war, after Florence Nightingale ar-
rived upon the scene, and in the Franco-Prussian war
almost all the nursing of the British and German
troops respectively was performed by women. Never-
theless many experienced authorities hold, among
whom are Surgeon-General Sternberg and those at the
head of the British Army Medical Corps, that the front
is no place for women. A writer in B/ac/^wooifs Maga-
zine for March writes as follows :
" There is no doubt that in the line nearest the enemy,
where work must be to some extent rough and ready,
when grave danger is hovering near, and a hospital
must, as it were, ' come into action ' with the utmost
rapidity, and not always under the mos1: favorable cir-
cumstances, the men of the Royal Army Medical Corps
are the best possible nurses. It has been suggested
that some lady nurses should be attached to the field
hospitals; but the consensus of opinion among those
w^ho are responsible that the work is well done, and
among the poor Tommies who form the cases, is that
the ladies would be quite out of place so near the bat-
tlefield and that it is much better to rely entirely on
the men who have always proved themselves to be so
good and efficient. It is obvious too that if a lady
nurse falls sick it would be impossible in a field hos-
pital to provide that she should have the care and
privacy due to her sex. The British Army Medical
Corps consists not only of medical officers but of a
large body of trained male orderlies. These latter are
the real nurses who do the actual nursing work, and
they are under the orders of a highly efficient and
limited body of trained lady nurses who act practically
as ward sisters, and who while directing the orderlies
do not take any active part in nursing the wounded. . . .
The first and second lines of assistance are entirely
composed of men, and it has comparatively seldom
happened that a female army nurse has ever been any-
where near a field of battle except owing to some cir-
cumstances over which her medical superiors had no
control."
But although women may not be physically capable
of coping with the onerous duties which fall to the lot
of nurses with an army in action, still this is no reason
why their services should be wholly dispensed with in
time of war. The hospitals in the rear should ahvays
provide an ample field for their usefulness, and it
seems to us that the nursing staff of these hospitals
might be with advantage largely if not entirely com-
posed of women — that is, of women who have been
well trained in the routine of army hospital methods.
In order to have an efficient women's nursing service
in time of war it will be needful for the United
States army authorities to see that the candidates are
carefully selected and afforded the opportunity of gain-
ing experience in army methods.
THE MIDUTVES BILL IN GREAT BRITAIN.
The licensing of midwives in Great Britain, despite
the fact that, as shown by the result of the ballot
among the medical practitioners of that country initi-
ated by 77tc Lancet, the profession as a whole is strongly
opposed to the measure, will, it appears, shortly be-
come law. The necessity for such legislation is no
more apparent to the medical men of England that is
the proposed legislation for the licensing of midwives
in this city to the physicians of New York. Tlu-
Lancet sz.ys in reference to the obnoxious bill: "What
now remains to be done is for the medical profession
to bring such influence as they possess to obtain modi-
fications in the measure: (i) w'hereby the general
practice of midwifery in our country may not fall into
the hands of a semi-educated class; (2) whereby the
scope of the licensed midwifery shall be defined; and
(3) whereby encroachments upon medical practice and
April 7, 1900]
MEDICAL RECORD.
591
infringements of the medical acts may be obviated."
The same journal thus defines what should be the scope
of a midwife: "The due limits of the midwife's work
in an ideal condition of things would keep her to
nursing and nothing but nursing, including the first
care of the infant if healthy. In such an ideal condi-
tion of things the whole province of obstetric medicine
belongs to the fully qualified medical man, for it is
obvious that at one particular place or another a case
passes from physiology to pathology."
The licensing of midwives is a retrograde step and
one likely to prejudice severely the interests of the
medical profession. It will establish a precedent for
the licensing of so-called experts of every description,
and will open the door to quackery generally. Laws
medical and otherwise are made only for the protec-
tion of the public. No class of the community needs
protection more than parturient women, and it would
tlierefore appear reasonable that the law should insist
hat women in this condition should have the benefit
of skilful and intelligent treatment. This object will
not be effected by the licensing of midwives.
isch.+:mic paralysis.
Paralysis of a member with rigidity or contracture is
sometimes observed following the application of a
bandage, and the condition has usually been attributed
to nerve pressure too firmly made or too long con-
tinued. In the latter event some importance has also
been attached to want of use. On the other hand, in-
terference with the blood supply, with the resulting
nutritive disturbance in the muscles, has been thought
to be the active pathological factor. Necrobiotic
changes have been found in muscles that have been
rendered bloodless by circular constriction and also
after exposure to severe cold. Once developed, the
disorder has proved a most obstinate one. In a case
in which such a condition developed in a child four
and one-half years old, following a fracture of the
humerus and the application of splints and a bandage,
Page {Lancet, January 13, 1900, p. 83) secured a satis-
factory result by lengthening the tendons of the affected
muscles and long-continued massage and electric treat-
ment. The disabled extremity was the Seat of great
pain, and the wrist and fingers were in a position of
marked flexion. The ulnar distribution in the hand
was anaesthetic, and degenerative reactions were pres-
ent in the affected muscles. Improvement was slow,
but eventually quite considerable. The opinion is
expressed that the condition, in this case at least, is
not primarily or even in the main due to a nerve
lesion, but is dependent upon the combined effects of
pressure, immobility, and diminished blood supply
upon the muscular elements, the connective-tissue ele-
ments, and the nerve elements present in the muscle.
A New Hospital for the Insane has just been com-
pleted at Bridgeton, N. J., the handsome and commo-
dious structure being formally turned over to the county
by the building-committee on March 29th.
Hews of tlie "SSlleefe.
Dr. Schenk, recently dismissed from the chair of
embryology at the University of Vienna for having ex-
ploited his theories of sex determination in the news-
papers, announces that he will probably come to
America.
Statistics of Laryngectomy: A Correction.^Dr.
D. Bryson Delavan writes: "In the Medical Record
of March 24, 1900, page 523, I am reported as having
said in the discussion of a case of laryngectomy pre-
sented to the surgical section of the New York Aca-
demy of Medicine by Dr. A. T. Bristow: 'Partial
laryngectomy does not show more valuable statistics
than the complete operation, and the results of com-
plete extirpation are so much better that there can be
no choice between the operations,' etc. The state-
ment bears upon a subject of such great importance
that the misquotation of it should not go uncorrected.
What I actually said expressed not only my own views,
but the generally acknowledged opinion with regard to
this matter, namely, that exactly the contrary of the
above-quoted statement is true."
Work among the Lepers in the Far East — One of
the most interesting themes that will be considered at
the Ecumenical Missionary Conference in New York,
April 2ist to May ist, relates to the work done for
lepers in various parts of the world. It is to be spe-
cially reported on by Wellesley C. Bailey, secretary
and superintendent of the Mission to Lepers in India
and the East, and by Miss Mary Reed, a missionary
to the lepers. The mission to lepers in India begun
in 1874 found a necessitous sphere of work among this
large and afflicted class. There are nearly half a mil-
lion lepers in India alone, and large numbers are to
be found in other eastern lands. There are now fifty-
two leper asylums in India, Burmah, Ceylon, China,
Japan, and Madagascar. Much of this advance is said
to be due to Mr. Bailey, who joined the American
Presbyterian Mission in the Punjab in 1869, and spent
twelve years in India, working among the lepers and
part of the time having charge of two leper asylums.
In 1874 he visited Ireland. Securing the promise of
§150 annually for the relief of lepers, he established
the mission for them. In 1893 the title was enlarged
and the society became " the Mission to Lepers in India
and the East." In 1897 the mission helped nine
British and several other missionary societies, and had
twenty hospitals of its own, a number of homes for the
untainted children of lepers, and expended $37,960 in
its work. The number of inmates in the mission
homes is about one thousand, and there are about
seventeen hundred in aided institutions.
A Physician Punished for Incapacitating Re-
cruits.— Dr. Adolph Ziel, of Elberfeld, Germany, has
just been sentenced to a year's imprisonment for hav-
ing assisted conscripts in avoiding military service.
His plan was to give some cardiac poison just before
the conscript was to be examined, so that the heart
would be found irregular in its action. He had cheated
592
MEDICAL RECORD.
[April 7, 1900
the government out of over three hundred soldiers be-
fore he was apprehended. Several military surgeons
were also sentenced to short terms of imprisonment for
complicity in his scheme.
The Medical Association of Missouri. — The forty-
third annual meeting of this society will be held at
Me.xico, Mo., on May i5th-i7th. The subject for
formal discussion will be "Gall Stones."
The Pennsylvania Society for the Prevention of
Tuberculosis. — The annual meeting of this society will
be held on Wednesday, April i ith, at 4:15 p.m., at the
Academy of Natural Sciences, Logan Square, Phila-
delphia.
The Middleton Goldsmith Lecture of the New York
Pathological Society will be delivered at the Academy
of Medicine on Friday evening, April 13th, at 8:30
o'clock, by Dr. Simon Flexner, of the LTniversity of
Pennsylvania. The subject of the lecture will be
"The Pathology and Etiology of Dysentery."
Normal Appendectomy. — The St. Louis Medical
Revie-ii.1 oi March 17th contains replies from eighty-
nine surgeons in different parts of the country regard-
ing the advisability or justifiability of removing the
normal appendi.x as a prophylactic measure. Only one
expressed unqualified approval of the operation, and
three seemed to be in favor of it with reservations.
A Memorial to Dr. Love. — The Love Memorial
Association of Montclair, N. J., has presented to the
Free Library Association a bronze bust of the late Dr.
John J. H. Love, made by J. Scott Hartley. Charles
H. Johnson, president of the association, reviewed the
life of the physician and his services to Montclair, and
then formally presented the bust to the library. Ed-
win B. Goodell made the speech of acceptance.
A Mental Healer Not Wanted in Belgium.— It is
reported in London that a " professor of mental heal-
ing," an American citizen, has complained to the gov-
ernment of this country that he was expelled from
Brussels by the Belgian minister of justice. It is to
be hoped the Belgian authorities will be induced to
retract their edict of expulsion, otherwise the " healer "
might return to this country.
The Louisiana State Medical Society.— At the
meeting of this society in New Orleans, on April 19th-
2ist, there will be a special subject for discussion
before each of the several sections. In the section on
medicine the subject will be "Tuberculosis"; in that
on surgery, " Local and Regional Antesthesia in its
Applications to Minor and Major Surgery" ; in that on
obstetrics and gynaecology, (i) "Surgical Aspects of
Salpingitis," (2) " Electricity in Gynascology " ; in that
on pediatrics, "Measles and Smallpox in Children."
The Plague — It is stated that two hundred and
seventeen deaths from plague occurred in Calcutta on
March 27th, the number of new cases reported the
same day being one hundred and fifty-seven. In Sid-
ney, N. S. VV., eleven new cases were reported on April
ist, and two deaths occurred. In Honolulu, on March
24th, it was stated that no new cases of pest had de-
veloped in over a week, and the board of health was
considering the advisability of announcing ofificially
that the epidemic had run its course.
The New Naval Hospital at the Mare Island yard
in California has been completed and is now ready to
be turned over to the government. It is pronounced
one of the best-equipped hospitals in the country.
Typhoid Fever on the Prison Ships — A despatch
to IVie Sun from Cape Town says that rumors are cur-
rent there that there are not enough doctors and nurses
on the prison transports, upon which an epidemic of
typhoid fever is raging. Many civilians have offered
their services.
The New York City Hospital for Consumptives. —
Dr. Henry's bill to provide for the establishment by
the city of New York of a hospital for the regular treat-
ment of pulmonary tuberculosis, and appropriating
$350,000 therefor, passed the Assembly last week.
The local board of health is to have jurisdiction over
the new hospital.
St. Bartholomew's Clinic. — A member of St. Bar-
tholomew's Church has given $155,000 for a new
building and equipment for the eye, ear, nose, and
throat clinic maintained by that parish. Ground has
been purchased, and the new building will soon be
erected on East Forty-second Street adjoining the
present mission building.
The Hospital Ship "Maine."— A protest was re-
cently lodged by the committee in London against the
return of the Maine from South African waters. Gen-
eral Buller in reply said he thought that the ship in
going to England would confer the greatest benefit
upon the sick and wounded, as, with her excellent
medical staff, she would aid in that way the evacuation
of bad cases from the congested hospitals. He added
that if she went to England, her return would be de-
sired at the earliest possible moment.
Hospital-Ship Investigation. — The Secretary of
War has appointed Brig.-Gen. Alfred E. Bates, paymas-
ter-general. Major Henry S. Kilbourne, surgeon, and
Major John M. Carson, Jr., quartermaster, on a board to
make inquiry into all the facts relating to the equip-
ment of the hospital ships Missouri and RelieJ. The
cause of the appointment of the board was a request for
a large sum of money to place the ships in a seaworthy
condition. As both were only recently fitted up at
great cost, the secretary wishes to know why they have
so soon become unseaworthy.
Progress in Great Britain. — At an inquest recently
held in Belfast the coroner remarked that the post-
mortem examination had been made very satisfactorily
by Dr. Harriett Niel, and that this was the first instance
on record in the country of such a public duty having
been discharged by a woman. Another sign of dimin-
ishing prejudice is furnished by the announcement
that medical women will be admitted to the Liverpool
School of Tropical Medicine on equal terms with men.
Jn view of the fact that many medical missionaries are
April 7, 1900] MEDICAL RECORD. 593
women, it would seem only reasonable to give them bitemporal hemianopsia, or other symptom of pituitary
every opportunity to fit themselves for their future work tumor. There had been no recent marked increase in
as far as possible before leaving England. growth, and the patient had presented a similar appear-
ance for many years. There was present also a con-
The Eastern Medical Society.-The annual dinner ^-^-^^ resembling elephantiasis of the legs, but this
of this society took place at the St. Denis Hotel on the ^,^^ attributed to repeated inflammation of the cellular
evening of March 23d. There were one hundred and tissues Dr_ p. x. Dercum exhibited a man who pre-
seventy-five guests, including ladies. sented tonic spasm of various muscles on voluntary
The American Surgical Association.— The annual effort after a period of rest. The condition was not
meeting of this society will be held in Washington, in believed to be Thomsen's disease, and its nature was
connection with the Congress of American l^hysicians not clear, further than it appeared to be a form of
and Surgeons, May 1-3,1900. The address of the multiple myospasm. Dr. W. G. Spiller reported a case
president. Dr. Robert F. Weir, of New York, will be of poliomyelitis resembling Landry's paralysis in an
on " Perforating Ulcer of the Duodenum." The sub- adult. He exhibited also the brain from a case of
ject for set discussion will be "Surgery of the Stom- congenital blindness. The patient had been an idi-
ach." Titles of voluntary papers will be received by otic boy, without eyeballs and orbits, who had never
the secretary. Dr. Herbert L. Burrell, up to April loth. spoken, and there was found an absence of the optic
nerve and of the chiasm. The pulvinar was pre-
The Tropical Army Ration.— Dr. Munson, in the served, as well as the anterior quadrigeminal body,
essay which was awarded the prize of the Military but the external geniculate body was absent. The
Service Institute offered by Dr. L. L. Seaman, holds entire occipital lobe was much diminished in size,
that the present army ration contains too much nitro- and particularly the cuneus. The upper portion of
genous food and hydrocarbons and not enough carbo- the anterior central convolution on one side was much
hydrates, and the ration in general is too large. " It narrowed, and this seemed to account for a contract-
is evident," he says, " that such changes as are advis- ure that was present in the upper extremity on
able in the adaptation of the United States army ra- the opposite side. The external arciform fibres of the
tion to tropical conditions are chiefly in the line of a medulla were unusually distinct. Dr. Stewart Paton
reduction in the quantity of the foods at present pro- presented a communication entitled "The Study of
vided by a too generous government. It is true that Mental Diseases." He dwelt upon the utility of labo-
the sugars and starches should be slightly augmented, ratory investigation, but pointed out that careful clinical
but their increase is small when compared with the study is not less essential. He briefly outlined the
considerable reduction of nitrogenous and fatty matter plans contemplated for the Sheppard and Enoch Pratt
which is proposed. Many of the components of the Hospital for the Insane near Baltimore. Dr. J. Hen-
present ration, as is seen by the table, require no drie« Lloyd read a paper entitled " Rhythmic Motor
change in the consideration of the tropical dietary. Disorder in Hysteria," in which he referred to the case
being not only admirably selected, but also properly of a girl who presented rhythmic movements of both
proportioned." The quantities of the various com- extremities on one side which were dissipated by sug-
ponents of the rations are given in the following table: gestive therapeutics, and in whom convulsive seizures
, ., ouantityper apparently of epileptic charactcr also occurrcd.
A^'":'"- Ration (ounces.) " ^
Fresh beef (quarters) 10.00 Pure-Food Legislation The Medical Record is
I' resh mutton 10.00 °
Pork 6.00 in receipt of a communication from Hon. H. C. Adams,
c i*I°u "f dairy and food commissioner, Madison, Wis., referring
Salt beef 10.00 J > j > o
Dried fish (cod) 10.00 to the criticism of the Babcock bill in our issue of
Fresh fish, average (whole) 14.00 j^ j^ , jj^ "Section 8 of the Babcock
Hour 18.00 ' ■'
Soft bread 20.00 bill, which authorizes the food commissioner to call
Hard bread 18.00 , Association of Official Agricultural Chemists
Cornmeal .... 20.00 r- »
Beans 2.40 to determine Standards, was put into that bill rathei
S*^^ ^■'*° against my judgment. As I stated before the Pure-
Rice 4.00 a J J b
Hominy 4.00 Food Congress and also before the committee on in-
Potatoes. 16.00 terstate commerce, I do not believe that any outside
Potatoes, 80 per cent, and onions 20 per cent. .. . 16.00 . "^
Potatoes 70 per cent, and canned tomatoes 30 per official body can have the power to determine standards
-..j^"'.'-; ; '^•°° which shall be accepted in court, because it would
Dried fruit (average) 3.00 '^
Sugar 3.50 appear to be a delegation of legislative authority
Molasses i gill which no man or body of men outside of a legislature
Cane syrup ' giU . .
could exercise. I agree with you that that section
Philadelphia Neurological Society.— At a stated ought to be eliminated, and shall so inform Mr. Bab-
meeting, held March 26th, Dr. F. A. Packard pre- cock. I have observed the comments in the Medical
sented a case of possible acromegaly. The patient Record with reference to section 11. I think you
was a young man who presented enlarged nasal bones, misapprehend the purposes of this section. It is not
overhanging brows, a projecting lower jaw, im- to protect manufacturers, manipulators, compounders,
mense maxillary arches, somewhat enlarged hands, or dealers in compound mixtures or imitation, but it
and a striking facies, but there was no headache or is to relieve transportation companies from prosecu-
594
MEDICAL RECORD.
[April 7, 1900
tions under the law. You can readily see that it is
almost impossible for a transportation company to know
what is the character of the products which it trans-
ports. A transportation company certainly could not
be expected to open packages and subject them to
chemical examination, and the purpose of that section
is to throw the whole burden of the law upon the men
who make or deal in goods the sale or manufacture of
which is prohibited by law. I think you will decide,
upon reflection, that that section is a reasonable one."
Mr. Adams, we understand, was one of the authors of
the Babcock bill.
Dr. Edward Chapin, of Brooklyn, has been ap-
pointed by the State board of regents a member of
the New York State board of medical examiners, to
fill the vacancy caused by the death of Dr. A. R.
Wright, of Buffalo.
Addition to a Hospital A structure four stories
high, with a frontage of eighty-five feet and a depth of
one hundred feet, is to be built as an addition to St.
Mary's Hospital, Philadelphia, providing greatly in-
creased accommodations.
Reform in Bake-Shops — At a recent meeting of a
labor union one of the delegates from the Bakers'
Union lodged a complaint against a number of bake-
shops which he said were in a filthy condition and a
menace to the public health. He said that men and
animals slept together in these bake-shops, and he
asked the Union to request the board of health to make
an investigation.
General Endowments. — By the will of the late Mah-
lon H. Dickinson, of Philadelphia, a member of the
State board of charities, the sum of $5,000 each is be-
queathed to the Children's Homeopathic Hospital of
Philadelphia, the Pennsylvania Hospital, the German
Hospital, the Episcopal Hospital, St. Mary's Hospital,
and the Jewish Hospital, for the endowment of free
beds in perpetuity.
Philadelphia County Medical Society. — At a stated
meeting held March 28th, Dr. Mordecai Price exhib-
ited a specimen from a case of perforative appendicitis,
in which operation had been performed successfully.
Dr. John G. Clark delivered an address entitled "The
Anatomical Basis of the Menopause," illustrated by a
lantern demonstration. He showed that the function
of the ovaries depended largely upon their blood sup-
ply, and that the gradual destruction of ovisacs culmi-
nated in the menopause. Dr. James C. Wilson read a
paper entitled "The Symptoms and Complications of
the Menopause." Dr. John B. Chapin read a paper
entitled " The Psychoses of the Menopause," in which
he pointed out that the mental derangements that oc-
curred in this connection did not differ essentially
from those that occurred under other conditions. There
was a mistaken notion that this period of life pecul-
iarly predisposed to the occurrence of psychoses, but
the actual evidence did not support this view. Such
mental derangements might be expected at the meno-
pause as would occur in predisposed persons in the
presence of any other critical situation. Dr. J. M.
Anders presented a paper entitled " The Cardiac Mani-
festations of the Menopause," referring especially to
palpitation and tachycardia. Dr. F. X. Dercum made
some remarks upon " The Neuroses of the Menopause,"
pointing out that this period was one at which neurotic
disturbances were prone to occur, though not present-
ing any distinctive character. Dr. Judson Daland re-
lated a case in which periodical gastric disturbance
occurred in a woman at the menopause. Dr. J. Madi-
son Taylor suggested that nervous disturbances of the
menopause might be more common in the leisure class
than in those more humbly circumstanced.
Dr. Horner and Appendicitis — On page 519 of the
Medical Record, March 24, igoo, under the heading
" Medico-Surgical, Cr.," " Recoveries from interval
operations" should read "Recoveries from operations
advised by physicians in primary cases."
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
March 31, 1900. March 27th. — Assistant Surgeon J.
T. Kennedy ordered to additional duty at the marine
recruiting rendezvous, San Francisco, Cal. March
29th. — Pharmacist J. F. Pearson appointed pharmacist
from March 26th.
Dr. St. George Mivart died suddenly in London
on April ist. He was born in London in 1827. He
was formerly lecturer on zoology at St. Mary's Hos-
pital Medical School, and professor of biology at the
University of Louvain. He was a doctor of medicine,
but did not practise. He was recently excommuni-
cated by the Roman Catholic archbishop of Westmin-
ster for asserting that to ask a reasonable man to be-
lieve such "puerile tales" as those of the Tower of
Babel, of Jonah, and of the creation of the world in six
actual days, was an insult to his Intelligence. He
was a fellow of the Royal, of the Linnaean, and the
Zoological Society. Among his publications are " Gen-
esis of Species," " Nature and Thought," " Types of
Animal Life," "The Cat," "An Introduction to the
Elements of Science." " Man and Apes," and " The
Origin of Human Reason."
Obituary Notes. — Dr. John Cooper, of Brooklyn,
died at the Seney Hospital on March 29th, of gangrene
of the foot. He was born in London in 18 15, and ob-
tained the qualification of the Royal College of Sur-
geons in 1837. He became attached to the medical
corps of the British army, and later settled in New
South Wales, where he was a member of the medical
board for several years. In 1846 he came to this
country and began practice in Huntsville, Ala., where
he remained twelve years, and then removed to
Brooklyn.
Dr. Alfred E. Jones, of Brooklyn, died at the
Home for Aged Men in that borough on March 30th.
He was born in Lexington, Ky., in 1810.
Dr. David N. Taylor, of Amsterdam, N. Y., died
on March 28th at the age of forty-four years. He was
born in Albany and was graduated in medicine from
the Long Island College Hospital Medical School in
1884.
April 7, 1900J
MEDICAL RECORD.
595
Dr. William W. Rodman, of New Haven, died at
his home in that city on March 30th, of acute bronchi-
tis, at the age of eighty-three years. He was a gradu-
ate of the Jefferson Medical College in 1844.
Dr. Francis G. Warren died in Biddeford, Me.,
on April 2d, at the age of seventy-two years. He was
a graduate of the Jefferson Medical College in 1861,
and served during the civil war as surgeon of the Fifth
Maine regiment.
Dr. Joseph H. Vondy died at his home in Jersey
City on April 2d, at the age of seventy years, from
pneumonia. He was born in Miramichi, N. B., and
was graduated from the New York University Medical
School in the class of 1851.
Dr. James Cummiskey died at Philadelphia of pneu-
monia on March 2Sth, aged sixty-four years. He was
graduated from Jefferson Medical College in 1856, and
was for many years physician in chief to St. Mary's
Hospital.
Dr. Franklin B. Hazel died at Philadelphia on
March 28th, at the age of fifty-four years. He was
graduated from the medical department of the Univer-
sity of Pennsylvania in 1870.
Dr. Frank B. Keller died at Pottstown, Pa., on
March 24th, from erysipelas and septicaimia, at the age
of fifty-one years.
Dr. Edwin M. Smith died at Philadelphia on March
29th, aged seventy-seven years. I-Ie vi'as graduated
from Jefferson Medical College in 1846.
^rocjvcss of |Itc(Ucal Science
Medical Ne7vs, Manii ji, igoo.
Myocarditis in Infancy and Childhood Henry Kop-
lik states that the pathological anatomy of this condi-
tion has received most of its facts from autopsies upon
infants and children dying of the infectious diseases.
'I'his affection is one of the most important conditions
met with in the sick infant and child. The myocar-
dium is peculiarly susceptible to the action of any
toxin. Symptoms of functional cardiac disturbance
may appear in the convalescence, not only of diph-
theria, but of any severe throat disease of the strepto-
coccus or staphylococcus variety. The writer then
quotes cases showing the effects of malaria and pneu-
monia on the heart muscle, and then mentions the re-
lations of pertussis and rheumatism to the heart. This
organ must be carefully guarded, and depressing drugs
should be cautiously used. The hope of these cases
lies in well-sustained nutrition.
Uterine Fibroids Complicated by Pregnancy —
Willis E. Ford draws the following conclusions from
several quoted cases. When the lower third of the
uterus and the entire cervix are free from any neoplasm,
the physician may safely await the result of the preg-
nancy, even if the fibroid is of considerable size. If
a neoplasm of any considerable size is found opposite
the internal os, especially if it is large enough to block
in any way the birth canal, then the question as to
waiting until the child is viable and doing a Cesa-
rean section, or whether a total hysterectomy must be
done early, is determined by whether the fibroid is in
the anterior or posterior wall of the uterus. The dan-
gerous position of the fibroid is in the anterior wall of
the uterus, low down.
Alcohol as a General Stimulant and Heart Tonic ;
its Use to the Animal Economy in Health and Dis-
ease.— T. J. Hillis believes that alcohol should never
be given in lingering diseases, nor in convalescence
from acute diseases, if it irritates or upsets the stomach.
Alcohol should never be taken after eating. It cannot
aid digestion, and so must retard it by its weight and
bulk. Further, it precipitates the digestive ferments,
coagulates the albuminoids, and often completely ar-
rests the digestive process. Tlie amount to be con-
sumed varies with the individual and the circum-
stances. Alcohol is a form of food already digested,
but it is not adapted to the normal wants of the body,
and is indicated only at a time and under conditions
which render the digestion and assimilation of other
foods impossible.
A Case of Pneumohydrothorax with Great Per-
manent Displacement of the Heart. —Charles Ross
Jackson quotes the case of a young man, seventeen
years of age, in whom the cardiac impulse is present
in the right fifth intercostal space in the nipple line.
Dulness extends almost from the nipple line to about
the right sternal border and upward to the third space.
The past history is of a pain in the chest, which began
about a year ago and became chronic. In an acute
attack which followed, the perforation probably oc-
curred, and pneumothorax developed. Creosote and
tonics ameliorated these symptoms. The prognosis is
unfavorable.
Toxins from a Chemical and Pathological Stand-
point.— A. E. Austin quotes Gautier's description of
the nature of toxins : " All infectious microbes act upon
the organism by the poisonous products or toxins which
they secrete. These poisonous products are chemical
substances susceptible of filtration, precipitation, and
resolution. These toxins are usually complex, made
up of an alkaloidal material and a nitrogenous sub-
stance, which is very active. The primary effect of
all these toxins is rise of temperature, and probably all
fever is produced by the agency of some one of them."
Austin then gives several methods of extraction.
The Treatment of Whooping-Cough. — Henry Cog-
geshall first cocainizes as much of the nasal mucous
membrane as can be done by the use of a spray, fol-
lowed by cotton-tipped probes wet with the solution ;
then an application of a two- or a four-per-cent. solu-
tion of nitrate of silver to the nose and naso-pharynx,
to be followed by a mild alkaline and antiseptic wash
by spray or by post-nasal douching. He also speaks
of belladonna and suprarenal extract.
Journal of the Amer. Med. Association, March ji, igoo.
Observations in Laryngotomy ; Tracheotomy ; In-
tubations ; Based on Clinical and Experimental Evi-
dence.— George W. Crile says that for these experi-
ments the animals were reduced to full surgical
anaesthesia by ether, and were killed before recovery
therefrom. The results of the tracheotomy experiments
are of practical importance mainly in pointing out
the very great safety of operative procedures, so far as
the immediate results are concerned, on the trachea,
as compared with like operations on the larynx. The
intubation experiments show that the reflex inhibition
is due to efferent impulses set up by mechanical irri-
tation of the terminals of the superior laryngeal nerves.
The author urges the necessity for a differential diag-
nosis between obstruction from membranes pushed
down and the collapse from reflex inhibition. As to
the prevention of collapse from reflex inhibition, sO'
far as the heart is concerned, this is done by a prelimi-
nary hypodermic injection of atropine. Or the local
596
MEDICAL RECORD.
[April 7, 1900
application of cocaine on the laryngeal mucosa may
prevent not only the reflex inhibition of the heart, but
of the respiration as well.
Albuminuria. — Charles Ailing Tuttle considers al-
buminuria from the point of view of its prognostic
value in chronic nephritis. He says that the mass of
evidence which has come to us of late from the autopsy
table shows conclusively that chronic nephritis e.xists
and is an unrecognized cause of death in a proportion
of cases far beyond ordinary belief, and the compari-
son of carefully kept records of cases before death
with autopsy findings shows that little reliance can be
placed on the mere urinary examination, either posi-
tive or negative, as a means of absolute diagnosis or
prognosis of Bright's disease. The writer's own expe-
rience leads him to believe that (i) Bright's disease
may exist without the ordinary urinary manifestations,
viz., albumin or casts; (2) albumin and casts may be
found in the normal urine and do not necessarily mean
Bright's disease; (3) given a case of chronic Bright's
disease with albuminuria, the fact of its presence, its
constancy, or its amount has absolutely no prognostic
significance.
Notes on Fractures of the Long Bones without
Deformity ; the Sub-Periosteal Type of Fracture in
the Young. — James Porter Fiske's conclusions are
that (i) subperiosteal fractures usually present certain
typical features which we should be able to recognize
and differentiate from complete fractures; (2) their
union is characterized by the formation of a slight
amount of callus, and solid union takes place in much
less time than in complete fracture; (3) ineverycon-
tusion to the limbs in the young, no matter how slight,
a systematic search should be made for this particular
lesion; (4) in rickets there is a greater liability toward
tlie occurrence of incomplete fracture; (5) many cases
of subperiosteal fracture are undoubtedly converted
into simple fracture through improper manipulation
or by too forcible examination.
A Pathological Study of Eighty Tumors of the
Mammary Gland, with Special Reference to the
Occurrence of Malignancy. — Fritz Carleton Hyde
gives the results of a microscopical analysis of eighty
tumors of the breast, which he classifies according to
their histological structure. The relative occurrence of
the different varieties of the eighty cases is as follows:
Carcinoma, 70 ; carcinoma medullare, 12.5 ; carcinoma
simplex, 27.5; carcinoma colloides, 6.25; carcinoma
scirrhosum, 12.5; adeno-carcinoma, 10; sarcoma, 7.5;
tuberculosis, 3.75 per cent. Five per cent, not classi-
fied as carcinoniata show carcinomatous proliferation.
The writer concludes that it seems justifiable, from the
microscopical examination only of these eighty cases,
to state that there is no strictly benign tumor of the
breast, and that the only rational treatment is com-
plete removal as soon as discovered.
Are We Degenerating ? If So, Why ?— E. Stuver
says the enormously increased percentage of the in-
sane as compared with the whole population within
the last twenty or thirty years is a strong proof that
mental stability is not increasing, and that the spread
of venereal diseases, tuberculosis, and carcinoma, to-
gether with the widespread use of stimulants and nar-
cotics, has done much to taint the blood and lower the
vital resistance of the people. Also that the intellec-
tual faculties have been cultivated at the expense of
the moral nature, with the result of asymmetric devel-
opment.
A Physiological Consideration of the Food Value
of Alcohol. — ^Frank Woodbury and Seneca Egbert, in
considering the experiments of Professor Atwater, are
forced to the conclusion that he has produced prac-
tically no evidence whatever to support the claim that
alcohol is a wholesome or useful food, nor to change
the generally accepted view that its physiological ac-
tion on the human body is destructive and never con-
structive.
A Study in Anaesthesia.— Rosalie M. Ladova sub-
mits a record of one hundred and one cases of anes-
thesia in which notes were taken as to the duration,
pulse and respiration range, condition of the pupils,
gastric irritation, how soon anaesthetized, how soon out,
and the amount of the anaesthetic. The writer thinks
it inconceivable that the idea of a trained anajsthetist
in every hospital should gain ground so slowly.
The Interdependence of Physiology and Morphol-
ogy, and their Educational Importance. — James
Weir says biology should be taught in every school in
the land, and that medical schools especially should
establish biologic chairs, from which should be taught
the great truths of physiology, morphology, and psy-
chology.
Simple and Ethereal Sulphates. — G. W. McCas-
key describes a simple and rapid method for the sepa-
rate determination of these bodies, which, he says,
are an indication of the intensity of bacterial processes.
The principal compounds of this class of aromatic sub-
stances are phenol, indol, skatol, cresol, and pyrocate-
chin.
The Humane Side of Warfare — N. Senn says that
war is gradually becoming more humane, a result
largely contributed to by the Geneva Convention. He
gives some personal experiences from the Santiago
campaign.
Boston Ml- dual and Surgical Journal, March 2g, igoo.
Typhoid Spine. — R. W. Lovett reports a case of
muscular rigidity, excessive pain in the lumbar region,
tenderness of the spine, and pain referred to the pe-
ripheral end of the nerves, following typhoid fever.
The tuberculin test was negative. The Widal test
was positive. Recovery followed in less than a year.
The typhoid bacillus has frequently been found in
bone marrow. The author holds that, reasoning from
the analogy of other posttyphoidal bone lesions, we
may conclude that an osteomyelitis, or possibly perios-
titis, of the vertebra is present in some of the cases
which have been supposed to belong in the neurotic
class of typhoid spines.
Idiopathic Pneumohasmothorax with Recovery
after Aspiration. — Klisha S. Boland describes a case
which he calls idiopathic, because to all appearance
there was no objective or subjective evidence of pre-
existing trouble. The case suggests: (i) That we can
have (practically) a primary pneumohannothorax; (2)
that without diagnostic aspiration we cannot be sure
of the nature of any pleural effusion; (3) that aspira-
tion may precipitate an influx of air into the pleural
cavity, even if the lung is not touched by the needle;
(4) that the pleural cavity can unaided take care of
aseptic blood as well as of air.
The Open or Operative Treatment of Fresh Frac-
tures ; is it Ever Justifiable ? — Charles L. Scudder
concludes from the previous number an article wWch
is the result of an analysis of one hundred and fifty-
three cases of fracture of the lower extremity. Tlie
ideal result to be aimed at is union of the fracture
without deformity or impairment of the function of
the limb. The usual methods are often unsatisfac-
tory. Anaesthesia and the ,r-ray afford the means of
accurate diagnosis. Sepsis is practically abolished.
April 7, 1900J
MEDICAL RECORD.
597
Closed fractures can safely be treated by open incision
when other methods fail to secure reduction and im-
mobilization.
Bradycardia, with Intermittent Albuminuria. —
Andrew H. U'hitridge reports a case in which there
was a periodof permanent bradycardia of three months,
with intermittent albuminuria of over two years' dura-
tion. The etiological factors were probably occlusion
of the coronary arteries, Bright's disease, and irritation
caused by the removal of a lipoma of the neck, caus-
ing stimulus to the vagus nerve.
Neic York Medical Journal, Mairk ji, igoo.
Report of a Case of Tumor of the Cerebellum
with Drainage of Fluid through the Nose. — The
case of a young woman, aged twenty years, is reported
by G. W. McCaskey. Her history, which began after
an attack of the grippe, e.xtended over three years, the
diagnosis being an inoperable tumor at the base of the
brain located in or adjoining the pons on the left side.
Autopsy showed the tumor to be a mi.xed angeionia,
having an apparent origin from the anterior margin of
the left lobe of the cerebellum. About two months
before death the patient began to have a daily serous
discharge from the right naris amounting to several
ounces. At times the discharge was so profuse as to
threaten strangulation. Another curious feature was
that the escape of the fluid was followed by a partial
restoration of hearing, which for three months had
been in complete abeyance.
Spontaneous Discharge of Cerebro-Spinal Fluid
from the Nose. — W. Freudenthal reports the case of
a woman, aged fifty years, who had for over a year a
dropping from the nose. The amount was increased
when the head was bent forward. E.xamination of the
discharge showed a watery appearance, with alkaline
reaction, and a specific gravity of 1.007 -f-. The re-
sults of chemical analysis seemed to prove beyond a
doubt that it was cerebrospinal fluid. There were
loss of smell, nasal polypi, and chronic otitis media.
The general nervous condition was one of blunting of
mental activity. The author discusses the literature
of this class of cases, about which so little is known.
Stoppage of the flow seems to excite the cerebral symp-
toms. Concerning treatment we know nothing, nor has
any satisfactory theory of causation yet been estab-
lished.
Arthritis Deformans and the Benefits of Elec-
trical Treatment M. A. Cleaves gives the clinical
histories of two cases. One was treated with P>ank-
linic current, negative insulation, convective discharge
with crown electrode for ten minutes, and with the
brush electrode to the entire general surface (nutri-
tional), localized to the afifected joints (pain and dis-
ability). This patient was a laundress, aged fifty-one
years. The other patient, a typewriter, aged nineteen
years, received a continuous current bath, active con-
tact, body immersed in decinormal salt solution in an
insulated porcelain tub. Results in both cases were
excellent.
Diabetes Mellitus with Special Reference to the
Treatment with the Double Bromide of Gold and
Arsenic. — G. D. Barney dilates upon the efficacy of
this combination in the treatment of diabetes mellitus.
He believes that it affects the nervous system, re-
storing the integrity of the glycogenic centre. It acts
also as a powerful vasomotor regulator, increasing the
vascular tone and diminishing the amount of blood
supplied to the liver. It improves the digestion and
the blood state itself. Clinical tables from three cases
are given showing effects as measured by reduction
of sugar and increase of hemoglobin.
Leucocytosis. — J. H. Burch states that nearly all
inflammatory and infectious diseases are characterized
by leucocytosis, the exceptions being typhoid, measles,
grippe, malaria, and tuberculosis. The author gives the
results of blood tests made in pneumonia, typhoid, and
tuberculosis, his findings being the same as already
noted by other observers. He gives, as a fairly accu-
rate average of the normal relationship of the leuco-
cytes, the following figures: Two polymorphonuclear
leucocytes to each microscopic field, one small lym-
phocyte to every five fields, one large lymphocyte to
ten fields, and one eosinophile to twenty fields.
Is there a Rheumatic Periostitis ? — Basing his
opinion on the literature of the subject and one per-
sonal case, A. Stern believes that we have a true
periostitis as the result of the rheumatic poison. In
a boy aged ten years, who had had scarlatina and
measles, upon the subsidence of the latter the joints
began to swell, but were promptly relieved by the
salicylates. Later a painful spot developed on the
sternum, followed by swelling in various joints, also
relieved by the salicylates. Gradual recovery super-
vened ; but later a heart murmur appeared, with chorea.
Phihitielphia Medical Journal, March ji, igoo.
A Case of Poliencephalitis in an Adult. — De Witt
H. Sherman and William G. Spiller report a case of
this nature in a medical student, twenty-one years old.
There was no history of mental or nervous disease in
the family, and the patient's previous history was good.
The disease presented the clinical picture of Landry's
paralysis, and terminated fatally in thirty -eight hours
after the appearance of the first definite symptoms of
motor disturbance. From a study of the clinical
symptoms and the autopsical findings, the conclu-
sions are arrived at that (1) Landry's paralysis may
be due to poliomyelitis; (2) the latter is an infectious
disease, the inflammation being greatest in the ante-
rior horns, but occurring also in the posterior horns,
the white matter, and the meninges; (3) the symptoms
are motor in type, because the diseass! is especially of
the anterior horns; (4) meningitis is not uncommon
in poliomyelitis; (5) poliom)elitis in the adult is es-
sentially the same disease as poliomyelitis in the
child; (6) it is related pathologically to the non-puru-
lent form of encephalitis and to the poliencephalitis of
Wernicke.
The Inaccuracies of Home Modification of Cow's
Milk. — Charles E. Woodruff discusses the difiiculties
of modifying milk accurately at home: i. To be ac-
curate, we must know the exact composition of the in-
gredients, which is impossible outside of a labora-
tory. 2. Extreme accuracy does not seem to be so
necessary as we have been taught. 3. Women are so
inaccurate in their methods that the specific directions
of the physician are not carried out. 4. Infants vary
so much that one cannot tell beforehand what any in-
dividual one will like. 5. Specialists are not agreed
as to the proportions of proteids, fats, and sugar to
use.
The Prevalence and the Diagnosis of Leukaemia.
—George Dock gives the statistics of this disease,
which lead him to think it is more common in Ann
Arbor than in Germany. The diagnosis is difficult,
and can rarely be made except by a blood examination.
Pallor is not always present at first, but shortness of
breath is common. The splenic tumor almost always
has the characteristic sharp edge on the right side, and
598
MEDICAL RECORD.
[April 7, 1900
the anterior surface is large, smooth or broadly curved,
and firm to the touch. Notches on the edge are not
always found in a leuksemic spleen. Pain is almost
invariably present.
Research into the Cause of Collapse or Death
from Blows upon the Lower Chest and the Epigas-
trium.— George W. Crile concludes from animal ex-
periments that the solar plexus may be disregarded as
a factor in these cases, and that the cause of the col-
lapse or death is the mechanical violence exerted
either upon the heart muscle itself or its nerve mechan-
ism. Collapse may be caused entirely independently
of the vagi, though injury to these nerves probably
contributes slightly to the result in most cases.
An Unexplainable Congestion and Enlargement of
the Left Arm Cured by an Exploratory Operation ;
Splenectomy. — Orville Horwitz reports these cases.
The first one occurred in a man, age not stated. The
operation consisted in exposing the subclavian artery
and vein and exploring the axilla. Nothing abnormal
was found. The second case was in a woman, thirty-
five years old, who had a splenic tumor weighing nine
pounds. The patient died on the fourth day after
operation.
A Case of Membranous Non-Diphtheritic Croup
with Recurring Laryngeal Stenosis. — Herman B.
.Sheffield reports a case of this kind in a child two
and one-third years old. The dyspnoea was relieved
by intubation. Repeated cultures revealed no Klebs-
Loeffler bacilli.
British Medical Journal, 1^1 arch 24, igoo.
A New Method of Performing Perineal Prosta-
tectomy.— In describing his operation, P. J. Freyer
says that, while advantage is taken of the perineal in-
cision recommended by Dittel, Nicoll's object is at-
tained by a much less heroic and dangerous pro-
ceeding than suprapubic cystotomy, namely, by a
preliminary perineal opening in'o the urethra. The
advantages claimed are: (i) The preliminary external
urethrotomy permits of the introduction of the finger
into the bladder, which, with a finger in the rectum,
enables the surgeon to define accurately the shape, den-
sity, size, and extent of the prostatic growth. (2) The
finger can be hooked over the enlarged lateral lobe
and the latter pushed well into the ischio-rectal wound,
thus to a large extent obviating a deep and dangerous
dissection. (3) With the tumor pushed well into the
wound, the capsule is easily incised and erased, and
the cutting forceps and scissors are easily applied. (4)
The finger in the bladder enables the surgeon to feel
when the cutting instruments are approaching that vis-
cus, so that he can remove the whole growth, except a
thin layer for the support of the mucous membrane of
tlie bladder and prostatic urethra. (5) The tube in-
serted into the urethral wound carries off' all the urine,
and prevents the perineal wound from becoming sep-
tic.
Vomiting Considered from Some of its Surgical
Aspects. — William H. Bennett limits his observations
to two classes of vomiting: (i) Vomiting occurring in
connection with operations; (2) feculent vomiting,
which is sometimes curative. With regard to the first,
he says that when there is any possibility of the
stomach being a reservoir for offensive material or
half-digested food, the proper practice is to adopt
stomach lavage, in order to prevent the possibility of
lung implication from the passage of portions of the
contents of the viscus down the trachea. As to the
second point, the author concludes that in cases of ab-
dominal disease or injury feculent vomiting as such is
no positive indication for surgical interference, un-
less it is accompanied by increasing abdominal dis-
tention.
Punctured Wound of the Skull with Escape of
Brain Substance. — William Odell reports a case of a
child, aged sixteen months, who fell, piercing its head
with a carpenter's gouge. After the child had recov-
ered from the shock, which lasted till the second day,
there was no rise of temperature or apparent constitu-
tional disturbance. The child now seems perfectly
well, has no squint, and its intellectual progress has
been maintained.
Gastric Ulcer in Pregnancy and Hysteria J. W.
Mcintosh reports a case of a priniipara (sixth month),
in whom characteristic symptoms of gastric ulcer were
present, including paroxysms of pain, vomiting, and
haematemesis. Rest in bed, lavage, medication, absti-
nence from food for thirty-six hours, followed by a
very gradual restoration of diet brought about a re-
turn to her normal condition.
A Case of Smallpox during Pregnancy. — In this
case, reported by A. Dean Roberts, the disease resulted
in premature labor. The only ill symptom was ex-
treme weakness. The strength was maintained with
plenty of liquid nourishment, and the patient made an
uninterrupted recovery. She had been successfully
vaccinated as a child, which probably saved her life
by mitigating the severity of the disease.
When is Cancer Cured ? — E. T. Fison reports a
case of mammary cancer. The patient is now seventy
years of age. Twenty-five years ago the left breast
was removed ; immunity existed for fifteen years, and
recurrence took place ten years ago, yet the patient is
still living.
Kernig's Symptom in Meningitis. — James Barr
quotes several cases in which Kernig's sign occurred
in the upper as well as the lower extremities, and says
that he does not consider the sign necessarily diagnos-
tic of cerebro-spinal meningitis.
7'hc Lancet, March 24. igoo.
The Typhoid Bacillus and Typhoid Fever. P.
Horton-Smith gives a general description of the bacil-
lus and enumerates its culture reactions. He believes
that there is no proof as yet that the bacillus can mul-
tiply outside the human body. It has, however, great
power of resisting the effect of desiccation, and hence
may cause disease a longtime after the original infec-
tion has existed. It produces a weak toxin. Further
points in the lecture discuss the relative frequency of
the germ in the different bodily organs, the eruption,
the excretions, etc. We can no longer look on the dis-
ease merely as affecting the alimentary canal. It is
rather a modified septicEemia.
Practical Observations on Cancer of the Breast. —
W. M. Banks, in the second of the Lettsomian lec-
tures, mentions the fact that these growths are fre-
quently without pain, cachexia, nipple retraction, and
other clinical manifestations generally spoken of as
characteristic of the affection. Cancer may be simu-
lated by chronic mastitis, small chroiiic abscess, small
fibro-adenoma, and small, very tight, simple cyst.
Special mention is made of acute mania after opera-
tions for removal. Finally the author calls attention
to chronic interstitial mastitis, which, he thinks, is
liable to become carcinomatous.
The Surgery of the Stomach. — .A. Mayo Robson
di.scusses dilatation and atony, due to various general
and local causes, and persisting after the original cause
April 7, 1900]
MEDICAL RECORD*.
599
has disappeared. He gives a statistical table of gas-
troplication (gastrorrhaphy), speaks of acute gastric
dilatation, and describes gastro-enterostomy, tetany
and tetanoid spasms in association with gastric dilata-
tion, injury to the stomach, and finally cancer and
other tumors of this organ. The lecture closes with
statistical tables of the various surgical procedures.
Phosphatic Diabetes. — G. Rankin calls attention to
a form of phosphaturia in which the urine contains
excess of phosphate of lime, is of low gravity, and
later may contain albumin and sugar. The patient
complains of thirst, polyuria, and languor. Later
symptoms are those of the diabetic coma type. No
treatment is of avail, though buttermilk seems to have
given some relief.
A Case of Irreducible Dislocation at the Elbow —
H. H. Russell describes this case, which was the re-
sult of a football accident in a boy of eight years.
Both bones were dislocated backward. Reduction
under chloroform was impossible, and an operation
was performed. The eventual result was good.
On the Influence of the Temperature of Liquid
Air on Bacteria. — A. Macfadyen's experiments show
that bacteria may be cooled down to — 190° C. for a
period of twenty hours without losing any of their
vital properties.
Note on the Causation of Cancer. — J. Sawyer at-
tributes the increase of cancer in England to the in-
creasing consumption of fresh meat, which is rela-
tively undercooked.
Medical I'ress and Cirtii/a>; March 21, igoo.
General Paralysis of the Insane. — Fletcher Beach
says causes are physical and moral ; the chief physical
ones are excesses, syphilis, cranial injury, and heredity.
Among moral causes are anxiety, prolonged intellec-
tual labor, etc. The most common moral symptom is
perversion of moral sense; another is irritability, or
loss of determination, fntellectual change is the next
most important symptom; absent-mindedness, loss of
memory, mental confusion, inability to make calcula-
tion; sometimes hypochondriasis. The disease almost
always ends in death. The diagnosis is from syringo-
myelia, diphtheritic paralysis, multiple peripheral
neuritis, disseminated sclerosis, and bulbar paralysis.
The patient in whom premonitory signs appear should
be sent to the country. If there is excitability, bro-
mides should be given, and especially if there are
epileptic seizures.
The Influence of Heredity on Disease. — Hamilton
says there are two theories, Darwin's of pangenesis and
Weissmann's of the germ plasm. Tuberculosis is now'
believed by most pathologists not to be hereditary and
seldom to be congenital. Of all diseases the neuroses
are the most markedly hereditary. Syphilis is not re-
garded as an hereditary disease, while haemophilia is
eminently so. Since it is transmitted to males along
the female line, it might bear some analogy to men-
struation. There is no evidence that diseases due to
external agencies can be transmitted. Hereditary ten-
dencies to disease occur as variations of the germ
plasm. These variations arose far back in the history
of the race, and have been perpetuated, or may recur
atavistically. There is little evidence of the impor-
tance of maternal impressions. Telegony may prevail
in the case of hereditary disease.
Contributions to the Topical Diagnosis of Cerebral
Disease — H. Oppenheim reports a number of cases.
After a fall on the head, there was dulness of intel-
lect, sensory and amnesic aphasia, alexia, agraphia.
Tumor of the left hemisphere was assumed, extending
to the large ganglia and to the gyrus fornicatus.
Trephining and e\acuation of fluid gave temporary
improvement, but after death a tumor was found as
suspected. Other cases are given. After convulsions
a patient became blind. At autopsy a tumor in the
cerebellum was found compressing the left hemisphere.
A case of carcinoma metastasis to the brain is men-
tioned.
Cases of Skin Diseases Presenting Unusual Fea-
tures.— Artliur Hall found the frequent application of
rectitied spirits, with a little menthol added, useful in
cases of lupus erythematosus. Parakeratosis palmaris
was treated with pumice stone and salicylic-soap plas-
ter. A spreading ulcer at the root of the nose proved
fatal in an infant. A recurrent ringed vesiculo-bul-
lous eruption in children is mentioned. An erythema
induratum in a young woman had recurred each
autumn for four years, lasting through the winter.
Sherwell's treatment for scabies is recommended.
Berliner klinische VVocl/enschriff, March [2, IQOO.
Glass-Blower's Mouth and its Complications •
Scheele calls attention to a dilatation of Steno's duct
and consequent parotid symptoms from the enormous
pressure exerted in the anterior oral cavity from glass-
blowing. Players on wind instruments are not subject
to the lesion, for in them the air pressure comes from
the back of the pharynx, and the anterior oral cavity
becomes a mere conduit for the air. He makes the
suggestion that it may become possible by a suitable
mechanical device to employ compressed air in glass-
blowing, instead of using the breath as is now done.
Pathogenesis and Therapy of the So-Called Anal
Fissure. — C. Rosenbach finds the most common cause
of the affection to be a disturbed innervation of the
muscular apparatus of the lower bowel, as a result of
which the rectal sphincter does not relax from various
forms of irritation, while the muscular fibre higher
up continues to contract. This causes a great strain
on the rectal mucosa, producing partial or complete
rupture of the same and the fissure formation. He
recommends digital manipulation of the lower rectum,
with the later use of the soft tube and irrigation.
South Africa ; its Prevalent Diseases and Sani-
tary Conditions. — W. Kolle describes the geography
and climatic conditions of the country and the organi-
zations of the various departments of health in the
different sections. He then calls special attention to
typhoid, dysentery, smallpox, syphilis, and other affec-
tions as seen in this part of the world. Tuberculosis
is not an indigenous disease, and most of what there
is has been introduced by foreigners. He also briefly
describes some of the affections peculiar to this region.
Wiener klinische IVochenschriJf, March 8, igoo.
The Radiographic Appearance of the Normal
Thoracic Aorta. — G. Holzknecht states that the re-
sult of both sagittal trans-illuminations from before
back, and 7'ice 7'ersa, is that no part of the thoracic
aorta is visible as a distinct shadow in the picture, but
the whole normal thoracic aorta is covered by the mid-
dle shadow. The trans-illumination in the frontal
direction can be made from right to left, and z'ice
versa. The most valuable trans-illuminations for the
estimation of the condition of the aorta, next to the sa-
gittal method discussed in the beginning, are the
four follow'ing: The direction of the projection is,
6oo
-MEDICAL RECORD.
[April ;, 1900
oblique through the thorax: (i) From left back to
right front; (2) from right front to left back; (3) from
left front lo right back; (4) from right back to left
front. The frontal plane of the patient is in every
case brought to an angle of 45° with the direction of
the rays.
A Case of Congenital Stenosing Hypertrophy of
the Pylorus. — Franz Hansy reports a case of this
kind which is comparatively rare, and which does not
commonly present itself for operation. It is certain
from the observations made during the operation that
the case is one of congenital hypertrophy of the
pylorus, which has resulted in relative stenosis of the
pylorus, and that has led gradually to a decided dilata-
tion of the stomach. There is no question about the
correct treatment : gastro-enterostomy in front of or be-
hind the colon with the Murphy button or suture, ac-
cording to the nature of the case, should be performed.
Contribution to the Biology of the Malarial
Parasite. — Xaver Lewkowicz says that there are clin-
ical grounds for assuming that in cases of intermittent
fever at long intervals — twenty-three-day type — it takes
the crescents twenty-two days to develop. The benign
tertian, the twenty-three-day type, ahd the malignant
tertian are due to the same polymorphous parasite.
All of these forms are due to mosquito inoculation.
Miincheiier mcdiciiiisclie Woi/iensi/iriff, AlaixJi 20, igoo.
Upon the Indications for Operation in Appendi-
citis.— Adolf Schmitt takes up the recent statement of
Gossman that in Munich operation is too infrequently
undertaken, and considers the question from the stand-
point of hospital cases, which are getting more fre-
quent because the indications for operation are becom-
ing each year more clearly defined. Operation is
imperative in large peri- and paratyphlitic abscesses.
The course of treatment is most difficult to decide in
the great majority of cases. The attack itself is
usually recovered from under expectant treatment,
but the underlying condition remains, predisposing to
recurrence. Internal treatment and surgery should
here go hand-in-hand. The indications and operative
measures are considered in e.xtcnso.
A Serious Danger from Faulty Injections in
Gonorrhoea. — From a reliable source is published an
account of severe complications extending over a period
of nine months following a gonorrhcea treated by injec-
tions of zinc. There were besides epididymitis, pros-
tatitis, etc., large abscesses and vesico-rectal fistula
necessitating operations. It was discovered too late
that the acorn-pointed syringe had been inserted within
the lips of a phimosed prepuce, and the injection made
so that the preputial sac liad been distended and the
smegma probably washed at different times into the
canal, aided by manipulations carried out by the pa-
tient to make the fluid penetrate.
A Case of Acute Cocaine Poisoning. — Dr. Berg-
mann gave a cocaine injection of 5 cgm. of the drug
for the relief of severe pain. Within five minutes
the pain had all disappeared. The next day 3 cgm.
only were injected, when within three minutes there
was a faint feeling, with collapse, followed by rapid
heart action and respiration; after ten minutes clonic
contractions occurred, with widened pupil, bulging
globes, and other severe symptoms. These all passed
off, and by the next day the man was out. The pain,
which had been of long standing in the region of the
hip joint, did not return.
Experiments with Alcohol as a Local Application
in Gynaecology. — J^uduig Seitz cites instances of
chronic metritis, gonorrhceal infections, etc., in which
the local use of alcohol has been tried, and concludes
that, with the exception perhaps of tuberculous proc-
esses in the peritoneum, the results are not very en-
couraging. In one case only of chronic endometritis
and metritis, with excessive secretion, was the action
favoraljle. The power of abstracting fluid from the
tissues may make alcohol useful in such cases, and in
tuberculous peritonitis it should have further trial.
Hemorrhoidal Nodes in Earliest Childhood.— Dr.
Burwinkel says the books teach that hemorrhoidal
nodes are among the rarest observations. He relates
the case of a girl about two years of age, who soon
after birth showed this condition, which after eleven
months of general treatment disappeared. He attrib-
utes their occurrence largely to the lack of submucous
fat deposit about the rectum, due to a general maras-
mic state.
Flexible Aluminum Splints. — Dr. Steudel already
in i8g6 recommended pliable aluminum for splints.
The bending apparatus has been improved, as shown
in an illustration, while other figures show its mode of
employment at the bedside. The price in the various
widths is quite moderate.
Bidlctiii ik r Aaiilemie de Makiine, March 6, igoo.
Dysenteric Abscess of the Liver. — M. Kelsch and
M. Minier hold that in the light of modern patholog-
ical findings hepatitis and dysentery are alike in their
elementary lesion, which is a necrosis, differing in
course only by reason of the difference of structure in
liver and intestines.
Treatment of Obesity.— G. M. Debove treats obes-
ity by a diet unmodified by cooking or preserving,
such as raw milk, eggs, meat, salads, and fruits. He
reports the case of a man whose weight after less than
a year of treatment was reduced from 148 to 93 kgm.
(325 to 204 pounds).
Fieiiih Jountah.
Symptoms and Pathogeny of Isolated Paralysis
of the Great Denticulated Muscle. — A. .Souques adds
some new cases to the short list in which the serratus
magnus has alone been implicated in paralysis. The
signs vary with examination in repose and when the
arm is voluntarily raised. The opinions of various
observers are given. The truth, he thinks, lies be-
tween the extreme views of Duchenne and of Berger,
and tiiat tliere is moderate displacement of the sca-
pula, which may escape superficial examination. To
the sixteen cases collected by Barreiro he adds one of
his own and two found in literature, and studies them
together. He advances the theory that the paralysis is
consecutive to sudden violent effort. It occurs almost
always in men and upon the right side. In one case,
involving the left, it was found that the man was left-
handed. — Gazette i/es JJ(>/</taiix, March 17, 1900.
Treatment of Muco-Membranous Entero-Colitis.
— G. Lyon concludes liis paper, discussing the injec-
tion of large quantities of oil in spasm of the intes-
tines; various sedatives, prolonged baths, thermal
treatment, painful paroxysmal crises, febrile forms,
and treatment in infantile forms, etc. — Ke'iie de 7/iha-
peiiti<iiie MedJiv-C/zin/rgiea/e, March 15, 1900.
The Necessity of Stomach Lavage Preceding Gas-
tro-Enterostomy.^Rene Belin concludes that what-
ever may be the condition of fatigue of tiie patient, it
is indispensable in interventions for pyloric afTections,
contractions, or cancers, to place lavage of the stomach
at the head of the list of the necessary precautions be-
fore operation. — Le Fiogirs Mcdiial, March 17, 1900.
April 7, 1900]
MEDICAL RECORD.
601
Julirnatioiial Medical Magazine, Manh, jgoo.
Tuberculosis of the Nervous System.— D. J. Mc-
Carthy states that in this field there must be differen-
tiated those processes in which the tubercle bacillus
itself is the causative factor, and those in which poisons
produced by tuberculous processes elsewhere in the
body are at fault. He then speaks of the different
varieties of tuberculosis of the nervous system.
Tuberculin, Anti-Tuberculin, and Anti-Tubercle
Serums. — Joseph McFarland says that tuberculin is
prepared from the fully-grown cultures by a process of
concentration. He then speaks of progressive admin-
istration of tuberculin to animals and the development
of an anti-tuberculin. He mentions the anti-tubercle
serums of different investigators.
Diagnosis and Treatment of Tuberculosis of Bones
and Joints. ^De Forest Willard states that this diag-
nosis when the disease comes from acute osteomjelitis
or epiphysitis is usually readily determined by the
sudden onset of these latter conditions with extreme
pain, and the rapidity with which they advance to
destruction of bone and suppuration.
The Treatment of Pulmonary Tuberculosis — S.
Edwin Solly believes that the great defect in the treat-
ment of tuberculosis is the time of its application.
The tuberculous as a rule do best in high climates
which are sunny, but in which the air is dry and cool
rather than warm.
Tuberculosis of the Skin. — Jay F. Schamberg speaks
of tuberculous ulcerations of the skin (tuberculosis
cutis orificialis), anatomical tubercle (tuberculosis ver-
rucosa cutis), scrofuloderma, and lupus vulgaris. In
all of these affections the tubercle bacillus may be
found in the skin.
Tuberculous Ulcerations in the Stomach and In-
testines ; the Use of Tuberculin Boardman Reed
declares that as far as his experience goes in the use
of tuberculin for tuberculosis of the stomach and intes-
tines, the remedy is perfectly safe in proper doses, and
is curative when there is no septic complication.
The Treatment of Consumption W. Blair Stewart
advises fresli air, as perfect hygienic surroundings as
possible, a careful diet, and exercise. He approves of
the use of guaiacol carbonate, strychnine, capsicum,
and quinine — also belladonna or codeine if sweating
and cough are bad.
The Laboratory Diagnosis of Tuberculosis of the
Urinary System. — VV. Wayne Babcock ad\ises the
necessity of greatest cleanliness in this manipulation.
It is well also to examine the urine immediately after
it has been voided.
Annals oj Gyncccology and Pediatry, Februai-y, igoo.
Intra-Abdominal Adhesions. — A. L. Beahan states
that operative procedures have taught us all we know
regarding abdominal adhesions. It is possible that
they bear close relations as a factor to the production
of malignant disease. Their prevention requires that
all raw surfaces be covered and possibly dusted witli
powder; that bleeding be checked and oozing be
stopped; while open treatment with drainage completes
the toilet. Drained cases are always safest and least
painful.
Tolerance of the Gravid Uterus, with a Case. — H.
C. Young cites the case of a woman, thirty-five years
old, who on becoming pregnant had a convulsion
about five weeks after conception. The cervix was
painted with tincture of iodine, and later dilated sev-
eral times with the introduction of bougies. Finally,
all measures failing to give relief, or to cause expulsion
of the fcetus, the cervix was manually dilated and the
fcetus delivered.
Exploration of the Abdomen as an Adjunct to
Every Coeliotomy. — Howard A. Kelly states that there
are three classes of cases to which this examination
may be applied: (i) When it is made simply as a
routine procedure ; (2) when, on opening the abdomen,
contrary to expectation no disease is found near at
hand; (3) when the disease operated on is probably
complicated by the affection of some other organ.
Notes on the X-Ray; its Usefulness and Mis-
takes.— J. Rudis-Jicinsky describes the usefulness of
the .r-ray in the detection and diagnostication of frac-
tures and dislocations. Calculi and encapsulated
trichinae may sometimes be seen. Chest affections
without physical signs may be diagnosticated. The
manipulator must know " how to read the shadows," in
order to avoid mistakes.
Oophorectomy for Gross Functional Nervous Dis-
eases Occurring during Menstruation. — 1). C. Brock-
man, after reporting four cases of this nature, says that
it is only by patient, painstaking work along this line,
with the careful experience of three or four years, that
we shall learn on what cases to operate, and what not
to treat surgically.
Obstetrical Prophylaxis in Gynaecology. — James
Clifton F.dgar affirms that a large proportion of cases
that apply to the gynecologist for relief of crippled
pelvic organs owe their condition to mismanagement or
avoidable accidents of the pregnant, parturient, and
lying-in states.
Meddlesome Gynaecology Herman E. Hayd be-
lieves that, in spite of the cry that too much operating
is done nowadays, most of the symptom-producing
definite and discoverable lesions in women are cured
best and quickest by operative measures.
How to Prevent and How to Treat Ununited Frac-
tures.— A. C. Bernays says tliat non-union can always
be prevented by proper approximation and immobiliza-
tion, in the absence of a constitutional vice.
Illinois Medical Journal, March, igoo.
A Mechanical Method of Treating Sciatica.— C.
C. Hunt advocates the use of the Hodgen splint, which
prevents movements which are the result of the action
of muscles of the hip and thigh over which the great
sciatic nerve presides, but scarcely interferes at all
with passive motion, especially at the hip joint. The
patient can move from one side of the bed to the other,
or turn slightly on the opposite side, and the toilet of
bed and body can be arranged with little discomfort.
In about sixty cases treated by the author pain was re-
lieved in from one to six hours after the splint was
adjusted, and in two weeks practical cure resulted.
The Medico-Legal Aspect of Bright's Disease. —
Columbus Barlow believes that if the cerebral symp-
toms in cases of nephritis are marked, the patient's
mental capacity should be tested before he is allowed
to make a will.
Why and When to Operate for Appendicitis. —
W. F. Grinstead believes in treating a first and second
attack of catarrhal appendicitis medically, and in an
interval operation after a second attack.
6o2
MEDICAL RECORD.
[April 7, 1900
Diagnosis and Clinical Course of Puerperal Eclamp-
sia.— Frank B. Karle attaches much importance to
severe frontal or unilateral headache, associated with
insomnia, as one of the earliest symptoms of eclampsia.
An Unusual Case of Perforating Gastric Ulcer. —
C. \V. Hall reports a case of four severe gastric ulcers
without any history of gastric disturbance.
Two Affections of the Knee Joint — George X.
Kreider reports a case of gonorrhoeal synovitis and one
of loose body in the joint.
University Mediail Magazine, March, igoo.
Absorption and Metabolism in Exclusive Rectal
Feeding. — D. L. Edsall narrates his experience with
enemata in a case of gastric ulcer occurring in a house-
maid who was under close observation for a consider-
able time. The enemata consisted of 250 c.c. of pep-
tonized milk with the yolks of two eggs, given three
times daily, and in each instance being preceded by a
cleansing enema of plain water. Results were most
satisfactory. Edsall calls attention to the fact that the
mere retention of rectal enemata is no sufficient evi-
dence that the patient is being properly nourished by
them.
Report of the More Interesting Cases in a Month's
Service in the University Maternity. — By A. H.
Remington. The following were reported: Cesarean
section ; abdominal section for extra-uterine pregnancy
or sepsis following abortion ; the same for appendicitis
complicating pregnancy and the puerperium ; the same
for streptococcic infection and an enormous necrotic
ulceration of the caput coli, and the same for late in-
fection in the puerperium; two cases of primary repair
of lacerated cervix.
On the Use of Antitoxin in Diphtheria with Special
Reference to Small Doses. — J. H. Musser employs in
children up to six or eight years an initial dose of 500
units, to be repeated at intervals of six hours if the
fever does not fall, if the strength of the patient does
not improve, or if the local manifestations are spread-
ing. For children over eight years, 1,000 units are
given as an initial dose, and this is repeated at inter-
vals of eight to twelve hours as needed.
The Fertilization of the Egg and Early Differenti-
ation of the Embryo — By F. G. Conklin. A paper
read before the University of Pennsylvania Medical
Society, February 16, 1900.
©ort'espoiulcncc.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special CorresponcleiU.)
More Remarkable Recoveries from Bullet Wounds. —
The remarkable recoveries from bullet wounds which
Sir William MacCormac and Mr. Frederick Treves,
the principal civilian surgeons serving as consultants
with the British forces, have already recorded, still con-
tinue. Sir William MacCormac sends the notes of
twenty cases to The Lancet, which had been brought
under his notice since his publication of tlie series
which I have already quoted to you, and I can only
echo his astonishment at the favorable results of treat-
ment. Among other cases he mentions the following :
An officer received a shell wound in the head, five
inches long by three inches at the widest part, the skull
being exposed over the mastoid process. He was also
shot transverselv throusrh the back at the level of the
ninth dorsal vertebra. Within three weeks the wounds
were practically healed, and the paralysis of the lower
limbs which was at first present disappeared.
A bullet entered the skull in another case just out-
side and slightly above the left ala nasi, and emerged
behind the tip of the right mastoid process. There
were copious epistaxis and deafness of the right ear.
The wounds healed at once, and the man is quite well,
though the deafness persists.
A bullet in a third case entered the sternum at the
junction of the manubrium with the gladiolus, and
emerged just external to the juncture of the right arm
with the thorax posteriorly. There was haemoptysis,
but the wounds healed without pulmonary trouble,
though neuralgia of the arm and wrist-drop ensued.
Another patient, a colonel, was wounded by a shrap-
nel bullet which entered one inch below the spine of
the left scapula. It was cut out beneath the skin one
inch to the right of the xipho.d cartilage. In this case
also there were hemoptysis and symptoms of nerve-
lesions in the arm, but no pulmonary trouble.
An officer was shot beneath tiie outer end of the
right clavicle, the bullet emerging just to the left of
the spine of the fifth dorsal vertebra. Cough, haemop-
tysis, and dyspncea gradually gave way to convales-
cence.
A bullet in another case entered at the inner end
of the fifth right intercostal space close to the sternum,
and emerged half an inch below the twelfth right rib,
and two and a half inches from the middle line of the
back. There was hamaturia, which subsided, and the
patient recovered with no further symptoms.
In the case of a private wounded at an unknown
range, the bullet after traversing the left arm entered
the thorax one and a half inches internal to the left
nipple, and emerged through the trapezius muscle at
the level of the spine of the sixth cervical vertebra,
two inches to the right of the middle line. There was
haemoptysis, which ceased, and the wounds healed
without any untoward symptoms.
In another case the bullet entered at the eighth right
intercostal space in the mid-axillary line and emerged
half an inch above and two inches posterior to the
left anterior superior spine of the ilium. The patient
vomited after the injury, but recovered without further
symptoms.
These eight cases are perhaps the most astonishing
of Sir William MacCormac's latest series, but several
of the others are nearly as wonderful. There can be
no doubt that in the cases I have briefly noticed tre-
mendous injuries must have occurred — injuries of the
sort that until recently surgeons ha\e considered fatal
— with no disastrous sequels. In the last case the bul-
let must have traversed the liver and probably the
intestine; in the case preceding it the escape of the
big vessels is marvellous, while the lung must have
been wounded; and in the case recorded before that
the kidney was clearly injured. Perforating wounds
of the skull, abdomen, and thorax, if made with a
Mauser bullet, appear to have no particular terrors.
Mr. E. L. Acutt, a Durban resident, has given to the
British hospitals one hundred and fifty portable and
comfortable sick-beds. They are distributed between
the hospitals at Frere, Chieveley, and F.stcourt, and
have been immensely appreciated by the wounded.
Mr. Acutt also offered to equip and maintain at his
own expense a hospital of one hundred beds, but in
view' of the large amount of voluntary aid received by
the British in this direction the principal medical
officer did not consider it necessary to accept the Oblfer.
Mr. Acutt has certainly done as much as any one citi-
zen could be expected to do without maintaining a hos-
pital at his private expense; but the authorities at the
Cape and the organizers of charity in England ought
to make their stories agree. The Duchess of Montrose
April 7, 1900]
MEDICAL RECORD.
603
has quite recently appealed to Scottish residents in
London for subscriptions, on the ground that the army
medical department has stated that " further hospital
accommodation is greatly needed for the troops in
South Africa."
Dr. Conan Doyle has started for South Africa to act
upon the staff of the Langman Hospital. If Dr. Doyle
can put into practice just those marvellous qualities of
patience, discrimination, and keen observation with
which he endowed his popular hero, what an ideal
scout he would make! I do not suggest that such
qualities are thrown away upon medical work, for medi-
cal work may be described as scouting to find out
where pathological foes are lurking and threatening;
but it is a noteworthy thing that Sherlock Holmes
should have been selected by Colonel Baden-Powell,
the defender of Mafeking, in his recent pamphlet upon
scouting, as the type of man required as a scout, and
that now Sherlock Holmes' creator should be gone to
the seat of war. It is rather a long time, I believe,
since Dr. Doyle was occupied in practical medicine,
while he has been using his faculties of imagination
and intuition unceasingly; and I am tempted to sug-
gest— without conveying the least reflection upon the
medical novelist's therapeutic skill — that he should be
allowed out scouting.
Miss Mary Kingsley, the celebrated traveller in
South Africa, has arrived in Africa as a nurse. She
is the daughter of the late George Kingsley, and niece
to the authors of " Ravenshoe " and " Hypatia."
.\s late as March 23d the relief of Mafeking had not
been effected. Probably when it comes it will come
at no particular moment and with no dramatic entry
following upon a pitched battle. What will happen
will be that Colonel Plumer advancing from the north
and the Kimberly relief column coming up from the
South will threaten a union that would be fatal to the
investing force, which will then disappear. It must be
remembered, however, that both relieving columns can
advance only slowly, as they must carry with them
sufficient food and medical stores for both themselves
and Mafeking, otherwise their presence would only
add to the straits of the garrison. Colonel Plumer,
moreover, is meeting with fierce resistance.
OUR LONDON LETTER.
• (From our Special Correspondent.)
TWO DISCUSSIONS ON RHEUJIATISM SKIN AFFECTIONS
IN BRIGHT's DISEASE — MORTALITY RETURNS ROYAL
ARMY MEDICAL CORPS — DEFENCE UNION — ^A FAT
LEGACY PROFESSOR CAMERON SIR WILLIAM GAIRD-
NER — TROPICAL EXPEDITION — COURT SURGEONS —
DEATHS OF DRS. ORIGG AND CORY.
London, March 23, 1000.
Two lengthy discussions on the same disease within
a week may be thought to e.xhaust the subject. Yet
I cannot say they have done so, for tiie subject was
rheumatism. Dr. Caton introduced it to the Clinical
Society of London in a paper referring chiefly to the
prevention of cardiac complications, founded on some
five hundred cases treated in the different ways pre-
vailing for the last twenty years. About fifteen years
ago he formulated a plan which he has followed since,
and which consists in (a) absolute rest in bed for sev-
eral weeks; (/') a series of flying blisters, each rather
less than a florin, in the course of the first, second,
third, and fourth dorsal nerves, followed by a poultice;
(r) sodium or potassium iodide, gr. viii.-x. ter die.
Sometimes small doses of mercury were given. Omit-
ting all cases of slight transitory bruit, all of h;i;mic
origin, and all which seemed due to a weakened or
dilated ventricle, eighty-five cases with distinct signs
remained. Of these fifty-four patients had a bruit on
admission, probably of recent origin; twenty-four of
them left with sound hearts, and twenty with valvular
disease. Out of thirty-one cases in which the com-
plications came on in hospital or had been observed
just before admission by the practitioner attending,
twenty-seven left with apparently sound hearts, three
with valvular affection, and one remained under treat-
ment. Dr Caton believes that there is a brief stage
in endocarditis when treatment is effectual, and in
adults this does not last longer than two or three weeks,
though in cliildren it is longer. Persistent rest is
the most important measure, but he holds that there
are more recoveries when all three are persevered in
for at least six weeks. The bruit becomes softer, vari-
able, and eventually vanishes. It is, however, advis-
able to avoid active exertion for a further two months.
The other discussion took place at the Chelsea Clin-
ical Society, which has lately made efforts to come to
the front. It was opened by Dr. W. Ewart in a long,
didactic paper setting forth various opinions on vari-
ous points, such as the prevalence, mortality, and pre-
ventability of the disease as compared with phthisis;
infectivity and the arguments about that hypothesis;
the various cases called rheumatic, with a classification ;
the liability of the several forms to cardiac complica-
tion, and the several methods of treatment in vogue,
whether directed to the joints or to the heart. This
resume, able enough in its way, scarcely gave a clear
idea of the author's own views — indeed it requires
very close attention to disentangle disputed points in
a paper of this kind read at a society. He concluded,
however, with the remark that the main questions he
submitted for discussion were how to prevent rheuma-
tism and how to put a stop to the rheumatic heart evil.
As to the two discussions following these papers, I
must, put of respect to your space, treat them together
and that in the briefest way, touching only some of the
points raised, for you may be sure the differences of
opinion were marked.
Dr. Maclagan, as the introducer of the salicylate
treatment, which has obtained such extensive vogue,
naturally put in a plea for his own method. Salicin,
he said, has an absolutely curative action on both
joints and heart. What recovered in the one recovered
in the other —the one structure which was not apt to
do so being the endocardial lining. He could not,
therefore, accept Dr. F.wart's statement that the heart
was more often affected under salicylates than under
other treatment, and asked what support could be pro-
duced for such an assertion. If salicylates controlled
the rheumatic process, they must act on the heart as
well as the joints. The difference is that the heart re-
covers more slowly because we cannot give it the ab-
solute rest that we can to the joints.
Dr. Sansom and others expressed their confidence in
the salicylates, Dr. A. E. Garrod remarking there must
be something in a treatment that had been almost uni-
versal for twenty years, although he did not think its
influence over the heart very marked. Dr. Hood fan-
cied that there was more crippling after this treatment,
and that we must not be led astray by its great power
to relieve pain. He had collected ninety cases in
which cardiac disease came on while the patients were
under the influence of salicylate. He usually em-
ployed a modified alkaline treatment. Here I may
say many practitioners of experience are in the habit
of combining the alkaline and salicylate treatments in
various ways. Others prefer the iodides, especially
later on, or as soon as the salicylates have arrested the
pain. Comments were also made on the comfort of
the patient under the salicylates, though it was asserted
that these had also disagreeable and sometimes dan-
gerous effects.
Now, as to blistering. The plan is older than
6o4
MEDICAL RECORD.
[April 7, iQOO
any of the speakers seem to remember. No one re-
ferred to Cotugno, and only one to the late Dr.
Herbert Davies, who published in the " London Hos-
pital Reports" for 1864 a series of twenty-four cases
treated exclusively by blistering, and all of these left
the hospital without any cardiac imperfection. I re-
member very well Dr. Davies and this treatment of
acute rheumatism. With much swelling, he put a
small blister near to the joint, and his success was
great, both as to pain and fever.
Sir D. Powell suggested that in young or nervous
patients blistering might somewhat interfere with the
absolute physiological rest that was of the greatest mo-
ment. This, however, has not been the experience of
those who have tried it.
Dr. Sansom professed to have seen the treatment by
blisters, both big and little, and thought they only
added to the patient's discomfort. Dr. Longhurst
would not blister nervous women or children, nor would
he confine himself to any one plan of treatment. Dr.
Seymour Taylor said a blister gave the greatest relief
to a rheumatic joint. If applied for the heart, it
should be over the upper dorsal segments of the cord.
Dr. A. Morison found a blister over the heart quieted
it to a marked extent, and he mentioned that the late
Dr. Hope advocated blisters some sixty years ago.
The question whether the blister should be opened
was mentioned. If it acted by removing the poison,
one would consider that the fluid should be evacuated,
but one speaker said no, as the serum would be anti-
toxin, which is certainly carrying the serum notion far.
Effusion into the joints is generally accompanied by re-
lief to the general symptoms, and it is natural to at-
tribute this to the withdrawal of the poison. If this
is so, blistering would be a reasonable attempt to
withdraw it from the system. That the toxin should
then change to antitoxin is a mere assumption.
At the last meeting of the Medico-Chirurgical So-
ciety Dr. Hugh Thursfield read a paper on '" The Skin
Affections Met with in ISrigiit's Disease," and so gave
the dermatologists a chance of which they were slow-
to avail themselves. Dr. Crocker indeed made some
remarks, but admitted his experience did not show
whether an eruption necessarily suggested renal origin.
Considering the relations of the skin to the kidney,
one might anticipate a more frequent complication
than is actually found. But unless the skin affection
is very troublesome, it would be neglected in the pres-
ence of so grave a disease as JJright's. Dr. Thursfield
proposed to classify the affections thus: (d) Those in
the early stages, as pruritus, eczema, and urticaria; (/')
those in the final stages, as erythematous, bullous, and
desquamative eruptions; (r) purpura and hemorrhagic
cases; (i/) those seen with marked oedema, and he
thought due to local infection by pyogenic microbes.
There was some conversation on the supposed influ-
ence on prognosis and other points, but it did not ap-
pear that the speakers had any exact information to
give.
The mortality returns show further improvement.
In the large towns the rate has fallen to 20.3. Lon-
don's register of deaths last week was 1,659, which is
315 below the average for the corresponding week.
Lord Methuen, in an official dispatch, brings to the
notice of the authorities Major O'Donnell and Lieu-
tenant Delass, of the Royal Army Medical Corps,
for their " indefatigably attending the wounded under
fire." The last named, he says, advanced in the open
and attended Captain Gordon, and afterward Major
Robinson and others, " under a fearful fire." Other
reports of this kind are adding to the fame of the
Royal Army Medical Corps. The gallantry and de-
votion of the corps has also been acknowledged by
the government in the House of Commons, and that in
a manner which should warn the War Oflice that its
treatment of the medical service will be one of the
counts in the indictment to be tried after the war.
The Medical Defence Union held its annual meet-
ing last week. There was some talk about amalgama-
tion, but it was stated that the Council had decided
against the proposal. It seems a pity that division
should weaken the two societies.
The late Prof. David Edward Hughes, F.R.S., has
left a sum of between three and four hundred thousand
pounds to the London, Middlesex, Charing Cross, and
Kings College hospitals. The capital is to be kept
under certain conditions.
Dr. Hector Cameron succeeds Prof. George Buchanan
in the chair of clinical surgery the latter has resigned
in Glasgow University. I also hear that Sir William
Gardiner is resigning the professorship of medicine in
the same university. This veteran clinical teacher
finds with advancing years that it is a strain on his eye-
sight to keep up with bacteriological and microscopical
work.
A second malarial expedition is organized by the
Liverpool Tropical School.
Lord Lister succeeds the late Sir James Paget as
sergeant-surgeon to the Queen, and Mr. Treves is ap-
pointed one of Her Majesty's surgeons extraordinary.
The death is announced in his sixty-first year of
Dr. \V. C. Grigg, late physician to Queen Charlotte's
Hospital, and a past president of the Gynaecological
Society. He recently retired from active practice.
He went to South Africa, thinking he might be of
some use, but contracted typhoid at the Modder and
died in Wynberg Hospital on the twelfth inst. He
was an Edinburgh graduate, a genial gentleman, and
long enjoyed a good position among the obstetrical
men of London.
Another death I must note is that of the director of
the Animal Vaccine Establishment, Dr. Robert Cory,
which took place on Monday. He was a Cambridge
graduate, a F.R.C.P., and physician in charge of vac-
cination at St. Thomas' Hospital.
EARLY OPERATIONS FOR CANCER.
To THE EUITOK OF THE MeDICAL ReCOKI).
Sir: The discussion on cancer before the New York
Academy of Medicine cannot have failed to interest a
large number of your readers.
Leaving out cancer of the respiratory and digestive
tracts, because cancer in these locations does not often
come under my observation, I will refer only to malig-
nant disease of the uterus and female breast. In the
paper on cancer of the breast, by Dr. Abbe, and cancer
of the uterus, by Dr. Coe, early and complete removal
of the diseased organ was advised; and in the case of
the breast removal of a large area of skin together with
fat, glands, and pectoral muscles was insisted upon.
This is as it should be^ for anything short of this would
probably not confer immunity from recurrence. The
difficulty in the way of a complete cure from operation
in cancer of the breast and uterus lies in the careless-
ness of the laity, and to a great extent of the profession,
in regard to this subject. When a patient over thirty-
five years of age consults a physician in regard to a
small tumor of the breast, which she may have noticed
some weeks or months previously, the doctor, after a
very cursory examination, is apt to say, "Yes, madam,
you have a lump there, but I hope that it is nothing
serious; paint it with iodine or rub it with camphor-
ated oil, and let me see you again after a while."
"After a while" not being a very definite period, the
patient returns anytime between six months and a year
later; she then has a tumor the size of a hen's egg.
The nipple is retracted, the axillary glands are en-
larged, and the patient suffers from lancinating jiains
April 7, 1 Qoo]
MEDICAL RECORD.
605
in the breast and bonietimes in the arm of the affected
side — in fact, when any old woman could make a diag-
nosis. The case is now referred to a surgeon, who
does as radical an operation as can be done under the
circumstances; but the disease recurs in a few months
and the patient dies a short time later. The practi-
tioner who first saw the case lays tlie flattering unction
to his soul that he has done his duty by his patient —
he has not been rash, but conservative. Could the
grave speak, how eloquent and damning an accusation
could be brought against this sort of conservatism,
which ought ratlier to be called criminal procrastina-
tion I
In cases of cancer of the uterus the same careless-
ness is met witli. A woman about fort} years old begins
to have irregular discharges of blood from the vagina.
She consults some elderly dame, who says, " It's all
right, dear. I had that myself when I was getting change
of life." It may be that she consults the family physi-
cian, who indorses the opinion of the old lady to the
effect that the irregular bleeding is due to the advent
of the menopause. He prescribes ergot or hydrastis or
some equally useless stuff, and sends the patient away
satisfied that all will be right in time. Delusive hope!
The bleeding continues; leucorriuea and an offensive
watery vaginal discharge supervene, and at this stage
the patient is advised to consult a gyna-cologist, who
finds that the disease has passed the operable stage.
Had the physician who was first consulted made a
careful vaginal examination, it is probable that the
true nature of the disease would have been detected;
and if the patient had been promptly referred to an
operative gynaecologist, and a vaginal hysterectomy
performed, the chances of a radical cure would ha\e
been very good.
Vaginal hysterectomy for cancer of the uterus in the
early stage gives excellent results, but if the disease
his invaded the vaginal walls and broad ligaments,
even though the operator may be able to extirpate the
uterus, no benefit results from the operation, as the dis-
ease always recurs and rapidly goes on to a fatal termi-
nation. It is highly desirable that the laity and a
large proportion of the members of the medical profes-
sion should realize that the so-called change of life
is a physiological process, and quite as natural as the
coming on of the menstrual periods in a young girl,
providing the generative organs of the woman are in a
normal condition; and that unusual symptoms con-
nected with the pelvic organs occurring at that time of
life are probably dependent upon some pathological
condition which demands recognition and proper treat-
ment. Viewed in this light the menopause as such
will cease to be a bugbear to womankind in general —
a period in her existence during which all sorts of ter-
rible occurrences are supposed to be entirely en irgk —
and when symptoms indicative of disease of the geni-
tal tract show themselves she would appreciate their
importance and apply for treatment before it is too
late. Viewed in this light by the medical practitioner
the menopause will cease to be for him a stumbling-
block and a rock of offence.
G. H. Ballerav, M.D.
JCkw Vurk-, Marcl: 24, 1900.
Circumcision. — Inject one drachm of a five-per-cent.
solution of eucaine beneath the prepuce and retain it
there. With a three-per-cent. decinormal saline solu-
tion of eucaine inject just beneath the skin about two
minims at each puncture, each new puncture being at
the margin of the preceding bleb, until the line to be
incised is anjEsthetic. Now let out the solution held
beneath the foreskin and proceed with the operation,
using carbolic or chinosol solution and not bichloride.
— GEEAL15 Dalton.
NEW YORK ACADEMY OF MEDICINE.
SEC'l'IOX OX MKDICIM';.
Stated JMrctiiig, Ma/r/i 20, igoo.
John Huddi.esion", M.D., Chairman.
Treatment of Rheumatism at the New York Hos-
pital.— ^Dr. Hughes Dayton read a paper on this sub-
ject (see page 585).
Treatment of Rheumatism at Mount Sinai Hos-
pital Dk. L. a. S. Bodine read this paper. He said
that in acute articular rheumatism, after a thorough
clearing out of the alimentary canal by means of calo-
mel and salines, sodium salicylate was used, in doses
of gr. x.-xv. every three hours. Sodium bicarbonate
was often associated w ith it in order to maintain a
proper alkalinity of the urine. In addition, rest in
bed and fluid diet were insisted upon. If, for any rea-
son, the salicylates were not well borne, owing to tin-
nitus aurium, eruptions, or gastric disturbances, either
oil of wintergreen or the citrate or acetate of potassium
was used as a substitute. The bowels were kept open
bv cathartics, preferably by the use of salines and
by enemata. I'henacetin, acetanilid, antipyrin, and
codeine were all used to relieve pain, and sometimes,
though rarely, morphine. To produce sleep, trional,
in combination with sodium bromide, was a favorite
remedy. During the acute stage only a fluid diet was
permitted. Nitrogenous food was avoided as much as
possible, and large quantities of water we;-^a taken by
the patients daily. The salicylates were always given
well diluted, and never on an empty stomach if this
could be avoided. Methyl salicylate was used locally.
Tincture of iodine, bandaging, ice-bags, and elevation
of the limb were measures in use for inhibiting the
exudation. If in spite of these the effusion continued
to increase, the joint was aspirated to determine the
nature of the contents of the joint cavity. Hot-air
baths at a temperature between .too" and 400° F. had
been used locally for from twenty to thirty minutes
daily. During the convalescent stage iron, strychnine,
and quinine were administered. The salicylate of
iron was often employed. After the temperature had
remained at the normal for two or three days, the diet
was enlarged to consist of eggs, bread, potato, toast,
and fresh vegetables, but meats were still excluded.
All patients were kept in bed for three or four days
after the tem])erature had reached the normal point.
Differential Diagnosis of Chronic Rheumatism. —
Dr. James J. Walsh read this jiaper. He said that
there were four classes of cases, viz., (i) recurring
subacute rheumatism, the attacks occurring at short
intervals and yielding rather promptly to the ordinary
treatment for rheumatism; (2) cases presenting symp-
toms of articular rheumatism, and recurring again and
again in children, especially during damp weather, or
alternating with chorea, tonsillitis, or certain cutaneous
manifestations; (3) cases in which the joint lesions
occurring during an acute attack persisted and became
worse, sometimes permanently injuring and deforming
the joint — true chronic rheumatism; (4) a numerous
class of cases often diagnosticated as chronic rheuma-
tism, but really consisting of a varied assortment of
ailments. The latter were specially characterized by
pain, and this pain was often relieved by the treat-
ment usually employed for rheumatism. The reason
was that this medication usually consisted in the ad-
ministration of tlie coal-tar products, which relieved
pain not only of rheumatism, but pain in the peripheral
nerves produced by a great variety of causes. Any-
one who knew how soothing were the salicylates when
6o6
MEDICAL RECORD.
[April 7, 1900
used in surgica] dressings could readily understand
this. A similar method of treatment had proved ex-
ceptionally useful in relieving the pain associated
with the formation of an abscess at the root of a tooth.
A very common affection often diagnosticated as rheu-
matism was weak foot, or flat foot, and it was fre-
quently diflficult to convince such patients that, the
cause was not rheumatism. If, however, a small pad
of felt was placed under the inner border of the sole
of the weak foot, it would not be difficult to convince
one's self of the correctness of the diagnosis. A some-
what similar condition was found among dentists from
the frequent use of the dental engine. In these in-
stances the pain was not felt in the foot used to oper-
ate the engine, but in the other foot which sustains
the weight of the body at that time. There were, of
course, many other occupation neuroses which were
apt to be confounded with rheumatisju. These should
be excluded before diagnosing chronic rheumatism.
Many of these functional cases were observed in per-
sons who had become anaemic, or whose general health
had become temporarily deteriorated. He had recently
known of two cases of varicose veins of the leg of slight
degree that had been treated for rheumatism because
of the pain that had been felt in the vicinity of the
knee.
The Hot-Air Treatment of Chronic Rheumatism.
— Dr. Thomas E. Satterthwaite spoke of this
method of treatment. He said that it was an old one,
but until quite recently had been carried out only
under certain difficulties. The great objection to the
older bath method of giving it was the breathing in
by the patient of the superheated or moist air, and to
obviate that the well-known "hot box" had been de-
vised. In this the body, excepting the head, was ex-
posed to the heat. In the modern machines, such as
those exhibited by him now, the temperature could be
readily raised to 400° F. The essential idea was to
keep the body dry while the air about it was super-
heated. The hot air was not allowed to impinge
directly upon the skin, because unless provision was
made for the absorption of the perspiration the skin
would be scalded. By wrapping the limb in Turkish
towelling this was accomplished. Again, the inner
surface of the cylinder was lined with asbestos to
avoid contact of the skin with the heated metal.
These forms of apparatus had been used since
May 30, 1893. The speaker said that the claim put
forward for such apparatus by those competent to
judge was that the superheated air was merely an
adjuvant to other treatment. Dr. George L. Kessler,
of Brooklyn, after an extensive experience with the
method, had drawn the following conclusions as to the
effect of the treatment: (i) It produced contraction
followed by dilatation of the superficial blood-vessels;
(2) the pulse became more rapid, but at the same
time its strength was improved; (3) the bodily tem-
perature rose from one to six degrees, and the accom-
panying perspiration was profuse and acid; (4) the
respirations were also increased; (5) nerve exhaus-
tion was experienced if the treatment was too pro-
longed. The limb should be snugly swathed with
about four thicknesses of blanketing or Turkish towel-
ling. If this was not snugly applied, the perspiration
might lodge between the towelling and the skin and
cause blistering of the skin.
Brief Notes on Rheumatic Joints Treated with
Hot Air. — Dr. H. W. Gibney gave, in this paper, ex-
tracts from the clinical records of several cases which
he had successfully treated with the portable hot-air
apparatus. He said that in several cases of rheumatic
flat foot he had been able to break up the adhesions
more satisfactorily by first exposing the part to the hot
air.
Use of Electricity in Chronic Rheumatism Dr.
W. J. Morton read a paper on this subject, dealing
chiefly with the effect of the high potential high-fre-
quency current. He used the current in one of its
forms in the treatment of chronic rheumatism. The
current was obtained from a powerful influence ma-
chine, using a condenser. One form of this current,
but little known as yet, was that designated as " the
electric-wave current." The patient, in this instance,
was subjected to what might be called a " condenser
current." With long sparks passing the patient be-
comes practically one coating of a Leyden jar, and
was subjected to very powerful condenser waves.
Under the use of this current, heat production was in-
creased, and while the body weight was diminished
during these applications, it was restored to its former
amount in the interval. The therapeutic effect of the
increased nutritional activity of the patient's organism
was an improvement in the general health and nutri-
tion. These currents could be applied locally as well
as generally. Most chronic diseases were constitu-
tional, and many forms of chronic arthritis might be
so considered. Certainly, in most cases of rheumatism
the physician aimed to treat the diathesis as well as
the local manifestations. The electrodes might be of
any pliable material, block tin being specially suit-
able. The spinal electrode used by him measured
one inch by twelve inches. When a strictly local
effect was desired, a small electrode was selected.
These block-tin electrodes were wrapped about the
joint without any moistening or covering. Instead of
block tin, he often made use of metallic cloth, such as
was furnished by military clothing stores. From this
cloth rude garments could be quickly made and ap-
plied. All cases received an application of the wave
current for a period varying from fifteen to thirty min-
utes. If the patient felt exhausted after the treatment,
it was evidence that the application had been too pro-
longed. The application of the sparks would, in a
single treatment, temporarily relieve the pain and in-
crease the mobility of the affected part. In subacute
and chronic rheumatism the treatment was general,
after the manner described, and this was followed by
a local treatment with the sparks if these could be
borne. He had tried the hot-air treatment and many
other methods, but had found none of them equal to
the electrical treatment just described. It was par-
ticularly applicable to gout, and when there was only
a watery oedema present the relief was apt to be per-
manent. The speaker said that the progress of rheu-
matoid arthrit's could be arrested in any stage of the
di.sease. If seen in the early stages, it could be ar-
rested easily and quickly; if it was r^'eady more ad-
vanced, such a result would be secured only after more
prolonged treatment. The long spark applied to each
individual joint affected seemed to him essential in
establishing a new and improved joint nutrition. One
of the first effects noticed was that the shiny appear-
ance of the skin disappeared. In private practice he
placed all his rheumatic patients on a meat diet.
Dr. William M. Leszv.n'skv commented upon the
fact that a large number of patients complaining merely
of pain were not examined, by many physicians, but
were treated for rheumatism or neuralgia. Nothing
had been said that evening regarding a simple method
of local treatment — the wet pack. He thought much
could be accomplished in many cases by means of the
wet pack, assisted by massage and passive motion. A
recent case was recalled in which there had been
much swelling, stiffness, and pain in the hand follow-
ing an attack of acute rheumatism. In this case com-
plete recovery had taken place at the end of three
weeks simply from the use of the wet pack at night, and
the local application of oil of wintergreen and mas-
sage during the day. This was no unusual experience
with him. He had not personally had a satisfactory
April 7, 1900]
MEDICAL RECORD.
607
experience with the use of static electricit}- in the treat-
ment of clironic articular rheumatism, although he
had, like many others, obtained most brilliant results
from such electrical applications in cases of muscular
rheumatism. In private practice he had not been will-
ing to confine himself to the use of static electricity.
A common fault was, not to apply this current long
enough, and hence the frequent assertion that this
treatment succeeded chiefly by its mental effect.
The Splint Treatment. — Dr. Morris Manges said
if one were dependent solely upon the use of the sali-
cylates convalescence would be slow and unsatisfac-
tory, and there would be niany complications. It would
not be too emphatically stated, to say that we were far
from having any specific treatment for rheumatism.
To treat rheumatism by the salicylates alone was cer-
tainly an error. The physicians at the Mount Sinai
Hospital had been particularly impressed with the in-
tense anaemia observed in their cases of rheumatism.
Another fact which had impressed them there was the
value of splinting the affected joints. These joints
should be absolutely immobilized, leaving, if desired,
an opening for local medication. Any one who had
not tried this method would be agreeably surprised at
the result. It was exceedingly important also to watch
the urine, for this alone afforded a proper index to the
quantity of alkali to be given. The urine should be
made alkaline, and kept alkaline. If a pronounced
alkaline treatment was combined with a moderate sali-
cylate treatment, and proper attention was given to the
immobilization of the affected joints, and to the care
of the heart, the results would be good. The hot-air ap-
paratus was useful, but -should not be relied upon too
much. There were certain drawbacks to the use of
this apparatus, one of these being danger of fire. He
knew of one or two instances in which a subacute
rheumatism had been rendered acute again b\' the
chilling which had followed the exposure of the part
to the cooler atmosphere of the treatment room after
having been removed from the hot-air chamber.
Dr. Mary Putnam Jacobi said, with regard to the
question of differential diagnosis, that no mention had
been made of the tendency to confound incipient rheu-
matoid arthritis with gouty deposits around the joints.
She had recently had an opportunity of witnessing
the good results obtained by Dr. .VV. B. Snow in rheu-
matoid arthritis from the use of the electric-wave cur-
rent. There could be no doubt about the excellent
effect of electricity in muscular rheumatism.
Lactic Acid a Useful Remedy. — Dr. G. L. Kess-
LER said that he had treated about three hundred and
fifty cases of rheumatism with the Sprague hot-air ap-
paratus. In the chronic form of rheumatoid arthritis
he had found the deformity lessened and the mobility
increased. Out of twenty such cases, eighteen had been
positively benefited, and five of the patients had re-
sumed work, although unable to work for several years
previously. In the cases in which the joints suddenly
became stiff good results were obtained from the use
of hot air locally, and the free use internally of lactic
acid. He did not pretend to say how this remedy
acted, but was positive of the good effect. The treat-
ment should be continued for a number of months.
He would not think of treating a case of acute articu-
lar rheumatism without the aid of the salicylates, be-
cause he looked upon rheumatism as an acute infec-
tious disease. He would never think of immobilizing
a rheumatic joint, because he met with so many such
joints which had become stiffened, and which proved
most obstinate to subsequent treatment. He did not
think it safe to run the temperature in the hot-air ap-
paratus above 350^ F. In such apparatus the temper-
ature was indicated by a thermometer affixed to the
top, but there the temperature was at least 20° lower
than in the lower part of the hot-air chamber. Burns
should not occur if the temperature did not exceed
350^ F. For the local application of heat in cases of
gout, the Japanese hand-warmer would be found ex-
ceedingly convenient. Certain cases of neuralgia
seemed to relapse after the hot-air treatment, appar-
ently from the subsequent chilling of the part.
SECTION OK OBSTETRICS AND GVN.E;C0L0GV.
Stated Meeting, March 22, igoo.
J. Riddle Goffe, Chairmax.
New Operation for Repair of a Complete Lacera-
tion of the Perineum. — Dr. J. Riddle Goffe e.\-
pected to present a patient showing the results of a
new operation which was suggested by Dr. Kelly at the
meeting of the American Gynaecological Society, which
met in Philadelphia last year. It was suggested for
those cases in which the tear went through the sphinc-
ter muscle, and up to the rectal w'all. Instead of split-
ting the tissues and dissecting off the mucous mem-
brane of the vagina, one should commence above and
work down, so forming an apron, which turned down
and covered the anus, and which was held in position
by an artery clamp. Using a figure-of-eight suture,
the fascia of the sphincter muscle was taken up and
ligated; this drew together the fascia and brought up
the sphincter muscle until it got in the middle line.
Dr. Ristine, of Knoxville, Tenn., had been using this
same procedure during the past two years, and Dr.
Kelly acknowledged his prior claim. In this opera-
tion nothing must be done within the rectum whatever,
and so dangers from infection were lessened.
Dr. Edwin B. Cragin said the advantage of this
new operation was that the rectum was left intact,
and the only objection was that there was a flap which
was liable to superficial sloughing. He thought the
operation would come into general use.
Dr. George G. Ward had operated last summer on
three cases in which he did not use this new method, and
all did well. He was careful not to tie the sutures on
the rectal side. The torn roof of the rectum was picked
up but not penetrated. The ends of the sphincter
muscle were dissected out, and, with traction, silver
wire sutures were p' ed, and these were reinforced
by catgut. In none <„ ese cases did a fistula result.
Dr. Simon Marx thought that another objection to
this operation was that the line of union between the
mucous membrane was such a small one that possibly
sloughing of that part might occur. In a case he had
operated upon that day he found that he did not have
enough vaginal tissue to make an anterior rectal wall.
He feared sloughing of the tissue.
Dr. Balleray said he was not disposed to try this
new operation just yet, because, up to the present time,
he had had but one failure. In the earlier days he
had practised the method of Emmet, regarding which
operation he once heard Dr. Price say that it was a
wonder that the patients did not die of tetanus; but
he got excellent results. In lacerations not involving
the sphincter he did the Pozzi method.
Results of Conservative Treatment. — Dr. George
G. \\'ard had operated upon a case recently which was
interesting because two years ago the patient had had a
laparotomy performed for ovarian disease, and the left
tube and ovary had been removed, the right ovary
being left /;/ situ. Last Saturday he operated because
there was an ovarian cyst upon the right side the size
of a small orange. When the abdomen was open, he
found great difficulty in freeing the cyst on account of
the extensive adhesions. The bowels were adherent
in three distinct loops to the side of the uterus, and it
was diflficult to tell which was cyst and which was
bowel. In one of these cases the bowel was torn
6o8
MEDICAL RECORD.
April 7, 1900
through and in the other two there was denudation of
the peritoneal covering. The point of interest was as
to the conservative work done upon the ovary; it was
a question how far we could go in conservative work.
Was an ovary treated conservatively apt to undergo
cystic degeneration?
An Enormous Corpus Luteum — Dr. Harris, of
Paterson, N. J., described an interesting case which
showed the importance of conservatism. A trained
nurse, aged thirty-three years, from whom a large cyst
and the left ovary had been removed wiien she was
twenty years old, presented lierself to him about four
months ago for a slight hernia occurring in the ab-
dominal incision. When he opened the abdominal
cavity, he thought he would investigate the condition
of the right ovary on account of the pain that she com-
plained of. He did so, and found a condition that he
then did not understand. The ovary was about the
normal size, with a reddish-brown colored mass over-
topping it. With a scalpel there was no difficulty in
shelling out about two-fifths of the ovarv. This over-
topping mass was about one and one-eighth of an inch
long, and occupied about two-fifths the entire length
of the organ, and was of an entirely different color.
This mass was removed and sent to the bacteriologist
at Johns Hopkins Hospital, Baltimore, who pronounced
it a corpus luteum.
Dr. Edwin 15. Cragin thought that each case should
be decided on its merits. If the patient was young, and
expected to be married, she should be given the benefit
of the doubt, and the ovary should be left; but if the
patient was an elderly woman, and had given birth to a
number of children, and if one suspected the ovary to
be diseased, it should be taken out.
Submucous Fibroids Dr. Simon Marx showed
these specimens, two in number, and referred to the
difficulty of the diagnosis in one case and the ease of
diagnosis in the other; again, both operations were
done with the greatest facility, yet one patient made
an uninterrupted recovery, while the other died three
hours after operation. In the case that offered diffi-
culty in diagnosis, the patient was rather an ignorant
woman, who had been married eight years. She was
well up to two years ago, when there was discovered
a small tumor in the pelvis; otherwise she was per-
fectly well. Until six months ago she menstruated
every four weeks, the discharge lasting five days, and
not being excessive. During the past three months
she had menstruated scantily. Examination showed a
tumor with a soft, boggy feel, reaching as high as the
umbilicus. The doctor first thought of pregnancy.
Examination for the foetal heart did not reveal any.
Hegar's sign was not present. Intermittent uterine
contractions were not present. Abdominal section
was advised because of the pressure symptoms, the
dyspnoea, and the symptoms referred to the bladder
and rectum. The abdomen was opened, and he then
thought he had to deal with a pregnant uterus, but the
history of the case prompted him to go on and do a
total extirpation; he knew the tumor had been discov-
ered six montiis ago and had been growing since, but
he could not hear the fatal heart, no fatal life was in-
dicated, and Hegar's sign was not present. The tumor
proved to be a large submucous fibroid. The other
case referred to was that of a woman who died three
hours after the operation, probably from shock. She
had atheromatous blood-vessels, which no doubt were
a factor in its production.
Two Cases of Appendicitis. — The next specimen
shown by Dr. Marx had been removed from a young
girl about twenty-two years of age, who had had re-
peated attacks of appendicitis; she desired operation
because she was going abroad and wished to be cured
here. The McBurney operation of splitting the muscle
fibres was done, and she made a good convalescence.
Another specimen had been removed from a single
woman aged thirty years. She had had one mild at-
tack of appendicitis three years ago. She complained
of intense headache, and almost constant vomiting
every morning. She was repeatedly examined, but no
diagnosis was made. Her eyes, nose, and all parts
were treated without benefit. A rise of temperature
gave severe headache. McBurney's operation was
done, and the tip of the appendix was found bent upon
itself and adherent at the base, where it sprang from
the ca:'cal wall. She made a good recovery.
Appendicitis; Operation, Infection, Death.— This
patient. Dr. Marx reported, had had a baby two or
three years ago. She had consideiable trouble on the
right side, whicii was thought to be due to movable
kidney. Tiie kidney was stitched in place, but the
pains continued. She developed quite evident symp-
toms of recurring appendicitis. Because she had an
adherent and retroverted uterus an operation was de-
cided upon and done, the appendix being taken out;
it was quite long and full of pus. The left ovary
was liberated from adhesions and the uterus sewed
in place. The convalescence was an ideal one, ihe
pulse seldom being over 80. On the day she was
to be discharged, when the speaker went to bid her
good-by, he found the pulse 100, and the tempera-
ture 100° E. That night the temperature was 103° F.,
and there was pain in the abdomen. A boggy mass
was found posterior to the uterus. A posterior sec-
tion was made through the vagina, and stinking pus
was discharged; the finger on being introduced passed
up into the c;i;cuni. A rapid acute peritonitis devel-
oped, and the patient died w^ith absolutely a normal
temperature, but an enormously rapid pulse. The
speaker asked: Why had she a normal convalescence,
and why, at the end of the fifteenth day, did she have
these symptoms, and within twenty-four hours de-
velop an enormous boggy mass.' He did not know,
unless it was from a late catgut infection. Catgut in-
fection, sloughing of the appendix stump, and the de-
velopment of a sero-purulent abscess, were the condi-
tions that probably followed.
Dr. Ballekav related an instance of a woman aged
thirty-five years who had recurring attacks of pain.
Examination showed a short pedicle, partially twisted,
and he wondered whether the pedicle did not twist
itself, giving the patient pain, and then untwist itself.
Cases of Ectopic Gestation.— Dr. Balleray showed
this specimen. Tlie patient was unmarried but was
leading a dissolute life. She entered the hospital
with an acute gonorrhoea. She had skipped over her
period six weeks, when she was taken with severe
pain. There were two small masses posterior to tlie
uterus, the mass on the right side becoming larger
when pain was present. The abdomen was opened,
and the mass on tlie right side was found to be
a blood cyst, which accounted for the sudden in-
crease in size when pain was present. On one side
there was a pus tube. The entire pelvis was swabbed
out, and the patient put to bed with the pelvis elevated.
After the operation the temperature never rose above
100 ' F. It was interesting to note that there was an
absence of drainage when drainage seemed to be indi-
cated. In this instance there was a ruptured ectopic
gestation, with a pus tube and a cystic ovary on the op-
posite side. In another case, also shown by Dr. Bal-
leray, an ovary and a tube had been removed from a
woman twenty-five years of age, vvlio had been married
three years. She had never borne children, but had
suffered all her married life. Soon after marriage she
had had menorrhagia, very profuse, and later metror-
rhagia. She had a pyosalpinx. When she was oper-
ated upon, no blood was found in the peritoneal cavity.
The tube was adherent to the rectum. On the otiier
side was a small mass which was thought to be an
April 7, 1900]
MEDICAL RECORD.
609
ovarian cyst but proved to be a small cyst in the broad
ligament. There had been a ruptured ectopic preg-
nancy in the early stage, in which the foetus and a
small amount of blood had escaped into a circum-
scribed space in the pelvis, which was made by ad-
hesions formed by a chronic disease of the ovary and
tube.
Some Points in the Management of Obstetric
Cases in Private Practice. — Dr. J. B. Cooke read
this paper. He emphasized the importance of phy-
sicians making more careful and accurate histories of
all their cases. He advised the use of certain cards
which could be carried in the pocket; one card related
to the history of the pregnancy, the second to the labor,
and the third to the puerperium. These cards were
very complete, and, when used, should be placed on
file for future reference. The importance of an exami-
nation of the urine was entered into, and, on account
of patients neglecting so often to comply with requests
to furnish urine, he advised the use of laljelled bottles,
which were to be sent to the physician's office on cer-
tain days at a certain time. Such a procedure im-
pressed the patients, and one could get the desired
urine. He emphasized the point of maintaining abso-
lute asepsis from the beginning of labor to the end, and
told how he attained it. Boxes containing sterilized
water, certain solutions, gauze, etc., he had packed at
his office and ready for transportation. When sum-
moned to a case the Manhattan Delivery Company
called for and carried one of these boxes to the pa-
tient's home.
Dr. Slmon Marx thought that accoucheurs had
trouble enough in carting instruments and dressings,
without being obliged to carry sterilized water. He
said he was a nihilist so far as the uterine douche was
concerned. It was supposed that the woman was
healthy; that the living baby, or a baby that died
within a few hours, was also aseptic; that the hand of
the accoucheur was also aseptic ; therefore he seldom
used the douche before or after labor unless there was
a bad discharge or a putrefied child. He was also a
nihilist in regard to urinary analysis. He examined
the urine of a pregnant woman once in every two
weeks; he seldom examined for albumin, but always
for urea. He believed that more women died from the
toxffimia of pregnancy than from the true acute nephritis
of pregnancy. He had seen women die when there
was not a trace of albumin, and others get well wlien
the urine was filled with albumin. If the amount of
urea was diminished, he believed something was wrong
with the patient. If a woman had a large amount of
albumin in the urine, only one kidney might be affected,
and the woman should be allowed to go to term. He
did not believe so much in pelvimetry. Personally he
had found small pelves and small children in many
instances, and no trouble was experienced in handling
these cases. On the other hand there was the greatest
source of danger to women from a form of contracted
pelvis in which there was minor contraction but a very
large child. He knew of three cases, in two of which
preparations were made for doing a Ca_'sarean section,
and, too, by a distinguished operator; the labor pro-
gressed without interference, and he was later called
in to sew up a tear. In another case a symphyseotomy
was thought to be indicated; in this instance the posi-
tion, which was a mento-posterior at the brim, was not
taken into consideration; the correction of this was
soon followed by delivery. His method of procedure
was as follows: From the seventh month, if he found
a relatively normal pelvis, he attempted the engage-
ment of the head by Hofmeier's method ; if the head
would not engage he induced labor. Many of these
heads would accommodate themselves and readily en-
gage by the suprapubic method.
Dr. Ballerav advocated the douche before and
after labor. He had seen a case of puerperal sepsis
following a normal labor; if the douche had been used
before labor puerperal sepsis would never occur. He
used a solution of creolin and green soap as a prelimi-
nary douche, which was followed by a solution of bi-
chloride of mercury, i : 5,000, and then by sterilized
water. After labor he used the douche as long as the
patient remained in bed, giving it twice daily. He
agreed with Dr. Marx that pelvimetry gave many mis-
leading indications. He had known cases in which
there was supposed to be a contracted pelvis, and a
Cesarean section was performed; subsequently the
woman gave birth to a child in the natural way by
natural efforts, and the child was as large as its prede-
cessor. He knew of another instance in which sym-
physeotomy was done; here, again, subsequently a
child of about the same size was born naturally.
Dr. Edwin B. Cragin thought the great advantage
to be derived from Dr. Cooke's paper was in emphasiz-
ing tlie importance of details in the care of the women
before and after pregnancy. Regarding the examina-
tion of the urine he could hardly agree with Dr. Marx.
He believed both albumin and urea should be tested for;
either one might be present as a danger signal. These
occurred in some cases as premonitory symptoms, and
should be looked out for. Regarding pelvimetry all
physicians acknowledged that they were much disap-
pointed with it. At the .Sloane Maternity, pelvimetry
showed sometimes that they had to deal with a small pel-
vis, yet the child came through all right. Pelvimetric
instruments were only an additional help in determin-
ing the relationship between the head and thp pelvis.
In regard to douches, when he went on duty at the Sloane
Maternity Hospital it was customary to use the douche
before and after labor; he allowed them to continue
the practice for a number of months. He then thought
he would try to do without douching. In looking over
the temperature charts he found there was just a little
increase in temperature during those months, so he
ordered the douching to be resumed. A few months
later the temperatures, as a whole, went higher than
they did when no douches were used, so the douches
were stopped altogether, and had not been used for
several months, unless special indications were present.
The parts might be disinfected when soap, bichloride,
ether, etc., were used, but he did not believe the douche
could do it. He wished to emphasize the importance
of instructing the nurse to take the baby's temperature
as well as the mother's, during the first week. This
starvation temperature showed whether the mother was
furnishing her child with proper nutriment.
Dr. Marx asked Dr. Cragin if it was the urea or
the albumin that killed in these cases.
Dr. Cragin replied that either acted as the "red
flag."
Dr. Mar.x said it was the urea that killed; even if
the urine was loaded with albumin, it was the urea
that killed.
Dr. Cragin stated that one year ago he tried the
expectant plan with albuminurics, and he found the
mortality was higher, and he regarded this as one of
the reasons why women thus aifected had better not
go on with pregnancy. He agreed with Dr. JMarx that
the examination for urea was very important, and in
fifty or fifty-five per cent, of tiie cases in which it was
present he found that the urea did not subside under
rest in bed, flushing the alimentary tract, hot baths,
and stimulating all the emunctories, and that it was
better to remove the pressure by inducing labor. He
did not believe that all was known about this toxfemia.
Plastic Operations on the bladder are often useless,
since the bladder has diminished resisting and expul-
sive power, and incrustations are apt to form. — Son-
NENBURG.
6ro
MEDICAL RECORD.
[April 7, 1900
NEW YORK COUNTY MEDICAL ASSOCIA-
TION.
S/atid Meeting, March ig, igoo.
Frederick. Holme Wiggin, M.D., President.
Report of a Successful Case of Excision of the Caecum
with End -to -End Anastomosis Dr. Frederick
Holme Wiggin reported a case of this kind in which
there had been long-standing and continued recur-
rences of appendicitis, which had led to complete oc-
clusion of the bowel. The patient, a woman of fifty-
four years, had been seen by him in consultation with
Dr. I). R. Rodger, of VV'oodbury, Conn. She gave a
history of recurring attacks of appendicitis e-xtending
over a period of ten years. Her last attack had been
exceptionally severe, and had begun about six weeks
previously. She was emaciated and mentally de-
pressed, and examination showed that her gums and
tongue were swollen and red. and that there were
ecchymotic spots all over her body. Her pulse was
74 and her temperature 99.4^^ F. Bimanual palpation
revealed a tumor attached to the uterus and broad liga-
ment, and extending up into the right inguinal region.
An incision was made over the right rectus muscle,
and the tumor exposed. It proved to be within the
cEBCum and appendix. Fearing that malignant disease
was present, the bpwel had been divided on either
side, some distance from the tumor. The mesenteric
attachment was clamped off before the vessels were
divided, and then the vessels were caught with forceps
and ligated, so that it was estimated that the patient
had not lost over an ounce and a half of blood during
the whole operation. In making the anastomosis the
suture method of Maunsell with some modifications
was followed. Large quantities of foul fecal matter
had been discharged from the bowel during convales-
cence, showing that it must have been retained in the
intestine a long time. Convalescence was satisfactory,
but was rendered somewhat tedious by the presence of
a condition analogous to scurvy. The condition of
the tongue and gums at the time of operation, and the
occurrence of a bloody vaginal discharge shortly after-
ward, served to emphasize the nature of this constitu-
tional vice. Convalescence was greatly assisted by
the early and constant use of saline enemata and by
the early administration of food in considerable quan-
tity. Dr. Fl. K. Dunham had examined the specimen,
and had found evidence of nothing more than a chronic
inflammatory growth.
Symposium on Serum Therapy — Dr. E. K. Dun-
ham introduced the general subject by a brief paper.
He said that the practice of serum therapy was based
on the fact that animals or man could acquire immu-
nity against a gi\en infection. The blood and the
lymph of the body were known to confer immunity in
some instances, especially when freshly drawn, and it
was probable that this action was dependent upon the
presence of certain enzymes or ferments, which had a
solvent effect on the bacterial cell and its envelope.
It was probable that tiiis action was closely related to
the agglutination familiarly exemplified in the Widal
reaction for typhoid fever. The most philosophic
theory of immunity was one based upon the chemical
theory of the action of poisons. It was known as Ehr-
lich's "side-chain hypothesis." The protein mole-
cule was known to be one of very great complexity.
The chemist expressed the constitution of such com-
plex molecules by means of a nucleus, consisting of
closely united atoms, and added to these other atomic
combinations or radicles composed of atoms more
loosely attached. These were known as '' side-chains."
The molecule might suffer cleavage, splitting intosim-
p'er combinations, and the direction of such cleavage
w.)',ild depend upon the conditions under which the
splitting took place. Under ordinary circumstances
the tissues of the body possessed a certain reserve of
activity. When this was drawn upon, it was not merely
replaced, but an additional store was laid by. Ehrlich
supposed that such an excess of side-chain radicles
might be stored up and appear in the circulation as an
antitoxin.
Natural Immunity.— An animal might be naturally
immune to substances poisonous to other animals.
Thus, rabbits were not affected by atropine; fowls were
not susceptible to the toxins produced by the tetanus
bacillus. According to Flhrlich's theory, natural im-
munity would be the necessary result of the absence of
side-chains having an affinity for a particular poison,
and the blood of naturally immune animals would not
contain any antitoxin because the conditions for its
production were not present.
Active Immunity. — Active immunity was that
which resulted when gradually increasing amounts of
poison were introduced into the organism, whether
in solution or formed in the body by the growth
of bacteria. It was not essential for the growth of
active immunity that toxic symptoms should be pro-
duced. An excessive dose of toxins, according to the
theory of Ehrlich, arrested the function of the cells,
but in smaller dosage it caused the formation of an
additional store of side-chains. The theory also
showed that the antitoxin introduced must bear a defi-
nite chemical relation to the poison which had called
forth its production. It did not follow that all of the
cells of the body were equally affected; the toxins
might be localized. When this localization obtained,
the particular side-chains having an affinity for the
toxins must be confined to the tissues susceptible to
the poison. In the case of tetanus, they should be
found in the nervous system, but those tissues should
be able to neutralize to some extent the toxins. Ex-
periments with tetanus had shown this to be the case,
particularly with animals that were remarkably suscep-
tible to the tetanus toxin. The side-chains affected
by diphtheria antitoxin were probably situated in the
lymphadenoid tissues, the bone marrow, the spleen,
and the lymph nodes. If the animal had been par-
tially immunized, these tissues had a distinct anti-
toxic value. An exceedingly interesting fact was that
other complex proteid poisons besides those of bac-
terial origin produced effects very similar to the latter,
and could induce the production of antitoxins.
Passive Immunity. — Passive immunity differed
from active immunity in that in the former the free
antitoxins introduced into the blood were not replaced
by a fresh supply, but were gradually eliminated. In
order to obtain a curative result from the use of anti-
toxins, it was necessary to use much larger quantities
than were required to confer passive immunity. It
was possible that a toxic radicle might leave a side-
chain, which was already partially satisfied by union
with a central nucleus, to unite with similar side-chains
when they were present in a sufficient abundance and
in a free stale. The antitoxic character of immunity,
and of immunity to infection, though closely related,
were two distinct conditions. An animal might be in-
oculated with a given species of bacteria and not suffer
because the bacteria were killed or could not develop,
and yet the animal might be susceptible to the toxins
produced by these same bacteria. This side-chain
theory seemed to the speaker to explain more satisfac-
torily than other theories the subject under discussion.
Tuberculins and their Use — Dr. E. A. de
ScHWEiNiTZ, chief of the biochemical division. Bureau
of Animal Industry, United States Department of
Agriculture, at Washington, D. C, read a paper on this
subject. He said that two different preparations
passed under the general name '"tuberculin,'' and
were respectively designated as "old tuberculin " and
April 7, 1900]
MEDICAL RECORD.
6ii
"TR." The old tuberculin was prepared by using a
culture medium consisting of ordinary beef broth, salt,
peptone, and from five to seven per cent, of glycerin,
and inoculating it with tubercle bacilli. The cultures
were then allowed to grow in a thermostat for several
weeks until the germs had become well developed, and
then the flasks containing them were placed in a steril-
izing oven and heated for about half an hour to a tem-
perature of 120° C. They were then removed from
the oven and heated to the boiling-point, and, while
boiling, were filtered. The filtrate was concentrated
over a water-bath. This tuberculin contained the ma-
terials used in the preparation of the culture media,
the products of the growth of the germs which had
passed into solution during their development, and
also those products which had been retained within
the cell walls, and which had been extracted during
the preparation of the tuberculin. The newer tuber-
culin, or " TR," contained, on the other hand, none of
the materials entering into the composition of the cul-
ture media, but only the cell contents which had been
produced by the growth of the bacilli, and had not
passed through the cell wall into the media. The old
tuberculin was a solution containing a number of for-
eign substances in addition to the poisons of the
germs, whereas "TR," or " tuberculo-plasmin," as it
was sometimes called, was a solution of the substances
which had been produced within the cells as the tuber-
cle germs developed. In the new tuberculin the con-
tents of the germ cells had never been raised to a tem-
perature sufficiently high to destroy the germs or affect
in any way the products, and, in this respect, differed
very markedly from the old tuberculin. Brieger, the
chief of staff in Koch's laboratory, had made the as-
sertion only a few months ago that the old tuberculin
was not without some value. The following conclu-
sions regarding the old tuberculin seemed to be war-
ranted: (r) It apparently liad a decided curative ac-
tion for lupus ; {2) It was a valuable diagnostic agent,
both in animals and in man, and it should be used
very much more extensively than heretofore in diag-
nosing incipient cases. Beck, of Berlin, reports that
from 1891 to 1897, out of 4,254 patients admitted to
the Institute for Infectious Diseases, 2,508 received
the tuberculin injections. Of these, 1,525 reacted.
If 371 cases, including phthisis, bone tuberculosis,
and lupus were deducted, which could have been easily
diagnosticated without tuberculin, there remained
1,154 cases in which the diagnosis had been deter-
mined by the use of tuberculin. Such a result cer-
tainly warranted the belief that tuberculin should al-
ways be used by skilful hands in diagnosing disease,
and in determining if the disease had been arrested or
cured. Tuberculin TR might contain in much small-
er quantity than the old tuberculin what was known
as "the necrotizing substance." This being the case,
different results were to be expected from its use than
from old tuberculin in producing immunity in animals
and man. In the experiments that he and his associ-
ates had been conducting for some years, the animals
had been uniformly treated with a solution of the
germ entirely free from the culture media. It seemed
to him that the results obtained with these tuberculins
indicated that in the incipient stages the disease
might perhaps be arrested, and partial, if not perma-
nent, immunity secured by injecting into the patient
the products of the bacilli, provided these had been
freed from the necrotic principle already referred to.
Such a serum could be readily obtained if the extract
was made from attenuated instead of from virulent
germs.
Antipneumococcus Serum Dr. Alexander Lam-
bert, in this paper, referred to the use of this serum in
pneumonia. Comparing the pneumococcus serum with
those of diphtheria and tetanus, it would be found, he
said, that it had a different action in the body. This
serum was antitoxic, neutralizing the toxin absorbed
from the localized focus of infection. This serum was
not bactericidal, but bacteriolytic. The serum alone
had no effect on virulent cultures of the pneumococci,
but when the pneumococcus serum and the leucocytes
from immune or non-immune animals were mixed with
the cultures the leucocytes in a short time became filled
with the germs. For this reason this serum alone
could not bring the infective process to a close. The
blood-vessels surrounded the exudate, and absorbed
from it the deleterious products of the myriads of
cocci. This germ was a septicaemic germ, and
tended to invade the system and produce a general in-
fection. There was a physical limit to the amount of
protection that any serum would give. Any pneumo-
cocci left alive had the power to increase in number
and augment the toxin, thus necessitating the use of
more and more of the serum. If a certain leucocyte
could destroy six or eight germs, and could neutralize
the toxins of these germs, it might take into itself other
germs whose toxins it could not neutralize, and hence
be itself destroyed, allowing these organisms to con-
tinue their growth. Dr. Lambert said that the serum
he had used had been obtained from horses, and it
would invariably protect when o.t c.c. was mixed with
T,ooo cc. of culture and injected subcutaneously. This
serum in the laboratory would invariably protect the
animal against a sulisequent dose of a culture not over-
whelmingly large, but if the cocci were already pres-
ent in the blood, even several large doses of the serum
would not save the animal, though it would prolong
its life. He had used this serum in twelve cases,
with nine recoveries and three deaths. The serum
seemed to cause a slight reduction in the temperature
and improvement in the pulse, but it did not bring on
a crisis in any case, or cut short the pneumonic process.
In one patient it caused a disappearance of the pneu-
mococci from the general circulation, though it did not
prevent the development of an empyema. This patient
eventually made a good recovery. In two alcoholic
cases the serum had had absolutely no effect, and both
cases had terminated fatally. He had not persisted in
the use of the serum because he could not see that it
shortened the disease or held in check the pneumcnic
process. It had seemed to do good in one or two
cases only. In certain cases it did seem to prevent a
general pneumococcus septicaemia.
Diphtheria Antitoxic Serum. — Dr. W. H. Park
read this paper. He said that when a minute quan-
tity of diphtheria antitoxin was mixed with a quantity
of toxin it completely neutralized the toxin in about
twenty minutes. Recent investigation seemed to prove
that the antitoxin acted in the body on the diphtheria
poison. Its action was to neutralize the toxins in the
blood, not to heal cells already injured by the disease
process. Secondary pneumonia and septictemiacame,
as a rule, only after the diphtheria poisons had pre-
pared the way for such infection by injuring the body
cells. This was another argument in favor of the early
use of diphtheria antitoxin. Diphtheria presented
peculiarly favorable conditions for the application of
serum therapy, for we were in possession of a strong
antitoxin, and the diagnosis could be made early. Ac-
cording to the records of New York City, in the pre-
antitoxin days, about every sixth year the deaths from
diphtheria amounted to 3.000. and would then gradu-
ally diminished to 2,000. For the fifteen years prior
to the introduction of diphtheria antitoxin, the aver-
age number of deaths annually from diphtheria was
2,373, the highest number having been 3,287 in 1881,
and the lowest 1,653 '" 1883. In the year next pre-
ceding the introduction of antitoxin, or 1893, the deaths
had been 2,870. In the last four years, during which
diphtheria antitoxin had been quitegenerally used, the
6l2
MEDICAL RECORD.
[April 7, 1900
average number of deaths had been 1,341 annually, or
more than 1,000 less than the average for the previous
years. The same remarkable decrease in the average
number of deaths had been noted in all parts of the
world in which diphtheria antitoxin had been exten-
sively employed. Statistics made it very clear that
the death rate rapidly rose in those cases in which it
was not given until late in the disease. Regarding
immunizing injections he stated that from January 1,
1895, to January i, tgoo, 6,500 cases had been immu-
liized by the board of health. Twenty-eight cases had
developed in the first twenty-four hours, and all had re-
sulted in recovery. After twenty-four hours and within
thirty days, twenty-seven patients had developed the dis-
ease, and all of these had recovered. The only one dy-
ing within one month was a case of scarlet fever and
diphtheria, dying in the first two or -three days of the
sickness. About three per cent, of the persons injected
had shown rashes, and about five per cent, febrile dis-
turbance. In several the symptoms had been quite
distressing for twenty-four to forty-eight hours, but in
no instance had any permanent injury been done.
The average mortality in the Willard Parker Hospital
before the use of antitoxin had been thirty per cent.;
since its use, twenty-three per cent.
Dosage of the Serum. — The serum should be
clean-looking and sterile, and should not be over six
months old. Old antitoxin contained nothing objec-
tionable, but it did not contain the original quantity
of antitoxin, and hence the dosage must be very uncer-
tain. Other things being equal, the higher grades of
serum were better and more convenient than the lower
ones. There was still some difference of opinion
among observers regarding the dosage of antitoxin.
In cases seen early and presenting a mild onset, he
would recommend a dose of 1,000 units; in cases seen
early but having severe symptoms, the dose should
be 2,000 to 4,000 units; in cases seen late but appa-
rently mild, 1,000 to 2,000 units should be given; in
severe cases showing necrosis, swollen glands, and
laryngeal stenosis, 3,000 or 4,000 units was the dose.
The local disease should not extend after the adminis-
tration of a sufficient dose of antitoxin; the swelling
and hyperaemia should lessen and the constitutional
symptoms should abate within twelve hours after the
injection. If this did not occur, the dose should be
repeated, and, in rare instances, even a third dose
might be required at the end of another period of
twelve hours. In a child under one year he would
advise more than 3,000 units in the severest cases, and
in a child of six months or under, not over 2,000 units.
In a small percentage of cases diphtheria antitoxin
had produced very unpleasant but, so far as known,
not serious symptoms. In closing, he would recom-
mend the use of the antitoxin in all suitable cases for
immunization. It guaranteed immunity for at least
two weeks.
Yellow Fever Antitoxic Serum — Dr. Alvah H.
Doty, health officer of the port, being unable to be
present, sent his associate, Dr. Charles B. Fitz-
PATRicK, who presented the results of their use of this
serum at the quarantine station. He said that the
serum prepared from the bacillus icteroides had been
used on a dozen or more selected cases, and had ap-
parently exerted no controlling influence upon the dis-
ease. The same strength of serum had been used as
that employed by Sanarelli. Eleven cases had been
treated at New Orleans by a physician, using the Sana-
relli serum, but no curative effect from it had been
noted. Professor Lutz, of Santos, had carefully inves-
tigated this subject, and had also been unable to ob-
serve any curative effect from this serum. The use of
the prophylactic fluid, prepared by Haffkine's method
from the bacillus icteroides, had given favorable re-
sults in animals, but had not as yet been tried on man.
The serum therapy of yellow fever, therefore, was still
in the stage of investigation, and one was not warranted
in drawing any conclusions other than that the blood
serum of the bacillus icteroides of Sanarelli did not
cure or modify the disease, and that further investiga-
tion was necessary.
Typhoid Serum. — Dr. William H. Welch, of Bal-
timore, sent a communication stating briefly his views
on this subject. Concerning the value of this method
of treatment, he stated that it did not appear to him
that we had at present any satisfactory .xperimental
or clinical evidence in support of the opinion that
this method of treatment was beneficial, but there was
a fair experimental basis to justify, under proper cir-
cumstances, the use of the vaccine which had been in-
troduced for the prevention of typhoid infection. The
data were as yet insufficient, and for manifest reasons
extensive and prolonged observation would be required
before any conclusion could be reached. Such evi-
dence as was now in our possession was sufficient to
encourage a continuance of this prophylactic measure.
Antirabic Serum.— Dr Robert J. Wilson, of the
board of health, read a brief communication on this
subject. He said that the method consisted in giving
the animal to be immunized seventeen injections in a
period of twenty days, and, after twenty-five days, col-
lecting the serum in the usual way. The immunizing
dose was one part of the serum for every twenty-five
thousand parts of body weight. Much had been
claimed for this method, but there were good reasons for
doubting the genuineness of these claims. The serum
might, however, be useful in those cases in which a
long time had elapsed between the infection and the
commencement of treatment. The best method of pre-
ventive inoculations failed completely after the advent
of symptoms, and here the serum might possibly be of
benefit. The serum, unlike the attenuated virus, con-
ferred its protective action immediately.
Antistreptococcus Serum.— Dr. H. Lilienthal
read this paper. He said that no case which he had
observed had ever resulted in recovery when strepto-
cocci had been clearly demonstrated in the blood.
Recovery, however, was by no means common when
staphylococci, even in the blood, were the offending
germs. In his earlier cases the dose of the serum had
probably been far too small. Not less than 20 c.c. of
the serum should be used. Troublesome urticaria had
followed the use of the serum in a number of instances.
Abscesses containing streptococci had appeared at the
site of the injections in one case in which the germs
had been jneviously demonstrated by blood culture.
The serum in this instance had been procured from
the New York board of health, where it had been care-
fully tested and proved sterile. The case was one of
general sepsis, following amygdalitis and cervical ab-
scess. The only fairly constant effect of each dose
had been a temporary lessening of the delirium.
Whenever there vias severe sepsis with a visible cause,
the first tiling was to remove or thoroughly drain the
contaminating foci. The sediment from the urine ob-
tained by catheter should be stained for bacteria and
examined. The discharge from the wound should be
smeared upon a slide and examined with the micro-
scope. Cultures should be made from the wound dis-
charges and from the blood. If streptococci were
found in the urine, the serum treatment should be at
once instituted in addition to the proper local meas-
ures. If streptococci were found in the wound dis-
charges, and not in the urine, it was better to await
the result of the blood culture test, treating the patient
meanwhile on general principles. So far the efficacy
of the serum had not been proved. Antistreptococcus
serum might be used in any case of bad sepsis when
the exact bacteriological diagnosis was in doubt, but
never to the exclusion of other rational therapy.
April 7, 1900]
MEDICAL RECORD.
613
Serum Containing Mixtures of the Toxins of
Erysipelas and Bacillus Prodigiosus. — Dr. William
B. CoLEY presented this paper. He said that his re-
cent e.xperience had given no reason for changing the
conclusions advanced in his earlier papers. He still
used the mixed unfiltered to.xins of erysipelas and
bacillus prodigiosus, made from cultures grown in the
same bouillon. In patients much reduced in strength,
and in children, it was safer to use the filtered toxins.
The dose depended very largely upon the vascularity
of the tumor and the condition of the patient. The
initial dose should seldom be larger than half a minim.
The injections should be made into the tumor itself,
and should be repeated on alternate days, or sometimes
every day. The temperature reaction should not be
allowed to rise above 103° or 104° F. If within three
or four weeks improvement was not noted, it was hardly
worth while to continue the treatment. These toxins
could be given at short intervals for a long period of
time without harm. In a few instances they had been
administered for three or four consecutive years. He
believed that the action of these toxins furnished ad-
ditional evidence in support of the infectious nature
of cancer. Eleven of his successful cases had been of
the spindle-cell variety, and four of the round-cell
type. In a former paper he had detailed thirty-five
cases more or less successfully treated by other sur-
geons, in twenty-six of which the tumors had disap-
peared. In a few instances the patients had been
known to be alive six or eight years after the treat-
ment. He had used the method in two hundred and
thirty cases, with only two deaths, and these two deaths
had occurred in his early experience, and in patients
who had been so nearly moribund that the treatment
should never have been begun.
Dr. W. Travis Gibb spoke of the use of antitoxin in
diphtheria. He had used it in nineteen fully devel-
oped cases of the disease, in all of which a bacterio-
logical diagnosis of true diphtheria had been made.
Two cases had proved fatal, one of the patients hav-
ing been moribund at the time he had been first seen.
In this case, although the antitoxin had been given early
in the disease, the latter had progressed apparently
without any effect from the antitoxin. The speaker had
ordinarily employed somewhat smaller doses than were
generally recommended. In his experience the tem-
perature had been markedly and permanently reduced,
usually in twenty-four hours, and the extension of the
exudate had been checked and its exfoliation hastened.
He had never seen any unpleasant constitutional symp-
toms follow the use of the antitoxin, and the only local
effect had been an urticaria in the vicinity of the punc-
ture, lasting for a day or two.
Dr. S. a. Knopf said that it was certainly most diffi-
cult to determine the true value of tuberculin in the
treatment of pulmonary tuberculosis, because no phy-
sician would feel justified in treating this disease with
tuberculin alone, neglecting all those measures well
known to be useful. He failed to see that any figures
had been presented pointing definitely to the curative
or beneficial effect of this treatment. He had tried
the antistreptococcus serum in a few cases, but had
not felt that the results were sufficiently definite to
justify conclusions regarding its value.
Varicose Ulcer.— The excellent results obtained in
mal perforans by elongation of the plantar nerves have
led Dr. Chipault {Le Bull. Mai., November 4th) to
extend this procedure to the relief of obstinate varicose
ulcers of the leg. In five cases he has had complete
success, two patients being well after an interval of
two years. The most frequent indication is for elon-
gation of the musculo-cutaneous, associated or not
with that of the internal saphenous.
THE MEDICAL SOCIETY OF THE COUNTY
OF NEW YORK.
Staled Ateeli7ig March 26, igoo.
George B. Fowler, M.D., President.
Senate Bill for the Prevention of Cruelty to Ani-
mals.— This bill had been sent to the committee of the
United States Senate for action. It was the bill that
sought to place restrictions upon experiments on ani-
mals, and was calculated to hamper the advance in,
and imparting of, knowledge indispensable to science.
It was resolved that the Medical Society of the County
of New York protest against the favorable report of
this bill.
Some of the Reasons Why the Surgical Treat-
ment of Nasal Disease Had Been Placed upon a
Conservative Basis. — Dr. Clarence C. Rice believed
that specialists were hampered by certain limitations.
One of the reasons why surgical operations upon the
nose and throat had been modified in frequency and
character was that the specialists were better edu-
cated and were taught that no one portion of the econ-
omy could be considered apart, i.e., independently of
the body as a whole. The difference in nasal opera-
tions to-day as compared with those in the earlier days
was due to the kind of instruments advised at the dif-
ferent periods. A few years ago tissues which were the
seat of vascular swellings were thought to be suitable
for the use of the snare, hence the turbinated tissues
were encircled by the cold wire and removed. This
was a temptation for physicians to perfect themselves
in the use of the snare, also in the use of the galvano-
cautery, as well as of drills and trephines. The injudi-
cious use of these instruments injured the specialists.
Some specialists were operating all over the country.
At the daily clinics the use of these instruments was
demonstrated. Men became infatuated with the desire
to become nose and throat specialists. This infatua-
tion he thought was now rapidly waning. The nasal
cavities in the anterior parts were so easily reached
that much surgical work was encouraged. . This was
really the source of much trouble. A large proportion
of cases of nasal swelling formerly supposed to be
characteristic of hypertrophic rhinitis were really due
to irritation from other parts of the chambers, and the
passive hyperemia was due to disease of organs of the
body quite distant. It was difficult for rhinologists to
determine whether the swellings in the nose were due
to causes remote from the respiratory tract or not.
Etiological factors should be recognized. Before the
use of cocaine it was impossible to determine whether
these swellings were due to remote or local causes.
Men got bad reputations from the distressing consti-
tutional disturbances, due to septic absorption, which
followed surgical work on the nose; to-day this was not
true. Nasal surgery had been greatly improved by the
use of formaldehyde preparations, and greater cleanli-
ness. The etiology of nasal disease was now better
understood, and so operations were less frequent and
smaller amounts of tissue were sacrificed. With proper
treatment many nasal difficulties now disappeared with-
out surgical interference. Alcohol and tobacco were
powerful factors in causing nasal disturbances. Opera-
tions upon persons accustomed to their use were fol-
lowed by a dry, atrophic condition ; often a traumatic
dry rhinitis was caused. He believed that swellings
at the posterior ends of the turbinated bodies, whether
composed of dilated blood-vessels or not, depended
upon anterior obstructions and would disappear when
the septal deformities were removed. The results of
surgical treatment in the field of rhinology were far
better to-day than years ago; this was due to the in-
creased knowledge and a clearer understanding of the
6i4
MEDICAL RECORD.
[April 7, icoo
etiology of nasal affections; and operators had a
greater desire for conservatism.
Dr. Beverley Robinson said that a few years ago
the general conditions of the body, different diathetic
influences, the habits, surroundings of the patient, etc.,
were supposed to be more important than any local
conditions found in the nose. The judgment formed
by him twenty years ago he still retained. At one
time a great many men made skilful use of these in-
struments, and they found they could take away tissue
with relative impunity; a time came, however, when
accidents followed these nasal operations. Some-
times these accidents happened during the operations,
and sometimes they occurred subsequently. A certain
number of nasal affections required the physician
only, and others remained within the province of the
surgeon. When an operation upon the nose of some
moment was required, previous training was very es-
sential. Unfortunately a number of men were going
into this specialty, and this fact caused him consider-
able dread. The majority of young fellows, he thought,
could make a fair diagnosis, but they did much harm.
Advice should be given only by thoroughly trained
men, those who have had opportunities of learning
what to do and knew how to do it, who have had such
previous education as to render them fit to work with-
out doing harm by useless interference. He hoped to
remain long enough in the Academy of Medicine to
see every general practitioner control every specialty
in the land, and to tell one how far to go and that he
should go no further. The dermatologist thought the
human body could not be right unless the skin was
right; the rhinologist thought that the body could not
be right unless the condition of the nose was correct;
and so with every specialty. He wished to convey the
idea that it was impossible for a man in any specialty,
no matter how trained, not to take an exaggerated view
of his own work. He advocated common " horse
sense."
Dr. W. C. Phillips thought the remarks on an
unqualified specialist were out of order in connection
with any medical discussion. All present knew that
a little knowledge was dangerous in any department
of medicine. Many who worked in this region of the
body had come to the conclusion that simply because
they looked into the nose and found a swelling over
the turbinated bone, or a congested septum, surgical in-
terference was necessary. These conditions were very
frequently, in his opinion, symptoms of some disease
in a remote part of the body. He wished to emphasize
the point that no specialist could attain great profi-
ciency without having had large experience as a general
practitioner. Only that day a patient had been sent to
him to have a nasal polypus removed; the patient had
an atrophic rhinitis and slightly swollen tonsils, but
required no surgical interference because he had no
polypus. The speaker referred to disturbance of the
gastro-intestinal tract as a causative agent in certain
diseases of tlie nose and throat; he thought this was
one of the most common causes of nasal symptoms.
The over-use of alcohol and tobacco entered largely
into the causation of nasal troubles. He looked upon
the presence of "colls in the head" in many indi-
viduals as something else than exposure to draughts
and other 'causes. Two patients might be dressed
about alike, and go out on certain days, using great
care to prevent taking cold, yet one would catch cold
and the other would not; why? He believed the ex-
citing causes here were over-work and lack of rest, or
fatigue. Again, he believed that there were many
pathological conditions in the nose that could be
relieved only by surgical interference. When certain
conditions which caused the patient suffering were
found and removed, he called that conservatism.
Dr. Francis J. Quinlan emphasized the importance
of removing the cause and not the effect of diseased
conditions. He referred to certain dyscrasise or dia-
theses, especially the syphilitic and tuberculous. Pro-
phylaxis was something in the reach of everybody, and
he considered the greatest of all such measures water,
both without and within; sunshine, air, and exercise.
These four factors could destroy more disease than
could anything else. If one destroyed the turbinals,
he thought one destroyed the portal to the lungs. In
the study of many of these conditions "knowledge
came but wisdom left."
Dr. Ewil Mayer said it was not generally known
how many sins the general practitioner had to answer
for in the use of the electro-cautery; a large percent-
age of the work done by rhino.logists was in correcting
the work done by the general practitioner in the use of
this instrument. In the nose, the use of the electro-
cautery was very limited. He believed that any work
done was worth doing well, and therefore he never
performed the simplest operations without using the
most rigid aseptic details, with a trained assistant and
trained nurse.
Dr. David Goodwillie referred to the importance
of a knowledge of tiie physiological processes concerned
in respiration. The gateway to the nose was very
important. The mucus in the nose was of use in keep-
ing the nasal membrane from becoming dry, and the
extra amount of it protected against irrespirable gases
or bad air. He had great respect for the mucous
membrane of the nose, which covered so large a sur-
face in so small a space. In the treatment of diseases
of tlie nose he believed we should be more careful in
saving the muciparous glands. He never forgot the
experience of a friend of his, who went to a rhinologist,
who removed hypertrophied tissue and the jnucous
membrane covering it; his friend has since wished he
had never gone, on account of the ease with which he
"caught colds." Much injury was done to the Eu-
stachian tubes and the pillars of the palate by bad
surgery.
Dr. Rice, in closing the discussion, said that every
man was entitled to breathe through his nose, and if
the occlusion in the nose was permanent, it must be
relieved, and the nasal surgeon was competent to do
this, in a conservative way. A great many cases must
be operated upon no matter what the source of irrita-
tion was. The specialist could help the general prac-
titioner, even in cases of intestinal catarrh; here he
could help by curing the existing upper- catarrh, and
so pre\enting the patient swallowing the mucus and
pus.
The Requisites of the Modern General Practi-
tioner ; his Relation to the Community and to Spe-
cialism.— Dr. Augustus Cailli; read this paper. He
said the time was in the memory of all present when
the family practitioner was a trusted counsellor. The
introduction of general and local anaesthetics, asepsis
and antisepsis, and serum therapy, etc., gave such op-
portunities of diagnostic and therapeutic possibilities
that one could not grasp them all. The introduction
of cocaine had been followed by rapid development of
the nose specialist. Bacteriological and chemical re-
search gave such a complexity of terms, and an ava-
lanche of literature that completely swamped the
ordinary medical man, and he could not keep abreast
with the times. These vast strides made the position
of the general practitioner a peculiar one; every young
practitioner felt superior to the older ones. To what
extent should we encourage young men and women to
take up the practice of medicine for a livelihood? It
would appear that medicine was looked upon as a
promising field. That was not so now if the existing
conditions were studied. During the past ten years
the profession had been overcrowded ; there had been
a production of medical men far above the demand.
April 7, 1900]
MEDICAL RECORD.
615
He advised that no one should enter upon this career
without appreciating the difficulties to be overcome
and the hard work and drudgery that were entailed,
(competition was a strong master; it elevated and
degraded. He, then briefly discussed what was the
place in society of the family practitioner, and under
what conditions he would be in demand. He did not
believe that the family practitioner was to become
extinct, for two reasons: first, many intelligent people
would refuse to give up a good practitioner; second,
the public had already largely and seriously suffered
by indiscriminate consultations with immature spe-
cialists. Much of the specialists' operative work de-
served the highest praise, yet the families turned to
the general practitioner. He felt convinced that all
medical men would become competent diagnosticians
and formulate plans of treatment without using so
many worthless drugs, and that they would do more
work at the bedside. The family practitioner must
(1) be master of physical diagnosis; (2) he must have
some laboratory training; (3; he must be able to make
local or regional examinations; (4) he must have a
good knowledge of hygiene and dietetics; (5) he must
be able to perform minor surgery as well as emergency
operations; (6) when feasible, obstetrical cases should
not be handled by the general practitioner. The diffi-
culties of making correct diagnoses were not great if
one went about it in a systematic way. For some
years past he had used diagnostic charts, which he
found to be a great help in making and recording
diagnoses in the office and at the bedside, or in hos-
pital. The reasons why the general practitioner should
not attend obstetrical cases were two in number: first,
it was usually night-work, and the physician who
worked from 10 a.m. to 10 p.m. should go to bed;
second, he was at all times in contact with contagious
or communicable diseases, and so might infect the
parturient woman. He condemned the hurry and
bustle of the present life; it was all wrong. The gen-
eral practitioner, in his opinion, was not sufficiently
paid for the work he did. To counterbalance the loss
of fees from obstetrical work the general practitioner
would have more time at home and in his family, and
more time and ambition to practise minor surgery.
He believed that minor surgery belonged to the general
practitioner; if he had no surgical training, he was
handicapped from the beginning. The knife in con-
servative hands gave much relief. Rheumatism, ty-
phoid fever, tuberculosis, pneumonia, diabetes, and
other so-called medical diseases often presented com-
plications requiring surgical knowledge. Pure surgical
cases frequently developed non-surgical complications.
A simon-pure prescription writer had no future in
practical medicine. Yet he believed that every man
should know his limitations in doing surgery. In
country practice, lie advised that the neighboring doc-
tors should combine and help one another in doing
surgical operations. He thought that nurses, espe-
cially obstetrical nurses, should be encouraged to go
to the country. The rural communities should be
educated to the need of such service. All practitioners
should become familiar with the clinical microscope.
The speaker condemned the drugging habit. Books
on materia medica placed a lot of therapeutic ballast
in our hands. Every few weeks new drugs were forced
upon the physician with the claim that they were a
specific, and many physicians were gulled into trying
them and were disappointed. IMedical literature, he
thought, was on a rampage, and he felt happy that
many physicians could read but one language. The
average practitioner would do well to take one good
weekly journal and one or two monthlies devoted to
some particular line. How else could the general
practitioner keep up with progress and art? He ad-
vised country practitioners to take a post-graduate
course. He did not believe that the dispensaries and
hospitals were utilized as they should be; the best
hospitals were teaching hospitals. Must post-graduate
work be taken abroad, or could it be gotten better here.'
He had visited Germany, England, and France, and
was familiar with the ;iost-graduate institutions there.
In laboratory work he believed that Europe was ahead
of us, but not in any practical work in medicine and
surgery. " Why fly to a foreign shore, when the best
is at your door? "
Dr. George M. Edebohls thought the advice to the
general practitioner was timely, as the successful ones
occasionally found it difficult to determine Just what
course to pursue. For the first fourteen years of his
professional career he was engaged in general practice;
at the end of that time he was in the same dilemma
that many practitioners were to-day, and could not
decide whether to pursue a general practice or take up
some specialty. At that time the specialists were
having the best of it ; they were better paid for their
work; they were able to time their work, and could
devote some time to occupations other than that of
medicine; they could take vacations. So when the
opportunity offered he embraced the career of a spe-
cialist. A young man working in the city should from
the beginning work every day on some special line.
He then cited an instance showing the importance of
a knowledge of general medicine in following a spe-
cialty. He was called by a general practitioner of
excellent reputation, of great accomplishments, who
stated the case of a woman, four or five days after
delivery, having puerperal fever, with a tempera-
ture of 104° F. and rapid pulse, etc. He was asked
to curette 'the uterus, as it was desired to have the
uterus emptied. He took the precaution of first ex-
amining the patient thoroughly, and he found an acute
pericarditis, and nothing at all wrong with the sexual
organs. Had the woman been chloroformed death
would certainly have followed.
Dr. S. Adolf Knopf said he was much impressed
with what had been stated regarding materia medica
as taught in medical schools; there they lacked train-
ing in hygiene and diet, especially in telling how food
should be prepared. We must look to the general
practitioners to combat tuberculosis, because they saw
the incipient cases. To them we must turn for detect-
ing early tuberculosis.
Plcdicat Items.
Review of Surgery for the Past Hundred Years.
— Mr. H. G. Howse ends his elaborate review of sur-
gery during the last one hundred years, delivered be-
fore the Royal College of Surgeons of Great Britain,
on December 13th, with these words: "And yet while
wondering at and admiring all the great advances of
the last one hundred years, while hoping for similar
great advances in the future, while urging our pathol-
ogists and bacteriologists to pursue these investiga-
tions which may have such an important influence
upon the treatment of disease in the future, it may be
wise to add a word of warning. There is a tendency
in making these complicated investigations to con-
clude too much from a single instance. Very grave
errors will arise in the conclusions of the future unless
investigators will guard themselves most carefully from
this error. In other directions we are all apt to be-
come too dogmatic in our views, which are based on
indisputable facts — views, however, which on further
examination we find it necessary to modify in accord-
ance with our increasing knowledge and experience.
Nowhere is this shown more strikingly than in the
6io
MEDICAL RECORD.
I April 7, 1900
rapid changes of antiseptic and aseptic details in the
treatment of wounds which have chased each other
like cloud-shadows across our surgical stage during
the last twenty years. It may reasonably be doubted
how far some of these details are really scientific and
how far they are mere fads. I would conclude this
lecture, then, by quoting an admirable saying attributed
to the late master of Trinity College, Cambridge:
•■ We are none of us infallible; no, not even the young-
est of us."
Confectionery in Army Rations. — The Germans
about ten years ago introduced the use of candy into
the diet of their soldiers. The idea was the outcome
of experiments undertaken by the German government.
It was demonstrated that the addition of candy and
chocolate to the regular ration greatly conduced to the
improvement of health and endurance of the troops,
and at the present time the army authorities in Ger-
many issue cakes of chocolate and a limited amount
of other confectionery. The British were the next to
follow this example, and the queen, as has been ex-
tensively advertised, forwarded five hundred thousand
pounds of chocolate in half-pound packages as a
Christmas treat for the soldiers in South Africa. Jam
has also found great favor with the British War Office,
and 1,450,000 pounds have been dispatched to South
Africa as a four months' supply to 116,000 troops.
The United States is following in the same path, and
candy has been added to the regular army ration of
the American soldier. It is stated that one New York
firm has shipped more than fifty tons of confectionery
during the past year for the armies in the Philippines,
Cuba, and Porto Rico. The candy supplied is of ex-
cellent quality, consisting of mixed chocolate creams,
lemon drops, cocoanut maroons, and acidulated fruit
drops. These are packed in tins specially designed
to fit the pockets of a uniform coat. The question of
providing jam with the army ration is also under con-
sideration.
Insects as the Cause of Contagion. — The role taken
by insects as vehicles of contagion assumes every year
a more important position in the estimation of clini-
cal observers. It is exceedingly probable that the
common house-fly was the carrier of contagious mate-
rial from wound to wound in the days when hospital
gangrene prevailed in epidemics. The initial case
was usually one of syphilitic phagedaena, and the flies
did the rest. The same might not improbably be the
case in many instances of hospital erysipelas. In
purulent ophthalmia as observed in hot climates and
in the army, and to less extent occasionally in Eng-
lish practice, flies no doubt were the chief agents in
its spreading. In the epidemics of school ophthalmia
they are again to be suspected. The spread of the
ague germ by means of mosquitos is now an estab-
lished fact, but here we have an instance of the para-
site breeding in the tissues of the insect and not of its
mere transference. The suggestion that mosquitos
are a means of contagion in leprosy has had its advo-
cates. It is, however, I think, conclusively negatived
by the fact that of the European immigrants into lep-
rosy districts scarcely any contract the disease. — Jon-
athan Hutchinson's "Archives of Surgery."
Seats for Shop Assistants in Great Britain.— The
" Act to provide for seats being supplied for the use of
shop assistants," which received the royal assent on
August 9th, this year came into force on January ist.
Tlie act is short — it only contains four sections; so
" Ignorantia legis neminem excusat " specially applies
in this case. As the first two sections, which contain
all the necessary information on this new piece of
legislation, do not occupy many lines in the statute
book, it will not be out of place to set them forth
verbatim. The first section describing the scope and
effect of the new law provides that " in all rooms of a
shop where goods are actually retailed to the public,
and where female assistants are employed for the re-
tailing of goods to the public, the employer carrying
on business in such premises shall provide seats be-
hind the counter, or in such other position as may be
suitable for the purpose, and such seats shall be in
proportion of not less than one seat to every three
female assistants employed in each room." The sec-
ond section deals with the penalty for non-compliance
with the above provisions. The last section states
that the new act is to be construed and read as one
with the Shop-hours Act, 1892 to 1895, or, in other
words, the provisions of these acts, in so far as they are
not inconsistent, are. to apply to this act. The Shop-
hours .Act places a limit on the number of hours dur-
ing which young persons under eighteen years of age
may be employed in a week.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended March 31,
1900 :
Cases. Deaths*
Smallpox— United States.
Illinois, Aurora March 3d to 17th 7
Chicaso March 17th to 24th 3
Indiana. Evansville March 17th to 24th 6
Kansas, Wichita March 17th to 24th ■!
Kentucky, Covington .March 17th to 24th
Louisiana. New Orleans March 17th to 24th /i 14
Maine. Portland March 17th to 24th i
Michigan, Detroit March 17th to 24lh 2 i
Minnesota, .-Mbert Lee March 20th 2
Anoka Co. March zoth 15
Butterfield.. March 20th i
Freeborn Co .... March 20th 15
Lesueur Co March 20th i
Minneapolis March 20th 43
Northfield March 20th 7 "
Rice Countv.,.. March 20th i
St. Paul March 20th 6
W^atonwan Co. . , March 20th 2
Nebraska, Omaha March 17th to 24th i
New York, New York March 17th to 24th 2
Ohio, Cincinnati March 17th to 23d i t
Cleveland March 17th to 24th 10
Pennsylvania, McKeesport , March 17th to 24th i
South Carolina, Greenville. ..March 17th to 24th 2
Utah, Salt Lake City March 17th to 24th 6
Virginia, Millboro, liath Co. March i6th 12
Portsmouth March 17th to 24th 1 X
Washington, Spokane March 17th to 24th 2
, West Salem .. . .March 21st 5
Smal
-FOKE
Austria, Prague March 3d to loth 3
Belgium, .\ntwerp March 3d to loth 3
Brazil, Rio de Janeiro February 2d to oth 25
Canada, Province of Mon-
treal March 26th i
Cuba, Santiago March 14th Reported.
Ei;ypt, Cairo February i8th to 25th
England, Birmingham March 3d to toth 2
London February 24th to March 3d 7
France, Lyons February 24th to March 3d
Greece, Athens March 3d to loth 7
India, Bombay February 13th to 20th
Calcutta February 3d to loth
Kurrachce February nth to i8th 12
Mexico, Chihuahua March loth to 17th
City of Mexico February 25th to March 4th. . . . 68
Vera Cruz March loth to 17th
Russia, Moscow February 25th to March 3d 6
Odessa March 3d to loth 7
St. Petersburg February 17th to March 3d 47
W'arsaw . . February 17th to 24tli
Spain, Corunna March 3d to icth
Madrid . February 24th to March 3d
Straits Settlements. Singa-
pore February 3d to loth
Yellow Fever.
Brazil, Hahia February 17th to March 3d 2
I^io de Janein February 2d to qth
Colombia, Barranquilla March 3d to 10th '. 2
Panama March 1 5th to 20th 2
Cuba, Havana March nth to 17th
Mexico. Laguna .March 4th Several.
. February 13th to 20th .
. February 3d to 10th . . .
PLACfE— iNStfLAR POSSESSIONS UnI'
Hawaii, Honolulu March 22d
Philippine Islands, Manila ..To February 13th .
India, Bombay February 13th to 20th. . .
Calcutta February 3d to loth . . , .
Kurrachce February nth to 18th. . .
Medical Record
A Weekly yottrnal of Medicine and Surgery
Vol. 57, No. 15.
Whole No. 1536.
New York, April 14, 1900.
$5.00 Per Annur
Single Copies, fo\
©figinal ^^vticlcs.
DIFFUSE SEPTIC PERITONITIS, WITH SPE-
CIAL REFERENCE TO A NEW METHOD OF
TREATMENT, NAMELY, THE ELEVATED
HEAD AND TRUNK POSTURE, TO FACILI-
TATE DRAINAGE INTO THE PELVIS. WITH
A REPORT OF NINE CONSECUTIVE CASES
OF RECOVERY."
By GEORGE R. FOWLER, M.D.,
URGEON TO
The peritoneum is virtually an enormous lymph sac,
and therefore peritonitis is lymphangitis. The ab-
sorbents of the structure of the peritoneum are repre-
sented by the lymphatics, and the protection which
these afford against infecting agents by exudative ma-
terial thrown out (thrombo-lymphangitis) to act as
a defensive barrier by blocking the lymph channels
serves to preserve the life of the subject, on the one
hand; while a failure in this respect, either because of
the enormous and overwhelmingly rapid increase of sep-
tic material and the large size and number of channels
necessary to destroy or obstruct, on the other hand,
permits the destruction of the organism. Hence
rapidly proliferating bacterial invasion means more or
less absorption, perhaps sufficient to destroy life, be-
fore proper protection has been afforded in the manner
mentioned. Or, on the contrary, a slow proliferation
permits of the formation of exudative barriers to the
extent of arresting further absorption and saving life.
The bacterial fluid present in a case of peri-
tonitis is a transuded fluid, which, in the process of
transudation, forces the endothelial cells from the
peritoneal lymphatic surfaces; the desquamated cells,
together with leucocytes and other cell-forms, floating
about in the fluid. In cases of recent origin flakes of
lymph are also present in the fluid. Patches of a
coagulated albuminous substance, the result of the exu-
dation of an albuminous fluid from the lymph channels
and of fibrin from the blood (fibrinous exudate), appear
as a soft, reddish-gray substance more or less adherent
to the peritoneal surfaces, and here and there bridging
over the spaces between adjacent coils of intestine,
through the medium of which they adhere together.
The infecting agents also present in the fluid are
invaders to be gotten rid of or prevented from pro-
liferating and exerting their baneful effects, through
the medium of the larger leucocytes, or macrophages
of Metchnikoff, which migrate to the peritoneal cavity
for this purpose. In order to effect their purpose
these must come in contact with the microbes, either
investing the latter to imprison and sterilize them, or
checking their movements by simply adhering to them.
The presence of a large quantity of fluid in the cavity
of the peritoneum must necessarily interfere greatly
with this contact between the leucocytes or macrophages
and the invading and proliferating bacteria, since the
' Read before the Brooklyn Surgical Society, March I, 1900.
Enlarged and revised since its first presentation.
contact, under these circumstances, must be more o\
less infrequent and of an accidental character. It ia
now believed that one of the functions of the omentum^
is to bring about this contact by its movements in the
peritoneal cavity causing the bacteria to adhere to its
surfaces, where they are readily attacked by the leu-
cocytes. This view is supported by the clinical fact
that whenever a focus of infection exists in the peri-
toneal cavity, there are more than likely to be found
omental folds, reaching out, so to speak, for the bac-
terial intruders and becoming adherent to the perito-
neal surfaces adjacent to the focus during the process.
Not all of the regions of the peritoneum possess the
physiological power of absorption to the same extent,
for the reason that certain anatomical differences pre-
clude this. For instance, the portion possessing this
in the highest degree is the region of the diaphragm,
where large lymph trunks are present, the open mouths
or stomata of which stand ready to take up and transport
to the system at large whatever fluid with its contained
pus, blood, bacteria, or toxic products of the latter,
may present itself. The size of both lymph trunks
and stomata in this region is such as to prevent
their early or rapid obliteration through thrombo-
lymphangitis, and hence the organism may be destroyed
through the widespread distribution of septic material
before this can occur. This is particularly true of that
portion of the region of the diaphragm known as its
central or tendinous portion.
The region in which the anatomical conditions
favoring rapid absorption exist in the next highest de-
gree is the intestinal. Here there likewise exist large
lymph trunks and stomata, but not to the same extent
as are found in the region of the diaphragm. These
are, however, sufficiently numerous to render this
region a dangerous area of absorption.
Turning now to the remaining region, namely, the
pelvic, we find that the non-absorptive character of the
peritoneum is apparent. Microscopical study of this
portion of the peritoneum reveals the fact that, while
it is rich in capillary lymphatics, large lymph trunks
and stomata are comparati\ely absent. The smaller
lymph vessels of this region become much more
rapidly obstructed, and hence absorption from this
region proceeds very slowly, and finally ceases alto-
gether, the arrest being coincident with plugging of
the capillary lymph vessels with lymph thrombi, the
result of infection and consequent inflammation of the
lymph vessels themselves, aided by pressure from with-
out, the latter resulting from peri- and paralymphan-
gitis. This cessation persists until the toxic properties
of the contents of the pelvic cavity are either destroyed
or neutralized, when absorption is resumed through
some, but not all, of the vessels. Many of the latter
remain permanently closed. The latter circumstances
correspond to the clinical fact that in some patients
many attacks of pelvic peritonitis result in the forma-
tion of chronic exudates, due to the inability on the
part of the absorbents to remove the latter, at least
for a long time.'
' See the able presentation of the facts bearing- upon this sub-
ject by Dr. Byron Robinson, of Chicago, in an article entitled
" The Pathology of the Lymphatics of the Peritoneum," in the
Annals of Surgery, vol. .x.\xi.. No. 2, p. 214.
6i8
MEDICAL RECORD.
[April 14, 1900
It is likewise probably true that a certain immunity
is conferred upon the peritoneal structure of the pelvis
through previous attacks. And inasmuch as invasion
of the pelvic cavity may readily occur through fecal
stasis in the adjacent rectum in both sexes, and
through the open mouths of the Fallopian tubes in the
female, it is fair to assume that a certain degree of
immunity or non-susceptibility is possessed by the
peritoneum in that region through the permanent
closure of its lymphatics, which is not shared by that
in the other regions.
Reasoning from the facts above set forth, the prac-
tical surgeon should be able, in support thereof, to
bring to bear evidence that the pelvic peritoneum is
less liable, to become the seat of danger in cases of
septic invasion of the latter. He should be able to
show, first, that the pelvic peritoneum possesses a cer-
tain degree of non-susceptibility to bacterial invasion;
second, that when this does occur the spread therefrom
is sufficiently slow to permit of the formation of exu-
dativ barriers protecting the more susceptible ente-
ronic and diaphragmatic areas; and third, that the
occurrence and retention of large quantities of septic
fluid in the pelvic cavity do not give rise to the symp-
toms referable to the system in general character-
istic of the presence of such fluid in the cavity of the
peritoneum. In support of this contention that these
requirements are successfully met by clinical experi-
ence, the following is offered:
It has long been noted by surgeons that septic in-
flammatory processes when confined to the most depen-
dent portion of the peritoneal cavity remain quiescent
and without urgent symptoms for quite a period of time,
as compared with a like condition of affairs existing in
that portion of the peritoneal cavity situated above the
pelvis. The facts that puerperal infection occurs with
comparative infrequency in the large number of cases
of labor among the poor, attended by those but little
if at all acquainted with aseptic methods; that this,
when it does occur, extends to the general peritoneum
in a relatively small proportion of cases in which the
peritoneum of the pelvic region is involved; and, still
further, that infective processes in this region do not,
as a rule, give rise to the same grave symptoms as an
equal area of peritoneum infected in the abdominal
cavity — still further suggest the theory that the peri-
toneum in this region is possessed of qualities which
enable it, first, to resist infection; second, to limit the
infection within its own area when it does occur, and
third, either so to modify the virulence of the infec-
tion or to resist the absorption of its toxic products as
to prevent, in the great majority of cases, the grave
constitutional symptoms characteristic of an equally
extensive infection of the peritoneum above the pelvis.
These qualities are still further emphasized by the fact
that operative procedures involving the pelvic peri-
toneum performed by the vaginal route, conducted as
they must necessarily be in close proximity to a region
difficult, if not impossible, of even relative disinfection
and isolation, namely, the anal region, seem less
liable to be followed by septic peritoneal inflammation
than the same procedures conducted by the abdominal
route. In the case of suppurative salpingitis, at least,
it cannot be urged that this comparative immunity is
due to the non-entrance of septic or pyogenic micro-
organisms, since, in order to remove the parts involved,
it becomes necessary to breakdown limiting adhesions;
in some instances rupture of the walls of abscess cavi-
ties occurs as well, thus leading to contamination of
the surroundings in spite of a preliminary aspiration
of the contents. Yet the patient escapes the peritoneal
inflammation which so frequently follows when inva-
sion of the general cavity of the peritoneum by the
pus occurs, as it will in spite of every precaution.
The claim that this comparative immunity is due to
the fact that the infecting organism largely concerned
in pelvic inflammation, namely, the gonococcus of
Neisser, is not necessarily pyogenic in character, in
the cases of pyosalpinx at least, falls to the ground in
the face of the experience of surgeons in those instances
in which this micro-organism is sufficiently virulent
to produce the metastatic joint conditions known as
gonorrhoeal rheumatism, which, after all, is but a va-
riety of pyeemia. So pronounced does this joint con-
dition sometimes become that destructive processes
following this infection occur, bacterial examination
of the fluids of the joint removed by operation show-
ing the undoubted presence of the gonococcus. I am
aware that a contrary view is held by many competent
and careful observers, Kelly particularly, who states
that, in many hundreds of bacteriological examina-
tions made, he lias never yet been able to demonstrate
this micro-organism as the etiological factor in the
production of septic peritonitis. It is nevertheless
true that other and well-known organisms capable of
producing both local and general septic conditions are
destroyed after a time by the growth of other and more
vigorously active bacteria, failure to identify these
resulting. It cannot therefore be absolutely claimed
that the gonococcus is non-infecting to the peritoneum,
since the micro-organism frequently attacks the serous
lining of joints. On the contrary, experience seems
to prove that it has a special affinity for serous mem-
branes, since it rarely invades by metastasis other
structures. In common with many others, I at one
time believed that the pus from a pyosalpinx ruptured
during the removal of a gonorrha;al pus tube by the
abdominal route would do but little if any harm, even
if it did come in contact with unprotected intestine
and thereby found its way into the general peritoneal
cavity. But I have long since learned by sad experi-
ence the fallacy of this view, and while admitting that
the gonococcus infection may do comparatively but
little if any harm to the peritoneum of the pelvic
cavity, yet I am more than convinced that its contact
with that portion of the folds or reflections of the peri-
toneum constituting the mesentery of the small intes-
tine is fraught with danger. At the present time my
plans to prevent this accident are as well laid, and my
anxiety lest it should occur as keen, as if I knew for
a certainty that I was dealing with a violently infec-
tious micro-organism.
Aside from the virulence of the bacterial contents
of abscesses resulting from non-puerperal pelvic in-
flammation, the latter, as it arises from full-term deliv-
eries and from abortions as well, may be considered.
Here the claim cannot be made that the infecting agent
is of a less virulent character than those which gain
entrance to the cavity of the general peritoneum; cer-
tainly it will not suffice to say that all cases of pelvic
peritonitis in the female are due to gonococcus infec-
tion. Yet how many of this class come under the sur-
geon's knowledge in which the septic processes are
confined to the pelvis, and in which the local infection
is out of all proportion to the general symptoms, in
precisely the same manner as the cases indubitably
due to gonorrhceal infection. And the same may be
said of those cases in which the uterus is accidentally
punctured during a curettage for septic conditions of
the endometrium. That such accidents occur more
frequently than is generally supposed, I am convinced,
yet I am informed by a well-known obstetrician and
gynaecologist who comes in frequent and intimate
contact with those who follow especially this kind of
surgical work, that these do not regard the occurrence
of this class of accidents as of grave importance; not
sufficiently so, at least, to warrant opening the peri-
toneal cavity for purposes of repair, much less for
cleansing and drainage.
So too with cases of infection of the pelvic perito-
April 14, 1900]
MEDICAL RECORD.
619
neum occurring in tlie male — such, for instance, as the
production of false passages between the bladder and
rectum, and involving the recto-vesical pouch of peri-
toneum at the hands of careless or unskilful practi-
tioners. In one case of this kind I opened the abdom-
inalcavity and found the pelvis the seat of what was
evidently a virulently infective inflammatory process,
yet the latter was absolutely confined to the pelvis,
although but few limiting adhesions were present, and
these of the flimsiest character. Sufficient time had
elapsed, and ample opportunity had been afforded for
spread of the infection to the peritoneum, yet this had
not occurred. Certainly the local symptoms possessed
a gravity out of all proportion to the general symp-
toms present in the case.
I turn now to the cases in which opportunities for
the invasion of the pelvic peritoneum by the most
indubitably virulent micro-organisms, such as those
escaping from the intestinal canal, are afforded. This
mode and character of infection are perhaps exemplified
more frequently in cases of appendicitis in which the
organ points downward into the pelvis, and in which
early perforative ulceration or gangrene leads to the
escape of the contents of the organ. It not infre-
quently happens, in tracing the appendix into the
pelvis, that the latter is brought up to view either per-
forated or gangrenous, this being followed by a gush
of sero-purulent fluid, or, as sometimes happens, the
presence of the latter is discovered only by passing
gauze grasped in a long forceps into the depths of the
pelvis; and then follows the removal of quantities of
this septic fluid by the same means. I have thus re-
moved astonishingly large quantities of this material,
and yet the patient's condition, either general or local,
gave not the least suggestion beforehand that such a
condition would be encountered. And, unfortunately,
in some of these cases the manipulations incident to
the removal of the fluid has led to infection of the peri-
toneum above the pelvis in spite of every effort to pre-
vent this, with the result of loss of the patient's life
from diffuse septic peritonitis, the infecting material
coming into contact with the general peritoneum not-
withstanding every precaution of walling off the latter
with a large number of gauze compresses.
It was during the after-treatment of a case of diffuse
septic peritonitis the result of early perforation of a
violently inflamed appendix directly into the peri-
toneal cavity and between the coils of small intestine,
and in which I had placed a glass drain as well as a
number of wick drains deep in the pelvis, that the line
of thought above expressed occupied my mind. My
assistant. Dr. R. S. Fowler, had been in the habit of
treating cases of vomiting following etherization by
raising the head of the bed as high as possible con-
sistent with comfort, thus bringing the force of gravity
to bear in facilitating normal peristalsis. In view of
the favorable course which the case then in hand was
pursuing, it was determined to adopt this as a routine
procedure for the purpose of facilitating the passage of
septic fluids from the general peritoneal cavity to that
of the pelvis, where, according to the reasoning above
outlined, it would do but little harm, comparatively
speaking, and from which locality it could be more
readily removed by drainage methods. This has been
done, and a further experience with the method seems
to bear out the favorable opinion first entertained of
this measure as of value in aiding to combat the mor-
tality in this much-dreaded condition.
The angle assumed has varied somewhat, but I in-
sist that the elevation of the bed from the horizontal
shall be at least from twelve to fifteen inches. In
order to prevent the patient from sliding down in the
bed a large pillow is placed folded beneath the flexed
knees, and upon this the buttocks rest. The pillow is
prevented from sliding by a piece of stout bandage
passed through at the folded portion and secured to
the sides of the bedstead.
The following is a list of the cases consecutively
treated by this method to date;
Case I. — October 17, 1899; Brooklyn Hospital.
Diffuse septic peritonitis from a combined appendic-
ular and adnexal lesion, originating, in all probability,
in the appendix. The accessible parts of the cavity
of the peritoneum were treated with equal parts of
peroxide of hydrogen and saturated solution of bicar-
bonate of sodium, which was finally flushed away with
decinormal saline solution, after which the abdominal
cavity was dried out as thoroughly as possible. Two
glass drains were placed in the pelvis and wicking
drains inserted in these. The drainage tubes were
dressed separately from the abdominal wound.
After-treatment; The head of the bed was raised
and kept so for seventy-two hours. The glass tubes
were cleared every two hours by aspirating their accu-
mulated contents by means of a long pipette. Copious
saline enemata were given, with the usual stimulating
treatment, consisting of sulphate of strychnine and
citrate of caffeine. The glass drains were withdrawn
on the eighth day, and hemmed gauze strips substi-
tuted. Recovery resulted. Bacteriological examina-
tion of material taken from the remote upper portion
of the peritoneal cavity at operation showed staphylo-
coccus infection.
Case II. — October 23, 1899; Brooklyn Hospital.
The patient presented the typical clinical picture of
diffuse septic peritonitis, with a history pointing to
perforative appendicitis as the cause. No hope was
held out for recovery, and I hesitated about operating
at all. The operation revealed a perforated appendix
lying free in the peritoneal cavity and a large quan-
tity of foul-smelling sero-pus. The abdominal cavity
was flushed with the peroxide of hydrogen and bicar-
bonate of sodium solutions, finally washed away with
decinormal saline solution. The abdominal cavity
was dried out, and combined glass and wicking drains
were placed in the pelvis. •
After-treatment: The head of the bed was raised.
The tube was cleared of its contents every hour for the
first six hours, then every two hours. Saline enemata,
one pint, were given every hour as long as the rectum
was tolerant. The ice coil was applied for relief of
pain. Sulphate of strychnine in gr. y\ doses was given
every three hours. There was no vomiting until the
third day, when the head of the bed was lowered; in
a short time the passage of flatus, which had occurred
at intervals previously, ceased, and vomiting occurred.
The latter was at first bile-stained, but with rapid dis-
tention it soon became fecal. Through a misunder-
standing the head of the bed was not raised again for
twelve hours, at the end of which time, following a
return to the elevated head and trunk posture, improve-
ment in the symptoms commenced and was steadily
progressive, so that at the end of another twelve hours
the patient expressed himself as feeling comfortable.
Owing to delay in the bacteriological report antistrep-
tococcic serum was employed for the first three days,
but this did not seem to exert any influence. The
glass and wick drains were removed on the tenth day.
Right-sided phlebitis of the saphenous vein developed
on the nineteenth day. The head of the bed was kept
elevated for three w^eeks. Staphylococcus growth was
identified. The patient recovered.
The phlebitis .vhich occurred in this case may have
been due to the increased difficulty experienced by the
return circulation owing to the unnecessarily prolonged
elevated head and trunk posture. Sonnenburg, who
has called attention to the complication of phlebitis
of the veins of the lower extremity following abdom-
inal section, advises raising the foot of the bed as a
prophylactic measure.
620
MEDICAL RECORD.
[April 14, 1900
Case III. — October 31, 1899; Brooklyn Hospital.
Operation by my assistant, Dr. Russell S. Fowler;
recurrent appendicitis, with diffuse septic peritonitis.
The abdomen was distended and rigid, and no gas had
passed for thirty-two hours. The appendix, gangrenous
throughout and perforated at the tip, and containing
an enterolith as large in diameter as the thumb nail,
was found lying against the cjEcal wall, which was
likewise gangrenous. The appendix was removed and
the gangrenous spot on the bowel wall enclosed in
Lembert suture. A large quantity of foul-smelling
pus and sero-purulent material was scattered through
the peritoneal cavity. Cultures were taken from dis-
tant portions of the latter. The cavity was sponged
thoroughly with dry gauze, and twenty-one wick drains
were disposed throughout the cavity of the peritoneum,
including the pelvis, and led out of the operation
wound. After-treatment consisted in raising the head
of the bed, saline enemas every hour, and large doses
of strychnine. The amount of fluid which flowed
from the drains during the first twenty-four hours
soaked the dressings copiously, the patient's clothing,
and the bed. The distention showed marked decrease
within twenty-four hours, and gas passed per rectum
freely and frequently. The temperature reached nor-
mal on the third day and remained so. All drains were
removed by the eighth day. Both lower extremities
were massaged daily to prevent blood stasis and con-
sequent phlebitis. Bacteriological examination showed
both staphylococcus and streptococcus infections, the
latter predominating.
Case IV. — December 7, 1899; German Hospital.
The patient was admitted with perforative peritonitis
of appendicular origin, and presenting the typical pic-
ture of diffuse peritoneal inflammation. Upon opening
the abdomen free sero-pus was found to be present.
The peritoneum was of a dusky cherry-red color as far
as could be seen in all directions, and the coils of
intestine were greatly distended and covered in places
with lymph. The appendix was gangrenous and per-
forated. The peritoneum of the abdominal and pelvic
cavities was sponged clean with simple sterile gauze
and all lymph deposits were removed. Gauze-drain-
age strips were placed in different directions, includ-
ing a large drain of the same material into the pelvis,
and led out of the abdominal wound.
After-treatment: The head of the bed was elevated
and kept so for six days. Fluids were given ad libi-
tum, as soon as the patient recovered from the anaes-
thetic, and of these he partook freely. There was no
vomiting. Distention rapidly disappeared, gas passed
per rectum, and the patient was practically beyond the
period of anxiety by the fifth day. The drainage strips
were removed in stages, a strip being removed each
day, that from the pelvis being the last; they were all
out by the eighth day. During the first three days the
amount of fluid removed by the drains from the peri-
toneal cavity, as represented by the soaked dressings
and bed, was enormous. Recovery followed. No
bacterial examination was made.
Comment: This patient received scarcely any medi-
cation, the main reliance being placed upon drainage,
posture, and the free ingestion of fluids. The latter
was made possible by the absence of vomiting after
the operation, although this had been a distressing
feature before the abdomen was opened. The removal
of large quantities of fluid from the peritoneal cavity
through the medium of the drains was a pronounced
feature of this case. I have always looked upon this
as being exceedingly favorable from the prognostic
standpoint. This seems to be borne out by the obser-
vation that cells suspended in fluid cannot act so vigor-
ously as when localized in the endothelial surface, and
hence cannot, when so suspended, destroy so many
bacteria, not only on account of the lessened chance
of encountering the bacteria, but because the latter are
not so liable to adhere to the cells. With the with-
drawal of the fluid the cells reach the endothelial sur-
face, where they assert their aggressiveness upon the
bacteria by their own power of movement {vide supra).
Case V. — December 13, 1899; German Hospital.
The patient was admitted with peritonitic facies, dis-
tended and rigid abdomen, with a history of a two-
days' illness and symptoms pointing to appendicitis.
The onset of the attack had occurred while the patient
was on her knees scrubbing the floor. No previous
history pointing to the existence of a tumor or of
menstrual disturbances was obtained. The operation
revealed a diffuse septic peritonitis with evidences of
recent rupture of an ovarian cystoma, the chocolate-
colored fluid from which had invaded the cavity of
the peritoneum above the pelvis. This was carefully
wiped away as far as possible with dry sterile gauze,
and two glass drains with wicking inserted were
placed in the pelvis.
After-treatment: The head of the bed was elevated;
strychnine and citrate of caffeine were given in moder-
ate doses, vi'ith hourly enemas of saline solution. The
tube was cleared by the aspirating pipette every two
hours, and from a half ounce to two ounces of dark-
colored serum was removed each time. There was no
vomiting. Rapid improvement followed. Gas passed
within six hours. The tubes were removed and re-
placed by gauze strips on the fifth day. Recovery was
uneventful. No bacteriological examination was made.
Comment: In a case bearing a remarkable resem-
blance to the one narrated in all respects, wliich came
under my care shortly before I commenced the postural
feature of the after-treatment, and in which every de-
tail of the treatment was identically the same with the
exception of the elevated head and trunk position,
death took place on the fifth day from steady and pro-
gressive advance of the disease and general septic
infection. In fact, I have always looked with much
apprehension upon cases of this character, in which
the rather heavy and chocolate-colored contents of an
ovarian cystoma have escaped into the general perito-
neal cavity. This case will be referred to later in this
paper.
Case VI. — December 15, 1899. The patient was
admitted to my service at the German Hospital with a
perforative peritonitis of appendicular origin. Dis-
tention and general rigidity were marked. Operation
by my assistant. Dr. R. S. Fowler, revealed a perfo-
rated appendix lying free in the peritoneal cavity, and
a diffuse septic peritonitis present. The peritoneum,
as far as could be determined by the incision, was
deeply reddened. The intestinal coils were covered
in patches with lymph and greatly distended. There
was a large quantity of free sero-purulent material in
the cavity of the peritoneum. The abdominal cavity
was sponged dry with sterile gauze, and all lymph de-
posits were removed. Numerous strips of iodoform
gauze were placed in different parts of the. abdominal
cavity and pelvis, and led out of the operation wound.
After-treatment: The head of the bed was raised
and left so for three days. Saline enemas were given
to the extent of their toleration by the rectum, and
fluids v^'ere administered freely, with moderate stimu-
lation by means of strychnine and citrate of caffeine.
The drains were removed singly and upon separate
days; the last was removed on the sixth day. Recov-
ery followed. There was no bacteriological examina-
tion.
Case VII. — The patient was admitted to my service
January 24, 1900, in the German Hospital, with a his-
tory of recurring attacks of appendicitis, the last of
which came on six days previously. Upon admission
the usual anxious expression was visible, with greatly
distended and rigid abdomen. Operation was done
April 14, 1900]
MEDICAL RECORD.
621
by my assistant, Dr. R. S. Fowler. The abdomen was
opened by an incision placed at the outer edge of the
right rectus muscle. Free pus was present in the peri-
toneal cavity, with the usual widespread and deeply
reddened peritoneum. Three distinct abscess cavities
were found in addition: one in the neighborhood of
the appendix, one just below and extending behind the
liver, and a third, containing about sixteen ounces of
sero-purulent material, in the pelvis. The first two
contained about four ounces each. The appendix was
perforated. After excision of the appendix the ab-
scess cavities were emptied and carefully cleansed with
gauze wetted with i : 3,000 bichloride solution. The
general peritoneal cavity was carefully dried, and
gauze drainage strips led from the remote portions of
the latter to the operation wound. The abscess cavi-
ties were also drained in the same manner.
After-treatment: Elevation of the head of the bed
was kept up for five days. Strychnine and citrate of
cafiFeine were given in moderate doses. There was
gradual withdrawal of the drains. No vomiting took
place. Fluids were allowed to the extent of the pa-
tient's desires in that respect. There was an enormous
amount of fluid carried off from the peritoneal cavity
by the drains. The patient recovered. No bacteri-
ological examination was made.
Case VIII. — February 27, 1900; Methodist Epis-
copal Hospital. This was a case of post-operative
diffuse septic peritonitis. The patient was operated
upon for extensive ventral hernia resulting from an
operative attempt to remove a myomatous uterus five
years previously. Infection probably resulted from
the use of an unusually thick strand of catgut (always
difficult of sterilization) in ligating an exceptionally
dense adhesion. Symptoms of peritonitis commenced
within eight hours of the operation and increased with
alarming rapidity until the entire peritoneal cavity
was involved. The distribution and tenderness were
extreme, the pulse 160 and feeble, and the peritonic
facies well marked. The head of the bed was raised
twelve inches from the horizontal; stimulants were ad-
ministered (strychnine and caffeine), calomel was given,
followed by salines; enemata of lac asafoetida were em-
ployed, and antistreptoccic serum was given. In spite
of all these the alarming symptoms continued until
the fourth day, when I accidentally learned that when-
ever the enemata were given the head of the bed had
been lowered and the foot raised, to facilitate the re-
tention of the latter. This had occurred quite fre-
quently for the reason that saline enemata were likewise
given in the intervals of giving the lac-asafoetida rectal
injections. Upon investigation I found that this had
been done about every three hours since the com-
mencement of the treatment, the patient remaining
in this position on an average of a quarter of an hour
each time. The patient's condition at this time
was alarming in the extreme. She lay with her eyes
half opened and the globes rolled up; the abdo-
men was barrel'-shaped; the pulse was almost imper-
ceptible at the wrist, and the jactitation required the
use of morphine. She had complained after each time
of raising the foot of the bed of a burning sensation
along the oesophagus; finally vomiting set in, and she
rejected what was given by the mouth. The rectum
had finally become intoleraiit, and her sufferings were
extreme. It was at this time that the error was dis-
covered and rectified. The head of the bed was per-
manently raised, and from this time improvement
commenced. Flatus was expelled in copious quanti-
ties, and liquid movements of the bowels were obtained.
The morphine was stopped, the ice coil being found
to be sufficient to relieve the abdominal distress. By
the second day following the persistent use of the ele-
vated head and trunk posture her morale had so
improved that she greeted me with a smile- the pulse
had gradually fallen to 116 and was greatly improved
in strength, and she was beyond the stage of anxiety.
She finally recovered completely.
Case IX. — March 2, 1900; German Hospital. The
patient, a young man aged sixteen years, was admitted
with acute appendicitis of two days' standing. In
spite of the fact that the attack was comparatively
recent, a diffuse septic peritonitis was already under
way. The abdomen was board-like and tympanitic,
the peritonitic facies was present, and tenderness was
extreme. Upon opening the abdomen sero-purulent
fluid was found to be present, in which flakes of lymph
were floating; the entire tract of the small intestine
was intensely reddened, and fibrinous exudate was pres-
ent. A long perforated appendix lying in the midst
of the unprotected small intestines was brought out of
the wound and removed. Eventration was then per-
formed, the intestine being laid on the abdominal wall
and well covered with gauze compresses, which were
frequently wetted with warm saline solution. The
immediate region from which the appendix had been
removed was treated with two ounces of equal parts
of peroxide of hydrogen and a saturated solution of
bicarbonate of sodium. No attempt was made to dis-
seminate this throughout the peritoneal cavity; and as
much of this was removed as possible by flushing with
saline solution, before proceeding further. The ab-
dominal and pelvic cavities were then repeatedly
washed out with large quantities of saline solution
poured from a pitcher, at least twelve gallons being
thus employed. The abdomen was then dried out, and
the intestines were returned; a glass drain carrying a
strip of iodoform gauze was placed in the pelvis and
dressed separately from the abdominal w'ound, which
was sutured down to the glass drain.
After-treatment: Elevated head and trunk position.
Plenty of fluid was allowed, and no medication save
small doses of strychnine and caffeine to bridge over
the first shock of the operation, which was severe.
Aspiration of the glass drainage tube was done every
six hours. No vomiting occurred. Small doses of
calomel (gr. 4 every half-hour) were given until two
grains had been taken. Normal peristalsis commenced
within four hours, resulting in the expulsion of flatus,
and liquid stools passed on the second day. Recovery
followed. Bacteriological examination of cultures
taken from remote portions of the peritoneal cavity
showed infection.
Thus it will be seen that, of nine consecutive cases
of diffuse septic peritonitis treated by the combined
methods of elevated posture and drainage, all have re-
sulted in recovery. I have not included among these
several cases in which a spreading peritonitis existed
about a focus of infection, as shown by decided redness
of the coils of intestine in the neighborhood, and which
were apparently arrested by the elevated head and
trunk position. I may say, however, that in these cases
the convalescence has been rapid, and the patient's con-
dition has seemed to be more comfortable than is usual
during the first few hours following the operation,
mainly through the absence of vomiting. Because of
this, however, and with the object of utilizing the ele-
vated head and trunk posture as a prophylactic meas-
ure, I would strongly recommend the latter in all cases
of abdominal section, even at the risk, if Sonnenburg's
view of the mechanism of the production of phlebitis
of the veins of the lower extremity following this
operation should prove to be correct, of the occurrence
of this complication.
For the purpose of comparison I have taken an equal
number of cases of diffuse septic peritonitis occurring
in my hospital services, the dates of which embrace
a period of time corresponding as nearly as possible
to that in which the foregoing were observed, and
which were subjected to the same measures of treat-
622
MEDICAL RECORD.
[Apni 14, 1900
nient with the exception of the elevated iiead and trunk
posture. Of these nine cases four patients recovered
and five died. These cases were not taken consecu-
tively, nor yet, on the other hand, were they selected
cases. Had they been taken consecutively there would
have been made a manifestly unfair record to any
method of after-treatment, since the group would have
included two cases which resulted fatally within
twenty-four hours of- the operation, and there would
have been seven fatal cases out of nine, instead of five.
Further investigation of the records does not increase
the proportion of recoveries greatly, and, after making
all due allowance for those cases which have ended
fatally from conditions which destroyed the patient
before any plan of after-treatment could have been
effective, say within twenty-four hours of the opera-
tion, it has been practically impossible to lower the
death rate but slightly below fifty per cent. It may
likewise be stated, in passing, that the further back
the records are searched the higher the mortality be-
comes.
The record of nine consecutive cases of diffuse sep-
tic peritonitis terminating in recovery is extraordinary,
not to say startling, and no reasonable surgeon could
expect such uniformly good results, even in groups of
cases in which milder forms of infection are alone in-
cluded, and from which patients living less than twenty-
four hours are excluded. For it falls to the unhappy
lot of every surgeon occasionally to encounter cases
in which the deep brown or mahogany color of the
intestine indicates a profoundly septic inflammation
present in its muscular structures, which no means yet
known is capable of successfully combating, and in
which the patients even live beyond twenty-four hours.
Yet in three cases in this group the infecting organism
was identified, and in at least one of these the much-
dreaded streptococcus was present. The following is
Aihiiiiic of the nine cases treated without the addition
of the postural feature of the first nine:
Case I. — January 26, 1898; Methodist Episcopal
Hospital; acute appendicitis with perforation and
diffuse septic peritonitis. Gauze drainage was used.
The patient died. No bacteriological examination
was made.
Cask II. — January 27, 1898; Methodist Episcopal
Hospital; acute salpingitis from infection by a uterine
sound while under office treatment by the family phy-
sician. Diffuse septic peritonitis was present. Gauze
drainage was used. Antistreptococcic serum, with
saline infusion, wa-s given. The patient recovered.
No bacteriological examination was made.
Case III. — May 23, 1898; Methodist Episcopal
Hospital; gangrenous appendicitis and diffuse septic
peritonitis. Gauze drainage was used. Recovery took
place. No bacteriological examination was made.
Case IV. — March 17, 1899; Methodist Episcopal
Hospital; acute appendicitis and diffuse septic peri-
tonitis. The abdomen was cleansed with decinormal
salt solution. Flakes of lymph were removed with
sterile gauze. Gauze strips for drainage were inserted
in the general peritoneal cavity. Recovery took place.
No bacteriological examination was made.
Case V. — April 8, 1899; Methodist Episcopal Hos-
pital; acute appendicitis with perforation, and diffuse
septic peritonitis. The abdominal cavity was flushed
with decinormal saline solution. A glass drain was
inserted in the pelvis, and iodoform-strip drains were
passed from the abdominal peritoneum to the operation
wound. The patient died. No bacteriological ex-
amination was made.
Case VI. — September 14, 1899; Brooklyn Hospital;
ruptured ovarian cystoma with chocolate-colored con-
tents. Diffuse septic peritonitis was present. Glass
drains were inserted in the ptlvis and gauze strips
from the abdominal cavity to the operation wound.
Saline infusion and antistreptococcic serum were used.
The patient died. No bacteriological examination
was made.
Case VI. — October 28, 1899; Methodist Episcopal
Hospital; gangrenous appendicitis; diffuse septic peri-
tonitis. The abdomen was dried out with sterile gauze.
Glass drains were used in the pelvis. Recovery re-
sulted. No bacteriological examination was made.
Case VIII. ^November 2, 1899; Methodist Epis-
copal Hospital; acute appendicitis; diffuse septic peri-
tonitis. Iodoform gauze drains were used in the
abdominal cavity, and a glass drain in the pelvis. The
patient died. No bacteriological examination wais
made.
The remaining case in this series possesses an espe-
cial interest in this connection for the reason that a
novel and what may prove upon further trial a valuable
addition to present methods was employed. I refer to
the plan of securing drainage at the site of the root of
the mesentery of the small intestine by a transversely
placed rubber drainage tube through the latter, and
repeated irrigations through this of large quantities of
decinormal saline solution.'
Case IX. — February 22, 1900; German Hospital;
the patient was admitted with diffuse septic peritonitis
of appendicular origin. Operation revealed large
quantities of sero-purulent material scattered through-
out the general peritoneal cavity, with intestines mat-
ted together, pus, and with large patches of lymph.
The appendix was violently inflamed, but not perfo-
rated. After removal of the appendix eventration was
done, the intestines being removed loop by loop, and
the coils carefully cleansed and the fibrinous patches
removed by carefully wiping with sterile gauze. The
intestines were then allowed to rest upon the abdominal
wall and carefully covered with towels wrung out of
warm salt solution. These were reinforced as to their
heat from time to time, and shock from the disem-
bowelling process was thus effectually guarded against.
The peritoneal cavity was then flushed with several
gallons of warm saline solution. A large rubber drain-
age tube was then passed through the root of the mes-
entery of the small intestine at about the middle of the
abdominal cavity, and the ends were led out of open-
ings made for the purpose in each flank in such a
manner that the tube traversed the abdominal cavity
in a transverse direction, being held down in the cen-
tre by passing through the mesentery. A similar tube
was led from behind the liver and spleen, and two
from the pelvic cavity, separate openings being made
for the passage of these as directly as possible through
the abdominal wall.^ The intestines were then returned
to the abdominal cavity, and the operation wound was
closed. Saline solution was passed through the upper
tubes; this flowed freely from the lower ones.
After-treatment: Strychnine and citrate of caffeine
were given for stimulation, with saline solution and
whiskey by the rectum. Irrigation of peritoneal cavity
through the tubes was done with a gallon of saline solu-
tion at 100° F. every six hours. With each irrigation
gas passed freely per rectum. The distention subsided,
vomiting ceased, and several spontaneous evacuations
of fluid fneces took place. At the commencement of
each irrigation seance, the fluid came through the
lower tubes turbid, but before the gallon of irrigating
fluid was exhausted it became clear. The general
septic symptoms from which tlie patient was suffering
when admitted, however, steadily progressed; she be-
came delirious, and death took place from septicaemia
thirty-six hours after the operation. No bacteriological
examination was made.
I am aware that there are several sources of fallacy
in estimating the value of conclusions drawn from the
study of any method of treating diseases of bacterial
' Bode : Centralblalt fur L'hirurgie. No. 2, Kjoo.
April 14, 1900]
MEDICAL RECORD.
■ 62-
origin, and the relation which the method bears to tlie
results in any group of cases. Briefl}', these fallacies
have their origin in the relation which the following
factors in the individual case bear to the result: (i)
The pyogenic properties of the infecting agent; (2)
the number of organisms present; (3) the suscepti-
bility of the individual; (4) the inhibitory influences
sometimes exerted by the peritoneal fluids upon micro-
organisms. Elimination of the first of these, namely,
the pyogenic properties of the infecting agent, is pos-
sible to a certain extent by proper bacteriological
examination. The second, the number of organisms
present, is capable of elimination only within certain
limits, such, for instance, as the statement that the
fluids were " swarming with bacteria," that the latter
vera present in " moderate quantities," or that " but few
were found." But how shall we estimate the degree
of susceptibility of the patients who perished, or the
influences exerted by an immunity present in those
who survived.' To this individual factor of vital
resistance are to be ascribed many of the discrepancies
in results in groups of cases as they are presented, and
which vitiate more than anything else statistics as they
relate to different plans of treatment as advocated.
This relates not only to the local susceptibility to in-
fection and its spread, but to the general susceptibility
as well. Yet the individual may possess an immunity
to infection entirely independent of the factor of vital
resistance. While it is true as a general proposition
that those greatly depressed physically are more liable
to perish from suddenly developed infectious processes,
whether or not the latter is made possible by an oper-
ative procedure, it is likewise true that some individ-
uals possess a decided immunity to infection entirely
independent of any apparent high grade of physical
condition on the one hand, while others exhibit a
susceptibility altogether disproportionate to previously
existing active or actually debilitating influences on
the other hand.
A word as to the conditions present in the cases
that have been denominated " diffuse septic perito-
nitis." It has been my happy lot to meet occasionally
with conditions in which large quantities of opaque
milky material, consisting of desquamated endothelial
cells, leucocytes, and perhaps other cell forms floating
about in a copiously transuded peritoneal fluid, have
been found present in the general abdominal cavity,
unaccompanied by any signs of peritonitis, the pa-
tient's recovery following as if such fluid had not been
present. In these instances the fluid has been found
as to its infective qualities to be insufficient to pro-
duce more than enough irritation to lead to an in-
creased quantity of secretion of the peritoneum and to
add some turbidity to the latter as described, the inhibi-
tory or even destructive powers of the peritoneal fluids
to the micro-organisms accounting for the sterility and
consequent failure of infection. These have not been
classed as cases of peritonitis. But when all perito-
neal structures, both parietal and visceral, within sight
from an ordinary abdominal section are observed to
have exchanged their pearly pink color for a decided
red or bluish-red, and particularly if this condition
extends to the mesenteric folds of the small intestine,
and patches of fibrin and pus cling to the surface of
the latter, there can be no question as to the propriety
of designating such a case as one of diffuse septic
peritonitis.
If asked what, in my opinion, is the best general
line of treatment for diffuse septic peritonitis as found
to exist upon opening the peritoneal cavity, I might
hesitate to express myself as being either for or against
eventration or disembowelling for purposes of method-
ical cleansing; as well as the employment of peroxide
of hydrogen solution, or the use of large quantities of
decinormal saline solution for purposes of flushing out
the peritoneal cavity. But there are two points upon
which I would not hesitate to speak with confidence,
namely, the employment of the elevated head and
trunk position, and drainage of the pelvic cavity at
least by means of properly placed and protected glass
drains. I offer this as a method preferable to Clark's
position, which is the exact reverse of this treatment,
and I do it with the full knowledge of the alleged ana-
tomical and physiological reasons advanced in support
of the last-named method. Clark's position certainly
does jiot empty the pelvic cavity of septic fluid, for the
extent to which the patient must be inverted to accom-
plish this is incompatible with safety, or with his
comfort to say the least, since practically he must be
placed standing on his head. This was demonstrated
by Dr. Eastman, the resident pathologist at the Brook-
lyn Hospital, in a series of experiments performed
upon cadavers at my request. It is fortunate for those
patients who have recovered under this treatment (and
I might have said, in spite of this treatment) that this
is true, for the reason that this would not only lead to
the still further spread of septic fluids through the in-
testinal region of the peritoneal cavity, of itself a suffi-
ciently dangerous area from the infective standpoint,
but the septic fluids from the pelvis would finally reach
the exceedingly dangerous infective area of the dia-
phragm, particularly the central tendinous portion of
the latter, with its large lymph trunks and numerous
stomata, which rapidly absorb blood, pus, and in fact
fluid of whatever sort, with its contained bacteria and
toxic de'bris, instead of being allowed to remain in or
flow to the pelvic cavity, in the peritoneum of which
are found but very few lymph trunks and stomata, and
the capillary lymphatics of which soon become ob-
structed by lymph thrombi which prevent further spread
of infectious material. For with the involvement of
these lymph vessels the function of the latter is de-
stroyed by the obstruction caused by thrombi, this
constituting the method by which further invasion of
peritoneum is prevented and the organism itself pro-
tected as well. Under these circumstances transfer-
ence of the septic fluids from the most dangerous areas
of the enormous lymph sac constituting the peritoneal
cavity to its least dangerous region, namely, the pelvic
portion thereof, and in case of operative attacks re-
moving these from the latter by properly placed and
protected means of drainage, constitute not only a
rational but an imperatively demanded procedure.
OBSERVATIONS AND SUGGESTIONS CON-
CERNING HYPODERMOCLYSIS.
By ROBERT COLEM.A.N KEMP, M.D.
NEW VORK,
The Ilio - Lumbar Region for Hypodermoclysis:
There have been numerous locations advocated for
the subcutaneous injection of normal saline solution
— such as beneath the breasts in females, in the chest,
abdomen, thigh, axillary space, cellular tissue of the
neck, back, etc. I would suggest, however, a re-
gion that seems especially advantageous — the space
between the highest part of the crest of the ilium, and
the lower border of the ribs — in effect the loin, but
rather the outer margin of the lumbar region, and
which for convenience I have denominated ilio-lum-
bar. It does not interfere with the dorsal posture, nor
do movements of the limbs or neck, or thoracic or ab-
dominal respiration, cause discomfort. It would seem,
in fact, to be a point of very little motion. The illus-
tration (Fig. i) which was drawn from life by Mr.
Thomas Nast, Jr., clearly demonstrates the method.
624
MEDICAL RECORD.
[April 14, 1900
I am aware that some inject antitoxin into this
region, and also that the lumbar site has been em-
ployed for hypodermoclysis, but I believe the punc-
ture to be more dorsal in location. The lateral lum-
bar region would seem to be more advantageous, and
I think it should be more frequently made the point
of selection. It is not within the province of this
article to describe the methods and indications for
hypodermoclysis, but to direct attention to certain fea-
tures, M'hich I trust may prove to be of some interest.
The normal (or, strictly speaking, decinornial) saline
solution should be employed; the formula, roughly
speaking, being in the proportion of 3 i. of salt to
Oi. of water. The solution should be sterile, also the
needle, and the region to be punctured should be ster-
ilized. The fountain syringe or the Davidson's sy-
ringe should also be sterilized. The character of the
increased renal secretion, and at the same time the
Prussian-blue reaction with chloride of iron, in one
and one-half to two minutes. The urine drops were
counted by means of the registering lever and kymo-
graph to avoid possible error. The quantity infused
was so small as to have no appreciable effect on the
general circulation, no rise of tension being noted.
As regards hypodermoclysis, a subcutaneous injec-
tion of saline solution, to which a weak solution of
potassium ferrocyanide had been added, caused in-
creased renal secretion in three and one-half to four
minutes, coincident with the Prussian-blue reaction to
chloride of iron. This was the average length of time
under normal conditions, and even when very small
quantities were employed the increased renal secre-
tion was noted as before.
By enema, I have noted clinically, as have others,
needle, the temperature of the fluid, and the regulation
of tlie flow, together with the rapidity of absorption,
I shall speak of later.
The Specific Efl'ect on Renal Secretion Produced
by Small Quantities of Normal Saline Solution: That
there is a specific effect produced oa renal secretion
by even small quantities of normal saline solution, I
believe it to be impossible to controvert. This holds
true whether it is administered by infusion, hypoder-
moclysis, or enema. Thus Foster has demonstrated
an immediate increase in the renal secretion, follow-
ing an infusion with saline solution, even when an in-
fusion of so small a quantity was given that no change
in the general blood pressure occurred, and when in
addition there was a complete severance of all the
renal nerves, evidently a specific effect on the secret-
ing cells of the kidney. Also in my own article,
entitled " Physiological Experiments with Intestinal
Irrigation," etc., published in the AWc' York J\fcdi-
cal Journal, January 29, 1898, experiments were re-
ported regarding the effects of infusion and hypoder-
moclysis on renal secretion. An infusion of saline
solution, to which a small amount of a weak solution
of potassium ferrocyanide had been added, the total
amount of fluid infused being less than 3 ss., gave
the enormous increase of renal secretion following
even very small enemata of normal saline solution.
Thus in response to 3 ix. of normal saline solution,
given at half-hour intervals in divided doses — 3 iii.
at each injection^ — there resulted forty ounces of urine
within five hours from the first injection. Only ten
ounces of bloody urine had been voided in the previous
ten or eleven hours. The urine after the injections also
was much less bloody in appearance. This is reported
in "Transactions of the Association of American Phy-
sicians," vol. xiii., 1898, page 402, as a case of chronic
infective endocarditis, a patient of Dr. William H.
Thomson. I have noted frequently this enormous re-
sponse to small enemata of normal saline solution- —
often three to five times the amount of urine being se-
creted, as compared with the quantity of saline ir.-
jected. My own experience seems to show that the
smaller quantities frequently repeated give better re-
sults than a few single large injections.
With hypodermoclysis, I have observed clinically,
in a case of nephritis complicating diphtheria, an in-
jection of 3 iii.-iv. of normal saline solution caused
a secretion of urine nearly five times the quantity,
within four hours. The blood and albumin previously
existing disappeared and the casts diminished in num-
April 14, 1900]
MEDICAL RECORD.
625
ber. In another case, the patient, having albumin and
casts in the urine, was operated on for tuberculous el-
bow-joint. Nitrous oxide and oxygen were adminis-
tered for thirty-five minutes. A hypodermoclysis of
3 vi. of normal saline solution was given before the
anaesthetic was removed. The patient passed a third
more urine in volume, the first twenty-four hours after
operation, than in a corresponding time before it.
The albumin disappeared and the casts lessened in
number. Other illustrations could readily be given,
and I have already called to your attention the phy-
siological demonstration of the diuretic action of small
quantities of normal saline solution by subcutaneous
injection.
In the Deutsfhes Archiv fiir klinische Alcdici/i, Len-
hartz, in an article entitled "The Therapeutic Value
of Saline Infusion in Acute Diseases," advocates fre-
quently repeated injections, preferably subcutane-
ously and in moderate quantity, as promoting the
excretion of injurious substances better than the em-
ployment of a very large volume of saline at each in-
jection, given less frequently. My own view coin-
cides with that of Lenhartz. I believe that the
specific action of small quantities of normal saline
solution on renal secretion has been clearly demon-
strated, and advocate 3 ii.- 3 vi. injected frequently — •
every three or four hours — as a better diuretic and
causing less strain on the kidneys than Oi. given
three or four times daily.
Elimination, as I have demonstrated, begins in
three and one-half to four minutes, and the smaller
quantities of saline would soon be cast off. Hypo-
dermoclysis is an excellent method to employ. The
objection often urged as to a large quantity being neces-
sary and hence painful, thus "falls to the ground,"
since small amounts are frequently more efficacious.
The Rapidity of Absorption is Modified by Ex-
isting Clinical Conditions: I have already briefly
described the method by which I demonstrated that
elimination of normal saline solution, given subcuta-
neously, begins in three and one-half to four minutes
after the injection has been made. This is under
normal conditions of the circulation. In the course
of my experiments I noted that when normal saline
solution was infused into the veins, elimination through
the kidneys commenced in one and one-half to two
minutes. If normal saline solution was given by
enema or enteroclysis, the weak solution of potassium
ferrocyanide again being added to it, the reaction ap-
peared in the urine in twenty minutes. Dr. L. Bolton
Bangs clinically has secured the reaction of potassium
iodide in the urine in twenty minutes after its admin-
istration by enema.
Now though hypodermoclysis under normal condi-
tions is in rapidity of entering the circulation next to
infusion itself, yet under certain other clinical condi-
tions the absorption is much delayed, and for practi-
cal use it is actually the least rapid in its action of
the three methods. For a clearer understanding of
the matter I will speak of certain, so to speak,
"mixed" or rather "complex" effects of enteroclysis,
since this can be employed as an adjunct to hypoder-
moclysis to hasten the absorption. With hot saline en-
teroclysis at iio°-i2o° F., I have the following effects:
First: An instantaneous marked increase in general
arterial pressure — in other words, an immediate stim-
ulation of the circulation and of a most marked char-
acter. This powerful effect does not occur when lower
degrees of temperature are employed, but does so at
from iio°-i2o° F.
Second: At about the end of ten minutes this stim-
ulation seems to attain its highest degree, and the
pressure remains stable. This was demonstrated in
the experiments on " shock from hemorrhage," in the
article to which I have referred.
Third : The increase of renal secretion as a result
of saline enteroclysis at a high temperature (iio°-
120° F.) begins after about ten minutes' irrigation,
coincident with this " height," so to speak, of gen-
eral stimulation of the circulation.
Fourth : The increase of blood and body tempera-
ture also begins to manifest itself about this period
(ten minutes after enteroclysis is begun).
Fifth : A second, and quite m'arked, increase of
renal secretion is noted at the end of twenty minuets'
enteroclysis, and this is coincident with the appear-
ance of the Prussian-blue reaction, or due to absorp-
tion from the intestine.
Now, in urasmic conditions with a feeble circula-
tion, or in shock, or any condition of such a character,
the absorption of the lymphatics will also be nearly
at a standstill; and even a small hypodermoclysis will
take a considerable length of time to be absorbed. A
subcutaneous injection, besides, has a certain degree
of tension to overcome (caused by the pressure of the
fluid itself), and also does not possess the advantage
of stimulating by its heat, since a high degree of heat
might be harmful in circumscribed cellular tissue
under high tension, especially with the blood supply
already enfeebled. In fact sloughing has occurred in
the breasts from a too great (or too rapid) injection
of saline solution.
Hot saline solution distributed over a large surface,
as the peritoneum, or given by enteroclysis or enema,
is an entirely different matter. There is here no re-
sistant tension of high degree to be overcome; the
fluid has a wide area of distribution for absorption,
and, most important, there is an immediate reflex stim-
ulation of the circulation itself from the heat, and
hence in turn rapid lymphatic absorption.
In any clinical condition in which the general circu-
lation is markedly impaired, hypodermoclysis is natu-
rally a slower method than under other conditions;
nevertheless it is of great value, for I find that, even
so, absorption can be hastened by the addition of en-
teroclysis (af iio°-i2o° F.) while performing the
hypodermoclysis, or even by a simple hot saline
enema. I would advocate enteroclysis (continuous)
at iio°-i2o° F. while giving the subcutaneous saline
injection. Gentle peripheral massage during the in-
jection also hastens absorption, and clinically I have
noted excellent results secured by this combined
method.
On the other hand, I shall mention a certain class
of cases in which, though the rapidity of absorption is
lessened, yet the results secured by hypodermoclysis
would seem exactly to fulfil the indications. I refer
to hypodermoclysis in hemorrhage from typhoid or
gastric ulcers. This method seems to possess consid-
erable value in these conditions. As I have just
demonstrated, if the shock is severe, the method is
somewhat slow, and more active measures are also re-
quired. In hemorrhage with moderate or even fairly
severe collapse it may be of itself efficacious. It re-
places the loss of blood, and also on account of enter-
ing the circulation indirectly through the lymphatic
system is not so likely to start up hemorrhage by
a more sudden and marked stimulation, as is in-
fusion. The saline solution is claimed by some also
to have certain hemostatic qualities. I have fre-
quently noted during the past seven summers in the
Adirondacks, that some advocate giving small amounts
of salt water by the mouth in cases of pulmonary
hemorrhage, claiming this effect. Saline solution by
the mouth I believe might be liable to cause vomit-
ing and thus aggravate the bleeding, but I mention
nevertheless the claims set forth. Overstimulation
after pulmonary hemorrhage I have noted, however,
with resulting secondary hemorrhage. I mention
this danger, therefore, and believe hypodermoclysis
626
MEDICAL RECORD.
[April 14, 1900
to be safe and often efficacious, stimulating, so to
speak, to tfie " safety line." Dr. William H. Thomson
recently secured brilliant results in a case of hemor-
rhage from typhoid ulcer at Roosevelt Hospital, and
I obtained an excellent result in a case of gastric
ulcer with severe hemorrhage.
Hypodermoclysis in Poisoning: This method would
certainly seem of value in cases of poisoning, espe-
cially by alkaloids, as it aids elimination through
the kidneys and stimulates the heart and respiration.
In mushroom poisoning this method has been em-
ployed, and with success, it is claimed. Infusion has
also been used. In belladonna poisoning I would
suggest its value. Since belladonna is markedly elimi-
nated through the kidneys, hypodermoclysis in mod-
erate amount and frequently repeated would be of
service. Frequent catheterization of course should be
employed. In opium poisoning, or in poisoning from
other causes, it is worthy of trial.
Hypodermoclysis in Pleurisy with Effusion : I
have found this of value in this condition, especially
if insufficient diuresis is an etiological factor. In
a case of this character it has been recently employed
immediately following aspiration. An excellent re-
sult in double pleurisy with effusion due to renal in-
sufficiency was secured on similar principle by hot
enteroclysis in a case of Dr. U'illiam H. Thomson's.
The effusion was absorbed without aspiration, in con-
sequence of the diuresis produced. Renal insufficiency
was the cause of the effusion. Hypodermoclysis could
be employed in ascites or dropsy, or pulmonary oedema,
etc. It should not be given in cedematous tissue.
Hypodermoclysis in entero-colitis in infants and
children, etc., is of special value to replace the loss
of fluid. The method has long been employed. Dr.
R. H. M. Dawbarn in 1892, I believe, was the first
so to use it in this country.
Hypodermoclysis as an Eliminative in Diphtheria
following Antito.xin Injection : Experimentally we find
that if a serum injection is followed later by a nor-
mal saline hypodermoclysis, renal congestion is much
lessened. Thus in ral)bits large doses of normal
horse serum or antistreptococcus serum caused con-
siderable renal congestion, as shown by pathological
examination. The same doses of these serums if fol-
lowed by saline hypodermoclysis caused markedly
less congestion. Naturally hypodermoclysis should
not immediately follow antitoxin injection, as it would
probably eliminate the serum rapidly; but if given
three or four hours later, it would aid in the elimina-
tion of the toxic products of the diphtheria, and also,
it would seem to me, in the removal of any toxic prod-
ucts of the serum if such existed, or if the patient
should be especially susceptible.
Hypodermoclysis in Nephritis Complicating Diph-
theria; Enteroclysis also of Value: In this condition
I recently secured a brilliant result in a patient of
Dr. William H. Thomson. Renal complications ap-
peared at once before antito.xin was administered —
casts, albumin, a small amount of blood, and dimin-
ished secretion. Antitoxin (board of health), 4,500
units, was given: 1,500 the first dose, with no im-
provement; 3,000 five hours later. I believe frankly
that a much larger dose should have been given on the
first occasion. The renal condition still persisting
four hours after the second injection, a hypodermo-
clysis of 3 vi. of normal saline solution in the loin
was given, followed at once by enteroclysis with nor-
mal saline solution at 115° F. for thirty minutes.
Four hours later a second enteroclysis was given, and
the urine immediately increased in quantity; in twenty-
four hours only a few casts were found, and in forty-
eight hours there was nothing abnormal. This was
certainly most satisfactory.
Hypodermoclysis with Sodium Salicylate as a Diu-
retic in Uraemia, etc. : Dr. S. J. Meltzer has reported
a most interesting case- — a patient of Dr. Robert Abbe,
of this city. The patient was suffering from urjemic
suppression, and Dr. Meltzer, having noted the diu-
retic eft'ect of sodium salicylate in his experimental
researches, employed it clinically and with excellent
results.
Hypodermoclysis in Preparation for Operation, or
during Anaesthesia; Indications: One frequently sees
patients brought to a hospital suffering from trau-
matism, such as a compound fracture, or even cases
requiring minor amputations, in which there has been
some loss of blood, and moderate stimulation may be
necessary. I do not mean a condition of true shock,
or a border-line case even, when infusion would be in-
dicated. The customary procedures of heat, strychnine,
whiskey, and hot rectal enema may have been em-
ployed. In such a case I advocate a preliminary
saline hypodermoclysis of moderate size, ; vi.-viii., to
replace the loss of blood, and to be given before opera-
tion. The somewhat slow absorption under such con-
ditions could not overstimulate the heart and cause
increased hemorrhage at operation, an objection that
has been made to preliminary infusion in moderate
collapse. I believe in just such cases hypodermo-
clysis to be an ideal method, to be followed on the
operating-table by a hot saline infusion for the "pre-
vention of shock," as first suggested by Dawbarn. In
other words, a hypodermoclysis given as a " preven-
tive" on the same principle with the "hot saline
enema" added, may often render the "preventive in-
fusion " unnecessary. I do not mean to minimize
the value of " Dawbarn's method," since I thor-
oughly advocate it, having frequently seen its gqod
results. I merely follow in his footsteps, believing
that more attention should be paid even to slight hem-
orrhage before operation, and by replacing this loss of
blood I aid in eliminating some danger.
In a case in which renal trouble is suspected, or is
known to exist, a preliminary hypodermoclysis before
operation might prove of value, f iv., ; vi., or 3 viii.,
and repeated again before the anaesthetic is removed.
In the AtK' York Midkal /oiimal, December 2, i8gg,
in the conclusion of an article entitled " Further Ex-
perimental Researches on the Effect of Different An-
aesthetics on the Kidneys," I cite a patient of Dr.
William H. Thomson, upon whom I operated for
tuberculous disease of the elbow-joint. Nitrous oxide
and o.xygen were selected as the anaesthetic, as the pa-
tient had a small amount of albumin in the urine and
also granular casts. Dr. Bennett administered the
anaesthetic for thirty-five minutes. A hypodermocly-
sis of 3 vi. of normal saline solution was given in the
iliolumbar region just before the removal of the anaes-
thetic. Though albumin was present in the urine the
day before and the morning of the operation, even in
the urine voided just before anaesthesia was begun,
and also a considerable number of casts were found,
the albumin was absent after operation; the casts di-
minished in number, and the urine increased twenty-
three ounces, twenty-four hours after operation, over
the amount voided twenty-four hours previously. The
patient had at no time any difficulty whatever. This
case is certainly suggestive at least, and as such is
reported. If shock occurs during operation, or if it is
feared from any cause, hypq/dermoclysis should be em-
ployed as an adjunct to other methods. As a post-
operative procedure, in renal complications, sepsis, or
shock, it is unquestionably a valuable adjunct.
A Single Attachment Converting an Aspirating
or a Hypodermic Needle into a Needle for Hypo-
dermoclysis.— This attachment consists merely of a
small fitting, with a screw thread of a size suitable to
screw into the average aspirating or hypodermic-needle.
It has an enlargement adapted to fit snugly the rubber
April 14, 1900]
MEDICAL RECORD.
627
tube of a fountain syringe or Davidson's syringe. It
is a simple and cheap device to save tlie trouble of
tying into the tube the average needle, which is gen-
erally of small calibre even at its base. The attach-
ment being metal can be boiled. An aspirating-needle
of convenient size for hypodermoclysis can be pur-
chased with it if so desired.
JOHN R£y:ID£HS &Ca/V.>
Regarding the needle, I may say that I have per-
formed hypodermoclysis with successful results, even
with the finest hypodermic needle and a fountain sy-
ringe. In such a case the fountain syringe had better
be elevated six or seven feet, as the force exerted by
the fine stream is slight, and extra back pressure is
desirable. The fluid should flow freely from the
needle as the puncture is being made. If the flow
ceases, on account of the resistance to the small stream,
pushing the needle in and then withdrawing it slightly
or rotating it will generally start it again. This ces-
sation of the flow is generally due to the small point
of exit becoming clogged by the cellular tissue, and
these movements will free it.'
There is a great loss of heat when the fine needle is
employed, and the fluid in the fountain syringe should
then be about as hot as the hand can bear comfortably,
or about 110° F. It will reach the tissues at about
the proper temperature. If the larger aspirating-needle
is used, the fluid can be at 105° F., as even here there
is considerable loss of heat.
The pain of the puncture can be avoided by freezing
with ethyl chloride. Peripheral massage hastens ab-
sorption.
Doubtless many of these suggestions may prove to
be already well known, yet I believe that merely by
calling them to the attention of my professional breth-
ren they may be more frequently employed with benefit
than they have been heretofore.
NITROUS OXIDE AND ETHER AN.^.STHESL\.
By H. W. carter, M.I).
Nitrous oxide and ether anaesthesia, the nitrous oxide
being used as a preliminary to ether, has been em-
ployed in England for a good many years, but until
recently has been little used in this country. Tlie
method heretofore commonly employed in the United
States was to use the gas through the American appa-
ratus to the point of complete surgical narcosis, after-
ward using a separate inhaler to carry on the ether
administration. This method, though a great im-
provement over the ordinary way of giving ether, is
still imperfect, as a great deal of gas is required, and
patients frequently partially recover from its effects
before ether narcosis is established. The method
usually employed in England, that of using a com-
bined gas and ether inhaler, is far preferable, as the
two agents are mixed after unconsciousness is pro-
duced, and the gas is not discontinued until satisfac-
tory anjEsthesia results. Owing to the expense of the
English apparatus, however, and to the difficulty of
replacing its parts when out of order, it has been little
' This attachment can be converted into an improvised anti-
tcxin syringe, by connecting a small glass syringe with a sharp
point by means of a short piece of tubing. The antito.xin can
be measured with the barrel of the hypodermic syringe, before
taking it up with the glass syringe. The impiovised syringe can
be easily boiled.
used here. Recently there has been placed upon the
market an apparatus of American make which is the
equal in every detail of the English (Clover-Hewitt)
apparatus, and in some respects is superior. The ap-
paratus was devised by Dr. Thomas L. Bennett of this
city, and is manufactured by Messrs. G. Tiemann & Co.
Nitrous oxide is a colorless gas having a faint but
pleasant odor and a sweetish taste. Four gallons
weigh one ounce. It is liquefied by a pressure of fifty
atmospheres at a temperature of 44.6" F. It is now
generally sold in liquid form, being put up in strong
portable steel cylinders.
When nitrous oxide is inhaled, the patient experi-
ences a pleasant sensation of warmth and numbness, and
has an irresistible desire to breathe quicker and more
deeply. The pulse under the finger is accelerated and
feels full and strong. After a few seconds conscious-
ness is lost, the pupils begin to dilate, and the pulse
appears to be lessened in tension. The respirations
are somewhat slower, but are still regular and increased
both in number and depth over the normal. At this
stage the features begin to lose their normal color, and
slight twitching of the extremities may be observed.
This duskiness of countenance is most pronounced in
full-blooded or extremely florid subjects, while ansemic
or sallow persons show little change. If tiie inhalation is
continued a few seconds longer without the admission of
air, the pupils usually become widely dilated, the pulse
is rapid and weak, and the respiration slow, stertorous,
or irregular in character. The features grow darker,
tonic spasms of the thoracic and abdominal muscles
or the muscles of the extremities occur and may be
pronounced or sliglit, and the conjunctival reflex is
abolished. Anaesthesia is now complete, and air must
be admitted.
In nitrous oxide and ether anaesthesia it is not nec-
essary to push the gas to the point of stertor, jactita-
tion, etc.
In this short paper it is impossible to give a full de-
scription of Dr. Bennett's apparatus {z'/t/e page 524). It
consists of a face piece, ether chamber, gas inhaler, and
a gas and ether bag. The ether chamber is composed of
an inner cylinder which is made to revolve within an
outer one. Running through the inner cylinder is a
large tube which permits the passage of air or gas
through the ether chamber. Around this tube is
placed a removable wire cage (for gauze or sponge),
leaving abundant space between it and the chamber
wall for the free circulation of air or gas. The gas
inhaler is much smaller than the ether chamber, and
is so constructed that when the inner cylinder is ro-
tated breathing may be made to take place through
valves, or valve action may be suspended and to-and-
fro breathing employed. The apparatus can be used
separately as an ether or gas inhaler, or may be com-
bined.
Before beginning the adininistration of an anaesthetic
it is necessary to observe a few precautions which will
bear repeating here. The administration should not
be made after a full meal. If it is absolutely neces-
sary to give an aucEsthetic within six hours after taking
solid food, the stomach should be thoroughly washed
out before beginning. The bowels should be thor-
oughly evacuated the night before operation, and if
necessary followed by an enema the next morning. In
my experience the salines act best for this purpose,
and if the liver is inactive may be preceded by small
doses of calomel. The salines, particularly the mag-
nesium sulphate, act quickly, clear out the intestinal
tract thoroughly, and leave its secretions in a healthy
condition.
The vegetable cathartics cause more or less violent
and irregular peristalsis, which keeps the patient awake,
and they usually leave the intestinal tract in an irri-
table condition. I have frequently recognized in the
628
MEDICAL RECORD.
[April 14, 1900
dark vomited material following an afternoon opera-
tion the compound licorice powder taken the night be-
fore, and have observed that patients who had taken a
saline did not vomit to the same extent and suffered very
little from intestinal disturbances afterward. Solid
food of any kind should not be permitted for twelve
hours previous to operation. Some light liquid diet
may be given a few hours before the administration,
and I have found that patients who have taken such
are less liable to suffer from nausea than those whose
stomachs are entirely empty for several hours before
the operation.
The heart, lungs, and arteries should be carefully
examined and the urine tested for albumin before and
after administration. Inquiry should be made with
reference to false teeth, and if present they should be
removed. The patient should be warmly clothed in
loose garments, and all constricting bands about the
waist, or anything that might in any way impede or
embarrass respiration, should be removed.
The room in which the operation takes place should
be warm and free from draughts to avoid chilling of
the body. Weak or emaciated patients or patients
having a weak heart should be given gr. -^\ of the sul-
phate of strychnine three times daily for several days
previous to operation. The importance of this point
cannot be too much emphasized, as it strengthens the
heart and circulation, stimulates the respiration and
nervous system, and fortifies the patient against shock.
When this course has not been pursued gr. ^l should
be given hypodermatically half an hour before com-
mencing the administration.
If the patient is in good general condition, I do hot
think it advisable to use previous stimulation.
In extremely nervous patients, morphine in small
doses administered subcutaneously fifteen minutes
before beginning the administration of an ansesthetic
sometimes proves a very valuable drug, inasmuch as it
quiets the nerves, stimulates the heart, relieves the
pain after operation, and lessens the dangers of shock.
Owing to the fact, however, that some patients have an
idiosyncrasy against morphine, it is best to inquire if
it has ever been taken ox any unpleasant effect from its
use experienced. On two or three occasions when I
have anassthetized the same patient more than one
time, I have observed that the vomiting after ether was
much more persistent when morphine had been admin-
istered, and inquiry elicited the information that it
had always made the patient sick. On account of the
marked similarity between alcohol and ether, whiskey
or brandy should not be given immediately before
etherization.
When administered in the ordinary way it is not
always absorbed in time to produce the desired effect;
it sometimes increases the excitement of the patient
and oftentimes retards rather than accelerates narcosis.
When the stimulating effect of alcohol is desired it is
best to administer it subcutaneously. No one should
undertake the administration of an anaesthetic withgut
first being prepared to meet any emergency. All in-
struments and remedies necessary for resuscitation or
in case of accident should be within reach. Such
remedies as amyl nitrite, spirit of ammonia, and oxy-
gen for immediate inhalation should be at hand, as
well as prepared hypodermics of strychnine, digitalis,
whiskey, atropine, camphor, etc.
A suitable mouth gag, tongue forceps, and sponge-
holder should be within reach. Apparatus for the
transfusion or rectal injection of saline solution should
be available, and also instruments for tracheotomy.
While these extreme measures will rarely be necessary,
still if a patient should die on the table the anaesthe-
tist would hardly be excused for not being prepared
to meet any emergency. All these things, together
with the inhaler, gas cylinder, and ether supply,
can be neatly packed into an eighteen-inch dress-suit
case.
A careful record should be taken of every case an-
esthetized.
The Administration. — The face-piece, cushion, and
ether chamber being sterilized and the whole apparatus
carefully inspected to see that the valves, etc., are in
perfect working order, the wire cage within the ether
chamber is packed with sterilized absorbent gauze,
and from one-half an ounce to an ounce of ether poured
in. The index on the ether chamber is turned to " air,"
and the cushion moderately inflated to secure perfect
adaptation to the face. The gas inhaler is attached to
the chimney of the ether chamber. The aperture on
the gas inhaler is left open, the air tap on the face-
piece closed.
The gas bag, all air being first pressed out, is filled
and attached to the gas inhaler.
The cushion is now gently but firmly adapted to the
patient's face, the patient being informed that he is
breathing nothing but pure air, and instructed to take
long and deep breaths. As soon as he has become
accustomed to the apparatus and his fears are some-
what allayed, the tap of the gas bag is quietly closed.
The patient inhales gas through the inspiratory valve
and exhales a part of it mixed with the residual air of
the lungs through the expiratory valve. When the
bag has become about two-thirds emptied, the aperture
of the gas inhaler is closed by turning the thumb-
screw, and valve action is suspended. The patient
now breathes back and forth into the bag. As soon as
unconsciousness takes place, the index on the ether
chamber should be immediately turned to a little be-
yond the mark between "'air'' and "ether," admitting
a small quantity of ether fumes. The patient is al-
lowed to take two or three inspirations, when the index
is moved a little farther along, permitting a mixture of
gas and ether to be inhaled. The respiration and
countenance at this stage should be carefully watched,
and if any signs of asphyxia develop, the tap of the
gas bag should be opened and a single inspiration of
air allowed. The index should be slowly moved for-
ward, pausing long enough between each advance for
the larynx to become accustomed to the increased
strength of the ether vapor, and admitting air as neces-
sary until the ether is fully on. The patient continues
to breathe a mixture of gas, ether vapor, and a small
quantity of the residual air of the lungs to and fro into
the gas bag, these passing through the gas inhaler and
around the wire cage of the ether chamber to the face-
piece.
When anajsthesia is completed, which usually takes
place in from two to three minutes, the gas inhaler
and bag should be detached from the ether chamber,
and the ether bag attached.
Ether may now be added through the revolving disc
on the side of the ether chamber opposite the thumb-
screw or through the face-piece, and the admission of
air regulated as desired.
By leaving the tap of the ether bag open, the appa-
ratus can be used practically as an open inhaler, or by
closing it to-and-fro breathing can be employed, air
being admitted through the tap on the face-piece.
By detaching the bag, the inhaler fulfils every re-
quirement of an open cone.
The administration is now continued in the ordinary
way.
The Guides to Proper Anjesthesia. — Of all the
guides to the proper depth of anaesthesia, the respira-
tion is the most important, and in the respiration lie
the chief dangers of etherization.
I think all will agree with me that the principal
troubles with this function arise during the first stage
of narcosis, and are due to the strong ether vapor com-
ing in contact witii the upper air passages, causing
April 14, 1900]
MEDICAL RECORD.
629
clinching of tiie teeth, attempts at swallowing, cough-
ing, or vomiting, closure of the glottis, profuse secre-
tion of mucus, and spasm of the chest muscles, which
may embarrass or arrest respiration. These symptoms,
though usually only troublesome, do sometimes occa-
sion great alarm, and have necessitated the perform-
ance of artificial respiration and even tracheotomy.
Thanks to nitrous oxide they are now eliminated, and
the patient enters directly into the second stage of
ether narcosis.
When ether is properly administered, the respiration
as a rule is regular and distinctly audible, slightly
stertorous in character, and somewhat accelerated, a
puffing movement of the lips and cheeks with each
expiration being frequently observed. However, each
case is a law unto itself, and by studying the effect of
more or less ether upon the rate, depth, and audibility
of breathing, a fixed standard can soon be obtained.
If the breathing becomes inaudible or loses its stertor
more ether is required, and this sign will soon be cor-
roborated by a slight cough or a swallowing movement.
If the respiration becomes deeply stertorous or embar-
rassed it is indicative of paralysis of the muscles of
the soft palate, and the ether should be diminished.
This condition should not be confounded with the
loud snoring noise sometimes made by patients under
ether.
While the chief dangers to respiration arise during
the first stage, it must not be forgotten that an abun-
dant secretion of mucus at any stage may partially cut
off the air supply, causing marked cyanosis, and that
too great a restriction of oxygen may cause sudden
respiratory failure.
Great care must be taken to keep the mouth and
throat clear and the air passages open by frequently
using the sponge-holder, lowering and turning the head
to one side, and extending the neck well upon the
shoulders, at the same time lifting the chin. This
manoeuvre raises the base of the tongue from over the
glottis, causes the mucus to run out, allows free inspi-
ration, and opens the air way.
I have notes of the following case : Mr. H •,
aged forty-eight years; general condition poor; very
nervous temperament; temperature, 99° F. ; pulse, 88;
respiration, heart, and blood-vessels normal; urine
contains some pus and slight trace of albumin. He
had taken gas before. Ten minutes after operation
began aUiTsthesia was progressing favorably, though
there was slight cyanosis about the ears. The patient
was getting plenty of air and there was little or no se-
cretion of mucus. The respiration was good, the pulse
full and strong. The air passages were open, the mus-
cles relaxed. The blood was of good color. Suddenly
the respiration ceased; the pulse continued full and
strong. The ether was withdrawn, artificial respira-
tion performed, and oxygen administered; at the same
time hypodermatic injections of atropine and strych-
nine were given. The operation was continued. In a
few minutes the respiration became fairly satisfactory,
but as soon as the ether was resumed it suddenly
stopped. Artificial respiration was again resorted to,
and the operation finished under chloroform. This
was evidently a case of idiosyncrasy for ether, the drug
causing paralysis of the respiratory centre, as the pa-
tient continued to breathe under small quantities of
chloroform. After the operation the patient had no
further trouble and made an uneventful recovery.
Soon after the administration of ether is begun the
arterial pressure rises and the peripheral blood-vessels
dilate, leading to flushing of the face and profuse dia-
phoresis. As long as the skin remains flushed or
heightened in color no danger need be feared on ac-
count of the circulation, but should it assume a marked
degree of pallor or lividity, there is danger of heart
failure, and cardiac stimulants should be administered.
The Reflexes. — By placing the finger on the throat
the occurrence of any swallowing is easily recognized,
'i'his is often the first indication of returning reflex
activity, and is soon followed by coughing or vomiting
if the ether is not increased. While the conjunctival
reflex is a very valuable one, it is a bad practice to
touch the cornea, on account of a possible resulting
conjunctivitis. If it becomes sufficiently strong to re-
quire an increase of ether, it will usually respond to
lifting of the upper lid.
The pupil is of little value as a reflex until anses-
thesia is fully established. By noting the effect of
more or less ether, the proper size for surgical narcosis
is easily learned. If the anaesthetic is used too lightly
the pupil will dilate; also if it is used too freely it
will dilate. That is, there may be two causes of dila-
tation, the first of reflex origin, the second of profound
etherization. It is sometimes difficult to tell just what
a dilated pupil means. In such a case the other guides
should be consulted, but if a little more ether is used,
the pupil will either contract or dilate still further.
If it contracts it shows that the dilatation was of reflex
origin; if it dilates still further, that the ether has
been pushed too far and should be decreased. It is
easily seen that the pupil may dilate reflexly from
some operative procedure, and that an increase of ether
may at first cause it to contract and a little later to di-
late again, but this second dilatation is the dilatation
of profound anaesthesia and shows that the increase
lias been carried too far. As a rule the pupil grows
smaller as the administration is continued, and occa-
sionally remains contracted throughout a long opera-
tion.
It should be remembered that the restriction of air
always tends to make the pupil dilate. No one guide
or reflex can always be entirely relied upon, but they
are all of value for corroborating one another, and
cases sometimes arise in which the corroborative evi-
dence of all must be taken into consideration in de-
termining the exact depth of anaesthesia. In conclu-
sion I will briefly state the advantages of this method,
viz., economy, safety, saving of time to the operator,
and elimination of the disagreeable features of ether
inhalation. As the quantity of ether inhaled is com-
paratively small, patients recover more promptly, nau-
sea and vomiting are of much shorter duration, and
intestinal after-disturbances are reduced to the mini-
mum.
In ordinary ether administration it often takes more
ether to induce narcosis than is afterward required for
a long operation. The almost absolute safety of gas,
its pleasantness and rapidity of action make it a most
welcome agent to any patient who is to undergo a
surgical operation. Indeed, the small quantity of
nitrous oxide actually required is sometimes surpris-
ing, one bagful (about two gallons) being sufficient for
any case, and I have succeeded in inducing perfect
anjesthesia, without the least discomfort to the patient,
with only half a bag.
The quantity of ether required in ordinary cases is
less than one-half, and oftentimes one-third, of that
consumed when the open cone is used, a single 250-gm.
tin sometimes sufficing for three lengthy operations.
In kidney or lung affections in which the condition
of the heart forbids the use of chloroform this econ-
omy of ether is certainly a very great advantage. The
following case serves to illustrate this point:
Mr. B , aged seventy-four years, three weeks
previous to operation had marked ascites with oedema
of the lungs and general anasarca of the lower extrem-
ities, face, etc. At this time he was passing nine
ounces of urine in twenty-four hours, which contained
about fifteen per cent, of albumin. The heart was
slow and very weak, but its sounds were normal.
Under treatment these symptoms practically disap-
630
MEDICAL RECORD.
[April 14, 1900
peared. At the time of operation the patient was pass-
ing forty-five ounces of urine daily, which contained
a slight trace of albumin, but on account of the weak-
ness of the heart it was decided to administer ether
instead of chloroform. Anaesthesia was induced with
gas, and the patient kept under ether one hour and a
half. The urine was e-xamined every day for a week
after without any increase of albumin being noted, and
the patient continued to pass a satisfactory quantity.
Finally, I would advise any one who may use this
method to reassure the patient by explaining the pleas-
ant effects of gas, its safety and rapidity of action, and
the fact that none of the disagreeable sensations of
ether inhalation will be experienced.
It is also very important that the administration
should take place in a quiet room, and that nothing,
such as loud talking, should occur to distract the pa-
tient's attention. If the patient's confidence in the
administrator and the agent he employs is thus won,
and these precautions are strictly observed, the slight-
est difficulty with the administration will rarely ever
be experienced.
14S East Thirtv-fjfth Street.
CHRONIC VERTEBRAL RHEUMATISM
(RHEUMATIC SPONDYLITIS) AND ITS
PSEUDO-NEURALGIC FORM.'
By H. FORESTIER, M.D.,
The question of chronic spondylitis is just now be-
fore the medical profession. Lately two important
papers were published on this question in this coun-
try: one by Dr. Zenner, of Cincinnati," the other by
Dr. Dana, of this city,' and at the same time the New
York Neurological Society, in November, 1899, had
an important discussion of this subject in which Drs.
Sachs, Gibney, Dana, Collins, and Peterson took part.
The variety of spondylitis which they have spoken of
is the one characterized by ankylosis of the spine,
presenting two distinct types, one described by Bech-
terew, the other by Marie and Striimpell.
Cases of chronic spondylitis which I have observed
in Aix-les-Bains, and which I am going to describe as
a pseudo-neuralgic form of chronic vertebral rheuma-
tism, are somewhat different, having the following
clinical characteristics:
I. Temporary rigidity of the vertebral column,
without any ankylosis, from muscular contraction, giv-
ing the patient a peculiar stiff gait; these symptoms
depend upon the pain which the patient feels when he
moves the trunk. 2. Predominant pseudo-neuralgic
symptoms, nerve-roots symptoms; intercostal girdle
pains; pains radiating from the back through the
lower limbs, simulating in some instances either
tabes or pachymeningitis spinalis externa, or even
Pott's disease. 3. Coincidence of arthritis involving
some peripheral joint, showing there is a rheumatic
process. 4. Curability under such treatment as the
Aix-les-Bains douche-massage, the recovery showing
that the pathological process may be considered as
rheumatic.
As far as I know, but little has been written on such
cases. Classical text-books give but a short account
of vertebral rheumatism. They describe the usual
varieties, torticollis, lumbago, and simply mention the
fact that pseudo-neuralgic symptoms may occasionally
occur in some cases.
' Read before the Section on Medicine of tlie New York Acad-
emy of Medicine.
* Journal of Nervous and Mental Disease, November, iSgg.
* Medical News, November 25, iSyq.
Papers published on the subject of spondylitis or
chronic stiffness of the vertebral column (as reported
by Dr. Zenner and Dr. Dana) and on the subject of
articular lumbago' do not record cases presenting the
clinical features of those I am about to describe. I
must mention that I have published a first account of
them at the International Congress of Hydrology at
Liege, October, 1899.
Case I. — Mr. M , priest, aged forty-one years;
family history negative. Personal history: He was
generally healthy up to the age of thirty-five years.
Since then he has become stout through rich food and
lack of exercise. Three years ago he had pains in
the left lower limb and in the neck. The present
illness began in March, 1897. At that time he began
to complain of pain in the region of the right hip,
called sciatica, and accompanied later on with swell-
ing of the left lower limb, suggesting the possibility
of phlebitis. Shortly after pains appeared in the
chest (girdle pains) radiating through the lower limbs;
and in the mean time there was rigidity of the posture
and gait. His physician thought there might be dis-
ease of the spinal cord, but after a while, the patient's
condition being no worse, he sent him to Aix-les-
Bains. Present state, May, 1897: He is a man of
medium height and well-built. At first glance the
attitude strikes one: the patient walks rather slowly,
the trunk keeping rigid. He complains of an almost
continuous pain in the back (girdle pain), increased
by coughing and sneezing, and radiating through the
thighs, with shooting pains. Movements of the trunk,
lateral or antero-posterior, as getting into or out of the
bed, cause marked pain. He feels more comfortable
when seated than when lying down. He cannot straight-
en the body. Movements of the neck are free from pains.
Examination shows that the vertebral column is rather
straight, the normal lumbar concavity being absent,
and that there is no real impairment of motion, the
rigidity being simply muscular in consequence of the
pain. There is tenderness on pressure along the spine
from the fourth dorsal vertebra to the sacrum, and over
the sciatic nerve, but there is no tenderness over the
loins. The knee jerk is exaggerated. Signs of artic-
ular rheumatism are present; the right foot is swollen
and painful, all the joints being involved. There is
no sign of a previous phlebitis. The knees are stiff.
There is cardiac arrhythmia; the sounds are not very
distinct; the heart is fatty. The urine is normal.
Thermal treatment : The patient was put under the
general douche-massage, applied by two masseurs es-
pecially to the back, the patient being in a reclined
posture; the temperature of the water was 85 "-90°
F. ; duration ten to twelve minutes. Twenty douches-
massages were taken with an interruption every four
days. There was an immediate improvement which
three months after the treatment was greater and con-
tinued. When I saw the patient in 1898 he was per-
fectly well.
Case II. — Mr. M , aged forty-eight years. Fam-
ily history was negative. Personal history: At the
age of thirteen years he had acute articular rheumatism
with several relapses. He had thermal treatment in Aix
in 1888. Since then he has been healthy for some years.
His present illness began in November, 1897; he be-
gan to complain of pains in the lower limbs, like sci-
atica, alternately on the right and left side, with inter-
costal and girdle pains. These symptoms getting worse,
his doctor thought of a disease of the spinal cord, and
made several times a Paquelin cauterization along the
spine, which gave a pretty satisfactory result. Later
on, giving up the idea of a nervous disease, he sent
the patient to me in Aix-les-Bains. Present state,
June, 1898: He is a tall and well-built man. His
general condition is not satisfactory. He is in a state
' Albert Robin et I.oude; Kevue de Mcdecine, 1894.
April 14, 1900]
MEDICAL RECORD.
631
of nervous excitement (confesses he takes brandy
pretty often). His posture and gait are stiff; he can-
not straighten the body, and walks, keeping tlie trunk
immobile, with his feet far apart. He complains of
intercostal and girdle pains. When he has walked
any distance he feels weak and has shooting pains in
the lower limbs. In the early morning he has a back-
ache. Examination shows in the upper part of the
spine a slightly rounded curvature; slight lumbar sco-
liosis. He has tenderness over the spines of the lum-
bar region and over the lower intercostal spaces, and
over the sciatic nerve also. Pressure upon the head
produces pain in the lumbar region. The movements
of the trunk are difficult and painful. The patient can
hardly lie flat on his stomach and turn in bed. The
knee jerks are brisk.
Thermal treatment : Twenty-five general douches-
massages were given. At the end of the treatment
the patient felt a very distinct improvement, which re-
mained for two months afterward. In September he
came back to Aix to have a second course of treat-
ment. At that time I found the tenderness over the
spine had disappeared. The recovery was almost
complete. When I saw the patient last summer he
was all right.
Case III. — Miss P , aged twenty-five years, mil-
liner; family history negative. Personal history : She
has been generally healthy, although she was not of a
strong constitution. In December, 1894, she took a
walk of about twenty miles in the snow, after which
she was seized with an acute articular rheumatism.
She was laid up almost fourteen months, partly in
the General Hospital of Lyons. Recovery was tedi-
ous in consequence of arthritis of the knees and ankles.
She was sent to me in Aix-Ies-Bains. Present state,
September, 1895 : The patient is of medium height and
thin body. The posture and gait are stiff; she walks
rather slowly, keeping the trunk immobile. She com-
plains chiefly, after walking, of pains in the back (gir-
dle pains) irradiating through the lower limbs. She
has a limp on the right side. Examination shows
wasting and flaccidity of the muscles of the limbs;
tenderness along the entire spine with the exception
of the upper thoracic region ; tenderness over the sci-
atic nerve. Movements of the trunk are painful and
accordingly diminished. At the neck there is tender-
ness on pressure over the lateral processes, causing
radiating pains through the upper limbs. The knee
jerks are exaggerated. The general condition is pretty
good, but she has chronic catarrhal colitis.
Treatment : The patient took a course of twenty
general douches-massages.
September 29th: Improvement was shown. The
pains were relieved; no limp was visible.
In the course of the winter of 1895-96 the pains
recurred in the limbs and trunk. She was admitted
to the General Hospital in Lyons, where for a time
Professor Teissier, impressed by the neuralgic symp-
toms, thought of a possible pachymeningitis spinalis
externa. After an accurate observation the case was
considered one of rheumatism, and the patient was
sent again to Aix-les-Bains. When I saw her in the
season of 1896 her condition was the same as the year
before, the neuralgic symptoms being more marked.
She took a thermal treatment of about twenty general
douches-massages and was improved. The improve-
ment has been continuous since then. In 1897 the
patient, having recovered, went back to work. When I
saw her in 1898 she was perfectly well, except that
the catarrhal colitis still existed in a slight degree.
Case IV. — Mr. C , aged thirty-nine years, com-
mercial traveller. Family history negative. He has
been generally healthy, but he has taken little exer-
cise and lived high. In 1886 he had his first attack
of regular articular gout, and since then has had fur-
ther attacks every year. For four years (namely, since
1888) he has suffered from girdle pains and pain in
the right lower limb (sciatica), and has become stiff.
Being afraid that he was affected with a disease of the
spinal cord he consulted Charcot, who sent him to me
in Aix-les-Bains, diagnosis being reserved. Present
state, May, 189 1: He is a tall and well-built man.
Posture and gait are stiff. He takes short steps with
his feet far apart, keeping the trunk immobilized be-
cause of the pain on attempted movement. The pa-
tient complains of intercostal and girdle pains, of pain
in the right hip region increased by coughing. In the
early morning he usually feels a backache. Exami-
nation: The normal lumbar concavity is absent; the
patient cannot straighten the body; slight dorsal sco-
liosis is present. There is tenderness on pressure
over the second, third, and fourth lumbar vertebrae.
Pressure upon the head and shoulders produces girdle
pains. Partial mobility of the spine exists, but the
movements are painful. The patient suffers when at-
tempting any act which necessitates a movement of
the trunk, as picking up something from the floor, or
getting in and out of the bed. The knee jerks are
rather weak. A gouty swelling remains in both feet.
Thermal treatment: Twenty-two general douches-
massages with two masseurs, applied especially to the
back in reclined posture.
June 2 I St: The patient is very much improved; he
can pick up things from the floor; he moves the trunk
well. When I saw the patient one year after he was
much better: he had had no further attack of gout, no
pains; the mobility of the spine was greatly restored.
Since then the patient has come every year to Aix and
is getting on very well.
Case V.- — ^Mr. C , aged thirty-five years, manu-
facturer. Family history is negative. Personal his-
tory: He has been generally healthy, but has been
accustomed to a sedentary life and excesses at table.
In March, 1894, he suffered from subacute arthritis
in the wrists, shoulders, and knees, which was prob-
ably subacute rheumatism. He received tliermal treat-
ment at Aachen. In November, 1895, ^^^ began to
complain of intercostal pains, increased by coughing,
together with pain and stiffness in the neck and in the
large joints. He was sent to me in Aix. Present
state, June, 1896: He is a tall and well-built man.
Posture and gait are stiff. When he walks he keeps
the trunk and neck immobile, the head being a little
pushed forward. He complains of intercostal and
girdle pains, increased by coughing. Examination
shows the upper half of the spine to be slightly bent
and pushed forward. The lower half is rather straight
because of the absence of the normal lumbar concav-
ity. There is tenderness on pressure along the entire
spine, most marked in the middle dorsal region;
there is also tenderness on pressure over the lateral
processes of the cervical vertebrae. Mobility of the
spine exists, but the movements are painful. The cer-
vical spine is stiff; flexion of the head is diminished.
There is a tendency to a more advanced stiffness than
in the former cases. Shoulders, elbows, wrists, knees,
ancj ankles all are more or less the seat of a rheumatic
process as marked by swelling and pain.
Thermal treatment : A course of twenty-five general
douches-massages was taken within thirty days. At
the end of the thermal treatment the patient was im-
proved; he had less stift'ness in the neck, fewer pains,
and the rheumatic arthritis had resolved. Improvement
has continued since then. Later on the patient was
entirely cured, the neck remaining a little stiff.
Summary of Cases All these cases present a
peculiar clinical aspect. The posture and gait of the
patients strike one. The patient stands up, slightly
Isent forward, and cannot straighten the body. He
walks slowly, with the feet far apart in some cases,
632
MEDICAL RECORD.
[April 14, 1900
keeping the trunk immobile. The neck not being
involved, the patient is not so stiff as in the Bechterew
type.
The subjective symptoms are very characteristic;
there are pseudo-neuralgic symptoms predominant from
the onset of the disease. These nerve-roots symp-
toms are very like the one reported by Drs. Dana and
Zenner, in ankylosing spondylitis. Patients complain
of various pains irradiating from the back: intercostal
pains, girdle pains, radiating pains through the lower
limbs, sometimes the upper limbs (Case III.). These
radiating pains may have the character of shooting
pains (Case IV.). These pains are increased on at-
tempted movements of the trunk when walking, or when
coughing and sneezing. A very peculiar feature is
the backache occurring in the early morning or when
the patient has been lying down for some hours.
I must notice here that there are no more marked
sensory troubles, no paraesthesia, no trophic changes,
no muscular atrophy as it occurs in cases of the Bech-
terew type. There may be simply a certain degree of
wasting and flaccidity as in Cases I. and III.
The knee jerks are exaggerated, as a rule, with the
exception of one case. There may be ankle clonus
as in a case recorded here.
Examination shows: (i) No deformity of the spine,
but either the absence of the normal lumbar curva-
ture or a slightly rounded posterior curvature of the
upper half of the spine (Cases II., IV.). The lower
half is rather straight. (2) Mobility of the spine ex-
ists when the patient moves the trunk in spite of the
pain. Of course there is a certain stiffness because
of the immobility. But there is no real ankylosis as
in the Bechterew type. The trunk is immobilized be-
cause of the pain which even slight movement causes.
{3) Tenderness on pressure over the spine and lateral
processes (Case III.) sometimes is deep-seated. It is
not simply hyperoesthesia of the skin as in spinal irri-
tation. Tenderness exists too along the lower inter-
costal spaces (Case II.), and over the upper sciatic
nerve, as in all cases. As it appears from the topog-
raphy of tenderness the whole spine as a rule is not
involved. The dorso-lumbar column is mostly af-
fected, the neck being rather seldom involved (Case
v.). Besides the tenderness over the spine there may
be pain in the back when pressure is made upon the
head or shoulders (Cases III., IV.). There is no ten-
derness in the loins in any case, which is not in favor
of a primary muscular trouble (myositis).
The etiology of the cases is marked by a rheumatic
history in all patients; sometimes gout is in question,
as in Case IV. In Case I. there was slight chronic
rheumatism in one foot, and sciatica probably. But
the otiier patients have been affected with more or less
severe acute or subacute articular rheumatism.
A clinical feature which differentiates the pseudo-
neuralgic form from the ankylosing one of vertebral
rheumatism is that the former is curable. All these
patients have been more or less entirely cured; I mean
they have recovered for a time at least, a further re-
lapse being possible.
Myxoedema. — Nicola de Dominicis considers this
affection to be a complex of lesions of every part and
every system of the organism, with multiform manifes-
tations. It maybe considered as a special type of di-
abetes', the primary lesion being in the thyroid gland,
with secondary alterations of the nerve centres and of
the various tissues of the organism. We may call it
thyroid diabetes just as we speak of pancreatic diabetes.
The injection of thyroid extract may be of value be-
fore incurable lesions of vital organs have been formed.
— Gazzetta Ititeniazionak di Mediciiia Practica, Febru-
ary 28, 1900.
TREATMENT OF SUPERFICIAL WOUNDS
WITHOUT SUTURES.
By JOHN F. W. WHITBECK, M.D.,
ROCHESTER, N. Y.
To close superficial wounds many of us have used hair
braiding for the scalp, and compresses, adhesive strips,
bandages, collodion, and other available means, but
sutures have been so universally employed that most
physicians think they are indispensable. The ques-
tion generally is not why, how, or when to dispense
with sutures, but what suture material to use and how
to apply it.
A comparison of different materials and methods ex-
tended over many years of observation has convinced
me that absorbent cotton and collodion combined will
secure prompt and good union of superficial incised
and lacerated wounds. To obtain good union, how-
ever, it is important to observe a few first principles.
We must have an aseptic wound and a clean skin.
The skin can be cleansed with soap and hot water,
close shaving, and alcohol. Asepsis of wound and
skin is then made sure by a careful wiping with dossils
of absorbent cotton which have been soaked a few
minutes in a i : 500 solution of bichloride of mercury.
As soon as the parts are dry enough for the collodion
to adhere, the edges of the wound are brought together
and secured by cotton and collodion alone, or with the
help of narrow strips of isinglass plaster moistened
with the bichloride solution, or by similar strips of
muslin or linen painted over with a thin coat of fresh
flexible collodion. The thinnest possible layer (a mere
layer of fibres) of dry, aseptic absorbent cotton is to be
applied, and it should overlap the angles and edges of
the wound far enough to have a firm hold on the skin.
It will do no harm, and it will not prevent, but will
rather help, the union, if a little blood oozes under
the dressing. The discoloration is objectionable in
appearance only. The following day a fresh coating
of cotton and collodion will whiten the dressing so
that it will be less noticeable.
After four or five days the entire covering may be
removed; better still after eight days. Or the dress-
ing may be left on from ten to fourteen days, when it
may be easily removed by peeling it off dry or by
moistening it with a little ether.
The cases to which this dressing is" applicable are
numerous and various. I have used it with entire sat-
isfaction in extensive and angular lacerations of the
scalp, the skin of the nose, the face, the lips, the ears,
the hand, the thigh, and the calf of the leg. And the
use of this dressing has been very successful after the
excision of glands and small growths.
The advantages of a dressing without sutures which
will secure the union of wounds of the bald scalp, the
face, the ear, need hardly be mentioned. The cosmetic
effect alone is desirable, but if we can dispense w'ith
the dread, the pain, the anaesthetic, incident to stitch-
ing, and liave fewer and finer linear scars, we shall the
more defer to the wishes and the comforts of our pa-
tients. This dressing will not fail in suitable cases,
and usually one has the pleasure of seeing so fine a
linear cicatrix as to suggest a wrinkle in the skin
rather than the tracing of a wound.
,5, Park Aveme.
Prostatic Obstruction.— My present feeling is, that
prostatectomy offers a distinctly better prospect of re-
lief than orchidectomy, and is especially applicable to
the cases in which the obstruction is due to the growth
into the bladder of prostatic projections which en-
croach on the urethral orifice. — A. T. Cabot, Boston
Medical and Surgical Journal, vol. cxl., No. 17.
April 14, 1900]
MEDICAL RECORD.
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M.,- M.D., Editor.
Publishers
WM. WOOD & CO., 51 Fifth Avenue.
New York, April 14, 1900.
HYGIENE AND STATE MEDICINE IN THE
UNITED STATES.
No branch of medicine is more neglected in this coun-
try than hygiene and State medicine; in fact, its im-
portance is almost completely ignored. The opportu-
nities provided for special instruction on the subject
are so small as to be scarcely worthy of mention. This
seems to be a strange oversight on the part of State and
municipal authorities, who should for the sake of its
citizens afford the medical man every means of obtain-
ing practical and scientific training in sanitary work.
In Great Britain and on the European continent gen-
erally the value of the physician possessing a compe-
tent knowledge of hygiene is well recognized, and in
the former country a physician is not eligible as a
medical officer of health unless he holds a special
diploma in public health. It is to be hoped that pro-
gressive States in America may soon discern the ad-
vantage of following this example. In "Medical Edu-
cation of the Future," an essay by President Eliot,
quoted in the January Bulletin oj the University of the
State of New Fi^r/^, is the following intelligent appre-
ciation of the important part which the State, in con-
nection with the physician, should play in the preser-
vation of the health of the people at large:
" State medicine has many objects in view. It aims
not only to protect the public health, but also to in-
crease it. In State medicine individualism is imprac-
ticable, for it is impossible for the individual to pro-
tect himself. The social co-operation, which in our
days the State alone can enforce, is needed to promote
security against disease and progress toward better
average health and longer life. To take all possible
precautions against the spread of infectious diseases
is simply an act of good citizenship. Nothing but
medical supervision will accomplish the objects of
State medicine, and there are no agents so effective as
physicians to spread through all classes of the commu-
nity an educated sense of sanitary decency. Only the
State can guard against dirty milk, corrupted water
supplies, impure ice, adulterated drugs, spoilt meat
and fruit, and filthy and overcrowded tenements. Only
the State can enforce the isolation of cases of conta-
gious disease, the suppression of epidemics, and the
exclusion of pestilences, like cholera and yellow fever.
In exercising such control the State needs every aid
which medical experts in chemistry, bacteriology, and
comparative pathology can place at its disposal. The
medical profession itself hardly recognizes as yet how
great promise there is in the further study of the con-
nections between diseases in animals and in man —
connections which smallpox, scarlatina in cows, tuber-
culosis in men and animals, and diphtheria already
illustrate. Not even the State — that is, a single state
or nation — can deal effectively with such a problem
as the suppression of cholera or yellow fever. That
is an international problem. The evils which the
social and gregarious instincts of men create, by in-
ducing the modern crowding into cities, must be
socially remedied; and the most effective force which
society can exert to this end is the influence of the
highly trained medical officer. Every physician should
be a medical philanthropist and missionary, zealous
to disseminate knowledge of public hygiene."
BURIAL ALIVE.
For all popular fears there is probably some germ of
truth — often infinitesimal, and generally magnified and
distorted. Among the most dreaded of these, and not
improperly so, is the fear of burial alive. It seems
not impossible that under rare and exceptional in-
stances such an occurrence could happen, but the
authentic cases on record are exceedingly few in num-
ber. An accident of this kind is conceivable only if
burial is undertaken within a short time of death, as
has sometimes been practised during the prevalence
of epidemics of virulently contagious disease, and a
sufficient interval is not permitted to establish the
certainty of death by the beginning of putrefaction.
Several instances that illustrate the possibility of
burial alive, though they cannot be said actually to
prove its occurrence are related by the Rome corre-
spondent of The Lancet (Febrary 24, 1900, p. 582). It
is recorded that shortly after the great cholera visita-
tion in Italy in 1866, Pacini, at the time professor of
anatomy in Florence, cited cases in which patients cer-
tified as dead had returned to life on the way to the
cemetery. In the next epidemic of cholera in 1884 a
well-known physician of Turin was attacked by the
disease, and, worn out by professional duty, failed to
rally. Certified as dead, the body was prepared for
the undertaker, but after a time consciousness returned.
The man failed, however, to rally, and finally died.
Recently, in southern Italy, it is reported, a young
woman apparently died as the result of an exceedingly
difficult laborn ecessitating much unavoidable inter-
vention, the foetus also being given up as dead and re-
maining in utero. In accordance with Italian custom
the funeral was fixed for the next day and the body
was left in a coffin in the mortuary chapel adjoining
the cemetery. Early in the morning a photographer,
who was commissioned to secure a likeness of the
woman, obtained permission to open the coffin, and he
found that the body, which had been placed upon its
back, was now on its side, and close to it was a " lovely "
child without arms, as these had been detached in the
obstetric manipulations. The custodian of the chapel
634
MEDICAL RECORD.
[April 14, 1900
now recalled that during the night, while a storm was
raging, he had heard feeble cries, as of some one calling
for help, from the mortuary chapel. An official inquiry
is to be made. This is certainly a remarkable story,
and, before accepting it as an instance of burial alive
in the form in which we have quoted it, we would prefer
more convincing evidence. In commenting upon this
report 77/,? Laiicet points out the unlikelihood of the
child being born alive, as the mutilation to which it
had necessarily been subjected would seem to preclude
the possibility of its survival. Post-mortem expulsion
of the foetus is not unknown as a result of the mus-
cular rigidity that occurs after death. In a later letter
the correspondent of T/ie Lancet at Rome reports an-
other case in which an old countryman fell ill, failed
to recover, was certified as dead, and was laid in his
coffin with the despatch characteristic of Italian cus-
tom on such occasions. As the lid of the coffin was
being screwed down the man was felt to move and
heard to speak. Medical aid was at once invoked and
consciousness restored, but the patient failed to rally,
and real death took place in the course of two days.
There was recently reported in the newspapers, from
the city of Rochester, the case of a man, thirty-five
years old, who became unconscious in the course of
an attack of scarlet fever and was pronounced dead,
burial taking place two days later. A short while af-
terward the father of this man died, and to accommo-
date his remains it became necessary to disinter those
of the son. When this was done the glass front of the
coffin was found, according to the report, shattered to
pieces, the bottom kicked out, and the sides consider-
ably sprung. On removing the lid the body was
found resting on its face, the arms bent at the sides,
and handfuls of hair tightly clenched in the fingers.
Comment upon this account seems scarcely justified
further than to say that its correctness does not appear
to be probable.
While we have no wish to deny the possibility of
burial alive, and while its impossibility is not suscep-
tible of demonstration, we may safely allay any fears
that the condition is other than most exceptional.
THE PREVALENCE OF INFLUENZA.
There is reason to believe that influenza has been un-
usually virulent during the past winter. The records
of the Philadelphia bureau of health show that for the
week ending March 31st there occurred in that city
679 deaths, being 42 more than during the preceding
week, and 175 more than during the corresponding
week of the previous year. Of this number 151 were
due to pneumonia, 60 to pulmonary tuberculosis, 56 to
disease of the heart, 29 to influenza, 26 to old age, 20
to nephritis, 21 to measles, 20 to inflammation of the
stomach and bowels, 17 to convulsions, 15 to bron-
chitis, 15 to apoplexy, 15 to diphtheria, 14 to maras-
mus, 14 to urcemia, 13 to typhoid fever, 13 to inanition.
These figures show the fatal prevalence especially of
diseases attributable to cold — the diseases of the lungs
and catarrhal conditions, as well as of influenza and
its complications.
For the week ending April 7th there were reported
732 deaths — 53 more than for the preceding week, 146
more than for the corresponding week of last year, and
313 more than for the corresponding week of 1898.
Pneumonia is credited with 144 deaths, congestion of
the lungs with 14, bronchitis with 24, pleurisy with 4,
pulmonary tuberculosis with 66, diseases of the heart
with 52, influenza with 42.
THE STRUCTURE AND FUNCTION OF THE
KIDNEY.
In the presence of certain grave conditions of the
kidney, as for instance laceration, suppuration, hem-
orrhage, the surgeon is at times confronted with the
question whether it Were better to ligate the afferent
or the efferent vessel, or to perform nephrectomy.
As the result of experimental observations under-
taken with the object of shedding light upon this im-
portant subject, Aiessandri {Revue de Chiriirgie, 1899,
Nos. 8 and g) has found that ligation of the renal vein
gives rise at first to marked stasis, which interferes
greatly with the nutrition and the function of the renal
epithelium, almost completely suppressing the secre-
tion of urine. After a time a certain degree of collat-
eral venous circulation is restored, and this may be
sufficient to compensate wholly for the obliteration of
the renal vein. The volume and the weight of the
kidney, which at first are greatly increased, rapidly
diminish; and the signs of stasis disappear. While
one portion of the organ, in which the circulatory
equilibrium becomes re-established, resumes its vitality
and its function, other portions of the kidney are de-
stroyed, sometimes by anaemic necrosis, but more often
by hemorrhagic infarction, and the newly formed
epithelium accumulates in the greatly altered lacunae
of the tubules. In consequence in many instances,
after a time, the structure of the kidney is found pre-
served and its function almost normal. This restitution
may permit the kidney to sustain the eliminative func-
tions of the organism if the activity of its fellow should
be abruptly suppressed. For this reason the deduction
is made that in case of wound or other lesion of the renal
vein ligation should be preferred to nephrectomy.
Ligation of the renal artery is followed by deficient
vis a tergo, with the phenomena of anaemia due to sud-
den cessation of the nutritive arterial flow. The mani-
festations of stasis disappear with the establishment of
a collateral arterial circulation, particularly in the cor-
tical structure. The phenomena of anaemic necrosis
may progress to necrobiotic infarction when the com-
pensatory arterial circulation fails to take place or is
inadequate. These zones may be more or less exten-
sive, and they may occupy the entire renal parenchyma,
as they do in the cat. In the dog, on the other hand,
the collateral circulation may be so fully established
that the integrity of the kidney is almost completely
restored, and, although this has never been done, it
may be possible to remove the other kidney success-
fully. In the cat, therefore, nephrectomy is to be pre-
ferred to ligation of the artery, while in the dog liga-
tion is the preferable practice. In man, the possibility
of a collateral circulation through the adrenal, the dia-
April 14, 1900]
MEDICAL RECORD.
635
phragmatic, the lumbar, and the ureteral arteries justi-
fies the conclusion that results similar to those in dogs
may be looked for.
Simultaneous ligation of both renal artery and vein
is incompatible with the continuance of the vitality
and the maintenance of the function of the epithe-
lial elements of the kidney. The collateral vascu-
lar anastomoses are sometimes sufficient to prevent
rapid necrosis of the organ. On the other hand there
may be a gradually progressive cirrhosis, which little
by little destroys the remaining canaliculi and glo-
meruli. In consequence, if, after ligation of both the
renal artery and vein, the functional portion of the
kidney is not preserved, the organism is not exposed
to the danger of rapid necrosis of the renal tissue,
which still retains a certain vitality and is capable of
fibrous transformation through proliferation of the
interstitial connective tissue.
THE RESIGNATION OF DR. McBURNEY.
The resignation of Dr. Charles McBurney from the
staff of the Roosevelt Hospital deserves more than a
passing mention, for it marks the close not only of a
personal hospital career of singular value and bril-
liancy, but also apparently of an important experiment
in hospital management.
Some fifteen or eighteen years ago the managers of
the Roosevelt Hospital, under the inspiration of the
late Dr. Henry B. Sands, established a continuous sur-
gical service under a single head. In 1888 Dr. Sands
gave place to a successor of his own choice. Dr. McBur-
ney, under whom the plan has been continued for
twelve years, and who has made it for the greater part
of that time the most notable surgical service in the
country. It is a duty, as well as a pleasure, to testify
to the fidelity, the devotion, and the skill he brought
to it, and to the brilliant results he has obtained.
But it must also be recognized that the work has
been so heavy that without such faithful and skilful
service as he has given it could not have been properly
done, ind it is not surprising that a new generation of
managers should feel that they cannot count upon al-
w.iys commanding an equally good supply for the posi-
tion and should modify their organization accord-
ingly, as it is reported that they have done.
The service has been divided, and Drs. Bull and
Weir, whose eminent positions are known to all, have
been appointed to the two divisions.
This reduces each service to about forty beds, a
smaller number than that found in some other hos-
pitals, and deprives Roosevelt of the unique charac-
ter heretofore given to it by the size of the service and
by the singleness of its control. The change is prob-
ably even more marked than these facts indicate, for it
must include also a severance of the close relations
that have heretofore existed between the hospital
proper and its out-patient department, and a loss of
the advantages coming from the control and influence
of a single chief extending down through all the de-
partments, and the support and enthusiasm of subor-
dinates closely in touch with him.
The hospital, therefore, ceases to have for the pro-
fession the peculiar interest which it has heretofore
had, and we have only to note the results cf the ex-
periment which has been conducted there for the past
decade and a half, distinguishing so far as may be
between those due to the system and those due to the
character and abilities of individuals.
The service has become most notable. No other
hospital in the city can show for the same period so
important a list of operative cases and successes, and
such noteworthy additions to surgical therapeutics and
methods. The fame of the hospital has spread, and
its reputation has brought patients to it in constantly
increasing numbers.
The effects of organization under a single head ap-
pear, so far as they can be separated from those of the
personal qualities involved, in the exceptionally high
standard of methods and results, and in the training of
those who at various times have held the subordinate
positions. Halsted, Hartley, and Johnson served there
for many years. It is enough to mention tiieir names;
and they served not only as substitutes in the absence
of the attending surgeon, but also as his assistants in
important operations and at the clinics, aiding in and
profiting by his experience and methods. In this man-
ner experience was widened beyond a single life, and
a greater continuity was given to the ideas developed
thereby.
Another striking fact, which appears to be an effect
of the weight of the service, is the age at which the
two surgeons who held the position resigned from it.
Sands at fifty-seven, McBurney at fifty-five, while con-
tinuing in private practice.
We extend to Dr. McBurney the expression of our
warm appreciation of what he has done in the past,
and our best wishes for the future, and we congratu-
late the community and the profession that they are
still to have the benefit of his valuable services. To
his worthy successors we commend his example, and
offer congratulations accordingly.
Brinton Professorship of American Archaeology
and Ethnology. — It is proposed to perpetuate the
memory of the late Dr. Daniel G. Brinton by endow-
ing in his name a professorship of American archaeol-
ogy and ethnology in the University of Pennsylvania.
Dr. Brinton shortly before his death presented his
valuable library to the university, in which from 1886
he occupied the chair of American archeology and
linguistics.
Treatment of Fractured Patella.. — At a meeting of
the Orleans Parish (La.) Medical Society, on March
2sth, Dr. E. D. Martin demonstrated a new method
for the treatment of fractures of the patella. The
method proposed is the fixing of the fragments in ap-
position and securing them with silver staples driven
into the anterior surfaces. At least two staples were
to be used, placed at different angles to prevent lateral
motion. Several specimens of patellse united w'ith
6;6
MEDICAL RECORD.
[April 14, 1900
staples were shown to demonstrate the action of the
method. Dr. Martin proposed to apply the same
method in ununited fractures of the long bones, and
especially those of the inferior maxilla.
Jefferson Medical College. — Dr. Francis X. Der-
cum has been elected professor of neurology and Dr.
J. Chalmers Da Costa professor of the practice of sur-
gery and of clinical surgery.
University of Pennsylvania. — At a recent meeting
of the board of trustees of the University of Pennsyl-
vania it was decided to reorganize the department of
surgery by the election of a professor of surgery and
two professors of clinical surgery.
The Cartwright Lectures of the Alumni Associa-
tion of the College of Physicians and Surgeons of Co-
lumbia University for 1900 will be delivered at the
New York Academy of Medicine, No. 17 West Fort}'-
third Street, on the evenings of April 18, 24, and 26,
1900, at 8:30 o'clock, by Prof. John G. Curtis, M.D.,
of Columbia University. Subject: "The Discovery
of the Nerves and of their Function."
Membranous Croup a Notifiable Disease. — At a
recent meeting of the Philadelphia bureau of health
the following preamble and resolution were adopted :
" Whereas, Diphtheria and membranous croup are
considered by the medical profession as identical dis-
eases ; therefore be it
"Resolved, That hereafter all cases of membranous
croup reported to this office be considered and re-
corded as diphtheria."
St. Joseph's Hospital Training-School for Nurses,
Yonkers, N. Y. — At the commencement exercises for
trained nurses, held March 29th, the following young
ladies received the highest honors of the training-
school: Anna J. Collins, Newport, R. I.; Anna St.
George, Wappingers Falls, N. Y. ; Anna M. Bissett,
Nova Scotia; and Mary E. Duffin, Lockburn Province,
Quebec. A history of the training-school was read
by Dr. A. C. Benedict, and the address to the graduates
was delivered by Dr. Valentine Browne, after which Dr.
P. A. Callan presented the diplomas to the graduates.
College of Physicians of Philadelphia.— At a
stated meeting held April 4th Drs. W. H. Keen and
W. G. Spiller presented a communication entitled
"Multiple Neurofibromata of the Ulnar Nerve." Dr.
S. Weir Mitchell read a paper on "The Manuscript
Letters of Jenner in Possession of the College," which
are not known to have been published hitherto. Dr.
Laurence F. Flick read a paper entitled "The Regis-
tration of Tuberculosis." Dr. John Chalmers Da
Costa read a "Report of a Case of H'p-joint Amputa-
tion." The patient was a girl, fifteen years old, in
whom a new growth rapidly appeared in the upper
part of the thigh, and so involved the vessels as to
preclude the application of the ordinary methods of
haemostasis. Accordingly, digital compression of the
external iliac artery against the psoas muscle was
made in accordance with the suggestion of McBurney,
and the femur was disarticulated Recurrence, how-
ever, took place in the stump. On histological exam-
ination the growth was found to be a small spindle-
cell sarcoma. Dr. Robert G. Leconte reported the
case of a young man, eighteen years old, in which
amputation through the acetabulum was performed for
a large spindle-cell osteo-sarcoma of the thigh. Dr.
Richard H. Harte presented for himself and others a
large portrait in oil of Dr. John Ashhurst, Jr.
The American Gastro-Enterological Association.
— The third annual meeting of this association will be
held in Washington on May ist, under the presidency
of Dr. Max Einhorn,*of this city. The sessions, at 10
A.M. and 2 :3o p.m., will be held at the Shoreham.
A German Report on the British Sanitary Ser-
vice in South Africa. — Drs. Krummacher and
Schmidt, German army surgeons, who returned re-
cently to Berlin from the British camps in South
Africa, are reported to have spoken in commendation
of the sanitary arrangements there. They deny that
Dum-dum or other expanding bullets are used by the
British, and assert that they did not witness a single
instance of actual breach of the rules of the Red Cross
Society.
The Adirondacks Hospital. — Acting under an emer-
gency message from Governor Roosevelt, both houses
of the legislature passed on April 5th the Davis-Hill
bill for a State sanatorium in the Adirondacks for the
care of persons suffering from incipient pulmonary
tuberculosis. The bill was amended to reduce the
appropriation from $150,000 to $50,000. In the As-
sembly a motion to reconsider the bill was lost by a
vote of 91 to 14.
Mountain Toothache. — An observation of Mr. Haf-
ner, of Zurich, published in Die ISlatiir, forms a curi-
ous contribution to medical geography. He finds that
all the engineers and workmen on the Jungfrau rail-
way who are obliged to remain a considerable time at
altitudes of about 2,600 metres above the sea level are
liable to a disagreeable complaint. After eight or ten
days they are seized with violent pains in several teeth
on one side of the jaw, the gums and cheek on the same
side becoming swollen. The teeth are very sensitive
to pressure, so that mastication is extremely painful.
These symptoms increase in severity for three days,
and then gradually and entirely disappear. It seems
to be purely a phenomenon of acclimatization, for all
new-comers go through the complaint, and it appears
never to recur. — Janus.
Insanity in the Army. — In reply to a Senate reso-
lution, the secretary of war has prepared a statement
in regard to insanity and suicide among the troops in
the Philippines. The statement shows a smaller rate
of insanity among the troops in the Philippines than
in the regular army for ten years. It says that from
late in July, 1898, to March 20, 1900, 35 cases of in-
sanity have been reported from the Philippine Islands.
During this period the mean strength of the force
under General Otis was 32,000 men. Based on this
strength the rate of insanity for twelve months was
31.3 cases. The mean strength of the regular army
for the ten years ending July, 1898, was 29,000 men
with a rate of insanity of 33.1, 7 officers and 22 en-
April 14, I goo]
MEDICAL RECORD.
637
listed men committing suicide in the Pliilippines
between April 11, 1899, and March 27, 1900. The
statistics on this subject embrace the period from the
ending of the war with Sp^in, and the mean strength
of the Philippine army trom that time to March 27,
1900, is given as 47,800. Based on these figures the
rate of suicide is reported as 30.7 for the year, or about
.64 per thousand. In the regular army for ten years,
with a mean strength of 29,000 men, the rate of suicide
was 18.4, or about .63 per thousand. Another compar-
ison is shown by the table giving the number of cas-
ualties each year in the regular army. In 189 1, with
26,000 men, there were 22 suicides; 1892, with 26,000
men, 22 suicides, and in 1893, 22 suicides among 27,-
000 men. The conclusion drawn from these figures is
that the statements regarding the increase of suicide
and insanity in the army are entirely unsupported by
the facts.
The American Climatological Association will
meet in seventeenth annual session at the Arlington,
Washington, on May ist-3d, under the presidency of
Dr. A. Jacobi, of this city. The sessions will be from
10 A.M. to I P.M. each day. The annual dinner will
take place on the evening of May 1st.
The Indian Famine. — Nature holds out no prospect
of relief to the famine which has prevailed so long in
India, but on the contrary there is every prospect that
the conditions will be worse this year than last. In
the course of a recent speech on the budget, the vice-
roy. Lord Curzon, said the loss to the wheat crop,
caused by the drought during the present year, was
from ;£'8,ooo,ooo to ;^io,ooo,ooo. He added that the
loss to the cotton crop was ^7,000,000, while the oil-
seed crop, usually covering eighteen million acres, was
non-existent outside of Bengal and the northwest pro-
vinces. The loss to cultivators in Bombay alone, in
food crops, was ;{j"i 5,000,000 and in cotton ^4,000,-
000. It was impossible, he said, for any government
to anticipate the consequences of a visitation of nature
on so gigantic and ruinous a scale.
Professor Neisser, of Breslau, has been made the
subject of a sharp debate in the Prussian Diet for hav-
ing performed some unwarranted inoculation experi-
ments. The facts of the case, as stated by the Berlin
correspondent of The Lancet, are briefly as follows:
Professor Neisser injected sterilized blood serum of
syphilitic persons into prostitutes and into two chil-
dren in order to immunize them against the disease.
The experiment had no bad sequelaj whatever. Sev-
eral years afterward some of the prostitutes suffered
from syphilis, which first manifested itself on the gen-
itals, so that the attempted immunization had proved
a failure. That they had been infected by the injec-
tion, as was alleged by Professor Neisser's adversaries,
was quite impossible owing to the length of time be-
tween the giving of the injections and the appearance
of the syphilis, together with the fact that none of the
patients other than the prostitutes contracted the dis-
ease. These facts were gravely misrepresented by
different speakers. Professor Neisser being said to
have injected syphilitic virus in order to see whether
it was contagious or not. Several members of the
Diet asked the minister of public instruction if Pro-
fessor Neisser had been or would be prosecuted for
what he had done. The minister. Dr. Studt, and the
chief of the university department, Herr Althoff^
stated that Professor Neisser had not performed his
experiments for frivolous reasons, but for the emi-
nently humane purpose of combating syphilis. They
said that he no doubt erred in making experiments on
patients without previously asking them whether they
consented to the injections or not. The minister ad-
mitted that he might have been prosecuted under the
criminal law, but as the acts complained of were com-
mitted six years ago there was, under the circum-
stances, no likelihood of a prosecution. The govern-
ment had not yet considered whether it would be
advisable to make use of its disciplinary power over
him as a professor of a State university.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
April 7, 1900. March 31st. — Passed Assistant Sur-
geon J. C. Rosenbleuth ordered to the Wilmmgton
sailing from New York City, April 5th, to join ship at
Rio de Janeiro, Brazil. Passed Assistant Surgeon F.
C. Cook detached from the Wilmiiigtoii and ordered to
proceed home by mail steamer. April 2d. — Surgeon
F. Urie commissioned surgeon from October 25, 1899,
Passed Assistant Surgeon W. M. Wheeler commis-
sioned passed assistant surgeon from May 27, 1899.
Passed Assistant Surgeon D. N. Carpenter commis-
sioned passed assistant surgeon from October 24, 1899.
Passed Assistant Surgeon F. L. Pleadwell commis-
sioned passed assistant surgeon from October 25, 1899.
April 3d. — Passed Assistant Surgeon W. F. Arnold
detached from the naval hospital, Norfolk, Va., and
granted leave for three months. Passed Assistant Sur-
geon G. D. Costigan detached from the naval hospital,
Chelsea, Mass., and ordered to the Boston navy yard
immediately. Assistant Surgeon D. N. Carpenter de-
tached from the Boston navy yard and ordered to the
naval hospital, Chelsea, Mass., immediately.
The Plague. — The epidemic at Honolulu being
now at an end, no case having been reported since
March 25th, the public is beginning to count the cost.
It is estimated that the bill for fighting the disease
there will come to at least $2,000,000. A large part
of the expense was incurred in finding homes for the
persons who were burned out by the fires, particularly
the conflagration of January 20th. The building and
provisioning of the detention camps have been costly,
and the salaries of physicians, at $250 per month,
have amounted to a large sum, to say nothing of paid
inspectors, fumigators, heads of departments, etc.
From December 12th to March 31st there had been
seventy cases of plague in Honolulu, of which sixty
resulted fatally. Nine patients were cured, and one
was still in the hospital at the end of March, but was
in a fair way to recovery. — In Manila, we learn from
a correspondent of the Associated Press, the disease
has prevailed for about three months, but little anxiety
MEDICAL RECORD.
[April 14, 1900
is felt by the foreigners. During the first two months
of its prevalence there had been over two hundred
cases, according to the estimate of the health officials,
and about eighty per cent, of these had resulted fatally.
The sanitary measures have been simple but effective,
consisting in the enforcement of cleanliness, as far as
possible, and in a system of inspection by Filipino
and Chinese employees. There are now one hundred
inspectors at work in Manila, thirty of them China-
men and the others Filipinos. They are sent out in
squads, usually two Filipinos and a Chinaman with a
soldier to boss them and see that they do their work
and abstain from blackmailing. Whenever a plague
victim is discovered he is sent to the Chinese or Fili-
pino hospital if it is possible to move him. The house
is thoroughly disinfected, a bonfire is made of everj--
thing movable, a yellow placard announcing "bubonic
pest " appears on the door, and a sentry stands guard
to keep persons away. For four days the house is
kept closed and the inmates are isolated. When two
or three cases develop in one street, the street is barred
against business. Two-thirds of the cases have been
among the Chinese coolies, and the rest among the
Filipinos, the whites having thus far escaped.
Dr. William Camac died at Philadelphia on April
3d, at the age of seventy-one years. He was gradu-
ated from Jefferson Medical College in 1852.
some of the symptoms resembled opium poisoning,
belladonna suggested itself to me, which I prescribed
in III i. doses of the tincture to be given every hour
till seen again. The following morning, to my great
surprise, I found the child in an almost normal con-
dition— with healthy color and breathing, good pulse
and normal temperature- — except that it was still
somewhat somnolent and that the pupils were dilated
from the belladonna. The parents told me that it had
had another attack of apncea with cyanosis in the
middle of the night, when the mustard bath was re-
peated. The eczema had wonderfully improved over
night. The child has been well since then.
Wood describes a form of iodoform poisoning with
contracted pupils and coma, and I am convinced that
this was such a case, for the following reasons: No
opiate in any form had been used to account for the
extremely contracted pupils; there was a strong odor
of iodoform about the child when I first saw it; the
symptoms set in soon after applying the " yellow
salve"; the violent eczema improved so rapidly after
washing oft" the salve in the bath that on the following
morning the affected skin was perfectly dry and only
of a delicate pink in place of the angry red of the
night before.
I am inclined to ascribe here some antidotal or
rather antagonistic virtue to the belladonna. The
laryngeal spasm is worth noticing as a symptom.
A COMPLICATION OF MISCARRIAGE WITH
APPENDICITIS, DUE TO TRAUMATISM.
By C.\RL D. S. FRUH, M.V.,
IILADELFHIA
©Ilnical g^artmciit.
A CASE OF IODOFORM POISONING IN AN
INFANT TWO WEEKS OLD.
By J. C. JOSEPHSON, M.D.,
Recently I was called to see Hillel B , two
weeks old, with the following history : The child had
been circumcised six days previously, and as the
wound would not heal well the mohel (circumciser)
gave the mother a salve to apply. This again proving
unsatisfactory he changed it on the day previous to my
visit for a yellow salve. The following day the child
■was very somnolent, had stridulous breathing, and
refused the breast. I found the child comatose, cya-
nosed, with feeble but stridulous breathing, and retrac-
tion of the epigastrium, evidently from laryngeal
spasm. The pupils were contracted to the size of a
pin point. No paregoric had been used, nor any of
the patent nostrums for which the baby cries. There
was a strong odor of iodoform about the child. On
removing the diaper I found the following condition :
The circumcision wound had not yet healed; the
whole under surface of the penis, the scrotum, and the
inner surface of both thighs were the seat of an
eczema, so severe as to bleed on contact. The tem-
perature was 100° F., the heart action feeble. I will
not detail the measures adopted — as the hot mustard
bath, friction with alcohol and with mustard, a hot
enema and stimulation with a few drops of brandy
now and then. As I considered the child moribund, I
declined to prescribe any internal remedies. An hour
later, however, I was called again. The child had
regained its color after the bath, but had just had
another attack of apnoea with cyanosis. The parents
importuned me to "do something for the child." As
ANATOMY, JEFFERSON MEDICAL COLLEGE.
Mrs. A- — — , aged twenty years, pregnant seven months,
primipara, was passing from the kitchen of her house
to the ground, when she suddenly slipped, and being
in danger of falling she grasped a support, severely
twisting her body, as she herself describes it. From
this moment for eleven days she was in constant pain
and discomfort, matters finally getting so bad that the
writer was sent for. The patient was in dire distress
(temperature, 104.5" ^■)'-< she was constantly vomiting
matter admixed with bile, suffering intensely with every
such attack; there were hiccough, tympanites, tender-
ness of the entire abdominal region, intense agony when
she passed water, the simple action of the muscles in-
volved in this act causing the greatest suffering; move-
ment was almost impossible on account of the pain.
Constipation was present for some five days. A slight
show was in evidence ; after four days the foetus and
placenta were delivered, with relief from the inten-
sity of pain for some twelve hours, when there was a
repetition of the above symptoms, with pains passing
from the epigastrium to the left inguinal region, then
to the right side. There being no flow whatever after
the delivery of the fcetus and placenta, one would
naturally have supposed that all this severe state of
the patient was one due to sepsis, and that the womb
must be curetted to remove the offending cause. The
symptoms here, however, led the writer to appreciate
the condition of a typical traumatic appendicitis, and
the final recovery of the patient would seem to prove
the diagnosis correct. There was no return of the
flow.
The writer has omitted all detail of the medical
treatment, wishing merely to call attention to the pos-
sible error of judgment which might have tempted one
to locate the material fault in the uterus. Every
diagnostic point of appendicitis was borne out in this
case.
April 14, 1900]
MEDICAL RECORD.
639
gtrogrcss at pXcrtical J>cieuce.
Bostoti Medical and Surgical Journal, April j, igoo.
Conservative Operation for Uterine Fibroids. —
R. A. Kingman reports two illustrative cases, and
urges conservatism, especially in young women. Cer-
tain cases undoubtedly demand hysterectomy, but
whenever possible the endeavor should be toward the
preservation of functional integrity of the pelvic or-
gans. Neither size nor number Df tumors should be
necessarily a bar to this attainment, nor should the
fact that at a single sitting we cannot entirely clear
the uterus of nodules compel the sacrifice of that or-
gan. The author praises Dr. Burrage's morcellation
forceps, which do not wound a Hat or concave surface
but will cut or strongly seize any projecting mass.
The frequent association of ovarian disease with
fibroid tumors will make it necessary at times to re-
sect or do other conservative operation upon one or
both ovaries, for it must not be forgotten that removals
of the new growths will be followed by uterine invo-
lution and by greatly improved conditions in the ap-
pendages as well.
A Peculiat Case of Adeno-Carcinoma of the Body
of the Uterus. — Agnes C. Victor reports the case of a
woman, aged sixty-seven years, in whom apparent tem-
porary improvement of an adeno-carcinoma followed
the administration of tablets of mammary substance.
By abdomino-vagino-rectal examination a hard nodu-
lar tumor was found apparently springing from the
posterior wall of the body of the uterus, extending up
into the fundus and projecting backward into the cul-
de-sac. A vaginal hysterectomy was performed, and
on attempting to deliver the fundus it suddenly fell to
pieces in the operator's hand, and she had only a hand-
ful of pieces of soft tissue. The posterior wall of the
uterus was found to be perfectly smooth and regular,
with no sign of a tumor, this being on the anterior
wall and projecting into the uterine cavity. The pos-
terior wall was a mass of soft tissue retained only by
a paper-like layer of peritoneum.
A Case of Extra-Uterine Pregnancy. — Frederick
W. Johnson describes a case of ruptured extra-uterine
pregnancy. Laparotomy was performed, and a green-
ish-yellow tumor, the size of an orange, found adherent
in the pelvis and connected with the left Fallopian
tube, while the thickened right tube was adherent to it.
This mass was removed, and the sac-like dilatation was
found to be filled with clotted blood, which was in
layers and considerably decolorized. At one end of
the tnass was a little thready tissue. On microscopical
examination there were found fine branching filaments
of a fibrous character terminating in round, enlarged
ends, similar to the chorionic villi in the first half of
pregnancy. In the ovary was a large cystic cavity
filled with blood (corpus hsmorrhagicum). No true
corpus luteum was found.
Empyema of the Frontal Sinus. —John D. Paige
reports a case of empyema of the antrum of Highmore,
bilateral empyema of the ethmoid cells, and empyema
of the frontal sinus on the left. The antrums were
opened and drained through the alveoli, and the eth-
moid cells opened and curetted; the frontal sinus was
irrigated through the enlarged natural opening, with
great relief to the symptoms and discharge. An .v-ray
picture shows the existing conditions.
On Distortion of the Spine.-- -J. W. Courtney re-
ports two cases of diplegia brachialis due to distortion
of the spine, which he defines as a pause in the act of
luxation. The author gives the symptomatology of
the affection, and says that the determinate factor in
its diagnosis as against fracture or luxation is the ab-
solute failure to discover any change in contour or ab-
normal mobility of the spine. If the patient has a
tuberculous taint, the process may become chronic,
otherwise the prognosis is good. Treatment consists
of rest in bed with support and immobilization cf the
neck, with very slight extension of the spine.
The Conservative Operative Treatment of Fi-
broids.— N. L. Burrage reports three cases. The first
consisted of abdominal myomectomy, removal of eleven
subperitoneal nodules and the right ovary. The second
was a vaginal myomectomy, removal of fibroid nodule
of subperitoneal evolution from the front wall of the
uterus by anterior colpotoniy. The third was morcel-
lation of submucous nodule at fundus, and polyp with
pedicle springing from fundus. The author considers
it a greater glory to patch up a diseased organ and put
it in fair working condition than to remove it because
it may cause trouble in the future.
Journal of the Amer. Med. Association, April 7, jgoo.
Curious Facts You Find in General Surgery
The first case reported by Lucien Lofton is that of a
negro who had been struck on the head with an axe,
with the , result that the external temporal and the
transverse facial arteries had been entirely severed,
besides a number of peripheral arterial twigs; the
outer and inner tables of the skull were crushed, while
internally the middle meningeal artery was severed,
and the meninges suffered greatly. This man was on
his feet in forty-eight hours, and in twelve days he
had resumed his position as a sawmill hand. The
writer dismissed him after the third dressing, and his
recovery was uninterrupted. The second case was
that of a negro who, in spite of a broken radius, held
his position as a sawyer for ten days, working steadily
twelve hours a day with little or no inconvenience.
The third case was one of cornu cutaneum in a man
aged seventy years. It was removed under cocaine
anaesthesia and healed by first intention. Three
months after the patient returned with another horn
springing from the original core. This was removed
together with all horny cells, resulting in complete
enucleation. The fourth case was a shattered humer-
us in a boy ten years old, which had been neglected
by his family for three weeks. Operation resulted in
a perfectly sound arm.
Diagnostic Value of the Deep Reflexes of the
Lower Extremities.— D. S. Fairchild says that in a
case of motor or sensory paralysis, or both combined,
the questions which will occur to the examiner are
three in number: (i) Is the paralysis due to an or-
ganic change in the anterior or motor side of the spi-
nal cord, or in both anterior and posterior sides, or
are the lines of communication impaired or destroyed
by injury to, or disease of, the afferent or efferent
nerve-fibres, or both? (2) Is the paralysis hysterical
in character? (3) Is the' paralysis feigned? The
author then considers the differential diagnosis of va-
rious forms of paralysis and says the real diagnostic
value of the deep reflexes can be determined only by
a very careful consideration of the facts in the case,
and by a careful study of the reflex itself. There is
no certain and absolute guide to the intensity of a nor-
mal reflex.
Differentiation between the Bullous, Vesicular,
and Pustular Eruptions of Early Life. — Charles
Warrenne Allen says that although dermatologists
cannot invariably distinguish betwen rare forms of
bullous affection, or classify them in an acceptable
manner, it is usually no hard matter to distinguish the
640
MEDICAL RECORD.
[April 14, 1900
non-specific from the specific. This is a general rule
to which there are few exceptions. But the subject,
even when thus restricted, remains a very broad one,
and in order to cover the ground the writer takes up
the various bullous, vesicular, and pustular affections
of the skin, showing some of the points of differentia-
tion between them and syphilis. He thus considers
pemphigus, pemphigus acutus, pemphigus neonatorum,
pemphigus chronicus, pemphigus epidemicus, pemphi-
gus foliaceus, epidermolysis hereditaria bullosa, der-
matitis herpetiformis, impetigo, ecthyma, hydroa, and
generalized vaccinia.
Uniformity in Definition and Application of the
Terms Position and Presentation. — Frank A. Stahl
deplores the unfortunate ambiguity of definition and
application of terms in descriptive obstetrics. The
writer says that although at the meeting of the Ninth
International Medical Congress held in Washington,
D. C, in 1887, the committee cleared up much that
needed simplifying, still many inequalities remain.
So far as pertains to uniformity in definition and ap-
plication of the two terms "position" and "presenta-
tion," they are not synonyms and should not be used
synonymously. Etymologically considered, position
refers to " aggregate of spatial relation of a body or
figure to other bodies or figures; the situation; the
place of a thing." Presentation refers " to that which
is before; in view; appearance."
Uric Acid and the Serious Results when Not
Eliminated. — M. S. Marcy speaks of the serious re-
sults that follow the taking into the system and retain-
ing an excess of urates. He protests against intro-
ducing urates into the system in large quantities by
taking into the stomach meat, especially extracts, con-
taining 63 grains of urates to the pound; tea, 174;
coffee 70, and cocoa 59 grains to the pound, as well
as many other foods and drinks containing a less
amount. The author concludes that if we would en-
joy the best of health we should leave out of our diet
all foods and drinks containing a large amount of
urates, and live on a vegetable, cereal, fruit, and milk
diet.
Pathological Changes Occurring in the Unob-
structed Nostril in Cases of Deviated Septum. — E.
Larue Vansant says that these changes in a case of
marked deviation of the septum may be divided into
three stages: The first stage, that of hyperplasia of
the tissues from over-function, is a compensatory hy-
pertrophy; the second is that of atrophy from inflam-
matory changes; and the third that of atrophy associ-
ated with sepsis of the nasal chamber and accessory
sinuses. When the deflection is very moderate a
slight compensatory hypertrophy of the turbinals of
the more open nostril may be the only pathological
change noticeable.
A Case of Rhizomelic Spondylosis. — Augustus A.
Eshner reports this case. He says that though the
disease has been known for a long time, particularly
to surgeons, unusual attention has been directed to it
of late, and reports of cases have been made from all
parts of the world. The writer says of this case that
it w^ould appear from the symptoms and physical signs
that the disease is one not only of the vertebra and its
appendages, but also of the spinal cord. Also the
history of rheumatism obtained maybe significant from
an etiological point of view, as it has been thought to
play such a role in other cases of the kind.
Dilatation of the Ophthalmic Veins; Cure.— R.
Ortega reports the case of a woman, thirty-two years of
age. who had exophthalmos and complained of intense
pain on one side of the head. An orbital tumor was
diagnosed, and operation revealed a dilatation of the
ophthalmic veins. The eye was enucleated with relief
to the symptoms.
Medical News, April 7, igoo.
Malignancy. — Arthur L. Fuller sums up his re-
marks on this subject by saying that malignancy is a
term which implies some special form of pathological
activity, not present in other conditions. Since the
cachexia alone seems to depend on forms of cell ener-
gy which are absent in other conditions, it alone must
be considered the essential feature of malignancy.
The relation of cachexia to the embryonic character
of the tumor cells is such as to suggest that it is due
to the retention of products of embryonic cell metabol-
ism in the system, constituting a form of toxtemia.
This suggestion is borne out by the fact that the pres-
ence of embryonic cells pouring their metabolic prod-
ucts into the system in the absence of the thymus
gland, constitutes a pathological condition similar to
those present in myxoedema and Addison's disease.
Therefore the administration of thymus in malignant
disease might prove useful to sustain the strength, as
the administration of thyroid has done in myxoedema,
and of suprarenals in some cases of Addison's dis-
ease.
Cancer of the Breast. — Robert Abbe says that
progress toward the cure of mammary cancer has come
from the recognition of the anatomical distribution of
the lymphatics; that too much emphasis cannot be
laid upon the danger of the operative infection of the
wound by cutting infected glands and lymphatic chan-
nels, or discharging into the healthy wound infected
cells squeezed from the parts being removed. ' Dr.
Abbe remarks the improvements in the statistics that
immediately followed the adoption of radica' surgical
methods, and says that such results as thiee years'
immunity are now within the easy reach of all good
operators. He finally concludes that a recurrence
after operation need not discourage patient or surgeon.
If the recurrent growth be speedily and thoroughly at-
tended to there is a strong probability of its eradication,
as the recurrence is not a return of the disease, but a
continued growth of invisible metastatic foci left at the
time of operation.
Hypnotism. — F. X. Dercum says that hypnotism is
interesting to physicians from two points of view:
First, the explanation of its principles; and, second,
the extent of its practical application. The writer
then discusses the theory of hypnotism, and the meth-
ods and precautions to be observed in its employment.
Coming to the question of its practical value to physi-
cians he thinks it of slight value, having a very sub-
ordinate place in therapeutics. It can have no patho-
logical effect, and is practically limited in its scope to
hysterical and neurasthenic patients.
A Case of Spontaneous Rupture of the Uterus. —
Bradford Woodbridge reports a case of this accident
in an apparently healthy young woman, before the
advent of labor and witliout history of trauma or pre-
monitory symptoms. The patient had received two
years before a blow in the pregnant uterus severe
enough, as she believed, to hasten labor, and the writ-
er suggests that as a result there may have been a
weakening of the uterine muscle at the point of injury.
Causes, Diagnosis, and Treatment of Cystitis. —
Ramon Guiteras discusses cystitis separately in the
acute and chronic forms, touching upon the many sub-
varieties of each during his consideration of causa-
tion and treatment.
April 14, 1900]
MEDICAL RECORD.
641
Neiv York Medical Journal, April j, igoo.
Puerperal Septicaemia ; Especially its Bacteriol-
ogy and Treatment by Serum — L. A. Hering re-
gards the streptococcus as the chief source of mischief,
but does not believe that the infection is ever purely
streptococcic. The staphylococcus and bacillus coli
communis are also at work in many cases. The latter
germ probably gains access to the parturient tract by
the lymph route. Serum treatment often fails because
either the serum is old, or there is a mi.xed infection
to deal with, or treatment may be delayed and too lit-
tle serum given, or the patient may be over-stimulated.
Hering does not hesitate to curette, flush out with
warm, weak bichloride, and introduce a drain of iodo-
form gauze. Pus must be removed whenever present;
the bowels kept open at all costs; serum injections
should be begun early, and be made into sterile tis-
sue under most rigid antisepsis. Large doses of
strychnine, gradually tapering off in conjunction with
three-grain doses of caffeine sodio-salicylate, can be
administered with profit.
A Critical Test of the Justus Blood Test for
Syphilis D. H. Jones experimented with thirty-five
syphilitics and eighteen control patients. He believes
that the test has a value in the recognition of doubtful
cases of syphilis, but that it often fails in two classes
of cases in which early diagnosis is especially desired,
viz., in latent cases and in early chancre, and some-
times at the beginning of the secondary stage. He
believes, however, that the limitations of the test have
not as yet been fully determined. The test is based
on the asserted fact that a single inunction of mercury
in all cases of untreated cases of secondary, tertiary,
and congenital forms of syphilis causes a reduction in
the hsemoglobin due to the sensitiveness of the red
blood cells to the action of the drug, while in non-
syphilitics no reaction follows.
The Treatment of Gouty Deposits — E. L. H. Mc-
Ginnis narrates his experience with the use of the
lithia salts administered by cataphoresis. The meth-
od is described as follows: The fingers ^re washed off
with chloroform; thin sheets of borated absorbent
cotton are wrapped around the affected joints and
thoroughly wetted with a solution of iodide of lithium.
The fingers are then covered with the metal handles
of the ordinary galvanic battery, each being connected
with a terminal from a cord leading to the positive
pole, the negative being a flat metallic plate upon
which the other hand is laid. The current is allowed
to flow for ten minutes (15 to 25 milliamperes in the
case described). Following this the joints are vigor-
ously massaged for several minutes.
Some Critical and Desultory Remarks on Recent
Laryngological and Rhinological Literature (Tenth
Paper). — J. Wright discusses some of the more recent
contributions to the literature of tuberculosis, having
to deal especially with modes of infection. He takes
up particularly the statements of Lewin, who claims
that five per cent, of all adenoids in the naso-pharynx
contain foci of latent tuberculosis. This proportion
Wright believes to be overestimated by Lewin, though
he admits that the difference in the frequency of tu-
berculosis in European and American cities may easi-
ly explain the discrepancy between the figures of
different observers.
Chronic Carbon-Monoxide Poisoning. — T. J. Yar-
row gives an outline of the chemistry of this com-
pound and enumerates the tests used for its detection.
In one case, that of a man aged fifty-two years, who
lived in a house in which there was a leakage of gas,
and who suffered from the evidences of constantly
inhaling it. Yarrow employed bone marrow and ton-
ics with good effect. He believes that this gas leak-
age in modern houses is a far more common source of
bodily ills than is usually imagined.
Creosote: Some Clinical Observations of its Use
in Various Conditions. — F. C. Test gives clinical
histories of ten cases in which the use of the remedy
was followed by good results. The list includes cases
of gastro-enteric auto-intoxication as shown in various
nervous symptoms, whooping-cough, bronchitis, and
tuberculosis.
Philadelphia Medical Journal, April 7, igoo.
The Soldier in the Tropics. — Charles E. Wood-
ruff discusses the question of the soldier's food, the
effect upon him of alcohol, and his acclimatization in
the tropics. The American ration, he says, is, con-
trary to the general opinion, one of the least liberal
rations among civilized nations. He thinks, however,
that the refusal of Congress to change the ration was
the point of wisdom. He declaims against the advice
not to eat heartily in the tropics. The writer favors
the use of alcohol, saying that " experience has demon-
strated that in a hot climate the moderate use of intox-
icating drink is essential to continued health and effi-
ciency." He does not believe that the white man can
become acclimated, and characterizes such an asser-
tion as nonsense.
Intestinal Fever. — G. W. Richardson describes a
fever which prevailed largely among the members of
the eighth army corps in the rhilippines. It was
characterized by anorexia, weakness of the limbs, head-
ache, backache, cramps in the stomach, diarrhoea, and
fever. The digestive symptoms were the most promi-
nent, the fever seldom being as high as 102° F. The
exciting causes of the condition he classifies as: (i)
Excessive heat of the sun with insufficient head pro-
tection; (2) indigestible and improperly cooked food;
(3) unsuitable clothing; (4) drinking of native li-
quors. The writer speaks far from favorably of the
food supplied to the army in the Philippines. As
a preventive of diarrhoeal troubles he thinks the ab-
dominal bandage is very valuable.
Notes on the Philippines — Samuel O. L. Potter
describes the people, the water-supply, the sanitary
condition, and tire health of Manila. The city, he
says, is a very healthy one, and with moderation in
eating, drinking, and working, one need no more be
ill in Manila than in New Orleans, St. Louis, or New
York. As to heat, " Washington in summer is an in-
ferno compared with Manila," American women and
children do very well so long as they remain well, but
recovery in case of illness is difficult.
The Share of the White Man's Burden that Has
Fallen to the Medical Departments of the Public
Services in Puerto Rico. — John Van Rennselaer Hoff
gives an account of the establishment of the superior
board of health in Puerto Rico, and of the work it has
done. He gives the statistics of the work; of vaccinat-
ing the entire population of the island, which was
inaugurated by him, and which resulted in the stamp-
ing out of what threatened to be a serious epidemic of
smallpox.
The Sanitary Condition of the Far East as it
Affects the United States — Stuart Eldridge speaks
of the danger of the spread of infection across the sea
which has resulted from the increased speed of ships,
and describes the measures which have been taken by
the Marine-Hospital service to prevent, by means of
642
MEDICAL RECORD.
[April 14, 1900
systematic inspection of ships at the port of departure,
the introduction of any of the epidemic or endemic dis-
eases of the East into this country.
Amoebic Dysentery. — I. B. Diamond reports four
cases of this affection contracted in Texas and in
Georgia. The treatment which he recommends con-
sists in rectal injections of solutions of hydrogen di-
oxide or of potassium permanganate. Relapses are
frequent, and the writer says that a patient should not
be considered out of danger for at least two months
after apparent recovery. During that period the pa-
tient should remain on a liquid diet.
Cuban Malaria in the North Atlantic Squadron
of the United States Navy in 1898 W. F. Arnold
concludes from a study of the statistics of malaria in
the navy off the southern coast of Cuba in the summer
of 1898, that the disease is water-borne in some cases,
while in others the infection would seem to have been
spread by mosquitos.
Histology and Microchemical Reactions of Some
Cells to Aniline Dyes ; Identity of the Plasma Cell
and Osteoblast; Fibrous Tissue a Secretion of the
Plasma Cells ; Mast Cell Elaborates Mucin of Con-
nective Tissues. — H. F. Harris contributes a paper
with this comprehensive title.
Bubonic Plague. — H. F. Harris and W. F. Arnold
describe the clinical symptoms, pathology, and bacte-
riology of the plague. They speak highly of Yersin's
antitoxic serum and Haffkine's prophylactic serum,
though they have had no personal experience with
either.
The Methods of Control of Leprosy in the Ha-
waiian Islands, with a Description of the Leper
Settlement in Molokai. — R. S. Woodson recounts the
familiar history of the leper colony at Molokai, and
gives pictures of three cases of leprosy.
The History and Etiology of Bubonic Plague. —
George M. Sternberg gives in the Tower lectures, de-
livered at Georgetown University, a brief rhiune of
the history of the plague in the middle ages and mod-
The Parasites of .Sstivo-Autumnal (Remittent)
Fever. — Charles F. Craig describes the various stagc-s
of the cycle of development of the jestivo-autumnal
Plasmodium in man.
The Hospitals of Puerto Principe, Cuba S. T.
Armstrong presents an interesting article, with illus-
trations, of the three hospitals in this city, which he
believes to be typical of those of other Cuban cities.
The Lancet, March ji, igoo.
Note on the Superficial and Deep Reflexes. — J.
M. MacCormack finds that in the initial stage of gen-
eral paralysis of the insane there is generally a weak-
ening of painful sensibility and of the cutaneous re-
flexes with the exception of the plantar reflex. On
the other hand, the deep reflexes are exaggerated. In
the second stage the plantar reflex is markedly exag-
gerated and the other reflexes both deep and superficial
are increased. In the third stage all the reflexes be-
come weaker and finally disappear. During an epi-
leptiform attack the superficial reflexes are decreased
or abolished, but the tendon reflex is exaggerated, and
is often accompanied by fibrillary contractions which
may be transmitted from a limb to the trunk and then
may pass to the limbs of the opposite side. In epilep-
tic insanity sensibility to pain and the skin reflexes
are generally lessened, but the tendon reflexes are
normal. After some convulsive attacks the tendon
reflexes are increased, while the cutaneous reflexes are
considerably weakened, with the exception of the
plantar reflex, which is augmented and may be associ-
ated with trembling or even with epileptoid move-
ments of the foot. Hypochondriacs and neurasthenics
generally present an increase of all reflexes both
superficial and deep. In hysteria there is a decrease
of painful sensibility and of the cutaneous reflexes.
In alcoholic paralysis painful sensibility and tendon
reflexes are exaggerated, while the cutaneous reflexes
(except the plantar reflex) are weakened. In acute
mania the reflexes are normal. In secondary dementia
all reflexes are exaggerated. In melancholia painful
sensibility and cutaneous reflexes are normal, while
the tendon reflexes are exaggerated. In the stage of
melancholic stupor painful sensations, which on su-
perficial examination may appear feeble, are in reality
normal, the cutaneous reflexes are feeble, and the ten-
don reflexes are exaggerated.
The Typhoid Bacillus and Typhoid Fever : Sec-
ond Goulstonian Lecture. — P. Horton Smith con-
siders the abnormal varieties of infection and the
relation which the bacillus bears to the chief compli-
cations and sequelae of the disease. He believes that
we may have the fever without the intestinal lesions.
In these cases the bacillus passes into the blood and
becomes generalized in the organs without causing
lesions in the bowel even though the latter may be the
channel of entrance. He then discusses the various
complications, paying special attention to bacteruria.
Concerning suppurative conditions, he states that it is
very common to find the bacillus in pure culture in
the abscesses connected with bone, but in suppurations
occurring elsewhere its presence is undoubtedly rare.
Attention, too, is called to the persistence of the ba-
cilli in the body after recovery. The patient may be
in the mean time in perfect health, but under the in-
fluence of some passing stimulus the bacilli may re-
sume their activity and give rise now to periostitis,
now to osteomyelitis, or it may be to cholecystitis.
On the Abortive Treatment of Suppuration of
the Eyeball. — S. Snell counsels the following pro-
cedure: Ether having been administered, the cornea,
unless it is already destroyed, is divided across by a
cataract or Beer's knife. The next step is to remove
the remains of the cornea up to the sclerotic, and this
can be well done with scissors. After removal. Mules'
scoop may be used to aid further in the cleaning of
the interior of the globe, or cotton-wool and forceps
can be employed to wipe out the contents. Lastly,
sublimate solution is freely syringed into the eye cav-
ity until all the contents have been removed or washed
away and only the bared sclerotic remains. Gauze is
lightly packed into the eyeball and a bandage is ap-
plied. Almost immediate relief from pain follows
the operation, with no return, and the swelling of the
orbital tissues gradually subsides. The dressings are
changed on the night of the operation, and during the
next few days the eye is syringed twice a day and the
gauze is re-applied. For about the fii:st three days
there is some discharge; after that practically none.
On the Treatment of the Rheumatic Diseases of
the Heart in the Early Periods of their Manifes-
tation.— A. v.. Sansom considers that the distinct ad-
vances of recent therapeutics which are established
by satisfactory evidence are: (1) the employment of
salicin and the salicin compounds; (2) the use of the
icebag and cold applications; (3) the employment of
physical means for directly influencing the nerve
mechanism; and (4) the judicious employment of
April 14, 1900]
MEDICAL RECORD.
643
bathing, hygienic methods, massage, and mechanical
exercises. In the swollen and dilated heart of rheu-
matism failing cardiac power is best combated by am-
monia and kindred diffusible stimulants in small
doses of camphor water or with musk in doses of gr.
iii. ; tincture of sumbul TH xx., or the hypodermatic
use of some strychnine salt in doses of gr. ^^ may be
i\sed. A somewhat novel recommendation is the em-
ployment of the continuous current in the areas of the
vagi.
Some Cirrhoses of the Liver. — In this, the first of
the Lumleian lectures, W. B. Cheadle discusses the
symptoms of the affection and takes up some of the
disputed points in its pathology and causation. The
atrophic form is caused almost invariably by alcohol.
Hypertrophic cirrhosis is not an earlier stage of the
atrophic form, though Cheadle believes that in tlie
latter there may be a stage of engorgement and con-
gestive swelling before fibrotic contraction is fairly in
progress. In eighteen cases examined the fibrosis
was diffuse only once; in all the others it was coarse
andYnultilobular. In hypertrophic cirrhosis, there is
now no question that a fine fibrosis, monolobular or
intralobular in arrangement, occurs in conjunction
with hypertrophy due to alcohol; this diffuse fibrosis
appears to be met with also in the cirrhosis attributed
to malaria and in pure cardiac cirrhosis.
The Treatment of Rheumatism, its Prophylaxis
and Cardiac Complications. — R. Douglas Powell does
not believe that any germ thus far isolated has been
proven to stand in a causative relation to the disease.
Such proof may come later, but we do not have it now.
He gives an enthusiastic indorsement of the use of the
salicylates. In regard to the criticism sometimes
made that under this plan of treatment cardiac com-
plications are more frequent and relapses more to be
feared than with the alkalie§, Powell believes that
Ewart has hit on the fallacy of these statistics when he
remarks upon " the indirect risk that arises that we
may be misled into overestimating its [salicylic acid]
anti-rheumatic powers, and relax too early both treat-
ment and diet."
A Case of Lymphatic Leukaemia. — The case was
that of a man aged thirty-eight years, under the care
of M. H. Spencer. The main features were the di-
minution in the number of ordinary leucocytes (fine
granulated oxyphils), a great increase in the lympho-
cytes, and the presence of a number of nucleated red
cells. Another feature of the case was the presence of
an excessive enlargement of the liver accompanied by
moderate ascites.
Death from Carbon-Dioxide Poisoning in a Brew-
ery.— W. S. Thompson reports the case which occurred
from a man's attempt to clean out a vat. A candle
was taken into the vat, and as the man was found
asphyxiated, the exact nature of the accident was un-
known. Thompson declares that the candle is not a
safe test, and that a watch should always be main-
tained at such times.
Suprapubic Cystotomy Painlessly Performed
after the Hypodermic Injection of Eucaine. — T. V.
Jackson did the operation on a man aged fifty years,
using in, xl. of a seven-and-one-half-per-cent. solution
of the muriate of the drug. The operation was abso-
lutely not felt by the patient.
Extraordinary Case of the Loss of Both Eyes,
One After the Other, from Similar Accidents. — A.
Benthall records the case, the accident being that of
"sticking the finger in the eye."
British Medical Journal, March ji, igoo.
Spleno-Myelogenous Leukaemia. — This case is re-
ported by Thomas McCrae on account of the unusual
features shown in the course of the disease. The pa-
tient came twice under observation with the typical
condition of spleno-myelogenous leukemia. On each
occasion, under the use of arsenic, the leukasmic con-
dition disappeared. The spleen became reduced to
normal size, and the myelocytes disappeared from the
blood. At these periods his health was good, and
there was not any intercurrent affection present. The
subsequent history of the case was unfortunately not
obtained in detail. The patient went to California
and died there some months later. His death was
sudden, and was considered by his physician to be due
to cerebral hemorrhage.
Piece of Amber in a Bronchus for Ten Weeks.
— J. Frank Crombie reports this case, in which the
patient swallowed a portion of the mouthpiece of his
pipe. For the following two months the man contin-
ued at his work as coachman, and then had to take to
bed. There were diminished expansion and dulness
at the left base, and all over the left lung numerous
sibilant rhonchi could be heard. Rest in bed was the
only treatment that did any good. Finally, more
than ten weeks after the accident the patient coughed
up the foreign body without any trouble. It measured
one and one-eighth inches long, one-half an inch
broad, and five-sixteenths of an inch thick. The
rhonchi, cough, and other symptoms disappeared at
once.
The Condition of the Blood in Two Cases of Per-
nicious Anaemia. — Alfred C. Coles presents tables of
the more important numerical alterations in the cor-
puscular elements of the blood in these two cases.
They show very clearly the temporary improvement
which may take place in this disease, and also the
relapses and ultimate failure of all treatment. Each
chart shows how difficult it would liave been at certain
stages to make a diagnosis from one examination, and
also the impossibility of a definite prognosis for the
immediate future, as both patients might at one time
have been regarded as cured.
A Case of " Spurious Hermaphroditism." — J.
Chalmers Brown reports this case. The conditions
are summed up as follows: (i) absence of breasts;
(3) absence of fat over trochanters; (3) absence of
uterus and appendages unless a body in the right la-
bium majus would be considered an ovary; (4) the
presence of a body in the right labium majus, if con-
sidered a testicle. On the other hand, there were: (1)
Feminine voice, hair arrangements, and "feelings";
(2) the presence of a clitoris, urethra, vagina, with
hymen; (3) the pelvis had female dimensions; (4)
the presence of a body in the right labium majus — an
ovary.
Will-Making in Aphasic Paralysis.— James Ed-
munds reports the case of a single lady, sixty years of
age, who was the subject of partial right-sided hemi-
plegia, with motor aphasia complete both as to speak-
ing and writing. Instructions for the will were given
by the patient by the selection of printed cards con-
taining various directions, the patient selecting those
expressing her desires. Death took place twenty-two
days later. The will was probated, and the method de-
vised for the ascertaining the wishes of the testatrix
was approved by the court.
Anthrax of the Thigh Treated by Operation —
Thomas Sinclair reports this case, in which a healthy
laborer, aged twenty-three years, while wheeling a bar-
644
MEDICAL RECORD.
[April 14, 1900
row laden with bone manure was accidentally pricked
in the inner side of the thigh by a splinter of wood on
the barrow handle. Ten days after operation was per-
formed, followed by a good recovery. The case is in-
teresting because of the unusually clear history as to
mode of infection and because of the bacteriological
proofs.
Amputation without Anaesthesia. — Jasper Cargill
reports this case, in which his patient, a black woman
in Jamaica, while suffering the removal of a leg under
chloroform, showed symptoms of heart failure. When
told that the operation could not go on, she said :
" Please cut it off, doctor; I can stand it without chlo-
roform." After a brief consultation this was accord-
ingly done, without a sign of resistance or even a
groan from the patient.
Wiener kUnische Wochenschrijt, March 13 and 22, igoo.
Some Results of the Estimation of Blood Press-
ure in Cases of Mental Disease. — Alexander Pilcz,
in reviewing his work in this line, remarks on the
scarcity of the literature on the subject. This may be
due to the fact that till recently there was no suitable
instrument for conducting experiments. We now have
Gartner's tonometer. Pilcz made from nine hundred
to nine hundred and fifty estimations among two hun-
dred and forty patients. The forms of disease inves-
tigated were: general paralysis, hebephrenia, periodic
mania, circular insanity, melancholia, and epilepsy.
Normal blood pressure was estimated at from 105 to
130 mm. Hg. In paralytics the blood pressure varied
with the age of the patient and the stage of the dis-
€ase, falling lower with the progress of the latter, till
in the terminal stage it reached from 50 to 80 mm.
Hg. In hebephrenia the experiments were not very
satisfactory. In the cases of periodic mania and cir-
cular insanity the blood pressure varied according to
the special phase of the disease at the time of exami-
nation. During tRe melancholic stage the pressure
was high, during the maniacal low. In patients
affected with melancholia the pressure was high. The
author was not able to make satisfactory experiments
on epileptics during the convulsive attacks, but quotes
Fe'rd as saying that at the time of the convulsion blood
pressure rises, while it falls in the interval between
attacks.
Haematocolpos and Haematometra Resulting from
Congenital Atresia of the Hymen. — E. Topp reports
the case of a girl, thirteen years of age, who had never
menstruated. On examination the labia majora were
somewhat separated and between them there was seen
bulging out a dark-red, smooth, fluctuating tumor.
The nyniphte were invisible. The tumor was then
palpated through the rectum and appeared to be quite
extensive. The diagnosis was established. Under
cocaine anjesthesia the tumor was incised and about
one litre of dark brownish-red, thickish, odorless fluid
was evacuated. At the same time the pain, which had
been severe before the operation, ceased. The incised
membrane was about 6 mm. thick, and was fibrous in
consistency. The cavity was irrigated with weak
sublimate solution, six stitches were taken, and an
iodoform dressing was applied. Menstruation has been
normally established since the operation, and is pain-
less. It is interesting to note that an aunt of the pa-
tient had suffered from the same anomaly, but after
operation married, and bore three children.
A Contribution to the Diagnosis of Diverticula of
the (Esophagus. — Victor Blum, in discussing this
subject, says that in some cases the etiology is so ob-
scure that all available diagnostic measures must be
applied in order to reach satisfactory conclusions. If,
however, certain symptoms present themselves, such as
the appearance of a swelling in the neck after the in-
gestion of food, the disappearance of the tumor after
the regurgitation of the food, etc., then the diagnosis
is very clear. The use of the Roentgen ray is often
valuable. Another diagnostic aid is oesophagoscopy.
The author reports the case of a man, sixty-six years
of age, with characteristic symptoms of an oesophageal
diverticulum. Tlirough radiographic investigation it
was discovered that there was a diverticulum of the
posterior wall of the oesophagus, its position being be-
tween the fourth and seventh vertebra;. The shape
was oblong. The etiology in this case was traced to
traumatism of the pharynx about ten years before.
The extirpation of the sac was strongly indicated in
this case.
Cirrhosis of the Liver. — Richard Kretz believes
that cirrhosis of the liver is a localized, recurrent,
chronic degeneration process, with here and there re-
generation of the parenchyma. The process begins in
small foci of degeneration in the periphery of the
acini; this is followed by regeneration which results
in the rebuilding of the normal acini with a moderate
change of form. The change especially affects the
distribution of the capillaries, and consequently the
nutrition of different parts of the parenchyma. Then
areas of deeper-lying cells die, and the process pro-
ceeds to the complete destruction of acini in certain
places. Secondarily the function and capacity for re-
production in the islands of parenchyma are destroyed.
P'inally, after the organ has been repeatedly destroyed
and rebuilt in different areas, the destructive process
preponderates and progressive atrophy supervenes till
death occurs, unless the patient falls victim to a sec-
ondary or intercurrent process.
The So-Called Pericardiac Pseudo-Cirrhosis of the
Liver (Fr. Pick).— Victor Eisenmenger writes of the
disease named pericardiac pseudo-cirrhosis of the
liver. Its essential characteristic is that clinically it
presents a symptom complex which has a certain re-
semblance to that of cirrhosis, namely, a high grade
of ascites, and either no or very slight oedema of the
legs, while as the pathologico-anatomical foundation
of the affection there exists a chronic adhesive peri-
carditis. After reviewing the subject in its different
phases, he states that as a result of adhesive pericar-
ditis there develops a comparatively high grade of
ascites in the absence of oedema of the legs. If the
pericarditis is latent, then the symptom complex has
a certain likeness to cirrhosis of the liver. There is
no one invariable anatomical cause for this affection,
neither are its symptoms absolutely characteristic, and
therefore tliis name should not be accepted.
Berliner klinische Wochenschrijt, March ig, igoo.
Antip3a"esis.— Liebermeister gives an interesting
review of the changing opinion regarding the treat-
ment of fever during the past two hundred years. The
older physicians believed that it was dangerous to re-
duce temperature too quickly, and so they most care-
fully avoided all cooling drinks and even fresh air in
fever cases. Here and there through the literature of
medicine are scattered references to the advantages to
be derived from the generous use internally and exter-
nally of cold water, but the modern views of antipyre-
sis really dale from the work of Ernst Brand in Stettin,
who in 186 1 began that series of observations which
have revolutionized the treatment of fevers. We now
realize that the high temperature itself is dangerous
regardless of its exciting cause, and the reaction from
earlier enthusiastic views has simply been in the direc-
April 14, 1900]
MEDICAL RECORD.
645
tion of learning how to employ antipyretic measures
safely, so as to reduce the temperature without depress-
ing the system in other directions.
Curative Results in Pulmonary Tuberculosis in
the Charite Hospital during the Last Ten Years.
— Schaper gives a comparative table of results obtained
in tlie above institution in Berlin and those noted in
the Institute for Infectious Diseases. In the former
the mortality ranged from thirty-four to fifty-four per
cent.,' the mortality curve showing with the exception
of one or two years a progressive reduction; in the
latter the percentage of deaths ran from thirty-three
to twenty-seven, the average being twenty-seven per
cent. There was not, however, the progressive lower-
ing of the mortality curve as in the former case. He
attributes the good results obtained in the Charite'
Hospital to various factors. We now have a much
broader view of the essential problem of tuberculosis
as to dietetic management and general hygiene. More-
over, the public is better educated as to the necessity
of early intervention, and the patients come under ob-
servation at an earlier stage of the disease.
Tuberculin and the Early Diagnosis of Tubercu-
losis.— B. Fraenkel regards tuberculin as a definite
and sensitive test for the disease, claiming that when
local and general reaction appears we can surely pre-
dict the presence of the malady. He believes its di-
agnostic employment to be without danger. Such
diagnostic tests should be conducted in a hospital, for
it is necessary to take the temperature every three
hours and to keep the patient under the closest obser-
vation. In pronounced cases in which the test fails, we
have either an encapsulated focus which the injected
material cannot penetrate, or else an advanced condi-
tion in which the process itself has caused the produc-
tion of so much tuberculin that the little we inject can
exert no effect. A few cases are on record in which
reaction has ensued without the presence of the dis-
ease. The test finds a valuable field for employment
ir» cases of chlorosis with cough and slight physical
signs, which of themselves alone do not afford us
ground for a positive diagnosis.
French /ounials.
Actinomycosis. — A. Poncet and L. B^rard study
the prevalence of human actinomycosis during the past
two years in France. The cervico-facial region gives
twenty-one cases, the pleural one, the caecal and peri-
cecal two, the umbilical one, and the vesico-ano-rectal
one. The yellow grains are not always to be found in
fistulae, etc., unless they are carefully sought in scrap-
ings, etc. Iodide should always be given, though its
curative effect cannot be guaranteed. An early diag-
nosis is essential, since later the disease may be beyond
the resources of therapy. The clinical symptoms
should precede and lead to the search for the yellow
grain, which is the criterium in diagnosis. — Le Bulletin
Medical, March 28, 1900.
Extra-Visceral Sarcomatosis.— L. Lapayre and M.
Labbe present with illustrations an account of a young
man of low physical and mental development, the sub-
ject of a congenital, hairy, pigmented mole covering
the middle portion of the body like bathing trunks.
Besides pigmented moles over the entire body there
were numerous painful soft tumors, varying from the
size of a pigeon's egg to that of the double fist.
Three months after these tumors began to appear the
man was dead. All viscera were found free, as well
as the nervous and lymphatic systems. The case bears
analogy to neurodermatosis in the evidences of race
inferiority, but differs in absence of nerve involve-
ment.— La Fresse Medicale, March 2, igoo.
Note on a Case of Resection of the Stomach. —
A. Ricard presented a patient whose stomach, the first
portion of the duodenum, and a large portion of the
pancreas had been resected for epithelioma. The op-
eration lasted one hour and a quarter. The first day
ii7S° gn'' of serum were given, 500 in the veins.
The patient was shown eleven months after operation,
having gained fifty-two pounds, with a fresh, rosy
color and signs of perfect health. Eight personal py-
lorectomies by the writer have recently been published,
with seven recoveries. If done early, stomach cancer
can be operated on as well as those of the rectum and
uterus. — Gazette des Hbpitatix, March 22, 1900.
Shall Basiotripsy be Given Up ? — Dr. Audebert
concludes that an operation with all exposed to view
is preferable to a blind procedure, and that the head
should be held with tractors so that the borer does not
slip at the moment of perforation. While a surgeon,
deprived of the basiotribe, may in an urgent case di-
minish the size of the head piecemeal, the writer is
convinced that basiotripsy, thanks to its absolute
safety and uniformity of results, as well as to its sim-
plicity, remains for the majority of cases the operation
of choice, and that it cannot well be banished from
obstetric practice. — Gazette Hehdomadaire de Medecitie
et de Ckirurgie, March 25, 1900.
Poisonous Fish. — J. Pellegrin leaves aside the in-
jurious effects produced by inoculation and by wounds
made with the attacking apparatus with which some
fish are armed. These have recently been studied in
the same journal by Coupin. He confines himself to
poisonous effects due to the use of fish as nourish-
ment. The poisons are either those inherent in the
flesh, or due to substances taken in feeding from pois-
oned and polluted streams, toxic plants, or to diseases
attacking the fish, often of microbic nature. All these
factors are studied. — La Medeci/ie AJoder/ie, March
28, 1900.
Urinary Secretion in Eclampsia. — Paul Bar pre-
sents the results of his researches made with the view
of determining the action of the kidneys in puerperal
eclampsia, how oliguria appears, and fixing the place
to be assigned to it. The most important point deter-
mined from the observations is that the functional
trouble in the kidneys is secondary, and that good ac-
tion of the kidneys does not prevent the fatal ending.
— Le Bulletin Medical, March 28, 1900.
Black Taenias.— Charles Fritz finds a single in-
stance of "negro taenia" in literature. He reports
one instance personally observed in a practice of
thirty years. He attributes the extremely jjlack color
to the patient's long use of bismuth during a chronic
diarrhoea. With the expulsion of the worm the diar-
rhoea ceased. — Le Bulletin Medical, March 31, 1900.
American Journal of the Medical Sciences, April, igoo.
A Contribution to the Diagnosis of Diverticula in
the Lower Part of the (Esophagus. — Franz A. R.
Jung states that the reason why diverticula in the lower
part of the cesophagus are usually overlooked is that
this part of the tube is not generally examined in an
ordinary autopsy. He reports two cases, and draws
the following conclusions in relation to the differential
diagnosis of diverticula: With dilatation, as well as
with diverticula, there occur painful cardio-spasms
(Kelly, Jung), as well as painless cases (Reitzenstein).
In both vomiting occurs from the cesophagus, occasion-
ally from the stomach. If food eaten one or two days
before is vomited, while other food eaten in the mean
time remains down, the case seems to be one of diver-
ticulum. The swallowing sounds are abnormal in all
646
MEDICAL RECORD.
[April 14, 1900
cases of dilatation. If after emptying the cesophagus
it is easy to enter the stomach, a diverticulum prob-
ably exists. The entrance of the diverticulum can
easily be overlooked in oesophagoscopy. The value
of gastrodiaphany varies with the individual case.
X-rays show an enlargement of the oesophagus only.
The Value of Electrolytic Dilatation of the Eus-
tachian Tubes in Chronic Tubal Catarrh and Chronic
Catarrhal Otitis Media. — Arthur B. Duel concludes
from experience gained in fifty cases that the patholog-
ical process in inflammatory conditions of the Eus-
tachian tube and the tympanum is the same, i.e.,
hyperffimia, followed by the exudation of round cells,
which organize into new connective tissue, and subse-
quently atrophy. Chronic tubal catarrh and chronic
catarrhal otitis media are different only in position,
not in character. On account of its effect on hearing,
obstruction of the Eustachian tube should be removed
as rapidly as possible. The best method is electroly-
sis, for it is more rapid, more efficient, and its results
are more permanent. In a word, all narrow tubes
should be restored to their normal calibre, and when
narrowing is due to an organized inflammatory exudate,
electrolysis is the best method.
A Critical Summary of Recent Literature on the
Localization, Diagnosis, Prognosis, and Treatment
of Gonorrhoea in Women. — John G. Clark, after speak-
ing of the different parts of the genital tract which
may become affected, declares that the diagnosis of
this affection in women is far more difficult than in
men, chiefly because leucorrhoeal discharge is more or
less normal in the former, whereas in healthy men
there is no urethral discharge. The most certain
method of diagnosis is the demonstration of the gono-
cocci in the secretions. In women, so far as the ques-
tion of prognosis is concerned, the localization of the
pathological process is the deciding feature. Different
authorities vary in their opinions on this point. As to
the treatment, absolute rest in the acute stages is one
of the most important essentials. Silver salts, ichthyol,
and immediate germicidal treatment in acute cases
maintain an important place. Asto the extent in oper-
ative treatment, authorities also differ.
Gumma of the Iris and Ciliary Body ; Recovery
with Normal Vision. — Charles A. Oliver reports this
case of a man thirty-seven years old (a self-pro-
claimed syphilitic), who had lost the sight of the other
eye six years previously. The interesting points in the
case are : That the first eye affected probably suffered
from a similar type of affection as that under consid-
eration in the present instance; the recovery of the sec-
ond eye with normal vision after three exacerbations;
the endurance and positive value of larger doses of
mercury; the comfort obtained by the local use of heat,
mydriatics, and cyclopegics; the discharge of the gum-
mous material into the ocular media, with the rapid
disappearance of the mass; the temporary change of
refraction from far-sightedness and astigmatism to
near-sightedness and astigmatism; and the appearance
and retention of the most curious ophthalmoscopic pic-
ture of chorio-retinal disturbance.
A Remarkable Case of Probable Thoracic Aneur-
ism Presenting Intermittently through the Ster-
num.— Richard C. Cabot cites this case, of a woman
aged forty-two years. The remarkable features are,
that the aneurism eroded and perforated the sternum
in two places without ever causing pain or any other
pressure symptoms; that it presented externally as a
tumor, and then disappeared under treatment by iodide
of potassium, the skin rupturing without letting out
any blood. This series of events was repeated sev-
eral times in the course of seven years. Death oc-
curred from the sudden bursting of the aneurism as the
patient lifted a pitcher of water.
An Experiment in the Transmission of Syphilis
to Calves Mazyck P. Ravenel used in this work two
calves, and states that the results of the experiments,
which were conducted with the greatest care, have been
entirely confirmatory of the work of those observers
who, like Neumann, have failed in all attempts to trans-
mit syphilis to the lower animals, and who hold it to
be impossible.
Pediatrics, March ij and April i, igoo.
Ophthalmia Neonatorum — J. A. Day says it is
difficult to overestimate the seriousness of this disease,
which causes nearly thirty per cent, of all blindness.
The eyes should be the parts to receive first attention
from the physician who officiates at the birth. After
cleansing them, a few drops of some mild antiseptic
should be instilled, after which he should see that the
eyes are not molested. If gonorrhoea is suspected, a
few drops of a two-per-cent. silver solution should be
dropped into each eye. Energetic treatment must be
instituted in all cases of " inflamed eyes." The most
important point is the early detection of beginning in-
flammation, and daily inspection should be the rule.
The cardinal principle is to keep the eyes free from
irritating discharges. Lid retractors should be avoided,
as apt to cause injury. General rules of management
are given.
Five Years' Experience in Private Practice with
Diphtheritic Antitoxin Serum Frank W. Wright re-
ports upon two hundred and sixty-eight cases, divided
into four classes: (A) Environment the best and care
most perfect; (B) good family care and sanitary con-
ditions; (C) ordinary care; (D) poorest care and un-
sanitary surroundings. In class A were 33 cases and
6 deaths; in B, 60 cases and 7 deaths;- in C, 95 cases
and 17 deaths; in D, 80 cases and 29 deaths. Of
those receiving antitoxin on the first day 12 died and
99 recovered; on th^ second day, 9 died and 58 recov-
ered; on and after the third day, 37 died and 51 re-
covered. He concludes that the serum usually cures
in favorable cases, and often in unfavorable ones. It
prolongs life and lessens the severity; tends to pre-
vent stenosis, and when intubation becomes necessary,
it lessens the mortality. It prevents complications
and sequelae.
Cretinism. — Cristopher Graham reports a case of
the sporadic variety. Thyroid treatment here finds a
fruitful field of usefulness. It is commonly agreed
that the condition is due to maldevelopment of the
thyroid gland, its absence, atrophy, hypertrophy, per-
verted or abolished secretion; that it manifests itself
either in early embryonic life, appears at birth or soon
after, or is delayed until late childhood. The views
of many writers are discussed. The capabilities of
treatment are : ( i ) Removal of the myxoedematous con-
dition; (2) quickening of physical development; (3)
awakening of the intellect. Treatment must be con-
tinued through the entire life of the individual, other-
wise relapses occur. The dose of thyroid varies for a
child from gr. ss. to gr. i., gradually increased to gr. v.
or more.
A Case of Mitral Regurgitation and Pulmonary
Obstruction. — Augustus A. Eshner relates the history
of a girl, aged eight years, who showed " nervousness"
of the hands and feet, with shaking and weakness, for
three months. At the apex a loud systolic murmur
was heard transmitted to the axilla, and at the left base
were a rough systolic murmur and an accentuated sec-
April 14, 1900]
MEDICAL RECORD.
647
ond sound. Treatment consisted in regulating the
mode of life, digitalis, strophanthus, and iron, under
which improvement took place. The writer considers
the possibility of pressure exerted upon the pulmonary
artery by the necessarily enlarged left auricle, though
endocarditis of the pulmonary valves could not be
wholly excluded.
Night Terrors. — Francis Huber reviews the opin-
ions of Coutts. The term may be applied to a mild
form of temporary mental disturbance, or the mani-
festations may be of central origin. In all instances
there is an underlying neurotic or neuropathic state.
The causes are very varied. No one remedy answers
as a routine measure. The habits and life must be
studied. Scolding should be interdicted. Tonics,
ventilation, avoidance of stimulants, light evening
meals, regulation of bowel function, are necessary.
Adenoids or large tonsils should be removed. In
neuropathic subjects, bromides, chloral, etc., render
good service.
The Hygiene of Children's Sleeping-Apartments.
— Joseph Byrne gives the results of daily observation
in the habitations of working-people. The deficiency
of pure air and light is generally deplorable, causing
restlessness. The gas stove in such apartments is
considered little short of murderous. VVindowless
middle rooms should be abolished. The best room
should be the bedroom, and should be properly ven-
tilated during the night. Bedrooms should not be
swept, but mopped with a moist cloth. Stoves, as well
as adenoids and nasal obstructions, are to be taken
into account in treating diseases of infancy and child-
hood. Backward children should be protected by the
physician.
Injuries of the Nerves due to Fracture.— Charles
G. Cuniston speaks of a girl aged seventeen years, who
received a fracture just above the condyles of the
humerus. After uniting the hand was practically pow-
erless. Symptoms pointed to a lesion of the median
nerve, due to callus or cicatrix. The nerve was ex-
posed and a bony projection was chiselled away. No
improvement took place for five weeks. After eleven
weeks the functions were nearly perfect. An opera-
tion should be done as soon as the diagnosis is made,
since much may be expected from early operation even
in complicated cases.
A Fatal Case of Carbolic-Acid Poisoning in an
Infant. — R. Abrahams relates an instance of death due
to absorption by the skin in an infant seven days old.
Convulsions came on five minutes after the fingers of a
nurse, on which were a few drops of pure carbolic acid,
came into contact with the skin. Symptoms of dysp-
noea, shallow and labored respiration, cyanosis, rapid
and feeble pulse continued for ten hours.
The Montreal Medical Journal, February, igoo.
Clinical Notes. — Stanley S. Cornell notes four cases.
The first was that of a man aged sixty-fiv^e years, who
contracted gonorrhoea. This was followed by arthritic
and cardiac phenomena, and in about eight months he
died. The second case was that of a man aged forty-
seven years, the subject of chronic hip disease for
forty-three years. He died during chloroform ana;s-
thesia. This third case was that of a woman aged
twenty-three years, suffering from tuberculous osteo-
myelitis of the terminal phalanx of the index finger
succeeded by tuberculous invasion of the lungs. The
primary cause was given as trauma. The fourth case
was that of fatal haematemesis in a boy aged fifteen
years, probably the result of perforation of a gastric
ulcer.
Notes from Practice in the Argentine Republic.^
F. G. Corbin reports three cases of mycosis narium
— maggots in the nose. They are rare even in the
semitropical climate of the Argentine. The first case
was treated by a nasal douche of bichloride of mercury
1 : 2,000, followed by insufllations of calomel and iodo-
form in equal parts. The bichloride was later changed
to carbolic acid i : 40, while camphorated naphthol
was used as the paint. The second case being mild
was treated with chloroform and gum camphor. The
third case was treated much as was the first one noted.
Corbin reports also two cases of diaphragmatic hernia,
in both of which operation was refused.
Report upon Eighty-Nine Cases of Appendicitis
Treated in the Royal Victoria Hospital, Montreal,
during the Year Ending December 31, 1898. — E. L.
Archibald states that many of these cases dated their
first attack back to the age of ten or twenty years.
They rarely came under observation during a first at-
tack. There were fifty-five males and fifteen females
in the series of seventy case reports. The "onset
pain " is very variable both in character and degree.
Chill is a rare event. Painful micturition as a sign
of pelvic peritonitis was inconstant.
Medico-Legal Cases. — Georges Villeneuve describes
two cases under the foUovi'ing headings: i. Offense
against Morals, Allegations of Irresponsibility on
Account of Insanity and Epilepsy Set as a Defence,
Disproved by Medical Examination; Condemnation.
2. Mere Mental Weakness Associated with an Entire
Absence of Moral Sense; Two Previous Convictions
Followed by Imprisonment in the Jail and in the Peni-
tentiary; Another Arrest with Medical Examination
and Subsequent Commitment to a Lunatic Asylum.
Two Cases of Auditory Peripheric Hallucina-
tions.— E. P. Chagnon cites these two cases, in which
it is necessary for the patient to undergo an impression
either upon the sense of hearing or of touch to experi-
ence auditory hallucinations; no noises, no voices are
heard. If everything is quiet they have no halluci-
nation whatever.
On the Etiology of the Nausea and Vomiting of
Pregnancy. — David James Evans advances the theory
that the essential exciting cause of the nausea and
vomiting of pregnancy is frequently the physiological
contraction of the muscular fibres of the gravid uterus.
A Case of Rupture of the Rectum,; Operation;
Recovery Frank R. England notes this case of a
girl aged twelve years. The child fell on a broom-
handle which penetrated the anus to the extent of from
twelve to fifteen inches.
The Journal oj Tropical Medicine, March jj, igoo.
A Case of Ainhum. — A. B. Dalgetty reports a case
of this peculiar disease, consisting in an encircling
band, or furrow, of fibrinous tissue around the fifth toe
of each foot. No cause for the condition can be as-
certained. The patient is in good health, there is no
sign of syphilis or leprosy, and the toes have not been
injured in any way. Dr. Manson inclines to the view
that the fibrotic change is analogous to keloid, and is
started by an injury or irritation of some sort. He
thinks it may be related to leprosy. Leprous parts
are sometimes strangulated off by a fibrotic constric-
tion without much ulceration, and ainhum ends by the
toe being cast off.
The Endemic Centres of the Plague — Frank G.
Clemow says that in a region lying between 23° and
28° north latitude and between 100° and 104° east Ion-
648
MEDICAL RECORD.
[April 14, 1900
gitude plague has been endemic at least since i860,
possibly for one or more centuries. In 1894 it ap-
peared for tlie first time in history in Canton and
Hong Kong. In the year preceding this extension,
which proved to be the commencement of an almost
world-wide extension of the disease, plague was unusu-
ally active in its endemo-epidemic home in China.
This extension was due to spread of infection, and not
to any universal change simultaneously affecting the
centres of the disease at distant parts of the earth's
surface.
Notes on Beri-Beri in the Australian Pearling
Fleet, 1883 to 1887.— T. H. Haynes reports forty-
five deaths from this disease among five hundred and
six men in voyages lasting altogether fifty-three months,
and says that nothing has been reported to alter the
opinion (i) that beri-beri is confined to a very great
extent to rice-eating races, and with proper care will
not develop in less than sixteen months, (2) that the
substitution of a mixed diet of wheat flour, beans, pota-
toes, etc., to the exclusion of rice, mitigates, even if it
does not prevent, the disease. Lime juice is not very
useful, but beer is very beneficial.
Observations on the Epidemiology of Plague
Frederick Pearse gives an account of the courses of
three successive outbreaks of plague in Bombay, of one
in Poona, and of one in Calcutta. Each outbreak in
Bombay occupied about the same period of time. The
average weekly mortality is between five and six hun-
dred, and on this basis it is assumed that about twenty-
two thousand lives have been lost each year from
plague alone. The mortality is estimated at one in
forty of the population; but in the last outbreak in
Poona it was one in ten.
Five Cases of Terminal Dysentery. — W. J. Bu-
chanan says that it appears certain that the occurrence
of dysentery as a terminal symptom of many diseases
of the tropics is a fact. Rethinks, to use Sir William
Gull's words, that it is "rather a mode of dying than a
cause of death." The germ of dysentery is everywhere
present in the tropics, and finds in dying persons a
favorable soil to assert its virulence and hasten the
end. The author reports five cases which illustrate
his point.
Monatsschr.Jiir Geburtsh. und Gynak., March, igoo.
Contribution to the Etiology and Therapy of
Genital Prolaipsus. — A. Theilhaber states that the gen-
eral cause of vaginal prolapse is from atrophy of the
underlying fat and connective tissue. If prolapse of
the anterior wall of the vagina continues for a long
time, there follows prolapse of the uterus. Treatment
for vaginal prolapse is plastic operation on the vagina;
no operation on the uterus unless for rare primary pro-
lapse of the uterus. For primary anterior vaginal
prolapse, operation on the anterior wall; for posterior
vaginal prolapse, excision; in complicating perineal
ruptures, building up of the perineum.
Contribution to the Colpeurynter Question — O.
Kaufmann declares that in all those cases in which
an early emptying of the uterus is indicated, but in
which the conditions of the uterine wall do not allow
this without danger, the use of the balloon is the
safest and best procedure.
Sclerosis of the Uterine Arteries. — S. Cholmogo-
roff has observed in three cases primary lesions of the
uterine arteries; this lesion was arteriosclerosis, not
having an inflammatory process as a basis. In the
first case the affection was part of a general process;
in the other two, local,
A Laparotomy with Unusual Difficulty in Asep-
sis.— E. Meusel reports this case, in which he performed
the second operation. The patient was a woman fifty
years old, with a malignant proliferating cystoma,
adenocystoma papilliferum.
A Case of Missed Labor with Myoma of the Uterus
and Placenta Praevia A. Hartz believes the early
death of the fcetus in this case was due to compression
of the placenta and cord. There was no severe hem-
orrhage. The myoma was on the left side.
Retroversio-Flexion of the Partially Incarcerated
Gravid Uterus; Urachus Fistula. — Unterberger cites
a case of this kind, the cause of which he considers
was traumatism in the first part of pregnancy.
Archives Frovinciaks de Chirurgie, March i, igoo.
The Treatment of Tuberculosis of the Prostate.
— H. Sarda considers this an affection which should
sometimes be treated surgically, medical treatment by
means of acids, silver nitrate, iodoform, etc., having
given little satisfaction. The longitudinal prerectal
perineal incision may be used in cases of perineal ab-
scess, which, with the prostate, should be curetted.
The transverse incision is preferable when there is
neither abscess nor fistula. Should there be fistulae,
these should be followed up to reach the prostate. The
longitudinal incision, as used byRoux or Delage'niere
or Guelliot, should be used in cases of prostatectomy.
General treatment should not be neglected.
Burns from the X-Ray. — Ch. Fevrier and G. Gross
report two cases. To avoid such ai. acciden', they :;d-
vise the interposition of a shee' of luminum onnected
with the ground, or else the ampulla should be 1 'laced
at least 25 cm. away from the :kin-. Aluminum is
transparent to the .v-rays and retains all the electricity
discharged by the tubes and conducts i*^ o the ground.
The discharges in tlie ampulla should be diminished
in frequency, or a static machine may be used in con-
nection with the ampulla. Individual susceptibility
must be taken into account. Arthritic patients are
especially susceptible.
A Grave Case of Anthrax of the Upper Lip By
treatment with Marmorek's serum Alfred L. Dupraz ob-
tained a cure in a case in which incision and curetting
had been of no use. Albumin in the urine disap-
peared after use of the serum.
Annales de Medecine et Chirurgie, March 75", igoo.
The Prognostic Value of Lenticular Rose Spots.
Exanthematic Form of Infantile Typhoid Fever. —
Etienne Boulin concludes that in light forms of infan-
tile typhoid fever the exanthem and enanthem are
equally slight. In severe forms the cutaneous eruption
and digestive troubles are equally developed. Among
the forms of medium intensity there is the exanthe-
matic form (Weill and Lesieur) characterized by {a)
the importance of the lenticular rose spots; (J)) the
attenuation of intestinal symptoms; (c) the good prog-
nosis. The abundance of rose spots is an unfavorable
sign only if it coincides with the absence or reduction
of digestive disturbances in cases of medium intensity.
The Essential Toxic Symptoms of Diphtheria
John Biernacki says that the arterial pressure falls
gradually; temperature falls equally. The urine grad-
ually diminishes. In the cases he notes the fall of
blood pressure has been slight in the beginning, then
goes on progressively in this manner to the end. The
symptoms that are considered essentially toxic have to
April 14, 1900]
MEDICAL RECORD.
649
a certain degree a constant character, and their devel-
opment as well as their consecutive intensity is in inti-
mate relation with the fall of blood pressure.
Cold Bathing in the Course of Typhoid Fever in
Infants. — E. Ausset believes in the systemjttic bathing
of infants suffering from typhoid fever, but considers
the Brand method too severe in many cases. The
favorable action on the nervous system and on the cir-
culation is obtained frequently enough by baths at 26°
or 28° C. When cases are not benefited at first by these
milder baths, the writer gradually cools them down to
the Brand temperature. He has never seen ill effects,
even from the last method.
Lo Spcrimentale, No. i, igoo.
The Specific Serums.— Gino Galeotti says that Ehr-
lich's theory is that in order that any substance should
be to.xic to the organism it must possess the power to
fix itself chemically upon the molecules which consti-
tute the living protoplasm of the organism itself.
This theory the author finds in complete harmony with
the results of experimentation in regard to the action
of serums and antitoxins.
Umbilical Tumors — Teodoro Stori from his re-
searches concludes, (i) that there may be developed
upon the umbilical cicatrix an adenopapilloma, pos-
sessing the same histological characteristics as those
originating from the intestinal tract — that is to say, de-
veloped from the remains of the omphalo-mesenteric
duct; (2) that the omphalo-mesenteric duct may persist
in the umbilicus and in the extra-peritoneal abdominal
walls to an extent of about 5 cm. without any apparent
connection with the intestines, presenting, however,
marked involution extending to its deepest portion.
Morphological Study of the Thyroid Arteries. —
Ferdinando Livini bases his work upon the examina-
tion of one hundred cadavers. He submits graphic
representations of conditions observed, and describes
first the types most frequently found.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondent.)
Preparations for a Change in Weather are being
made in South Africa by both belligerent parties.
The splendid summer is giving way to the rains that
usher in the cold, and the cold when it comes is known
by experience to be sometimes very severe. Already
the hardships of the English army, a large proportion
of whom have poor camping accommodations, have be-
come considerably enhanced by the persistent wet, and
a prolongation of the campaign will necessitate the
supply of more suitable kits. Flannel shirts, warm
underclothing, and thick uniforms are being rapidly
manufactured in England for the forces, while articles
of a similar nature are said to be reaching the Boers
via Lourenro Marques. These and other preparations
seem to show that, in spite of the sanguine forecasts
of journalists, there is no immediate expectancy on
either side of a declaration of peace. The Boers are
still in possession of the north of Natal ; their army is
to a great extent intact, and their positions in their own
country are strongly fortified, all of which things make
it a little difficult to understand why.their capitulation
is so persistently looked for by a section of the British
press. On the other hand. Great Britain is perfectly
determined, before discussing the future of the Repub-
lics, to obtain an unqualified submission, and Lord
Roberts' peaceful stay at Bloemfontein is only the
prelude to an organized attack upon the Transvaal ter-
ritory.
The Condition of Mafeking — I am still unable to
report the relief of the Mafeking garrison, but since
my last communication several telegrams have come
through from Colonel Baden-Powell to Cape Town
showing that he is still able "to keep his end up."
Undoubtedly the relief columns have a difficult task
before them, as they have to maintain intact lines of
communication of immense length. To gallop into
Mafeking without bringing stores and without opening
and keeping open a way by which stores might be
brought, would be to insure the immediate downfall of
the town by starvation and disease. The town re-
mains fairly healthy, and the food supply should last
some time yet. The number of the garrison is not
large. I have seen it given as 10,000. This figure is
too high. It is the figure of one of the big contractors
who supplied stores in view of a possible siege, and in-
cludes both those who have since died and those who
made their escape from the town in the last day or
two. It will probably be found that Colonel Baden-
Powell has under his care rather under 2,000 whites
and about double as many blacks — that is, including
civilians of both sexes, children, and troops. The
contract to supply Colonel Here's forces specified as
soldiers four hundred and forty Europeans and one
hundred and ten natives, and specified also four hun-
dred and forty horses and seventy-three mules, and the
outside duration of the siege was estisnated at three
months. The investment has now lasted over five
months, but the contractor sent a much greater supply
of stores upon his own well-inspired initiative, and if
the town is saved his action will have mainly saved i*
The Herbert Hospital, at Woolwich, just outside
London, which Queen Victoria has recently visited,
was built at the instance of Mr. Sydney Herbert, after-
ward Lord Herbert of Lea, who was Secretary of State
for War during the Crimean war. It was designed by
the late Sir Douglas Galton, and within its walls Sir
Douglas' famous cousin. Miss Florence Nightingale,
carried out the views on hygienic nursing which have
made her name famous throughout, the world. The
Herbert Hospital, like the other big service hospital
at Netley, is crowded with sick and wounded who have
returned from the war.
Professional Jealousy among the Boer Medical
Men. — ^I have already referred to the very cold wel-
come extended by the Boers to the medical men and
ambulance establishments which, with the kindliest
motives, have gone to the Transvaal. This attitude
was at first explained by the fact that the Boers, hav-
ing obtained from the various foreign powers to whom
appeal has been made, much verbal sympathy but no
substantial help, feel a deep distrust of Europeans;
but it seems likely that professional jealousy has
played a part. Major F. A. B. Daly, of the Royal
Army Medical Corps, who was captured by the Boers
after the battle of Dundee, and who has since regained
his freedom, says that during his captivity lie helped
to alleviate the sufferings of the wounded Boers, with
the result that he excited so much jealous feeling
among the Boer doctors that it was decided to send
him back to his own troops. Thus was virtue re-
warded.
The Death of General Joubert.— Petrus Joubert —
"Slim Piet" — the commander-in-chief of the Boer
army, died in Pretoria on March 27th from intestinal
obstruction and peritonitis. The diagnosis is conjec-
tural, but it is known that he has been suffering from
symptoms of the condition for some time, and it has
certainly required the greatest fortitude on his part to
remain in the field. In him the Boers have lost a
great gencal, and the British a fine foe. He was a
650
MEDICAL RECORD.
[April 14, 1900
Frenchman by birth, but had lived forty-five years in
Dutch South Africa, and had held high civilian oflfice
in the Transvaal before being called to his military
position. He is known to have been opposed to going
to war with England, although his aspirations for an
independent Dutch Republic, free from British tram-
mels, were every whit as real as those of President
Kruger. But Joubert, though a good soldier, believed
implicitly in diplomacy, and earned his nickname by
his skill in conducting negotiations. He was averse
to losing all chances of achieving Dutch aims peace-
fully, a position which he knew would follow if his
countrymen made an armed invasion of British terri-
tory. But his advice was overruled, and when he found
that he had to fight, he fought with great strategic skill.
His invasion of Natal was an admirably planned affair,
and, in spite of Sir George White's pluck and resource,
the Boers might have reached Pietermaritzburg, and
even Durban, had it not been for the grand work of
the British naval brigade, who were present at Lady-
smith more or less by accident.
The Boer Ambulance Wagons, wliich fell into the
hands of Lord Roberts during his march into Bloem-
fontein, show well that the Republics have made very
good preparation for the care of their wounded. I sug-
gested that when we knew more about it we should
probably find this to be the case, for there never seemed
any grounds for believing that an army so well pro-
vided with all military iinpcdiiiiaita had no proper ar-
rangements for the succor of the wounded. Over and
over again this, has been stated, but never upon trust-
worthy information. As a matter of fact, the Boer am-
bulance wagons turned out to be very comfortable
vehicles. There is no uniformity of pattern about
them; on the contrary, covered vehicles of every shape
are used, the only external thing in common being the
flying of the Red Cross. But all the ambulances are
well furnished within with mattresses, and clearly only
conveyances with good springs have been selected.
Also the wounded are expected to require transport in
a lying-down condition, and the ambulances are pre-
pared with this in view. The British ambulance wagons
are very neat, clean, and uniform in pattern; but a
large proportion of the wounded have to be removed
in a sitting posture, and the build of wagon is one
that does not run lightly. On the whole it is probable
that the Boer wounded suffer less than the British
wounded during transport along the abominably rough
roads of South Africa.
■ OUR LONDON LETTER.
(From our Special Correspondent.)
LECTURES AT THE COLLEGES — BROWN INSTITUTION^
LETTSOMIAN LECTURES AT THE MEDICAL SOCIETY —
SURGERY OF THE SPINE — MIDWIVES BILL.
I.ONnoN, March 30, 1900.
We are in the lecture season. Those who have so
often inveighed against overlecturing students might
very well direct some of their criticisms to the pro-
visions made for practitioners. Both the royal col-
leges give courses of lectures on various subjects.
Some of the societies have lectureships, and there are
other fixtures each season. Of late, too, the Post-
Graduate School has extended the system. If he tried
to attend many the practitioner would have little time
left to digest all he heard. But he knows better, and
' most of the courses fail to attract him. I have been
at lectures by distinguished men when the audience
could be counted on the fingers. Still the older estab-
lished courses have an imposing history and may usu-
ally be heard with profit.
The Arris and Gale lectures at the College of Sur-
geons were delivered last month by Mr. P.. G. A.
Moynihan, of Leeds, who devoted them to the anato-
my and pathology of the rarer forms of hernia. The
Hunterian course was entrusted to Mr. Mayo Robson,
who lectured on the surgery of the stomach. He pro-
duced statistics gathered from various sources and
gave the results of his own operations. He takes a
hopeful view of this branch of practice and thinks its
success should be as great as in that of the gall blad-
der. He appeals to the medical side for earlier diag-
nosis and earlier consultation with the surgeon.
At the College of Physicians the Milroy lectures
have been given by Dr. F. J. Waldo, one of our lead-
ing medical officers of health. He took for his sub-
ject epidemic diarrhcea, and suggested that the dust of
towns might be the purveyor of the infecting microbe.
Such dust being always polluted with horse-dung, this
might be the chief agent of distribution. If the idea
only leads people to be more careful to preserve milk
and other foods from dust it will be a benefit to many.
The Goulstonian lectures have just been concluded.
They were given by Dr. Horton Smith, who discoursed
on typhoid and its bacillus. I may name one point he
enforced, viz., we cannot regard it as an intestinal dis-
ease. It is more like a modified septicaemia, for in
all cases the bacilli pass into the blood and thence to
the various organs, and the symptoms are referable to
the poisons there produced, except those of the intes-
tine. It is modified in that there is in nearly all cases
the definite local primary disease whence secondary
dissemination of the microbe takes place.
The Lumleian lectures were begun yesterday by Dr.
Cheadle. The subject is cirrhosis of the liver.
The Lettsomian lectures of the Medical Society of
London have been delivered by Sir William M.Banks.
Now he is one of the advanced surgeons and always
expresses himself with clearness. His style is easy
and forcible, often picturesque, and everything he
writes is worth reading. He took as his subject can-
cer of the breast, and gave a synopsis of what is known
about it from his own point of view. His impressions
after thirty-three years of surgical work must be of
value, although, as he remarked, statisticians hold such
evidence in contempt. It is often said figures cannot
lie, but, said Sir William, " it has long been painfully
manifest that nothing can be more lying and delusive
than statistics if not properly used.'' As a result of
improper use of medical statistics he found that
" many errors have been long handed down from book
to book until some disagreeable doubter has arisen
who has exposed them." Further he observed that
erroneous conclusions may be drawn from correct fig-
ures. "If any one wants to know how statistics may
be manipulated and applied, let him consult the liter-
ature of the anti-contagious diseases, anti-vivisection-
ist, and anti-vaccinationist propaganda — all prepared
by persons of the most superior virtue." The ques-
tions of increased prevalence, local distribution, cause,
heredity, and traumatism were then looked at. Diag-
nosis occupied the whole of one of these interesting
lectures. "There are some delusions about cancer of
the breast to which almost the entire public still give
credit, and, I regret to say, not a few medical men.
They are partly the result of text-book statements not
properly explained, and partly the result of popular
tradition. They are difticult to eradicate, because there
is just that small amount of truth in them which makes
it possible to argue about them." And with this pref-
ace the lecturer proceeded to examine a number of
these errors.
Prof. Rose Bradford, physician to University Col-
lege Hospital, is also superintendent of the Erovin
Institution, and delivers five lectures a year at the
London University, as required by Mr. Brown's will.
The work of the institution consists of three depart-
ments: First, there is the animal hospital under the
April 14, 1900]
MEDICAL RECORD.
651
care of veterinary officers, by whom many animals are
continually treated for the diseases to which they are
liable. Then there is the routine investigation of
cases of suspected rabies in the laboratory of the in-
stitution; and, thirdly, there is the work of research
concerning the diseases of man and animals, conducted
in the laboratory by the professor and others. This
year Dr. Biadford opened his course with two lectures
on rabies, the other three being devoted to the tsetse-
fly disease of South Africa. In the last five years be-
tween three hundred and four hundred cases of sus-
pected rabies have been investigated at the Brown
Institution, and some useful statistics accumulated.
Dr. Bradford prefers the term rabies for the disease in
man as well as in animals, hydrophobia being to a
great extent a misnomer. Having noted that the dis-
ease was mentioned by Aristotle and described by
Celsus, he briefly followed its history down to Pasteur,
whose work was of course carefully described. This
concluded the first lecture; the second dealt with the
diagnosis of rabies in both man and animals.
In these days of daring surgery it is difficult to feel
more than slight surprise at desperate attempts at op-
eration. The spine is not a very promising part for
interference, but modern surgery has met with some
successes in that region. A case was related at the
Clinical Society last Friday in which an attempt was
made to remove a dermoid tumor growing in the spi-
nal canal and pressing on the cord. The patient was
a man aged twenty-six. years, suffering from chronic
Hodgkin's disease. Symptoms came on indicating a
collection of fluid or some growth, irritating the second
dorsal nerve and compressing the cord below it. This
diagnosis having been arrived at, and there being no
evidence of malignancy or of syphilis, laminectomy
was performed, the second, third, and fourth dorsal
arches being removed, when a gray tumor was exposed
on the outer surface of the dura mater, reaching out of
sight above and below. Pieces of the growth were
snipped away and the patient rallied. Pulse and tem-
perature fell to normal from 120 and loi'^ F., and
great improvement followed, but as the relief was far
from complete a second attempt to remove the tumor
was made. The first, fifth, and sixth dorsal lamina;
were accordingly removed, but no limit could be seen
to the growth. The patie.it died eight hours after-
ward.
Sir D. Powell, president, remarked that the case
was interesting as bearing on the question how far in-
terference was justifiable in such cases.
After this there was some discussion on the reduc-
tion of the deformity of Pott's disease by manual rec-
tification. You will remember, perhaps, that I told
you at the time of the cases brought before the society
in 1897 by Messrs. R. Jones and Tubby. Since then
they have had many cases, bringing the total to ninety-
nine, of which they now gave their report. They
showed some of the cases of the first series, that the
fellows might judge of their results. They advise
the plan only when the spine is yielding in young,
strong children free from abscess or tubercle. They
insist on the necessity of unremitting personal care
and mention numerous contraindications, and say fresh
air is an all-important adjuvant. Altogether they
seemed less enthusiastic than before. The speakers
who followed gave little encouragement, seeming to
consider the correction of the deformity more apparent
than real. The estimate of the usual mortality of
Pott's disease, placed by the authors at twenty-five per
cent., was challenged by Mr. Marsh, who put it at five
or six per cent., and said paraplegia was recovered from
under other treatment.
Eventually the meeting agreed to appoint a commit-
tee to report on the subject, the terms of reference to
be drafted by the council.
The advocates of the midwives bill have managed
to rush it through the standing committee, to which it
was referred without material change. In a couple of
sittings that committee finished its work, and the bill
will soon come on in the report stage. The difficulty
of defeating it is thus necessarily increased, and
only the most strenuous efforts will avail to change it.
But where are these strenuous efforts to hail from?
The corporations and societies have done nothing.
Apathy seems to have fallen on all but a few who have
pointed out the dangers to the profession and the pub-
lic, but have failed so far to arouse either. Sir George
Pilkington, Mr. T. P. O'Connor, Mr. Lloyd-George,
and Dr. Commins deserve credit for the efforts they
made to amend several clauses, but the opposition was
too strong. Mr. Atherley-Jones, whose name you may
recall as having on other occasions made himself rid-
iculous, objected to midwives being subjected to re-
strictive rules by the General Medical Council, which
he spoke of as "a body of rival practitioners." and he
quite let the cat out of the bag as to the wish of the
promoters of the bill to set up a distinct class of prac-
titioners— a wish they had up to this period absolutely
repudiated. The country practitioner was also sneered
at as if his five years' curriculum scarcely entitled him
to a position equal to that proposed for the Mrs. Gamps
to be registered on account of their present experience,
or their successors who are to be trained for three
wliole months! The society ladies who are working
for the bill on behalf of "poor women in their trou-
ble" will probably take care not to engage the new
midwives in their own time of trouble.
A meeting of the constituents of the Southeastern
divisions of London is called for Monday to impress
on their parliamentary representatives the dangers of
the threatened legislation.
PUBLIC SERVICE AGAINST PRIVATE
WORK.
Sir: As indicating how the public mind has been
and still is being educated, the incidents in an acci-
dent case are interesting.
While walking down Broadway on March 28, 1900,
I saw a man start to run with a small boy in his arms,
followed by several persons, and just after he passed
me I heard him asking of those near him the shortest
way to the New York Hospital.
Only a few doors below on the corner is a cigar
store — about it was a crowd, some also in the store.
Thinking others might have been injured besides the
boy, I crowded my way in and offered my services to
the policemen (there were two).
They told me no one was hurt there, and said the
boy had been run down by a truck. They were trying
to induce the woman in charge of the cigar store to
make a charge against the truck driver, which she
was declining to do. She was rapidly becoming hys-
terical because of the injury to the boy — how serious
she did not know — and because of the crowd. I ad-
vised the policemen to disperse the crowd, lest they
have another case; assured the woman that the boy
seemed much more frightened than hurt, from what lit-
tle could be learned by mere observation, and went on
about my business; which having completed, I walked
up Broadway and again met the cigar man with the
boy. This time the boy was walking; he looked a
trifle pale; he had one arm out of his sleeve and sup-
ported in some kind of sling.
The man informed me that at the New York Hos-
pital tiiey had told him the boy was little injured, and
then said: "You know he was only knocked over by
the truck."
652
MEDICAL RECORD.
[April 14, 1900
Why should this man's first impulse be to run off to
the hospital, six or seven blocks, when he thought his
boy injured, and pass, in doing so, several doctors'
offices by any possible route? Again, why should
the police press upon the boy's mother — if mother she
was — in the cigar store the necessity of her making a
charge against the driver of the truck, when she stout-
ly refused to do so? Was it because they were afraid
of having some irresponsible persons attack them for
not doing their duty ? They urge a woman after she
has said: "I want nothing of this driver or his peo-
ple."
Surely there is no hope of financial reward in this
case, and to my mind is only another evidence of
the direction in which we are drifting, i.e., toward
having everything done by public officials or public
institutions.
Is it not wise to pause and ask ourselves the ques-
tion : Is there no way to check this tendency ? Would
not the people who give so much time to worrying
officials do well to institute measures, if possible, by
which people should do more for themselves, and ask
less of the officials and of institutions?
Put every one on his honor, officials, citizens, and
all, leaving paternalism on the part of the government
as much as possible in the rear. At our present pace
it will not be long before there is none left besides the
official and the dependent classes.
WicKEs Washburn, M.D.
March 31, igoo.
LEPROSY LEGISLATION.
To THE Editor of the Medical Record.
Sir: Shortly after the appearance of my article on
leprosy in your journal of January 27th last. Dr. A. S.
Ashmead, of New York, who appears to be a biblio-
graphical leprologist (a gatherer of facts in regard to
the subject of leprosy), sent to some eastern newspa-
pers an article making substantially the same recom-
mendations in regard to national legislation that I
made in my contribution to the Medical Record.
Since the appearance of this article, it has been e.x-
tensively copied east and west, in literary, medical,
and daily publications, in several instances misquoted
and misrepresented, especially by political papers that
have tried to arouse partisan prejudice. I have been
forced (much as I dislike discussing medical matters
in the newspapers) to deny some of these statements
attributed to me. For one thing, it shows where the
Medical Record goes, and, by the way, Current
Literature for March credits my article to another
medical 'ournal.
My contribution was written not to alarm the gen-
eral public, but to call the attention of the profession,
and, through it, the attention of our legislators, to the
fact that we have no protection in this country against
a spreading disease. I wished to emphasize the need
of national and State legislation upon tlie matter; of
wise, comprehensive, prompt measures that shall pre-
vent any considerable spread of leprosy on the main-
land. We want such legislation now, not because we
have annexed Hawaii, Puerto Rico, and the Philip-
pines, and are in closer relations with the West Indies
and the Orient, or because there is a sudden, emergent
need to act, but for the reason that the obligation rests
urgently upon us, because the obligation is long past
due. In a legislative way, we have left undone the
things we ought to have done, and therefore should
now do the things that ought to be done.
I am glad to see that Dr. Prince A. Morrow, in his
article on leprosy in the eighteenth volume of the
"Twentieth Century Practice," just out, has seen fit
to express his belief that leprosy may become a cur-
rent disease, and to recommend national legislation
in order to control the disorder. A year ago I made
the same recommendations, and, with the permission
of the Medical Record and of some other medical
journals, I shortly shall have reproduced in book form
these same suggestions. Referring again to Dr. Ash-
mead's article, I think that his figures are misleading,
if they are not entirely incorrect. He places the num-
ber of lepers in Hawaii at four thousand, which is an
overestimate by twenty-nine hundred. As for our
eastern islands, with eight thousand lepers on one isl-
and, I may say that no one at present has any means
of knowing how many lepers there are either in the
Philippines or in Cuba. Had annexation changed
the physical status of the islands, these uncertainties
might alarm us; but the truth is, we are as far away
from our annexed territory as we were before the war.
However, if the annexation of these islands does not
materially increase the danger here, it may serve the
purpose of rousing our government to action that
should have been taken years ago; even before we
had lepers of our own.
That we need not be hysterical about the matter is
shown by the fact that New Brunswick has had its
lazarettos many years without any alarming spread of
leprosy in the locality. The danger lies in our not
having any efficient provision against the spread of
leprosy in our midst from existing, permanent foci in
several of our States, and from the fact that isolated
cases are going here and there among us with more
personal liberty than the healthy negro is enjoying in
the South to-day. Our general quarantine laws are
not specific enough to affect this disease, and any of
us are liable at any moment to be exposed to leprosy
in its worst forms.
Besides, without going to lands across the sea, we
are exposed to the lepers of Mexico 'and Central
America — contiguous States. I would recommend that
a commission be appointed to inquire into leprosy in
this country; that this commission be empowered to
visit Hawaii and other leper-infected countries, for the
purpose of studying their laws of segregation, and their
methods of dealing legally and therapeutically with the
disease; that the report and recommendations of this
commission be acted upon without delay. Such a
course would stamp out a disease that may ye spread
to all parts of the United States, and become as gen-
eral as it was in Europe at one time.
The national medical officers we have at the pre. -
ent time are particularly well .^ualified to handle this
matter, and our learned surgeon-general would no
doubt gladly use his abilities with the special powers
granted him, to provide some safeguard against the
spread of leprosy. E. S. Goodhue, M.D.
Los Angeles, Cal., March 23, 1900.
Decapitation with the Karl Braun Key-Hook. —
Karl A. Herzfeld gives a detailed account of the
method of using the Karl Braun key-hook, and states
that it may be used to perform embryotomy as well as
decapitation, eventration, thoracotomy, etc. Its appli-
cation is indicated in the wedged shoulder position, if
the child is dead and version is impossible or contra-
indicated, as well on account of the wedging of the
child as the stretching of the lower uterine segment.
The key-hook is formed like the small upper end of
Smillie's instrument, only it has a somewhat more
parabolic curve, and at its lower end a knob — a knobbed
hook — while the lower end of the metal rod is in-
scribed in a cross handle. In the three Vienna clin-
ics (Gustav Braun, Chrobak, Schauta) the Karl Braun
hook has been used for decapitation, always with the
best results. — Ceiitralblatt fi'tr Gyndkologie, March 17,
1900.
April 14, 1900]
MEDICAL RECORD.
653
'^cvxnvs and polices.
A CoMPEND ON Diseases of the Eye and Refrac-
tion, INCLUDING Treatment and Surgery. By
George M. Gould, A.M., M.D., formerly Ophthalmolo-
gist to the Philadelphia Hospital, and Walter L. Pvle,
A.M., M.D., Assistant Surgeon to Wills Eye Hospital.
Philadelphia : P. Blakiston's Son & Co. 1 899.
This is one of a series of quiz-compends, and is as good as
most books of the kind.
The Trained Nurses' Directory. Compend of Names
Carefully Selected by Prominent Physicians and Surgeons
of New York and Vicinity from their Private Lists. Com-
piled and Edited by M. Louise Longe\vay, Graduate
of the New York Training-School, Bellevue Hospital.
Si.tth edition. New York. 1899.
This is a new edition of this useful publication. The work
is designed for the use of physicians and families who may
need the services of graduate nurses, who have been specially
selected and recommended by leading physicians and surgeons
as having had requisite hospital training and subsequent prac-
tice in private duty. The names are alphabetically arranged,
giving address, telephone number, school, year of graduation,
and the special cases taken by the graduates doing private
duty in New York, Brooklyn, Albany, Orange, N. J. ; Pitts-
field, Mass. ; Hartford, and New Haven, Conn., and the towns
adjoining those cities.
Materia Medica and Therapeutics. An Introduction
to the Rational Treatment of Disease. By T. Mitchell
Bruce, .M. A., M.D., Fellow of the Royal College of Phy-
sicians of London ; Physician and Lecturer on Medicine,
Charing Cross Hospital ; Consulting Physician to the Hos-
pital for Consumption, Brompton ; E.xaminer in Medicine
in the University of Cambridge ; formerly Examiner in
Materia Medica in the University of London and the Vic-
toria University, and Examiner in Medicine on an Exam-
ining-Board in England. Philadelphia: Lea Brothers
& Co.
This is a handy duodecimo volume containing all the essen-
tials of materia medica in compact form. The author attaches
importance to the plan which he has adopted in the descrip-
tion of special therapeutics, of tracing the physiological actions
and uses of the different drugs in their passage through the
body, from their first contact with it locally until they are
eliminated in the secretions. The work is divided into tliree
parts, dealing respectively with the inorganic materia medica,
the organic materia medica, and general therapeutics. The
third section is particularly to be commended, though those
on the materia medica will be found very useful for reference.
Bacteriology in Medicine and Surgery. A Prac-
tical Manual for Physicians, Health Officers, and Students.
By William H. Park, M.D., .A.ssociate Professor of
Bacteriology and Hygiene in the University and Bellevue
Hospital Medical College, New York. In one i2mo vol-
ume of 688 pages, with 87 illustrations in black and colors,
and two full-page colored plates. 1 899.
Dr. Park's well-known studies in the laboratories of the
New York City board of health especially fit him to write
with authority upon the subject of bacteriology and hygiene.
In this volume we have not only a practical exposition of all
laboratory methods such as health departments should em-
ploy, but also the simpler methods such as the active practi-
tioner can use at home. The value of the laboratoiy diagnosis
is also discussed in full. The subject of hygiene has been
particularly well treated in so far as relates to the methods of
disinfection and purification of water supply, and the book
can be recommended as one which meets every requirement
of the health officer as well as of the practising physician.
An appendix describing the more common micro-organisms
not bacteria, such as the streptothrix group, plasmodium ma-
laria;, amoeba coli, etc., -is of additional interest, while an in-
dex of infectious diseases with the bacteria found in each
affords a ready reference which is helpful to a busy man.
The language throughout is exceptionally clear and crisp, the
details of laborator)' technique are wonderfully complete, and
the illustrations are excellent.
Children, Acid and Alkaline. Health, the Golden
Mean; the Law of Diet Selection, Contraria; the Thera-
peutic Law, Similia. By Thomas C. Duncan, M.D.,
formerly Professor of Diseases of Children, Hahnemann
Medical College and Chicago Homoeopathic Medical Col-
lege. Philadelphia: Boericke & Tafel. 1900.
The author of these one hundred and forty-eight pages di-
vides children into normal, acid, and alkaline. Hahnemann
had already discovered the chemical tendency. Contraria is
assigned a permanent place in diet selection. Other writers
are freely quoted, and the aim of the little work is to aid in
developing healthier, happier humanity.
Christian Science: An Exposition of Mrs. Eddy's
Wonderful Discovery, including its Legal As-
pects. A Plea for Children and Other Helpless Sick. By
William A. Purrington, Lecturer in the University
and Bellevue Hospital Medical College upon Law in rela-
tion to Medical Practice; one of the authors of " A Sys-
tem of Legal Medicine." New York: E. B. Treat Com-
pany. 1900.
This Is a collection of the author's writings upon the subject
of Christian science as originally published in the Korth
American Reincw, the MEDICAL Record, and the New York
Sun. Taken together they form a strong arraignment of the
Eddy cult and the crimes perpetrated in the doubly sacred
name which it has adopted.
Herman Ludwig Ferdinand von Helmholtz. By
John Gray McKendrick, Professor of Physiology in
the University <Tf Glasgow. New York : Longmans, Green
& Co. 1899.
Undoubtedly Helmholtz possessed one of the most bril-
liant minds of the present century, and the study of such a
man's qualities, and the powers which secured for him such
a high place among the investigators of the world, must be a
pleasure and a profit to all lovers of nature and of nature's
noblest works. The biographer has had a delicate and in-
deed in many particulars difficult task to perform in looking
into the working of so creative a mind, and following up the
inquiries pursued by this scientist. Little has been known
and less published about the private life and personality of
Helmholtz, and the present work, though small, gives an ex-
cellent and most entertaining account of the philosopher from
the earliest to the closing years of his life.
The Nervous System of the Child, its Growth
and Health in Education. By Francis Warner,
Physician to and Lecturer at the London Hospital, etc.
New York : The Macraillan Company. 1 900.
This is a work addressed to all those who work for the wel*
fare and education of children and to those seeking knowl-
edge as to the workings of the youthful mind and body.
Scientific methods of work in accomplishing the ends desired
are pointed out. The study of the nervous system has much
to do with questions of training as with those of health, and
the whole question of management is discussed from the
school rather than from the family standpoint. The needs of
teachers have been kept in the foreground, and still questions
of hygiene as it concerns boarding-schools hav'e not been
overlooked. The feature of the work v\ould appear to be an
indication, by a medical man, of the aids which medical
science may render those who have to do with the bringing
up of children.
Cheloid of the Lobule of the Ear. — Marcel Natier
reports an interesting case of this nature occurring in
a woman, aged forty-one years, and belonging to the
better class. The exact cause of the mass could not
be determined, as it dated back to the early childhood
of the patient. Both ears were aftected, and there were
similar lesions in dififerent parts of the body. Atten-
tion is called to the rarity of these formations at this
site in the white race, though they are more common
in the black races. Reference is made to the literature
of other cases, and a re'sume is given of the dififerent
modes of treatment. None of the latter seems to be
very satisfactory so far as concerns the permanent re-
moval of the growths. — La Farole, February, 1900.
654
MEDICAL RECORD.
[April 14, 1900
J»acietij Mcpoxts.
THE NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, February 7^, igoo.
Eugene Hodenpyl, M.D.,-Presidext.
A Case of Malaria following Wound Infection. —
Dr. F. M. Jeffries reported this case. A surgeon of
this city who had never had malaria, and who had been
in the city up to July 15, 1899, had then gone to Sea-
bright, and had remained there from July 15th to 20th.
While there he had driven around during the daytime,
but had remained indoors at night. This neighbor-
hood was not considered a particularly malarious one.
From July 25th to September 15th he had been in the
northern part of New Hampshire, where malaria is
entirely unknown. He had returned to this city on
September 15th, and on September i8th had performed
a vaginal hysterectomy on a patient who, the next day,
had had a distinct and marked malarial chill. This
patient was from North Carolina, and had previously
had frequent attacks of malaria. The next two days
she had had chills, and as she had been given quinine
on the second day there had been no further chills.
At the time of the chill examination- had shown no
evidence of infection. During the operation referred
to the surgeon had pricked his finger several times.
On October 4th, or sixteen days after the operation,
the surgeon had had his first chill. This had been
followed by several others, each attack lasting for four
or five days. On November 24th, or just prior to one
of the paroxysms, the speaker had examined his blood
and had found the plasmodium malarias in great abun-
dance. It was of the variety known as the ajstivo-
autumnal — a variety not commonly met with in this
locality except in those who have had it previous to
coming here. The evidence presented by this history
certainly led one at least to suspect very strongly that
the surgeon had become infected with malaria by
wound infection. Specimens of the blood were ex-
hibited under the microscope.
A Case of Advanced Tuberculous Coxitis — Dr.
Jeffries showed an extreme case of tuberculosis of the
hip. The specimen had been removed from a girl
aged ten years. The acetabulum was almost wanting,
and the head and neck of the femur were entirely gone.
Pus had burrowed as far back as the sacrum. The
right hip was normal. In the left knee joint was found
a nail such as is used in holding together the bones
after excision of this joint, but there was no history of
such an operation having been done in the hospital in
which she had died. At the autopsy the upper right
apex of the lung contained a small tuberculous nodule.
The liver and spleen were enlarged and amyloid. The
bladder showed a few tuberculous ulcers. The left
kidney was fatty and tuberculous in its upper half.
The uterus presented a tuberculous endometritis, and
there was also a tuberculous salpingitis. The mesen-
teric glands were enlarged throughout.
Dr. Carlin Philips asked whether the woman upon
whom the operation of vaginal hysterectomy had been
done had originally had the ajstivo-autumnal variety of
malaria.
Dr. Jeffries replied that this patient had come
from a region in which this variety was common, but
there had been no opportunity of determining this
point positively.
Two Cases of Perforation of Tuberculous Bron-
chial Lymph Nodes into the Trachea.— Dr. F. S.
Mathews presented the first of these cases. The spec-
imens had been taken from a child, aged four years,
who had been in the St. Mary's Hospital for Children
for several months under treatment for tuberculous dis-
ease of the knee. On the night of January 19th the
child, while apparently in his usual health, had sud-
denly begun to cough, and had soon choked to death.
At the autopsy, made the next day, there had been found
on the right side an opening from which pus was ooz-
ing. This connected with the abscess cavity. The
trachea and right bronchus contained a considerable
quantity of pus. Tubercle bacilli were found in this
pus, and also in the mediastinal glands. No other
tuberculous lesions had been found in the thoracic or
abdominal cavities.
Dr. M. Nicoll, Jr., presented the history of a second
case. The specimens had been taken from a child one
year and a half old, who had been in the out-patient
department of tiie New York Foundling Hospital under
treatment for bronchitis for about one week. The
child had then been taken into the hospital because of
the urgent dyspncea and cyanosis present. Expiration
was more ditficul tthan inspiration. The child had been
immediately intubated, but without relief, and death
had taken place in a few minutes. When the thorax
was opened the left lung had been found over-inflated,
and in a condition of very acute emphysema. On cut-
ting through the left primary bronchus a large plug of
mucus had forcibly escaped, and the lungs had then
immediately collapsed. In the trachea, near the origin
of the right primary bronchus, was an oval opening
communicating with a cavity formed by the breaking
down of a large tuberculous gland. The bronchus
leading to the right lower lobe ended in a mass of tu-
berculous consolidation. The over-distention of the
left lung was apparently due to the valve-like action
of the inspired mucus plug; the power of expiration
was not sufficiently strong to expel the air taken in at
each inspiration.
A Case of Membranous Laryngitis Complicating
Typhoid Fever. — Dr. Alexander Lambert presented
the larynx from a person who had died of gangrenous
laryngitis. The man was an alcoholic subject who
had entered the hospital with a temperature of 105° F.,
marked dyspnoea, severe cough, and laryngitis. The
leucocytes had been reported as being only five thou-
sand, and on that basis a diagnosis of typhoid fever
had been made. The next day the spleen had become
palpable, and a profuse typhoid eruption had appeared.
Toward the end of the third week the temperature had
fallen very decidedly, and the man had shown every
evidence of improvement. About this time the laryn-
gitis had become much more severe. The fauces were
red, and in the back of the pharynx was a slight gray-
ish deposit. In the course of three days aphonia had
become complete. Preparations had been made for a
rapid tracheotomy should suffocation seem imminent.
A tracheotomy had finally been demanded for an acute
attack of suffocation, and this had given great relief.
At midnight, however, the man had died suddenly of
heart failure. At the autopsy a thick membrane was
found extending from the epiglottis down into the
larynx, and in the sulcus on the left side was an ab-
scess cavity. There was also a peribronchitic inflam-
mation which would probably have resulted in time in
a septic broncho-pneumonia. There were some ulcers
in the c.x'cum, which were practically healed. On
searching the literature he had found that Keen had
reported most of the cases, and that most of them had
developed well on in the period of convalescence.
Often the first symptom had been aphonia, or evidence
of suffocation, and death had often occurred almost
instantly. In two of the reported cases the patients
had recovered without tracheotomy, and two with it.
The gangrenous area extended from the epiglottis down
two and a half inches into the trachea itself.
Dr. E. K. Dunham said that he had examined mi-
croscopically the specimens from this case. The most
April 14, 1900]
MEDICAL RECORD.
655
interesting of these had been the one taken from the
pharyngeal surface of the arytenoepiglottic fold. In
this there had been a diphtheritic inflammation, and a
line of demarcation had formed, causing a loosening
of the necrotic tissue. A little beneath this line of
demarcation there was an acute exudative inflammation
with interstitial hemorrhage. Apparently, therefore,
there had been two infections; an earlier one causing
necrosis of the surface, and a later one causing an
interstitial hemorrhage at the base of the granulation
tissue. On the inner or laryngeal aspect of the aryteno-
epiglottic fold there was a fibrinous exudate on the
surface with granulations beneath, and a rather exces-
sive diapedesis of red corpuscles. This exudate was
probably due to the second infection. Over the cri-
coid the condition was very much the same as on the
inner surface of the aryteno-epiglottic fold. Nearly
all the micro-organisms found were diplococci or strep-
tococci.
Dr. George P. Biggs asked why this case was de-
scribed as a gangrenous laryngitis.
Dr. Lambert replied that the tissue in the upper
and back part of the pharynx had been perfectly black
and gangrenous.
A Case of Aneurism of the Aorta.— Dr. Alex-
ander Lambert reported this case. The subject was
a man, alcoholic, forty years of age. Syphilis had
been suspected but not definitely made out. He had
had an attack of pain in the shoulder with dyspncea
some years before. Five years before that attack the
man had walked into the Vanderbilt Clinic with
typhoid fever, and at that time the aneurism had been
discovered. During 1898 and 1899 the man had
worked laboriously and drunk excessively. When seen
last summer, there had been a large mass projecting
out under the chin. This mass measured vertically
five and a half inches. Physical examination had
revealed evidence of compression of the left lung.
The man had left the hospital in August. When seen
again, on November 14th, the tumor had extended from
the deltoid muscle on the left side across to within
three inches of the opposite deltoid. It measured
eleven and a half inches transversely and projected
three and a half inches. Its circumference was twenty-
four inches. At that time the skin had been exceedingly
thin over the tumor. About a month later the tumor
had measured thirteen inches transversely. Five days
after this the man had coughed up a rather large clot
of blood. One or two nights afterward the aneurism
had ruptured. The autopsy showed that the anterior
wall of the aneurism was made up of the skin, and that
there was no true sac. The entire thoracic wall had
been eroded by the tumor. The blood clot weighed
1,500 gm. The cartilages on the left side had been
completely absorbed, and the ends of the ribs had been
eaten away. The lungs, trachea, and larger bronchi
were normal. There was hypertrophy of the left ven-
tricle of the heart, but the valves were normal. The
lateral portion of the arch opened into the aneurism
by a large aperture. The interesting feature about the
aneurism was that a hole had been made in the aorta
by the giving way of an atheromatous patch. The
blood had then been diffused into the areolar tissue
of the mediastinum, and had become organized there.
This mixture of connective tissue and coagulated blood
had formed the aneurismal sac.
Dr. Biggs took issue with Dr. Lambert as to the
explanation of the formation of the aneurism. He
thought there had probably been the usual gradual de-
velopment due to local weakening of the vessel rather
than to a rupture of the vessel.
Dr. Lambert replied that it was probable that the
aneurism had started originally like other aneurisms,
but there was, at the time of the examination, no longer
any evidence of the first formation.
Two Cases of Acute Intestinal Obstruction from
Intussusception. — Dr. H. J. Boldt presented speci-
mens from two cases of acute intestinal obstruction due
to intussusception. In the first case the intussusception
had been caused by a polypus. The second specimen
was from an intussusception occurring in a child as a
result of a diverticulum in the bowel. He said that
he had never met with a case of this kind in which
cathartics had not been administered, and he wished
to direct attention to the great importance of avoiding
the administration of such drugs. If an acute intes-
tinal obstruction could not be relieved in a few hours
by the use of high enemata with inversion of the pa-
tient, and massage of the intestines, an abdominal sec-
tion should be performed ere serious symptoms became
manifest.
Gangrenous Dermoid from Twisting of the Ped-
icle.— Dr. Boldt also exhibited a gangrenous dermoid
tumor of the left ovary. The condition had been pro-
duced by a complete twist of the pedicle from left to
right. Apparently the condition had lasted for three
or four days.
A Case of Suppurative Metritis. — Dr. George P.
Biggs presented specimens taken from a woman, thirty
years of age, who gave birth to a full-term child sixty-
three days before death. On the seventh day after
confinement she had a chill, followed by fever and
pelvic pain. Curettage was done two days later and
the symptoms gradually abated so that three weeks
later she was able to sit up. After two days she was
obliged to return to bed for three weeks, but was up
again for two weeks before coming to the hospital.
She entered the New York Hospital sixty-one days
after parturition, and at that time was very anaimic
and markedly septic. On examination considerable
bloody fluid escaped from the uterus, and a sound
passed directly into the peritoneal cavity. Her con-
dition was so bad that a radical operation could not be
attempted, but free drainage was established through the
uterus and posterior cul-de-sac. At the autopsy marked
pelvic peritonitis with extensive adhesions was found.
The uterus was but little larger than normal and showed
an area of advanced softening 2 cm. in diameter in
the anterior portion of the fundus. It was through
this area that the sound had passed into the peritoneal
cavity. The right cornu of the uterus was 3 cm. in
diameter and contained a series of communicating
abscesses. In the left broad ligament there was an
abscess 3 cm. in diameter. Smears and cultures from
these abscesses showed an abundance of streptococci.
The Fallopian tubes and ovaries on each side appeared
normal except for surface inflammation. Interesting
points in the case were the distinct suppurative metritis
which the speaker had not seen before, and the long
duration for such a process of necrotic softening. The
cscum from this case was much contracted, and its
wall was thickened and ulcerated. The process was
evidently one of long standing. Partly from a few old
tuberculous lesions in the lungs, and partly from the
presence of a few miliary tubercles in the peritoneum
over the site of a similar ulcer in the ileum, he inferred
that this was a tuberculous process.
Dr. Boldt commented upon the small size of the
uterus, in view of the amount of sepsis present. Fur-
thermore the uterus was much firmer in consistence
than in a case of puerperal sepsis. The suppurative
metritis present in this case was exceedingly interest-
ing. He had seen only one other case somewhat re-
sembling this.
Typhoid Infection of the Uterus ; Report of Two
Cases — Dr. A. J. Lartigau read this paper. He
stated that there were only a few recorded cases of
typhoid infection of the uterus. The first case reported
was that of a married woman, thirty-one years of age,
who had entered the Albany Hospital in 1899. In
656
MEDICAL RECORD.
[April 14, 1900
November, 1898, she had been sick for three weeks
with what had been supposed to be typhoid fever.
Her present illness had begun with severe pain in the
lumbar and left iliac regions. A diagnosis had been
made of ectopic pregnancy, and this had been removed
by abdominal section. She had died three days after
the operation. The autopsy revealed typhoid fever
without intestinal lesions, and acute splenic tumor and
an acute hemorrhagic endometritis. The uterus meas-
ured 5.5 by 4 by 3 cm., and was of normal consistence.
The cavity was patent, and the endometrium soft, red,
and congested, especially in the fundus. The mucosa
was covered with a quantity of viscid mucus. The
microscope showed considerable multinuclear infiltra-
tion of the mucous and submucous tissues. The uterus
contained the typhoid bacillus and the streptococcus
pyogenes. The second case was that of a woman,
aged twenty years, who had entered the hospital with
a history of having suffered from severe headache and
muscular pains for ten days previously. Her history
was that of typhoid fever until the end of the second
week, when she had become delirious and comatose,
and had died quite suddenly, with symptoms of pneu-
monia. At the autopsy the uterus had been found not
to be enlarged; its peritoneal surface was smooth, as
was also the endometrium. A number of pin-point-
sized hemorrhages were seen in the mucosa. Cultures
from the heart's blood, liver, spleen, gall bladder,
mesenteric glands, bone marrow, kidney, and urine
showed pure growths of the typhoid bacillus. From
the uterus the typhoid bacillus had been isolated in
pure culture.
Dr. W. p. Northrup asked if the method of differ-
entiating between the typhoid bacillus and the colon
bacillus was sufficiently exact as to enable one to make
a positive differential diagnosis.
Dr. Lartigau replied that he thought with proper
care there should be no longer any question as to the
identity of the two organisms, especially when the
serum of typhoid patients was used for an additional
test.
The Death of the Neuron. — Dr. Ira Van Gibson
presented a preliminary communication under this title.
He said that perhaps no other cell in the body so
readily responded to trifling stimuli as the neuron.
The crude pabulum of this cell was built up into the
unstable and e.xplosive material which made it pos-
sible for the nerve cell to do its work. There was ex-
cellent evidence that every part of the long neuraxon
derived its nourishment from the nerve cell itself.
Whatever material surrounded the slender filament, it
was capable of storing a considerable supply of ner-
vous energy. When the catabolic process gained the
ascendancy the tip of the neuraxon no longer received
its proper nourishment, and the death of the neuraxon
proceeded very gradually from the tip toward the cen-
tre. When this process was confined to the tip of the
axon, its vitality might be alternately restored and
destroyed. Even when the axon had been destroyed
up to the cell body the latter was still able to generate
energy. When this process was going on the nerve
cell excreted what he had termed " metaplasm parti-
cles." This hypothesis, the speaker thought, thor-
oughly explained the whole process of fibre death in
the nervous system. Tosummarize: (i) In all chronic
fibre death the necrosis proceeded from the distal to
the central portion-, (2) the rate or intensity of death
in the neuraxon was directly proportionate to the pre-
ponderance of catabolic over the anabolic process ; (3)
the presence and excretion of metaplasm particles in
the cell body were indications of the death or impend-
ing death of the peripheral ends of the nerve fibres.
Dr. p. a. Levene said that the theory of biotonus
was first advanced by Max Verworn. According to
this theory, the anabolic and catabolic always coexisted
in cells or tissues, and the condition of the tissues
depended on the relation between the two processes.
There were conditions when the process of anabolism
was prevailing (growth), or conditions when catabolism
was stronger (degeneration), and also when the two
processes were in a state of equilibrium. The theory
of Max Verworn was corroborated by the speaker in
his researches on the developing egg. Although these
facts were well known as applied to cells in general,
he did not know that an application of it to cells of
the nervous system had been made previously. He
thought that there was not sufficient proof to consider
the " metaplasm granules'' anabolic elements of the
cell; they could just as well be regarded as catabolic
products. The latter view would be in accord with
the speaker's studies regarding mucin.
Dr. Van Gieson replied that there were several
kinds of metaplasm granules, so far as they could be
identified morphologically. He had identified three
of these. He had at first been inclined to think that
all of the metaplasm granules were anabolic, but he
now took the view that they might be both of the
ascending and descending kind. The theory just pro-
pounded had thus far received most extensive confirma-
tion. Around each metaplasm particle was found a
zone of clear material, and this he took to be indica-
tive of the fact that the protoplasm was endeavoring
to isolate them. The straw-colored metaplasm gran-
ules existed in the living cell, and were not precipi-
tated bodies or artefacts. The pigment bodies he
looked upon as metaplasm particles which, for some
reason, had been retained within the cell for a long
time and had been transformed in their chemical prop-
erties.
NEW YORK ACADEMY OF MEDICINE.
Siatfii Meeting, April j, igoo.
William H. Thomson, M.D., President.
Prevention, Management, and Early Diagnosis of
Scarlet Fever. — Dr. Floyd M. CRANOALLread a paper
with this title. His object was to call attention to cer-
tain details in prophylaxis of scarlet fever. Children
known to have been exposed to scarlet fever, he said,
should be kept under close observation, if not isolated.
Evidence had been recently presented to show that
children who had been in close contact with scarlet-
fever cases for several hours after the initial vomiting
had escaped the contagion. In scarlet fever there was
a distinct advantage over measles because in the latter
disease the period of contagion began several days be-
fore the appearance of the eruption, whereas the conta-
gion of scarlet fever was present chiefly after the erup-
tion had become fully developed. In ninety percent,
of the cases the period of incubation was between two
and six days. The important question of whether or
not other children in the family should be sent away
must be decided largely upon whether or not these
children had been exposed before the appearance of
the eruption.
Diagnosis. — Four symptoms occurring together were
exceedingly suggestive of scarlet fever, viz. : vomiting,
fever, a rapid pulse, and sore throat. The vomiting,
as a rule, occurred suddenly with little or no nausea,
and was often projectile in character. In his own ex-
perience it had been the most constant symptom.
Usually the temperature rose quite rapidly. An ab-
normally rapid pulse was exceedingly suggestive of
scarlet fever, to say the least. A pulse of 150 at the
outset was not unusual. At the first visit there might
be nothing but redness of the fauces, in mild cases, the
throat symptoms being very slight at an early stage.
April 14, 1900]
MEDICAL RECORD.
657
Probably many practitioners in New York City had
seen recently a considerable number of cases of grippe
associated with eruption, sore throat, and symptoms
suggesting scarlatina. A white tongue with red spots
was not in the least characteristic of scarlatina, and
was seen in many other diseases. The true " straw-
berry tongue," on the other hand, was exceedingly
characteristic, but was a decidedly late symptom.
Moreover, it should be remembered that such a tongue
did not present red spots upon the whitish ground, but
like the strawberry reddened spots on a roughened red
ground. The general statement that the disease ter-
minated within forty days should be taken with allow-
ance; the duration was apt to be longer rather than
shorter than this period. The lingers should be sub-
jected to special scrutiny before raising quarantine.
Desquamation was not the only factor to be taken into
consideration in determining the period of quarantine.
It had been conclusively demonstrated that there was
danger of contagion so long as there was any purulent
discharge present, such as a suppurative otitis, a
pharyngitis, or suppurating glands. Holt had reported
a case in which the opening of a post-scarlatinal em-
pyema in a surgical ward had ben followed by an out-
break of scarlet fever. In some of the mild cases des-
quamation was very slight, and there was no purulent
discharge. In these cases it was well to remember
that the desquamation was apt to linger longer than
one would expect. Every doubtful case should be iso-
lated until the occurrence or absence of desquamation
settled the matter. The disease was often dissemi-
nated by the error of diagnosticating as roseola, Ger-
man measles, or "stomach rash" mild cases of scarlet
fever. The question of the advisability of closing tlie
schools during an epidemic of scarlet fever must be
settled by a consideration of the particular conditions
found in each community. For example, in a rural
district where the children would probably be separated
if the schools were closed, and where the families knew
one another, the close of the schools would probably
check the disease. In a large city like New York, on
the other hand, the closing of the schools would proba-
bly have a directly opposite effect. The speaker urged
that physicians attending scarlet-fever cases should
provide themselves with a cotton gown reaching from
the neck to the feet, and wear it while in the sick-
room. The garment should be kept in this or an ad-
joining room. There was great danger of the physi-
cian carrying the disease to others unless such a
precaution was taken. Moreover, it was a measure
which protected not only the patient but the physi-
cian, for the family were usually impressed with the
notion that a physician taking so much pains was a
careful man, and if a case of scarlet fever should hap-
pen to appear in an unexplained way in one of the
families attended by the physician, it was not probable
that he would be blamed for its occurrence.
Inunctions. — During the stage of eruption a simple
bland oil was the most desirable substance with which
to anoint the skin. Antiseptics, used in this way,
were of little avail, and it was advisable to avoid irri-
tants. Vaseline was commonly employed, but when a
more elegant application was desired, lanolin or a
mixture of lanolin and cold cream might be substi-
tuted. Some cheap forms of yellow vaseline would be
found to be decidedly irritating in some cases, and
care should be taken not to apply carbolized vaseline
over too large an area, for, although it was true that
absorption did not take place through the sound and
healthy skin, it must be remembered that the skin was
not healthy in scarlet fever. When there was much
itching, a five-per-cent. boric-acid ointment sometimes
gave relief. Resorcin soap was advocated oy some
practitioners. Lard was prone to become rancid and
hence was best avoided,, as irritation resulting from
the use of a rancid ointment or oil was apt to prolong
the period of desquamation.
Treatment of Scarlatinal Nephritis.— Dr. Robert
Coleman Kemp read this paper. He said that the oc-
currence of anasarca, the general course of the disease,
and the favorable prognosis in the majority of cases of
scarlatinal nephritis, all afforded reasonable ground
for the belief that scarlatinal nephritis was an affec-
tion stii generis. It developed, as a rule, in the second
to the fourth week of the disease. Acute suppression
of urine and death might occur before inflammation
had had time to take place. Holt stated that albumi-
nuria occurred in almost all cases of scarlatinal nephri-
tis; albumin, casts, and even blood being found in the
urine. Post-scarlatinal nephritis was a diffuse nephri-
tis which ordinarily developed in the third week of
the disease, and was accompanied by general dropsy.
The urine contained a large quantity of albumin and
numerous casts of all varieties. Febrile albuminuria,
due to acute degeneration of the kidney, often occurred
from the second to the fifth day, according to Dela-
field, and might last four or five days. In febrile al-
buminuria the urine rarely contained epithelial, hya-
line, or blood casts.
Symptoms. — The first symptom often noted in the
urine was a fall of specific gravity. Dr. Kemp said
that his attention had been first called to this sign by
Dr. William H. Thomson. The specific gravity of the
urine should be taken twice daily at least, and the
daily quantity of urine noted. The next symptom ob-
served was a sudden rise in the specific gravity, asso-
ciated with a diminution in the quantity of the renal
excretion, and with an abnormally high color. Atthis
time there was engorgement of the renal vessels. As
a rule, there were no anasarca, no albuminuria, and
no pyrexia at this stage. Active treatment should be
at once instituted. During this preliminary stage a
marked increase of urates occurred, frequently before
the appearance of albumin. Anasarca was a typical
symptom of the disease, and pain in the back was com-
mon. The hemorrhagic form was often fatal in the
first twenty-four hours.
Uraemia. — There were usually prodromic symptoms
of ursmia, such as vomiting and diarrhoea. With
these there might be headache, followed by convulsive
twitchings of certain muscles, and later by convulsions.
There was often enlargement of the heart. Rapid en-
largement of the liver should be looked upon as an ex-
tremely unfavorable sign, and one usually pointing to
a speedily fatal termination.
Oxygen in Scarlatinal Nephritis. — In the pulmo-
nary complications due to nephritis oxygen should be
employed from the very beginning. As o.xygen was a
good cardiac stimulant, and aided in the elimination
of the toxins, there was good ground for using it. It
should, for the same reasons, prove of value in cases in
which no pulmonary complications existed. The early
use of oxygen he believed to be the keynote of success.
Whenever there was toxfeniia dependent upon the kid-
neys oxygen was indicated. He only asked that this
treatment be given a fair test clinically, instead of
being condemned on purely theoretical grounds.
Saline Solution in Scarlatinal Nephritis He had
employed enteroclysis at iio°-i2o° F. for periods of
from fifteen minutes to one hour, and as often as three
or four times a day. As a rule, from three to five
times as much urine would be secreted as the quantity
of saline solution employed. Hypodernioclysis and
saline infusion were also useful.
Carbonated Baths. — These were recommended in
ura;mic conditions, given at a tempearture of 98^-100"
F. Such a bath at a temperature of 100° F. felt al-
most as hot as an ordinary bath at a temperature of
105° F. These baths were useful also for reduction
of temperature, and had the advantage of being more
658
MEDICAL RECORD.
[April 14, 1900
stimulating. In this connection, a very convenient
portable rubber bath-tub was exhibited^ — a device which
was likely to be found especially useful in rural dis-
tricts.
Sourcesof Contagion. — Dr. H. D. Chapin expressed
the opinion that the type of scarlatina had changed in
recent years, having become milder. He had experi-
enced considerable difficulty in differentiating between
a very mild type of scarlatina and a severe grade of
rotheln. On the second or third day of scarlet fever
the tip and edges of the tongue were apt to assume a
peculiar red, beefy appearance, and the papillse be-
came prominent. He looked upon this sign as of
some diagnostic importance. In many cases it was
impossible for the family to have a separate attendant
for the child sick with scarlet fever, and here the
mother or other attendant should be directed to keep
a special gown for wearing in the sick-room only. He
believed that the most potent factors in spreading scar-
let fever in New York City were the dispensaries.
The public schools were almost equally responsible
for the dissemination of this and similar diseases,
largely because of the unsanitary custom of having the
outer clothing of the pupils crowded into ill-ventilated
wardrobes. Regarding the occurrence of albuminuria,
the speaker said that diarrhoea and very many other ail-
ments of early childhood were apt to be associated with
albuminuria. For this reason it did not seem to him
practicable for the average physician in the average
family to carry out the elaborate study of the urine advo-
cated by Dr. Kemp. His experience had been that the
first clinical sign was usually a puffiness about the eyes.
Period of Incubation. — Dr. C. G. Kerley said that
at one time he had had an opportunity of observing and
studying carefully, in an institution, an epidemic of
one hundred and nine cases of scarlet fever. The
majority of these had developed the usual manifesta-
tions of scarlet fever within five days, but in one the
period had been seven, in another twelve, and in an-
other fourteen days. He heartily agreed with the
reader of the first paper, that the " strawberry tongue "
was of no diagnostic value whatever. The rash was
also very uncertain; he had seen it disappear in a very
few hours. The lower part of the abdomen and the
lower part of the thighs were the favorite locations for
the eruption. Sometimes the temperature was very
moderate. If scarlet fever was present, there would
always be a marked congestion of the throat. In his
experience the period of quarantine had been from
four to six weeks. The desquamation was prone to
continue on the hands and fingers in spite of the most
assiduous inunction. He wished to insist upon the
fact that the mildest cases of scarlet fever were capable
of communicating to others the severest types of the
disease. The sick-room should be large and the tem-
perature not allowed to go over 70° F. The inunc-
tions not only prevented the spread of the disease, but
allayed the irritation and reduced the fever. His most
successful treatment for cases of scarlatinal nephritis
and acute suppression of urine had been the use of
colonic washings at a temperature of 110° F.
Varying Type of the Disease. — Dr. J. E. Winters
said that at times scarlet fever was so severe that al-
most every case terminated fatally, whereas at other
times the disease was exceedingly mild. M'hile the
truth of this was generally admitted, there might come
under observation a series of mild cases, and, at the
same time, a few very severe ones.
Isolation Most Effective. — Regarding the control
of the infection the speaker said that there was no other
disease so easily controlled by isolation as scarlet
fever, although the contagium of the disease was ex-
ceedingly tenacious of life.
Nature and Treatment of Scarlatinal Nephritis.
— He thought very few physicians had seen scarlatinal
nephritis terminate fatally. There was good author-
ity for the statement that scarlatinal nephritis did not
occur in the early stages of the disease, and he would
assert positively that albuminuria was no more fre-
quent in the early stages of this disease than in mea-
sles; but that, if albuminuria did occur in the early
stages, it never developed into the scarlatinal or post-
scarlatinal nephritis without an interval in which there
was no-evidence of renal disease. He did not believe
that the scarlatinal poison was the cause of scarlatinal
nephritis — indeed, such teaching seemed to him most
dangerous because it was likely to lead to carelessness.
It was a fact that it occurred chiefly in epidemics of a
mild type, and in the mild season of the year, and, for
the most part, in dispensary or tenement-house prac-
tice. His own opinion was that scarlatinal nephritis
was the result of a neglect to attend properly to the
condition of the skin. A statement that had been made
many years ago, and that was as true now as then,
was that scarlatinal nephritis occurred almost invari-
ably on the twenty-second day. Again, it occurred
most commonly in those children who were allowed
out of bed and around the room too soon. Scarlatinal
nephritis was in every instance a glomerular nephritis,
and was always announced by a rise of temperature,
from twelve to twenty-four hours before any other
symptom or even before the urine gave warning. The
Malpighian tuft might become so engorged that the
two capsules about it would fill up the space naturally
existing between them, and the result would be acute
suppression of urine. The plain indication for treat-
ment was to diminish the quantity of blood in the
Malpighian tuft, and for this purpose he would cer-
tainly not resort to the use of saline solution; but, on
the contrary, would administer aconite up to its phys-
iological effect. Such medication would be quickly
followed by a return of the urinary secretion. While
this was being done another indication was met. Free
perspiration was at the same time induced, and hence
the kidneys were relieved and elimination greatly
aided. This should be encouraged by the use of hot
wraps, and the bowels should also be effectually emp-
tied. He believed there were other types of nephritis
in which the only treatment which would prove effectual
was that recommended, this evening for scarlatinal
nephritis, but he would most emphatically dissent from
adopting such a plan of treatment in the latter disease.
P^cxiT ItistmtnvcMts.
A NEW GYNAECOLOGICAL PAD.
By W. J. GREANELLE, M.D.,
Serviceable as it is, the Kelly pad has been more or
less disappointing in this: that, even with the utmost
care, one is apt to find some back drainage has oc-
curred, and that there is more or less wetting and
soiling of linen under the small of the patient's
back. This is particularly the case in house practice,
where the weight of the patient on tiie usual woven-
wire spring-bed cannot always be prevented from caus-
ing sagging by the expedient of putting a board (I
usually ask for a " cutting board ") under the mattress.
I have worried and labored over this, using all man-
ner of contrivances to prevent it, and have in but few
cases succeeded, on removing things, in finding a dry
bed, until I adopted the plan of folding a blanket in a
suitable manner to permit its use as a support to the top
of the pad, favoring drainage toward the sleeve only.
Finally I hit upon the elaboration of this idea,
which has been well worked out for me by the David-
son Rubber Company. From my drawings and de-
April 14, 1900]
MEDICAL RECORD.
659
scription they have made the pad shown in the accom-
panying cut. It consists in the simple addition, on tlie
under side of the Kelly pad, of a crescentic air-cush-
ion, so applied as to provide a firm support to the top
of the pad when inflated and in use. In this way the
floor of the pad under a patient's back
and buttocks is maintained on a level
higher than that of the entrance to the
sleeve, even in a fairly soft bed. The
cushion can be inflated partly or com-
pletely, as any one case may require.
In addition, the floor of the pad lying
in the helix of the crescent, and leading into the sleeve,
is made a little broader than the actual measurement
across the space, in such wise that it sags somewhat,
causing a depression to appear, leading all drainage
directly into the sleeve.
I find this arrangement very serviceable and prac-
tical, preventing, as it does, the wetting of clothing
and linen. When not inflated, the new pad may be
folded so as to take up but little more space than the
the extent of the excursion of the short arm, and, in
consequence, of the cutting blade.
In using the instrument, the larger screw is set so
that, when the blades are opened to the fullest extent,
the indicator marks the desired size upon the scale.
It is then inserted, closed, into the urethra, and the
blades being again fully separated, is withdrawn open,
an even cut, through all the tissues traversed, resulting.
The little instrument, which was made for me by
Louis and H. Loewenstein, of Berlin, has given very
satisfactory results in actual use. Repetitions of the
operation, in order to attain the requisite size, are
avoided, as are also the unsightly effects of too exten-
sive an incision.
Kelly pad, fitting readily into one's obstetric-bag or
ordinary satchel.
I am indebted to Prof. G. C. Mason, of New York
University, for the plate.
Univeksity Heights.
A NEW MODIFIED URETHROTOME.
I5v FREDERIC BIERHOFF, M.D..
In the performance of the simple operation of meatot-
omy, the use of the ordinary meatotomes often results
unsatisfactorily to the operator, this result being due
usually to the lack of any gauge as to the desired size
of the cut. Especially is this the case with the be-
ginner. In order to remove this difficulty I have had
the accompanying meatotome constructed. It is a
modification of the Collin-Oberlander meatotome, and
is furnished with a scale and indicator, by means of
which the exact sized cut desired may be obtained.
By setting the larger screw, the indicator may be set
at any desired point upon the scale, which is marked
in divisions of tens and subdivisions of fives, from 10
to 40 of the Charriere scale. This screw also checks
^edtcat Items.
Boys Gasoline Drunkards According to the Phil-
adelphia Ledger, the police of a small Pennsylvania
city were much mystified by finding boys fast asleep
and in a semi-conscious condition, stowed in vacant
houses, sheds, and brickyards ; it was finally discovered
that the boys had gotten into this condition by inhal-
ing the fumes of gasoline, and some of them have
really become gasoline drunkards. — Scientific American.
Suitable Food. — The adaptation of a great variety
of suitable foods to meet the dififerent conditions of
the imperative requirements of man is influenced by
climate, the food of a cold climate differing from that
of a warm one; by occupation, the laborer requiring
coarser food than the brain worker; by bodily health,
the sick cannot be fed like the well ; by idiosyncrasies,
through which are precluded the use of certain articles
of food which are poisonous to the system and which
after eating exhibit their elTects in cutaneous eruptions,
as urticaria, erythema, and other like symptoms. —
Dr. De M. Blocker, Chattahoochee, Fla.
Sensational Sanitation. — The aim of sanitary teach-
ing should be to encourage better environment of the
individual, of healthful living, comfort, happiness,
and peaceful repose; not of excitement, fear, and su-
perstitious awe. Therefore when those who are
charged with the responsible duty of caring for the
public health, seemingly for personal notoriety and
sensational effect unnecessarily parade to the public
slight errors of sanitation or magnify the existence of
contagious disease, a crime is committed in the name
of sanitation because of the injurious influence upon
the timid and nervous, who are thus given the oppor-
tunity to exaggerate fears and not only to invent but
to circulate all kinds of sensational rumors. — Dr.
Joseph Y. Porter, Key West, Fla.
A Wonderful Triumph in Surgery. — According
to Lloyd's Weekly Jourtial, London, a remarkable feat
in surgery has just been achieved by Dr. Hermann von
Schrotter in the clinical department of the University
of Vienna. A boy, aged twelve years, had swallowed
a piece of lead of the size of half a sovereign, which,
passing through the trachea, descended into a bronchus
of the second order. Dr. Schrotter extracted this piece
of lead without tracheotomy and even without using
anesthetics; the operation was, nevertheless, quite
painless. This, it appears, is the first time that a
bronchus of the second order has been penetrated and
a foreign body extracted from it without a surgical
66o
MEDICAL RECORD.
[April 14, 1900
operation. The extraction was effected under the
guidance of Dr. Schrotter's eyes. First, by means of
the Roentgen rays the piece of lead was located at the
height of the fourth rib; then Kilian's (Berlin)
bronchoscope was in the ordinary way introduced into
the trachea and electrically lighted up, and the piece
of lead was at last extracted by a pincette expressly
constructed for the purpose. Professor Kilian has
suceeded only once in introducing his bronchoscope
into a bronchus of the first order, and then only by
performing tracheotomy.
Tincture of South African Karoo for Dysentery.
— In tropical dysentery an extract and tincture of the
South African karoo, collected and introduced by Mr.
John Maberley, have proved of great value, not only
in dysentery, of which one hundred consecutive cases
treated with the drug are reported by Mr. Maberley
with only one death, but also in hemorrhagic ulcera-
tion of the stomach and intestine. The drug has a
long-standing reputation among the natives and Boers,
but has only recently been identified and used in Eu-
rope in cases of acute and chronic ulceration of the
stomach and intestines. — Lancet.
Housing the London Poor. — The housing-of-the-
working-classes committee of the London County
Council intends, says Lloyd's Weekly Jouriial, shortly
after the Christmas recess, to ask the sanction of the
council to a large scheme for housing the poor in the
neighborhood of Tooting. The site of the proposed
new buildings is known as the Totterdown-fields site,
and consists of about thirty-eight and one-half acres.
The purchase price is agreed at the rate of ^'1,150
($5,750) an acre, so that the total amount will be about
jJj44,5oo ($222,500). The cottages which it is pro-
posed to erect on the site will be constructed so as to
provide for two families each. They will each consist
of two self-contained tenements, one of two and one of
three rooms. Separate gardens will be provided, and
on an average not less than thirty cottages will be
built to the acre. The rent of the tenements should
average about yjr. dd. ($i.go) per week. The commit-
tee are unable at present to state precisely the cost per
cottage, but it is probable that the total cost of land,
road and buildings will be about ^500,000 ($2,500,-
000).
What Becomes of the Wounded ? — A British weekly
journal says : " An army loses far more of its strength
through its wounded than through its killed. In the
first place, there are four or five wounded to one killed,
and in the second place the dead men give no trouble,
while the wounded require an immense number of non-
combatants to attend to them. A great many of the
wounded return again to their duty. But, as a rule,
more than half of them take no further part in the war.
Probably the same thing is occurring out in Africa
now as occurred in previous wars, for the effects of the
new weapons do not seem to differ greatly from those
of the old. In that case it is easy to calculate what
our generals lose by having so many men wounded.
If they fight a battle, for instance, in which one hun-
dred are killed and wounded, the probabilities are that
twenty would die on the field, twelve of the wounded
would die later on, twenty-one would be invalided
home, while forty-seven would return cured to duty.
These are the averages for big battles in which there
are several thousand casualties."
Soldiers on British Transports.— "The treatment
of our soldiers," says an influential English journal,
"on board the transports calls for a searching inquiry.
Letters which we have seen from men who sailed in
the Kildonan Castle and the Nubia reveal disgraceful
mismanagement, if nothing worse. The supply of eat-
ables was insufficient, the quality most inferior.
When the men complained, they were treated with in-
difference, though food had to be thrown overboard by
reason of its absolute rottenness. Need it be said that
after three weeks of such treatment the men on their
arrival were utterly unfit to sustain the fatigue of a
long railway journey and heavy marches? If these
complaints came from one or two troop-ships they
might be passed o\er, but the same scandal attaches
itself to all. Those who are the cause of our troops
being treated like cattle deserve the severest punish-
ment that can be given them."
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended April 7,
1900 :
Cases, Deaths.
Alabama, Mobile March 24th to ^ist 1
Florida,- Jacksonville March 24th to 31st 2
Indiana, Evansville March 24th to 31st .. - — 5
Kansas. Wichita... Maich 24th to 31st 8
Kentucky, Covington March 24th to 3:st 12 i
I-e.xin-^t'Mi .March 24th to 31st 1
Louisiana, New t)rleans .... March 24th to 31st 64 2X
Massachusetts, Boston. . .. March 24th to 31st 1
Michigan, Detroit March 24th to 31st 4
Nebraslja, Omaha .. .March 24th to 31st i
New Mexico, Catskill March 21st 2
Kolsom March 2tst 5
New York, New York March 24th to : 1st i
Ohio, Cleveland .... March 24th to 31st 17
Utah, Salt Lake City March 24th to 31st i
W'ashington, Spokane March 24th to 31st \
Smallpox- FoKEKiN.
England, Liverpool March loth to 17th i
London.- March 3d to 17th 12
France. Lyons March 3d to loth
Rheims March 3d to 10th
Gibraltar March 4th 10 i8th 14
India, Bombay February 20th to March tth
Calcutta February icth to 24th
Kurrachee February i?th to March 4th 32
Japan. Yokohama February 24th to March 3d i
Korea, Seoul January 20th to 27th 2
Spain. Madrid March 3d to 17th
India, Hombay February 20lh to March 6th .
Calcutta February 10th to 24th ,
Pt.agve— Insula
ii, Honolulu Ma
Possessions Un
ch loth to 17th.. .
Plague— Foreign.
.\rabia, .-Vden February 22d to March loth. .
India, iiouibay February 22d to March 6th . . .
Calcutta February loth to 24th
Kurrachee February iSth to March 4th . .
Japan, Formosa January 1st to February 28th .
|5ocths ^ecctuctt.
While the Medical Record is pleased to receive all new pub-
lications which may he sent to if, and an acknowledgment will be
promptly made of their receipt under this heading, it must be with
the distinct understanding that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it which in the judgment of its editor will not be
of interest to its readers.
Home Nursing. By Eveleen Harrison. i2nio, 235 pages.
The Macmillan Company, New York.
Vice and Insanity. By George R. \Yilson, M.D. 8vo,
234 pages. The Macmillan Company, New York.
The International Text-Book of .Surc.ery. Edited by
J. Collins Warren, M.D., and A. Pearce Gould, M.D. Vol.
II., Regional Surgery. Illustrated. 8vo, 1,072 pages. W. B.
Saunders, Philadelphia.
SiRcicAL Pathology and Therapeutics. Second edition.
By John Collins Warren, M.D. Illustrated. 8vo, 873 pages.
W. H. Saunders, Philadelphia.
Transactions of the American Pediatric Society ;
Eleventh .Session, held at Deer Park, June 27, 28, and 29, iSgg,
with the Constitution. Edited by Floyd M. Crandall, M.D.
Nordrach at Home ; or, Hygienic Treatment of Consump-
tion. I!v Joseph J. S. Lucas. i2mo, 60 pages J, W. Arrow-
smith, I'.ristol, England
Medical Record
A IVeekly yonrnal of Medicine and Surgery
Vol. 57, No. i6.
Whole No. 1537.
New York, April 21, 1900.
$5.00 Per Annum.
Single Copies, loc.
©trighxaX Jirticlcs.
O.V THE FORMATION OF AN ARTIFICIAL
ANUS."
By ROBERT F. WEIR, M.D.,
An artificial anus is fortunately required in but com-
paratively few conditions. It is demanded, for ex-
ample, in the rather rare instances of total or danger-
ous obstruction of the large bowel; in which cases
the opening may be made just above the stricture, if
the seat of this is recognized, or at a place of elec-
tion, if the site of the obstruction remains undiscover-
able. It is also resorted to when extensive and often
painful intractable ulcerations of the rectum exist,
whether they be of syphilitic, tuberculous, or cancerous
origin. When so employed, the principle of rest of a
damaged part, with withdrawal of the irritation of the
fffices, generally benefits the local conditions, and even
in malignancy ameliorates many of its distressing
symptoms. It is further and rightly employed in
certain rare conditions of amcebic or follicular ulcera-
tions which are usually confined to the colon. Here,
besides the rest that is afforded to the damaged mucous
membrane, the new opening, which is usually in these
troubles placed high up, allows medication to be ap-
plied in either direction throughout the whole extent
of the large intestine. It is also performed for the
relief of an imperforate rectum. Of increasing im-
portance, however, is the creation of a false anus as a
preliminary step in various surgical operations on the
rectum which look finally to its removal, total or in
part, for neoplasms, or possibly for extensive and
more benign ulcerations. Here, as in nearly all the
preceding cases, the part to be played by the artificial
anus is intended to be but a temporary one, the devia-
tion of infecting faeces; the enforced rest of the bowel,
with the greater case of treatment through the two
openings, one the natural anus, and the other the
artificial one, aids and ften secures a cure, after which
the need of the adjunct anus passes away. Then the
additional and now no longer required opening in
the bowel has only to be closed, and the function of
the cured intestine is fully restored.
This side-tracking of the fsces through an artificial
anus in the iliac region (for lumbar colostomy may
be regarded as an extinct operation) was first sug-
gested by PoUosson in 1884, and was later rendered
popular by Schede in 1887. It is now in frequent use
as the first step in severe rectal operations, that is to
say, in those that bring about much exposure of the
parasacral tissues. Its use diminishes the risk of sep-
sis, and when suture of the preserved anal end of the
rectum tc the drawn-down sigmoid end is carried out,
after the removal of a cancerous section of the bowel,
it promotes favorable union. Hence, for these reasons
it is well worthy of consideration.
There is evidence which becomes weightier with
' Read at a meeting of the Medical Association of Greater New
York, held February 12, 1900.
gathered experience, that an artificial anus should be
employed as a permanent factor in certain troubles to
which it has hitherto been applied only as a temporary
help,. I refer now not only to those well-known cases
of inoperable cancer of the rectum in which the relief
by a colostomy is all that surgery can do, but to those
instances in which either the ulceration or stenosis,
though not malign, is so great, so rebellious, and so
distressing, that colostomy only is to be thought of.
To these should be added not only the more common
form of severe rectal trouble, the low-down cancers,
where after their extirpation an incontinent artificial
anus is usually left, but also those cancerous involve-
ments that demand extensive removal of the gut. In
all these conditions it is felt with augmenting convic-
tion that the temporary nature of the artificial anus
should be changed to the formation of a permanent
opening.
This brings me to the presentation of the differences
of intent and technique that exist between a permanent
and a temporary artificial anus.
In the temporary false anus, as has been alluded to,
the surgeon has to keep in mind that in the near future
he must close up the opening he has just effected in
the intestine, and hence he finds that the diversion of
the fasces froiA the bowel situated below the artificial
anus is not the easy job that he has anticipated, be-
cause his future reparative operation demands that the
distal leg of the loopof intestine that has been opened
should be near to the upper or proximal leg so that
they can be readily joined together when the proper
time arrives. With the establishment of a permanent
artificial anus no such difficulty arises. The surgeon
then may deliberately cut the bowel in two primarily,
or after waiting a day or two (if time is afforded) ; or,
better still, he may close up, by inverting Lembert
sutures, the distal opening and leave it thus in the
wound, or even do more than this — he may, after
closing the rectal end, drop it back into the abdominal
cavity, as Schinzinger, in 188 1, and Madelung, in
1884, have advised, and thus obtain the surest way of
keeping the fasces from slipping by the artificial open-
ing, and accumulating in or disturbing the bowel below.
The attempts that have been resorted to to render
effective, as a fecal outlet, an artificial anus as ordi-
narily established in the left iliac region, have been
many, and few have any positive value. It may be in-
teresting, I think, to run over some of these trials.
The classical and older way of performing a colos-
tomy was by an incision two and one-half to three inches
long, the centre of which was on a line running from
the anterior superior spine of the ilium to the umbili-
cus and one and one-half inches inward from the iliac
spine. The skin, muscles, and peritoneum were cut
through, the finger was introduced and the large bowe!
hooked up and drawn to the surface, and duly recog_-
nized by its band or by its epiploic fringes. If any
difficulty was felt in finding the bowel, the surest way
was to pass the finger inward along the hollow of the
ilium until the bowel or its mesocolon was felt.
Formerly on being exposed it was customary to suture
it by many stitches to the incised skin, in the centre
or at one end of the wound. Some surgeons would,
before doing this, carefully draw forward and sew the
662
MEDICAL RECORD.
[April 21, 1900
peritoneum to the skin, in order, as it was said, that a
broader surface of plastic union with the peritoneum
of the bowel might be offered. This extra care, I may
here state, is a wasted efifort, for while perhaps a wider
adhesion is so eiTected, yet when the stitches are re-
moved or melt away, the adherent bowel sinks often
quite deeply in the wound, because, although adhesion
between the serous surfaces goes on quickly, it pro-
gresses much more slowly between the exterior of the
peritoneum and the muscles which have been brought
face to face by this circumferential suturing of the
peritoneum. Two improvements which have come into
the above technique, and that have risen into general
esteem, are appropriately to be mentioned here. First,
by the teaching of Maydl in 1888, and Reclus in 1889,
surgeons have learned that it is entirely unnecessary
to use any sutures whatever to hold the bowel in its
sometimes a rather thick and long mesh of iodoform
gauze (see Fig. i), on which the loop of the bowel
was slung for seven to ten days, sometimes longer, by
which time adhesions strong enough to safely hold in
position will have formed. Sutures were seldom used
to fasten the bowel to the skin unless an immediate
opening for the escape of faeces was urgently required.
The second improvement is not so satisfactory a one,
though it is in the right direction. Its consideration,
however, will lead me into somewhat of a digression
which I trust you will excuse. The great advance that
has been made in the treatment of appendicitis by the
use of jVIcBurney's plan of separating rather than
dividing the muscular layers of the abdominal wall
is well known to all here present. This was pub-
lished by its justly distinguished author in 1894,
but the endeavor to utilize the musculature of the ab-
dominal and pelvic wall to control the surgically
created outlets of the stomach and intestines dates
back many years anterior to this. Howse,' an English
surgeon, was in 1879 ^'^^ first, I believe, to apply this
idea of splitting or pulling apart the muscles to obtain
a sphincter-like grasp of the rectus abdominis muscle
'V,.,.
I \
protruded position. Maydl simply drew the bowel
out through the opening far enough to show the attach-
ment of the mesocolon, and then through this, just be-
low the intestine, was thrust a rubber or glass rod, or
Fig. 3.
for gastrostomy. Von Hacker, in 1890, popularized
this method by using the same muscle in a similar
operation. Gersuny made a figure-of-eight twist of the
same muscular fibres about the stomach opening.
Without, however, going through all the improvements
that have been evolved for this purpose in gastric sur-
gery, I will only ask your attention to two of the later
efforts in this direction, since they appertain, as will
be shortly seen, to the present mode of formation of
an artificial anus. Sabaneef and Frank as well as
Hartniann have suggested that, in a gastrostomy, in
order to render the opening retentive, the protruded
stomach should be drawn, not vertically, as in the
preceding method, but through a laterally split left
rectus muscle, and sometimes be further made to open
on the skin surface by a second incision some little
distance from the emergence of the viscus through the
peritoneum which had been divided through the first
incision. \\'ithout more words at this time, I can now
go back, after calling your attention to Figs. 2 and 3
to illustrate more clearly the foregoing remarks, to
the question of the artificial anus. For since 1892,
when I began to employ von Hacker's plan of gastros-
tomy, I have applied the same idea to my colostomies,
'Holmes: ".System of Surgery," 18S3, vol. i. , p. 801.
April 21, 1900]
MEDICAL RECORD.
663
and in 1894 made a vertical incision througii the left
edge of the rectus muscle, separating the muscular
fibres, and drew the bowel out there and fastened it
after Maydl's plan. It worked better than by incising
the abdominal wall, but it required for anything like
an improved control that the intestinal opening should
be subsequently much narrowed by several clippings-
awao of the mucous membrane. Von Hacker has
lately' advised the use of the rectus muscle in colos-
tomy by splitting it both vertically and laterally as
Hartmann has likewise done, and Roux,- of Lausanne,
has further suggested that the emergence at the bowel
should be made through the rectus muscle at the
symphysis, hoping by muscular action and by conjoin-
ing this with a decided gouging out of the top of
the pubic bone to secure a more perfect fecal outlet.
Maydl,'' to obtain this sphincter action, as early as
1888 (thus antedating McBurney six years), suggested
separating thti muscular fibres of the abdominal wall
rather than cutting through them, and since 1892 my
colostomies have been done in this fashion.
With the increased rapidity of operation as secured
by Maydl's scheme, and by the use of the sphincter
grasp of the separated muscles, an improvement was
certainly made in the operation, but it was not yet
perfect, although Maydl iiad further enhanced the
value of his method by sewing together for a short dis-
tance the two legs of the loop beneath the rod or iodo-
FiG. ,.— Maydl's li.
- Separation. First lay
form-gauze support. He endeavored by this to in-
crease the spur that would be formed in this way by
the strongly kinked inferior wall of the bowel. This
formation of a spur was an idea of importance. It
originated with Verneuil, and has been carried out
more systematically by Bodine in 1897 (see Fig. 5).
This latter surgeon sewed together in a very thorough
manner the afferent and efferent legs of the intestine
for a distance of nearly six inches, if such a length
could be drawn out at the wound. The bent-up bowel
was then replaced within the abdomen, leaving its end
projecting, which was duly secured by several sutures.
If delay can be had, and in nearly all cases save for
acute obstruction such can be obtained, the opening
of the bowel should be postponed for at least twelve
hours, by which time, and often in less, sufficient ad-
hesion will have taken place to prevent peritoneal in-
fection, particularly if the opening of the bowel then
' Beitrage z. klin. Chirurg. , vol. xxiii., p. 628, i8gg.
■ Revue med. de la Suisse, i8g8.
^ " Zur Technik der Kolotomie. " Centralbl. f. Chir.,No. 24,
made be conducted with gentleness. This secondary
opening can often be postponed until the colicky attacks
of pain warn one of the accumulation of gas above the
surgical obstruction. Then a small opening is made
with a knife or with a thermo-cautery above the sup-
porting rod or mesh, tolerably close to the skin. If
the artificial anus is to be of a temporary nature, the
opening should be a longitudinal one; if likely to be
a permanent one, it is better to be a transverse open-
ing; but in either case it should at first be a small one.
I lay some stress on this point, for I have found that
patients with small openings, even if the ones first
made have subsequently to be enlarged, do better and
soil themselves less than when such are large. On the
other hand, a large opening with a good spur and with
a decided crowding on the distal leg to narrow it ' (see
i'|llllllf*IIilbi/// %
Fig. 6), often gives the best security against the slip-
ping by of fceces into the lower bowel. Hence my en-
deavor is to enlarge the opening little by little, mak-
ing it at first only large enough to allow gas to escape
' Greig Smith : Lancet, July 23, 1898.
664
MEDICAL RECORD.
[April 21, 1900
and to relieve the patient from immediate distress, and
subsequently by additional enlargements to secure the
end desired. After a lime there may come eversion or
pouting of the mucous membrane. This may attain an
annoying and even a painful size, and often becomes
difficult to manage. A little of it is considered a good
feature, as it makes a more cleanly discharge of faces
and allows the surrounding skin to be more easily pro-
tected. Lauenstein even advises leaving several inches
of the bowel to protrude beyond the skin for this pur-
pose, and also for better retentive compression; but no
one has followed his example, and he himself has aban-
doned the plan. This protrusion frequently abates as
the inflammatory thickening of the part subsides, but
it often persists. This mishap can better be avoided
at the time of operation than remedied afterward.
Then this expedient can be resorted to: after the loop
■ii intestine is hooked out of the wound by the crooked
linger of the surgeon, the upper end of the bowel
KiG. 7. -Paul's .-Xrliricial-Amis Truss.
should be pulled down until it becomes taut, and by
keeping the upper leg of the loop as short as possible
the subsequent tendency to prolapse is much dimin-
ished.
In spite of all this care, and of even the more rad-
ical treatment of cutting away all the bowel projecting
beyond the Maydl supporting bar or mesh, and thus
creating what has happily been described as the dou-
ble-barrelled shotgun anus, fseces from the upper open-
ing will from time to time escape directly into the
lower bowel, or indirectly from the upper bowel into
the retaining dressings, and thence into the lower open-
ing of the intestine. Hence it is not unusual to hear
of additional devices being presented to meet this
imperfection in the operation. Of the many that I
have tried, I will only mention two. One of them is
to insert at the time of the operation several large Lem-
bert sutures transverse to the axis of the bowel below
the supporting bar, so that the lumen of the intestine is
more or less completely shut off by deep wrinklings
of its wall. The other is, when the test of time has
shown that the anus is not satisfactory, to cut away
deliberately, under a cocaine swabbing, the mucous
membrane for a space of half an inch all around the
lower opening, so as to induce a contraction sufficient
to prevent or diminish the flow of faces toward the rec-
tum, and yet not render too difficult the subsequent
closure of the artificial anus when its purpose shall
have been fulfilled.
The spur formation, before alluded to, is not always
satisfactorily made in the left iliac region. It is more
easily accomplished in the transverse colon, of which
kind I now show you a living example, where it was
applied through the rectus muscle for multiple follicu-
lar ulcerations extending from the anus to the middle
of the large bowel. This situation for an artificial
anus has received lately the strong indorsement of
Koenig, as a preliminary .step in a Kraske's extirpation
of the rectum, because, among other advantages, it is
beyond the line of traction and the interference that
can possibly be made by the later sacral step in the
operation. In this particular case there was a short spur
made by suturing the legs of the loop together, and
now, though nearly cured of the ulcerations under
medicated applications, forced in through the colonic
opening, she has had but little annoyance from incon-
tinence, and has never had any escape of faeces into
the bowel below. In the CEEca! region the use of
Maydl's sling has networked well in my hands, though
Maydl says it is applicable even in this portion of the
bowel. I have preferred, when such a high opening
was required for an acute obstruction in the middle or
uncertain part of the large intestine, to open the caecum
or adjacent ileum after a careful continued or multi-
ple interrupted suturing, with a large trocar and can-
nula, hoping that after the discharge of a quantity of
the fluid faces, usually found above an obstruction,
had taken place, enough relaxation of the distended
intestine would occur to permit the introduction of a
long rubber tube of good size, which in turn was
secured by a purse-string suture in the intestine wall.
This device, with some impermeable dressing, as col-
lodion or gutta-percha tissue, conducts the fasces away
from the wound sufficiently well to insure, with pack-
ing of the wound area with iodoform gauze and a large
dressing which it perforates, enough cleanliness to
permit rapid serous adhesions. In two instances, as
preliminary to an operation for resection of the trans-
verse and high descending colon, I have made an arti-
ficial anus in the ileum just above the ileo-cacal valve.
Such openings are objectionable, not on the score of
nutrition, but principally on account of the skin irrita-
tion produced by the fluid faces of the small intes-
tine. A marked contrast is seen to this when the
cacum, only a few inches farther down, is opened;
when but little damage to the skin is afterward pro-
duced.
It can easily be inferred, from noting these various
expedients, that the difficulties of fecal control, when
once an artificial anus has been formed, are, in spite
of all that can be done, very great and very distressing;
for there is nothing more disgusting and more depress-
ing to the patient and to his caretakers than a leaking
false anus. The surgeon justly considers that he has
done well if the outlet permits one or two well-formed
movements per diem, which, perhaps, may be regulated
as to time by an ordinary enema. Such favorable
conditions I have more frequently found when the open-
ings have been kept of small size — of such a small
size, I may repeat, that from time to time a little en-
largement becomes necessary, or, in lieu of this, the
daily softening of an enema is demanded. When, how-
ever, a diarrhoea comes on, no ordinary dressing or ap-
paratus will prevent the patient from fouling. Numer-
ous mechanical contrivances have been presented to
obviate such mishaps and to plug up the opening. 1
will not detail them, but will call attention to two thai
have proved of service, in my experience. One advo-
April 2 1, 1900]
MEDICAL RECORD.
665
cated by Paul is fairly well shown in Fig. 7, where a
horseshoe truss compresses the track of the bowel, first
running beneath the skin a short distance before open-
ing on the surface. A truss with a cup of hard rubber
I have sometimes found of service in ordinary direct'
openings, but my best plug consists of a double in-
flatable bulb, connected by a hollow hard-rubber tube
for ease of introduction (Fig. 8), and furnished with
a stop-cock for inflation and deflation. The lower
bulb is passed into the upper opening of the artificial
anus, and inflation is begun. That this may not make
too great traction on the lower bulb and pull it out,
the upper bulb is covered by a perforated hard-rubber
disc that allows the little apparatus to be held ///
situ by adhesive straps or a well-fitting bandage. An
extra tube is sometimes added, provided with a stop-
cock to permit the escape of gas at will. This was
originally derived from Scheimpflug's apparatus for a
gastric fistula, but is now merely an improvement
on Jacobson's intestinal plug. A belt with an in-
flatable bag is also employed (see Fig. g) to arrest
the flow of faces. Sometimes a rubber bag with
an inflated edge will, when secured tightly to the
body, prevent soiling. When these contrivances fail,
large dressings are necessary. Gauze should not be
applied directly to the protruding gut, since it adheres,
and is painful when detached. It is better first to
cover the bowel with one or two broad overlapping
pieces of gutta-percha tissue prior to putting on the
absorbent dressings.
Before proceeding to the consideration of the estab-
lishment of a permanent opening, a few moments may
properly be occupied in speaking of the final clos-
ure of such openings when they have fulfilled their
mission, as for instance in the case just presented
to your inspection the ulceration has healed, or as
in other cases the intractable rectal ulcers and stenoses
have been overcome, etc. To effect this closure, it is
in my judgment better, after having previously well
washed out and disinfected both ends of the bowel, to
make an incision surrounding the artificial anus, and
then to invert the skin and close the intestine thor-
oughly by suturing. This is merely to protect other
parts, now to be opened, from infection. The old skin
scar is now to be cut through, or a new incision made
alongside, down to the peritoneum, for muscle separa-
tion is rarely practicable here a second time on account
of inflammatory thickening often present. The ab-
dominal cavity is carefully opened, not too close to the
adherent anvis, and with the finger as a guide, and cut-
ting a little wide of the intestine, the anal opening is
"circumscribed and freed. It is then lifted out beyond
the skin and the abdominal opening protected by iodo-
form gauze. The sewn-together opening is left undis-
turbed, and, after trimming away with scissors any
superabundant attached tissue, one or two rows of Lem-
bert sutures are applied, the parts washed off with a
sterile salt solution, and dropped back into the ab-
dominal cavity. The gap in the abdominal wound is
finally closed by layer sutures.
Another method has been suggested byGreig Smith
and others which is e.xtra-peritoneal. Usually such
essays as these fail or are too complicated, but Smith
separates the parietal peritoneum for an inch or two,
so that not only can the bowel be well lifted up, but
the edges of the opening can be inverted and sutured
without invading the peritoneal cavity (see Figs. 10
and II ; the dotted lines show the required incision).
Such extraperitoneal closures have in my own work
occasionally succeeded in small intestinal fistulas,
,5ut in these days of generally successful asepsis I
piefer the intra-peritoneal method. In the seven clos-
ures that I have notes of I had no need especially to
treat or consider the spur that had previously been
formed.
Let me pass on now to the management of the bowel,
when, for inoperable lesions in the rectum, or for a
total extirpation of the affected bowel, or in those cases
in which the rectum has been removed high up by a
Kraske operation, a permanent artificial anus has been
determined upon. This requires a somewhat different
disposition of the bowel. It may be drawn out by the
666
MEDICAL RECORD.
[April 2 1, 1900
usual incision with its muscle separation, etc., and its
legs may be sutured together, as Bodine has suggested,
and after twenty-four hours the mushroom-like project-
ing end of the loop can be cut squarely across. This
works fairly well with the subsequent contraction of
the lower orifice, as has been previously described, and
the method and its imitations have a merit that at-
tracts attention. It is that while fa;ces can or may be
kept out, the opening going to the rectum, even if
small, will allow the discharge from the possibly tight
stricture below to escape upward, or it will aid in
washing out or medicating the parts by irrigations
from above downward, and I'tte rersa. I do not lay
very much stress on this, for in the tests I have made on
this point I have not found so far any trouble to come
from the closure of the upper end of the loop going to
the rectum. In those cases in which I practised the
double-barrelled artificial anus — in two of them, to be
sure of preventing freces reaching the anus — I inverted
and stitched together the peritoneal edges of the lower
opening, and effectually shut it up, retaining it, how-
ever, in the wound. No unpleasant reaction followed
the treatment, and only rarely was an irrigation from
the' normal anus required.
But this method of two openings in the groin (and
some have placed one opening atone end of the wound
and the other at the opposite end [see Fig. 12], and
again others have placed the lower bowel above the
upper one, or, like Gersuny, have applied here the
twist to the upper bowel of one-half to a total turn on
its axis, hoping vainly to secure even the moderate
success that has been obtained when used in the lower
part of the rectum) nevertheless retains the objection
of more or less incontinence, and I now call to your
notice a plan of operation that, in three instances in
which I have lately employed it, has secured a conti-
nent anus without the help of any mechanical contri-
vances, and has effectually disposed of the question of
fecal overflow into the rectum below. It is the result
of a combination of the suggestion of Schinzinger with
that of Witzel. Schinzinger, as has been stated, ad-
vised cutting the colon in two at the time of operation
and closing the rectal end by inversion and suturing.
Then the closed-off rectal end is dropped back into the
abdominal cavity, and the other open end of the upper
bowel is duly fastened in the abdominal wound. This
portion of the bowel could be rendered free from in-
fecting qualities by also being inverted and sutured
— as a temporary matter — the sutures being taken oift
after adhesions had fully formed.
While this procedure is in itself the most effectual
in guarding against fecal irritation in the lower bowel,
the continence we wish for is not obtained in this way;
a further variation is needed, and I have obtained the
best success by adding to this closure and dropping
in again of the rectal end of the bowel by placing the
artificial anus outside the brim of the pelvis as pro-
posed by Witzel. In other words, the upper end of
the bowel is transplanted under the skin, to open
some two inches below the crest of the ilium (Fig. 13).
The intestine is made to come out through the usual
opening inside the crest of the ilium; the lower end is
cut off, inverted, sewed together, and dropped back into
the abdominal cavity (and this was done in the three
cases I have operated upon by this method), or it may
be retained in the original wound. The upper end,
duly contracted by a ligature and disinfected or sutured
together, is then drawn through a canal formed for it
by separating one layer of the abdominal muscle from
the other up to the outer edge of the ilium, where it
may be necessary to divide the limiting fascia, so that
the intestine can be brought out at a skin incision an
inch long, previously made outside the pelvis. This
opening was in my cases situated one to two inches
below and one inch behind the anterior superior spine.
The first, or abdominal, incision is now sutured, and
a row of stitches secures the bowel to the iliac skin
opening. I preferred to keep the bowel closed for
twenty-four hours to prevent soiling of the wound.
Witzel, who suggested this idea in 1889, says that his
patient then, six years after this operation, always con-
gratulated himself on the excellent function that his
artificial anus possessed. Lenkinheld and Borchardt,
who also tried it, said that not only was a bandage or
compress unnecessary, but that the new anus was abso-
lutely continent for gas as well as for faeces. I was
compelled to depart from Witzel's directions to draw
the whole loop under the skin and over the iliac crest,
for it was too bulky to effect this easily, and hence I
cut the bowel in two and dropped the rectal end
duly prepared back into the abdominal cavity. This
gave more room, and a moderate division of the meso-
colon permitted the intestine to be easily drawn out to
the required distance. An experience in my third
case, however, showed that this division of the meso-
colon should be cautiously conducted. In that in-
stance the artificial anus was placed gluteally, as Wit-
zel calls it, for a cancer of the rectum, for which I
intended at a subsequent period to remove the anus
and rectum and not to attempt to establish a sacral
anus. Two weeks after the creation of the artificial
anus, as described, I operated for the rectal extirpa-
tion, but the patient succumbed from sepsis. At the
autopsy the upper end of the rectum, which had been
inverted and sutured, was found to be gangrenous in
several large spots. This was evidently due to its
April 21, 1900]
MEDICAL RECORD.
667
vascular supply being interfered with by a too long
transverse cut in the mesocolon.
A glance at this diagram (Fig. 14), taken from an
article by Kiimmel,' detailing some successful implan-
tations of the descending and transverse colon in the
anal region, will show the anatomical reasons for carry-
ing, in this or any operation to free or lengthen the
colon, the liberating incisions in the mesentery at
about one and one-half inches parallel to and from
the bowel, as this damages least the arterial supply.
In my other cases, both operated upon for intract-
able and extensive chronic ulceration and stenosis of
the rectum, no mishap whatever occurred, and in each
there has been complete continence. No bandage or
mechanism is used. Only a piece of gauze is applied
over the opening, and the weight of the clothing, in
addition to the natural advantage of the operative
method, seems to afford pressure sufficient to close the
intestine effectually as it passes over the bony brim of
the pelvis.
One of these patients I have the opportunity of show-
ing you. In her case the escape of gas occurs but sel-
dom, and the finger passed in through the opening ap-
preciates very distinctly the compression of the bowel
as it comes over the edge of the ilium. In the other
case, living at a distance from the city, the report is a
similar one.
In conclusion I may state that the foregoing imper-
fect review shows: (i) That an artificial anus of a
temporary character can be best established by Maydl's
operation or by Bodine's modification.
(2) Thatoverslipping offices maybe prevented by
proper spur formation, by narrowing the rectal open-
ing, or by occluding the rectal end of the bowel, which
may be fastened in the wound or dropped into the ab-
dominal cavity.
(3) That continence of the abnormal outlet is aided
by muscle separation (Maydl) or by muscle bridging
(von Hacker and Hartmann), or by the use of inflatable
or moulded plugs or other apparatus.
(4) It is only, however, to be satisfactorily effected
(though larger experience in this is desirable) by an
extra-abdominal iliac outlet (Witzel's iliac colostomy)
to be made by opening the bowel outside and behind
the iliac spine. In this procedure the bowel is com-
pressed between the edge of the bony pelvis and the
skin.
Many other methods have been proposed. Some, like
' Arch. f. klin. Cliir., vol. li.x., p. 555, 1S99.
Witzel, have made the outlet externally, but by goug-
ing a hole through the iliac bone. Other schemes
have been tried and have failed. A few are so unsur-
gical that they have fallen still-born. Perhaps some
have yet promise, and may in time, their value not
now being recognized, develop into methods of note.
I find from my notes that in all I have resorted to
the formation of an artificial anus thirty times, with
nine deaths, of which there were two from cancer, three
ulcerations, and four obstructions. Of these sixteen
were for malignant disease, either inoperable or pre-
liminary to operation, nine were for chronic ulcera-
tion, and five were for intestinal obstruction.
Among the eighteen cases in which a colostomy was
a preliminary to operation or was a curative agent, were
seven instances in which the opening was subsequently
closed, five by the intra-peritoneal method and two by
the extra-peritoneal suture.
INDICATIONS FOR CONSTITUTIONAL
TREATMENT OF CATARRHAL AFFEC-
TIONS OF THE UPPER AIR PASSAGES.
I'.Y WALTER A. WELLS, M.D..
VASHINGTON, D. C,
-OCV, UNIVERSITY OF
ORGETOWN ;
The literature teems with reports of cases which illus-
trate the effects upon other organs and consequence to
the general health of nasal, pharyngeal, and laryngeal
diseases. Anamia, malnutrition, deformities of the
chest, neurasthenia, migraine, epilepsy, asthma, goi-
tre, functional heart affections, catarrh of the stomach,
bronchitis, laryngismus stridulus, urticaria, and melan-
cholia are among the affections which have been attrib-
uted to this cause; sometimes reflex, sometimes pro-
duced by mechanical causes, sometimes by direct
extension of the diseased process, sometimes by trans-
mission through the veins and lymphatics, and some-
times by other, it may be complex and obscure means.
How to determine whether or not a supposed effect is
in reality due to the nose or throat trouble, as well as
how to differentiate the various effects, as to whether
of reflex nature or not, has been sufficiently dwelt upon
in treatises upon the subject.
Let us now turn our attention to the other side of
the picture, viz., wherein the catarrhal trouble figures
not as cause but as an effect of the other pathological
conditions coexisting, and let us consider in what
manner we shall know that the relationship exists.
We will suppose then that we have a case before us
of catarrhal inflammation of the upper passages, asso-
ciated with a more or less grave disease either of some
particular organ or of the whole system. How shall
we know that the former is not the cause or primary
disease, or not a local or idiopathic state (the other
trouble being merely coincident), but is in truth symp-
tomatic of the coexisting disease? The latter conclu-
sion, that is, that catarrh is secondary to the other, is
justified when it conforms for the most part to the fol-
lowing criteria : (i) No adequate local cause is appar-
ent. (2) Direct local treatment has ultimately failed.
(3) The catarrhal inflammation has manifested itself
subsequent to the coexistent trouble. (4) Its pathol-
ogy presents features peculiar to one of the symptom-
atic catarrhs, (s) Catarrhal inflammations are pres-
ent in other parts of the body. (6) The supposed
cause is sufficient to produce these local effects. (7)
Treatment of the associated condition improves in like
manner the catarrhal trouble.
It is unnecessary to apply these criteria to such con-
ditions as lues, tuberculosis, lupus, rhinoscleroma, or
any of those chronic constitutional maladies which may
668
MEDICAL RECORD.
[April 21, I goo
attack the nose and throat or any other part of the
body, and whose diagnosis is given chiefly in the spe-
cific nature of the lesion itself. Nor will we need to
hesitate long over a number of acute infectious disor-
ders, suc^ as scarlatina and diphtheria, in which in ad-
dition to the specific characteristics the sudden and
contemporaneous occurrence of both local and general
affections is entirely sufficient for diagnostic purposes.
Greater difficulty of diagnosis, however, is presented by
the concomitant affection of the cutaneous system and
of the mucous membrane of nose and throat, between
which, as I endeavored to point out a couple of years
ago,' a very interesting sympathy may be found in their
pathological manifestations. Reasons were here given
for holding that cutaneous eruptions, more often than
ordinarily assumed, could appear as true reflex neuroses
of nasal origin, especially erythema of the nose and
face, erysipelatous eruptions, urticaria and, perhaps,
herpes and pemphigus, and affections of the angioneu-
rotic type. How often inversely the cutaneous erup-
tions are the primary affections, can be estimated only
by careful investigation and application of all diag-
nostic criteria at our command to each individual case.
When such relationship has been for a certainty es-
tablished, we shall have naturally to put our faith in
those remedies indicated in the particular skin affec-
tion present.
Without doubt, the responsibility for much the
greater number of secondary catarrhal affections of the
upper respiratory organs belongs to the gastro-intesti-
nal system. That diseases of this system exert a di-
rect and decided influence upon the nose and throat is
a matter of daily observation. Singers generally rec-
ognize that fact, and take advantage of it in avoiding
the overloading of the stomach just previous to an
engagement to sing. It is well illustrated, too, in the
experience of a number of persons in whom every at-
tack of indigestion induces a cold in the head or con-
gestion of the pharynx.
As with the acute, so with the chronic catarrhal
affections, which, if not essentially dependent upon
disorders of the stomach, at least will suffer exacerba-
tion from such causes. In every case of post-nasal
catarrh the condition of the stomach should receive
scrupulous attention. It will be found very often that
when the application of astringents is futile good re-
sults will be obtained by the use of correctives of the
gastric disorder, such as pepsin, bicarbonate of sodium,
or tincture of nux vomica. These may be given well
in combination, in a glassful of hot water just before
meals. Or one may find more effective pepsin and
hydrochloric acid, with perhaps nux vomica, given
after meals.
A form of throat inflammation frequently associated
with dyspeptic disorders is that of the lingual tonsil.
Amygdalitis lingualis occurs most frequently in mid-
dle-aged women, who complain of burning or sticking
in the throat, or not infrequently of the sensation of a
foreign body, and constant desire to swallow. It is
nearly always accompanied with more or less laryngi-
tis, and the voice, even if not hoarse, is generally easi-
ly fatigued. The tongue will be heavily coated and
more or less dyspeptic symptoms will be found.
VVhile local treatment should not be neglected in such
patients, the stomach also will generally need atten-
tion.
It may seem hardly necessary to refer to the influ-
ence of intestinal obstipation upon catarrhal diseases
of the throat, since this will be immediately admitted
by all who have had any occasion to make observation
in this particular, and readily understood by others
upon theoretical grounds. Nevertheless, as with
many other things which we know, we fail to bear it
always in mind. Whether the fault be with the secre-
' New York Medical Journal, October 15, 1S98.
tions or with the muscular activity of the intestines,
their sluggishness must be overcome by properly cho-
sen laxatives, if we are to have the desired success in
treating the affections under consideration. Often
quite a high degree of anaemia from this cause may be
present and show itself in the mucous membranes, es-
pecially in young girls. Sulphur is the lemtdy par
excelkiuc in such cases, according to some authors.
Moritz Schmidt lays much stress upon intestinal
flatulence as a factor in the production of catarrhal
diseases of the upper air passages. The abdominal
distention, according to him, obstructs the circulation
and produces nervous hyperemia of the mucous mem-
brane. His treatment consists in the complete separa-
tion of solid and liquid diet, taking as little as possi-
ble of the latter, and only between meals. I believe
that regulation of the diet, joined to massage and more
or less systematic exercise, are far more efficacious in
these cases than drugs or artificial digestives. The
most essential thing is sufficient mastication, which
may be lacking, either from the individual's careless-
ness in eating too hastily (the bane of American civil-
ization), or because of faulty or deficient masticating
apparatus. If the former is the case, we should ex-
plain the danger and emphatically enjoin better hab-
its; if the latter, the cure must rest in the hands of
the dentists.
When medicine must be given, I can think of no
better prescription for, intestinal dyspepsia with flatu-
lence than the following:
I{ I'epsini pur.,
Pancreatin. ext aa 2 gm.
Pulv. carb. lig.,
Bism. subgal aa 4 gm.
M. ft. chart, xii. S. One before meals.
Valvular heart lesions will, in case of failure of
compensation, constitute a serious cause of catarrhal
inflammation; for the mucous membrane must share
in the general nervous engorgement, as indicated by
a more or less purplish coloration and increased se-
cretion. It is therefore advisable, in every case which
does not readily yield to local treatment, to institute
an examination of the heart; more especially if symp-
toms (such as dyspncea, palpitation, oedema) should
be elicited pointing to cardiac trouble. The treatment
will of course resolve itself into that proper for the
particular form of heart disease present; and accord-
ing as the special conditions indicate or the physi-
cian's preferences dictate, rest, avoidance of stimulants,
and heart tonics will be prescribed, or perhaps the
Oertel or Schott treatment or the Nauheim baths.
Among the more unexpected pathological conditions
which are sometimes factors in causing and maintain-
ing throat inflammations may be mentioned the float-
ing kidney, which is now known to be present in a
very considerable proportion of adult female patients.
Schmalz, Bresgen, and Peyer, and in this country
McKenzie, have written upon the relationship observed
between nose and throat affections and diseases of the
reproductive system. Peyer states that maladies of
the genital organs may give rise to intermittent swell-
ing of the nasal mucous membrane (coryza nervosa),
abnormal dryness of nose and throat, sensation of heat,
arrested secretion, epistaxis, perversions of olfactory
sense, hyperEESthesia, ana;sthesia, and paresthesia. It
is not improbable that the relationship between these
two systems, which, though distant, present certain
anatomical and physiological analogies, may be recip-
rocal, that which is primarily affected in the point of
time being primary in the matter of cause and effect.
At any rate, abnormalities discovered in this part of
the body should be corrected if possible, as thereby
only good will be done, even though such far-reaching
influences as alleged do not obtain.
Among the diseases whose effects are sometimes
April 2 1, 1900]
MEDICAL RECORD.
669
seen in the upper air passages, we have yet to mention
diabetes, leukremia, and Hodgkin's disease. In every
case of persistent incurable pharyngitis sicca, we must
take into consideration the possibility of its being
d-ue to diabetes. Hodgkin's disease may give rise to
cedema in the mucous membrane, seen sometimes
chiefly in the palate and uvula, at other times in the
epiglottis or ventricular bands. Leukaemia can be at-
tended likewise with considerable infiltration in the
mucous membrane. It may reach such a degree in the
glottis as to produce a grave result.
Having considered the various specific affections of
organs and parts of the body or of certain systems, in
their bearing upon catarrhal diseases of the upper air
passages, we may now pass to what are known in gen-
eral as diathetic conditions or dyscrasias. These, as
a rule, are manifested to a pronounced extent upon
the mucous membranes, and in some cases, as scrofula
for example, the nose and throat are the places of
predilection. It is as impossible to ignore them in
treating of nose and throat affections as it is to ignore
the mucous membranes of the nose and throat in con-
sidering them. Unfortunately for both medical writer
and practitioner, the various diatheses or tempera-
ments of the body have never yet been accurately
defined and satisfactorily determined; but these boun-
daries remain hazy and their nomenclature is conse-
quently much confused. This we understand at once
to be due to the circumstance that they have no demon-
strable pathology, but rest upon the insecure foun-
dation of a symptomatic nosology. Thus it comes that
imagination and speculation have made the most of
the meagre material at their command, and disputes
have arisen which cannot be settled. In the mean
time, as discoveries are made in the field of pathologi-
cal anatomy and bacteriology, we will immediately
attempt to adjust them to our purpose, but still in some
cases we must subordinate our meagre knowledge to
the dictates of convenience.
Scrofula, for example, is now well known to be
identical with tuberculosis, but since it lacks some
demonstrable gross lesions, and possesses a distinct
clinical picture, we find it convenient to retain the
term.
Hysteria is a very much abused word, owing not
half so much to the backwardness of science as to the
ignorance and carelessness of the practitioners, who
are wont to call everything hysteria which they do not
understand. Clinicians have by careful observation
in a great measure made up for the deficiency of the
pathologists by giving such unerring symptomatic
guides for this disease that it may now be said
that he who diagnoses hysteria without discovering
the so-called stigmata commits a blunder that should
disqualify him for practice from that time forth.
But the greatest whirl of confusion is that which
has been thrown about a condition generally passing
current under the name of the uric-acid diathesis.
We here fall into an apparently inextricable difficulty
before which so far both clinical and pathological en-
deavors have stood helpless, but, as I believe, not
hopeless. As the subject is one so inseparable from
a study of the nose and throat affections, and so im-
portant, too, in a therapeutic sense, the laryngologist
is compelled to take it into account. It seems almost
impossible to gather from the interminable maze of
literature on this subject a perfectly clear and defi-
nite conception of the conditions to which this name is
intended to apply, owing chiefly, no doubt, to the per-
plexity which pervades the subject of the origin and
formation of uric acid in the living organism. The
first difficulty to be overcome is the continual con-
founding of neurasthenia with the conditions in ques-
tion, when they are in reality the antitheses one of the
other. The second difficulty consists in the error of
giving to uric acid both in name and in fact a too
prominent place in the pathology of the conditions
with which it is found associated. There is beyond
doubt a strong undercurrent of opposition to the doc-
trine which makes uric acid the centre and source of
all the trouble with which it is accompanied, and it
should be given its right place as a result and not a
cause. Instead of being the chief and essential feature
it is a by-product or side issue, and we may say a sign
of the operation of other and more important phe-
nomena.
Some writers, while minimizing the importance of
uric acid, have sought to show that xanthin, paraxan-
thin, or so-called alloxuric bodies were of chief impor-
tance, and that the diathesis should be denominated
accordingly. For some time I have been of the
opinion that this uric-acid or lithsemic diathesis was
not attribuable to the chemical products of whatever
nature that were found, but rather to a certain morbid
state of the vasomotor nervous system, consisting es-
sentially in an hypersensitiveness and hyperactivity
leading to nutritional changes.' The signs of the
time seem rather to point to change of opinion in
favor of this view. Granville'^ has recently written
these significant words: "Cullen was nearer to the
discovery of the secret than we now are, when he in-
sisted that to the primary moving forces of the organ-
ism, viz., to the nervous system, the physicians must
look for the cause or causes of gout."
Evidently, a new name needs to be invented which
would better designate a morbid state of the nervous
system, which underlies these uric-acid phenomena.
This state, consisting, as I believe, in an abnormal
excitability and over-activity of the nerve cells — that
is to say, the reverse of neurasthenia (nerve-cell ex-
haustion), might, in lieu of some better term, be des-
ignated " neurohyperkinesia." As neurasthenia is
marked by lowered arterial tension, in neurohyperki-
nesia, on the other hand, we have increased arterial
tension prevailing. The cardinal symptoms of ne*u-
rasthenia are headache, tachycardia, and insomnia.
There is usually a hypochondriacal tendency, with
irritability or depression of spirits. IVJuscular trem-
or, disordered sensibility, dyspepsia are nearly always
present, and to these may be added a long list of other
symptoms according to the degree or particular phase
which the malady assumes. Neurohyperkinesia, as I
understand it, presents an utterly different picture.
All who call to mind their patients who have had the
so-called uric-acid trouble will bear me out that these,
instead of being of the weak, anaemic, wiry type of
the neurasthenic, are generally stout or even corpulent,
often with flushed face or generally plethoric habits.
As a rule, too, they are persons of superior intellectual
calibre and vigor. Eczema, hemorrhoids, hay fever,
asthma, epilepsy, angina pectoris, true migraine, and
a host of affections which are included under the term
reflex neuroses, are seen in patients possessed of this
diathesis.
There are two types of cases to be distinguished,
according to the more or less prominence of a certain
group of symptoms. These are (i) neuro-arthritic or
gouty; (2) vasomotor sympathetic. The last-men-
tioned is the one which interests us, as being that in
which all that class of affections depending, as I be-
lieve, chiefly upon vasomotor irritation arise, known
generally as reflex neuroses. They are characterized
by their periodically current, spasmodic nature, their
want of an organic pathological basis, the occurrence
of certain nutritional changes indicated by the urolog-
ical examination, the etiological influence of psychical
factors, and, as a rule, by more or less increase of leu-
' New York Medical Journal, November 12, iSgS.
• Medical Press and Circular, London, February and March,
670
MEDICAL RECORD.
[April 21, ico<3
cocytes, the striking feature of which is the eosino-
philia.
As the nose is probably the commonest source of
retlex troubles, the rhinologist will have frequently to
do with these symptoms, under the head of nasal reflex
neuroses.
Having said so much of diatheses in general, let me
now take them with particular reference to their effects
upon the mucous membranes of the nose, and the best
treatment which should be employed against them.
Scrofula. — The lowered vitality of the system in
scrofula is particularly manifested in the proneness of
mucous membranes to become catarrhally affected.
VV'hile I know of no peculiarities in the catarrhal in-
flammation, the clinical picture is generally sufficient
for diagnosis. The characteristic facies (broad nose,
thick lips, etc.), the lymphatic swellings, the rhinitis
with eczema of the lips, are almost classical. Atro-
phic rhinitis and oza;na are comparatively common.
The association of conjunctivitis and marginal bleph-
aritis as complications will be present in a great pro-
portion of the cases.
Local treatment of the nose and throat affections is
not out of place here, any more than in the disease of
the eye of the same origin. It will prove of little avail,
however, if not supplemented by well-directed internal
medication. Our sheet-anchors are cod-liver oil and
iodine in some form. The former is best given as the
pure uncombined Norwegian product, when it can be
so taken, but also in emulsion, of which there are to
bi found a number of elegant products in the shops;
or, if we like, it may be given in combination with the
hypophosphites. The indication for iodine is best of
ail met by an old-time but highly valuable prepara-
tion, the syrup of the iodide of iron. The certainty
and the rapidity of improvement following its admin-
istration are among the most pleasing e.\periences in
medical practice. In some cases, however, idio-
s;^ncrasies will be found, and then we must find sub-
stitutes. Arsenic, iron in some other form, the hypo-
phosphites, or the syrup of hydriodic acid may be
found to suit individual cases. The hypophosphites
are thought to be especially indicated in cases of re-
tarded osseous development. Of course, fresh air and
supporting diet will be understood to be of prime im-
portance. Salt-water b.iths, when they are within
reach, will prove of the highest benefit.
Hysteria. — The real nature of hysteria is as yet so
inadequately known that it is difficult to predicate
anything w ith certainty as to its relation to nose and
throat affections. If, as appears to be the case, real
structural changes may be produced, it might be said
to present the anomaly of a functi»:ial disease giving
rise to organic changes. Whether or not inflammation
may be produced, at any rate those who treat diseases
of the nose and throat will with suspicious frequency
encounter the associated condition of hysteria, and will
be called upon to decide whether at all or how much
the hysteria has to do with the symptoms present.
About a year ago I reported a case of extraordinarily
frequent and long-continued sneezing' (ten thousand
to forty thousand times a day), going on for a month
or more, in which there was such a combination of
hysteria and local inflammation in the nose as to
baftle all attempts to place the blame where it be-
longed. Overwhelming doses of sedative or antispas-
modic drugs, however, having proved futile in control-
ling the sneezing, and removal of a hypertrophied mid-
dle turbinate having been followed by a cessation of
the symptoms, all the a poslciiori evidence was in favor
of a local causation. Hysteria, though, no doubt plays
something of a role in giving rise to nose and throat
symptoms. Anaesthesia and paresthesia of the mucous
membranes are very common attendants upon the hys-
' National Medical Review, Washington, May, 1S99
terical diathesis. Also laryngeal spasms and para-
lyses and the peculiar condition known as globus hys-
tericus will come quite frequently under the notice of
the laryngologist.
As already indicated, in the event of the concur-
rence of nasal or pharyngeal trouble and a hysterical
constitution in the same patient, there may be no small
difficulty in discovering their true relations one to an-
other. It is possible that they are independent, but
it is also possible that when associated they may act
as reciprocally causative factors. Both local and gen-
eral treatment, at any rate, are in order, and so, while
we use our douches, spray, powder, or ointments, or, as
may be necessary, our cautery, saw, snare, or curette,
we will at the same time not overlook the needs for
internal medication. Bromides, valerian, and asafet-
ida have for long time been supposed to exercise a
special influence over the hysterical state. We may
try them, but I believe the newer therapeutics look
rather to rational physical and hygienic methods for
the best results. Electricity and balneology are the
chief among these, but the sine qua rion in many cases
is a complete change of environment, especially the
separation from over-sympathetic and too indulgent
relatives.
Neurohyperkinesia — As in both types of this di-
athesis, the gouty or neuro-arthritic and the vasomotor
sympathetic, the upper air passages play a very promi-
nent role, it will be necessary to consider them both,
and, for reasons which will become at once obvious,
separately. Much has been said recently about the
uric-acid origin of catarrhal inflammations of the
nose and throat, and it has become certainly estab-
lished that a relationship of some kind exists. Not
only do cases of acute tonsillitis and pharyngitis give
evidence of a true rheumatic causation, yielding read-
ily to the salicylates and their congeners, but we must
reckon as of a rheumatic or gouty origin many chronic
cases of rhinitis, rhino-pharyngitis, tonsillitis, and lar-
yngitis. They are found so often in persons of the
gouty, or, as the French would say, neuro-arthritic
habits, in persons who have gravel or present other
evidences of this diathesis, having manifestations, it
may be, such as asthma or migraine, belonging to the
sympathetic type, that mistake is out of the question.
The appearance in the throat of inflammations of a
gouty origin are in a measure characteristic. The soft
palate, fauces, and posterior walls of the pharynx
will present a highly engorged condition, approaching
a degree of bogginess. The palate and uvula will
frequently become cedematous. The redness of the
membranes is intense, but most marked along the pil-
lars of the fauces. There will be severe pain in the
throat, pain and ma)be difficulty in swallowing, and
soreness in the cervical muscles. In the more chronic
forms these symptoms will be less acute, and the pa-
tienfwill complain of intermittent burning or sticking
in the throat; or frequently the sensation of dryness,
tickling, or stiffness felt in swallowing. The larynx
becomes likewise involved, and prolonged use of the
voice is impossible or is followed invariably by
hoarseness and soreness of the throat and a feeling
more or less of exhaustion. The crico-arytenoid joints
become, like other articulations, the seat of inflamma-
tion, as evidenced by swelling discerned by the laryn-
goscope in this locality. Gouty deposits are found
here, and even in the cords themselves.
Throat specialists who are desirous of obtaining the
very best results in these cases of inflammation of
gouty or neuro-arthritic origin will, at the same time
that they make use of the various topical applications
which have been found of service (thiol in glycerin
two to four per cent, has proved valuable in my expe-
rience), recognize the necessity of resorting to consti-
tutional remedies. However discordant the theories
April 2 1, 1900]
MEDICAL
of different authors and investigators on the subject of
the etiology and pathology of the diathesis I am dis-
cussing, all are agreed in the efficacy of certain medic-
inal agents and special lines of treatment, of which
the most prominent to be mentioned are the salicy-
lates, the iodides, and the alkaline treatment. The
salicylates (salicylic acid and salicylate of sodium, and
its congeners salol, salophen, salipyrin, etc. ) are in-
dicated in the acute cases. The iodides, alone or in
combination with colchicum, are chiefly relied upon
for the more chronic forms. The salts, which owe
their only virtue to their alkaline properties, are given
with good results in both acute and chronic cases. It
is said (Bence Jones, Chevreuil) that an alkaline me-
dium favors oxidation, which probably explains the
good results obtained from the alkaline method of
treatment in the gouty habits, as here we have to do
with a condition of disturbed tissue metabolism,
marked chiefly by suboxidation and increase in the
products of disassimilation. By some bicarbonate of
sodium is given in large doses, by others- bicarbonate of
potassium, while phosphate of sodium or carbonate of
ammonium is preferred by yet others. Mineral waters
that are prescribed for this class of patients depend
for their virtues upon the alkaline constituents. The
waters having greatest reputation are those containing
large proportions of bicarbonate of sodium, as Vals,
Viciiy, Fachengen, etc. The Carlsbad and Marienbad
Springs, which are also very popular, are rich in the
sulphate of sodium and magnesium. The lithia waters
are very widely advertised and generally used for their
supposed efficiency in these conditions.
In England, where the gouty habit is even commoner
than in this country, the chemical constituents of cer-
tain of the mineral waters (Friedrichshall, Seltzer,
Kissingen, and Vichy), put in the form of compressed,
effervescent tablets, are very much prescribed. These
tablets, not only of the mineral waters but also of
lithia, lithia and potash, piperazin, etc., have been
recently introduced, and on account of their conven-
ience and elegance, having the advantages of occupy-
ing small space and therefore of being portable in the
pocket, and of ready solubility, producing a pleasant
effervescent drink, I have used them for about a year
w-ith very satisfactory results. In the present-day
practice of medicine we have to look as well to the
elegance of our prescriptions as to their physiological
effects, as our ends may as well be defeated by the one
as by the other. In chronic conditions, in which the
patient must continue taking medicine for a long period
of time, we must be careful to avoid giving doses
which are disagreeable and difficult to take, else the
patient will become disgusted and cease undergoing
treatment altogether. If lithia is to be given for its
therapeutical effects, it is much more rational to pre-
scribe it in certain definite doses (as in tablets of lithia
citrate, gr. iii. and v.) than in the so-called lithia
water. The indications for alkaline medications are
very precisely and thoroughly met by the tablet of lithia
and potash combined. The best method to pursue to
arrive quickest at the required alkalinization of the
system is as follows: As early as the patient awakes
two tablets should be taken dissolved in a full glass
of water; then before each meal and again at night one
or more, as necessary, to bring about an alkaline urine,
which will be determined by testing with litmus paper.
The Sympathetic Diathesis. — By this I under-
stand, as said, that type of the neurohyperkinetic di-
athesis marked by the disposition to the origin of re-
flex disturbance in various parts of the system. The
rhinologist is familiar with this diathesis, having so
frequently to do with reflex neuroses of nasal origin,
hay fever, migraine, asthma, etc. As a rule he is in-
clined to emphasize too strongly the local causation,
overlooking the important fact that the local trouble
RECORD. 671
would not have produced these secondary disturbances
without the existence of a certain underlying morbid
condition of the system. Treatment directed to the
overcoming of this general diseased state then is in
order. If our theory of vasomotor causation be the
correct one, we should expect those remedies to be
most efficacious which are known to exert a direct de-
pressing action upon the sympathetic. Examine the
list of remedies in highest repute for hay fever, asth-
ma, epilepsy, migraine, and angina pectoris (the group
of affections most frequently occurring as reflex neuro-
ses and having a close analogy among themselves),
and it will be seen that it is the class of sedative or
motor depressants which are most in vogue. Jn all
opium, bromides, chloral, amyl nitrite, and nitro-gly-
cerin are used with effect. In addition, quebiacho
and grindelia, classed as motor depressants, are found
particularly valuable in asthma. An apparent incon-
sistency may be thought to exist in the fact that atro-
pine, said to excite the vasomotor system, is recom-
mended in hay fever and asthma by some. While the
first effect, however, of belladonna is excitant, in large
doses it produces, on the contrary, a depressant, para-
lyzing eflect on the sympathetic ganglia. The disa-
greement in the experience of various observers may
perhaps be explained by this circumstance. While
for each kind of neurosis certain of the class of reme-
dies will be found of greater service than others, and
while regard must be had for thes]3ecial indication in
individual cases, in general it may be said that the
measures and remedies/<7/- i'.vC(r//<'7/,r for all affections
(nasal neuroses) falling under the head of the sympa-
thetic diathesis are those which act to depress the
vasomotor sympathetic nerves.
For hay fever, in addition to the local treatment
which is indispensable, 1 have found that the best
prescription for internal administration is a modifica-
tion of that of J. N. McKenzie. The only change
made is that of the substitution of belladonna for nux
vomica, the formula being then as follows:
IJ Zinci phospli gr- i^o
Quin. sulph gr. ii-
Kxt. belladonna; gr. \
S. One pill before each meal.
Neurasthenia. — It is not surprising that an affec-
tion so common as neurasthenia in this age should be
met with in the consultation room of the laryngologist.
The mad rush after success, the infection of modern
civilization, has naturally drawn upon the reserve
force of the overworked nervous system, until eventu-
ally, in a very large number of cases, nerve exhaustion
or neurasthenia is superinduced. That, however, the
association of neurasthenia with nose and throat affec-
tion is more frequent than would be expected from the
frequency of each separately, is not to be denied.
Some have thought from this that the neurasthenia
was the product of the existing catarrhal affection, and
have described cases which appeared to them to justi-
fy this view. But I am inclined to suspect that a care-
ful search into the history and development of such
cases will not fail generally to reveal that the com-
mencement of the neurasthenic condition antedates
the local trouble, and that other causes have existed,
acquired or inherited, which go to explain its presence.
At least it is not clear how a local lesion of this kind,
however grave or long continued, can give rise to the
general disordered state of the nervous system com-
prised under the name neurasthenia. So far as my
experience goes, the nose and throat in neurasthenic
patients present objective appearances that are very
insignificant as compared with the subjective symp-
toms. Neurasthenia, then, it seems more rational to
believe, is the essential and primary disorder; the
nasal or pharyngeal or laryngeal troubles, though real,
are secondary, and in a great measure symptomatic;
672
MEDICAL RECORD.
[April 21, 1900
that is to say, the neurasthenia, if not directly produc-
ing the local affection, prepares a ground of such
sensitiveness and disorder that a minimum organic
change shall give rise to a maximum of symptomatic
manifestations. Under these circumstances, our tirst
concern must naturally be the treatment of the consti-
tutional state. For neurasthenia, the requirement
above all to be insisted upon is rest from intellectual
work, and the withdrawal of all sources of undue ex-
citement. A complete surrender of the occupation,
and a temporary vacation spent away in some restful
surroundings, may have to be enforced in some cases.
Certain medicines are of demonstrable value, chief
reliance being placed in arsenic, nux vomica, and
phosphorus and its compounds. Of late the glycero-
phosphates have come very much into prominence
among the French, especially for the treatment of neu-
rasthenia. They are the products of the decomposi-
tion of lecithin, an agent known to play a very impor-
tant role in the activity of the nervous system. It was
found by Sarano, when introduced hypodermically, to
improve digestion, augment the number of red blood
corpuscles, stimulate nutrition, and increase the
weight. Excellent results have been obtained clini-
cally by the use of the glycero-phosphates by Robin,
Kahane, Starr, and others. The different forms of
neurasthenia will often require different treatment.
Hydrotherapy, rightly employed, is in general of much
real service. Most patients are benefited rather by
the tepid than the cold douches, according to Sorchet.
Insomnia and other symptoms will frequently demand
particular remedies. Electricity, massage, and very
moderate physical exercise will generally prove of ad-
vantage. One of the most recent writers, Dornbluth,'
advises against too strict dieting, permitting tea and
coffee, but interdicting alcohol. He advocates the as-
suming of the recumbent posture as much as possible,
and general faradization with weak currents.
1133 Fourteenth Street, N. W.
A CASE OF FRACTURE AND MEDICAL
ETHICS.
By E. S. GOODHUE. M.D..
LOS ANGELES, CAL,
U-LANI HOSPITAL
A THOROUGH knowledge of the theory and practice of
medicine is not more essential to the young doctor
than the experience which he lacks at the outset of his
career. He may have graduated with honor at one of
the best colleges in the country, and be thoroughly
conversant with the best modern and scientific methods
of treating disease, yet be ignorant of the ways and
means upon which his particular career shall depend.
He must know how to adapt himself to the local,
social, and professional phases of human nature he
touches; learn to be tolerant of faults, charitable tow-
ard meddlesome mothers, patient with fools; he must
relax his schoolish code, and discover that some very
reasonable . theories fade into unreality the moment
they are applied to a living subject. Just as the dan-
cer learns how to dance by dancing, so the doctor be-
comes proficient in his art by running foul of all the
accidents that befall the average practitioner: igno-
rant patients, dishonest patients, quackish patients,
dilatory patients; good consultants, bad consultants,
consultants that take advantage ; sin, sorrow, bad bills,
malpractice suits, backbiting, foolish gossip, malin-
gerers, inclement weather, night calls, Christian Sci-
ence, placenta prcevia, and the large number of patients
that don't follow directions. If he needs the tactus
eruditus for successful work in a strictly medical line,
' Muncliener med. Wochenschrift, January- 16, iqoo.
he cannot get along without another kind of tactus to
guard him on occasion, and keep him from spoiling
what good reputation he has gained in his work.
He must learn to be firm with his patients. "You
are the doctor" is a fact that will sooner or later be
thrown up to him by some patient who has been al-
lowed to have his own way.
He must learn to show a confidence that he may not
feel; appear hopeful when he is the reverse, and never
express damaging surprises. Early in my practice- —
a few months after I graduated — I came across a case
that taught me a lesson. If the experience shall help
any one else, I will report it as briefly as I can.
One Sunday morning, I was hastily summoned to go
out some ten miles to see a child that had "put its
elbow out of joint." As I was busy waiting for such
an opportunity, I went at once, taking with me L
and an emergency case. We rode over a rough road
through a canon that seemed interminable, and came
at last to the house where everybody was anxiously
waiting for us.- The patient was a girl aged ten years.
She had been thrown from a horse while riding "bare-
back." I was well acquainted in the house, as I had
been attending the father of the child, who was con-
valescing from a severe attack of typhoid fever. He
lay in bed near the door opening from the room in
which the patient sat crying. The mother, a large
Amazonian, stood w ith her arms akimbo, and a daugh-
ter patterned after her mother walked up and down the
veranda wringing her hands. Two of the girl's beaux
were present, and very soon another daughter with her
husband and child arrived. On examination, I found
a much swollen and somewhat discolored right fore-
arm and elbow, compressed by a dress sleeve that I
cut open. Although there were evident appearances
of backward dislocation of the radius and ulna, there
was not only no rigidity, but undue mobility, the fore-
arm dropping by its own weight. As the arm was
swollen, and the child cried loudly at even the gen-
tlest movement, there being intense pain on pressure
much increased by any attempt at flexion, I decided to
give an anesthetic, and soon had the child well under
the influence of ether. I was not able to accomplish
this without a long parley with the mother, and re-
peated interference from the elder daughter. They
had their doubts whether such procedure was justifiable
under the circumstances, and so on. I told them that
we probably had a severe fracture, and that with the
amount of swelling present and the involvement of the
joint it v^ould be necessary to give the arm a thorough
examination, which they must see could not be done
without an anesthetic. After some hesitation, they
consented. I found that the external condyle was
fractured, presenting movement and slight crepitus,
while the coronoid process was also fractured, allow-
ing the backward play of the bones of the forearm
when the elbow was extended. Evidently the force
upon the open hand and extended elbow thrown out
by the girl to save greater injury had been transmitted
through the radius to the ulna and the trochlear sur-
face. The coronoid fracture was a rather unusual one,
but not at all strange under the degree and distribu-
tion of indirect force present. The condyloid fracture
came from a more direct impulse; a result of common
enough occurrence. But although I had some doubts
at first as to whether the epiphyses were separated
(such an accident being not unusual in children), I
soon found that the diagnosis was made easy by the
play of the joint in my hands; now a dislocation, now
a reduction, according as I extended or flexed the arm.
At every moan or motion the child made, the mother
and sister would fly to my side, and the old man would
growl, "Say, can't you be easier with that child?"
Finally, I had to ask the mother and daughter to go
into the other room.
April
1900J
MEDICAL RECORD.
(^7?>
I then flexed the elbow at a little less than a right
angle, put it up in a fixed bandage, and left the girl
rather comfortable. I asked the mother to watch the
hand, and if there was more swelling, and the bandage
seemed too tight, slightly to loosen it. I said that I
should return in the morning, as the arm ought to be
seen every day for a few days, anyway. "Oh, I can't
pay fer that," said the mother, " I can't afford to pay
for another visit, an' I don't think it's necessary.
When a jint's once sot, I don't see that it needs the
doctor any more."
In the morning I came at my own expense, although
the family was well able to pay for the trip. I found
that the mother had all but removed the bandage, and,
while the swelling was less, the arm lay extended and
as much "out of joint" as ever.
With great care I put the arm up in a permanent
bandage as before. I was going to put it in a silicate
or plaster-of-Paris splint, but the mother urged so
against it that 1 foolishly gave in to her. As I left,
I asked the family to report each day, because I felt
very anxious to know the outcome of so serious a frac-
ture. The mother went on to tell me that she had
"sot many a jint as well as any sargint." She had
fixed her daughter's "public bone" (pubic, I suppose
she meant), and she had sent for a doctor in this case
only because people might talk.
I heard nothing from the case for four or five days;
then the daughter came to my otTice to tell me that her
sister was getting along "right smart." She said that,
the next morning after I left, Rosa complained so
much of the pain in her arm that her mother thought
it was best to take the bandage off altogether, wiiich
she did, putting in its place a strip of leather. She
had done it up " 'bout as you did," and Rosa was com-
fortable. " I am afraid," said I, " your mother has
made a mistake, and if there is deformity you must
not blame me. I have my doubts whether you will
have a good arm."
" No danger," answered the sister, laughing. " You
don't know what a good doctor mother is."
I had come to my professional " pons asinorum."
Such a blunder I could not make now, but I did actu-
ally let that woman control me and my reputation in
the case so far as to acquiesce in her demands. I
should have required either absolute control of my
patient, or my dismissal from any further attendance
upon the case; and why I didn't may have been due
to several things, the chief of which was want of expe-
rience in dealing with this class of patients. I have
found that nearly every doctor has, at some time or
another, done something, or failed to do something,
for which he mentally " kicks himself " ever after.
Six weeks after the accident I met the mother.
She said that Rosa was getting along well; that her
arm was somewhat stiff, but not more than it " orter
be."
In the mean time, I sent in a bill for services ren-
dered the family, not only in this case, but for the
long illness of the father. He was an old toper who,
by the goodness of Providence or tlie interference of
the devil, had pulled through an unusually severe run
of typhoid fever. During the illness, which was re-
tarded by several complications, the family had re-
quested me to call in their former physician, a homoeo-
pathic practitioner, who very courteously expressed his
opinion that Mr. J was getting along as well as
could be expected.
But when I entered the house for the first time, I
had an intuitive feeling that my directions would not
be carried out; that the ignorance and vanity of the
mother would have their perfect work. Had I been
wise (even as wise as I am now), I should have insisted
upon precedence. But when a young doctor is just
getting a foothold in this and that family, trying, as it
were, his doubtful skill, he is much inclined to insist
less and please more.
The bills were rendered again, bringing no answer.
At last they were sent with a suggestive footnote:
" Please call and settle at once." I don't remember
how many months later Dr. G called me into his
office as I was going by. There he told me that Mrs.
J • had been to see him with her daughter Rosa;
that the daughter had an unsightly deformity as the
result of a dislocation probably.
" They have been all about," said he, " to see other
physicians, and threaten a malpractice suit. I would
advise you to call on these physicians, and explain the
case as you have to me."
Like a true friend, this doctor had found out the
names of the physicians consulted, and gathered all
that would be of advantage to me.
" Well," said I, with all the inexperience of the
untried, "let them go ahead; it will advertise me.
They have not the shadow of a case at all, and I can
bring in other doctors— any doctor— to prove that I
was not to blame."
"Go slow," said the old doctor, smiling; "doctors
are not all just, not all even honest, and the laws are
not on the side of the doctor. I've had a malpractice
suit on my hands, and I know what it means. No
matter who's to blame, take this little girl into court,
dwell on her innocence and youth, show her deformed
arm, and the blame will be placed on the doctor that
attended her. You have a case if any one has, but the
world is a sad pickle-jar, my son, and a great many
doctors I know are better at furthering their own in-
terests than at telling the truth."
I went to see the doctors Mrs. J had consulted. ■
One was an eclectic. He said that he had seen the
arm; it was certainly an ancient dislocation. He did
not remember advising the woman to sue, but if he
had, he should not now% knowing the particulars. He
said that the family were unreliable and unstable.
The homoeopath said he thought that the woman had
no cause for suit, and told her so. The other physi-
cian seen was an old army surgeon who graduated in
the fifties, and he told the woman that the deformity
might be the result of a fracture of the condyles. He
had seen such cases after the best of care. I now
made another free trip to Mrs. J 's home. She
met me at the door with fire in her eye. " I know
what you come fer," she said, striking an attitude,
" but you needn't expect to git a cent here. We-uns
don't pay sech as you. You may have to pay we-uns
afore your bill's collected. My dorter's maimed fer
life. The doctors says it a bad piece of work, and
one of 'em tol' me not to give his name, as he's a
friend of yourn, but he says it's enough to land you in
jail."
I talked to this woman from my heart, and left noth-
ing unsaid of all the cruel truth, acknowledging, final-
ly, before I closed my address, that I was to blame for
one thing only, and that was in allowing such an ig-
norant, opinionated shrew as she to dictate to me.
Before going I examined Rosa's arm and found the
deformity that would naturally result from such a vi-
cious union. But the arm was not very unsightly, and
could be used to considerable advantage. But the ex-
perience, the lesson, elbowed itself into my memory
to stay.
Lynchage is the latest French term applied to exe-
cutions without the red tape of jury trial. The Gazette
des Hopitaux thus designates the removal of certain
organs from a man at Falls City, Neb., by a mob, who
believed him guilty of assault upon a young girl, thus
rendering him incapable of again making such an
attempt. The Gazette, wrongly we trust, suggests that
a medical man may have been in the party.
674
MEDICAL RECORD.
[April 2 1, 1900
THE USE OF ELECTRICITY IN CHRONIC
RHEUMATISM.'
By WILLIAM J. MORTON, M.D.,
NEW YORK Cn V.
Mr. President and Fellow-Members: The subject
assigned to me is the use of electricity in the treatment
of chronic rheumatism. First, as to our therapeutic
agent, electricity : It is often claimed that we do not
know what electricity is, implying hence that its med-
ical administration is a blind pursuit. It was Lord
Kelvin, I believe, or at least some one equally authori-
tative, who remarked: "We know more about electric-
ity than we do about shoemaker's wax." Now, shoe-
maker's wax is a very simple drug, and it follows, of
course, that we know more about the nature of electric-
ity than we do about any drug in the pharmacopoeia.
Next, I would remark that we are apt to be misled,
and adopt invidious distinctions, if in electrothera-
peutics we adhere too closely to the terms galvanism,
faradism, and franklinism. In reality these expres-
sions have no place in modern electrical science.
They are relics of a bygone time. Unfortunately, they
still serve us physicians as a peg upon which to hang
what we do know about electrotherapeutics, and there-
fore I cannot abolish them wholly from my pari of
this discussion to-night. In truth, electricity is elec-
tromotive force, pressure, voltage, or difference of
potential, whichever term one chooses to use. And
electromotive force may be developed (i) from a chem-
ical cell (galvanism); (2) in an induction coil (farad-
ism); or (3) by a static machine (franklinism) ; but it
may also be developed and modified in many other
ways not enumerable under the above nomenclature.
Again, we administer electricity, that is to say, elec-
tromotive force, to the patient's tissue, and the result
is work performed, represented in joule, namely, heat
units, upon that tissue. This "work" done is, first,
transformation of electric energy into other forms of
energy — electrolytic, when tissue is decomposed ; cata-
phoric, when fluids are moved along and diffused ; sec-
ondly, excitation of physiological function, when the
irritability of protoplasm is excited, and when nerve
and muscle tissue and gland cells exhibit their char-
acteristic irritability; or finally, though more re-
motely, but not less important, mechanical, when mus-
cles contract and set up circulatory movements in
arteries, veins, capillaries, and lymphatics. There is,
therefore, as is readily seen from the above analysis,
no question of galvanism, faradism, or franklinism, as
individual entities in electro-therapeutics, but simply
a question of the modality of electromotive force and
of the nature of the work done by each modality. In
regard to modalities, each will vary, as has been said,
according to its source, and may constitute a continu-
ous, a periodic, an alternating, or an oscillating cur-
rent, and one of high or low initial electromotive
force, and of high or low frequency, etc. It is then
to the sort of work done by varieties in the expression
of electromotive force in living tissue that we must
look for our curative results. This, so far as we have
gone, summarized briefly, is: (i) electrolytic and cata-
phoric (galvanism); (2) excitation of physiological
function (galvanism, faradism, franklinism); (3) me-
chanical, mainly circulatory (galvanism, faradism,
franklinism).
But there remains outside of galvanism, faradism,
and franklinism a modern modality of electricity to
which we must appeal to obtain our best results in the
treatment of not only chronic rheumatism, but also
many other diathetic conditions, involving many other
chronic diseases or conditions of health. This modal-
ity is the high potential, high frequency current (de-
' Paper read before the Section on Medicine of the -Academy of
Medicine, March 20, njoo.
scribed by the writer in 1881 and in 1891 — brilliantly
explored and exploited and completed in all its scien-
tific relations by Nikola Tesla in 1892, and by Elihu
Thomson; about the same time and independently
studied in various further phases by d'Arsonval, and
placed upon a firm therapeutic basis by him by posi-
tive laboratory experimentation upon men and the
lower animals, and now admitted to be the one form
of electrization which exerts by far the most profound
effect of all upon the metabolism of the human being).
This current, in none of its forms, produces any appre-
ciable electrolytic effect, but it profoundly affects
physiological function. In some of its forms it excites
the neuromuscular mechanism and produces sequent
circulatory effects ; in others it fails to excite the neuro-
muscular mechanism, while still setting up powerful
metabolic exchanges.
The current which I select for the treatment of
chronic rheumatism is the high potential, high fre-
quency current in one of its forms, and the work I ac-
complish in tissue is to affect both the local and the
general metabolism or nutritional exchanges. The
current I obtain from a powerful influence machine,
using condensers to produce the "static induced cur-
rent," or using the condenser principle to produce a
current which, until a better nomenclature is estab-
lished, is termed for temporary convenience of identi-
fication, the "electric wave current." This is, in real-
ity, the subjection of the patient's entire person to the
influence of powerful condenser waves. The patient
thus forms, as it were, one plate of a very large con-
denser (its effect may be greatly intensified by mak-
ing an independent connection to a near-by insulated
and large sheet of metal). I have published and de-
scribed both currents fully elsewhere.'
The specific work done upon tissue, in the treat-
ment of chronic rheumatism, that is to say, the meta-
bolic exchanges effected, are those amply demonstrated
by Professor d'Arsonval, of the College of France, in
his laboratory, and by Drs. G. Apostoli and Berlioz in
actual practice and observation upon their patients.
To these observations the writer has also contributed
frequently. These effects upon the patient may be
briefly outlined as follows:
1. (a) A total absence of action on sensation (d'Ar-
sonval and Tesla effects); (/') a minimum primary
effect upon sensation and a rapidly produced benumb-
ing effect (Morton currents).
2. ((f) Failure to excite muscular contractions
(d'Arsonval and Tesla effects); (/>) comparatively
painless muscular contractions and gradual benumb-
ing of the neuro-muscular mechanism (Morton cur-
rents).
3. Promotion of metabolic exchanges based upon the
experiments of d'.Arsonval. (<7) Respiratory combus-
tion; the oxygen absorbed is increased and the carbon
dioxide eliminated is greatly augmented; the elimina-
tion of H„0 is also greatly augmented ; (/') the urea is
increased in quantity, while (he proportion of uric acid
to urea becomes normal.
4. The heat production is increased.
5. Loss of weight occurs during applications, but
between applications the weight again increases.
6. Vasomotor action is influenced; the blood press-
ure at first becomes lower, and finally rises to a sta-
tionary point.
The increased combustions amount to from thirty to
fifty per cent. Professor Rienzi, of Naples, has re-
cently demonstrated that fifty per cent, more neutral
sulphur is oxidized by these currents, and that there
is a decisive effect upon the metabolism of nuclein.
' New York Medical Record, April 2, 1881. New York
Medical Record, January 24, 1691. New York Klectrical
Engineer, March 2, i?<j9. Hulletin Officie! de la Socicte Fran-
9aise d'Electrotherapie, January, 1899.
April 2 1, 1900]
MEDICAL RECORD.
675
The theurapeutic effect of this increase in the nutri-
tional activity of the patient's organism is a progres-
sive and rapid return of general health. He sleeps,
eats, works, and feels better; his normal secretory and
excretory functions return; soon in ratio with the im-
provement in his defective nutrition his local disor-
ders in turn improve, and the improvement is perma-
nently progressive Ijecause it is built upon the sure
foundation of the removal of a defective general mal-
nutrition. Such is the fundamental basis which I ha\ e
long maintained is the one most efficacious in modern
medical science for the treatment of numerous chronic
diseases, and in no disease more applicable than in
rheumatism.
These currents should be and can be also applied
locally. Moreover, in the local treatment of arthritism,
we must not neglect the spark, our ancient ally of the
static machine. The long, clean percussion spark, ad-
ministered to a rheumatic joint, sets up within the tis-
sue a commotion or perturbation of the physical tissue
particles, a sort of maladjustment of tissue particles,
followed at once by readjustment. We may speak of
it roughly as a sort of molecular gymnastics, impossi-
ble to accomplish by any other means. As a result of
this treatment, the joint assumes a new and healthful
nutritional activity.
In another form of spark treatment ("the friction
spark") an electrode is rubbed over the skin with the
clothing intervening, and produces a hot, burning feel-
ing; it excites all nerve end organs and delivers to
spinal and other centres through the afferent nerves
the peripheral impression, and thus produces, as has
been abundantly proved by laboratory experiment on
the lower animals, changes in the central nerve cells,
even to the extent of modifying their microscopical
structure (Hodge). Secondly, as to rheumatism : Clin-
ically and for purposes of treatment we may divide
rheumatism and its allied diseases into (i) muscular
rheumatism; (2) rheumatism, acute, subacute, and
chronic; (3) gout; (4) rheumatoid arthritis.
There are not wanting man)- and excellent authori-
ties, who regard all forms of rheumatism as a manifes-
tation of a disorder which has its primary seat in the
nervous system. A defect in the neurotrophic nerve
mechanism may well cause a defective metabolism
with excess of uric acid and consequent affection of
fibrous tissues by uric-acid deposit, or, indeed, in some
forms of arthritis, affect primarily the nutrition of the
joint structure. This general view, at present, is as
good as any other, and affords a working basis for the
therapeutic use of electricity.
Thirdly, as to the application of the foregoing prin-
ciples to the treatment of rheumatism : There is at the
present time a prevalent movement in favor of general
electrization of the patient, whether by the alternating
electric current bath of Clautier and Larat, by the high
potential, high frequency autoconduction and inductive
or direct methods of d'Arsonval, or by the electrostatic
and electrostatic-current methods w'hich I have long
advocated. The reason for this is obvious. Most
chronic diseases are constitutional, general, and dia-
thetic. Undoubtedly gout, and many if not all forms
of arthritis, may be so considered. Certainly no one
w ill deny that in most cases of rheumatism we have two
aims in view — one to treat the diathesis, the other to
treat the local manifestations. Of what use is it to
treat the affected joint alone and neglect the diathesis.'
It is like putting a new patch on an old garment. The
new patch will tear out.
At this point I feel that my paper is practically con-
cluded, for the application of the foregoing principles
is a simple matter, though implying, of course, some
technical skill, patience, and, may I add, enthusiasm. I
will, however, briefly apply these principles and methods
in practice, first adding a few words as to technique.
Technique.— I. The .Static Induced Current: 'I'his
current is fully described in textbooks, and is familiar
to all who use influence machines; it, therefore, needs
no description here.
2. The " Electric Wave Current " (temporary nomen-
clature): A powerful influence machine must be em-
ployed for this as well as for all currents and sparks.
The accompanying diagram illustrates the connections
necessary to produce this form of high potential current.
The electrodes may be of any pliable metal. I use
l)lock tin rolled out into fairly thin sheets, and cut off
electrodes of any suitable shape. I buy a few dozen
brass binding-posts and attach one to each electrode.
A spinal electrode is one inch by twelve inches. The
same strip serves to wrap around joints or for many
other local applications. Sometimes I encase an en-
tire arm or other member in a metallic mould. A flat
plate, say a foot square, may be laid upon the chest,
abdomen, back, or elsewhere. When a strictly local
Fiu. I.—/. Insulated platform ; /'.patient; /-.".electrode; (/, ground < .nnec-
lion ; 5. Cr". spark gap.
effect is desired, the smaller the electrode the more in-
tense the local action.
In place of block tin I often use metallic cloth (such
as military furnishing-shops sell) cut into bandages.
With such bandages I bandage a leg or arm, or, in-
deed, as is quite easily done, the whole body, thus en-
closing the patient's entire person in a complete me-
tallic suit of clothing; or a metallic cloth shirt or
jacket and trousers, resembling a suit of pajamas, may
be quickly made and worn by the patient for the pur-
pose of treatment. It will be noted that the bare me-
tallic electrodes lie against the bare skin. They re-
quire no moistening. If at first, for a moment, there
are points of prickling sparks, slight pressure will dis-
pel them. However the metallic electrode maybe ap-
plied, the patient's electric position is that of one tin-
foil coating of a Leyden jar, whose other tinfoil coating
is represented by the walls of the room and neighbor-
ing objects and the ground connection, while for dielec-
tric or insulation the air of the room corresponds to
the glass of the jar. That a condenser effect is truly
established may be noted by observing that under the
circumstances of administration described the spark
crossing the spark gap changes its quality exactly as
when ordinary Leyden jars are added.
As to the kind of rheumatism, all cases receive from
fifteen to thirty minutes of the wave current, to meet
the general and diathetic requirements. The duration
of a treatment must be decided by the effect upon the
patient, exactly as one would prescribe the duration of
a ride upon horseback or other physical work. If the
patient feels tired and exhausted, the treatment has
been too long. The next treatment can be curtailed to
a point where it ceases short of weariness. Often the
general treatment is given by applying the pliable elec-
trodes to one or more joints, thus combining the local
and the general treatment.
3. The Spark: This has been fully described, and
is well understood.
Special Applications. — i. Muscular Rheumatism:
As has long been known, the application of sparks, at
first gently and gradually increasing, will invariably.
676
MEDICAL RECORD.
[April 21, 1900
in a single treatment, relieve tlie pain and soreness of
the muscles, and permit of their free motion. The
symptoms return after twelve to twenty-four hours, and
are again treated with the same results, the duration
of relief being continuously lengthened until in a few
days to a few weeks, according as the case is acute or
chronic, a cure is effected.
2. Rheumatism — Subacute and Chronic: The treat-
ment is in general as described; then local by long
powerful sparks or by a local application of the wave
current or the static induced current. I have contin-
uously used some form of electrostatic treatment for
rheumatic affections for twenty years, both in an al-
most continuous dispensary practice and in private
practice, excluding for testing purposes every form of
medication. I hope some day to collect and publish
the cases. I can here only say in general that of
every form of treatment I have tried, I have found
none in any way comparable for relief and cure to the
electrostatic.
3. Gout: More especially will the above remarks
apply to gout. In the acute local attack I at once
wrap the joint in a metallic cloth bandage or encase
it in a pliable metallic mould, and give the wave cur-
rent, or, if one chooses, the static induced. Time and
again, a limping, suffering patient has walked off after
treatment, with a firm tread, stamping his foot on the
floor to assure himself that the pain had truly left him.
Often the relief is permanent; often again it is only
temporary, and requires a number of treatments to
make it permanent, for often the gouty attack may be
but an oedema, and again it may consist of a profuse
deposition of the sodium biurate. In gout also the
general treatment is indicated upon the most positive
basis of producing the increased metabolic e.xchanges,
fully alluded to.
4. Rheumatoid Arthritis: In regard to this disease,
I have little to add to what I have written in the Med-
ical Record of December 9, 1899, and to the general
presentation of results obtained in my hospital dis-
pensary work, described by my assistant. Dr. W. B.
Snow, in the j''i?j^G/vi'(/'«(7/f of November, 1899. This
I will say here, namely, that the progress of this dis-
ease in any stage may be completely arrested; if in
an early stage, very promptly (say a month) ; if in
later stages, with more difficulty (say in from three
months to a year).
For instance, a recent patient, with many joints pro-
foundly affected, came to me for treatment: first, in
ten to twenty days free motion of the cervical vertebrae
returned, then a free motion of the lower jaw with no
further grating sounds, then free movement of one af-
fected hip-joint — these were all recent invasions of the
disease, and merely proved that the earlier the stage is
treated the quicker are the results. In the same patient,
other joints, now affected for five years, progress tow-
ard recovery much more slowly. In this disease, the
long spark applied to each individual joint affected
seems to me to be essential in establishing a new joint
nutrition.
I may say here that my convictions as to the efficacy
of electrostatic treatments are, in the first instance,
based upon dispensary practice, in which no medicine
is added to the electricity. But in private practice I
put all my rheumatic patients upon a meat diet, because
in their usual condition it is more nutritious and more
easily digested, and in rheumatoid arthritis I have
believed that ten drops of iodide of potassium, three
times daily, with much water and after meals, and ar-
rived at by increasing from one drop upward to the
ten, is of assistance in treating the case.
In conclusion, I wish I could impress upon those
who can control hospital work for the treatment of
chronic diseases, especially arthritism, what a fruitful
field for labor they have before them in the intelligent
use of electrostatic administrations. In my opinion,
a good influence machine- — the most powerful that can
be obtained — should constitute a part of the equipment
of every hospital in the land. For while diagnosis,
prognosis, and pathology are the letter of the law, wc
may yet remember that therapeutics is the good Samar-
itan.
The Closure of Abdominal Wounds and Hernial
Openings by Means of Buried Silver-Wire Net (Heal-
ing in of Filigree Pads). — O. Witzel believes in the
efficacy of buried filigree pads for protection against
the development of abdominal ruptures and for the
avoidance of recurrences. The wire of these pads is
heavy. The diameter of the buried net should be at
least three times as large as the hernial opening. The
neighborhood of the femoral vein makes operation on
femoral hernias somewhat difficult. The wounds should
be closed by suturing the separate layers of tissue one
by one. — CentralbUitt Jiir C/iin/rgie, March 10, 1900.
Haemogastric Infection in Yellow Fever Carlos
J. Finlay revives this ancient term, and applies it to
the form of yellow fever marked by gastric or intesti-
nal hemorrhage. He suggests that this form is a
mixed infection with a bacillus of the colon group —
bacillus a of Sternberg or the colon bacillus, or not
improbably the bacillus icteroides of Sanarelli (hog-
cholera bacillus.'), the latter acquiring pathogenic
properties for man through association with the yellow-
fever germ, whatever that may prove to be. The black
vomit is therefore a sign of secondary infection. This
occurs in three varieties of cases: (i) In the super-
acute cases in which we have a simultaneous infection
with the hs'mogastric germ and the yellow-fever germ,
the former having already acquired pathogenic prop-
erties through previous association with the latter.
(2) In the more common cases in which black vomit
appears on the fourth or fifth day, we have a secondary
auto-infection with a bacterium, pre-existing in the
gastro-enteric tractor introduced there as a saprophyte,
which becomes suddenly pathogenic. (3) In cases in
which the black vomit appears suddenly in apparent
convalescence from a benign attack. Here there is
probably a reinfection with a new and malignant virus
mixed with the hamogastric germ. — Revisia de Medi-
(ina y Cirugia dc la Habana, March 10, 1900.
The Double Products of the Parasitic Fungus of
Human Cancer and of the Nectria Ditissima Para-
site of the Cancer of Trees — the Physiological and
Therapeutic Action of Nectrianin. — Bra and Mon-
gour in experimenting with these substances found
that the soluble products of the cultures of the para-
sitic fungus of human cancer have the same effect as,
only more powerful than, the triturated liquid taken
from the neoplasm. Nectrianin, though analogous in
its action, is still more powerful than either. It has
little or no effect on healthy animals, but in cancerous
animals and in the human being suffering with this
dread malady, its injection in doses of 5 c.c. several
times a week is followed in a few hours by elevation
of temperature from \ to 3^. An increased dose is
followed by chills, accelerated pulse, thirst, and head-
ache. The crisis comes at the end of several hours
with perspiration, polyuria, and profound sleep. It is
certain that treatment by nectrianin has improved the
local condition of patients — has arrested or diminished
the hemorrhages, suppressed the fetid discharges, and
has shown a tendency to cover the growth with epi-
dermis. It cannot be called a specific remedy for can-
cer, but it has certainly ameliorated the condition of
the patients. This therapeutic measure may well be
combined with surgical treatment. — Journal de Mede-
cinc dc Bordeaux, February 25, 1900.
April 2 1, 1900]
MEDICAL RECORD.
677
Medical Record:
A ]Vi-ck/j' Journal of Mc'diciiic and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
I'nU.ISHKKS
WM, WOOD & CO,. 51 Fifth Avenue.
New York, April 21, 1900.
PERNICIOUS ANEMIA AS A CHRONIC IN-
FECTIOUS DISEASE.
Blood impoverishment may obviously result from a
number of causes, and the cellular elements and the
haemoglobin may be affected variously. Far too little
is known concerning changes in the plasma. In ac-
cordance with the etiological factors a classification of
cases of anemia into primary and secondary has been
proposed, and in accordance with the relations between
the haemoglobin percentage and the number of red
blood corpuscles and with morphological variations in
the latter, together with the general clinical symptoms,
attempts at subclassification have been made, but in
neither instance with entire success. Although con-
siderable advance has been made in recent years on
the subject of haematology, a good deal is yet to be
learned with regard to diseases of the blood. Among
the most interesting and the most important of these
is that form of anaemia designated by Addison as
" idiopathic," and since known also as " essential " and
"pernicious." Although, according to Addison, the
disease arises without discoverable cause, it cannot be
concluded off-hand that it is therefore a primary or
independent disorder. Careful studies by VVilliam
Hunter pursued for a long time would seem to show
tliat in some cases at least the disorder may occur as
the result of intoxication from the gastro-intestinal
tract.
In a recent communication on this subject Hunter
(^Lancet, January 27, February 3 and 10, 1900) reviews
his previous work and makes some additional observa-
tions. He had already determined that the patho-
logical changes of pernicious anaemia are highly dis-
tinctive and indicative of excessive blood destruction
as the characteristic feature of the disease; and that
the latter is probably dependent upon the action of a
certain special blood poison derived from a specific
infectious process in the gastro-intestinal tract. Ob-
servations directed to the discovery of the nature and
the cause of the infection indicate that it is not
dependent upon general, but rather upon special con-
ditions. Attention is called to the frequency with
■which an unusually cario-necrotic condition of the
teeth is encountered in cases of pernicious anaemia as
an antecedent to the onset of the anaemia; the fre-
quency of the conditions of glossitis and stomatitis
among the first objective symptoms of the disease, and
sometimes as the first subjective and objective trouble;
the frequency of gastric symptoms (sickness, retching,
vomiting) pointing to gastric trouble; the presence
of gastric catarrh of an infective nature in pernicious
anaemia; the origin of infective gastric catarrh from
necrotic and suppurative teeth; and the conclusion
that in pernicious anamia the original infection un-
derlying the disease is in most cases to be traced to
the teeth and possibly in a few cases to exposure to
drain-poisoning.
As a result of observations made in seven cases and
of an analysis of the literature, Hunter reached the
conclusion that pernicious ancemia is a special form
of chronic blood poisoning — a toxeemia^the result of
a special infection of the digestive tract, especially of
the mouth and the stomach, and probably, although to
a less degree, of the intestine. The chief source of in-
fection is through the mouth from long-continued and
neglected cario-necrotic conditions of the teeth, and
sometimes possibly from stomatitis arising from other
causes. The usual effect of this infection is a chronic
infectious catarrh of the mouth and stomach which
may in time lead to deeper-seated changes, e.g., ulcers
of the mouth and tongue, chronic glossitis and atrophic
changes in the tongue, and chronic gastritis with
atrophy of the gastric glands. Evidences of the infec-
tivityof the micro-organisms of dental decay are over-
whelming, and in suitable cases the infective nature
of the resulting catarrh of the stomach can also be
demonstrated. The infection is chiefly streptococcal,
and probably derives its special character from being
of a mixed character. Such infection occurs the more
readily if the stomach or the intestine is already the
seat of disease from any cause. The gastric and in-
testinal irritation (sickness, retching, vomiting, loose-
ness of the bowels, and diarrhoea), so often noticed,
and which is even more common than is generally
stated (being observed in almost eighty per cent, of
cases), is the local effect of this infective catarrh,
while the excessive destruction of blood taking place
in the portal area is the result of the action of the
poisons in the blood. The fever so commonly en-
countered is not an accidental occurrence, the effect of
weakness, but is a feature of the disease, a result of
the infective process itself, and its variations corre-
spond to variations in the activity of the process. Such
variations are common, occurring from week to week,
sometimes from day to day, in the development of the
disease, even when it is pursuing a fairly progressive
course. In addition, however, the advance of the dis-
ease toward a fatal termination is often marked by one,
sometimes by two periods of marked improvement,
lasting, it may be, many months or a year or more, and
followed by relapses. This character of the disease is
regarded as the result of a relative immunity, unfortu-
nately only temporary in nature, conferred by the
disease itself^an immunity accelerated and greatly
strengthened for a time by suitable medicinal treat-
ment, notably by administration of arsenic.
The foregoing conclusions suggest certain new con-
siderations in regard to treatment, of which the chief
are minute attention to the hygiene of the mouth and
6;S
MEDICAL RECORD.
[Apr
ll 21, 1900
especially of the teeth, with the immediate removal of
every source of infection there; stricter antiseptic
treatment of the stomach and the intestines; and anti-
toxic serum treatment with the view of antagonizing
within the blood itself the poisons absorbed into it.
AURAL MANIFESTATION.S OF LEUK.^-:MIA.
Deafxess is not an uncommon symptom of leukae-
mia. It may appear early and has been attributed to
hemorrhage. Nausea and vomiting also may occur
early. Vertigo and headache are sometimes present,
and syncopal attacks may occur. An interesting case
in which symptoms of acute Meniere's disease, or
aural vertigo, were observed in a patient suffering
from spleno-medullary leukaemia was reported by
Weber at a recent meeting of the Royal Medical and
Chirurgical Society. The patient was a man thirty-
one years old, with advanced leukaemia and a liistory
of a malarial fever six years previously, who presented
great enlargement of the spleen and the liver. Death
resulted from collapse following internal hemorrhage.
During life ophthalmoscopic examination disclosed
the presence of so-called leukemic retinitis. About
six months before death acute aural symptoms set in,
namely, headache, vertigo, and vomiting. F.xamina-
tion indicated a leukaemic affection of the internal
ears, and marked deafness developed within a short
time. On post-mortem examination a portion of the
scala tympani and the perilymphatic spaces of the
semicircular canals were found filled with newdy
formed fibroid and bony tissue. The scala vestibuli,
the canal of the cochlea, and the vestibule presented
only comparatively sligiit changes. The nerve trunks
exhibited no obvious alteration.
A study of similar cases reported indicates that the
pathological appearances presented by the internal ear
after death differ in different cases, partly in accord-
ance with the length of time that has elapsed between
the onset of the acute aural symptoms and death. In
most cases the post-mortem appearances suggested
that the onset of aural symptoms (vertigo, headache,
vomiting, and deafness) marked the occurrence of
more or less extensive extravasation nf blood into the
semicircular canals and the cochlea, the process being
doubtless nearly always more or less symmetrical and
simultaneous in the two ears. In such cases, although
apparently lymphocytic infiltration and hemorrhages
may be found in various parts of the ear after death,
the labyrinthine hemorrhage is probably the essential
lesion responsible for the acute aural phenomena.
Subsequently, vascularization and organization pro-
ceed in the usual manner, the clot becoming gradually
replaced by newly formed connective tissue, connected
closely by its blood-vessels with the endosteum of the
bony labyrinth. In the course of time, should the
patient live long enough, more or less ossification oc-
curs in the newly formed tissue, and irregular processes
of bone project inward from the walls of the bony
labyrinth. At this stage of the pathological process
transverse sections of the bony semicircular canals
generally show the membranous canals surrounded by
a meshwork, or by irregular masses of newly formed
bone and fibroid tissue completely filling up the peri-
lymphatic spaces.
In addition to the cases presenting acute apoplecti-
form aural vertigo there occur also cases with aural
troubles of a less severe or less sudden nature. In
these the symptoms may be in part wholly independ-
ent of the leukarmia, but in part due to small hemor-
rhages and patches of lymphocytic (leukaemic) infiltra-
tion in various parts of the auditory apparatus.
At the same meeting Mott related a somewhat simi-
lar case. A man thirty-eight years old, who had been
in poor health for two years following an attack of
influenza, was seized six months before coming under
observation with sudden pain in the left side of the
abdomen, and a little later with pain in the head and
deafness, with loss of power of maintaining equili-
brium. The deafness came on suddenly, first in the
left and then in the right ear. The patient was a lit-
tle cyanosed, the temperature 97" V., the abdomen
distended, the li\er, spleen, and lymphatic glands
enlarged. The ha;moglobin estimation was fifty-four
per cent., and the leucocytes were enormously in-
creased, almost equalling the red corpuscles in number.
The muscular powers of the patient were good, and
there was no loss of co-ordination in the arm, but he
could not balance himself in walking, and could not
stand at all with his eyes shut. The knee jerks were
absent on both sides. Vision was imperfect; accom-
modation was good, but the reflex action of the right
pupil was sluggish. 'i'he fundi showed slight
changes. Hearing improved considerably. Taste
and smell were normal. After seven days the man
was found to be stone-deaf in both ears on waking in
the morning, and three days later he died in coma.
Upon post-mortem examination the liver was found to
weigh 5.5 kgm. and the spleen 1.8 kgm. The brain
was congested and the seat of hemorrhages. The
petrous bone was soft and friable from rarefaction.
The spinal cord and nerves exhibited no alteration.
There was hemorrhage into the posterior spinal roots
and into the cochlea. The hemorrhage into the semi-
circular canal accounted for the loss of equilibrium.
This and the deafness were accounted for by hemor-
rhage into the cochlea and labyrinth.
TREATMENT OF ACUTE LOBAR PNEU-
MO.MA.
It is now generally conceded that micro-organisms
play an important part in the causation and progress
of pneumonia, and consecpiently th^ disease must be
given a place among the infectious maladies. The in-
vestigations of Klebs, Friedliinder, F'rankel, and Stern-
berg have quite definitely settled this point. There-
fore it would seem that the time has come for new
methods of treatment to be put into practice. It used
to be the invariable custom to bleed freely and to ad-
minister heroic doses of antimony to all sufferers from
this complaint. This was the routine treatment in
every principal medical school of the world. Hughes
iiennett was the first English-speaking ph\sician to
April 2 1,1 900]
MEDICAL RECORD.
679
point out the defects of this treatment, and lie pub-
lished statistics some years ago showing that medical
interference did very little toward the cure of the com-
plaint. Balfour, of Edinburgh, at the time when tiiat
school was a veritable stronghold of the antiphlogistic
methods, went to Vienna and was astonished to find
that Skoda gave those under his care who were attacked
by pneumonia nothing but hay tea, and moreover ob-
tained better results than did the Edinburgh physi-
cians. Ultimately venesection and the giving of large
doses of tartar emetic were almost entirely abolished,
although many eminent authorities believe that in
certain cases both blood-letting and antimony are of
decided benefit. Sir Hermann Weber says: " Tiie
prejudice against the use of small doses of antimony
and against bleeding in moderation in suitable cases
is entirely unfounded. Sir Samuel VVilks and Sir
William Gairdner are of the same opinion. Dr. Ed-
ward F. Wells, at the last meeting of the American
Medical Association, spoke of the efficacy of venesec-
tion in plethoric persons, and considered that in these
cases the procedure had no satisfactory substitute.
He also recommended a simultaneous subcutaneous
injection in the chest of decinornial saline solution
or the use of an enema of the salt to replace the quan-
tity of blood withdrawn. Dr. Hobart A. Hare at the
same meeting said that he believed that the abortive
treatment by venesection, aconite, and veratrum viride
was applicable only in a few vigorous cases. Sir
William Broadbent opines {Frac/i/iomr, March) that
" in a large proportion of cases it cannot be said that
the regular administration of medicine of any kind
is necessary, but it is usually a comfort to the patient
and friends to have the feeling that something is
being done."
In regard to the germ theory of pneumonia, and re-
ferring to the investigations of scientists to establish
its correctness. Dr. Pye-Smith, in " Allbutt's System of
Medicine," says; "While recognizing the interest and
importance of these laborious researches, we must
observe that even the diplococcus of Talamon and
Frankel does not fulfil Koch's three tests of a patho-
genic organism; as they are fulfilled, for instance, in
anthrax, relapsing fever, and tuberculosis. It is not
invariably present in the tissue of pneumonic lung;
it does occur in other situations in health when in-
jected as a pure cultivation; it does not always repro-
duce itself and cause a fresh case of hepatization of
the lungs. Nevertheless the frequency of its occur-
rence and the fact that it often reproduces the disease
by inoculation make it probable that it plays an im-
portant part in the natural history of pneumonia."
Dr. Andrew H. Smith, in his exceptionally able mono-
graph on the subject in the "Twentieth Century Prac-
tice of Medicine," vol. xvi., believes that pneumonia
is not an infiammation of the lung, for the reason that
in his opinion it does not affect the nutrition of the
organ, but is a process of germ culture in which the
pneumococcus grows in a culture medium supplied by
the functional capillaries of the lung. The majority
of writers do not agree with Dr. Smith in this view.
Dr. James K. Crook, in Medicine, April, thus ex-
presses his opinion on the matter: "From the au-
thor's study on the subject, he would fully agree with
Dr. Smith that the process is one of germ culture, but
it may also be as properly described as an infiamma-
tion, as are the conditions set up by the same microbe
elsewhere, viz., in the pericardium, the pleura, and the
joints. It is, of course, a special form of inflammation
produced only by special forms of micro-organism and
not analogous to inflammations elsewhere, because the
lung itself has no analogue elsewhere in the body."
Time, however, alone can prove whether Dr. Smith is
right or wrong.
In the mean time the question before us is whether
the knowledge that acute lobar pneumonia is an in-
fectious disease has afforded any firm grounds for the
hope that it may be possible to abort the disease.
Again on this point there is a great divergence of
opinion. Most authorities hold that such an expec-
tation is not justified by the extent of our present
knowledge. Dr. Smith, with many others, thinks that
this may be done, and argues that therapeutic efforts
should be directed to the arrest or inhibition of the
germ culture from which the diplococcus obtains its
nourishment. He claims that inasmuch as this cul-
ture medium is derived from the blood, any substance
added to the latter will also be found in the former,
and if that substance is inimical to the growth of tlie
coccus, it will in so far act in the direction sought.
The fact that the pneumococcus is the most vulner-
able of the germs is in favor of this argument. Creo-
sote, calomel, quinine, and salicylate of sodium are
the drugs possessed of germicidal properties best cal-
culated to produce the desired effect. Leaving out of
the question the three former drugs, we will briefly
consider the use of salicylate of sodium in the treat-
ment of pneumonia, as demonstrated by the experience
of some who have witnessed its effects. Sir Hermann
^\'eber, in The Practitioner, February, writes as fol-
lows: " Salicylate of soda was tried in quantities of
gr, XX. to xl. per day at the German Hospital, London.
The effect was quite satisfactory on some persons in
diminishing the pyrexia, the pleuritic pain, the thirst,
the dry heat of the skin, and perhaps also slightly the
duration of the acute stage, but scarcely sufficiently
marked to be quite sure. In other persons the exces-
sive perspiration produced by the remedy, and the
noise in the ears, rendered this treatment disagree-
able; the most objectionable effect, however, on some
persons was excessive headache, and on some others
the appearance of blood and albumin and casts in the
urine, so as to oblige us to stop the remedy. Although
it cannot be denied that in some cases the salicylate
acted beneficially, it produced, as just stated, in oth-
ers unpleasant and in some even injurious effects."
Pye-Smith refers to the use of the salicylates in these
words: " Salicyl compounds are only indicated when
pneumonia occurs as a complication of rheumatism."
Dr. de Becker recommends salicylic acid for acute
pneumonia (Annales ct Bulletin de la Scciete de Mede-
cineirAmers, March and November, 1898), and believes
that if administered at an early stage of the disease
it is a sure preventive. Eleven out of twelve patients
treated thus by him were quickly cured. He has also
noted that the expectoration after the use of salicylic
68o
MEDICAL RECORD.
[April 2 I, 1900
acid becomes liquefied, and is of the opinion that in
the giving of the drug the expectoration should be the
guiding symptom. Debility and heart disease should
contraindicate this treatment. The most favorable
reports of the action of salicylate of sodium come, one
from Austria and the other from this country. The
first stated that a series of seventy-two cases of pneu-
monia occurring in Austria had been treated with
large doses of sodium salicylate, gr. cxx. daily. All
of these patients had recovered, and in not one had
the disease terminated by crisis. The second report
was published in the Medical Record, April 22,
1899, by Dr. Sebring, of Kingston, N. Y., and deals
■with seventy-five cases of pneumonia treated with gr.
•cxx. daily of the same drug, with the result that but
■one patient died. Dr. Sebring also says that out of
one hundred and twenty-five cases of pneumonia
treated with salicylate of sodium in his neighborhood
only one proved fatal. Of course these results are
magnificent, and if the drug should be found as effec-
tive after a more extended trial the problem of how
best to treat acute lobar pneumonia will be solved
once and for all. Until its use has been more wide-
spread than is at present the case it will be as well to
express no pronounced opinion as to its curative prop-
erties.
Investigators have not as yet succeeded in prepar-
ing a reliable antitoxin for pneumonia, although de
Renzi has used the serum prepared according to
Pane's instructions since 1896 in grave cases of pneu-
monia, and states that his former mortality in such
cases of twenty-four per cent, fell under the treatment
to nine per cent. The data at present available do
not warrant us in arriving at a definite conclusion as
to the value of this treatment. A great step in ad-
vance has been made in establishing the microbic
origin of lobar pneumonia, and it behooves us pa-
tiently to await the discovery of the most effective
means of meeting the attacks of those pathogenic or-
ganisms responsible for the condition. There has
been up to the present time no sufficiently strong
reasons brought forward for altering the existing ex-
pectant methods of treatment.
THE CRAIG COLONY FOR EPILEPTICS.
Dr. Frederick Peterson, of this city, some years ago
thus described what in his opinion is the best manner of
treating the epileptic : " There is but one kind of insti-
tution which can meet the case of those who suffer from
this disease. No asylum, no large hospital, no single
vast building in a great city is appropriate for the pur-
pose. It must" be an establishment combining many
unusual features. It must have schools and teachers
for the young epileptic. It must have offices, shops of
all kinds, stores, dairy, farm, gardens, granaries; for,
as they grow up, these patients should acquire trades
or professions. It must have a group of small hos-
pital and asylum buildings, where such as are sick or
mentally infirm may be cared for. It must have skilled
physicians. It must have a church, amusement hall,
gymnasium, and bathing establishment. It must have
finally a pathological laboratory presided over by the
keenest pathologist obtainable, so that in course of
time a cause and cure may be discovered for this terri-
ble disease. Such a place would not be a hospital in
the ordinary sense of the term. It would be a village
in itself, a colony for epileptics."
Mainly through the exertions of Dr. Peterson him-
self his ideal institution became realized, and Craig
Colony, founded and managed upon the lines indicated
in his sketch, was established. The results so far of
treating epileptics by these methods have been emi-
nently encouraging, and the prevailing belief that
detrimental effects would ensue from the close asso-
ciation of patients has been proved baseless. More-
over, viewed from a practical and economic stand-
point, ample justification has already been afforded
for the establishment of the colony. Dr. Spratling,
the chief executive officer, says there is every reason
to believe that the value of manufactured and home
products will ultimately reach seventy-five per cent, of
the entire cost of maintenance. The sixth annual re-
port of the board of managers states that " there have
been received into the colony since its opening, Feb-
ruary 1 , 1896, five hundred and four epileptics, of which
three hundred and seventy-eight remain. The build-
ings nearly completed and those in course of construc-
tion will increase the capacity of the colony to a
total of seven hundred and twenty beds. . . . There
will still be urgent need fur dormitories, when the
buildings now under construction are completed, par-
ticularly for an infirmary for each sex." In the report
of the medical superintendent mention is made of the
great urgency of securing money apart from mainten-
ance for the purpose of scientific research, ^nd the
same report, referring to admissions and discharges,
states that at the time of presenting the report a year'
ago there were three hundred and twenty-two colonists
under care; during the past twelve months this num-
ber was increased by admitting ninety-five new cases;
while during the same period thirty-nine were dis-
charged, either as recovered, unimproved, died, or
transferred to some other institution, leaving three
hundred and seventy-eight — a total gain of fifty-six
during the year, a number limited entirely by lack of
room for a larger number. With regard to treatment
and results the report says: "The good results to the
colonists of the various forms of treatment have been
more general and far more apparent during the past
year than any year in its history. Collectively they
have derived vast benefit, while many of them have
become important factors in the colony's daily life."
The results in treatment are summed up as follows:
"First, in cures effected; second, in the very marked
and general reduction in the number and violence of
seizures; third, in the great physical improvement,
often amounting to a complete physical regeneration,
in large numbers of cases; fourth, in the steady growth
and development of the idea of colony life; fifth, in
the marked increase in the ability and number of colo-
nists to become fixed and useful factors in the colony's
everyday life."
Craig Colony and kindred institutions have brought
into evidence the fact that the rational manner to treat
April 2 1, 1900]
MEDICAL RECORD.
681
epilepsy is not as heretofore by confining its victims
in asylums and by drenching them with drugs, but by
giving them the opportunity of regular exercise and
open-air work. Industrial and physical training per-
formed under healthful conditions and intelligently
directed will undoubtedly result in improvement to the
epileptic.
THE NEGRO QUESTION.
The abolition of slavery, instead of exercising a favor-
able influence upon the negro morally and physically,
would rather appear to have had a contrary effect. The
physical degeneracy of the Afro-American race yearly
becomes more and more evident, while it is to be feared
that the moral condition of the colored man in this
country is at a lamentably low ebb. The cause of
this retrogression is variously explained, the most pop-
ular theory being that it is owing to the sudden al-
teration in the mode of life which took place after the
Civil War. It is argued, and with much show of rea-
son, that the negro ought not as yet to be regarded as
altogether responsible for his actions; that, when free-
dom came, he resembled a child who had not learned
to take care of himself, and consequently plunged un-
thinkingly into vice and dissipation without counting
the cost. Other students of the negro problem take a
much sterner view of the case, and attribute the black
man's sins to inbred viciousness. Of this number is
Dr. Paul B. Barringer, of the University of Virginia,
who gave an address on the subject before the Tri-
State Association of Virginia and the Carolinas in
Charleston, S. C, on February 20th. After referring
to the cannibalistic propensities of the West Coast
African negro of the present day, Dr. Barringer speaks
of the American negro as follows:
"Thirty-five years have passed since the negro
changed from the condition of a slave to that of a freed-
man. In every part of the South, it is the opinion of
every man of unbiassed mind that the second genera-
tion is infinitely worse than the first. So patent is
this that I would be tempted to doubt the sanity of
any man, having fair opportunities to judge, who de-
clared the reverse to be true. The question for us to-
day, then, and the question of questions for the South
is, ' What is the cause of the change, and what can be
done to remedy the evil? ' The first thing is to seek
out the truth, however unpalatable it may be, and in
my opinion it is very simple: The young negro of the
South, except where descended from parents of excep-
tional character and worth, is reverting through hered-
itary forces to savagery. . . . Everything points to
the fact that the phylogeny of the negro is carrying
him back to barbarism ; that the temporary elevation
produced by the discipline of slavery is not being
maintained by the efforts we have made at common-
school education in the hands of his own race, and
that we must at once, if we would save the negro and
the South, try something else. I would finally urge
that we try henceforth an education of trade or indus-
trial type, given at the hands of well-chosen white
teachers, who will teach him to respect, to obey, and
to work. Under this, if experience be not fallacious,
he will improve in morality, in character, and in capac
ity as a taxpayer."
This is the judgment of an educated Southerner in
regard to the negro question, looked at from the moral
standpoint, and as such is entitled to the close atten-
tion of thinking men. The Medical Record has
many times called attention to the physical deteriora-
tion of the colored race on this continent, clearly owing
to the insanitary conditions in which its members live.
The matter is of the most serious importance, and
yearly assumes a more ominous aspect. It is certain
that steps must be taken to relieve the present situa-
tion.
SILVER WIRE AS SUTURE MATERIAL.
Silver wire is a material which has been used for a
long time more or less extensively for suturing, and
the qualities which have recommended it especially
are strength, ease of sterilization, and permanence.
These are obvious qualities, but only the second does
not include some disadvantage. The disadvantage of
great strength, perhaps small, consists in the fact that
it is very easy to draw sutures of such material too
tight, and thus cause tension which will give rise to
a certain amount of tissue necrosis, no matter what
the tissue. Furthermore, great strength in suture ma-
terial is apt to make us depend too much on force to
maintain apposition of surfaces, and to cause us to
forget that the function of a suture is to keep surfaces
in contact until cicatrization is well advanced or com-
plete. Force does not assist this process. Perma-
nence in a suture material does not appear entirely
an advantage, but rather an unfortunate quality in a
substance otherwise desirable. After a wound is com-
pletely healed, a suture remaining in the tissues is no
longer a suture, it is a foreign body. In one of our
prominent institutions, the Johns Hopkins Hospital,
the use of silver wire is very general, and in a recent
publication (1899), Johns Hopkins Hospital Reports
Nos. 5 to 9, a series of operations for the radical cure
of hernia, chiefly inguinal, is presented. The suture
material for the superficial parts of the wound as well
as the deep aponeurotic structures was, in this series
of nearly three hundred cases, practically always sil-
ver wire, and the primary results in the wounds were
almost invariably good. It has also been a frequent
practice in that hospital to cover the completely closed
wound with silver foil, copper foil having been tried
and found irritating. When either of these metals was
used in this way, it was found that its contact with
the skin and the wound exudate produced actual anti-
septic effects from the small amounts of metallic salts
thus generated, and we are able from this experience
to infer that silver wire used subcutaneously behaves
in the same way. This quality, while useful in the
foil covering the skin wound, is of no advantage in a
suture entirely buried, for there is no difficulty in
sterilizing silver wire, and there are no colonies of
bacteria under the skin, as there are in it, to requiru
post-operative attack with an antiseptic. We cannot
think that silver wire is the suture par excellence in
operations for hernia on account of its permanence,
682
MEDICAL RECORD.
[April
1900
because the final result after these operatives does
not depend spon the firmness with which the aponeu-
rotic and muscular structures are held together, but
upon the completeness and promptness of the cicatri-
zation, and the accuracj' of apposition. Consequently
non-absorbability is not an advantage and may be a
distinct disadvantage. It is well known that non-ab-
sorbable foreign bodies may remain harmlessly under
the skin for long periods, and then for some undiscov-
erable reason begin to cause trouble. Many of these
Johns Hopkins cases have apparently carried their
silver sutures for many months without annoyance,
and may continue to do so for many more, but this
does not alter the fact that future trouble is possible
for them, even if improbable, something which is
avoided if an absorbable suture is used. The diffi-
culty of securing and sterilizing satisfactory absorb-
able sutures is familiar enough, but cannot be logi-
cally urged against the suitability of the suture when
we have it properly prepared. We know that it is
possible to get a sterile absorbable suture if we are
careful enough, and we know also that such a suture
is more desirable than one which remains in the tis-
sues. We may, then, fairly conclude that a complete
case is not made out for the silver suture, while the
properly prepared absorbable suture seems unassail-
able.
STATE HOSPITAL FOR CONSUMPTIVES.
Thk universally recognized methods of treating pul-
monary tuberculosis nowadays are by the common-sense
ones of fresh air and diet. This mode of treatment
is, however, by no means new, but was known and
practised ages ago. The beneficial effects of an open-
air life as a remedy in consumption is perhaps as old
as civilization itself. Hippocrates' views on the mat-
ter would probably differ but little from those held by
the foremost exponents of the modern sanitarium sys-
tem. The Romans, too, had pronounced opinions as
to the efficacy of fresh air in the treatment of phthisis.
To the Germans belong the credit of introducing the
isolation methods now in vogue everywhere, combining
exposure to the open air with enforced diet. Dr. Hreh-
mer, whose establishment at Goerbersdorf was founded
in 1844, was undoubtedly the pioneer in this move-
ment. Hisexample has been largely followed in Ger-
many, America, and elsewhere.
But these institutions are one and all for the benefit
of persons in easy circumstancs. Up to quite recent
times, says Dr. Goghill, writing in The Kineteenth
Ccntitry Magazine, February, 1899, "no attempt has
been made on the European continent, and, it may be
added, nor in this country, to provide like resorts for
the necessitous. In Great Britain, on the other hand,
the position is reversed. No private sanatoria have
existed until quite lately, but consumptive hospitals
for the poor and needy have existed for long periods,
and to them is probably due the remarkable decrease
in phthisis that has taken place in England since a
date corresponding to their establishment. Among the
principal consumptive hospitals in Great Britain are
Prompton, founded in 1841,321 beds; Victoria Park
in 1848, 164 beds; North London in i860, 78 beds;
The City Road Hospital in 1863, 75 beds; and the
Royal National Hospital in V^entnor in 1869, 138 beds.''
It must, nevertheless, be understood that, although
these establishments are solely for the benefit of the
indigent, they are not supported by the state, but de-
pend for their maintenance on public and private char-
ity. If, therefore, Assemblyman Henry's bill to pro-
vide the City of New York with a hospital for the
treatment of pulmonary tuberculosis, at the expense of
the State, becomes a law, as it doubtless will, a new
departure with regard to this disease will have been
taken. The desirability, and, indeed, the need, of
special hospitals for consumptives is obvious, for, leav-
ing out of the question the danger such patients are in
general hospitals as a source of infection, the fact
should be considered that, while they themselves will
benefit to an immeasurable degree by the change of
treatment, they will also no longer be a burden upon
institutions which can ill bear the extra pecuniary
stress. The projected undertaking is in the nature of
an experiment, the success of which will hinge mainly
on the manner of its conduct. It is consequently in-
cumbent upon those intrusted with the control of this
institution that they proceed warily and discreetly, that
they insist upon the medical staff being selected for
their professional ability alone, irrespective of political
considerations. Provided that this course is pursued,
.ind if the good results anticipated from the system are
justified by experience, it will be safe to predict that
money expended in so worthy a cause will be readily
forthcoming, and similar establishments will be erected
in sufficient numbers to meet the requirements of the
situation. The tentative efTort of New York City to
deal with its dependent consumptives will be watched
with interest in all parts of the country.
A BOARD OF EXAMINERS IN MIDWIFERY.
,\ BILL has passed both houses of the legislature of
this State, authorizing the creation of a Board of Ex-
aminers in Midwifery in this city, composed of the as-
sistant sanitary superintendents of the board of health,
-■^s representing the medical profession of the State,
we have protested against the enactment of this meas-
ure, for the reasons, first, that the practice of mid-
wifery, being a part of the practice of medicine, should
be restricted to registered practitioners of medicine;
the legalizing of this practice by others will tend to
perpetuate a system which we hope in time to succeed
in having abolished; and second, if by any train of
circumstances it should be considered advisable to
legalize this practice by other than registered physi-
cians, we believe any act of legislature with this object
in view should apply to the whole State, and not be
restricted to one city or county. We believe, if mid-
wives are to be examined and licensed, the work of
examining them should be placed in the hands of the
State board of medical examiners.
Examine for fisii bones in the throat with the finger,
since they are not always seen in the throat mirror.
April 2 1, 1900J
MEPICAL RECORD.
683
l^cius of the m^cch.
For a Free Dispensary. — By the will of the late
Jacob Justice, who died recently in Philadelphia, his
residual estate, amounting to about $60,000, is de-
vised for the establishment of a non-sectarian dispen-
sary for the treatment of the poor and the distressed,
at Mt. Pleasant, Westmoreland County, Pa.
Philadelphia Pediatric Society — At a stated meet-
ing held April loth, Dr. Alfred Hand, Jr., read a pa-
per on " The Pathology of Congenital Heart Disease "' ;
Dr. J. Button Steele one on " The Pathology of Ac-
quired Heart Disease in Children"; Dr. F. A. Pack-
ard one on "The Symptomatology of Heart Disease
in Children"; Dr. J. P. Crozer Griffith one on "The
Diagnosis of Heart Disease in Children"; Dr. A. V.
Meigs one on "The Prognosis of Heart Disease in
Children "; and Dr. H. A. Hare one on "The Treat-
ment of Heart Disease in Children."
Philadelphia County Medical Society. — At a stated
meeting held April nth. Dr. A. A. Eshner read for
Dr. David Riesman the report of a case of elephantia-
sis of the leg, and e.xhibited the patient. The disor-
der was unilateral, involving more especially the leg,
but also to a less degree the thigh. No known etio-
logical factor could be elicited, nor did examination
of the blood disclose the presence of filaria sanguinis
hominis. Dr. Herman D. Allyn read a communica-
tion entitled "The Symptomatology and Diagnosis of
Kmpj'ema, with a Report of Illustrative Cases," Dr.
Joseph MacFarland one entitled "The Etiology and
Pathology of Empyema," and Dr. Edward Martin one
on " The Surgical Treatment of Empyema."
College of Physicians of Philadelphia — At a
stated meeting of the section on genera! medicine held
April 9th, Dr. F. A. Packard presented intestinal
casts from cases of mucous enteritis, and concretions
of fat from a case of possible pancreatic disease. Dr.
William G. Spiller presented a case of progressive
bulbar paralysis and one of progressive spinal muscu-
lar atrophy, pointing out that in both the lesions in-
volved the gray matter, in the one instance of the
medulla oblongata and in the other of the anterior
horns of the spinal cord. Dr. Spiller exhibited a
specimen of spinal cord presenting a hard, flattened
neoplasm in the cervical region, and reported a case
of compression of the upper part of the cervical cord
with unusual symptoms. Dr. C. W. Burr reported a
case of Pott's disease presenting varying types of an-
aesthesia. Dr. M. Howard Fussell reported a case of
niyxoedema that had not been benefited by thyroid
treatment.
Pathological Society of Philadelphia. — At a stated
meeting held April 12th, Drs. S. Solis-Cohen and
T. S. Kirkbride, Jr., presented communications en-
titled "Tumor of the Mediastinum and Bronchial
Glands and of the Right Lung," " Metastasis in the
Liver," "Rupture with Fatal Hemorrhage." Dur-
ing life the growth was thought to be a carcinoma,
but on histological examination it was found to be
a sarcoma. The liver weighed fifteen pounds, and
death was due to spontaneous rupture of this organ.
Dr. H. F. Harris read a paper entitled "Remarks
upon the Pathological Alterations in Bubonic Plague,"
and he exhibited microscopic preparations of the
diseased tissues. Dr. F. P. Henry exhibited a hyda-
tid cyst of the liver. Dr. J. Walsh made a re-
port of a pathogenic sarcina. Drs. J. M. Anders
and Joseph McFarland presented a specimen of carci-
noma of the stomach with perforation. Dr. Joseph
McFarland presented a specimen of carcinoma of the
stomach. Dr. S. Solis-Cohen presented a specimen of
valvular disease with hypertrophy of the heart and
healed hemorrhagic .infarct in the spleen.
The American Dermatological Association will
hold its twenty-fourth annual meeting at the Hotel
Gordon, Washington, on May ist-3d, in connection
with the fifth triennial session of the Congress of
American Physicians and Surgeons. The president is
Dr. Henry Weightman Stelwagon, of Philadelphia.
The Pennsylvania Society for the Prevention of
Tuberculosis, at its eighth annual meeting held at
Philadelphia on April i ith, elected the following offi-
cers: President, Dr. Guy Hinsdale; Vice-Presidents,
Drs. H. S. Anders, J. Solis-Cohen, and S. A. Knopf,
and Messrs. William Moss, Moses Veale, and Walcott
Williams, Miss E. W. Redfield, and Mrs. Helen C.
Jenks.
State Hospital for Consumptives. — Governor
Roosevelt has appointed the following trustees of
the New York State Hospital for the Treatment of
Incipient Pulmonary Tuoerculosis, which is to be
established in the Adirondacks: Howard Townsend,
of Manhattan, for the term of five years; Dr. John H.
Pryor, of Buffalo, for four years; Dr. Willis G. Mac-
donald, of Albany, for three years; Walter Jennings,
of Manhattan, for two years; Frank E. Kendall, of
Saranac Lake, for one year. A preliminary appropri-
ation of $50,000 has been made to establish the hospi-
tal, which will cost in the neighborhood of $200,000.
The hospital is to be established in the Adirondacks,
upon a site to be approved by the State board of
health and the State forest preserve board. The
trustees are to purchase a thousand acres as a site
for the hospital, and the State forest and preserve
board is to set apart a like amount of State lands for
such purposes.
The Tenement-House Commission, recently ap-
pointed by Governor Roosevelt, is constituted as fol-
lows: Messrs. Raymond T. Almirall, of Brooklyn;
Hugh Bonner, of Manhattan ; Paul D. Cravath, of
Manhattan ; Robert W. De Forest, of Manhattan ;
William A. Douglas, of Buffalo; Otto M. Eidlitz, of
Manhattan; F.Norton Goddard, of Manhattan; Wil-
liam Lansing, of Buffalo; William J. O'Brien, of
Manhattan; James B. Reynolds, of Manhattan; I. N.
Phelps Stokes, of Manhattan ; Myles Tierney, of Man-
hattan ; Alfred T. White, of Brooklyn ; and Dr. George
B. Fowler, of Manhattan. The duty of the commis-
sion is to make careful examination into the tenement
houses in New York and Buffalo; their condition as
684
MEDICAL RECORD.
[April 2 1, 1900
to the construction, healthfulness, safety, rentals,
and the effect of tenement-house life on the health,
education, savings, and morals of those who live in
tenement houses, and all other phases of the so-called
tenement-house question in these cities that can affect
the public welfare. An appropriation of $10,000 is
made for the expenses of the commission, which may
subpoena and compel the attendance of witnesses, em-
ploy counsel, assistants, and experts, and make such
recommendations to the next legislature as it deems
wise, to enable the best and highest possible condi-
tion for tenement-house life in New York and Buffalo
to be attained.
Incorporation of the New York State Medical
Association. — The governor has signed Dr. Henry's
bill incorporating the New York State Medical Asso-
ciation for the purpose of the cultivation and advance-
ment of the science of medicine, the promotion of
public health, and the establishment of a death benefit
fund for the dependents of its members.
The Marine-Hospital Service. — A board of officers
will be convened at the Service Building, 378 Wash-
ington Street, New York City, Wednesday, May 23,
1900, for the purpose of examining candidates for
admission to the grade of assistant surgeon in the
United States Marine-Hospital service. Candidates
must be between twenty-one and thirty years of age,
graduates of a reputable medical college, and must
furnish testimonials from responsible persons as to
character. The following is the usual order of the
examination: (1) Physical; (2) written; (3) oral;
(4) clinical. In addition to the physical examina-
tion candidates are required to certify that they be-
lieve themselves free from any ailment which would
disqualify for service in any climate. The examina-
tions are chiefly in writing, and begin with a short
autobiography of the candidate. The remainder of
the written exercise consists in examination on the
various branches of medicine, surgery, and hygiene.
The oral examination includes sub jects of preliminary
education, history, literature, and natural sciences.
The clinical examination is conducted at a hospital,
and when practicable candidates are required to per-
form surgical operations on a cadaver. Successful
candidates will be numbered according to their at-
tainments on examination, and will be commissioned
in the same order as vacancies occur. Upon appoint-
ment the young officers are, as a rule, first assigned to
duty at one of the large marine hospitals, as at Bos-
ton, New York, New Orleans, Chicago, or San Fran-
cisco. After five years' service, assistant surgeons are
entitled to examinations for promotion to the grade of
passed assistant surgeon. Promotion to the grade
of surgeon is made according to seniority, and after
due examination as vacancies occur in that grade.
Assistant surgeons receive $1,600, passed assistant
surgeons $2,000, and surgeons $2,500 a year. When
quarters are not provided, commutation at the rate of
$30, $40, or $50 a month, according to grade, is al-
lowed. All grades above that of assistant surgeon
receive longevity pay, ten per centum in addition to
the regular salary for every five years' service up to
forty per centum after twenty years' service. The
tenure of office is permanent. Officers travelling un-
der orders are allowed actual expenses. For further
information, or for invitation to appear before the
board of examiners, address Supervising Surgeon-
General, United States Marine-Hospital service,
Washington, D. C.
The Texas State Medical Association. — The thirty-
second annual meeting of this society will be held at
Waco on April 24th, 25th, 26th, and 27th, under the
presidency of Dr. A. B. Gardner, of Bellville.
A New Hospital, constructed and equipped on
modern lines, was dedicated at Phcenixville, Pa., on
April 14th. The building is one hundred and two
feet deep by one hundred and fifteen feet long, five
stories high, contains sixty-seven rooms, and cost
about $50,000.
The Drug Clerks' Bill.— Governor Roosevelt has
signed the bill providing for shorter hours for the
drug clerks in the city of New York, and for the in-
spection of drug stores by the local board of health.
Under its provisions drug clerks are prohibited from
sleeping in the stores or in apartments connecting
with the stores.
The International Medical Congress. — The three
general sessions of the Paris Congress will be held
in the large amphitheatre of the Sorbonne. As this
hall accommodates only three thousand persons it is
feared that many of the members will be excluded
from the opening session. At the two subsequent ses-
sions the difficulty will probably be to secure an
attendance large enough to compliment the orators.
Mothers and Babies' Hospital, New York. — Mrs.
Howard Gould has equipped an operating-theatre for
this hospital which will seat an audience of one hun-
dred and twenty students. This will be a very desir-
able addition to the teaching facilities of this grow-
ing institution, as obstetric clinics are now being held
there in connection with four of the medical colleges
of this city.
The Cartwright Lectures — The first of the Cart-
wright Lectures of the Alumni Association of the
College of Physicians and Surgeons, Columbia Uni-
versity, was delivered at the Academy of Medicine on
April i8th. The subsequent lectures of the course
will be on April 24th and 26th. The subject is "The
Discovery of the Nerves and of their Function," and
the lecturer is Prof. John G. Curtis, M.D., of Colum-
bia University.
A Relief Ship for India. — A joint resolution of
Congress adopted in 1897 authorized the Secretary
of the Navy to charter two ships, one on the Atlantic
and one on the Pacific coast, to carry relief supplies
to India. One ship was sent from San Francisco, but
it was decided to sell the supplies intended to go from
New York and transmit the money obtained by that
means. Recently application was made to the gov-
ernment to charter a ship from New York to take a
large quantity of supplies awaiting shipment from this
April 2 1,1 900]
MEDICAL RECORD.
68 =
port. The treasury officials have decided that the
authorization of 1897 has not lapsed, the famine still
existing, so an order has been issued to charter the
vessel.
Dr. Francis M. Banta, who was dismissed from
his position as surgeon in the fire department in Sep-
tember, 1898, has been reinstated by the supreme
court. The dismissal was made by the fire commis-
sioner without cause or charges, after Dr. Banta had
served more than three years.
The Fatality of Influenza still continues, forty-six
deaths from this cause being reported to the Philadel-
phia bureau of health for the week ending April 14th.
Diseases of the respiratory tract were responsible for
a large proportion of the whole number of deaths.
Thus, 134 were due to pneumonia, 9 to congestion of
the lungs, 53 to pulmonary tuberculosis, 15 to bron-
chitis. In addition 47 deaths were due to disease of
the heart, 28 to convulsions, 36 to nephritis, 24 to
apoplexy, 22 to measles, 21 to old age.
The Pretoria Red Cross. — The chairman of the
American committee to aid Red Cross work within
the Boer lines in South Africa has received a letter
from a member of the committee, who is in the Trans-
vaal, in which it is stated that Pretoria Red Cross is
in great need of medicines, instruments, wagons, etc.,
and the committee is asked to send money for supply-
ing those necessities directly to the Red Cross authori-
ties in Pretoria. The treasurer of the committee is
Mr. T. G. Bergen, 55 Liberty Street, New York.
The Spitting Nuisance An effort is being made
by the sanitary superintendent of the board of health
in Brooklyn to enforce the law against spitting on the
floor of elevated and trolley cars in that borough.
There are notices in the cars there, as there are here,
but hitherto the law has been ignored there, as it is
still in Manhattan. The penalty for spitting on the
floor of a public conveyance is a fine of from $1 to
$250. In Paris a law has recently been passed for-
bidding spitting in public places, and our London
contemporaries are lamenting that no such rule exists
there. It is, however, better to have no law at all
than to have it so persistently defied as it is in New
York.
The New York State Board of Charities, at its
annual meeting on April 12th, re-elected Mr. William
Rhinelander Stewart, of New York City, as its presi-
dent for the eighth consecutive term, and Dr. Enoch
V. Stoddard, of Rochester, as vice-president for the
sixth consecutive term. The incorporation of the fol-
lowing institutions was approved by the board: The
Dobbs Ferry Hospital Association; the Maronite
Benevolent Society of New York City; Guild for
Crippled Children of the Poor of New York City;
House of Calvary, New York City; Ladies' Hebrew
Benevolent Association of Greenpoint; Hebrew La-
dies' Relief Association of Rochester, and the Corn-
ing Hospital. The board also approved plans for
a hospital for both the Monroe and Onondaga county
almshouses and plans for small buildings at the
Craig Colony and Western House of Refuge, as well
as plans for building improvements by the Brooklyn
Charities' Department. Dispensary licenses were
granted to the following institutions: The Vanderbilt
Clinic, Sixtieth Street and Amsterdam Avenue, New
York City, and Dispensary of Loomis Sanitarium for
Consumptives, City Branch, 104 VVest Forty-ninth
Street, New York City.
Yellow-Fever Ships in Port. — Deaths from yellow
fever occurred on several steamships arriving here
recently from Brazilian ports. Quarantine against
vessels from Cuba has already been established in the
southern coast cities.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
April 14, 1900. April nth. — Passed Assistant Sur-
geon F. W. Olcott ordered to duty at the naval recruit-
ing rendezvous, Philadelphia, Pa.
The Hospital Saturday and Sunday Collection.
— The collections of the Hospital Saturday and Sun-
day Association for this year amount to more than
$74,000, nearly $4,000 above last year. The Woman's
Auxiliary collected over $9,000. The books are now
closed, and the money collected will be distributed
among the hospitals soon.
Hospitals for Animals in Central Park. — A hos-
pital for sick horned animals is being constructed
between the deer paddock and the east bridle path in
Central Park. The building will contain four stalls.
Another hospital for invalid lions, tigers, and other
caged animals is to be put up in another part of the
menagerie.
Damages for a Dislocated Kidney. — A man and
his wife have obtained a verdict of $10,000 against
the Pennsylvania Railroad Company in the New Jer-
sey supreme court, for injuries received by the woman
while on a train. A jolt occasioned by attaching a
new car to the train threw the woman down, and her
physician testified at the trial that the accident was
the cause of a movable kidney from which she suf-
fered. The court awarded the woman §8,000, and her
husband $2,000 for the loss of her companionship.
The Plague.— In Sydney, N. S. W., one hundred and
eleven cases of bubonic plague and thirty-eight deaths
had occurred up to April 13th. A death from the dis-
ease has been reported from Fremantle, a town of Wes-
tern Australia, at the mouth of the Swan River, twelve
miles south of Perth. — Several cases of plague have oc-
curred at Cawnpur, in the Northwest Provinces, India,
not far from Lucknow. The natives opposed the sani-
tary measures instituted, and a riot took place. The
segregation camp was burned, and ten persons were
killed. The rioters killed five constables and threw
their bodies into the burning camp. It was necessary
to call out the garrison and volunteers before order
was restored.
The State Orthopedic Hospital Governor Roose-
velt has signed the bill establishing the New York
State Hospital for the care of cripples and deformed
686
MEDICAL RECORD.
[April 2 I, 1900
children in or near New York City, and appropriating
$15,000 therefor. The governor has also appointed
a board of managers for the institution, as follows:
To serve for six years, Dr. Newton M. Shaffer; four
years. Right Rev. Henry C. Potter and Mr. J. Hamp-
den Robb ; two years, Messrs. J. Adriance Bush and
George Blagden, Jr. Dr. Shaffer is also appointed
surgeon in chief of the hospital.
A Death from Hydrophobia occurred recently at
St. Vincent's Hospital. The man was bitten by a
St. Bernard dog on March 9th, and appeared to be
well until April 7th, when he began to suffer from
depression, and soon symptoms of rabies appeared
and he rapidly succumbed.
Obituary Notes. — Dr. George H. Conklin, the
oldest physician in Suffolk County, died April 12th
at Babylon, N. V., at the age of eighty-nine years.
Dr. Edward Mulheron, of Binghamton, N. Y.,
died at his home in that city April 6th, aged fifty-
three years. He was a graduate of the medical de-
partment of the University of Buffalo in 1872.
Dr. John Stirling Bird, of Hyde Park, Dutchess
Connty, died April 3d of pneumonia. He was born
in Winchester, Conn., August 29, 1836. He was a
graduate of the College of Physicians and Surgeons
in this city in the class of 1863, and opened an office
in Hyde Park for the practice of his profession in
1865. He was a member of the Dutchess County
Medical Society.
Dr. Thomas R. Hossie, of Gouverneur, N. V., died
on April 14th, at the age of forty -one years. He was
a graduate of Queen's University, Kingston, Ontario,
in 1878. He was a prominent Mason.
Dr. Frank D. Ki.mball, twenty-four years old, for
two years house surgeon of the City Hospital on
Blackwell's Island, died April 12th at the New York
Eye and Ear Infirmary of suppurative meningitis fol-
lowing influenzal mastoid disease. Dr. Kimball was
a graduate in arts of Dartmouth College and in medi-
cine of the New York University Medical Colle;^e in
the class of 1898.
Dr. Thomas Francis Roche, for fourteen years
resident physician at Deer Island, Boston harbor, died
at his home in East Boston, .April 8ih, at the age of
thirty-seven years. He was graduated from the Belle-
vue Hospital Medical College, New York, in 1883.
Dr. Charles C. Eastman, assistant manager of
ilie Binghamton State Hospital, died .April i2lh. He
was a graduate of the Geneva Medical College in
1866, and had been connected with tiie hospital since
it was opened in 1881.
Dr. Robert F. Cunnion, of Brooklyn, died sud-
denly on .April 7th, at the age of thirty years. He
was a graduate of the College of Physicians and Sur-
geons, New York, in the class of 1892.
Rev. Alfred Young, a Roman Catholic priest,
and one of the founders of the Paulist community in
this city, died on .April 4th. He was born in Bristol,
England, on January 21, 1831, and when seven years
old he was brought to this country by his parents.
He was graduated from Princeton University in 1848
and entered the medical department of the University
of New York. From there he was graduated in 1852.
He then began practice, but a year later abandoned
it to study for the priesthocxl.
Dr. William Henry Stuart died at his home in
Norwich, N. Y., on April 8th, at the age of fifty-nine
years. He was a graduate of Albany Medical Col-
lege in 1 86 1, and served as surgeon of New York
volunteers during the civil war. .At the close of the
war he began practice in Ellenville, and in 1871 re-
moved to Norwich.
Dr. Frances C. Hatchette died at Philadelphia
on .April 13th, at the age of forty years. .She studied
medicine in the Harvard .Annex and did post-grad-
uate work in Philadelphia.
Sir William Overend Priestly, member of the
House of Commons for Edinburgh and St. Andrew's
Universities, died in London on April iith. He was
born in 1829, and was a grand-nephew of Joseph
Priestly, the celebrated chemist. He was M.R.C.S.
in 1852, M.D. Edin. in 1853, and F.R.C.P. Edin. in
1858.
Dr. Isaac C. Haring, of West Nyack, N. Y., died
April 1 6th. He was a graduate of the .Albany Medi-
cal College in the class of 1850, and had practised in
Rockland County for half a century.
^^voovcsB of BXcttical J>cicucc.
A'ac i'o/i- Mediuil Joiiniiil^ April 14, jgoo.
Remarks on Perineorrhaphy, Chiefly in Reference
to the Mechanics of Deep Sutures. — J. M. Mabbott
maintains that in order to perform this operation
properly the suture should be introduced so as to be
elliptical with its long axis transverse. If we use
sutures passing beneath the deep angle of the wound,
we must carry them so far out to the sides that they
will include enough tissue for each suture to be drawn
to a circular form without crowding the lacerated sur-
faces out of tiieir natural relations to each other and
surrounding parts. 'Jhe more deeply we carry the
suture toward the sides of the pelvis the more traction
we shall secure in the right direction — toward the
median line. And until such a suture approaches a
circular shape, it will not only be drawing the sides
together, thus holding the lacerated surfaces in forci-
ble coaptation, but it will at the same time have some
tendency to bulge the cutaneous vaginal and rectal
surfaces away from each other, thus giving a thick,
firm perineal body.
Ankylostomiasis in Puerto Rico. — B. K. .Ashford
reports upon twenty cases of the severe form of anamia
seen in the island, giving in detail the typical family
history, the previous history of the patient, subjective
and objective symptoms. ( Jbservations show that
these conditions are due to an intestinal parasite
known as the ankylostoma duodenale. Thymol in
large internal dose seems to be an efficient anthelmin-
tic. Examination of the blood showed a severe an-
amia, falling as low as that of .Addison's disease in
count of red cells, a low ha-moglobin average, and a
very low color index; an occasional eosinophilia, no
leucocytosis common to the disease itself, frequent
presence of normoblasts, and in some instances
megaloblasts but never a majority of the latter, and
April
igooj
MEDICAL RECORD.
687
commonl)- poikilocytosis. Blood foods are utterly
unreliable without the removal of the cause, \iz., the
ankylostoma.
A Few Experiments in Transfusion of Complete
Blood. — From experiments of transferring blood from
a chicken to a rabbit, A. D. Hard found that the tem-
perature of the latter was increased. The same result
followed transfer from sparrow to guinea-pig, but from
land turtle to guinea-pig the temperature of the latter
was diminished. In all three instances it was some
days before the normal temperature was restored.
Results are also given of transferring blood from a
goat to the author's own veins, which produced an
increase in red and white blood cells and in haemo-
globin ]5ercentage. Subjectively the author noticed a
"peculiar mental acuity and facility of thought proc-
esses accompanied by undue exuberance of spirits of
an optimistic nature."
Books are Injurious to the Eyes — F. G. Murphy
discusses what may be called the mechanics of read-
ing with reference to the angle of vision, the direction
from which the liglit falls on the printed page, and
the differences in the mechanical problems presented
by books and newspapers, the wide page of the book
causing greater strain on the eyes than the narrow-
column of the newspaper.
A Report of Gunshot Cases in the Spanish-Ameri-
can War, and Deductions Therefrom.— l!y W. C.
Jlorden.
Primary Diffuse Small-Celled Sarcoma of the
Parietal Pericardium. — By J. C. Williams.
Boston MeJiia! aiul Siirgica/ Journa!, April 12, rgoo.
Folia k Deux. — Arthur C. Jelly writes of communi-
cated insanity, cases of which, he says, are very rare.
Heredity is the most important etiological factor.
Women are affected more than men. The young and
the aged are most liable to the infection. Two groups
show clearly the effects of contagion: (i) Where A,
who is insane, infects with the same disorder of mind
i!, who was previously sane; (2) where A, who is in-
sane, infects with the same disorder of mind B, who
was already insane. In other cases it is doubtful how-
much of the disturbance is clue to actual contagion,
for example: (i) Where A and B, living together,
suffer simultaneously from the same form of insanity
due to the same causes; (2) where B becomes insane
from association with A, not necessarily because he
accepts A's morbid ideas, but in consequence of the
shock produced by the news, or of the pain felt on
witnessing the attack, or of the continued strain due
to nursing the patient. The author gives illustrative
cases. Separation is the best treatment.
The Use of the Angiotribe.— J. Riddle Goffe
claims that with the use of this instrument the blood-
vessels are better controlled than with forceps, and
more space is gained to work in. There is no protru-
sion of forceps handles, no removal of forceps with
perhaps attendant hemorrhage. Convalescence is
smooth and comfortable, and there is less pain than
h\ the use of forceps or ligatures. The angiotribe is
superior to forceps in that it is more easily and
quickly applied, and is attended by less discharge
ciuring convalescence, whether the ligature used is
catgut or silk. In the author's opinion the angiotribe
has a field of application in dealing with hemorrhoids,
and he believes that it will be pro\ed to be superior
to the ordinary clamp and cautery.
A Case of Intestinal Obstruction from a Hair-
Ball. — G. W. W. Brewster reports a fatal case of a
girl from whom a hair-ball three and one-half inches
long and four and one-half inches in circumference
was removed from the small intestine. She had had
the habit of chewing her curls.
Hair-Eating Children and Convulsions.— Fred-
erick Lyon was called to see a child in convulsions,
and learning that it had a habit of swallowing hair or
fibre from blankets, carpets, shirt, etc., gave it calomel.
A ball of hair was passed and the convulsions ceased.
The Problem of Boston's Insane. — By Philip
Coombs Knapp.
The Work of the Trustees of the Boston Insane
Hospital.' — By Henry C. Baldwin.
Philctdi-lphict Alediial Joiinial, April 14, rgoo.
The Control of Hemorrhage in Penetrating
Wounds of the Chest — Robert G. LeConte formu-
lates the following rules of action in case of penetrat-
ing wounds of the thorax: When the wound of the
lung is giving only slight hemorrhage, close tiie ex-
ternal wound with gauze and watch for the physical
signs of bleeding. When the hemorrhage is more
marked, open the chest, insert a small drainage-tube,
and regulate the admission of air according to the
difficulty of respiration in the patient. When the hem-
orrhage is large and its symptoms are alarming, open
the chest and insert a large drainage-tube, so as to
form a rapid and complete pneumothorax, and at the
same time, when necessary, inject salt solution into
a vein. When this does not control the hemorrhage,
resect one or more ribs, and deal radically with the
bleeding. In severe hemorrhage from a lung, the first
object of treatment should be to get pressure on that
lung. By opening the chest, air will do this as well
as blood in the pleura; it will do it instantly instead
of waiting until a sufficient amount of blood has been
poured out; it will save to the patient the amount of
blood necessary to e.xert this mechanical pressure; it
will permit the vessels to close by clots; and the re-
mote benefits are that it eliminates the dangers of a
pyothorax or of universal adhesions of the pleura.
A Peculiar Manifestation of Uraemia. — Frederick
Krauss reports the case of a woman who had several
attacks of convulsions followed by coma. There was
conjugate deviation of both eyes to the left, and the
twitchings were on this side; the right side seemed
paralyzed. The woman was a stranger to him, but
suspecting uraemia he catheterized her and examined
the urine. It was apparently normal, containing no
albumin and having no sediment. The woman died
soon after the writer saw- her, and at the autopsy the
kidneys were found to be the seat of nephritis. The
brain was slightly oedematous and congested, as it
frequently is in uraemia, but there were no gross
lesions and no fracture of the skull. The only lesions
that could possibly have caused the symptoms ob-
served and death were those of the kidneys.
A Case of Death from Psychic Insult — E. Pagen-
stecher reports the case of a manufacturer, fifty-one
years of age, in apparent mental and physical health,
who cut his finger slightly when sharpening a pencil
and then accidentally soiled the wound with ink. He
was greatly alarmed, fearing blood-poisoning, and
begged his physicians to amputate the arm. He
complained of pains in the arm, and fainted. The
following day he was delirious, and he died thirty-two
hours after the receipt of the injury. The cause of
death was difficult to determine, but as there was
688
MEDICAL RECORD.
[April 21, 1900
marked concentric hypertrophy of the left ventricle it
was thought possible that cardiac insufficiency may
have been the immediate cause of the fatal ending.
Selections from the Lane Lectures. By T. Clif-
ford Allbutt.
A Case of Malarial Fever.— By Albert VVoldert.
Abdominal Pregnancy. — By Center.
Medical Press and Circular, March 28, igoo.
Infantile Insanity. — Walter Bernard thinks the
family physician, holding as he does the key to the
family pedigree and ancestral history, and by reason
of his opportunities of observation before mental
action and mentation are evolved, is in a position to
control inherited conditions. Reformatory influences
must commence at home. The earliest possible diag-
nosis is of vital importance. Peculiarities and dis-
ordered states of the faculties can at this period be
blotted out.
Cases of Skin Disease — Alfred Eddowes presented
a girl with lupus of the face simulating verruca necro-
genica requiring surgical treatment ; also a case of
lupus erythematosus of the scalp of twelve years' dura-
tion with horny plugging of the hair follicles, showing
beginning butterfly-forms on the face. The third case
was that of a girl recovering from leucoderma. The
writer believes the disease curable by drugs, but re-
frains from mentioning what line of treatment he
pursues.
Acute Inflammation of a Subperitoneal Fibroid.
— Dr. Walter relates the case of a patient four months
pregnant, who five days before admission had been
seized with pain in the abdomen. A hard tumor was
felt on the left side. An exploratory incision revealed
a subperitoneal fibroid the size of an orange attached
to the left and front part of the fundus. Rapid re-
covery took place. There had been no miscarriage
up to the time of the report.
Some Cases of Gynaecological Surgery. — By E.
Stanmore Bishop.
Surgery of the Stomach. — By A. Mayo Robson.
Journal of the American Medical Ass'», April 14, igoo.
Some of the Aspects of Renal Inadequacy from
a Neuropathic Standpoint — H. A. Tomlinson re-
ports twj cases. He considers the following conclu-
sions warranted by our study of the clinical aspects of
renal inadequacy during the past five years, supple-
mented by the uranalysis and post-mortem verification
of the deductions made: Renal inadequacy as a tem-
porary condition, not necessarily dependent upon his-
tological changes in the kidney structure, is quite com-
mon, especially during adult life and after. There is
definite clinical evidence that in some people renal
inadequacy is congenital and dependent on limited
potentiality — usually nervous. The amount of the
total solids in the urine, or the presence or absence of
albumin or casts, furnishes no direct evidence of im-
pending uramia, but the relative proportion of the
solid constituents to each other does furnish such evi-
dence.
Use of Atropine Sulphate as a Means of Diag-
nosis in Certain Persistent Headaches.— Otto Land-
man says that the headaches which are most frequently
produced by ocular defects are situated, as to their
frequency, in the following regions: supraciliary,
occipital, occipito-frontal, vertex, and temporal ; and
his conclusion is that when a persistent headache
situated in any of these localities disappear.^ on the
instillation of atropine, the case is probably due to
eye strain, and can be remedied by proper glasses.
To obtain the result, the atropine must be pushed to
the complete suspension of accommodation. The di-
rections for use are as follows: A solution of gr. ^4^
of sulphate of atropine to 3 ii. of water, three drops in
each eye, three times a day, until ten instillations
have been made.
Dosage in Chloroform Anaesthesia. — A. S. v. Mans-
felde speaks of the responsibility of antesthetizers and
the partisan spirit of controversy as to the relative
value and safety of ansesthetics. The writer says that
to obtain the full value of an anesthetic it is quite
necessary that the ingredients be in the form of a
vapor, to be inhaled by the patient in exactly meas-
ured quantities in a given time, and diluted to a
known strength with air. He describes the apparatus
of Professor Geppert, which claims to meet these re-
quirements, and which this author believes will fur-
nish the ideal solution of the problem for the future.
Shoulder-Humero-Scapula Articulation. — In a pa-
per with this title Thomas H. Alanley concludes a
review of some complications and sequela; attending
or following reducible or irreducible dislocations, to-
gether with various modern operative measures now
employed for their treatment.
Symposium on Serum Therapy. — Papers read at
a meeting of the New York County Medical Associa-
tion, reported in the Medical Record of April 7,
1900.
Report of a Successful Case of Excision of the
Caecum, with End-to-End Anastomosis. — By Fred-
erick Holme Wiggin.
Medical Neics, April 14. igoo.
Ligation of the First Portion of the Right Sub-
clavian for Aneurism of the Third Portion In
this case, reported by A. E. Halstead, the aneurism
involved the entire third portion of the subclavian
and encroached slightly upon the second portion, so
that the only rational method of treatment was liga-
tion of the first part. The ligatures employed were of
formaldehyde catgut. The author says that probably
the most important factor in securing favorable results
in these cases is the preservation of an aseptic condi-
tion of the wound. As regards the results thus far
obtained in the ligation of the first portion of the right
subclavian, the writer believes this case to be the sec-
ond on record in which the patient survived the opera-
tion.
Two Cases of Recurrent Tubal Pregnancy —
Philander A. Harris reports these two cases, in each
of which abdominal section was performed twice, re-
sulting in good recoveries. The writer says that cases
of ectopic gestation recurring in the same individual
are, no doubt, rare. He refers to four other cases,
three of which are reported by Kelly.
Recent Advances in the Treatment of Insomnia.
— By Reynold Webb VVilcox.
Purulent Meningitis: Report of Six Cases.— By
L. Napoleon Boston.
The Legislation Needed in Regard to Apparent
Death. — By Henry J. Garrigues.
British Medical Journal, April 7, igoo.
The Gelatinous Form of Sodium Biurate and
its Bearing on the Treatment of Gout. — Arthur P.
Luff has studied the action of various drugs upon the
sodium biurate in the blood, and formulates the fol-
April 21, 1900]
MEDICAL RECORD.
689
lowing conclusions: (i) The sodium salts accelerate
the conversion of the gelatinous biurate into the less
soluble crystalline variety ; (2) potassium salts delay
the conversion of the gelatinous biurate into the crys-
talline form, and when the conversion is once started
it is slowed by the presence of these salts; (3) lithium
salts do not delay the initial conversion of the gelat-
inous biurate, but when the conversion is once started
it is slowed by the presence of these salts, and espe-
cially by the carbonate; (4) piperazin does not delay
the initial conversion of the gelatinous biurate, and
but slightly slows the conversion when once started;
and (5) lysidin delays the conversion of the gelatin-
ous biurate into the crystalline form, but when the
conversion is once started it has practically no effect
in slowing it. From the results of the experiments it
appears that in the treatment of gout the potassium
salts are the most useful, the lithium salts rank next,
and piperazin and lysidin are not nearly so useful.
These results, the writer says, are in accord with his
clinical experience.
The Action of Various Drugs and Diets on the
Excretion of Nitrogen in Gout. — William Bain re-
cords the results of a number of dietetic experiments
in a gouty subject. The diets were as follows: Fixed
Diet — Cacao i pint, tea 2 pints, milk i pint, tea cake
2 oz., bread 1 1 oz., butter i oz. ; dinner, i lb. 6 oz., in-
cluding 4 oz. of meat and i apple. Vegetable Diet —
This consisted to a large extent of peas and beans.
Milk 1^2 pints, oatmeal porridge J.2 pint, pea soup '^
pint, peas porridge '2 pints, bread 11 oz., butter i oz.,
peas, beans, and other vegetables i lb. 8 oz. Animal
Diet — Milk i )4 pints, lemonade i pint, meat 10 oz.,
bread 10 oz., butter i oz., potatoes 4 oz., and i apple.
In addition to being dieted, the patient took the same
amount of exercise each day. The excretion of uric
acid, phosphorus pentoxide, and alloxur bases was
greatest while the man was on the vegetable diet, and
least when he was on the fixed diet. The administra-
tion of guaiac caused a marked and of colchicuni a
slight increase in uric-acid excretion.
A Note on the Telephone Probe. — J. C. Ogilvie
Will says he made use of a telephone probe for the
location of a bullet in a patient at the Aberdeen Royal
Infirmary thirteen years ago. The employment of the
instrument was suggested by Mr. McKenzie David-
son.
When is Cancer Cured ? — George Elder reports
cases of recurrence of cancer in loco or in a distant
part five and eighteen years after removal. He also
reports the case of a woman dying of pulmonary dis-
ease in 1899, who had had an atrophic cancer of tlie
breast since 1880.
Puerperal Eclampsia in a Patient Aged Fifteen
Years ; Recovery. — By D. R. G. Corrigan.
Incomplete Inversion of the Uterus. — By J. H.
Wilson.
An Operation for Complete Atresia Vaginae. — By
J. M. Cotterill.
Practical Observation on Cancer of the Breast. —
By Sir William Banks.
The Typhoid Bacillus and Typhoid Fever.— By
P. Horton-Smith.
Some Cirrhoses of the Liver. — By W. B. Cheadle.
The Lancet, April 7, 7900.
Practical Observations on Cancer of the Breast.
— In the third Lettsomian lecture Sir William Banks
reviews the various stages of development of the para-
sitic and infective views of cancer. He believes that
as yet there is no clear and indisputable proof of its
infectivity, and that any strong statements to that
effect, or to the effect that surgeons infect wounds by
disseminating cancer products through them by opera-
tion, are not justified. On the other hand the results
of recent study render it impossible to dispose of this
phase of the cancer question lightly. The present is
not the time for positive assertion in this regard.
Rather should we patiently experiment and carefully
collate facts for future judgment.
Some Cirrhoses of the Liver In the second
Lumleian lecture W. B. Cheadle considers several of
the associated lesions such as degeneration of heart
muscle, concurrent interstitial fibrosis of other organs,
and the liability to erysipelas and tuberculosis. He
believes that the lines of distinction between the vari-
ous forms of cirrhosis are at present too rigidly drawn,
and that, as at present laid down, they hold good only
with regard to typical examples. Favorable condi-
tion are, first, the enlargement of the liver; second,
good nutrition, and third, youth. Even some of the
cases directly referable to alcohol and syphilis do
surprisingly well.
A Parasitic Crustacean as a Foreign Body on the
Cornea. — R. D. Batten reports the case of a fishmon-
ger who probably rubbed his eye after handling fish.
The parasite was of the variety known as "caligus
curtus."
The Uses of Oxygen Inhalation. — P. G. Lodge
gives his personal experience with this remedy in
various pulmonary affections. He believes in using
it intermittently so as not to set up a dangerously
protracted state of apnoea.
A By-Result of Vaccination. — W. G. Mortimer
vaccinated a man who had been greatly troubled with
warts around the nails and on the chin. Four days
after inoculation the warts began to diminish, and
in a short time they had entirely disappeared.
Concurrent Pneumonia, Diphtheria, and Typhoid
Fever. — This unusual combination of maladies oc-
curred in a soldier under the care of D. Harris; re-
covery took place.
Typhoid Fever of Prolonged Duration. — H. E.
Belcher narrates the history of a case in which the
temperature did not reach the normal until the one
hundred and fifth day of the disease.
Remarks on the Physical Signs of Pulmonary
Disease.— By P. H. Pye-Smith.
The Surgical Treatment of Dilatation of the
Stomach. — By L. A. Bidwell.
Miinchcner medicinische Wochenschrijt, March 2J, jgoo.
Epigastric Hernia.— Eichel says that epigastric
hernia occurs between the xiphoid process and um-
bilicus, mostly in the middle line but occasionally a
little to the right or left. It produces a tumor of vary-
ing size, usually as large as a hazelnut. Its causa-
tion, diagnosis, and treatment are discussed at length.
Nervous Disturbances of the Heart in their
Relation to Military Service. — J. Bauer concludes
that all young men with functional cardiac disturb-
ances are by no means unfit for military service; on
the contrary, for some the gradual strengthening of
the heart muscle acts as a direct cure.
Tuberculosis. — Henkel advocates puncture of the
lung in order to find the tubercle bacilli in the incipi-
690
MEDICAL RECORD.
[April 21, 1900
ent cases. He maintains that the earliest physical
signs are auscultatory, and are heard over the supra-
and infra-spinatus regions.
Operation upon the Heart after Pistol Wounds. —
Carl Stern descrilses a case in which he followed the
typical operation of Rother with a fatal result. The
diagnosis and indications for interfernce are also dis-
cussed.
Pseudomucin in Ovarian Cysts By Zangerle.
Agglutinin. — By Hahn and Trommsdorff.
Addison's Disease. — By L. Huysmans.
Berliner kliiiiscJie WiHiienschriJt. Mareli 26, igoo.
Diagnostic and Therapeutic Significance of Tu-
bercle Bacilli and Other Bacteria in the Sputa.—
L. Brieger corroborates the statements of Fraenkel as
to the diagnostic value of tuberculin when properly
employed, and calls attention to the necessity of deter-
mining at the earliest possible moment the existence
(if present) of mixed infection. This is shown by the
occurrence of fever (for pure tuberculosis is essen-
tially an afebrile disease) and by the presence of va-
rious microorganisms in the expectoration. This
mi.Ked infection frequently appears as a lobular or
even lobar pneumonia, producing the presence in the
sputa of staphylococci, streptococci, and pneumococci.
The later stage of pulmonary tuberculosis therefore
becomes a chronic sepsis. The condition is still
more rapidly accelerated by the occurrence of the in-
fluenza bacillus in the lungs. Various other organ-
isms have been found, as for instance the bacillus
pyocyaneus. Much of the evil from this mi.xed infec-
tion san be averted or lessened if vigorous nie.isures
are instituted early in the course of the disease.
Etiology and Operative Radical Treatment of
Genuine Ozaena. — Nobel and Lohnberg conclude a
series of articles by advancing the following proposi-
tions: (i) By far the greater number of cases of nasal
purulent discharge appearing as ozana are referable
to affections of the sphenoid and ethmoid sinuses.
(2) Fetor, atrophy, and crust formation as expressions
of pus in the nose can be produced by a number of
causes, but as a rule are referable to purulent foci in
sphenoid and ethmoid. (3) A rational treatment of
ozaena in any given case can be expected only upon
the discovery of its primary cause. (4) Since the.se
causes are mostly sphenoidal or ethmoidal in origin,
the therapy of ozaina must be a surgical one or it will
be without result.
The Development of the Theory of Inflammation
in the Nineteenth Century.— I'onfick discusses in
this final paper the causes of inflammation, especially
in the light af the establishment of the science of bac-
teriology. He defines inflammation as "a disturbance
which, produced by an overthrow of tissue balance,
associated with a change in the vessel walls, consists
in an exudation of Huid and solid blosd elements, and
is regularly accompanied by formative and frequently
by degenerative changes in the cells of the basement
substance.""
The Diagnostic and Prognostic Significance of the
Diazo Reaction in Phthisical Patients.— Michealis
finds that a positive reaction to this test in pulmonary
tuberculosis signifies a bad prognosis. Out of 167
cases, 56 gave a negative and 1 1 1 a positive reaction.
Of the former group, 5 patients were cured, 44 im-
proved, 5 unchanged, and 3 died. Of the latter group
none were cured, 15 improved, 13 not improved, and
80 died.
Local Anaesthesia and Narcosis. — C. L. Schleich
makes a plea for the more general employment of
local anaesthesia, showing that many operations
thought to require general anaisthesia can be done
under local methods as at present elaborated.
La Rijorma Aledica, March ig, 20, and 2r, igoo.
The Disinfection of the Nasal Cavity with Cer-
tain Essences and Essential Oils. — A. de Simoni
initiated a series of experiments upon animals in order
to ascertain what substances would destroy certain
germs in the nasal cavity, and at the same time prove
innocuous to the mucous membrane. He reaches the
conclusion that pure essences are so decidedly curative
in grave lesions of the mucosa as to justify their more
extensive use in the field of rhinology. I^isinfection
by means of volatile essences is the most thorough,
and the most practicable. They are less toxic than
dilute solutions of bichloride, carbolic acid, etc., and
at the same time they stimulate activity of the mucosa
and accelerate the healing of the epithelial cells.
Congestion of the Liver from Mercury Poisoning.
— Angelo Lisanti writes of the effect upon the liver of
mercury in men who use it in their work, as well as
in syphilitics who have long taken it therapeutically.
In a large number of cases he has found it sensitive
to pressure and painful, with smooth surface and in-
creased in size. Rapid modifications in its size occur,
and coincide with crises of polyuria and albuminuria.
Subjectively there are sensations of fulness and ten-
sion in the epigastrium and right hypochondrium,
with pain radiating to the right shoulder, and increased
by respiration or movement of the body. Suspension
of mercurial treatment will cause a cessation of the
liver congestion in two or three weeks.
/Cert/t- ih Meileeine, M<n\-/'i 10, igoO.
Nervous Hyperthermia in Women G. Leven says
that out of thirteen cases of so-called nervous fever,
which he thinks it would be more exact to call hyper-
thermia, two patients menstruated normally. In the
other cases there was some abnormality of menstru-
ation; in two the fever appeared when menstruation
was bruskly interrupted, and in two others the tem-
perature fell whan the flow began. The author con-
cludes that there is a relation of cause and effect
between menstrual troubles accompanied by symptoms
of peritonism and hyperthermia, and that the phe-
nomena can be explained by irritation of the uterine
nervous system.
The Anatomical and Chemical Alterations of ^he
Liver in Scarlatina. — H. Roger and M. Gamier find
that the liver is increased in size, of a -pale color, fre-
quently mottled with red or purple, and with white, or
more rarely red, spots on its surface. l"he lesions
are situated near the porta hepatis; leucocytes abound
there, and the cells undergo degeneration, especially
fatty degeneration, 'i'he amount of albumin is usually
increased. Further researches are necessary in order
to ascertain what symptoms are caused by this condi-
tion of the liver during an attack of scarlatina.
The Rubeoliform and Scarlatiniform Erythema of
Typhoid Fever. — Paul Remlinger gives a table of
fifty-nine cases showing the time of appearance of the
erythema in relation to the onset and to the termina-
tion of the disease, the character, duration, and locali-
zation of the eruption, the gra\ ity of tlie disease and
its complications, and the method of termination of
the eruption and of the disease.
April 2 1, 1900]
MEDICAL RECORD.
691
Revue Je Chiniigie, Manh 10, igoo.
Tumors of the Biliary Passages I\ Terrier and
M. Auvray submit tables showing the result of opera-
tive interference in sixty cases of tumors of the gall
bladder and bile ducts. The mortality in cases of sim-
ple cholecystectomy was thirty-tive per cent.; in cases
of cholecystectomy combined with resection of the
liver it was 11.7 per cent. In nearly all cases of
radical operation there was return of the tumor sooner
or later. Yet in cases of cancer, operation constitutes
the only known means of relief, and should be per-
formed unless contraindicated by extension of the dis-
ease to neighboring organs, or by cachexia.
Treatment of Renal Retention. — Antonin Gosset
urges operation performed at two different times. In
the first nephrostomy will cause diminution in the size
of the sac, and the fluid whicii escapes through the
lumbar fistula can be analyzed and will indicate the
condition of the organ. .Should the retention be sep-
tic, this preliminary nephrostomy will rest the ureter,
and facilitate disinfection of the tissues. In the second
the ureteral passage can be re-established either by
section of the sac or lateral anastomosis of the ureter
to the sac.
Generalized Infected Psorospermosis. — .Alexandre
Posadas describes a case of this disease. The para-
sites producing the tumors are sporozoa; they are con-
stantly present in the lesions in man; when inoculated
in animals, they produce the same disease and the
same lesions as in man, and are constantly present in
these lesions. All other micro-organisms are absent
from the tumors.
A Study of Burns Caused by Electricity in In-
dustrial Pursuits. — By M. Mally.
Branchial Epithelioma of the Neck.— By Victor
Veaii.
Freiuli Journals.
Semeiological Value of a Painful Point in the
Left Hypochondrium, Symptomatic of Gas in the
Large Intestine. — Paul Reynier crlls attention to a
pain often complained of on the left side at the mar-
gin of the ribs, or more especially in men at a point
opposite the suspender button, and in women causing
them to loosen the corsage. Dilatation of the stomach
is usually found, and the pain frequently disappears
upon the passage of flatus. The pain is at the angle
formed by the transverse and descending colon, and is
believed to be due to distention with gas. The dila-
tation of the stomach must be treated, the bowels kept
active, and if there are recurrences massage should
be given. Two cases are related. — Journal de AleJe-
ciiic tie Paris, .\pril i, 1900.
The Diagnosis of Pulmonary Tuberculosis in
Young Children — Ur. Bertherand says the diagnosis
of pulmonary tuberculosis in children is based less
upon a distinct symptom than upon an ensemble of
functional and physical signs; and still this ensemble
has only a presumptive value. It is well to employ
the more precise means of diagnosis. Tuberculin and
artificial serum injections, and especially bacilloscopy
of sputum and stomach contents, and as accessory
measures radioscopy and radiography, may give im-
portant results. It is often necessary to employ them
simultaneously, in which way they will control one
another. — Gazette Hebdomadaire de Mhtecine et de Clii-
ruri;ie, April i, 1900.
The Technique of Pylorectomy — H. Hartmann
and B. Cune'o draw their deductions as to operative
measures required from a study which convinces them
than cancer of the pylorus extends but little toward
the duodenum; that it extends, on the other hand,
toward the stomach and particularly toward the lesser
curvature. It invades the ganglia especially toward
the smaller curvature. In the operation they propose
but two ligatures are required to control hemorrhage,
one placed upon the gastric coronary, the other on the
gastro-duodenalis, after which one can operate rapidly
and methodically. — J.a Prcsse Mhlicale, March 31,
1900.
Two Very Rare Varieties of Phlegmonous An-
gina in Infants. — Albert Katz relates an observation
of an abscess at the summit of the uvula in a nursing
infant which presented all the signs of a retropharyn-
geal abscess with intense dysphagia, dyspncea with
paroxysmal attacks, etc. All were promptly relieved
by incision. The second case was one of peritonsillar
phlegmonous inflammation of the tongue in an eight-
year-old child. No similar case was found in litera-
ture. Paroxysms of dyspncea came near causing the
child's death. — Le Progres Medical, March 31, 1990.
Interlobar Purulent Pleurisy.— Pagliano and Loss
relate an instance of streptococcic empyema in which
the use of the Marmorek serum was followed by cure,
and conclude that in this remedy we possess a means
of treatment which is not to be disdained. In many
cases of streptococcic infection it may give almost
unhoped-for results, and if its action is as favorable
in other cases as in this it will not remain a resource
of last resort.- -Za Presse Aledicale, March 28, 1900.
Isolation of the Tuberculous.— J. Thienot dwells
upon the utility of treatment by sanatoria, of which
there are relatively few in France as compared with
(Germany, where there are now over thirty, with about
three thousand beds, capable of caring for ten thou-
sand phthisical subjects yearly. He urges the erec-
tion of sanatoria in the country throughout France. —
J.a Medeciiie Moderne, March 31, 1890.
Journal 0/ Nervous and Mental Disease, April, igoo.
A Case of Unilateral Progressive Ascending
Paralysis, Probably Representing a New Form of
Degenerative Disease.— Charles K. IMills reports a
case which he thinks may represent an unusual form
of amyotrophic lateral sclerosis. The most probable
diagnosis would seem to be that of a slowly increasing
degeneration of the pyramidal fasciculi or of the cere-
bral motor neuron system. A slowly increasing focal
cerebral lesion does not seem probable, for in this
case the motor fasciculi for the leg and then those for
the arms and face were affected. Special and general
symptoms of focal lesions, such as tumor, hemorrhage,
softening, and abscess, were not present. A degenera-
tive motor neuritis would not be likely first to select
the leg and then the arm and face of the same side.
The deep reflexes were too exaggerated for a periph-
eral nerve affection. P'unctional hemiparesis was im-
probable from the persistence and progressive increase
of the symptoms and the absence of hysterical stig-
mata.
A Case Presenting Right-Sided Hemiplegia with
Hemianaesthesia, Right Homonymous Hemianopsia,
Jargon Aphasia, Wernicke's Pupillary Reaction
Sign, and Neuritic Pain in the Arm of the Para-
lyzed Side. — F. X. Dercum reports a case which is of
interest because of the association of the above-named
unusual number of symptoms. The presence of Wer-
nicke's hemipupillary inaction sign in keeping with
the profound hemiplegia, and with the persistent hemi-
anaesthesia, hemianopsia, and sensory aphasia, indi-
cates a most extensive lesion — one involving the entire
6g2
MEDICAL RECORD.
[April 2 I, 1900
posterior limb of the internal capsule, adjacent struc-
tures such as the thalamus and radiations of Gratiolet,
and probably a large portion of the substance of the
left hemisphere as far as the cortex. The lesion was
doubtless vascular, though whether hemorrhage or em-
bolism it is difficult to say.
Transient Real Blindness in Hysteria. — George
C. Harlan reports the case of a woman who complained
of loss of vision in the left eye of three days' duration.
Every known test was applied, even the application of
the modified Graafe prism test, viz., watching the be-
havior of the eyes behind a prism, but the eye seemed
absolutely blind. Ten days later the sight was so
rapidly returning that the patient could read with it
No. LXX. of Snellen's type at twenty feet. The
author divides hysterical blindness into two classes:
in the first there seems to be a more or less deliberate
deception, a symptom perhaps of "ganglionic insan-
ity," as hysteria has been called; in the second the
patients are themselves deceived, and are not capable
of conscious vision. The author is half tempted to
add a third class, in which blindness is real and abso-
lute, but transient, and without recognizable cause.
A Case of Acute Poliomyelitis Anterior in a
Youth Seventeen Years of Age. — Wharton Sinkler
reports a case which he says possesses three points of
interest: First, the unusual age at which poliomyeli-
tis occurred; secondly, the fact that although there
was reaction of degeneration in the anterior tibial
muscles of the left leg, there was still good response
to the faradic current, and that, although all the mus-
cles of the right leg have regained almost the normal
amount of strength, there still remains reaction of de-
generation in the anterior tibial group. The third
point wliich is notable is, that there is exaggerated
knee jerk in the right leg, whereas two months ago
this was entirely absent. The author has seen one
other case in which, after recovery from poliomyelitis,
there was exaggerated knee jerk.
Landry's Paralysis — E. W. Taylor and J. E. Clark
offer a clinical case and pathological findings as evi-
dence to support their view that the disease cannot be
classified as an individual entity. If Landry de-
scribed a certain disease, they say, it is clear that we
must find the pathological anatomy and etiology of
this supposed disease and not of some other, or else
give up the word as an unnecessary encumbrance to
our already overburdened nomenclature. Inasmuch as
there is no essential constancy in the clinical symp-
toms nor in the pathological findings of so-called
Landry's paralysis, and inasmuch as the etiology is
wholly vague, it is probable that the affection does not
represent in itself a process to which the term "dis-
ease" may properly be applied.
Annals pJ Surgery, April, igoo.
On Volvulus in Association with Hernia. — R. L.
Knaggs narrates histories of eighteen cases divided
into the following classes: volvulus of the hernial
contents (cases in which all the intestinal contents
are involved or only a part of them), volvulus in which
the hernial contents are implicated, but in which the
neck and some of the coils lie within the abdomen,
volvulus produced within the abdomen by the reduc-
tion of the hernia, and volvulus occurring within the
abdomen from some predisposing condition more or
less directly connected witfi a hernia. The various
operative modifications called for by these conditions
arc then discussed in detail, and a careful study is
made of the mechanical factors leading to the various
morbid conditions.
Surgery in the Presence of Sugar in the Urine.
— A. L. Fisk believes that while patients with glyco-
suria are not good surgical subjects, the opinion is
growing that with extreme care in the selection of
cases and scrupulous perfection in surgical asepsis
they must not be denied the benefits of surgical relief.
He then gives histories of operative cases, including
mammary carcinoma, suppurative appendicitis, and
two cases of gangrene of the foot and toes, in all of
which, except one of the last two, recovery occurred.
Fiske calls attention to the necessity of as little inter-
ference as possible with the vascularity of the tissues,
and every operation should be planned with this point
in view. He thinks it better to cut down upon and
ligate the artery in gangrene of the extremities rather
than to attempt the bloodless amputation method by
means of the Esmarch band.
On the Principles Involved in the Immediate
Hermetic Sealing of Aseptic Wounds. — H. O. Marcy
makes a plea for the recognition of the vitalized struc-
tures with which we have to deal. They should be
injured as little as possible. Hence dissection should
be clean. But little force should be applied in oc-
cluding the largest blood-vessels, and coaptated struc-
tures are to be placed at rest so that they furnish a
minimum of exudates. Suture material serves a better
purpose by being antiseptic rather than aseptic, and
for this reason he urges the importance of soaking ten-
dons (which the author prefers) for thirty minutes in
a I : 1,000 solution of bichloride, taking the suture
directly from the solution as required for use. A
strong advocacy is given to the use of iodoform col-
lodion strengthened by a few fibres of cotton.
On the Use of Fixation Plates in the Treatment
of Fractures of the Leg — In this paper by L. \\ .
Streinach, and illustrated by some excellent skia-
graphs, the author's personal experience with the fixa-
tion plates is detailed in the recital of four cases. An
incision is made under ether with its centre over the
line of fracture, and the soft parts are retracted, spe-
cial care being taken not to disturb the periosteum.
A small silver plate is then inserted in the shape of a
cleat to the flat subcutaneous surface of the tibia, se-
cured by small galvanized steel screws. The wound
is then sewed up, though a small gauze drain may be
left in to take off the oozing. The plate seems to be
a harmless tenant in the leg, and is left until bony
union has taken place. It is then removed under local
anaesthesia.
Traumatisms Inflicted by Animals — R. Harvey
Reed makes a short but interesting study of this class
of injuries, giving two illustrative cases in which
trauma was produced by a lion and grizzly bear re-
spectively. He counsels the conversion of all punc-
tured wounds into open ones by means of free incisions.
He has had much satisfaction with an evaporating
bichloride solution, for which he gives the following
formula: Three-per-cent. boracic-acid solution, 80
parts; alcohol, 10 parts; glycerin, 10 parts; and eight
drops of a saturated solution of bichloride to the pint.
The latter is made by adding two ounces of bichloride
to two ounces of alcohol and six ounces of glycerin;
of the latter eight drops to the pint equal i : 3,500.
The Relationship between Cholecystitis, Jaun-
dice, and Gall Stones. — A. MacLaren believes that
jaundice is a very much over-rated symptom of gall
stones, as during the last year he has operated on nine
cases of gall stones, in none of which was jaundice
present. All of the patients had had colic requiring
relief by morphine. In all but one the gall bladder
was found inflamed, thickened, and frequently adher-
ent to neighboring organs. He adds some interesting
April 2 1, 1 900]
MEDICAL RECORD.
69;
observations on the infection of the gall bladder by
micro-organisms which may enter from the bowel or
more likely be filtered out of the general circulation
by the liver.
Conical Stump after Amputation in Childhood.—
C. A. Powers calls attention to the fact that after am-
putation through the upper part of the arm or leg in
childhood, a slow development of a conical condition
is physiological and is to be expected because the
humerus and leg bones are developed in large part
from the upper epiphyses. Parents should be warned
at the time of operation of the possibility of such an
occurrence.
The Surgery of Gastric Ulcers T. \V. Hunting-
ton describes the operative procedures in two cases,
one of perforating ulcer followed by cicatricial con-
traction of the pylorus and extensive dilatation of the
stomach, and the other perforating ulcer with peri-
toneal extravasation. Reference is made to recent
statistical literature on the subject.
Excision of the External Two-Thirds of a Gas-
serian Ganglion, by the Hartley-Krause Method,
after Preliminary Ligation of the External Caro-
tid Artery — By J. M. Spellissy.
Two Cases of Anomalous Spinous Processes of
the Seventh Cervical Vertebrae Articulating with
the Scapula By J. T. Rugh.
New Operative Table and an Improved Bowl
Stand. — By A. Scachner.
The Montreal Medical Jounial, March, igoo.
Gonorrhoea in its Relation to Diseases of the
Eye. — Frank BuUer says that bacteriological investi-
gations have demonstrated that in the early stages of
gonorrhceal ophthalmia the gonococci are present only
in the conjunctival epithelium, but that later on they
penetrate deeply in the subconjunctival tissues. If
an early diagnosis can be made the logical inference
is that an antiseptic powerful enough to render asep-
tic the entire epithelial structure should be capable of
arresting the disease. The author has the conjunctiva
thoroughly washed with perchloride of mercury solu-
tion, 1:3,000, the patient being etherized; the outer
canthus is freely divided, and the lids are thoroughly
everted so that every part of the conjunctival sac is
exposed, and irrigated with warm water; after protect-
ing the cornea with vaseline, the entire conjunctiva is
freely swabbed with an eight-per-cent. solution of silver
nitrate, and after a few minutes with perchloride,
I : 2,000, and lastly smeared abundantly with vaseline
and cold borated compresses are applied. This meth-
od he has found effectual.
History of Gonorrhoea — John Macrae says that the
first history of this disease which merits any consider-
ation was written forty-five hundred years ago, and that
thirty-six centuries of silence intervened. About 1500
A.D., when syphilis had somewhat spent its severity,
gonorrhoea again comes into prominence. Paracelsus
classed it as a variety of syphilis, an error which
passed unchallenged until the protest of Cockburn in
1728. From 1770 onward the Edinburgh school
taught with no uncertain voice that gonorrhoea was a
disease sui generis. In 1870 Neisser, of Breslau, an-
nounced that he had found an organism existing in
gonorrhoea! pus, and since that time the presence of
the gonococcus can be decided as " an immoral cer-
tainty." Of late years this organism has been found
in most of the serous cavities of the body, and it has
been demonstrated in peritonitis, arthritis, iritis, and
salpingitis; in the pleura, and elsewhere. "The end
is not yet."
Acute Gonorrhoea and its Complications in the
Male — A. E. Garrow gives the symptoms of the affec-
tion, and a list of the complications, i.e., balanopos-
thitis, with phimosis or paraphimosis, folliculitis and
peri-urethritis with their complications, abscesses and
cowperitis, lymphangitis, lymphadenitis, cavernitis,
posterior urethritis, acute prostatitis, rarely cystitis,
vesiculitis, and epididymitis. The method of treat-
ment which he has found most satisfactory consists in
copious irrigations with Aveak antiseptic solutions;
with bichloride or with permanganate of potash, using
them in large quantities and hot, at least 115" F. and
sometimes 120° F. These he applies by means of
rubber catheters, glass catheters, special irrigators,
and meatus nozzles. Within the last six months he
has followed each irrigation by an injection of protar-
gol, one-half to two per cent., which is retained from
fifteen to thirty minutes.
Hammer Toe — G. A. Charlton describes a case in
which the four outer toes of each foot were in a posi-
tion commonly designated as "hammer toe." Each
toe showed marked hyperextension of the first pha-
lanx; the second phalanx was flexed at a right angle
to the first, and held so firmly as to give the impres-
sion of ankylosis of the joint. Upon dissection no
ankylosis was found, and the lateral ligaments were
found definitely not to be contracted, in opposition to
what has been observed and described in other cases
of hammer toe. Upon division of the extensor tendon
the toe was straightened out into the natural position.
Cases of hammer toe are either congenital, being a
distinct condition, or a primary stage in the develop-
ment of club-foot, or acquired from traumatism pro-
ducing inflammation, or the long-continued pressure
of an ill-fitting shoe.
Gonorrhoea in the Pregnant Female. -^J. Chalmers
Cameron urges the importance of early diagnosis and
energetic treatment in these cases. The cocci may
lurk in so many pockets and corners of the genito-
urinary tract, the rectum, and the parturient canal,
that great care must be taken to turn them out from
all their hiding-places. Treatment which does not
succeed in doing this will probably fail, because of
the lasting properties of the gonotoxin. The expec-
tant attitude cannot be defended. Careful diagnosis, a
thorough local examination, persistent treatment, the
results being checked from time to time by bacterio-
logical examination, seems to be the line now indi-
cated.
Gonorrhoeal Arthritis. — James Stewart gives an ac-
count of forty-eight cases. Only six were women.
The average age of the patients was thirty years. Only
three had a decidedly rheumatic history. To judge
from these cases, arthritis is as liable to follow a mild
attack as a severe one. The commonest form of the
disease was the polyarthritic. These resembled sub-
acute rheumatism. Inflammation began either sud-
denly or gradually in one joint, and extended to others
with moderate fever and constitutional disturbance.
Most of these cases when admitted early did well, but
at least half were left with partial ankylosis of some
of the joints involved.
Chronic Gonorrhoea in the Male. — George E. Arm-
strong is strongly in favor of dilating all dilatable
strictures, and considers that nearly all gonorrhoeal
strictures behind the peno-scrotal angle are dilatable
by the interrupted or continuous method. In a gen-
eral way he reserves for cutting gonorrhoeal strictures
of the pendulous urethra, traumatic stricture, and con-
genital stricture of the urethra. In one case of trau-
matic stricture involving fully two inches of the ure-
thra, he found it necessary to lay open the stricture
694
MEDICAL RECORD.
[April
1900
area by dissection, and then to form a new floor, as in
the operation for hypospadias. The result was en-
tirely satisfactory.
The Ediitliitrgk MeJicql Joitnial, April, igoo.
Reflex Salivation from Abdominal Disorders. — F.
Parkes Weber writes of the reflex salivation which
sometimes occurs in pregnancy, in cirrhosis of the
liver, and in various disorders of the stomach and ab-
dominal viscera. Most of these cases, he believes,
are examples of what may rather loosely be termed
'• mistaken reflex action," because they are purposeless.
Reflexes excited by abnormal irritation of the gastric
and intestinal mucous membrane can all be explained
as attempts to clear the alimentary canal of irritating
matter. Vomiting, increased peristalsis, and exces-
sive secretion from the bowel, stomach, and salivary
glands dilute any irritating matter in the alimentary
tract, and get rid of it upward by vomiting and spit-
ting, or downward by diarrhoea. When the same
symptoms are reflexly induced by other abdominal
disorders, they may be considered as examples of ap-
parently purposeless or "mistaken" reflex action.
Gastro-Intestinal Self-Intoxication as a Factor in
Nervous Diseases. — O. J. Kauffmann believes that a
certain number of cases of nervous disorder and ner-
vous organic disease are reasonably explicable by gas-
tro-intestinal self-intoxication. What proportion of
the cases which are not attributable to other causes
may be explained in this way, can be determined only
by much more extensive clinical observation. As re-
gards indicanuria, and its importance as a sign of
disordered digestion, it must be borne in mind, first,
that it is a variable sign, apt to be present one day
and absent the next, and that, therefore, value can at-
tach to it when its presence is more of Ifess constant;
secondly, that it may well happen that there is much
disorder of the digestive processes without the produc-
tion of indol, and that consequently we must not
allow the absence of indicanuria to exclude the pos-
sibility of disordered intestinal digestion.
Pathological Amenorrhoea from Other than Con-
stitutional Causes — F. W. N. Haultain says that in
the absence of pregnancy and deteriorated constitu-
tional states amenorrhoea is not a common condition.
From a general point of view it may be classified as
of two types, primitive and acquired ; and from a phys-
iological aspect each may be considered as due to (i)
atresia of the canals; (2) uterine conditions; (3)
ovarian conditions. In acquired amenorrhea, that
due to impairment of the functions of the ovary,
uterus, or controlling nerve centre (the last being per-
haps the most frequent and most easily overlooked),
treatment is often successful. The constant electric
current is satisfactory. Ovarian inactivity is in many
cases overcome by the administration of ovarian ex-
tract. The usual dose necessary is only gr. xv. per
diem, but gr. xl. daily may be administered without
untoward symptoms.
Perigastric and Periduodenal Abscess. — N. Soltan
Fenwick describes in detail the symptoms and course
and results of the formation of these abscesses. .\s
to treatment, he says that as soon as the existence of
the abscess can be determined, the cavity should be
opened and drained, for every day that the operation
is postponed increases the risk of secondary inflamma-
tion of the thoracic viscera and perforation of the dia-
phragm. The abscess is most conveniently opened in
the left hypochondrium, care being taken not to dis-
turb the adhesions between the stomach and the ab-
dominal wall, which prevent extravasation into the
general cavity of the peritoneum. When the pus is
situated in contact with the diaphragm, a counter-
opening may be made between the ribs behind, in
order to secure free drainage.
Preventive Operation in Acute Inflammation of the
Appendix. — Mansell Moullin says that if all the cases
of inflamed appendix which come to operation at last
were operated upon at once, say before thirty-six hours
have elapsed, some lives which are lost now would be
saved; and there is no reason to think that any of the
patients who are saved now by operation would be ex-
posed to additional risk, while certainly the duration
of their illness would be materially curtailed, and the
chance of grave accidents setting in considerably less-
ened. .An operation to be preventive must be per-
formed before forty-eight hours from the time of onset,
and must not be confounded with operation upon the
fourth or fifth day, when conditions are materially dif-
ferent and much more complicated.
On "Washing" Dysenteric Stools. — Kenneth
MacLeod describes the process, and enumerates the
points of information learned by it. The color of the
fluid indicates the amount of blood contained in the
evacuations; the size, shape, and character of the
feculent masses give information as to the condition,
calibre, and tone of the diseased gut; the activity of
the digestive process may be inferred, and the charac-
ter of the ingesta determined; the floating flecks of
mucus will show the stage of the dysenteric process;
the residuum, especially casts or sloughs, will indicate
the nature of the destructive process; and the results
of treatment may, to some extent, be judged.
A Ckse of Murder and Suicide.
I.ittlejohn.
-By Harvey
The Bristol Mcdico-Chiriirgical Jouni,i!, March, igoo.
Rheumatic Disease of the Cardiac Muscle —
Theodore Fisher writes of the lesions found in the
heart in rheumatic cases. It does not require the vis-
ual evidence of disease of the heart muscle in cases
of pericarditis, he says, to show us that there is poi-
soning of the cardiac walls. The rapid fatality of
many cases is the best evidence of the poisoning, for
it cannot be considered possible that mere inflamma-
tion of the serous covering of the heart can arrest its
action. In some cases there is acute rheumatic
poisoning of the heart muscle without any pericarditis
at all. Dilatation of the heart has been frequently
noticed in cases of acute rheumatism, so tiiat perhaps
the mitral regurgitant murmur developing during the
course of the disease will often not indicate a lesion
of the mitral valve, but be secondary to cardiac dila-
tation. Weakening of the heart, tachycardia, and
mild anginal attacks may all follow rheumatism.
The Spontaneous Disappearance of a Sarcomatous
Tumor. — G. Munro Smith reports a case in which the
primary lesion appears to have been a lympho-sarcoma
at the angle of the jaw. 'Fhis was extirpated; it re-
curred, and after an unsuccessful attempt at removal
of the recurrent growth, the latter spontaneously dis-
appeared. IHcers on tonsil and palate and ascites
seemed clearly due to malignant disease, yet recovery
from both took place. The microscopical examination,
the clinical features, and the termination by numerous
pigmented tumors, etc., causing death from exhaus-
tion, all this is in favor of the cycle of events being
malignant. The late Mr. Greig Smith reported three
cases of solid abdominal tumors which spontaneously
disappeared.
April 2 1, 1900]
MEDICAL RECORD.
695
Russki Arklih' Paii'logii, etc., Jan. a)id Feb., igoo.
The Curability of Syphilis.— V. M. Tarnovski re-
ports fifty cases of syphilis, most of which he saw at
the beginning and kept under observation for from
twenty to forty years. All cases are excluded in wliicli
there was reason to suspect syphilis in the parents,
and no case is included in which less than si.xteen
years had passed since the last symptoms. He con-
cludes from a study of these cases that syphilis is
curable in all its stages, but it is in the secondary period
that a cure is most frequently obtained. The use of
mercury and of iodide of potassium is the main reli-
ance in the cure, but there are other factors which aid
in bringing about this effect. Of these factors the
most important are a robust constitution and an ab-
sence of hereditary or acquired taint of any kind.
The natural power of resistance, which varies in each
organism, is also an important factor. The danger of
syphilis does not reside exclusively in the general le-
sions produced by the disease, for these are amenable
to our present modes of treatment, but in the special
localizations and in the so-called parasyphilitic affec-
tions.
Orrhotherapy of Streptomycosis. — N. P. Nesh-
chadimenko reports in a preliminary communication
the results of a series of experiments in artificial im-
munization against streptococcal infection. He says
that there is no essential difference in the streptococci
provoking various diseases in man, but that they are
identical in their biological and pathogenic proper-
ties. By means of a new method elaborated in tiie
Bacteriological Institute at Kieff, he claims to have
prepared a serum, called polystreptococcic, \vhich ag-
glutinates streptococci, attenuates remarkably virulent
cultures of these micro-organisms, confers immunity
upon animals, and cures those already infected. The
details of his method of cultivating streptococci, of
increasing and diminishing their virulence, of immu-
nizing animals, as also of the pathogenosis of strepto-
mycosis in man and its orrhotherapy, are now being
elaborated by him, and will be published as soon as
possible.
Echinococcus of the Brain Complicated by He-
miatrophy of the Face.— V. A. Muratoff reports a
case of this nature in a boy eleven 3ears of age, who
entered hospital with the following symptoms: Severe
headache with a chronic otorrhcea of two years' dura-
tion; double neuroretinitis; hemiatrophy of the left
side of the face, tongue, and soft palate; weakened
sensibility to pain on the same side. The child died
at the end of two months, and at the autopsy there
was found an echinococcus cyst of the posterior cra-
nial fossa which compressed the protuberance and the
bulb. There was marked atrophy of the nucleus of
the twelfth nerve on the left side, together with a
degeneration of the intramedullary portion of the root
of the hypoglossal nerve. There were also atrophied
cells in the left nucleus of the facial nerve.
A Case of Pemphigus Foliaceus of Cazenave. —
G. M. Nazaroff reports this case occurring in a woman
sixty-seven years of age. On the mucous membrane
of the palate and of the lower lip there were raw
patches, denuded of epithelium, surrounded by strips
of tissue which had apparently formerly covered the
blebs. On the scalp, the neck, the chin, the breast,
and the back there were bullce of various size>3 and
denuded patches; these bullae were red, shining, and
moist, and their periphery was covered with delicate
epithelial strips. A slight sliding pressure on the
apparently normal epidermis was sufficient to detach
it from the subjacent tissue. At the autopsy, beyond
the changes in the internal organs incidental to ad-
\anced age, nothing abnormal was found except the
cutaneous lesions.
The Absorption of Bacteria by the Lymphatic
Ganglia. — A. S. Egoroff has repeated Halban's ex-
periments, and confirms his conclusions that the time
of appearance of bacteria in the ganglia nearest the
point of infection varies with the different species.
The pathogenic microbes are absorbed by the ganglia
less rapidly than the non-pathogenic or the pathogenic
in animals naturally or artificially immune. The
bacteria are carried through the lymphatic vessels in
a free state, and it is only when they have penetrated
into the interior of the ganglia that they are fre-
quently englobed by the macrophagi.
The Inoculability of Typhus Fever.— O. O. Mo-
chutkovski reports some experiments made a num-
ber of years ago, but not before published, as a result
of which he formulates the following conclusions:
The primary infection in typhus fever occurs in all
probability in the blood. The inoculation into a
healthy person of blood taken during the height of
the fever produces an attack of typhus fever. The
incubation period of the disease thus caused is eigh-
teen days.
The Antitoxic Nature of the Aniline Colors. —
G. Gabrichevski reports in detail a number of experi-
ments with fuchsin, vesuvin, pyoktanin, and other
aniline dyes to determine their antitoxic properties.
He concludes that while the fact of an antitoxic
action of these substances is undoubted, the way in
which this action is effected is uncertain.
// Policliiiiio, March ij and April I, igoo.
The Development of Cancer in the Lymphatic
Glands. — Concluding an article from a previous num-
ber, Oreste Sgambati says that in all cases of mam-
mary cancer there exists, independently of metastasis,
a homolateral tumefaction of the axillary lymphatic
glands, which differs macro- and microscopically from
ordinary acute or subacute inflammations. The
glands have the clinical characters of those really
invaded by cancer; the first traces of cancer in the
glands are usually found in the afferent blood-vessels,
and are followed by more or less pediculated vegeta-
tions on the wall of a lymphatic space or vessel.
Necrosis and the formation of lymphatic infarcts may
follow the complete occlusion of an afferent lymphatic
vessel, with the fibrification in mass of all the glandu-
lar tissue dependent on that vessel. These changes in
the glands are due to some toxic influence proceeding
either from the retrogressive products of the cancer
cells, or from the parasites which may be the etiologi-
cal factors of the neoplasm.
Generalized Hydroa in its Relations to Poly-
morphous Erythema.— Angeloni, concluding an ar-
ticle from a previous number, says that from the clin-
ical facts observed it is evident that erythema iris
and hydroa are identical : that is to say, that a mor-
phological distinction is justifiable only as a conven-
ience in the differential diagnosis between polymor-
phous erythema and pemphigus. Hydroa does exist
without any intermediate phenomena of erythema, and
it is well to recognize this fact, in order not to jump
to the conclusion, in these cases, that we are dealing
with cases of acute pemphigus.
Relation between Intestinal Putrefaction and the
Sterilization of Milk Angelo Volpe from the result
of experimentation and careful observations concludes
that by sterilization the qualities of milk are so
696
MEDICAL RECORD.
[April 21, 1900
changed that its assimilation is rendered more diffi-
cult. In the feeding of infants with sterilized milk,
what is gained on the one hand by a diminution in
the number of bacteria is lost on the other by the fact
that only a portion of the milk is digested, the rest
remaining in an undigested condition in the intes-
tines, where it gives rise to putrefaction, which is not
a harmless occurrence. Rather than submit all milk
to this process of sterilization, the author would in
most cases make sure that the source of the milk sup-
ply is all that it should be, and leave it in its natural
condition.
Meditsiiiskoe Obozrcnie, March, igoo.
A Case of Streptococcal Endocarditis. — G. A.
Guseff reports the case of a lad nineteen years old,
who was brought to the hospital suffering from fever,
right-sided hemiplegia, and loss of speech. A year
before he had had acute articular rheumatism, follow-
ing which he suffered from dyspnoia and palpitation
of the heart. In about two months he returned to
work in pretty fair condition. He was again taken ill
about three weeks before admission, and a week later
he fell, losing consciousness, and when taken home
was found to have hemiplegia and aphasia. On ad-
mission he had a temperature of 99.5° F., and a pulse
of 98. A diagnosis was made of endocarditis, the cere-
bral symptoms being due to embolism. Examination
of the blood revealed no micro-organisms, but there
was a marked leucocytosis with predominance of
multinuclear forms. Cultures made from the blood
showed the presenee of streptococcus pyogenes albus.
Two injestioHS of antistreptococcus serum were made.
After ea«h there was a fading out of an erysipelatoid
eruption on the forearm, but the temperature rose and
the general condition was made worse. The parents
removed the patient from the hospital, fearing a repe-
tition of the injection, and he died soon afterward.
Malarial Insanity. — Alexander Ivanoflf says that
malarial psychoses may ocGur under two forms: (i)
Periodical malarial insanity, occurring only on the
day of the paroxysm, which may either be accom-
panied by other symptoms on the part of the temper-
ature, pulse, etc., or be the only manifestation of the
malarial infection. (2) Post-malarial insanity which
develops after the subsidence of the febrile attacks or
during a malarial cachexia. He attributes the occur-
rence of the psychical disturbance to the direct action
of the malarial toxin on the cerebral cortex, or to the
poor nutrition of the latter, because of the diminished
ha;moglobin and the consequent lessened oxidation.
Tlie prognosis of malarial psychosis is very good.
The treatment is antimalarial and symptomatic. Six
cases are reported.
A New Method for the Closure of a Vesico- Vaginal
Fistula. — S. Spasokukotski operates as follows: He
passes a loop through the vesical mucous membrane
on each side of the fistula, and by pulling on these
everts the edges of the opening toward the vagina.
Then he cuts into the connective tissue between the
vaginal and the vesical mucous membranes. Now the
loops are threaded through the eye of a large blunt-
pointed probe, which is passed through the urethra,
thus drawing the vesical flaps of the divided vesi-
co-vaginal septum into the bladder and approximat-
ing the raw surfaces. Finally, the vaginal flaps are
brought together by sutures, with their raw surfaces in
apposition. The writer reports several cases in which
his method was employed with success.
Treatment of Cicatricial Stenosis of the Pylorus.
—A. Th. Kablukoff reports two cases of stenosis of
the pylorus following cicatrization of gastric ulcer, in
which a Heincke-Mikulicz operation was performed
with successful result.
A Receptacle for Suture Materials By G. Graefe.
(fPXiuical §cpnvtmznt.
HOW TO SEND MOIST ANATOMICAL SPECI-
MENS BY MAIL.
By FREDERICK T. GORDON,
HOSPITAL
AGUE ISLAND,
It is often both desirable and necessary that specimens
for sectioning should be kept in their appropriate pre-
serving solution while being transported by mail and
express, lest they dry out, shrink, and become wholly
spoiled. The postal regulations act as a bar to the
sending by mail of bottles containing liquids unless
certain precautions are taken, and it is sometimes very
difficult so to pack specimens that they may arrive at
their destination in the proper condition. Necessity
being the mother of invention, the writer had recently
to find a means of surmounting these difficulties, and
the method used has so far given perfect success. It
is, in brief, as follows:
A bottle is to be selected of a capacity twice that of
the bulk of the specimens to be mailed, and fitted with
a sound cork. The specimens are taken out of the
preserving fluid (alcohol, etc.) and rolled up in pieces
of lint, turning the ends over and twisting them tight;
then this bundle is dipped into the preserving fluid
and any excess squeezed out. The roll is placed at
the bottom of the bottle. The next specimen is pre-
pared in the same way, and so on until all are wrapped
up in their saturated coverings of lint and packed into
the bottle. Then a wad of absorbent cotton is taken
large enough to fill the remaining space in the bottle,
dipped into the fluid, and the excess pressed out,
and then it is packed snugly on top of the rolled-up
specimens. The bottle is corked tight and sealed with
paraffin or wax, wrapped in paper in the usual manner,
and addressed for mailing. There will be no liquid
to spill if the bottle is broken.
The rationale of this method lies in the presence of
an atmosphere saturated with the vapor of the pre-
serving-fluid in the bottle, it thus being impossible for
the solution to evaporate from the specimens and leave
them dry and hard. The method is as applicable to
a specimen half a cubic inch in size as to an entire
tumor or organ; the ease of its details and the cheap-
ness are arguments in its favor, to say nothing of the
convenience in being able to send the most delicate
specimens absolutely safely by mail or express. If the
bottle is not uncorked, the contents will preserve their
freshness endefinitely ; the writer has had a bottle with
two sections imbedded in celloidin for a month before
opening, and the celloidin was as fresh and in as good
condition when opened as when packed. Moreover,
by making the package weigh lighter, there is quite a
saving in postage.
It is also suggested that the same method might be
of use in preserving large specimens when it is impos-
sible to secure enough preserving fluid to cover them
at the time. They should be wrapped in lint saturated
with the appropriate fluid, and packed into a bottle or
jar with a wad of absorbent cotton soaked in the same
fluid and corked tightly.
Ununiting Fractures, it was thought, might be
beneficially influenced by thyroid opotherapy, but the
experiences of Ciuinard, Poirier, and Rochard oppose
this view. — Gaz. Hebdom., January 4th.
April 2 1, 1900]
MEDICAL RECORD.
697
<£javvzsvoni\cncc.
MEDICAL ASPECTS OF THE SOUTH AFRI-
CAN WAR.
(From our Special Correspondent.)
The Prolongation of the War is now, I think, inevi-
table. At the beginning of fighting, Christmas, 1899,
was fixed by the British public as the probable date
for the cessation of hostilities. When the fall of
Kiniberley or that of Ladysmith was expected to occur
any day, opinion flew to the opposite extreme and the
British spoke of preparations to carry on a guerilla
war for ten years if necessary. Then came Lord Rob-
erts' victories, and Easter, 1900, was popularly accept-
ed as a convenient and Jitting date for unfurling tlie
Union Jack at Pretoria. But by the end of the first
week in April it has become obvious that the Boers
may be able to make effective resistance for at least
twelve months, though, of course, they may decide not
to do so. But Lord Roberts cannot move until his
cavalry is remounted; for witliout cavalry he cannot
clean up the Orange Free State behind him, while he
dare not go farther forward while his lines of commu-
nication are so seriously menaced as Colonel Broad-
wood's recent experience and the disaster to the Irish
Rifles show to be the case. A long and waiting game
— just the game to allow the Boers time to recover
their courage and reorganize their defences — is forced
upon the British commander-in-chief. The medical
aspects of this prolongation of hostilities are obvious.
The British troops — a large proportion of whom are
quite young men unused to campaigning or severe cli-
matic influences — will have to spend the inclement
season of the year under canvas or actually fighting;
and camps, the sites of which will be dictated by other
than sanitary considerations, will have to be formed.
It is certain that there will be a great increase in sick-
ness among the invading troops, who, save when be-
leaguered and actually suffering from hunger, have so
far enjoyed a remarkable immunity from disease. It
is almost certain that as the South African winter
draws on there will be among the soldiers of both sides
many more cases of pneumonia, typhoid fever, and
malaria, and when this occurs the medical arrange-
ments that so far have been sufficient may fall terri-
bly short of the ideal. For there will be, perhaps and
most probably, stubborn fighting as well as much sick-
ness. Hitherto on the Boer side the losses have been
small and the medical care required small also; while
the British Royal Army Medical Corps, supplemented
by excellent civilian aid, has proved competent to
keep abreast with the demands of the much more nu-
merous English wounded. But if many victims of epi-
demic sickness are added to the same proportion of
wounded men in the future, the English medical staff
will require much augmenting. I think it should be
reinforced already.
Sickness among the Boer Prisoners. — There is a
great deal of sickness on board tlie transports lying off
Simonstown, in which the Boer prisoners are confined.
Typhoid fever and measles have broken out, and up-
ward of two hundred cases are serious ones, while at
the end of March two or three deaths occurred daily.
Everything has been done for the sick that skill and
humanity can suggest.
Expanding Bullets That some of the Boer com-
mandos are using expanding bullets has been proved
by the actual finding of such bullets upon prisoners
and in deserted laagers, but the changed character of
the wounds of the British soldiers at Paardeberg would
have suggested this without further evidence. Many
of the wounds involving soft parts only have lately ex-
hibited characters quite out of keeping with the injuries
inflicted by ordinary Mauser bullets, while primary
amputations have become more numerous as a result
' of the increased difficulty of keeping the wounds free
from suppuration. Mr. G. H. Makins, one of the
civilian consultant surgeons to the British forces, has
made some pertinent remarks upon this point, and his
evidence will convince all fair-minded people that the
British complaints as to the use of expanding bullets
have not been unfounded.
The Irish Hospital is located at Naauwpoort, and
a contingent under Dr. George Stoker has gone up to
De Aar.
The Hospital Ship " Princess of Wales " has
been the subject of much adverse criticism. I have
already referred to the unfortunate circumstances at-
tending her start. She left Tilbury dock on Novem-
ber 23, 1899, but had to stop almost immediately
through some accident. She started again and had to
put into harbor at Sheerness. There nothing wrong
could be discovered, and she went to sea and arrived
at Cape Town on January 8, 1900, taking forty-seven
days to do a journey which ordinary transports do in
a fortnight. At Cape Town certain repairs were found
necessary, and all the electric lights had to be over-
hauled, and the return journey to England occupied
nearly as long as the journey out. To some extent
the long time occupied is accounted for by the fact
that the Princess of JValfs is only an eleven-knot boat,
but there seem to have been considerable carelessness
and negligence as well, into which there will be an
official inquiry. The practical utility of using such a
slow vessel to transport the sick and wounded is very
doubtful, and most medical men at the seat of war
consider that the value of hospital ships is mainly as
stationary hospitals. Well-found transports doing the
journey from Cape Town to England in a fortnight are
much better for conveying the sick, while operating-
theatres, -T-ray chambers, etc., are not required, as no
patients are sent back to England until their condi-
tion is diagnosed and its acuter stages relieved. As
hospitals, the hospital ships do splendid work. The
Nubia, for example, out of six hundred and seventy-
four cases discharged has sent back four hundred and
forty-three to resume duty at the front.
UNRESTRICTED DIET IN TYPHOID FEVER.
To THE Editor of the Medical Record, •
Sir: The tenor of the article in the Medical Record
of January 6, igoo, by Dr. Morris Manges, on "The
Diet in Typhoid Fever," is so much in accord with
the extensive, though not tabulated experience I have
had out here in Asia that I gladly add my mite of
confirmation to it. In a communication to your jour-
nal which was published in the issue of February 5,
1898, I wrote: ''Affections that would confine Anglo-
Saxons for two weeks are thrown off here in half the
time. Whether no restrictions as to food in fevers,
and a little more trusting to nature than is usual, have
anything to do with it or not, is an open question."
I have long been of the opinion that an unrestricted
diet in fevers — and I came first to allow it because I
could not help myself, treating so many in their homes
and with them so ignorant of even the simplest meas-
ures— I have come to think that an unrestricted diet,
trusting to the craving of the patient largely, instead
of doing harm actually does good. I cannot assert
that many of my cases were the usual typical text-book
typhoid-fever cases. On the contrary, most of them
seem to be mixed. The type of which there has been
quite an epidemic the past month or so is of quite a
different character from that which was prevalent this
time three years ago, but the very general recovery
under quinine, phenacetin, and unrestricted diet is a
698
MEDICAL RECORD.
[April 21, 1900
marked feature in common. And while it is true that
by far the most of the cases are malarial, I feel sure
that many would have developed into what we know
as typical typhoid if they had had a chance. I lately
treated in one hovel five patients wlio were taken down,
one after the other, with what, while I would not call
it typhoid here, is what I feel sure, in an American,
would have been that disease; and I am inclined to
think that the free feeding of rice paste and other such
indigestible (?) stuffs so modified the disease, as we
note in the reports of Dr. Manges has been done, that
its typical character never came out.
I wish to report the success of an ordinary and a
liberal diet not only in fevers in general and typhoid
in particular, but also in membranous enteritis as
we have it rather commonly among Americans out
here. The restricted diet reduces the strength of body
and of mind so much that what might be thrown off
in a comparatively short time, and which has done so
in the cases in which it has had opportunity in full
diet, has run on for months under the old plan. This
subject has been well elucidated by Dr. Max Einhorn
in the issue of January 28, 1899, and I am merely re-
porting clinical experience corroborating his plan of
treatment.
Patients who date their recovery from fevers from
the time they surreptitiously obtained some forbidden
food are known to all of us, and one whom I recall,
who attributed his recovery from yellow fever to
molasses cake which he hid in his bedclothes, is in
point. Out here in Asia they do not have to sneak it
in, but their friends give them anything they want,
and as yet, I must say, I have not seen so much evil
resulting from it as I have good. This may not be
scientific and it may shock the laboratorians, but it is
fact, and if you wish to pass it by with the thought
that Asiatics are different from Anglo-Saxons, very
well. All I know about it so far is that they recover
from fevers under unrestricted diet and very simple
medication, with a promptness and an ease which
I longed to see manifested in such cases in private
practice in the Ifnited States before I came out
here to the shining Orient. As everything else — ven-
tilation, or rather, the lack of it, huts low on the
ground (though they have hot floors, which must be a
good thing), no drainage, invariable crowding, and
filth in general — is against them, there must be some-
thing greatly in their favor, for their weak constitu-
tions, rice fed, cannot count for much; so for the
present, and as the drugs used are so simple it can
not be they, I will say it is the unrestricted diet w hich
is the secret, and so I will go on that presumption un-
til some one shows me my mistake about it.
J. Hunter Wells, M.D.
Pye.nuvang, Korea, t'ebruary 27, 1900.
A NAVAL ENCOUNTER IN THE PHILIP
PINES.
Sir: Generally little is interesting in the detail of a
normal case of labor, but it is different sometimes in
our tropical possessions, as the following tale will show.
It is a perfectly true " yarn," and I merely "tell the
tale as told to me," leaving comments to those who read.
It was after mess at district headquarters in the
quaint town of Zamboanga that a handsome young
naval officer, sitting with us, gave his unique experi-
ence. He had been stationed at a place called Bala-
bac, near the most southern end of the Philippines,
with a small detachment of sailors to guard a light-
house. One of his men having a slight wound on a
foot, the officer had been furnished with dressings for
it, and, seeing him apply these dressings, the natives
believed he was "el medico." It should be said this
young gentleman is one of those highly favored indi-
viduals w ho fear naught and are ever ready to go where
work is hardest or most dangerous.
We were sitting on our veranda enjoying the moon-
light on the water and our after-dinner cigars, w'hen
one asked our naval guest to tell his experience as a
doctor. Briefly stating the reason for his being at
Balabac and the dressing of the wound above referred
to, he continued :
"But all I could say would not make the natives be-
lieve I was not a doctor, and one evening a man came
to me and said his wife was going to have a child, and
would I come and help her get rid of her cargo. I
refused, and he persisted, putting down my assertions
of ignorance to modesty ; so at last I gave way, and we
got under way for his shack. When we entered, the
woman was on the floor. She got up shortly and
walked up and down, seemingly in a good deal of pain.
By and by she lay down on the bed, an ordinary
bamboo bed, and sung out something I did not under-
stand, for I know but little Spanish, and she appeared
to heave more than before. Watching, I saw the big
lump in her belly went down a bit with every heave,
but came back again as big as ever, so I concluded
something had fouled inside, and some help was neces-
sary, and I told the husband to board and push, not
punch, with his knees on the top of the lump. He did
— and for fair, and evidently cleared the jam below,
for before long the kid's head came out, and it began
to yell. So did the mother. I took hold of the young
one, and it was easy enough to finish the launch after
his head had come clear.
"There was a string that came along that I did not
know what to do with. However, I took up the slack
so as to give the youngster room to swing in, and then
saw I must cut him adrift. How long a line to give
him was a puzzle, but I decided he would ride all clear
if he had a line the length to his knee; so measuring
I stood by to cut. Then I thought if I let all go the
line might unstrand, so I got some stops ready, making
them out of heavy thread. Now how many stops to
put on was another question; so, to guard against any
chance of the line parting, I put a stop about every
inch and cut away between the seventh and eighth.
The kid being all clear, I shoved it over to an old
woman who was in the room.
'"For all the child was away the lump did not go
down, and I thought there might be more inboard. I
had stowed the fast end of the line back where it came
from as well as I could ; but now to find out if there
was a consort. A little girl was in the room, and, cut-
ting her nails so they could not tear, and disinfecting
her hand and arm, for I had brought my kit along,
some permanganate, two or three darning-needles, and
a pair of scissors, I told her to go up in there and
see if she could find anything. She said she had hold
of something, and, being directed to haul away, she
fetched out some li\'er. Told her to see if anything
else would come away, and I kept her at it until we
had a big heap on the floor of liver and intestines. I
was a little uneasy for fear we had hauled out every-
thing inside of the woman, but, as she seemed easier
and the lump had gone down, I considered that all the
fixings had not fetched away, so I washed down decks,
put the old woman on watch, went back to quarters,
and turned in."
" And — and did the mother and baby live? "
" Oh, dear, yes! But I don't want any more like
cases. Say, doctor, how do you fellows get on in such
foul-weather work ? " L. B.
Two Drops of Spirit of Camphor on the tooth-
brush will produce a fresh feeling in the mouth and
prevent sore tongue, gums, etc.
April 2 1, 1900]
MEDICAL RECORD.
699
NEW YORIv ACADEMY OF MEDICINE.
SECTION ON SURGERY.
Stated Meeting, April g, igoo.
'Charles N. Dowd, M.D., Chairman.
•arcoma of the Sphenoidal Sinus, Removed Three
('ears and Eight Months ago Without Recurrence.
— Dr. Joskph a. Blake presented this case, that of a
woman twenty-four years of age, who had been ad-
mitted to the Harlem Hospital in July, 1896. He
had first seen her on August i8th. At that time the
left nasal fossa had been completely filled with a large
tumor, but there had been no implication of the mus-
cles of mastication. On August 20th, a portion of the
tumor had been removed for examination, and it had
been found to be a round-cell sarcoma. After previ-
ous ligation of the external carotid, the operation for
the removal of the tumor had been undertaken a few
days later. The tumor had been friable and had been
enucleated easily with the fingers. The woman had
made an imeventful recovery, and had left the hospital
in two week;?. The vision of the left eye was perfect.
There had been no eye symptoms except a slight
diplopia when not wearing glasses.
Ligation of the Subclavian Vein for an Arterio-
venous Fistilla. — Dr. John F. Erdmann presented
a young man upon whom he had performed ligation of
the subclavian vein for an arterio-venous fistula, the
result of a gunshot wound received in August, 1898.
.The bullet had lodged in the supraspinous fossa, and
had been removed a few days later. At. the operation
it had been found necessary to saw through the clavi-
cle. The communication between the artery and vein
had been about one inch and a half in width. The
functional result had been perfect, so that his injury
in no way interfered with his occupation, which was
that of an acrobat.
Persistent Suprapubic Fistula following Lithot-
omy on a Prostatic ; Cured by Bottini's Operation.
— Dr. Willy Meyer presented a man aged forty years,
who had come under his care in November, 1898, with
a urinary trouble that had existed since 1891. Physi-
cal examination had revealed the presence of vesical
calculi and a moderate prostatic enlargement. There
had been at this time a very marked catarrh of the
bladder. He had opened the bladder from above
on November 25, 1898, removing three rather large
stones. The bladder had been in wretched condition
at the time, and as a result some tissue had sloughed
away. At the end of the fourth week the patient began
to pass urine through the natural channel, but a fistula
persisted. When seen on October 5, 1899, '^'^^ "^^"
stated that only about half of the urine passed through
the normal channel. On October nth three incisions
had been made into the prostate, according to the Bot-
tini method, and without the slightest reaction result-
ing. The patient soon began to pass a much larger
quantity of urine through the normal channel, and
less through the fistula. The latter had been tortuous
and funnel-shaped, and efforts to secure its closure by
injections of balsam of Peru had failed completely.
He had then introduced 200 c.c. of water into the blad-
der, and had followed this by V\ xv. of pure carbolic
acid. Alcohol had next been introduced to neutralize
the acid. As a result of this treatment the fistula had
healed promptly.
Removal of Half of the Tongue. — ^Dr. B. Far-
quhar Curtis presented a man, sixty-two years of age,
having a negative previous history. He had used a
pipe moderately. About September 15, 1899, he had
noticed a small fissure on the left side of the tongue,
apparently due to the irritation of a sharp tooth. He
had been admitted to St. Luke's Hospital in February,
and on the 2 2d of that month the operation had been
done. The Kocher incision had been made below
the jaw and a flap turned up, but left attached. The
mouth being held open with the Whitehead gag, the
tongue had then been drawn forward and split, and half
removed. All of the tissues in the floor of the mouth
had been removed at the operation. The patient had
made a very rapid recovery. The tip of the tongue
had been turned around to one side and secured with
three or four sutures in order to avoid the disagreeable
narrow point left. Although it was only six weeks
since the operation, he had regained the use of his
tongue, and could talk fairly well.
Removal of Half of the Tongue with Removal
of the Tonsil. — Dr. Curtis also presented a man of
sixty years who had been admitted to the General
Memorial Hospital on December 15, 1899. At that
time he had been suffering great pain; the saliva had
been dribbling from the mouth, and there had been a
deep ulcer at the tonsil extending over to the root of
the tongue. However, the mouth could be freely
opened, showing that there was no involvement of
the pterygo-maxillary parts. The operation had been
done on December 7th, beginning with the Mikulicz
method. The vertical incision had also been made
over the carotid. After separating the periosteum the
ramus had been divided, and twisted out of its socket
without any division of the soft parts above. This
operation had always given him free access to the ton-
sil, and perfect control of hemorrhage. With the fin-
ger in the mouth, hemorrhage could be stopped en-
tirely, or the bleeding point could be turned out and
secured. This method of operating, particularly in
elderly people, was far better than by dividing the
jaw. The growth had been cut away, including the
entire tonsil and wall of the pharynx. The tongue
had been found extensively involved, and hence it
had been removed by the method of splitting it
and dividing it at the root. The man had made a
rather slow recovery, but the result was good. This
method of operating seemed to him far better than the
splitting of the cheek or dividing the jaw vertically as
was done so often.
Resection of the Rectum and Anastomosis by
Maunsell's Method. — Dr. A. A. Berg presented a
woman who had been admitted to the Mount Sinai
Hospital on September nth with a history dating back
about eighteen months. For a few weeks previously
blood had been passed in the stools. She was slightly
cachectic. About three inches from the anus the rec-
tum was constricted by a tumor. The growth was
movable over the sacrum, and the vagina was not in-
volved. On September 15th, under chloroform anaes-
thesia, he had removed the rectum. He had first cut
down upon the rectum, and freed it up to the peritoneal
reflexion. He had then opened the peritoneal cavity
and drawn down the peritoneum and sigmoid flexure.
He had ne.xt closed the peritoneal cavity before open-
ing up any channels of possible infection. The supe-
rior hemorrhoidal artery had been ligated and divided
so that there had been almost no loss of blood. Hav-
ing resected about six inches of the rectum the proxi-
mal end of the rectum had been inverted into the distal
end by the Maunsell method. The patient had been
in bad condition at the time, and hence this method
of inversion had been adopted as the most rapid and
the safest under the circumstances. The patient had
rallied well from the operation, and there had been no
leakage after the third day. The patient had insisted,
however, on lying on the back, and as a result there
had been a marginal necrosis, ind, on the sixth day
there had been a fecal discharge from the opening on
700
MEDICAL RECORD.
[April 2 1, 1900
the posterior margin of the anastomosis. On Decem-
ber nth Dr. Gerster had operated to close the fistula.
The mucous membrane had been dissected free and
inverted, and the fistula closed with the Lembert
suture. There was now considerable induration at the
site of the anastomosis, but not so much as had existed
some time ago. It was possible that some of this in-
duration was due to a recurrence.
A Rapidly Recurring Carcinoma. — Dr. George
K Brewer presented for Dr. H. Lilienthal a woman
who had been admitted to the Mount Sinai Hospital
on September 17th with a marked carcinoma of the
left breast and glandular involvement. On September
26th the radical operation had been done, including
the removal of the pectoral muscles; yet on January
31st she had been readmitted with a recurrence. At
this time she had been found in very poor condition.
Dr. IMunde' had done a double salpingo-oophorectomy,
and since then improvement had been very marked
and rapid.
Dr. T. H. Manley, speaking of Dr. Erdmann's
case, commented upon the excellence of the collateral
circulation after this operation, and also upon the ad-
mirable shoulder action that the man was said to have
had even while there had been only ligamentous union
in the clavicle. In this case the lumen of the vein
had not been occluded. The collateral circulation
had been so well restored that the radial pulse could
be felt on that side eight months ago.
Dr. Willy Meyer said that in cases like those
presented by Dr. Curtis he had been accustomed to do
a tracheotomy and insert a tampon cannula, provided
the patient was operated upon in the ordinary recum-
Ijent position. With the Kocher operation there was
great risk of the blood entering the trachea.
Dr. Erdmann remarked that by the use of the
Trendelenburg position the necessity for a preliminary
tracheotomy was avoided.
Dr. a. a. Berg said that recently Dr. Gerster had
done a resection of the superior maxilla for a retro-
nasal sarcoma, and had done a low tracheotomy. Fol-
lowing the latter operation there had been an inflam-
mation bet\veen the pericardium and the pleura, and,
as a result of this process in the mediastinum, the
patient's life had been in great danger for some time.
This was another reason for avoiding tracheotomy in
such cases.
Dr. William B. Coley thought that in some cases
tracheotomy greatly facilitated the operation. In a
case that he had presented to the Surgical Society a
preliminary tracheotomy had been done, the glands of
the neck removed, and the Unguals tied.
Dr. Franz Torek said that if one wished to pre-
vent blood from running down into the trachea it was
not sufficient to lower the head slightly, but the head
should be allowed to hang down completely over the
end of the table. This was not the ordinary Trende-
lenburg position.
Dr. Charles N. Down said that by the method of
operating employed in Dr. Curtis' cases hemorrhage
was almost entirely avoided by the ligation of the
lingual arteries in the first stage of the operation;
hence there was but little reason for doing a trache-
otomy. He had seen the operation on Dr. Curtis' sec-
ond case, and the hemorrhage had been under full
control. He could not but think that the danger of
allowing blood to run into the throat had been exag-
gerated, especially in view of the many cases of opera-
tion on children suffering from adenoids.
Dr. James P. Tuttle, referring to Dr. Berg's case,
said that while he could not say positively that this
was a recurrence, there was present what he had seen
in every other case in which he had used the Maunsell
method, i.e., a stricture. This stricture was very much
more marked by the Maunsell method than by the end-
to-end method or by the use of the Murphy button. If
after the gut had been brought together by the Maun-
sell method, or by end-to-end union, a large-sized silk
suture was passed into the lower rectum and brought
down and sutured rather tightly into the edge of the
skin wound, the parts were relieved from tension. If
this was done there was very much less risk of fistula.
This anchoring suture could be cut away in four or
five days. His own three cases, and the one just re-
ported by Dr. Berg, in which the Maunsell method
had been employed, were certainly very discouraging
for those desirous of using this method.
Dr. Maxley said that in one case of recurrent car-
cinoma of the breast which had reached the operable
stage he had adopted this plan of removing the ovaries
and tubes, although the woman was forty-seven years
of age. The operation had been followed by a very
decidedly beneficial effect on the growth in the breast.
He had also followed the suggestion of the originator
of this plan, /.c:, to administer after the operation the
thyroid extract, and he thought the result had justified
its use.
Dr. Coley said that the improvement in these cases
following the removal of the ovaries seemed to him
to be entirely explicable by the change in the blood
supply. He did not think there was a single case on
record in which the improvement following this opera-
tion had been of sufficiently long duration to warrant
one in considering it a cure.
The Relative Bearing of the Conjoined Tendon
and the Internal Oblique Muscles upon the Radi-
cal Cure of Inguinal Hernia Dr. Joseph A.Blake
read a paper with this title. He said that by the con-
joined tendon was usually understood the insertion of
the lower fibres of the internal oblique and trans-,
versalis muscle, extending along the ilio-inguinal line
laterally for a short distance. As a rule the lowermost
fibres of the internal oblique did not form a part of
the conjoined tendon. The speaker said that he had
made a series of observations in the dissecting-room
on twenty-five subjects, and had found that the con-
joined tendon never extended on the internal surface
of the rectus more than five-eighths of an inch. In
all cases it consisted only of scattered muscular fibres.
The true conjoined tendon was ordinarily such a weak
affair that it was negligible in operations. In the
radical cure of hernia the main reliance of the surgeon
must be the external oblique. As a rule it was futile
to attempt to drawdown the transversalis aponeurosis.
The author closed his paper by a consideration of
various operations for hernia, and the parts usually
divided in the incision, as on this point, he said, there
had been some confusion in the pufjlished descriptions
of the operations.
Dr. William B. De Garmo said that in the Bassini
operation he had been in the habit of separating the
internal oblique from the fascia beneath and the ex-
ternal aponeurosis above, so that it came down to Pou-
part's ligament without undue tension. He had not
felt that it was necessary in any case to split the
rectus. Even in the largest hernias he had succeeded
in closing them by the Bassini method pure and sim-
ple. His first puncture of the internal oblique and
transversalis was made considerably higher than that
of many other operators. He did not cut the muscular
fibres passing above the cord ; he stripped them up and
tried to preserve them. He had operated upon over
six hundred unselected cases, and there had been only
six recurrences. These patients had been of all ages
— from five months to extreme old age.
Dr. Coley said that the cutting of the fibres of the
internal oblique had ahvays seemed to him a great
defect of the Halsted method. In the Bassini opera-
tion, as he had done it, great care had been taken not
to cut these fibres. By thoroughly freeing the apo
April 2 1, I goo]
MEDICAL RECORD.
701
neurosis over the internal oblique, and bringing the
internal oblique from the transversalis fascia below,
he had never experienced an)- difficulty in bringing the
fibres down easily to Poupart's ligament. The only
conditions in which Bloodgood's operation seemed
indicated were in cases of large direct hernia. E\en
in the few cases of this kind that he had had there had
been no difficulty in securing good apposition of the
parts and firni union without splitting the rectus.
Such division of the muscle seemed to be called for in
only a very small number of cases.
Dr. J. P. TuTTLE asked what the drawings exhib-
ited by Dr. Blake showed that had not been brought
out by Alexander H. Ferguson in his paper published
last June.
Dr. Blake replied that in Dr. Ferguson's paper it
liad been shown that the internal abdominal ring was
normally situated a considerable distance lateral to
the insertion of the fibres of the internal oblic|ue.
The paper had been entirely upon the anatomy of the
internal oblique muscle. Dr. Blake's paper, on the
other hand, was intended to show just what was meant
by the conjoined tendon.
Preliminary Report and Demonstration of a New
Method of Sterilizing Catgut.— Dr. C. A. Elsber(;
presented this report. He said that there was much
difference of opinion regarding the relative value of
the non-absorbable ligatures and the absorbable ones.
The use of catgut had been considerably curtailed by
the difficulty of uniformly securing complete steriliza-
tion without interfering with certain properties of the
catgut. Sterilization by dry heat had been recom-
mended, but time, care, and special apparatus were
required. Most of the fluids that had been used for
this purpose were inflammable, or their vapors were,
so that they must be boiled in special apparatus.
Formalin catgut was often excellent, but under the
same conditions of preparation it was sometimes soft
and strong, and at other times hard and fragile. This
catgut was absorbed somewhat more slowly than that
which was prepared by other methods. Prolonged
immersion in dilute solutions of antiseptics required
time, and the catgut so prepared was not always relia-
ble. Sterilization by dry heat was impracticable.
The requisites for good catgut were sterility, strength,
softness, and pliability. In the method about to be
described he had made use of a very well-known
chemical principle, i.e., that animal substances were
insoluble in solutions of those drugs by which they
were themselves precipitated. Thus, ammonium sul-
phate was precipitated by albumin, and therefore
albumin was insoluble in solutions of ammonium sul-
phate. This substance was made use of in this con-
nection, and certain hitherto unknown properties of
this substance had been discovered and applied in the
new method of sterilization about to be described.
Technique The fat should be removed from the
catgut by immersion for forty-eight hours in a mixture
of one part of chloroform and two parts of ether. The
catgut should be wound tightly in a single layer on
spools. The chloroform and ether mixture was then
allowed to evaporate. The spools were' next boiled
from ten to thirty minutes in a hot saturated solution
of ammonium sulphate in water. This solution was
made by adding chemically pure ammonium sulphate
to boiling water until saturated or almost saturated.
This salt was a neutral salt which became acid on
boiling. It boiled at 22o"-226° F. When the spools
were removed from the boiling solution, some of the
salt crystallized out upon them, but this was removed
by a momentary immersion in a cold or warm sterile
water. It might then be preserved dry, or in alcohol.
Careful experiments showed that the catgut was as
;trong as before treatment, and sometimes stronger,
[t was readily absorbed in the tissues in from four to
eight days. Bacteriological experiments showed that
the catgut was always sterile after boiling in the am-
monium-sulphafe solution for five minutes. The cat-
gut could be chroiTiicized by boiling it in a chromic-
acid solution of the desired strength. It was probable
that catgut could be made more or less absorbable at
will, depending upon the strength of the chromic-acid
solution. His experiments on this point were not yet
completed. Ordinarily the catgut siiould be boiled for
twenty or thirty minutes in a saturated solution of
ammonium sulphate in a i : 1,000 chromic-acid solu-
tion. The ammonium-sulphate solution could be used
over and over again. As this salt costs only fifteen to
twenty-five cents per pound, the method could not be
said to be expensive; moreover, the solution was non-
inflammable, and the method was so simple that no
skill or elaborate apparatus was necessary. As a rule,
the catgut should be boiled in the saturated aqueous*
solution of ammonium sulphate for from ten to twenty
minutes. A method founded on the same principle,
though somewhat modified, could be applied to the
sterilization of sponges or other material of a similar
nature.
Dr. Georc;e E. Brewer said that he had made some
tests with this catgut in hospital practice, and had
found it very soft and pliable, and exceptionally
strong. The method was- so simple that the profession
should feel greatly indebted to Dr. Elsberg.
Dr. Willy Meyer said that for many years he had
been accustomed to prepare his catgut by immersion
in a I : 1,000 watery solution of bichloride of mercury,
and preserving it in alcohol. However, the method
just described seemed to be more in accordance with
modern ideas of aseptic surgery. He would like t'
know if the raw, cheap catgut could be sterilized \\
this manner.
Dr. Blake said that it was admitted that to insure
perfect sterilization there should be hydration of the
albuminous elements, and hence the objection to dry
sterilization or to boiling in alcohol. The method
just presented subjected the albuminous materials to
this process of hydration.
Dr. Elsberg said that he had tried a great many
difTerent grades of catgut, obtained from various man-
ufacturers, and the bacteriological results had been
absolutely identical in all of them, though the number
of germs in these different grades had varied very
greatly. It was important to wash out the ammonium
sulphate after boiling, by immersion and agitation
either in sterile water or in a solution of bichloride
or of carbolic acid. This catgut had been used by
Dr. Gerster in several herniotomies and in one very
extensive radical operation on a carcinomatous breast
in which over one hundred ligatures had been used, and
the results had been perfect.
THE MEDICAL ASSOCIATION OF THE
CxREATER CITY OF NEW YORK.
Stated Meeting, February 12, igoo.
Robert F. Weir, M.D., President.
Inaugural Address: Remarks on the Formation of
an Artificial Anus (see page 661).
Report of a Case in which the Operation was
Done, with Remarks. — Dr. \\. Gill Wylie, re-
ported the case of Mrs. N. M , aged forty-five
years, who had been married twenty-five years. Her
family history was negative as to cancer. Her gen-
eral health had been good. At sixteen years of age
she had had typhoid fever. She had had no intestinal
affections previous to the present trouble. During
May, June, and July of 1898 she had chronic intes-
702
MEDICAL RECORD.
[April 21, 1900
tinal obstruction, followed by jaundice in August.
She had, at that time, vomiting, obstipation, and a
great deal of pain in the abdomen. The jaundice
slowly disappeared. In September, during an attack
of acute obstruction, she was operated upon at Clifton
Springs. She had a left inguinal colostomy performed,
and the surgeon thought the obstruction was due to
"bands." In November, 1898, an exploratory lapa-
totomy was done by one of the surgeons. He found a
tumor of the bowel as large as a goose-egg in the
splenic flexure of the colon, and the artificial anus was
apparently made in the hepatic flexure. He thought
there was a carcinoma of the gut, and closed the inci-
sion. Since then the patient had been perfectly well
up to four weeks ago (the history was taken July 5,
1899). Then she began to have pain in the left side
and back, which became constant and caused her con-
finement in bed. There were no bladder symptoms,
no chills, no nausea, no constipation, but the temper-
ature ran daily between 99° and 103° F. On July 9,
1899, operation was performed. Aspiration brought
pus; then a free incision was made in the lumbar
region and about two quarts of very foul-smelling pus
was evacuated. A small sinus apparently communi-
cated with the bowel. With the hand inserted into
the cavity nothing could be felt but an apparently
small stump of the left kidney. The wound closed
up by granulation. On January 1 1, 1900, she returned
and the artificial anus was closed. The bowel was
freed from the edge of the skin and separated very
carefully downward, freeing the fascia without open-
ing the peritoneal cavity. The mucous membrane was
first stitched, then came the muscles; and finally Lem-
bert sutures of silk were introduced into the peritoneum.
The fascia and abdominal wall were closed in the
usual way with silk.
Discussion. — Dr. Robert Abbe said that if an arti-
ficial anus could be made to contain fluid this would
be an admirable procedure. To-day the operation
was much more often done than a few years back, es-
pecially when a bad cancer was situated below. If
such a procedure could be resorted to he believed that
it should be done in every case of inoperable cancer,
in order to give patients better health. His own ex-
perience had been with the Maydl method, which he
found very satisfactory; but in the future he certainly
would adopt Dr. Weir's method. Maydl's method
had certain advantages; for instance, in most cases
the operation could be done under cocaine anasthesia ;
probably one-half of all the cases could be done in
this way. He had resorted to the use of the inter-
muscular method, but it did not seem to him to be of
great value, having certain disadvantages; the two
ends of the intestine could not be brought through the
intermuscular layer with the same satisfaction as to
the future closure of the opening as when brought out
through the end of the wound. If it was desirable to
get the two ends .separate we must go through the deep
muscular layers of internal oblique and transversal is
muscles, because, when the two ends wert brought out
of the wound, there was not enough room to unite the
skin well together. Returning the lower end of the
intestine was the most popular method, and he had
adopted it in the last two or three of his cases. This
got it out of the way; it was perfectly innocent; the
slight secretion of mucus discharged itself. Inverting
the lower end, at the same time handling the upper
end, was not easy in cases of stout people; sometimes
extensive epiploic masses became very troublesome;
if the attempt to invert was made, the question arose,
whether it could be done satisfactorily. The ends
popped out; if they were cut off there was slight hem-
orrhage; therefore, with fat people he thought it was
very difficult to invert. The question of circulation
should not be overlooked in bringing out the upper
portion of the bowel; occasionally gangrene of the
distal end had occurred because the circulation had
been none too good.
Dr. William B. De Garmo said his experience had
been largely mechanical in trying to prevent leakage.
He appreciated the importance of trying to secure
some operation that would aid in preventing leakage
of the bowel. The appliances usually shown had
been in the form of a truss with a hard-rubber pad;
he thought the soft-rubber pad better. He had labored
many hours in trying to adjust appliances to prevent
soiling, but with poor satisfaction. He believed the
operation suggested was a rational one.
Dr. Arpad G. Gerster said that if we would think
back twenty years and recall to memory the status of
colostomy, and compare it with what it was to-day we
all must see an enormous revolution in the operation.
Colostomy was then considered a dreadful thing. It
was then only a palliative measure — to relieve patients
of uncontrollable vomiting. To-day it was one of the
most useful operations. To illustrate : one experience
he had was in the case of a man who was a waiter in
Delmonico's for twelve or thirteen years; he waited
on his various customers with an artificial anus in his
groin, and none of them knew of it. He was able to
attend to his business perfectly well. He recalled
experiences with lumbar colostomy years ago, when
the surgeons dreaded coming in contact with the peri-
toneum; the peritoneum tyrannized every surgeon.
Often the old war-horses, following the old strict pre-
cepts, failed to find the colon, but found the uppe;
part of the small intestines, and so had a most alarm-
ing form of fistula result, which tended to hasten their
patients over to the majority more quickly than other-
wise. This operation became useful only when tlie
bowel was attacked from in front. The greatest draw
back to lumbar colostomy was that the patients couici
not control their movements. This was obviated when
the artificial anus was made in front. Regarding the
various methods he wished to state, from his own ex-
perience and that of his colleagues, that there was no
one operation invented that would obviate all the
drawbacks of an artificial anus, such as leakage, etc.
He believed that the old operation, the old Maydl
procedure, gave just as admirable results in that the
patients could control their bowels. These muscular
methods he did not thir.k were always successful;
certain conditions arose which each surgeon must con-
tend with, and which were peculiar to each individual
case. He called attention to the enormous difference
in the tonus of muscles in various individuals — a
strong muscular man had a tonus of muscles different
from that in a woman who had borne ten or fifteen
children. All this showed that the operation was
not yet what it ought to be. On the other hand, he
stated that old operations had given good results.
Why any operation had not been successful we have
learned to explain in some cases, but not in all. For
instance, in some cases there was found an extremely
long mesocolon; sometimes there was found a short
mesocolon, and then the operator was in a quandary
as to further procedure. The status of the colon was
very important. Prolapse could be prevented by with-
drawing as much as possible of the bowel, making a
tense mesocolon, and then sacrificing to prevent ever-
sion of the mucous membrane. Most disagreeable
effects were produced by the irritation of the skin,
which was caused by the irritable qualities of the
acidulated contents of the intestines. If the intes-
tinal contents were neither alkaline nor neutral, but
acid, an eczema would be produced which was difficult
to control. The speaker emphasized the importance
of intestinal hygiene, regulation of the diet to keep
the fteces solid, often dosing with alkalies; he advised
experimenting with the patient to learn what diet
April 21, 1900]
MEDICAL RECORD.
703
would keep the faeces solid in consistence. If tiiese
endeavors proved successful, large scybala would act
as in the rectal pouch, and would produce an energetic
contraction of the bowel, and the whole mass would be
expelled.
Methods of Closure. — Very frequently and very
fortunately, surgeons were called upon to close an
artificial anus after its purpose had been fulfilled.
This was one of the most agreeable duties a surgeon
had to perform. The two methods were (i) extra-
peritoneally ; (2) intra-peritoneally. The extra-peri-
toneal operation was less risky, yet a great drawback
was the fact that it so often resulted in ventral hernia.
In women this was very disagreeable. He could
hardly indorse the opinion expressed by the president
that it was best to dissect away the colon from its ad-
hesions, invert it, and then perform the radical opera-
tion for the cure of a ventral hernia.
Dr. Howard Lilienthal said that an artificial
anus could be made wind and water tight by the Ger-
suny method, in the sacral region. He was glad that
Dr. Gerster had referred to the changed conditions re-
garding colostomy, and especially that he had brought
it before this society. Many family physicians had
old-fashioned ideas that the formation of an artificial
anus meant an earlier grave; he did not believe that
too much could be done to get rid of that idea. In
spite of what Dr. Gerster had said regarding the closure
of an artificial anus, he certainly believed that tiie
danger was a pretty real one. He had had the hard
luck to lose one patient in closing an artificial anus.
The disease had been cured, but the patient died from
his attempts to close the artificial anus. He believed
that such a tiling could happen, and it ought to make
us more careful in advising colostomy in every case of
cancer. He was not afraid of the operation, but he
thought that patients should be made aware of the
dangers in closing an opening of that nature. Re-
garding the extra-peritoneal method giving rise to
subsequent hernia, it seemed to him that a subsequent
operation could be performed safely. He felt that we
were justified in attempting to close these openings
extra-peritoneally.
Dr. George Woolsev confessed that he still re-
tained a certain dislike to the formation of an artifi-
cial anus belonging to that class called the permanent
type. The reason had already been mentioned, that no
operation had been invented that could control the
evacuations. Personally he had never tried the oper-
ation reported to-night, but so far as the control of
the movements went it seemed to him that it was better
than Maydl's, which he had used. Regarding Dr.
Abbe's question in reference to the vitality of the in-
testine brought out through the opening, he understood
that it was the lower end of the gut that was necrotic
in the third case of the president's, the upper end not
being affected. He thought that, at the present time,
intestinal anastomosis could in most cases take the
place of the formation of an artificial anus in the
small intestine. When an artificial anus was required
simply as a temporary measure, he thought it might
prove of value. If we had a perfect method of pro-
ducing an artificial anus he thought all surgeons would
admit, the usefulness of the procedure to be very great.
Dr. Markoe said that the protrusion of the mucous
membrane could be prevented by drawing down the
upper loop; in that way there was no question that the
discharge from the upper into the lower loop could be
avoided. At the present time he had two patients in
whom, by slight attention to the food and by a pro]5
erly fitting pad, this was prevented. In the presence
of a diarrhcea there was no remedy for this great draw-
back. By attention to intestinal hygiene he thought
we could get a fair control. The relief of pain and of
a certain amount of sepsis by the establishment of an
artificial anus in cases of ulcers, carcinomas, etc., he
thought was very marked.
Dr. Brewer said that if the operation was done in
the region of the ca:cum there was less likely to be
gangrene than if it was done in the descending colon;
the anastomosis there was freer.
Dr. Robert F. Weir closed the discussion. He
believed the determining question was the possibility
of gangrene in that portion given back into the ab-
dominal cavity.
l^ccXicat Items.
A Trichobezoar (hair tumor) weighing 160 gm. in
a dry state, and removed by laparotomy from a twelve-
year-old girl, was demonstrated by Schopf on October
27, 1899, at the Gesellschaft der Aerzte of Vienna.
The girl, from her fifth year on, had been in the habit
of biting at her hair. About a year before the time of
operation the patient began to vomit and to have pains
in the stomach; a tumor appeared in the region of the
stomach, and was diagnosed as a Hoating kidney. A
long process of the hair tumor extended into the duo-
denum. With the operation all disagreeable symptoms
disappeared. According tA Schopf bezoars are com-
mon in animals (horses, goats, cattle, swine, etc.), but
only sixteen cases have thus far been described in
man, and of these seven have been cured by operation.
— Wiener med. Blatter, No. 44, 1899.
Traumatic Aneurism of the Carotid Artery
Caused by a Sewing Needle. — Douty {Laiurt, De-
cember 9, 1899, p. 1584) reports the case of a man,
sixty-two years old, thin but healthy in appearance,
without a history of syphilis or of other previous ill-
ness of importance, who three weeks before coming
under observation began to complain of soreness of
tlie throat, with difficulty and pain in swallowing.
Nineteen days later a lump appeared on the right side
of the neck, and on the following day the patient be-
gan to spit blood. This latter symptom had persisted
for two days. The blood was bright red in color, and
frothy in character. It was generally expectorated in
small quantities, although it was stated that on two oc-
casions the patient had been nearly choked by a sud-
den rush of a pint or more of blood. On examination
a pulsating swelling was found on the right side of
the neck reaching from the angle of the jaw to the
clavicle. A thrill and a loud bruit synchronous with
the systole of the heart were present over the swell-
ing. The area of cardiac dulness was normal. On
auscultation nothing abnormal could be detected in the
heart-sounds except that the aortic second sound was
accentuated. There was no appreciable diliference be-
tween the radial pulses on the two sides, but the right
temporal pulse was markedly smaller than the left,
and also delayed in time. The right pupil was con-
tracted. Digital examination of the pharynx revealed
an ulcer behind and below the epiglottis on the right
side, from which point the blood appeared to come.
The patient was operated upon within a few hours
after coming under observation. The swelling ex-
tended so far down that it was thought necessary to
tie the innominate artery. This vessel was explored,
but the proximal part of the carotid being found
healthy, this vessel was tied with two silk ligatures
about a quarter of an inch from the bifurcation, and
the pulsation of the tumor ceased absolutely. There
was much restlessness after the operation, but this was
controlled by hy^iodermic injections of gr. \ of mor-
phine. On two occasions during the following day
there was marked left unilateral sweating of the face
and head, each lasting for about an hour. A small
704
MEDICAL RECORD.
[April 2 1, 1900
quantity of blood was expectorated. Subsequently the
patient again became restless and the pulse weak, and
death occurred suddenly. On opening the incision
after death the artery was found to be securely tied by
double ligatures, below which there was no aneurisnial
dilatation. The first part of the aortic arch appeared
to be dilated, but when opened afterward nothing ab-
normal was to be seen, and its circumference was found
to be normal. The common carotid was lost in a mass
that was copiously suffused with blood, so that it was
impossible to dissect out the various structures. The
carotid artery, however, did not open into anything like
an aneurisnial sac. In the process of dissection the
mass broke down, and much soft coagulum appeared.
The tumor-like mass was formed below the angle of
the jaw or on a level with the thyroid cartilage. On
careful dissection it was found that the spine was not
affected — i.e., not eroded, etc. — and that the bleeding
had extended behind the pharynx and the oesophagus,
forming a small tumor-like mass on the left, on a level
with the cricoid cartilage. On opening the carotid
and tracing it upward, no aneurismal dilatation what-
ever was found, but on a level with the cricoid carti-
lage there was an eroded opening through which blood
had passed into the parts around, so as to produce the
hemorrhagic tumor-like mass. Just outside, i.e., to the
right of the carotid artery, on a level with the eroded
opening, a sewing-needle was found, point downward
and blackened. On opening the pharynx and the
oesophagus, on a level with the upper border of the cri-
coid cartilage, an ulcer was found opening into a cav-
ity as large as a hazelnut. This cavity was continuous
with the hemorrhagic mass on the left and on the
right. It was, therefore, assumed that the needle had
caused the ulcer and that it had passed through the
oesophageal and pharyngeal walls, and pierced the
carotid artery, producing a traumatic aneurism. There
was neither atheroma nor granular kidney. There
was much redema of the veil of the palate and the
posterior wall of the pharynx, and also of the larynjc.
There was, however, no evidence of paralysis of the
vocal bands, although the right band was cedematous.
Lungs, heart, and brain were normal. It was learned
that the patient had been a beer-drinker, and that he
drank large quantities. A week before his symptoms
had begun, he had, when with friends, drunk a very
large quantity, and more than was good for him. It
is probable that while semi-intoxicated he swallowed
the needle, which became impacted in the pharynx,
working its way subsequently into the carotid artery.
Deadly Drugs are manufactured on a large scale in
Baltimore, and a recent publication of that city gives
many interesting facts connected with their production
and the care necessary on the part of the workmen em-
ployed. Hydrocyanic acid is produced in air-tight
retorts and receivers to obviate the danger from inhal-
ing the fumes, which even in minute quantities are
deadly. While the compounds of copper and sulphu-
ric acid are considered dangerous, the manufacture of
nitric acid seems to be especially dreaded, because of
its volatility. The story is told of the accidental break-
age of a carboy of the acid, setting fire to some saw-
dust and then to a room in which many men were at
work. Four workmen who volunteered to put out the
fire to save the entire works succeeded in their efforts
and were apparently unaffected by the fumes, until
four hours later, when each became ill with distress
in the chest, and in less than an hour all four were
dead.
X-Rays in Pregnancy. — The Lancet, in its annual
review of the Annus Medicus in its issue of December
3Qth, discourses as follows upon the above subject;
"Very little progress appears to have been made in
the use of the ;r-rays in cases of pregnancy. Professor
Varnier, writing in April last, announced that while
he had been able to obtain fairly good photographs of
the child's head and its relation to the pelvis, he had
not so far been able to obtain complete photographs of
the whole fcetal skeleton in any one case. It is pos-
sible to obtain a good idea from an -r-ray photograph
of the volume, position, degree of flexion, and amount
of engagement of the head, but so far no attempts have
been successful with the mother in the dorsal position
in obtaining a complete view of the whole foetal skel-
eton in utero. He believes the difficulty to lie in the
fact that the pelvic and abdominal parts of the uterus
lie in dilTerent planes, and, further, in the extreme
thickness of the intervening maternal tissues — namely,
the back muscles and the spinal column.
Modesty is a characteristic of physicians as a class,
just as it is of all the truly great. Recent literature
has shown one or two lapses. An Australian physi-
cian, for example, has described what he thinks to be a
new affection, and has named it after himself in large
type, instead of waiting for others to pay him the com-
pliment.
Health Reports — The following cases of smallpox,
yellow fever, and plague have been reported to the
surgeon-general of the United States Marine-Hospital
service during the week ended April 14, 1900:
-Un
States.
Cases. Deaths.
Alabama, Huntsville .\pril 4th 19
Mobile April 1st to 7th ti
Colorado, Arapahoe Co March 28th 4
Kl Paso Co March 28th i
I.as Animas Co ..March 28th i
Rio Grande Co . . . March 28th
Weld Co March 28th 3
District of Columbia, Wash-
ington April ist to 7th 6
Illii
Ann
.March i8th I
■4
37th.
Chicago .\pril ist to 7th
Indiana. Evansville. April ist to 7th 3
Kentucky, Covington April 1st to 7th 12
Lexington April ist to 7th 2
Louisiana, New Orleans .. . April ist to 7th 50
Michigan, Detroit April ist to 7th 2
Grand Rapids. . . .April ist to 7th i
Minnesota, .-Vlbert Lee March 20th to 28th 2
Anoka March 20th to 28th 4
Anoka Co March 20th to 28th 1
Buttertield March 20th to 28th .. 2
Duluth March 20th to 28th i
Freeborn Co .... March 20th to 28th 1
Kandigohi March 20th to 28th 5
Minneapolis. ... March i8th to 31st 18
Rice County March i8th to 31st 1
Watonwan Co. . . March 20th to 28th 5
Missouri, St. Louis March loth to 31st 20
Ohio. Cincinnati March 23c
Cleveland April ist t
Pennsylvania. McKeesport. .April 3d to loth 2
South Carolina, Greenville, .Aj>ril ist to 7th 2
Virginia, Roanoke March 30th to 31st 7
Washington, Spokane April ist to 7th 7
Tacoma March 24th to 31st i
Smallpox— United States Insiilar Possessions.
Philippine Islands, Manila. . February 17th to 24th 5
Smallpox — Foreign.
.January ist to 31st 2
.March loth to 17th 3
. March loth to 17th ; . . . 3
February 25th to March nth
.March 3d to 17th 12
. March loth to 17th
. February 22d to March 15th 9
. March 17th to 24th
.March i8th to 25th 11
. March loth to 24th .... 9
. February 20th to March 6th
.March 17th to 31st
March 24th to 31st
. March loth to 24th 15
. March 3d to loth 31
.March 3d to loth
. March 3d to loth
. March i8th to 24th i
Argentina, Buenos Ayre
Austria, Pra.eue
Belgium, Antwerp
Brazil, Cairo
England, London
France, Lyons
Nice
Paris
Gibraltar
Greece, Athens
India, lioinbay
Mexico, Chihuahua
Vera Cruz ....
Russia, Odessa
St. Petersburg
Warsaw
Spain, Corunna
itzerland, fifteen towi
irkey, Constantinople
. February 1 7th to 24th . . .
. February loth to March loth .
.March 19th to 26th .....
. February oth to 23d
March 20th to 27tn 1 ... - 3
. March 24th to 31st
.March 24th to 31st
Plague — United States Insui
Hawaii, Honolulu March 25th
Philippine Islands, Manila. . February loth to 24th..
Medical Record
A JVeekly Journal of Medicine and Surgery
Vol. 57, No. 17.
Whole No. 1538.
New York, April 28, 1900.
$5.00 Per Annum.
Single Copies, loc.
BOTTINI'S OPERATION FOR THE CURE OF
PROSTATIC HYPERTROPHY.'
By willy MEYER, M.D.,
fROFESSOR OF SURGERY AT THE NEW YORK POST-GRADUATE MEDICAL
SCHOOL AND HOSPITAL ; ATTENDING SURGEON TO THE GERMAN AND
NEW YORK SKIN AND CANCER HOSPITALS; CONSULTING SURGEON TO THE
NEW YORK INFIRMARY.
Mr. President and Gentlemen: Bottini's operation
for the cure of prostatic hypertrophy has come to stay.
The e.xperie'nce of the originator of the method, cover-
ing a period of more than twenty years, and of many
operators all over the world during the last three
years, has proven the value of the procedure beyond
the show of a doubt. If properly carried out in a
suitable case, Bottini's operation am cure the patient
afflicted with prostatic hypertrophy. It, therefore,
clearly belongs to the class of radical procedures that
have so far been devised for the treatment of this
trouble. And it can cure such a patient in a compar-
atively simple way at a stage of the disease when
even the most enthusiastic advocates of prostatectomy
would not propose the operation, and the patient sure-
ly would refuse to submit to it; it can cure when
prostatectomy might be impossible on account of, for
instance, the too great softness of the gland, or of the
too far advanced age of the patient. VViiat remains
to be done is to give Bottini's" operation its proper
place among the various radical operations for the
relief of prostatic enlargement, to determine its proper
indication.
Certainly this operation must not be done indis-
criminately. The cases must becarefully selected, the
same as has to be done for prostatectomy. Nor do I
believe that the latter procedure will ever be entirely
supplanted by Bottini's operation. But we shall have
to learn which class of prostatic enlargement will be
suitable for the former and which for the latter
method of operation. It will, no doubt, take us a
good while to determine this definitely, since nearly
every case of prostatic enlargement in the advanced
stage has its peculiarities, and is different in some
respect from every other. A much greater series of
cases will have to be operated upon, carefully ob-
served, collected, and unbiassedly published by each
individual operator, before we shall learn to decide
this question of indication. I personally am inclined
to believe, however, that the result of such investiga-
tion, based, not on " enthusiasm " as is so often claimed
by the opponents of Bottini's operation, but on cold
facts, will tend to lessen the indication for prostat-
ectomy and establish the necessity of early operation
for the disease in question according to Bottini's
method.
As regards the results so far obtained with Bottini's
operation, they have demonstrated: (i) that the uri-
nary troubles of prostatics are not dependent upon
a weakness of the muscles of the bladder, due to
arteriosclerosis (Guyon and Lannois' theory), but are
' Read by invitation before the Medical and Library Associa-
tion of Detroit, February 26, 1900.
the direct result of a true mechanical obstruction to
the normal outflow of the urine at the neck of the
bladder, viz., the enlarged prostate gland; (2) that
we are able to overcome this mechanical obstruction
in a comparatively simple manner, namely, by the
multiple division of the swollen gland with the gal-
vano-caustic knife, which latter is part of a modern
and reliable instrument; (3) that we can generally
accomplish this without any additional operation on
the cords, testicles, or bladder; (4) that we have
every reason to expect that, if the desired result of the
operation be once thoroughly obtained, the cure will
in most cases be a permanent one.
In view of these facts it becomes the duty of ever\
one who takes an interest in the further development
of this procedure to give a resume' of his work from
time to time, and make known the conclusions he
draws from his experience. \ proper comparison and
study of these conclusions of the various operators
will call forth suggestions as to the still further im-
pro\ ement of the technique of this delicate operation,
and will place the indication for its performance on a
firmer basis.
This is all the more important as there still are
colleagues who not only condemn the operation
as such, but deny that it does or ever will deserve
the designation " radical." One of them recently
claimed ' that a cure could not be obtained by the
operation, because the division of the prostate gland
with the galvano-caustic knife could never effect "the
restoration approximately to its normal position of the
attachment of the vesical muscle to the prostate."
This he considers one of the essential points in cur-
ing prostatic hypertrophy by direct interference. Of
course, the argument is advanced on purely theoretical
reasoning, according to the doctor's own statement.
The author of the dictum as reported in the Medical
Record " had done the operation but once. In spite
of all efforts, the result was most unsatisfactory. He
had seen several cases which had been operated upon
by this [Bottini's] method by well-known surgeons,
and in all of these the later results of this operation
had been unsatisfactory. The operation did not
promise to accomplish sufficient drainage to the blad-
der. The best that could be said for Bottini's opera-
lion was, that it caused temporary amelioration in the
symptoms of retention. He desired to protest against
the views which were being so freely expressed, by
men whose opinion was entitled to respect, in favor
of this operation; too much had been claimed for it.
... It was a good thing to be progressive and to try
new things, but it was most unfortunate to permit our
enthusiasm to interfere with our scientific judgment." "
How a medical man can make so sweeping a state-
ment in face of the entirely different experience we
find published by surgeons all over the world, I can-
not understand. He either did not follow the recent
literature on this subject, or he refuses to accept as
true the statements made by some of the most con-
' Report in Medical Record, December 30, 1899.
- The doctor's part in the discussion was read from a type-
written manuscript and then handed to the gentleman represent-
ing the Medical Record at the meeting. The report, as
printed, is therefore authentic.
yo6
MEDICAL RFXORD.
[April 28, 1900
scientious and unbiassed observers. However, with
purely theoretical reasoning and sweeping statements,
one can no longer nullify such absolutely positive and
favorable results as have been achieved with Bottini's
operation here and abroad. That time is past.
In view of the fact, however, that there still are
such disbelievers among us, I deemed it my duty
again to come forward and tell what I have learned
regarding this operation in the course of my experi-
ence, which now covers thirty operations on twenty-
four patients. Hence it was with a great deal of
pleasure, indeed, Mr. President and gentlemen, that I
accepted your kind invitation to come to Detroit and
address you on a subject of my own choice. I really
could find no better one than that now before us. I
dare say it is superfluous for me to tell you how high-
ly I appreciate your courtesy, which enables me to
lecture here to-night before so distinguished a body of
men. I know that the interest of the profession in the
West for this fascinating procedure has been great
from the start, that is, since the time when Freuden-
berg of Berlin revived it, and the first Bottini opera-
tions on this side of the ocean were done in New York
in the fall of 1897.
Bottini's operation, at first glance, appears to be a
very simple interference indeed; and while this is
true of its immediate technique, it is by no means so
with regard to many of its details. The point in this
operation, the same as in every other, is not so much
to do it, but to do it properly. And this certainly re-
quires a great deal of personal experience, especially
yet at present, when the patients afflicted with a
hypertrophied prostate do not apply, as a rule, to the
surgeon for relief until the disease has reached a very
advanced stage. If we extirpate a vesical growth, or
if we crush and evacuate a stone from the bladder, we
know more or less what we have accomplished. We
see the result of our work before us. Barring unfore-
seen complications, we are able to predict, with a rea-
sonable amount of certainty, the future course of the
disease. Not so with Bottini's operation. It will be
a long time, I think, before we shall be able to state a
definite prognosis in a given case immediately after
the operation has been performed. The patient as
well as the doctor must await further developments.
It is just this uncertainty, however, that makes the
after-treatment of the operation so interesting, and
that, if the outcome be successful, gives the surgeon
an amount of satisfaction that he can rarely hope to
find in any other branch of operative surgery.
In order to unroll before your eyes a proper picture
as to the present status in the evolution of Bottini's
operation, it appears to me best to review, as briefly
as possible, the different phases of the technique of
the operation as they present themselves to us during
its performance. This will enable us to determine, to
some extent at least, how we can hope to avoid com-
plications during the after-treatment, how we can hope
to bring to the patient not only partial and temporary,
but total and permanent relief, and that by means of
one single operation.
I. Preparation of the Patient. — The patient is
prepared in general the same as he is for any other
surgical procedure. On the day prior to operation the
bowels are thoroughly emptied, and the whole body is
cleansed in a lukewarm bath. Shaving is unneces-
sary, as is also fasting. Local anaesthesia suffices for
the operation. Fifteen grains of quinine are given on
the night preceding the operation, eight more about
one hour before the latter is done. As Nitze has
found in his intravesical mode of removing benign
tumors of the bladder with his operating cystoscope,
internal administration of quinine prior to operation
is the best prophylactic against the appearance of the
so-called urethral fever. If one wants to be especially
careful, the quinine is administered a number of days
in advance of the operation, best, it seems, in connec-
tion with two to three grains of methyl blue (Freuden-
berg). See below under "urethral fever."
II. Instruments As stated in my paper read be-
fore the New York Academy of Medicine, November
3, 1898,' Bottini's incisor, as modified by Freuden-
berg, is now manufactured in New York, in a most
satisfactory way. In my last twelve cases I have
made use of this incisor and have not had a single
complaint to make of it. Once only within the
last year did it become necessary to have the incisor
repaired, the knife not sliding in its groove with
sufincient ease. For safety's sake, however, I in-
variably have two instruments on hand for every
one of my operations; for it could well happen that
the operator or his assistant might drop the instru-
ment, or injure a part of it, etc., and thus the opera-
tion would be rendered impossible for that time. I
certainly have derived great comfort from the sense of
security afforded by the presence of a second instru-
ment, the proper working of which I had also pre-
viously tested, to fall back on in case of an accident
to the first. The incisor I use — which is a copy of
that made by Kiss, of Berlin — can be easily-unscrewed
and sterilized in boiling water.^
A very important point is the proper heating of the
knife. Recently I was informed that a colleague in
Boston had had trouble with the incisor made in New
York. Great difficulty had been experienced in ex-
tracting it, and when finally removed from the urethra
it was seen that the blade had bent sideways. I fancy
that in this instance too much current had been ap-
plied. It can be readily understood that if we over-
heat the knife, a slight unintended twist of the shaft,
the handle of which rests in the left hand of the
operator, or a sudden move on the part of the patient,
may turn the knife sideways. On its return trip
through the prostate gland it will then not re-enter
the groove at the beak of the female part. The
best means of heating the knife is certainly the
current supplied by a central station. With the
help of an alternator and rheostat we have full
control of it and an inexhaustible, steady supply.
Unfortunately, it is not everywhere at hand.
Hence we need a storage battery. The one with an
amperemeter, as recently brought out by me — best
answers the purpose, I think.' It gives 50 amperes,
and if properly charged will furnish sufficient current
for the work. It must be well taken care of, however,
a weakness which it shares with all other batteries.
Special directicns are sent out with each battery. If
they are properly followed, many repairs and conse-
quent annoyances to the operator will be avoided.
To guard against possible disappointment, it is advis-
able to recharge the battery the day previous to the
operation. When using two 50-candle-power lamps
it will take ten hours to charge the battery; five hours
when two i co-candle-power lamps are employed.
When fully charged, the battery will store sufficient
electricity to do three successive operations, each last-
ing about ten minutes; but if they are not done on the
same day, recharging is advisable, for the current
steadily diminishes during non-use.
To demonstrate the importance of personally super-
vising the charging of the battery in cases in which the
street current is not available for doing the operation,
I will relate the following instance: Recently a col-
' " Personal K.xperience with Bottini's Operation in the Radical
Treatment of Hypertrophy of the Prostate." Medical Record,
January 14, iSgg.
■' Cf. Author : ' ' Bottini's Galvano-Caustic Radical Treatment
for Hypertrophy of the Prostate. " Medical Record, March 5,
iSyS, p. 327.
■' The addition of an amperemeter to the battery used for
Bottini's operation, we owe to Freudenberg.
April 28, 1900]
MEDICAL RECORD.
707
league who, with me, believes in the efficiency of Bot-
tini's operation, told me that the storage battery, as
designed by me, had given out in the midst of the
operation, and therefore could not be looked upon as
a reliable supply. Upon my query whether he had
charged the battery himself, he answered that it had
been sent to him with the statement that it was prop-
erly charged. On further inquiry I learned that the
company which had furnished the battery was not in a
position to charge batteries, for the reason that it
was not connected with the street current, and that
it therefore sent all batteries entrusted to it for
charging to another concern. I am sure my friend
would have been saved the annoyance above men-
tioned, had he personally supervised the charging of
the battery. The only disadvantage of this battery is
its weight. It is heavy. Experience has shown, how-
ever, that cells of smaller size cannot be trusted for
;his particular kind of work.
III. Operation. — Bottini's operation is certainly one
of detail. "The oftener I applied the galvano-caustic
incision," says Bottini,' "the more I became convinced
that the technique requires adroitness and care in or-
der to avoid annoying surprises. To be successful
with the operation is not mere chance, but the result
of careful study and conscientious performance." I
therefore do not hesitate to describe to you minutely
all the various steps to be observed in the course of
the procedure, even at the risk of overtaxing your pa-
tience.
I personally carry the operation out in the following
manner: The surgeon, after proper sterilization of his
hands, should stand on the right side of his patient,
who is placed on a table and covered below and above
the pubes with sterilized sheets or towels. The glans
and prepuce are thoroughly cleansed with soap and
water, bichloride solution, and alcohol, the same as
is customary in our daily operative work. The battery
is placed on a table to the left of the patient, so
that it is always in full view of the operator. A soft-
rubber catheter which has been boiled for three to five
minutes is taken from the bowl of sterilized water and
handed to the surgeon, its tip being lubricated with
boiled glycerin or sterilized paraffin. It is first intro-
duced down to the cut-off muscle, and the anterior
urethra is then irrigated with a two-per-cent. sterilized
boric-acid solution. After that the catheter is pushed
on into the bladder. If the soft-rubber catheter can-
not successfully overcome the obstruction at the neck
of the bladder, a Mercier's gum-elastic — which I keep
disinfected in a five-per-cent. solution of formalin
with glycerin — must be used. Then the bladder
is thoroughly irrigated with the same two-per-cent.
sterilized boric-acid solution, until the water returns
clear. As soon as the latter has been accomplished,
50 c.c. of a three-per-cent. sterilized boiled eucaine-M
solution is drawn into a hand syringe; the catheter
is pulled out so far that its eye still rests within the
posterior urethra, and the solution is slowly injected.
This will produce local anaesthesia of the parts to be
operated upon." The catheter is pushed back into the
bladder and its outer end closed with a stopper. Dur-
ing the following five minutes — the time required to
produce sufficient and proper local anaesthesia — the
(operator will do wisely to test once more the proper
working of the incisor, which has meanwhile been
taken apart and boiled. Bottini himself advises to
test the heat of the knife on a piece of moist gauze or
potato. I must confess that I no longer do this, but
trust in the reliability of the instrument and the prop-
er charging of the storage battery which I personally
' Langenbeck's Arcliiv, vol. liv. , p. ilS.
■ For the L'lst four weeks 1 am trying a one-per-cent, sterilized
watery solution of chloretone, for producing the desired local
anesthesia, with quite satisfactory results so far.
superintend. If the current turns the knife to white
heat, I am satisfied. This generally occurs when the
needle of the amperemeter in my battery points to
45-48. A properly instructed attendant takes charge
of the battery and, later on, turns the rheostat till 48
or 50 is reached, according to the orders of the opera-
tor. The cable attachment is now pulled off the in-
strument, and a long and small rubber tube, previously
boiled, is slipped over the two metal tubes which are
attached to the handle of the incisor, for the purpose
of supplying and carrying off the ice-water used to
cool off the instrument when at work. Thus pre-
pared, the incisor is placed on an aseptic towel.
After the expiration of the five minutes allowed for
the local anaisthetization, the eucaine solution is
withdrawn, and 150 c.c. of a sterilized boric-acid solu-
tion introduced. The catheter is pulled out. Then
the patient's pelvis is placed on a hard pillow some
twelve inches high, so that the upper part of his body
is tilted slightly downward.
He spreads his legs, between which a pus basin is
placed on the table. With a small sterile glass
syringe the anterior urethra is now once more washed
out with sterilized boric-acid solution and then filled
with three-percent, eucaine solution. While the fin-
gers of the left hand compress the urethra near the
external meatus, those of the right hand gently mas-
sage for a while the urethra toward the bladder. By
doing this a part of the eucaine solution is pressed
into the posterior urethra. This still further insures
complete local anaisthesia of the latter. After the re-
maining part of the solution has run out of the meatus,
a syringeful of sterilized paraffin is slowly injected
into the anterior urethra, the meatus being com-
pressed. The nurse then hands the incisor to the sur-
geon for introduction into the bladder. In the major-
ity of cases the handle must be deeply pressed down
before the beak slips into the viscus. Cases in which
the instrument cannot be introduced at all will be a
rare occurrence, I think. In one only of my twenty-
four cases did I find difficulty; but I succeeded in my
third attempt.' As soon as the instrument has entered
the bladder, it is turned around, and the glass nozzle
of the fountain syringe which contains the ice-water is
attached to the long rubber tube previously fastened
to the handle; the short tube is made to enter the pus
basin between the legs of the patient. Now the cable
attachment is slipped over the upper end of the in-
strument, and the prostate well hooked with the beak
of the incisor exactly in the median line. This is
one of the most essential parts of the operation. At
this stage the right forefinger (covered with a finger
cot) of the operator should be pushed into the rectum
in order to control the place of the tip of the beak
within the bladder and properly gauge its distance
from the anus. In patients with a very much en-
larged gland, a short forefinger will never succeed in
feeling the tip of the beak. For such instances it
will be well to have an assistant at hand on whom
nature has bestowed a forefinger long enough to en-
able him to reach up four inches and more above the
anus, as I have found it necessary in two cases.
Having measured the distance of the beak from the
anus, the operator must make up his mind how long
the incisions should be made in the given case. Now
the rheostat is turned, so that the needle points to 45
' Freudenberg had an interesting e.xperience in this respect in
a patient sixty-seven years of age, who had had complete reten-
tion for the last two years. He was absolutely unable to enter
the bladder with any stiff instrument ; cystoscope, stone searcher,
sounds, as well as Bottini's incisor, were all unsuccessfully tried.
The operation had to be abandoned for that day. On the fol-
lowing days sounds of increasing size could be introduced ; three
days after the first attempt the introduction of the incisor suc-
ceeded, though with some difficulty. Bottini's operation was
done, and the patient was cured.
7o8
MEDICAL RECORD.
[April 28, 1900
amperes. The screw of the cable-attachment, which
makes and breaks the current, is turned to the right
and tightened. We wait about fifteen seconds — the
time required for properly heating the knife. The real
operation may now be started. I now generally make
three cuts, one in the median line directly posteriorly
and one through each lateral lobe. The posterior cut
is, of course, the most important one. It is made
first. As stated in my former paper, the incisions are
made very slowly, by turning the outside screw as if
the knife had to overcome a very great obstacle, with
45 amperes. For the return trip 49-50 amperes
are turned on; this, too, is made at no greater speed
than fhe first. The lateral cuts I make at an angle of
from 45" to 90,° and I must confess that I have no
definite rules yet that guide me in determining the
e.xact angle. So far I have based my decision in this
respect on the previous cystoscopic examination and
on rectal palpation ; that is to say, the larger the lobe
the more acute the angle. The anterior cut I have
given up entirely since it caused me the loss of a pa-
tient (see below. Case XVII.). While the incisions
are being made the assistant now and then auscultates
the suprapubic region to make sure of the sizzling
noise produced by the cauterization. However, the
odor of burnt flesh, escaping from the meatus, and
especially the needle of the amperemeter give us as-
surance that the work is being properly done. The op-
eration performed this way takes me generally about
ten minutes, counting from the moment the current
has been turned on until the third incision through
the gland has been finished. During this time I never
turn off the current, but only reduce its strength to 45
amperes after each return trip of the platinum knife.
The three cuts having been properly made, the cur-
rent is turned off and the cable detached from the
instrument; the latter is turned 180° and slowly with-
drawn. During this procedure I continue to let the
current of ice-water pass through the instrument. A
reintroduction of the catheter for final irrigation I
deem unnecessary. The patient, after being cleansed,
is brought to bed.
IV. After-Treatment. — In my former cases I gen-
erally insisted upon the patient's attempting to pass
some water immediately after the operation, but found
that very few only were able to discharge a few drops
under pain, and I therefore no longer make this re-
quest; although I am sure that in a number of cases
the occasionally following urethral fever would be
avoided if the patients could, immediately after
operation, clean the urethra with part of the fluid re-
tained in their bladder. I have also given up at-
tempts at introducing the catheter into the bladder as
a routine practice directly after the operation, with the
view of leaving it in place, except in cases with a very
pronounced vesical catarrh, and in which catJieteriza-
tion had always been difficult. I now prefer to await
further developments, but must confess that I am
always relieved to learn that the patient has begun to
void urine voluntarily within the first hours after
operation. If, on the other hand, retention sets in,
the reactive swelling of the gland in advanced cases
may be so tremendous as to tax to the utmost our capa-
bility of emptying the viscus (see below, Case XX.).
If the patient begins voluntarily to urinate, the after-
treatment is comparatively simple. "Hands off" is
the watchword as far as instrumental interference is
concerned. The probably following painful spasms
at the neck of the bladder are overcome by morphine
and suppositories of opium and belladonna. Salol,
urotropin, and strychnine (as stated in my former
article) constitute the drugs used for internal medica-
tion.
Some patients, while they are able to pass .some
water after the operation, are subject to such great
and constantly recurring pain during and after each
act of micturition, day and night, that they are soon
worn out. In such instances, whatever we may em-
ploy, anodynes, sitz-baths, or permanent catheter, is
of no avail. With the withdrawal of the latter — even
after six or seven days of continued drainage — the
pain reappears, and early repetition of the operation
is the only alternative left to these sufferers. This
brings relief, as I have observed in two instances (see
Cases VII. and XX.). In cases in which absolute re-
tention follows, and the introduction of the catheter
is not difficult, I should prefer the use of the latter at
regular intervals of six to eight hours, rather than to
leave it in place permanently. The latter, no doubt,
produces funiculitis and epididymitis oftener and
more easily than frequent catheterization.
In instances in which a chill sets in, the surgeon must
be careful to interpret its cause correctly. The chill
may simply mean urethral fever of a few hours' dura-
tion; it may mean the beginning of a prolonged fever-
ish attack, or of a more profound sepsis or pyamia;
or it may be the first warning of a perforation of the
urethra from within with the galvano-caustic knife.
Careful local and general examination will soon en-
able us to make a distinct differential diagnosis. The
first three occurrences would have to be treated on
general principles. Perforation of the urethra js
promptly attended to by a perineal incision under
eucaine, followed by drainage. If perforation has oc-
curred, one can rest assured that the posterior incision
has been efficient (!).
Inflammation of the cavum Retzii will not happen
if we omit the anterior incision.
The length of time that I keep patients under my
immediate supervision averages three weeks. While
this may seem, and is, longer than necessary in some
instances, it is not safe to let patients go any earlier,
for the reason that hemorrhages may set in as late as
twelve to twenty days after operation, the time when
the eschars are cast off from the gland. If patients
walk around, these hemorrhages may become more
serious. They are generally easily controlled by rest,
if more severe by the permanent catheter. In a few
instances they have required suprapubic cystotomy and
packing with gauze in the hands of others.
In favorable cases tlie quantity of urine discharged
at each micturition will with lessening frequency
gradually and continually increase until the normal
amount is reached, in say two or three weeks, some-
times earlier.
I should now like to discuss a few important ques-
tions in connection with the operation, regarding a
number of which differences of opinion still exist.
Should Cystoscopy Invariably Precede Bottini's
Operation ? — There can be no doubt that cystoscopy
is of utmost importance, not only in establishing the
diagnosis of prostatic hypertrophy, but also in deter-
mining the configuration of the gland. In cases in
which the enlarged prostate is not palpable per rec-
tum, and, according to Albarran and iVIotz, this is so
in almost twenty-eight per cent, of all the cases — the
cystoscope alone can establish the exact diagnosis.
VVe see the pathognomonic groove at the internal
urethral fold; on turning the prism posteriorly down
to the fundus, w-e see the body of the gland often
bulging into the bladder; on turning it to the sides,
we recognize distinctly the enlarged lateral lobes,
though not in full illumination. V\'e are, further-
more, enabled to determine the absence or presence
of a median lobe. And even if all these symptoms
should, in exceptional cases, be but imperfectly devel-
oped, the finding of a trabecular bladder in the ab-
sence of a urethral stricture would still settle the
diagnosis beyond dispute. Then, too, the cystoscope
enables us to diagnosticate the presence of a vesical
April 28, 1900]
MEDICAL RECORD.
709
calculus which had not been suspected before, on ac-
count of its symptoms having been masked by those of
the prostatic enlargement. Only very recently did I
thus detect a stone in the bladder of a patient who
had not had one of the clinical symptoms generally
attributed to vesical stone.
Yet, notwithstanding the great benefit that may be
derived from cystoscopy in obscure cases, it may be-
come harmful in some instances, as for example in
prostatics with chronic sepsis. Here cystoscopy, the
same as any other intravesical instrumentation, may
be followed by serious urethral fever. One should
therefore well weigh the pros and cons in deciding
whether this most desirable visual inspection should
be added. I have grown particularly careful in this
respect since I lost a case a few months ago as an in-
direct result of cystoscopy. The patient, a man of
seventy-six years, who had been sent to me for Bot-
tini's operation, was suffering with chronic cystitis
and pyelo-nephritis. Cystoscopy was performed by
me and followed by a protracted urethral fever to
which he finally succumbed. I insisted upon the ex-
amination only because all symptoms pointed to the
presence of a stone, so that it was necessary, under all
circumstances, to resort to intravesical instrumentation
of some kind in order to ascertain the correct diag-
nosis. The cystoscope proved the suspicion to be
unfounded.
To sum up, I would therefore say : cystoscopy
should precede Bottini's operation, provided there be
no contraindication to its performance. What de
serves to be especially emphasized, however, is, that
in cases of doubt, i.e., when the symptoms are mis-
leading, and when all other means at our disposal for
rendering the diagnosis could not be relied upon with
absolute certainty, it is the cystoscope alone that can
definitely clear up all doubt and enable us to establish
the correct diagnosis even at an early stage of the dis-
ease.
Filling of the Bladder Shall we do the operation
with the bladder empty, as Bottini at one time pro-
posed, or shall we fill it with a fluid, or with air, or
with carbonic acid gas?
1. Operation with the Bladder Empty: This proce-
dure should be, and I think has been, dropped alto-
gether. It is well known that by filling the bladder,
at least to some extent, entrance to the same in
prostatics per vias naturales is greatly facilitated. In
the distended viscus the projecting hypertrophied
rugae of the detrusor muscle furthermore are smoothed
out, and not so apt to be hooked by the tip of the in-
cisor when gliding over the fundus of the bladder in
order to hug the prostate. It was when doing the
operation in this way that Freudenberg cut through a
transversely running fold of the fundus of the bladder
and lost his patient from acute sepsis.
2. Operation with the Bladder Filled with Sterilized
Boric-acid Water: This is the procedure which, as
stated above, I personally am still adhering to in my
liottini operations. What others claim to have ex-
perienced in their patients does not seem to me
proven, viz., that the heating of the fluid immediately
surrounding the galvano-caustic knife produces the
scalding sensation. If the prostate is thoroughly
hugged with the beak of the incisor, the knife must at
once enter the prostatic tissue, and surely is sur-
rounded by so very small an amount of fluid that I
cannot understand how just the heating of this bit of
fluid could be the principal source of the sometimes
rather great pain to the patients. On questioning the
latter regarding this point, I almost invariably re-
ceived the answer that they did not mind the burning
part of the operation, but that the pain produced by
the compression of the prostate by far overshadowed
all other sensations.
3. Operation with the Bladder Filled with Air: I
personally should have no hesitancy about doing the
operation with the bladder filled with air, were it not
for the unfavorable results of the experiments made
by Lewin and Goldschmidt, already referred to in my
former articles.' I there stated that these two investi-
gators had found that, under certain conditions, un-
known to us, air may pass upward through the ureter
into the pelvis of the kidney, and from there, by way
of the branches of the renal vein, enter the inferior
vena cava and the heart. Instant death is the result.
I am aware of the fact that Dr. Bransford Lewis, of
St. Louis, Mo., in his experiments," has obtained re-
sults entirely at variance with the findings of the Ger-
man investigators, and it was this report that impelled
me to write direct to Professor Lewin, at Berlin, with
a view to eliciting from him some data that might per-
haps explain the apparent difl'erence in their conclu-
sions. Dr. Lewin, under date of June 29, 1899, sent
me a most interesting answer, from which, with the
author's permission, I quote as follows:
" The phenomenon of air ascending into the renal
vein, etc., as well as the antiperistaltic transmission
of liquid from the bladder into the pelvis of the kid-
ney, does not occur in every animal. I have opened
the abdomen of about two hundred animals in all, but
have not succeeded in determining the conditions
under which the experiment gives a positive result.
" I can say, however, almost with absolute certainty,
that a constant pressure of air within the bladder, fill-
ing this viscus nearly to bur.sting, never produced the
phenomenon in question, \\henever it appeared, it
did so immediately after the injection of air, even
when the bladder had been filled to a small extent
only. It occurs, as it were, during the first moments
when the air enters the bladder, sometimes also while
injected air is allowed to escape again through the
catheter; eventually, also, immediately after the sec-
ond or third injection. Death is the absolutely cer-
tain consequence of the entrance of air into the venous
system in this manner.
" I shall take opportunity, within the very near
future, to demonstrate the aforesaid to Ur. Freuden-
berg" [who had then just stated, in a letter ad-
dressed to Dr. Lewis,'' that he now also prefers to do
his Bottini operations with air injection into the blad-
der, and who also, according to Professor Lewin, had
interpellated him regarding the latter's entirely dif-
ferent findings from those of Lewis] "that he may
learn from the same, what such experiments must
teach, viz., the possibility of the occurrence of the
phenomenon in question also in the human subject.
More than that can, of course, not be claimed. The
same conditions are extant here as obtain in the case
of other dangerous operations. Hundreds of pa-
tients are unscientifically narcotized, the quality, the
concentration, and dosis of the narcotic may not come
up to the standard, yet, thanks to unknown circum-
stances, the patients do not die. But, in view of such
occurrences, the conscientious physician will be mind-
ful of the possibility of a fatal result."
With a view of obtaining personally further light on
this important question, I have carefully studied the
various original and other treatises of Professor Lewin
regarding this subject.* The doctor's researches prove
' Cf. Author; Loc. cit.. Medical Record, 1898, vol. liii., p.
332 ; and 1899, vol. Iv., p. 41.
■•' Medical Record. 1899, vol. Iv. , p. 425.
^Medical Record, 1899,. vol. Ivi. , p. 34.
•* " Experimental Studies on the Relation between Bladder and
Ureter," by Drs. L. Lewin and H. Goldschmidt. Berlin, klin.
Wochenschrift, No. 32: paper read before the Berlin Med. Soc,
July 12, 1893. — " Experiments on the Relation between Bladder,
Ureter, and Renal Pelvis," by Drs. L. Lewin and H. Gold-
schmidt. Arch. f. pathologische Anatomic und Physiologic und
klinische Medicin, vol. cxxxiv., i., Berlin, 1893. — "Absorption
of Foreign Substances from the P.ladder," published in the Arch.
yio
MEDICAL RECORD.
[April 28, 1900
that the possibility of air entering the venous system
by way of the renal vein does exist.
In the face of these positive statements of Dr. Lewin,
i believe I shall never agree to do Bottini's operation
with the bladder filled with air. If sudden death
should set in as a result of such filling, the conscien-
tious doctor would have to confess that the lamentable
outcome might have been avoided.
4. Operation with the Bladder Filled with Carbonic
Acid Gas or O.xygen: As just stated, some colleagues
claim that the operation is less painful and, perhaps,
also more effective when done with the bladder filled
with a gaseous instead of a fluid medium. It was on
the strength of these assertions and of the unknown
amount of risk attached to ballooning the bladder
with air, that, upon the suggestion of Dr. A. Rose, of
this city, I experimented with carbonic acid gas fill-
ing the viscus. The blood is, of course, capable of
absorbing large quantities of carbonic acid gas as
well as of oxygen. The small flasks filled with lique-
fied carbonic acid gas, make the ballooning of the
bladder with this gas a very simple procedure. I have
not yet done a Bottini operation with the bladder in-
flated in this way. The question which has first to
be solved is the amount of expansion of the gas caused
by the presence of the red- or white-hot platinum knife.
This question does, of course, not concern us, if we
would work . with oxygen. However, the chemical
production of this gas in smaller quantities, instead
of making use of the large tanks sold in cities by
every druggist, is less handy than the use of carbonic
acid gas in the manner just mentioned; oxygen also
does not possess that slight anajsthetizing property
which various authors have claimed for carbonic acid
gas. I shall not fail to report on the further evolution
of this interesting question in the near future.
Length of Incisions. — The question as to the length
of the incisions to be made through the gland un-
doubtedly constitutes the most important and, at the
same time, the most difficult point in the technique of
Bottini's operation.
(7. In cases of Jr'/'rous prostates the length of the
urethra measured from the external meatus to the in-
ternal sphincter muscle, that is to say, up to the spot
where the water of a filled bladder begins to flow
through a catheter which had been introduced, may
serve as a reliable guide in estimating the proper
length of the incisions to be made. Such a prostate
can be but very little compressed. If we have found
the length of the urethra, for instance, to be 29
cm., the incision may with propriety be made 8 cm.
long, because we know that the normal urethra is on
the average 21 cm. long. In other words, we make
the incision correspond to the difference in length
between the normal urethra and that in the given case.
It will be wise to control and possibly modify this
decision reached before the operation according to the
result of rectal examination after the prostate has been
well hooked during the operation.
A useful clew in regard to the required length of
the incision is furnished by rectal palpation, performed
in the following manner: If an assistant (the proper
length not only of whose forefinger, but also of each
phalanx of the same, has been previously ascertained)
inserts his finger into the rectum as soon as the pros-
tate has been firmly hooked, and gropes for the tip of
the instrument at the upper end of the gland, he can
determine the exact distance of this tip from the anal
ring. If he then again introduces his finger, measur-
f . experimentelle Pathologie und Pharmacologie, vol. .xxxvii. .
1896, by Professor I^ewin. — " The Passage of Hard Substances
from the Bladder into the Kidneys and Remote Organs of the
Human System," also " The Entrance of Air from the Bladder
into the Heart and the Path it Follows," by L. Lewin, with
microscopical contributions by Dr. Lommen. Arch. f. Experi-
mentelle Pathologie und Pharmacologie, vol. xl., 1897.
ing the distance of the lower end of the prostate from
the sphincter muscle, and deducts the latter measure-
ment from the former, we know the palpable length of
the prostate per rectum. The length, thus found,
can then be compared with the abnormal length of the
urethra, previously ascertained. If, however, we now
make the length of the incision exactly correspond to
such rectal diameter of the prostate, we may find quite
often that the incision has not been sufficiently long.
I have noticed this in a number of instances, and have
come to the conclusion that it will be best to make the
incision about i to 1.25 cm. longer than the longi-
tudinal diameter of the prostate found per rectum.
That is to say, if the tip of the beak was 8 cm. distant
from the sphincter muscle and the lower end of gland
4 cm. in diameter, we should not make the incision 4
cm., but 5 to 5.25 cm. long.
l>. All these points are entirely different, however,
in the other far more frequent class of prostatic en-
largement, namely, that in which ///c glandular elements
preponderate, and in which, consequently, the organ can
be compressed. Here the simple means of measuring
the length of the urethra is of little avail, for it is
obvious that the length of the urethra foimd before
operation will be entirely different after the beak of
the incisor has hugged the compressible gland. This
shows clearly that in this class of cases the length of
the cut to be made cannot be determined beforehand,
unless we should, as a preliminary measure, ascertain
to what extent the prostate may be compressed. Such
a procedure, however, generally is inadvisable, inas-
much as it might be followed by very serious symp-
toms, so much so that Bottini's operation, the one
interference that is likely to bring relief to the patient,
might be rendered impossible. This question, how
long must and dare we cut in the given case, must
therefore, in the majority of our Bottini operations, be
reached during the operative work. Some of the
unforeseen occurrences that may then baffle the opera-
tor are, that a large median lobe may be turned back
and thus increase the length of the urethra by almost
an inch; or it may happen that the gland, which ap-
peared quite large on rectal palpation, is so much
compressed by the hugging beak that its diameter
shrinks to almost nil, and the surgeon will ask him-
self whether his diagnosis, clearly established by all
the exact clinical methods at his disposal, was correct,
and whether there ever was an enlarged prostate.
That the occurrences here mentioned may often put
the operator into a most annoying position, will be
readily admitted. For if, in the case of a fibrous
prostate with lengthened urethra, he should exhaust
the full length which the ordinary incisor permits of
cutting, namely, 4 cm., the incision may easily be too
short and never properly divide the obstruction down
into the prostatic urethra; an experience which I have
had in a few cases. Or if in a soft, compressible
gland he should make an incision of only 2.5 to 3 cm.
in length, he may at once do a real internal posterior
urethrotomy and perforate the urethra, an accident
that happened to me in two instances. When oper-
ating on a patient with a very large prostate, and cor-
respondingly lengthened urethra. I therefore now al-
ways make use of an instrument which allows of
making incisions as long as 8 cm. This I have had
made specially for such cases, in February, 1889.
I should strongly advise to make use of the incisor
that permits of the long cut, (i) whenever the pros-
tatic enlargement is very jsronounced, so that the up-
per border of the gland cannot be reached on palpa-
tion per rectum, and particularly if the organ be of the
fibrous variety; (2) whenever there is a median lobe
of some size present; (3) whenever the length of the
urethra has been found to be materially beyond nor-
mal.
April 28, 1900]
MEDICAL RECORD.
711
In patients with a very soft and compressible pros-
tate, on the other hand, I now make incisions not
longer than i to 2 cm. I do not, however, in such
cases omit to explain to the patient or his relatives
why I had to make short cuts: that, in case of partial
relief only being obtained by the operation, a pos-
sible repetition might become necessary, and that this
would surely be preferable to perforating the uretiira
in our endeavors to overcome the obstruction by a
single operation.
Number and Direction of Incisions — As a rule
three incisions should be made at every operation.
Of these, as I have repeatedly stated in the course of
this paper, the posterior one is the most important,
since upon it principally depends the success of the
operation. If properly carried out it must and should
lower the prostatic urethra to the fundus of the blad-
der. In very much enlarged glands, and especially
in the fibrous variety, I shall in future make it a point,
when doing the posterior incision, to have the knife
plough through the same groove twice in succession.
Such a procedure is not likely to be followed by com-
plications; at the same time it is sure to enhance the
probabilities of obtaining the desired result.
The question of definitely determining the proper
angle at which the lateral lobes had best be divided
has not yet been solved. Practical experience has
shown, however, that it is not of very great impor-
tance. As stated before, I am guided by rectal palpa-
tion and cystoscopic examination, that is to say, if
these sliow considerable difference to exist between
the size of the lobes, I cut through the larger lobe at
a smaller angle than through the other, in order to
obliterate more thoroughly the communicating blood-
vessels. For it is evident that the closer together the
cuts, the more effective will be the destruction and
obliteration ; in other words, local atrophy must be the
result of sucli close division.
The anterior incision I have found to be of real
danger. It should therefore be dropped; or at least
made only in cases in which the result after the first and
second operation is incomplete, and in which cysto-
scopy plainly shows the mechanical cause to be situated
in the anterior aspect of the internal urethral fold.
Freudenberg has recently published a very striking
illustration of this condition.'
Depth of Incisions. — In order to insure the proper
depth of the incisions the following three factors
should be carefully observed: (<?) Position of the in-
strument during the operation ; (/') the height of the
knife and the proper heating of the same; (i) due
slowness in making the incisions.
(?. To bring the instrument into proper position for
making the posterior incision, the outside handle has
to be raised to such a point that one can feel the tip
of the beak glide over the fundus of the bladder. In
this position the prostate should be firmly hooked,
after which the position of the instrument should not
be changed again. Of course, care must be taken
not to raise the handle too much, as by doing this the
tip of the beak will be pressed down too far, and dam-
age might result to the posterior wall of the bladder.
b. Freudenberg' considers 1.2 cm. (y'L.inch) the
best average height of the knife. He has knives the
heights of which vary between 0.8 and 1.5 cm.
{-f^iy- j^iP inch) and bases his selection of the proper
one on the cystoscopic examination and rectal palpa-
tion of the tip of the incisor, which had been put in
position and turned posteriorly. Although this may
perhaps be useful in some instances, I fear it compli-
cates matters unnecessarily, and am, therefore, in
' " Neue .Mittheilunfjen zur Galvanokaustischen Radikal-He-
liandlung der Prostatahypertrophie per vias naturales (Bottini-
sche Operation)." Deutsche Medizinal-Zeitung, 1900, Nos. 1-6.
* Loc. at.
favor of trying to operate with one and the same
size of knife in every instance. Moreover, the knife
when brought to white heat and drawn very deliber-
ately over the field — if needs be, twice in succession
— will produce such a far-reaching eschar that a
difference in heigiit of 3 mm. can be of no appreci-
able account, as Freudenberg himself also admits. It
is, of course, of greatest importance that the knife be
brought to white heat in its entire length, a point to
which particular attention should be paid when test-
ing the instrument as to its proper working. The
height of the knife of the American instruments aver-
ages 1. 2-1. 5 cm.
Complications that Have so far Been Observed
to Arise during Operation — Complications that may
arise during operation are:
1. Perforation of the liladder: This may occur by
hooking a transverse fold of the vesical wall with the
tip of the beak of the instrument and perforating it by
drawing through it the galvano-caustic knife when
hugging the prostate. Filling the bladder with a
liquid or gaseous medium will, I believe, avert this
danger in every instance.
2. Perforation of the Urethra with the Electric
Knife: This is a consequence of the incision having
been made too long, an occurrence which, I fear, can-
not be easily guarded against, if the work is to be
done thoroughly, so as to avoid the necessity of a sec-
ond interference. The complication, however, comes
into question only in case of extremely soft prostates
that are more compressible than the operator antici-
pated or could have imagined. I believe that in these
instances the incision should not exceed two centime-
tres in length, and it will be well, as mentioned before,
to prepare the patient or his relatives after the op-
eration for the possibility of a repetition of it, in case
the work just done should prove unsatisfactory or
entirely unsuccessful. As much as I am in favor, in
every other instance, of trying to get through with one
operation, I believe that in these cases treatment in
two or more sittings is to be preferred.
Other complications which might arise as a conse-
quence of the instrumentarium as such, can, I am
convinced, always be avoided. The accidents in
question are bending of the knife, and giving-out of
the battery. Bending of the knife will result from [a)
overheating; {l>) not steadying the instrument proper-
ly during operation; [c) an accidental movement on
the part of the patient; (li) an assistant's finger press-
ing the prostate against the instrument.
By using the instrument manufactured here and keep-
ing within the limits of 45-50 amperes, it seems to me
that point <j can always be avoided.
/'. The surgeon should steady his instrument thor-
oughly during the operation, which rarely takes longer
than ten minutes. The continuous cooling of the
handle with ice-water may sometimes render a firm
hold almost impossible, and it will be well, there-
fore, to slip a sterilized, thick knitted glove over the
left hand.
<-. A sensible patient, if warned beforehand that a
move on his part may have annoying consequences,
will rarely disregard such warning. I have never met
with any trouble from this cause.
iL The finger of an assistant should never rest on
the prostate during the operation; I consider this a
fundamental mistake.
Complications that Have so far Been Observed
Occasionally to Occur Sooner or Later after Opera-
tion I. Urethral Fever: I'nfortunately, it is not in
our power, in spite of most scrupulous asepsis in every
particular b.efore and during operation, always to avoid
the occurrence of this complication, which is to-day
looked upon as a more or less serious form of septic
infection. It is evidently caused by the absorption of
712
MEDICAL RECORD.
[April 28, 1900
micro-organisms or their toxins tlirough a superficial
or deeper wound of the posterior urethra. It will be
found to set in sometimes on the first, more often on
the second, rarely on the third day after the opera-
tion. As is well known, in patients who are inclined
that way the simple introduction of a catheter may
sufiice to produce it. It is all the more likely, there-
fore, to occur after the use of steel instruments and
prolonged intra-urethral and intravesical manipula-
tions. In favorable cases pulse and temperature will
suddenly rise after a pronounced chill and then drop
again within twelve to sixteen hours, without mate-
rially affecting the general condition of the patient.
This I have seen only the other day in a neuras-
thenic subject, twenty-three years of age, who had
been suffering for years from gonorrhoeic prostatitis,
but whose urine had been absolutely clear for the last
month, at least macroscopically, although it evidently
still contained bacteria. I used Bottini's cauterizator
on him, after which he developed a chill at 3 o'clock
in the afternoon of the second day after the operation ;
but his pulse and temperature dropped to normal again
the next morning, after profuse perspiration. In less
favorable cases the chill may recur on one of the
following days, or there may be no chill at all, and
only rise of temperature, after which the normal is
reached again only after a distinct lysis in the course of
a few days. In these instances the general condition
of the patient is usually not particularly alarming.
In malignant cases the normal condition is not
reached so soon; fever will continue and then be-
come a symptom of true sepsis or pysemia. It is to
be hoped, as Freudenberg' mentions, that bacteriology
will here come to the surgeon's help. It cannot be
doubted that one or more kinds of certain micro-or-
ganisms are responsible for the disturbance. If they
could be found, we might hope to prevent the occurrence
of urethral fever and its sequela; by previously admin-
istering hypodermic injections on the basis of sero-
therapy.
As mentioned above, Nitze has found, in connection
with his intravesical work with the help of the oper-
ating cystoscope, that gr. xv. (i gm.) of quinine ad-
ministered on the night preceding the operation exerts
a distinctly prophylactic influence. Freudenberg ad-
vocates the use of methyl blue in conjunction with
quinine. He prescribes gr. viii. (0.5 gm.) of quinine
with gr. ii.-iii. (o.i to 0.2 gm.) of methyl blue to be
taken three times daily for two or more days prior to
operation, and to be continued for a few days after-
ward. This certainly seems a very useful addition,
in that, as we all know, methyl blue has a most power-
ful antiseptic influence upon the uropoietic system.
Even if it should not be an absolutely reliable
preventive, I believe that it would, nevertheless, be ad-
visable always to make use of the drug.
If the fever once has occurred, it will have to be
combated on general principles. The internal regu-
lar administration of urotropin, salol and quinine,
also small doses of phenacetin, alcohol, strychnine,
caffeine, etc., hypodermically and by mouth, for
stimulating the heart's action, and the ingestion of
large quantities of liquids, has given me the best results.
The more serious class of urethral fever is:
2. True Sepsis : This complication generally results
fatally in older patients, especially if they have been
suffering from similar attacks in former years, also
from pyelonephritis. As stated in my former article,
there are chronic septics among the prostatics, and in
these the least cause may suffice to bring on the catas-
trophe. It would be gratifying indeed, if this com-
plication could in time be avoided by the application
of proper sero-therapy.
3. Pyaemia has been observed by Freudenberg. In
my Case XXII. I had the peculiar experience that
varicose veins on the left leg and thigh became in-
flamed on the third day after the operation, the im-
mediate result having been simply ideal. This pa-
tient had passed through a tedious treatment at
the hands of hii family physician for a cellulitis
of the hand, which, at the time of the operation, had
been almost overcome. Whether multiple minute
abscesses were present in his extremely soft prostatic
gland, I am unable to say. I believe, however,
that streptococci still circulated in his blood and
produced an infected thrombus at a place where the
blood-current was the slowest, i.e., in the varicose
veins. In a similar case I would certainly raise the
lower end of the bed of the patient immediately after
the operation, thus having him in a recumbent posture.
As he died suddenly on the twelfth day after the oper-
ation, I believe that an embolus was thrown into his
pulmonary artery or one of its branches. To my re-
gret, an autopsy was not permitted.
4. Embolism into the lungs has been observed by
Freudenberg, as proved by autopsy.
5. Absolute Retention: As I have already stated in
my first article on Bottini's operation, every operator
undertaking to treat his prostatic patients according
to Bottini must be able to meet this complication in
an absolutely aseptic manner. As will be seen further
down, in Case XX., I could not enter the bladder for
fully three days in any other way than by aspirating
above the pubis every eight hours ; thus the trocar
had to be pushed into the bladder eight times. I
found it very useful in this case first to penetrate
transversely the thick adipose tissue with the knife
under cocaine, by making an incision of about one-
eighth of an inch, and then pushing the trocar through
this wound into the bladder. In this way I avoided
always re-entering the same tract with the trocar tube.
On the fifth day at last I was able to introduce an
olive-pointed Mercier with a double curve. No. 12
French, which, of course, was left in place.
6. Hemorrhage : This, if it occurs at all, is apt to set
in at the time when the eschars are thrown off, that is
to say, usuall)' between the twelfth and the twentieth
day, although I have in one instance seen a large
piece come away as late as thirty-five days after the
operation. However, I am inclined to think that
here the eschar had dropped into the viscus some time
previously, but had not been expelled before. On the
whole I believe that, if the patient keeps quiet and
the doctor abstains from washing the neck of the blad-
der during the first three weeks after the operation(!)
this complication will rarely be observed. The intro-
duction and tying in of the permanent catheter will
almost in every instance enalale us to cope with the
complication. Yet a number of cases have been re-
ported in which only immediate suprapubic cystotomy,
followed by tamponade, saved the patient's life.
7. Very Frequent and Painful Spasms at the Neck
of the Bladder w ith Partial Retention : As repeatedly
mentioned in the course of my article, this is a com-
plication rather often met with, especially in cases of
a large median lobe and too short an incision. If a
large projecting median lobe has been turned back by'
the pressing down of the beak at the time of the oper-
ation and the cut is then, for instance, made only 4
cm. long, it will be readily understood that such an
incision will end within the parenchyma of the prostate
itself, instead of entering the prostatic urethra, as I
believe is necessary for a satisfactory result. We
then have to deal with a condition similar to that
found when performing immediate suture of the supra-
pubic incision of the bladder after the removal of a
vesical tumor, the base of which had been thoroughly
burnt with Paquelin's thermocautery. Experience has
taught me in such cases not to sew up the bladder, but
April 28, 1900]
MEDICAL RECORD.
713
to drain it. It will be seen thus, that by learning to
give our incision the proper length we shall probabl)-
be able to avoid the occurrence of such painful and
frequent desire to urinate. In case it does set in,
large doses of morphine with suppositories of opium
and belladonna, extr. hyoscyami in two-grain pills at
regular intervals of four to six hours, may be found
valuable. If the catheter enters without great diffi-
culty, it ought to be introduced every six or eight
hours according to necessity. If the desire to empty
the viscus should be too frequent, the catheter must
be left in situ. In that case, provided there is no
chronic pyelitis present, which so often causes fever,
we have to watch the temperature carefully; for a rise,
as I have seen, may be the precursor of a funiculitis
with abscess formation of the same or of the testicle.
The catheter should be removed just as soon as a rise
of temperature occurs. If the patient does not begin
to urinate voluntarily within a reasonable time after
the operation, the latter will have to be repeated.
How Soon Should the Operation be Repeated if
the Result of the First Operation was Not Satis-
factory?— This question certainly is of very great
importance. To answer it definitely is impossible
at the present time owing to lack of sufficient experi-
ence. Then, too, there are individi " differences
that have to be considered in each Zo.z>^. Of course,
if, as just stated, the first cauterisation of the gland
produced continuous, painful vesical spasms, accom-
panied by inability of the patient to empty the viscus
sufficiently, a second operation sl.ould be soon per-
formed. The unceasing and undiminishing suffering
of the patient will here have to be the guide. Thus
it became necessary for me to repeat the operation in
my Cases VII. and XX., eighteen and twenty-nine
days, respectively, after the first interference. In Case
XXL, in which I thought I should have to do a prompt
instrumental revision, I could temporize on account of
the steady improvement that set in on the eighth day
after the operation.
On the other hand, if the suffering of the patient
be not the immediate cause for a second operation, if
the amount of residual urine still present is the only
indication, the decision as to when to repeat the oper-
ation is far more difficult. Many patients will be
perfectly satisfied as soon as the frequent painful
spasms at the neck of the bladder are relieved, and
will not care about the residual urine, no matter how
large the amount may be. And that Bottini's opera-
tion can remove these pains, and permanently, is
absolutely certain. The proposition to repeat the
operation at a later time will, therefore, often meet
with opposition on the part of the patient. He nat-
urally shrinks from going through a second operation
as long as the former ever-present pain no longer con-
stitutes a causa mflTe?is.
In patients with large fibrous prostates in whom the
first operation did not effect the entire removal of
residual urine, we should not be, it seems to me, too
hasty in repeating the operation. I have seen a case,
that of a man seventy-one years of age, a pronounced
diabetic (eight per cent.), getting decidedly worse after
the third operation when the second had brought
great improvement. I have mentioned that, if we
make our incision to correspond to the difference
in length between the normal urethra and that of
the given case, as explained fully in the foregoing
pages, we may hope to help our patients at once. If it
be found that an incision longer than 4 cm. be neces-
sary, while the instrument at hand permits only of
cutting 4 cm., the surgeon had better temporize. The
case just referred to has made a very strong impres-
sion upon me, so that I would venture to give warning
to my colleagues, although my experience is based on
one case only. In this instance the prostate was ex-
tremely hard and did not yield a bit to pressure. At
present the patient passes but a small amount of water
voluntarily during the day. However, all his many
pains and annoyances prior to the Bottini's opera-
tions have been overcome by catheterizing himself
twice in twenty-four hours. He now lives a compara-
tively comfortable life. Catheterization, which had
been practised for seven years, is much easier than it
was ever before. Of course, had I made my incision
sufficiently long at once, and had I burned the poste-
rior groove twice in succession, the result might have
been entirely different.
Recurrence. — It is, no doubt, too early to say much
about this question. Bottini claims not to have seen
a single recurrence in all of his more than eighty
cases. As stated in my former article, it is to be re-
gretted that he never gave a careful synopsis of his
experience. Nobody, therefore, can blame the man
who shakes his head when reading that, even in pre-
antiseptic times, this operator never met with any
complications in his patients. Nor will it be taken
amiss if he should express his doubts as to the correct-
ness of the statement that a recurrence was never seen.
It certainly would seem necessary to have reports on
re-examination at a later period.
In my eleven cases which belonged to the category
of "so far cured," I have seen but one case in which
at present the trouble has returned to some degree,
and which now is about as it was a short time before
the operation, at least as far as frequency of micturition
is concerned. This patient (Case XL), however,
was operated upon at the time when I still used the
original small battery, which did not enable me to
read the strength of the current from an amperemeter
during the operation. I therefore cannot claim that
the four cuts were made with the same strength of the
current throughout. In fact, I rather incline to the
belief that this was not so, for the reason that this is the
only one of my cases, so far observed, in which the trou-
ble has reappeared to some extent. I have, of course,
advised the patient to undergo a second operation. He,
however, refused to have it done, being satisfied with
his present condition. In this respect also, Freuden-
berg's latest article is of particular importance, for he,
too, has carefully traced his cases. In eleven out of the
twelve selected cases published by him — of which six
were operated upon once, three twice, and two three
times on account of a previously insufficient result —
the cure obtained by the last operation, that established
perfect vesical drainage, is reported by him to be still
lasting and unchanged. In five of these the operation
was done as long ago as thirty-one, twenty-six, tw^enty-
two, twenty, and sixteen months ; in the other six it was
done less than a year since. In the twelfth case the
result of the operation was negative, the retention not
having been overcome. Thus the foregoing shows that
in the oldest case, i.e., the one in which the operation
dates back furthest, the perfect condition primarily
brought about by Bottini's operation has so far con-
tinued absolutely unchanged for over two and one-half
years. I personally can prove the lasting effect of the
operation in my patients, who were primarily cured
of all their subjective and objective symptoms — in
one only the vesical catarrh did not entirely disappear
— twenty-two, twenty-four, and twenty-five months af-
ter the operation (Cases V., VI., and VII.).
The Advantages to be Derived from Bottini's
Operation Aside from its Main Purpose, i.e., the
restoration of vesical drainage, are: (a) The disap-
pearance of the vesical spasms ; {l>) cure of the gener-
'ally present chronic constipation ; (c) improvement in
general condition, as shown by increase in weight.
a. As I have stated in a former article, Bottini's
operation seems to me to take the same place in re-
gard to the spasmodic contraction of the sphincter-
714
MEDICAL RECORD.
[April 28, 1900
vesicffi muscle, as forcible stretching or division of
the sphincter-ani muscle takes in connection with anal
fissure. The muscle is divided in two or three places
and therewith comes to rest. P'urthermore, the three-
fold division of the glandular tissue interferes with the
former blood supply of the gland, and thereby prevents
the intermittent "congestion" (Guyon), the cause of
the recurrent attacks of cystitis and acute retention.
b. It is interesting to observe how almost invariably
the chronic constipation these patients so frequently
suffer from disappears after Bottini's operation, even
though the latter has been but partially successful.
This is probably attributable to an improvement in
the nervous condition of the patients. For with the
cessation of the former continuous spasms at the vesi-
cal neck, the irritability of the nerves supplying the
lower sigmoid and rectum will also disappear, and
thus the normal function be restored.
c. An other striking feature observed in connection
with Bottini's operation is, that in nearly every in-
stance the patients gain in weight, and that even in
cases in which the obstruction to the proper flow of
urine has been but partially or not at all overcome.
Every one of my patients illustrates this point. It is
explained, I believe, by the fact that these poor suffer-
ers, who sometimes for ten or fifteen years have not
known what a fair night's rest means, are again able
to sleep five or six, sometimes eight to ten hours in a
stretch. Their nervous system at once recuperates,
and this naturally reacts upon all other functions.
Freudenberg has paid considerable attention to this
interesting phenomenon, and proves his observation
by figures. Thus, one of his patients, in whom the
operation was performed twice but the functional
results remained nil, wrote him that everybody con-
sidered that he looked younger by ten years, and that
he had gained thirty pounds within about two years.
What Constitutes a Cure after Bottini's Opera-
tion ? — The three factors that, in my opinion, would
determine an ideal cure of a prostatic are:
(a) Removal of the obstruction to the outflow of
the urine; in other words, complete elimination of
residual urine, or reduction of the same to an insig-
nificant amount; (/') return to normal frequency of
micturition; {c) disappearance of vesical catarrh.
As regards a, the mechanical effect of the operation,
of course, must remain the decisive factor. So long
as the obstruction is not satisfactorily removed, the
surgeon has no right to consider his patient cured.
However, it should be remembered that it is more or
less within his power to accomplish this result by re-
peating the operation, or, if need be, doing it a third
time. The patients' demands are not, as a rule, very
exacting. So long as they have been relieved of
their former continuous suffering, they consider them-
selves cured, even though there still be a residual
urine of 250-300 c.c. (eight to ten ounces). From a
scientific standpoint, such a definition of the meaning
of a cure is, of course, untenable.
With regard to point /', the re-establishment of nor-
mal frequency of micturition, this evidently depends
upon the success or failure of the surgeon in remov-
ing the residual urine and the vesical catarrh or
pyelitis. In proportion to the degree to which one or
the other or both of these factors have been overcome,
will the frequency of micturition be reduced. To give
any exact figures as to what constitutes " normal fre-
quency" would be impossible, since this must depend
largely upon the total quantity of urine passed within
twenty-four hours. A diabetic, for example, or a man
with a contracted kidney will probably urinate twice*
or three times as often as one not so afflicted, although
the residual urine may have been removed in the latter
as well as in the former.
Now, as regards the vesical catarrh, this disappears
in exceptional instances as a direct result of the
operation, i.e., as soon as the obstruction to the proper
outflow of the urine has been removed. In other
cases careful after-treatment is imperative. The ad-
ministration of the different drugs so often mentioned
in the course of this paper, aided by local irrigation
— best with increasing doses of nitrate of silver —
will often clear up a patient's urine that has been tur-
bid for years. Nevertheless we should not be sur-
prised if our efforts in this direction are not always
crowned by success, even if pyelitis be absent. Who-
ever has looked through the cystoscope into the tra-
becular bladder of a prostatic, with its larger and
smaller acquired diverticula, its numerous and deep
grooves between and behind the protruding bundles of
the detrusor muscle, will understand the difficulty,
nay, impossibility, in some instances, of curing an in-
fectious catarrh that has once been thoroughly grafted
upon such a surface. However, it has been my ex-
perience that patients in whom the urine remained
more or less turbid after Bottini's operation are not,
as a rule, in the least disturbed by this condition.
They have no pain; they are well able to retain their
urine when the natural call comes; they have no
tenesmus. If they did not see their urine, they would
not know that they had a catarrh; in other words,
if the catarrh should disappear, this would cause
no difference to them as far as their feeling is con-
cerned. I personally have observed the entire dis-
appearance of all turbidity in the urine in five of
my cases. In these the urine cleared up by itself
after the removal of the obstruction, without any
further vesical irrigation, the patients merely having
continued taking salol and urotropin internally. In
none of the remaining cases, however, was I able to
carry out a suitable after-treatment. All of them left
my immediate supervision three to four weeks after
the operation.
Indications for Bottini's Operation. — I have pur-
posely reserved the discussion of this question because
it is by far the most important of all.
I'he principal decision the surgeon is called upon to
render in the case of a patient with hypertrophy of the
prostate who needs radical relief is : Which of the many
operations in vogue for this affection is indicated.'
Simultaneous ligation of the internal iliac arteries —
a procedure which certainly belongs to the radical
operations, in my estimation — has been abandoned on
account of the severity of the interference in old pa-
tients, and the possible complications arising.
Castration, an operation which has brought perma-
nent relief to many prostatics, is losing ground owing
to the objections offered by the patients, many of
whom have heard that .there are other means at our
disposal, nowadays, to help them. It also seems in-
advisable to propose the operation, because quite a
number of patients thus treated have become mentally
affected.
Ligation of the vasa deferentia (including resec-
tion of the spermatic nerves — angioneurectomy) has
received a severe blow by the compilation of cases
from Mikulicz's clinic, in 1897, by which, as will be
remembered, it was found that even in cases with, at
first, favorable result, the old trouble recurred at
about the end of the first year. In my former two
articles I expressed the opinion that the prelim-
inary performance of vasectomy might be a ration-
al procedure in order to reduce the hypera;mia of
the prostate gland. In my twenty-four cases I have
worked upon this basis in two instances, but must
confess tliat I have not been particularly impressed
by this method; at least I have no proof that it. has
been of value. In the second patient treated in this
way (Case XIX.), in which I left a permanent cathe-
ter in the urethra for five days, a suppurative funicu-
April 28, 1900]
MEDICAL RECORD.
715
litis set in, which it was very interesting to see stopped
short at the point of ligation and division of the vas
.deferens. Here the suppuration following gave me a
good deal of trouble during the after-treatment, inas-
much as it took almost half a year before the sinus
definitely closed. I am, therefore, rather inclined
now not to let this interference precede Bottini's
operation.
Prostatectomy, suprapubic or perineal, will, 1 be-
lie\je, at the present time be advisable only in cases of
large, fibrous prostates, provided the patients are not
too far in the seventies and seem able to stand an
operation under general anajsthesia.
It is interesting to note the marked divergence of
opinion with regard to the value of Bottini's operation
in patients with a fibrous prostate. Morton, of Brook-
lyn, when publishing his five cases of hypertrophy of
the prostate treated by Bottini's operation, expressed
the view that only fibrous prostates were amenable to
improvement or cure by the said method. Also, a
renowned American surgeon, after much refiection on
this subject, wrote me the other day that it was his
belief that hard prostates only could be relieved by
Bottini's operation. On the other hand, I personally
have seen the most beautiful results in those patients
in whom the glandular enlargement preponderated,
and had less success when operating on patients with
a hard gland. A similar divergence of opinion as to
the effect of Bottini's operation still exists in regard
to the significance of the amount of residual urine.
Lohnstein in a re'sume' covering the experience of
many operators claimed that the best results are ob-
tained in cases of absolute retention, while I person-
ally have had more success in cases with incomplete
retention. Thus it will be seen that the class of cases
that were most successful in the hands of one operator
proved less so in the hands of another — a circumstance
that, in my opinion, speaks well for the operation, since
it demonstrates that eacli type of prostatic enlargement
with its varying clinical symptoms has shown good re-
sults in the hands of some operator. Of course, this
may be perhaps, to some extent, explained by the fact
that no two cases of prostatic enlargement are exactly
alike. Further experience of individual operators is
absolutely necessary, before it will be possible de-
finitely to settle the points here under consideration.
The question, when Bottini's operation shall be
done, I would to-day answer in the same way as I did
eighteen months ago: namely, as soon as it will be-
come necessary to give the catheter into the hands of
the patient himselj. As I have said in my previous
paper on this subject, the danger to life begins at
this period. A single mistake in regard to asepsis
may set up an incurable cystitis with pyelitis or
pyelonephritis. That the surgeon will be able to
avoid these complications by doing Bottini's opera-
tion on a patient with a hitherto uninfected urinary
system can, of course, not be guaranteed. Yet if the
work was properly carried out, under the most scrupu-
lous asepsis, I do not think it likely that the compli-
cations mentioned should set in.
I do not share the view expressed by various
authors, that Bottini's operation is absolutely contra-
indicated in the presence of a pyelitis. Among my
twenty-four cases there certainly were at least two in
which a marked degree of uni- or bilateral pyelitis
was present. Both patients stood the operation very
nicely, the one being absolutely cured, the other much
improved. Nevertheless it is certainly necessary to
make it plain to the relatives, if not to the patient
himself, how greatly the risk is enhanced in the pres-
ence of pyelitis.
That Bottini's operation is a safe and harmless pro-
cedure, as might be inferred from the original pub-
lications of the author of the operation, will no longer
be claimed by any one in view of the experience of
operators all over the world. It will have its deaths,
if done in more or less advanced cases, the same as
every other operation so far devised for prostatic en-
largement has had. However, it should be remem-
bered that a comparative compilation of the cases of
the various authors up to date shows Bottini's opera-
tion to have had the lowest mortality, while at the
same time it shows the greatest percentage of cures.
And I believe we shall be able to decrease consicjer-
ably even the present low rate of mortality, by making
use of the experience we have meanwhile acquired,
and by advising an early operation, that is to say, as
soon as unmistakable clinical symptoms have ap-
peared. Whenever the doctor finds the premonitory
symptoms of prostatic enlargement slowly developing,
he should insist upon a distinct diagnosis of the
trouble. At this stage, too, the diagnosis can be
made with absolute certainty with the aid of the cysto-
scope. If that well-known groove at the internal
urethral fold at the neck of the bladder is seen during
cystoscopy; if, furthermore, there are symptoms of a
beginning trabecular bladder, in cases in which the
catheter repeatedly finds a small amount of residual
urine, the diagnosis, according to my belief, is defin-
itely established. These cases, as Freudenberg so
well says, are not yet ripe for the incisor. Neverthe-
less, from a prophylactic point of view it would be
well for the patients if the indication for radical
treatment even at this early date could be established.
I refer to the use of Bottini's prostatic cauterizator.
As is known, Freudenberg has also, within the
last year, improved the original cauterizator of Bot-
tini with reference to aseptic principles. It can
now be boiled the same as the incisor, and is a re-
liable instrument. It shows two platinum blades,
resting on a porcelain plate, at the concavity of the
junction of shank and beak, which can be brought to
red or white heat by the electric current." If these
blades are pressed against the projecting prostate at
the neck of the bladder, a slight or stronger effect can
be produced, according [a) to the amount of pressure
used, (b) to the amount of heat applied, and (<') to the
length of time the cauterization is made. It will be
readily seen that a great amount of prostatic tissue
can thus be burnt away right at the neck of the blad-
der and the prostatic bar just appearing lowered down
to the base of the bladder. It is further evident that
such a surface cauterization does not share the certain
amount of risk attached to the interference witii Bot-
tini's incisor. The only complication, the operation
otherwise being aseptically carried out, might be
hemorrhage at the time when the eschars are cast off,
and this can here be more easily coped with than when
occurring after the ordinary Bottini operation. Ac-
cording to the author, one must not be surprised to see
improvement begin as late as at the end of the third
or fourth week, in some instances. However, even if
future experience should prove the aforegoing as-
sumption to be correct, it is more than questionable
whether doctors will be ready to propose such an
operation to prostatics in the early stage of the dis-
ease, and whether the patients will accept such advice.
I fancy that time is far distant; perhaps it will never
come. Yet I am inclined to believe, with Freuden-
berg, that such an early cauterization of the begin-
ning prostatic enlargement would have to be looked
upon as an operation void of all danger, which bids
fair to save the patients thus afflicted all the untold
suffering that is otherwise bound to come sooner or
later.
(T'l' be coiicliided with report of cases.)
' The improved instrument was demonstrated by me before the
Section on Surgery of tlie New York Academy of Medicine,
December 11, iSgg. See Medical Record, December 30, i8gg.
yi6
MEDICAL RECORD.
[April 28, 1900
THE PAST AND PRESENT OF REFRACTION.
By FRANXIS VALK, M.D.,
OF DISEASES
Some years ago I had the pleasure of reading a paper
before the State Medical Society on " Our Refraction
Cases," at a time when the objective examination of
the dioptric apparatus of the eye was just beginning to
demand the attention of the profession, and in that
paper quoted these words: " It has the misfortune to
depend for its promulgation and practical application
upon the specialist, and almost upon the specialist of
a specialty, and this in a profession and in an epoch
in which it is fashionable to sneer at specialism and at
the specialist who dares to plead for the truth he knows
— and that at first, at least, only he can know." Yet
to-day how materially all our work has changed!
Before that time we had no objective methods of
quickly ascertaining what was the refractive condition,
except by the use of the ophthalmoscope, and in refer-
ence to the use of this most excellent instrument for
the estimation of refraction I may state that at that
time, in a case fully under the influence of a complete
mydriatic, examined at. the Manhattan Eye and Ear
Hospital by all the surgeons and attending physicians,
out of nearly twenty records only two were very near
the exact refractive condition as shown by the " trial
by glasses,"' while all the others concluded that the
case might vary in all the degrees of myopia to hyper-
metropia, two exactly opposite conditions. Hence
only a decade ago all ophthalmologists were compelled
to rely, almost constantly, on the use of atropine to
paralyze fully the action of the ciliary muscle, and
then to depend on the statements of the patients exam-
ined as to what glass would secure tlie best vision and
correct the refractive condition. This was considered
the crucial test, to be followed by ordering the glass that
would be accepted after the effects of the cycloplegic
had passed off. All this would require three careful
examinations, at the same time depriving the patient
of the use of the eyes for distinct vision for about ten
days.
It is very true even at the present day that the use
of atropine in refraction is the crucial test, and the ex-
amination of the refraction under this mydriatic leaves
nothing to be desired, but, except in the case of chil-
dren, it causes extreme inconvenience to others, and
has a certain amount of danger when used in old per-
sons; while to-day, in many cases, it is not needed.
In 1876 the late Dr. C. R. Agnew, whom every one
remembers for his kindness and admires for his skill,
pliblished a monograph on "One Thousand Cases
of Asthenopia," in which he reported two hundred and
eighty-one with normal or emmetropic eyes and four
hundred with hypermetropia and its complications;
but at the present time how few cases of emmetropia
do we meet in our daily work — almost none at all. So
seldom do we find these cases that some of our best
men have concluded that this condition of the refrac-
tion does not exist; that the hypermetropic eye, of low
degree, is truly the emmetropic eye. This is a propo-
sition I do not fully indorse, as we do at times find
an eye that is perfect in reference to its vision and its
refraction, and this, in my estimation, must always rep-
resent the standard eye. We do meet these cases in
our clinical work and in the office, not often, I must
confess, but we must remember that the human beings
so fortunate as to have emmetropic eyes either do not, or
rarely do, need the services of an oculist. They never
have any symptoms of astlienopia, so we do not have
the opportunity to test this vast number we believe
must exist, and if they do need glasses it is only when
old age has come to them; when they have passed the
age of forty or forty-five years, their " arms are not long
enough,'"' and almost any simple convex glass will give
the necessary reserve power to see at their reading dis-
tance, only requiring a slight change every three or four
years.
We had other tests in those days besides the ophthal-
moscope, as that of Green's, with the radiating lines,
that was useful in myopic astigmatism, but in my opin-
ion in that condition only ; also Placido's disc and the
cobalt blue test; but all these, as you are well aware,
depended entirely upon the statements of the perjons
examined. As I look at my records of those days and
at my notebooks of to-day, I am sure we must have
but imperfectly corrected the refraction of very many
cases.
It was not until about 1885 that we began to realize
the importance of the objective examination of the
dioptric apparatus, though the same instruments of pre-
cision were in use as at the present day, in the private
offices of several ophthalmologists, yet those who pos-
sessed them seem to have placed very little reliance
upon their use until the past fifteen years.
When I published the results of my examinations of
the first one thousand cases, they were as follows:
Hypermetropia, 35 I cases; simple hypermetropic astig-
matism, 192; compound hypermetropic astigmatism,
165; compound myopic astigmatism, 90 ; myopia, 75;
emmetropia, 54; mixed astigmatism, 49; simple
myopic astigmatism, 26; "giving a total of 2,004
eyes examined, of w-hich I found that in 774 cases the
refraction error was the same in each eye, and in 174
cases the refraction error was different, or the condi-
tion of anisometropia, the largest percentage being in
the cases of mixed astigmatism. In all statistics of
refraction the hyperopic eye stands foremost in num-
bers,'" but do we find it so at the present day with our
improved methods of examination?
All the above examinations were carefully made ac-
cording to our knowledge of refraction at that time,
but I feel very positive that if I would take the results
of my last examinations of one thousand cases from
my case-book I would find the figures very different,
and simple hypermetropia would not stand at the head
of the list, for it is in the diagnosis of this condition
that I find the most pronounced changes.
About 1885 I commenced the study of the method
of retinoscopy, or the so-called shadow test, with Dr.
George J. Bull, who is now associated with Javal of
Paris, and recommended it to the profession in a paper
read before the County Medical Society in February,
1890. At that time we had no retinoscopes, but sim-
ply pieces of looking-glass to observe the phenomenon
that was shown in the pupillary space. This was the
first practical test lliatwe had for the objective exami-
nation of the total refraction, and in my hands it has
been in constant use ever since, and to-day, fifteen
years afterward, I still consider it one of the best tests
in the hands of the oculist for the examination of the
refraction. By the use of this instrument — as we
notice the movements of the retinal refiex as it passes
across the pupillary space — we estimate the refraction
of the entire dioptric apparatus, or, in other words, the
parts of the eye through which the rays of light pass
in the act of seeing both at the distant and near points
of vision. Wishing to carry this test to its full com-
pletion, we may place glasses before the eye until we
neutralize the movements of the refiex in the two prin-
cipal meridians, testing each meridian separately, and
the glass so placed will very nearly indicate the refrac-
tion. In this way we rapidly and accurately note the
existence of any astigmatic error, its amount in diop-
ters, and the axis of the correcting glass.
.\bout 1890 my honored friend. Prof. D. B. St. John
Rossa, brought from Europe one of Javal's ophthalmo-
meters, and, though there were several in use in this
country, yet it was due to his persistent and earnest
April 28, T900]
MEDICAL RECORD.
717
advocacy of this most excellent instrument that its
use has spread and extended from one end of the
country to the other, and at the present time no ocu-
list's armamentarium can be complete without one.
Hence I feel that to Dr. Roosa all honor is due for the
introduction, in this country, of one of the most valued
objective instruments for the diagnosis and measure-
ments of corneal astigmatism. As this condition al-
most always exists in the anterior surface of the cornea,
its findings can be relied upon with almost positive
exactness in reference to the axis of the glass and the
amount of the astigmatism. I published a full descrip-
tion of this instrument in my book on the " Errors of
Refraction," in the issue of 1890, and since then —
though many improvements have been added by others,
in its mechanical advantages only — no changes have
been made in the use of the ophthalmometer for the
diagnosis of corneal astigmatism.
I also remember that about fifteen years ago we be-
gan to hear rumors of the relief of certain reflex symp-
toms by the use of glasses. One physician, speaking
to me on the subject, said a certain physician "could
relieve corns by the use of glasses," a very sarcastic
remark in reference to the work of a brother physician;
but in spite of the opposition, at that time, to the in-
fluence of the eye upon certain reflex symptoms, per-
haps clearly indicated, the work was still going on;
effects and results were noted; some cases with certain
reflex symptoms were relieved by the correction of the
refraction error, but in others the glasses failed to give
the required relief, and our attention was turned to the
movements of the eye in reference to its power of fixa-
tion. Then Dr. George T. Stevens demonstrated that
many nervous phenomena were due to the want of bal-
ance in the movements of the eyes, one_ to the other,
and he gave us the excellent nomenclature so frequently
in use at the present time. So heterophoria has taken
its place as one of the causes of certain reflex phe-
nomena that may be relieved by the correction of that
condition. Hence the tendency to a deviation of the
visual lines has been established, more or less, in this
special branch of medicine, and no examination of the
eyes is complete until the power of " duction " has
been fully studied, and, if need be, corrected. \Vhile
I appreciate the great advances Dr. Stevens has made
in his study and explanation of this most intricate con-
dition of heterophoria, and while I think his nomen-
clature of these various conditions, so frequently found,
is all that could be desired, yet I cannot say I fully
commend his methods of diagnosis. In my private
as well as clinical practice, I prefer to base all my
conclusions in reference to the action of the ocular
muscles, as regards their power, on the old and simple
prism test, firmly believing that nature intended there
should be a certain balance of power between the ac-
tion of the antagonizing muscles of tlie eye, and in
■which we may expect to find a certain standard in the
power of the muscles one to the other.
In the finding of this standard condition, ortho-
phoria, then, we will have no muscular asthenopia;
and all this has to-day convinced me that we should
have three fields for examination, namely, the field of
vision, in which we estimate its quantitative and its
qualitative extent; the field of fixation, in which we
estimate the excursions of the eyeballs within the field
of perfect vision — in other words, the extreme limit of
the visual lines in all and every direction with perfect
fixation, this being about 90° laterally and vertically;
and lastly, we have the field of fusion, a region shown
and estimated by the prism test, representing the power
to fuse, upon the macula, rays of light falling upon
other parts of the retina. This field is generally found
to be, taking the macula as a centre, about 30" out-
ward, 8° inward, 2° upward, and 3° downward, form-
ing what I consider the normal field of fusion, con-
trolled by the guiding sensation or fusion force of the
retina and limited by the individual power of the eye
muscles.
The last two fields have attracted much attention
from the profession within the last few years, and they
seem to be controlled by separate centres of the brain.
'iTie extent of the field of fixation is a voluntary act,
while that of the field of fusion is, to my mind, invol-
untary, as no force of the will can make the images
fuse beyond this certain extent, though it may be ex-
tended in certain directions by constant practice.
All this shows what the past of refraction has given
to us; and now- what is the present state of refraction
to-day? Do not all these exact and useful objective
methods, all the advances in the examination of the
eye and our better understanding of the ocular move-
ments, show that we can now, in almost all cases, esti-
mate the true and total refraction of the eye without
depending upon the subjective tests — in fact, correct
the refractive error without asking a single question of
our patients? I have done this over and over again in
my clinical work, and afterward proved it by the sub-
jective examination, by the ready acceptance of the
glasses, or by the crucial test, the use of atropine, and
the test by glasses.
To do all this requires many hours of constant prac-
tice in the examination of our cases; the eye of the ex-
aminer must be trained to know and to appreciate all it
sees, just as the fingers of the surgeon, by their delicate
touch and skilful manipulation, will indicate the diag-
nosis, and the surgeon will know, almost to a certainty,
what is the condition of the underlying parts he exam-
ines. We may look through the aperture of the oph-
thalmoscope and see the details of the fundus, but that
will by no means tell us what is the refraction. This
we must estimate by the appearance of the most deli-
cate parts of the retina as the correcting glass is placed
before the aperture, and this must be done in the prin-
cipal meridians of the eye. In my opinion the oculist
who can diagnose and estimate the true refractive con-
dition in a case of mixed astigmatism has truly learned
and mastered'one of the most useful instruments in
our hands.
Then with the retinoscope we can quickly see and
estimate the true and total refraction in the two meri-
dians as we note the reflex as it passes across the
pupillary space, and we can confirm all this by the ex-
amination with the ophthalmometer, at the same time
showing the corneal curve by the length of the radius,
in which we may find a clew to the refractive condi-
tion; and finally we conclude our examination by test-
ing the eyes for any want of balance in their movements
in reference to the fusion power. After we have cor-
rected all these findings, brought about normal vision
and normal balance, we may reasonably conclude that,
if relief is not obtained, the eyes cannot be at fault,
and the reflex symptoms must be due to some other
cause.
And now, as we look over the notes of refrac-
tion in our books, we find that hyperopia, pure and
simple, is not the leading refractive condition; that in
the vast number astigmatism, both simple and com-
pound, stands at the head of our list, which, when cor-
rected, may give success in many cases; that if we
fail with the use of glasses we may find some unbal-
ance of the ocular muscles that can be adjusted; and
that, having placed the eyes in the condition originally
intended by nature, we may feel confident that our
work has been performed in a truly scientific manner.
Projectiles of hard exterior are more humane than
the old leaden bullet, and amputations are not so
often required, while less cripples are returned to the
state. This agrees with recent experiences in Cuba.
— Major Louis A. La Garde.
7i8
MEDICAL RECORD.
[April 28, 1900
PROGRESSIV^E PERNICIOUS AN.'liMIA AND
MALIGNANT DISEASE OF THE STOMACH.
Bv ALBERT ABRAMS, M.D.,
SAN FRANCISCO.
In the cases of pernicious anemia counterfeiting caf-
cinoma of the stomach, culled from the medical litera-
ture, I can find no instance in which simulation has
been more marked than in the two cases which have
been made the subject of this contribution.
Case I. — A man aged forty-three years, referred by
Dr. W. Barrett, of Redwood City. The patient for
more than a year has grown progressively weak. He
suffers from dyspnoea, palpitation of the heart, and
gastric irritability. He has lost twenty pounds in
weight. The status prassens in brief is as follows:
Marked pallor; malleolar cedema; haemic murmurs at
the cardiac base and in the cervical veins; slight
evening exacerbations of temperature. The stomach
contents, after an experimental meal of I.eube, shows
the absence of hydrochloric acid and the presence
of large quantities of lactic acid. Palpation reveals
marked tenderness in the region of the pylorus, and
percussion easily demonstrates ventricular dilatation.
The glands of the neck and inguinal region are slightly
enlarged. In this patient a pulmonary lesion was
suspected, and in the absence of palpable physical
evidence he was submitted to a Roentgen-ray examina-
tion. The rays demonstrated a dark patch in the apex
of the right lung. The question naturally arose whether
in this patient I was dealing with the ana;niia of the
pretuberculous stage of phthisis, a condition of the
blood which I have designated elsewhere as pulmonary
anaimia.' Pulmonary is distinguished from all other
forms of anaemia, the one exception being pernicious
anaemia, by the fact that while the ferruginous prepa-
rations benefit pure anajmics, in pulmonary anaemia
they are practically of no value, or at any rate the
benefit accruing from their use is only evanescent.
The pathognomonic sign of pulmonary ana;niia is the
therapeutic test. If a suspected individital is subjected
to a single pneumatic treatment, employing inhalations
of compressed air, one invariably finds, after an ex-
amination of the blood, an increase in the percentage
of haemoglobin. A collective investigation made by
me, in a number of patients demonstrated that the
hasmoglobin percentage could be increased fifteen
per cent., on an average, after a single pneumatic-
cabinet exercise. This test proved negative in my
patient.
Case II. — A woman aged seventy-four years, seen
in consultation with Drs. von Hoffman, Thorne, De
Vecchi, and Aronstein of this city. The symptoms were
similar to those in the previous patient, excepting that
there were more pronounced emaciation and gastric
irritability. Vomiting in the incipiency of the dis-
ease was of daily occurrence, and repeated examina-
tions of the vomitus invariably demonstrated the ab-
sence of hydrochloric acid and the presence of lactic
acid. One of us detected the presence of an intumes-
ence in the pyloric region, while all concurred in the
demonstration of increased sensitiveness and resistance
in that area. Pronounced cachexia was present, but
there was not the characteristic yellow lemon tint of
pernicious ansmia. The foregoing anamneses were
decidedly suggestive of malignant disease of the stom-
ach, and would, in the prehaematological era of medi-
cine, be accepted as conclusive clinical evidence of
its existence.
The following differential table, taken from the ex-
cellent text-book of Anders on the " Practice of Medi-
cine," suggests the conventional evidence employed in
' Medicine, December, iSyj, and The Medical .Standard, Jan-
uary, 1900.
differentiating obscure gastric carcinoma from progres-
sive pernicious anaemia:
Pernicious Ainrmia.
Gastric Carciu
Red corpuscle count falls to, or Count does not fall to 1,000,000,
below, 1,000,000 per c. mm. as a rule.
Found earlier in life. Occurs after middle life.
Gastric symptoms not pro- Gastric symptoms more sugges-
nounced. tive.
Lemon-tinted skin common. .Skin pale, muddy, or jaundiced.
Adipose tissue fairly preserved. Progressive emacialion.
No glandular enlargement. Supraclavicular or inguinal
glands enlarged.
Nq physical signs over stom- Increased area of resistance over
ach. stomach.
Gastric contents after test meal Deficiency or absence of hydro-
negative, chloric and presence of lactic
acid.
Some improvement may be Condition becomes steadily
brought about, even cure, worse until death ends the
though rarel)'. case.
To the foregoing table the dictum of Osier may be
added: "In carcinoma of the stomach, the condition
is an anaemia with wasting, and the layer of pannicu-
lus is not retained as in the ordinary forms of per-
nicious anaemia."
Hamatology has won so many triumphs in modern
medicine that no clinical examination may be re-
garded as complete without a methodical blood exami-
nation. Cabot, in his monograph on the blood, gives
expression to the following epigrams: "Malignant
disease may bring down the blood count to 1,000,000
or lower, but in such cases leucocytosis is always
present"; on another page: "In pernicious anaemia,
the leucocyte count is very low and may fall below
1,000 cells per cubic millimetre." A few years ago,
the preceding statements would have been regarded as
the utterances^ of a doctrinaire, yet now clinicians
everywhere accept them as truisms.
In the first patient, the blood count showed i ,000,000
erythrocytes with a haemoglobin percentage of 40, or a
color index of 2. The leucocyte count was reduced to
one-third the normal. In the second patient, besides
the presence of normo- and megaloblasts, the red cells
were reduced to 800,000 per cubic millimetre, the
haemoglobin to thirty-five per cent., and the leucocytes
to one-half the normal number.
Both patients were placed on increasing doses of
Fowler's solution and bone marrow. The latter had
to be discontinued at once owing to the gastric irrita-
bility which it provoked. The therapeutic test with
arsenic only confirmed the evidence of the blood exami-
nation (marked reduction in red corpuscles, leucopenia,
and high color index), and the improvement in both
patients was immediate and progressive. The first
patient returned to his work as a laborer, and when I
last saw him he said, " I can work harder than I have
for years." He took twenty drops of Fowler's solution
three times a day for two weel:s, and the number of
his red corpuscles at the end of that time increased to
500,000 above the normal. The same marked improve-
ment, though not so rapid, was noted in the second
patient, and hydrochloric acid reappeared in the stom-
ach contents.
The following conclusions may be formulated:
I. Arsenic is a true specific in pernicious anaemia,
and is as certain in its immediate results as is mer-
cury in syphilis, quinine in malaria, or iron in chlo-
rosis. The specificity of arsenic is so great that in no
case of grave anspmia are we justified in excluding the
progressive jiernicious variety, even though the blood
examination is negative, without a heroic trial of ar-
senic. Like the other specifics, it produces relative
cures and cannot be regarded as a prophylactic owing
to the frequent relapses which occur. It may be given
as Fowler's solution, beginning with three-minim doses
well diluted after each meal, and increased by one or
two minims daily according to the urgency of the case,
April 28, 1900]
MEDICAL RECORD.
719
until twenty-five or thirty minims are taken three times
a day. A safer rule is to push it to the point of tolera-
tion and maintain it at this point until the blood
examination shows the result desired. The appear-
ance of its physiological effects (cedema and itching of
the eyelids, gastro-intestinal irritation, etc.) is a signal
for its temporary discontinuance. When arsenic can-
not be given by the stomach, it may be administered
subcutaneously or even by the rectum.
2. In association with arsenic, assimilable food and
rest are indispensable adjuvants.
3. The use of intestinal antiseptics in this as well
as in other diseases is a mere therapeutic refinement
not sanctioned by bacteriological reasons, and they
ought, therefore, not to be employed as a routine meas-
ure. In the Italian literature one finds some authentic
evidence of the good effects from thymol, its adminis-
tration being suggested by the theory that pernicious
anaemia is caused by intestinal absorption of products
which are destructive to the red blood corpuscles.
4. Iron is not only useless but is apt to create diges-
tive disturbances.
5. Bone-marrow is said to be curative, but in my
experience it induces nausea and aggravates existing
gastro-intestinal troubles.
6. Gastric disturbances suggest stomach lavage.
Tlie character of the food ingested must be determined
by the results of a chemical analysis of the stomach
contents.
7. 'J'o counteract the great reduction in the quan-
tity of blood (oligasmia) weak saline solutions may be
given by the colon (enteroclysis) or preferably in the
subcutaneous tissue (hypodermoclysis).
8. Relapses are best prevented by minute attention
to dietetic and hygienic details.
7S4 Geary Street.
Contribution to the Knowledge of Some New
Remedies. — Overlach describes the advantages of for-
toin as: Its taste has not the biting sharpness of cotoin
crystals; it is a stronger antiseptic. It is formal-
dehydcotoin or methylendicotoin. It is formed by tiie
action of formaldehyde on cotoin. It consists of beau-
tiful yellow crystals. I'he fusing-point lies between
211° and 213° C. It is easily soluble in chloroform,
acetone, and glacial acetic acid, difficultly soluble in
alcohol, ether, and benzol, insoluble in water, but very
easily soluble in alkalies. It is an expensive remedy,
but reliable after the failure of other measures. — Cen-
tralblatt Jiir innere Median, March 10, 1900.
Application of Forceps in the Dead Mother; Living
Child. Remarks on Death in Labor and Delivery
in the Upright Position on Account of Orthopncea. —
Alfred Egon Neumann reports the extraction of a living
child from a dead mother. The child showed scarcely
a trace of aspliyxia, soon cried, and lived. The case of
orthopncea was that of a woman forty years old. There
was general cedema ; systolic and diastolic cardiac mur-
murs were present. Urine was spare in quantity, with
one per cent, of albumin. After delivery, the patient
was tapped, and then improvement began. On the
ninth day there was still one-half per cent, of albumin,
with no casts. The oedema had almost disappeared. —
Cenlralblatt Jiir Gyndkologic, March 10, igoo.
The Mechanism of the Action of the Anti-Diph-
theritic Serum against the Toxin in the Animal
Organism — Nicola Pane believes that instead of exert-
ing a chemical influence, as do some other serums, the
anti-diphtheritic serum produces a relative and tem-
porary immunity in the organism by exciting special
defensive powers in the cells. This immunity is not
essentially different from that caused by the toxin in-
troduced into the body in non-lethal doses, except that
the latter works more slowly and is much more lasting
in its effects. — La Rijonna Alcdica, March 15, 16, and
17, 1900.
On the Therapy of Epilepsy with the Flechsig
Method. — Lad Haskovec states that the cases he de-
scribes show that the bromine therapy in connection
with a properly regulated life has a good influence on
the course of epilepsy. The combination of opium
and bromine, potassium bromide, as Flechsig directed,
give good results. Diet has a great influence and
should be carefully regulated. The milk diet is con-
sidered very efficacious. More time is yet needed
wholly to prove the benefits of Flechsig's method. —
Wiener klinische RuihlsiJtaii, February 25, 1900.
The Association of Paraldehyde with Chloro-
form.— Cosimo Nolo belie\es, from the results ob-
tained by experimentation, that the association of
paraldehyde with chloroform to produce anasthesia
completely suppresses tlie period of chloroform excite-
ment, prevents profuse secretion of saliva, and causes
anaesthesia in a very short time and with a small dose
of chloroform. The sleep is sound, respiration calm,
heart regular, and blood pressure sufficiently strong.
The sleep is much prolonged, even after the cessation
of anaesthesia; the patient awaking some time after
the operation is over, already revived and without
suffering the effects of trauma. — AVn' Orleans Medical
and Suri^ii 111 Journal, March, 1900.
A Case of Total Laryngectomy for Sarcoma ;
External Artificial Larynx. — N. Taptas records the
case of a woman, aged forty-six years, who had suffered
from hoarseness for three years, and who had worn for
the eight months before being seen by him a tracheal
tube. Pains in the neck were severe, and she was un-
able even to swallow liquids. A tumor was made out
in the lower pharynx, but its relations to neighboring
parts could not be determined. Examination caused
vomiting, in the course of which the patient expecto-
rated a small piece of the mass, which upon examina-
tion proved to be a sarcoma with round and fusiform
cells. The rapid progress of the growth rendered a
laryngectomy necessary, and this was successfully
done. A novel form of artificial larynx was inserted,
it being worn externally and supplied with air through
the tracheal tube. — Annalcs des Alaladies dc F Oreille,
du Larynx, elc, January, 1900.
Laryngeal Ictus and Asthma. — Moncorge' gives
brief histories of nineteen cases which have come
under liis personal observation, and refers to similar
cases published by others. Special study is made of
thirteen cases which came to light upon interrogating
three hundred and twenty patients of all ages with
reference to this matter. All suffered from some form
of cough. Among the three hundred and twenty, Mon-
corge found one hundred and thirty-seven cases of true
asthma furnishing twelve cases of ictus, while among
the one hundred and eighty-three non-asthmatics only
a single case of ictus appeared. The author believes
that the prolonged congestion of the pharynx and
larynx which occurs in asthmatics favors the onset of
distinct laryngeal spasm. Moreover, asthmatics are
predisposed to all forms of spasmodic seizure. — A/males
des Maladies ,/e l' Oreille, dn Larynx, etc., February,
1900.
On Malignant (Edema. — Alois Brabec reports the
case of a man, twenty-five years old, with malignant
cedema. This was clearly a case of sepsis through
intoxication, for: (i) a local focus of infection was
present; (2) the bacteriological blood findings were
negative. (3) A dose of 0.5 c.c. of the cedema fluid
MEDICAL RECORD.
[April 28, 1900
could kill a mouse, while o.i c.c. had no effect. This
is of practical value, for in a septic intoxication only
an operative procedure will be effective — in this
case exarticulation of the shoulder joint — while in a
septic infection surgery seems without result. — JV/eiier
klinische Rundschau, March 4, 1900.
The Action of Iron. — Guiseppe Poggi concludes
from experimentation that while under normal condi-
tions iron has a hasmogiobinogenetic action, in the
pathological conditions created by chlorosis it is first
of all a cytogenetic agent, and in some unfavorable
cases that alone. — Rivista Critica di Clinka Mcdica,
March 3, igoo.
Hemorrhagic Syphiloderma of Adults. G. I'icardi
believes: (i) That in addition to the macular, papu-
lar, pustular, etc., forms of syphiloderma, there is a
secondary hemorrhagic form, characterized by special
clinical symptoms and histological structure; (2) that
it is exhibited chieHy in situations where there have
been previous circulatory disturbances; (3) that it is
produced by a process of pericellular and connective-
tissue infiltration from the vessels of the derma and
subjacent tissue, resulting in extravasation of the
blood with all its elements, either from oozing through
the degenerated walls or by rupture of the capillaries.
— II PoUcUiiico, March i, 1900.
The Cure of Uterine Prolapse by the Mazzoni
Process. — G. Parlavecchio describes this method,
which consists in laparotomy, and then in lifting the
uterus as high as possible and passing a strong silk
thread into the uterine substance at the point of in-
sertion of the round ligament of each side. The peri-
toneal wound and that of the rectus muscles having been
reunited, the two loops of silk which have been brought
up through the rectus muscles and their aponeuroses
are drawn upon, and each is tied separately. The
abdominal opening is then closed. — La Clinica Oste-
tiica. January, 1900.
Treatment of Keratitis Profunda. — Emil Gutt-
mann sums up his ideas concerning this subject as
follows: The mercurial treatment, except for small
children, is without especial influence and is rather
dangerous. Atropine is without influence on the proc-
esses in the cornea and should therefore be used as
sparingly as possible. Irritating measures should be
avoided throughout the inflammatory stage. On the
other hand, the systematic application of cocaine as a
non-irritating and, indeed, soothing remedy should be
followed up, since its use is attended with favorable
results in corneal processes. — Wiener klinisclie Rufid-
se/iau, February 11, 1900.
An Uncommon Manifestation of Cholelithiasis. —
P. Grocco calls attention to the cases in which very
slight and long-continued fever or feverishness is ap-
parently the only indication of disorder. The spleen
is not enlarged, but the liver is usually enlarged and
at some point sensitive to pressure. Urobilin is usu-
ally present, with polycholia. The author believes
that this condition is frequently due to hepatic cal-
culus from infection of the bile passages, and that it
may be cured by treatment addressed directly to the
liver, even when antiseptic treatment of the intestines
has failed. — Rivista Cntica di Clinica Medica, Febru-
ary 17, 1900.
The Heart in Life Insurance.— According to J. X.
Upshur, functional murmurs should lead to a rating of
postponement, but not unqualified rejection. Cases
with murmur which fail to develop hypertrophy or
displacement to the right may be safely taken, so also
cases in which there has been an endocarditis in infancy
or early childhood, but in which the growth of later years
has led to a compensating hypertrophy so that there is
no failure of the circulation. On the other hand, no
risk is first-class when the sound of the valve fails in
clearness or is muffled, because this indicates rigidity
and loss of elasticity. Alcohol and tobacco, even
though their use has been given up, frequently dis-
qualify a man for insurance.- — Charlotte Medical Jou?--
nal, March, 1900.
Still Another Contribution to the Knowledge of
Kakke in Sucklings Z. Hirota, after giving some
statistics on the subject and reporting several cases of
kakke, sums up his observations as follows : Sucklings
are infected through the mother's milk; the infants
suffer from severe symptoms of the disease, not only
when the mother is affected by the lightest form, but
also at such an early stage that the mother appears to
be perfectly free from t'..e affection. It is most im-
portant to note that a very constant symptom of kakke
in the adult is the indican reaction; this can always
be found in the urine of the mother, even when there
is no other change from the normal condition. — Ce?i-
tralblatt fiir innere Medicin, March 17, 1900.
Coupling and Redoubling of the Second Sound in
Mitral Stenosis. — Luigi Ferrannini says that the dou-
ble sound heard at the base of the heart is a coupling
of the second physiological sound, due to unequal
pressrire in the large arterial trunks, because of which
the aortic semilunar valves do not close simultaneously
with the pulmonary. The double sound at the apex is
a redoubling because due to the addition of an entirely
new sound, and not a part of another sound. The two
phenomena are absolutely separate and distinct, and
as such cannot be due to the same cause. — La Rijorma
Medica, March 10, 12, and 13, 1900.
Contribution to the Question of Crerative Treat-
ment of Neuralgia of the Trigeminal Nerve. — A.
B. Tichonowitch, after reviewing various operative
measures in the treatment of neuralgia of the trigem-
inal, states that the method of Quenu and Sebileau is
in his opinion the best. It offers a perfectly free en-
trance to the Gasserian ganglion; the technique of the
operation is comparatively simple; the extent of bone
resection is limited; the course followed to reach the
foramen ovale between the bone and the periosteum is
without danger; there are no great vessels to be en-
countered; the tissues concerned are easily recogniz-
able; the favorable opportunities for ligating the mid-
dle meningeal artery, and the rather small dimensions
of the opening made in the bone, show this method to
be the most advantageous. — Centralhlatt Jiir Chirurgie,
March 24, 1900.
Hypertrophy and Dilatation of the Colon in an
Infant. — Lyder Nicolaysen reports the case of an in-
fant who suffered from constipation since shortly after
birth, the abdomen becoming gradually distended.
The child was sickly, and had frequent attacks of
vomiting. When six months old, he presented a de-
plorable spectacle. The abdomen was enormously
distended, measuring 70 cm. in circumference at the
umbilicus; from the navel to the symphysis pubis it
measured 15 cm., and from the navel to the ensiform
process 27 cm. But little effect was produced by
enemata, and at the age of twenty-one months the
child died from a slight attack of bronchitis. At
autopsy the large intestine was found to be greatly
enlarged, measuring 26 cm. in circumference, and its
walls were exceedingly thin. No obstruction could be
found in any part of tiie intestine. Axel Johannessen
reports three similar but less marked cases in the
same journal. — Norsk Alagazin Jcrr La!gevidenskaben,
March, 1900.
April 28, 1900]
MEDICAL RECORD.
721
Medical Record:
A Weekly Journal of Alcdiciiie and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
PUBLISHERS
WM. WOOD & CO., 51 Fifth Avenue.
New York, April 28, 1900.
THE DIAGNOSIS OF SMALLPOX.
In its early stages and in a modified form smallpox
presents many points of similarity to various diseases
and particularly in the latter form to chicken-po.\.
Its correct diagnosis is by no means at all times an
easy matter, and many physicians among those who
have had little or no practical experience in treating
the disease, and whose knowledge as to its diagnostic
features is chiefly derived from the text-books, are
liable to be led astray by its similitude to chicken-pox.
As a rule, too, the medical practitioner is conversant
only with typical smallpox. When smallpox in a mild
form is extremely prevalent, as it is at present in Illi-
nois and many other States, the necessity for medical
men to be able to distinguish with unerring accuracy
between the above maladies will be clearly under-
stood. Through a mistaken diagnosis an epidemic
may be spread far and wide, not only causing much
sickness and mortality, but entailing also financial
and trade embarrassments of a serious nature.
Public Health Reports., March 23d, publishes a cir-
cular sent by the Illinois State board of health to the
physicians of that State with regard to varicella in
the adult. Among other apropos remarks are the fol-
lowing: " The occurrence of chicken-pox in adults is
so rare as to have escaped the observation of many of
those who have devoted years to the study of exanthem-
atous diseases. That it does occasionally exist dur-
ing adult life is not denied, but its appearance at this
period is so uncommon as to excite comment. All
cases of so-called chicken-pox in adults seen by this
board during the present epidemic presented a well-
defined variolous eruption." In support of the asser-
tion that chicken-pox rarely attacks other than chil-
dren, and that an epidemic eruptive disease affecting
adults and children alike is not ciiicken-pox, many
quotations from text-books of unquestionable authority
are tendered. Dr. John MacCombie, in Allbutt's
'•Practice of Medicine," says: "A large proportion of
cases that occur nowadays in a well-vaccinated com-
munity are of the modified form. In many instances
so completely is the course of the eruption altered
and the symptoms after the initial stage is over are so
modified that it is often diflScult to recognize the
identity of the ordinary and modified diseases. In
modified smallpox as a rule the whole of the eruption
is out within twelve hours of the appearance of the
first papulffi. In ordinary cases it is not abundant
and may be macular at first or from the very beginning
papular. In either case much of the eruption is
vesicular within twelve to twenty-four hours, and the
vesicles attain their full growth in about three days,
while some of the papules abort without becoming
vesicles. In size they are usually smalle- than those
of natural smallpox, less regularly ci- alar, more
conical, and very often not depressed in the centre,
although many show a faint line of redness from the
beginning. On the third and fourth days of eruption
the vesicles are opaque, the lymph is cloudy, and in
many patients they do not become pustules, but de-
siccate unruptured, inspissated lymph forming small
brown, flat, and slightly raised prominences about the
size of a small sago grain or less under the epidermis.
If they do become pustules they attain the size of full
pustulation within five or six days of the appearance
of the eruption, and thereafter desiccate ruptured or
unruptured, as the case may be. The crust or desic-
cated pustule falls off in the course of a week or less,
exposing a flat, reddened, healed surface of epidermis
where usually a little desquamation follows." The
same author writes: "The diagnosis of chicken-pox
must be determined by the distribution of the eruption
and the character of the vesicles distributed on the
trunk, thighs, and arms. In chicken-pox the eruption
is most abundant on the trunk, less so on the face, still
less so on the forearms and legs, and least of all on
hands and feet. This circumstance attracts attention,
and if the eruption be carefully examined, typical
unilocular oval vesicles are invariably found on the
abdomen, chest, sides of trunk or back, mixed very
often with macules, papules, and small abortive
vesicles. . . . On the extremities the similarity of
the vesicles of chicken-pox to those of modified small-
pox usually increases in direct ratio to the distance
from the trunk. In many cases the vesicles on the
forearms, legs, back of hand, and back and dorsum of
foot are round and hard, small in size, not unlike the
eruption of modified smallpox. But all cases of
chicken-pox present typical vesicles on either the ab-
domen, chest, back, thighs, or arms."
From the foregoing description it will be gathered
that in the case of an eruptive disease resembling
smallpox or chicken-pox, if a careful examination be
made as to the character and location of the vesicles
a correct diagnosis should be arrived at without much
difficulty. When, however, an epidemic of smallpox
is abroad, all complaints of an eruptive nature should
be viewed with suspicion, and if a physician feels in
the least doubtful with regard to any particular case it
will be better, for him to err on the side of caution
and to observe strict precautions, than by a mistaken
diagnosis perhaps to menace the health and lives of a
whole district.
Cocaine Effect upon the eye can be increased by
instillation of a watery solution of suprarenal extract.
MEDICAL RECORD.
[April 28, 1900
THE ETIOLOGY OF GENERAL PARALYSIS
OF THE INSANE.
The view ihat both paretic dementia and tabes dorsalis
are largely due to syphilis is receiving gradually in-
creasing acceptance, although there are still wide dif-
ferences of opinion as to the frequency of this etio-
logical relation. In the present state of knowledge it
would be a mistake to maintain that this association
exists in all cases, and if it is admitted, as it must be,
that other causative factors are operative, it can be
readily seen that the proportion of each will vary
widely, in accordance with numerous conditions.
Further, it is scarcely contended that the two diseases
of the nervous system named are truly syphilitic dis-
orders, but rather that they are secondary degenerative
results of the antecedent infection, and this assump-
tion also renders it probable that other infectious proc-
esses may exert a like influence.
An interesting statistical contribution to the litera-
ture of this subject is made by Se'rieux and Farnarier
{KiTiie de Medccinc, February 10, 1900, p. 97), w'ho
report the results of an analysis of 58 carefully in-
vestigated cases of paretic dementia, of which 46 oc-
curred in men and 12 in women. Of this number 16
were rejected because the evidence was inadequate.
The remaining 42 were divided into four groups: i,
those in which syphilis had certainly been present;
2, those in which, from the history and the physical
signs, syphilis had probably been present; 3, those
in which syphilis had probably not been present; and
4, tliose in which syphilis had certainly not been pres-
ent. As a result of this analysis it was found that
syphilis had been present with certainty in 21 cases,
50 per cent., and with probability in an additional 12
cases — 28.6 per cent. Syphilis had probably been
absent in 6 cases, 14.3 per cent., and certainly absent
in 3 cases — 7.1 per cent. Syphilis was found to be
the sole etiological factor in 13 cases — 31 per cent.
Among other etiological factors were found the follow-
ing: Neuropathic or psychopathic heredity in 14
cases — 33.3 percent.; alcoholism in8 cases — 19. i per
cent.; arthritism in 7 cases — 16.7 per cent.; typhoid
fever in 7 cases — 16.7 per cent.; cranial traumatism
in 4 cases — 9.5 per cent.; variola in 2 cases — 4.8 per
cent.; carbon-monoxide poisoning in i case — 2.4 per
cent; furunculosis in \ case — 2.4 per cent.
It thus appears that syphilis is twice as frequent a
cause of paretic dementia as typhoid fever, smallpox,
and alcohol combined; two and one-half times as fre-
quent a cause as neuropathic or psychopathic heredity,
and eight times as frequent a cause as cranial trauma-
tism. Neuropathic or psychopathic heredity is encoun-
tered in about one-third of the cases, but this figure is
probably too small, as heredity appears to be the basis
necessary for the development of general paralysis.
The duration of the period of incubation was found to
be in the mean fourteen or fifteen years, with six and
thirty-two years as the extremes. This period includes
the so-called period of invasion, that is, the period
during which morbid phenomena are so little marked
that restraint is not necessary. This period, so far as
can be judged, may have a duration of two or three
years, and the true period of incubation is thus re-
duced to about twelve years. The mean age at which
restraint of general paralytics becomes necessary is in
the neighborhood of forty years. Deducting fifteen
years from the latent period (incubation and invasion),
twenty-five years would be about the age of contagion.
Whatever may be the significance of syphilis as a
cause of paralysis, it is not the sole cause. The action
of syphilis is incidental and not specific, and it ap-
pears demonstrated that toxic substances of various
kinds — chemical poisons (lead, alcohol), vegetable
poisons (diseased rye), microbic poisons (syphilis),
and perhaps also agents of auto-intoxication, are
capable of causing meningo-encephalitis in predis-
posed individuals. This disease does not, therefore,
merit the designation exclusively of a parasyphilitic
or even a parainfectious, but the more general one of
a paratoxic afTection.
THE RELATIONS BETWEEN THE LYM-
PHATICS AND THE BLOOD-VESSELS.
It is commonly taught that the lymphatics discharge
their contents into the venous system through the
thoracic duct on the one hand and the right lymphatic
duct on the other hand, at the junction of the jugular
and subclavian veins on either side, and by inference
it is implied that there is no other communication
between the lymphatics and the blood-vessels. There
is, however, evidence that such communication exists
and perhaps not rareTy. A contention to this eflfect
w-as made by Lippi of Florence in 1825, and more
recently MacAl lister has also come to the support of
the same view. Boddaert demonstrated experiment-
ally in rabbits and by dissection the existence of
communication between the lymphatics and the veins.
Additional observations of a like character have been
recorded by Leaf {Lancet., March 3, 1900, p. 606),
who in several dissections has observed a communica-
tion in the inguinal region in the human subject be-
tween the lymphatics and the veins. In one instance
the thoracic duct was double. One of the lower left
intercostal veins terminated in the lesser azygos vein
and was connected by a small communicating branch
with the left half of the thoracic duct. In another
instance a large lymphatic trunk terminated directly
in the greater azygos vein, and an intercostal lymphatic
terminated in the lowest intercostal vein on the right.
Leaf believes that the communications between these
two sets of vessels are not uncommon, and he is in-
clined to regard them as normal. He has frequently
observed that some of the intercostal lymphatics pour
their contents into some of the intercostal veins or
into one or both azygos veins; or that some large
lymphatic trunks in the neighborhood of the receptacu-
lum chyli empty into the greater azygos vein. Some-
times blood apparently passes from a vein into a lym-
phatic, quickening the sluggish movements of the
lymph-current. In some instances a communication
was found also to exist between lymphatics and arteries
and occasionally between lymphatics and arteries and
veins. These facts may help to explain the pink or
April 28, 1900]
MEDICAL RECORD.
723
reddish color sometimes presented by lymph, and also
some peculiarities connected with the dissemination
of sarcoma and carcinoma. Thus, sarcoma, while
usually spread by the veins, sometimes invades the
lymphatic glands, and carcinoma, while usually in-
vading the lymphatic glands, is sometimes spread by
the veins.
A Bureau of Materia Medica. — At the annual meet-
ing of the Medical Society of the State of New York
in January, a resolution was adopted to the effect that
the interests of medical science require the establish-
ment of a bureau of materia medica in order to insti-
tute disinterested investigation into the character and
value of new drugs. And the society recommended to
the Decennial Convention of 1900 for the revision of
the United States Pharmacopceia, the creation of such
a bureau by and under its authority, with the provision
that it shall report annually upon the matters coming
properly within the scope of its work.
An Impostor. — A medium-sized, corpulent man,
dressed as a laborer, is visiting certain physicians
with the statement that they have been proposed as
lodge physicians. He is armed with a letter of in-
troduction, obtained by false representation, from one
reputable practitioner to another. Professing that
neither of these physicians, for various reasons, can
take the position, he offers it to his intended victim,
from whom he asks for from' $3 to $5 as a proposition
fee to be forwarded to the physician-in-chief.
The New York Genito-Urinary Society. — A new
medical society has been formed under this name, the
membership in which will be confined to medical men
engaged in active clinical work in connection with
one branch or another of this specialty. Meetings
will be held once a month, when cases will be re-
ported, and at least one paper read. The officers for
the first year are: President, Dr. Ramon Guiteras;
First Vice-President, Dr. Winfield Ayres; Second Vice-
President, Dr. Otis K. Newell ; Treasurer, Dr. George
W. Blanchard; Secretary, Dr. A. D. Mabie; Corre-
sponding Secretary and Stenographer, Mr. Samuel Ben-
nett, 161 Garfield Place, Brooklyn. The correspond-
ing secretary will furnish information as to terms of
membership, etc.
The Fourth International Congress of Derma-
tology and Syphilography will be held in Paris at
the Hospital St. Louis, August 2d-gth. The subjects
for discussion are: Dermatology: The parasitic ori-
gin of eczema (reporters, Kaposi, Unna, Jadassohn,
Galloway, Brocq, assisted by Bodin and Veillon);
the tuberculides (reporters, Boeck, Colcott Fox, Cam-
pana, G. Riehl, J. Dairer) ; the "pelades" (reporters,
Malcom Morris, Lassar, Mibelli, Parloff, Sabourand) ;
the leukoplakias (reporters, Behrend, Springle, Per-
rin). Syphilography and venereology; Syphilis and
associated infections (reporters, Neisser, Bulkley,
Ducrey, Hallopeau) ; the descendants of hereditary
syphilitics (reporters, J. Hutchinson, Tarnowsky, Fin-
ger, JuUien) ; causes of generalized blennorrhagic in-
fections (reporters, W. R. Taylor, Lesser, Tomniasoli,
Lane, Balzer). Those desiring to become members
of the Congress should address Dr. G. Thibierges,
7 Rue de Surene, Paris, or the secretary for the United
States, Dr. George T. Elliot, 36 East Thirty-fifth Street,,
New York. The membership fee is $5.
The Ohio State Medical Society.— The fifty-fifth
annual meeting of this society will be held in Colum-
bus on May gth-iith, under the presidency of Dr^
Rufus B. Hall, of Cincinnati.
Bequests to Hospitals.— By the will of the late
George W. Miles, of Philadelphia, contingent bequests
were made to the following institutions: Episcopal
Hospital, St. Joseph's Hospital, Presbyterian Hospi-
tal, each ^8,000; Maternity Hospital, Pennsylvania
Hospital, Children's Hospital, Methodist Episcopal
Hospital, Germantown Dispensary, Protestant Epis-
copal City Mission for the Home for Consumptives,
Hahnemann College and Hospital, to each $5,000.
Philadelphia Neurological Society. — At a stated
meeting held April 23d, Dr. F. Savary Pearce pre-
sented a case of peripheral facial palsy, with crossed
hemiparesis. The patient was a colored man, who
after exposure to cold developed disease of the middle
ear and facial palsy on the left side, and some months
later, with partial loss of consciousness, developed
weakness upon the right side of the body, probably
in consequence of hemorrhage into the left cerebral
hemisphere. Dr. W. G. Shallcross presented a case
of acromegaly, and also a case possibly of acromegaly
in an early stage. Both patients were young men,
deficient mentally, and inmates of the Pennsylvania
Institution for Feeble-minded children. Dr. C. W.
Burr exhibited a case of treadler's palsy occurring
in an elderly man whose work compelled him to raise
and depress many hundreds of times daily a treadle
weighing nearly thirty pounds, and who thus devel-
oped an occupation neurosis. Dr. A. A. Eshner re-
ferred to an analogous condition observed in a motor-
man and resulting from the manipulation of a gong
with the foot. Dr. Charles S. Potts exhibited a case
of amyotrophic lateral sclerosis occurring in a man who
had been employed in lead works, but who presented
no blue line on the gums or other symptoms of lead poi-
soning. The nervous symptoms predominated on the
right side, and were in part bulbar and in part spinal.
Dr. C. W. Burr reported a case of general anaesthesia
involving both general and special sensibility, only
a slight degree of hearing being retained, while the
motor sphere was unaffected, except indirectly through
the sensory disturbance. The possibility of meningi-
tis was suggested, as there had been acute attacks
earlier in life that seemed to be of this nature. Dr.
J. Hendrie Lloyd exhibited a specimen of large sub-
dural hemorrhage over the motor region, causing hemi-
plegia and aphasia, derived from a case that during
life suggested only intracerebral hemorrhage, and he
referred to another case in which during life the con-
dition was thought, from the symptoms, to be one of
subdural hemorrhage, while after death no lesion what--
724
[EDICAL RECORD.
[April 28, 1900
ever was found in the brain, and the symptoms were
necessarily attributed to uramia. Dr. F. X. Dercum
reported a case of rhizomelic spondylosis. Dr. VV.
G. Spiller exhibited the brain from a case of hydroceph-
alus. The patient was an elderly woman, with en-
largement of the head from birth, with a history of
convulsions, but without paralysis, and with fair intel-
ligence. The ventricles of the brain were greatly di-
lated and the cerebral structure was extremely attenu.
ated, with adhesions between the occipital lobe of the
brain and the cerebellum.
Dr. Josef Gruber, professor of otology at the Uni-
versity of Vienna, died on March 31st, at the age of
seventy-three years.
The Administration of Solid Food to Infants
under one year of age is forbidden by law in France,
except it be upon the prescription of a legally quali-
fied physician.
American Gynecological Society. — The twenty-fifth
annual meeting of this society will be held in the
lecture hall of the Columbian University, Washington,
on May ist-3d, under the presidency of Dr. George J.
Engelmann, of Boston.
Dr. Robert Abbe Consulting Surgeon to Roose-
velt Hospital. — At a meeting of the board of man-
agers of Roosevelt Hospital held this week. Dr.
Robert Abbe was unanimously elected consulting sur-
geon to the hospital in place of Dr. Robert F. Weir,
transferred to the staff of attending surgeons. We
congratulate Dr. Abbe on this well-merited honor.
American Neurological Association. — The twenty-
si.xth annual meeting of this society will be held in
Washington, in conjunction with the Congress of
American Physicians and Surgeons, on May ist-3d,
under the presidency of Dr. Edward D. Fisher, of
New York. The sessions will be held at The Nor-
mandie.
Dr. Jacobi's Seventieth Birthday.— .\ number of
the friends and professional associates of Dr. A.
Jacobi, of this city, have constituted themselves a
general committee for the purpose of arranging for
the proper celebration of the seventieth birthday of
Dr. Jacobi, in May. Under the auspices of the com-
mittee, a complimentary subscription dinner will be
tendered Dr. Jacobi, at De.monico's, Forty-fourth
Street and Fifth Avenue, on Saturday, May 5th, in
which the physicians of the city are invited to parti-
cipate. The price of the dinner will be $10, includ-
ing wine. An application blank may be had bv ad-
dressing Dr. A. G. Gerster, P. O. Box 3,032, New
York City.
The Hospital Ship " Missouri " is to be converted
into a transport, having been found unsuitable for a
hospital ship without very extensive alterations. The
sick and wounded will hereafter be brought from the
Philippines in the ordinary transports, sailing every
two weeks. The Missouri was fitted out as a hospital
ship at New York at great expense several months
ago, and has since made a trip from this port to
Manila, and thence to San Francisco. On the second
half of the voyage she carried a large number of sick
and wounded soldiers. Throughout the entire voyage
there was constant friction between the medical officer
in charge and the master and other officers of the
vessel. Soon after her arrival at San Francisco the
charges made by the officers against each other were
officially investigated, with the result that the surgeon
was sustained and the civilian officers were dismissed
from the transport service.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
April 21, 1900: April 13th. — Medical Inspector G.
E. H. Harmon detached from the Baltimore and or-
dered to the Oregon. Surgeon F. B. Stephenson de-
tached from the Oregon and ordered to the Baltimore.
April 16th (changes by cable from Asiatic station). —
Passed Assistant Surgeon L. Morris to the Baltimore.
April 17th. — Passed Assistant Surgeon S. G. Evans,
order of April 13th modified; ordered to proceed
home when detached from the MarHehead and to be
ready for sea duty.
The Dry Tortugas Quarantine Station.— A con-
troversy between the Treasury and Xavy departments
over the retention of the Marine-Hospital station on
the island of Dry Tortugas, forty miles west of Key
West, has been settled by the agreement of the Navy
department to issue an order permitting the quaran-
tine station to remain where it is until the expiration
of the quarantine season against ships from Cuba next
autumn. The authority of the Navy department was
recently extended over Dry Tortugas, and the Marine-
Hospital service, which has used the place for a quar-
antine station for many years, was directed to vacate.
Proposed Taxation of Medical Practitioners in
Turkey — According to the Moniteur Oriental the
Turkish government has hit upon an ingenious device
for checking unqualified practice and at the same time
levying a tax on the legitimate practitioner. It is
proposed to make the use of prescription books bear-
ing a government stamp compulsory on all medical
practitioners. It is estimated that this would yield
to the treasury a revenue of 300,000 or 400,000
piastres a year, while quacks would be hindered in
their depredations by the fact that in each prescrip-
tion book the name of the doctor using it and the
number of his diploma must be inscribed. The pro-
posal has been referred to the directing committee of
military schools. Similar plans have been suggested
more than once before, and have been rejected, and
it is thought unlikely that the present proposal will
be more successful. — The British Aledical Journal.
The Plague.— The deaths from the bubonic plague
in India during the week ending April i8th aggre-
gated more than 4,000, which is slightly less than in
the preceding week. — Tlie disease appeared some
three weeks ago in the Javanrood district in Persia,
near the Turkish border, 200 deaths having occurred.
Cases have also been reported in several places on the
Red Sea.^A despatch from Manila, dated April 21st,
April 28, 1900]
MEDICAL RECORD.
725
states that a number of sudden deaths of Filipinos
and Chinamen in Quiapo Market have led to an in-
vestigation, showing that fifteen cases of the plague,
fourteen of which were fatal, have occurred within a
week. The market is located in the centre of the
city. Some of the plague victims were stricken and
died within an hour. After all the market people
had assembled the health officers threw a guard around
the buildings and will keep the inmates quarantined
there for a fortnight. They will then burn the mar-
ket. The plague elsewhere in the city has been sup-
pressed, not a single case having been reported from
the Chinese district for ten days. The total number
of deaths is 185 — 119 Chinamen and 66 Filipinos.
Women in the Boer Army. — It is said that a num-
ber of women in male attire have been discovered
among the captured Boers and among the dead on the
battlefield.
The Famine in India is reported to be steadily in-
creasing, especially in the districts of Bombay and
Rajputana. Five and a half millions of people are
now on the relief lists.
The Hospital Ship "Maine " has arrived at South-
ampton with many wounded soldiers from South Af-
rica. The patients were taken to Netley, and the ship
will return to the Cape as speedily as possible.
Treatment of Tetanus in the French Army —
By a recent order of the French army medical ser-
vice medical officers are directed to use injections of
antitetanus serum in large and repeated doses in all
cases of pronounced tetanus. In justification of the
order is a statement that experience has shown that
such injections have a favorable effect in many cases.
A Case of Counter Prescribing. — A man went into
a Bowery drug-store last Sunday and asked for some-
thing to relieve a headache. The clerk, for some
unexplained reason, gave him a bottle of tincture of
larkspur. The man with a headache took a table-
spoonful of the tincture, and was next heard of in the
hospital with gastritis.
A Large Gift to Mt. Sinai Hospital.— A gift of
$200,000 has been made to Mt. Sinai for the purpose
of erecting the pavilion for private patients on the
new site at Fifth Avenue and One Hundredth Street.
The money is given by Mr. Meyer Guggenheim and
his seven sons in memory of their deceased wife and
mother. This gift leaves only about $400,000 still
to be raised in order to erect all of the nine buildings
constituting the new hospital.
Stealing the Livery of Heaven. — The United
States consul at Pretoria has informed the State de-
partment that members of the ambulance corps sent
from Chicago and other places by American sympa-
thizers with the Boers to attend the Boer sick and
wounded have taken up arms against the British.
The State department will probably complain to the
Transvaal government against permitting these Ameri-
can citizens to serve in the Boer army, on the ground
that they were permitted to leave the United States
with the understanding that they were to serve as neu-
trals in humane work. All these men took an oath,
before leaving this country, that they would not join
the combatants on either side, and it was on this rep-
resentation and because of the indorsement of Miss
Clara Barton that they were permitted by the Portu-
guese authorities to pass through the Delagoa Bay
territory. Dr. MacNamara, one of the physicians who
went with the corps- from Chicago, is reported to be
at Louren^'o Marquez on his return home, disgusted
with the treachery of his companions. Despite this
abuse of the Red Cross name, it is reported from
Chicago that another ambulance corps will be fitted
out and sent to the scene of war. The promoters are
now working hard, and an expedition of fifty men, it
is said, will be sent to the Transvaal, fully equipped,
within a month. According to a despatch to The
Daily Mail, of London, these are not the only men
who have gone to the Transvaal under the pretence
of healing wounds and then have set out to inflict
them, for all the ambulance corps which have been
sent from the continent of Europe have repudiated
the Red Cross as soon as they reached Pretoria.
The Death Rate in Philadelphia continues unusu-
ally high. For the week ending April 21st there
were reported to the bureau of health 739 deaths, 48
more than for the preceding week, and 294 more than
for the corresponding week of the previous year. Not
less than 123 of these deaths were due to pneumonia
(and 10 besides are attributed to congestion of the
lungs and 5 to pleurisy) ; 84 deaths resulted from
pulmonary tuberculosis, 56 from disease of the heart,
36 from nephritis (together with 23 attributed to
ursmia), 34 from convulsions, 31 from influenza, 25
from apoplexy, 24 from measles, 21 from inflammation
of stomach and bowels and senility each.
College of Physicians of Philadelphia.— At a spe-
cial meeting held in conjunction with the Philadel-
phia Neurological Society on April 20th, a discussion
was held on " The Fifth Nerve in its Neurological and
Cervical Aspects," and the following papers were
read: "Peripheral Resection of the Fifth Nerve," by
Dr. VV. W. Keen and Dr. W. G. Spiller. " Pathological
Report on Two of the Gasserian Ganglia Removed by
Dr. Gushing," by Dr. \V. G. Spiller. "Microscopic
Studies of Gasserian Ganglia," by Dr. L. F. Barker,
of Baltimore. "The Natural History of Tic Doulou-
reux, with Some Observations on Treatment," by Dr.
C. L. Dana, of New York. " On a Method of Total Ex-
tirpation of the Gasserian Ganglion by an Infra-Menin-
geal Route, through the Temporal Fossa, with a Report
of Four Cases," by Dr. H. W. Gushing, of Baltimore.
" Method of Exposing the Gasserian Ganglion ; Re-
moval of the Superior Maxillary Nerve," by Dr. G.
G. Davis. " Endothelioma of the Gasserian Ganglion ;
Two Successive Resections of the Ganglion: First,
by the Extradural (Hartley-Krause) Operation; and,
secondly, by an Intradural Operation." Clinical Re-
port by Dr. F. X. Dercum; Surgical Report by Dr.
VV. VV. Keen ; Pathological Report by Dr. W. G.
Spiller. •• Contribution to the Surgery of the Fifth
726
MEDICAL RECORD.
[April 28, 1900
Nerve," by Dr. Robert Abbe, of New York. '• Con-
tribution to the Surgery of the Fifth Nerve," by Dr.
L. McL. Tiffany, of Baltimore.
Obituary Notes. — Dr. John Joseph Crane, of this
city, died on April i8th, at the age of forty-nine
years. He was born in Elizabeth, N. J., and was a
graduate in arts of Princeton in 1873, and in medi-
cine of the College of Physicians and Surgeons, New
York, in 1876. Upon receiving his degree he became
the resident physician of Roosevelt Hospital. From
Roosevelt Hospital he went to Elgin, 111., and became
the first assistant physician in the insane asylum
there. He remained in Elgin for several years, and
then returned to this city and entered upon practice.
Dr. Edward Frank Grant died from smallpox on
his coffee plantation near Mettalalteyuca, Pueblo,
Mexico, on April 5th, at the age of forty-five years.
He was a native of this State, but soon after gradua-
tion went to Lodi, Cal., and later purchased a planta-
tion in Mexico. The disease which killed him was
contracted while visiting a peon living on a neighbor-
ing ranch.
Dr. John Habirshaw died at his home in this city
on April 20th, at the age of forty-six years. He was
a graduate of the College of Physicians and Surgeons
in 1877.
Dr. Alvin B. Allvn, a homoeopathic physician of
Chardon, Ohio, died in Cleveland on April 20th of
injuries received by being shut up in a folding bed.
He had been under treatment for some time for ner-
vous prostration. He was a graduate of the medical
department of the University of Michigan in 1879.
Dr. William F. Robinson died at Philadelphia on
April 15th at the age of sixty-three years. He was
born in Boston, but was educated in the schools of
Philadelphia, being graduated from the medical de-
partment of the University of Pennsylvania. He
practised medicine for ten j'ears in Hatboro, Mont-
gomery County, and in 1873 established the Ilathoro
Free Spirit, of which he was the editor until his death.
He was for six years State quarantine physician at
the lazaretto, and for eight years connected with the
bureau of health. For four years he was surgeon to
the Bucks County regiment, the One Hundred and
Fourth Pennsylvania volunteers.
Night Sweats. — In the hyperidrosis of phthisis we
may employ white agaric in dose of 0.25 to 0.30 cgm. ;
sulphate of atropine, one or three granules each con-
taining a quarter of a milligram, at intervals of two
hours during the evening. Ergot is also used. Cam-
phoric acid in cachets of i gm., two or three times a
day; tribasic phosphate of lime 4 gm. in two doses a
half-hour apart in the middle of the day; tannin in
doses of 0.30 to 0.50 cgm. ; zinc oxide same dose; fluid
extract of hydrastis canadensis, gtt. xxx. at bedtime.
Best of all is the tellurate of sodium. It should be
prescribed in average daily dose of from z]i to 3
cgm. for three or four days consecutively. A daily
quantity of 5 cgm. should not be exceeded. It may
be given in alcoholic solution or preferably in pill
form. — Ernest Barie, Journal iles J'raficieiis, Feb-
ruary 17th.
^tocjvcsB of ^ctXical Jicicnce.
The Boston Med. ami Surg. Journal, April ig, igoo.
Treatment of Cancer of the Cervix of the Uterus
Complicated by Pregnancy.— George Ben Johnston
says that when the cancer appears before the termi-
nation of the fourth month of pregnancy and is lim-
ited to the cervix, the sole consideration must be the
welfare of the mother, and hysterectomy must be per-
formed, usually per vaginam. When the disease has
extended to the vagina and possibly neighboring struc-
tures, rendering the condition inoperable, the efforts
should be entirely in behalf of the child; the mother
must be sustained until the end of term if possible,
or until the child is viable. Delivery by the natural
channel is fraught with such formidable dangers —
laceration, hemorrhage, infection with peritonitis — that
Csesarean section should always be resorted to as less
perilous. When the disease is discovered after the
fourth month and remains limited to the cervix, imme-
diate ablation of the uterus is demanded if the disease
is progressing with rapidity; if slowly, postponement
until the completion of the seventh month or later,
when a Caesarean section may save both mother and
child, is to be advised.
Intermenstrual Dysmenorrhoea. — Malcolm Storer
reports twenty cases of pain which appeared with regu-
larity usually from the twelfth to the sixteenth day
after the beginning of the last menstruation, lasting
from two to four days, paroxysmal in character, or
constant with exacerbation. There was no menstrual
discharge, but leucorrhcea. The author oft'ers the fol-
lowing theory in explanation of the phenomenon :
The intermenstrual pain coming about the fourteenth
day from the beginning of menstruation, the nine-
teenth after the climax of Stephenson's wave, occurs
just about the time the pressure line has reached its
lowest point. Cannot then the intermenstrual wave,
if one exists, be one of preparation rather than of sub-
sidence, a nervous explosion, so to say, as if nature
were waking up with a more or less violent effort to
make ready for the coming activity, whether menstrual
or ovarian ?
A Hair Ball in the Stomach.— John Homans de-
scribes a case in which a mass of hair, nine inches
long by two and a half inches wide, was removed from
the stomach of a young woman who had for twelve
years swallowed the hair combings. The patient re-
covered. This was in London, in 1866.
The Practical Value of the White Blood Count
in Surgical Cases.— J. C. Hubbard says that from
our present knowledge of the causes and variations
of leucocytosis we cannot yet make any deductions
which are simple enough to be of any great use to the
surgeon at the bedside.
Third International Congress of Obstetrics and
Gynaecology Held at Amsterdam By George J.
Engelmann.
Gunshot Wounds of the Abdomen, with Multiple
Wounds of the Intestines. — By Howard A. Lothrop.
Journal of the Aweticiu M d. Asi'n, April 21, igoo.
Affections of the Kidney in Relation to Preg-
nancy.— J. Clarence A\'ebster reviews different theo-
ries regarding the changes in the kidneys during
pregnancy, advanced by the principal workers in this
difficult field, and says it must be admitted that much
April 28, 1900]
MEDICAL RECORD.
727
is to be said in favor of each; that it is probable that
something of the truth is contained in all of them,
and that in most cases no single factor is causal, but
rather a combination of various factors, these varying
greatly in different cases. The most important of
these is undoubtedly the toxic element. As to treat-
ment, the writer says it is to be carried out on lines
followed in the non-pregnant state. The strictest
watchfulness on the part of the physician is neces-
sary. As to the question whether the pregnancy shall
continue, it is difficult to decide. Certain symptoms,
however, point imperatively to the induction of prem-
ature delivery, in the interests of the mother, viz.,
visual disturbances and continued headache, pulmo-
nary or other marked oedema, marked cardiac disturb-
ance, frequent nose bleedings, continued increase in
the casts and albumin in the urine, and ursemia.
Castor Oil in the Treatment of Neuralgia — Har-
old M. Moyer reports several cases of neuralgia which
he has treated with castor oil with good results. The
results with acute neuralgias were, as might be ex-
pected, better than with the chronic, although even in
the latter only one failure is recorded, when a patient
with a neuralgia of the third division of the nerve on
one side continued the treatment for two or three
weeks with no improvement in the symptoms. The
oil is administered in the morning before breakfast,
and the dose is from one to two ounces. The most
efficient means of administration is in ale, preferably
Dogshead or Bass', which contains a large quantity of
gas. When first given it acts freely on the bowels,
but if continued daily its cathartic effect rapidly di-
minishes. The author does not think that the value
of this oil in neuralgias is due to its cathartic proper-
ties, but thinks it probable that substances are present
in it which have not been fully identified, which sub-
stances may have some effect on the sensory nerves.
Thyroid Extract in Juvenile Obesity. — I. N.
Love reports four cases of juvenile obesity which he
has treated with the thyroid extract, especially that
of a boy, aged eight years, wiio weighed before treat-
ment one hundred and thirty-one pounds. In connec-
tion with proper purgation, diet, and exercise he was
ordered one-half of a five-grain tablet of thyroid ex-
tract three times a day, with a gradual increase until
one tablet was taken four times a day. After fourteen
months' treatment this boy now weighs one hundred
and six pounds, the chief feature of his case being
that he has developed muscle to a considerable degree.
The writer has found strychnine, in doses ranging from
gr. -fl„- to gr. -g'ij, a most excellent drug to be taken
with the thyroid in order to prevent depression and
unpleasant effects.
Primary Tuberculosis of the Kidney. — In this
case, reported by Dudley Tait, lumbar nephrectomy
was performed with subsequent total resection of the
ureter, followed by complete recovery. The points of
interest in the case are: (i) The perirenal tubercu-
lous infiltration, a rare and troublesome condition,
complicating both the operation and the subsequent
treatment; (2) the absence of vesical lesions, causing
this case to be a strong evidence in favor of the reflex
theory advanced by Le Dentu and most of the English
authors, Newman, Roberts, and Morris.
Cerebral Cyst. — This case is reported by Van
Buren Knott to illustrate the following point: Every
operation on the brain must be considered as largely
exploratory, and promises of a definite result cannot
be made. Nevertheless, such operations properly per-
formed will do no harm, and whenever in any given
case the symptoms point to a lesion, the localiza-
tion of which seems probable, the patient should be
given the chance of relief which may follow a prop-
erly conducted operation.
Septic Conditions in Some Acute Infectious Dis-
orders in Children. — By A. C. Cotton.
Suggestions on the Rights and Liabilities of
Surgeons. — By T. J. Mahoney.
Resection in Case of Ununited Fracture of the Fe-
mur.— By 1. P. Klingensmith.
Evolution of the Animal Cell. — By Joseph Smith.
Successful Pylorectomy By H. O. \\'alker.
The Smegma Bacillus — By Oscar A. Dahms.
Ureterectomy — By J. Wesley Bove'e.
Medical News, April 21, igoo.
Pain as a Pathognomonic Symptom of Ectopic
Pregnancy. — Henry C. Coe, after citing several cases,
concludes that pain alone, when not accompanied by
a clear history of menstrual irregularity, symptoms of
pregnancy, and the presence of a tumor at the side of
the uterus or in Douglas' pouch, known to be of recent
development, is pathognomonic of extra-uterine preg-
nancy only under certain conditions, viz., the pain is
of a sharp colicky character, distinctly localized on
one side, attended with faintness more or less marked,
and is usually followed by intervals of hours or days
of complete remission. The pulse is accelerated, but
there is no rise of temperature as in inflammatory
conditions.
Tuberculous Disease of the Urinary Apparatus.
— J. M. Gile states that this condition is of consid-
erable frequency. Its course is as variable as that of
the same disease when affecting other organs, and
may prove rapidly fatal or run an indolent course.
For certain diagnosis we must depend on the bacte-
riologist, but even this will not definitely localize the
trouble. The hereditary character is more marked
than in pulmonary tuberculosis. The age incidence,
from the writer's cases, is markedly in young adult
life rather than in middle age, while the location is
merely a matter of circumstance.
Lateral Sinus Thrombosis and Acute Lepto-
meningitis Complicating Acute Suppurative Otitis
Media By Wendell C. Phillips.
A Case of Probable Accidental Inoculation with
the Malarial Parasite. — By William H. Katzenbach.
The Curability and Treatment of Early Phthisis.
—By W. F. Hazelton.
Phihuh-lphia Medical Journal, April 21, igoo.
Appendicular Abscess Rupturing into the Sac
of a Reducible Inguinal Hernia.— Orville Horwitz
reports this case in which the sac was opened and
drained, the result being a permanent cure of the
hernia. The same writer reports a case of intussus-
ception of the bowel which was relieved by operation :
a relapse occurred, another operation was performed,
and the patient died three days later. A third case
was one of chronic hematocele of the tunica vaginalis
testis, associated with an encysted omental hernia,
resembling malignant disease of the testicle.
Early Operation in Appendicitis by the Country
Practitioner R. H. Harper reports a case of appen-
dicitis in a boy, aged thirteen years, who had just
recovered from an attack of typhoid fever. The oper-
728
MEDICAL RECORD.
[April 28, 1900
ation was performed with the child on a kitchen table ;
the assistants were two women and a man ; the towels
and instruments were sterilized with boiling water.
By an oversight the silk was not sterilized, and there
were stitch-abscesses along the upper half of the in-
cision, but with this exception the result was all that
could be desired.
Infection through the Tonsils, Especially in Con-
nection with Acute Articular Rheumatism.— By
Frederick A. Packard.
Two Cases of Fracture of the Shaft of the Ra-
dius.— By W. B. Lowman.
Selections from the Lane Lectures. — By T. Clif-
ford Allbutt.
New York Medical Journal, April 21, I goo.
Cancer of the Stomach in the Young. — W. Osier
and T. McCrae collate the records of cases of this na-
ture, dividing them into classes based on the first three
decades of life. Six cases only are on record below
ten years. Thirteen are recorded during the second
decade. The authors record six additional cases oc-
curring between the ages of twenty and thirty. An
analysis of the various symptoms is given, and the ar-
ticle closes with the following conclusions quoted from
Mathieu: (i) Cancer of the stomach below the age of
thirty has generally a rapid progress in some months,
and often ends suddenly by incidents more or less
abrupt. (2) Early cancer is not latent; it is often
overlooked.
A Consideration of the Neuro-Muscular Elements
in Hip-Joint Disease, with Especial Reference to
the Question of the Abolition of Protective Treat-
ment.— By N. M. Shaffer.
Hepatic Abscess. — J. F. Richardson reports a case
in a man aged twenty-four years. The abscess rup-
tured into a bronchus, but the patient eventually re-
covered.
The Present Status of the Widal Reaction as a
Diagnostic Test in Typhoid Fever. — By A. E. Guerard.
Some Practical Remarks on Clinical Examination
of the Blood.— By W. N. Berkeley.
Mysticism among the Negroes. — By F. J. Carroll.
British Medical Journal, April 14, igoo.
Amputation without Anaesthesia.— D. Mackinder
reports the case of a delicate woman of the pallid,
nervous temperament who objected to chloroform and
submitted to an amputation of the breast without an
anffisthetic of any sort. She did not make a sound, but
simply compressed her lips, and said "Thank you! "
when all was over. Another case was that of a large,
athletic man whose finger was amputated in conse-
quence of an injury. He refused to take an anaesthetic,
and kept laughing and joking throughout the operation.
J. Campbell Hall also reports the case of a large, stout
woman, seventy years of age, whose right leg was am-
putated above the knee for gangrene some twenty years
ago. She took no anresthetic then. Recently gan-
grene appeared in the left leg, and amputation between
the lower and middle thirds of the thigh was per-
formed, this time also without anaesthesia, the patient
never uttering a sound or moving in the least. She
made an excellent recovery.
The Seat of Pain in Biliary Colic. — J. H. Keay
says that, from a distressing personal experience and
from observation of other sufferers, he is convinced
that the usual description of the pain given in the text-
books is incorrect. In his own case, he says, long be-
fore an acute attack tliere are pains in the back, often
mistaken for lumbago, but when the calculus is fairly
lodged in the duct, the pain begins about the tenth or
eleventh dorsal vertebra, and gradually passes round,
giving place to excruciating pains in the right and
often the left hypochondrium, middle or lower abdomen,
frequently above the right nipple, but practically
never in the right shoulder. Immediately before the
pain subsides, when probably the stone is just enter-
ing the duodenum, a peculiar gliding sensation is
sometimes felt about two inches to the right of the
tenth or twelfth dorsal vertebra.
Non-Diabetic Glycosuria.— Robert Saundby dis-
cusses the various conditions under which sugar may
appear in the urine in the absence of true diabetes
mellitus. In examining for sugar, if the copper is re-
duced on the first test, he makes sure that it is sugar
and not some other reducing agent (such as glycuronic
acid, chloral, etc.) by filtering the urine seven or eight
times through animal charcoal. This removes all of
the reducing agents except sugar. The various forms
of non-diabetic glycosuria which he reviews are alimen-
tary or physiological, alcoholic, hepatic (many of which
are really alcoholic), gastric, neurasthenic, and senile.
Notes on a Case of Bright's Disease Complicated
with Gangrene. — By Alexander D. H. Leadman.
Swelling of the Eyelids with Intermittent Albu-
minuria in Children. — By Theodore Fisher.
A Case of Glandular Fever Associated with Ery-
thema Nodosum. — By Bertram Thornton.
Some Cirrhoses of the Liver. — By \V. B. Cheadle.
Diphtherial Stomatitis.— By E. F. Trevelyan.
The Lancet, April 14, igoo.
Some Cirrhoses of the Liver In this lecture \V.
B. Cheadle considers the subject of treatment. Abso-
lute abstention from alcohol and all stimulating in-
gesta is the first requisite. Diet should be restricted
to milk, eggs, simple proteids, bread, and fresh fruit
and vegetables. Predigested foods are necessary in
some instances. Mild laxatives, together with iron or
other tonics, are all of service. Mercury and the
iodides are indicated, of course, in syphilitic cases,
and, owing to the possibility of diagnostic error, should
be tried even in the alcoholic cases. When tliere is
cardiac weakness, digitalis will give us the best re-
sults. For the ascites diuretics and tapping are ad-
vised, but after the latter is done the patients should
be kept under close observation for a long period.
The Typhoid Bacillus and Typhoid Fever.— P.
Horton-Sniith devotes tliis lecture to a consideration
of the Widal test, speaking of its discovery, technique,
nature of the agglutinating substance, limitations of
the test, etc. He considers the agglutins to belong to
the ferment class. Under tlie head of treatment, he
considers preventive inoculation, and highly extols the
use of urotropin, which practically does away with the
danger of spreading infection by means of the urine.
Results of certain bacteriological experiments are
given to prove the claims made in this direction.
A Case of Spontaneous Rupture of the Heart and
Hemorrhage into the Pons Varolii.— P T. Goodman
reports this condition occurring in a woman who had
indulged in spirits, though not addicted to their use.
She complained of loss of power on the right side, and
April 28, 1900]
MEDICAL RECORD.
729
became comatose, dying in five hours. Rupture was
found on the anterior surface of the left ventricle, with
hemorrhage in the left pons.
Intestinal Obstruction Caused by Meckel's Diver-
ticulum and Relieved by Operation By H. J.
Mackay.
Gunshot Wound of Head ; Perforation of the
Brain; Recovery — By D. Durran.
Experiments on Intestinal Suture. — By W. Ed-
munds and E. C. Stabb.
Plague Viewed from Several Aspects. — By W. J.
Simpson.
Deutsche mediciiiisclie Wochenschrijt, April j, igoo.
Two Practically Important Cases of Hysteria. —
The first of the cases reported under this title by Ernst
Fuerst was that of a woman thirty-six years old, who
had suffered for several weeks from vomiting and
pains simulating those due to an impacted gall-stone.
The case was diagnosed as one of hysteria, but in
order to relieve the bilious vomiting it was decided
to wash out the stomach. The sound seemed to enter
readily, but no fluid could be made to pass through
it, and all attempts to withdraw it were unavailing, as
it was firmly held by a spasmodic stricture of the
oesophagus. It was only when the patient was pro-
foundly narcotized that the tube could be drawn out.
Under careful treatment the patient fully recovered.
The second case was that of a man who had suffered
a fracture of two ribs and who subsequently presented
symptoms leading to a suspicion of tuberculosis. The
tuberculin test was applied several times, and each
time a characteristic febrile reaction followed. Hys-
teria being suspected, an injection of water was made
and the same reaction was produced, and then a simple
puncture with- the needle of the syringe was made in
the back, but not a drop of fluid was expressed, yet the
reaction followed as before.
The Serum Diagnosis of Tuberculosis. — Ernst
Bendix has applied the agglutination test in thirty-
six cases of tuberculosis and obtained the reaction in
all but two. Various dilutions were employed, in one
case as high as i : 50. In both the cases in which the
reaction failed the disease was far advanced, and in
one of those there was even a minus value, the serum
reducing the agglutination power when added to other
agglutinating sera, there seeming t(j be an " anti-agglu-
tinin " in this patient's blood. If one might reason
from two cases only, it would seem as though the
Gruber-Widal serum reaction was not only of diag-
nostic value in tuberculosis, but that one might draw
certain conclusions regarding the course of the disease;
that is to say, that a serum of high agglutination value
would indicate in general the presence of a less active
tuberculous process than one of less power.
Two Cases of Syphilis with Peculiar Features.
— The first of the cases reported by Heinrich Kobner
was that of a healthy-looking man, who had a sharply
circumscribed, round, slightly raised, bluish, hard in-
filtration on the anterior surface of the thigh. A scar
was visible in its centre. The patient said he had
had a boil which was incised. The femoral and in-
guinal glands were enlarged. There was a very pain-
ful, soft, elastic periostosis on the right parietal bone.
No eruption was visible. The diagnosis of syphilis
was disputed, but subsequent events proved its cor-
rectness. Infection had been occasioned probably by
the scalpel used in incising the furuncle. The second
case was one of constitutional syphilis following a
non-indurated initial lesion, which had been diag-
nosed and treated as a soft chancre.
Syphilis of the Lingual Tonsil and its Relation
to Smooth Atrophy of the Follicular Glands of the
Tongue. — By \V. Lublinski.
Agglutination of the Red Blood Corpuscles.— By
G. M. Malkoft".
Treatment of Uterine Hemorrhages By H. Oster-
mann.
Berliner klinische Wochenschrijt, April 2, igoo.
Experimental Contribution upon the Effect and
After-Effect of the Thyroid Poison M. Forges calls
attention to a peculiar form of glycosuria which may
follow the administration of the thyroid preparations
and which is followed by disturbances in the carbonic-
acid metabolism. Experiments were made by feeding
the thyroid substance to a dog together with other
diet, the bodily excreta being carefully estimated be-
fore, during, and after the thyroid feeding. From his
experience with animals Forges believes that there is
a very great variation in susceptibility to the effects
of the thyroid extract, and that this accounts for the
conflicting results obtained with it as a therapeutic
agent.
A New Method of Employing the Silver Com-
pounds in Histology. — Salge and Stoeltzer claim
that staining-results in histological technics can be
made far more striking if with the use of the silver
preparations there is introduced the employment of
that class of substances which in photography are
called developers. Their method, the description of
which must be read in the original, is in brief to im-
merse the specimen in a silver solution and then
transfer it to the " developer,'' and they enumerate the
various solutions which have served them for this pur-
pose in good stead.
The Pyogenic Origin of Chorea Rheumatica and
of Rheumatic Processes S. Mircoli believes that
many cases of rheumatism are directly referable to
streptococci, while others may be ascribed to staphy-
lococci, diplococci, and gonococci. In seventeen cases
of chorea which he has studied the infection was
referable to the staphylococcus in fourteen and to the
diplococcus lanceolatus in three. From animal ex-
perimentation he finds the same effects upon the heart
and serous membranes as are afforded by clinical
rheumatic manifestations.
The Treatment of Tuberculosis in the Nine-
teenth Century.— By Baumler.
Wiener klinische Rundschau, March 2j, igoo.
Psychical Deafness. — Ferdinand Alt, in the begin-
ning of his article, mentions the fact that the term
'' psychological deafness " was first used by Heller
(who is not a physician, but a pedagogue) to desig-
nate a condition of seeming deaf-mutism in weak-
minded subjects or idiots, that may, however, be cured
in many instances. Alt takes exception to the promis-
cuous use of tlie term, demonstrating that, for instance,
the loss of intellectual perception of sound is by no
means identical witii psychical deafness. He tries to
establish certain points of differentiation and generali-
zation on the basis of the various phenomena observed
in connection with this subject.
The Treatment of Eczema in Childhood.— J. H.
Rille gives a very extensive description of the most
important methods of treatment to be employed in the
7?>o
MEDICAL RECORD.
[April 28, 1900
various types of this disease. In children he has found
the use of salicylic-lanolin salve, one-half to one per
cent., to be most efficient and reliable. \\'ith refer-
ence to prophylaxis, he states that vaccination should
be omitted, if possible, in patients with eczema, es-
pecially if the latter be present on the face, as cases
of generalized vaccine, leaving numerous disfiguring
marks, have been observed as « result of vaccination.
IViener kliiiischc Wochenchrift, March 2g, IQOO.
The Haemamoeba of Ldwit in the Blood of Leu-
kaemics. — -Wilhelm Tiirk in a "preliminary report"
refers to the demonstration by Lowit at the last Con-
gress for Internal Medicine at Karlsbad, of prepara-
tions of the "hcemamoeba leukaemiae magna," and de-
clares that these protozoa do not represent parasitic
formations, but so-called "mast-cell granulations.'"
He calls special attention to the fact that Lowit in his
experiments with rabbits did not succeed in producing
the anatomical and histological picture of a leukae-
mia, but bases his claim of having transferred the dis-
ease to rabbits upon the presence of a chronic re-
current leucocytosis and the authenticity of his
hjemamcsba. Recognizing the statement above made,
that Lowit's " amoebse " are not parasites, his argumen-
tation would, of course, be without ground, for a chronic
recurrent leucocytosis is not identical with leukaemia.
Contribution to the Knowledge of the Semeiotics
of the Secondary Pulmonary Sound. — Adolf Hecht
gives a very extensive account of his experiments with
Bettelheini-Giirtner's stetho-phonometer. He found
this instrument to be especially useful in determining
the relative strength of cardiac tones, and considers
the relation of the second pulmonary to the second
aortic tone of greatest value. While he believes that
one single examination can be of but little utility, he
is convinced that systematic observation enables us to
draw important conclusions as to the course of circu-
latory, respiratory, or abdominal diseases. He also
claims that exact physiological studies regarding
changes in the lesser circulation are possible, and that
many of the facts obtained as a result of experimental
research may thus be confirmed in the human subject.
A Case of Intra-Abdominal Torsion of the Omen-
tum.— J. Hochenegg reports a highly interesting case,
which is probably the only one of its kind ever pub-
lished. It is that of a man, forty-one years of age,
with congenital hernia, who suddenly developed symp-
toms of abdominal inflammation, pointing to appendi-
citis witfi sacculated exudate. However, the operation
revealed a threefold torsion of the omentum, the par-
ticularly remarkable features being that the twisting
of the pedicle had occurred entirely intra-abdominally,
the sac being empty, and that the omentum was not ad-
herent to any of the neighboring organs. The patient
made an e-xcellent recovery.
Miiiiiiieitcr fiuulicinisihe IVochciisdirift, April j, igoo.
Dormiol.— Peters has used dormiol for the past nine
months in various conditions. It consists of one mole-
cule of chloral, combined with one molecule of amy-
leuchydrate, and is an oily, colorless Huid, of a specific
gravity of 1.24, a camphor odor, and a cooling taste.
It has been used in organic and functional nervous
diseases, and in other affections in which insomnia is
a prominent symptom. It is given in ten-per-cent.
watery solution or in gelatin capsules. It is agreeable
to the taste, and no bad effects are noted on the heart,
kidney, bladder, etc. In eighty-four per cent, of the
cases a deep sleep was produced. It is especially use-
ful in functional neuroses. The initial dose is gr.
viiss., increasing to gr xv.
Causes of Climacteric Hemorrhages. — Theilhaber
says that in many instances we find carcinoma of the
vaginal portion of the cervix uteri, of the mucous mem-
brane of the cervix, or less frequently of the body of
the uterus; still less frequently polypi and sarcoma of
the uterus are found. Infiammatory conditions of the
adnexa are rare in advanced age. " Hyperplasia uteri
praeclimacterica " is a source of these hemorrhages.
Apoplexy of the uterine vessels, analogous to hemor-
rhagic infarcts, is occasionally a source of climacteric
hemorrhage.
Embolism of the Mesenteric Arteries. — Ott states
that, though embolism of the mesenteric arteries is
rare, it is still more frequent than generally supposed.
Two cases, with a typical history, course, and recovery,
are reported. The necessary symptoms for a diagnosis
are a source of the embolus, intestinal hemorrhage, re-
duction of body temperature, colicky abdominal pains,
tympanitic distention, and rigidity of the abdomen,
the presence of some exudate in the abdominal cavity,
and the pre-existence or coexistence of other emboli.
Tannopin (Tannon) as an Intestinal Astringent.
— Eugen Doernberger recommends as an intestinal
astringent, especially for children, tannopin, which is
a condensation product of tannin and urotropin. The
dose for children is gr. viiss. three times daily, for
adults gr. xv. three times a day. The dose must be
regulated for the individual case. It is especially ap-
plicable to children, since it is tasteless; its greatest
disadvantage is the expense. Successful cases are
tabulated.
Determination of Bile Pigment in the Faeces with
Special Reference to Schmidt's Test. — By Schorlem-
The Influence of Ichthalbin on Metabolism and the
Intestinal Function in Children. — By Roily and Saam.
A Journey in the Famine Districts of Central and
East Russia. — By Lehmann.
Epileptic Equivalents. — By Ernst Schultze.
French Journals.
Action of Salicylate of Sodium upon Nutrition
and in Particular upon the Secretion of Bile. — A
report taken from the Societe' de Me'decine et de Chir-
urgie Pratiques, the author's name not being given,
contains fourteen conclusions, among which are: That
under the influence' of the drug a slight dimiuution in
diuresis is noted, and an increase in the coloring mat-
ters, uric acid, and acidity of the urine. The biliary
secretion is increased, as are also the phosphoric acid
and fixed matters. The property of the drug in increas-
ing the activity of the biliary function, and the known
property of the bile in retarding products of fermenta-
tion in the intestine even when it contains no salicy-
late of sodium, together with the other properties of
the drug, make its application of great interest in
pathology. — Journal de Mcdccine de Paris, April 8,
1900.
A Case of Chyliform Ascites. — L. Z. Kahn re-
cords a case which came to autopsy in which the
abdomen of a woman, aged sixty-six years, was dis-
tended with a milky fluid. Stomach cancer was found
extending to the peritoneum. There was no solution
of continuity of the lymphatic channels to account for
chylous ascites. Chylous ascites, chyliform ascites,
and milky ascites form together a group presenting
an exterior appearance only to bind them together.
They may be encountered in all affections with ascites
April 28, 1900]
MEDICAL RECORD.
731
in which they present always the same clinical charac-
ters. They have therefore no diagnostic value. There
has never been a cure in any one of these forms. — Le
J3u!letin Malical, April 7, 1900.
Modern Conceptions of Neuron and Nerve Plexus.
■ — A. Sicard discusses the ancient reticular theories,
the cellular or neuron theory, and recent reticular and
fibrillary theories. He concludes that the neuron
theory should stand because it is founded on posi-
tive anatomical observations. No one has yet shown
that the appearances are deceptive or result from
faulty technique. Anatomical objections have been
refuted. Physiology opposes nothing tenable against
the theory. Other conclusions are also given. The
article is illustrated. — La Prcssc Mccikalc, April 7,
1900.
Nasal Obstruction in the New-Born — Leopold
Cauveau considers the various causes for difficult
breathing in infants: Superficial lesions at the nasal
orifices; acute coryza; coryza in the eruptive fevers;
pseudomembranous coryzas; those produced by for-
eign bodies; syphilitic coryza; adenoid vegetations;
retro-pharyngeal abscess; and congenital occlusions.
The distinction between that due to syphilis and the
other forms is of much importance. — Gazette Hebdo-
madaire de Medecine et de Chinirgie, April 8, 1900.
Hypogastric Meatus. — X. Delore gives an account
of an operation by suprapubic section and establish-
ment of permanent fistula in a case of cancer of the
prostate, with survival for eleven months in compara-
tive comfort. The patient died of a pneumonia dur-
ing the evolution of a generalization of the cancerous
process. In most cases operation for cancer of the
prostate can be but palliative. Hypogastric meatus
meets most of the requirements. — Gazette Hebdoiiia-
daire de Medecine et de Chirurgie, April 5, 1900.
Treatment of Acne — D. Leistikow, basing his
views upon the pathological conditions present, gives
rules for rapid and slower cure of acne in its various
clii^^l forms. Formula recommended by well-known
derin^tologists are given, as well as prescriptions for
acne varioliformis. — La Aledecine Aloderne, April 4,
1900.
Anhives of L''ediatrics, April, igoo.
The Treatment of Whooping-Cough without
Drugs. — N. R. Norton writes of (i) the administra-
tion of carbonic acid gas by rectum, and (2) the use
of O'Dwyer's laryngeal tube. The treatment by gas
was given three tin^^ daily, two or three hours after
meals. In infantsMfe treatment lasted five minutes
each time ; in the " Smabouts," ten minutes. Ephraim
explains the effect as the result of the extra oxygen
that reaches the air vesicles, there to be exchanged for
the extra amount of carbonic acid gas. Of one hun-
dred and fifty children thus treated, one hundred and
forty-three were apparently decidedly benefited. As
to the laryngeal tube, O'Dwyer held its use to be jus-
tifiable, provided the tube was of hard-rubber, in grave
cases of whooping-cough accompanied by frequent
and severe vomiting, with consequent loss of flesh and
strength. Ey this means the spasm of the glottis is
absolutely relieved.
Drug Values as Observed in the Management of
Seven Hundred and Fifty-two Cases of Whoop-
ing-Cough.— Charles Gilmore Kerley reviews the ef-
fects of a number of drugs, and concludes that: (i)
Every case of whooping-cough may be ameliorated
either by modifying the severity or diminishing the
number of paroxysms. In many cases both effects
may be obtained. (2) Remedies sedative in charac-
ter, with fresh air, give the best results. (3) If the
remedy is to be of service, its effects will be noticed
within twenty-four hours — always within forty-eight.
(4) The best results are obtained when the antipyrin
and bromide are commenced at the height of the
paroxysmal stage and then pushed. (5) The effect
of these remedies may be lost in a prolonged case, re-
quiring a change of treatment. (6) Children may
have whooping-cough and never whoop.
A Case of Congenital Goitre and Diaphragmatic
Hernia — Isaac A. Abt reports an interesting case of
this kind, with illustrations. Congenital goitre is
comparatively rare. It has been observed particularly
in mountainous regions, where the condition is en-
demic. This affection occurs also in animals. Con-
genital diaphragmatic hernia is of comparative infre-
quency. In most cases, it is the result of arrest of
development. Its recognition during life is extremely
difficult, and consequently the condition is apt to be
overlooked. The greatest danger to these children is
to be expected in the first few days of life or during
the act of birth.
Hypertrophic Pyloric Stenosis in Infancy Eric
Pritchard, after reporting twenty-four cases, concludes :
(i) That the hypertrophy is secondary to over-action
of the sphincter, and the stenosis chiefly due to spasm;
(2) that the stenosis, as measured "postmortem," is
but an accurate gauge of its organic degree during life;
(3) that over-action and inco-ordinated contractions of
the sphincter may be due to some fault in the nervous
mechanism; (4) that injudicious feeding, either quan-
titatively or qualitatively, may be a contributory factor
of the nervous incoordination.
A Note upon Kernig's Sign in Infants. — Frederick
A. Packard calls attention to the possible error that , .
might arise from attaching too much importance to*'
this sign in infants, although it is of undoubted value
in the diagnosis of meningitis in the adult and in older
children. He reports three cases, all of which were
proved by autopsy to have had meningitis, and in all
of which this sign was absent during life. These cases
were aged sixteen months, sixteen months, and four
months respectively.
Tlie Medical Chronicle, April, igoo.
The Treatment of Necrosis of the Frontal Bone.
• — Arthur H. Burgess dresses the ulcer with hydro-
chloric acid of a strength sufficiently great to dissolve
the lime salts contained in the exposed bone at its
base, i.e., ten per cent. This is applied on a double
fold of lint, cut to the shape of the necrosed area, and
covered with a layer of gutta-percha tissue; over this
is placed lint smeared with boracic ointment, a pad of
absorbent wool, and a bandage. This is left on for
twenty-four hours, then removed, and the ulcer washed
with boracic acid, and pepsin in the powdered form
dusted lightly over the surface. The lint, impregnated
with a 0.2 per cent, solution of hydrochloric acid, is
applied as before. The dressing is removed next day,
and replaced by the strong acid dressing, and so on
alternately. By this means the bone is slowly dis-
solved, the necrosed parts are cast off, and a healthy
granulating surface is left. The boracic-acid dressing
is used, cicatrization proceeds, and the ulcer becomes
covered witlr epithelium.
Salol and Petroleum in the Treatment of Infan-
tile Diarrhoea.— W. E. Fothergill and John Penny
made careful observations in cases of bottle-fed in-
fants. Unsatisfactory results were obtained in eight;
the remaining sixty children recovered on salol or on
petroleum ; twenty-eight children recovered from their
732
MEDICAL RECORD.
[April 28, 1900
diarrhcea on salol alone; thirty-one recovered rapidly
and completely without any treatment beyond the ad-
ministration of petroleum emulsion. One dose of salol
every day combined with three or four doses of petro-
leum has proved very useful in many subacute and
chronic cases. Bismuth may, of course, be used at
the same time. Calomel and hydrarg. cum creta act
better when followed by petroleum than when taken in
conjunction with mixtures of a more classic nature.
The observations reported teach that the various forms
of infantile diarrhoea can usually be successfully
treated without the use of opium in any form, and
also without astringents.
A Case of Aneurismal Varix and Injury to the
Median Nerve at the Elbow — J. E. Piatt describes
a case of varix, due to the lodging of a piece of steel
in the brachial artery, with division of the median nerve
for the outer three-fourths of its extent. The brachial,
radial, and ulnar arteries were tied on each side of the
communication with the vein. The ends of the nerve
were freshened and brought into accurate approxima-
tion by fine silk sutures. The median basilic vein was
ligated. After division of a motor nerve, even if the
cut ends be accurately sutured shortly after the acci-
dent, a considerable time is necessary for the functions
of "the muscles supplied by it to be fully restored.
The time necessary is more prolonged when the nerve
is injured nearer to the trunk. Under the most favor-
able conditions it takes from three to six months for
complete recovery of muscular power after section of
the median or ulnar nerve at the wrist, and in certain
cases may take as much as twelvemonths. Sensation
may return very early.
Two Cases of Tumor of the Bladder — F. A.
Southam reports these cases, which are good illustra-
tions of the fact that for a long period a painless
hsematuria is often the only symptom given by a papil-
loma of the bladder. In epithelioma pain and irrita-
bility of the bladder are always early symptoms, often
preceding the onset of hasmaturia. Though recurrent
attacks of painless hematuria may be the only symp-
tom for months, or even for years, in cases of papil-
loma, sooner or later cystitis is set up, being often ex-
cited by retention of blood clots in the interior of the
viscus, and the straining efforts which attend the at-
tempts to expel them; then there are superadded pain
and all the other symptoms of cystitis.
Practice and Precept in Children's Diseases. — By
T. C Railton.
Bulletin of Johns Hopkins Hospital, March, igoo.
Notes on an Improved Method of Removing the
Cancerous Uterus by the Vagina. — Howard A. Kelly
states that glandular metastases, which play such an
important part in the extension of mammary cancer,
are relatively unimportant, and, as a rule,, only ob-
served in the latest stages of uterine cancer. The lat-
ter growth extends progressively through the tissues
from its cervical focus, and the great aim of the opera-
tion for its extirpation is to give the diseased cervix
the widest possible berth, instead of being, as before
supposed, the removal of the uterus plus the extirpa-
tion of the pelvic glands. The enucleation is begun
on the vaginal side, far below the limits of the in-
vasion. The writer emphasizes the imp^ortance of ca-
theterizing the ureters as a preliminary to the radical
operation. The method of enucleation is carefully de-
scribed, and after its accomplishment the anterior and
posterior peritoneal surfaces are drawn down, attached
to the vagina, and again sutured in the middle line.
This leaves only two small openings into the pelvis,
which are loosely stuffed with gauze.
A Preliminary Report on the Surgical Treatment
of Complicated Fibroid Tumors of the Womb, with
a Description of the Two Methods of Operating. —
Howard A. Kelly describes his method of operating
in the first of these cases as follows: Two long-jawed
pedicle forceps were used, one on either side. One of
the open jaws of the forceps was thrust through the
capsule of the tumor at about the level of the round
ligament from the front of the broad ligament until
the point appeared on the posterior surface of the tumor
behind the broad ligament. The forceps was then
clamped powerfully down on the uterine and ovarian
vessels, entirely controlling the circulation. The
uterus was bisected and the incision was continued
down into the tumor as far as the vesical peritoneum,
which was freed and pushed down, when the tumor
was completely bisected. The right and left halves
were then enucleated. The two halves of the uterus
were enucleated separately, the bed of the tumor was
closed by buried sutures, and the vesical peritoneum
was drawn over and attached to the posterior perito-
neum, concealing the wound.
The Pathological Findings in a Case of General
Cutaneous and Sensory Anaesthesia without Psy-
chical Implication. — Henry J. Berkley, after review-
ing this case, states that the fundamental pathological
basis for the nervous phenomena of this case is as fol-
lows: (i) A hyaline-fibrous degeneration of the arte-
rial system existed, not confined to the central nervous
regions, but equally evident in the roots of the spinal
nerves and in the skin tissues. This varied in degree
from slight thickening of the muscular layer to com-
plete closure of the lumen from hypertrophy of the
middle coat of the vessel walls. The maximum altera-
tion was in the vessels of the lower dorsal cord, the
meninges of the bulb and cord, and in certain of the
root bundles of the cerebro-spinal nerves. (2) As a
consequence of the vascular lesions, there were degen-
erations of an atrophic order in the nerve cells of the
gray horns of the cord, particularly in Clarke's column
and the medulla oblongata.
Observations upon the Neural Anatomy of the
Inguinal Region Relative to the Performance of
Herniotomy under Local Anaesthesia. — Harvey Cush-
ing, after carefully reviewing this subject, sums up the
advantages of the local an.-csthetic. There is an
avoidance of unpleasant or dangerous post-etheriza-
tion sequelae. There is no vomiting or retching.
Urinary disturbances are much less apt to occur, and
catheterization is rarely necessary. The diet may
practically be continued as before the operation.
There is no backache. The dressings maybe applied
originally to suit the comfon of the patient, and there
is no subsequent disarrangement of them. Above all
an advantage is gained in being able to operate with
comparative safety in patients who would incur imme-
diate risk in submitting to general anaesthesia. The
disadvantages seem trivial; the operation is longer,
and there is some distraction to the surgeon.
Congenital Malformations of the Heart as Illus-
trated by the Specimens in the Pathological Museum
of the Johns Hopkins Hospital.— By \V. G. MacCal-
lum.
J'culiijl//,s, .If'ril jj, igoo.
Some Reasons Why Tuberculosis Spreads More
Rapidly among Cattle than in the Human Race
\\'alter \V. Gardiner shows by diagram of stable, etc.,
how an infected cow becomes a source of infection to
other cows through the water pot and fodder trough.
One tuberculous cow in a modern barn may during a
winter infect a whole herd. The prevalent lines of
April 28. 1900]
MEDICAL RECORD.
7ZZ
breeding followed generation after generation detracts
from the vitality and power of resisting disease. The
disease develops most rapidly at a temperature of ioi°-
103 F. The normal temperature of the cow is 101°,
and when in a warm stable and grain-fed it may reach
102°, or the temperature at which tubercle bacilli will
thrive best. Generations of in-breeding are factors
which favors the cow's greater susceptibility.
Nephritis in Childhood.— Moncorvo goes over the
literature and dwells especially upon the nephritis
which occurs in the course of malaria. Scarlatinal
nephritis is rarely found in the pathological reports of
Rio de Janeiro, because scarlatina occurs so infre-
quently there. Malarial nephritis has hitherto at-
tracted but little attention. The author called attention
to it in 1895. In thirty-five recent cases twenty-six
coexisted with malaria. Examples are related show-
ing that in the young malaria plays the same part as
does scarlatina in cold and temperate climes. They
are usually benign, terminating favorably. The oedema
is often in the nature of true anasarca.
The Care of Premature and Feeble Infants. — By
S. W. Ransom.
Aiinals of Gynecology and Pediatry, Alarc/i, igoo.
The Correlation of Sexual Function with Insanity
and Crime. — H. Macnaughton-Jones concludes that
the correlation of insanity and disordered sexual func-
tions, arising out of affections of the generative organs, .
is a factor to be taken into serious consideration in the
treatment of women mentally'afiflicted. When there is
ground for the suspicion that some abnormal condition
of the genital organs exists which is causing the men-
tal condition, examination, under an anaesthetic if nec-
essary, should be made. The special dangers of the
climacteric period and the symptoms indicative of
threatening mania must be noted. Women who
have been previously insane are predisposed to a re-
lapse by the development of disease in their sexual
organs, especially to temporary recurrence of insanity
after operation on these organs.
Some Remarks on the Operative Treatment of
Uterine Fibroids W. J. Gow writes that in his series
of forty-seven cases there has been one death. He be-
lieves that abdominal hysterectomy, properly per-
formed, is not so dangerous an operation as it is gen-
erally thought to be, and, further, that the subperitoneal
treatment of the stump gives as good or better results
than any other plan. The writer has not in one of
these cases done an oophorectomy. Drainage was em-
ployed only on one occasion. The lessened mortality
of abdominal hysterectomy enables the surgeon to save
patients not merely from death but from invalidism.
Some Pathological and Clinical Phases of Gall
Stones. — A. H.Cordier states that cholelithiasis is of
frequent occurrence, and usually gives rise to manifest
symptoms, either severe or obscure. Cholesterin, as
a gall-stone-producing agent, must be present in an
abnormal quantity, and is in great measure a product
of the destruction of the epithelium of the biliary ducts
and gall bladder. Bilirubin calcium forms the nucleus
of the majority of stones. Jaundice, ptomain poison-
ing, and suppuration are late symptoms of cholelithia-
sis. Dyspeptic symptoms and loss of weight are some
of the remote results.
A Case of Bilharzia Haematobia.— Edwin Walker
describes the case of a woman in whose bladder this
parasite was found. The urine was pale, specific grav-
ity 1.001-1.006, reaction neutral, and containing but
little urea. In this fluid were the ova and embryos of
the parasite. The treatment consisted of santonin gr.
V. three times a day, and bicarbonate of potassium in
large doses. The ova disappeared in a few weeks, but
since some blood has been passed at times. The para-
sites have been found in most parts of Africa.
A Case of Porro's Operation Milo B. Ward cites
a case whose special points of interest are: The ab-
sence of any history of rupture of the amniotic sac;
the oblique and fixed position of the uterus, prevent-
ing the possibility of uterine contraction; no symp-
toms of labor were present, but constant backache;
the gangrenous condition of the endometrium with en-
tire destruction of the placenta, yet no marked dis-
turbance of the patient's health; the patient's excel-
lent recovery.
Mouatssihrijt J'iir Gel'i/rtsh. mid Gyntik., April, igoo.
Contribution to the Knowledge of Placental
Tumors. — G. W. van der Feltz reports two cases, on
the basis of which, in connection with a most careful
study of the literature, he comes to the conclusion that
the term "neoplasm " generally applied to these pla-
cental anomalies is a misnomer. He claims that
these so-called placental tumors do not answer the
requirements of a neoplasm, and seems to furnish
ample proof for his assertion. It is his opinion
that the anomalies in question are but transformed
villi with a more or less pronounced increase of con-
nective tissue; and that hence there is no justification
for the terms myxoma, fibroma, etc.
Contribution to the Knowledge of the Serous In-
filtration of the Para-Uterine Connective Tissue and
its Extension into the Region of the Subserous
Cavity in the Living — E. Ehrendorfer describes a
\-ery interesting case of extensive subperitoneal infil-
tration which he believes to be the only one reported
in the literature. He states that while he, and no
doubt others likewise, have frequently observed a
pretty thorough serous infiltration of the parametric
protoplasms, when extirpating fibromyomata, he has
never seen so intense and extensive a subperitoneal
serous effusion in abdominal tumors.
Primary Tumor Formations of the Nipple and
Mammary Areola. — A. O. Lindfors publishes most
valuable statistics, comprising thirty-seven cases of
primary tumors of the mammilla and areola, collected
in the literature. Ten of these refer to the areola,
twenty-seven to the papilla mamma;; seven occurred
in men, thirty in women. He states that only the
myomata and pedunculated tumors can be classed as
absolutely benign ; the other forms are already malig-
nant at the beginning or become so sooner or later.
As regards recurrence after the operation, he has been
unable to obtain sufficient data.
Vaginal Operations in Cases of Extra-Uterine
Pregnancy Max Madlener reports two cases. The
first one, in which posterior elytrotomy was done,
shows that a child carried to full term may be removed
from its fcEtal envelope through the vagina. The sec-
ond case was one of tubal pregnancy in which an ante-
rior colpotomy was performed. Although both opera-
tions were successful, the author declares that he will
never again undertake colpotomy in cases in which ex-
tensive adhesions are to be expected. He believes that
the field for this operation is a very limited one.
Concerning the New Building to be Erected for
the Imperial Clinical Institute for Obstetrics and
Gynaecology, at St. Petersburg By v. Ott.
The Orthopaedic Results of the Alexander-Adams
Operation. — By B. Kroenig and J. Feuchtwanger.
734
MEDICAL RECORD.
[April 28, 1900
^cmcxos mxA |lotices.
•General and Local An.esthe.sl-\. By Ai.me Paul
Heineck. Pp. 124. Chicago; G. P. Engelhard & Co.
1900.
This monograph should be read by all who are engaged in
administering anssthetics. It treats the subject in a most
thorough and concise manner, enumerating the dangers and
the causes thereof, with the treatment and prophyla.xis em-
ployed for each. Most of the space is devoted to chloroform,
ether, and cocaine, with a brief yet sufficient description of
the infiltration method of anesthesia.
The Modern Treatment of Wounds. By John E.
Summers, Jr. 149 pages. Omaha: Medical Publishing
Co. 1899.
To one who would inform himself briefly, yet accurately and
well, upon the latest principles of surgical technique, and the
therapeutic procedures which are practised in wounds of the
special regions, a book like the one before us will always be
acceptable. The author has presented the subject-matter
very well. E.\ception might be taken to his general use in
infected wounds of pure carbolic acid followed by its neu-
tralizant alcohol; for whereas this procedure has certainly
been followed by e.xcellent results in some cases, yet we must
never forget that it destroys the tissue cells as well as the
bacteria, and so diminishes the resistant power of the affected
part. The book is w-ell printed and contains a few good
illustrations.
Imperative Surgery. By Howard Liliexthal, M.D.
8vo, 412 pages. Illustrated. New York : The Macmillan
Co. 1 900.
The author has intended this book for the use of the general
practitioner and recent graduates in medicine," and deals only
with the diagnosis and treatment of conditions which demand
immediate operative measures. The opening chapters,
which are given up to antiseptic and aseptic surgery in gen-
eral, including a description of how to prepare for an opera-
tion in a dwelling-house, are particularly good, and will be
of especial interest to all physicians who have not had the
benefits of a general surgical training. In the chapters de-
voted to regional surgery, the author, by mentioning but one
good type of operation for each pathological condition, has
removed from the shoulders of those who do not devote
themselves to surgery, and who are therefore hardly capable
of selecting the best method to be practised, the onerous duty
of deciding which operative procedure to employ, It may
be said in general that the symptoms and diagnosis of the
special surgical diseases are concisely pictured, the indica-
tions calling for "imperative surgery" clearly outlined, and
the methods of operating briefly and yet minutely described.
A complete inde.x is appended. The book is richly and ex-
cellently illustrated, from entirely original photographs and
drawings. The author has certainly supplied to those who
practise surgery only when absolutely necessary a valuable
work, and both he and the publishers are to be heartily con-
gratulated on the manner in which the book has been pre-
pared.
Manuel Pratique d'Hygiene a l'Usage des Mede-
ciNS ET des Iltudiants. Par le Dr. Guiraud, Pro-
fesseur d'hygiene i la faculte de medecine de I'Universite
de Toulouse. Deuxieme edition, revue et augmente.
Paris; G. Steinheil. 1899.
This is a very excellent handbook for the use of practition-
ers and students of medicine and for those interested in the
problems of hygiene. Its scope is broader than that usu-
ally embraced by a work of the kind, for it not only has for
its object the conservation of health, but also the improve-
ment of the general conditions of the individual and of the
community. The work contains the applications of the latest
discoveries and experiments in chemistry and physiology to
the body of man, and in maintaining it in sanitaiT relation to
his environment. The effects of the soil, the atmosphere,
and the climate are discussed in connection with disease and
healthful and unhealthful occupations. Clothing, ventila-
tion, dwellings, the care of the body, and exercise are treated
broadly and thoroughly from the several standpoints of age.
race, custom, locality, profession, and occupation. The con-
ditions of human life in its modern transformation are sensi-
bly dealt with ; the problems of overcrowded cities, the com-
plex social relations, the development of new industries, and
the struggle for existence are all recognized as factors in the
health of the race. Perhaps the most valuable and up-to-
date chapters of the book treat of the affections which until
recent times have so often been termed " the scourge of the
Lord, " the infectious diseases that sweep over whole coun-
tries. The methods of preventing these murderous plagues
are clearly and concisely shown, by pointing out the sources
of infection, the practical means of disinfection, and the laws
of sanitation that must be observed to check the various dis-
eases. The work comes to us as a fat, compact, well-
printed, badly bound volume of about eight hundred pages,
in the cheap paper covers that our foreign works don to make
the sea voyage ; but it is worthy of a place on the shelves of
every one who would attempt to solve the many questions
that are constantly confronting the student of municipal sani-
tation.
L'Appendicite, For.mes et Traitement. Par A.
Broca, Professeur Agrege a la Faculte de Medecine de
Paris, etc. Avec 8 Figures dans le Texte. Les Actua-
lites Medicales. Paris : Librairie J. B. Bailliere et Fils.
1900.
This is an interesting little monograph upon the subject of
appendicitis, in which the author's conclusions are drawn
mostly from his own experience, so that some of them are a
little different from what is supposed to be the consensus on
the subject at present. This is, however, not necessarily a
drawback in a work on any subject. The various forms of
appendicitis are clearly described, and a discussion of the
modes of treatment leads the author to his conclusion that
timely surgery alone is proper, though he states that this
does not mean immediate operation in every case. The de-
scription of operations in the quiescent period is certainly in-
complete without reference to the Vi'orkof American surgeons
in this field.
Svste.m of Diseases of the Eve. By American. Brit-
ish, Dutch, French, German, and Spanish authors.
Edited by ^\'II.LIAM F. Xorris, A.M., M.D., and
Charles A. Oliver, A.M., M.D., of Philadelphia. Pa.,
U.S.A. Volume IV. : Motor Apparatus, Cortiea, Lens,
Refraction, Medical Ophthalmology. With 5 1 full-page
plates and 211 text illustrations. Philadelphia and Lon-
don; J. B. Lippincott Co. 1900.
This volume, like the others of this system, is, on the whole,
most excellent. It contains sixteen articles by authors of
different nationalities. The translations are exceptionally
good, apparently fully presenting the ideas that were ex-
pressed in the original manuscripts. The first article is by
Edmund Landolt, M.D., on " The Anomalies of the Motor
Apparatus of the Eyes." It occupies one hundred and sixty-
seven pages, and is very creditable. The second article,
which treats of • • Diseases of the Cornea, " fs one of the weak
parts of the volume. The chapter on diseases of the crystal-
line lens, that follows, is comprehensive and up to date in
every particular. A discussion of ametropia occupies the
next chapter ; it consists of an exposition of the views of the
author on the subject, evidencing careful observation and
study. Much that is speculative, argumentative, and advi-
sory is found here. The article on ' ' Ocular Lesions depen-
dent upon Diseases of the Circulatoiy System " is exhaustive
and of much value. •' Eye-Diseases and Eye Symptoms in
their Relation to Organic Di.seases of the Brain and Spinal
Cord " forms the title of a very carefully written article,
which could be produced only after extensive research and
profound consideration of the subject. The articles entitled
" Ocular Lesions dependent upon Disorders of the Secretory
and Excretory Organs," "Ocular Lesions in \"ariola." etc.,
and the "Ocular Lesions of Influenza, Dysentery," etc., are
all excellent, treating of the subjects in a clear, succinct
manner. The article on ' ' The Ocular Manifestations of
Hysteria" is somewhat unsatisfactory. "Eye Affections
due to Graves' Disease and Herpes Zoster, " a contribution
by Jonathan Hutchinson. Jr., is brief and as complete as the
space permits. "Motor Changes in the Ocular Apparatus
Associated with Functional Neuroses " is the title of the next
article ; it consists of a narration of cases observed by the
author, and an expression of individual views. The name
April 28, 1900]
MEDICAL RECORD.
735
of the author, George E. de Schweinitz, TiI.D., is a sufficient
guarantee of the excellence of the article on "Toxic Ambly-
opias " which follows ; exhaustive, clear, concise, it is one of
the gems of the collection. Following this article are those
entitled "The Entozoa of the Human Eye," "Simulated
Blindness," and " The Ocular Signs of Death." All are of
merit. The contributors have won enviable reputations in
the fields of research which they here represent ; however,
some of the articles are not of the exhaustive character that
one would expect to see in a system of diseases of the eye
which purports to cover the whole subject with the greatest
completeness. Evidence of crowding, which cannot be elim-
inated in a work the extent of which is fixed at the outset, is
apparent here.
The Lute and Lays. By Charles Stuart Welles,
M.D. New York: The Macmillan Company. London;
George Bell & Sons. 1899.
A COLLECTION of about sixty short but pleasing poems, or
"songs" as the author calls them, composed in and some
about America. The presswork is characteristic of the
house.
The Retrospect of Medicine; a half-yearly journal.
Edited by James Braithwaite and E. F. Trevelvan.
Vol. 120, January, 1900. London: Simpkin, Marshall,
Hamilton, Kent & Co., Limited.
This semi-annual review of medicine and surgery continues
to present in an attractive way much of the progress made in
different lands, but chiefly abstracted from English and
American sources.
The International Medical Annual Synoptical In-
dex TO Remedies and Diseases, for the twelve years
1887 to 1899. New York: E. B. Treat & Co. 1900.
The aim has been to present an index of facts likely to be
wanted for reference in everyday practice. Even to those
who do not possess the twelve volumes here systematically
indexed with reference to drugs and diseases, it will be of
use to those looking up any given subject, covering as it does
a very wide range of literature and giving the important
points in regard to new remedies. There is a supplementary
index for cross references.
A Practical Treatise on the Disorder of the
Sexual Organs of Men. By Bukk G. Carleton,
M.D., Genito-Lhinary Surgeon and Specialist to the
Metropolitan Hospital and Polyclinic; Consulting Genito--
Urinary Surgeon to the Hahnemann Hospital, etc.. New
York. Revised and enlarged edition. New York : Boe-
ricke & Runyon Co. 1900. .
The work as it now stands is twice the size of the original
edition. There have been added anomalies, injuries, and
non-venereal diseases of the male genital organs. The latest
special methods of treatment have received recognition. It
is justly stated that surgical treatment is often required be-
fore the selected remedy will remove the morbific phenom-
ena, and modes of procedure are brought up to date. The
author is to be congratulated upon the early exhaustion of
his first edition.
A Practical Treatise on Diseases of the Skin, for
the use of students and practitioners. By James Nevins
Hyde, A.M., M.D., Professor of Skin, Genito-L'rinary.
and Venereal Diseases, Rush Medical College, and
Frank Hugh Montgomery, M.D., Assistant Professor
of Skin, Genito-Urinary, and A'enereal Diseases, Rush
Medical College, Chicago. Fifth and revised edition.
Philadelphia and New York : Lea Brothers & Co.
The outside cover, the two names upon the title-page, the
increased size, and especially the new monochrome and col-
ored plates would cause one almost to think a new book iay
before him. Opening to the frontispiece, however, one feels
at once at home with his old friend Nsevus Lipomatodes of
the hairy back and pendulous buttock. Other friends are
recognized as the pages fall away from the thumb. It is
perhaps natural that the authors should feel a reluctance to
part with time-honored pictures, but the leprous gentleman
on page 701 and the specific lady on page 655 have reached an
age when they should be put on the retired list. The new
illustrations are of a much higher order of excellence than
many of the old, and add decidedly to the interest of this new
edition. In the matter of pathology there is an appreciable
improvement in many chapters, reflecting most of the recent
investigations, while scarcely a new discovery in dermatology
up to the date of issue has been overlooked. Among these
may be mentioned especially blastomycetic dermatitis and
porokeratosis. Many chapters have been wholly rewritten
or revised and brought well up to date. There are twelve
new full plates and two engravings. The work has proven
justly popular.
A Manual of Surgery. By Charles Stonham,
F.R.C.S. Eng., Senior Surgeon to Westminster Hospital,
Lecturer on Surgery and Clinical Surgery, and Teacher of
Operative Surgery, Westminster Hospital. 3 vols. i2mo.
New York : The Macmillan Co. London : Macmillan &
Co. 1900.
The volumes are amplified much beyond the scope of ordi-
nary manuals, but are not complete enough for what is gen-
erally recognized as fulfilling the conditions of an elaborate
treatise. They may be said to occupy, however, a very de-
sirable middle ground especially adapted to the requirements
oLthe student and general practitioner. Under the different
divisions of general surgery, injuries, and regional surgery
a vast and varied field is covered, comprising all the essen-
tial facts which are of practical value to the busy worker in
different lines who has neither time nor opportunity for con-
sulting larger works. The style is necessarily concise, which
is itself a great recommendation, and the illustrations are
numerous and carefully selected. All the topics are treated
from the teacher's standpoint and are thoroughly up to date.
A Manual of the Practice of Medicine, prepared es-
pecially for Students. By A. A. Steyens, A.M., M.D.,
Professor of Pathology in the Woman's Medical College
of Pennsylvania ; Lecturer on Terminology and Instructor
in Physical Diagnosis in the University of Pennsylvania;
Physician to St. Agnes' Hospital and to the Out-Patient
Department of the Episcopal Hospital, etc. Fifth edition,
revised and enlarged. Illustrated. Philadelphia: W. B.
Saunders. 1898.
The fact that this work has gone through five editions
speaks for its popularity, and for students it certainly is most
useful, giving concrete descriptions of nearly all diseases, eti-
ology, pathology, symptomatology, diagnosis, prognosis, and
treatment This, the fifth-edition, has been thoroughly re-
vised and many of the articles have been rewritten. Among
the new subjects are : Acute Cholecystitis, Tuberculosis of the-
Kidney, Gastroptosis, Enteroptosis, and Chronic Cerebral
Leptomeningitis. The work is published in a handy form,
with a flexible leather cover, and makes an excellent vade
The Vagina and Perineum, and how to Mend Them.
By Byron Robinson, IM.D. 134 pages. Chicago:
The Clinic Publishing Co.
The r:u'siui d'etre of a medical book should either be the
presentation of a new subject, or of an old one in an original
manner, and in either case the facts should be stated by the
author accurately and tersely. The book before us lacks
most of these essentials, and the really important part, viz.,
the anatomy and function of the pelvic fascise, is obscured by
too frequent repetitions. Altogether had the author devoted
one-eighth the space he has to this volume, and been more
accurate in his descriptions, the object he had in view, which
was to point out the importance of the pelvic fascije in peri-
neal lacerations and in their repair, would have been better
accomplished. The book contains numerous illustrations of
the muscular and fascial structures of the pelvis, and of the
operative procedures which have been designed for their re-
pair after laceration.
International Text-Book of Surgery. By Ameri-
can and British Authors. Edited by J. Collins
Warren, M.D., LL.D., Boston, Mass., and A. Pearce
Gould, M.S.F.R.C.S.. London, Eng.: Vol. II., Re-
gional Surgery. 8vo, 1044 pages. Philadelphia: ^^'. B.
Saunders. 1 900.
This is a work without introduction or other pretension of
excellence, and which comes to us on its own intrinsic tnerits.
Of the latter it has very many. The arrangement of sub-
jects is excellent, and their treatment by the different authors
736
MEDICAL RECORD.
[April 28, 1900
is equally so. The work is divided into thirty-three chap-
ters, which comprise all the conceivable subjects liable to
come under the notice of surgeon or general practitioner.
What is especially to be commended is the painstaking
endeavor of each writer to make his subject clear and to the
point. To this end particularly is the technique of opera-
tions lucidly described in all necessary detail. This is the
case above all with the chapters on abdominal surgerj',
wherein are treated the surgical diseases of intestines — in-
cluding, of course, appendicitis and the operations upon the
bile ducts. These as well as other portions of the work are
suitably illustrated, so that the merest tyro can gain a clear
idea of the indications in a given set of cases. And withal
the work is up to date in a very remarkable degree, many
of the latest operations in the different regional parts of the
body being given in full detail. There is not a chapter in the
work from which the reader may not learn something new —
at least such was the case with the reviewer, which fact
may excuse him from the charge of any partiality when he
unqualifiedly recommends the work to all in need of a first-
class guide.
OPER.A.TIONS-VADEMECUM FUR DEN PRAKTISCHEN ARZT.
Von Dr. Ed.mund Leser, Professor an der Universitat
Halle. Mit 144 Abbildungen. Berlin: Verlag von S.
Karger. 1 900.
As its dtle indicates, this is a handbook of surgery for the
practitioner who is not specially a surgeon. There is no at-
tempt made to cover the whole field of operative surgery, but
only those operations are described the performance of which
may be required when there is no specialist at hand. There
are many good illustrations, and the different procedures are
tersely described. The author recommends ether as the an-
aesthetic of choice, and does not mention any of the modern
operations for the removal of the diseased but quiescent ap-
pendix.
Progressive Medicine: A Quarterly Digest of Ad-
vances, Discoveries, and Improvements in the Medical
and Surgical Sciences. Edited by Hobart Amorv
Hare, M.D. Volume IV., December, 1899. Phila-
delphia and New York : Lea Brothers & Co. 1 899.
This last volume of the year takes in diseases of the diges-
tive tract, genito-urinary diseases of the male, syphilis, frac-
tures, surgery of the extremities, orthopedics, diseases of the
kidneys, physiology, anatomy, hygiene, and practical thera-
peutics. The contributors or sub-editors are H. B. Baker,
W. T. Belfield, J. C. Bloodgood, J. R. Bradford, A. P.
Brubaker, F. H. Gerrish, C. G. Stockton, and E. O. Thorn-
ton. The work of the various editors has resulted in cover-
ing pretty well the field of more recent advances in the de-
partments here presented. Non-scientific writers are not
wholly ignored, and we find a description of Delhi boil taken
from Kipling's "The Day's Work." The press-work has
been done in an excellent manner.
Operative Surgery. By Joseph D. Bryant, M.D.,
Professor of the Principles and Practice of .Surgery, etc.,
University and Bellevue Hospital Medical College ; \'isit-
ing Surgeon to Bellevue and St. Vincent's Hospitals, etc.
Volume I. : General Principles, Anaesthetics, Antiseptics,
Control of Hemorrhage, Treatment of Operation Wounds,
Ligature of Arteries ; Operations upon Veins, Capillaries,
Nervous System, Tendons, Ligaments, Fascite, .Muscles,
Bursa;, and Bones; Amputations; Deformities; Plastic
Surgery. Illustrated. New York : D. Appleton & Co.
1899.
The third edition of this well-known book is practically a
new work, for it is rewritten, remodelled, and divided into
two volumes, of which the present is the first. There are
interesting and lucid preliminary chapters on the preparation
of room and patient, on the choice of the ana-sthetic, and on
the instruments and apparatus in general use in the operating-
room. The pre-eminence of ether as the safest anar-sthetic
is upheld by the author's statistics. The chapter devoted to
the ligature of arteries contains many excellent plates illus-
trating the anatomy of the vessels, and, in addition to a dis-
cussion of the operations themselves, there are many useful
historical references. There are clear descriptions of the
operations for the relief of various forms of neuralgia, and
again many good illustrations. The operation which in this
book and elsewhere is called the Hartley-Krause operation
should be called simply the Hartley operation, if priority
counts for anything. The various operations upon the bones
receive a large share of attention, and the surgery of the
cranial bones is given special consideration both in the text
and in the illustrations. The photographic plates, here and
elsewhere, of the instruments used at various operations form
a useful addition to the more customary illustrations. The
subject of amputations is treated in a satisfactory manner,
and the descriptions and illustrations are of great didactic
value. The last chapter, on plastic surgery, contains among
other things a description of the forms of support which have
been used in restoring the saddle-shaped deformity of the
nose, with the very just comment that one can never be cer-
tain that such supports will remain in place more than a lim-
ited time without causing trouble. The book is much im-
proved over its former editions, and when complete will be
one of the best on the subject. The bookmaker's work has
been verj- well done.
(KUnical gepartmeiit.
THORACIC ANEURISM: TWO CASES IN-
VOLVING THE DESCENDING ARCH OF
THE AORTA; WITH AN AUTOPSY."
By STEPHEN SMITH BURT, A.M., M.D.,
During my present service in New York Post-Gradu-
ate Hospital, and within the same month, there have
been two cases of thoracic aneurism which seem suffi-
ciently important and interesting to warrant my plac-
ing them upon record, and bringing them to the atten-
tion of the Hospital Graduates' Club. It is well
known that the diagnosis of a thoracic aneurism may
be a simple matter, a difficult matter, or an impossi-
bility, according to the existing circumstances. From
the smallness of its size and the position which it oc-
cupies, the rupture of a minute sacculated aneurism
may be its first manifestation. And unless a fairly
large dilatation of this nature impinges somewhere
upon the surface of the chest, its less evident pressure
symptoms are in danger of remaining unrecognized.
Moreover, even when an aneurismal tumor is within
reach, the amount of laminated fibrin deposited in its
cavity may so modify the typical physical signs of
aneurism as to render a differential diagnosis a some-
what difficult problem. On the other hand, wherever
upon the surface of the thorax there is a pulsating tu-
mor which is not the heart, but which is beating with
as much force as, or with greater force than, that or-
gan, and withal of the same rhythm, whether or not
there is a bruit, in all probability it is a thoracic aneur-
ism. Meanwhile, in the more obscure cases, the ex-
treme rarity of a non-aneurismal thoracic tumor is a
fact which I am convinced it is the part of wisdom
always to take into consideration. Aneurisms of the
thoracic aorta are much more common than those of the
abdominal aorta. Aneurisms of the descending portion
of the arch of the aorta are rare as compared with the
ascending or even the transverse. Those familiar with
the investigations of Sibson know that out of 880 aor-
tic aneurisms, he found 703 were of the thoracic aorta,
and the remainder of the abdominal and its branches.
Of these but 72 were of the descending portion of the
arch. There were 120 of the transverse, and 193 be-
longing to the ascending aorta; ascending and trans-
verse aorta conjointly, 112; transverse and descend-
ing portion of the arch, 20; descending thoracic aorta
below the arch, 71; whole arch, 28; sinuses of Val-
salva, 87. The two cases brought to your notice this
evening were situated in the descending portion of the
' Read at the meeting of the Hospital Graduates' Club, Janu-
ary 25, I goo.
April 28, 1900]
MEDICAL RECORD.
m
arch of the aorta, but they differed materially in their
physical signs and their symptoms. Rupture is the
most common termination of an aneurism. Pressure
upon the trachea by an aneurism of the descending
arch is quite exceptional. In one of the following
cases death was due to exactly this condition; in the
other it was due to a rupture with hemorrhage, prob-
ably into the left bronchus.
Case I. — Thomas IJ , age thirty-four years, sin-
gle, occupation clerk, came under my observation
December i, 1899. Family history: His father was
living and in good liealth ; his mother died of some
heart trouble; four brothers and one sister were all
dead ; tiie causes of death were unknown. Previous
history: He had rheumatism when sixteen years of
age, and the grippe ten years ago; he had pain in the
chest one year ago. Present history: About ten weeks
ago he was taken with pains in his chest under his
left shoulder blade, which were most severe when
breathing; he has had poor appetite for the past sev-
eral weeks; he sleeps poorly; he complains of pain
also in the left shoulder, which extends down the left
arm.
Physical examination gave the following: The apex
beat of the heart was below and to left of the normal
position. The impulse was strong. Respiratory move-
ments of the left side were restricted. Pulsation was
synchronous with the heart, and of nearly equal force,
at the upper left side of the chest above the third rib
in front. On palpation there was absence of vocal
fremitus over tlie left side of the chest in front and
behind. There was no thrill over the area of pulsa-
tion, and no " tracheal tugging." There was no in-
crease in the semi-circumference of the left side. On
percussion, flatness was found over the lower two-
thirds of the left side of the chest: there was dulness
at the upper part behind. There was a triangular area
of exaggerated resonance with base in the upper left
axillary region, and apex extending forward between
the flatness below and the area of pulsation above.
Dulness, with decided resistance, was found from
near the right edge of the sternum across the anterior
surface of the chest to the left above the level of the
third rib. Auscultation showed absence of vesicular
respiration in the left side of the chest. There was a
loud systolic murmur, rough in quality, with the point
of greatest intensity at the second right intercostal
space, extending across to the left through the area
of pulsation. There was accentuation of the aortic
iecond sound, not, however, transmitted far from its
source. My diagnosis was obstruction at the aortic
valve, aneurism of the descending arch of the aorta,
with probable occlusion of the left bronchus, compli-
cated by pleurisy.
There were no evidences of pressure upon the
trachea, oesophagus, left recurrent laryngeal nerve,
sympathetic nerve, left common carotid, left subcla-
vian artery, or left innominate vein. Chemical and
microscopical examination of the urine was negative.
The sputa were examined for tubercle bacilli; none
■was present. Temperature was normal from the day of
entrance, August 30th, to within three days of death.
The pulse varied from 80 to 100; respiration, from 20
to 30 per minute. There was no record of hasmopty-
sis. There was neither tuberculous nor cancerous
cachexia. His general condition was good. His
complaint was chiefly a pain in the left chest and
likewise down the left arm. The area of dulness, in
which were the pulsation and systolic murmur, was
distinct from the region of flatness lower down, there
being an interval of hyper-resonance between.
The treatment was rest and iodide of potassium gr.
X., increased gradually to gr. xx. three times a day.
The patient died December 20, 1899, ^^ * sudden and
very profuse hemorrhage, probably from rupture of the
aneurismal sac into the left bronchus. Permission
for an autopsy was refused.
Case II. — Edward T , age thirty-seven years,
colored, married, occupation porter, was admitted to
hospital December 6, 1899. His family history was
good. At the age of twelve years he had had frequent
attacks of malaria. At eighteen he had had rheu-
matic pains in the knees and hips. Twelve years ago
he had had pneumonia. He has never had syphilis.
There was no history of alcoholism. One year ago
he had a sharp pain in the left side lasting one week.
Since then he has had repeated attacks of pain in the
chest, shoulders, and back, and has been unable to
work. At night he has a feeling of oppression in the
chest, and for the past week a choking sensation in
the throat.
Analysis of the urine gave the following: Reaction
acid; specific gravity 1.030; color dark amber; trans-
parency clear; chemical reaction, no sugar, small
ring of albumin; on microscopical examination, no
casts, pus cells very numerous, epithelium, a few
squamous and round bladder cells.
The temperature was normal; pulse, 88; respira-
tion, 24, on admission to the hospital. There was no
oedema of the extremities. The voice was hoarse; no
aphonia. There was cough, hoarse but not metallic
in quality. The larynx was reported normal upon e.x
amination. There was no complaint of dysphagia.
A physical examination showed: The apex beat of
the heart was in normal position. There was no vis-
ible pulsation elsewhere in the chest. There was no
localized bulging; the superficial veins of the chest
and both arms were distended. There were a spongy
elastic swelling at the base of the neck and angular
curvature of the spine in the upper dorsal region, with
especial prominence of the spinous process of the third
dorsal vertebra. No inequality of the pupils and no uni-
lateral sweating of the face were present. Palpation
showed decided pain upon pressure over the second,
third, and fourth dorsal vertebra;. The apex beat was
normal in force and position; pulsation was equal in
strength and rhythm in the radial arteries; there were
no palpable pulsation or shock in the chest outside
the precordial region, no thrill, and no tugging at
the trachea. On percussion, dulness was found with
marked resistance, extending from one inch to the
right of the sternum, across and for three inches to
the left of that bone, and from the level of insertion
of the third ribs in this area upward. Abnormal dul-
ness from the third dorsal spine upon both sides be-
hind, and marked vesiculo-tympanitic resonance from
the third dorsal spine on both sides downward, were
noted. Auscultation showed sonorous breatliing over
the entire chest and trachea, with point of greatest in-
tensity at the lower end of the trachea and the left
bronchus; vesicular respiration was either diminished
in intensity or masked by the sonorous breathing; no
cardiac murmurs, no thrill, no murmur over the area
of dulness, nor intensification of either heart sound;
there was neither systolic nor diastolic shock over the
tumor or the trachea. Upon a subsequent examina-
tion slight pulsation was detected on palpation and
on auscultation over the area of dulness on the left
side in front, which entirely disappeared the day fol-
lowing.
My diagnosis was aneurism of the descending por-
tion of the arch of the aorta, pressing upon the verte-
bra; behind and the lower end of the trachea and the
left bronchus in front. The location of the tumor was
determined by the evidences of pressure u_ ..n the ver-
tebrae behind and the trachea and bronchus in front,
and by the absence of any signs of pressure on the
left recurrent laryngeal nerve, the sympathetic nerve,
or of involvement of the left subclavian artery. The
nature of the tumor was a question not so easily an-
7.^.8
MEDICAL RECORD.
[April 28, I goo
■ swered, owing to the absence of many distinctive evi-
dences. Nevertiieless, the vigorous frame and well-
nourished condition ; the peculiar shifting character of
the pain except in the back; the paroxysmal expira-
tory dyspnoea; the fact that non-aneurismal tumors are
more apt to be located in the anterior mediastinum,
and that pain is more common with aneurism than
with growths in the mediastinum, while the reverse
holds in regard to fever and emaciation; the entire
lack of evidence of cancer elsewhere; the absence of
a characteristic expectoration; the absence of glandu-
lar enlargement; the age, sex, and occupation of the
patient; the history of the case together with the ob-
servation of the course of the disease; the results of
medication (the pain on pressure entirely disappearing
from the vertebra; under the iodide of potassium) ; and
repeated physical explorations — led me irresistibly to
the conclusion of aneurism.
Treatment consisted chiefly of rest in bed, and io-
dide of potassium gr. xv. three times a day, with now
and then, as required, morphine hypodermically.
The daily notes show that the temperature remained
about normal; the pulse varied between 80 and 100,
the respirations between 20 and 30 per minute.
There was never a complaint of difficulty in swallow-
ing; however, the appetite was poor, and he ate little
solid food. His bowels were constipated. There was
no record at any time of hemorrhage. There never
was any paraplegia. He had dyspnoea with a hoarse
cough which was not metallic in quality, and a slight
mucous expectoration. He was less uncomfortable
when lying on the back, yet there was at all times
great restlessness. He complained of a feeling of
fulness and oppression in the chest. He had frequent
paroxysms of pain and dyspnoea, but above all toward
the end a distressing dyspnoea, and finally asphyxia,
which terminated in death on December 29, 1899,
twenty-three days from his entrance to the hospital.
The autopsy was performed by Dr. H. A. Gribbon,
a member of the house staff, in the presence of Dr. J.
F. Siler, also of the house staff, and myself.
Autopsy on the body of Edward T (colored)
January 3, 1900: General condition, well nourished.
There was marked kyphosis in the upper dorsal re-
gion. The lungs, liver, spleen, and kidneys were
moderately congested. The heart and stomach were
normal. The brain was not examined. There was a
large sacculated aneurism in the descending portion
of the arch of the aorta, beginning about three-quar-
ters of an inch beyond tlie origin of the left subcla-
vian artery, and situated behind the trachea and fill-
ing the upper quarter of the left thoracic cavity,
together with the posterior mediastinum, and extend-
ing about three inches into the upper part of the right
thoracic cavity. The tumor pressed forward against
the lower part of the trachea and the left bronchus,
but was not adherent. It likewise compressed the
vena cava superior and the vena; innominata;. The
walls of the aneurism were adherent on the posterior
aspect to the spinal column, and on tiie right side
somewhat anteriorly to the oesophagus. The oesoph-
agus, with canal still patent, seemed to have been car-
ried forward and outward on the right side of the tu-
mor, to which it was closely adherent for about four
inches. The aneurism was filled with a dense lami-
nated fibrous clot, leaving free the channel of the
aorta. The aneurismal tumor was of an irregular
ovoid shape, with a long diameter of from six to eight
inches. The bodies of the second, third, and fourth
vertebrae were extensively eroded. The erosion of the
third opened into the spinal canal. The inter-articu-
lar discs were not affected by the erosion to any de-
gree. The borders of the second, third, and fourth
ribs were roughened near the spine, and slightly
eroded.
MUMPS VERSUS RHEUMATISM.
Bv E. \V. HEDGES, M.D.,
fLAINFIELU, N. J.
One year ago there came to my office a young man
suffering from gonorrhoea. This innocent infection
proved most obstinate and resisted every mode of treat-
ment. Two months later, in April, 1899, he devel-
oped a well-marked attack of rheumatism in his right
foot. The ankle joint was not involved, but the top
and sides of the foot were swollen and very painful.
This, like the urethritis, was not amenable to treat-
ment, and for three months the two diseases vied with
one another in their power to annoy.
Some time in July the pain and swelling left the
right foot and took up their home in the left foot,,
which in turn became tender, painful, and swollen.
This continued until December 20th. Not a single day
was the patient without pain and swelling. He could
not walk a block without suffering, and was frequently
kept awake nights by pain in his foot, meantime run-
ning the gamut of all the anti-rheumatic remedies
without avail.
About the middle of November the clap stopped.
The last remedy used was an injection of 1 : 4,000 bi-
chloride solution, but whether that had anything to do
with the cessation of the discharge I do not know.
On December 20th he retired with the usual pain and
swelling in his foot. He awoke with both parotids
big and painful, but with his foot absolutely well.
The mumps ran the usual uneventful course of about
a week, but from its first appearance to the present
time (two months") he has had no vestige of rheuma-
tism anywhere in his body. The mumps appeared at
a time when the disease was epidemic in the city, and
hundreds of young and old were affected by it.
The interesting questions come up. Was the mumps
merely metastatic from the rheumatism, or was it
regular epidemic parotitis, and if so, is there some
antagonism between the toxin of the diplobacillus of
mumps and the rheumatic poison, whatever that may
be? Mumps certainly cannot confer a lasting immu-
nity to rheumatism, for we can all recall cases of the
latter disease in patients who have had mumps earlier
in life; but may it not have some temporary antidotal
power, just as the diphtheria antitoxin has? I am
aware that "one swallow does not make a summer,"
and that arguments based on one case are not weighty,
so I send this brief history hoping that others of your
readers may have had one or more cases of mumps
develop in the course of articular rheumatism, and
that they may be willing to give their testimony for
or against this hypothesis of antidotal effect.
TRANSPOSITION OF VITAL ORGANS.
I5y S. J. SOMDEkGEK, M.D.,
On February ;, 1900, Mr. W , aged twenty-three
years, came to my office to be examined for life insur-
ance. I found the heart with its bast situated about
in the normal position, but with its apex inclined
toward the right side, the apex beat being at about
the same point on the right side as we usually find
it on the left. The liver dulness is absent on the
right side, and its place is occupied by normal lung
resonance. In the nipple line the lung extends down
to about the costal border. The liver dulness is
found to the left of the median line and slightly lower
than the usual position. The right testis hangs lower
than the left. This seems to be a case of complete
transposition of organs. The man appears in perfect
health.
April 28, 1900]
.MEDICAL RECORD.
739
J-ocietij ^vcports.
THE PRACTITIONERS' SOCIETY.
One Hiindrcd and Fijty-Jourth Regular Aleetiiig, held
Friday, March 2, igoo.
A. Alexander Smith, M.D., President, in the
Chair.
A Case of Bradycardia. — This was presented by Dr.
E. G. Janeway. The patient was a young man, a
soldier by occupation, whose usual pulse-rate, for sev-
eral years past, had ranged from 30 to 36 per minute.
It sometimes dropped as low as 20 and occasionally
rose to 60. No satisfactory cause for the bradycardia
could be elicited. When the patient was eight years
old, he had an attack of diphtheria, from which he
apparently made an uneventful recovery. He had
never had rheumatism or scarlet fever. He had never
smoked. The heart was large; its action was slow and
forcible. A faint aortic and mitral systolic murmur
could be made out. There was no suspicion of arterial
sclerosis. There was no acceleration of the pulse
upon exertion. Occasionally a faint accessory pulsa-
tion could be detected at the wrist. At the age of
twenty, on entrance to the army, the pulse was 100;
at twenty-one it was 90 when nervously excited; at
twenty-two it was 84; and at twenty-three it had be-
come 38, slow and strong, without disease intervening.
The patient stated that when his pulse rose to 60 per
minute, as it occasionally did, it might maintain that
rate for several hours or only for a few minutes, and
•during those periods he felt comfortable. When it
dropped back to its usual rate, however, he felt very
uncomfortable on account of the long intermissions.
When the beat occurred, there was apparently a rush
of blood to the head, giving rise to headache and dizzi-
ness. When the beats fell as low as 20 per minute,
syncope might result. Numerous cardiac stimulants had
been tried without effect : some of them made the heart
beat harder, but no faster. Application of mustard
to the neck, with the idea of stimulating the sym-
pathetic, had also been unsuccessfully tried. Inspec-
tion of the chest and palpation made out a slight pulsa-
tion of the heart between the stronger beats. At times
two such beats, one extremely feeble, could be detected.
The cardiogram prepared by Dr. T. C. Janeway showed
the same. The carotid tracing exhibited this to a less
degree. The sphygmogram of the radial showed no
extra beat as a rule.
Dr. Janeway, in reply to a question, said he thought
there was some thickening of the aortic valves, a
slight leakage at the mitral, and perhaps myocarditis.
Dr. George L. Peabody referred to a case of brady-
cardia which was reported to the society some years
ago by Dr. Ball. The patient was an elderly lady in
whom the slow pulse persisted for years, and during
that time she failed in general health and had attacks
of syncope. She was over eighty years old, and grad-
ually senile symptoms developed until she failed to
recognize even members of her own family. Without
any special treatment, the heart's action improved, the
pulse rate increased to 60 and 70, and this was fol-
lowed by a clearing up of her mental symptoms and
she again became bright and cheerful. Dr. Peabody
said that usually the slow pulse was associated with
arterial sclerosis of the coronary vessels, but that when
we remembered how common this lesion was and how
rare was this symptom, the association between the
two was hardly apparent.
The president. Dr. A. Alexander Smith, reported
a case of bradycardia seen in consultation in which the
pulse rate fell as low as sixteen beats per minute.
The patient was a man seventy-three years old, with
arterial sclerosis and, apparently, myocarditis. He had
a systolic murmur at the apex and a very rough systolic
murmur at the base. He had always led an exceed-
ingly active life. About a week ago he visited the
office of a physician who lived near by, and while
there he had a convulsive attack and lost conscious-
ness. When he returned to consciousness he was
somewhat delirious, and there was a partial loss of
power on the left side of the body which soon cleared
up. He was carried to his own house and put to bed,
and remained delirious for several days. He was able,
however, to impart the information that for the past
five years he had known that his pulse rate was slow-
about 40 per minute, and occasionally dropping to 38
and 36. He was suffering from interstitial nephritis,
which had developed to a moderate degree, and there
was some arterial sclerosis. The heart and pulse beats
were entirely synchronous. Since his attack in his
physician's office a week ago, the patient, in addition
to his delirium, had been extremely irritable. Several
times his pulse had fallen as low as 16 beats per min-
ute, and then gradually gone up to 28 or 30.
A Case of Suffocating Laryngeal Papilloma. — This
case was presented by Dr. Robert Abbe. The patient
was a girl thirteen years old, who was first brought to
him at the Post-Graduate Hospital in 1892, suffering
from an obstructive condition of the larynx which had
rendered her cyanotic and comatose. The trachea was
at once opened, and the child's condition immediately
improved. The larynx was found to be filled with
papillomata. Subsequently, Dr. Abbe made a vertical
section of the larynx and removed at least a teaspoon-
ful of these growths. The child made a good recovery,
and the wound was allowed to close. In two months
there was a recurrence; the larynx was again opened,
a complete laryngotomy being done, and a consider-
able mass of papillomatous tissue removed. The
actual cautery was then appli-ed to the base of the
growths, and everything that was likely to produce a
recurrence was apparently destroyed. In spite of these
precautions, a second recurrence took place within a
few months. The larynx was again split and the
papillomatous growths were removed. Monochlor-
acetic acid was then applied to the base of the growths,
and the child was allowed to breathe for a time through
the tracheotomy tube. Again a recurrence took place,
and again the growths were removed and the site from
which they sprang was cauterized — this time with car-
bolic acid. The tracheotomy tube, which had been left
in only for brief periods after the previous operations,
was now left undisturbed for six years. It was removed
last year, and up to the present time there had been no
signs of a further recurrence. The child was in good
health, but her voice was necessarily impaired by the
fact that some of the growths involved part of the vocal
cords; she was only able to speak in a whisper. Pre-
vious to the last operation, the tracheotomy tube was
replaced for a time by an intubation tube, but the
child did not derive much benefit from it. The idea
in leaving the tracheotomy tube in place for so long
a time was to give rest to the larynx. Cases were on
record, Dr. Abbe said, in which the prolonged use of
a tracheotomy tube had apparently prevented the re-
currence of papilloma in the larynx.
Dr. Beverley Robinson said the rest afforded to the*
larynx by the prolonged use of a tracheotomy tube
probably modified the tissues of the interior of the
larynx. This was the explanation given in those cases
in which a cure had apparently been effected by this
means.
A Case of Extensive "Hairy Mole." — Dr. Abbe
showed this case. The patient was a boy three years
old, with a hairy mole which covered a considerable
portion of the left side of the face. It embraced the
740
MEDICAL RECORD.
[April 28, 1900
entire cheek, most of the nose, both eyelids, the temple,
and half of the forehead. The skin of the lesion was
hypertrophied, deeply pigmented, and covered with a
growth long of hair. The child's mother attributed the
deformity to a maternal impression received during
the third month of her pregnancy, when a boy, in play,
brougiit a dead rat to her, and whirling it round his
head struck her with it. Dr. Abbe said that on account
of the disagreeable appearance of the deformity in this
case, the parents were very anxious to have something
done, and he thought that even a surgical scar would
be preferable. He intended to shave off the pigmented
layers of the skin, going down as deeply as was found
necessary, and then to apply skin grafts by Thiersch's
method.
Dr. Charles SxEDArAX Bull said that any opera-
tion upon the external surface of the lids, even by
Thiersch's graft method, would probably tend to pro-
duce an ectropion, particularly of the lower lid. Cau-
terization of the lesion would be even more apt to
produce ectropion than skin-grafting. Dr. Bull said
he did not think there was the slightest danger to the
eye itself from any proposed operation on the lids.
Pneumothorax Occurring in Persons with Appa-
rently Healthy Lungs. — This paper by Dr. Walter
B. James detailed the history of three cases in which
the symptom occurred after severe exertion and with-
out any demonstrable lung lesion. In all recovery
took place in comparatively short periods.
Dr. Janeway said he had met with five cases like
those described by Dr. James. One of the cases,
which he saw last summer, was that of a young man,
who, after rapidly running up five flights of stairs, was
taken with a severe pain in the chest. The pain was
thought to be due to heart trouble. Dr. Janeway saw
him two days later and found a pneumothorax, from
which the patient made a good recovery in about a
month. In another case, that of a young man eighteen
years old, the perforation of the lung also occurred
after a good deal of exertion. In that instance. Dr.
Janeway said, he suspected that a small nodule or
emphysematous bleb had given way. Occasionally,
around a fibroid nodule, there might be a compensatory
emphysema which might give way. In all of the cases
which had come under the speaker's observation, com-
plete recovery took place ; in none did fluid occur, and
in only one did he suspect a coexisting phthisis.
Even in phthisis we might have a pneumothorax with-
out the presence of fluid. The condition of pneu-
mothorax was a comparatively rare one, and the prog-
nosis was good. In one of his cases the patient was
a woman who suffered from bronchitis and emphysema,
and during a severe fit of coughing a pneumothorax
developed. She made a good recovery.
Dr. H. M. Biggs said he had seen two cases of
pneumothorax in hospital practice. Both patients
made a good recovery in a short time. The speaker
said his impression had always been that while in
these cases there might not be any demonstrable lesion
in the lung, the perforations took place at some point
of the lung where the resistance had been diminished
by some pathological process.
Dk. Beverley Rorinson said he had seen one case
of this kind, and had attributed the perforation of the
lung either to the presence of a tubercle on the surface
or to the bursting of an emphysematous vesicle.
Dr. Peap.ody narrated the following case, which
occurred during his student days in Vienna. The pa-
tient was a little girl who swallowed some caustic
potash, producing a stricture of the oesophagus which
was being dilated by sounds. The passage of these
instruments gave rise to severe coughing fits. In the
course of time she learned to pass these sounds her-
self. During one of her coughing-spells induced by
the passage of the sound there was a sudden collapse
of the lung. From this she recovered, but the accident
happened again some months later and caused her
death, in syncope. In the diagnosis of pneumothorax.
Dr. Peabody said, he would suggest the use of the
hypodermic needle as a corroborative sign, just as it
was employed in pleurisy with effusion. In the second
case reported by Dr. James, Dr. Peabody said the chest
could not have been filled with air because the fceart
was not displaced. It could have been only partially
filled.
Dr. James said that in neither of his two cases were
there any symptoms or evidences of tuberculosis. In
the first case there was not even a suspicion of it.
In the second case the disease might possibly develop
later.
Dr. Robert F. Weir said he wished to say a word
about the cohesion of the lung to the chest wall.
Many years ago he witnessed some experiments made
by Dr. A. H. Smith on animals, and they demonstrated
very clearly that when the opening in the chest wall
was made over one of the lobes of the lung, cohesion
continued, but if, on the contrary, the opening involved
one of the clefts between the lobes, immediate collapse
of the lung took place. This observation he had since
corroborated in several cases in which in operative
procedure the pleural cavity had been moderately
opened. Dr. U'eir said that in certain cases of pneu-
mothorax, in which there were symptoms of overdisten-
tion, it was perfectly proper to relieve the pressure by
opening the chest cavity. It might occasionally be
necessary to do this in order to save life. The speaker
recalled one such case, in which, while removing some
enlarged glands from the deeper tissues of the neck,
he accidentally opened the pleural cavity without
knowing it. The patient began to breathe heavily and
was almost moribund before the cause of his condition
was made out. The chest was then punctured, with a
great outrush of air, but the patient was too far gone
and succumbed. A second analogous case had since
then come under his care in which similarly the neck
wound acted valvularly, allowing air to be sucked in
but none to escape. Here a chest incision was made
and the. patient recovered. Dr. Weir said it was also
considered justifiable to open the chest wall for the
arrest of a persisting and dangerous traumatic pulmo-
nary Jiemorrhage. The lung collapse in this instance
brought about pressure on the damaged vessels.
Dr. Janeway said experimentation had shown that
under pressure air could be forced through the pleura
and even through the veins. After such experiments,
air bubbles had been found in the pleural cavity and
in the left heart. This had been suggested as one of
the causes of sudden death.
Dr. Biggs said that some years ago he reported a
number of cases in which exploratory puncture of the
chest had been followed by pneumothorax, and in
some instances by death. " In one case a double pneu-
mothorax followed exploratory punctures; this was
proved at autopsy. In two cases which he saw at
autops)', the needle-puncture of the lungs could ap-
parently be seen.
A Case of Diabetes in a Child with an Unusual
Family History.— This case was reported by Dr. A.
Alexander S.mii h. The patient was a well-nourished
boy, twelve years old, who was born in Colorado, at
an elevation of five thousand feet above tide-water,
and had always lived there. His parents were alive
arid apparently in good health. The boy was brought
to New York last November by his motJier, a very in-
telligent woman, who stated that his urine had been
known to contain sugar for at least the past four years.
She also said that she had lost one child, about four
and one-half years old, of diabetes, the disease proving
fatal in two years: also another child, a daughter,
aged seven years, of the same disease, lasting in that
April 28, 1900]
MEDICAL RECORD.
741
case three years. She then found, upon investigating
the family history, that her husband's father had had
diabetes for fourteen years, and that his sister — a
great-aunt of the boy who was brought to New York —
had suffered from diabetes when she was sixty-five
years old. The boy's father had apparently escaped
the disease. There was also a rather uncertain history
of diabetes in one of the mother's ancestors, namely,
a sister of the mother's grandmotiier. An examina-
tion of the boy's urine upon his arrival here showed
the presence of considerable sugar. Without any
medication and with only a partial restriction of his
diet the sugar steadily decreased in amount, and after
a few weeks it disappeared entirely. Dr. Smith said
he attributed the improvement to the change of resi-
dence, and he advised the child's mother not to take
him back to the high altitude where his disease ha,d
developed. The family to which this boy belongs.
Dr. Smith said, were not Hebrews. The frequency of
diabetes in that race was well known. The speaker
said he was familiar with one Hebrew family, three
members of which were suffering from this disease.
He suggested the possibility of some causative rela-
tion between the high altitude and the development of
diabetes in some instances. The influence of the alti-
tude on the nervous system might possibly be a factor
in the production of the disease.
Dr. J. W. Brannan said that during a four years'
residence in Colorado, at an elevation of six thousand
feet, he examined many specimens of urine, and while
there were numerous cases of albuminuria, he could
not at the moment recall a single case in which the
urine contained sugar. He remembered, however, one
case of diabetes insipidus which came under his ob-
servation in Colorado in 1880. The case was that of
a physician who had two uncles in an eastern State
who were sufferers from diabetes mellitus. The pa-
tient himself . had simple polyuria, accompanied with
excessive thirst. He had a phthisical history and
was also rheumatic, and recently some rather obscure
mental symptoms had developed.
Dr. Robinson said he had a patient whose urine
contained sugar when he was in the city, but when he
went to the country and was free from business worry,
the glycosuria entirely disappeared.
Dr. Janeway said lie did not think the altitude had
anything to do with the diabetes in the case reported
by Dr. Smith.
Dr. Smith said this boy's mother had noticed some
time ago that when he was taken to a lower altitude
than that of his home, the quantity of sugar in the
urine diminished.
Skiagram of (Esophageal Stricture. — This was
exhibited by Dr. Roi'.ert Abbe, in connection with the
following case. The patient was a married lady, who,
since she was sixteen years old, had suffered from
great difficulty of swallowing. The obstruction was so
pronounced that she almost died from inanition. Her
trouble was due to a congenital stricture of the cesoph-
agus at the level or the diaphragm, and just above
this there was a pocket or diverticulum into which the
food which she swallowed would pass. A gastrotomy
revealed a minute, atrophied stomach, and extending
upward a short tube which represented the lower por-
tion of the asophagus.
A Case of Chyluria — Dr. Franci.s P. Kinnicutt
exhibited (through Dr. Weir) a specimen of urine from
a case of chyluria or hsmato-chyluria. It had the
appearance of milk of a good quality. The patient
was a woman who was admitted to the Presbyterian
Hospital suffering from a lobar pneumonia which ran
a mild course, and from which she made a perfect re-
cover)'. The chyluria appeared ten days after conva-
lescence was established. The patient presented no
other symptoms of any kind, and physical examination
at present was absolutely negative. The urine was
free from casts, contained blood discs, and no more
albumin than was accounted for by the blood. It also
contained a moderate number of leucocytes and fat in
a molecular form. From time to time she passed urine
entirely free from blood. The patient's blood had
been examined a number of times, the specimens being
taken both at night and during the day, and none con-
tained the filaria sanguinis hominis. Dr. Kinnicutt
said that these cases of non-parasitic chyluria were of
very rare occurrence.
A Case of Sudden Death This case was reported
by Dr. J. W. Brannan. The patient was a laborer,
forty-nine years old, who had been an inmate of Belle-
vue Hospital more or less constantly since October,
1898. His family history was negative. Personally,
he was a hard drinker and smoker; he had rheumatism
twenty years ago, but denied syphilis. He never had
had any cardiac symptoms. About one year previous
to his admission to the hospital he began to suffer
from shortness of breath, and his feet became swollen
at night. The shortness of breath gradually became
more pronounced, and he grew weaker. When he en-
tered the hospital, his symptoms were limited to the
heart and kidneys. He was decidedly cyanotic; the
heart's action was irregular and intermittent. The
apex beat was in the sixth intercostal space, outside
the nipple line. There was a soft, blowing systolic
murmur, transmitted to the left. The urine contained
albumin and casts. Under the administration of car-
diac stimulants his condition improved and the murmur
disappeared, occasionally reappearing without any
assignable reason. Later on it disappeared perma-
nently and was replaced by a pre-systolic murmur which
was also inconstant. The patient then left the hos-
pital for a time, and was readmitted about a month
later. He was then troubled with a severe bronchitis.
There were no signs of any valvular lesion. The
bronchitis gradually improved, but three days ago,
while he was resting quietly in bed, he suddenly died
without any apparent cause. The autopsy showed a
large heart, with dilated cavities and thickened walls.
The heart muscle was pale and flabby. There was no
affection of the coronary arteries, excepting that they
were somewhat thickened. They were pervjou-s through-
out. The mitral valve was constricted, admitting but
one finger. Otherwise the heart was normal. It
weighed between eighteen and nineteen ounces. An
examination of the brain showed a chronic leptomen-
ingitis on both sides, but nothing else. There w^as no
embolism. The kidneys showed the lesions of a
chronic diffuse nephritis. Their surfaces were rough-
ened and the capsules adherent. Each weighed be-
tween seven and eight ounces, about one-half as much
again as the normal kidney. Dr. Brannan said he
could assign no satisfactory cause for the sudden death
in this case, unless it could be attributed to acute
dilatation of the heart. The cavities were large and
filled with blood. The post-mortem specimens in this
case, which Dr. Brannan exhibited, had not yet been
subjected to a microscopical examination. In reply
to a question by Dr. Janeway, the speaker said that the
patient was receiving no medication whatever at the
time of his death. The case was one of a type not
infrequently seen in the class of patients admitted to
Bellevue Hospital. The man had' lived a life of hard
work, exposure, and strong drink, and the time came
when the heart simply gave out, though not at the mo-
ment under anv unusual strain.
Cardiac Dropsy. — Calomel, gr. J, should be given
every two hours for four or five days; then combined
with small doses of digitalis leaves, gr. 1 to gr. \. —
Finkelstein.
.742
MEDICAL RECORD.
[April 28, 1900
©orrespontlcuce.
OUR LOxMDON LETTER.
(Fr.
■ Special Correspondent.)
TMIDWIVES BILL — RUPTURE OF (T.SOPHAGUS — SARCOMA
OF GASTRO-HEPATIC OMENTUM CHEMISTRY OF
GC'JT DISINFECTING WATERWORKS DEATHS OF
DRS. MIVART, J.ICKSON OF UGANDA, DICKSON, AND
GUNNING.
London", .Aprils, 000.
The midwives bill is by no means dead. It is giv-
ing signs of even more vigorous life. It will prob-
ably not come before the House of Commons again
until after the Easter recess, but then a determined
attempt to force it through will be made. Many
members of the profession have lately waked from
their apathy and begun to realize the danger. Ac-
cordingly they are blaming the Medical Council and
the corporations for giving it a qualified sanction.
The promoters have eliminated the safeguards and
shamelessly told the committee that these bodies sup-
port the bill. They are trying to prevent penalties
and to protect all the ignorant women who have called
themselves midwives — in fact to establish them as in-
dependent practitioners. If they succeed we may look
for great injury to the public, and there are dangers
which ought not to be forgotten in trusting this class
of women with midwifery practice.
The meeting to protest against the bill was held on
Wednesday, when Mr. George Brown presided. He
showed that the bill would authorize only the incom-
petent, whereas the opponents desired that all women
allowed to practise should be educated and qualified.
Resolutions condemning the bill were unanimously
passed. The meeting then rapidly thinned — the num-
iDcr falling from nearly one hundred to seventeen or
eighteen, or certainly under twenty. A resolution was
brought forward asking Dr. Glover to resign his seat
on the Medical Council and appeal to his constituents
to re-elect him. Mr. Brown before this had vacated
the chair, and Dr. Toogood took his place. There was
some difference of opinion as to whether this would
be in order, and whether it would be advisable con-
sidering that so large a majority had left before the
subject was broached. Eventually the resolution was
carried. You should understand that it is solely on
account of the position he has all along held on the
midwives question that Dr. Glover has given umbrage
to a large and increasing section of his constituents.
In every other way he retains their confidence, and he
is universally esteemed.
Rupture of the oesophagus is so rare that only six-
teen cases seem to have been recorded as such, though
others have almost certainly been related under differ-
ent names. A case was described at the Medico-
Chirurgical Society by Messrs. Bowles and Turner in
a woman aged sixty-two years, who in vomiting was
suddenly seized with collapse and severe epigastric
pains. Vomiting ceased; emphysema of the neck
came on, e.xtending to the face, and she sank in
twenty-two hours. The post-mortem left no doubt
that the rent occurred before death ; it was longitudinal
and one and one-half inches long. Some remarks
were made on the diagnosis of this lesion and its pos-
sible treatment by surgery. Drainage of the posterior
mediastinum and suture of the rent were suggested.
Some similar cases were mentioned, including two in
the Pathological Transactions, which were attributed
to post-mortem softening, but which were very likely
rupture. The clinical history has to be considered.
In this case it was said the pulse was only 50, but the
arterial tension was maintained in spite of collapse.
It was thought irritation of the vagi might e.xplain
this. Dr. Rolleston remarked that the rupture was
always in the lower third, although the weakest part
was at the junction with the pharynx, and he suggested
this might be because the lower third is composed of
smooth muscular fibre only. He thought rupture was
often preceded by a small ulceration which was con-
cealed by the rent. Mr. Turner had made some ex-
periments, and could not think ulceration necessary;
he was surprised how easily rupture was produced, and
it was always longitudinal and in the lower third. A
case was also related at the Academy of Medicine in
Ireland, by Professor McWeeney, who showed the spec-
imen. A workman aged forty years, an alcoholic, after
retching violently, was seized with extensive em-
physema of the face and neck and died in a few hours.
At the post-mortem the rent was found one-half inch
Icjng just above the diaphragm.
Mr. Pearce Gould showed a man aged thirty-eight
years, from whom he had removed a spindle-celled
sarcoma of the gastro-hepatic omentum four and one-
half years ago. The tumor weight twenty-one pounds,
and was also shown with some sections. He had found
only one other such case. The chief clinical feature
of tumors of the small omentum is the pushing down
of the stomach and so obscuring its resonance, which
may reappear below. There is also great elongation
and displacement of important structures without such
definite grave symptoms as might be expected.
There were two papers on gout at the Medical So-
ciety's meeting. The first was by Dr. Luff, who cor-
rected a misapprehension in some quarters of an
article of his which called in question the solvent
action of certain drugs, but did not deny their utility.
Dr. Luff is an able chemist; he was a teacher of
chemistry before he was a medical student, and nat-
urally brings his special knowledge to work on clin-
ical material now that he is a hospital physician.
His present paper is on the bearing of the gelatinous
form of sodium biurate on gout. He holds, as did
Roberts, that the deposition of quadriurate, at first
gelatinous in form, becomes crystalline and almost
insoluble, thus setting up a gouty paroxysm. If the
change from gelatinous to crystalline form can be de-
layed, the gouty attack can be postponed. Now the
conversion is accelerated by sodium bicarbonate but
delayed by potassium bicarbonate, which also retards
the process after it has started. Lithium does not
delay the initial change, though it retards it when
started. Piperazin does not delay tiie initial conver-
sion, though it slightly retards it when started.
Lysidin delays the initial conversion, but when once
started has no effect. Thus it would seem that the
potassium salt is best, and the lithia next, while
piperazin and lysidin are inferior; and these results
accord with Dr. Luft's clinical experience. Not that
he would gauge the value of alkaline salts solely by
their solvent action on deposits of sodium biurate, or
by their inhibitory action on the conversion of gelat-
inous into crystalline forms of biurate. He admits
they may be useful by stimulating metabolism, acting
on the stomach, liver, and kidneys and reducing the
acidity of the urine. An important fact which Dr.
Luff claims to have established is that the higher the
alkalinity of the blood from sodium bicarbonate the
more rapid and the more complete is the conversion
of the soluble gelatinous into the comparatively in-
soluble crystalline biurate. He holds that the alka-
linity of the blood in gouty patients is higher than
normal. In the blood of healthy adults he found an
average of 0.185 per cent, of sodium carbonate, and in
the gouty this rose to 0.217 P'^'' cent., an increase of
nearly one-third. It would seem therefore that we
must dismiss the notion of an "acid dyscrasia." The
inference from all the experiments is that increased
alkalinity determines the gouty paroxysm.
April 28, 1900]
MEDICAL RECORD.
743
The second paper was by Dr. Bain, of Harrogate.
He related observations made to determine the varia-
tions in nitrogenous elimination in a case of gout
under ordinary conditions, and the effect of diet and
drugs. After sodium salicylate a slight increase of
uric acid was noted, but under guaiacum there was a
marked increase of this acid, and vegetable diet also
increased it. Iodide of potassium increased both uric
acid and urea. Referring to Minkowski's e.xperiments
it was suggested that one or more of the alloxur bases
might be concerned in the evolution of gout; for one
of these bases, adeiiin, had been followed by violent
action of the heart, vomiting, increased blood pressure,
while the urine contained leucocytes, albumin, casts,
and epithelial cells. Post-mortem crystals of biurate
were found in the renal tubules. Uric acid does
not produce such effects and possibly may be rele-
gated to a secondary place as a cause of gout.
Dr. Sims Woodhead and Mr. J. \V. Ware described
to the Society of Engineers on Monday the plan they
had adopted todisinfect the water-mains at Maidstone
after the typhoid epidemic three years ago. On a
Saturday night the water-service was shut off except
from a small portion reserved to be treated separately.
Chloride of lime was mixed with the water in the
reservoirs and forced through the mains until the flow
from the house taps became milky. Then the mains
were emptied with five engines, the reservoirs thor-
oughly cleansed, and pure water was then sent through
the whole service. The work occupied twelve hours,
the mains being sixteen and three-quarter miles long,
with a capacity of one hundred and eight thousand
gallons.
Dr. St. George Mivart died on Sunday, aged seventy-
two years. His "Genesis of Species" controverted
Darwinian views, and he kept a close hold on the at-
tention of a large section of scientists by his bio-
logical and other contributions to literature. He
joined the Roman Catholic Church in 1884, but his
independence of view in treating scientific questions
offended the priestly party, and about two months ago
Cardinal Vaughan peremptorily ordered him to sign a
confession of faith. On his declining to obey the car-
dinal served his clergy with orders to refuse the sac-
raments to the aged invalid scientist, who thus suffered
all the persecution that the Roman Church can inflict
on her adherents in this age and country.
Dr. Dickson, who has been physician to the British
embassy at Constantinople since 1856, died on Tues-
day, the 27th inst., at an advanced age.
Dr. H. C. Jackson, of the Uganda service, suc-
cumbed to fever on February i6th in his thirtieth
year. He had achieved a considerable position by
his work in the Protectorate.
The death is also announced of His Excellency R.
H. Gunning, M.D., LL.D., Edinburgh, Grand Digni-
tary of the Order of the Rose of Brazil. He founded
eleven Victoria Jubilee prizes in Edinburgh Uni-
versity and the Cullen scholarship of the College of
I'hysicians. Of late years he was quite blind, but
bore his affliction bravely and took the greatest inter-
est in scientific progress and current news. He died
on the 22d ult., aged eighty-one years.
Hernia in Children — Operation is advised (1) in
children over four years of age in whom a truss has
been given a fair trial without marked improvement.
(2) In cases complicated with fluid in the hernial sac
(reducible hydrocele) ; in all cases of femoral hernia,
since this form of hernia offers little or no hope of
cure through mechanical treatment. The practice of
operating upon infants under one year of age or even
two or three years is, I believe, open to serious criti-
cism,— W. B. COLEV,
LETTER FROM CONSTANTINOPLE.
(From our Special Correspondent.)
TURKISH MEDICAL SCHOOLS — REFORM IN PUBLIC
HEALTH ADMINISTRATION — DEATH OF DR. DICKSON.
There are three medical teaching establishments
in Turkey, one at Constantinople, " The Imperial
Faculty of Medicine," Turkish; and two at Beyroot
in Syria, American and French. Recently a dele-
gation from the Imperial Faculty of Medicine of Con-
stantinople was sent to Beyroot to assist at examina-
tions for the doctorate of the French school. This
delegation was presided over by Haireddin Pacha,
and it is understood that his excellency, on his re-
turn, has presented a report in favor of establishing
an Ottoman school of medicine at Damascus or Bey-
root (probably Damascus), for the consideration of
the minister of public instruction.
The medical teaching at the American college is
simply an outcome of the general progress of the
course of education, and is admitted to be good. It
has sent forth some fairly well-trained men, who,
though holding the diploma of the school, must pass
an examination at the Imperial Faculty of Medicine
before being permitted to practise; as must also all
foreigners. The French Medical College is of more
recent date, and doubtless the teaching is on a level
with that of the American. This projected medical
school at Damascus may possibly be associated with
certain other projects of reform being carried out in
the medical service of the empire, if it be not inspired
by jealousy and as a set-off against the other schools.
Otherwise there would appear to be an overlapping
of medical institutions.
The medical school of Constantinople was estab-
lished in the reign of Sultan Mahmoud, 1838 or 1840,
under Austrian administration, and for several years
was successful in turning out a class of medical prac-
titioners superior to the barber-surgeons of the day.
Difficulties, however, arose about the teaching. Con-
fusion of tongues and want of text-books in the Turk-
ish language, religious feelings, which discouraged
dissection of the dead, had to be taken into considera-
tion. Hence, for a time, the scheme for improved
medical teaching languished, though it was continued
on the improved basis until the present day.
Like most Turkish institutions, the school had a bril-
liant short period, then a lapse of indifferent regime,
reformation, reconstruction, and so on periodically;
depending upon the amount of imperial support and
the solicitude of the army direction. Although the
school may not have given the results expected by its
founders, yet it has provided a better class of army
and navy doctors, which was the original intention.
Located at first in Galata-Serail, it was liberally
provided with library, museums, horticultural garden,
amphitheatre, and anatomical cabinet, and being the
first scientific institution of the country, it became an
object of great solicitude to the sovereign. In 1848
Galata-Serail was burned down and all its scientific
riches perished. The school took refuge in a build-
ing in the Golden Horn, and for a period of seventeen
years was almost forgotten, though its work was
continued. Then again a revival, and progress, until
the time it was transformed into a faculty, with very
considerable powers. During the past ten or tw-elve
years there has been a steady improvement in the
teaching of the faculty, and as many of the students
were sent to the higher continental schools of medi-
cine a certain number of good class surgeons and
physicians have been produced.
It is now proposed further to extend and improve
the medical teaching, especially in relation to the
army and navy, and an extensive and imposing army
medical school, with modern improvements and ap-
744
MEDICAL RECORD.
[April 28, I goo
pliances, is in course of construction (nearly finished i
at Haidar Pacha on the Asiatic shores of the Bos-
porus. To this will be added a bacteriological in-
stitute, an antirabic establishment, etc. The re-
forming process has been entrusted to Dr. Rieder
Pacha, a German officer in the Turkish service. It
includes a course of German, botany, chemistry,
physics, and natural history, and apparently it is in-
tended to use German as the medium of teaching, for
in the instructions it is stated, " As there exist many
works on medicine in German, the administration of
the military schools is enjoined to give particular care
to the study of that language." The pupils of the
faculty of medicine will, after two years, attend the
Haidar Pacha school. The scheme presupposes a
preparatory school, which already exists and is in-
cluded in the reforms.
It will be interesting to watch the progress of the
new departure, in which his imperial majesty the
Sultan takes deep interest, as indeed he does in all
matters of education. There will be certain difficulties
to overcome, as of old. The selection of a foreign
language as the medium of teaching is an important
one, as former experience has shown, and one cannot
but think that the natives of a country would be better
taught in their own tongue, and so be more in touch
with their teachers.
In matters of public health also, Turkey is in a
spasm of reform; new regulations of the Council of
State, sanctioned by Imperial irade, have been pro-
mulgated with regard to the examination of foods,
drinks, chemical and pharmaceutical specialties. A
chemical laboratory is to be established at the custom
house, at which five chemists and two doctors are
ordered to be on service. Of the twenty-four articles
of the regulation, those applicable to drugs may be
quoted: "The following specialties, the use of which
are recognized as hurtful, i.e., cocaine and its com-
pounds, sulphonal, anti-tuberculous serum of Dr.
Koch, picrotoxin of Gneiss — that is to say, specialties
prepared from haschish — are prohibited. The entry
of articles such as chlorate of potassium, nitrate of
sodium, nitrate of potassium, chlorate of sodium, and
picrates, is forbidden, and they w^ll be confiscated.
"The following drugs comprised among the articles
prohibited, but of which the use in medicine is oblig-
atory, such as chlorates of potassium and sodium,
etc., will be furnished through the agency of the grand
master of artillery at their original prices, and in
quantities fixed by the Imperial School of Medicine
for each pharmacy and each ahtar (druggist).
"However, the entry of pastilles of chlorate of
potassium and other analogous preparations, in form
of specialties, which cannot be employed for the
preparation of explosives, is permitted."
It is also proposed to create a bacteriological es-
tablishment at the international health board, with a
highly paid professor — a somewhat costly scientific
luxury — the purpose of which is not very evident.
These and other regulations of municipal hygiene of
the most elaborate character are the order of the day.
But — and alas! — they are likely to be paper plausi-
bilities, inasmuch as they are costly in practice, and
money is not now an abundant article in Turkey.
A notable presence in the medical profession has
passed away. Dr. E. D. Dickson, physician to the
British embassy, and British delegate at the Ottoman
health council, died yesterday. A highly educated
and courteous gentleman of the old school, an ac-
complished physician, an excellent linguist in Kast-
ern and Western tongues, a charming raconteur, he
was esteemed by all classes. He had reached the ripe
age of eighty-seven years. He was well known for
his genial courtesy to his .\merican colleagues who
visited Constantinople.
THE USE OF ARSENIC, ETC., IN CANCER-
OUS AND OTHER MALIGNANT NEO-
PLASMS.
Me
Re
Sir: In a recent article by my friend and colleague.
Dr. A. R. Robinson, of New York, appearing in the
Medical Record of March 31, 1900, entitled, "Ob-
servations on the Treatment of Cancer," I am promi-
nently mentioned as favoring the internal use of ar-
senic in all cases of cancer — an assertion which, while
it does not misstate facts, it being unqualified, leaves
my position open to the inference that I rely upon the
internal use of this remedy alone, to the exclusion of
other and more radical primary surgical procedures.
So far is this from being so, that I wish to say right
here, that I can unhesitatingly indorse the author's
valuable paper in its premises, tenor, and conclusions
(all of the latter save one), and in his criticisms on
those who are inclined to rely on the knife, and that
alone, for relief or cure of those maladies. I will also
add that as a medical contemporary of the doctor I be-
lieve I have as long, as earnestly, though probably not
so ably as himself, used, advocated, and defended the
employment of escharotics in the treatment of these
malignant tumors, as my colleagues of the American
and New York dermatological societies can testify, in
the many years of my membership.
It may be as well to say now that the caustic I have
used most and which is my chief reliance at present is
the acid nitrate of mercury (fifty-per-cent. solution).
I employ it for the exact reasons which Dr. Robinson
claims for his arsenical pastes, viz., first, as to its
having in my belief a certain elective, destructive ac-
tivity on the pathological tissue, far beyond the sphere
of its escharotic action ; and also, second, to my mind
a greater facility in handling; and third, its easy man-
agement by those having any experience as to its rapid-
ity and extent of destruction of tissue, etc.
As a preliminary to application of this caustic I use
either knife, or curved scissors, or curette to take away
the redundant mass of the tumor or fungating ulcer,
etc. ; usually, however, much preferring the curette
energetically employed. Then after mopping the tis-
sues needing it with a twisted pledget of cotton dipped
in the fluid once, twice, or many times, according to
circumstances, I allow it to remain any length of
time from five to thirty minutes; this is where experi-
ence and frequency of this operative method naturally
come in; after such time I neutralize with bicarbon-
ate of sodium, leaving a layer of that salt on as a dress-
ing. Nothing further then remains to be done except
to await the falling of the blackened dry eschar,-
occurring at any time from eight to fifteen days,
which leaves ordinarily an almost healed or quickly
healing surface to be treated as any other open wound.
I think Dr. Robinson will excuse me if I here make
a transcript of his conclusions, six in number, given at
the finish of his valuable paper, the whole of which,
excepting absolutely No. i, I look upon as aphorisms.
My experience and reasons as stated allow me at least
to question the accuracy of the first:
"Conclusions. — i. At present we know of no drug,
animal extract, serum, or toxin, which, given inter-
nally by any avenue of the body, can be relied upon
for the cure of cancer of any part of the system.
"2. That the statement that the knife is the only
reliable agent in the treatment of cancer is not cor-
rect.
" 3. That certain caustics judiciously chosen and
properly applied may attack deposits of the growth in-
accessible to the knife, and in these cases should be
employed even if the knife is necessary to prepare the
way for their use.
"4. That in some ca.ses both the knife and caustics
April 28, I goo]
MEDICAL RECORD.
745
should be used, and in some other cases curettage, fol-
lowed by a caustic, is the proper procedure.
"5. That the > lajorit)' of cases of cutaneous cancer
can be removed with the greatest certainty and with
least deformity by caustics, provided the patients are
seen before the lymphatic glands are invaded.
"6. That the knife should be used when the lym-
phatic glands are invaded, and also in some other
cases of external cancer."
The doctor's destructive agent is, as will be noted,
an arsenical preparation, and he speaks (p. 538) "of
its specially selective antagonistic action on the epi-
thelia in this disease." I believe this proposition
he states as being unquestionably a fact; but how,
then, is he to escape the rational inference that arsenic
administered internally would not have in a certain
degree the same, though perhaps lessened and modi-
fied, action? I do, as aforesaid, so believe, and in the
short bibliography of my own papers annexed would
point to proof of its action not alone on epithelial
structures, but also on those of the kako-plastic, non-
viable fibrous neoplasms we call sarcomas. I am not
unmindful either of the destructive action of inflamma-
tion on these errant and aberrant cells, and believe it
to be great and beneficial, therein excelling the knife;
but must insist that the preparation I use acts in much
the same way as his, and I think with at least equal
power, as it is not only absorbed from the raw surface
to which it is applied, but finds its way along the
lymph channels of the adjacent skin. It is a com-
mon occurrence with me to see slight ptyalism re-
sult under my method of treatment in wounds of
less than a fifty-cent piece in area, and this is some-
times quite severe in cases of a larger circumference
— a thing itself, however, that never causes me the
least anxiety, and, from the very nature of things, it
quickly subsides.
I begin to give arsenic, usually Fowler's solution
(sometimes one-fifth of the quantity given will be
Donovan's), the second or third day after operation;
I do not want to bother the patient too much at the
time. The pain of the operation is generally severe at
first, but can be modified and subdued by the usual
mearis (too long and commonplace to treat of here),
but my method, as it seems to me, has this advantage
over the arsenical pastes, that the pain in my procedure
is greatest at first contact, then gradually lessens, which
I think is entirely the reverse in the use of the pastes;
at least it has been so in my employment of them.
One more criticism of this paper which I so much
admire, and I have done; and that is this. When I
have cooked the seat of tiie affected tissues sufficiently
I can leave the patient, knowing that beyond a result-
ant irritant inflammation of that and the near sur-
rounding tissues, which inflammation, by the way, I
have never found dangerous, I have finished. It does
not seem to be so with these pastes, however benefi-
cently they may act otherwise. This fact may be due
to idiosyncrasy, peculiar susceptibility of tissue, or
what not; but the fact remains that in using the same
paste, one which will in one patient hardly cause any-
thing but a superficial eschar will in another case
cause gangrene of tissue of the highest grade, and
therefore needs, as the doctor says, careful and dili-
gent watching.
One bad result of an arsenical application will al-
ways remain in my mind; it was applied by a past
master of this form of treatment, and one I know to be
very successful ordinarily ; it caused excessive destruc-
tion of tissue in a most unfortunate location, and yet
the patient had obeyed instructions an pied de la lettrc,
the excessive and increasing agony only leading to re-
moval of the applied plaster an hour or little more
before instruction to do so. I have also seen pastes
apparently penetrate unbroken and seemingly at least
sound epithelium, almost or quite as readily as tis-
sues that were evidently disorganized.
The second, third, and fourth clauses in Dr. Robin-
son's conclusions I believe to be eminently sound and
true, at least in proper hands; as to the fifth I am
equally certain. There are many points he brings out
in support which I will not touch upon; but to one,
not usually considered, I must refer, agreeing with
him as I do — and that is, that the occurrence of a fair
amount of granulation tissue after a procedure like his
and mine tends to improve the cosmetic effect by ren-
dering the depression less marked; and that ordinarily
about the face in particular the resultant effect is ex-
tremely good. It is astonishing often to see the slight
scar deformity where one would have expected under
any procedure to have had great disfigurement. As
to clause No. 6, I here again agree with him in gender,
number, and case. Certain tumors, perhaps most of
those of the lips, penis, and ears, may and can be
most efiiciently treated by the knife, or combination
of methods.
I may add in conclusion that I operate and have
done so in hospital and private practice fairly fre-
quently; my cases must, I think, run into the hundreds
now. Since commencing tiiis paper two or three days
ago I have operated three times on epitheliomas of the
face, in the persons of two men and one woman ; the
woman and one man are aged about sixty years respec-
tively, the other man about eighty. The woman's le-
sion was on the forehead, that of the younger man on
the left ala of the nose. In neither of these cases do
I have any fear of recurrence at any future time.
They will be put upon the usual internal treatment.
In the case of the older man I am decidedly of the
opinion that while the disease will probably not recur at
the site of that particular point operated upon, appear-
ance may be looked for at others. He was operated
on once before, and his is a curious and interesting
case from other points of view. He has been under
my observation now nearly a year, and I consider him
to have not only a cancerous but a general diathetic
degenerate condition ; that he is in fact a senile degen-
erate. On his first appearance at the hospital his face
and forehead were found to be studded with large ex-
crescences of verrucje latas seborrhceica, that common
sign of senile degeneration of skin; there was also an
epithelioma on the cheek, the object of the first
operation ; and besides these he had two or three subcu-
taneous tumors, as large as horse-chestnuts, on and
over the right shoulder blade and on the ridge of the
shoulder itself. These lumps were all to a small ex-
tent movable under the skin, and were pronounced by
all medical men who examined him as being in all
probability sarcomatous tumors. They interfered with
his freedom of arm motion and were painful to touch.
He vi'as put under large and increasing dosage of ar
senic. Under that treatment these tumors in a few
weeks completely disappeared, and have not since re-
curred. His movements, save for age-stiffness, are as
free as they have ever been; his face has cleared up
greatly, and complexion freshened. No history of
syphilis, no subjective or objective symptoms were
obtainable. I think it extremely likely that in this
particular case other manifestations of malignant pre-
disposition will occur; as I have stated, he is the sub-
ject of senile degeneration as to the tissues, and noth-
ing but the results of this state can be expected.
I have had other cases of multiple sarcoma in >vhich
some of the tumors have been by competent authorities
examined after excision, so that no possible doubt
could exist as to their nature, in which the same treat-
ment has been used with equally good and very much
more surprising results, t will not further speak of it
here, but reference will be found noted at the foot of
page 746, to which publications I would refer anyone
746
MEDICAL RECORD.
fApril 28, 1900
interested in the subject.' Kobner's and Funk's writ-
ings, and perliaps experience, antedate my own in this
connection with sarcoma. I do not claim originality by
any means; several of the older writers have recorded
experiences in connection with epitheliomatous growths
with similar treatment and favorable result; and I am
inclined to think still, in spite of the dictum of the
doctor and others, that its usefulness will at some day
in the near future be recognized. As to reasons for its
inhibitory and relatively curative action I am past the-
orizing. I simply recognize, as I think, the fact and
let it end there (there is a temptation to quote Goethe
here, but I will resist). Certainly, however, arsenic
has great power in some of the keratoses and affec-
tions of the epithelial strata of the skin; this is a
well -recognized fact in dermatology, as it is a fact
also that some skins are more recalcitrant and less
affected by it than others. Another claim that it has
great action also on the fibrous tissues, at least in
those in which a morbid state is present, cannot, I
think, well be controverted. In what peculiar way or
means it furnishes its power, whether by formation or
antagonism of varying toxins, etc., I have not the re-
motest idea; my only comprehension lies in observa-
tion of a clinical fact. The same may be said about
mercurials and their action on the economy. I do not
believe any one can give me absolute and unqualified
instruction thereon. From Rokitansky to Koch, and
later, I have seen pathology twirled like a shuttle-
cock, and am content to wait, but not to expect during
my life a final decision on many of these moot points.
At the commencement of this explanatory paper I
had not intended to make it so long, and perhaps dif-
fuse, but I cannot now resist the inclination and op-
portunity of adding a few words in general advocacy
of the caustic agent I employ, and place such reliance
on, in other affections of the skin — to wit, " acid ni-
trate of mercury." In leucoplasic growths on the lips,
buccal mucous membranes, etc., I use it with great ad-
vantage, as can be certified by members of the New-
York Dermatological Society. My method in these
cases is first to protect the normal mucous membranes
and mouth in toto, by packing with absorbent cotton,
then applying the solution in full strength to the parts
affected, and, when I am satisfied that sufficient escha-
rotic action is obtained, neutralizing as usual with
bicarbonate of sodium in substance and solution.
In cases of the little teleangiectases (so-called spi-
der cancers) of the face and other parts of the body, I
find that the point of a toothpick dipped into the so-
lution, and pricked into the centre of the arborescent
lesion, is, from the adhesive inflammation it causes,
much more effective than, we will say, the touching
with the galvano-cautery point so often employed in
these cases.
One last word. In an able review of the modern
varieties of treatment of lupus, by Dr. McLeod," enti-
tled " Observations on Some of the More Recent Meth-
ods of Treating Lupus Vulgaris," he mentions and
extols Ur. Unna's latest mode, consisting of soaking a
number of small wooden pegs in a mixture of the solu-
tions of acid nitrate of mercury and carbolic acid,
boring these into the nodules of the lupus growths,
then cutting the ends off just above the niveau of skin,
and allowing the rest to remain. Now, for the life of
me, I cannot understand wherein the advantage lies of
' " Remarks on, and Queries as to Relative Frequency of Patho-
logical Changes in Moles and Other Tumors on Face and Head. '
Journal of Cutaneous and Genito- Urinary Diseases, vol. v.,
January, 1SS7. — ".Multiple Sarcomata: History of a Case
Showing Modification and Amelioration of Symptoms under
Large Doses of Arsenic." The American Journal of the Medical
Sciences, October, 1892. — Remarks in Transactions of the
'American Dermatological Association, Twenty-third Annual
Meeting, 1S99.
■' British Journal of Dermatology, vol. xi., 1899, p. 341.
making a human being a sort of hedgehog, instead of
curetting at once and applying the remedy more di-
rectly, which has been my ordinary method for many
years, and a fairly successful one; so much so that I
can hardly understand the jeremiads of many better
men over their acknowledged almost total failure in
the treatment of this class of cases.
I am bound as freely to admit that recurrence
more often happens in them than in any of the other
classes mentioned; as to the reasons for this, whether
owing to the extent and greater diffusion of lesion, the
almost consequent lighter curettage and application,
etc., I confess that I am not altogether clear, but suc-
cess certainly is very frequent.
S. Sherwell, M.D.
33 SCHEB.MERHORN STKEET, BROOKLYN, N. V.
HOSPITAL SURGICAL SERVICE CONDUCTED
BY A SINGLE CHIEF.
Sir: In a fitting encomium of the services rendered
by Dr. McBurney to the Roosevelt Hospital, in the
editorial pages of your issue of April 14, 1899, atten-
tion is directed to the demonstration he has afforded
of the practicability and feasibility of a large hospital
surgical service being conducted by a single chief.
I would like to call attention to a similar demon-
stration, afforded by Dr. A. G. Gerster, at the Mount
Sinai Hospital of this city, where for three years, from
December i, 1896, to December i, 1899, he, with the
aid of two adjunct surgeons (Drs. Lilienthal and Van
Arsdale) conducted and directed a most active sur-
gical service of seventy beds.
A. A. Berg, M.D.
774 Madison Avenue.
THE STATIC INDUCED CURRENT.
To THE Editor of the Medical Record.
Sir: I have examined the references kindly furnished
by Dr. E. L. Squire in your issue of March 31, 1900,
concerning the above subject, and find that they
have not the slightest relation to it. I have carefully
read the quotation from Beck's Murray, " A System of
Materia Medica and Pharmacy," published in 1828,
vol. ii., p. 240, and find (as appears by Dr. Squire's
quotation) merely the usual classical description of
the medical applications of statical electricity, with
no allusion to currents of any sort. The reference
therefore, however interesting, has no bearing upon
the discussion in question, and I am at a loss to ac-
count for its being adduced on any reasonable basis.
Dr. Squire's second reference is to " Braithwaite's
Retrospect," 1845, part xi., p. 33. The article (really
on pages 29 and 30) is taken from the Alfdico-Clii-
rxirgiciil Review, vol. i., p. 319, published in 1845.
This Medico-Cliirurgical Review article in turn is
based upon an article by MM. Longet and Ch. Mat-
teucci, "Upon the Connection between the Direction
of the Electric Current and the Muscular Contractions
Excited by that Current " (translation), published in
the Comptes roidits de f'Academie des Sciences of Sep-
tember 9, 1844, and upon the electrophysiological
work of C. Matteucci. Turning to the above and to
" I^e(;ons sur les Ph^nomenes Physiques des Corps
Vivants, par C. Matteucci," p. 255, published in Paris,
1847, "'6 ^^ '^s*^ gst 3t the true reference, which is
(translated): "A current which circulates by jerks in
an animal during a certain time produces tetanic con-
vulsions; the direct current, if continued sufficiently
long, produces, on the contrary, paralysis."
At this point our researches come to a sudden
April 28, 1900]
MEDICAL RECORD.
747
termination, not witli an electric, but with a moral
shock, for in reading over the articles referred to we
find that Matteucci's investigations relate only to
interrupted galvanic currents and not even remotely to
statical electricity. And w^e find that the writer in
the Aledico-Chirurgical Review quoted does nol use
the term "static induced current," which in Dr.
Squire's quotation is included within his quotation
marks as if the original writer had so used it. It is,
therefore, evident that Dr. 'Squire's juxtaposition of
quotations, at one point referring to the common
statical electrizations and at another to the common
galvanic electrizations, and at no point referring to
the static induced or any similar current, is more
ingenious than it is ingenuous.
It goes without saying that an interrupted galvanic
current produces, and always did produce, tetanic con-
tractions, but what I said, before any one else said it,
was that currents were derived from electrostatical
machines by setting up a spark gap, independent of
the patient but in the same circuit. I have yet seen no
reason, nor can I believe any impartial observer sees
any, to cause me to withdraw this claim.
WiLLiA.M J. Morton, M.D.
April 10, igoo.
|lfiXedicat Items.
Bloodletting versus Leeches.— In an article on the
treatment of pneumonia in the Revista Ibero-Ameri-
cana de Ciencias Medicas for December, 1899, Dr.
Rubio says that a more marked and more prolonged
anaemic condition follows the loss of blood by leeches
than by phlebotomy. The abstraction of thirty-two or
more ounces by phlebotomy produces less pallor and
causes less weakness than does the loss of eight
ounces of blood sucked by leeches. This difference is
especially marked in children. He explains the
anaemia following the application of leeches by the
presence of a blood poison in the leech in consequence
of which the blood remaining in the body is vitiated.
Professional leech catchers, men who wade bare-
legged into places where leeches breed, rapidly acquire
a peculiar cachectic appearance, which is not due to
the loss of blood, for they remove the animals immedi-
ately they attach themselves, before an appreciable
amount of blood has been lost.
Hospital Train for South Africa. — A hospital train
for South Africa is being built at Birmingham, Eng-
land. The following is a description of the train
given in an English weekly journal : " After several
unsuccessful attempts to purchase and adapt carriages
which were being built for the South African Railway,
and were required for army purposes, the central
British Red Cross committee voted a sum of money
for the building and equipping of a complete hospital
train. The borough of Windsor having contributed a
sum of ^6,ioo ($30,500) to which Princess Christian
added ^£,650 ($3,250), the balance of a Red Cross
fund which was invested in her Royal Highness's
name after the Soudan campaign of 1885, and several
other donations having been made, including ^200
($1,000) from the Worcester committee and one of
;^5o ($250) from Canada, it was only natural that the
wish expressed by the Royal borough that the train
should be named ' Princess Christian,' should be car-
ried out. The train consists of seven bogie ' cor-
ridor ' carriages, each about thirty-six feet in length
and eight feet in width, the passage through the centre
being continuous. No. i is divided into three com-
partments for linen and other stores, for two invalid
r^fficers, and for two nurses respectively. The second
carriage is also divided into three compartments —
namely, for two medical officers, a dining-room, and a
surgery. Nos. 3, 4, 5, and 6 are each constructed to
carry eigliteen invalids and four hospital orderlies.
It is here that the greatest difficulty was experienced,
owing to the line being of narrow gauge and the space
being consequently so very limited. The beds have
been necessarily placed in three tiers, and any person
accustomed to the lifting and moving of invalids can
understand how difficult it is to place a helpless
patient sideways on a bed closed on all sides but one,
from a gangway two feet six inches in width, in which
there is only room for one bearer at the head of the
stretcher and one at the foot. This difficulty has been
overcome by an arrangement of pulleys in the roof
which enables each bed with a patient on it to be
raised to the proper level by one man, while the hands
of the two bearers are thus left free to guide and fix it
in position. Each carriage is provided with a stove,
a lavatory, and necessary storing lockers. No. 7 con-
tains the kitchen and pantry, including berths for two,
cooks and a compartment between for the guard.
There are perfect hygienic appliances for cooking,
several large cisterns containing cold-water storage,
two large filters, refrigerator, and in fact everything
necessary for ninety-seven persons, even if they had to
live on the train for two or three weeks. Many little
luxuries have been added by Princess Christian and
all the members of the Royal family, including the
Queen, who has sent some thick, warm blankets."
The Frisch Bacilli in Nasal and Oral Mucous
Membranes. — Simoni {CentralbkUt fi'tr Bakteiiologii,
Nos. 18, 19, 1899)' declares that he has long had
doubts, after studying recent literature on the sub-
ject, whether rhinoscleroma is contagious or not, and
whether the Frisch bacillus is really the specific etio-
logical factor of this disease which it has been claimed
to be. He has found in the secretions of ozaena en-
capsulated bacilli which could be isolated and which
were identical with those .seen in rhinoscleroma. He
now cites an extended experience of seventy-six cases,
of which fifty-eight were human beings, all suffering
from nose affections, while the remaining eighteen
were animals with acute and chronic catarrhal nasal
conditions. From these cases and from the nasal
mucus of healthy persons, the author made gelatin and
agar cultures. After thorough and painstaking inves-
tigation he comes to the conclusion that the Frisch
bacillus and the Friedlander pneumobacillus are mere-
ly varieties of the same species widely distributed in
nature, the extremes of which may be seen in the Frisch
bacillus on the one hand and the Lowenberg-Abel ba-
cillus (Bacillus mucosus) on the other. Besides this,
Simoni proves that these bacilli are found in the nasal
mucous membrane at the site of minor injuries, and are
almost always present in the mucous membrane of ani-
mals. He also declares that Frisch bacillus is a fre-
quent and innocent guest of both the nasal and laryn-
geal cavities.
Leeches and Bedbugs as Germ-Carriers. — In his
experiments, Muhling {Centralblatt fiii- Bakteriologie,
No. 20, 1899) used the bacillus of anthrax and proved
the existence of an internal infection of anthrax in
bedbugs which had fed on the blood of mice likewise
affected. Furthermore, a horde of bacteria settled on
bugs which had been allowed to wander over the re-
mains of mice infected with anthrax. The infected
bugs had present in their intestinal canal virulent an-
thrax bacilli which finally passed away unchanged in
the faeces. Muhling does not state that he experi-
mented further with the view of ascertaining whether
or not any virulence remained with these bacilli voided,
in the faeces. The bugs, however, were not visibly af-
748
MEDICAL RECORD.
[April 28, 1900
fected by the bacillus anthracis, which fact the author
proves by stating that he kept such a bug alive and
under observation for six weeks. The bite of such an
infected bedbug upon a mouse was without result.
However, if, while sucking at the wound, the bug was
crushed with a sterile glass rod, and rubbed therewith
over the surface of the wound, thereby insuring the
freeing of the intestinal contents and simultaneously
of the contained anthrax bacilli, there was obtained
in every single case as a result the infection of the
mouse. The author believes that the bedbug only
sucks blood from its victim, and that no germs can
escape from it to its host in the process (.-'). Leeches
are very similar to bedbugs in these respects. Thus,
they do not succumb to anthrax. Miihling declares
that he kept such an infected leech living for three
months. On the other hand, however, the anthrax germs,
after having been taken up by the leech, die in that
animal's intestinal canal after so short a period as a
single day. The author did not satisfy himself as to
the reason for this. Miihling concludes that even
though it should accidentally happen that the germs
attached to the external surface of the leech find their
way into the wound, they would be sucked up by the
leech in the process of blood-transfer, and therefore
that parasite could be used therapeutically without any
danger of infecting its host, on both man and animal.
Osteopathy has at last invaded the metropolis. The
first practitioner to make himself known here is out in
.1 circular telling of the many things he is capable of
.iccomplishing. It begins: " I, as an osteopathist, do
not advocate the use of drugs." He appeals to the
medical profession to send him cases. The strange
part of it is that some of its members will. However,
he would get them anyway.
Old Specula. --The Bulletin if OcuUstique relates a
story answering the query, " What becomes of the old
speculum? " A physician happening to enter the kit-
chen in a country hotel saw a brightly polished bivalve
hanging among the cooking utensils, and upon inquiry
learned that it was used by the cook for moulding sau-
sages. The proprietor had bought it at an auction of
second-hand household eflfects.
Alcoholism in the United States Army. — During
the calendar year 1898, 707 cases of alcoholism were
reported as having been under medical treatment in
the regular army. Ten of the cases had a fatal ending.
These cases gave for the year an admission rate of
15.16 per thousand of strengtii. This rate compares
favorably with the rate in 1897, 27.86, and the mean
annual rate of the previous decade, 36.90. These rates
do not represent the amount of intemperance existing
in the army or in any of its parts, but as they are all
calculated from similar data, to wit, the number of
cases in which medical assistance was invoked to avert
danger, they are useful for purposes of comparison.
The rates of admission in 1898 were highest during
the first three months of the year, when the troops
were in garrison under conditions of peace. They
w-ere lowest during the period of active field service.
May to August inclusive. In Cuba drunkenness was
measured by an annual admission rate of only 0.52
per thousand of strength, while in Puerto Rico a rate
of 18.65 ^3s associated with 2.07 deaths in every thou-
sand men. In the Philippines the facility with which
alcoholic liquors could be procured resulted in a rate
of 21.70, but this rate was somewhat exceeded in the
artillery arm of the service in garrison in the United
States. During the past year as in previous years the
colored troops had a lower rate, 4.81, than the white
tK)ops, 15.96. — Report 0/ the Surgeon- General oj the
United States Army.
Good Stomach, one of the Sioux Indians now ex-
hibiting in Paris, will have to change his name.
French brandy proved too strong for his gastric diges-
tion, and he was arrested the other day for going on
the warpath in the French capital.
Gonorrhoea of the Stomach. — Dr. J. H. Oyster, of
Paola, Kan., writes to the Medical World for the best
treatment in gonorrhoea of the stomach. He has a
patient so affected for five years, due to extension from
the mouth.
"La Fecondite."— The Gazette Medicale de Paris
takes exception to the statements made by Monsieur
Zola in his recent novel relative to the gart played by
reputable surgeons in the depopulation of France. It
is admitted that many women have their generative
organs unnecessarily mutilated, and that many do so by
choice, so as not to bear children ; but the Gazette claims
that all this criminal work is done by unscrupulous
members of the profession, who are generally known
and also generally detested.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended April 20,
1900 :
Cases. Deaths.
Smallpox — United States.
Alabama, Mobile April 7th to 14th i
District <Jf Columbia, Wash-
ington April 7th to 14th t
Florida, Jacksonville April 7th to 14th i
Illinois, Chicago April 7th to 14th i
Indiana. K.vansville April 7th to 14th 4
Kansas. Wichita .April ist to 14th ig
Kentucky, Covington April 7th to 14th 9
Lexington . ... April 7th to 14th 3
Louisiana. N*ew Orleans .\pril 7th to 14th 51 i^
Maine. Portland .April 7th to 14th
Maryland, Baltimore -April 7th to 14th 1
Michigan, Detroit April 7th to 14th 1
Minnesota, Minneapolis April ist to 14th 20
Nebraska, Omaha April 7th to 14th 4
New York, New York April 7th to 14th i i
Ohio, Cleveland -April 7th to 14th 11 2
South Carolina, Greenville- -April 7th to 14th 2
Utah, Salt Lake City April rst to 14th 3
Virginia, Portsmouth -April 7th to 14th i
Washington, Spokane April 7th to 14th 3
Smal
-Fob
> 24th .
Austria, Prague March 17th
Belgium, Antwerp March 24th
Ghent March 24th to 31st . . . .
Brazil. Rio de Janeiro February 23d to March
" nada, Quebec, Bona'
:Co ,
April 5th to i2th 25
March 24th to 3 rst 5
Colombia, Barranquilla
Egypt, Cairo March nth to iStn
England. Liverpool March 24th to 31st
London March 17th to 31st
Gibraltar March 26th to April 1st
Greece, Athens March 24th to 31st
India. Bombay March 6th to 13th
Kurrachee March 4th to nth
Italy, Palermo March 17th to 24th
Mexico, City of Mexico March i8th to April ist
Vera Cruz April ist to 7th
Russia, Moscow March loth to 17th
Riga January ist to 31st
.St. Petersburg March 3d to loth
Warsaw March loth to 17th
Corunna March 24th to 31st
Madrid March i6th to 24th
Valencia March 24th to 31st
Straits Settlements, Singa-
pore February loth to .March 3d .
Yki.low Fbvek.
- February 23d to March 2d
-March 24th to 31st I
-March 27th to -April loth- 3
-March ist to April 17th 2
i ndia, Bombay March 6th to T3th
Plague— Insular Possessions United States.
Philippines, Manila. , ., February 24th to Manh 3d
Plague — Foreign.
India, Bombay March 6th to 13th
Kurrachee March 4th to nth 90
Japan, Formosa, Tamsui .... January 1st to Februarv aStli ... 09
Osaka April i6th Present.
Paraguay, Asuncion February 8th to 15th
Persia, Djiranro March 29th Present.
Medical Record
A Weekly yournal of Medicine and Surgery
'V
Vol. 57, No. i8.
Whole No. 1539-
New York, May 5, 1900.
$5.00 Per Annum.
Single Copies, loc.
©rigitiat Articles.
PERFORATING DUODENAL ULCERS."
By ROBERT F. WEIR, M.D.,
PRBSIDBNT OF THE
The interest that has been lately directed toward the
surgical treatment of gastric perforations has also
been turned to the operative relief of the allied round
or peptic ulcer of the duodenum. This affection is
much rarer than the ulcer of the stomach, is much
more difficult to diagnosticate properly, and is more
apt to be confounded with other more distant surgical
lesions, such as appendicitis, etc.
Site. — Its site is in the upper part of the duodenum,
and according to Morot " and Vonwyl ^ it is always situ-
ated within one and one-half inches of theplyorus;
but Schwartz* gives one case in which the perforation
existed on a level with or a little below the ampulla
of Vater, and thus allowed a free escape of bile into
the peritoneal cavity. The figures given by recent
authorities show that in the two hundred and sixty-two
collected cases of Collin,' the perforation occurred two
hundred and forty-two times within two inches of the
pylorus, in the descending portion fourteen times, in
front of the aorta three times, and in the ascending
portion three times. Or, expressing the same a little
differently, one hundred and sixty-two of the two hun-
dred and sixty-two cases were situated at 2-4 mm.
from the pylorus; seventy-five close to it; four en-
croached on the pylorus itself, and two extended
through the pylorus to the duodenum and to the stom-
ach. Perry and Shaw' found, in one hundred and
forty-one cases of duodenal ulcer, one hundred and
twenty-three in the first part of the duodenum, sixteen
in the second part, and only two in the third part.
Number. — These ulcerations are usually single.
Collin says that one ulcer was found in eighty per
cent, of his cases; two ulcers in eleven per cent.; and
three or four ulcers in four per cent. Morot in twen-
ty-two cases found eighteen had a single ulcer; two,
two ulcers ; one, three ulcers, and one four ulcers.
Location — These perforations are encountered most
frequently on the anterior wall. Oppenheimer''in fif-
teen cases noted that the perforation had taken place
in the anterior wall eleven times, three times pos-
teriorly, and once superiorly. Of the one hundred and
nineteen cases of Collin in which the first portion of
the duodenum was perforated, in sixty-eight it occurred
on the anterior wall of the bowel, in thirty-nine the
posterior wall, in ten the superior, and in one the in-
ferior portion. In eight ulcers perforating in the
second portion of the bowel, five occurred in the inter-
' The presidential address in surgery, delivered before the
American Surgical Association.
'^ These de Paris, iSga.
^ " Ulcer Perforans Duodeni." Th4se de Paris, 1893.
■* Schwartz : " Ulcere perforante du duodenum." Bullet, et
Mem. Soc. de Chirurg. , January, i8g8.
^ These de Paris, 1894.
'Guy's Hospital Reports, 1894.
' " Das Ulcus pepticum duodenale." Thesis, 1891.
nal wall, two in the posterior, and one in the external
wall; and in the ulcers presenting in the third part of
the duodenum, four in number, in three the anterior
and superior walls were involved, and in one the pos-
terior wall. This is of considerable surgical impor-
tance. The anterior perforations are, for obvious
anatomical reasons, less likely to be closed off by
adhesions, and hence a free and rapid involvement of
the peritoneal cavity takes place in the openings here
situated. Reckmann' states that half the cases of duo-
denal ulcer result fatally from perforation into the
peritoneal cavity.
Frequency of Perforation. — Perforation is said to
take place one hundred and eighty one times in Col-
lin's two hundred and sixty-two cases, or in sixty-nine
per cent. ; Chvostek, however, places the frequency
of perforation at about forty-two per cent, of the cases.
In these two hundred and sixty-two cases there was a
generally diffused and fatal peritonitis, one hundred
and twenty-five times. But occasionally in anterior
openings, but more commonly with the perforations
existing elsewhere, adhesions or ulcerations with ab-
scess and hemorrhage of the duodenal wall or adja-
cent organs have been encountered. Examples of
such complicating lesions are subphrenic abscess,
which follows more commonly a perforation m the
superior wall of the horizontal portion of the duode-
num (according to Oppenheimer). Liver and pancre-
atic adhesions are at times met with (Oppenheimer
gives six cases and Collin thirt3'-eight cases of such
adhesions). Perforations into the gall bladder have
been reported, but more important and dangerous are
the ulcerations into the aorta (Stich," two cases), or
the vena porta (Rayer and Habershon, two cases), or
the superior mesenteric vein (Warfinger), or the he-
patic artery (Vonwyl). The ulceration lias been also
known to invade the adjacent colon (Murchison and
Saunderson, two cases).
Sex. — Duodenal perforations are more common in
men than in women ; about seventy-nine per cent., ac-
cording to Collin, are in males. From the tables of
Morot, Kraus, Lebert, and Chvostek I have gathered
one hundred and seventy-six cases of duodenal ulcers,
and of these one hundred and forty-four were in men
and thirty in women.
Cause. — This has been explained by Boas' to be
due to the rougher food, and, in men, to their addic-
tion to alcohol and tobacco, which intensify the acid-
ity of the gastric juice, and thus acts unduly on the
glandular mucous membrane of the duodenum, which
is not protected until the alkaline bile and pancreatic
fluid is poured into the intestine at the opening of
Vater. Koch and Ewald, by giving to animals hy-
drochloric acid, 5:1,000, caused duodenal ulcers to
appear. Pyloric spasm, Talma states, produces necro-
sis and aneemia of the membrane there. On the other
hand, alcoholics are not found to be prone to duodenal
ulcer, and though the spasms and lesions of gastric
hyperacidity, which are now accepted as a causative
of stomach ulcer, will doubtless apply in many in-
stances to the development of a similar duodenal
' Reckmann . " Ulcus duodenale u. seine Diagnose," 1893.
- Deutsch. Arch. f. klin. Med.. 1874.
^ " Diagfnostik u. Therapie der Darmkrankheiten," 1899.
75c>
MtJJlL-AL
damage, there are other causes for duodenal ulceration
to be mentioned beside the foregoing.
Burns. — The principal and best known, though now
somewhat disputed factor in their etiology is the influ-
ence of external burns. Holmes,' for instance, states
that in one hundred and twenty-five cases of burns,
sixteen cases of duodenal ulcer were found; Perry
and Shaw in one hundred and forty-nine cases of
burns met with duodenal ulcers five times; and in
Collin's two hundred and ninety-seven cases of duo-
denal ulcer he states that burns produced the ulcera-
tion in thirty-eight instances. According to Holmes,
the duodenal ulcerations after burns present them-
selves from the seventh to the fourteenth day, but
Ponfick found in one instance a duodenal ulcer within
eighteen hours after the reception of the burn. Curling
also had a case in which s3'mptoms of duodenal ulcer
were recognized one day after the burn, and the autopsy
confirmed the diagnosis.
The explanation most accepted at the present day is
that this complication of a burn is due to septic in-
farctions such as may be developed in frost-bite, of
which Billroth and Adams each cites a case, or in
erysipelas, eight instances, or in tuberculosis (La-
tham). In the cases in which trichinosis (Ebstein),
or heart or kidney disease, or cirrhosis, or hepatic or
other carcinoma (Latham) exists, it is not quite so
easy to trace the connection, though embolism even
here has largely to deal with the question. The recog-
ized explanation offered by Hunter" and often quoted,
seems inadequate to elucidate the relation between a
cutaneous burn and a duodenal ulcer. This observer
proved that in animals treated by injections of to-
luylendiamin the bile was so changed that when dis-
charged into the duodenum ulcerations rapidly devel-
oped. His idea, therefore, was naturally that the
alteration of the cutaneous covering so altered the
bile as to beget the complicating duodenal ulcera-
tions. Unfortunately duodenal ulcers are so rarely
met with on a level with or below the bile discharged
into the bowel, that this at once disposes of the need
of calling on the liver and pancreas as accomplices
in their production. That septic infarction is the
most probable cause of duodenal difficulties after
burns may also be fairly inferred by the later collec-
tion of Lockwood, who, in one hundred and thirty-
eight cases of burns treated with more or less ap-
proach to an antiseptic idea, noted the complication
of duodenal ulcer in but one instance. A cancerous
ulceration is almost unknown ; but four cases (Eichert,
Ewald, Schrotter, and McKenzie) have been recorded.
Frequency A duodenal ulcer is, according to sta-
tistics, a rare lesion. Collin, whom one is compelled
to quote by the worth of his collected cases, in a
range of ten years could find onl}' twenty-six cases.
Houze^ in three additional years could add only three
more cases, though Darras* more than one year later
found five others. Since attention has been given to
the subject, and particularly to the surgical aspect of
it, by the present writer in 1896, when nine cases were
reported as having undergone surgical treatment, there
have been reported fifty-one operations for this dis-
ease.
The relative frequency as a cause of death deduced
from autopsies is as follows :
Willigt .... 1,600 sections with 74 gastric ulcersand 2 duodenal.
Starke 384 " "36 " " "3 "
Crunfeld... 1,150 " "124 " " "4 "
Steine 3,085 " " 89 " " " 12
Vonwyl. .. .12,806 " " 98 " " " 3 "
' " System of Surgery," vol. i., p. 733.
' Hunter : Brit. Med. Journal, vol. i., p. 76, 1S90.
' " De I'ulcere perforant du duodenum." These de Paris,
1896.
' " De la perforation de I'ulcere simple du duodenum." These
de Paris, 1896.
Klil^UKU. [may 5, 1900
Latham 8. 192 sections with . . gastric ulcers and 12 duodenal.
Perry and
Shaw 17,652 " ■' . . " " " 70
N. Y. Hos
pital (un-
published) 1,000 " " . . " " " 2 "
45,86g 421 108
or about 0.2 per cent, in frequency.
Kinnicutt,' however, in thirty thousand autopsies,
which probably included many embraced in the above
table, has given a rather higher percentage of fre-
quency, placing it at 0.4 per cent. Though the pro-
portion is a small one, stress must be laid on the fact
that from forty per cent, to seventy per cent, of these
ulcers perforate, with an almost invariably fatal result.
The relative proportion of gastric to duodenal ulcers
is 12 to I (Burwinkel).
Age. — It is encountered at all ages. Chvostek in
eighty-seven autopsies on children under ten years
of age, found five duodenal ulcers, of which one was
seen in a seven-weeks-old child, another in a child
four days old, and a third in a babe of three hours.
Collin's table is the most complete in this respect,
and it is here presented. In two hundred and ninety-
seven cases of duodenal ulcers they were met with :
Under 10 years of age 42 times.
Between 10 and 20 24 ' "
20 •• 30 43 "
30 " 40 52 "
40 " 50 46 '*
" 50 " 60 41 "
60 " 80 28 • •
81 •' 95 3 "
Progress. — It has already been strongly stated that
nearly all perforations of the duodenum will prove
fatal from a generalized peritonitis unless surgical
intervention should relieve the patient. What this
consists of, what are its results and its difficulties,
will be considered a little later. At present one must
take account of the somewhat encouraging fact that
all duodenal ulcers do not go on to this severe com-
plication of perforation. At seventy autopsies. Perry
and Shaw found decided evidences of repair in nearly
fifty per cent, of the cases, and Collin also recorded
thirty-nine instances of cicatrized ulcerations. These
cured ulcers may prove innocuous, but they can, as in
the stomach, narrow to a dangerous degree the lumen
of the intestine and even encroach upon the bile open-
ing, or make such traction upon it as to bring about
gastric and hepatic dilatations. Some of the most
brilliant surgical triumphs have been obtained in re-
lieving such obstructions, of which examples may be
subsequently found in this article.
Symptoms The symptoms of a non-perforated
duodenal ulcer are, as shown by Schwartz, frequently
very slight. In twenty out of twenty-five instances of
perforation the patients were in apparent good health,
or so slightly indisposed that they had not consulted
a physician. In only five cases were there previous
stomach symptoms. Of these one patient was thought
to have dyspepsia, and two to have a gastric ulcer.
In my own collection of fifty-one cases treated by
operation, gastric symptoms previously existed in
twenty-five out of thirty-four cases.
The usual signs may be given as follows:
I. The pain, when characteristic, occurs several
hours after eating, and may be slight or severe, and
presents itself just below the gall bladder, and may
reach to the median line or to a level with the navel.
Many times the pain is absent. Reckmann in eighty
cases found sixteen in which little or no pain existed.
Pressure particularly over the region to the right of
the twelfth thoracic vertebra occasionally elicits pain.
' Jacobi ; Festschrift, 1900.
May 5, 1900]
MEDICAL RECORD.
751
Swallowing of a sour lemonade or a strong alcoholic
drink may arrest the pain by bringing about a pyloric
contraction, but Pagenstecher' denies the value of this
test.
Vomiting is present in about seventeen per cent, of
the cases, but it is of a reflex character. It is of
diagnostic importance if, like the pain, it shows itself
from an hour or so up to several hours after a meal,
and the matters rejected are broken-down food often
mixed with bile and blood.
The right shoulder pains are noted by Schwartz as
occasionally to be recognized. According to Vonwyl
and Bucquoy, the pains are often slight from the com-
parative immobility of the duodenum, and vary from
queer indescribable sensations to severe radiations of
distress. Vomiting, when it occurs, relieves the pain.
Jaundice, if present, which is rare, may be due to
simple duodenal tumefaction or to cicatricial contrac-
tion on the papilla.
Hemorrhage is to be expected in about one-third of
the cases of non-perforating ulcers. Probably it is
even more frequent than this, as Oppenheimer found
blood in the stools of one-half of his thirty-four cases,
and Krauss says it occurs even more frequently than
in this ratio. This bleeding can be severe and show
itself by mouth as well as per rectum. It can speed-
ily prove fatal, as larger vessels are opened than by a
gastric ulcer. Usually the blood is discharged from
the bowels in a tarry condition, which bespeaks a high
origin of the hemorrhage and an exposure of some
duration to the action of intestinal secretions. This
is spoken of as meleena. Its color may be, however,
a bright hue, and recently, with Dr. Peabody, the ques-
tion of the presence of a duodenal ulcer in a patient
with intestinal hemorrhage and rigljt-sided epigastric
pain and distress some time after eating, was nega-
tively decided because the blood discharged per anum
was of a bright red color and unclotted. As the pa-
tient, moreover, had hemorrhoids the possibility of this
origin led to the confusion in diagnosis. This escape
of fresh unchanged blood from the bowels is recog-
nized by Vonwyl, and some emphasis should hereafter
be placed on this possibility. The profusion of the
hemorrhage may be much beyond that encountered in
gastric ulcer, for larger vessels may be involved.
Collin gives twelve instances in which the blood came
from the pancreo-duodenal artery; three times the
gastro-epiploica dextra was opened into; twice the
pancreatic artery; once the hepatic; twice the aorta;
twice the vena porta; and once the superior mesen-
teric vein. Pagenstecher states that the ulcers on the
posterior wall are more apt to bring about hemorrhage
than the anterior ones, as the vessels are more abun-
dant and larger there. Burwinkel ^ says that except-
ing in vicarious menstruation and typhoid fever intes-
tinal hemorrhage in large amounts is very rare and
should excite suspicion of gastric or duodenal ulcers.
This writer, in spite of all that has been advanced by
Nothnagel, Ewald, Lemke, and latest of all Kinni-
cutt,' that in the great majority of cases a differential
diagnosis from gastric ulcer is impossible, claims that
by a careful study of the symptoms he has been able
to diagnose five cases of duodenal ulcers in the last
few years.
Diagnosis.' — The following contrasting symptoms
have been grouped by Vonwyl as an aid to this end :
Gastric ulcer: (i) More frequent in women, twenty-
fifth to fiftieth year. (2) Pain promptly after eating.
(3) Relieved by vomiting. (4) Frequent biliary,
mucous, and food vomiting. (5) Marked dyspeptic
' "Die chirurgische Behandlung des Duodenalgeschwiirs. "
Deutsche Zeitsch. f. Chir. , August, 1899.
'"Das peptische Duodenalgeschwiir. " Deutsche medicin.
Wochenschrift, December 20, i8g8.
^Loc. cit.
symptoms. (6) Frequent bloody vomiting. (7) More
seldom bloody stools.
Duodenal ulcer; (i) Occurs most frequently in
males. (2) Pain in right hypochondrium or to right
of parasternal line. (3) Comes on two to four hours
after meals. (4) No relief by vomiting; latter not
frequent. (5) Bloody stools (melaena or bright blood),
more common than bloody vomiting. (6) If jaundice
is present, this would contribute to the diagnosis.
That medical and surgical education in this line is
progressing has also been brought out in the cases of
operations which form the basis of this paper. Here
it will be seen that, notwithstanding that the greater
part of them have been treated as of appendical or
other origin, surgeons, awake to the possibilities
of the case, are making shrewder diagnoses, and the
reproach which was good up to a year ago, that no
operation for a previously recognized perforated duo-
denal ulcer had yet been performed, no longer holds
good. It may be expected that as the detection and
treatment of a perforated gastric ulcer have so rapidly
and so satisfactorily progressed, from 1892 when the
writer was able to add to his first operation of this
kind but four other instances, while now over one
hundred cases each year are operated on with a mor-
tality that has fallen (if operated on within twelve
hours) from thirty-nine per cent, to seventeen per
cent. (Keen),' a similar improvement will take place
in the recognition and the proper treatment of duo-
denal ulcers.
■ The picture is a far different one Avhen the duo-
denal ulcer perforates, and particularly if anteriorly,
which is the most common site of this complication.
Here there is usually no withholding adhesion, and a
rapid invasion of the peritoneum is probable." If the
stomach is yet filled, the extravasation may take an
anatomical course somewhat in the order spoken of by
Pagenstecher, and which is in accord with my own
analogous clinical experience in three perforations of
the gall bladder. Fluids escaping from the duode-
nun-' or gall passages flow at first between the liver
and the colon, and thence along the ascending colon,
sometimes to the outside of the bowel and sometimes
between the omentum and the parietal peritoneum,
toward the iliac fossa; from this point they may pass
over to the sigmoid flexure or into the pelvis. Given,
therefore, such a free course, and with a plentiful pour-
ing out of an acid fermenting food and gas through a
direct, though small (2 to 8 mm.) opening, the symp-
toms presented would naturally be severe.
Great pain is usually felt at the epigastrium or to
the right of this region, as was noted twenty-six
times in forty-seven of my cases. It has a few times
been observed at the umbilicus and in the left side,
but in twenty-three others of the forty-seven instances
it was simply recorded as abdominal pain. Vomiting
often follows the attack of pain. It occurred in twen-
ty-eight out of thirty-four instances. Shock is not often
met with, but may be severe and fatal. Peritoneal
symptoms rapidly develop with a tendency in some
cases to be localized in the upper part of the abdomi-
nal cavity and in the right side; when these signs
show themselves mostly to the right and at or below
the level of the umbilicus, an appendicitis is necessarily
simulated. When the liver dulness has been dissi-
pated up nearly to the mammary line, air extravasation
may be suspected, and when accepted as present it
will aid in concentrating the diagnosis. This symp-
' Keen: Brit. Med. Jour., June 11, i8g8. — Mayo. "Surgery
of the Stomach." Lancet, March ig, igoo.
'' It should also be remembered that generally the duodenum in
its first part is free and covered by peritoneum, so that extrava-
sation is likewise possible through a posterior perforation in this
region. It is, however, in this case more likely to enter the
omental bursa (lesser omental cavity) or invade the retro-
peritoneal tissues.
752 MEDICAL RECORD. [May 5, 1900
torn of liver resonance, unless marked, is so often experienced are succinctly shown in the following
found to be due to a distended colon that it should statement :
not be much relied on. Diagnosis wrong; ulcer not found:
In considering the diagnosis of a perforated duode- _. . ...
nal ulcer as just given, I cannot but feel that more D'^f^s.s as acme^pentomns^. ^ ^8 times.
weight and attention should be given, first, to the pre- ■• <■ intestinal obstruction or appendV-
vious history, which shows, contrary to the opinions of citis i time.
many anterior observers, that in the fifty-one collected " \\ strangulated hernia i ''^
cases of operations for the relief of such conditions, ^ ronep rosis ^
there was a history of gastric or dyspeptic symptoms 26
given in twenty-five out of thirty-four instances in . .
which this point was noted; secondly and also impor- Diagnosis wrong; ulcer found:
tant is the fact alluded to on a previous page, that the Diagnosis as acute peritonitis 5 times.
initial or early pain was developed in twenty-six in- " " intestinal obstruction 4 "
stances out of forty-seven in the epigastrium; and in " "appendicitis 3
the right hypochondrium thirteen times. The third fac- ~
tor of value in tlie diagnosis as well as the treatment
of the symptoms of perforation peritonitis, whether Diagnosis right or approximately so; ulcer found:
from stomach, duodenum, gall-bladder, appendbc, or Diagnosis as duodenal ulcer 5 times.
any other part of the intestinal tract, is the prompt resort •• " gastric or duodenal ulcer 6 "
to an exploratory incision. This need of an early solu- " " appendicitis or duodenal ulcer .. . 2 "
tion of the site of a perforation has been already shown
in the cases of a gastric perforation, in an article' em- ^-"
bracing seventy-eight cases operated upon for this trou- Treatment.— For the treatment of a duodenal ulcer
ble. The mortality in these cases clearly depended on the medical means applicable to the management of a
whether the patient underwent surgical intervention gastric ulcer also hold good. It is but seldom that
within twenty-four hours from the inception (i.e., the surgical aid is called for before perforation has oc-
pain) of the perforation. This is yet more strongly curred, but the cases reported by Codevilla' are of
marked in the latest collection of this class of troubles much surgical interest and instruction. This surgeon,
by Mayo,' who states that in four hundred and twenty- for the relief of symptoms that fairly well pointed to an
nine cases of gastric perforations those operated on intractable duodenal ulceration, resorted to a gastro-
in the first twenty-four hours were eighty-two, in enterostomy in two cases, with a cure as the result of
which forty-seven patients recovered, and thirty-five his intervention." In some cases of perforation the
died (forty-two per cent.) ; and that in operations done shock and progress of the infection are so rapid as to
after that period over seventy per cent, of the patients bring about death in a few hours. Stevens' quotes a
died. In duodenal perforations the same outcome is case in which a fatal issue occurred within twenty-one
observable. In the fifty -one collected cases herewith hours after the first symptom (sudden pain) had shown
presented of duodenal perforations, there were twenty- itself.
five cases in which the lesion was recognized and closed When the diagnosis has happily been narrowed
at the operation ; of these thirteen underwent opera- down to a perforation of either the stomach, duode-
tion after thirty hours' delay, and all resulted fatally;" num, or gall bladder, the incision to be advised is in
twelve other patients were operated on within that or along the edge of the rectus muscle four to six
time, and eight survived, giving thus only ^^^ i per inches in length and starting rather low down on the
cent, of mortality. Only, I say, and with much satis- abdominal wall, so as not to reach much above the
faction, since it marks an improvement on the statistics Hver edge but to extend far enough downward to get
of Pagenstecher, which gave a mortality of sixty per easily below the transverse colon, which might be nec-
cent. in the found and sewn-up duodenal ulcers col- essary. Supplementing this incision in its upper third
lected by him. Of equal value as illustrating the another transverse one in the skin to the left or toward
increasing alertness of the surgeon is the fact that prior the median line is advisable. This will permit the
to 189s, in the twenty-eight cases reported up to that cross-division of the fascia covering the right rectus
time in which laparotomy was done for duodenal per- muscle, which latter is in turn to be pulled to the left,
foration, in fifteen, or seventy-five per cent., the ulcer when its posterior sheath with the peritoneum is also
was not found; in five, or twenty-five per cent., it was to be divided. This gives a satisfactory and largely in-
found and sutured. In only two cases, or ten per creased exposure of the parts beneath, and the subse-
cent., was the possibility of a duodenal perforation quent suture of the upper and lower sheath of the rec-
considered. Contrast this with the thirty-one cases tus with the full replacement of the muscle adequately
operated on since 1895, when the analogous surgery restores the integrity of the abdominal wall. This
of gastric ulcer began to be developed. Of these incision I have made many times in operations on the
thirty-one cases the perforation was not found in only gall bladder, and similarly in numerous instances of
eleven per cent. It was found and sutured in twenty suppurating appendicitis when increased space is
cases, or sixty-five per cent. Its presence was consid- necessary.*
ered in diagnosis in eleven cases, or thirty-five per if gas or food material escapes when the abdomen is
cent. opened, the surgeon's action is rendered more certain,
Another indication showing the advance in our sur- and by a rapid and thorough inspection, after wiping
gical art since attention has been directed to this le- away any obscuring fluid, of the gall bladder, duode-
sion is the circumstance that it has been possible in num, and the anterior walls of the stomach, the perfora-
thirteen of the more recent instances either to arrive tion can be disclosed. If nothing is visible in these re-
at a correct pre-operative diagnosis, or to make the gions, the examination of the posterior gastric wall can
alternative diagnosis varying between a duodenal and
a gastric perforation. The difficulties that have been ' Codevilla : See Pagenstecher. /or. ^,7. J ^ ,
° ' • Berg and Koux also each report a case m which for a duodenal
ulcer with adhesions or pyloric stenosis a similar operation was
' Weir and Foote ; Medical News, April 25, 1896. done with success.
'Mayo: Loc. cit. ^Glasgow Medical Journal, vol. li.,p. 87, 1S97,
^ One case (No. 31), however, recovered after a delay of two * Weir . Medical News. February 17, iqoo. "On an Im-
hundred and sixteen hours, but here the perforation had formed proved Method of Operating for Acute Suppurating Appendi-
a chronic abscess and sinus. citis," Medical News, March, 1899.
May 5, 1900]
MEDICAL RECORD.
753
be accomplished by either tearing through the gastro-
colic omentum, or by turning up the omentum and large
bowel and entering the lesser omental cavity through
the mesentery as in posterior gastro-enterostomy.
From the lower end of this wound, which is large
enough to admit the hand, the appendical region can
be explored in many instances if it should be nec-
essary, though probably if this should be involved a
separate incision might be more suitable. If a duo-
denal perforation exists, it will generally be found on
the anterior wall of the duodenum as a small round
opening, rarely beyond one-quarter of an inch in diam-
eter, with comparatively thin edges and rarely adherent
to any adjacent intestine. Gas or fluids have fre-
quently been seen passing from the opening, and occa-
sionally bile, which latter may also stain the perito-
neal extravasation. Mayo has suggested that an acid
reaction of the peritoneal effusion might help in sug-
gesting, prior to its discovery, a gastric or duodenal
opening, but as the inflammatory effusion rapidly neu-
tralizes the stomach acidity, this will seldom be of
help.
Since several of the collected cases have shown in
the abdominal extravasation the presence of recogniz-
able medicines, such as castor oil, etc., given errone-
ously to move the bowels, it may be considered worth
while to utilize this fact, and to give, prior to the op-
eration, a certain amount of methyl blue or other in-
nocuous colored solution to aid in the detection of
the opening. When found, the perforation should be
closed by a double or triple row of interrupted silk
sutures. No attempt should be made, in my judg-
ment, to excise the ulcer before suturing. This takes
too much time, and the results in the collected opera-
tions show that in seven out of nine of the successful
cases suturing alone was relied upon. In one only
were excision and suturing employed, and in one other
case the ulcer was closed over by suturing over it the
duodenum, colon, and stomach. This experience is
confirmed in the large number of gastric perforations
that have been treated up to date.
The suggestions given by Pagenstecher in the con-
duction of this operation are worthy of remembrance.
They are, that the fundus of the gall bladder, when
distended, lies in front of the duodenum. By raising
up the transverse colon, which rests somewhat in front
of and below the horizontal part of the duodenum, and
by drawing it forward, this portion of the intestine is
immediately revealed. Crowding the stomach and
pylorus to the left and a little downward, with lifting
up the liver and pushing the colon down, a good view
of the locality of a perforation is obtained.
The closure of the perforated intestine, however,
leaves much of the battle for life unfinished. The
proper and systematic cleansing of the peritoneum is
of the utmost importance. If the extravasation is
limited, careful wiping out of the affected portion of
the peritoneal cavity, with especial attention to the
rstro-gastric and supra-hepatic spaces and to the
splenic and renal region, with ample gauze drainage,
will in most cases suffice better than the large warm
irrigations of sterilized salt solutions, which are, I
think, more suitable in extensive or general peritoneal
inflammations.
For those who favor multiple incisions and large
irrigations the specific directions of Lennander' are
of value. He considers, in suitable cases and in pa-
tients of sufficient vitality, that irrigation with water at
40° C. (104' F.) through several incisions, is the best
method of cleansing the peritoneal cavity. One must
go carefully and methodically about the solar plexus
and the diaphragm; methodically loosening adhe-
sions, irrigating, and then wiping clean with wrung-
out gauze. He begins with the upper surface of the
' Pagenstecher Op. cit.
liver, particularly on both sides of the suspensory
ligament; then passes between the liver and stomach
to the triangular ligament, then around the cardiac
portion ; then between the stomach and spleen, then
under the diaphragm to the left kidney, and along the
spleen to the phreno-colic ligament. The division of
the triangular ligament with a thermocautery has been
suggested, so that one might sweep around the left
lobe on both sides. He then cleans between the right
kidney and the liver, kidney and colon, colon and
liver; next the lumbar regions and both iliac fossae;
then both sides of the mesentery of the small intes-
tine, and last the pelvis, which is often infected at the
beginning of the trouble. A great quantity of hot
fluid is of undoubted benefit in the pelvis.
Drains and tampons are intended to remove ac-
cumulating fluids as well as to shut off infected areas.
Tubes surrounded by gauze are the best drains. He
places sterile gauze on both sides of the suspensory
ligament of the liver and between the liver and dia-
phragm. Drains should be placed in both lumbar
regions, the left passing alongside of (better through)
the phreno-colic ligament external to the spleen to the
middle of the diaphragm. The right one passes to
the duodenum. The pelvis of men is drained above
the symphysis pubis, that of women through the va-
gina.
My own experience in the surgical treatment of duo-
denal perforation is confinAi to one case, which is
briefly as follows :
Perforation of Duodenal Ulcer ; Laparotomy ; Sut-
ure ; Death. — A man, aged thirty years, who had previ-
ously symptoms, confusedly detailed, of gastric disturb-
ance but not of hffimatemesis, for several months, was
seized four days previously with severe epigastric pain,
chill, fever, repeated vomiting, and great prostration.
No blood was expectorated or dejected. His abdomen
rapidly swelled and became generally tender and pain-
ful. On his entrance into the New York Hospital,
April 30, 1899, nothing could be made out by palpa-
tion save that the liver dulness was nearly obliterated.
The abdomen was very tympanitic, and no special
point of tenderness or dulness was observed. He also
had a double hernia. On the right side there was a
protrusion of intestine beyond the external ring. The
pulse was 140; temperature, 104° F. The diagnosis
of a general peritonitis from a gastric or duodenal
perforating ulcer was made. A large median incision
was made with the umbilicus in the centre for general
exploration. The fingers showed nothing at the rings
or at the cscum, and then on carrying the examina-
tion upward a minute, sharply defined perforation, one-
quarter of an inch in diameter, was found on the ante-
rior wall of the duodenum near the pylorus, out of
which was oozing some brandy and water given just
before chloroformization. This was sutured with a
double row of Lembert sutures, and the peritoneal
cavity systematically and carefully washed out with
sterile salt solution. He was returned to the ward in
bad condition. -Salt transfusion, 75 oz., etc., was made,
but the patient succumbed shortly after the operation.
The autopsy showed the perforation to be in the
duodenum just below the pyloric termination and in
its superior anterior wall. Within the bowel was a
deep ulcer at the bottom of which had occurred the
perforation.
Later Effects of Duodenal Ulcer and Operation
for Same. — There yet remain a few words to be said
about the late consequences of a healed duodenal ul-
cer. The resulting cicatricial contraction may bring
about stricture of the duodenum and dilatation of the
stomach, and may by traction or primary ulceration
damage the bile entrance to the intestine. Several
interesting surgical cases have been reported in which
relief has been afforded by such circumstances. Pa-
754
MEDICAL RECORD.
[May 5, 1900
genstecher quotes a case by Lange' in which a gastro-
enterostomy was successfully resorted to for contrac-
tion of the duodenum to the hardness and size of the
finger, 3 cm. from the pylorus, with dilatation above
of the duodenum and stomach.
Codevilla^ details a more acute case with ulcer and
stenosis of the duodenum and dilatation of the stom-
ach. The duodenum was found at the operation mark-
edly stenosed as in Lange's case, and a gastro-enteros-
tomy was performed with a successful and permanently
good result.
Carle' had a similar case in the front part of the
duodenum, but the gastro-enterostomy resorted to
ended fatally. He also reported another instance
in which great emaciation and stomach dilatation de-
manded surgical interference. The first and second
parts of the duodenum were found strongly contracted
but with atrophic thin walls. Gastro-enterostomy was
employed with success, death occurred one year later
from lung tuberculosis
Rewidzow* also cites a case which is doubtfully
placed among these, as the locality of the stenosis
following bloody vomiting and gastric disorder for
twenty years was shown at the operation to be below
the bile papilla, where a stenosis existed. For this a
gastro-enterostomy was successfully resorted to.
Operations for Duodenal Perforations The fol-
lowing list embraces all the reported cases of perfora-
tion of the duodenum that have undergone operation
up to April, 1900, and 'which have been carefully in-
vestigated and epitomized by Dr. E. M. Foote, to whom
I am much indebted for this and other help in the pre-
paration of this article.
No. I. Male, aged thirty-five. A heavy drinker;
no history of indigestion. For a week or so loss of
appetite and indefinite epigastric pain, then sudden
acute pain while at work, followed by vomiting. Two
days later brought to hospital in collapse. Abdomen
distended, dulness in right flank; pulse rapid and
feeble; temperature, 98.8^ F. Laparotomy at end of
two days. Acute peritonitis, cause not discovered.
Death in a few hours. Autopsy showed perforation of
anterior wall of duodenum close to pylorus.^
No. 2. Male, aged thirty-one. Acute attack like
intestinal obstruction. Diagnosis, appendicitis and
general peritonitis. Operation third day. Appendix
normal, general peritonitis, perforation not found.
Death in a few hours."
No. 3. Male, aged twenty-nine. History of abdomi-
nal colic. While in usual good health he was seized
at 5 P.M. with sudden pain, followed by bilious vomit-
ing. Some lumps of feces and gas passed that even-
ing, but absolute constipation followed. Next day a
purgative only increased the vomiting and pain. He en-
tered hospital on the third day, with fecaloid vomiting.
On the fourth day great distention, tenderness, and pain
at its maximum in right hypochondrium; pulse, 120,
small, dulness in both flanks. Diagnosis, perforative
peritonitis. Operation in about ninety hours; general
peritonitis. The hand, thrust under the liver, broke
into a cavity containing two quarts of serous liquid.
The intestine was searched in vain for mechanical
obstruction, and on account of weakness of the patient
the operation was terminated. Death same evening.
Autopsy showed a perforation " near the end of the
second portion of the duodenum, externally." '
No. 4. Male, aged twenty-eight years, always well.
While drinking tea, he had a violent pain in the left
side of the abdomen. Next day, a tumor to the right
' Pagenstecher : Op. cit.
- • Loc. cit.
'' Pagenstecher : Op. cit.
■* Pagenstecher , Loc. cil .
' Mackenzie (Jones, operator): Lancet. iSoS, vol. ii., p. 1,060.
' Mackenzie (Croft, operator) Lancet, 188S, vol. ii. p. 1,060,
' Boiffin : Cong, fr, deChir., 1892, p. 210.
of umbilicus, sour vomit, later becoming fecal; tym-
panites; constipation, no blood. Third day, temper-
ature normal, pulse about 130. Operation in eighty
hours (about). Incision to left of umbilicus gave vent
to gas and pus, intestine sound, greatly distended;
incision of intestine; suture of collapse, drainage.
Death in seven hours. Autopsy showed perforation
in anterior wall of duodenum; purulent peritonitis.'
No. 5. Male, aged forty-one years, of good previous
health except slight indigestion. One year before
perforation, had an attack of abdominal pain with con-
stipation. While at work he was seized with violent
pain; gastric vomiting, later becoming fecal, no
blood; absolute constipation. In tympanitic stage
when first seen by reporter. Respiration, thoracic;
pulse, 120; temperature, 99.2'^ F. Diagnosis, septic
peritonitis. Operation, ^Iay, 189 1. Usual incision;
cavity searched, no cause for suppurative peritonitis
found, irrigated, drained. Death in ten hours. Au-
topsy showed perforation in posterior wall of duo-
denum, one inch below pylorus, freely communicating
into peritoneal cavity when intestines were lifted.^
No. 6. Female, aged twenty, servant. Of consti-
pated habit, otherwise health good. Bowels moved
by salts two days before the attack. A sudden attack
of pain occurred in the right fiypochondrium, passing
then to left side, and afterward becoming general.
Vomiting of sour fluid began twelve hours after the
attack of pain, and continued. There was tympanites
without loss of hepatic dulness. Diagnosis of gen-
eral peritonitis, cause unknown. Operation in twenty-
four hours. A median incision below the umbilicus
allowed the escape of inoffensive fluid. A second
incision above the umbilicus disclosed the perfora-
tion one-quarter of an inch in diameter, in the pos-
terior aspect of the duodenum, close to the pylorus.
Milk was escaping through it. The ulcer was excised
and sutured, the abdomen flushed. Death in six hours.
General peritonitis."
No. 7. Male, aged twenty-one, always in good health.
Sudden pain in the lower abdomen, followed by vom-
iting and collapse. After eighteen hours laparotomy
gave exit to much brownish, acid, non-feculent fluid.
There was adhesive peritonitis. The cause of peri-
tonitis was not found. Death in a few hours. Au-
topsy showed a perforation in the anterior wall of the
duodenum, about fi\e inches from the pylorus, and
about five inches in diameter; a second non-perforat-
ing ulcer of the posterior duodenal wall.'
No. 8. Male, aged fifty-six. Brought to the hospi-
tal in a condition of tympanites, and having a right
inguinal hernia. Laparotomy was done. The hernia
was explored and found to be in good condition, and
the incision was prolonged upward seven inches, giv-
ing vent to purulent and fecal fluid. No cause for
the peritonitis was found about the caecum or else-
where. Death in a few hours. On the anterior sur-
face of the duodenum, 0.5 inch from the pylorus, was
a perforated ulcer, 0.5 x 0.7 inch. It could easily
have been sutured.''
No. 9. Male, aged twenty-eight. Of good health
until two months before perforation; he did not feel
quite himself, but there were no localized symptoms.
While ascending an omnibus, he felt a sudden pain
in the abdomen; nausea and vomiting after an emetic
had been given; constipation for four days, then a
little fecal matter and flatus, after an enema. On the
seventh day entered hospital; abdomen distended;
general tenderness; respiration, 28, thoracic; pulse,
104; temperature, 99.8° F. Questioned with refer-
' Lockwood : Med. Soc. Transactions, 1S92, vol. xv. . p, 91.
■' Lockwood : Ibid.
^ Gould : Middlesex Hosp. Reports, 1S93, p. 168.
■* Perry and Shaw : Guy's Hospital Report, 1S93. vol. i,, p 261.
' Lockwood : Lancet, 1894, vol. ii., p. 964,
May 5, 1900]
MEDICAL RECORD.
755
ence to duodenal ulcer, could not localize first pain;
never any blood by mouth or in stools; only slight
history of indigestion. No evidence of trouble in up-
per part of abdomen. Diagnosis, septic peritonitis
with pus in pelvis. Operation in one hundred and
fifty hours (about) ; subumbilical incision; two pints
of pus were taken from pelvis; appendix, caecum, and
small intestine sound; higher search was abandoned
as there was less peritonitis in that direction; irriga-
tion, drainage, suture. Death in fifty-four hours.
Autopsy showed septic peritonitis in pelvis, and also
about duodenum, these areas being separated by a
middle zone, relatively free from peritonitis; perfora-
tion, 0.5 inch in diameter, 0.7 inch from the pylorus,
in the upper wall of the duodenum.'
No. 10. Male, aged sixty-one, with a long history
of gastric ulcer, with epigastric pain and vomiting,
never of blood. Sudden pain occurred in right hypo-
chondrium, with collapse. Diagnosis, perforation of
gastric ulcer. Operation in four hours fifteen min-
utes. Perforation in duodenum, anterior wall, 0.7
inch from pylorus, sutured; thorough washing, drain-
age. Death in six days. Autopsy showed suture
tight; a second ulcer in the back of the duodenum,
non-perforating; purulent fluid behind liver and in
pelvis.'
No. II. Male, aged twenty-eight, in good health.
One hour after a movement of the bowels, while lift-
ing a barrel from a dray, felt a sudden pain across the
abdomen like a knife; vomiting immediately began
and continued. .Third day fecal vomiting occurred;
pain especially on right side; pulse, rapid; tempera-
ture, 100.6° P\ ; respiration, rapid; cold sweat. Diag-
nosis, intestinal obstruction. Operation in sixty-two
hours. Subumbilical incision gave vent to a large
amount of sero-pus with a fecal odor; caecum, appen-
dix, hernial openings, and intestine in pelvis exam-
ined; incision prolonged upward; perforation as " big
as a florin," in anterior wall of duodenum, one inch
from pylorus, pared and closed with six or eight Lem-
bert stitches. Area covered by omentum; irrigation;
drainage in pelvis. Death in three hours. No au-
topsy.^
No. 12. Female, aged twenty-seven. For a fort-
night had epigastric pain, and constipation for seven
or eight days; treated for indigestion. Sudden pain
in epigastrium and collapse; vomiting frequently re-
peated. Thirty hours later, slight tympanites; abdo-
men uniformly tender; pain most marked in epigas-
trium; vomiting; respiration rapid and irregular;
pulse, 120; temperature, 100.6° F. ; diagnosis, general
peritonitis from mechanical obstruction. Operation
in thirty hours (about). Subumbilical incision gave
vent to fluid and fibrin; intestinal coils were con-
gested; no lesion found; incision prolonged upward;
gas noticed near gall bladder; perforation of duode-
num 0.7 inch from pylorus; surrounding induration
incised; suture; irrigation; sponging; no drainage.
Nothing was taken by mouth for seventeen days. Re-
covery occurred. Two months later symptoms of ob-
struction were shown ; operation on third day; adhe-
sions which obstructed the ileum a short distance
above the caecum were freed. Death took place from
perforation of the wall of the ileum just above the
obstruction. The suture of the duodenum was smooth
and thin.'
No. 13. Male, aged thirty-five, of alcoholic habit.
Upon going to work he was attacked by sudden ab-
dominal pain and vomiting; pain and nausea contin-
ued, though vomiting ceased. Thirty hours later the
patient lay with hollow eyes, alternately extending and
' Lockwood : Lancet, iSg4, vol. ii., p. 968.
^ Ibid.
'Eve : Lancet, 1894, vol. ii., p. iSgi.
■'Dean : Med. Soc. Trans., vol. 17, p. 305, 1894.
drawing up his legs as paroxysms of pain came on.
Nothing had passed by anus. There was tympanites
except for dulness in the right iliac region, where
pressure was painful. No tumor could be made out.
Temperature, 37.9° C. (100° F.) ; pulse, 104 and small.
Operation by Brissaud, fifty-one hours after the at-
tack, December 14, 1893. An incision was made over
the appendix, giving vent to a great quantity of fecal
matter. The appendix was not seen; drainage.
Death in a few hours. Autopsy showed general peri-
tonitis, and a fusiform collection of pus from the liver
to the right iliac region. 'J'here was perforation of an
ulcer in the anterior wall of the duodenum, just below
the pylorus.'
No. 14. Male. After a debauch the patient was
attacked with a sharp pain in the right side of the
abdomen. Forty-eight hours later there was general
tympanites, dulness over a tumor in the right iliac
region, and collapse. Operation in fifty-three hours
as for appendicitis; from the incision pus and milky
fluid escaped in large amounts. Irrigation and drain-
age; death. Autopsy showed a perforated duodenal
ulcer, the sac about the caecum containing much of the
milk and food which had been taken during illness.^
No. 15. Male, aged twenty. Slight indigestion.
While at the theatre a sudden attack of severe pain
occurred in the epigastrium with tenderness; no vom-
iting; passage of flatus; slight tympanites. Tempera-
ture, 96° F.; pulse, 100. On the second day greenish
vomiting, becoming fecaloid; obstipation; rapidly in-
creasing tympanites; tenderness in the cascal region.
Diagnosis of appendicitis. Operation in about sixty
hours. Gas without odor; thin, purulent fluid, and
lymph in peritoneal cavity. Perforation not found;
intestines washed ; abdomen closed. Death in twenty-
four hours. Perforation was in anterior aspect of first
portion of duodenum.^
No. 16. Male, aged twenty-three. Had an attack
of sudden pain, vomiting, and obstipation three years
previous; an acute attack of pain and vomiting last-
ing five days. There were two movements of the bow-
els in this period. When seen on the sixth day, there
were marked tympanites and a very rapid pulse, not
much tenderness, and pain in the cajcal region. Di-
agnosis of appendicitis. An incision about one hun-
dred and five hours after attack allowed odorless gas
and thin pus to escape. The intestinal coils were
covered with lymph, and greatly distended. An in-
cision into the jejunum permitted several pints of fluid
to escape. Perforation was not found. Abdomen was
washed and drained. Death in twenty-two hours.
Autopsy: There was a small perforation of the ante-
rior wall of the duodenum, one-half an inch below the
pylorus. At the same distance, there was in the pos-
terior wall the scar of a healed ulcer.'
No. 17. Male, aged twenty-eight, hard drinker.
Had sudden abdominal pain accompanied by vomit-
ing. Two days later admitted to hospital with general
abdominal distention and tenderness, but no loss of
liver dulness. Temperature, 103° F. ; respiration, 20;
pulse, 120. On the third day a liberal median incision
revealed a general peritonitis, with a small amount of
fluid; cause not found. Rapid irrigation and drain-
age. Death three days after operation. Autopsy
showed a sharply defined ulcer in the third part of
the duodenum, in its posterior wall. The ulcer had
for its base the pancreas, whose tissues were necrotic
and infiltrated with pus. The suppuration had ex-
tended as far as the jejunum, and had there entered
the general peritoneal cavity.'
' Collin : " L'ulcere simple du duodenum." These de Paris.
^ Brj'ant : Mkdical Record, 1895, vol. xlvii., p. 25.
'Shield: Lancet, 1S95, vol. i., p. 1,170.
■• Shield : Ibid.
^Bolton; Medical Record, 1900, vol. Ivii. , p 494-
756
MEDICAL RECORD.
[May 5, 1900
No. 18. Male, aged thirty-five, a hard drinker, with
history of a similar attack thirteen years previous.
For a few days there was a severe abdominal pain ac-
companied by vomiting. Was admitted to the hospi-
tal with very great general tenderness, no distention,
and a temperature of 102° F. The symptoms im-
proved until the fourth day after admission, and then
signs of a rapidly spreading peritonitis were manifest.
Diagnosis, appendicitis. Incision made on the fourth
day over the appendi.x showed that organ to be nor-
mal. General peritonitis was present and a large quan-
tity of odorless fluid was in the abdomen. Drainage.
Death in a few hours. Autopsy showed a perforation
in the superior wall of the first portion of the duode-
num just beyond the pylorus. The gut was adherent
to the liver by recent fibrin. There was also the scar
of an old healed ulcer.'
No. 19. Male, aged fifty-six. Had a long history of
gastritis and of diarrhcEa which was sometimes bloody.
Acute attack of pain, four hours after dinner; con-
stant vomiting; collapse. The usual lavage failed to
give relief and the water did not return readily. Mor-
phine administered; passage of gas per anum. The
next day symptoms disappeared, then returned with
vigor. Stool after enema. The second day there was
again a remission and again a relapse toward night.
Dulness and pain were most marked in the right iliac
fossa. Pulse, 112; temperature, 38.2° C. The third
day there was still iliac tumefaction; marked sepsis;
pulse, 160. Operation sixty-six hours after attack.
Incision over appendix, which was thought to be the
origin of the disease, allowed the escape of three pints
of reddish purulent fluid with fibrin masses. The
peritonitis appeared limited, and it was judged best
not to break up the adhesions to find the perforation.
Douche and drainage. Death nine hours after opera-
tion. Autopsy showed an ulcer just below the py-
lorus, occupying two-thirds of the circumference of
the duodenum, the anterior wall not being involved.
The perforation was on the postero-external surface."
No. 20. Male, aged thirty-three. No previous gas-
tric trouble. Sudden colicky pain in right hypochon-
drium; collapse; no defecation nor passage of wind.
Following day, tympanites; liver dulness absent ; tem-
perature, 100' F. ; pulse, 122; respiration, 38. Opera-
tion in twenty-five hours. Incision was made in me-
dian line; purulo-fibrinous peritonitis; gas and fluid
from duodenal region ; perforation sutured by two
rows of stitches; intestines cleaned by moist gauze;
no drainage. Recovery after bronchitis, primary
union of wound. Patient was seen four years later,
in good health.'^
No. 2 I. Male, aged thirty-five, a hard drinker. Had
sudden severe abdominal pain, without vomiting. Ad-
mitted to the hospital eight hours later with a tense
abdominal wall, and tenderness over the gall bladder.
The pulse was 90, and there was no fever. Later the
temperature rose, and distention with obliteration of
the liver dulness developed. Diagnosis, appendicitis.
Operation in twenty hours. Incision made over ap-
pendix, which was normal. A well-marked general
peritonitis was present, but the patient's condition
prevented further search. Death in twenty-four hours.
Autopsy showed a perforation of the duodenum in the
posterior wall, one and one-quarter inches from the
pylorus, and a second non-perforating ulcer lower
down.'
No. 22. Male, aged fifty-two. Had an attack of
acute pain in epigastrium with obstipation and tym-
' Bolton : Ibid.
'Festal: Jour, de Med. de Bordeaux, 1895, vol. xxv. p. 4q.
*■ Herczel, 1S95, quoted by Pagenstecher : Deut. Zeit. f. Chir.,
1899, vol. liii. , p. 557.
■■ Bolton : Loc. cil. Also in previous article on perforating ulcer
by Weir and Foote. Medical News, 1896
panites, six years previous. Recovery in six weeks.
Had more or less pain since. Acute attack of severe
pain about pylorus, later extending downward and
backward. Absolute obstipation; tympanites slight
on second day and increasing, on third day vomiting
of moderate character; temperature, ioo°-ioo.5^ F.
Diagnosis of appendicitis. Operation on fourth day.
Intestines were distended and covered with lymph; no
pus. Perforation of duodenum into general peritoneal
cavity was found and closed; cavity douched with hot
water: gauze drain. Thirst and brownish vomiting;
rapidly rising temperature. Death on third day after
operation. No autopsy.'
No. 23. Male. Had sudden epigastric pain while
at work, followed by vomiting, tympanites, and loss
of liver dulness. Operation in about thirty hours.
Perforation in anterior wall of first portion was found
and sutured. Gas and yellowish fluid in peritoneal
cavity. Flushing with hot water; drainage for twenty-
four hours. During convalescence return of symptoms
necessitated a second laparotomy. Only adhesions of
liver to diaphragm were found. A needle thrust
through eighth intercostal space into these drew a
drop of pus. A mural abscess formed later which
probably caused the above recurrence of symptoms.
Recovery."
No. 24. Male, aged fifty, who for ten or fifteen years
had pain after meals, with vomiting and bloody stools;
last hemorrhage seven months before entrance to hos-
pital. Emaciated and anemic on entrance; stools
were black. Diagnosis of ulcus ventriculi. Two days
later sudden pain in right hypochondrium, with re-
tracted abdomen. Temperature, 100° F. ; pulse rate
normal. The signs of peritonitis with feelings of dis-
tention increasing, laparotomy was perfonned, twelve
hours after the attack. A long incision was made
above umbilicus with cross-cut to the left and right;
stomach and duodenum were examined and fluid like
coffee-grounds was squeezed from its posterior region
by pressure, but no perforation could be made out.
Duodenum, stomach, and colon were sutured together
to protect the general peritoneal cavity. Cavity was
irrigated and wiped, and drained at epigastrium and
through pelvis. Recovery. Six months later he w'as
in good condition, as far as duodenal ulcer went; still
had chronic gastritis. Death in eight months from
operation for suppurative peritonitis. Autopsy showed
a new perforation in the posterior wall at the begin-
ning of the second portion of the duodenum."
No. 25. Male, aged twenty-four years, with no gas-
tric trouble. After a large dinner he felt indisposed
for a few minutes. The next morning he rose at six
in usual good health and ate his customary breakfast.
At the last mouthful of a glass of white wine, he felt
a sudden most severe pain and lay down in bed.
There was vomiting of food, and afterward incessant
vomiting of bile. He described the pain as "not like
a general colic, but always in one point here,'"' indi-
cating a spot on the left, midway between the umbi-
licus and ensiform cartilage. A physician diagnosed
volvulus, and tried by enemata and massage to relieve
the pain. In five hours vomiting ceased and the pain
subsided somewhat and was referred to the lower ab-
domen. No fecal matter or gas passed the anus.
There was no tympanites nor difficulty in passing
water. Sixteen hours after the attack he was admit-
ted to the hospital. The abdomen was retracted and
board-like; the pain was less and vomiting had ceased.
There was costal respiration, and the appearance of the
face indicated severe abdominal trouble; the nose was
' Warren Boston Med. and Surg. Journal, 1896, vol. cx.xxiv. .
p, 460.
' Dunn : Brit. Med. Journal, 1S96, vol. i., p. 846.
' I.anderer and I'.lucksman ; Mitt, aus d. Grenzgebiet. d, Med.
und Chir., 1S96, vol. i., pp. 16S and 738.
May 5, 1900]
MEDICAL RECORD.
757
pinched, the eyes were sunken, the hands clammy, and
the patient was in a half stupor. Diagnosis was thought
to lie between appendicitis and duodenal perforation.
Nineteen hours after the attack an incision was made
in the median line from the pubis to above the um-
bilicus. The abdomen contained non-feculent fluid,
and there were light adhesions on the intestinal coils.
Appendix was normal; no intestinal lesion; pelvis
normal. Incision was prolonged upward and stomach
searched ; gas was found escaping from under liver, and
perforation near pylorus on anterior surface of duode-
num sutured. Abdomen was wiped and drained from
site of duodenum. Several saline injections were given,
amounting to 4,200 c.c. in all. Death in twenty hours
from peritonitis; suture tight.'
No. 26. Male, aged twenty-six; health perfect, never
had any gastric symptoms. Two hours after his usual
light breakfast, while making a slight effort to open a
sack, the patient experienced an intense pain in the
left side of his abdomen. He was taken almost at
once to a hospital. Diagnosis of appendicitis; treat-
ment by ice and opium. Following day had a feeble
pulse, without fever; abdomen distending; tenderness
in left iliac fossa. On second day vomiting set in,
becoming bloody and bilious. About fifty-six hours
after the attack, Sebileau made an incision as for ap-
pendicitis, permitting the escape of non-feculent fluid,
like bouillon. The appendix was normal. The pa-
tient was already collapsed, and nothing further was
done, except to drain with gauze and give a saline
injection. Death took place after incessant vomiting
in thirty hours. Autopsy: The abdomen contained
fluid. There was general peritonitis; perforation in
the anterior wall of the duodenum, i cm. from the
pylorus.'
No. 27. Male. An attack of sudden pain like lead
colic. Incision from the ensiform downward. There
was food under the liver, and a perforation was found
in the first part of the duodenum, and sutured. Death
in twelve hours.'
No. 28. Male, policeman, of alcoholic habit and
history of gastric attack. While on duty the patient
had a sudden attack of pain which made him writhe
in agony. His bowels had moved a short time before.
When seen soon after, the abdomen was retracted, as
hard as a board, excessively tender, especially under
the ribs and in the right flank. Diagnosis of hepatic
colic. Compresses were applied and morphine ad-
ministered. The following day he felt better. An
injection resulted in a large stool. Milk and Vichy
were administered. There was no fever, nor much
pain, but the abdomen was still retracted. Thirty
hours after the attack vomiting set in, soon becoming
bilious. The abdomen swelled and the patient was
taken to a hospital. Diagnosis, appendicitis, intesti-
nal obstruction, or volvulus. Abdomen was opened
forty-eight hours after the attack; nothing but general
peritonitis discovered. Dieulafoy, operator. Death
occurred in one hour. Autopsy showed a perforation
of the duodenum in the anterior wall just below the
pylorus.'
No. 29. Female, aged twenty-five, servant, giving a
history of gastric trouble with vomiting, but never of
blood. An increase of gastric pain, with general ten-
derness and abdominal swelling, was followed four
days later by marked distention. Palpation showed
the greatest tenderness to be in the csecal region.
There was no fever. A needle thrust into the right
iliac fossa brought out gas, and an odorless fluid con-
taining flakes of fibrin. An incision was made over
' Banzet and Lardennois : Bull. Soc. Anat. Paris, i8g7, vol.
Ixxii. . p. 479.
'' Lardennois : Bull. Soc. Anat. Paris, l8g7, vol. Ixxii., p. 46'
^ Soligeux : Bull. Soc. Anat. Paris, 1897, vol. Ixxii., p. 72.
* Beausse : Jour, de Med. de Paris, 1897, vol. ix., p. 146.
the appendix, which was congested. There was gen-
eral peritonitis. Death occurred in four days from
the operation. Autopsy showed pus in the pelvis and
about the duodenum, in the lower wall of which, close
to the pylorus, there was a perforating ulcer. A sec-
ond ulcer was situated in the posterior wall.'
No. 30. Female, aged thirty-four years, servant,
with a history of gastric troubles for twenty years,
with frequent vomiting of blood; last attack was one
week before admission to the hospital, the vomiting
being followed by bloody stools. Pulse, 84, regular,
strong; rectal temperature, 98.6° F. Maximum pain
was midway between ensiform and umbilicus to the
right of the median line. Ice-bag applied on abdo-
men; nothing but ice given by mouth. Next day
pain involved the whole right side: was relieved by
morphine, but recurred with vomiting. A small pulse
of 106, and cold sweat. More morphine was given.
Two hours later the pulse was 130; there was tender-
ness all over the abdomen, with oedema in the epigas-
trium. Diagnosis, gastric ulcer. Laparotomy two
days after admission to the hospital (thought by the
operator to be " at least fifteen hours after perfora-
tion "), through the left rectus above the umbilicus;
gas and fiuid escaped; no adhesions; general peri-
tonitis. Perforation at pylorus, thought to be in the
lesser curvature, was sutured. Abundant irrigation;
gauze drainage; 700 c.c. saline solution injected.
Death twenty-four hours after operation. Autopsy
showed perforation in the superior wall of. the duo-
denum near the pylorus. The suture was perfect."
No. 31. Female, aged fifty-four years, with history
of indigestion; no bloody vomiting. A sudden at-
tack of pain and vomiting, not of blood, followed by
a large bloody stool and several small ones of a tarry
character, was succeeded eighteen days later by a sec-
ond attack. There were tenderness and resistance to
the right of the median line above the umbilicus; no
fever. Laxatives and enemata relieved the abdomen
of gas and fecal matter, and the area of resistance be-
came a well-defined tumor. Nine days after the last
attack an incision was made through the right rectus
muscle, and in separating the abdominal wall from the
viscera several small abscesses were opened, arid
through one of these gas and gastric contents escaped.
Perforation was readily found and closed. It was at
the pylorus and thought to be in the stomach. The
gall bladder was opened and eight stones were removed.
Most of the omentum was excised. lodoformgauze
drains were inserted. Death took place in five weeks.
Autopsy showed that the abdominal condition was
perfect. Death was due to pulmonary thrombosis,
infarction from saphenous thrombosis. The sutured
ulcer had healed. Two others in the duodenum had
not perforated.'
No. 32. Male, aged thirty-seven, shoemaker, with
nausea and vomiting and indigestion more or less for
years. One morning he awoke feeling perfectly well.
On sitting up in bed he was seized by a terrible pain
in the umbilicus and to the right side, lasting several
hours and followed by vomiting. Enemata resulted
in several small stools. The next day he was taken
twenty-five miles in a sleigh to tiie hospital, where he
arrived with respiration 26 ; pulse, 140; temperature,
102.5 F., but free from pain while at rest; tender-
ness in left iliac fossa and in the right hypochon-
drium, and over right rectus muscle. Stomach and
bowels were washed out. Diagnosis of duodenal ul-
cer or appendicitis. Sixty hours after the attack an
incision was made in the median line, mostly below
the umbilicus. Fluid and gas and fibrin escaping
' Lennander ; Mitt, aus d. Grenzgeb. d. Med. und Chir. , i8g8,
vol. iv., p. 91.
- Lennander ; /diti.
^ Lennander ; //>id.
758
MEDICAL RECORD.
[May 5, 1900
mostly from above, the cut was extended upward and
the right rectus was cut across. A perforation into
which the index finger passed was found in the ante-
rior superior wall of the duodenum near the pylorus.
It was sutured and the cavity washed out with water
at a temperature of about 45° C, wiped out, and
drained in both loins as well as about duodenum and
liver. Compresses wrung out of hot saline solution
were placed in the wound, which was left open. The
pulse and temperature gradually rose, and in spite of
1,150 c.c. of salt solution injected into a vein, the
patient died in twenty-six hours after operation. Au-
topsy showed fibrous peritonitis without fluid. The
suture was firm. There was an abscess between the
stomach and colon.'
No. 33. Male, aged forty-six. While lifting a heavy
weight, he felt something snap, and immediately after-
ward there was intense pain (locality not given), which
soon spread to the whole abdomen. Four days later
he entered the hospital, not having passed gas or fecal
matter per anum. There was no localized pain, but
pressure was everywhere painful; no tumor or fluctu-
ation. The patient had not vomited but had a hic-
cough. Pulse, irregular, 110; temperature, 99° F. A
diagnosis of intestinal obstruction was made, and cas-
tor oil was given in small doses every hour. The next
day there was great prostration, with choreic move-
ments. Five days after the attack the abdomen was
opened by a median incision from pubis to ensiform
cartilage, with a cross-cut through the right rectus
muscle. There was a general peritonitis with pus
and membranes all over, but especially in the pelvis.
At the pylorus on the superior surface was a large
perforation which was sewed with difficulty, and the
.abdomm was flushed and closed. Death occurred two
.hours after the operation.''
No. 34. Female, aged thirty, with a history of indi-
:gestion and some epigastric pains. While eating
breakfast she was seized with terrible pain in the
lepigastrium and left the restaurant for a seat in tiie
park close by. She was taken at once to a hospital.
In six hours the pain was general and vomiting set
in. The following morning she was worse, without
stools or passage of gas, and scanty urine. The con-
dition grew rapidly worse, with rapid pulse, subnor-
mal temperature, tympanites, and loss of liver dul-
ness. A diagnosis of perforation, probably of the
stomach, was followed by operation, twenty-eight
hours after the attack. Incision above the umbilicus
gave escape to gas and a quart of bile and purulent
fluid. Stomach and biliary tract were normal, and
perforation was found in the right side of the second
portion of the duodenum. Opening was sutured and
abdomen closed over a rubber drain to duodenum.
Death in fourteen hours. Autopsy showed perforation
a little below and to the right of the opening of the
common duct, which explained why the bile flowed
so freely into the abdomen. The closure was perfect.
There was a second ulcer a little below the first which
had not perforated."
No. 35. Male, aged twenty-three, a soldier witii his-
tory of numerous sprees before he entered the army.
During a marcli he took a cup of coffee, and almost
immediately he was overcome by pain in the epigas-
trium and right hypochondrium, streaming into the
right shoulder. He was nauseated but did not vomit.
There were tenderness and muscular contraction on
pressure, especially on the right side. An enema pro-
duced a normal dejection. The pain spread over the
whole upper part of the abdomen, accompanied with
' Lennander ; //'/[/.
'Schwartz (Rochard, operator) : Bull, et Mem. de la Soc. de
Chir., January, iSgS, p. 3.
^.Schwartz (Guinard, operator) : Bull, et Mem. de la Soc. de
Chir., January, 1898, p. 3.
a certain amount of distention, constant vomiting of
greenish fluid, and a partial disappearance of the
liver dulness. Incision made above the umbilicus
forty-eight hours after the attack. General peritoni-
tis. Intestine was overhauled, then liver examined.
Bubbling at its base led to tlie discovery of the duode-
nal perforation in the postero-superior wall of the first
portion of the duodenum. The right rectus was di-
vided to give room for suturing, but the stitches would
not hold, and the perforation, of a size to admit the
little finger, was walled off from the peritoneal cavity
by omentum sutured above and below it. Death in
thirty-six hours of general peritonitis. There were no
other lesions found at autopsy.'
No. 36. Male, aged twenty-two; always perfectly
healthy. Had an acute attack of intense pain and
vomiting three hours after supper; pain referred to the
umbilicus and right side. On the following morning
temperature was 101° P". ; pulse, 120; respiration, 42 ;
moderate tympanites. Lower edge of liver dulness
was two inches above the costal margin; tenderness
most marked in the epigastrium, and on the right side
of abdomen. Diagnosis of peritonitis, probably due
to appendicitis. Operation fifteen hours after the on-
set of attack; incision made over appendix. General
sero-purulent peritonitis was found. The appendix
appeared normal but was excised. A second incision
above umbilicus revealed, after careful search, a one-
quarter-inch opening in the anterior wall of the first
portion of the duodenum, close to the hepatic liga-
ment. It was in the centre of an indurated area, and
on account of its deep situation no excision was made.
It was sutuied, and the peritoneum cleaned with
gauze; abdomen closed over iodoform gauze drain.
Recovery took place with severe illness."
No. 37. Male, aged thirty-eight, with history of at-
tacks of intense pain in the epigastrium three or four
hours after meals, without nausea or vomiting. 'U'hile
in his usual good health, he suffered an acute attack
of violent pain in the epigastrium with collapse. He
recovered somewhat and then grew gradually worse,
with vomiting on the third day; no movement of the
bowels for a week before the attack. On the third
day, temperature, 100° F. ; pulse, 99; respiration, 30.
Face was drawn; abdomen distended with gas; dull
in flanks; liver dulness absent. Operation about
seventy-two hours after onset of acute symptoms.
Through an incision in the median line, much gas
and thin greenish-yellow purulent fluid escaped, with
flakes of lymph; appendix was normal. A search over
the intestine showed the perforation to be in the
anterior wall of the duodenum near the pylorus. It
was sutured and the abdomen swabbed out. The op-
eration lasted two and a half hours; afterward one
quart of saline solution was injected into the basilic
vein. Deatli took place in eight hours. The perito-
neal cavity was dry, except six ounces of pus between
the diaphragm and liver. The suture was tight, and
adhesions had already formed around it."
No. 38. — Male, aged thirty, with a history of dys-
pepsia. While stooping to draw off his boots, the
patient suffered a severe pain in his stomach which
stretched him out. The following day an enema was
without result. The abdomen was swollen and pain-
ful, the pain being all about the umbilicus, the urine
scanty, and the pulse 120. About twenty-seven hours
after tiie accident an incision was made in the median
line at the umbilicus. The intestinal coils were dis-
tended and red. A mass of fecal matter seemed to
clog the lumen, and was pushed along for a couple of
yards. A suspicious yellow fluid was in the peritoneal
'Schwartz (Sieur, operator): Bull, et Mem. de la Soc. do
Chir., January, 1S68. p. 3.
■' Wanach ; Arch. f. klin. Chir., 1S9S, vol. Ivi., p. 425.
"Whipple ; Brit. Med. Jour., I8y8, vol. ii., p. 1429.
May 5, 1900]
MEDICAL RECORD.
759
cavity, and pus pas found in the pelvis. The appen-
dix was normal. The abdomen was flushed with
boric-acid solution and closed. The vomiting ceased ;
gas and a great quantity of f*ces passed, and the ab-
domen became soft. Five days later the patient was
attacked with dyspnoea, and double pneumonia devel-
oped. Death took place in nine days after the opera-
tion. There were numerous pus foci in the abdomen,
and a perforation of the duodenum partly shut in by
adhesions.'
No. 39. — Female, aged seventeen, and fairly healthy;
had rarely suffered from indigestion. One week be-
fore perforation occurred, there had been indefinite
pain in the abdomen for which she consulted a phy-
sician, who feared a beginning attack of appendicitis.
About three hours after eating a hearty supper, while
walking rapidly, she was seized with a violent pain
above the umbilicus. Prostration followed, with rapid
pulse, subnormal temperature, vomiting, and rigid ab-
dominal muscles. Infusion of saline solution and
stimulants failing to improve the patient's condition,
operation was performed twelve hours after tiie begin-
ning of the attack; incision as for appendicitis. Ap-
pendix and pelvic organs were normal, as was the
small intestine. In the upper part of the abdomen
there was a good deal of lympli and greenish fluid.
The perforation of the duodenum was in the anterior
wall of its third portion, and was about the size of a
goose-quill, and surrounded for about an inch by an
indurated area. Fluid was freely escaping. Direct
sutures would not hold, so a purse-string was inserted,
and afterward other peritoneal sutures. In this way
the opening was firmly closed. Lymph and fluid were
wiped away, and the abdomen was fluslied with a great
quantity of hot saline solution. Numerous gauze
drains were inserted. Convalescence was slow, as it
was a long time before the suppurating tracts, where
the drains had lain for a week, had healed, but the
patient ultimately recovered completely."
No. 40. — Male, aged thirty. Sudden pain in abdo-
men occurred, followed by shock and toxic symptoms.
Operation was done thirty-six hours later as for ap-
pendicitis. Perforation was found in first portion of
duodenum. No blood or food in peritoneal cavity.
Death occurred in a few hours.'
No. 41. — Male, aged forty, was seized with pain
while at work, followed by shock and toxic symptoms
and great tympanites. Operation in twenty hours.
Perforation was found in first portion of duodenum,
no blood or food having escaped. Death took place
in a few hours.'
No. 42. — Male, aged thirty-eight. A supposed pul-
monary abscess was opened and a large quantity of
pus escaped. Two weeks later an abscess formed in
the groin and was opened. Later the abdomen was
opened for appendicitis, and a quart of creamy pus
containing streptococci escaped. Death followed.
Autopsy showed two ulcers near pyloric ring, one in
the duodenum, tiie base of whicli had healed over, and
one in the stomach perforated. There were numerous
pus pockets in the abdomen, one in the head of the
pancreas being the original one apparently.^
No. 43. — Male, aged twenty-nine, alcoholic. For
three years had morning vomiting. Following a long
spree he felt umbilical pain, and vomited and had a
chill. The next day the abdomen was moderately dis-
tended and rigid. Diagnosis of general peritonitis
from appendicitis. Operation was done one to two
days after attack. About one quart of fluid and fibrin
escaped. Appendix was amputated. Death occurred
' Routier: Bull, et Mem. de la Soc. de Chir., iSgg, p. 17.
-Taylor. North Carolina Med. Jour., iSgg, vol. xliii., p. log.
^ Erdmann : Medical Re^tord, i8gg, vol. Iv. , p. 477.
* Ibid.
'Brooks: Medical Record, iSgg, vol. Ivi., p. 943.
in thirty hours. Autopsy revealed perforation in su-
perior anterior surface of duodenum near pylorus.'
No. 44. — Male, aged thirty, with history of gastric
disturbance; no heematemesis. Had sudden severe
epigastric pain, with chill, fever, and repeated vomit-
ing and great prostration. No blood passed by mouth
or rectum. Gradually increasing distention and ten-
derness were noted. Four days later, April 30, 1900,
he entered the New York Hospital ; the abdomen was
generally swelled, but not presenting any special
points of tenderness or dulness. Liver dulness was
absent. Patient had a double hernia, and in the right
hernial sac intestine was to be felt. Temperature,
104° F. ; pulse, 140. Median incision was made with
umbilicus in centre. Nothing abnormal was found at
the internal rings or about the caecum. From a one-
fourth-inch perforation in the antero-supeiior wall of
the duodenum close to the pylorus, brandy and water
was found escaping. Closed with a double row of
sutures; thorough washing of intestines and cavity;
saline transfusion of seventy-five ounces, etc. Death
occurred in a few hours. Operator, Weir. Case not
previously reported.
No. 45. — Male, aged twenty-seven, always healthy
but a steady drinker. Had colicky pain for four days,
above the umbilicus on the right side. Bowels moved
daily and he kept on working. Then suddenly he
had severe pain three inches above navel, and a little
to right of median line, with chill, no nausea. Nine
hours later, pulse, 80 , respiration, 20; temperature,
101.5° F. March 28, 1899, abdomen w'as opened;
ten hours after had sudden pain, along right semi-
lunar line above and below umbilicus, bile-stained
fluid escaped. Appendix was examined as a matter
of precaution and found normal. Incision extended
upward to ribs. There was a perforation of duode-
num on anterior surface, descending portion, big
enough to admit 26 F. sound, through which bile and
intestinal contents were escaping. All organs in the
vicinity showed signs of irritation and so were washed
with saline solution, while opening was closed by pad.
Suture of perforation was done, with repeated flushing
of peritoneal cavity without evisceration, and wiping
with dry gauze, gauze drain to ulcer; wound else-
where closed. No shock. Patient was fed by rectum
for forty-eight hours. Temperature on following day
101° F. There was infection of skin stitches, which
were removed. Recovery was otherwise uneventful
and perfect."
No. 46. — Female, aged twenty-five. She had a sud-
den attack of umbilical pain, with rigor and slight
vomiting, on following day, pain at pylorus and blood
passed per rectum. Temperature then and later 101°
F. or less. Attack gradually subsided, but in two
weeks a similar slighter attack occurred. Later a
fluctuating tumor was found in region of gall bladder,
gradually increasing in size until it occupied the
whole right upper quadrant of abdomen. It was
crossed by resonant colon, elsewhere dull on percus-
sion. Di.ignosis was hydronephrosis. Through lum-
bar incision a quart or more of clear amber, odorless
fluid drawn off. Cyst reached from liver to iliac crest,
and backward to spine. Kidney was not felt. Wound
was stufled with gauze, which next day was soaked
with sour fluid. On third day food was noticed in
dressing. Patient developed acute bronchitis and
died on fifth day. Autopsy showed duodenal perfora-
tion three and one-half inches from pylorus forming
this retroperitoneal cyst below right kidney and reach-
ing behind duodenum as far as pancreas.'
No. 47. — No history was given. Incision made
' Brooks (Le Boutillier, operator) : Medical Record. 1S99,
vol Ivi. , p. 944.
■Johnson ; Am. Surp., 1899, vol. xx.x., p. 634.
^Wright and Bury: Lancet, i8gg, vol. ii., p. 215.
760
MEDICAL RECORD.
[May 5, 1900
from ensiform cartilage to pubis; ulcer found at back
of the duodenum and with difficulty stitched. Patient
collapsed and the abdominal wound was hastily closed.
Death from hemorrhage from a vessel in the abdomi-
nal wound.'
No. 48. — Patient was neurasthenic and little atten-
tion was paid to his statement that he had great pain.
Operation on the fifth day, when liver dulness was
entirely obscured. Gas had escaped from the per-
foration, but no fecal matter; the ulcer was there-
fore sutured and the abdominal wound closed without
drainage. Death on the third day from infection
leading from the site of perforation to the pelvis.
Suture firm. The operator thought that pelvic drain-
age might have saved this patient."
No. 49. — Male, aged fifty-two years. Epigastric
pain of three days' duration was followed by violent
exacerbation. There was no vomiting. Six hours
later the abdomen was tense, rigid, almost motionless,
with complete absence of liver dulness in the line of
the nipple. A diagnosis of perforated duodenal
ulcer was made and operation decided upon. Ten
hours after the attack an incision was made through
the right rectus, and a clean-cut perforation was found
at the junction of the first and second portions of the
duodenum. There >was intestinal injection but no
well-marked peritonitis. The perforation was closed
with two rows of sutures; the intestines were brought
out and washed with sterile water; a gauze slip was
passed to the site of the ulceration, and the cavity of
the abdomen was otherwise closed. Recovery was
imeventful. The gauze plug was removed on the sec-
ond day, and the bowels moved on the third day."
No. 50.^ — Male, aged twenty. Seven months previ-
ously he had an attack of epigastric pain and vomiting
lasting two weeks; sudden severe pain in the right
side of the abdomen, accompanied by vomiting. A
few hours later the tenderness was greatest over the
appendix. Temperature, 102° F". ; respiration, 48;
pulse, 118. Diagnosis, appendicitis. Twenty hours
after the attack, an incision over the appendix allowed
the escape of a quantity of odorless gas and fluid. On
account of feeble condition, further operative attempt
was abandoned. Death in twenty-four hours. Au-
topsy showed a perforation in the duodenum, anterior
wall, just beyond the pylorus.'
No. 51. — Male, aged forty-five, a moderate drinker.
Four years previously he had a similar attack. While
in perfect health he was seized with severe pain in the
right side of the abdomen, referred to the iliac region.
A few hours later the abdominal wall w-as tense, with-
out distention or loss of liver dulness; tenderness over
the appendix. Temperature, 100° F; respiration, 32;
pulse, 104. Diagnosis, appendicitis. Twenty-two
hours after the attack an incision over the appendix
evacuated considerable turbid serum. The appendix
was normal. The peritonitis was most marked on the
right side, and was followed up the colon to the hepa-
tic region, but no cause for it could be found. The
whole abdomen was flushed and drains were placed in
the duodenal region and in the pelvis. Death oc-
curred in seven days. Autopsy showed a general exu
dative peritonitis, without free fluid. In the duode-
num, anterior wall, just below the plyorus, was a
perforated ulcer, with the scar of a healed one."
Scabies in infants and pregnant women:
1$ Ung. styracis,
01. olivcE p.ce
— Bull. gen. lie Therapie.
' Elliott: Boston Med. and Surg. Jour., igoo. vol. cxlii., p. 41.
'Elliott; Ibid
' Perkins and Wallace: Lancet, 1900, vol. i., p. 458.
•* Bolton : MF.niCAi, Record, 1900. vol. Ivii., p. 494.
'Bolton : Ihid.
A PRELIMINARY REPORT ON A NEW AND
SIMPLE METHOD OF STERILIZING
CATGUT.'
By CHARLES A. ELSBERG, M.D.,
ATTENDING SURGEON, MT. SINAI HOSPITAL DISPENSARY.
Ever since the time that the absorbable ligature was
introduced into surgical procedure by Lister, catgut
has held a prominent place in our surgical armamen-
tarium. There has been, and still is, however, much
difference of opinion regarding the relative value of
the non-absorbable ligatures — silk, silkworm gut, sil-
ver wire, and the more recently recommended celluloid
thread, and the absorbable ligatures — catgut, kan-
garoo tendon, etc. Without giving an account of the
indications for the use of the one or the otiier, it suf-
fices to state in this place that the use of catgut has
been much curtailed because of the difficulty — by
some considered an impossibility — of always steriliz-
ing it perfectly. For well-known reasons the ordi-
nary method of boiling is not applicable to catgut.
Immersion for a short time in strong antiseptic solu-
tions may render the catgut sterile, but it becomes
hard, fragile, and useless. Prolonged immersion in
dilute solutions of antiseptics has been found to suf-
fice in most cases and has been extensively used. In
this class of methods may be placed the catgut of
Lister, von Bergmann, Braatz, the juniper-oil catgut of
Kocher, the silver catgut of Crede, and the chroini-
cized catgut of Macewen. Sterilization by dry heat
has been recommended by Reverdin, Kiimmel, Lauen-
stein, and others, but time, care, and a special heating
oven are required.
A number of boiling methods have been recom-
mended: the cumol method of Kronig, the xylol
method of Brunner, the alcohol method of Dowd and
of Fowler, the carbolic-acid alcohol method of Saul,
the more recent formalin method of Cunningham and
of Hofmeister, etc. In most of these procedures the
catgut is first freed of its fat and then boiled in a spe-
cial solution for various lengths of time. Most of the
fluids that have been used are inflammable or their
vapors are inflammable, and some of them have a low
boiling-point so that they have to be boiled under
pressure. As a result a more or less elaborate ap-
paratus is necessary ; hence the procedures are not
available for general use. Large diug houses that
prepare sterile catgut for the market use one or the
other of these methods. The immersion of the catgut
in a dilute solution of formalin (two to four per cent.)
fixes the albuminous substances so that the catgut can
then be boiled in water or in decinormal salt solution
without injury to it. Catgut prepared in this manner
is often of very good quality. But under the same
conditions of preparation it is sometimes soft and
strong, at other times hard and fragile. Considerable
practical experience is necessary, and even then one
cannot succeed in obtaining uniform results with the
formalin method. Formalin catgut is absorbed some-
what more slowly than catgut prepared by other
methods.
VVq have, therefore, up to the present time no abso-
lutely satisfactory and practical means of sterilizing
catgut. Prolonged immersion in dilute solutions of
antiseptics requires time, and is not always certain ;
sterilization by dry heat is impracticable; most of the
boiling methods require a complicated apparatus; the
formalin method does not give constant results even
in experienced hands.
The requisites for a good catgut are: (i) sterility;
(2) strengtii; (3) softness and pliability.
In a series of investigations on the preparation of
' Read at the meeting of the Surgical Section of the Academy
of Medicine, .\pril 9, 1900.
May 5, 1900]
MEDICAL RECORD.
761
catgut and other suture materials, the writer had occa-
sion to apply to the work a chemical principle seldom
described but much used in chemistry — that animal
substances are insoluble in those solutions which pre-
cipitate the animal substances themselves. Thus
ammonium sulphate precipitates albumin, and there-
fore albumin is insoluble in solutions of this chemical.
Among other substances ammonium sulphate, one of
the most perfect precipitants of albumin known to
chemistry, was used; it was discovered that this
material has some liitherto unrecognized properties.
One of these properties is made use of in the method
of sterilizing catgut now to be described.
The fatty matter is removed from the catgut by im-
mersing the latter in ether or chloroform for from
twelve to forty-eight hours. It is advisable to use a
mixture of chloroform one part, ether two parts, as
such a mixture seems to have greater penetrating
A
B
Glass Spools for Use in the Sterilization of Catgut bj'
phate Method. A, Spool with single layer of catgut
with perforations at its ends.
power; besides chloroform is an antiseptic. A stock
of catgut from which the fat has been removed in this
manner may be kept on hand in the dry state, the
ether and chloroform mixture having been allowed to
evaporate, and the catgut kept in a clean receptacle.
When the catgut is to be sterilized, it is wound in a
single layer and as tightly as can be done with ease
with the fingers on spools or frames of any conven-
ient size and shape. I have found the spools here
pictured (see figure) useful; they are of a convenient
size, and from five to ten yards of catgut can be wound
in a single layer on them. The spools are then boiled
from ten to thirty minutes in a hot saturated solution
of ammonium sulphate in water. This solution is
made by adding chemically pure ammonium sulphate
to boiling water until the latter is saturated or almost
saturated. The solution boils at io6°-io8° C. or
22o°-226° F. — a high boiling-point, as will be ob-
served.
When the spools are removed from the boiling
solution some of the salt crystallizes upon them.
This is at once removed by a moment's immersion
and agitation in warm or cold water, carbolic acid, or
bichloride solution. The catgut is then ready for use
or for preservation in strong alcohol.
Catgut that has been prepared in this manner will
be found to have lost none of its physical properties.
It is fully as strong as catgut prepared by other
methods; indeed, comparative experiments, which it
would take too long to detail here, have shown that
very fine catgut is stronger after having been boiled
in the ammonium-sulphate solution than after it has
been prepared by other methods. The catgut does
not swell up; it remains of the same thickness as the
raw material. It is readily absorbed in the tissues of
the body, and its absorption takes place between the
fourth and the eighth days.
Bacteriological experiments have shown conclu-
sively that catgut prepared by this method is always
sterile after five minutes of boiling. The accom-
panying table gives a summary of some of my experi-
ments and results. As will be seen in the table, the
anthrax catgut was always rendered sterile in less
than five minutes and the staphylococcus catgut in less
than three minutes.
Instead of in plain water the ammonium sulphate
can be dissolved in one or two per cent, watery carbolic-
acid solution, or in o.i to 0.5 percent, watery chromic-
acid solution. The subjoined table shows how much
less time is required to sterilize the catgut when two-
per-cent. carbolic-acid solution is used instead of
plain water. Thus, while it takes between three and
five minutes to sterilize catgut that has been infected
with anthrax spores when boiled in the watery solu-
tion of ammonium sulphate, it takes from two to three
minutes to sterilize it when two-per-cent. carbolic-acid
solution is used instead of plain water.
Bacterium.!
Boiled in Ho
rated Solu
Ammonium
phate in
Temp. 108°
t Satu-
tion of
Su 1 -
Water
c.
Boiled in Ho
rated Solu
Ammonium
t Satu-
ion of
Sul-
phate in T
Cent. Carbo
Temp. 108'^
wo Per
ic Acid.
C.
Catgut bacillus (0)
Control,
++
Control,
+ +
2 minutes
+
I minute.
5
3 minutes,
—
10
—
5
—
15
—
20
—
25
—
30
-
Staphylococcus pyogenes
Control.
++
Control,
+ +
aureus, from acute ton-
I minute,
+
30 seconds.
+
sillitis.
2 minutes
+
I minute.
3
—
2 minutes
—
4
—
3
—
5
—
4
—
ID
—
5
—
15
—
20 "
—
30
-
Staphylococcus pyogenes
Control.
++
Control,
+ +
aureus, from phlegmon
I minute,
+
30 seconds,
+
of arm.
2 minutes
+
I minute.
+
3
2 minutes,
4
—
3
—
5
—
4
—
10
—
5
—
15
—
20
—
Spores of bacillus anthra-
Control,
++
Control,
+ +
cis grown at 28° C. for
I minute,
+
I minute.
+
4S hours killed by five-
3 minutes
+
2 minutes.
+
per-cent. carbolic acid
5
—
3
—
at room temperature in
10
—
4
—
three and one-half days
15
—
5
—
and by steam at 100° C.
20
—
in three to four minutes.
30
-
Bacillus anthracis and
Control,
++
Control,
+ +
spores killed by steam
I minute.
+
I minute.
+
at 100° C. in two to
3 minutes
+
2 minutes.
—
three minutes.
5
3
—
10 "
15
_
4
5
I
20 "
—
30
"
Catgut can be chromicized by boiling in chromic
acid of any desirable strength. My experiments in
' Sterile coarse catgut threads were immersed in bouillon cul-
tures of bacteria for twenty-four hours, and were dried and boiled
in the solutions. The threads were then washed in sterile water,
cut into short pieces, and dropped into nutrient bouillon. -| — |-
= profuse growth, + = growth, — = no growth.
76:
MEDICAL RECORD,
[May 5, 1900
regard to this matter are not as yet completed, but
from the results thus far obtained it is probable that
catgut can be made more or less absorbable at will,
depending upon the strength of the chromic-acid solu-
tion used and the length of time of boiling. For
general use I have made chromicized catgut by boil-
ing it for twenty to thirty minutes in a saturated solu-
tion of ammonium sulphate in i . 1,000 chromic-acid
solution.
The ammonium-sulphate solution can be used any
number of times; the salt crystallizes out unchanged
as the solution cools, and redissolves on heating. An
excess of ammonium sulphate does no harm. The
catgut can be resterilized any number of times by boil-
ing it in the solution for from five to fifteen minutes.
During the last two months catgut prepared in this
manner has been used by myself in a number of cases,
mostly minor operations, and by several gentlemen in
major operations in their services in Mt. Sinai and
the City hospitals. The results obtained have been
very satisfactory. The catgut was well borne by the
tissues; it was absorbed in from four to eight days; it
was strong, soft, and pliable — in short, it had all the
qualities of a good catgut.
The advantages of this new method of sterilizing
catgut are its cheapness (c. p. ammonium sulphate
costs from 15 to 25 cents a pound), its availability for
general use (no previous experience with the proce-
dure is necessary), the non-inflammability and high
boiling-point of the fluid used; its simplicity (noth-
ing need be measured or weighed out) ; and, above
all, the fact that all grades of catgut can be used and
no apparatus of any kind is necessary. Any one who
desires to prepare sterile catgut for himself need only
obtain catgut free from fat or prepare such for him-
self, and then boil it, wound up on spools in single
layers, in a hot saturated solution of ammonium sul-
phate in one or two percent, carbolic-acid solution, for
from three to five minutes, or in a saturated solution
of ammonium sulphate in plain boiling water for from
ten to thirty minutes; then the ammonium sulphate is
washed off by immersing and agitating the spools for
a minute or two in cold or better warm water, carbolic
acid, or sublimate solution, and then the catgut is
ready for use or for preservation in strong alcohol.
In this preliminary report the theoretical principles
on which this method is based are hardly touched on.
Upon the same principle, with a little difference in
teciinique, sponges and other surgical materials can be
sterilized repeatedly by boiling. The further descrip-
tion and discussion of these matters the writer reserves
for future publication.
To recapitulate, the steps of the procedure are the
following:
1. Catgut, freed from fat as above described, is
tightly wound in single layers on suitable spools.
2. The spools are boiled for from ten to thirty min-
utes in a hot saturated solution of ammonium sulphate
in water, made by adding chemically pure ammonium
sulphate to boiling water until no more will dis-
solve.
3. Two-per-cent. carbolic-acid solution may be sub-
stituted for the water if a quicker sterilization (three
to ten minutes) is desired; or 1:1,000 chromic-acid
solution, if the catgut is to be chromicized.
4. The spools are thoroughly washed by agitation
for from one to two minutes in cold or better warm
sterile water, carbolic acid, or bichloride solution of
any strength.
J. The catgut spools are preserved in strong alco-
hol.
6. For resterilization the catgut spools are boiled
for from five to fifteen minutes in any of the solutions,
and washed in the same manner as described under 4.
105 East Fifty-seventh Street.
Interesting Case of a Pin Transfixing the Eye.
— Christian R. Holmes reports the case of a woman
who was struck in the face by the free end of a rug
she was shaking, with the result that a pin entered the
conjunctiva and penetrated the globe, the head show-
ing superficially to the conjunctiva 2 mm. below the
horizontal line, and 5 mm. from the inner corneal
margin. There was subretinal hemorrhage where the
pin entered the eye, and also where it penetrated the
posterior part of the globe. Under cocaine the pin
was extracted by means of forceps, without loss of
vitreous or of blood, but with difficulty on account
of the end having become hooked. Pain and inflam-
mation subsided three hours after the operation. —
The Cincinnati Lancet-Clinic, March 31, 1900.
Ambulatory Treatment of Fractures Charles D.
Lockvvood defines this treatment as any method that
enables the patient to be about in an erect posture —
while bony union is taking place — and that materially
shortens the period of enforced recumbency. His
conclusions are: (i) That orthopedic measures and
appliances should be more widely used in the treat-
ment of all bone diseases and fractures; (2) all frac-
tures of the lower limb are adapted at some period of
their existence to ambulatory treatment, the time de-
pending upon severity, nature, and site of fracture; (3)
this form of treatment does not materially hasten bony
union, but it makes it more often attainable; (4) the
dangers attending ambulatory treatment are largely
theoretical, and may be practically disregarded; (5)
the early application of ambulatory apparatus, to-
gether with early massage, as practised by the French,
is the ideal treatment for fractures. — I llinois Medical
Journal, April, 1900.
The Early Diagnosis of Idiocy. — J Park West
urges careful observation with a view to early diag-
nosis of this condition in children, because of the
great importance of early giving the proper treatment.
He mentions many of the physical signs of idiocy,
with the dift'erential diagnosis from hydrocephalus.
One of the earliest symptoms in congenital cases is
abnormal movements, or rather the absence or the
slow performance of the constant movements of nor-
mal healthy children. Likewise, a great increase in
the " normal unrest," as tremor, twitching or jerking,
indicates trouble of the nervous system. Congenital
idiots grow slowly, both physically and mentally.
Defective development and defect in the formation of
some part or parts are not unusual. — Columbus Medi-
cal Journal, March, 1900.
Tuberculous Osteitis of the Patella. — Maurice
Gross considers that primary tuberculous osteitis of
the patella is of more frequent occurrence than is
usually supposed. It is a disease of much gravity,
the tuberculous area rapidly perforating the thin pos-
terior cartilaginous layer of the bone, causing a tuber-
culous arthritis of the knee. If a diagnosis be made
sufficienty early in the disease, a relatively simple
operation will suffice to check it. The operations
which are of value are the following: (i) Scraping
out the infected area; (2) ablation of the patella in
nearly all cases of disease of this bone, especially in
adults. Synovectomy may be done in connection with
this procedure. (3) The patella can be removed with-
out interfering with the functions of the knee joint.
After total subperiosteal suppression of the patella, it
has the power of reproducing itself. — A'cruc J/cdicale
de la Suisse Romande, March 20, 1900.
Experimental Researches in Regard to the Con-
veyance of Tuberculous Poison from Parent to
Child. — Angelo Maffucci concludes that the tubercu-
lous poison is more often passed on to the child than
May 5, 1900]
MEDICAL RECORD.
763
is the bacillus; that it may be conveyed by the ovum,
spermatozoon, or placenta; that embryonal intoxica-
tion is manifested by imperfect development, abor-
tion, premature labor, death, and cachexia in extra-
uterine life. The embryonal tissues resist and often
destroy the bacillus, generating a toxin which be-
comes fixed in them. The children of tuberculous
parents are not more susceptible to the tuberculous
virus than those of healthy parents, the greater fre-
quency of tuberculosis among them being due to con-
tact and to the possibility of a germ carried from
embryonal life rather than to a hereditary predispo-
sition. Good hygienic conditions can overcome he-
reditary and embryonal tuberculosis. — Rirista Critica
di Clinica Alcdica, March 24, 1900.
Cultivation of the Lepra Bacillus — Juan de Dios
Carrasquilla says that Hansen's bacillus may be cul-
tivated in gelatinized human serum when this is sown
with lymph taken from a leper by Herman's method. A
second culture, identical with the first, may be obtained
by transferring to other tubes of gelatinized human
serum. The bacillus may also be cultivated in bouil-
lon after previous culture in gelatinized human serum.
The bacillus grown in both is aerobic and motile. The
optimum temperature is 37° C. The temperature may
be reduced to 25" for a few hours without injury, but
the bacillus is destroyed at a temperature of 45° C. — •
Gacctii Medial Catahma, February 15, 1900.
A Case of Bilateral Facial Paralysis Jolly re-
ports the case of a man forty-four years old who had
suffered for nearly twenty years from facial paralysis
on both sides. The trouble had followed an injury
incurred by being caught by a revolving wheel and
thrown violently on to a heap of coal. The patient
was unable to wrinkle the forehead, to wink the eyes,
or to change the expression of the mouth. The only
movements possible were those of the jaw ; all the mus-
cles supplied by the facial were paralyzed. One eye
was nearly destroyed by the original injury, and the
other suffered greatly through its exposure to dust.
The nerves were injured in their passage through the
petrous portion of the temporal bone, and there must
have been a transverse fracture through both these
bones. — Deutsclie mcdicinische WochoiscJn-iJt, March 15,
1900.
The Fate and the Action of Acid Sodium Urate
in the Abdominal Cavity and Joints of Rabbits. —
As the result of an experimental investigation under-
taken for the purpose of determining the alterations
induced by acid sodium urate in the tissues and the
fate of this substance in the body, His found that this
substance, injected into the abdominal cavity and
joints of rabbits, excites inflammation, attended with
necrosis. This is distinguished from that induced
by indifferent foreign bodies by beginning earlier, by
its greater intensity and extent, and by extension of
the necrosis to adjacent parts. On injecting the urate
into the joints the cartilage remains intact, while the
synovial membrane and the periarticular structures
become inflamed. Acid sodium urate acts in part as
a foreign body and in part as a feeble tissue-poison.
The toxic action is attributable to the solution of the
salt. Within the body the amorphous salt may un-
dergo crystallization. Even considerable amounts of
urates are absorbed from the abdominal and articular
cavities within eight or ten days at most. In the re-
moval phagocytes participate in an active manner;
also uninuclear and multinuclear leucocytes, granu-
lation cells and giant cells. Within these cells the
urate is rapidly destroyed, and it can no longer be
demonstrated in the regional lymphatic glands. It
is probable that the same processes take place in cases
of recent gout in human beings, but that in cases of
chronic gout the reactive powers of the organism are
diminished. In future autopsies in cases of gout at-
tention should be directed to the changes in the re-
cently inflamed parts, and among therapeutic measures
vital processes should be taken into consideration in
addition to the chemical. — Dctitsches Archiv fur kli-
nisc/ie Mcdia'ii, Bd. 67, Heft i and 2.
Rupture of the Pregnant Uterus.— Alexander
Doktor reports the case of a woman, thirty years old,
who Was brought to the hospital in a state of partial
collapse. She had passed through a normal preg-
nancy and had been in labor for a while, but the pains
suddenly ceased after about twenty hours, and the pa-
tient's condition became very grave. A diagnosis of
rupture of the uterus was made. Caesarean section
was performed, and the patient made a good recovery.
The fcetus was a male, weighing nine pounds five
ounces, with a large head (fifteen and three-fifth inches
in circumference) the bones of which were in great
part ossified, and the sutures and fontanelles were
narrow. — Der Frauenarzt, March 16, igoo.
Human Actinomycosis. — Anton in Poncet gives the
results of a study of twenty-six cases. In twenty-one
the tumors were situated in the cervico-facial region,
one in the pleural region, with perirenal infiltration
and secondary nucleus in the breast, two in the cffical,
one in the umbilical, and one in the vesico-ano-rectal
region. Out of fifteen of the cases in which the ulti-
mate results of the disease could be traced, there were
five deaths, two relapses, and eight temporary cures.
The author advises the iodine treatment, but consid-
ers its value problematical. He urges great vigilance,
early diagnosis, and prompt surgical interference.
Mere evacuation is not sufficient, but should be fol-
lowed by curetting and cauterization. — Bulletin de
r Acadhnie de Medeci?ie, March 27, igoo.
Sciatica and its Treatment. — Francesco Tomma-
soli refers to the various methods of treatment used in
this affection, such as the rest cure, injections of anti-
pyrin or carbolic acid, mud baths, electricity, com-
pression, and nerve stretching. He then describes the
surgical treatment of the nerve as performed by him-
self. The usual pre-operatory procedures are followed,
and the patient is given an injection of morphine and
atropine and anaesthetized. An incision about 8 cm.
long is made in the posterior median line of the thigh,
between its upper and middle third; the sciatic nerve
is seized by the curved index finger of the right hand,
and gently pulled until it is lengthened by several
centimetres. The wound is then irrigated and dried,
and sutured with catgut. The results have been satis-
factory in several cases. — II Raccoglitore Medico,
March 20, 1900.
Septic Maculo-Papular Erythema in Conjunction
with a Follicular Angina. — Karl Dehio says that
through clinical observation alone must we expect
light to be thrown upon most questions involved
in erythema multiforme. He relates a case in a
female nurse, twenty-three years old, who after chills
had on the third day a temperature of 40.5° C, and
pain in swallowing (angina lacunaris). The same
night there appeared an erythema upon hands, feet,
and neck, disappearing under pressure. This was
followed by delirium, increased temperature and pulse,
vomiting, increase in size of original dark red maculae
and many new ones, \n\\y subsequent change of the cen-
tral parts into livid red, which on pressure left behind
a dark brown pigmentation. Desquamation in large
flakes and convalescence set in on the fourteenth day
of the fever. He regards the process as an infection
akin to the exanthemata. — St. Fetersburger mediciiiische
Wochetischrijt, March 17, 1900.
764
MEDICAL RECORD.
[May 5, 1900
Journal of the American Med. Ass'n, April 28, igoo.
Congenital Aphakia and Irideremia. — Flavel B.
Tiffany reports several cases in the same family, and
states that congenital aphakia is an exceedingly rare
anomaly, being usually accompanied with other seri-
ous defects of the eye. Iridodonesis is generally ex-
plained by the loss of the crystalline lens, that is, the
posterior support of the iris. The writer attributes
the trembling of the iris in these cases not only to
congenital aphakia, but probably to a weakness of the
ciliary body and suspensory ligament, and the dimness
of vision to an arrest of development or defect of one
or several of the ten layers of the retina. Very curi-
ously, concave glasses gave improvement of vision,
showing a high degree of myopia, whereas hyperme-
tropia was expected.
The Smegma Bacillus. — Oscar A. Dahms, among
the differential points distinguishing the smegma and
syphilis bacilli, says the latter are, as a rule, slender
straight or curved rods, while the former are smaller,
plump rods. The smegma organisms are more read-
ily decolorized by alcohol. They may also resist the
action of acids for two minutes or longer, while the
organisms of syphilis are decolorized by acids in thirty
to forty seconds. The latter are stained well by
Doutrelepont's method, while the smegma bacilli are
not. In differentiating the smegma from the tubercle
bacillus, Marion Dorset has found that Sudan iii.
stains the tubercle bacillus a bright red, while it does
not stain the smegma bacillus.
Treatment of Variola by Bichloride Baths — H.
A. Ingalls believes in regard to this treatment that:
(i) There is practically no mortality. (2) The sup-
purative fever can be shortened four to six days if the
patient is treated from the onset. (3) A minimum of
pitting is secured, and there is an almost entire ab-
sence of the characteristic disagreeable odor. (4)
The period of desquamation is materially lessened,
owing to the thinness of the scab formation. (5) Pain
is much reduced, morphine being rarely indicated.
(6) Distorting of features is eliminated to a great ex-
tent.
Double Inguinal Hernia upon the Same Side ;
Illustration. — Charles C. Allison describes this case
of a man fifty-six years old, operated on February 3.
1900. The hernial protrusion was oblong in shape
and extended into the upper part of the scrotum. It
was reducible, and its reduction revealed a very marked
attenuation of the abdominal muscle over the inguinal
region. It is a case of exceeding rarit}'.
Endothelioma of Gasserian Ganglion : Two Suc-
cessive Resections of Ganglion — First by Extradural
(Hartley-Krause) Operation, and Secondly by Intra-
dural Operation. — Lly F. X. Dercum, W. \V. Keen, and
W. G. Spiller.
Peripheral Resection of Fifth Nerve. Three
Cases with Microscopic Examination of Portions cf
Nerves Removed, and Report on Later Condition
of Patients. — By \V. W. Keen and \<i . G. Spiller.
Method of Total Extirpation of Gasserian Gan-
glion for Trigeminal Neuralgia, by a Route through
the Temporal Fossa and beneath the Middle Menin-
geal Artery. — By Harvey Gushing.
Method of Exposing Gasserian Ganglion; Removal
of Superior Maxillary Nerve. — By Gwilym G. Davis.
Medical Ethics and Medical Journals — By P.
Maxwell Foshay.
Philadelphia Medical Journal, April 28, igoo.
Exophthalmic Goitre ; its Complications and Af-
finities.— Roberts Bartholow says that the most use-
ful single remedy for this affection is galvano-farad-
ism, the descending stabile current being applied so
as to include the pneumogastric and cervical sympa-
thetic nerves wdthin the circuit. In the cases in which
cardiac symptoms predominate sparteine sulphate and
picrotoxin, combined perhaps with the sulphates of
iron and manganese, are of value. In the more chronic
cases, associated with valvular lesions, fibroid degen-
eration of the thyroid, and pigmentation of the skin, he
has had the best results from a solution of sodium iodide
3 v., sodium bromide 3 iii., sodium arsenate gr. i., in
distilled water 3 iv., in teaspoonful doses three times
a day.
An Early Sign of Tuberculosis. — Thomas F. Har-
rington calls attention to a widely dilated condition
of both pupils as symptomatic of very early tubercu-
lous infection. He says that he has time and again
observed dilated pupils in patients with other diseases
or in apparent health, and has so frequently seen tuber-
culosis occur at a later day that he has come to asso-
ciate this sign with incipient tuberculosis.
Extra-Abdominal Shortening of the Round Liga-
ments by an Inch Incision Over the Internal Ring
for Freely Movable Posterior Dislocation of the
Uterus.— By A. H. Goelet.
Infection through the Tonsils, Especially in Con-
nection with Acute Articular Rheumatism. — By
Frederick A. Packard.
A Study of the Rectal Valves, Experimental and
Clinical. — By A. B. Cooke.
Some Obstetric Notes By Francis H. Stuart.
Bos/on Medical and Su?-gical Journal, April 26, igoo.
Splenic Pseudoleukaemia — R. C. Cabot says that in
the diagnosis of this disease we have to distinguish (i)
cases of idiopathic splenic enlargement without any
ana;mia or any other symptoms, which are not very un-
common. (2 ) We must exclude pernicious anaemia,
in which a slight enlargement of the spleen is almost
always present, and sometimes a very considerable
one. (3) We must distinguish the disease from cir-
rhosis of the liver, which is often extremely difficult.
(4) Splenic tumor associated with chronic malarial
poisoning must also be excluded. (5) From leukaemia
the disease may be easily and quickly distinguished by
the blood examination. (6) The anaemias of children
are frequently associated with enlargement of the
spleen, with or without leucocytosis, and their classi-
fication is still unsatisfactory. As a rule such cases
are usually considered secondary to rickets or syphilis.
As to the prognosis, some of Osier's cases have lasted
twelve years, and the patients are still in good health.
Splenectomy was done in one of his cases with favor-
able results. The author considers it a reasonable
method of treatment, as splenic enlargement seems to
have preceded the anaemia in all the recorded cases in
which the question has been looked up thoroughly.
Splenic Anaemia James Marsh Jackson reports the
case of a woman twenty-eight years of age. At the
physical examination a mass was found on the left
side extending from the seventh rib diagonally across
to the umbilicus, and then toward the riglit anterior
spine; dulness extended over into the left llank, and
back and down to the crest of the iliac bone on the left
side. The mass descended slightly with inspiration;
edge (right), notched twice; otherwise the mass was
perfectly smooth. The rest of the abdomen was soft,
May 5, 1900]
MEDICAL RECORD.
765
tympanitic, and not tender. The examination of the
blood showed: red cells, 4,076,000 ; white cells, 5,200 ;
differential count, 500 cells; polymorphonuclear neu-
trophiles, 36.2 per cent.; lymphocytes, 58.7 per cent.;
myelocytes, 4.5 percent.; eosinophiles, 0.6 per cent.
Splenic Anaemia. — John Lovett Morse reports two
cases. Ana;mia of various grades of severity, with en-
largement of the spleen, with or without leucocytosis,
is not at all uncommon in infancy. It is especially
common in rickets. The splenic tumor and ansemia
seem independent of each other, and are both proba-
bly the results of some common cause, which in in-
fancy is apparently always some profound, complicated,
and obscure disturbance of the nutrition. Reasoning
from analogy the author is inclined to think that these
unusual cases of anajmia and splenic enlargement in
adult life may be due to obscure disturbances of nutri-
tion, and may also be independent of each other and
the results of a common cause.
Splenic Anaemia Henry Jackson reports a case in
a young man aged twenty years. The physical exami-
nation showed splenic dulness from the eighth rib to
just below the costal margin, where the edge was plainly
felt, smooth and rather hard. Red cells, 4,000,000 ;
hsemoglobin, twenty per cent.; polymorphonuclear
neutrophiles, sixty-one per cent. ; lymphocytes, twenty-
nine per cent.; large mononuclear and transitional
forms, eight per cent. ; eosinophiles, two per cent. He
suffered greatly from bleeding hemorrhoids. At the
present time he is not anaemic, but the spleen remains
enlarged. The diagnosis is obscure, but it was prob-
ably a case of splenic anaemia.
Medical News, April 28, igoo.
Interesting Case of Syphilis. Epithelioma In
the first of these two cases reported by L. Blake Bald-
win, the condition of the patient before treatment was
appalling, the entire body being covered with ulcerat-
ing lesions, two hundred and eighty-four in all, and
the weight having fallen from one hundred and sevent)'-
eight pounds to ninety pounds in fourteen weeks. The
stomach resisted five-grain doses of potassium iodide,
and he was treated with wet bichloride-of-mercury
dressings applied to all ulcerated surfaces except the
cranium. After the first week the wet dressing was
applied to the head also. Internally he was given the
pure juice of five pounds of beef daily, seasoned with
salt and pepper, which amount was increased during
the first week to eight pounds. He was also given
gr. xl. of potassium iodide three times daily, the dose
being increased during the first week to gr. cxv. t.i.d.
Following the removal of the crusts and cessation of
the suppurative process, the ulcers were dressed with
Unna's emplastrum hydrargyri mull. His recovery
was rapid: on the fourteenth day he walked unassisted
to meals, and two months after the first consultation
he weighed one hundred and eighty-seven pounds.
The second case reported was one of epithelioma of the
face in a Polish woman, together with eruptions on the
abdomen, breast, and thigh. The original eruption on
the face began eleven years ago as a black pimple with
but little discharge. The patient had borne fifteen
children. There was no history of sore throat or fall-
ing of the hair, nor any necrotic ulceration.
Cancer of the Breast and the Results of Opera-
tion.— Clarence A. McVVilliams studies the statistics
of one hundred cases, and presents the following sum-
mary: Trauma present in 44.6 per cent.; married,
74 per cent.; children born to 66.6 per cent.; aver-
age number of children to each, 5; pain present
in 56.2 percent.; nipple retracted in 45.2 per cent.;
right breast involved in 51; left breast involved
in 49; axillary glands palpable in 48.9 per cent;
axillary glands found cancerous by microscope, 78.6
per cent. Average age was forty-nine years six
months twenty-six days. Mortality of operation, four
per cent. Average length of time in hospital, twenty
days. Prolongation of life for one year, fifty-nine per
cent.; for two years, thirty-six per cent. Cured (no
recurrence at end of three years), thirty-four per cent.
Recurrence took place in one year in twenty-one cases;
in two years in twenty-eight cases; locally in fifteen
cases; in lung in six cases. Average length of time
in recurrent cases from operation to death, one year
two months twenty days; average length of time from
period of recurrence to death, five months.
Cancer Occurring in Acid Parts of the Body.— A.
L. Benedict presents statistics tending to show that the
great majority of cancers develop in acid media.
Whether acid parts of the body happen to be where
mechanical traumatisms are frequent, or whether the
localization is due to some unsuggeSted cause, the
writer does not pretend to state.
Some of the Reasons why the Surgical Treat-
ment of Nasal Disease has been Placed on a Con-
servative Basis.— By Clarence C. Rice.
After-Treatment of Tenotomy of the Eye Mus-
cles.— By Alexander Duane.
A New Traction Hip-Splint By L. Blake Bald-
win.
New Yorl; Medieal Joiunal, April 28, igoo.
The Relation of Hydrochloric-Acid Secretion to In-
dicanuria. — According to A. A. Jones, indican bears
no constant relationship to the secretion of hydrochloric
acid in the stomach. The later portion of the article
discusses the matter of indican in its general relation
to various diseases. It now seems settled that this sub-
stance is the product of putrefaction of albuminous
matter caused by bacterial action. It is produced
when pus formation, gangrene, necrosis, or ulceration
takes place. The mother-substance is indol. It is
always present in the bowel excepting in the sterile gut
of the new-born. An excessive amount of indican is
present in ileus and in gastric ulcer.
Ethylic Bromide (C HBr) Anaesthesia Prelimi-
nary to the Use of Sulphuric Ether.— G. R. Fowler
commends the following plan: From one to two
drachms of ethylic bromide is placed upon the inhaler,
and in fronj thirty to forty-five seconds, according to
the freedom with which the patient breathes, the ad-
ministration of the sulphuric ether is begun, without
changing the inhaler, and proceeded with as in ordi-
nary ether anesthetization.
A Contribution to the Histo-Pathology of Epider-
molysis Bullosa (Hereditaria).— By G. T. Elliot.
Nitrous Oxide ; Ether ; Chloroform By S. Or-
mond Goldan.
The Diagnosis of Hysteria.— By C. W. Burr.
The Lancet, April 21, igoo. '
Coxa Vara.— C. B. Keetl^y defines this affection
as a deformity of the upper epiphyseal region of the
femur in which the head of the bone sinks to a lower
level than normal, in extreme cases almost touching
the lesser trochanter. The upper border of the neck
of the femur is longer and the lower border shorter
than normal; hence the neck is more horizontal than
normal, or it may descend instead of ascending in the
766
MEDICAL RECORD.
[May 5, 1900
usual way. The articular surface of the head may
thus come t3 look downward. The neck is also bent
in a horizontal as well as in a perpendicular plane,
with the convexity forward. The underlying condition
is rachitis of adolescents. The author was the first to
recognize the nature of the deformity, and reported a
case in the Ilhistrated Medical Netas of September 29,
1888. Since then Ernst Miiller and Kocher have de-
scribed the affection at great length.
Note on the Influence of the Temperature of
Liquid Air on Bacteria.— Allan Macfadyan and S.
Rowland report the results of exposing various micro-
organisms (bacillus typhosus, bacillus coli communis,
bacillus diphtheria, bacillus proteus vulgaris, bacil-
lus acidi lactici, bacillus anthracis, spirillum choleras
asiaticas, staphylococcus pyogenes aureus, bacillus
phosphorescens, a sarcina, a saccharomyces, and the
bacteria in unsterilized milk) to the temperature
of liquid air (— 190"^ C.) for a period of some days.
In no instance could the slightest structural alteration
in the bacteria be discovered, nor could any impair-
ment in the vitality of the organisms be detected, ex-
cept that in one or two instances the growth in the
sub-cultures was slightly delayed.
The Production of Local Anaesthesia in the Ear.
■ — Albert A. Gray comments upon the difficulty of in-
ducing anesthesia of the unperforated drum mem-
brane with aqueous solution of cocaine or eucaine, due
to the fact that the nerves terminate in the inner layer
of the tympanic membrane, and the drug must be inade
to penetrate the epithelial and dense fibrous layers be-
fore it comes in contact with the nerve termination.
The author has overcome this diiificulty by employing
a solution of five parts of cocaine hydrochlorate in fifty
parts each of dilute alcohol and anilin oil. He finds
that a few drops of this solution instilled into the
meatus and allowed to run down on to the tympanic
membrane will quickly induce complete anesthesia of
this part. Several cases of the successful employment
of this solution are reported.
On Backache as a Symptom of Rectal Disorder.
- — E. Harding Freeland calls attention to the fre-
quency with which the presence of backache points
to disease of the rectum, and says that when it is as-
sociated with symptoms referable to the other pelvic
organs, the bladder or the uterus, the rectum will not
infrequently be found to be the organ primarily at
fault. He reports several cases in support of this
view. As the earliest sign of incipient cancer of the
rectum he thinks it ^s of especial value.
On the Causation of Nervous Symptoms in
Typhoid Fever, with an Experimental Study of
the Action of Typhoid Toxins on the Ganglion
Cells of the Central Nervous System. — By Alexan-
der G. R. Foulerton.
Epileptic Attacks Preceded by Subjective Audi-
tory and Taste Sensations, Probably due to a
Tumor of the Left Temporo-Sphenoidal Lobe. — By
J. Mitchell Clarke.
The Modern Treatment of Uterine Fibroids, with
a Table of Sixty-Eight Consecutive Cases of Hys-
terectomy.— By William Duncan.
A New Method of Treating Femoral Fractures in
the Infant.— By John D. Rice.
Dislocation of the Epiphysis of a Metacarpal
Bone. — By E. Kerr Herring.
The Medical Press and Circular, April ii, igoo.
Complicated Case of Double Ovariotomy in a
Girl. — J. Halliday Groom relates a case in which there
had been a swelling of sixteen months' duration in a
girl of eighteen who had never menstruated. Every-
thing pointed to cancer except the age. Blood-stained
fluid was removed from the pleural cavit}', as well as
from the abdomen. A dermoid tumor was removed,
the ovafy on the opposite side being found healthy.
Two years later the patient came again under observa-
tion for a swelling of six weeks' duration, and a large
hard tumor was found along the middle line with dul-
ness almost continuous with that of the liver. A
cystic papilloma, probably starting from the other
ovary, was removed.
A Case Simulating a Perforating Gastric Ulcer.
— J. W. Thompson and Conway Dyer relate an in-
stance in which the symptoms pointed to ulcer of the
stomach. The abdomen was opened and a coil of
jejunum was found intensely congested with two gan-
grenous spots. Resection was done with the Murphy
button, and the bowel was flushed with sterile salt solu-
tion. The bowels moved on the fifth day, and the but-
ton passed on the eighteenth day. Prompt operation
in such cases m.ay save life.
A Case of I^upture of the Quadriceps Tendon
Arthur H. Burgess relates the steps of an operation
for injury above the knee with loss of power of exten-
sion. The tendon was drawn down and sutured to the
patella by three stout silk sutures. The course was
satisfactory, the sutures being removed on the twelfth
day. Five weeks later the patient walked without sup-
port. Non-operative treatment is not likely to yield a
good result.
Practical Observations on Cancer of the Breast.
— By Sir William M. Banks. (Lettsomian lectures.)
A Case of Removal of Appendix Caeci. — By P. G.
Lodge.
On Obstructive Dysmenorrhoea. — By Alexander
Duke.
British Medical Journal, April 21, igoo.
Lengthening of Hamstrings by Operation for Con-
tracture after Burn — W. Y. Brook reports this case
in which the biceps tendon was split for three inches
near its insertion, divided, and sutured. The inner
hamstrings were divided transversely at different levels
three inches apart. The proximal end of the semi-
tendinosus, which had been cut at the lower level, was
sutured to the distal end of the semimembranosus,
which had been cut at the higher level. The other
ends were shunted into their neighbors and sutured.
The boy was admitted to the hospital in February,
1899. In February, igoo, he walked without a limp
and without the slightest effort.
Calculi Impacted in the Ureters. — David New-
man writes of the pathology, symptoms, and surgical
treatment of this subject. The calculus may be im-
pacted in one ureter, the other kidney being compe-
tent, or the calculus may be impacted in one ureter,
the other kidney being incompetent. The symptoms
depend upon whether the morbid processes involve
one or both kidneys. The blocking of the ureter is
generally preceded by renal colic coincident with
blood in the urine. The operative procedure depends
upon the position of the stone.
Large Sarcomatous Neuroma of the Internal Pop-
liteal Nerve. — George Buchanan recounts the occur-
rence of a large sarcomatous tumor of the trunk of the
internal popliteal nerve following a blow on the leg.
The leg had finally to be amputated. The tumor was
a round-cell sarcoma. This case showed that nerves
may be extensively infiltrated and disassociated with
comparatively little degeneration resulting.
May 5, 1900]
MEDICAL RECORD.
767
Five Cases of Complete Forward Dislocation of
the Knee-joint Occurring Simultaneously. — Ernest
V. Eames reports these five cases, the result of an ac-
cident at the Shipley collieries, Derbyshire. All but
one patient recovered. They all feel " a change in
the weather " in the injured member.
A Clinical Lecture on the "Riding Fragment"
in Fractured Leg. — By C. H. Golding-Bird.
A Case of Enterectomy by End-to-End Suture in
a Boy Aged Seven. — By F. C. Wallis.
A Case of Uraemia Closely Simulating Cerebral
Hemorrhage. — By Cecil Firmin Lillie.
On Double Castration for Tuberculosis of the
Testes. — By F. A. Southam.
Twin Pregnancy with Central Placenta Prasvia.
— By David P. Gaussen.
Twelve Cases of Mauser Bullet Wounds. — By
George Ashton.
Sclerema Neonatorum — By John William Taylor.
Miinchencr mt'dicinische Wochenschrijt, April 10, igoo.
The Catgut Question Carl Lauenstein believes
that the question has come to the point of definite solu-
tion, since during the past twenty years a whole series
of methods of preparation have come up for secur-
ing a germ-free article. If infection occurs, it must
be secondary, from the hands, air, skin, or mucous
membranes. Attention must be paid to the best meth-
ods of using the catgut suture. Aseptic catgut should
be further subjected to antiseptic processes. The pos-
sibility of making it germ-fiee, added to the advan-
tages of its being absorbed, make catgut the best suture
and ligature material. It will be surpassed only by
some material having equally good qualities, while
not swelling up in the tissues nor offering a favorable
medium for bacterial growth. Various methods of
sterilization are given.
Periosteal Transplantation of Tendons in Paral-
ysis.— Fritz Lange says that orthopaedics is no longer
a trade, but a science. It must be wrested from the
bandage makers, manipulators, etc., just as surgery a
few years ago was taken from the hands of the barbers.
He presents numerous illustrations and diagrams to
show how transplantation of muscle directly to the
periosteum acts better than when active muscle is at-
tached to the tendons of paralyzed muscle.
The Treatment of Pes Valgus.— A. Hoffa presents
an illustrated article, a new method of treatment for
pes valgus, which, in recent years, has been distinctly
separated from ordinary flat-foot. He thinks that by
shortening the tendon of the tibialis posticus a decided
advance in the treatment of the affection will be made.
Bacteriology of the Mechanico-Chemical Disin-
fection of the Hands — By Ferdinand Schenk and
Gustav Zaufal.
The Determination of the True Size of Objects
by Means of the Roentgen Process — By Professor
Moritz.
The Newest Method of Field Treatment of Bul-
let Wounds. — By von Bruns.
On Restricting the Antiseptic Operative Field. —
By G. Walcher.
A Pocket Sterilizing Apparatus. — By Dr. Bofinger.
(Illustrated.)
Surgical Suture and Ligature Material. — By H.
Braun.
Asepsis Contra Antisepsis. — By Otto Lanz.
French Journah.
Rheumatic and Neuropathic States Maurice
Faure treats of conditions secondary to the grippe with
persistent infections of the naso-pharynx. He con-
cludes that these infections may persist for a long time,
being accompanied by fever, malaise, intense fatigue,
night sweats, insomnia, and loss of flesh. Articular
and nervous affections may be due to toxins secreted
in the infected cavities. These manifestations disap-
pear rapidly under the influence of orrhotherapy in
weak repeated doses. — La Mcdecinc Aloderjie, April
1 1, 1900.
The Role of Engorgements of the Liver in the
Predisposition to Pulmonary Phthisis and Second-
arily in its Course. — Dr. Guerder gives thirteen ob-
servations, and discusses the causes, symptoms, na-
ture, pathogeny, and treatment. The latter consists in
the application of revulsives over the liver region, in
intestinal antisepsis, regimen, and rules of hygiene, all
of which are dilated upon. — Revue de Therapeutique
Medico-Chirurgkale, April 15, 1900.
Acute Dermatomyositis. — L. M. Bonnet speaks of
this severe disease, which may prove fatal within a
few weeks or months. The history, etiology, symp-
toms, forms, course, diagnosis, pathology, pathogeny,
and treatment are given, together with a full bibliog-
raphy. The only treatment is symptomatic, directed
to the pain. Internal remedies seem useless.- — Gazette
des Hopitaiix, April 14, 1900.
Concerning Some Renal Accidents Observed in
the Course of Acquired Syphilis.— Gabriel Delamare
discusses the nature and frequency of renal complica-
tions of syphilis, and whether malaria may be, in such
instances as he brings forward, the underlying cause
and syphilis the determining factor. — Gazette des
Hopitaux, April 12, 1900.
Polymorphous Dermatitis. — L. Brocq presents with
colored pictures a case of painful pruriginous circum-
scribed polymorphous dermatitis, and discusses its re-
lationship to Duhring's disease. Successful means of
treatment have not yet been found. ^Z(7 Presse Medi-
cate, April 14, 1900.
The Jouriia/ of Tropical Medicine, April, igoo.
Ticks and Tick Fevers. — L. W. Sambon describes
the life history of ticks, and the diseases caused by
the several varieties, such as redwater fever, louping
ill, the disease of Miana, the disease of Tete, and
various diseases of Central and South America. Few
measures suggested for the destruction of ticks are
adequate or practicable. A valuable remedy for im-
mediate use is the powder of the pyrethruni flower,
which should be dusted between the sheets of the bed.
When a tick has fixed itself on the skin, the only indi-
cation is to induce the voluntary detachment of the
animal by the application of a drop of olive oil, tur-
pentine, benzene, or petroleum on the parasite, rub-
bing its ventral surface with a feather or spill of pa-
per dipped in oil. Forcible detachment gives great
pain, and the rostrum remains embedded in the skin.
The Endemic Centres of Plague. — In a second
article on this subject, Frank G. Clemow reviews the
history of the hill plague of India. The relation of
the centres of plague in the Himalayas to the epidemic
which has raged in India since 1896 has been the
subject of much discussion. Either the disease de-
768
MEDICAL RECORD.
[May 5, 1900
veloped spontaneously in Bombay, or it was imported
from elsewhere. Some published facts seem to point
to a possible importation of the plague to Bombay
from its endemic home in the Himalayas. The only
other alternative suggestions are that it came either
from Central Asia or from Mesopotamia or Persia.
The author considers each of these possible sources
of infection in turn.
Peculiar Condition of the Hair. — R. C. Bennett,
of Trinidad, describes a peculiar condition of the hair
in a negro child, illustrating his description with
photographs. The hair grows luxuriantly and sepa-
rates itself into thin rope-like strands, made up of
closely interwoven meshes. The strands measure from
six to twelve inches in length. The parts nearest the
skull are black; the distal ends are a pronounced red,
due to exposure to the sun. The condition is con-
genital. There is much superstition among the na-
tives affected, and children are obliged to carry this
abnormal mass until they are old enough to cut it
away with their own hands. After cutting, the condi-
tion does not recur.
Upon the Part Played by Mosquitos in the
Propagation of Malaria.— By George H. F. Nuttall.
A Sketch of the Leper Asylums, British Guiana.
—By F. A. Neal.
American Journal oj the Medical Sciences, May, igoo.
Senile Bronchitis Reynold Webb Wilcox dis-
cusses the bronchitis of the aged and the best meas-
ures for its amelioration. He condemns the employ-
ment of opium or any of its alkaloids, which, he says,
leads simply to an accumulation of secretion in the
lungs, killing the patient by asphyxia, or more gradu-
ally by a septicaemia, resulting from gradual absorption
of putrid material. The best remedies are strychnine
and ammonium carbonate. When the expectoration is
markedly purulent and foul, much good may be effected
by the administration of creosote carbonate in twenty-
drop doses in sherry every four hours. The inability
to exercise, existing in many cases, may be compen-
sated for in a measure by massage. Finally the great-
est care must be taken to improve the patient's general
health by regulation of the diet, attention to the skin,
the ordering of suitable clothing, etc.
An Analysis of Fifty-One Cases of Pneumothorax.
■ — John Lovett Morse says that from seventy to eighty-
five per cent, of all cases of this affection are tubercu-
lous in their origin. The prognosis of traumatic pneu-
mothorax is good, and that of the condition when
secondary to abscess of the lung is fair. Tuberculous
pneumothorax is twice as frequent on the left side as
on the right. Its onset is usually rather acute, sudden
pain and dyspnoea being the most common initial
symptoms. Recovery occurs in about fifteen per cent,
of all cases, but these generally terminate in death from
pulmonary tuberculosis later. The pneumothorax is
usually complicated by the presence of fluid, but it
may be simple. Fluid is almost always present in
cases lasting longer than a week, and it is more often
purulent than serous.
The Acute Pneumonic Form of Tuberculosis
Arthur W. Elting reports a case of this nature, and
sums up the main clinical features of the disease as
follows: The onset is often without a definite cliill.
The fever at first is regular, irregular, or remittent, and
is practically always of a remittent character in the
later stages. Marked dyspnoea and cyanosis are usu-
ally absent. The consolidation is of variable extent.
There is pain in the side, with cough and a sputum,
which is at first typically pneumonic, but in a week or
ten days may assume a greenish tinge, and will then be
found to contain tubercle bacilli. The leucocytosis
usually associated with acute lobar pneumonia is ab-
sent, in some cases at least, in acute tuberculous pneu-
monia.
The Differential Diagnosis of Ectopic Gestation.
— Edward P. Davis reports three cases illustrative of
the difficulty of diagnosis in many of those cases. He
says that shock referred to the abdomen occurring in
woman capable of pregnancy should invariably cause a
suspicion of ectopic gestation, and if the shock is pro-
nounced, the abdomen should be opened and any ab-
normal conditions there found should be promptly
treated.
A Critical Summary of the Literature on the
Surgery of the Stomach. — By Charles H. Frazier.
A Case of Multiple Neuro-Fibromata of the Ulnar
Nerve.- By W. W. Keen and William G. Spiller.
Two Cases of Tabes Dorsalis in Negroes —Husband
and Wife By Albert Phillip Francine.
The Clinical Aspect of Plague. — By Frank G.
Clemow.
Zeitsch.J. diiitct. iind pliysilc. Tlier., vol. iv., No. i, igoo.
Therapeutic Use of Vegetable Diet Th. Rumpf
reports his experiments with a subject fed on a vege-
table diet. Some vegetarians take vegetables pure
and simple; others add milk, cheese, and butter to
their diet. All animal food is excluded. Vegetable
diet has certain dangers, namely, an underfeeding,
and in women often a chlorosis with marked weak-
ness. The advantages of a vegetable diet lie in the
fact that overfeeding, especially with proteids, is
avoided, that the intestinal function is increased, and
that large and free movements occur. The number of
pulse beats per minute is lessened with vegetable diet.
In one case Barlow's disease and in another a severe
rickets followed the prolonged use of Lohmann's vege-
table milk. In cardiac weakness a pure vegetable
diet is contraindicated. Vegetable diet is most useful
in chronic constipation.
Should Physicians Suffering from Pulmonary
Diseases Seek Ship Service? — Emanuel Freund re-
lates his observations as based upon a two years' ex-
perience. During the first five months the catarrhal
symptoms, bad breathing, and cough disappeared. The
winter storms caused exacerbations of the old catarrh.
In all, a two-years' sea-voyage produced (1) a marked
increase of the bronchial catarrh, (2) a weakness of
the digestive apparatus, (3) a loss of body weight
amounting to twelve pounds.
The Newer Methods of Treating Lupus. — O. Las-
sar discusses at length, with eighteen photographs, the
methods of cauterization by superheated steam, photo-
therapy, and radiotherapy. All three have improved
numerous inoperable lupus cases.
The Osmotic Pressure of the Secretions in their
Relation to the Occurrence and Amelioration of
Disease Processes. — By Alexander Poehl.
Nourishment of Prisoners. — By Felix Hirschfeld.
Ze't. jiir klinische Med., vol. .x.xxi.x., JVos.j and 6, igoo.
Pathogenesis of Eclampsia. — W. Stroganoff con-
cludes that eclampsia is an acute infectious disease,
caused by a volatile contagium which usually enters the
system of the woman by way of the lungs. The causa-
tive agent possesses a weak degree of virulence, and in
some women finds toward the end of pregnancy, dur-
May 5, 1900]
MEDICAL RECORD.
769
ing parturition, and in the early days of the puer-
perium favorable conditions for its development. The
same may be conveyed to the foetus and attacks boys
and girls indifferently. The contagious element of
the disease possesses great resistance and retains its
virulence for about three weeks. The incubation of
the disease is most generally from three to twenty
hours. Being an infectious disease of a contagious
nature, it occurs mostly in lying-in institutions and
attacks healthy women. Primipars, twin cases, and
nephritic subjects are particularly predisposed. Cases
must be isolated and the rooms and attendants disin-
fected.
Experiments upon the Metabolic Processes in a
Diabetic Patient, with Special Reference to the
Sugar Formation out of Proteids and Fat. — Hugo
Liithe concludes that certain forms of proteids, namely,
animal tissues, when given to diabetic subjects are not
indifferent as to the elimination of sugar; indeed, after
the use of a casein and pancreas diet the sugar elimi-
nation is greater than that following the ingestion of
roast beef and the calf thymus. The sugar excretion
is greatest after the use of roast beef. If but little
proteids and no carbohydrates are used for food, then
a great amount of fats must be oxidized. Daily
observations and analytical tables accompany the
article.
The Blood Pressure in Healthy Persons. — S. Jel-
linek concludes that (i) normal blood pressure varies
within very wide limits, 80 mm. Hg. being the mini-
mum and 1S5 mm. Hg. the maximum; (2) that in
many instances the blood pressure of the right hand
is greater (one-quarter) than the left; (3) external ir-
ritations and influences — baths, marches, shooting, etc.
— do not show any fixed effect upon the blood pres-
sure. In some there is increase, in others decrease of
blood pressure, while in others again there is no vis-
ible change. (4) No relation could be ascertained
between blood pressure and pulse count.
Leucopenic Anaemia. — A. v. Decastello and Lud-
wig Hofbauer say that in all cases of ana;mia un-
complicated with glandular involvement, there is
an increase in the percentage of lymphocytes and
correspondingly a diminution in the quantity of the
multinuclear neutrophile elements. Leucopenic ana;-
mias associated with glandular disease (spleen, lym-
phatic glands) show a varying quantity as to the rela-
tive percentage between the multinuclear and uni-
nuclear elements. Numerous cases of different ane-
mias without apparent changes in the lymphatic ap-
paratus are tabulated.
Experimental and Clinical Tests with the Riva-
Rocci Sphygmomanometer. — Gumprecht mentions
the advantages of this instrument over others such as
Hiirthle's, Mosso's, Gaertner's, and Basch's. The
idea of the instrument is based upon the obliteration
of the pulse by means of a measured pressure. Its
use with experimental and clinical observations at all
ages, both in health and disease, is given at length
with charts, diagrams, and illustrations.
Sensory Crises in Tabes Dorsalis F. Umber
states that while gastric, enteric, laryngeal, vesical,
cardiac, testicular, and ophthalmic crises have been
occasionally reported, the disturbances in the course
of sensory nerves, such as those of smell and taste, are
little known and seldom observed. The full history
of a case in point is given.
Pentosuria. — Manfred Bial describes two instances
of chronic pentosuria occurring in his practice; only
two other cases have thus far been reported. Unlike
glucose there is no fermentation and no polarization
to the right. Other tests and reactions are formu-
lated.
Gonorrhoeal Peritonitis. — By Metzner.
Aniiires Gencralcs de Medccine, April, igoo.
Pathological Thirst in General and the Thirst
of Bright's Disease in Particular M. Klippel dis-
tinguishes the following groups of pathological thirst:
(i) Compensatory thirst, as, for example, in cholera
or after hemorrhage; (2) necessary thirst from poly-
uria for the elimination of a substance such as
sugar, or urea, or chlorides, found in excess in the
blood; (3) the dyscrasic thirst from alteration of the
blood; (4) the thirst of the nervous diseases. The
thirst of Bright's disease is found three or four times
in every ten cases of interstitial nephritis in the arte-
riosclerotic patient. There is a sensation of heat
and dryness almost always present in the mouth and
pharynx. The mouth is not healthy in appearance;
the saliva is diminished. Thirst is more frequent in
the arteriosclerotic with Bright's disease than in the
patient suffering from parenchymatous nephritis, when
the quantity of urine is much less. This variety
should be classified under the dycrasic group.
Lesions of the Thyroid Gland in Tuberculosis.
— H. Roger and M. Gamier conclude that in the
thyroid gland, as in other parts of the organism, tuber-
culosis can cause lesions the most diverse, and at first
sight the most unlike. On more careful examination,
however, they are more simple than would appear at
the first glance. There are, indeed, two kinds of le-
sions: the phenomena of degeneration caused by the
bacillus or its toxins; the defensive reactions or
processes of cicatrization wrought by the organism.
The initial lesion is a cellular degeneration. If the
bacilli are located at certain points of the thyroid
the lesions of the cells will be followed by abundant
diapedesis, and the leucocytes forming clusters about
the colonies of microbes will give rise to tuberculous
granulations. At the same time the diffusion of the
toxin will cause in the rest of the gland diffuse or
systematic sclerosis.
Curative Orrhotherapy of Traumatic Tetanus
M. Loeper and R. Oppenheim state that the intra-
cerebral injection in traumatic tetanus is not so suc-
cessful as was first hoped. The statistics show it to
be inferior to all other methods of treatment. This
probably results from the dangers inherent to its
method of introduction. Subcutaneous injection ap-
pears at present the most rational treatment for teta-
nus. The number and quantity of the injections
should be proportional to the intensity of the process.
The method will probably save a number of cases. In-
travenous injection has been successfully tried.
Two Cases of Vertebral Ankylosis of Gonorrhoeal
Origin. — P. LerebouUet and H. Bernard believe that
the history of these two cases proves that a true verte-
bral ankylosis can be caused by gonorrhoeal rheu-
matism.
Practical Method of Direct Estimation of the
Quantity of Haemoglobin in the Blood — By T. \V.
Tallquist.
Revue de C/iintrgie, April 10, igoo.
Intra- and Peri-Hepatic Suppurations of Typhlo-
Appendicular Origin. — Ed. Loison says that although
the coexistence of appendicitis and of hepatic abscess
is rare, still enough cases exist to show a causal rela-
tion between them. Microbes can be transmitted from
the region of the appendix through the bile ducts, the
MEDICAL RECORD.
[May 5, 1900
hepatic artery, the portal vein, the lymphatics, and the
peritoneum. Dieulafoy believes that in a closed ap-
pendix the colon bacillus acquires increased virulence
and expansive force which enable it to migrate through
the blood and lymph channels and invade distant or-
gans. The author leans to the belief that impaired
power on the part of the liver to destroy micro-organ-
isms is the chief etiological factor in the production
of the disease. True prophylaxis of hepatitis and
peri-hepatitis will consist in removal of the appendix
as soon as possible after the onset of appendicitis.
Advantages of Anterior Incision in Certain Cases
of Resection of the Hip. — M. Rochet, comparing
the advantages of anterior and posterior incision, con-
cludes in favor of the former, as ankylosis in good
position is more rapidly and easily obtained. Dress-
ings are more easily applied, and with little disturb-
ance of the patient, who can remain lying on the back
during the process. The articulation has a relative
firmness from the first dressing. The likelihood of
secondary infection by inoculation of the wound is
greatly diminished. The operation should, as a rule,
be reserved for suppurating cases; still when there is
painful osteo-arthritis, with night exacerbations and
sensitiveness to the slightest movement or pressure,
in spite of bandages and immobilizing apparatus, re-
section should be performed.
Epithelioma of Both Breasts. — A. Le Dentu and
H. Morestin describe a case which occurred in a
young woman aged twenty-seven years. There was
an early stage of induration and tumefaction of both
breasts, which came on very suddenly, each breast in
two days' time becoming as large as the head of a
child of six years. Acute mastitis was followed by
a nodular stage, during which ascitic peritonitis de-
veloped; coincidently with the subsidence of the lat-
ter affection, the breasts became softened and smaller.
In a fourth stage there was evidently a neoplasm of
both breasts, but its course was long and torpid, in
decided contrast with the precipitate onset. At the
autopsy, the growth was found to be epithelioma.
Some Points in the Pathological Anatomy of
Gastric Cancer B. Cune'o says that the extension
of cancer of the stomach is distinguished by three
peculiarities: early and extensive invasion of the sub-
mucous tissue, a tendency to extend toward the lesser
curvature, and habitual integrity of the duodenum.
Like all varieties of epithelioma, cancer of the stom-
ach has a tendency to invade the lymphatic ganglia.
Histological researches have shown that all the para-
stomachal glands should be extirpated, the endeavor
being to remove them with the tumor. To extirpate
the glands of the lesser curvature, this portion of the
stomach will have to be resected as far as possible.
Scapulectomy, or Primary and Total Ablation of
the Scapula, with Preservation of the Arm, in
Cases of Malignant Tumors of the Bone. — By Lu-
cien Picquc and Dartignes.
Uterine Fibroma with Multiple Pedicles — By F.
Terrier and F,. Reymond.
Inoperable Cancer of the Vagina Treated with
Local Applications of Methyl Blue.— H. R. Coston
relates an instance of cancer of the uterus and vagina
to within an inch of the vulvo-vaginal orifice, in which
hemorrhage ceased and the condition improved under
applications every second day of a three-per-cent. solu-
tion of methyl blue.. — Therapiutic Gazetk, April 15,
1900.
Society ^eyorts.
CONGRESS OF AMERICAN PHYSICIANS
AND SURGEONS.
FIFTH TRIENNIAL SESSION.
Held at Washington, D. C, May i, 2, and j, igoo.
First Day — Tuesday, May ist.
The first session of the fifth meeting of the Congress
of American Physicians and Surgeons was convened
in the Lafayette Square Opera House at 2 :4s p.m.,
with Professor Henry Bowditch, M.D., LL.D., D.Sc,
in the chair, and William H. Carmalt, M.D., secretary.
After introductory remarks and announcements, the
scientific business of the congress was taken up.
Adaptation of Pathogenic Bacteria to Different
Species of Animals. — This paper was by Prof. Theo-
bald Smith, of Boston. The doctor showed that med-
ical science and medical art were concerned chiefly
with the phenomena of human disease. All that med-
ical science desired to know was the series of causes
or antecedents leading to any given disease and the
series of phenomena which unfolded itself within the
body during disease. Medical art w ished to know where
human ingenuity might enter to modify, suppress, or
eliminate portions of this series, so as to interfere with
the progress of the disease and bring it to a standstill.
By general consent hygiene devoted itself to the ex-
ternal phenomena; pathology, to the internal. A
small proportion of the infectious diseases of man and
a large proportion of the infectious diseases of higher
animals were transmissible, or at least inoculable
upon smaller animals, producing in them diseases hav-
ing more or less constant characters. The range of in-
fectiousness varied considerably and arbitrarily with-
out any reasons at present assignable. The range of
infective power seemed to a certain extent to coincide
with the readiness with which the bacteria could be
artificially cultivated on various substrata; or, in other
words, with their degree of saprophytism. Thus the
plague bacillus, the colon derivatives, the rabid sep-
tica;mia group, and anthrax, were quite readily culti-
vated, and their range was very wide. The investiga-
tion of infectious diseases of animal life had brought
before us another phenomenon which was of consider-
able importance. Certain bacteria causing disease
among different species had certain affinities which
caused us to classify them together, and which enabled
us, at the same time, to separate them clearly from
other pathogenic groups. One of the most important
of these groups consisted of derivatives of the colon
bacillus, which produced epizootics among swine,
guinea-pigs and field mice, and spermophiles, which
had been found associated with disease in horses, cattle,
and certain birds. The tubercle bacillus furnished us
still another illustration. The avian type has been
recognized as a variety for some years. Similarly the
tubercle bacillus of cattle had certain uniform charac-
ters which had thus far been found in culture from the
human subject. There was one other question which
was more or less associated with the subject, namely,
the fluctuation of the virulence of pathogenic organ-
isms and the bearing of this upon tiie appearance of
infectious diseases in epidemic form. The commonly
accepted view of the gradual self-limitation of epidemic
diseases was the exhaustion of susceptible material.
The recrudescence was similarly ascribed to the reap-
pearance of a young, susceptible generation. Thus,
the reappearance of the eastern plague after an interim
of months was ascribed by one observer to the new
generation of rats. If we indulged in a little specula-
tion along teleological lines we should see that the at-
May 5, 1900]
MEDICAL RECORD.
771
tenuation of virus limited to one host was not an un-
reasonable hypothesis. We could assume that all
parasitism tended toward a more or less harmless sym-
biosis. Dr. Smith was inclined to think that the great
specific energy of many disease germs was acquired
in early geological ages, possibly in animals of very dif-
ferent type from ^hose now living. But it was not im-
probable that the process of making pathogenic bacteria
was going on now in the animal world, if we noticed
only that these bacteria had been transported by some
accident from their unseen habitat to species which
happened to be susceptible. In the South the micro-
organism was practically a harmless symbiont of the
blood. North of a certain line it produced a highly
fatal disease in the same species, which endangered
and might entirely interfere with the normal transmis-
sion of the blood parasite itself.
After the reading of Dr. Smith's paper, the president
announced that opportunity for general discussion
would be given after the reading of all the papers.
The Physiological Resources of the Body in its
Defence against Bacteria and their Toxic Products.
— Dr. Samuel J. Meltzer, of New York City, read
this paper.
A Study of the Mechanism of Agglutination. —
Prof. Harold C. Ernst, of Boston, presented this
paper. He said that in the early observations upon
the agglutinating properties of the serum of inmiune
animals the facts in the case were developed with mo-
tile bacteria, as with Charrin and Rogers' (1889)
studies with bacillus pyocyaneus in cultures in the
serum of immune animals, and Pfeiffer's reaction in
cholera, typhoid, etc., and it was notably the case now
that the most definite reactions were obtained usually
with motile bacteria. After reviewing the literature
on the subject, he said that the relationship between
the agglutinating property and the bactericidal property
was indefinite from the point of view of immunity.
The rat's serum, though extremely bactericidal, did
not agglutinate at all. In the dog, also with a bac-
tericidal serum, agglutination occurred very remark-
ably. Nor were the origin or chemical properties the
same. The studies already made seemed to support
the principle that the agglutinating property did not
lie in and was in no way connected with the flagella
of the bacteria concerned ; that agglutination was not
to be accepted as a specific property connected with a
condition of immunity, although this was a difficult
idea to give up; that a homologous nature of aggluti-
nation could be considered a positive characteristic,
for how, then, could be explained the clumping of
typhoid bacilli by diphtheria antitoxin? Finally, no
universally applicable explanation of agglutination
had yet been offered.
The Relation of Bacteriology to Clinical Medi-
cine This paper was by Dr. Richard C. Cabot, of
Boston. He said that bacteriology was in the closest
relations with clinical medicine through the help it
gave us in clinical diagnosis. Such assistance was
given through the demonstration of the bacilli them-
selves in secretions or in the products of disease;
through the agglutination test, and through the injec-
tion of soluble products of the growth of certain bacilli
(tuberculin, mallein). So far only two, or possibly
three, such bacteriological tests could be said to be in
general use throughout this country, viz., the search for
the tubercle bacillus in sputa, the search for the diph-
theria bacillus in the throat, and possibly the aggluti-
nation test for typhoid. Other such aids to diagnosis,
which seemed likely to come into more general use,
were the examination of the blood, the sputa, the urine,
the faces, the cerebro-spinal fluid, the urethral, vagi-
nal, and uterine secretions, the nasal, pharyngeal, and
conjunctival secretions. Next to typhoid, Malta fever
seemed at present the disease in the diagnosis of which
we were most helped by the agglutination tests. To
other diseases the diagnostic assistance of the aggluti-
nation reaction had not extended. Individual observ-
ers had reported success in the attempt to apply the
serum tests to diagnosis of tuberculosis and croupous
pneumonia, but their results had not been extensively
confirmed. To a limited extent we were able to re-
verse the use of the agglutination tests. Instead of
using the well-identified bacillus to test the body fluids
of a doubtful case, we could use the body fluids of a
well-identified case to test a doubtful bacillus. Of
the diagnostic use of tuberculin, it was only necessary
to say that, despite the warnings of Virchow, it had
passed into general use, and deserved to be utilized
much more widely still. The few who objected to its
use were for the most part those who had not tried -it.
The use of mallein was well established. Statements
regarding prognosis were apt to present an unrivalled
material for the study of the art of hedging. Bacteri-
ology was helping us to make our prognoses less mean-
ingless. The clinicians had realized how difficult it
was to interpret the results of bacteriological examina-
tions; for example, how to draw the properly limited
inference from the announcement of a positive Widal
reaction, to be enough and not too much alarmed by a
positive reaction to tuberculin, or by the finding of the
Klebs-Loeffler bacilli in a patient's throat. Especially
was this true when relatively indefinite quantitative ex-
pressions entered into the bacteriologist's report. Only
he who made the test could really appreciate what was
meant in a given case by such phrases as " very numer-
ous tubercle bacilli, very virulent streptococci, very
motile organisms, very numerous malarial organisms,
etc." The municipal laboratory of the city of Boston
now offered to examine for physicians material sus-
pected as coming from any of the following diseases:
Typhoid, tetanus, tuberculosis, rabies, diphtheria, ma-
laria, glanders, influenza, pyogenic organisms, gonor-
rhoea.
Bacterio-Therapeutics with Especial Reference to
Tuberculosis. — This paper was read by Dr. Edwin
R. Baldwin, of Saranac. The speaker dealt with
the various uses of bacteria and serums in the preven-
tion and treatment of disease, with a more detailed ac-
count of those in tuberculosis. Living bacteria were
little used except in vaccination for variola and an-
thrax. Dead cholera, plague, and typhoid bacilli were
useful in prevention but irrational in treatment.
Diphtheria and tetanus were as yet the only conspic-
uously antitoxic serums of practical value. Strepto-
coccus, pneumococcus, cholera, typhoid, plague, and
recurrent-fever serums were either bactericidal or bac-
teriological, and of greater value in immunization than
in treatment. There were many extracts of tubercle
bacilli under the general name of tuberculin, which the
speaker enumerated and described. No permanent
immunity was produced by any of them, though the
new tuberculins had some immunizing power in ani-
mals. The method was not applicable to man, nor
safe, because it was likely to produce chronic poison-
ing, even in healthy subjects. Research at present
aimed to discover and utilize the mechanism of rela-
tive immunity produced by injections of bacillus sub-
stance. The nature of the tuberculin reaction was of
importance. Of the various theories promulgated, that
which assumed a ferment action, chiefly produced by
secretions from leucocytes, was most in line with pres-
ent knowledge. Many bacterial extracts, nucleins, and
digestive albumoses excited the same reaction as tu-
berculin produced. Tuberculin used therapeutically
had only a limited application, and as it did not im-
munize for any length of time, it might not be better
than other substances that could produce local hy-
peremia. The production of local hyperasmia was
rational in lupus, tuberculosis, peritonitis, and, to a
772
MEDICAL RECORD.
[May 5, 1900
limited extent, in pulmonary tuberculosis. Serums
were not yet successful as to antitoxic properties. They
might be bacteriological or bactericidal. There was
still hope for some efficient serum or extract of tissues,
though possibly it might not be antitoxic.
The Etiology of Malarial Fevers.— Prof. Wil-
LI.4M S. Thayer, of Baltimore, read this paper. He
was of the opinion that the disease was acquired
through the gastro-intestinal tract, especially by drink-
ing water; through inhaled air; by the bite of insects.
The experiments of Celli, Marino, Zeri, Grassi, and
Feletti were strong evidence against the idea that the
disease might be acquired through the gastro-intestinal
tract; while a careful study of the literature, as well
set forth by Norton, revealed the utter lack of evidence
in support of such an idea. With regard to the theory
that the disease was acquired by inhaled air, it could
only be said that while some general facts spoke in its
favor, no positive evidence in its support had ever
been adduced. That the disease might be acquired
through the bites of insects, and especially of mos-
quitos, had become an attractive hypothesis. It then
might be considered as proven that the malarial para-
site possessed an extra-corporeal cycle of life, which
was completed in the stomach wall of mosquitos of
the genus Anopheles, and that members of the genus
Anopheles were capable of transmitting malaria from
infected to non-infected individuals. The doctor then
reviewed the bites of insects indigenous to certain lo-
calities in relation to the pathological effects, and
especially referred to the class of mosquitos which in-
fected the suburbs of Baltimore.
The Bacteriology of Dysentery. — Prof. Simon
Flexner, of Philadelphia, read this very interesting
paper. He said that there were few subjects in medi-
cine that had attracted more attention than dysentery.
Its history dated from the earliest written records, and
its ravages, unlike those of many of the pestilential
diseases, had continued perfectly unabated to the pres-
ent day. The most ancient writing upon medicine —
the Papyrus Ebers— contains allusions to dysentery; the
oldest Indian medical writers referred to it under
the name afisar, while Herodotus spoke of its preva-
lence in Thessaly. Hippocrates, however, was the
first to regard dysentery as an independent disease.
The speaker said that he should hesitate to bring be-
fore this audience a subject so time-worn, were it not
for the fact that the nature and more especially the
etiology of dysentery were among the problems which
still awaited a satisfactory solution. The imperfec-
tion of our knowledge of the nature of dysentery was
not due to lack of opportunity for, or of energy in, its
study. The literature contained some of the most
distinguished names among clinicians and investiga-
tors, thanks to whose efforts its clinical history, its
epidemiology, and, to a less extent, its pathological
anatomy had received partial elucidation. Nor had
the disease, in the past quarter of a century, escaped
the attention of the bacteriologists, although it must
be confessed that the results of somewhat extensive
studies along these lines had been far less conclusive
than might have been predicted. Given a disease
that was never entirely absent from temperate and
tropical regions, that appeared with epidemic severity,
that permitted of easy access to the materies morbi,
one would certainly have been tempted to predict that
the success achieved in so many other and apparently
no less difficult fields would probably be repeated.
That the attempt to establish a common etiological
factor for all cases of dysentery had thus far failed,
this audience need not be reminded. That this fail-
ure emphasized the existence of several pathological
states for which the term dysentery was employed
merely as the collective designation, need not be de-
fended here. But that these conclusions regarding tire
disease might, after all, not be in keeping with the
facts, was at least open to suspicion. When we recalled
the protean nature of other infectious diseases, among
the most common of which were tuberculosis and ty-
phoid fever, there could be no a priori objection to
the hypothesis that the causative agency of dysentery
need not necessarily vary for each of. the many types
of the disease that had, from time to time, been dis-
tinguished. For the purpose of his inquiry he should
consider brieHy the clinical and pathological types.
That the lines of demarcation between the several
clinical and pathological types should be inaccurate
was not a matter of wonder. Both the beginning and
the end of any given instance might vary very widely,
and the symptoms and lesions of cases arising spo-
radically in temperate climates might agree with those
of dysentery occurring endemically in the tropics or
epidemically in both localities. The terms "catar-
rhal," "tropical," "epidemic," and "diphtheritic"
were far from signifying sharp-cut entities. The clin-
ical manifestations and pathological lesions of the ca-
tarrhal variety occurred in all kinds of dysentery and
in all places where the disease prevailed. Ever since
the time of John Hunter there had been those who,
upon pathological-anatomical grounds, had separated
the endemic from the epidemic disease, and the line
had been even more sharply drawn during the past
decade, since the discovery of the amceba coli in its
relations to tropical dysentery. But the distinction
between tropical dysentery, which was characterized by
ulceration and thickening of the intestines — especially
the colon, the lesions beginning in the submucous coat
of the gut — from the epidemic disease in which a false
membrane existed, usually associated with ulceration
without any primary involvement of the submiicosa,
was far from being sharp and constant. In this coun-
try diphtheritis liad not been commonly observed in
the ulcerative and amoebic form of dysentery, while in
Egypt the two pathological conditions were not infre-
quently found together.
ASSOCIATION OF AMERICAN PHYSICIANS.
Fijieenth Annual Meeting, Held in Washington, D. C,
May I, 2, and 3, jgoo.
Edward G. Janeway, M.D., of New York, Presi-
dent.
First Day — Tuesday, May ist.
The President's Address. — Dr. Edward G. Jane-
way, of New York, in this address spoke of the ad-
vancement made in the last few years along the lines
of pathology and chemistry, and in looking back had
but one regret, i.e., that of lost opportunities. He
advised the younger members of the association to
work assiduously for the advancement of true pathol-
ogy and true chemistry.
An Experimental and Clinical Study of Acid In-
toxication Dr. C. a. Herter, of New York, the
author, being unavoidably absent, his paper was read
by the secretary. Experimental evidence showed that
calcium oxalate was precipitated on the addition of
ninety-five-per-cent. alcohol. By this means one was
able to separate it in the urine. In certain diseased
conditions, such as melancholia, nervous fears, and
indigestions, the amount of oxalic acid was markedly
increased. On a diet free from oxalates, such as
milk, no oxalates appeared in the urine, but on a
mixed diet, as much as 67 ngm. of the oxalate might
be excreted in twenty-four hours. Much of the exper-
imentation had been done on dogs. When a dog was
May 5, 1900]
MEDICAL RECORD.
m
fed on a sugar diet no symptoms made their appear-
ance until after about six weeks; then the dog had
attacks of nausea and vomiting witli interrupted diar-
rhoia, and organic acids and oxalates appeared in the
urine. This went to show that the oxalates were
formed in the body. The author raised the question
of where the oxalates were formed in the body. He
claimed that they were produced in the stomach of the
dog by a ferment. In health there were no oxalates
formed, but in certain morbid conditions in which
there was a deficiency of hydrochloric acid, in the
stomach, oxalates were formed there, probably by an
organized ferment.
Dr. Tyson, of Philadelphia, said that if one exam-
ined the urine of certain individuals, apparently in
perfect health, either during the day or night, one
would find oxalate of calcium in the urine. He
agreed with the author that a milk diet eliminated the
oxalates from the urine.
Notes on Diabetes. — Dr. James B. Herrick, of
Chicago, read this paper. He spoke of the occasional
low specific gravity of the urine in diabetes, and said
it was even lower than the normal. In one case cited,
a man who had been drinking beer all the morning
came into his office partially intoxicated and asked for
a urinal. He passed 1,100 c.c. of urine having a
specific gravity of i.oio. This specimen gave the
usual reaction for sugar. Out of twenty-seven cases,
twelve per cent, had had a specific gravity of i.oio or
less, and some as low as 1.004. Hence all urine
should be tested for sugar, regardless of its specific
gravity. Dr. Herrick also spoke of casts in the urine
during diabetic coma. He said that polyuria was
often associated with nephritis. In some cases
he had found a trace of albumin, v;ith a number of
granular casts. Just preceding the attack of coma,
casts became very numerous. Formerly this had been
considered accidental. He had seen cases in which
casts appeared in the urine twenty-four hours before
coma came on ; and he thought, therefore, their pres-
ence might forewarn one of the coming attack. The
pathology was unknown, but he thought it probable
that the condition was due to a toxico-chemical change
taking place in the excreting cells in the kidneys at
or around the loops of Henle.
The Relation of Uric-Acid Secretion to Epilep-
tic Attacks. — Drs. James J. Putnam and F. Pfaff, of
Boston, presented this communication, which was read
by Dr. Putnam. After examining the urine excreted
in twenty-four hours, and over a period of time includ-
ing several seizures, he had come to the conclusion
that there was no difference in the amount of uric acid
excreted before or after the seizures.
Report of a Case of Acute Ascending Paralysis,
Showing Haematoporphyrinuria Dr. Charles G.
Stockton, of Buffalo, read this paper. It was the
case of a young woman, a servant by occupation, who
was hysterical and anxmic. Her urine was much
darker than normal, and contained a trace of albumin.
Sulphonal and salicylates failed to give relief. She
was admitted to the Buffalo Hospital in September,
and the physical examination showed a higher pitch
at the left apex of the lungs. She had several areas
of anaesthesia over the breast and buttocks, and she
complained of weakness and loss of sensation in the
legs. The urine was claret-colored, and remained so
until the end. Her temperature was 100° F. Oph-
thalmoscopic examination showed optic neuritis. The
patellar reflex responded slightly. She grew rapidly
worse, and finally died. No autopsy was obtained.
The claret-colored urine was examined most carefully.
No xanthin or indican bodies were present. The color
was not due to sulphonal, he said, for she had not
taken it for two weeks. It was due to the pigment
depending upon h^matoporphyrinuria, which, as he
thought, bore a direct relation to the inflammation of
the spinal cord.
Dr. J. J. Putnam said he had had a similar case
associated with multiple neuritis and progressive an-
cesthesia, with claret-colored urine. The patient lived
thirteen days. The autopsy showed no change in the
spinal cord.
Dr. E. G. Janeway said that the discussion re-
minded him of a lady who had been in the habit of
taking trional, from gr. x. to gr. xx. every night for a
year, to make her sleep. She was taken suddenly
with nausea and vomiting and developed a mitral in-
sufficiency and a general neuritis. She recovered.
The Relative Infrequency of Acute Transmissi-
ble Diseases during the First Year of Childhood,
with a Discussion of the Probable Reasons for the
Same. — Dr. A. C. Abbott, of Philadelphia, read this
paper. He had some very interesting charts showing
the percentage of death rates of children from the first
to the tenth year, deaths being considered from mea-
sles, scarlatina, and diphtheria. The deaths from
measles in children one year old were 27.4 per cent.,
and in those five years old 64.8 per cent. In children
three months old the deaths from measles were 2.7 per
cent., and in those of six months 7.7 per cent. He
thought this could be explained without considering
acquired immunity, and that it was due to the period
of nursing. He thought that the mother conveyed
something to the child through her milk which caused
the child to become immune.
Dr. George B. Shattuck, of Boston, did not agree
with tire author as far as diphtheria was concerned. He
thought that there was some other cause besides that
of immunity from the mother's milk which kept a
three-months-old child from having the disease.
Recurrent Vomiting in Children. — Dr. J. P. Cro-
zer Griffith, of Philadelphia, read this paper. He
reported four cases. The first one was a mild case of
vomiting, lasting one day, and followed by recovery.
The second case was more severe. The child had
been sick four or five days and was obstinately consti-
pated. On the fourth day the bowels moved, but this
did not relieve the symptoms. Some bloody mucus
escaped from the child's mouth, the patient being too
weak to vomit. He had advised morphine hypoder-
mically, and when the child seemed at the point of
death the symptoms abated and the child recovered.
The third case was similar, but an operation v>as per-
formed for a supposed appendicitis, and the child died.
The fourth case was complicated by nephritis, abdom-
inal pains, sighing respirations, and slow pulse. It
terminated fatally. Dr. Griffith said, in closing, that
the exhaustion in these cases was excessive, so that
the physician felt death was inevitable, but the change
for the better came suddenly. The attacks lasted from
one to ten days and occurred at irregular intervals.
He thought that there was a tendency to outgrow the
disease, and that it was probably due to some toxicity
of the blood.
Dr. Stockton, of Buffalo, said that the vomited
matter was pure gastric juice. He thought it occurred
most frequently during the third and sixth month, and
was a neurosis. He had never seen any deaths re-
ported.
Dr. Johnson said he had had a case of coffee-
ground vomiting, followed by rapid prostration, cyano-
sis, and cold extremities. The patient seemed to be
just on the point of death when he began to improve.
The condition seemed to be due to precocity of the child
and an inherited neurasthenia, and not due to cold or
tonsillitis. In the treatment, rest was of the first im-
portance. He believed in hypodermics of water and
the administration of food by rectum.
Sanitarium Treatment of Pulmonary Tuberculo-
sis and its Results. — Dr. E. L. Trudeau, of Saranac
774
MEDICAL RECORD.
[May 5, 1900
Lake, read this paper. In speaking of the so-called
pre-tuberculous stage, he thought that the .v-rays would
give additional evidence, for a slight shadow might be
seen corresponding to areas of consolidation. Tuber-
culin raised the temperature and made the diagnosis.
He generally gave i mgm. as an initial dose. The
treatment could be summed up in the words, rest, food,
restoratives. It was customary to immobilize a tuber-
culous joint, and the same should be done with the
lungs. Dr. Trudeau gave a number of statistics show-
ing the results of sanatorium treatment. He had had
twenty-three per cent, of cases apparently resulting in
cure, but, he added, "Time was the only test of cure."
Dr. Bridges, of Los Angeles, said that he thought
three-quarters of the cases of pulmonary consumption
could Ijest be treated outside of institutions.
Dr. Solis-Cohen, of Philadelphia, asked what Dr.
Trudeau meant by rest, whether he meant rest of the
lungs or of the body as a whole. In his experience
exercise of the lungs was beneficial.
Dr. Trudeau closed the discussion. He said that
if the temperature was 99°-99-5° F- once or twice dur-
ing a week, and there were slight disturbances of
health, this was enough to make him suspicious of the
presence of tuberculosis.
Phlegmonous Gastritis, with Specimen. — This
paper was read by Dr. Francis P. Kinnicutt, of
New York.
Dr. William H. Welch, of Baltimore, recalled a
similar case, in which death had resulted from peri-
tonitis.
Dr. jANEWAYsaidhe had had a case which had been
diagnosed as perigastritis, general peritonitis being
absent.
AMERICAN SURGICAL ASSOCIATION.
Twenty-first Annual Meethig, Held in Washington,
D. C, May i, 2, and j, igoo.
Surgery of the Stomach. — Dr. Robert F. Weir, of
New York, introduced the general topic for discus-
sion, viz., " The Surgery of the Stomach," by reading
a paper on "Duodenal Perforation." (See page 749.)
Gastric Ulcer Dr. W. L. Rodman read a paper
on gastric ulcer, non- perforating, with especial refer-
ence to hemorrhage. Passing over etiology, pathology,
differential diagnosis, and prognosis, he spoke of the
importance of intelligent medical treatment. From
one-half to three-fourths of all cases resulted in cure
thus in from four to five weeks. Kocher said that
after five weeks there was danger, if the ulcerative
process continued, of neoplastic change. Hence the
speaker advised operation in cases which, after five
weeks, refused to yield to treatment. He asked, should
the ulcer be excised in cases in which hemorrhage
was not prominent? It seemed doubtless the best
treatment, because of neoplastic possibilities. The
radical treatment was gaining in favor, but it must be
conservatively used. The adhesions were of very
great importance in determining whether partial gas-
trectomy or pylorectomy should be chosen. If they
were very dense posteriorly, gastrectomy might be
necessary. Gastro-enterostomy relieved hyperchlor-
hydria, and was of great value if shock was present,
or if, when dense adhesions were present, the case
could not stand partial gastrectomy. This was possible
only in the absence of neoplasms. The indications
for operation were: (i) Hemorrhage. The first time
this occurred it must be treated medically. (2) If the
patient was rallying from shock, operation should not
be done, but venous infusion given. Only eight per
cent, of cases resulted fatally from primary hemorrhage.
(3) In a case in which there had been one free hem-
orrhage, with recovery, bleeding again two or three
days later, operation seemed indicated. The speaker
cited many cases to show that there should, at this
time, be surgical intervention. Speaking of pylorec-
tomy, he said it seemed the ideal operation when gas-
tro-enterostomy was not necessitated by posterior
adhesions, and when the neoplasm, if present, was
localized and young. Gastro-enterostomy had a very
useful future in multiple ulcer, and when the bleeding
point could not be found. Excision of the ulcer was
hopeful, and should be used unless adhesions were
present. Ligation en masse promised well and should
be practised by placing Lembert sutures on the out-
side as a first step. In closing. Dr. Rodman said that
operation for acute hemorrhage was indicated with
limitations, but for chronic hemorrhage the operative
was the only course to pursue.
Perforating Ulcer of Stomach. — Dr. J. M. T.
Finney, of Baltimore, discussed this subject. He
spoke of the diiificulty of adding anything new, and
emphasized the importance of early diagnosis. The
mortality of perforated cases was from 6.5 to eighteen
per cent, in Johns Hopkins Hospital in cases treated
medically. Since 1880, when Mikulicz first operated,
two hundred and sixty-eight cases had been reported.
There had been a rapid increase since 1896. The
etiology was unknown, trauma and food being unim-
portant. Locality and sex were factors; it viias more
frequent in women (five cases) before the age of thirty
years, than in men, in whom it occurs often after forty.
He spoke of the importance of adhesions in protecting
from subphrenic abscess, and of their influence in
guiding pus, once formed, to remote quarters of the
body. As to the site of the perforation, it was most
frequently near the cardia, next at the pylorus, third,
at the lesser curvature. The severity of the symptoms
and the prognosis depended on: (i) the size of per-
foration; (2) whether, at the time of perforation, the
stomach was empty or full; (3) the position of the
patient (unimportant) ; (4) the nature of the infection,
character and number of bacteria being of the utmost
importance. Experiments with a case of duodenal
fistula at Johns Hopkins Hospital showed that infected
milk was discharged with the infectious organisms
still active. Hence the speaker urged the necessity of
using sterilized food, and of sterilizing the mouth for
two days prior to operation. Hyperacidity seemed,
under certain conditions, to favor development of
germs. (5) As in typhoid, leucocytosis was of great
importance when present. An important question
was. Shall we use opium, and how much? The an-
swer was, most emphatically, to use only as much
opium as was absolutely necessary to ease the pain.
Anotiier question was. Shall we aw^ait shock?
Equally emphatic was the answer, i.e., to operate im-
mediately. This was particularly true if the symp-
toms were growing more pronounced. Local anaesthe-
sia, combined with a few whiffs of chloroform, if
necessary, was of great importance in operating for
diagnosis. Indeed, in this manner the entire opera-
tion was best done. The steps Avere as follows : the
cardia should first be examined; second, the pylorus;
third, the lesser curvature, and last, the posterior
surface. He closed by speaking of the hopeful results
of surgical intervention.
Malignant Diseases of the Stomach and Pylorus.
— Dr. William J. Mayo, of Rochester, Minn.,, dis-
cussed this topic. He said that carcinoma was en-
tirely a surgical disease, and emphasized the need of
exploratory incision for early diagnosis. The cura-
bility of carcinoma depended largely on its histological
structure : the greater the amount of stroma, the more
favorable was the post-operative prognosis. Colloid
degeneration seemed very unfavorable, while the cylin-
drical-celled growth yielded the largest percentage of
May 5, 1900]
MEDICAL RECORD.
775
non-recurrence. The location was another factor in
considering curability. The diagnosis at the cardia
was easy, and the prognosis was bad, while the oppo-
site was true at the pylorus. Lymphatic involvement,
so called, was now known to be a simple septic glandu-
lar enlargement — the relation between the abdominal
glands and the carcinoma being utterly different from
that which existed between the breast and the axilla.
Abdominal adenitis was, therefore, of little importance.
The patient's condition was an indication of value,
particularly -if cachexia and ascites were present.
These made the prognosis unfavorable. Every opera-
tion should be at first for diagnosis. The incision
was median, and it was important that the pylorus
should be freed enough to lift it from the wound. If
necessary, the gastro-hepatic omentum should be cut.
The conditions found might indicate a radical opera-
tion, palliation, or, the inadvisability of attempted re-
lief. In the latter case, the wound should be closed
by Halsted's method. Complete gastrectomy was the
operation particularly for cancer of the body. We
should be proud that this was first done by an Ameri-
can. Kocher's operation was preferable to Billroth's.
The stomach should be cut away inch by inch and
ligated as the operation proceeded. Suturing should
be done in two stages. Czerny operated in two steps
for extirpation, the operations being about three weeks
apart. Curettage and cautery were not effectual. Gas-
tro-enterostomy was the most useful of all gastric opera-
tions for palliative operation. Whether the suture or
the Murphy button should be used depended on the
operator. The peristaltic directions must be made to
coincide. The speaker felt certain that the anterior
portion of the stomach wall was the better to use in
making the anastomosis, because of its easy access ; for
he did not agree with those who believed that the but-
ton might fall back into the stomach from the anterior
wall, because of the formation of a funnel-shaped pouch
which prevented it. Regurgitation of bile and vomit-
ing were rare complications of this operation, and so
rare as not to justify, at the preliminary operation, the
introduction of a complicated technique, involving
entero-anastomosis and other modifications.
THE AMERICAN GYNECOLOGICAL SOCIETY.
Twenty -Jijih Annual Meeting, Held at Washington,
D. C, May i, 2, and j, igoo.
First Day, Tuesday, May ist. — Morning Session.
The meeting was called to order at 10 a.m., the presi-
dent. Dr. George J. Engelmann, of Boston, in the chair.
Dr. Joseph Taeer Johnson, of Washington, D. C,
gave the address of welcome.
Cancer of the Vagina. — Dr. Prvor, of New York,
read this paper. He reviewed the fact that cancer of
the vagina was very rare. It usually involved the pos-
terior wall of the vagina and extended underneath the
rectum, then to the vaginal structures and to the uterus.
He described the operation which he employed in two
cases, giving as the first step a primary and preventive
haemostasis. By this not only the field of the opera-
tion was rendered dry, but migration of the cancerous
cells was prevented. He avoided all injury to the
cancerous field until haemostasis was secured and the
cancer had been charred by the cautery. He removed
all the organs in which recurrence was apt to take
place, and removed from above downward. He estab-
lished an artificial anus near the site of the normal
outlet of the rectum. The cancer was prone to spread
by invasion of the tissues having a common source of
blood. This operation sought the removal of all organs
belonging to the vascular group in which the affected
organ was placed. The speaker detailed the history
of two cases operated on. The form of operation per-
formed formerly was that of Olshausen, which was a
blunt dissection of the vagina from the rectum. This
was rather a failure. The steps in Dr. Pryor's opera-
tion were: (i) The general preparation of the patient;
(2) the incision from the umbilicus to the pubes; (3)
the ligation of the vessels and ligaments; (4) dissec-
tion of the bladder from the cervix and entrance to the
vagina anteriorly; (5) removal of the vagina and the
entire rectum; (6) ligation of the obturator artery to
prevent anastomotic circulation being formed. The
actual cautery was used for charring the cancerous
mass. The vagina and rectum and the perirectal tis-
sues were excised, and the formation of the artificial
anus was establislied near its normal situation. The
technique of the operation was illustrated by drawings,
and the author emphasized the fact of the rarity of
this form of malignant disease; he called special atten-
tion to the method of removing the rectum as high up
as the sigmoid flexure, as well as almost the entire
vagina.
Dr. Munde considered it fortunate that these cases
were rare. He had seen only two cases of primary
cancer of the vagina in a long experience. He had
curetted and cauterized.. He did not consider that
such bloody and radical work repaid for the slight
benefit received by the patient, as recurrence was in-
evitable.
Dr. Sutton had seen but one case in thirty-four
years, and had little faith in such radical operations.
The pathology of cancer should engage our attention.
Instead of a new method we needed to find the factor
producing cancer.
Dr. E. Van de Warker felt that nothing had been
gained by operation for cancer.
Dr. Montgo.mery said that the great frequency of
recurrence of malignant disease, when it involved the
vagina and extended into the parametrial tissue, and
when it invaded the broad ligament, led him to believe
questionable the operative treatment of these cases.
It had been said that there was no plan of treatment
by which a patient could be insured against relapse, and
unfortunately we were unable even in the early devel-
opment of the disease to say that it was not already
carried into the parametrial tissue and beyond. He
had frequently seen patients in whom he felt that an
operative procedure would result favorably, in whom
there was early return of the disease. He had seen
other cases in which there was extensive destruction of
the cervix, in which the question of the wisdom of an
operation was a grave one, and yet in these patients
several years had elapsed without recurrence. We
were at present in a position of simple uncertainty ; we
could say in individual cases w'hether operation w-ould
afford a favorable opportunity for the recovery of the
patient.
Dr. a. Lapthorn Smith said he had had little ex-
perience with cancer of the vagina, but considerable
with cancer of the rectum. By removing the lower
half of the rectum, drawing it down and removing all
the glands that could be felt from below, he thought
that he had removed all the disease, but the longest
period that the patient lived was one year. Though
little was gained in many cases, the uselessness of the
operation ought not to be considered, but rather the
number of women who were prevented by these adverse
reports from being operated on; these being cases
which possibly could have been cured.
Dr. Sutton said that in his experience the patients
who were apparently in the best general health, but in
whom there was a diseased blood condition, were almost
universally the first to succumb to a return of the dis-
ease.
Dr. Byrne had had no experience with isolated can-
776
MEDICAL RECORD.
[May 5, 1900
cer of the vagina. He was gratified to hear the gen-
tlemen declare that there was absolutely no use in re-
moving a cancerous uterus. This had been his feeling
for many years, and he hoped that eventually the treat-
ment which had been so successful in his hands might
be given a fair and impartial trial.
Dr. T. a. Reamy would like to ask if the statements
as made by these gentlemen meant that in no case was
cancer of the uterus cured ; or were the incurable cases
confined to those in vihich the vagina and the lower
portion of the uterus, the parametrial tissue, the lym-
phatic glands, and the region round about were in-
volved ?
Dr. Sutton replied that his remarks in a general
way applied to all cancers in the vagina or uterus. He
would make this reservation, that he had never seen a
case of cancer of the uterus until it was well developed.
As to seeing a case of cancer of the uterus when the
epithelium was juet beginning to break down, when it
was almost impossible to make a diagnosis save by
microscopical examination, he did not see one such
case in a thousand.
Dr. E. Van de Warker said that he referred to sim-
ple epithelioma or cancer of the cervix, and to no par-
ticular stage.
Dr. T. a. Reamy must say that the gentleman was
mistaken. It might be true that that was the history
of the cases operated on and described by this distin-
guished man and his friend. We knew that these state-
ments were not due to the fact that these gentlemen who
had spoken in support of the statement were incom-
petent to do the operation thoroughly or successfully.
He knew half a dozen women who had lived from six
to ten years and two of them twenty years after having
the cervix removed. The condition was proved to be
cancer by the examination and report of the ablest
pathologist and microscopists to whom he could have
access.
Dr. George J. Engelmann thought that when it was
said that cancer could not be cured, it was time to en-
ter a protest. He granted that in a large percentage
it could not be stayed; any man who would look at
the diagram exhibiting the location and extent of the
lymphatics would recognize that so soon as the disease
had existed sufficiently long to involve the lymphatics
to any considerable extent the disease was beyond the
pale of operation, and in a large percentage no treat-
ment would prolong the life of the patient. In order
to tell how much benefit there was from cautery or knife
in these excessive cases, it was only necessary to watch
clinically the history of those left untouched, and it
would be found that the patient lived longer when not
disturbed; and therefore Dr. Engelmann spoke as
radically as his friends. He had, however, seen cases
in which the operation was done in time, in which the
result was satisfactory. He had seen these results in
the work of his friends, and had read the reports of
other men all over the country of the same results, and
therefore he protested again. In the earliest stage,
the condition was primarily local.
Dr. Sutton said he had seen several cases of pri-
mary epitheliomatous growth of the vagina involving
the rectum, and had had the opportunity to operate on
two. It was reasonable to suppose that the growth
would return much more quickly than it would in any
other part of the body. Epitheliomatous growth, so
far as his knowledge went, was much more rapid than
scirrhous forms. It the operation advocated by Dr.
Pryor did the most one could possibly do by ligating
the vessels which led to the structures of the pelvis,
and thereby retarded the disease, it seemed to him that
it was a worthy operation. It might not be so radical
as it seemed to be on paper. If we operated with the
patient well exposed and in the Trendelenburg posi-
tion, the vessels could be easily reached.
Dr. Pryor, in closing, said that possibly the next
copy of the Ccniralhlait fiir Gyniikologie would tell us
how to detect the cancer bacillus and point us to some
antiseptic to apply to it; but up to that time we must
be surgical. Cancer of the vagina and rectum must
be viewed not as cancer of the vagina or of the rectum,
but in the light of its complications. If the cancer
could be operated for and a colostomy be done low down
in the body, it provided a cloaca for retained faeces,
and so seemed to him to be the operation of choice.
As to the advisability of an operation apparently so
severe as this, he took issue with Dr. Lapthorn Smith,
and would not sacrifice the life of a woman with so
grave a disease if his conscience indicated that she
should be operated on, for fear some remote patient
in the mountains might decline operation should the
result be fatal. The operation was for cancer of the
rectum and of the vagina, and was applicable to the
graver forms of cancer in which the uterus may be in-
volved.
Fecal Fistulae. — Dr. I. S. Stone, of Washington,
read a paper with this title. He said that one of the
most distressing and annoying of post-operative sequelae
was fecal fistula. As was well known, the greater num-
ber closed spontaneously, yet it was occasionally found
necessary to resort to some form of surgical relief. Per-
haps the larger number of fistula; followed in the wake
of appendical abscess. It might be safely said that
there was no routine treatment of fecal fistula. Men-
tion was made of certain methods believed to be fol-
lowed by the best results. A permanent fistula fol-
lowing an operation upon an appendical abscess might
require anastomosis by exclusion. This operation had
probably been the result of Dr. Senn's experimental
work upon animals, and was especially required in
fistula with a tortuous sinus not connecting with the
intestine immediately under the external wound. In
cases in vihich the coscum and ascending colon were
greatly thickened and firmly bound by adhesions, the
surgeon might take a section of ileum as near the caput
coli as convenient, and transplant it or make end-to-
side anastomosis to the transverse colon. Reference
was made to Dr. Kammerer's case, in which a very rad-
ical method was employed, and which the speaker de-
scribed in detail; also to a suggestion byGreig Smith
to cut down upon each side of the fistula (yet not
through it) to the peritoneum without opening it, dis-
sect about two inches of this away from the abdominal
wall on each side or around the fistula as a centre, and
then withdraw the peritoneum with attached and ad-
herent bowel, far enough easily to close the fistula.
Greig Smith took the position that peritoneal surfaces
did not unite so firmly as though denuded, and claimed
that these openings in the gut were closed safely and
speedily by rough cicatricial coaptation. The pelvic
surgeon frequently had to fear fistulas resulting from
uninjured bowel, which he encountered during enuclea-
tion of pus sacs, etc. These fistulas were most difficult
of closure, owing to their situation and to the fact that
the function of the rectum served to perpetuate the fis-
tula, since it was a receptacle or reservoir for gases
and fecal matter. The speaker's successful experience
with two cases of recto-al)doniinal fecal fistula of long
standing was detailed, and the following conclusions
were submitted: (i) that in all persistent fistul.^ we
must for obvious reasons remove any foreign body such
as silk; (2) that all attempts at skin closure or by cau-
terization or curettage of persistent fecal fistuls were
generally successful. (3) In all cases in which a fis-
tula connected with a superficial coil of intestine, the
method of Greig Smith might be tried before resorting
to radical operation. (4) In the deep-seated fistula;
requiring abdominal section choice must be made be-
tween excision and some form of anastomosis, for the
case will rarely be found so simple as to permit inver-
May 5, 1900]
MEDICAL RECORD.
m
sion of the fistulous portion and direct suture. (5) In
operating for such deep-seated fistulas we must not fail
to liberate imprisoned bowel and restore the normal
peristalsis, permitting free motion of intestinal coils
and directing the fecal current in its proper course.
(6) Finally in recto-abdominal fistula, it should if
possible be converted into a recto-vaginal fistula, and
closure of the tract be secured before the temporary
fistula was allowed to close.
Dr. Currier had seen but one case of fistula of the
small intestine, and that remained obstinately open
and the patient continued to lose ground. The patient
was cured by section of the small intestine. In the cases
including the small intestine nature could not be ex-
pected, according to ordinary anatomical and physio-
logical conditions, to help much, and it was not there-
fore wise to wait. Radical operation involving portion
of the bowel must be attempted as soon as possible.
On the other hand, in the cases situated low down, and
in which there was a discharge of fecal matter, he
thought it was well not to be too hasty to institute opera-
tive procedures. He had seen a number of such cases
in which by waiting nature had instituted a cure. In-
asmuch as the applications which Dr. Stone had indi-
cated were so varied and so severe, the speaker would
advise giving nature a chance. This w'as a rule which
he thought might well be laid down. He questioned
whether the removal of silk or other foreign body in
most cases would effect a cure. The silk, as a rule,
was not applied to that portion of the bowel in which
the fistula took place. He would say for himself that
his general rule had been, when the condition seemed
to be undergoing a rational process of development
pointing to a cure, to wait and see if nature would not
effect a cure, and not by attempting operative proced-
ures possibly make the condition worse.
Dr. a. VV. Johnstone said that, as a matter of jus-
tice to two dead men, he would state that the method
outlined by Dr. Stone was taught by Lawson Tait to
Greig Smith. The speaker assisted Mr. Tait the first
time he closed a fistula in that way, which was his sev-
enteenth operation. Ever since 1886 Dr. Johnstone had
used that method in closing fistulte of every descrip-
tion, and he succeeded on the third operation for clos-
ing ureteral fistula. He always used it on a vesico-
vaginal fistula, splitting the viscus and turning part of
it in and part out. In ureteral fistula none but the
very finest instruments could be used.
Dr. C. p. Noble said he had seen a goodly number
of fecal fistulae, and all had closed spontaneously ex-
cept four. Three remained obstinately open ; one re-
covered after operation. When the fistula was in the
larger bowel and the case was not tuberculous, it was
his experience that the prognosis was most excellent.
In tuberculous cases the prognosis was very bad whether
or not operation was done. In one such case operated
on the result was a failure, and in quite a number the
patients had died or the results had been unsatisfac-
tory.
AMERICAN PEDIATRIC SOCIETY.
Ttt'cifth Animal Meeting, at Washington, D. C,
May I, 2, and j, igoo.
First Day — Tuesday, May ist.
The Care and Treatment of Summer Diarrhoea.— The
first session was called to order by the president,
Henry Koplik, M.D.,of New York, who gave an ad-
dress upon "The Proper Care and Treatment of Sum-
mer Diarrhcea Cases." The speaker said in part, that
he invited the society to a subject so broad and catho-
lic that it could not fail to interest both physicians
and laymen. The care of the poor children, whether
sick or well, was assumed by the State in some in-
stances, by private individuals in others. Improving
the condition of these wards tended to our own better-
ment. The close housing of the poor during the colder
months tended to the increase of accumulating filth
and general dirt, to lack of fresh air for breathing, and
to little personal cleanliness. If infectious diseases
were not also increased the debilitated children were
the more ready victims when they were exposed. In
the summer the general health improved, but the ten-
dency to intestinal disease increased, as there was an
increasing liability to infection from improper or un-
wholesome food. In France one-half of the children
below one year of age died each year from intestinal
troubles. In three years eighteen thousand bottle-fed
children died in Paris alone. The breast-fed did not
escape entirely, but were less liable to intestinal in-
fection. Nearly all children fed artificially got more
or less cow's milk, and the many times it was handled
gave many chances for infection, not only with animal
filth but also dairy dirt, and particularly streptococci,
which caused diarrhoea. The great medical congress
of i88i laid great stress on cleanliness. Soxhlet
emphasized cleanliness in preserving milk. The
greatest lights on the problem were those relating to
cleanliness. It could be successfully accomplished
in many ways. The foundation of infant feeding must
be the mother's breast, yet this might vary from eighty-
nine caloric equivalents to one hundred and twenty-
six calories. The absolute quantity at the breast be-
ing unstable, our rules fcr artificial feeding must vary.
Meigs showed that the proteids were usually low in
mother's milk, and that the fats varied much. Lead-
ing minds differed as to how the variations should be
accomplished: some diluted only; others, as Meigs
and Rotch, reconstructed. Jacobi and others diluted,
and added ingredients. The key-note of intestinal dis-
orders was infection; therefore the sick children
should always be separated from the well. We had as
much responsibility in the intestinal infections as of
prophylaxis in scarlatina or measles. The ignorant
motiier should be taught the possibility of carrying
contagion, and that (he utmost care should be exer-
cised in washing thoroughly after changing the child's
napkins, and that there be no rapid change from toilet
oprations to feeding. The physician should have con-
stantly in mind the distinguishing characteristics of
stools, that he might know when streptococci had dis-
appeared and when milk could safely be resumed.
Cases might be treated as ambulatory, coming to a
dispensary, or in hospitals and sanitariums. Those
patients taken out of doors did best, as they had fresh
air. The stools should be examined grossly and mi-
croscopically at a laboratory in connection with the
dispensary. For ten years the speaker had so man-
aged his intestinal cases; and two hundred infants
daily, the year around, received their proper milk
supply there at the dispensary. Increasing weight
encouraged the mothers. Mothers should not be al-
lowed to get prepared or modified milk except on a
physician's order, as they usually overfed. Even water
was furnished for the preparation of albumin water.
It impressed upon the mother the necessity of attention
to details. Examining the stools was not a fad. It
was a sure way of determining the proper treatment
and food. The speaker advocated, as the ideal man-
agement, the treatment of one or two cases only to-
gether, in barracks or camps or huts on high ground,
not necessarily near the seas but inland. These tents
or camps could be comfortable but very simple, warmed
if need be by a stove. The mothers should live with
the babies and take them once a day to the central
camp, where the physician could see them and pre-
scribe. Infections like measles and scarlatina were
not likely to spread there, and intestinal infection
778
MEDICAL RECORD.
[May 5, 1900
would rapidly subside. Here was a new future for
the summer management of the poor.
Studies of the Blood in Childhood — This paper,
by Drs. Alfred Stengel and C. Y. White, of Phila-
delphia, was read by title.
Intestinal Obstruction through a Loop Formed by
Meckel's Diverticulum, with Ligamentous Attach-
ment.— Dr. Irving M. Snow, of Bulfalo, read this
paper, and presented the specimen. The speaker
stated that the cases were very obscure in many ways
as to origin, formation, and symptoms. The case nar-
rated was that of a boy, three years old, who fell from
the doorstep and struck about the navel. A few days
later he ate a quantity of grapes. The fall occurred
on the 9th of the month; vomiting began on the 12th
and lasted five days. There was pain about the navel,
and opium was administered from the 14th to the 17th.
The belly was slightly distended, but the temperature
remained normal, and there was no abdominal tender-
ness. Vomiting of fecal matter occurred on the 17th.
An intestinal injection with oil brought away a few
grape-seeds and caused collapse. There was visible
peristalsis of the intestines. At the autopsy no peri-
tonitis was found. The ileum seemed to be snared
close to the ileo-caecal valve, and oil was found above
the strangulation. One-third of the reported cases
were of this character, but the condition was rarely seen
in childhood. The obliterated portion of the omphalo-
mesenteric duct created an arcade that readily caught
the gut. The exact nature of the case was not recog-
nized until after death.
In the discussion. Dr. Caill^, of New York, said that
every case of chronic intussusception that had vomit-
ing should be submitted to exploratory laparotomy.
Dr. S. S. Adams also favored early operation, bas-
ing his remarks on a recent experience. It was well
known that usually hospital cases resulted fatally from
delay. The case mentioned had the characteristic
straining and screaming, but no tumor. Rectal ex-
amination proved nothing. Three drops of tincture of
opium had been given, which completely narcotized
the child. Next day, salt injections failing to relieve,
operation was done. A profuse stool occurred while
under anssthesia, but the abdomen did not collapse.
Four inches of intestine were found invaginated. The
child made a complete recovery, though only five
months old. Very few recovered without operation.
Dr. \V. S. Christopher alluded to a case of his, of
a child four months old, nursed at the breast, which
suddenly showed symptoms of intussusception with-
out cause and without fever. Blood was passed
from the bowel, but there was no vomiting. There
was neither tumor nor tenderness. At the operation
one and a half inches of small intestine were found in
the colon. Recovery was complete, the child nursing
half an hour after operation, and six hours from the
onset of the attack. Six months later the same symp-
toms occurred. The belly was again opened, and air
injected with great force into the bowel. It did not
budge, but this constituted a direct experiment not
often possible. The invagination was reduced and
the appendix removed. Recovery was complete as
before. No double case has been found thus far on
record.
Dr. VV. L. Carr also emphasized the necessity of
early operation even in the absence of symptoms. He
recalled three cases during the past year without tumor,
but with symptoms of ordinary colitis. One intussus-
ception was found unexpectedly at an operation.
The Pancreatic Digestion of Casein. — Dr. B. K.
Rachford, of Cincinnati, read a short paper on this
subject. His experiments consisted in collecting
fresh pancreatic juice from rabbits, also bile from rab-
bits, and placing the same in tubes with ordinary fresh
cow's milk filtered and neutralized. These tubes were
placed for five or six hours in a water bath at 38^ C.
Lactic acid and ammonia were used to complete co-
agulation of the milk, and the remainders were washed,
dried, and weighed. Maltose was prepared by boiling
one of the Liebig foods. As a result of these experi-
ments it was found that maltose aided the pancreatic
digestion of casein. It was also found that the pres-
ence of rabbits' bile facilitated the action of pancreatic
juice. It increased the diastatic action when starch
accompanied the casein. Dr. Jacobi had long taught
that starchy gruels aided in digestion of the milk ca-
sein. The experiment with lime-water showed that it
increased proteolytic action of milk in the stomach.
Lime helped the activity of the rennet. In milk feed-
ing, lime water not only neutralized acidity, but stimu-
lated pancreatic digestion in the intestine. Sodium
bicarbonate greatly increased the proteolytic power of
pancreatic juice on casein. It also neutralized the
fermentative acids of milk. Hydrochloric acid was
found to retard proteolytic action. Bile and hydro-
chloric acid caused the pancreatic juice to act with
greater intensity. The intestinal contents lost their
acidity at some distance from the stomach. The fact
that acid so strongly aided pancreatic action should
greatly influence its use in infant feeding; besides
being an intestinal antiseptic it aided the pancreatic
enzymes. Greasy and fatty stools came from deficient
bile supply.
In discussion Dr. Rotch stated that cereals, while
having no retarding action, had but slight proteolytic
action, and besides called up amylolytic action. He
would be against their use. He did not regard the
presence of fat in the stools as abnormal. ^~
Dr. C.\ille spoke highly of hydrochloric acid, which
he had used for fifteen years in all cases in which the
tongue was coated, especially in children two years
old or more. U'hen the tongue became clean, the acid
should be stopped and iron given.
Dr. Fruitnight gave testimony in accord with the
last speaker. He esteemed hydrochloric acid highly
from many years' use of it.
Dr. a. C. Cotton spoke of the fact that fat as such
was rarely found in the stools. Not all light floccu-
lent masses were fat. It could be surely recognized
only by chemical arialysis.
Dr. Holt had seen little efficacy from any of these
drugs. He claimed more for stomach washing. The
use of drugs was purely empirical. Drugs played no
part if the food was proper. Proper food should be
given, the- stomach washed, and the child kept in the
fresh air.
Dr. Blackader confessed that the use of acid was
contrary to our knowledge of physiology, as it was
found late after eating, not immediately. Washing
was troublesome. Catarrhal processes were present
and demanded alkalies. Acids disappointed. The
society should not emphasize the use of drugs, but the
broad principles of management.
Dr. Rotch noted th it it was necessary to dilute
cows' proteids, as they went farther than those of hu-
man milk. Drugs should seldom be used.
Dr. Rachford called attention, in closing, to the
fact that this was but an announcement of experimen-
tal facts and not a treatise on treatment in general.
They threw light on pancreatic juice and what influ-
enced it. Bile with pancreatic juice emulsified fats;
this was destroyed when in contact with strong alka-
lies, and the fat was absorbed, not emulsified. Cream
in the stools did not appear with its albumin and soap
covering, but as butter fat. When hydrochloric acid
was absent, it was needed and should be given. Clin-
ical use in proper cases abundantly proved that it was
not empirical treatment. Acid at most was an addi-
tion. It would not take the place of proper selection
of food and of cleanliness.
May 5, 1900]
MEDICAL RECORD.
779
Clinical Observations upon the Operative Treat-
ment of Tuberculous Peritonitis. — Dr. Augustus
Caillk, of New York, read this paper. Two points
were of interest, the behavior of cases before opera-
tion and their behavior after operation. The cases
narrated were mostly from the babies' wards of the
Post-Graduate Hospital. In all cases examinations
were made of the urine, blood, fceces, and puncture
fluids. As an example, he gave the case of a boy,
aged six years, with abdomen swollen, tense, not pain-
ful. Fluid was present. Rectal irrigation and
creosote had been used for some time. Dr. Curtis op-
erated and found the usual pathological nodules of tu-
berculous infection. Two years afterward the boy was
well. The general abdominal cavity had not been en-
croached upon. Another case was that of a boy two and a
half years old, who gave a negative history except a tu-
mor on each side of the abdomen. These were foutid to
be large tubercles, not adherent. No other glands were
theninvolved. Eighteen months afterward small tumors
could be felt there. In a third case, that of a girl aged
five years, fluid was encysted as high as the umbilicus.
At the operation adhesions and miliary tubercles were
found covering the intestines. A sinus persisted for
a year and closed. When it did so rales were found
over the right lung. The sinus was curetted and cured
and the lung also healed. She was now well. J.
C , another patient, had flatness due to a cyst, as
high up as the umbilicus. It was opened and dressed
with ten-per-cent. glycerin and iodoform. He was
now healthy but pale. A girl, aged nine years, had
pain in the abdomen for six months, with eight or ten
stools each twenty-four hours. The blood and urine
were normal. After two years' treatment an operation
was done and disclosed adherent tuberculous peritoni-
tis. The diarrhoea and paroxysmal pain had lasted
two years. The speaker gave the following rtsiim!: :
Diagnosis was based on pain, fluid, loss of weight, etc.
Febrile rise was always found if careful observations
were made. Bacilli were rarely found in fluids. The
pain might be intestinal. He regularly employed the
tuberculin test in human subjects. These cases showed
the futility of medicine in tuberculous peritonitis.
Early operation was always to be advocated. He was
sceptical about complete cures.
Discussion — Dr. Fruitnight mentioned the case
of a young woman, aged twenty years, with an ulcer of
the palm, which the microscope showed to be tubercu-
lous. She had also recurrent peritonitis. He thought
early excision of the lump in the hand might have
spared the woman the general infection.
Dr. Rotch spoke of sixteen cases of tuberculous
deposits found in patients dead of diphtheria. It
showed how important in every way was tuberculosis
to a pediatrist; particularly, that it should be kept out
of the alimentary tract. If the case was one second-
ary to lung infection, laparotomy would do little good;
if primary, it might cure. Certainly it would not give
bad results. In one case followed for seven years the
patient was now well. Secondary cases were the rule;
hence bad results. Laparotomy was really more defi-
■ nite and at times less harmful than castor oil. One
should never hesitate to make an exploratory inci-
sion. The bacteriologist had not kept up with the
surgeon here. Many cases that we felt uncertain about
were doubtless tuberculous. Cases without effusion
did well. The vast majority of abdominal tumors
were tuberculous. Tuberculous mesenteric glands
must be removed to prevent general infection. When
the trouble was secondary to tuberculosis of the lung
it was a general, not an abdominal disease. He was
strongly in favor of tuberculin for diagnostic pur-
poses.
Dr. Cotton agreed that tuberculosis was para-
mount to any disease of childhood and very difficult
to diagnose. He asked how far we could insist on an
exploratory incision for diagnosis only.
Dr. Rotch replied that it should be done as a lou-
tine.
Dr. Johnston called attention to the absence of
leucocytosis in differentiation from ordinary peritoni-
tis.
Dr. Caille, in closing, reiterated his statement that
medicine was of no avail here. The abdomen must
be opened. The other causes for ascites, as heart dis-
ease or cirrhosis, were easily eliminated.
The meeting adjourned to Wednesday at 9 130 a.m.
AMERICAN NEUROLOGICAL ASSOCIATION.
Twenty-sixth Annual Alccting, Held at Washington,
D. C, May i, 2, and j, /goo.
First Day — May ist.
President's Address — This was delivered by Dr. E.
D. Fisher, of New York.
Christian Pseudo-Science and Psychiatry This
was the title of a paper read by Dr. Smith Baker, of
Utica. He reviewed the claims of healers and the
cures they were said to have effected, and gave an analy-
sis of the condition of mind and body commonly in-
duced by the Christian Science healer. He found it
to consist of a variety of imperative conceptions very
difficult to manage. The conclusion reached was that
these cases required a most comprehensive study of
both the psychical and physical state in order that the
proper cultural treatment could be instituted and main-
tained. This was the only method which would thor-
oughly cure.
Imperative Ideas in the Sane and their Manage-
ment.^— Dr. Edward B. Angell, of Rochester, read a
paper on this subject. He said that imperative ideas
were to be distinguished from fixed ideas, or delu-
sions. The former involved the element of conscious
and painful resistance in the ego against their accept-
ance; the latter were appreciated as real conditions
and were accepted as true. In imperative ideas or ob-
sessions the psychical reaction in feeling was against
the idea; in tlie fixed idea or delusion it was in har-
mony with it. Imperative ideas were largely emo-
tional in their character and related to abnormal sen-
sations of a somatic character. They were dependent,
however, for their manifestation upon a state of mental
feebleness, an instability of mental synthysis. These
ideas might affect either the sensorium, the motor
sphere, causing impulsive acts, or produce vasomotor
disturbances. The subjects of this mental vice might
be divided into two groups — those whose mentality was
dependent upon hereditary, congenital, and acquired
defects of organization, the degenerates; secondly,
those who through accidental causes became unduly
subject to emotional disturbances, the weak-willed.
In treatment it was the primary emotional state one
should counteract. The morbid idea might be replaced
by a real one through strong sensory stimulation. The
idea might be altered by attaching to it some associa-
tion, ludicrous or painful in character. Isolation of
the patient, education through diversion, and increase
of the power of attention toward normal feeling and
action, constant yet not too stimulating change of
scene, all entered into proper treatment. In some
cases hypnotism, which had enabled us to learn much
regarding these morbid mental phenomena, might be
utilized to advantage.
Dr. Smith Baker said that persistent mental stress
on the part of parents was likely to predispose the
child to imperative ideas. He was in favor of educa-
tional methods in preference to hypnotism.
78o
MEDICAL RECORD.
[May 5, 1900
Dr. p. C. Knapp, of Boston, did not agree with Dr.
Angell's views as to the relationship between obses-
sions and imperative ideas. He did not approve of
hypnosis in the treatment of such cases, but preferred
educational methods.
Dr. S. Weir Mitchell, of Philadelphia, referred to
a case of mania of repetition, in which the patient
would repeat certain acts several times, and associate
the number of times with the thought of various rela-
tives. This was relieved by sudden pinching by her
attendant at the time of the act, thus substituting an-
other form of sensation for its relief. After many
years of experience he was opposed to the use of hyp-
notism alone as a method of treatment. He knew of
no case in which a cure had taken place by hypnotism
alone, unassociated with other means.
Dr. B. Sachs, of New York, believed that impera-
tive conceptions, so often morbid, were closely related
to the psychological, and were often based upon some
definite reasoning. They did not arise spontaneously.
Hypnosis not only did not cure but originated such
concepts.
Dr. J. J. Putnam, of Boston, thought that the origi-
nal idea passed over into a mechanical symbol which
influenced the patient. The use of suggestion without
hypnotism was of value, but hypnosis itself was very
valuable in certain cases.
Dr. \V. Browning, of Brooklyn, said that imperative
movements were somewhat similar. One type simu-
lated melancholia and differed in the results of treat-
ment. It could be successfully overcome by enlarging
the mental sphere of the individual.
Dr. Angell, in closing the discussion, said that if
the ideas were carefully analyzed much could be ac-
complished toward effecting good results. It was
sometimes difficult to establish the difference between
fixed ideas and imperative ideas. The latter were
usually amenable to treatment. Hypnotism was of
value as an educational method. American men and
women, however, were not as susceptible to hypnotism
as the French and German.
Wernicke's Conduction Aphasia with Autopsy. —
This was the report of a case by Dr. Howell T. Per-
shing, of Denver.
Bullet-Wound of the Spinal Cord. — Dr. Joseph
Sailer, of Pliiladelphia, reported the case of a Cuban
officer who was shot through the spinal cord, the bullet
injuring the fourth and fifth lumbar and the first four
sacral segments. Three years after the injury a lami-
nectomy was performed for the relief of fulgurant
pains, and a pachymeningitis was found. The opera-
tion was successful. During convalescence allocheiria
appeared and persisted for three days.
Dr. Weir Mitchell thought that the most remark-
able feature in the case was the disappearance of the
gluteal muscles. He had been the first to describe
the symptom of allocheiria. It was at the time of the
war, over thirty years ago.
Dr. J. W. Putnam, of Buffalo, referred to the case
of a patient who had fallen and injured the spine, pro-
ducing pain and rigidity in the cervical muscles. This
was followed two years later by paraplegia and anaes-
thesia. There was deformity at the sixth and seventh
vertebrae. Operation revealed fracture of the sixth cer-
vical spine and thickened dura. Improvement fol-
lowed. There was restoration of bladder function and
sensation improved. Irritation applied to the lower
extremity was referred to the seat of the injury.
The ''Babinski" Reflex.— Dr. G. L. Walton, of
Boston, read a paper on this subject, in conjunction
with Dr. W. E. Paul. He had examined the plantar
reflex of one hundred normal individuals, seventy in-
fants, two hundred cases of nervous disease other than
that of the pyramidal tract, one hundred cases with
other than nervous disease, two hundred hemiplegics
and diplegics, and thirty cases of pyramidal spinal
disease. The following conclusions were drawn,:
(i) In health either of the following conditions
might appear on taking the plantar reflex: (a) flexion
of all toes; (/') flexion of some (generally outer) toes;
(r) flexion of all toes on one side, and of some (gen-
erally outer) on the other; (d) entire absence of move-
ment on both sides (about ten per cent.); (e) flexion
of all or of some (generally outer) toes on one side,
with absence of movement on the other (at least ten
per cent.) ; (/) occasionally (in sensitive individuals)
quick, semi-voluntary, indeterminate movements, some-
times of flexion, sometimes of extension. (2) In early
infancy no constant or characteristic movement of the
toe appeared, though extension was rather more fre-
quent than flexion. (3) The Babinski reflex obtained
in about seventy per cent, of hemiplegics and diple-
gics, and in approximately the same percentage of
cases with disease involving the pyramidal tract in the
spinal cord. (4) The Babinski reflex (deliberate and
constant extension of the great toe, with or without
extension and separation of other toes) was never
present in health, and our observations led us to doubt
its existence in either functional or organic nervous or
other disease not implicating the pyramidal tract. (5)
This reflex was oftenest the earliest to appear in pyra-
midal tract disease, e.^., at the onset of a hemiplegic
attack before the establishment of the exaggerated
knee jerk and ankle clonus; it may persist during a
period when other refle.xes are absent, e.g., when knee
jerk and ankle clonus were wanting on account of
ankylosis, contracture, and muscular wasting, as in
long-standing diplegia, or of degenerative sequences,
as in combined systemic disease. This reflex fur-
nished, therefore, a most important practical aid in
diagnosis. (6) This reflex very exceptionally ap-
peared in cases not conforming to recognized types of
pyramidal disease (meningitis, hydrocephalus, poison-
ing as by alcohol or ura;mia). These instances were
too few materially to impair the diagnostic value of
the phenomenon — in fact, the Babinski reflex alone
should here rather lead us to suspect pyramidal in-
volvement as by cedema or indirect pressure.
Clinical Study of the Reflexes — This was the
title of a paper read by Dr. Joseph Collins, of New
York. It was based on the study of two hundred cases.
This and the preceding paper were discussed together.
Dr. Weir RIitchell said that the whole physiolo-
gical literature on this subject came from this side of
the ocean, since the Jendrassik method was first ex-
pounded. All muscle jerks were capable of re-enforce-
ment as well as tendon jerks. He called attention to
the fact that it was impossible to re-enforce the skin
reflexes.
Dr. Knapp said that we did not know why the skin
reflexes were so persistent in tabes. As to the normal
plantar reflex, it was usually present unless affected
by disease.
Dr. B. Sachs differed from the views of Dr. Collins
and believed that the condition of the reflex did not
depend on the tonus of the muscle. The Babinski re-
flex was most unreliable in children.
Dr. W. G. Stiller, of Philadelphia, referred to two
acute cases of cerebral hemorrhage with hemiplegia,
in which on the paralyzed side the knee jerk was ab-
sent and the Babinski reflex present. Both patients
died. He was therefore inclined to look upon such a
combination of symptoms as indicating a bad prog-
nosis. Babinski's sign was of value only in connec-
tion with other symptoms.
Tumor of the Superior Parietal Lobule — This
was the report of a remarkable case by Drs. Charles
K. Mills and W. W. Keen, of Philadelphia. The
tumor was accurately localized and removed by opera-
tion. There were localized partesthesiffi, astereognosis,
May 5, 1900]
MEDICAL RECORD.
781
and later hemiplegia. None of the general symptoms
of cerebral tumor was present. The eye symptoms
relating to the fields were suggestive of hysteria. The
patient made a good recovery and was restored to use-
fulness.
Dr. Spiller stated that the growth was endotheli-
oma.
Dr. Walton mentioned the case of a patient with-
out any of the general symptoms of tumor. There
were twitching of the hand and temporary paresis,
later followed by hemiplegia. Subsequently, optic
neuritis developed in one eye.
THE AMERICAN LARYNGOLOGICAL ASSO-
CIATION.
Tcoenty-seavid Annua/ Meeting, Held at Washington,
D. C, May /, 2, and j, igoo.
President, Samuel Johnston, M.D., of Baltimore.
Opening Session — Tuesday, May ist.
President's Address. — After returning thanks to the
members of the association for the honor conferred
upon him, the president spoke of the future policy of
the association. He believed that new memlDers
should be elected by a two-thirds affirmative vote of
the entire membership. Old members should be en-
couraged to continue in active work. Scientific and
clinical work should go hand-in-hand. One should
avail himself of all possible advances in diagnostic
ability — as, for instance, the determination of leuco-
cytosis as an initial feature of malignant disease.
More attention should be paid, in teaching students in
rhinology and laryngology, to operative work on the
cadaver. Members of the association were looked to
as teachers, and consequently great care should be
taken in the selection of new candidates. The aim
should be not mere numerical strength, but skill in at-
tainment. In the programmes of the future it might
be well to limit the number of papers, but more atten-
tion should be given to discussion. The former should
be grouped in two general classes, scientific and clin-
ical. No opinion should go out from the meetings as
official unless it was founded on facts. Mild meas-
ures, especially as concerned the use of the cautery,
saw, and trepliine, should be strenuously urged. A
committee of censors, to be elected annually, should
be established which should pass on all matter to be
published in the annual Transactions. In conclusion,
a feeling tribute was paid to the memory of two active
fellows who had died during the year — Dr. Max Thor-
ner, of Cincinnati, and Dr. Joseph C. Mulhall, of St.
Louis.
Fractures of the Nose. — This paper was read by
Dr. T. a. De Blois, of Boston. He said that " broken "
noses, so-called, were not, as a rule, really fractured.
They were rather cases of bony displacement and dis-
location. They might be classified according to the
degree of injury and also according to the relation of
the parts involved. There might be a dislocation (not
fracture) of the nasal bones, i.e., a solution of bony
continuity, or there might be a fracture of the nasal
process of the superior maxilla or of the zygoma. In-
juries might also result during parturition or from nurs-
ing or sleeping, from the constant impact of the nose,
delicate at this period, against the mamma; or the pil-
low. Then again there were the cases occurring from
falls, blows, and collisions. In the " upper-cut " blow
of the boxer, there was injury to the septum, followed
by swelling, possible abscess, and detachment from
the subjacent parts. The "side" blow gave a double
dislocation of the nasal bones, while in the direct
" front '' blow the internal nasal border was driven
downward and outward. Treatment consisted in the
reduction of the dislocation, which might require a
general ana;sthetic. These flat noses might be prop-
erly manipulated so as to dispense with external appa-
ratus. For an internal splint, a bit of stiff rubber
tubing inserted by means of a closed pair of scissors
(well greased so as to facilitate their withdrawal)
might be of service. The elastic recoil of the rubber
slowly acting will often force a dislocated nose into
place, though some few days might be required to pro-
duce the full efl'ect. Plaster-of- Paris bandage made
an excellent external splint. Illustrative clinical cases
were then described.
Dr. De Blois also exhibited an illustration of an ab-
normality of the uvula, which was double, one mass
seeming to come from the anterior and the other from
the posterior faucial arch. The former was amputated,
leaving the latter appearing as a perfectly normal
organ.
Dr. Emil Mayer, of New York, inquired of Dr. De
Blois if he had not found the rubber internal splint ir-
ritating to the nasal mucosa. He himself preferred to
use gutta-percha, which could be accurately moulded
to fit each individual case, and was less collapsible.
Elongated forceps could be used for the replacement
of recent cases.
Dr. De Blois replied that the rubber was to be re-
tained only temporarily, until perfect reduction had
been secured.
Dr. W. E. Casselberry, of Chicago, recommended
the use of a general anaesthetic for perfect diagnosis
and reduction. Deeper injuries were very painful,
and in children without an anaesthetic proper exami-
nation was impossible. He commended the external
plaster-of-Paris dressing. The objection to all forms
of special apparatus was that they were rarely at hand
when wanted, and were difficult to keep in position.
Plaster could be moulded over the nose, carried back
to the line of the ears, being made thinner posteriorly,
and secured by tapes passing above and below the ears
behind the head. Such splints had to be worn ten
days, and were, of course, a disfigurement. For inter-
nal splinting nosophen gauze applied under cocaine
acted admirably. For fractures low down in the nose,
the ordinary vulcanized tube answered very well.
Dr. Jonathan Wright, of Brooklyn, called atten-
tion to the statements found in the writings of the
fathers of medicine respecting the treatment of nasal
injuries. The fingers of a child, thongs attached to
plugs on the concave side of the injury, etc., had all
been advocated. In a recent case, one authority had
inserted a plug made from the lung of a sheep. All
the ancients objected to the use of absorbent material
as rapidly tending to become foul.
Dr. John O. Roe, of Rochester, commended the
use of a thin metal splint externally with an internal
dressing. An ana;st!ietic should be given when the
injury was at all severe. Adhesive plaster was an ad-
mirable retaining material.
Dr. H. L. Swain, of New Haven, Conn., called at-
tention to the mechanics of the nasal arch, saying that
if one could bring the two nasal bones into proper ap-
proximation, they would support each other. If the
patient could be seen frequently, he would dispense
with all apparatus.
Dr. F. C. Cobb, of Boston, had had as good results
without as with apparatus. The behavior of the nose
during the first two days after the receipt of injury
would determine whether or not apparatus might be
safely dispensed with.
Dr. W. K. Simpson, of New York, advocated the
use of the Bernays sponge specially shaped to fit the
inside of the nose. It offered ideal requisites for this
purpose, being easy of introduction and haemostatic
by the equable pressure it exerted.
782
MEDICAL RECORD.
[May 5, 1900
Dr. W. F. Chappell, of New York, had used the
sponges, attaching them by iodoform collodion to a
thin plate of gutta-percha, a device which had, in his
hands, proven of great value.
Atrophic Rhinitis.— Dr. J. E. Logan, of Kansas
City, j\Io., read this paper. He reviewed the various
theories of the pathology of this condition, condemn-
ing the introduction of the very large number of. clin-
ical terms which had been used to describe it. Four
theories as to causation seemed worthy of special con-
sideration: (i) hypertrophy, cutting ofi the blood sup-
ply by pressure, thus inducing atrophy; (2) suppura-
tive rhinitis in children; (3) bacterial causation; (4)
sinus disease. For himself, he was inclined to attach
importance, on the basis of his own experience, to the
last-named theory. He narrated the histories of sev-
eral cases in which opening and curetting of the eth-
moid cells cured the atrophic rhinitis. One unex-
plained fact in these cases was the real source of the
immense amount of secretion.
Dr. Cobb had observed in his own ethmoid cases
marked atrophy on the side of the sinus disease. In
persistent sinus discharge he had noted a steadily in-
creasing atrophy of the intranasal structures.
Dr. Wright stated that post-mortem examination
did not show that close connection between atrophic
rhinitis and sinus disease that had been claimed by
Griinwald and others. In his own personal experi-
ence, the inferior and not the middle turbinate was
the structure primarily attacked. The etiology of
atrophy here was hard to determine. There was no
analogous process in any other part of the body. He
was inclined to attach much importance to the recent
views of Cholerva and Cordes, who looked upon the
process as the result of a rarefying osteitis, commenc-
ing with a bony hypertrophy, the little canals in the
bone containing an artery and vein becoming occluded
by the bony growth. As a result the blood supply to
the mucosa was shut off. How this process actually
began was a matter of much less importance. Recent
anthropometric investigations had confirmed Hop-
man's view as to the causative relation of a short
antero-posterior nerve dimension, and still more
strongly Fraenkel's contention as to the special occur-
rence of the affection in the brachio-cephalic type of
skull. This latter observation, however, might be
referable only to certain geographical areas, especially
in Germany and Switzerland, and not applicable to
American patients. No one cause was alone appli-
cable in every case. In his own experience, seventy-
five per cent, of the cases had occurred in women, and
the sexual life might be an important factor.
Dr. Swain called attention to the fact that the rare-
fying osteitis had been marked as the cause of intra-
nasal oedema and polyp formation, but he realized that
intranasal conditions might differ in different types
of skulls. The brachio-cephalic type of naris might
cleanse itself with more difficulty than would other
types.
Dr. J. E. Bovlan, of Cincinnati, inquired if Dr.
Wright had ever seen patients spontaneously recover
after the menopause.
Dr. Wright answered that he had noted a cessation
of symptoms, while the objective atrophy remained.
Dr. Casselberrv declared that we must not over-
look the associated atrophy of adjacent parts; there
was also an atrophy of the lymphoid structures, a non-
sensitiveness of the parts, and either a lack of devel-
opment or an early shrinkage of physiologically asso-
ciated tissues. The bony walls of the sinuses were
especially thin in these cases. All of these lesions
strongly suggested to him the theory of a tropho-neu-
rosis.
Dr. Simpson had seen cases persisting beyond the
menopause with as much virulence as before.
Recurring Membranous Rhinitis due to the Ba-
cillus of Friedlander, with Report of a Case. —
This paper was read by Dr. E.mil Mayer, of New
York. The clinical history of the case described was
a later chapter of the case previously reported before
the American Medical Association by Dr. McRey-
nolds, of Dallas, Tex. After the case came under
Dr. Mayer's observation exhaustive microscopical and
bacteriological tests were made, proving to his own
mind that the membranous formation was due to the
bacillus of P'riedliinder. Some thirteen or more pre-
vious cases were on record and were carefully analyzed
by Dr. Mayer, who gave a complete resume of the lit-
erature of tiie subject.
At the close of the session Dr. Bovlan exhibited a
hypodermic syringe for the application of cocaine to
the pharyngeal vault for adenoid operations.
Dr. J. H. Bryan, of Washington, showed an aseptic
syringe for nose and ear work and improved drainage
tubes for the frontal sinus ; Dr. R. P. Lincoln, of New
York, a v\ax model of a recurrent tonsillar tumor with
illustrative plates; Dr. Mayer, a hollow intubation-
tube introducer for use in laryngeal stenosis, the intu-
bation tube itself being retained by an arm screwed
in through the tracheotomy incision.
Dr. T. R. French, of Brooklyn, exhibited photo-
graphs of a chair to be used in the employment of the
upright position in ether operations on the nose and
throat.
AMERICAN ASSOCIATION OF GENITO-URI-
NARY SURGEONS.
Fotirti'e?!fh Annua/ Meeting, Held ai the Raleigh Hotel,
Washington, D. C, May i, 2, ami j, igdo.
President, James Bell, M.D., of Montreal.
First Day — Tuesday, May ist.
Chronic Pyelonephritis and its Pathogenic Relation
to Diseases of the Opposite Kidney.— Dr. John P.
Bryson, of St. Louis, Mo., read this paper, and his ob-
servations suggested the following conclusions: (i)
Post-operative observation in a number of cases of
primary unilateral nephrectomy, as well as secondary
nephrectomy after nephrotomy and drainage, seemed
to confirm the belief that long-continued unilateral
pyelonephritis had a pathogenic effect upon the previ-
ously unaffected kidney of the other side. (2) This
pathogenic relationship seemed to hold good even when
the primarily diseased organ was adequately drained
either by the ureter or by a renal fistula. (3) Obser-
vations, as yet inadequate, seemed to show that the
pathogenic effects upon the organ secondarily diseased
manifested themselves primarily in the tubular epithe-
lium, determining a parenchymatous nephritis. (4)
Suppurative pyelonephritis seemed to add the element
of amyloid degeneration to the secondary nephritis;
but whether this change took place in the kidney be-
fore other viscera well known to be commonly affected
in this way by chronic suppuration became involved,
was wholly undetermined. (5) The mechanism of
this secondary nephritis was not yet determined.
Whether it was caused by the " reflex " action through
the nervous system, or by the absorption of toxins or
bacteria from tlie primarily'diseased kidney carried by
the blood stream to the other kidney, increasing its
burden of elimination, and thus irritating the tubular
epithelium, seemed to be a question for the experi-
mental laboratory. (6) So far as our information
went at present, it served to increase the probable
benefit of frequent observation of the segregated urines,
which might serve not only to localize the disease, but
to determine the time of surgical interference by giv-
ing warning of tiie beginning of crippling of the pre-
May 5, 1900]
MEDICAL RECORD.
783
viously healthy kidney. (7) Repeated observation of
dilTerentiated urines had a distinct prognostic value in
suigical intervention, even to the extent of influencing
the choice of nephrectomy and nephrotomy.
Some Observations upon Hydronephrosis.— Dr.
A. T. Cabot, of Uoston, read this paper. He instanced
the history of a boy, eleven years of age, who during
the past nine and a half years had had repeated attacks
of severe abdominal pain. During these attacks it was
noticed that there was a swelling in the left renal re-
gion which diminished with the subsidence of the pain.
These attacks were accompanied by fever and vomiting.
During later years the attacks lasted a number of days.
The diagnosis of hydronephrosis, already made, was
concurred in and operation advised. The operation
showed it to be a case of ruptured hydronephrotic sac
with a pseudo-hydronephrosis around it. The rent in
the dilated kidney was closed in the hope that the
urine would re-establish its passage through the ureter,
as had happened often before. This hope was not
gratified. At the end of twenty-four hours the pseudo-
hydronephrotic sac filled and became very painful;
then the hydronephrotic sac was again opened and a
drainage tube was introduced, which was followed by
complete relief, and the boy gradually recovered his
strength. In this way he lived for two years without
pain, when he entered the Massachusetts General Hos-
pital for the relief of the urinary fistula. Before pro-
ceeding to operation it was thought wise to increase
the secretion of the kidneys, which were acting insuffi-
ciently. As tlic hydronephrotic kidney was discharg-
ing all of its urine through the fistula, it was possible
to collect the secretion from each organ separately,
which was done. It was interesting to note how much
good work was done by a kidney in which the secret-
ing substance was stretched out to a mere shell on the
surface of a hydronephrotic sac; also, how decidedly
this work c<iidd be increased by the diuresis produced
by the exhibition of large quantities of water. I5y this
simple diuresis the total amount of urine was increased
from eighteen to seventy ounces, and the amount of
urea was increased from 1 1.07 gm. to 16.73 S.^- Hav-
ing improved the condition of the patient, the hydrone-
phrotic sac was exposed and stripped off from the sur-
rounding tissues. When the hilus was reached, the
ureter was readily recognized, and the following con-
dition was made out: The ureter, of normal size, after
leaving the pelvis of the kidney, pursued the ordinary
course toward the bladder for a distance of an incli,
when it turned backward and upward to loop itself over
an accessory artery which ran from the aorta and en-
tered the kidney at a point somewhat below the origin
of the ureter. This loop was S-shaped, and while the
canal was of nearly normal size above the point where
it hung over the vessel, below that point it became
very narrow with extremely thin walls. The ureter
could not be followed with a probe, and it was shown
that this undeveloped condition of the ureter continued
down toward the bladder. It was then decided to re-
move the kidney; this was done, and the patient made
a good recovery.
Dr. L. Eolton Bangs, of New York, said that two
years ago he operated upon a gentleman who seemed
to be in an extremely dangerous condition; he was
septic from a prostatic abscess which had opened into
the rectum; there was a residual abscess left which
drained through the perineum. There was an exten-
sive pyelitis, and the man seemed to be dying from a
suppurative left kidney. There were evidences of the
right kidney being distinctly enlarged; it could be
felt. The left kidney seemed to be the one most dan-
gerous to the patient, and it was decided to operate
upon him. The left kidney was drained through the
loin, and the patient made an excellent recovery.
There did not seem to be any evidence of disease of
the right kidney, although what would have been the
result of a careful microscopical research he could not
say; so far as was evidenced by his general condition
and the urinary findings there was no disease of that
kidney. He wore a tube in his right groin. He had
gained ten pounds in weight; he travelled; he was be-
coming plethoric; he was not incommoded by his sinus,
and he refused positively to have anything done fur-
ther. In this case there was apparent recovery of the
diseased kidney, which, so far as an examination could
determine, was diseased before operation. Hydrone-
phrosis was not a simple infection; it manifested itself
in many ways,- and this was an interesting question,
bearing, as it did, on the etiology and treatment.
One year ago he had had a lad brought to him who
gave a history somewhat analogous to that read by Dr.
Bryson. The urine was segregated by Harris' method,
and it was determined that the case was one of hydrone-
phrosis of congenital origin. The patient was run-
ning down so rapidly that it was decided to do a
nephrotomy for drainage purposes. As the large sac
was cut down upon, he was much astonished at the
gush of blood that followed. The finger in the kidney
sac revealed a large kidney which bled freely while it
was being palpated. The sac was held open and de-
luged with hot water, which stopped the hemorrhage.
He was thus drained for one year. He recovered, and
many observations were made upon him as to the urine
and the elimination of different things. When uro-
tropin was administered by the mouth, each kidney
would eliminate formaldehyde, as determined by ap-
propriate tests. This showed that the statements made
regarding urotropin were true. The question of second-
ary nephrotomy came up; as the work of excreting urea
was being well done, he refused to do a nephrotomy
until it was demonstrated that the other kidney could
do extra work if required. Two weeks ago he did a
nephrotomy. Instead of dividing the muscles, he sepa-
rated them and came down upon the ureter and kidney
with comparative ease. The operation proved to be
quite a formidable one; the kidney tissue bled much,
and he had simply to wrap the kidney up for a few
minutes and squeeze it while the adhesions were being
separated. He had to leave a portion of the tunica
propria. The patient suffered a good deal from the
shock, and had to be given salines repeatedly. Within
the first twenty-four hours ninety-eight ounces of urine
was excreted. A large amount of urine was excreted
by that kidney, this urine being of a low specific grav-
ity; when the saline was stopped, the amount was re-
duced to fifty-three ounces, and one day but nineteen
ounces was excreted; it then ran up to twenty-seven
and thirty ounces and thereabouts. The saline solu-
tion was given per rectum. He could not account for
the condition of hydronephrosis..
Dr. George Chismore, of San Francisco, recalled a
case that had been reported to this society early in its
career. The patient was a young man who was seen
early in 1870 with Drs. Keyes and Van Buren. He
had severe illness, lasting several months, with symp-
toms mainly referable to his bladder; this was followed
by lumbar abscess, which was opened; this abscess
filled again, and was again opened, and at last he made
a recovery. The condition of the remaining kidney
certainly was an interesting question. In 1877 the
patient was apparently in the last stages of consump-
tion. In addition to his renal and bladder trouble he
had a large fistula, apparently of tuberculous origin. In
course of time this healed spontaneously. There had
always been albumin in the urine, and there was to-day
a certain amount of it present. After a lapse of nearly
thirty years, he was still living.
The Pathogeny of Gonorrhceal Pyelonephritis ;
Presentation of a Gonorrhoea! Kidney.— Dr. Brans-
ford Lewis, of St. Louis, Mo., presented this speci-
784
MEDICAL RECORD.
[May 5, 1900
men. He stated that it was possible for the infecting
agent to reach the kidneys in three ways: (i) ascend-
ing infection by continuity along the mucous mem-
brane of the urinary tract; (2) ascending infection
through the lymphatics accompanying the ureter; (3)
metastasis or general infection. The specimen pre-
sented was infected along the mucous membrane of the
urethra, bladder, ureter, and thence into the renal
tubules. Restated that gonorrhceal nephritis from an
infection occurring through the lymphatics and blood
systems was an established fact. Many authors, in-
cluding Souplet, Jacquinet, Balzer, and Geraud, looked
upon albuminuria, aside from that for which pus would
be accountable, as one of the principal symptoms of
the disease. In four hundred and twenty-four gonor-
rhoial cases, Balzer and Souplet found albuminuria
ninety-nine times; in twenty-one of these cases they
were uncomplicated otherwise, but in seventy-three of
them there was orchitis. In this series it had been
noticed that albuminuria was especially liable to occur
in the cases in which there was the complication of
orchitis; from this was deduced the belief that the
danger of renal complication was augmented in propor-
tion to the extent of surface involved in the complica-
tions of the urethral gonorrhoea. The greater the sur-
face involved, the larger was the port of entry for the
general infection.
Dr. Young, of Baltimore, and Dr. J.\mes P. Tuttle,
of New York, discussed this paper.
The Modern Urethroscope : its Value and Limi-
tations.— Dr. W. K. Otis, of New York, read this
paper, and demonstrated many urethroscopic instru-
ments. One instrument referred to was adapted to the
Klotz form of tube by placing at the distal end a small,
flat foot, at the outer extremity of which was a smooth
pin. This pin fitted into a hole in the tube plate, and
on revolving the instrument a quarter of a circle the
foot swung under a shoulder riveted to the plate and
was securely fastened. This joint was firm and easy
of manipulation, readily allowing the illuminator to be
attached or removed at any time during the examina-
tion. The fault of this instrument was that it still per-
mitted the escape of a large amount of extraneous light,
which soon became annoying to the eye of the opera-
tor. On this account he abandoned this instrument,
and in 1892 devised one on an entirely different prin-
ciple, using a lens as a condenser instead of the re-
flected light from a concave mirror. This instrument
consisted of a metal tube or cylinder, an inch and a
quarter in length by one-half an inch in diameter,
closed at one end. A quarter of an inch from the
open end was a plano-convex lens, so arranged that it
could easily be removed for cleaning. On the interior
surface, near the closed end of the tube, an elbow was
let in, a quarter of an inch in length and half an inch
in diameter, through which the source of illumination
was introduced, a row of holes being bored at its base
to allow of ventilation. The handle of the instrument
was a piece of hard-rubber, with electrical connection
running through it to the lamp placed on top. This
handle fitted into the elbow by means of a bayonet
joint, bringing the lamp immediately behind the plane
side of the lens. A thumb-screw switch in the handle
placed the lamp under control so that it could be turned
off at pleasure. The instrument was attached to the
urethroscopic tube by a stout wire an inch and a half
in length, with hinged joints at eacli end which swung
in opposite directions, and furnished with set-screws,
thus allowing it to be put in any position, though when
once adjusted it was rarely necessary to move it. This
instrument had stood the test of some eight years' con-
tinuous use, and had demonstrated its superiority over
all others designed for the practical examination and
treatment of the urethra under direct ocular inspection.
(^To be continued.^
Anaphrodisiac. —
I{ I.iipulin 10 gm.
For ten powders. S. Take one at bedtime.
Elixir of Paraldehyde. —
'B, Paraldehyde 10 gm.
-Syr. mentha; 20 "
Eli,x. aromat 40 "
Aqure destil 80 "
M. S. Teaspoonful once or twice daily.
Hemorrhoids. —
R E.xalgin 0.30 cgm.
Ext. bellad o. 10 "
Cera: alb i.o gm.
01. theobr 3.0 "
For one suppository.
Stomach Pains. —
I^ Morphin. hydrochlorat 0.02
Syr. simp 30-
Aq. chloroformi sat 60.
Aq. aurantii flor 60.
M. S. Dessertspoonful at onset of attack.
— Journ. ties Praticiens.
Basedow's Disease in Childhood. —
If Strontii bromidi 6 gm.
Strontii iodidi 12
Aq. destil 4° "
Aq. mentli. pip 20 "
Syr. menth. pip 20 "
M. S. Teaspoonful three times daily.
— SOCQUART.
Severe Aphthae. — Paint with
"S, Ac. salic 2
Spirit, vini 10
Glycerin! 25
Gastric Catarrh — *
R -Acid. hydrochlorici-(C. p.) 2.50gm.
Acid, azotici o. 80 cgm.
Spir. vini rect. (go per cent.) 18. gm.
AquK font 150. "
Syr. limonis 100.
M. S. A teaspoonful in a half glass of water after meals.
— Lc Pr ogres Med.
Headache in Neurasthenia. —
I^ Zinci Valeriana!. ,
Ferri sulphat. ,
E.xt. rhei,
Asafoetid^e aa gr xviij.
M. ft. pil. No. x.\. S. Onet.i.d.
Drink for Diabetics
I^ .\cid. citrici i gm.
Glycerini,
Sp. vini gallici aa 50 "
Aq. destill 500 "
Aphthae.—
If Sodii borat 4
Tinct. benzoin 4
Syr. rubi idsei 40
Touch with aid of a brush six times daily.
Chapped Lips. —
If I'arathn 80 gm.
Vaselini 80 "
Ext. aeth. alkanna; o. 50 cgm.
01. bergamottCB,
01. limonis aa i gm.
Melt in a water- bath and make into sticks.
— La Aledecine Modeme.
Picric Acid in Chronic Urethritis. — Begin with half
of one-per-cent. solution and gradually increase to
ten-per-cent. strength. Apply by means of a Guyon
injector. Contraindicated in the acute stages. —
DESNOS and GUILLON.
May 5, 1900]
MEDICAL RECORD.
785
Medical Record:
A Wcck/y Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM WOOD & CO , 51 Fifjii Avenue
New York, May 5, 1900.
NATIONAL QUARANTINE.
At present there is enough of intention on the part of
Congress to effect some legislation in national quar-
antine matters, as is manifested by the different bills
presented, but so far the indications for practical re-
sults are not very promising in view of the fact that
there is not much time left for the different parties in
interest to fight over the varied issues at stake. It is
not so much the ends aimed at that invite criticism,
for these in the main are laudable enough — as regards
national quarantine as a whole — but the means by
which they can be brought about. The question of
actual result must narrow itself down to one of pure
expediency.
So far there are three important bills before the
House which deserve consideration regarding the
prospects of passage. The one fathered by Senator
Spooner is virtually the same as that under the same
name that was before the last Congress. Its effect is
practically to relegate all quarantine to State and
local authorities. Mr. Ray has introduced its coun-
terpart in the House. Another bill has been pre-
sented in the House by Mr. Mahon, and still another
by Mr. Vest in the Senate, the latter being backed by
the Marine-Hospital service. The prospects for the
passage of either are narrowed to the possibilities of
reconciling the interests of parties who appear to be
diametrically opposed to each other. Virtually it
comes to the question whether the local authorities
with States' rights as their plea shall have control,
or whether the general government as more directly
represented by the Marine-Hospital service shall
effect the unification of the forces. In one way it
must be confessed that in the attempts to better pres-
ent conditions the bills favoring widely varying in-
terests are cumbersome in the extreme, and are very
liable to fall by their own weight. They would seem
in a general way to verify the danger of too many
cooks for the broth. Thus Mr. Spooner's bill advo-
cates the creation of a commission of public health
composed of representatives from every State and Ter-
ritory, and an executive or controlling body consisting
of nine members, also from different sections of the
country. With the very laudable purpose of educating
the public on sanitary matters and of securing uniform
legislation in the different States, the commission is
loaded with so many special directions for work, so
much conference with local authorities, and withal so
much detail and red tape regarding other details, that,
should an epidemic actually appear, there would be
more time spent in getting ready to act than in doing
the real thing necessary. Mr. Mahon's bill is obvi-
ously open to the same objection, only perhaps in a
more marked degree, as by its provisions the country
is divided into health districts, each having its respec-
tive head. While none of the measures is positively
objectionable in either bill, the difficulties in making
them work harmoniously in the required direction is
apparently very great. In times of emergency the
surest means to the end are the speediest and sim-
plest. In trying to accomplish too much we may gain
nothing in the end.
Almost by a natural conclusion it would appear far
safer, instead of striving after vague and impossible
reforms, to content ourselves by improving such sys-
tems as we may have at hand. From such a point of
view the bill of Mr. Vest advocating the imposition
of extra duties and increased powers on the Marine-
Hospital service is worthy of very favorable consid-
eration.
The bill amends a section of the law of 1893 so as
to provide that upon the arrival of an infected vessel
at any port not provided with proper facilities, the
Secretary of the Treasury may send her to the nearest
national or other quarantine where proper facilities
exist, and, after the treatment of an infected vessel (or
the inspection of a vessel not infected) at a national
quarantine station, she shall receive a certificate which
shall entitle her to entry at any port named in the
certificate.
At any port where sufficient quarantine provisions
have been made by State or local authorities, the Sec-
retary of the Treasury may direct vessels bound for
that port to undergo quarantine at the State or local
station.
The bill adds also a very important section to the
present law — empowering the supervising surgeon-
general of the Marine-Hospital service, with the ap-
proval of the Secretary of the Treasury, to designate
and mark the boundaries of quarantine grounds and
anchorages, and officers of vessels or other persons
trespassing on such grounds or anchorages are to
be subject to arrest and to a fine of not more than
$300, or imprisonment for not more than one year, or
both.
There is nothing in the law forbidding the estab-
lishment of a State quarantine, notwithstanding a
national quarantine be established, and this will only
prevent the annoyance of a subsequent inspection,
with a charge for the same, by the local quarantine,
after the vessel has been thoroughly inspected and
given a certificate by the national quarantine officer.
The provision relating to vessels arriving within
the limits of any collection district of the United
States without a bill of health, is meant to apply par-
ticularly to fishing-smacks and other small craft which
leave Havana and other Cuban ports, and, under the
guise of fishing, come within the collection districts
of Florida and there land any sick who may be aboard,
786
MEDICAL RECORD.
[May 5, 1900
and smuggle aguardiente, rum, and tobacco, thus hold-
ing communication with the shore and being liable
to convey infection. These small vessels are particu-
larly dangerous, inasmuch as they are manned by la-
borers recently from Spain and who are, therefore, not
immune to yellow fever, and lie in the portions of
Havana harbor particularly exposed to yellow-fever
contagion. The effect of this section will be not only
to prevent the introduction of contagious disease, but
also to suppress smuggling.
Another section authorizes the Secretary of the
Treasury to establish quarantines at points of danger
either on the coast or on the Mexican or Canadian
borders. The necessity of having this authority is
self-evident. Under the present law, to establish a
quarantine requires either that there should be no
State quarantine regulations in existence, or the dem-
onstration and proof of inability or negligence to en-
force such regulations as the Secretary of the Treasury
has made, meanwhile leaving opportunity for disease
to enter while the subject is under investigation or dis-
pute.
Aside from the good features of the Marine-Hospi-
tal bill already noted it is gratifying to know that no
attempt is made to legislate on any matters save those
that relate to maritime and border inspection. Alto-
gether it would appear that the latter bill, being the
simplest and most practical one, has the best chance
for its passage.
RELATIVE EARNINGS OF THE PROFES-
SIONS THROUGHOUT THE WORLD.
The law is probably the most profitable of the so-
called learned professions. There are more and
larger prizes to be gained by an acute and eloquent
disciple of the legal art than are open to the medical
man or the minister. In this country and in Great
Britain the incomes of the foremost advocates and of
attorneys in lucrative practice for the most part over-
shadow the yearly earnings of the best-known jDhysi-
cians and surgeons, and to a still greater extent those
of our spiritual advisers. Occasionally one hears of
very large fortunes being left by prominent doctors-
Sir William Gull, Sir Andrew Clarke, Dr. Pepper,
and Sir William Jenner are cases in point; but these
are exceptions, and sums accumulated by medical men
cannot be compared either in number or magnitude to
the colossal amounts amassed by members of the legal
fraternity. VVhen, however, the average incomes of
these three classes of the community are considered,
their relative position in the United States and in
Great Britain will be found to differ. Viewed thus
in the United Kingdom the clergyman is at the top of
the list, the lawyer second, and the doctor last; while
here the lawyer or doctor gets a larger share of the
" loaves and fishes," and the minister has to be con-
tent with the crumbs.
An article in Medicine for April refers to a recent
editorial in the Chicago Times-Herald, discussing the
relative incomes of Chicago doctors and lawyers,
which says: "It is doubtful if the average income of
lawyers in Chicago is $1,500, but that is because the
average is reduced by the large number of failures and
of lawyers who Scarcely make their board during the
early days at the bar. There are a few law firms in
Chicago which make from $50,000 to $100,000 a year;
perhaps twice as many from $25,000 to $50,000; many
more from $5,000 to $25,000; perhaps five hundred
from $2,000 to $5,000, and the multitude from $2,000
down to nothing. Of physicians the same is true on
a reduced scale. We doubt very much if the average
income of doctors in Chicago is $2,000. The city is
full of young M.D.'s without enough practice to give
them a personal atmosphere of disinfectants. One or
two successful specialists may make as high as $50,000;
but the fingers of one hand would probably keep track
of the regular practitioners who can count on $25,000
a year."
The average income of a physician in large cities
on this continent may be placed at $2,000, in the
smaller towns at $1,500, and in the rural districts at
$1,200. Two or three New York physicians are said
to make over $100,000 a year, five or six about $50,-
000, but the average income, although rather higher
than in Chicago and in other American large cities,
does not greatly exceed $2,000 yearly. The minister
averages in the city perhaps $1,200, and in the coun-
try certainly not more than $800 yearly. As regards
living expenses, both the lawyer and minister have an
advantage over their professional brother. In New
York, for example, office accommodation suitable to a
physician is very dear, in a good neighborhood cost-
ing not less than $70 or $80 a month, which with board
and lodging and other necessary disbursements will
represent a sum of $120 monthly, a sufficiently weighty
burden for a struggling youthful practitioner to bear.
The young minister has no rent to pay, while the legal
neophyte can regulate his outlay in this respect ac-
cording to the length of his purse. Nevertheless the
lot of the medical beginner compared with that of a
pastor in a like situation has its compensations. He
is at least more or less independent. The minister,
on the contrary, is as a rule permitted to exercise
his own will but to a limited degree, and often is
doomed to go through a lifetime of toil, subservient
to the caprices of censorious elders and deacons. An
excellent description of the trials of an American
country minister, and the various unpleasantnesses
with which he has to contend at the hands of his con-
gregation, is given in the " Damnation of Theron
Ware," the best novel written by the late Harold
Frederic.
When all is said that can be said, the first few years
of medical practice are years of arduous effort, full of
disillusionment and disappointment. The late Sir
Andrew Clarke told Dr. Osier: " From the vantage
ground of more than forty years of hard work he could
say that he had striven ten years for bread, ten years
for bread and butter, and twenty years for cake and
ale." The truth undoubtedly is, and especially in
the large centres of population in America, that the
opportunities for a physician to obtain adequate com-
pensation for his services are yearly becoming less.
This is not due to any deterioration in the quality of
the present-day practitioner or an evidence of falling-
May 5, 1900]
MEDICAL RECORD.
7»;
off in medical or surgical skill. The fact is irrefutable
that the medical profession in this and in all civilized
countries stands on a higher plane in the matter of
training and knowledge than ever before. The reason
for the decrease in medical incomes is indubitably
almost wholly owing to the more eager competition
among regular practitioners, to hospital and dispen-
sary abuse, and to the lamentable increase in quackery.
The supply of medical men is greater than the demand ;
the market is flooded, and the most potent remedy we
can suggest for this evil is that, as has been many
times advised in the Medical Record, a uniform high
standard of medical education should be established
in every State.
THE DINNER TO PROF. A. JACOBI.
The complimentary dinner which will be tendered to-
night to our esteemed townsman. Prof. A. Jacobi, in
celebration of his seventieth birthday, will give proper
expression to the kind and appreciative regard in which
he is held by his hosts of friends. Few men ha^'e been
spared to labor so effectively as physician, educator,
and civic reformer for nearly half a century, and few
indeed have during such a period lived to better pur-
pose. The kindly words which will be spoken and
the hearty good wishes that will be offered by those
who may gather at the festive board will at the best
be but faint reflections of the host of his distant friends
everywhere, who, while absent in body, will be present
in spirit. On behalf of these making the large and
unseen majorities, and representing the profession at
large, we tender our hearty congratulations.
A Threatened Milk Famine in Syracuse.— A de-
spatch to the New York Suu states that the milkmen
of Syracuse, N. Y., have determined to serve no more
milk in that city until a recent requirement of the
board of health, enforced by the commissioner of pub-
lic safety, forbidding the issuance of licenses except
to dairymen who can show certificates of the tubercu-
lin test of all their cattle, has been rescinded. The
associated dairymen, who furnish the city's milk,
adopted resolutions and signed a compact binding
them to this course. The dairymen assert that their
herds have been injured by recent tuberculin tests,
many cows which have been tested having been found
dead without apparent cause. They say that the test
is still an experiment, and that they will not submit
to the health board's requirements. They will sell
milk at their farms to such persons as wish to go
there and buy, but they will not bring it into the city
until the rule has been repealed.
The Health Board and the Schools The princi-
pal of a private school in this city has recently made
a public complaint of remissness on the part of the
board of health, alleging that the department neg-
lected to notify him of cases of contagious disease
in the families represented in the attendance of his
school. An investigation has been ordered by the
sanitary superintendent. It is stated, however, that
there is no law making it the duty of the board of
health to notify the principal of a private school of
illness in the families of his scholars. There is a
law, however, enjoining upon the principals of, all
schools, public and private, not to permit any child
or minor having scarlet fever, diphtheria, smallpox,
or any contagious disease, or any child in any family
in which any such disease exists or has recently ex-
isted, to attend the school until the board of health
shall have given its permission.
Dr. Otto G. Ramsay, of the Johns Hopkins Uni-
versity, has been appointed to the chair of gynaecol-
ogy at the Yale Medical School to succeed Prof. B.
Austin Cheney, who has recently resigned.
Dr. William C. Braisted, U.S.N. , surgeon on the
Detroit, has been decorated by President Castro with
the Order of Bolivar for services rendered the wounded
of the Venezuelan forces at the taking of Puerto
Cabello in November of last year.
Medical Practitioners in Great Britain and Ire-
land.— The recently issued " Medical Register " for
1900 contains 35,836 names as contrasted with 35,057
names last year; ten years ago it contained 28,348
names. Complaint is made, however, that the lists
are very faulty, the names of many dead men being
on the roll.
Latin Diplomas Forbidden in Germany — It is
reported from Berlin that Emperor William has
empowered the Prussian minister of education. Dr.
Studt, to forbid hereafter the use of Latin in all uni-
versity and faculty degrees, assigning as a reason the
importance of a " more general use of the German
tongue." An order to this effect has just been is-
sued.
Cholera Accompanies Famine in India. — A de-
spatch from Bombay, dated April 27th, states that
cholera is raging fearfully at the great camp at
Godhra, where thousands of stricken natives are re-
ceiving relief. A hundred and fifty corpses were re-
moved in one day, but one hundred others had to be
left because it was impossible to procure bearers.
Glanders on an Army Transport. — The transport
Siam, which sailed from San Francisco March nth
with a consignment of three hundred and eighty-six
horses and mules, arrived at Manila on April 26th,
and was placed in quarantine owing to the fact that
seventeen cases of glanders have developed among the
animals on board.
Priority in the Serum Diagnosis of Typhoid
Fever. — Dr. Albert S. Griinbaum, of Vienna, writes
to The Lancet making a claim of priority in the dis-
covery of the agglutination test of typhoid fever. In
support of his contention he produces a document
signed by Nothnagel and Mannaberg in which it is
certified that Dr. Griinbaum at the commencement of
the year 1896 made systematic experiments with the
material of one of the wards in the Vienna General
Hospital on the agglutination of typhoid and cholera
MEDICAL RECORD.
[May 5, 1900
bacteria by serum taken from sick and healthy per-
sons. It is stated further "that in March, 1896,
therefore long before the publication of M. VVidal on
this subject, he had observed in two cases of typhoid
in the ward that their serum, in considerable dilu-
tion, agglutinated typhoid bacilli. Dr. Griinbaum was
fully aware of the diagnostic utility of this observa-
tion, and he delayed publishing it only on account of
regard to the necessity of confirming the reliability of
the reaction on a larger number of cases of typhoid.
Dr. Griinbaum therefore discovered the agglutina-
tion reaction of typhoid serum independently, and
to acknowledge this is a matter of justice." In these
rapid times scientific workers have presented to them
the disagreeable alternative of perhaps speaking too
quickly, as Koch did, or of running the risk that some
one else will anticipate the publication of the discov-
ery and take the credit, as may be the case in this
instance.
Honor to a Surgeon. — The Victoria Cross has been
conferred on Surgeon-Major William Baptie, of the
British array, for attending the wounded under fire at
Colenso and for bringing in a wounded officer from
the battlefield. Major Baptie was under a heavy fire
all the time, and his horse was hit three times.
Dr. Edward J. Messemer was tendered a dinner
on April 21st by the dispensary staff of Mt. Sinai
Hospital, in honor of the twenty-fifth anniversary of
his connection with the dispensary. Over thirty of
his professional friends were present. Dr. Henry S.
Stark occupying the chair as toastmaster. Congratu-
latory addresses were made by Drs. Mannheimer, Max
Rosenberg, and Nathan Oppenheim, and original
poems were read by Drs. Brickner and Rheinthaler.
The City Hospital for Consumptives. — Dr. Alfred
Meyer writes that in Dr. Henry's bill, to which we
referred recently, there is no provision for the appro-
priation of money by the State for its maintenance.
The bill provides that a hospital which is for resi-
dents of this city may be built outside of the city
limits but at the expense of the city, which is author-
ized to issue corporate stock therefor to an amount not
exceeding $350,000. The State will not be at any
expense whatever for the establishment or mainten-
ance of the city hospital.
The Omega Upsilon Phi is the name of a frater-
nity established at the University of Buffalo in 1894,
its membership being limited to medical students and
practitioners. A chapter has recently been estab-
lished in the medical department of the University
of Cincinnati. The order now has chapters at the
University of Buffalo, the University of Denver, the
New York University, Trinity University (Toronto),
and the University of Cincinnati. There are also
three graduate chapters. The Grand Scribe of the
order is Dr. H. J. Knickerbocker, of Wilson, N. Y.
The International Tuberculosis Congress was
held at Naples last week, from the 25th to the 28th
of April. It was opened at the San Carlo Theatre
in the presence of the King and Queen of Italy, the
Prince and Princess of Naples, the Duke of Genoa,
the Premier, General Pelleux, and the minister of
public instruction. Dr. Baccelli. The latter delivered
the inauguration speech, and a delegate from each
country represented at the congress followed. All
the diplomats, including United States Ambassador
Draper, attended the session.
.The Board of Health of Havana, which was ap-
pointed by General Ludlow just before he left the
city, has resigned, the reason alleged being that the
municipal authorities pay no attention whatever to
the recommendations of the board.
Philadelphia Medico-Legal Society — At a stated
meeting held April 24th, Dr. J. Madison Taylor read
a paper on " Hypnotism and Some of its Medico-Legal
Aspects.''
Pathological Society of Philadelphia — At the an-
nual conversational meeting, held April 26th, Prof.
Theobald Smith, of Harvard University, delivered an
address entitled " Comparative Pathology and its Re-
lations to Biology and Medicine." After the meeting
a reception was tendered Professor Smith at the Uni-
versity Club.
Philadelphia County Medical Society. — At a stated
meeting, held April 25th, Dr. Joseph Head read a
paper entitled " Consanguineous Marriages," in which
he contended that such unions are not in themselves
necessarily harmful, but that, in general, better results
are to be obtained by their avoidance. Dr. Henry
Beates, Jr., read a paper entitled " Some Facts con-
cerning Medical Education Elicited by the Applica-
tion of the Law Governing Practice in the State of
Pennsylvania." A discussion on " Medical Educa-
tion " was then opened and participated in by Dr. W.
W. Keen, Dr. H. C. Wood, Prof. John S. Stahr, presi-
dent of Franklin and Marshall College; Prof. Isaac
Sharpless, president of Haverford College; Professor
E. D. Warfield, president of Lafayette College ; Prof.
VV. W. Birdsall, president of Swarthmore College; Dr.
John B. Roberts, James Tyson, and Martin B. Tinker.
The discussion revolved principally around the ques-
tion whether the fourth year of the course in a literary
college should be accepted as the equivalent for the
first year of a course at a medical college, and the
general consensus of opinion seemed to be in the
affirmative, providing that all of the work of the first
year at the medical school was previously done at the
literary college.
Smallpox in Winnipeg. — A despatch from Winni-
peg to the New York Times states that smallpox is
becoming epidemic in that city. Eighteen cases had
been reported to the health authorities up to April
27th, and a special meeting of the city council has
been held to devise means for stamping out the pest.
Health Officer Inglis says the disease is of the most
malignant type, and that many of the cases now in
quarantine will terminate fatally. A meeting of all
the doctors in the city will be called, and a house-to-
house visitation made. The physicians who treated
the early cases are blamed for not having recognized
the disease and reported it to the authorities.
May 5, 1900]
MEDICAL RECORD.
789
Yellow Fever in Mexico. — It is reported from
Vera Cruz that several cases of yellow fever have
occurred among people recently arrived there, and the
fever has broken out at Salina Cruz on the Pacific
coast. Unusually hot weather for this season is be-
lieved to be the cause. The fever has also appeared
again at Tehuantepec, where Sir Wetman Pearson has
offered the authorities a suitable site for a hospital.
American Nurses in P^ris — We are informed that
in June there will be est^ b.'shed in Par's a perma-
nent bureau for American trained nurses, under the
direction of Mrs. W. H. Booth, ir,-merly superintend-
ent of nurses at St. Luke's Hospital in this city. The
address of the bureau will be Rue Vaugirard, No. 102,
Paris, France.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
April 28, 1900. April 20th. — Passed Assistant Sur-
geon L. Morris detached from the Brooklyn and or-
dered to the Baltimore. Passed Assistant Surgeon J.
Stoughton detached from the Benningtoti and ordered
to the Castine. Assistant Surgeon T. M. Lippitt de-
tached from the Baltimore and ordered to the Oregon.
Assistant Surgeon J. C. Thompson detached from the
Castine and ordered to the Bennington. Assistant Sur-
geon A. G. Grunwell detached from the Yosemite and
ordered to the Brooklyn. Passed Assistant Surgeon J.
F. Leys detached from the Essex on reporting of re-
lief, and ordered home and to wait orders. Assistant
Surgeon C. H. Delancy detached from the Amphitrite
and ordered Xo\hQ. Essex. April 21st. — Assistant Sur-
geon J. C. Thompson will return to the United States
by the Bennington. Passed Assistant Surgeon A.
Farenholt will return to the United States by the Con-
cord. April 23d. — Passed Assistant Surgeon M. R.
Pigott detached from the Naval Academy and ordered
to the Chesapeake same day. Assistant Surgeon K.
Ohnesorg detached from the Naval Academy and or-
dered to the Newp07-t same day.
Obituary Notes.— Dr. G. R. C. Todd, of Barnwell,
S. C, died on April 28th. He formerly lived in
Kentucky and was a graduate of the now extinct medi-
cal department of Transylvania University, Lexington,
Ky., in the class of 1850. He was a surgeon in the
Confederate army during the Civil War, and after-
ward settled in South Carolina. He was a brother-
in-law of Abraham Lincoln.
Dr. George E. Frothingham died at his home in
Detroit on April 25th. He was born in Boston in
1836, and was a graduate in medicine of the Univer-
sity of Michigan in the class of 1864. He was for-
merly a member of the faculty at that university, and
enjoyed a wide reputation as an ophthalmologist.
Dr. William E. Eggert, a homoeopathic physician
in Santa Fe, N. M., died on April 26th at the age of
seventy-six years. He was a surgeon in the Union
army during the Civil War.
Dr. Charles H. Bronson, a homcEopathic practi-
tioner of Brooklyn, died on April 24th at the age of
seventy-six years.
Correspondence.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondent.)
The Progress of the War — Everything— and not
least the recall of General Sir William Gatacre to
England — that has occurred since my last letter points
to a prolongation of the war, and the sensible person,
whether Boer or Briton, is he who recognizes this and
makes the fullest preparation for a winter campaign.
Both in Durban and Cape Town it is pathetic to see
the manner in which hot and cold fits succeed each
other in influencing the public mind, while such au-
thentic reports as come through from Pretoria — neither
frequent nor full, by the way — show that the Dutch,
like the English, are alternately jubilant and despond-
ent. The ups and downs of the fortunes of war have
a most marked effect upon convalescing patients. The
seriously sick remain sick, of course, whoever is win-
ning, but those who have turned the corner and are
simply in hospital to regain their strength have shown
themselves remarkably susceptible to the influences of
hope and fear, getting better when their side wins and
worse when it loses. This curious but very natural
phenomenon has been frequently observed during the
war, and attention has been called to it by many med-
ical men.
Firing on Hospitals. — The British have protested
in the course of the war very vigorously against v/hat
they allege to be a Boer habit of firing upon ambu-
lance wagons and hospitals. I know that many mem-
bers of the Royal Army Medical Corps implicitly be-
lieve that this has happened, and that statements to
the same effect have been made by officers in the Brit-
ish army who would not condescend to traduce a brave
foe. Still, I do not believe these enormities to have
occurred. Hospitals have been hit by shells, ambu-
lance wagons have come to similar grief, and even the
laagers of women and children have been fired upon,
, but never of set purpose. The excitement of war in-
creases the liability present in the minds of all men
with 2. parti pris, to inaccurate observation, and I am
convinced from the evidence offered by the complain-
ants that such occurrences of the sort as are known to
have happened have been simply unfortunate acci-
dents. The Boers have throughout treated the British
sick and wounded with humanity, and the offences al-
leged against them by some would be in contrast with
their conduct in the war and their general character.
The Health of the Boer Prisoners. — The sick-
ness on board of the transports on which the Boer
prisoners are confined, though not so severe as it was
at the end of March, has not yet subsided, and the
population of Simonstown is apprehensive of the
spread of disease from the prisoners to the town.
Over one hundred Boer prisoners were down with ty-
phoid fever in the first week in April, and deaths were
still occurring daily. The prisoners receive the best
medical care and attention that the British can give.
Lord Roberts' Impending Advance. — Before Lord
Roberts gives the word for the next great advance
toward Pretoria he will certainly make some syste-
matic and probably successful attempts to drive back
the various Boer commanders which are operating to
the east of Bloemfontein and thus bring up the right
wing of his force. To do this mounted men are ur-
gently required, and the supply of horses is still very
limited with the invading army; but the veterinary
surgeons give a much more hopeful report on this
matter than might be expected. They appear not to
anticipate any great epidemics of horse-sickness, but
rather believe that if the supply of remounts is regu-
790
MEDICAL RECORD.
[May 5, 1900
larly maintained so that the animals are not grossly
overworked, the other conditions are not unfavorable
to their remaining healthy. It is generally believed
at headquarters that when Lord Roberts does advance
his army will have its centre at Bloemfontein, its ad-
vance guard at Karll Siding (where there has recently
been fighting), its right wing at Ladybrand and its left
wing at Boshof. In this case the right wing will have
far the most difificult ground to traverse. The sources
of the Modder River will have to be crossed, and
throughout the march from ridge to ridge over a suc-
cession of water-courses it will be easy for an insigni-
ficant number of Boers to hold commanding situations.
Many old campaigners are hoping out loud that Lord
Kitchener, who is responsible for all the transport and
commissariat arrangements with Lord Roberts' army,
will recognize the extreme difficulty of the eastward
advance, for they think that he has asked too much of
the men hitherto. Sir Redvers BuUers has recently
been censured by his chief, but his men have always
been well cared for.; on the other hand the troops
under Lord Roberts have marched and fought under
the most difficult circumstances upon half-rations, while
the ambulance arrangements for their wounded have
been faulty. It is possible to lose as many men by
treating them injudiciously as by exposing them to
fire. If Lord Kitchener should give way to the feel-
ing that to be a hard man is to be a strong man he
may impede his chief's advance seriously, as well as
fill the hands of the Royal Army Medical Corps to an
inconvenient extent with young soldiers suffering from
nothing but hunger and overexertion.
The Casualties in the British Army show suffi-
ciently that the Royal Army Medical Corps has had
an enormous lot of work to do, and the fact that with
its small numbers it has been able to cope with the
results of all the casualties in such a way as to win
the good opinion of every one is very significant. Up
to the end of the first week in April the official figures
of British casualties were as follows: Officers killed,
211; oificers died from wounds, 48 ; officers died from
disease, 47 ; officers died from accidents, 3 ; non-com- ,
missioned officers and men killed, i,g6o; non-com-
missioned officers and men died from wounds, 465 ;
non-commissioned officers and men died from disease,
1,485; non-commissioned officers and men died from
accidents, 34; total deaths, 4,253. Officers wounded,
627; non-commissioned officers and men wounded,
9,883; total wounded, 10,510. Officers missing and
prisoners, 168; non-commissioned officers and men
missing and prisoners, 3,722 , total, 3,890. Grand to-
tal of casualties, 18,653. To these must be added 29
officers and 1,828 men who have been invalided home
sick, distinct from wounded. The proportion of deaths
from disease is mounting a little as the year goes on,
and this must be expected, for protracted camp life has
its own dangers to be added to the ordinary dangers
of disease. The proportion of deaths from wounds is
also going up.
Under False Pretences. — It is stated, and by this
time probably the statement has been telegraphed to
the United States, that the members of the Chicago
Ambulance Corps have taken up arms for the Boers
instead of remaining with the hospital as they were
understood to be pledged to do. If this be true, there
will be still greater need of British surveillance at
Delagoa Bay, for such recruiting ought to be stopped.
The numbers of the Chicago Ambulance Corps are not
large, and the result of their step — if it has been taken
— will be of no consequence, but it is to be hoped that
the story will be contradicted The ambulance corps
of a non-belligerent nation present at the seat of war
is understood to be neutral in sentiment and inspired
only by humanity. If on either side the soldiers get
the idea that the ambulance arrangements are used as
a mask to offensive action, they can hardly be blamed
if they do not regard the Red Cross with the sanctity
which perfect international arrangements should se-
cure for it.
Plague in Cape Town. — There are five cases of
plague in the quarantine station at Cape Town, but all
are progressing favorably, or were by the third week
in April. So far there has been no spread of the dis-
ease, and it is certainly most devoutly to be hoped that
there will not be. All the larger towns of South Af-
rica contain at the present moment double, if not
quintuple, their proper population, and all the medi-
cal men, military and civil alike, have more work than
they can do quite properly. An epidemic of plague
under such conditions would produce a situation
whose horrors will not bear pondering over.
Count Gleichen, a relative of Queen Victoria on
her mother's side, was very severely wounded at the
Modder River engagement, but is now back at duty.
A Mauser bullet entered through the anterior margin
of the right sterno-mastoid muscle behind the angle of
the jaw, and emerged on the left side of the neck two
inches from the middle line at the level of the sixth
cervical vertebra. All important structures escaped,
numbness of the palm of the left hand being practi-
cally the only symptom.
Hero- Worship Extraordinary.— Rudy ard Kipling
is now in Bloemfontein. He has made a tour of the
hospitals, and his visits are described as being very
good for the patients, who worship him, and are al-
ways immensely heartened by a few words from him.
It is said that on one occasion he gave a bottle of
opium to an officer, who in handing a dose to a dysen-
teric patient, mentioned the name of the provider.
The soldier tried to keep it as a memento instead of
swallow'ing it.
The Welsh Hospital, under the charge of Major
Cockerill, R.A.M.C, left England on April 14th, and
embarked on the steamship Canada. Several of the
medical staff had already started for Africa.
Mr. Samuel Osborn, chief surgeon to the metro-
politan corps of the St. John Ambulance Brigade, has
gone up to Kimberly and will join Lord Roberts at
Bloemfontein preparatory to the next advance. It is
probable that Bloemfontein, which is an exceedingly
pleasant and healthy place, will be made the site of
the base hospitals which can hardly remain at Wyn-
berg, as the lines of communication become more
extended in the direction of Pretoria.
A Victoria Cross for Major Babtie, R.A.M.C.
— The queen has been pleased to signify her inten-
tion to confer the coveted decoration of V.C. on Ma-
jor William Babtie. C.M.G. of the Royal Army Medi-
cal Corps, for conspicuous bravery at the battle of
Colenso. I have already described Major Babtie's
heroism to your readers in a letter which you pub-
lished in your issue of February 17th, and I then
anticipated the honor for Major Babtie. The act of
courage for which he was recommended for decoration
is thus described in the official gazette- "At Colenso,
on the 15th December, 1899, t'^^ wounded of the 14th
and 66th Batteries, Royal Field Artillery, were lying
in an advanced donga close in the rear of the guns
without any medical officer to attend to them, and
when a message was sent back asking for assistance.
Major W. Babtie, R.A.M.C, rode up under a heavy
rifle fire, his pony being hit three times. When he
arrived at the donga, where the wounded were lying
in sheltered corners, he attended to them all, going
from place to place exposed to the heavy rifle fire
vi'hich greeted any one who showed himself. Later on
in the day, Major Babtie went out with Captain Con-
greve to bring in Lieutenant Roberts, who was lying
wounded on the veldt. This also was under a heavy
fire."
May 5, 1900]
MEDICAL RECORD.
791
OUR LONDON LETTER.
(From our Special Correspondent )
MIDWIVES AGAIN — CHANGES IN THE BLOOD IN DISEASE
ANTHRAX — LIVERPOOL TROPICAL EXPEDITION — ■
COLLEGES OF PHYSICIANS AND SURGEONS — DEATHS
OF SIR WILLIAM PRIESTLEY, M.P., M.D., AND SIR
DOUGLAS MACLAGAN, M.D.
London. April 13, iqoo.
The midwives bill nearly slipped into the report stage
through another accidental interference with the pro
gramme of the House of Commons. Government
business included an adjournment for the Easter recess
and was got through with amazing alacrity The sup-
porters of the midwives were waiting for their chance
and seemed likely to get it, when the House rather
unexpectedly emptied, and a count-out ensued. It is
now understood that the bill cannot come forward until
Whitsuntide, but the opponents need to keep a sharp
lookout for accidents. I was told the other day that
the General Medical Council will meet a little earlier
than usual so as to be able to see the bill as it has
emerged from the committee on law. It can be of lit-
tle advantage to any one for them to see it, unless they
take on a degree of activity of which they have hither-
to appeared incapable. Energy is required, not talk.
Unless the council moves it will lose the little confi
dence it has retained. Some people fancy it will move
for fear the expense of supervising midwives will oth-
erwise be saddled on it. The bill will injure a good
many reputations. The discussions have already done
something in that way to individuals as well as public
bodies.
On the 3d inst. the Pathological Society began a
discussion on the changes in the blood in disease.
Dr. Sidney Martin opened it with a careful paper sum-
marizing the changes (i) in coagulability, (2) in the
corpuscles, and (3) in the presence of toxic substances.
Coagulation could be ascribed to the interaction of
lime salts with one another and the proteids of the
blood. The fibrin ferment was considered by many
as a lime compound of nucleo-proteid. The changes
in corpuscles affect the number of both red and white.
So, too, there are changes in size and shape. The
pale, watery blood of chlorosis coagulates rapidly, that
of pernicious anaemia slowly. In the latter the cor-
puscles showed no rouleaux formation, but exhibited
great variations in size and shape. The white corpus-
cles show greater variations in number than the red.
They are increased in some infective diseases, in gas
poisoning, and under the influence of quinine and sal-
icylates. There is great increase in leukaemia, in
which too myelocytes appear derived from the marrow.
As to toxic agents in the blood. Dr. Martin thought
their explanation lay in an auto-intoxication. Such
poisons led to the formation of anti-microbic and an-
titoxic substances respectively.
Professor Sherrington also read a paper on the sub-
ject, in the course of which he dwelt on the great and
rapid changes in the volume of the blood, such as oc-
curred in injuries or surgical operations, especially
those involving the abdominal cavity or in collapse
from any cause. The reduction in volume might be
enormous in the course of a few hours. The reduc-
tion fell entirely on the plasma. Hence the thirst,
often distressing, after abdominal operations. The
blood was inspissated and its specific gravity increased ;
he had seen it rise twenty degrees in a few hours.
The frictional resistance of the blood would increase
with this viscosity, and this would impose a heavy bur-
den on the heart to overcome it. The gravity of such
a strain on the ventricle was manifest in the algid
stage of cholera. Death was often due to the inabil-
ity of the heart to meet the extra demand put upon it
in that stage, and a similar strain was imposed in col-
lapse due to traumatism. The drmking of a certain
quantity of fluid would then not only allay the thirst,
but assist the circulation and so diminish the tendency
to collapse.
After these two papers, of which only some salient
points are noted above, the discussion was adjourned
until the May meeting.
The Home Office has determined to give assistance
to practitioners in obtaining bacteriological evidence
in cases of suspected anthrax in which the infection is
believed to have taken place in a factory or workshop.
The directions laid down savor so much of red tape
that it is to be feared the good intention may often be
frustrated. The approval of the medical inspector
in each case has to be sought, on receipt of which the
material has to be collected and sent with a report to
the bacteriologist appointed
The report of the Liverpool expedition under Major
Ronald Ross is an interesting production. It contains
an account of the numerous facts from which the con-
clusion is derived that the mosquito is a purveyor of
malaria. But the term malaria is rejected by Major
Ross, and so, of course, is malarial fever. Nor does
he hold with paludism. Hasmamoebiasis is proposed,
but I doubt if it will obtain much favor. " Gnat fever "
is suggested as a popular term, and is certainly prefer-
able, and may serve to popularize more correct notions.
So, of course, the word mosquito is also rejected for
the English synonym gnat.
The College of Physicians has re-elected Dr. Church
as president. His address commemorated the de-
ceased fellows of the year, according to custom. The
College of Surgeons has elected two members of twenty
years' standing to the fellowship, and awarded its
prizes — the Jacksonian to Dr. Lambert Luck and the
John Tomas prize to Mr. Mummery. Both colleges
sent telegrams of congratulation to the Prince of Wales
on his happy escape from assassination.
The death of Sir William Priestley was announced
yesterday. He had been ill for some time, and in-
quiries showed that the end was approaching. He
was born June 24, 1829, took his M.D. at Edinburgh
in 1853, having previously joined the College of Phy-
sicians here, of which he was made a fellow in 1864,
about two years after he had been appointed professor
of obstetric medicine at Kings College. This posi-
tion, with that of obstetric physician to the hospital,
he held until indue course he retired to the consulting
rank. He was physician accoucheur to the late Prin-
cess Alice and to the Princess Christian, and enjoyed
for many years a large practice as a leader in his
specialty. In 1893 he was knighted, and three years
later was elected without opposition member of Parlia-
ment for the Universities of Edinburgh and St. An-
drews. He was not a voluminous writer, but his con-
tributions to medical literature were of value. His
Lumleian lectures, " On the Pathology of Intra-Uterine
Death," were printed in i8S7,and he contributed arti-
cles to Reynolds' "System of Medicine" and to All-
butt's Gyneecology. In the Annals of Natural His-
tory for 1850 there is an account of British carices
from his pen, showing that his scientific pleasure was
not of a restricted character.
Edinburgh has also lost one of her foremost profes-
sors, for Sir Douglas Maclagan died on the sth inst.
"full of days," for he had reached the age of eighty-
eight years, and full of honors. He made his chair of
forensic medicine famous, and was consulted by the
crown in many a cause dlcbi-e. He was indeed the lead-
ing toxicologist for a long period. He also did much
to raise the position of public health, the teaching of
which was attached to his chair. He was president of
the College of Physicians of Edinburgh in 1864, and
in 1884 was elected to the same office in the sister col-
lege. This unusual honor from the two colleges had
792
MEDICAL RECORD.
[May 5, 1900
only once before been conferred, and that was on his
father, Dr. David Maclagan, surgeon to the Queen in
Scotland and physician to the forces in the Peninsular
war. Sir Douglas received his knighthood in 1886.
He had retired from active work for some years. Out-
side his professional work he was an able writer, and
even indulged in poetry, his " Nugje Canors Medics "
being known to most Edinburgh men, and maintaining
his reputation as a versifyer, which was as consider-
able as that which he possessed as a musician. In
fact his general attainments were so extensive that
even in a learned society like that of Edinburgh they
were regarded with admiration.
THE SALICYLATES IN PNEUMONIA.
To
Medical Recor
Sir : Since Dr. Andrew H. Smith published his article
last year regarding the treatment of acute lobar pneu-
monia by creosote, the salicylates, etc., I have suc-
cessfully treated six cases — some with salol, others
with salicylate of ammonium or of sodium. If there
be any preference, it is in favor of ammonium salicy-
late, as less irritating to the digestive apparatus. This
method of treatment has great value in certain cases.
I can recall several which terminated fatally in former
years that I am sure would probably have been saved
by this treatment. These cases tolerated large doses
and made quick recoveries.
William Crawford Johnson, M.D.
Fkederick, Md.
SANATORIA FOR CONSUMPTIVES.
To
Recok
Sir: In your editorial of April 21, 1900, you say in
regard to sanatoria for consumptives : " But these in-
stitutions are one and all for the benefit of persons in
easy circumstances. Up to quite recent times, says
Dr. Goghill, writing in the Nineteenth Century Maga-
zine, February, 1899, ' no attempt has been made on
the European continent, and, it may be added, nor in
this country, to provide like resorts for the necessi-
tous.' "
May I call your attention to the fact that the Adi-
rondack Cottage Sanitarium has been making such an
attempt for the past sixteen years, and that its object
is purely philanthropic. Although its work has appar-
ently not come to your attention or that of Dr. Goghill,
I hope it has not been without some slight influence
on bringing about the recent action by the State for
the care of consumptives. I enclose the fifteenth an-
nual report. E. L. Trudeau, M.D.
Saranac Lake, N. Y., April 21, 1900.
Lumbar Puncture in Meningism and in Syden-
ham's Chorea. — C. Bozzolo reports several cases of
meningism and meningitis in which this procedure
was resorted to, but afforded only temporary relief, the
disease going on to a fatal termination. In three
cases of chorea, however, it calmed restlessness and in-
duced refreshing sleep, and restored co-ordination of
movements. The symptoms of the disease returned
after an interval of improvement, but repeated punc-
ture again produced a beneficial effect. In a fourth
fatal case the puncture was of no value, nor did it ren-
der any assistance to the diagnosis, as the liquid ex-
tracted was in every way normal and absolutely sterile.
Cultures of the nerve substance, however, showed the
staphylococcus pyogenes aureus. — Rivista Critica di
Clinica Medica, March 31, 1900.
IpcdicaX Items.
Enzymes and Immunity. — Charles T. McClintock
states that after looking over all the evidence, which
is voluminous, it appears to him to be fairly well proved
that the body does destroy disease germs and organ-
isms with enzymes. As to toxins, the evidence is not
so conclusive, although many facts indicate the prob-
able truth of the enzyme explanation. The writer be-
lieves that modern investigators are pursuing the right
methods and little by little are learning how the
tissues combat disease-producing agents. — Medicine,
April, 1900.
Dysmenorrhoea. — Edward E. Montgomery divides
dysmenorrhcjea into obstructive, congestive, inflamma-
tory, and nervous. In the first three forms the most
effective method of treatment would consist in the in-
stitution of measures with a view to the correction of
the condition. Fibroids should be removed. Dilata-
tion and curettage should be performed for obstruc-
tion and inflammatory conditions. In the neurotic
cases, the rest treatment and change of scene are invalu-
able. Arsenic, quinine, strychnine, good diet, and large
quantities of water are most advantageous in these
cases. — International Medical Magazine, April, 1900.
Health Reports The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended April 28,
1900 :
Smallpox — United States.
Alabama, Mobile April 14th to 21st
District of Columbia. Wash-
ington April 14th to 21st
Florida, Jacksonville April 14th to 21st
Illinois, Aurora April ist to 7th
Chicago April 14th to 21st
Indiana, Evansvjlle April 14th to 21st
Indianapolis April ist to 21st
Kansas, Wichita April 14th to 21st
Thirty-three towns
and connties March ist to 31st
Kentucky, Covington April 14th to 21st
Lexington April 14th to 21st
Louisiana, New Orleans April 14th to 21st
Maine, Portland April 14th to 21st
Michigan, Detroit April 14th to 21st
Nebraska, Omaha April 14th to 21st
Ohio, Cleveland April 14th to 21st
Pennsylvania, Philadelphia. .April 21st
Pittsburg April 14th to 21st
South Carolina, Green\'ille. .April 13th to 20th
Utah, Salt Lake City April 14th to 2ist
Washington, Spokane April 14th to 21st
Wisconsin April 14th
Cases. Deaths.
Sma
-Foreign.
Austria, Prague March 24th to 31st 5
Belgium, Ghent April ist to 7th
Egypt, Cairo March 18th to April ist
England, Liverpool April ist to 7th 8
London April ist to 7th 3
Southampton April 1st to 7th i
France, Paris April ist to 7th
Gibraltar .^pril ist to 8th 4
Greece, Athens April ist to 7th 4
India, Bombay March 13th to 27th
Calcutta February 24th to March 3d
Kurrachee March nth to 25th 24
Mexico, Chihuahua April ist to X4th
Vera Cruz April 7th to 14th
Russia, Odessa March 24th to April 7th g
St. Petersburg .... March i8th to 24th 30
Warsaw March 18th to 31st
Spain, Madrid March 24th to 31st
Straits Settlements, Singa-
pore March 3d to loth
Yellow Fever.
Costa Rica. Limon April 20th , 1
Mexico, Vera Cruz April 7th to 14th
India, Bombay March 13th to 27th
Calcutta February 24th to March 3d
Plague — Insular Possessions United States.
Hawaii, Honolulu March 26th to April 9th 4
Plague — Foreign.
Brazil, Rio de Janeiro April 20th 6
India, Bombay March 13th to 27th
Calcutta February 24th to March 3d
Kurrachee March nth to 31st 292
Medical Record
A IVeekly youmal of Medicine and Surgery
Vol. 57, No. 19.
Whole No. 1540.
New York, May 12, 1900.
$5.00 Per Annum.
Single Copies, loc.
@rt0itiaX %x\xt\zs,
BOTTINI'S OPERATION FOR THE CURE OF
PROSTATIC HYPERTROPHY.
REPORTS OF CASES.
By willy MEYER, M.D.,
SURGERY AT THE NEW YORK POST-GRADUATH MEDICAL
3 HOSPITAL ; ATTENDING SURGEON TO THE GERMAN AND NEW
YORK SKIN AND CANCER HOSPITALS ; CONSULTING SURGEON TO THE NEW
YORK INFIRMARY.
In my former paper, frequently referred to, published
in the Medical Record, January 14, 1899, ^ ''^ve
given detailed histories of the first twelve patients
on whom I had performed Eottini's operation until
the end of 1898. Since then, up to the time of clos-
ing the present report, April i, 1900, I have had
twelve further cases, thus making a total of twenty-
four. In these Bottini's operation was done thirty
times; that is to say, it was repeated in four in-
stances (Cases I., VII., XX., and XXIII.), and done
three times in one case (XIV.). In the first eleven
cases a small battery without amperemeter and im-
ported instruments were used; in the last thirteen,
instruments of American manufacture and a battery
with amperemeter were employed. In nine cases
(IV., v., VI., VII., XII., XVI., XX., XXL, XXIV.)
a cure was effected; and this could be proved to be
lasting as shown by final examination made between
three and twenty-five months after operation in six.
Two patients did not present themselves again al-
though requested to do so by me. Seven of my cases
(I., X., XIII., XV., XVIII., XIX., XXIII.) were
much improved by the operation, and this result was
shown to be lasting by examination made six months
to two and a quarter years after operation. Two (Cases
XI., XIV.) were improved and have remained so to date,
twelve and nineteen months respectively after opera-
tion. One patient (Case XL), who was at first com-
pletely cured, to-day shows a recurrence of a number
of his former symptoms, although his general condition
is excellent, and the catheter has been dispensed with
since the day of the operation. It must be remembered,
however, that this patient was the last of the series
operated upon with the help of the old battery without
amperemeter, so that I am unable to say whether any
of the four cuts made were carried out with the knife
heated to a sufficient degree. Certainly the patient's
condition is improved by the operation. Another pa-
tient. Case XIIL, who also was originally cured, and
considers himself so to-day, has been classed as " much
improved " only, because he shows a residual urine of
about thirty-three per cent, at the present time. This
is the case in which the urine cleared up perfectly, but
in which only one cut was made with the current at
full strength. Then there were two deaths directly due
to the operation (Case III., acute sepsis, and XVII. ,
suppuration in cavum Retzii) ; and two deaths with
Bottini's operation as the remote cause (Case IX.,
suprapubic cystotomy, followed by sudden death eight
days after Bottini's operation; and Case XXII. , phle-
bitis of the lower extremity followed by probable pul-
monary embolism). Three patients have died since
the operation was performed (Case II., six weeks after
operation, of pyelo-nephritis of long standing; Case
VIIL, of persistent suprapubic fistula and chronic pye-
litis; death, due to pyelitis, occurred three months
after operation; and Case XII., a patient who was
absolutely cured, urinating up to his death better than
he had ever done as long as he could recall — of per-
nicious anaemia, nine months after operation). In
other words, my cases show thirty-eight per cent, of
cures (so far); twenty-nine per cent, much improved;
eight per cent, improved; and a mortality of eight
per cent, directly due to the operation, and eight per
cent, indirectly due to the operation.
With regard to the mortality, it will be seen that
death occurred equally often as the direct and indi-
rect result of Bottini's operation. In counting deaths
it is clear that if a patient, although he may have had
some slight rise of temperature for many weeks or
months, undergoes the operation and promptly devel-
ops a chill with high fever, to which he succumbs
after a day or two; or if with the posterior incision
the bladder is perforated; or if after a too deep ante-
rior incision suppuration of the cavum Retzii with its
sequelae appears as a complication— death must, of
course, be counted as directly due to the performance
of Bottini's operation, at least so far as statistics are
concerned.
If, on the other hand, constant vesical spasms after
the operation wear out the patient, and he then asks
for immediate relief, which, for special reasons, is
granted — suprapubic cystotomy being done- — and the
patient then suddenly dies a few moments after gen-
eral anjesthesia was discontinued; or if, in a patient
who has been laid up for some time with an obstinate
cellulitis of the hand previous to operation, a phlebi-
tis of old varicose veins of the thigh sets in a few days
after Bottini's operation, and the patient dies eight
days later, although his bladder functions had been
perfectly and most beautifully restored by the opera-
tion, such an occurrence certainly must be looked
upon as but indirectly attributable to the operation,
although, when making up our statistics, we should
have to count such case among the deaths after Bot-
tini's operation.
If, however, a man with a pyelonephritis of long
standing successfully pulls through the operation, is
discharged from the hospital, and then, some weeks
later, develops more serious symptoms of pyelonephri-
tis, under which he finally dies in another hospital —
such a patient cannot be said to have succumbed to
Bottini's operation. It would be unfair, in estimating
the value and risks of the operation, to put such a
case in the category of deaths due to the operation.
Or, if a man who was repeatedly operated upon for
prostatic enlargement by other surgeons, a man in
whom vasectomy, perineal prostatectomy, suprapubic
cystotomy, castration, and Bottini's operation had been
successively done, and who at last carries a wide-open
suprapubic fistula — I say, if such a patient submits to
Bottini's operation for a second time, makes a rapid
convalescence, is up and about, kept in the wards be-
cause he has no home, and dies eight to ten weeks
later of an aggravation of his old trouble the pyelo-
794
MEDICAL RECORD.
[May 12, 1900
nephritis, such death is surely not ascribable to Bot-
tini's operation. One might as well attribute it to the
castration or prostatectomy that had been done.
In estimating the value of these personal statistics,
it is but fair to bear in mind what I have said before,
that these cases were not selected ; they were operated
upon as they came along. Had I been guided by a
desire to be able to present still more favorable statis-
tics, I should have certainly refused operation in quite
a number of the twenty-four cases. I should have had
fewer deaths, but also not the satisfaction of having
saved the life of a patient (Case XVI.) for whom there
was absolutely no help except by Bottini's operation,
and in whom, besides, death would have been a real
torture. It should further be borne in mind that in
this series are included all cases so far operated upon
by me; also the very first ones in which I proceeded
without any personal experience. Then, too, one of
the fatal issues was due directly to the anterior in-
cision, which, as I have stated, I have since aban-
doned. We are, therefore, justified, I think, in ex-
pecting to reduce the mortality considerably in the
future.
Before proceeding to give the full reports of my
second series of cases, I shall here append a brief
synopsis of the past history of my first twelve cases,
together with a report of their present condition, one
and a half to two and a quarter years after operation.
Case I. — Age fifty-eight; has been suffering for one
year; urinates every fifteen to thirty minutes day and
night; excruciating pain when bladder is empty.
Residual urine, 25:300 c.c. (1:10 oz.). Operated
upon twice.
First operation, October 7, 1897; Schleich's solu-
tion No. I.; bladder empty; Bottini's original incisor
used; insufficient storage battery.
Second operation, December 18, 1897. Freuden-
berg's modified incisor, imported small battery.
January 14, 1899 (the date of publication of my
former paper), the patient was classed as " much im-
proved."
March 26, 1900 (two and a quarter years after sec-
ond operation): The patient considers himself cured;
has no pain whatever; feels splendid, just as if he had
never been sick; is back to work. He urinates every
two to three hours during the day ; nights twice or
three times. Bowels in good order. He has gained
more than ten pounds since the operation. When call-
ing at my office he had urinated about an hour before;
upon request he then voided 55 c.c. (about 2 oz.);
residual urine 225 c.c. On irrigation the water soon
returns clear. The urine is slightly turbid; acid.
Prostate per rectum is hard; its upper border can be
reached; length of urethra, 20 cm. He still refuses a
third operation, which was advised fifteen months ago.
Case II. — Age seventy-three; patient in desperate
condition; chronic pyelo-nephritis. Operation De-
cember 23, 1897. No improvement. He died six
weeks later, in spite of operation.
Case III. — Age sixty -four; bilateral pyelitis,
chronic sepsis. Death from acute sepsis, thirty hours
after operation.
Case IV. — ^Age sixty-four; his trouble started seven
years ago, but has become much worse within the last
four years; he urinates three to six times during the
night, oftener in the daytime. Incomplete retention;
he uses catheter three times in twenty-four hours.
Chronic cystitis; kidneys free. Residual urine, 10:
200 c.c. (^3:673 oz.).
Operation February 26, 1898, under eucaine anaes-
thesia; bladder empty ; three cuts, posterior, left lat-
eral lobe, anterior. Freudenberg's incisor; small bat-
tery.
November 18, 1898: Frequency of micturition three
to four times during the day, nights once; no pain
whatsoever. He has gained in weight. He voids 150
c.c. (5 oz.) in a good stream; 300 c.c. injected are
passed up to the last drop. There is some cystitis.
Catheter dispensed with since operation.
Last examination January 4, 1899: the same good
result.
With my request of March, 1900, to present himself
at my office for examination, the patient failed to
comply.
Case V. — Age fifty-nine. There has been increas-
ing frequency of micturition for the last four years,
which has become much aggravated since two years.
There is incomplete retention ; some incontinence.
He urinates every half-hour to hour day and night;
much pain; frequent catheterization; chronic cystitis;
no kidney lesion; residual urine, 150-180 c.c.
March 28, 1898, Bottini's operation ; eucaine anaes-
thesia ; bladder empty ; two cuts, one posteriorly, the
other through projecting growth in posterior urethra.
Incisor; small battery.
October 18, 1898 : He urinates once every six hours;
at times slight incontinence. Catheter not used since
operation. No pain. He has gained in weight.
March 24, 1900 (written communication); Two
years after operation: "urinates three to four times
during the day; sleeps through the night; general
condition, 'tip-top'; catheter never used again;
passes normal quantity of water; urine absolutely
clear; stream good; no pain; is relieved as far as his
bladder trouble is concerned."
Case VI. — Age fifty-two; incomplete retention ; uri-
nates every fifteen to thirty minutes in the day-time;
nights every hour to hour and a half ; much pain ;
catheter not used; cystitis; pyelitis surely present;
residual urine 150: 175 c.c.
Operation May 7, 1898: Eucaine anesthesia; blad-
der filled with 150 c.c. (5 oz.) sterilized boric-acid
solution;' three incisions, one posteriorly and one
through each lateral lobe. Incisor; small battery.
October 24, 1898: Urinates four to six times in
twenty-four hours; no pain; has gained in weight.
Residual urine, 325-75. Of 350 c.c. (about 12 oz.)
every drop is passed with two short intermissions; no
sign of cystitis or pyelitis; urine cleared up com-
pletely.
Final examination March 29, 1900 (twenty-three
months after operation) : Urinates three to four times
during the day, nights once; no pain; urine passes in
a forcible, good stream; toward the end he has to
strain. He emptied his bladder about one and a half
hours ago. He now passes 150 c.c. of beautifully
clear urine; residual urine 50 c.c. Of 200 c.c. ni-
trate-of-silver solution, i : 5,000, injected, every drop is
passed. The patient states that he sometimes voids
more than 12 oz. at a time. He has gained consider-
ably in weight and feels excellent; is steadily at
work.
Case VII. — Age sixty-eight. His suflering dates
back nearly one and three-quarter years. Incomplete
retention; he urinates every fifteen to sixty minutes
during the day; twice in the latter part of the night,
always with pain; has been using the catheter once
or twice a day for the last fifteen months, always be-
fore retiring; chronic cystitis; no renal lesion. Re-
sidual urine, 30:300 c.c.
Operation June 8, 1898: Eucaine; three cuts, one
backward and one through each lateral lobe. Incisor;
small battery.
September 29, 1898: Empties his bladder every
three or four hours during the day, nights once; no
pain. General condition improved ; no residual urine;
urine still slightly turbid; catheter laid aside.
Last report (in writing), March 24, 1900 (one and
' From this time on I have done all my operations with the
bladder filled, as in this case.
May 12, 1900]
MEDICAL RECORD.
795
three-quarter years after operation) : Has gained seven
pounds since operation. He urinates five times dur-
ing the day, nights not at all. Quantity in twenty-four
hours 1,500-1,600 c.c. (50-53 oz.). To use the pa-
tient's ovifn words in response to my queries: "The
stream gives me entire satisfaction. General condition
is first-class in every respect; my health is fine since
the operation; I feel now that life is worth living."
Case VIII. — Age sixty-eight. The following op-
rations were done by other surgeons before he came
to me: Ligation of both vasa deferentia; six months
later, removal of left half of prostate through perineum ;
fifteen months later suprapubic cystotomy. One week
later, bilateral orchidectomy; seven weeks later, on
May 12, 1898, Bottini's operation. He has persistent
suprapubic fistula. He then, by request of the former
attending surgeon, was placed under my care.
June II, 1898: Second Bottini operation, done by
me. First result good; greater part of urine passed
through normal channel; later, fistula opens again.
Patient kept in hospital. August 25, i8g8, patient
died under symptoms of septic pyelitis (report of house
surgeon, who had taken charge of the case during my
absence from the city).
Case IX. — Age sixty-four; he has been having
bladder trouble for the last nine years. Incomplete
retention ; a great deal of pain ; catheterizes himself
three times in twenty-four hours; cystitis; quiescent
chronic nephritis; no pyelitis. Residual urine 30:
300 c.c. (i : 10 oz.).
June 15, 1898: Operation; eucaine anaesthesia;
three incisions, one posteriorly, one through each lat-
eral lobe. Six hours later chill with rise of pulse and
temperature. Slow improvement. Kiss' instrument;
small battery had been used. June 23d, suprapubic
cystotomy on account of continuous spasm. Patient
died a few minutes after having reached his bed. No
post-mortem.
Case X. — Age sixty-six; incomplete retention ; fre-
quency of urination every ten to sixty minutes during
the day; three to five times in course of the night;
calls very sudden ; wears urinal; chronic cystitis; no
kidney affection. Residual urine, 30 : 30 c.c. Bladder
scarcely holds 90 c.c. (3 oz.).
Operation June 22, 1898 : Eucaine; three cuts; pos-
terior, through right lateral lobe, and anterior. Kiss'
incisor; small battery.
October 31, 1898: Urinates in a strong stream with-
out pain, every two or three hours during the day, night
three times; has gained in weight. While at my office
he passed 85 c.c. (3 oz.), residual 10 c.c. ( V3 oz.). On
irrigation, the water soon returns clear. Of 100 c.c.
injected, every drop is passed; urinal put aside three
weeks after operation.
Patient has not presented himself for examination,
so far.
Case XI. — Age sixty-two; trouble for the last five
years; incomplete retention which becomes complete
now and then. Micturition every twenty to thirty
minutes during the day; half -hourly during the night,
very painful. Catheter is used three times in twenty-
four hours. Chronic cystitis; slight pyelitis; residual
urine 100 : 50 c.c.
Operation September 22, 1898: Four cuts; local
anaesthesia. Incisor (Kiss), small battery. Difficulty
experienced in removing instrument. When at last
withdrawn, it is found that the knife, in re-entering
the groove of the female part, has become bent side-
ways at an angle of fully 45°.
November 11, 1898: Urinates six times during the
day; nights three or four times; total amount about
2,000 c.c. (70 oz.). Vesical capacity 360 c.c. (12 oz.) ;
stream excellent; not a particle of residual urine.
Patient looks well; has gained in weight; catheter
has been laid aside.
November 3, 1899: Urinates more frequently — five
to six times nights; every one or two hours during the
day; stream less forcible; largest amount voided at
one time 150-180 c.c. (5-6 oz.). Upon request uri-
nates 150 c.c. (5 oz.); residual urine not quite 50 c.c.
Slight cystitis. Of 250 c.c. of boric solution injected
175 c.c. are passed, leaving a residual urine of 75 c.c.
Prostate large and hard.
Final examination, April 13, 1900: The patient re-
ports that he urinates every one to two hours during the
day; nights three to five times; has no strain. When
calling he had urinated over three hours ago; he
passes 200 c.c; residual urine 20 c.c; of 250 c.c. of
boric-acid solution injected, 175 are voided. He states
that he is subject to colds, when his condition is al-
ways worse. He looks well, has gained in weight;
bowels normal. Does not take medicine of any kind;
has not used catheter since operation. His general
condition is splendid. In view of the change that has
taken place since the operation, this case, which was
originally classed as cured, will now have to be rele-
gated to the " improved " cases.
Case XII. — Age fifty-two; increased frequency of
urination since the last six weeks; nights five to six
times; often during the day; has had poor stream all
his life; urine passes in drops, has to strain a good
deal; pains in glans. Residual urine 30 : 100 c.c. (i
to about 3 oz.); is intensely anaemic, has lost fifteen
pounds within last nine months.
Operation October 4, 1898: Four cuts; incisor and
storage-battery of American make.
October 30, 1898 : He empties his bladder two to
three times during the day; nights once or twice;
does not remember ever having had a better stream
of urine than at present.
Some time after his discharge from the hospital, the
patient came under the care of a colleague, who kindly
furnished me with the following notes:
'■ Mr. I continued to suffer from an intense
ana;mia with very irregular temperature, the same ris-
ing later as high as 106° F. at times. He had the
same symptoms until his death on March 6, 1899,
save occasional periods of delirium. Blood examina-
tion showed no plasmodium malaria, no increase in
white blood corpuscles, no change in size of red blood
cells, no free pigment. The blood culture made at the
time of the autopsy also proved negative. Post mor-
tem revealed absolutely nothing save an intense anae-
mia of the entire system. During the remainder of his
life he had absolutely no symptoms referable to either
bladder or kidney. He frequently remarked on the
great ease with which he could pass his urine. Uri-
nary examination was also negative."
Case XIII. — J. S , forty-seven years of age;
married; had been suffering from bladder trouble for
the last two years. Micturition had become more fre-
quent and required straining. There was pain before,
during, and after the act; also some after-dribbling.
The urine appeared clear. Two months after the on-
set of these symptoms the patient consulted his family
physician, who pursued internal treatment. Another
physician was consulted, who introduced a sound and
diagnosed prostatic enlargement. Then some haema-
turia appeared ; the pains increased and also the fre-
quency of micturition. The patient saw another
physician still, who found residual urine, advised him
to use a catheter at night, and employed irrigation for
the catarrh that had meanwhile appeared. Dissatis-
fied with his condition, the patient called on a fourth
doctor, who suggested bilateral castration as the only
means of curing the trouble; if not accepted, the use
of the catheter, which, it was added, he would prob-
ably not be able to discard for the remainder of his
life. The patient thereupon continued treating him-
self for about a year, becoming much reduced in gen-
796
MEDICAL RECORD.
[May 12, 1900
eral health. The thought of what he considered his
fate, to use tlie catheter for the remainder of his com-
paratively young life, or submit to emasculation, greatly
depressed him.
At this stage the patient was referred to me by a
colleague, that I might determine whether Bottini's
operation would be advisable. He called on Novem-
ber 5, 1898. At that time he urinated under a good
deal of burning pain, every half-hour to hour during
the day; six to seven times during the night. He
used the catheter regularly every evening before retir-
ing and also irrigated his bladder. He stated that he
had had a chill five months ago, followed by fever;
the latter was of short duration, however. Complete
retention had never occurred. He urinated, volun-
tarily, 75 c.c. of a turbid urine; residual urine 80 c.c.
It took some time before the bladder was cleaned
out, so that the water returned clear. Of 150 c.c. in-
jected, the patient was able to pass not quite 100 c.c.
in a fine stream. His prostate appeared much en-
larged per rectum; its upper portion could be just
reached by the tip of the finger.
Report on urinary examination: chronic cystitis,
kidneys not involved'.
November 8th, cystoscopy : Pathognomonic groove
at vesical neck nicely developed; both lateral lobes
equally enlarged; post-prostatic pouch and trabecular
bladder well marked; no stone.
November nth, Bottini's operation: The new stor-
age battery with amperemeter was again used. Ac-
cording to advice given, it had been charged for eight
hours with two fifty-candle-power lamps. Four in-
cisions were contemplated; however, the posterior cut
only could be carried out with the full strength of the
current; on the return trip of the knife through the
right lateral lobe, which was next divided at an angle
of 45°, the needle dropped ten points; the two other
cuts then were omitted. A like accident will not hap-
pen to me again. We have since found a way of
charging the battery in such a manner that it can be
absolutely relied upon for the full strength of current
during the entire operation. (See above.) Besides, I
superintend the charging personally.
The day following the operation the patient mic-
turated much more easily than before; then absolute re-
tention set in, accompanied by a slight rise of tempera-
ture, 101.6° F., but no chill. Regular catheterization
became necessary and was performed every eight
hours. To avoid the pain that was caused by the
introduction and removal of the catheter, it was left
in permanently on the third day and not removed un-
til six days later. From that time on improvement
was noted and the capacity of the bladder gradually
increased. The patient was given urotropin and
strychnine, also salol; no vesical irrigation was done.
On December 6th, the bladder holds 16 ounces at a
time, which is voided in one single act. He urinates
74 to 96 ounces within twenty-four hours, with little
pain and at regular intervals of two to three hours,
night and day. The stream is full and strong up to
the last. He had urinated last at 8 o'clock in the
morning with his stool, and had retained his urine
until 12 M., when he passed 575 c.c. in a good contin-
uous stream, with the normal jerks at the end. The
catheter then introduced found 70 c.c. of residual
urine; 250 c.c. of a two-per-cent. boric-acid solution
thereupon injected is passed to the very mark of the
graduated glass. The urine was still slightly turbid.
The patient was told to continue urotropin and
strychnine three times a day and to reduce the quan-
tity of liquids ingested.
When seen again, on December 17th, he stated that
he urinated seven to eight times in twenty-four hours;
nights once. At the time of the nocturnal micturition
17 to 18 ounces is passed in a good stream, and with-
out pain. The catheter has not been used again since
the operation. The patient urinates 250 c.c. in a good
stream; the catheter introduced about three minutes
later finds 5 c.c. of residual urine. On irrigation the
water soon returns clear. His general condition is
much improved, and he has gained in weight.
Under date of December 31st, the record says: The
patient is doing nicely. He urinates six to seven times
in twenty-four hours; nights once or not at all. Aver-
age capacity of the bladder, 15 ounces; there is no
pain. He had urinated at 8 in the morning, and when
calling at my office at 9, passed 50 c.c. The catheter
then introduced does not find a drop of residual urine
in the bladder. Of 300 c.c. injected, 280 c.c. is passed.
The patient stated that he thought, if he had tried, he
could have probably passed the entire amount. He
has returned to business and works hard all day.
February 18, 1899: The patient feels splendid and
has gained considerably in weight. He urinates four
times during the day, nights once or not at all, and is
entirely free from pain. He does not have sudden
calls for micturition. He urinates 300 c.c. in one
good continuous stream with normal jerks toward the
end. The urine is absolutely clear. The catheter
immediately introduced does not find a drop of re-
sidual urine; 200 c.c. of the two-per-cent. boric-acid
solution then injected are passed up to the mark of the
graduated glass.
June 3d: Everything is in the best of order. He
urinates three or four times during the day; nights
once or not at all.
November 27, 1899: The same good condition pre-
vails. He urinates four or five times during the day
in a good stream; nights twice. When calling at my
office, had just urinated. He passed 75 c.c. Re-
sidual urine found, 10 c.c. Of 250 c.c. then injected,
every drop is voided in a good stream.
March 29, 1900 (one year and four months after the
operation): Patient feels well; he urinates five or six
times during the day, nights once; no pain; good
stream. While at my office, having urinated three
hours ago, he passed 500 c.c. of absolutely clear
urine; residual urine 250 c.c. Of 300 c.c. (10 oz.)
of nitrate-of-silver solution, 1:5,000, 200 are passed.
Patient has gained considerable in weight; considers
himself cured; bowels normal; catheter no longer
used.
This case very nicely illustrates that the posterior
cut alone, if properly carried out, may sometimes be
sufficient to relieve the patient. Nevertheless, no
conclusion should be drawn from such a single case,
but the rule of making one posterior incision at the
median line, and one each through the two lateral
lobes, should be followed. I feel confident that the
originally achieved ideal result would have continued
had all three incisions been done with equal thorough-
ness. I intend to propose a second operation if the
amount of residual urine should increase.
Case XIV. — ^H. J , seventy-one years of age.
Eighteen years ago retention set in for the first time,
but ceased after one week's use of the catheter. Dur-
ing the last fourteen years he has recurring desire to
urinate when walking down-stairs. There is gradu-
ally increasing frequency of micturition. He has had
diabetes for fifteen years, with varying quantities of
sugar, and is also suffering from constipation. The
patient went to Wildungen to take the baths in 1892,
where the doctor advised him to use the catheter twice
a day on account of his prostatic enlargement and
vesical catarrh. Since then he has used the catheter
twice daily and never urinated a drop voluntarily.
He has never had a chill or pains in the lumbar re-
gion. After the use of the catheter there has fre-
quently been some discharge of blood. Lately the
trouble has become much aggravated; he has to use
May 12, 1900]
MEDICAL RECORD.
■97
the catheter every three or six hours; nights rarely
less than twice. He requires the longest catheter in
the market, one that measures fifteen inches (38 cm.)
from tip to eye. Recently the meatus has become in-
flamed and infiltrated, which produced a stenosis.
Since then his condition had become much more
troublesome. When calling at my oiifice on January
9th, 1899, he stated that it had been impossible for
the last twenty-four hours to introduce the web cathe-
ter, always used thus far. I found the prostate very
large and hard ; its upper border could not be reached
with the finger. I succeeded in introducing a Tren-
delenburg prostatic catheter sound (No. 14) a descrip-
tion of which was first published by me in the New
York Medical Journal for August 6, 1892, and relieved
the retention. January 11, 1899, the patient was ad-
mitted to the German Hospital, where meatotomy was
performed, and after that catheterization was regularly
carried out.
January 23d, cystoscopy: Great difficulty was expe-
rienced in introducing the instrument. The condition
found was: a large median lobe; right lateral lobe
larger than the left; sacculated bladder. The exami-
nation was followed by a hemorrhage, which, however,
was not alarming.
Bottini's operation was performed on January 25th,
with the bladder filled with 200 c.c. of sterile boric-
acid solution. When the introduction of the incisor,
after two unsuccessful attempts, was finally accom-
plished, the beak of the instrument well hugging the
prostate, the latter's tip could be palpated about four
and a half inches (11.5 cm.) above the sphincter and
muscle. Four incisions were made, the posterior one
4 cm. in length; the one through the right lateral
lobe at an angle of 45°, 4 cm., the one through the
left lateral lobe at 90°, 3.5 cm., and the anterior cut
with the handle of the instrument depressed, 2 cm.
long. The patient was unable to urinate just after the
operation; there was no general disturbance, although
he suffered much from vesical and rectal tenesmus.
Catheterization being difficult, the permanent catheter
was introduced and left in place for five days. On
February 20th, the patient was still unable to urinate
voluntarily, but catheterism was certainly much easier.
He soon left his bed.
On February 21st, a second Bottini operation was
performed. Introduction of the incisor was markedly
easier; again four incisions of same length as those
at the first operation were made. There is no general
disturbance, but voluntary micturition does not begin.
On the twenty-sixth day following this operation, on
March 19th, after the discharge of exceedingly large
eschars, the patient passed water voluntarily for the
first time within the last six and a half years, first in
small quantities, which, however, rapidly increased.
On March 28th he urinated 50 c.c. without having
the desire. The catheter found 500 c.c. residual
urine. A N(^laton catheter passed with the greatest
ease and the irrigation water promptly returned clear.
Upon reflecting on my failure, thus far, in relieving
the patient of the greater amount of residual urine, I
sorely felt, for the first time during my work on the
prostate with Bottini's operation, the need of an in-
strument that permitted of making incisions longer
than 4 cm., this being the limit of the one theti in my
possession. I therefore had constructed for me an in-
cisor allowing of an incision 8 cm. in length.
As soon as the instrument was completed, I proposed
a third operation to the patient, to which he readily ac-
ceded. It was done on April 4th. On firmly hugging
the prostate the beak, to my dismay, suddenly slipped
into a distinct groove, an accident which naturally
frustrated my plan of reducing the urethra to 21 cm.,
since I could not know how many centimetres the in-
strument had slipped forward. Under the circum-
stances I contented myself with a posterior cut of 3)^
cm., one through the right lateral lobe at 45°, of same
length, and one through the left at 90 , 2 cm. long.
There was absolutely no reaction ; the permanent cathe-
ter introduced immediately after the operation was left
in place for three days. After its removal the patient
was regularly catheterized twice to three times a day,
first with Mercier's, then with Nelaton's soft-rubber
catheter. Commencing with the eleventh day, large
escharotic pieces were discharged.
The patient soon began to urinate spontaneously,
using the catheter only before retiring. Average
amount of residual urine 500-600 c.c.
On April 27th he urinated every one to two hours,
day and night. Spontaneous micturition at office
upon request, without inclination, gave 50 c.c, resid-
ual urine 450 c.c. Ne'laton catheter entered with
greatest ease. Irrigating water returned clear after
the first washing. Of 500 c.c. injected, only 100
could be passed.
May 13 : Diabetes has become aggravated (eight per
cent.). Average amount of urine in twenty-four hours
over four quarts. On June 30th, under proper treat-
ment, the amount has been reduced to 1,060 c.c. in
twenty-four hours. He uses catheter only once; feels
comfortable; urinates spontaneously four to five times
during the day and about the same number of times
during the night. Largest amount of urine passed in
one act 180 c.c, residual urine 530 c.c.
October loth: Length of urethra i^Yi cm. (10
inches). Amount of urine voided in twenty-four hours,
1,500 c.c. He irrigates his bladder every morning.
Residual urine, 400-500 c.c. He has no desire to
pass water after that for eight or ten hours. Greatest
amount voided at one time, 80-100 c.c. His bowels
move regularly, and his general condition is much
improved.
December 26th : He urinates spontaneously between
1,100 and 1,150 c.c. at irregular intervals within
twenty-four hours. He has no pain and is not an-
noyed by a frequent desire to urinate. Residual urine
always between 600-650 c.c. He enjoys good rest
during the night without the call to rise. Largest
quantity of urine passed spontaneously, 150 c.c. The
call is never urgent; he can retain the urine some-
times for longer than two hours. The patient consid-
ers himself very much improved.
Final examination April 4, 1900: Quantity of urine
passed in twenty-four hours 2,400 c.c. (80 oz.); great-
est amount voluntarily voided at one time 150-250
c.c. He catheterizes himself twice daily, after which
he has rest for seven to eight hours. Residual urine
between 500 and 700 c.c. No irritation at neck of
bladder; he is able to retain; bowels normal; marked
gain in weight. He is well satisfied with his present
condition.
In reviewing this case, I cannot help thinking, as
mentioned before, that a far more favorable result
could have been obtained at the time of the first oper-
ation, had I been in possession of an instrument so
constructed as to permit me to make the incisions long
enough to cut through the prostate in its entire length
and thus to reduce the urethra to its normal length.
" Insufficient length of the incisions," then, is evi-
dently the cause of the imperfect result in this in-
stance. There can be no doubt that this would have
been a fit case for prostatectomy, had not the very
marked diabetes and the senile condition of the pa-
tient presented an absolute contraindication to such
an interference. With my present knowledge, I feel
convinced I should achieve a better result in a similar
case with a large fibrous prostate. As indicated above,
I should compare the length of the urethra with the
measurement of the prostate per rectum just before
the beginning of the operiition, and make my incision
798
MEDICAL RECORD.
[May 12, igoo
to correspond to this difference if not to exceed it by
I cm. I also would slowly go over the same route
with the galvano caustic knife twice in immediate
succession.
Case XV. — J. H , seventy-eight years of age.
Nine years ago he had first complete retention. He
was first seen by me in 1896. He then had to rise
three to six times during the night, and urinated every
two hours during the day under considerable strain-
ing. There was slight after-dribbling; residual urine
50-60 c.c. The prostate was very large. He was
then comparatively well for the following three years.
I saw the patient again on December 29, 1898, when
he complained of intermittent complete retention, the
last onset having occurred December 26th; the one
previous to that five to six months ago. He has his
bladder washed out about twice a week; otherwise the
catheter is not used. His condition has become much
worse during the last few weeks, especially as regards
frequency of micturition. His nights' rest has been
greatly disturbed, the call coming eight to ten times.
There is slight epididymitis. He urinates 35 c.c, re-
sidual urine 25 c.c, turbid. The bladder holds not
quite 200 c.c. Prostate palpated per rectum is very
large; its upper border can just be reached; it is
somewhat tender and compressible. Treatment : reg-
ular irrigation, increasing doses of salol ; urotropin.
January 12, 1899: His condition has improved;
micturition less troublesome. There is no pain. Mic-
turition, nights four to five times; during the day
about every two houiS. He urinates 90 c.c. ; residual
urine. 100 c.c.
January 29th: Cystoscopy; introduction of instru-
ment ver} difficult. In passing the prostate the beak
distinctly slides over a very irregular surface; there is
hemorrhage, which necessitates change of water in
bladder. There is a large median lobe; the right
lateral lobe distinctly projects into the lumen of the
bladder; left lateral lobe smaller. Complete reten-
tion follows examination, but is relieved by silver
catheter with large curve. The patient remained in
bed for five days, after which the same condition as
before cystoscopy prevailed.
February nth: Bottini's operation was performed at
the German Hospital, four incisions being made: pos-
terior, 3 J.^ cm. through right lateral lobe at an angle
of 45°, through left lateral lobe at 90°, of same length;
anterior incision, 2 cm. The bladder had been filled
with 150 c.c. of sterilized boric-acid solution. Reac-
tive swelling of gland was very marked. Retention
set in; catheterizaticn was very difficult ; relief was
obtained by Trendelenburg's prostatic catheter sound.
February 12th (thirty hours after operation) : Rise
of temperature up to 103° F., with corresponding pulse.
Both slowly subsided in the course of a few days.
February 13th: Introduction of soft-rubber catheter
on metal guide was successful; it was left in place
for six days; after that regular catheterization, which
became gradually easier. The patient commenced to
urinate spontaneously on the 22d of February. Vesi-
cal irrigation was carried out twice daily. He left
the hospital on March 15th.
March 20th; He can retain urine for fully three
hours; micturates three or four times during night in
a good strong stream, without pain. When calling at
my office he had passed his water an hour and a quar-
ter previously and had no desire to urinate; on re-
quest, however, he passed 90 c.c. ; residual urine was
withdrawn by Mercier catheter, which entered without
difficulty after a Nelaton had refused to pass, 30 c.c.
Catarrh is still marked. Of 250 c.c. of boric-acid
solution then injected, 210 c.c. are passed. Medica-
tion, urotropin and strychnine.
March 27th: Frequency of micturition during the
day is every three hours; nights three to four times
without pain. In comparing his former condition
with the present the patient states as follows: For-
merly there was a burning sensation during micturi-
tion; long waiting before the water would appear; no
stream. Now, the burning sensation is very slight;
he does not have to wait, and water passes in a good
stream. He had not urinated for two and a half hours
before calling, and then passed 175 c.c. in a good long
stream; residual urine, 75 c.c. Vesical catarrh was
still marked. Of 250 c.c. injected, 40 c.c. were re-
tained. Continued regular irrigation of bladder with
nitrate of silver was ordered.
May ist: He urinates every two or three hours,
nights two to three times, retains easily 250-270 c.c.
He passed about 120 c.c. three hours ago; now 175
c.c, residual urine 50 c.c. Length of urethra, 24 cm.
June 8th : The patient feels splendid, has no pain
and no annoyance. Of 200 c.c. injected, 150 are
passed, leaving a residual urine of 50 c.c. The pa-
tient is perfectly satisfied with his condition and
would consider himself cured, if frequency of urina-
tion could be still somewhat reduced and if he did
not see that his urine is still slightly turbid. He
has gained considerably in w'eight.
Final examination March 27, 1900 (thirteen months
after the operation) : Patient urinates every two or
three hours daily; nights four or five times; no
pain ; stream much better than before operation. He
has no desire to micturate, but on request passes 55
c.c. (nearly 2 oz.), residual urine 80 c.c. (2| oz.).
Very slight cystitis; irrigation water returns clear at
once. Of i8o c.c. 100 are passed. Length of urethra
is 23 cm. Prostate is of medium consistency; its up-
per border cannot be reached ; catheter has not been
used since he was discharged from after-treatment at
the time of the operation. The patient — although the
father of three doctors — is absolutely opposed to tak-
ing any medicine internally; therefore, he also refuses
urotropin. He has no pain; would consider himself
entirely well if he urinated less frequently.
This case certainly belongs to the class of "' much
improved." As stated, the length of his urethra still
measures 23 cm. Here too, therefore, the insufficient
length of the incisions was the reason that perfect uri-
nary drainage was not established by the interference.
I suggested to the patient that he have a second opera-
tion performed. This, however, he refused, stating
that he is entirely satisfied with his present state.
C.\SE XVI. — M. M , fifty-eight years old ; has
had urinary trouble for the last three or four years.
A year ago he urinated every two hours during the
day; four or five times at night, with considerable
pain in urethra; some tenesmus; no lumbar pains; no
chills. He has been treated with medicine. There
was steady aggravation of all symptoms, until, about
two weeks ago, he had to urinate every three or four
minutes during the night and every fifteen minutes
during the day. Absolute retention; overflow; regu-
lar catheterization. He now catheterizes himself four
or five times during the day. On December i8th there
was haematuria for the first time, following the intra-
vesical interference.
The patient called at my office for the first time on
December 19, 1898. He was unable to urinate spon-
taneously, having drawn off his water in the morning
before leaving home. Nelaton catheter withdraws 625
c.c. There is a good deal of catarrh. The prostate
is large and soft. The patient is very weak and ex-
tremely emaciated. Pulse is irregular, about 122;
temperature, 103.6° F.
Urinary analysis: Chronic cystitis with alkaline
fermentation; renal hypera;mia or possibly a more
marked renal lesion, but no pyelitis. It is not easy
to make a definite diagnosis, as it is difficult to ac-
count for the continuous fever. The lungs are not
May 12, 1900]
MEDICAL RECORD.
799
affected; there is no tuberculous family history ; there
are no symptoms of typhoid. Blood test for Plasmo-
dium and Vidal negative. With regard to malaria it
is not absolutely reliable, since quinine had been
given before. His temperature is reduced after about
one week's time by the continuous use of methyl blue
and quinine.
December 23d: Resection of the vas deferens was
done on both sides. No particular improvement was
noticed during the following two weeks. Overflow as
before. Regular catheterization. The bladder con-
tains never less that 480 c.c. (16 oz.).
January 4, 1899: Cystoscopy. Some difficulty is
encountered at the neck of bladder when the instru-
ment is introduced. Marked trabecular bladder; deep
characteristic groove at the internal fold. Left lateral
lobe larger than right; there is no median lobe; no
stone. Internal medication of methyl blue is con-
tinued.
January 6th: Bottini's operation. After repeated
attempts, the incisor enters the bladder. On hugging
the prostate with the beak the rectal diameter of the
same seems alarmingly reduced. Had not all the
characteristic symptoms been seen, everybody would
have doubted the presence of prostatic enlargement.
Not knowing exactly what best to do under the cir-
cumstances, but eager to get through with one opera-
tion, the posterior cut was made 3'j cm. long; the
one through the left lateral lobe at an angle of 45°,
and the one through the right lateral lobe at 90°, 3
cm. each. The anterior cut was omitted, because in
the attempt at turning the beak toward the symphysis,
the instrument suddenly slipped out of the bladder.
When removed, much thoroughly burned prostatic tis-
sue was seen to adhere to the knife. Immediately
after the operation the patient complained of a great
deal of pain and had some rectal tenesmus. A few
drojjs of urine were passed per urethram; there was
much pain in perineum. At 5 p.m., temperature, 104°
F. ; pulse, 116. Attempt at entering the bladder with
a catheter was unsuccessful, although the instrument
could be introduced pretty far. Another effort at 9 p.m.
met with the same result. The patient felt an urgent
desire to empty the viscus; therefore, aspiration was
done above the pubes, about 600 c.c. being drawn off.
From hour to hour there was continually increasing
swelling of the right part of the scrotum, extending up
to the right inguinal canal. Diagnosis: perforation
of urethra; urinary infiltration. Operation at 1 1 p.m.
(fourteen hours after Bottini's operation) under super-
ficial general anjesthesia. Multiple incisions were
made in scrotum; the subcutaneous tissue was thor-
oughly infiltrated and blue (methyl blue). Burnt
shreds of tissue were found in the median incision just
above the anus; the urethra here was perforated. In-
troduction of tube from perineum into bladder was
unsuccessful. Drainage of scrotal wounds; moist
dressing.
January loth: Temperature almost normal; pulse
still slightly elevated. Since the last operation, the
patient has emptied his bladder through the perineal
wound in short, frequent intervals, over which he has
no control, except that he feels the desire to urinate.
He rests on a rubber air bed-pan. VVith the help of
very careful nursing, I succeeded, to my delight, in
saving this patient's life. For a long time his pulse
ranged around 120; the rectal temperature never rising
above 100° F. On February 15th his pulse for the
first time fell to 96, his temperature being about as
usual, 98.4° F.
March 3d: Pulse 88. His condition now slowly im-
proved. He left his bed at the end of February and
by the middle of March was able to walk around.
Meanwhile the perineal wound had slowly contracted
so that, on March isth, not quite ten weeks after the
operation, he urinated spontaneously for the first time
in the normal way, about two ounces. On March 22d
the report states that he urinates every hour to hour
and a quarter, about 120 c.c. (4 oz.) at a time, 30 c.c.
(i oz.) still passing through the wound. On March
28th he weighed one hundred pounds.
April 2d: The patient urinates every two to two
and a half hours.
April 3d: Weight one hundred and one-half pounds.
April 7th: Atypical attack of gall-stone colic set
in, with a pulse of 128; temperature, 103° F., which,
however, slowly yielded under proper treatment, so
that everything is normal again on April 9th. On
April loth he left for his home in the northern part
of this State, accompanied by his faithful nurse. The
perineal wound had completely closed; he urinated
every two or three hours in a satisfactory stream, with-
out pain. The catheter had been laid aside since the
operation.
March 16, igoo (fourteen months after the opera-
tion) : The patient reports that he urinates every hour
during the day; nights seven or eight times; the
stream is satisfactory; the perineal fistula has re-
mained closed ; he has gained in weight; the bowels
are normal. He has had no local treatment since he
left my care.
It will be readily understood that the experience I
had with this patient immediately after the operation
greatly embarrassed me, although the final result was
most gratifying. It is plain that the too great length
of the cuts here produced the perforation of the ure-
thra. As stated before, I did an unintentional inter- »
nal perineal urethrotomy. I believe and hope that,
with my present experience, such an accident will not
happen again. I had, up to that time, never made the
posterior cut shorter than 3 to 3'j cm., neither had
I encountered a gland of such sponge-like compressi-
bility as this one. It was, furthermore, imperative
that the obstruction be relieved without delay, lest
the life of the patient, who was greatly reduced, should
be lost. I believe that an incision of i to 1^2 cm. in
length would have been ample in this case, and, most
probably, would have effected a cure with less distress
to the patient.
In this particular instance Bottini's operation not
only entirely relieved the patient, but directly saved
his life. Any colleague, seeing the patient at the
time I undertook the treatment, would have agreed
with me that he was nearly dying. It was only on ac-
count of the intense suffering of the man, night and
day, that I was induced to try Bottini's operation.
Case XVII. — H. U , seventy-nine years old,
well preserved; absolute retention of urine for the last
twenty-two years. In the beginning he used the ca-
theter once a day ; later twice, then three times, and
up to about a year ago every six hours. At that time
he had a severe hematuria. Since then the call to
urinate has become rapidly more frequent, so that now
he is obliged to use the catheter every hour to hour
and a half, day and night; introduction of the instru-
ment at times is very painful. Amount of urine
discharged, about three quarts in twenty-four hours.
On March 23, 1899, when calling at my office, 200
c.c. of urine were drawn off by means of a soft-rubber
catheter which entered the bladder without difficulty.
The latter did not prove irritable on irrigation. On
rectal palpation the prostate was found to be soft, the
right lateral lobe being larger than the left. He has
prostatorrhcea. Length of urethra, 23 cm.
Urinary analysis: Chronic pyelo-nephritis; chronic
cystitis with alkaline fermentation.
Cystoscopy shows the characteristic groove pointing
obliquely toward the right of the patient. The right
lateral lobe does not appear very large in the picture;
toward the median line a perpendicularly rising mass
8oo
MEDICAL RECORD.
[May 12, 1900
is distinguished, evidently a large median lobe;
marked trabecular bladder. Toward the right lateral
vesical wall there is a dark yellowish spot, about the
size of an almond, the meaning of which cannot be
distinctly determined. Sudden pressure repeated at
short intervals on the suprapubic region of the patient
does not alter its position. Drawing off the liquid in
the bladder and forcibly injecting new fluid through
that tube of the irrigating cystoscope which ends with
a wide opening at the lower end of the shank to the
side of the prism, does not move it either. The e.x-
amination is much interfered with by a continuous
hemorrhage from the prostate, which at once destroys
the transparency of the injected fluid. A superficial
ulceration, its surface covered with adherent mucus, is
suspected. Doubt as to the correctness of this as-
sumption is entertained, however, on account of the
fact that mucus covering vesical ulcers generally ap-
pears white on cystoscopic examination, and not yel-
lowish.
March 31st: Bottini's operation. After the incisor
has been introduced, and turned around its axis for
180°, its handle cannot be well raised; the tip cannot
be felt with the finger in the rectum. Conclusion:
The middle lobe has been turned down and backward.
On pulling the incisor firmly forward, the beak sud-
denly slips forward and toward the right of the patient
into a groove; its tip can then be reached per rectum.
It evidently rested in the deep groove between the
right lateral and middle lobe of the gland. Posterior
incision as well as that through right lateral lobe at
an angle of 45^ and through left lateral lobe at 90'', 4
cm. long. Before carrying out the anterior incision,
which is made 2 cm. long, the handle of the instru-
ment is well pressed down, so that such prostatic tis-
sue as might possibly press down and backward .the
posterior part of the urethra should be thoroughly
divided. There is profuse hemorrhage. Immediate
introduction of a Mercier catheter is impossible.
Seven hours after operation the temperature rises to
102° F. ; pulse, 88.
April 1st: Temperature not exceeding 101.6° F. ;
April 2d, it is below 101° F. ; pulse,8o. The patient
is unable to urinate voluntarily. During the first
thirty-six hours after operation catheterization is regu-
larly carried out two to three times in twenty-four
hours, with the prostatic catheter sound. On the sec-
ond day after operation there appeared a slight, pro-
gressive oedema in the suprapubic region, which
slowly spread over the penis and scrotum down to the
gluteal region.
April 3d: A Nelaton catheter on metal guide is
successfully introduced and left in place; r57 ounces
(4.710 c.c.) of urine are passed through the same in
twenty-four hours. There is pain on pressure in the
suprapubic region, and a slight resistance is palpable.
On .April 4th drainage is less satisfactory; there is
much vesical pain, which, however, yields under the
administration of opiates. The soft-rubber catheter
is exchanged for Mercier's and left in the bladder.
The pulse at one time suddenly rises to 120, but soon
drops again. Temperature not over 102° F.
April 5th: Pulse irregular; temperature lower, but
soon increasing. Infiltration above symphysis. Su-
prapubic incision into cavum Retzii under eucaine was
decided upon and set down for 2 p.m., when pulse
and temperature suddenly rose after a chill and the
patient's mind began to wander. Further interference
was suspended. The patient continued to sink, and
died on April 7th, at 1 :30 a.m.
Post-mortem examination demonstrated a suppura-
tive inflammation of the cavum Retzii and a far-reach-
ing pericystitis, but no urinary infiltration. The blad-
der was found to contain a stone of about an almond's
size. The galvano-caustic incisions are plainly vis-
ible. The posterior cut runs in the groove between
the right lateral and median lobe (which latter is of
tremendous size), and the left lateral incision trans-
versely through the median lobe. The specimen is of
great interest.
The unfortunate result in this case was evidently
due to my still having carried out the anterior inci-
sion. Death clearly resulted from a suppuration in the
cavum Retzii, due to infection by contiguity — not by
perforation of the anterior bladder wall, since a care-
ful examination at the autopsy failed to reveal any
trace of perforation. It will be remembered that in
my Case IX. I also observed pain on pressure above
the symphysis. On traversing the cavum Retzii, when
performing suprapubic cystotomy, on the eighth day
after the operation, a very slight oedema only was
found to be present. Recollecting this experience, I
hoped at first that the complication might prove no
more serious in this instance. Increasing evidence of
local inflammation, however, soon convinced me that
an incision was imperative; the sudden change in the
patient's general condition prevented me from carrying
out my intention. It had been my privilege, just be-
fore doing this operation, to listen at the Academy of
Medicine to a most instructive demonstration of the
anatomy of the prostate gland, by one of our New
York colleagues. I believe to have understood the
doctor at the time to say that, in a number of cases
of marked prostatic enlargement, the posterior urethra
was depressed by a mass of glandular tissue lying in
front of the prostatic urethra. The large size of the
gland palpated per rectum as well as seen through the
cystoscope, made me think that just such a condition
was present in this case. I therefore depressed the han-
dle in order to divide the anterior prostatic tissue as
thoroughly as possible. Of course, I now very much
regret having done so. It was in consequence of this
sad experience that I decided discontinuing the ante-
rior incision. Only in those exceptional cases in which
the cystoscope plainly will show the cause of an in-
complete result after a first Bottini operation to be a
mass of prostatic tissue situated above the internal
sphincter (Freudenberg reports such a case) shall I, in
future, lend my hand to make an anterior incision.
That the beak of the incisor slipped off the median
lobe at the beginning of the operation, and the gal-
vano-caustic division then deepened the groove be-
tween the median and the right lateral lobe, happened
by chance. It is questionable whether it would have
proven beneficial to the patient. I personally am in-
clined to think so. It appeared to me from the speci-
men that the posterior urethra had been well lowered
to the bas fond. On the other hand, a large median
lobe frequently proves to be the main obstacle to
proper drainage. I therefore think that, on the whole,
it should be the aim to prevent the instrument from
slipping off the median lobe and to try thoroughly to
divide the tumor-like projection into the bladder, ex-
actly in the median line. For such cases we will, of
course, need the incisor which permits of making the
cut 8 cm. long.
The indistinct yellowish spot I had seen through
the cystoscope on the right side of the fundus, and
which I could not explain at the time, was the stone.
Had I introduced the stone searcher immediately af-
terward, tlie diagnosis could probably have been easily
cleared up. As matters were, the patient was eager
to get through with the one examination, and so it was
omitted. In future, of course, I shall not again be
satisfied with an indistinct abnormal spot in the blad-
der, but shall ascertain its meaning before doing Bot-
tini's operation.
Case XVIII. — X , a very active man all his
life, has had increasing urinary trouble for the last
four to five years. In May, 1897, the catheter was
May 12, 1900]
MEDICAL RECORD.
801
used for the first time; later it liad to be resorted to
occasionally. Soon the urine became turbid. In the
fall of 1897 double epididymitis set in, which kept
the patient in bed for three weeks. After this attack
had been overcome urination was more free. In
April, i8g8, Bottini's operation preceded by cystoscopy
was carried out by a competent surgeon. Cystoscopy,
which was done rather hurriedly, had shown the blad-
der in a state of chronic catarrh, and demonstrated the
pathognomonic groove at the internal urethral fold.
Three incisions were made under eucaine, one directly
posteriorly, the others at right angles. Very little
reaction followed. The patient went back to his home
five days later. He there had little chance to take
proper care of himself. During the third week, after
having jumped from a car, a vesical hemorrhage set
in which necessitated catheterization and rest in bed.
Six days later it recurred. The bladder then became
more irritable and remained so for a long time. No
special improvement could be observed as a result of
the operation. One year later, in the early part of
April, 1899, the patient consulted me. His condition
then was as follows: urination every few hours day
and night, sometimes accompanied with much pain;
the catheter introduced after the act always found
residual urine, varying in amount from two to over
eight ounces. N'o blood; no renal elements. Cysto-
scopy, on April 8th, with the irrigating cystoscope,
reveals the presence of four rather small concretions,
lodged in a shallow groove to the left of the fundus.
They are easily thrown aside by the water which is
forcibly injected into the bladder through one of the
channels of the cystoscope. When the latter is with-
drawn into the vesical neck, two or three of the con-
cretions follow and suddenly are seen to rest near the
prism of the instrument. The characteristic groove
at the neck of bladder is still present. The prostate
can be seen in silhouette and shows distinctly two
lateral rather shallow incisions running in a horizon-
tal direction. In view of the presence of the stones,
the second Bottini operation had, as a matter of
course, to be deferred. Upon special request of the
patient, the necessary intravesical manipulations were
done under general anaisthesia. Thus, on April i ith,
an attempt at washing out the stones with Otis' evac-
uator was made. To my delight two stones at once
w-ere drawn into the large opening at the vesical end
of the catheter. They were freed by withdrawing the
instrument. The latter was then re-introduced, but in
spite of repeated efforts at e.xtracting the other calculi
by suction of the rubber bulb, this could not be com-
pletely accomplished, a portion remaining behind.
Further operative interference was then desisted from,
it being hoped that the patient might pass the last
stone spontaneously. This, however, did not happen.
On the contrary, absolute retention set in which neces-
sitated regular catheterization. On the fifth day after
the operation the patient again commenced to void a
small amount of urine per vias naturales. On April
iSth, cystoscopy was repeated. The remnants of the
third and a fourth calculus, which had been broken
in two when trying to remove the stones by suction,
were plainly visible. It was determined to make an-
other effort at evacuating the stones by flushing the
bladder under general anaesthesia, and then immedi-
ately adding Bottini's operation. On April 20th this
was successfully carried out, just as planned. The
stones appeared promptly, and the galvano-caustic
division of the gland could be at once added. On in-
troducing and turning the incisor in order to hook
the prostate, I was struck by the extreme softness of
the organ. The finger when introduced into the rec-
tum in order to palpate the beak of the incisor, could
easily detect it about two inches above the sphincter
ani muscles. After the necessary hugging of the
gland, the tip of the beak was palpable immediately
above these muscles. It was evident that the gland
was of extreme softness. This recalled to my mind the
case (XVI.)of exactly the same character in which I had
operated a few months before, and in which I had the
misfortune of doing an unintentional internal urethrot-
omy with the galvano-caustic knife. I therefore re-
solved to profit by my former experience, and to avoid,
by all means, a repetition of the accident. As, how-
ever, my patient was ready to go to Europe, in fact had
already engaged his berth, it was particularly desirable
that the work be done radically in one sitting. In this
emergency I made the median cut 2.75 cm.; the two
lateral ones, at right angles, 2.5 cm. long each. The
patient stood the operation exceedingly well. With the
exception of some very severe pains setting in about two
hours after the operation, which, however, could be con-
trolled by a hypodermic of morphine, there was no re-
action whatever. Absolute retention followed on the
eve of the operation. I succeeded in introducing a
soft-rubber catheter on a metal guide. Twenty-two
ounces of a sanguinolent urine were evacuated. The
bladder was washed out and the catheter left in place.
On the following day some slight fever set in, which,
on the second day after operation, at noon, reached
104° F. with a pulse of 116. Examination made of
the perineum showed distinct symptoms of an abscess,,
which was immediately incised under eucaine. Im
holding the borders of the wound apart with sharp
retractors, it was seen that the posterior incision had
entirely cut through the prostatic urethra and a part
of the membranous. The end of the two lateral in-
cisions could also be detected from the wound. For
convenience' sake a permanent catheter, introduced
through the external meatus, was left in place and
the wound tamponed. The temperature dropped
promptly and was normal on the following day, the
third after the operation, never to rise again. From
now on careful vesical irrigation was carried out with
the additional internal use of urotropin, cafieine, and
strychnine. The catheter which had been introduced
at the time of the perineal incision was not changed
until May ist, that is, the eleventh day after the opera-
tion. On removing it the patient at once passed from
eight to twelve ounces of urine spontaneously, of course
through the perineal wound, but the same was slightly
tinged with blood. On the evening of the same day a
rather alarming hemorrhage set in, which, however,
was controlled by perineal compression; the catheter
was purposely not introduced. Slight vesical hcema-
turia followed and continued for four days. On May
1 2th, or the end of the third week after operation, the
patient urinated for the first time per urethram. The
perineal wound then rapidly contracted and soon defi-
nitely closed. The amount of urine voided every three
to four hours was between six and ten ounces.
In the early part of June the patient left for Europe,
where he spent a number of months. On his return
in the fall he had very much improved in general con-
dition, urinated spontaneously without discomfort, but
invariably had to press out the last drops of urine
with his hand on the perineal scar. He evidently had
been much benefited by Bottini's operation, and there
was every reason to hope that the trouble was perma-
nently cured. To my sincere regret I learned that,
three months after the patient's return from Europe, a
residual urine, varying from a few drachms to a num-
ber of ounces, had again appeared, and that the vesical
catarrh, which had been present for many years, was
not materially improved in spite of continuous local
and medical treatment. As far as I could ascertain,
a sound of No. 8 American passes into the bladder
without trouble, showing that no material contraction
followed the unintended multiple galvano-caustic divi-
sion of the posterior urethra. I am unable to account
802
MEDICAL RECORD.
[May 12, 1900
for the reappearance of the varying residual urine, but
should not be surprised if it were found, on cysto-
scopic examination, that another small calculus is the
chief cause of the trouble. It certainly is by no
means excluded that further developments will yet
show the second Bottini operation to have been a per-
manent cure. So far we can only claim " material
improvement" in this particular case. The patient
otherwise has considerably gained in weight, looks
well, and is back in active work.
Case XIX. — S. H , seventy-four years of age.
The first urinary symptoms date back seven years :
frequency of micturition; after-dribbling. Three
years ago retention and overflow set in for the first
time. The catheter was employed for a time, when he
again was able to urinate spontaneously, about once
every hour. For the last nine months ischuria para-
doxa; urine discharged involuntarily. Eight weeks
ago he consulted a doctor for the first time; 30 to 60
c.c. (i to 2 oz.) were slowly passed; residual urine
960 c.c. (32 oz.). Vesical catarrh was present. The
bladder was irrigated. Internal medication: salol,
urotropin. No improvement was noted, but on the
contrary, the patient got gradually worse. When he
first called upon me, on May 6, 1899, ^^ stated that
he was regularly catheterized twice daily, and that
generally 1,000 c.c. (^^ oz.) were drawn off. In spite
of this, the frequent desire to urinate persisted day
and night, although he voided but a few drops each
time, under great pain. Two days ago he had a chill,
followed by fever. I requested the patient to urinate,
but he was unable to do so. A Ne'laton catheter then
introduced without difficulty drew 285 c.c. The irrigat-
ing water soon returned clear. Length of urethra, 24
cm. The gland per rectum appears large. Its upper
border can just be reached with the finger tip; it is of
medium consistency and not expressible on massage.
Report of urinary analysis: Chronic cystitis with-
out fermentation ; nephritis, with most probably pyelo-
nephritis.
May 5th: Cystoscopy; funnel of cystoscope needs
much pressing down before beak slips into bladder.
Hemorrhage from prostate. After change of water, a
beautiful trabecular bladder can be viewed. The
mouths of both ureters seem to be wide and gaping
(hydro-ureter?). Characteristic groove at internal
fold nicely marked. On turning the prism toward the
fundus, a large projecting growth, evidently a part
of the body of the prostate, becomes plainly visible.
There is no stone. With the hope of reducing the
blood supply of the prostate, resection of both vasa
deferentia is done as a preliminary operation on May
22d. On May 24th the patient passes water sponta-
neously, first 150 c.c. (5 oz.), later 210 c.c. (7 oz.),
residual urine 780 c.c. (26 oz.). On the following day
he does not void more than 45 c.c. (j yi oz.).
On May 30th, 570 c.c. (19 oz.). are passed sponta-
neously, the greatest amount voided at one time being
180 c.c. (6 oz.). Residual urine 810 c.c. (27 oz.).
June I St: 60 c.c. (2 oz.) is the largest amount passed
without the catheter.
June 2d: Bottini's operation, under eucaine. On
firmly hugging the prostate, the tip of the beak is
palpable about one and one-half inches above the
anus. Posterior incision 3.25 cm. long; the two lat-
eral ones, both at an angle of 60°, 2 cm. After the
operation the patient is unable to pass water. At 11
P.M. a soft-rubber catheter is introduced and 540 c.c.
(18 oz.) of a slightly bloody urine are drawn off. The
catheter is left in place. The next morning the urine
is free from blood. The temperature that day rises to
101°; pulse normal. A slight elevation in the tem-
perature toward evening w'as noted the following days;
it never exceeded 101.3°, however. The patient com-
plains of pain in the left testicle.
June loth, eight days after the operation, the per-
manent catheter is removed. Catheterization becomes
necessary twice that day.
On the nth of June he commences to pass water
spontaneously, the first amount being 180 c.c. (6 oz.).
which is followed by a voluntary discharge about every
hour. The catheter is dispensed with.
On June 12th, the greatest quantity of urine voided
at one time is 240 c.c. (8 oz.), the total discharge in
twenty-four hours being 1,980 c.c. (66 oz.).
June 13th: Total amount passed 2,190 c.c. (73 oz.).
June 14th: Quantity voided in twenty-four hours
1,050 c.c. (35 oz.). The catheter introduced at 5 p.m.
finds a residual urine of 690 c.c. (23 oz.).
The next day the catheter has to be used twice, and
is again dispensed with on the 17th of June, never to
be employed again. Within the last days the patient
complained frequently of much pain along the left
spermatic cord and in the testicle. Temperature is
rising. A palpable infiltration is running through
the inguinal canal down to the spot of the ligation of
the vas deferens. Funiculitis; epididymis not in-
volved. The infiltration is incised on June 19th, and
pus evacuated. After this the quantity of urine
voided spontaneously rapidly increases and is, for in-
stance, on June 26th, 240 c.c. (8 oz_.). The greatest
amount passed at one time on July 3, is 300 c.c. (10
oz.); on the 12th of July again 300 c.c. (10 oz.).
This nicely shows the increasing capacity and decreas-
ing irritability of the bladder. During the summer
the patient returned under the care of his family phy-
sician, who regularly dressed the sinus on the left
side of the scrotum, which proved rather obstinate,
but permanently closed about six months after the
operation.
November 7th: The patient states that he urinates
every two to three hours during the day ; nights twice.
He has never used the catheter since it was laid aside
soon after the operation. He has a good stream, but
catarrh of the bladder is still present. Continued irri-
gation is strongly urged.
Final examination, April 16, 1900: Patient empties
his bladder every three hours during the day; nights
generally a quart, in two to three times ; forcible stream ;
no pain; he has gained considerably in weight;
bowels normal. The fistula resulting from the funic-
ulitis closed three months ago. He has no desire to
urinate, but on request passed 75 c.c. (2;J^i oz.); resid-
ual 225 c.c. The urine contains a large amount of
pus; marked pyelitis; the catheter has not been used
again since the operation. The length of urethra is
23'j cm. Patient feels as if he had regained perfect
health.
In reviewing the temperature chart of this patient,
it is evident that the temperature rose in proportion
to the length of time the permanent catheter remained
in place. I feel that it was worn an unnecessaril)'
long time. Three days might have been sufficient.
Had I removed it then and catheterized the patient at
regular intervals, the funiculitis might perhaps have
been avoided. As stated before, I am not in favor of
putting in a permanent catheter immediately after the
operation in every instance, but prefer to wait and see
whether the patient is not able to urinate voluntarily.
If this is impossible, I consider it better for the patient
in the end if he is catheterized at regular intervals, pro-
vided the introduction of the instrument is not attended
with any particular difficulty. The permanent cathe-
ter generally forces the patient to stay in bed.
Case XX, — W, W , seventy-one years of age.
His first trouble in micturition dates back thirty years,
the first symptoms being that he had to press long and
felt a burning sensation in his urethra. He never
had an attack of gonorrhoea or specific disease. At
that time sounds were passed, used for a year or two,
May 12, 19D0]
MEDICAL RECORD.
803
and brought relief. The diagnosis made by his at-
tending physician was prostatic hypertrophy. The
following ten years he felt much improved, but never
entirely well. Twenty years ago, during a severe at-
tack of dyspepsia, the prostatic trouble increased.
Absolute retention set in, which necessitated catheteri-
zation; since that time he never got entirely rid of
the catheter. Very often he was absolutely unable to
void a drop of urine for an entire day and night, and
then again he was better for several weeks. Fourteen
years ago the urine often contained blood, principally
in winter time. The patient claims to have frequently
suffered from chills and lumbar pain, more on the left
than on the right side. Five years ago a turn for the
worse took place. He had to catheterize himself
oftener, sometimes every hour, and suffered very severe
tenesmus and hasmaturia. Careful irrigation carried
out for three weeks brought improvement. The pa-
tient noticed that whenever the urine was tinged with
blood, urination was free, but as soon as it cleared
trouble set in. He also frequently suffered from epi-
didymitis, sometimes on the right, sometimes on the
left side. Four years ago a* doctor sounded him for
stone. Result, several days of continuous severe
hsematuria; three weeks of intense pain. Since then
he avoided all further e.xaminations. Lately he urin-
ated about every hour during the day and used a
catheter at night before retiring; this allowed him to
rest until midnight, when he would have to draw off
the water again, and a third time before morning.
When first seen by me, June 15, 1899, the patient, a
strong, robust man, was able to urinate 40 c.c, show-
ing a residual urine of 75 c.c. On irrigation the
water soon returned clear. Of 200 c.c. injected into
the bladder 100 c.c. could be passed. The prostate
per rectum was soft and very large in all its lobes.
I personally was able to reach its lower portion only;
a friend of mine with an extremely long forefinger was
also unable to reach its upper border.
Analysis of urine: Acid; albumin, 0.25 per 1,000;
urea, 26.4 gm. in twenty-four hours; no sugar; few
cells of blood; moderate amount of pus and mucus;
some hyaline casts; some blood cells and groups, pre-
sumably from renal pelvis; small amount of uric acid.
Conclusion, hyperaamia of renal parenchyma with
slight vesical catarrh.
On January 19th, cystoscopy with irrigating cysto-
scope. The instrument has to be introduced to its
full length before the cavity of the bladder is reached.
The light having been turned on, it is at once seen
that the prism is still in the region of the prostate.
One sees the characteristic groove not in the median
line as is usual, but somewhat to the right side of the
patient. That side of the angle near the median line
rises perpendicularly upward like a massive wall, and
is seen to be covered with multiple polypous ex-
crescences, after the cystoscope is pushed farther in.
There certainly is a median lobe of very large size.
It is extremely difficult to turn the instrument 180°
in order to observe the fundus. It is possible only
after additional 250 c.c. of water have been injected
into the bladder. There is no stone. In pressing
down the handle of the cystoscope, a procedure which
is exceedingly painful to the patient, one clearly recog-
nizes a large mass projecting into the bladder (body
of the prostate) . I did not, of course, hesitate to make
it plain to the patient that in his case Bottini's opera-
tion might be followed by a great deal of trouble.
However, the patient was so thoroughly tired of his
condition that he was ready to undergo the procedure
at all hazards.
Bottini's operation was done on June 21st. On
hugging the prostate the handle of the incisor was
forcibly pressed, evidently by the peculiar configura-
tion of the gland, toward the right of the patient. It
was, therefore, very difficult to keep the instrument
exactly in the median line of the body. It was clear
that the large median lobe had been turned back and
forcibly resisted, being twisted upon itself. At that
moment I felt the necessity of having on hand the in-
strument with which I could cut as long as I might
wish to within the limits of 8 cm. For my friend, who,
with his finger in the rectum of the patient trying to
localize the distance of the tip of the incisor from the
sphincter ani muscles, was just able to feel it, and
his finger measures 12 cm. As matters were, I could
make only three cuts, one in the median line directly
posteriorly, one through the right lateral lobe at 45°,
and one through the left at 90"^, 4 cm. each. The
result was just what we had expected. The injured
median lobe rapidly increased in size by reactive
swelling and represented an unyielding barrier to the
entrance of all instruments, gum-elastic and solid, that
we tried to introduce through the normal channel.
Absolute retention set in, and all attempts to bring
relief in the usual way were futile. Puncture of the
bladder above the pubes became necessary and was
carried out eight times (twice per day) within the
next five days. Strict asepsis being observed, no
trouble ensued. Prior to entering the bladder with
the trocar, each time a different spot of the skin with-
in the short distance between the symphysis and the
lower end of the prevesical peritoneal fold was selected.
As a preliminary the skin was here incised under
local anesthesia for about one-eighth of an inch,
always in the transverse direction.
On June 26th, five days after the operation, I suc-
ceeded for the first time in introducing a N^laton
catheter on a metal guide. This was left in place and
gave the patient a great deal of relief. Meanwhile the
scrotum had become swollen to tremendous size. The
pulse was between 90 and 106; the temperature had
never risen above 101.6° F., nor had there been a
chill at any time. These facts, in conjunction with
absence of infiltration in the perineum, showed that
urinary infiltration had not set in. I could, however,
not explain the oedema of the scrotum in any other
way than by assuming that some infecting material
had leaked out; perhaps the phenomenon was to be
considered a microbic infection by contiguity.
On June 30th, nine days after the operation, multi-
ple incisions through the scrotum, under eucaine, with
proper drainage, became necessary. All the tissues
down to the tunica vaginalis propria were densely in-
filtrated, without, however, showing the slightest trace
of pus.
On July 3d, the permanent catheter was removed
for trial. The patient was unable, however, to pass a
drop of water. In order to facilitate treatment a cath-
eter was again introduced and permanent drainage
continued until July 12th, that is, the twenty-first day
after the operation. Some six hours after the removal
of the instrument the patient passed about half an
ounce of thin bloody fluid, and once more half an
ounce of the same fluid two hours later. Then abso-
lute retention again set in, and regular catheterization
every six to eight hours became necessary. It was,
however, much easier than before. By July i8th
catheterism had become so painful and the spasms of
the bladder were so severe, that relief in some way
had to be obtained. In my opinion only a second
Bottini's operation could be of use. It was done
with the incisor allowing of an incision 8 cm. in
length, on July 20th, or twenty-nine days after the
first operation. The incisor slid into the bladder
with great ease; its handle was not forcibly pressed
toward the patient's right side, as had been noticed
during the first operation. On pulling from without,
the instrument suddenly slipped into a deep groove
for at least an inch (same as in case XIV.), an oc-
8o4
MEDICAL RECORD.
[May 12, 1900
currence which caused me to abandon my original idea
of making the incision 6 to 7 cm. long. Instead, I
made a posterior cut of but 4 cm. in length in the me-
dian line and one of the same length through each lat-
eral lobe. A Mercier English webbed catheter, No.
17 F., was introduced immediately after the operation
was completed. It entered with remarkable ease and
was left /// situ for five days. Reaction was compara-
tively slight. There was some rise of pulse and tem-
perature, the former reaching 118 at one time; the
latter stayed below 101.4° F-
On July 2 1 St, the nurse's report states: "The
patient passed a very comfortable night; drainage
per catheter was good, 38 ounces in twenty-four
hours."
On July 2sth, the fifth day after the operation, the
permanent catheter was removed. The patient was
still unable to urinate voluntarily. Regular catheteri-
zation with bladder irrigation had, therefore, to be
resumed, and was carefully carried out every four to
si.v or eight hours.
On July 27th the patient, for the first time, remained
out of bed for some time, and thenceforth got up for a
longer period every day.
On August 6th, the seventeenth day after the second
operation, and the forty-sixth day after the first, the
patient for the first time, and under considerable pain,
voluntarily passed 2 ounces of slightly bloody urine.
Four hours later he passed 3 ounces, and one hour
later again 3 ounces. On August 8th, he passed
18 ounces within twenty-four hours; residual urine as
drawn per catheter, between 9 and 15 ounces. On
August 9th he passed 25 ounces in the course of
twenty-four hours, and on August 14th 39 ounces. Im-
provement then steadily continued.
In the early part of September the patient left for
the country, where he took baths and massage. When
I saw him again, on October nth, he reported that he
had not had to use the catheter at all for six weeks.
He urinated about every hour and a half during the
day; four to six times during the night, in a good
stream and without pain. Now and then there is irri-
tation at the neck of the bladder so that the patient
has difficulty in retaining the urine when the call
comes. Otherwise he feels perfectly well. Since that
time the patient's condition has still more improved,
as I learned a few days ago. He so far did not pre-
sent himself at my office.
Case XXI. — The history of this case is, it seems
to me, not only of unusual interest, but also of great
importance. On November 25, 1898, 1 removed three
large, heavy uric-acid stones from the bladder of a
patient forty-nine years of age, who, on rectal palpa-
tion as well as on cystoscopy, had shown quite a de-
gree of prostatic hypertrophy. The urine at the time
of the operation, which was done seven years after the
onset of his troubles, was extremely fetid. In spite
of ample gauze drainage of the wound and proper
siphoning of the bladder with the T-tube, the peri-
vesical connective tissue became necrotic after the
operation. It was two to three weeks before all the
sloughs had been pushed off. It was eight weeks be-
fore the patient could be discharged from the hospital.
At that time he still suffered from a severe neuralgia
in both sacral plexuses, which was in time overcome
by warm baths, rest, and massage. There remained,
however, a very rebellious suprapubic fistula tiirough
which at least half of his urine was discharged.
During the summer months it closed for a short time,
but soon opened again after the formation of a peri-
vesical abscess. Cauterization carried out in various
ways had no effect. On injecting 200 c.c. of a steril-
ized boric-acid solution 150 to 175 c.c. were passed
simultaneously through the urethra and the suprapubic
fistula; the catheter then withdrew 25 to 50 c.c. of
residual urine. In the early part of October about
half of the urine was discharged through the fistula.
Cystoscopy carried out at that time showed the typical
groove at the neck of the internal urethral fold. Ac-
cording to the view already expressed in my last arti-
cle on the subject of Bottini's operation, namely, that
it was to be hoped that such an obstinate suprapubic
fistula might eventually be brought to a permanent
close by means of Bottini's operation, I proposed the
latter to the patient.
It was carried out at the German Hospital on Octo-
ber nth, under eucaine. Three cuts were made, one
posteriorly, 4 cm. long; one through the right lateral
lobe at 45°, 3.75 cm. long, and a third through the left
lateral lobe at an angle of 90°, 3.5 cm. long. There
was no reaction. The patient was kept on his back
and soon commenced to pass the greatest amount of
his urine through the urethra. The suprapubic fistula,
which before had been filled with somewhat protruding
granulations, soon became shallow and then funnel-
shaped. Three weeks later the patient was discharged
with his trouble much improved, though not entirely
cured. On November 21st, he urinated 70 c.c. ; resid-
ual urine, 25 c.c. Of 300 c.c. injected, every drop is
passed through the urethra in a very forcible stream.
There is still some slight leakage through the supra-
pubic fistula. It is impossible to introduce a probe
into the bladder from without. Cauterization of the
fistula with the actual cautery could thus not be done.
And I was not eager to do it, for it seemed to me that
in this case the aim should be not to destroy more tissue,
but to cause that which was present to heal by chem-
ical stimulation. I succeeded on that day in injecting
10 c.c. of pure balsam of Peru into the bladder, which
had previously been filled with sterile boric-acid
water. On passing the latter through the urethra, the
balsam of Peru escaped with it. This procedure was
repeated three times at intervals. Still, there was
some slight leakage, sufficient to saturate gradually
the piece of gauze that was worn by the patient in
front of the sinus. I therefore decided to increase
the strength of the chemical application, and on De-
cember 9th I injected 200 c.c. of sterilized water into
the bladder, and then with a small glass syringe forced
into the bladder through the sinus 15 minims of pure
carbolic acid (thus making a one-half-per-cent. car-
bolic solution in the bladder), a procedure which was
immediately followed by an injection of pure alcohol.
Five days later the patient reported that there had
been absolutely no leakage through the sinus since
this cauterization, and from that time on not a drop
has ever passed by the suprapubic route.
Final examination, March 29, 1900: The patient
urinates five to six times during the day; 'nights not
at all; good stream ; no pain; the suprapubic fistula
has remained closed; he has gained considerably in
weight; bowels normal. While at my office he passes
130 c.c, residual urine 20 c.c. The urine is entirely
clear. Of 250 c.c. nitrate-of-silver solution, 1:5,000,
injected, every drop is passed. Matrimonial inter-
course regular and enjoyable. The jiatient was pre-
sented before the Section on Surgery of the New York
Academy of Medicine, April 9, 1900.
In view of the success of the operation in this case
I have become somewhat doubtful as to the advisa-
bility of trying to perform litholapaxy in the majority
of prostatics as a preliminary measure to Bottini's
operation. We all know how much the prostate often
resents prolonged instrumental interference; how,
after litholapaxy, an incomplete retention may sud-
denly become complete. Hence, the possibility of
an already present pyelitis assuming a much more
serious aspect after the said procedure must be ap-
parent. With my present experience, therefore, I
should, in cases of a doubtful prognosis, prefer doing
May 12, 1900]
MEDICAL RECORD.
805
suprapubic lithotomy as the first step, adding, if nec-
essary, Bottini's operation at a later period.
The question as to whether it would not be advisa-
ble to do both operations at the same sitting, thus
being enabled to put the instrument in place under
the direct guidance of the eye, cannot yet be de-
cided. It is true, it is generally three weeks before the
eschars are pushed off, at which time the suprapubic
wound ought to be nearly closed and the flow of urine
through its normal channel could bo resumed. If,
therefore, both these phenomena occurred at the same
time, all would be well. On the other hand, with re-
tarded wound healing, the grooves cut through the
prostate might become more or less completely oblit-
erated on account of there being no urine passed
through them to prevent it.
With regard to the prognosis of Bottini's operation
in this class of cases, it is reasonable to assume that
most of the patients will better stand it than those not
afflicted with urinary leakage above the pubes, on ac-
count of the presence of the suprapubic fistula. If
by reactive swelling of the gland the normal passage-
way should first become temporarily blocked, the
fistula will give easy exit to the urine.
I believe that this case is the first of its kind in which
so obstinate a suprapubic fistula was brought to a
close by Bottini's operation. The case proves •that
to this class of sufferers also Bottini's operation may
prove of immeasurable benefit. I have no doubt that
it is destined in most of these cases to take the place
of bilateral castration, the only hope of a cure that
could so far be held out to these poor patients.
Case XXII. — B , seventy-two years of age. He
has suffered for the last three to four years from in-
creasing urinary symptoms; lately absolute retention;
regular catheterization. Two months ago he had a cel-
lulitis of the right hand, which was treated by the family
physician with repeated multiple incisions. The pa-
tient was sick for over si.x weeks. He was seen by me
in consultation October 1 1, 1899, on account of the ab-
solute retention. The patient was greatly emaciated.
The prostate was large and soft; its upper border
could be reached with the tip of the finger. Prosta-
torrhoea; vesical catarrh. Temperature varied be-
tween 100° to ioi° F. ; pulse not above 100.
October 14th: Cystoscopy. Trabecular bladder;
pathognomonic groove at internal fold not very
marked, but internal fold irregular, thickened, not
transparent; cystitis.
Urinary analysis : Chronic nephritis; no apparent
renal lesion of renal pelvis; chronic cystitis.
Bottini's operation was performed on October i8th
at 8 A.M., the patient having been carefully prepared
by the internal administration of quinine and urotro-
pin. The prostate was found to be extremely soft;
after compression the tip of the beak was palpable
about one inch above the anus. Posterior incision 1.5
cm. in length; the one through right lateral lobe at an
angle of 45°, that through the left lateral lobe at 90',
1 cm. each. Two hours after the operation the patient
voided 120 c.c. (4 oz.) of urine mixed with the fluid
which had been injected into his bladder, and con-
tinued urinating in somewhat smaller quantities every
hour or hour and a half, passing 2,010 c.c. (67 oz.) of
slightly bloody urine within the first twenty-four hours.
At 5 P.M. of the same day, nine hours after the opera-
tion, the patient had a slight chill, followed by rapid
rise of temperature and pulse. At 7 130, temperature,
105° F. ; pulse, 104. At 10:30 P.M. temperature,
104.8° F. ; pulse, 120. Pulse and temperature then
gradually declined and reached normal on the morn-
ing of the third day after the operation. Seven hours
after a second chill, which lasted thirty minutes and
occurred on the third day after the operation, phle-
bitis involving the saphenous vein of the left thigh
set in. The patient had had marked varicose veins for
many years, but, as he stated, never an inflammation.
His general condition was good. The spasms at the
neck of the bladder had discontinued; there was no
more pain. He voided his urine spontaneously every
three to four hours in quantities of 150 to 270 c.c. (5
to 9 oz.). Although the phlebitis had to be looked
upon as an annoying complication, I considered the
patient out of immediate danger and rejoiced with him
in the improvement of his vesical trouble. On October
22d, the fourth day after the operation, he passed about
330 c.c. (11 oz.) at one time in a good stream. The
following days the pulse was very satisfactory, never
above 100; but the temperature fluctuated between
101° and 104° F. The stomach was rather irritable,
but the bladder acted perfectly normally. On the fifth
day after the operation tiie patient passed 1,650 c.c.
(S5 oz). within twenty-four hours, in six times. How-
ever, his general condition did not keep pace with the
improvement in the functioning of the bladder. The
pulse begaA to rise again, and on October 28th (ten
days after operation) reached 128; temperature, 104°
F. ; respiration, 40. Urine voided at one time, 480
c.c. (16 oz.). Physical examination demonstrated the
presence of a lobular pneumonia, to which the patient
succumbed on October 29th, eleven days after Bot-
tini's operation.
To my regret, a post-mortem examination was re-
fused, and I was, therefore, unable to determine
whether the lung affection was due to hypostasis or to
an embolism. For the reason that the saphenous
vein has no direct communication with the internal
iliac vein, the one which might become thrombosed
after Bottini's operation, I can explain the peculiar oc-
currence of a phlebitis on the left thigh only by as-
suming that streptococci were still present in the cir-
culation of the patient from the time of his cellulitis.
The slow and weak action of tiie heart, in conjunction
with the equally slow and weak current of blood in
the varicose veins, then produced thrombi in the
latter, in which the streptococci of course found a
most favorable soil. It is certain that the patient did
not die in consequence of Bottini's operation, as such.
On the contrary, his bladder functions were restored
in a most admirable way and in so marvellously short
a period as I have not seen occur before or since.
What evidently caused his death was the phlebitis
with probably following embolism.
Case XXIII. — M. K , seventy-two and one-half
years of age, has been suffering from symptoms of
prostatic enlargement for the last six to seven years.
Retention has repeatedly had to be relieved by cathe-
terization. Often the region over the kidneys was
painful. The patient came under my care during the
summer of 1899, when he was suffering from a mild
sepsis, suppurating prostatitis, pyelo-nephritis, and
cystitis. Micturition was very painful. The prostate
was found to be very soft; its upper border could be
reached per rectum. Frequent slight chills and rise
of temperature were improved under regular catheteri-
zation and vesical irrigation. Residual urine was
never below 540 to 600 c.c. (18 to 20 oz.). The
amount of urine passed voluntarily within twenty-four
hours, at very frequent intervals — every half-hour to
hour — was between 1,200 and3,ooo c.c. (4010 100 oz.),
the quantity daily withdrawn per catheter being from
1,000 to 1,800 c.c. (;}^ to 60 oz.). Urinary analysis:
Chronic pyelo-nephritis and cystitis. In view of this
condition cystoscopy was omitted.
After a few months' treatment the patient strongly
urged me to perform Bottini's operation on him. Nat-
urally, I did not feel much inclined to do it. He
insisted, however, being anxious to get rid of the cath-
eter, so that finally I acceded to his wish, and, after
careful preparation of the patient, performed Bottini's
8o6
MEDICAL RECORD.
[May 12, 1900
operation on October 9th. One median incision, 3
cm. long, was made very slowl}', as usual. The lateral
cuts were omitted. No improvement resulted. Mic-
turition was painful and frequent. Ten days later,
October 19th, Bottini's o|,eration was repeated. Me-
dian incision 4 cm.; through right lateral lobe at an
angle of 45°, 3.5 cm.; through left lateral lobe at about
75^, same length. Four hours after the operation, the
patient commenced urinating, and from then on passed
between 3,000 and 3,500 c.c. (100 to 116 oz. ) daily.
There was only a very slight reaction. Temperature
on the second day was 101.8° F. ; pulse never above
100. On the third day both declined to normal. On
October 28th, the patient complained of a great deal
of fulness in the lower abdominal region, although he
had passed 3,810 c.c. (127 oz.) of urine within twenty-
four hours. The catheter thereupon introduced with-
drew 840 c.c. (28 oz.) of residual urine. Thereafter
he was regularly catheterized once in twenty-four
hours, and the amount of residual urine began to de-
crease after the eschars had been pushed'off in large
numbers during the third week.
On the 4th of December the patient left for his
home in the West. He felt better in every respect
and had gained in weight. Residual urine had
dropped to 210 to 240 c.c. (7 to 8 oz.). As its pres-
ence did not cause the patient any inconvenience, fur-
ther interference was advised against. The urine still
contains a good deal of pus.
In a letter to me, dated April 23, 1900, the patient
states: He urinates every four to five hours in the day-
time, once on retiring at 9 p.m., and twice thereafter;
he has not a bit of pain ; the stream is good and strong;
catheter not used since departure from New York;
does not think that there is any residual urine (to my
regret, it was not tested); bowels more regular; gen-
eral condition very good; has gained about eighteen
pounds.
This case nicely shows that Bottini's operation may
be done with impunity even in patients who sufifer
from pyelonephritis. This patient certainly belongs
at present to the category of " much improved " cases.
Had the amount of residual urine been tested at the
time of the last report, it might be shown that the case
had to be included in the class of "cured " (so far).
Case XXIV. — L. Z , sixty-two years of age.
Increased frequency of micturition first noticed after
a long bicycle ride, about two years ago. It was ac-
companied with pain and slight ha^maturia. Since
that time he could not retain his urine as well as be-
fore, and the calls, too, generally came oftener than
previously. The most annoying feature, however,
was that at the advent of the call a painful erection
regularly set in, and a few drops only of urine were
passed. After an interval of five to ten minutes, dur-
ing which the pain did not cease, and under consider-
able straining, a weak stream of urine appeared.
About a year ago he urinated every two to three hours
during the day, once or twice during the night. Being
obliged to make extensive tours through the States, he
often had attacks of very frequent micturition, every
ten minutes, an occurrence which, in the light of future
developments, will probably have to be looked upon
as overflow. Around Christmas, 1899, undisputed re-
tention set in for the first time. By the advice of a
friend who was similarly afflicted, he used a rather
stiff rubber bougie, of about No. 12 French. With
this he evidently injured his urethra in the region of
the cut-off muscle, for when his doctor tried to relieve
him by catheterization, quite a severe hemorrhage oc-
curred before the catheter had reached the prostatic
urethra. When I saw the patient with the doctor, later
in the evening of December 28th, the upper border of
his bladder was palpable about two fingers' width
above the umbilicus. Knowing from experience the
difficulties so frequently encountered when catheteriz-
ing these patients with absolute retention and a pro-
fusely bleeding prostate, I placed the patient's pelvis
upon a hard pillow and at once made use of Trende-
lenburg's prostatic catheter sound (No. 14 French), re-
peatedly referred to in this paper. I succeeded in
entering the bladder and relieving the patient at the
first attempt. Prolonged retention followed, vihich ne-
cessitated catheterization and irrigation of the blad-
der every eight to twelve hours. Digital examina-
tion showed the prostate to be of the size of an apple,
neither hard nor particularly soft; its upper border
could just be reacfied with the finger. Length of ure-
thra, 22 cm. About two weeks after this he began
spontaneously to void urine in small quantities, not
exceeding 150 c.c. (5 oz.) at a time, and always under
a great deal of pain. Residual urine was never less
than 300 c.c. (10 oz.). Cystoscopy was omitted on
account of the patient's great sensitiveness.
Urinary analysis, January, 1900: Glycosuria (0.3
percent.); no lesion of renal parenchyma or pelvis;
slight chronic cystitis. An analysis made two weeks
later proved the sugar to have disappeared.
After carefully preparing the patient with urotropin,
salol, and quinine, Bottini's operation was performed
under eucaine, on January 13, 1900, the bladder being
fille^ with 150 c.c. (5 oz.) of a two-per-cent. sterilized
boric-acid solution. There was no concretion palpa-
ble with the beak of the incisor. The prostate having
been hooked, the tip of the instrument could be felt with
the finger in the rectum, about 8 cm. above the anus
(median lobe!). The lower border of the prostate was
estimated at 4 cm. from the anal ring. The median
incision was therefore made 4 cm. in length; the two
lateral incisions at an angle of 45 , 3.5 cm. The pa-
tient stood the operation very nicely, and stated that
he had not felt the burning in the least, but had ex-
perienced pain throughout the entire length of the
urethra, due probably, as I believe, to the firm hugging
of the prostate. Two, five, and nine hours, respec-
tively, after the operation, he passed a drachm of
urine; twelve hours later a full ounce; 750 c.c. (25
oz.) of slightly bloody urine were then withdrawn per
catheter and the latter left in place. There was no
febrile reaction whatever. The permanent catheter
seemed to become obstructed at times, but a few
ounces of the usual irrigating fluid, thrown into it
with a hand syringe, restored proper drainage.
January i6th, three days later, the permanent cathe-
ter was removed; but 30 to 60 c.c. (i to 2 oz.) is the
largest quantity discharged by the patient. He is,
therefore, regularly catheterized and his bladder irri-
gated every eight hours.
January i8th: same status; the spasms are more
frequent; otherwise his general condition is very satis-
factory.
January 20th: A second Bottini operation is con-
templated. On the morning of the following day,
however, the patient voided 90 c.c. (3 oz.) at various
intervals, so that the catheter withdrew only 90 c.c.
of residual urine.
January 23d: Urination painless; increasing quan-
tities passed at more frequent intervals.
On the 25th of January he passed as much as 150
c.c. at one time. The catheter was then dispensed
with.
March 9th: The patient feels splendid; urisates
about 2,100 to 2,400 c.c. (70 to 80 oz.) in twenty-four
hours, eight times during the day; nights, three times.
Occasionally passes 400 c.c. (13 oz.) in one act.
There is no pain whatsoever; urine is very slightly
turbid. Eschars have been discharged up to two days
ago. He continues to take salol and urotropin.
Bladder irrigations were advised.
April 10, 1900, ten weeks after operation: Last
May 12, 1900]
MEDICAL RECORD.
807
eschar passed two weeks ago ; he urinates without pain
every two to three hours during the day; nights once,
that is to say, one time within ten hours; bladder
holds easily 400 10420 c.c. The stream is better tlian
ever before in his life; urine cleared up entirely.
Painful erection previous to the act of micturition has
ceased since the day of the operation. He feels ex-
cellent; weighs more than he did any time within
the last ten years; bowels normal; matrimonial inter-
course regular and mucli enjoyed.
THE MODERN TREATMENT OF DIABETES
MELLITUS.
By FREDERIC KRAUS, Jr., M.D.,
Considering how small is our knowledge regarding
the etiology of this disease even at the present day,
we are obliged to renounce the causal therapy and
concentrate our attention on a purely symptomatica!
one. The principal symptoms of diabetes are glyco-
suria and the malnutrition caused b\' constant loss of
non-assimilated nutritive material.
Since the disease became known, nearly all physi-
cians tried to reduce the glycosuria by restricting the
carbohydrates in the food. During a very short period
a very small number of physicians were led by the
entirely false conclusion that a greater amount of car-
bohydrates must be introduced into the diabetic organ-
ism to make up for the loss caused by glycosuria; one
of them was the celebrated physiologist Schiff, who,
himself a diabetic, thereby hastened his own death.
The medical therapy by drugs has shown itself in
nearly all cases, by careful scientific investigation, to
be a failure as far as the patient is considered, the
drug-manufacturer only profiting. If there is any good
effect, it is certainly due to the diet observed during
the use of the drug — without diet there is no diminu-
tion of the glycosuria. The opiates are exceptions, but
various reasons make us reserve them for the very se-
vere cases only. The dilTerent preparations of hydrargy-
rum may be used in the very rare cases of syphilitic (dia-
betic) glycosuria, also balneotherapy and hydrotherapy,
but both of these have also to be combined with die-
tetic treatment; I shall say a few words about them
later. Therefore the only remaining treatment is the
dietetic one {^Eriuilinuigstherapie). The object of
this is, in the first place, not simply to reduce the
glycosuria, but to keep the patient in the best form of
nutrition, which naturally results from reducing the
glycosuria as much as possible and replacing the e.x-
cluded carbohydrates by other nutritive material of
the same calory value.
The best way of finding out the proper diet in indi-
vidual cases is the following (Kuelz, Naunyn, v.
Noorden, etc.) : The patient is put for one day on a
"standard" diet, as v. Noorden calls it, which con-
tains, besides the indifferent albuminous and fat-pro-
ducing material, a certain amount of carbohydrates, for
instance, 100 gm. wheat bread per day, which contains
about 60 gm. of carbohydrates. Then the patient is,
told to collect twenty-four hours' amount of urine (he
must begin with the urine passed immediately after
the first breakfast and finish with the urine passed the
next morning before breakfast). This method is used
in aW cases in the clinic for diabetics of Professor v.
Noorden at Frankfort on Main. Then the amount of
sugar passed during twenty-four hours is ascertained by
polarization and titration, or by polarization before and
after fermentation, to find out also the amount of sub-
stances which turn the plane of polarization to the left.
There are now three possibilities: (i) that there
is no sugar at all; (2) that there is less; (3) that
there is more than 60 gm. of sugar excreted with the
urine. The first we find in all mild cases of diabetes
and in all cases of non-diabetic glycosuria. In all of
these cases after a period of four to five days the daily
portion of carbohydrates is • increased by a certain
amount, between 30 to 50 gm. of bread or an equiva-
lent of carbohydrates in another form. The urine of
the last day of such a period is collected in the for-
merly described way, and this is continued until a
trace of sugar is found in the urine; then we know
what amount of carbohydrates the organism is able to
assimilate, i.e., "its tolerance for carbohydrates."
Then the patient is kept for one or two days on a very
strict diet, in order to make the traces of glycosuria
disappear entirely, and thereafter the amount of car-
bohydrates in his diet is increased gradually day by
day up to the highest amount which he is found able
to assimilate.
In the other cases in which glycosuria is found the
amount of carbohydrates in the patient's diet is re-
duced until a diet is obtained as free from carbohy-
drates as possible. This reduction must be effected
gradually, as a sudden deprivation is very often fol-
lowed by disagreeable symptoms of collapse. The
patient is then kept on that strict diet for three or
four days; on the last day the urine is collected in the
formerly described manner, and if traces of glycosuria
are still found, such periods of strictest diet may be
repeated, or we may even, if we fail to free his urine
from glycosuria, restrict the amount of albuminous
food (Naunyn, v. Noorden, Pavy, etc.), substituting
fat for it. The fat is then given with certain vegeta-
bles which contain a very small percentage of carbo-
hydrates, which amount can be reduced still further
by a certain method of cooking. But during all this
time the greatest care is necessary; we must interrupt
such a severe diet if we find the patient is rapidly
losing in weight, and we must also carefuDy examine
the urine to find whether there is azoturia, whether
the amount of acetone is high, and whether diacetic
and oxybutyric acids are in the urine. Therefore it
is also recommendable to give large quantities of bi-
carbonate of sodium daily, to avoid hyperacidity of the
blood (Naunyn, Stadelmann, Magnus-Levy).
After the glycosuria has disappeared, we begin
again to add small doses of carbohydrates to the diet
till the highest limit is reached, proceeding as in the
mild cases. It is well known that periods of absti-
nence increase the assimilating force and that the
continued use of carbohydrates diminishes the same,
therefore the patient should also be told to include
from time to time, at regular intervals, three to four
days of strict diet, for instance the last three to four
days of each month or every second month. These
intervals are to be chosen according to the severity of
the case. After these four days the carbohydrates are
to be increased again up to the allowed amount. The
urine is to be examined immediately before the
periods of strict diet, in order to ascertain if there is
any change in the amount of glycosuria. In other
cases, in which it is impossible to suppress the glyco-
suria, even by strictest diet, we must also allow the
patient a certain, though small addition of carbo-
hydrates to his daily diet, for the following reasons:
(1) If not allowed, the patient would nevertheless
take it by himself. (2) We know that to live for any
length of time on a diet consisting exclusively of
albuminous material and fat is impossible for the
human organism ; but in these cases we will include
the periods of strictest diet at shorter intervals, and of
five to six days, if the general health of the patient
permits it. There are further cases of diabetes in
which any sort of antidiabetic diet is nothing but a
superfluous cruelty to patients whose days are already
numbered.
8o8
MEDICAL RECORD.
[May T2, 1900
It is also of great value to know in each case the
fluctuation of glycosuria within twenty-four hours, an
exact knowledge of which will in many cases allow
the possibility of a very liberal diet.' At any rate it
is always advisable to add the given carbohydrates to
the more copious meals, dinner, lunch, and supper,
and to avoid them more or less at breakfast. But it is
not only a question as to how much carbohydrates
may be given, but also in what form they are best given.
The best way is to give those carbohydrates which the
patient is accustomed to have; first of all to allow
him a certain quantity of the bread he is in the habit
of eating. It is only necessary that the prescribing
physician should know approximately the percentage
of carbohydrates in those articles of food which he is
willing to put on the patient's diet list. During the
first few weeks the patient will have to use scales, but
later on he will learn to guess the weight of his food
articles by their size, etc. Surrogate food is in the
most cases easily avoidable. No surrogate will ever
reach in taste the real thing ; therefore the patient very
soon gets tired of it, and, to choose a common exam-
ple, he will soon prefer a small piece of plain bread to
a large piece of a less palatable surrogate. Besides,
there are advertised, especially recently, a great many
surrogates which are not at all reliable. I have per-
sonally had occasion to examine a great number of
them, and, using the method of Allihn, which always
gives very exact results, I found that some of them
contained just as much carbohydrates as the common
flour and bread. But there are also some very useful
surrogates and preparations."
As said before, in order to make out a good diabetic
diet list one must approximately know the percentage
of carbohydrates in the various articles of food, and
must also know how to substitute the excluded carbo-
hydrates so as to satisfy the want of calories, just as
well as the exertions of appetite and taste, and this
requires not only scientific chemistry, but also some
culinary knowledge and experience, which are easily
obtained.
In regard to alcoholics, opinions vary, but used
moderately and with careful selection they certainly
deserve a place in the diabetic diet list; the quantity,
however, must be so chosen as to exclude any toxic
effect.
It is easily recognizable that all this is connected
with a great many difficulties in an all-around, gen-
eral practice. A treatment like this not only con-
sumes a great deal of the doctor's and of the patient's
time, but it may sometimes even be impossible for a
person who is very active either in business or in
social life to follow all these directions. In order to
avoid all those difficulties it is best to send the pa-
tient, as soon as the diagnosis is made and other
circumstances allow it, into clinical treatment, either
to a hospital or, if the patient has means enough, to
one of those private clinics which are entirely devoted
to diabetic patients. Then he will not only be under
careful examination and control, but — and that is one
of the greatest advantages of these clinics — he will
learn there how to live after having returned to his
home, and then it will be very easy for the family
physician to keep the case under control.
The balneo-therapeutic treatment has also main-
tained its place in the treatment of diabetes, and the
many good results attained thereby rather speak in its
favor, although strictly clinical experiments have
' F. Kraus : ' " Notes on the Variation of Glycosuria in Diabet-
ics " Albany Medical .A.nnais, August, iSgg.
' Any one more interested in tliis matter will find a list of very
useful surrogates, also a number of prescriptions as to how and
in what form carbohydrates may be put on the diabetic diet list,
in the " Handbuch fur Ernahrungstherapie," by Professor v.
Leyden, VIII A. ; " Ernahrungstherapie bei Diabetes mellitus,"
by Prof. Dr. C. v. Noorden, Frankfort on Main.
shown no results at all. The effect of balneo-therapy
in diabetes is not founded on the special water only,
but on the combination of many other circumstances.
First of all the patient, leaving his home, leaves be-
hind him all trouble and worriments, gets a rest from
his daily life (and we all know what an influence rest
and change of surroundings have on a diabetic patient) ;
he is better able and more willing to obey strictly all
that is asked of him by his medical attendant. He
will find at nearly all the hotels and restaurants, at
least in all the famous European spas, a list of dishes
which are free from carbohydrates, generally marked
out as dishes for diabetics. Another favorable cir-
cumstance is that, having all his time for himself, he
will do more muscular exercise, which, as we know,
decreases glycosuria (either by walking or undergoing
a regular course of the now well-known Zander treat-
ment, nearly all the famous spas having elaborate
Zander institutes). And last, but not least, it is a
well-known fact that the alkaline-sulphatic and alka-
line-muriatic waters of some spas have a good influence
not only on diabetes but also on gout, which we find
so often combined with diabetes, and on oxaluria,
another complication not seldom found. In many
other cases, especially of the neurasthenic type, it
will be better to send the patient simply either to the
seaside or to highly situated bracing places — to places
where he can find enough accommodation to follow
the diet prescribed.
Associated Frontal Sinus and Mastoid Disease. —
T. J. Harris reports the case of a South American
boy, aged seventeen years, who gome months before
coming under observation had had a mastoid opera-
tion done. Recurrence of symptoms led to the per-
formance by Harris of a Schwartze operation, from
which recovery had begun when the patient began to
complain of pain over the frontal sinus. Catheteriza-
tion of the latter relieved the pain, but did not evacu-
ate any pus. There was a continual purulent discharge
from the right naris. Suddenly there developed in-
tense pain in the forehead, which was rebellious to all
forms of treatment. The frontal sinus was opened by
Luc's method without relief. The pains grew even
worse, and a typhoid state developed. Finally the boy
began to improve on the iodide, but pain then returned
in the mastoid. This was reopened, this time by the
Stacke method, and much diseased bone removed.
This relieved the pain, and convalescence was unin-
terrupted. No history of syphilis could be elicited. —
The Laryngoscope, April, 1900.
A Report on the Question of Contagiousness of
Pulmonary Consumption. — Johann Flintermann finds
that in the city of Detroit, from July i, 1894, to June
30, 1895, one-fifth of all cases of death were due to
tuberculosis. The last report shows an increase in
the mortality. In New York City, in 1896, there were
35,000 deaths, and 6,000 of these were due to tubercu-
losis. Professor von Leyden estimates that in Ger-
many 1,300,000 persons suft'er from tuberculosis, and
180,000 die every year from this disease. The author
urges education of school children and people in gen-
eral as to the nature of the disease and the evils of
promiscuous expectoration. House disinfection should
follow death from tuberculosis. Houses, hospitals, all
public institutions should be under close observation,
and cases of tuberculosis isolated. Hospitals for
tuberculous patients should be provided. The author
does not approve of compulsory notification, and
agrees with Cornet's doctrine, " The consumptive in
himself is almost absolutely harmless, and only be-
comes harmful through his habits." — The Physician
and Surgeon, March, igoo.
May 12, I goo]
MEDICAL RECORD.
809
Medical Record:
A Wcck/y Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO., 51 Fifth Avenue.
New York, May 12, 1900.
MALARIA AND MOSQUITOS.
Malaria in its several forms constitutes perhaps the
greatest obstacle to a successful colonization of the
tropics. There are of course other diseases common
to those regions which occasion great loss of life, but
these chiefly affect the natives and can be usually con-
trolled by intelligent prophylactic measures. The
malarial fevers are by far the most deadly of the trop-
ical maladies in both white man and native. Large
parts of India are devastated and rendered valueless
by this scourge, and immense tracts of land in Africa
and South America cannot be inhabited by the white
race without almost inevitably fatal results. The
problem of the causation of malaria, which has been
the despair of scientists for generations, would appear
to be daily drawing nearer and nearer to its final solu-
tion. The large majority of scientific men throughout
the world have virtually accepted as decisive the theory
that it is mainly if not wholly by the agency of the
genus Anopheles, of the mosquito family, that ma-
larial fevers originate and are spread. In fact by
many this is no longer looked upon as a theory, but
as a doctrine.
A number of investigators have had a share in the
discovery that the mosquito plays an important part
in causing and disseminating malaria, but to Manson
and Ross is generally conceded the honor of bringing
the matter to its present advanced stage. Although
Americans have not specially distinguished them-
selves in these investigations, it should not be forgot-
ten, as was pointed out in the London Lancet, Febru-
ary II, 1899, that A. F. A. King, at the meeting of
the Philosophical Society of Washington, D. C, held
on February 10, 1883, read a paper entitled "The
Prevention of Malarial Fevers," in which he suggested
the likelihood of marsh fevers being produced by the
bites of proboscidian insects, notably in this and some
other countries by mosquito bites. This, we believe,
was the first occasion upon which the theory was pub-
licly mooted.
Great activity is now being displayed in Europe
with the object of deciding the question beyond cavil.
For years the Italian investigators have been perform-
ing splendid service in the endeavor to probe the mal-
aria mystery, and probably their researches have done
more toward its elucidation so far than has the work
of any other school. Since the establishment of the
two schools of tropical medicine in Great Britain a
vivid and practical interest has been taken in that
country in the diseases of the tropics in general, and
of malaria in particular. The British government in
conjunction with the Royal Society first despatched
a scientific commission to the west coast of Africa for
the purpose of attempting to find the malaria-bearing
mosquito, and to locate its breeding-places. Shortly
after this the Liverpool School of Tropical Medicine
equipped and sent out at its own expense an expedi-
tion under the leadership of Major Ross to the east
coast with a similar end in view. Major Ross and
his coadjutors succeeded in discovering the mosquito
Anopheles claviger, and in a few instances in deter-
mining the situation of its breeding-places. The
London School of Tropical Medicine, authoriz-ed by
the British Colonial Office, has just sent two of its
members, Drs. Sambon and Lowe, to the Roman Cam-
pagna, there to conduct certain experiments which, if
terminating favorably, should convince the most scep-
tical that the mosquito is the dominating factor in the:
causation of malaria. It may be said that experiments
of a like nature have already been prosecuted by the
Italians Celli and Grassi, with most satisfactory re-
sults. If, then, it be taken as proved that malaria is
caused by mosquitos — and the evidence in support of
this contention is so strong as to appear almost unas-
sailable— and when it is further considered that the
malady is conveyed by but one species of mosquito, it
follows as a natural sequence that by a wholesale de-
struction of the sinning insect the ravages of malaria
will be greatly curtailed and perhaps in time altogether
ended.
The Liverpool School of Tropical Medicine has
recently published a book entitled " Instructions for
the Prevention of Malarial Fever, for the use of Resi-
dents in Malarious Places," which is made the text of
an able article in the London Times of a late date, and
which has been transcribed in Public Health Reports,
March. The article, after giving a short summary of
what is now known of the mosquito theory of malaria^
concludes as follows:
"All speculations about air, about soil, about ' mal-
aria belts,' and the like have been rendered obsolete.
There is no reason to believe that the parasite of mal-
aria finds access to the human body through any
other channel than by means of the Anopheles mos-
quito, or that ' gnats ' or ' mosquitos ' which infest re-
gions free from malaria are examples of Anopheles.
If this particular insect could be extirpated, there is
every justification for the hope that malarious fevers
would disappear from the earth; and fortunately the
extirpation does not seem likely to present any insur-
mountable difficulty. The eggs are laid in water, and
the larvffi when hatched live in water for about a week
before they assume the mosquito form. As larvse, like
those of the common gnat, they rise to the surface to
breathe, and a film of oil on the surface is speedily
fatal to them by blocking up their air spiracles. The-
fully-formed mosquito lives for many weeks, but is not
presumed to travel far, and probably always obtains.
its food within easy reach of its native pool of water,
MEDICAL RECORD.
[May 12, 1900
to which it periodically returns for the purpose of
depositing its eggs. Much may be done therefore by
drying up the pools in the vicinity of houses or by
treating them once a week with a film of kerosene oil.
Much may be done also by killing the mature insect
when resting upon a wall after its meal; and it is to
be noted that the true Anopheles rests with its body
almost at right angles to the surface of the wall, while
the absolutely or comparatively harmless gnat rests
with its body parallel to the wall or even somewhat
inclining to it."
It is devoutly to be hoped that these sanguine ex-
pectations may be realized to their fullest extent, and
that the time may be in sight when malaria will be
swept away.
feasibility, economy, and perfection of the system of
public baths so ardently and successfully advocated by
Dr. Simon Baruch. It is a matter of pride that this
is the only country in the world which possesses pub-
lic baths furnishing at all seasons warm water, soap,
and towels free to any one, and that this great boon to
the poor is the result of persistent endeavor of a med-
ical man.
AN ABSURD CLAIM AND A UNIQUE
EXHIBIT.
In the New York Times of April 29th, Mr. Goodwin
Brown, an Albany lawyer, claims to be the originator
of "the system of public baths," which promises to
become an enormous sanitary factor in our tenement
life.
In our issue of December 6, 1890, we referred to
the subject of public baths, and wrote : " Much credit
is due to Dr. S. Baruch, of this city, for his -earnest
agitation of the subject." Since that time we have
frequently alluded to the free-bath movement inaugu-
rated by this gentleman. Before medical and philan-
thropic societies the doctor urged the sanitary impor-
tance of the rain bath, and he succeeded in so imbuing
Dr. Gertrude Wellington, of Chicago, with his views
that she secured the construction of the Carter Harri-
son Baths in 1894, and of four other baths since that
time.
Failing to overcome the opposition of Mayors Grant
and Gilroy, the doctor found an earnest and able coad-
jutor in Mr. Goodwin Brown, who in 1895 brought
about the passage of a mandatory act, in obedience to
which several free baths have been and are now being
constructed in this State (one city being compelled by
a supreme court mandamus to build a bath).
While, therefore, Mr. Brown deserves credit for aid-
ing Dr. Baruch in this important enterprise, his sweep-
ing claim is absurd. Mr. Brown relates that " he was
attracted in 1891 to the new method of bathing adopted
in the soldiers' barracks in Berlin." It is singular
that he had to go so far for this important informa-
tion, when Dr. Baruch had explained the rain bath in
i8go to the Academy of Medicine, and the prominent
New York dailies had referred to it as a matter of
great public interest, and the New York Juvenile Asy-
lum already had constructed a rain bath. We believe
that we voice the sentiment of the medical profession
in defending one of its members against encroachment,
and insisting that credit be not withheld from the man
who has so valiantly and successfully made the fight
for this great sanitary boon.
We are gratified to learn that an exhibit in the de-
partment of social science and hygiene of the Paris
exhibition will demonstrate to the world at large the
THE AMATEUR NURSE IN SOUTH AFRICA.
There has been within the past few weeks a rush of
female members of the British aristocratic and pluto-
cratic circles who have become infected with the dis-
ease now known as khaki fever, to Cape Town. So
great indeed has been the influx of society women to
that already overcrowded city, that Sir Alfred Milner,
the governor-general of the South African British pos-
sessions, has deemed it necessary to protest against
this invasion, and gravely to warn these ladies that
not only are they themselves running into needless
danger, but that their presence is inadvisable for
general sanitary reasons, as well as being an addi-
tional embarrassment to the authorities. Lord Rob-
erts concurs in this expression of opinion.
A banquet was given at the Reform Club in London
on Saturday, April 28th, the guests of the evening
being Sir William MacCormac and Mr. Frederick
Treves, both of whom have recently returned to Eng-
land after fulfilling their duties as consulting surgeons
to the British forces at the front. The latter gentle-
man, who is reputed to be almost as able a speaker as
he is operator and writer, delivered an incisive speech,
laying bare what he esteems one of the most objection-
able features of the present war. Referring to the
amateur nurses who have gathered in such numbers
in Cape Town and in some other parts of South Af-
rica, he spoke as follows: " So far as the sick are con-
cerned there are only two plagues in South Africa —
the plague of flies and the plague of women. The
flies we get rid of by horsehair wisps and other appli-
ances, and the flies at least depart at night. But the
women are absolutely and really a terror. They come
out in the guise of amateur nurses, after having ex-
hausted every other form of excitement. Considering
that we are engaged in war the number of well-dressed
ladies at Cape Town and elsewhere giving picnics is
a blot on the campaign." Doubtless some of these
ladies are guided solely by patriotic and humane sen-
timents, but it is to be feared that in the majority of
instances Mr. Treves' pungent criticisms are well war-
ranted, and that a very large proportion are impelled
by the failings common to the daughters of Eve and
by an insatiable desire not to be outvied by any of
their compeers. It is extraordinary, too, to notice, so
implicit is the belief of the everyday woman in her
powers as a nurse, that it is impossible to convince
her that in order to carry out efficiently the onerous
duties of an army nurse some training is necessary in
addition to the possession of a certain amount of men-
tal and physical fitness. However, the question of
women as army nurses has been of late considered at
May 12, 1900]
MEDICAL RECORD.
811
sufficient length in the Medical Record, and we can
only say that if, over and above the trials incidental
to the life of an army doctor in time of war, he is ex-
pected also to cope with a multitude of society wo-
men posing "in the guise of nurses," he is certainly
deserving of heartfelt sympathy.
SMALLPOX IN THE PHILIPPINES.
It is a somewhat curious fact that when, as now, both
plague and smallpox are prevalent in the Philip-
pines, and fifty thousand American soldiers or there-
abouts are in those islands, but small heed is paid in
either medical or lay journals to the presence of these
diseases. It is true, as was pointed out in an article
by Maj. C. F. Mason, M.D., U.S.A., published in
the Medical Record some few months ago, that
smallpox is universal throughout the islands among
all classes of the natives, and is consequently regarded
as a matter of course. It is also true that the efficacy
of vaccination as a preventive of smallpox has already
received further convincing proof among the L^nited
States troops campaigning there. Nevertheless it is
a matter for some surprise that the medical profession
of this country evinces a certain lack of interest in
the diseases of the Philippines.
The London JourNa/ 0/ Tropical Mcdidne for .April
publishes an editorial entitled "Smallpox in the
Philippines," in which, after briefly referring to the
article by Major Mason mentioned above, it goes on
to give a short history of the progress of vaccination
ifl the Philippines and in the East generally. The
writer of the editorial in question points out that vac-
cination was introduced into the Philippines by the
Spanish about the beginning of the nineteenth cen-
tury, and draws attention to the difficulties experi-
enced until quite recent times in procuring effective
lymph, owing to its deterioration in transit. The
editorial in the /ournal of Tropical Medicine concludes
as follows: "It is satisfactory to know that the far
East is better supplied with vaccine lymph than it
was ten years ago, when all lymph came from Britain
or America. The lymph from Britain, owing to the
voyage through the tropics, was often useless ; but
now there is a vaccine institution at Hong Kong; and
from Japan, Saigon, Calcutta, and even Sumatra and
Java, lymph is sent to China and the Philippines.
Seeing the unprotected state of the natives in the
Philippines no doubt the Americans will soon estab-
lish vaccine institutes in Manila and elsewhere in the
Philippines, and endeavor to induce the ignorant and
prejudiced natives to protect themselves against
smallpox, without doubt the greatest scourge known
in the far East."
The Rhode Island Hospital. — On May 2d the new
southwest pavilion of the Rhode Island Hospital was
opened with appropriate ceremonies, and on May loth
the bacteriological laboratories in the same pavilion
were opened. On the latter occasion addresses were
made by Drs. W. T. Councilman, J. W. C. Ely, and G.
Alder Blumer.
glcxus ot* tUe 'imeefe.
Dr. Jacobi's Birthday The saventieth anniver-
sary of the birth of Dr. A. Jacobi, of this city, was
celebrated at a banquet held last Saturday night at
Delnionico's, which was attended by more than four
hundred of his friends and professional associates.
His birthday was on Sunday, May 6th, but his friends
were too impatient in their desire to congratulate him
to wait. The speech-making was begun early, but at
the stroke of midnight all rose and drank to the health
and long life of the guest of honor. Dr. Joseph D.
Bryant presided, and speeches were made by Mr. Carl
Schurz on "Dr. Jacobi as a Citizen," Dr. William H.
Thomson on " Dr. Jacobi as a Physician," Dr. William'
Osier on " Dr. Jacobi as a Scientist," and President
Seth Low of Columbia University on " Dr. Jacobi in
Relation to Medical Education." A poem in honor
of Dr. Jacabi's life and works, by Dr. S. Weir Mitchell,
was read, and Dr. A. G. Gerster presented the guests
with a copy of the " Festschrift," which contains con-
tributions from fifty-three medical men of eleven na-
tions. In his reply Dr. Jacobi said he wished he
could proceed from man to man and in silence press
their hands, for words did not suffice for the throng of
feelings that swelled his heart. He reviewed the
events and changes that had taken place in medicine
during the nearly half-century that he had lived and
practised in this country. Closing, he said that he
did agree with some in believing that the moral tone
of the profession has been lowered in these latter days
when the spirit of trade is paramount. There have
been jealousy, strife, and competition at all times,
and medical men, like other men, are always human.
The "good old times" is an ideal that, while its con-
summation is too far ahead or beyond the horizon alto-
gether, is searched for backward. Doctors are now,
as they have always been, what their time, their peo-
ple, their surroundings make them. On Sunday the
board of directors of Mt. Sinai Hospital presented him
with a silver tankard bearing the following inscrip-
tion: "To Dr. Abraham Jacobi, on the seventieth
anniversary of his birthday, from the Mt. Sinai Hos-
pital, in grateful recognition of forty years of devotion
and fidelity, May 6, 1900."
Manuel Garcia, the inventor of the laryngoscope,
celebrated in London, on March 17th, the ninety-fifth
anniversary of his birth. He was born in Madrid,
March 17, 1805. When he was a lad of seven, the
family went to Naples. He had a fancy for the sea,
but, in deference to his parents' wishes, studied for the
operatic stage. His earliest appearance was in New
York, where he was the Figaro of the first performance
of " II Barbiere " in North America. His physique
was, however, too delicate for the exacting work of
the stage, and returning to Europe he established him-
self at Paris as a singing-master, later on becoming a
professor at the Conservatoire. Since 1850 he has re-
sided in London. His demonstration of the laryngo-
scope was made before the Royal Society of London,'
in 1855, in a paper entitled "Physiological Observa-
8l2
MEDICAL RECORD.
[May 12, 1900
tions on the Human Voice." The full significance of
his discovery was not at first appreciated in England,
but it was taken up and developed by Turck and
Czermak in Austria.
The Hospital Ship << Maine" sailed from South-
ampton on her return voyage to the Cape on May 3d.
The Plague is reported to have appeared at Suakim
in Kgypt, and Malta has declared a quarantine of
twelve days against all passengers from that country.
Cholera in India. — It is reported from Bombay that
cholera is alarmingly virulent among the natives at
the famine relief works, where there are fifty deaths
daily from the disease.
The Late Drs. Mulheron, Eastman, and McFar-
land.— At a special meeting of the Broome County
Medical Society, held at Binghamton, May ist, reso-
lutions were adopted regarding the recent deaths of
Drs, Edward Mulheron, C. C. Eastman, first assistant
physician of the Binghamton State Hospital, and S.
F. McFarland.
Medical Missions. — One of the sessions of the
Ecumenical Missionary Conference, recently held in
this city, was devoted to a discussion of medical mis-
sions. Papers were presented by Drs. George E. Post,
professor of surgery in the Syrian Protestant College
at Beyroui; C. F. Harford-Battersby, of Lokoja, River
Niger, West Africa ; F. Howard Taylor, of the China
Inland Mission; and O. R. Avison, of Seoul, Korea.
Dr. Post said that the first aim of medical missions
should be the relief of suffering from motives of
brotherhood, and they can be planted where no other
branch of evangelical work is possible, for they are
founded on a need which is universal and felt by all.
Every human being is sometimes ill, and, when not ill
himself, may be anxious on account of the illness of
some relative or friend. The physician therefore has
immediate and welcome access to vast numbers who
will not have any intercourse with other missionaries.
"Missions of every Christian nation," he said, "have
by an unerring instinct established and developed
medical work, and every year sees a wider extension
of its sphere and usefulness. Worldly people, who
look askance at other forms of mission work, applaud
medical missions and give of their substance to sus-
tain them. Kings and rulers in Mohammedan and
heathen lands have built hospitals and given means
for their endowment. Far out on the picket line of
evangelism heroic men and women gather around them
such crowds as collected on the pathways where Christ
•was wont to walk. Fearless of death, they grapple
with cholera, plague, leprosy, smallpox, scarlet fever,
diphtheria, and other contagious diseases. In the
tainted atmosphere of the dispensary they toil hour
after hour to relieve the mass of misery. They go late
to sleep, and often rise a great while before day to
-watch the crises of disease and operation. They re-
main in sultry, fever-stricken cities of the coast dur-
ing the long tropical summer, if haply they save some
of God's poor. They travel under the burning sun or
through blinding storms to reach new centres and
open up the way for a further extension of the work.
The church which sends them knows the value of that
work. The sick whom they cure have given proof of
it." Dr. C. F. Harford-Battersby spoke of the possi-
bilities of the missionaries of the future. He declared
that the home boards should see to it that they sent
only such men and women to the medical posts as
were thoroughly fitted, and that no greater damage
could be inflicted upon the work abroad than by send-
ing out incompetent medical men. He insisted that
the physicians should be earnest Christians, but argued
against the idea that missionary doctors should be
ordained ministers. He said a man should not be
compelled to bear the worry and anxiety of both a
medical and a mission station. Dr. F. Howard Tay-
lor, of China, emphasized the need of both spiritual
and physical qualifications. In speaking of the need
of more medical missionaries, he said that he was the
only doctor among twenty millions of natives. He
spoke of the physical qualifications of the missionaries
and said only men and women of sound body and
mind were wanted. " We must have men of sound
mind," he said. " We cannot use cranks, and as for
men with fads, they had better remain where old fads
pass and new fads appear, for in China we have no
fads." Dr. .A.vison said that physicians are sent to
the mission fields, first, to give medical care to the mis-
sionaries; second, to render that practical help to the
sick natives which must always be extended by Chris-
tians to those in trouble; third, as a means of advanc-
ing evangelistic work by disarming prejudice and
bringing the Gospel to the notice of many who, but for
the evident benefits to be gained from the former,
would decline to put themselves within reach of the
latter; fourth, to train native physicians and nurses
and prepare them to carry on the beneficent work
which the missionaries have inaugurated. Other
speakers were Dr. Franklin Pierce Lynch, of Congo;
Dr. Frank Van .\llen, of India; and Dr. Hepburn, the
first American missionary to go to Japan, who went to
the East as a medical missionary sixty years ago.
American Dermatological Association. — .At the
meeting just heid in Washington the following officers
were elected: Firsident, Dr. F. J. Shepherd, of Mon-
treal ; Vice-President, Dr. D. W. Montgomery, of San
Francisco; Secretary, Dr. F. H. Montgomery, of Chi-
cago. New members elected were Drs. C. J. VVhite, of
Boston, and O. H. Holder, of New York. The next
meeting will be held in Chicago in June, 1901.
A Test of the Mosquito Theory of Malaria On
June I St Drs. Sambon and Low, of the London School
of Tropical Medicine, will begin a summer residence
in a place in the Roman Campagna where asstivo-
autumnal malarial fever is most prevalent. They will
live in a small wooden building with windows and
doors protected with wire screens, which will also be
placed under the eaves and over the chimney opening.
During the daytime, when the Anopheles, or malaria
mosquito, does not bite, they will go about at will, but
from a little before sundown to some time after sun-
rise they will keep strictly within doors, although still
May 12, 1900]
MEDICAL RECORD.
813
exposed to the air and soil emanations. Tlieir drink-
ing-water will be the same as that "used by other resi-
dents of the Campagna, and in fact all their condi-
tions' of living will be the same, save only that they
will be preserved from the stings of the night mos-
quitos.
The Society of the Alumni of the Sloane Mater-
nity Hospital. — At the third annual dinner of this
society, on Friday, April 27th, the following officers
were elected: Presidetit, Dr. Samuel M. Brickner;
Vice-Fresidcnts, Drs. J. S. Waterman and L. A. di
Zerega ; Recording Secretary, Dr. L. E. La Fe'tra ; Cor-
responding Secretary, Dr. H. S. Carter; Treasurer,
Dr. W. V. V. Hayes; Fathologist, Dr. James Ewing.
Convention of Trained Nurses.— The third annual
convention of the alumna; of the training-schools for
nurses of the United States and Canada was held on
Thursday, Friday, and Saturday of last week at the
Academy of Medicine in this city. About two hun-
dred delegates were present. The president of the
alumnas was Mrs. Hunter Rodd. The address of wel-
come was delivered by Mrs. Cadwalader Jones.
Dentists for the Army. — There is now before the
House of Representatives a bill to authorize the ap-
pointment to the army, under regulations to be pre-
scribed by the surgeon-general, of dental surgeons to
be attached to- the different branches of the service, in
the same manner that medical officers are now pro-
vided. The necessity for dentists in the army was
manifested during the Spanish war and still more dur-
ing the Tagal insurrection. The bill was recom-
mended for speedy passage by the House committee
on military affairs over two months ago, and although
it has been on the calendar ever since it was reported,
for some reason it has never been acted upon. The
measure has the indorsement of army officers, dentists,
and physicians throughout the country.
Tonsorial Antisepsis in Boston. — The board of
health of Boston has issued an order enforcing cleanli-
ness in barber shops in that city, its provisions being
that " the place of business of all barber shops, together
with all the furniture, shall be kept at all times in a
cleanly condition. Mugs, shaving-brushes, and razors
shall be sterilized by immersion in boiling water after
each separate use thereof. A separate clean towel shall
be used for each person. Alum or other material used
to stop the flow of blood shall be used only in powdered
form and applied on a towel. The use of powder
puffs is prohibited. Every barber shop shall be pro-
vided with running hot and cold water. No person
shall be allowed to use any barber shop as a dormi-
tory. Every barber shall thoroughly cleanse his hands
after serving each customer."
American Therapeutic Society. — In pursuance with
a call for an American Therapeutic Society, issued by
the Therapeutic Society of the District of Columbia,
a meeting was held in Washington, May i, 1900.
The organization was effected and much enthusiasm
displayed. The following were chosen as officers
of the new society, which will become affiliated
with the Congress of American Physicians and Sur-
geons, which meets in Washington every three years:
President, Dr. Horatio C. Wood, of Philadelphia;
First Vice-President, Dr. Howard H. Barker, of Wash-
ington; Second Vice-President, Dr. R. W. Wilcox, of
New York; Third Vice-President, Dr. E. H. Long, of
Buffalo; Secretary, Dr. Noble P. Barnes, of Washing-
ton; Recorder, Dr. William M. Sprigg, of Washington;
Treasurer, Dr. John S. McLain, of Washington. The
meetings of the American Therapeutic Society will be
held annually; the next meeting being in Washington,
D. C, on May 7, 1901.
Quarantine against Yellow-Fever Ports On
May ist the usual summer quarantine regulations
went into effect at the port of New York. All passen-
gers who cannot show certificates of immunity are to
be detained at Hoffman Island under observation until
five full days have elapsed since they left Havana or
other yellow-fever port.
The International Dermatological Congress. — At
the meeting of the American Dermatological Associa-
tion, held in Washington in connection with the Con-
gress of American Physicians and Surgeons, a com-
mittee was appointed consisting of Drs. J. Nevins
Hyde of Chicago, Henry W. Stelwagon of Phila-
delphia, and T. Caspar Gilchrist of Baltimore, to
represent the association at the International Dermato-
logical Congress, to be held in Paris in early August,
and to extend a warm invitation, in the name of the
association, to the members of the congress to hold the
next international meeting in this country, in New
York. The committee was further instructed, in the
event of the congress giving favorable response, to
present the name, and urge the election, of Prof. James
C. White, of Boston, the first president of the American
Dermatological Association and an honorary member
of the French and Italian dermatological societies, for
the presidency of that congress.
College of Physicians of Philadelphia. — At a spe-
cial meeting of the section on gynajcology held April
30th, Dr. Henry J. Garrigues, of New York, read a
paper entitled " Periods in Gynaecology." At the con-
clusion of the meeting a reception was tendered Dr.
Garrigues at the University Club. At a stated meet-
ing held May 2d, Dr. J. C. Gittings read for Dr.
James Ely Talley a paper entitled " Angio-neurotic
QEdema of the Salivary Glands.''
Navy Department, Bureau of Medicine and Surgery,
VVashington, D. C, May 5, 1900. — Changes in the
medical corps of the United States navy for the week
ending May 5, 1900. April 27th (by cable from
Asiatic station). — Assistant Surgeon W. E. High de-
tached from the Manila and ordered to the hospital.
Assistant Surgeon D. G. Beebe detached from the
Yorkloran and ordered to the Is/a de Luzon. April
30th. — Surgeon T. A. Berryhill detached from the
Monongahela on reporting of relief, and ordered home
and to wait orders. Passed Assistant Surgeon W. M.
Wheeler detached from the Vermont May 3d, and
ordered to the Kearsargc. Passed Assistant Surgeon
8i4
MEDICAL RECORD.
[May 12, I goo
G. H. Barber detached from the Kcarsaige and ordered
to the Monongahc'la. Assistant Surgeon D. H. Morgan
ordered to the Vermont May 3d. May 3d. — Medical
Inspector J. C. Boyd detached from duty as assist-
ant to bureau of medicine and surgery, Navy Depart-
ment, and ordered to the Neio York as fleet surgeon of
the North Atlantic station. Medical Inspector P.
Fitzsimons detached from the New York as f.eet sur-
geon of the North Atlantic station, and ordered to pro-
ceed home and wait orders. Surgeon J. D. Gatewood
detached from the bureau of medicine and surgery,
Navy Department, May 8th, and ordered to duty as
assistant to bureau of medicine and surgery, same
day. Passed Assistant Surgeon C. D. Brownell or-
dered to the naval training-station, Newport, R. I.
Obituary Notes. — Dr. George Fulner, of Me-
chanicsburg. Pa., died on May ist, at the age of sev-
enty-five years. He was a graduate of the Jefferson
Medical College in 1853.
Dr. John Stockton Hough, once a practising phy-
sician in Philadelpiha, later a resident of Paris and
London, and for the last dozen years a gentleman
farmer at Ewingville, near Trenton, N. J., died on
May 6th, as the result of injuries sustained in being
thrown from his carriage by a runaway horse.
Dr. Edward E. Vincent, who was surgeon in
Peary's expedition to the arctic regions in 1893, was
killed in Detroit on May 4th. He was on a bicycle,
and in trying to escape from a buggy which was bear-
ing down on him he was thrown under a rapidly mov-
ing trolley car.
LANDON CARTER GRAY, M.D.,
Dr. Landon Carter Gray died at his home in this
city on Tuesday, May 8th, after a long illness. He
was born in New York City on April 3, 1850. While
in Columbia College he had serious trouble with his
eyes, on which account he went abroad for a rest, and
upon recovering he remained there, studying at the
University of Heidelberg. Eater he returned to this
city and studied medicine, taking his degree from the
Bellevue Hospital Medical College in 1873. After
practising for a while here he removed to Brooklyn,
where he remained until 1886.
Dr. Gray early turned his attention to the study of
diseases ^f the nervous system, and speedily won for
himself an enviable reputation in that line of prac-
tice. While in Brooklyn he was professor of neurol-
ogy at the Long Island College Hospital Medical
School, and was visiting neurologist to St. Mary's
Hospital. He was one of the founders of the New
York Polyclinic, and was the first occupant of the
chair of nervous and mental diseases in that institu-
tion. He was at various times president of the Medi-
cal Society of the County of New York, the .American
Neurological Association, the New York Neurological
Society, and the Society of Medical Jurisprudence,
and was for many years chairman of the e.xecutive
committee of the Congress of American Physicians
and Surgeons. He was the author of a work on ner-
vous and mental diseases, and was at one time a
frequent contributor to periodical literature in this
specialty.
progress of ^cdical J>cietice.
New York Medical Journal, May ^, igoo.
An Appeal for Systematic Treatment of the
Consumptive Poor. — J. F. Russell advances the fol-
lowing propositions: That a large number of poor
people sufferin-g with pulmonary tuberculosis in a
curable condition cannot go to sanatoria for treat-
ment; that dispensary treatment is practicable, suc-
cessful, and comparatively inexpensive; that curable
pulmonary tuberculosis by dispensary treatment is
confined to the early stage; that without organized
effort such cases are difficult to attract for treatment,
owing largely to ignorance of the disease and a belief
that it is incurable; that the treatment covers a long
period and patients require daily supervision; that
the majority of dispensaries at present make no ade-
quate provision for such treatment: that it is the duty
of such dispensaries to organize classes for this pur-
pose. The advantages to be derived from the general
adoption of the plan of treatment outlined are as fol-
lows: Many are cured; all are benefited; all are edu-
cated and made capable of protecting and teaching
others; all, laboring and idle alike, can come for
treatment. In the end it will break down the deep-
rooted belief that pulmonary tuberculosis in all stages
or any stage is incurable, and lead to the application
for relief early in the disease.
Management of the Hair during and after
Fevers. — G. T. Jackson advises the careful combing
of the hair during acute febrile conditions. The use
of the fingers, if the brush is inadmissible, will pre-
vent much of the snarling so often met with. He ad-
vises against cutting the hair and particularly against
shaving the scalp. Only diseased hair will come out
under the usual manipulations. Once or twice weekly
we may use a pomade of a drachm of precipitated sul-
phur in one ounce of cold cream. This should be
carefully worked into the scalp. Once in two or three
weeks a shampoo may be given, and for this purpose
the tincture of green soap is best. Just as little of
the soap should be used as will make a good lather.
A hose from the bath-room faucet should be used to
wash the soap out. Pomade is then to be rubbed in.
Practical Points in Ether Anaesthesia.— C. F.
Burrows advocates giving half an ounce of magnesium
sulphate twelve hours before anaesthesia, with a rectal
washing one hour before with a quart of warm water.
Only milk should be given during this period, and
nothing at all during the last four hours. Water may
be used freely, but the bladder should be empty just
before the ether is begun. He is opposed to the usual
morphine and atropine injection. The rest of the
article is an enumeration of the customary precautions
agreed to by all anaesthetists.
Nitrous Oxide; Ether; Chloroform.— By S. Or-
mond Goklan.
What is the Basis of Modern Medical Concep-
tions ? — By J. Homer Coulter.
Effeminate Men and Masculine Women. — By
William Lee Howard.
Journal of the American Med. Ass'n, May j, igoo.
Surgery of the Fifth Nerve for Tic Douloureux.
— R. .•\bbe gives his experience with twenty cases, the
Hartley operation being done five times, the Salzer
four, and the Carnochan eleven. He advocates a
thoroughly done Carnochan operation, with clean re-
section of the second branch to the foramen rotundum,
for most bad cases, even when the first and third
branches seem to share the neuralgic shocks. If one
chooses to do the Salter, then he advises a section of
May 12, 1900]
MEDICAL RECORD.
815
the zygoma turned down with skin, and a muscle
splitting of the temporal rather than coronoid section.
If the intracranial method is adopted, he advocates
tiie simple section and limited excision of the second
and third branches from the Gasserian ganglia to the
foramina, and interposition of a piece of sterile rub-
ber tissue. He sees no reason for believing that the
resection of the Gasserian ganglion is necessary to
the thorough severance of nerve connection with the
brain. In most cases of inveterate tic a chronic neu-
ritis exists, usually of the middle branch. Hence the
quick and permanent cures which we are able to
record by excisions anterior to the Gasserian ganglion.
The Early Diagnosis of Pulmonary Tuberculosis.
— E. F. Wells does not recognize a pretuberculous
stage. The disease is often preceded by ansmia, gas-
tric and intestinal disorders, but such states are purely
accidental and not premonitory. The beginning of
the attack must be coincident with the implantation
and parasitic development of the bacillus of tuber-
culosis. Special attention must be given to the pos-
sible occurrence of cough, expectoration, haemoptysis,
thoracic tenderness, fever curve, gastric symptoms,
nutrition, blood changes, and pulse characteristics.
Tuberculin may be used, but a negative result with
this agent is also of value, for it enables us to affirm
that not only is the suspected pulmonary affection not
tuberculous but that there are no latent pulmonary foci
and that tuberculosis does not exist in other parts of
the body. In a doubtful case the .v-ray may tip the
.balance for or against the probability of tuberculosis
being present. This is especially true when thoracic
soreness or pain is present, the .v-ray revealing re-
stricted movement of the diaphragm upon the affected
side.
Natural History of Tic Douloureux, with Re-
marks on Treatment. — C. L. Dana gives a table
showing the duration and treatment of forty-two cases.
He believes that the early forms, such as he calls a
■' migrainous tic," occurring usually in women, should
not be operated on. There are some exceptions to
this, however, in which tic douloureux occurs in early
life, due to a distinct local disease, such as an inflam-
mation of the nerve, or of the antrum, or of the jaws.
In true tic of the degenerative period of life, prompt
medical treatment will usually control the disease and
operation is rarely indicated at first. In tic which
has lasted three or more years, it may be safely said
to the patient that medical treatment may produce a
remission, and that this remission may be repeated, and
that eventually the disease may be controlled by re-
peated treatments, but this is not at all sure. It may
be said here too that a minor operation may give more
relief than medical treatment. The question of pre-
scribing major operations must be decided in each
individual case, on its special merits.
Further Observations on the Treatment of the
Abdominal Viscera through the Colon. — F. B. Turck
describes the method of forcing liot or cold air into
the bowel, a double tube allowing of escape. TJiis
hot-and-cold-air plan through its stimulant power pro-
duces what may be styled "gymnastics of the colon."
By other methods he executes massage of the colon,
secures colonic electrization, effects direct medication
of the colon, and also introduces alimentary sub-
stances. The varieties of tubes employed are figured
in the original article. Turck considers colonic
lavage to be of especial service in typhoid fever.
While the length of the disease remains the same,
there is a marked diminution in the lassitude, delir-
ium, pyrexia, and other constitutional expressions of
the typhoid poison.
Protocols of Microscopical Examinations of Sev-
eral Gasserian Ganglia. — By L. F. Barker.
Pathological Report of Two Gasserian Ganglia
Removed by Dr. Gushing. — By W. G. Spiller.
Operation for Exstrophy of the Bladder by Son-
nenberg's Method — By J. R. Eastman.
Vision and Color Perception for Railway Service.
—By W. C. Bane.
The Sight and Hearing of School Children.— By
H. V. Wiirdeman and Frank Alport.
Medical News, May j, igoo.
The Medical School of the Future.— H. P. Bow-
ditch sums his conclusions as follows: (i) A medical
school of the first rank will, in the immediate future,
be connected with a university, but will be independ-
ent of university control as to methods of instruction
and the personnel of the teaching body. (2) It will
offer advanced instruction in every department of
medicine, and will therefore necessarily adopt the
elective system of some sort. (3) The laboratory
method of instruction will be greatly extended, al-
though the didactic lecture will still have its place.
(4) The work of the students should be so arranged that
their attention will be concentrated upon one principal
subject at a time. (5) Examinations will be so con-
ducted as to afford a test both of the faithfulness with
which a student performs his daily work and of his
permanent acquisition of medical knowledge.
The Present Status of Rectal Surgery. — By
Joseph M. Mathews.
Perforating Duodenal Ulcers. — By Robert F. Weir.
Truth in Medicine. — By E. G. Janeway.
Fhilade!l>Itia Medical Journal, May ^, /i;oo.
Some of the Physiological Methods and Means
Employed by the Animal Organism in its Contin-
ual Struggle against Bacteria for Maintenance of
Life and Health. — S. J. Meltzer maintains that in
the struggle against bacteria the defence of the body
is not carried on by any single element. Neither the
body-fluids, nor the leucocytes, nor the other body-
cells alone can claim exclusive merit, but each does
its share. Further, in health at least, the actual de-
fence is carried on not by a single tissue, or a single
function, but by concerted action of several tissues
and functions, by the working of a mechanism. As to
the plan of defence the writer says the aim is to re-
duce greatly the number of bacteria by mechanical
methods, and then to destroy the remnant by some
biological means. The mechanical methods are: bar-
ricading the entrance, throwing out again the landed
bacteria, or cariying them to the place of destruction.
He then suggests two new factors which he believes
to be capable of assisting the work of the destruction
of bacteria within the body, viz., the process of plas-
molysis, and the vibrating effect of the heart impulse.
The conclusions are that the regular, moderate inva-
sion of bacteria into the interior of the body, so far
from being an infection — an evil — is a means of im-
munization; latent infection, therefore, is not a foe to
normal life or health, but is rather a confederate in de-
fence of it.
On Recent Advances in our Knowledge Concern-
ing the Etiology of Malarial Fever — William
Sydney Thayer reviews the investigations undertaken
in recent years which have resulted in the discovery
of the part taken by certain mosquitos in the spread
of malaria. In malarious districts around Baltimore
and in Virginia and North Carolina he has found
several varieties of Anopheles. As to the practical
deduction from this discovery he says that there is
reason to believe that if in any given region (i) proper
measures for treating the spring relapses of malaria
were adopted, and (2) efficient measures for destroying
8i6
MEDICAL RECORD.
[May 12, 1900
the dangerous mosquitos in their larval stage could be
carried out, the prevalence of malaria might be mate-
rially controlled. The importance to the community
of insisting upon the proper treatment of all cases of
malaria cannot be too strongly emphasized, for an in-
fected patient in a malarious district is a source of
danger to those about him. Before we can attempt,
however, to carry out intelligently measures to destroy
the mosquitos we must first determine definitely the
dangerous species of mosquitos in this country, and
must study their distribution, their habits, and their
breeding-places.
Nephrectomy for a Large Aneurism of the Right
Renal Artery, with a Resum6 of the Twelve For-
merly Reported Cases of Renal Aneurism. — By
W. \V. Keen.
President's Address at the Decennial Convention
for the Revision of the United States Pharmaco-
poeia.— By H. C. Wood.
Adaptation of Pathogenic Bacteria to Different
Species of Animals.— By Theobald Smith.
Bacterio-Therapeutics, with Especial Reference
to Tuberculosis. — By Edward R. Baldwin.
The Sociological Status of the Physician.— By
Clarence John Blake.
The Relation of Bacteriology to Medicine. — By
Richard C. Cabot.
The Medical School of the Future.— By H. P.
Bowditch.
Medical Press and Cinular, April 18 and 2j, igoo.
Case of Persistent Jaundice in which an Ex"
ploratory Operation was Performed. — E. F. Eliot
operated on a patient who for four and a half years
had been jaundiced. A tumor of the gall bladder
could be made out through the abdomen. The gall
bladder was found distended and a pint and a half of
thick black gelatinous bile was drawn off. After in-
cision the mucous lining of the organ was found cov-
ered with a gritty substance, which was scraped off
and the cavity was packed with iodoform gauze.
Death occurred on the sixteenth day from acute enter-
itis, supposed to have been caused by the gritty matter
and altered bile entering the gut after so long a period
of freedom from bile.
The Pathology and Treatment of Pneumonia. —
Natlian Raw considers pneumonia a self-limited dis-
ease, which can neither be aborted nor cut short by
any known means. It may terminate favorably with-
out medicines; still an immense amount of good can
be done by the physician. It is essential to control
the fever by sponging with iced water. Cardiac fail-
ure is the great stumbling-block. Here alcohol should
be given up to twelve ounces of good brandy in twenty-
four hours. In the majority of cases alcohol is not re-
quired in pneumonia. Strychnine up to yV grain hypo-
dermatically will often have a miraculous effect upon
the heart. The author's experience witii oxygen in
sixty-five cases has not been favorable. Saline injec-
tions are still in the trial stage.
Myotonia Congenita. — Leonard Guthrie reports
the case of a boy aged ten and one-half years, who for
a year had presented symptoms. The thumbs were
turned in and a tonic spasm of the hands resembled
that of tetany. The grasp of objects was slow and
awkward and he could not let go quickly. The spasm
was more marked after rest. The gait was jerky, and
he did not bring his heels fully to the ground. Run-
ning was easier than walking. Tonic contraction per-
sisted during sleep.
The Pathology of Acute Myelitis Mayer relates
the history of seven cases in which the microscope
showed degeneration of the white and gray substance
of the cord. The differences in appearance between
the "perforated " and " infiltration '' forms are given.
The Treatment of Talipes Equino-Varus. — Ab-
stract of a paper by R. A. Hibbs, of New York, on
lengthening tiie tendo Achillis.
Three Lectures on the Surgery of the Stomach.
— By Mayo Robson.
Protargol versus Nitrate of Silver. — By John
Moir.
British Medical Journal, April 28, igoo.
Inoculation with Typhoid Vaccine as a Preven-
tive of Typhoid Fever. — R. W. Marsden reports an
experiment with the typhoid vaccine in the Monsall
Hospital, Manchester. Of the twenty-two nurses in
the hospital, fourteen were vaccinated, four had had
typhoid fever, and four refused to submit to the ex-
periment. During previous seasons the number of
nurses who were attacked with the disease was: 1895-
96, three; 1896-97, two; 1897-98, eight ; 1898-99, six;
during the season of 1899-1900 following the vacci-
nations none of the nurses suffered an attack. One of
the nurses had an ephemeral fever in January, lasting
only a few days. Assuming that this ephemera! fever
was a genuine attack of typhoid, the author thinks its
very mildness and evanescent nature would speak
strongly for the contention that there is " an increased
power of resisting infection by living typhoid bacilli,"
and certainly the occurrence of sucfi attacks would
never be a cause of anxiety.
A Family with Addison's Disease.— Robert A.
Fleming and James Miller report five cases of an
affection presenting all the clinical features of Addi-
son's disease, occurring in a woman and her four chil-
dren, aged from two and a half to seven years. The
mother, a woman twenty-eight years old, showed all
the typical clinical features, including pigmentation
of the mucous membrane of the mouth and lips, while
the children, in order of age, demonstrated the same
phenomena in decreasing severity and distinctness.
The moles, placed so prominently in the list of im-
portant clinical features by Addison, Greenhowe, and
others, were specially characteristic of this family
group.
Antityphoid Vaccine. — T. Wilson says that his ex-
perience of the use of the antityphoid serum of Pro-
fessor Wright, of Netley, among troops in South Af-
rica, is that if it does not render the typhoid bacilli
innocuous, it at least will modify favorably an attack
of typhoid fever. Before making inoculations he had
the men abstain from alcohol for three days and take
an aperient on the morning of the fourth day, and on
the morning of the fifth day be inoculated.
On the Value of the Agglutination Test as a
Means of Diagnosis of the B. Typhosus from Co-
nform Organisms. — By ^^'. H. Horrocks.
Abstract of a Report on the Acoustic Principles
Affecting the Conduction of Sound by the Bones
of the Head.— ]!y Albert A. Gray.
Men and Horses Partially Incapacitated by the
Bites of the Simulium (Sand Fly), in a Hampshire
Wood.- — By James Cantlie.
Preliminary Note on a New Quantitative Method
of Serum Diagnosis. — By Richard T. Hewlett and
Sydney Rowland.
Epidemic Laryngitis and Tracheitis among
Troops on the Voyage to South Africa. — By
Charles Gibbs.
"Growing Pains" as a Symptom of Rheuma-
tism.— By E. M. Brockbank.
Failure of Respiration during Ether Adminis-
tration.—By G. P. Shuter.
May I 2, 1900]
MEDICAL RECORD.
817
A Case of Intestinal Obstruction Caused by a
Band and an Enlarged Uterus. — By C. Hamilton
Whiteford.
On Some Practical Points in Conducting the
Administration of Anaesthetics. — By H. Bellamy
Gardner.
A Clinical Lecture on Bulbar Paralysis and its
Counterfeits. — By G. A. Gibson.
Report of a Case of Tetanus Treated Success-
fully by Serum. — By G. Lloyd Roberts.
The Lancet, April 28, igoo.
A Case of Pernicious Anaemia Treated by Anti-
streptococcic Serum. — The treatment of a case is thus
described by W. Elder: the patient, a man aged thirty-
five years, was admitted to hospital February 3d, and
commencing one week later his mouth was thoroughly
washed and brushed with an antiseptic mouth-wash and
he was given gr. v. of salol and gr. xv. of salicylate of
bismuth internally every six hours. Gr. x. of anti-
streptococcic serum was at first injected into the
subcutaneous tissue over the dorsum ilii every second
day. At the first two injections, on account of a fault
in the syringe, he received only about 8 c.c, but after-
ward 10 c.c. was given on each occasion except on
February 9th, when he got only 5 c.c. From February
3d till March 19th he received in all eighteen injec-
tions of the serum, and the antiseptic treatment was
continued all through. With the exception of a hyp-
notic occasionally when his nervous symptoms re-
quired it, and a dose of castor oil or cascara sagrada
for his constipation, this was tiie only medicinal treat-
ment, fie got none of the usual remedies for anaemia
— neither iron nor arsenic nor bone marrow. On
March 20th (fifty-two days after his admission and
forty-five days after the commencement of treatment)
his blood had practically reached normal.
Strychnine as a Factor in Causing Cerebral Hem-
orrhage.—L. Grant sounds a note of warning against
the very prevalent practice of tiie public, which con-
sists in taking, whenever a feeling of depression is
felt, patent nostrums or even officinal preparations
which contain strychnine. This drug is a cardiac,
vasomotor, and gastric stimulant, and may so brace
the system as to lead one to overwork. Moreover, it
may show a cumulative action. All of these effects
combine to bring an unusually severe strain on the
vessels, and in patients who are the least atheroma-
tous may be the cause of some vascular break-down.
A case of apople.xy narrated by Grant tends to support
this view. This particular patient was in the habit
of taking syrup of the phosphates of iron, quinine, and
strychnine, together with bicarbonate of soda for a
morning " fizzing " drink.
On Cysts of the Breast ; their Relative Fre-
quency, Diagnosis, and Treatment.— From a careful
analysis of two hundred and forty-two cases of breast
disease, T. Bryant has come to the following conclu-
sions: Cysts of the breasts are far more common than
they are generally believed to be. They are chiefly
found in women during the same period of life as that
in which cancer is met with; they are mostly quite
amenable to local treatment without the sacrifice of
the breast gland in which they are situated. There is
no reason to believe that women who have these cysts
are more prone to cancer than those who have them
not. The article is an elaboration along the lines
indicated by the foregoing propositions.
An Experimental Inquiry into Scurvy F. G.
Jackson and V. Harley believe that the view requires
modification which attributes scurvy to the effect of
want of fresh vegetables or lime juice. They base
their opinions upon a study of the sanitary records of
various arctic expeditions and upon the results of
dietetic experiments upon monkeys. They conclude
that the presence of the vegetables or lime-juice is not
alone sufficient for the prevention or cure of scurvy,
and that we must regard the condition of the food in
general, and especially the state of preservation of the
meat, as the essential factor in the etiology of the
disease.
On the Value of Abdominal Distention as an
Indication for Exploratory Laparotomy in Intesti-
nal Obstruction.— J. J. Waddelow reports the case of
a man, aged fifty-four years, with complete intestinal
obstruction lasting seven days, and fecal vomiting
lasting two days. The onset of the disease took the
form of an acute biliary colic, but the exact cause of
the obstruction was unknown. Abdominal distention
was present, but, as it did not progress, operation was
deferred and reliance was placed on laxative enemata.
Recovery ensued.
Clinical Lecture on a Case of Internal Derange-
ment of the Knee Joint. — By E. Owen.
Inversion of the Myomatous Uterus. — By W.
Roger VVillianis.
Endoscopy of the (Esophagus and Stomach. — By
G. Kelling.
Berliner klinische Woc/ieiischrift, April g and 16, igoo.
Some Exceptional Points on the Diagnosis and
Therapy of Pulmonary Tuberculosis. — H. Senator
enumerates in this article some of the measures which
may be utilized for the relief of various symptoms.
For haemoptysis he suggests the feasibility of giving
large doses of gelatin internally. This remedy has
been shown to have the power of increasing the coag-
ulability of the blood. He also commends the liga-
ture of the limbs and inhalation of astringent agents.
For the fever, he has obtained the best results with
phenacetin, lactophenin, citrophen, and pyramidon.
For night sweats, pencilling of the skin with formol
has frequently afi:orded relief.
Contribution to the Apparatus Therapy in Affec-
tions of the Central Nervous System.— P. Jacob
states that there are three classes of apparatus capable
of employment in maladies of the central nervous sys-
tem. The first class is designed to replace the func-
tion of muscles which are completely powerless; the
second supports the action of muscles which are only
partially disabled, while the third is designed to rein-
force the action of muscles which are in themselves
normal but upon which additional work is thrown ow-
ing to the incapacity of muscular congeners. Illus-
trative cases are given under these respective headings.
Disturbances in the Filtration Power of Diffusely
Inflamed Kidneys.— G. Koresi and W. Roth-Schulz
give the follo.wing conclusions, based upon their own
observations: (i) In parenchymatous nephritis the
filtration power of the kidneys is lessened in propor-
tion to the severity of the case. (2) In the contracted
kidney this power remains more or less normal, some-
times completely so. (3) The same holds true of the
kidney of heart disease so long as compensation does
not fail. (4) The congested kidney occupies, in this
respect a transition stage between chronic parenchy-
matous nephritis and the contracted kidney.
An Unusual Case of Acute Anterior Poliomyeli-
tis of Infectious Origin Occurring in an Adult. —
K. Gumpertz reports the case, which occurred in a
young man aged twenty-three years, who after a slight
illness of a few days, during which he complained of
general malaise, dulness, anorexia, and fever, pre-
sented the typical paralytic symptoms of anterior polio-
myelitis, which gradually improved in the course of
the following three months. As he had been exposed
8i8
MEDICAL RECORD.
[May 12, 1900
to typhoid infection, it was concluded, after a careful
study of all the factors in the case, that this was the
nature of the infectious agent.
Experiences from Preliminary Examinations
for Admission to the Institutions for Pulmonary
Therapy in Grabowsee. — I!y K. Brandenburg.
A New Method of Examination of the Fundus
of the Eye for Erect and Inverted Images with a
New Electric Eye Mirror.— By H. Wolff.
The Plague in the Light of Recent Research —
By P. Frosch.
Cell Division. — By W. Flemming.
Aliinch. med. Wochenschrijt, April ij and 24, igoo.
On the Diagnosis of Changes in the Lungs due
to the Inhalation of Dust in Industrial Occupa-
tions.— Professor Baumler calls attention to the rela-
tive frequency in some localities of an affection of the
respiratory organs simulating phthisis, but which runs
a rapidly favorable course. There is usually a his-
tory pf many years of respiration of dust in the pa-
tient's occupation. Cases in which there is no accom-
panying tuberculosis must be distinguished from those
in which an occasional dust effect is added to an
already existing tuberculous process.
Glycosuria in Vagrants. — Hoppe-Seyler has re-
marked the frequency with which glycosuria occurs in
those who have led an irregular, wandering life,
being poorly nourished and having undergone hard-
ship. Five instances are recorded. They are not
true cases of alimentary glycosuria, but passing dis-
turbances in the carbohydrate metabolism, together
with disturbances of circulation, interstitial and par-
enchymatous diseases of tlie liver and pancreas, play
a role.
Late Diphtheria in the Nasal Pharynx. — Esch-
weiler relates a case, and believes the condition more
frequent than literature indicates. Many instances of
supposed primary rhinitis fibrinosa diphtheritica do
not begin in the nose but in the nasal pharynx. In
chronic cases the naso-pharynx must be carefully
cleansed by the physician, and after a cure is effected
any adenoid growths present must be removed to pre-
vent recurrence.
Upon the Causes of Hypertrophy of the Heart
in Kidney Diseases. — August Bier believes that hy-
pertrophy of the heart and the changes in the blood-
vessels which accompany it are purely compensatory
effects without which prolonged existence would not
be possible. This position he goes on to justify and
explain by physiological and physical conditions^^nd
facts, and to show that the changes are useful and nec-
essary to the economy.
Mucous Colic and Membranous Catarrh of the
Large Intestines. — R. Schuiz states that authors do
not agree upon questions of etiology in colica mucosa
and enteritis membranacea, and he presents four in-
stances, all in women, by which he hopes to throw
some light on the distinctions to be made between
them.
Case Reports of Tendon Rupture — Oscar Vulpius
gives notes of a number of cases observed in which
the extension apparatus of the forearm or other muscles
were involved, and quotes the literature of rupture of
the quadriceps tendon.
Muscle and Tendon Laceration of the Biceps
Brachialis. — Ernst I'agenstecher reports upon two
new cases, and refers to his previous article in the
Berliner klinische Wochenschrijt, "Ho. 16, 1895.
The Aggregate Occurrence of Sebaceous Follicles
upon the Mucous Membrane of the Mouth in Man.
— By Dr. Suchannek.
The Study of Internal Medicine in France, Eng-
land, and Germany. — By L. R. Miiller.
Clinical Observations upon Ichthalbin in Dis-
eases of the Intestines. — By Dr. Roily.
Surgical Suture and Ligature, and Ligature
Material By H. Braun fconclusionj.
New Contributions to the Pathology of the
CEsophagus By W. Fleiner.
Laryngeal Affections in the Course of Diabetes.
— By Otto Leichtenstern.
On the Detection of Tubercle Bacilli in the
Faeces. — By J. Strasburger.
On the Psychology of Voice Fatigue.— By Max
Breitung.
Deutsche med. U'ochenschrift, April 12 and ig, igoo.
Epidermolysis Bullosa Hereditaria. — Otto Mich-
aelsen reports the case of a young woman seventeen
years old, who presented herself for the treatment of
blisters appearing on the hands and feet, accompanied
with great pain and profuse sweating. She was of
healthy appearance, and the internal organs were found
on examination to be normal. The palms of the hands
were wet with perspiration and were covered with
numerous blisters, the size of a pinhead to that of a
walnut. Some had collapsed, their integumentary
covering lying in fine creases on the base. There was
no scar formation on the skin, and the nails were nor-
mal. On the soles of the feet, and especially between
the toes, there were many excoriations due to the
maceration of the integument, and there were also
numbers of blisters of various sizes, like those on the
hands, which were very tender on pressure. The pa-
tient had suffered from this trouble since her earliest
childhood, the bullous formation appearing first on
the feet and later (about the twelfth or thirteenth year)
on the hands. The affection was always worse in
warm weather and was intensified by hard work, espe-
cially harvesting. There were no lesions either pre-
ceding or accompanying the blisters which suggested
in any way an urticaria. An inquiry concerning the
girl's antecedents revealed the fact that she had in-
herited the disease from her father and he from his
mother. In all twelve persons, four males and eight
females, in this family suffered from epidermolysis.
There were four generations of sufferers, the patient
under observation being in the third, the children of
her sister constituting the fourth.
Ovarian Cyst Impeding Labor Removed by Pos-
terior Colpotomy. — A. Hesselbach reports the case of
a woman thirty-one years old, who had had five nor-
mal pregnancies. During the latter half of the sixth
she suffered severely from sacral pains. Labor began
but progressed slovv'ly, and examination revealed a
cystic tumor between the rectum and vagina, project-
ing into the latter in horseshoe shape partially encir-
cling the child's head. As the tumor offered an abso-
lute obstruction to delivery, and craniotomy was out
of the question, removal of the cyst was the only
alternative. The vagina was incised and the tumor
dissected out with the finger, and finally the entire
hand was introduced. It was impossible to replace
the cyst, so it was evacuated through a slight puncture
and the sac was drawn as far as possible into the
vagina. Delivery was then effected by means of the
forceps, the vagina was rapidly cleansed as well as it
could be, and the sac was pulled down so as to bring
the pedicle within reach. This was ligatured and in-
cised. The child was .slightly asphyxiated, but was
easily resuscitated. The woman made a good re-
covery.
Mobility of the Heart in Change of Position of
the Body. — Determann finds that in general the heart
May 12, 1900]
MEDICAL RECORD.
819
moves 2 '2 cm. to the left and i cm. upward when a
healthy person lies on the left side, and moves about
I 'j cm. to the right and Y^ cm. upward when he lies
on the right side. In some cases, however, the organ
may be displaced 6'.^ cm. to the left or 4 cm. to the
right without causing any distressing symptoms. The
greatest change of position of the heart in varying
positions of the body occurs in the emaciated, those
who lead a sedentary life and whose muscles are
flabby. In many persons who cannot lie on one or
the other side because of palpitation, pain, and other
distressing symptoms, this increased mobility of the
heart exists. Occasionally the symptoms are even
more severe — a rapid and irregular pulse, marked
oppression, etc. The treatment of this condition con-
sists, first, in improving the general health by means
of a generous diet, arsenic, iron, hydrotherapy, etc.
The abnormal sensitiveness of the heart, of which
many of these patients complain, may be relieved
somewliat by the bromides.
The Indication for 'a Mastoid Operation.— Rich-
ard Miiller says that every case of acute middle-ear
suppuration which, in spite of proper treatment, con-
tinues for two weeks in undiminished intensity with-
out showing any tendency to improvement, must be
treated by opening of the mastoid antrum, even when
there are no threatening symptoms present. This, he
says, is not to be taken too literally and absolutely,
for while it is a rule which one may always follow
with safety, yet in certain cases one might be justified
in delaying operation a little beyond the limit men-
tioned.
Unusual Displacement in Fracture of the Leg —
Reichenbach reports a case of fracture of the leg in
which the upper fragment of the tibia was displaced
to the inner side of the lower and in the same frontal
plane, the upper portion of the fibula being in front of
the lower and in the same sagittal plane.
Syphilis of the Lingual Tonsil and its Relation
to Atrophy of the Follicular Glands By W. Lu-
blinski.
A Case of Multiple Melanosarcoma with Pecul-
iar Complications in Both Eyes. — By A. \\'agen-
niann.
Bacilli Resembling Tubercle Bacilli in Gangrene
of the Lungs. —By Lydia Rabinowitsch.
A Case of Isolated Paralysis of the Suprascapu-
lar Nerve — By A. Hofmann.
Oxyphile Bacilli in the Stools of Nurslings. —
By H. Finkelstein.
The Toxicological Position of Raphides By L.
Lewin.
The Treatment of Obesity. — ByVVilhelm Ebstein.
The Growth of Bacteria. — By Feinberg.
Archives oj Pediatrics, May, igoo.
Tuberculosis of the Female Genital Tract in
Children. — Martha \\'ollstein reports the case of a
little girl aged two years, who died on Randall's Isl-
and. At the autopsy there was found marked puru-
lent bronchitis of both lungs, and discrete miliary
tubercles were scattered throughout the substance of
all the lobes. The peritoneal surface of the rectum
was covered with e.xudate and studded with tubercles.
The left ovary was normal, but the right ovary was
covered with a layer of cheesy material extending into
the cortical layer, where there were many miliary tu-
bercles which had undergone cheesy degeneration and
did not involve the medulla. The mucous membrane
of both Fallopian tubes was converted into a cheesy
mass. There were two abscesses, one in the right
broad ligament and one in the cul-de-sac of Douglas.
No clinical history of the case could be obtained.
The Ambulatory and Hospital Management of
the Gastro-Intestinal Derangements of Infancy in
the Summer Months among the Poor of Large
Cities. — Henry Koplik emphasizes the fact that the
gastro-intestinal diseases, both mild and severe, are in
the vast number of cases infectious, and urges scien-
tific examination of infants' diarrhoeal movements be-
fore treatment is inaugurated. Treatment is not so
laborious in the simple diarrhoea of the coli variety
as in the severer forms of streptococcal infection.
The ambulatory method of treatment (dispensaries
and out-door services) of summer diarrhoea is far more
satisfactory than the hospital or sanitarium method.
The author gives a long list of reasons why this is the
case. A camp or colony of huts in the country, with
arrangements for plenty of air and light, would be an
ideal hospital for the treatment of sick infants.
The Care of Premature Babies in Incubators. —
James D. Voorhees gives the results of the use of the
incubator in the Sloane Maternity in two years' time,
one hundred and six babies having been treated.
Twenty-nine died within four days, all but three of
these being more or less asphyxiated at birth. Seventy-
seven survived the first four days. Of these thirteen
died in the hospital. The condition of three was poor
at the time of discharge, fair in twenty-four, and very
good in thirty-seven ; thirty-two were above their birth
weights and fifty-seven were gaining in weight. Three
months later, thirteen were reported as having died,
twenty-eight were unheard from, and twenty-one were
found to be alive and doing well. The author gives
full description of incubators and methods of treatment.
The Application of a Rational Surgical Tech-
nique to the Removal of the Foreskin By Leon-
ard Woolsey Bacon, Jr.
Occasional Periscope of Teratology. ^By J. \V.
Ballantyne.
Arcliivfiir Dcnn. iiud Syph., vol. /., Nos. 2 and j, igoo.
The Favorable Effects of X-Rays in Lupus.—
Himmel makes a study of the results of Roentgen-ray
medication in lupus and the side effects upon intact
skin and appendages. He finds that the relatively
harmless inflammatory reaction produced upon the
skin by the action of the rays, as soon as the latter
have penetrated to the subcutaneous cellular tissue,
acts favorably upon the lupus infiltration and destroys
the bacilli and brings about healing of the skin. The
A-rays are, therefore, of benefit, but naturally do not
prevent new bacilli from lodging here and producing
new nodules.
Endothelioma of the Skin.— Eduard Spiegler pre-
sents with several portraits and microscopic drawings
a review of the literature of endotheliomas of the skin
or rare forms of skin tumor. The case represented by
a colored lithograph is a striking one from the great
number of tumors present and their peculiarity of
formation. Histologically, they resemble sarcoma at
times and become malignant in course, though usually
they appear to be clinically innocent.
A Method of Rapid Staining of the Gonococcus.
— Uhma gives a way of rapidly coloring Neisser's di-
plococci in fresh unfixed preparations. The object-
glass is moistened with a one-half to one-per-cent. neu-
tral red solution (Griibler) and dried. A small drop
of pus is placed on a cover-glass and laid upon the pre-
viously prepared object-glass, pressed down, and ex-
amined. The gonococci are the first morphotic ele-
ments to appear colored.
The Treatment of Some Instances of Blennor-
rhoea of the Eyes with Largin. — Almkvist gives a
brief account of this newer method of treatment, in
which he employs a two-per-cent. solution of largin.
820
MEDICAL RECORD.
^ALay 12, 1900
Much seems to depend upon early diagnosis and prompt
beginning of treatment, just as is tlie case with silver
solutions. When the cornea is not yet implicated, the
results are favorable.
Epidermolysis Bullosa. — Rona describes two new
instances, presenting as after-effects atrophy of the
skin, cysts of the epidermis, and trophic lesions of the
nails. As to the identity of this form with the hered-
itary form described by Goldscheider, the writer is
not at present willing to commit himself.
BuIUtin dc P Aaulhnic de Medccinc, April ij, igoo.
Post-Mortem Diagnosis of Canine Hydrophobia.
■ — M. Nocard instituted a series of investigations in
order to ascertain whether the lesions of the plexi-
form ganglia of the pneumogastric were always pres-
ent in rabies, as stated by Van Gehuchten and Nelis.
The first dog had rabies after seventeen days of incu-
bation, and was killed seventeen hours after the first
appearance of the symptoms. The cells of the ganglia
were absolutely unaltered. The same results were
found in the case of a second dog, killed in the first
attack after twenty-three days of incubation. The
third dog, seized with madness after thirty-two days
of incubation, had marked lesions of the ganglia.
Half the cells were destroyed, and the whole of each
ganglion was infiltrated with leucocytes. A fourth dog
had very slight lesions. On the whole, the author
thinks that when the results are negative the dog can-
not be considered to have been free from suspicion of
rabies, and the persons bitten should be taken to the
Pasteur Institute.
Goat Vaccine among the Kabyles. — M. Hervieux
reports the results of Fargin's experiments with this
vaccine in a country where bovine vaccine is most
difficult to obtain. The result was in every respect
equal to that obtained by cowpox, and the author rec-
ommends its use in that country, where cows are so
rare that in seven months' time Fargin never saw one,
and never had beef to eat.
OTorrespontlencc.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN WAR.
CFrom our Special Correspondent.)
The Progress of the War. — Since I last wrote Lord
Roberts has carried out some careful movements for
clearing the Boers from the southeastern part of the
Orange Free State. When this district is quiet, he
will be able to make a forward movement with much
less risk to his communications. But everything
proves that Roberts is not going to be in a hurry.
He is quite aware that a quick end to the war ha.;
been expected of him, but he is equally aware that if
he gets into "an entanglement"' (as the British
euphemism goes), there is no one to relieve him.
Therefore, he intends to be perfectly sure that his force
is properly equipped, adequately mounted, suitably
clothed, attended by all necessary medical men, and
provided with an unfailing supply of good food before
he starts. Humanity and prudence alike dictate his
proceedings, and I confess that I am a little aston-
ished to find otherwise clear-headed critics of the cam-
paign holding him to be dilatory. A little medical
knowledge would have saved them from rash judg-
ments. Besides Roberts' manoeuvres between Bloem-
fontein and the Basuto frontier, though primarily un-
dertaken to preserve his railway communication with
Cape Town, may at any moment become actively
offensive and even decisively successful against the
Boers; for while the Lritish cavalry drive them from
Dewetsdorp and Wepcuer northward, it may be possi-
ble for another force to cut off their retreat at Lady-
brand. In the course of the next few days it will be
decided whether the Boer forces still left south of
Bloemfontein are surrounded and made to sunender,
or prove able to escape and re-form between the Eng-
lish and Pretoria. There are many loopholes in Rob-
erts' projected circle, and with their great mobility
and perfect knowledge of this country I shall not be
surprised if the Boers burst through it; but I do not
believe that either event will have any rapid impres-
sion on the progress of the war. For, whatever hap-
pens, the road to Pretoria will be strongly held, and
Roberts will be resisted all along the line. The med-
ical oiificers of the British army, under whose care
many Boer sick and wounded prisoners have now
passed, all state that the spirit of the Boers is quite
unbroken, and that obstinate fighting must be expected
of them to the end ; and what the patient while he is
really ill tells the medical attendant is apt to be true.
Sir William MacCormac and Mr. Treves have, I
learn, both arrived back in England. During their
four months' service with the army they rendered ex-
cellent help to the Royal Army Medical Corps, their
moral support being as valuable as their scientific
aid.
The Imperial Yeomanry Hospital. — The staff of
this hospital, which arrived in Cape Town early in
March, have been ordered to Deelfontein, whicli Lord
Roberts has selected as the first site of the hospital.
This place, which is not marked on many maps, is
about four hundred miles from Cape Town and thirty
miles south of De Aar Junction. There is no town,
the only buildings being the railway station, the gen-
eral store, and a puniping-house with machinery capa-
ble of raising a practically unlimited amount of pure
water from a deep well. As De Aar Junction is the
place where the railway lines to Bloemfontein and
Kimberley diverge, it would seem that from every
point of view the spot chosen for the Imperial Yeo-
manry Hospital is a good one. However extended
Lord Roberts' front may be, the hospital will be di-
rectly behind it; it also will be a convenient stopping-
place for any sick and wounded following either upon
Lord Methuen's operations on the Vaal River or upon
the long-expected relief of Mafeking; being two days'
train inland, the sufferers will be saved much of the
weary railway journey vv'hich has been so trying to the
patients brought down to the base hospitals at Wyn-
berg; and lastly, Deelfontein is a pleasant and healthy
place with the splendid water supply to which I have
referred. It should be added that the place now- pos-
sesses a newspaper, for Mr. Newland-Pedley, the den-
tal surgeon to the Imperial Yeomanry, has started a
journal which is called Tlw Devil's Fotiiiiain.
The Effect of Typhoid Fever and Privation in
Ladysmith. — In Ladysmith, as was said in these col-
umns early in the investment of the town, none of the
factors were absent that should make for the develop-
ment and spread of enteric fever. The report of the
army medical department of Great Britain for 1898,
which has only just been given to the public, but
which presumably fell under official eyes at least a
year ago, mentions the place as one where enteric
fever is constantly prevalent — a fact which makes its
selection as a base for military operations appear
rather unfortunate in medical eyes. Add to this en-
demicity the circumstances of a protracted siege, and
you get a position in which it was safe to prophesy
that the worst scourge of armies would be severely
felt. And now we know the figures. The siege com-
menced on November 2, 1899, when the effective
strength of the garrison was 572 officers and 12,924
men. The effective strength at the end of the siege,
May 12, 1900]
MEDICAL RECORD.
821
that is, on March i, 1900, was 403 officers and 9,761
men, the majority of whom were, however, only
'"effective" in name. When the town was relieved,
154 officers and 2,624 nien were in hospital. The
total admissions to hospital during the siege num-
bered over 10,000, and during the last six weeks the
deaths numbered 8 per diem, chiefly from enteric
fever. About 560 persons (officers, men, and follow-
ers all told) died of disease during the siege, the
number of wounded being almost the same. Uut of
the wounded only 8 officers and 51 men died; while
18 officers and 193 men were killed outright in action.
From these figures it will be seen that enteric fever
was the worst foe encountered by the Ladysmith gar-
rison.
Ttie American Hospital Ship, the Maine, arrived
in England on April 23d, taking with her one hun-
dred and fifty-one men and twenty-one o.fficers. Nearly
all the patients were convalescent by the time the ship
readied Southampton, and Lady Randolph Churchill
was able to announce an excellent voyage with favor-
able weather all the way.
Seveie enteric fever has broken out in Kimberley.
Dr. Scholtz, a well-known physician in Cape Town,
has been appointed physician to the Langman Hospi-
tal. This, the second largest of the hospitals sup-
ported in South Africa by private enterprise, is sta-
tioned at Bloemfontein.
Assistant-Surgeon Jackson, a prisoner in Preto-
ria, has died there from dysentery. There are, by the
way, some ominous stories current in Lord Roberts'
army concerning the medical and sanitary care that
is received by the numerous British prisoners in Pre-
toria. These can be but stories, for no one has come
through from Pretoria for many weeks now. A fev;
released prisoners, and Mr. Winston Churchill, and
one or two officers who escaped have narrated their
experience and describe the treatment received by the
prisoners, as it came under their personal knowledge,
to be on the whole good. Feeding is rough, and the
price to be paid for even the smallest luxury is very
high, but there is not, unless there has been some
sudden deterioration in the Boers' humanity, the entire
absence of civilized treatment that has been described
in lurid terms by one or two correspondents for the
British press. The Boer prisoners in British hands
have suffered severely from enteric fevej. Doubtless
it is rumored in Pretoria that the British are treating
their prisoners shamefully, while, as a matter of fact,
these prisoners have received the most careful atten-
tion.
OUR LONDON LETTER.
(Fr
Special Correspondent.)
THE MIDWIVES CONTROVERSY SURGERY OF THE
STOMACH QUESTIONS CONCERNING CANCER — LATE
RICKETS — THE QUEEN IN IRELAND THE ROYAL
ARMY MEDICAL CORPS — SIR BATTY TUKE CANDI-
DATE FOR PARLIAMENT — LIVERPOOL TROPICAL
SCHOOL — DEATHS OF WALTER CLEGG AND R. G.
PATTESON.
London, April 20, igoo.
The midwives bill is rousing a good deal of opposi-
tion. It would have been more effectual if it had
been manifested earlier, but the profession seemed
apathetic and the corporations were hoodwinked. In
tiie report stage the supporters threw off the mask and
showed that they were determined to license midwives
and to decline all restrictions. Some, indeed, af-
fected to keep up the delusion that the midwives when
registered would not be independent practitioners,
and were willing for them to be required to send for
a doctor in dangerous cases. But they refused to
penalize not doing so. This has opened the eyes of
some, and the opponents are being encouraged.
A committee has been formed to oppose the bill,
and more meetings have been held or arranged for.
An attempt is being made to show members of Parlia-
ment the dangers threatened to the public. Dr. Ren-
toul is again to the fore with a plan to form an asso-
ciation of ten thousand members. He formulates
eight objections, and I am afraid that his effort will
not be sufficiently concentrated to defeat the bill.
Dr. Glover is being called over the coals by one
party for his action in this matter. As I told you, he
was challenged to resign from the General Medical
Council and offer himself for re-election. He has re-
plied to this that he is not a mere delegate. It is
natural that he will not accept the mandate of any
committee opposed to the views he expressed openly
when a candidate. It is obvious, however, that he is
losing touch with many electors on this subject, the
more so as events show the objects of the promoters
in their nakedness. I am sorry, because he is an ex-
cellent representative and has done good work. It is
said that he is a general practitioner, but then it is
only as a very high-class general practitioner that he
can be spoken of — quite on a level with the higher
grades. He lives in the most aristocratic part of Is-
lington, has been honorary surgeon to the dispensary,
and enjoys the confidence of a large, high-class clien-
tele, it may well be, therefore, that he looks upon
midwifery with a very different eye from that of the
struggling general practitioner in a poor neighbor-
hood.
If the present bill passes, a doctor may be expected
to be at the call of an ignorant midwife; but if he
keeps an unqualified assistant who has been recog-
nized for years as capable, he is liable to be removed
from the register. If these ignorant midwives are to
be registered, we may look for a great increase in
quackery of all kinds and of abortion-mongering.
Years ago a member of Parliament urged upon me
this last danger. We have seen enough of it without
registration.
A curious circumstance has occurred in connection
w'ith this bill. The Dublin College of Physicians is-
sued a circular letter, asking the Irish members of
Parliament to endeavor to get the measure extended
to Ireland. Now the Irish Medical Association has
issued an urgent appeal to the members of Parliament
to oppose such extension, and goes on to say that the
existing provision in Ireland is as nearly perfect as
possible. It appears that the college acted under the
misapprehension that the bill would prevent the mid-
wives of the Rotunda and Coombe Hospital from
practising in England. This is not the case. But
the bill would register a host of untrained women, who
could flood Ireland and compete with her trained mid-
wives.
Any one who had not followed the progress of sur-
gery on the stomach might well have been startled
when it was announced that Schlatter had performed
a resection of the complete organ, and that the patient
lived in comparative comfort for fourteen months.
Seven other complete gastrectomies have since been
performed, of which three of the patients lived for
thirty-six hours, six weeks, and several weeks respec-
tively. Thus of the eight cases the mortality is four,
or fifty per cent. Of almost complete gastrectomies,
in which at least three-quarters of the organ was re-
moved, fourteen cases have been reported, according
to Mr. Mayo Robson, who stated in his Hunterian
lectures at the Royal College of Surgeons that ten of
the patients had recovered, giving a mortality of 28.5
per cent. Of course the survival may be of very vary-
ing periods in different cases, but in these lectures
Mr. Robson could not give full details, as he had to
822
MEDICAL RECORD.
[May 12, 1900
go over the whole field of the surgery of the stomacli,
which he did with great etTect. He looks hopefully
on the future of gastric surgery, and appeals to physi-
cians with the usual surgeon's cry for earlier diag-
nosis, so that operations if necessary may be per-
formed before the patient's recuperative powers are
exhausted. In perforating ulcer this necessity has
been pretty well brought home to physicians, but there
are many other cases in which a consultation with a
surgeon might well be urged, and of course the earlier
the better. The cases in which surgery has made ad-
vances were thoroughly discussed by the Hunterian
lecturer, who was able to say that his last thirty-two
operations on the stomach in private practice had all
resulted in recovery.
Sir W. M. Banks has given new life to several ques-
tions connected with cancer by the views he expressed
in his recent Lettsomian lectures. One of these is the
relation of diet to cancer, and though this in some
form is a very old question, we have really hardly any
definite knowledge on the subject. The impression
of Sir VV. M. Banks is that overfeeding predisposes to
the disease, especially excess of flesh food. Here we
touch another undecided question — the alleged in-
crease of cancer. Sir \V. M. Banks believes that there
is a real increase; therefore, accepting this as a fact,
he appeals to it as supporting the view that excess of
meat food conduces to the development of the disease.
No one doubts that there has been a progressive in-
crease in the consumption of meat for some twenty or
thirty years, and that increase has been most marked
among the laboring class. This, however, is a long
way ofiE from proof of the hypothesis. Admitting the
concurrent increase of two circumstances by no means
proves a relation between them; and considering the
connection of gout with flesh diet, the suggestion that
cancer occupies a similar position is being warmly
disputed and in some quarters pooh-poohed.
Amony other explanations of the increase of cancer
— when such increase is admitted — may be named
more careful diagnosis, more accurate statistics and
nomenclature, and increased longevity. Cancer, be-
ing a disease of the later period of life, might be ex-
pected to increase with the prolongation of that period.
But whether the two have increased /fl/v /i^i'.f// is nat-
urally more difficult to show than that there has been
an absolute increase in one.
The question of parasitism was treated by Sir W.
M. Banks with a certain degree of reservation, but he
freely admitted that the bodies described as parasites
by various observers are special organisms. Whence
they come, what they do, is another point. He is
convinced they exist, and gave some experiments by
Mr. Montsarrat, of the Liverpool Infirmary, confirma-
tory of those of other bacteriologists. It is to these
specialists we must look to settle the question. The
question of treatment derives much importance from
the successes that have been achieved of late by ex-
tensive operations. Sir W. M. Banks was a pioneer
of this practice, but has never gone to the extremes of
some. His practice has been much the same as that
of Samuel Gross. Indeed, it is to thes3 two surgeons
that the modern operative treatment ought to be dated,
for they carried it out faithfully when not a few ac-
tively opposed them. Now it is rather sad to see sur-
geons attributing the origin of the practice they once
opposed, but now adopt, to the labors of later Ger-
mans, rather than to the British and American opera-
tors, Banks and Gross, who initiated the method.
Among the cases exhibited at the Medical Society
was one of late rickets, shown by Mr. Muirhead Lit-
tle. His patient was a girl aged seventeen years,
who was in good health up to the age of five, at which
time knock-knee was noticed. At seven years she
took to crutches. She was said to have broken both
thigh bones, one six, the other five years ago. \\hen
seen by Mr. Little (October, iSggj, her length in the
recumbent position was forty-four inches. The head
and ribs showed signs of rickets; the lower end of the
radii and the ulnae were much enlarged; the shafts of
the femora curved forward and outward, making pro-
gression cross-legged; the tibia were normal. Mac-
ewen's operation was performed on one knee, when the
bone, instead of being hard, was so soft that a mallet
was scarcely necessary. The bones were unusually
pervious to .r-rays. Only half the normal amount of
calcium was present in the urine. The marked en-
largement of the epiphyses distinguished this and
similar cases mentioned from rachitis adolescentium.
Mr. Kellock thought it might be a case of late rick-
ets, but there were points named which suggested to
him mollities ossium or fragilitas ossium, or perhaps
a combination of them.
The president (Dr. F. T. Roberts) said the case
strongly resembled rickets, and the bone ends were
certainly enlarged. The changes in the chest were
not those of early rickets, but this was not usually the
case in late rickets.
Mr. Little replied that the idea of rickets only af-
fecting the epiphyses was novel; the whole bone was
invohed ; fracture was frequent, but w as of the green-
stick kind in rickets. This patient had never suffered
any pain. He used the term " late rickets," as it re-
sembled cases so described more than any others.
The Irish royal colleges were naturally among the
institutions to present loyal addresses to the Queen
on the occasion of her majesty's happy visit. The
City of Dublin Hospital is henceforth to be distin-
guished by the prefix Royal.
The Royal Army Medical Corps continues to gather
fresh laurels at the war. This is the more significant
just now when reputations are being lost in other
directions. Mr. Treves has returned home, and Sir
W. MacCormac is on his way. They have had a
pleasant trip at the country's expense, and the army
surgeons received them as brethren.
Sir Batty Tuke is a candidate for the representation
of the universities of St. Andrews and Edinburgh,
vacant through the death of Sir William Priestley.
An anonymous benefactor has endowed a colonial
fellowship of ,^.100 a year for five years in the Liver-
pool School of Tropical Medicine.
Mr. Walter Clegg, M.R.C.S., died on Monday, aged
seventy-nine years. For nearly forty years he was the
coroner for the Boston division of Lincolnshire. He
was the son of a Wesleyan minister, and founded The
Boston Guardian in 1854. He served in the Crimea
as surgeon to the Second Battalion Rifle Brigade.
While tliere he acted as war correspondent for 7 /k II-
histratid London AVft'.f. He was one of the oldest
war correspondents, having begun that work nearly as
soon as Sir W. H. Russell, and he lived to be one of
the oldest coroners. He was mayor of Boston in
1868 and 1869. Subsequently he was medical officer
of health up to about three years ago.
The death is announced of Dr. R. G. Patteson, sur-
geon to the Meath Hospital, Dublin. Though hardly
forty years old, he had achieved a high position. He
graduated in arts and medicine at Trinity College in
1885, and took the travelling prize of Dublin Univer-
sity in 1886. After studying in London, Vienna, and
Berlin, he returned to Dublin, took the fellowship of
the College of Surgeons, became one of the examiners,
and carried on his work until ill health, which had
troubled him for long, compelled him to withdraw
from his arduous labors. He made many contribu-
tions to surgical and biological literature.
Tetanus. — Inject fifteen minims of a two-per-cent.
carbolic-acid solution every two hours. — II Foliclinico.
May 12, 1900]
MEDICAL RECORD.
823
DISINFECTION OF THE UMBILICUS IN
ABDOMINAL OPERATIONS.
Sir: Perhaps the following will be of some interest to
the readers of the Medical Record: In the prepara-
tion for abdominal operations, especially that of dis-
infecting the abdominal walls, there is a detail which
in this country is not perhaps very widely known, but
does deserve a wider acquaintance; it is the com-
plete cleansing and disinfection of the umbilicus,
made possible by traction upon it with a clamp for-
ceps. This smoothes out the numerous depressions
naturally situated there, and offers an uninterrupted
and smooth surface for thorough cleansing and disin-
fecting.
The above is from observation in the Paris hospi-
tals, in which it is part of the preparatory technique.
James Taylor Hanan, M.D.
Brooklyn, N. Y.
HOW TO SEND ANATOMICAL SPECIMENS
BY MAIL."
Sir: An article appeared in the issue of April 21st,
p. 6g6, by Steward Gordon, on " How to Send Anatom-
ical Specimens by Mail." I wish to mention one
class of specimens to which I have found practically
similar methods not applicable; namely, soft speci-
mens like the intestinal mucosa. The pressure of the
lint fibre in specimens I have seen caused a net like
indentation which rendered them almost valueless for
museum purposes; and the distortion, histologically,
unless understood, causes confusion, and in some
cases might lead to seriously incorrect statements.
Specimens of this kind are preferably sent in fluids;
and screw cases are made especially for sending them
by maiL D. S. Lamb, M.D.
Army Medical Museum, Washington, D. C.
WHAT IS THE BEST POSTURE FOR THE PA-
TIENT IN BED AFTER ABDOMINAL SEC-
TION, PARTICULARLY IN PUS CASES?
To THE Editor of the Medical Record.
Sir : ! was much interested in the article by Dr.
George R. Fowler, entitled " Diffuse Septic Perito-
nitis, with Special Reference to a New Method of
Treatment, namely, the Elevated Head and Trunk
Posture, to Facilitate Drainage into the Pelvis, with a
Report of Nine Consecutive Cases of Recovery," and
published in the Medical Record of April 14, igoo.
During the past ten years, in the after-treatment of
nearly all my abdominal sections — particularly pus
cases — and much for the same reasons given by Dr.
Fowler, I have employed the method advocated by
him, and have not been persuaded to change it. The
head and shoulders of my patient are elevated upon
several pillows, the castors in the lower posts of the
bedstead are removed, and a round hair pillow is
placed under the knees of the patient, for the double
purpose of preventing slipping down in bed and se-
curing additional relaxation of the abdominal mus-
cles; this relaxation affording comfort to the patient
and favoring peristalsis and the descent of fluids to-
ward the pelvic cavity.
In the after-management of these cases it is both
curious and instructive to note the different theories
upon which we act — a sort of theoretical mental gym-
nastics of kaleidoscopic change of tint and figure.
Only recently, it has been enjoined upon us that bet-
ter results will follow the employment of a posture
exactly the reverse of that advocated by Dr. Fowler;
that is, to elevate the hips of the patient in order to
favor the diffusion of fluids over'an extensive area of
peritoneal surface, which somehow digested the con-
tained poisons, or even absorbed them with greater
facility. To cite a common phrase: "A larger area
of peritoneal surface can take care of a phenomenal
amount of toxins."
Alirabile didu ! Dr. Fowler prefers, without pre-
vious irrigation, to wipe the abdominal cavity dry with
gauze, leaving in no decinormal salt solution to atten-
uate the toxins; rehabilitates glass drainage — some-
times employing several tubes, reinforced by numer-
ous wicks or strips of gauze, and then delights in
observing a copious exit of fluids into the superim-
posed dressings. Adding preliminary irrigation,
Lawson Tait also, throughout his brilliant and suc-
cessful career, laid the greatest stress upon an endeav-
or to keep the peritoneal cavity free of all accumu-
lating fluids; hence his constant reliance upon the
drainage tube in all pus cases or when bleeding was
feared from ruptured adhesions. He would keep the
peritoneal membrane as dry as possible; so would Dr.
Fowler. Each may have had a dififerent theory upon
which to base the practice, but the latter virtually is
identical with both operators. In the practice of our
art, truly "the heresy of to-day is the creed of the
next."
Dr. Fowler is to be congratulated upon his enviable
record in an ordinarily hopeless class of cases, and
his results speak volumes for the treatment employed,
although it cannot justly be claimed that this treat-
ment is a distinctly new method.
Henry K. Leake, M.D.
Dallas, Tex.
^jeuimuB and V^gXxzzs.
Transactjons of the British Orthop.edic Society.
Volume in. Published by the Society. Bristol: J. W.
Arrowsmith. 1899.
Eighty-nine bound pages, giving reports of various ses-
sions for 1897-98, of especial interest to the orthopedic sur-
geon.
Diseases of Women. A Text-Book. By Charles B.
Penrose, M.D,, Ph.D., Professor of Gynecology in the
University of Pennsylvania, etc. Illustrated. Third edi-
tion. Philadelphia: W. B. Saunders. 1900.
A few additions have been made in this new issue, but the
author has carefully revised the text. A feature of the work
is that in most instances but one method of treatment is
given for each disease, thus rendering the student's chances
of confusion less. Many problems are made much clearer
by the illustrations given. The work seems to be justly
popular.
Refraction and How to Refract: Including Sections
on Optics, Retinoscopy, the Fitting of Spectacles and Eye-
glasses, etc. By James Thorington, A.M., M.D.,
Adjunct Professor of Ophthalmology in the Philadelphia
Polyclinic and College for Graduates in Medicine ; Assis-
tant Surgeon at Wills' Eye Hospital, etc. Illustrated.
Philadelphia: P. Blakiston's Son & Co. 1900.
Those who have read the author's little manual of retinos-
copy with the plane mirror will not be surprised to find here
a complete but succinct guide to the determination and cor-
rection of ametropia, beginning with a consideration of rays
of light and of elementary optical principles. Successive
chapters deal in a thoroughly practical manner with the stan-
dard eye, the various errors of refraction, the balance of the
external eye muscles, cycloplegics, and, finally, with the ap-
plication of various methods to the prescription and fitdng of
correcting glasses. The book can be recommended not
only to beginners in the study of ophthalmology^, but to those
practitioners and students as well, whose limited knowledge
824
MEDICAL RECORD.
[May 12, 1900
of mathematics precludes the study of Helmholtz or Don-
ders. A purist might take exception to the author's use of
the word " refract," Hn the sense of testing refraction — a
barbarism which is not excused by its prevalence. Usage,
so called, is as unreliable a guide in the choice as it is in the
accentuation and pronunciation of words, to judge by the
coining of such terms as " refractionist " and "refracting
opticist. " As the author himself says, refraction has come
to mean the optic condition of an eye in a state of repose or
under the physiological effect of a cycloplegic. Let us use it
in this sense, then, and when we wish to speak of determin-
ing ametropia, let us use two simple words instead of a single
one which, in its misapplication, has a meaning " by courtesy
of complicity " only.
Essentials of Medical Chemistry, Organic and In-
organic, containing Questions on Medical Physics,
Chemical Philosophy, Analytical Processes, Toxicology,
etc. Prepared especially for students of medicine. By
Lawrence Wolff, M.D., Demonstrator of Chemistr)',
Jefferson Medical College ; Physician to the German Hos-
pital of Philadelphia; Member of the German Chemical
Society, of the Philadelphia College of Pharmacy, etc.
Fifth edition, thoroughly revised by Smith Ely Jelliffe,
M.D., Ph.D., Professor of Pharmacognosy, College of
Pharmacy of the City of New York ; Clinical Assistant,
Department of Neurology, Columbia L'niversity, New
York. Philadelphia: W. B. Saunders. 1899.
The chapters dealing with organic chemistry have been con-
siderably modified and enlarged, more particularly in the
discussion of physiological chemistry. An attempt has been
made to present a brief outline of the present status of our
knowledge of the chemical constituents of the human body.
The revision by Dr. Jelliffe brings the subject-matter well
up to date.
A Treatise on Surgery, by American Authors.
Edited by Roswell Park, A.M., RLD. Condensed
edition. 8vo, 1,262 pages. New York and Philadelphia :
Lea Brothers & Co. 1 899.
This condensed edition of the larger work is the result of a
wise conclusion to meet the growing requirements of the
busy practitioner, whose time and opportunities for the
consultation and study of elaborate treatises are necessarily
limited. From the standpoint of condensation, which is
the main one to consider under present circumstances, the
work is a conspicuous success, giving all that is required un-
der the respective sections and conscientiously preserving all
that is of practical value. The general arrangement of the
elaborate work is well preserved, and in many respects fully
answers all its essential purposes. On behalf of the editor
and his able collaborators, it is but just to say that the work
is fully up to the times, not only from a pathological but an
operative point of view. In respect to the bacteriolog)' of
surgery proper, substantial progress has been made in adapt-
ing the resources of the laboratory to the requirements of
advanced study of the blood constituents, tumor elements,
classification of growths, and possible microbic origin of
malignant processes. It represents a very large amount of
valuable research in a very small compass.
La Pratique des Accouchements Obst^trique
Journaliere. Par Henri Variner, Professeur Agrege
A la Faculte de Paris, Accoucheur des Hopitaux, Secretaire
General de la Societe d'Obstetrique, de Gynecologic et
de Psdiatrie._ Avec 387 figures. 437 pages. Paris:
G. Steinheil, Editeur. 1900.
This valuable work, founded upon the author's lectures,
aims at tJie instruction of the student by means of illustra-
tions reproduced from actual photographs. While promi-
nence is given to these, the text is none the less full and
clear. Chapter I., on the diagnosis and hygiene of pregnancy.
is especially useful to the student ; in fact we do not recall
any more lucid description of the details of obstetric palpa-
tion. The section on diagnosis is most practical. Chapter
II., which deals with normal labor, including a hundred and
thirty pages, is profusely illustrated. Chapter III. deals with
delivery, and discusses at length the placenta and its mode
of expulsion. Numerous photographs, taken at the bedside,
are introduced as in the previous chapter. American read-
ers will disapprove strongly of the advice to make traction on
the cord. Chapter IV., on the normal puerperium, treats
thoroughly of the subject of involution, especial attention
being paid to the changes in the uterine tissues. Numerous
original drawings are introduced. The last hundred pages
are devoted to a review of the subject of puerperal sepsis,
particularly the prophylaxis. Several sections are given to
bacteriology. In general it may be stated that this mono-
graph is most praiseworthy. The author's style is original
and pleasing ; the illustrations are numerous and, though not
always satisfactory from an artistic standpoint, they are well
calculated to catch the eye of the student and to impress upon
him the points made in the text. The paper, type, and general
make-up of the book are above the average.
Mentally-Deficient Children; their Treatment and
Training. By G. E. Shuttleworth, Baltimore, Md.
Second edition. Illustrated. Philadelphia: P. Blakiston's
Sons & Co.
In this new edition there is contained additional matter bear-
ing upon education, and special measures recommended and
adopted by school authorities, notably by the school board
for London. The author's experience seems to qualify him
well for a task which has been acceptably filled.
A Manual of the Diagnosis and Treatment of the
Diseases of the Eye. By Edward Jackson, A.M.,
M. D. , Emeritus Professor of Diseases of the Eye in the
Philadelphia Polyclinic; formerly Chairman of Section on
Ophthalmology of the American Medical Association ;
Member of the American Ophthalmological Society ; Fellow
and ex-President of the American Academy of Medicine.
With 178 illustrations and two colored plates. Philadel-
phia: W. B. Saunders. 1900.
This volume contains six hundred and four pages. It is of
convenient size, well printed on good paper, and so ar-
ranged that its contents are easily accessible. The author
states in his preface that the "book is intended to meet the
needs of the general practitioner of medicine and the be-
ginner in opthalmology. " It is truly an admirable work for
this purpose, and contains much that will interest the ad-
vanced worker in ophthalmology. Written in a clear, concise
manner, free from superfluous statements, it bears evidence
of the author's comprehensive grasp of the subject. The
text is divided into twenty chapters. One chapter is de-
voted to directions regarding " The Examination of the Pa-
tient, Case Records, etc.," one to "Remedies and their
Applications."' one to " Ocular Symptoms and Lesions con-
nected with General Disease. " The work is especially strong
in the chapters which are devoted to the examination of the
eye, the consideration of refraction and all that pertains to
it, the disorders of muscles, and the ophthalmoscope. A
valuable feature of the work is the short bibliography that
follows each chapter, affording a means for the more com-
prehensive investigation of each subject. The term " mul-
tum in parvo " is an appropriate one to apply to this work.
It will prove of value to all who are interested in this branch
of medicine.
©Hnical gc}.mrtmeiit.
A CASE OF RAYNAUD'S DISEASE.
Bv F. J. BOWEN, M.D.,
Mrs. G , twenty-eight j'ears of age, had for several
winters suffered from symptoms corresponding to the
description of the stage of local asphyxia of this affec-
tion. The fingers of both hands were affected, circu-
lation apparently disappearing from about the distal
and middle phalanges. Nutrition suffered in a corre-
sponding degree. The parts affected appeared shrunk-
en or withered and cold, the nails were dried and
lustreless, and at one time she said that the tips of the
fingers felt sore, as if almost to the point of ulceration.
The patient would hardly be called anremic, but was
slender and might be spoken of as "thin-blooded."
She was of nervous temperament. Her husband was
a laundryman whom she sometimes assisted. When
she came under my care in early winter, I advised her
first, in regard to this work, not to go out of doors to
May 12, 1900]
MEDICAL RECORD.
825
hang up clothes; to wash with the hands in warm
water for a moderate length of time was advised, but
for a longer time was forbidden. In the way of medi-
cine she was given tonics — compound syrup of hypo-
phosphites I believe — and a preparation containing
digitalis, nitroglycerin, and belladonna.
For the first time in several successive winters the
symptoms were avoided.
thirty-five days after the accident, the extension was
taken olif, because he complained so much of the dis-
comfort. 'J'he fracture at that time was quite firmly
united and the callus very marked. On January 24th
the patient got up and used the wheel chair, and the
next day began to walk with crutches. From that day
to the present he has continued to walk around, and
three weeks later even discarded the use of a cane.
The injured leg is one inch shorter than its fellow.
A PIECE OF CHEWING-GUM IN THE
URETHRA.
By W. II. peters, M.D.,
AN ABDOMINAL VARIX.
By C. M. galloway, ^LD.,
F. McG^ — , aged thirty-five years, consulted me for
retention of urine, due to a foreign body in his ure-
thra, which he said was chewing gum; that he inserted
it in the meatus in March, 1899. He states that he
has suffered the past ten months considerable pain in
urinating, but not enough to cause him to seek med-
ical advice. Lately his water has not been so free,
and at the present time he has been unable to pass
any water for eight hours. He gives a history of hav-
ing had gonorrhoea ten or twelve times, but not since
March, 1899. The bladder was very much distended,
and the pain radiating to the glans penis was severe.
There was a slight amount of blood about the meatus
caused by his trying to dislodge the mass. At the
bulb could be plainly felt a mass about an inch long,
nodular, about half an inch or more at its greatest
thickness, and hard to the touch. It was immovable.
A very small-sized silver catheter was pushed by it
with considerable difficulty; the water was drawn,
and the patient was relieved. With a sharp uterine
curette the body was broken up and found to be com-
posed of chewing-gum, coated with phosphate of lime.
The patient was given morphine gr. J_>, and sent to
the hospital, where a few small pieces of a calcareous
substance were removed by the visiting surgeon. The
patient recovered without a chill. Dorr, in the Brit-
ish Alcdkiil Journal oi May 14, 1892, reports a case
in which a man had passed up his urethra a piece of
chewing-gum, which in three months became largely
coated with phosphates. It was removed by the su-
pra-pubic method. As the gum was still soft and
sticky it would have been impossible to disengage
the jaws of the lithotrite or to crush the gum.
A CASE OF RAPID UNION IN FRACTURE OF
THE THIGH.
By clarence A. WELLS, M.D.,
Egbert H , aged fifty-eight years, a male nurse in
the hospital of the Illinois Soldiers and Sailors' Home,
while going from the ward to the hospital kitchen, one
hundred feet or more away, slipped and fell on the icy
walk and sustained a simple, oblique fracture of the
femur just below the trochanter. He suffered greatly
from shock, so that the fracture was not dressed until
the second day. All the signs and symptoms of that
injury were present. Buck's extension was employed,
and sand-bags weighing twenty pounds were applied
tentatively. Counter-extension was secured by eleva-
tion of the foot of the bed. As the patient was rest-
less, and as no fracture bed was used, the Hamilton
long-side splint was omitted, and instead long sand-
bags were used externally from the toes to the chest,
and internally the entire length of the leg. Aside
from some disturbance of the kidneys for a few days,
the patient did well. The calls of nature were attended
to in bed by means of the bed-pan. On January 20th,
T. G , Co. A, Twentieth Regiment Ohio Vol-
unteers, infantry, enlisted at Mansfield, Ohio, on
October 22, 1862. He was discharged at Louisville,
Ky., on July 15, 1865. The curious affection shown
in the illustration began to make its appearance very
shortly after his discharge from the service. It began
at about the centre of the epigastric region as a small,
tender swelling, and has gradually increased until it
has assumed the proportions seen in the illustration.
It cannot be reduced and is very tender on pressure.
The mass over the stomach is somewhat larger in pro-
portion to the other portion than the photograph indi-
cates. It is almost as large as his clenched hand.
On account of the movement of the abdomen in breath-
ing it does not show very plainly. It is diagnosed at
a varicose condition of the internal iliac vein. It
seems to have no valves. No varicose veins are found
elsewhere. It is supposed to have originated from
pressure of his cartridge belt. It has not increased in
size during the past few years.
Appendicitis. — Ice bag; opium by suppository; no
food save a solution of peptone and sugared water.
The bowels should be kept at rest for a week and then
be gently washed out with a decinormal salt solution
per rectum. — Laube.
826
MEDICAL RECORD.
[May 12, 1900
CONGRESS OF AMERICAN PHYSICIANS
AND SURGEONS.
FIFTH TRIENNIAL SESSION.
Held at Washington, D. C, May /, 2, and 3, igoo.
(Continued from page 770.)
Second Day — Wednesday, May 2d.
The second and final session of the Congress of
American Physicians and Surgeons was held in the
Lafayette Square Opera House in the afternoon. The
meeting was called to order by the president, Dr. Bow-
ditch, at 2 :55 P.M.
The proposition made at yesterday afternoon's meet-
ing for the appointment of a committee of three with
full power to draw up and execute a memorial and
petition to Congress of the United States, asking that
charitable, religious, and educational institutions be
relieved from such provisions of the war tax as are
levied upon them and likewise upon legacies left to
such institutions, was next taken up. The resolution
was passed by unanimous vote, and the president ap-
pointed the committee as follows: l")rs. F. C. Shat-
tuck, A. Jacobi, and William H. Welch.
Dr. Keen, of Philadelphia, then offered the follow-
ing resolutions of medical interest, which were unani-
mously carried:
" Whereas, The medical profession employs various
kinds of exact measuring apparatus, particularly clin-
ical thermometers, ureometers, lactometers, and volu-
metric apparatus; and
" Whereas, The physician should be able to obtain
a written official guarantee of the accuracy of such
apparatus; and
" Whereas, No bureau has been established by our
government for this purpose, necessitating the impor-
tation of certain apparatus from countries possessing
standardizing bureaus; therefore, be it
" Resolved, That the Congress of American Pliysi-
cians and Surgeons heartily indorse the movement
now on foot establishing such a standardizing bureau,
where such work and other equally important may be
undertaken.
"■ Resolved, Jiirther, That a copy of these resolutions
be forwarded to the Secretary of the Treasury, to the
president of the Senate, to the speaker of the House
of Representatives, and to the chairman of the House
committee on coinage, weights, and measures."
Sociological Status of the Physician. — Owing to
the unavoidable absence of Professor Osier, whose an-
nounced subject was " Modern Therapeutics," Dr.
Clarence J. Blake, of Boston, spoke on the above
subject. He said that the term " sociology," first used
by August Comte' less than sixty years ago, might be
briefly and broadly defined as "the science of the laws
of human relationship," and, as often happened in the
presence of cognate intellectual processes working tow-
ard the same end, the suggestion of a concise defin-
itive appellation furnished a rallying-point to which
the various workers converged, and from which they
went out strengthened by a sense of companionship
and encouraged to more extended effort by a better
comparative knowledge. Of all special educations
that of the science and practice of medicine, when it
was of the best quality, was the most exacting and
made the largest demand upon the staying-power of
the student; it was longer in duration, more confining,
and required more intense application than the cor-
responding courses which led to a degree either in law
or in divinity, and afforded a larger suggestive oppor-
tunity for collateral scientific reading. He believed
that the hospital of to-day was something very much
more than a repair shop; it was a school full of ob-
ject lessons in the application of those qualities which
are the "uprights," the "girders," and the "binding-
rods " of the modern social structure ; it was the most
absolutely clean of all human habitations, and the
present splendid successes of surgery in the ameliora-
tion of suffering and the preservation of life were due
not only to the application of trained skill and intel-
ligence, but to its operations under conditions of ab-
solute sterilization which were microscopic in their
minutise. He said that the entrance of women into
hospital life and work was one of the sociological ad-
vances for which the medical profession was mainly
responsible, a responsibility having a serious ethical,
as well as an important economic side. The teacher
had a regular stipend, allotted hours of work, and a
definite holiday; the nurse, in private practice, had
no regular stipend, no protracted leisure, and led an
economically irregular life, with occasionally extraor-
dinary demands upon her strength and powers of en-
durance. The medical profession, which had created
the trained nurse to its own great advantage and with
considerable extension of its helpfulness, was owed a
debt which should be acknowledged not only individ-
ually but generally. The doctor spoke of the utility
of medical inspection and of its necessity in many
cases. He covered at some length the establishment
and maintenance of charitable institutions, especially
those suited for the mental development of the feeble-
minded and mutes. In closing, he said that another
relationship which might be broadened beyond its in-
dividual phase was that between the doctor and the
clergyman, and recent experiments based upon a prop-
osition that the divinity student should have. oppor-
tunities to see the practical side of hospital and other
instituion work under medical guidance were so prom-
ising as to lead to the serious consideration of making
this a definite part of the regular divinity-school in-
struction.
President Bowditch, at the conclusion of Dr.
Blake's paper, stepped forward and said : " Now, gen-
tlemen, it is my pleasant duty to ask your attention to
our honored ex-president, who has cultivated the fields
of medicine and literature with equal success, and
who has kindly consented to express himself in his
own charming verse on the evolution of the physician."
Dr. S.,Weir Mitchell then spoke, in part, as fol-
lows: "Mr. President and Fellow-members of the-
Congress: I will say a word in explanation of the
unusual fact of my appearance here. It is perfectly
well known, I venture, that never before in the history
of medicine has a congress been addressed in verse.
For this novelty you may thank the committee of the
congress and my friend, its president."
Dr. ^litchell, upon rising to address the audience
and upon the conclusion of the reading of the poem,
was greeted with prolonged applause and was the re-
cipient of many congratulations. He spoke with em-
phasis, feeling, and gesture. He described the doc-
tor's honorable, dignified, and humanitarian station
in life. The priests disagreed, but the doctor extended
the universal hand of fellowship and good-will. The
sentimental and pathetic introductions were delivered
very impressively. One pretty verse reads:
" What sense of pleasure won that helping hand,
You best can tell, you best can understand ;
Who, looking back across your busy years,
Know what your hands have spared of pain and tears."
His lines, "One bugle-note or one battle-call, one
watch-word — Duty — that is all," was drowned in pro-
longed applause.
The congress was then adjourned until the evening,
when the president addressed the assemblage upon
"The Medical School of the Future." He said that
May 12, 1900]
MEDICAL RECORD.
827
among the intellectual movements that have charac-
terized the century now drawing to a close, there was
perhaps no one more deserving of careful study than
that which was concerned with providing education
for the people in the school, the academy, and the
university. The importance of popular education be-
came apparent in proportion as political freedom was
secured for the people. Thus Viscount Sherbrooke,
better known as the Hon. 'Robert Lowe, in the Re-
form debates of 1866 and 1867, after the passage of a
bill for the extension of the suffrage, uttered the well-
known words, " We must now, at least, educate our
masters." The same sentiment had also more recently
been embodied in the inscription on the Boston Pub-
lic Library, "The commonwealth requires the educa-
tion of the people as the safeguard of order and lib-
erty"; and in the presidential address of Dr. J. M.
Bodine, at the meeting of the Association of American
Colleges in 1897, we find the same idea thus ex-
pressed: "In America the citizen is king. The
king must be educated to wield aright his ballot scep-
tre." For many years educators looked upon their
work with no little complacency. The educational
systems of the various civilized countries were sup-
posed to be well adapted to the ends in view, and ed-
ucational exhibits had generally been regarded as
important features of international expositions; but
within the memory of most of those now before him
times of serious discontent had not been wanting.
Education had not always been found to furnish the
required safeguard for order and liberty. Highly
educated men had often been found singularly jack-
ing in mental balance. Schools for the inculcation of
"common sense" have never yet been established.
Even the great developments of psychology as an ex-
perimental sign had occurred chiefly within the last
twenty-five years; though it had served to establish
many a law of mental action, it had thus far failed to
justify the hope that pedagogy might find in psychol-
ogy a foundation for the erection of rational systems
of education. Indeed, we had recently been told by
one of the ablest expounders of the science that " it
was a great mistake for teachers to think that psychol-
ogy, being the science of the mind's laws, was some-
thing from which they could deduce definite pro-
grammes and schemes and methods for immediate
school-room use. Psychology was a science and teach-
ing was an art; a science only laid down lines within
which the rules of the art must fall, laws which the
follower of the art must not transgress, but what par-
ticular thing he should positively do within those
lines was left exclusively to his own genius." Even
this general guidance had been very imperfectly
afforded, for the limits set by the science of psychol-
ogy to the art of teaching had never been precisely
defined. In fact, the most fundamental question of
all, namely, the relation of mental to physical devel-
opment, had not yet been settled, though much mate-
rial for its study had been collected. It was not,
therefore, surprising that in many countries teachers
had made too great demand upon the time and strength
of growing children. This had been clearly the case
in some parts of Germany, where school-boys from
eight to fifteen years of age had found their vital
energy so far exhausted by the school work required
of them, that they had lost all inclination for the vig-
orous athletic amusements so naturally indulged in
by Anglo-Saxon boys. The deterioration of the race
as a result of too close application to intellectual pur-
suits to the neglect of the physique had been fortu-
nately obviated, in the case of Germans, by the army
system, which took entire possession of the youth and
forced him to devote three years to the education of
his body, turning him out at the end of that period a
young man with mind and body trained to a high de-
gree of efficiency, well fitted for civil as well as mili-
tary pursuits, and comparing favorably in all respects
with men of his age in other nations. Looked at from
this point of view, the German army must be regarded
as an important part of the educational system of the
country, though as a piece of educational machinery
its workings could not be considered economical. In
fact, the absurdity of depending upon the army to
remedy the defects of the school system had long since
been forced upon the attention of German educators,
and the difficulties above alluded to were i.ow in a
fair way to be removed. The relations between the
governing body of a university and its medical faculty
in matters of administration were often defined by
custom and tradition rather than by statutory provi-
sions, and differed very considerably in different insti-
tutions. In general, two methods of government
might be distinguished. Either the initiatory was
left with the teaching faculty, the governing body ex-
ercising a veto power, or the governing body acted
directly without necessarily asking advice from the
faculty or its members. The former method of gov-
ernment was most likely to be found in those cases in
which a well-established medical school had allied
itself to a university for the sake of the mutual bene-
fits that might ensue from the union, and the latter
method in those cases in which a university had com-
pleted its organization by the establishment of a med-
ical department. In speaking of the proper distribu-
tion of the work of a medical student. Dr. Bowditch
said that thirty years ago no such question seemed to
have presented itself to the minds of the instructors
in medicine. The medical faculties of that time con-
tented themselves with providing each year courses of
lectures covering the departments of medicine, as they
were then understood, and every student was expected
to attend as many of the lectures as he saw fit. Be-
tween 1870 and 1880 the fact that there was a natural
sequence in medical studies became generally recog-
nized, and graded courses of instruction were estab-
lished in the principal medical schools of the country.
The grading was not, however, carried sufficiently far.
Thus instruction in both anatomy and physiology was
generally given simultaneously through the whole of
the first year, though the knowledge of structure should
logically precede a knowledge of function. The time
seemed now to have come for taking another step in
grading medical instruction, and during the academic
year now drawing to a close instruction in the Harvard
Medical School had been given in accordance with a
plan of which the guiding principles were concentra-
tion of work and sequence of subjects.
AMERICAN CLIMATOLOGICAL ASSOCIA-
TION.
Seventeenth Annual Meeting, Beld at the Arlington
Hotel, Washington, D. C, May i, 2, and j, igoo.
First Day— Tuesday, May ist.
Abraham Jacoei, M.D., President in the Chair.
President's Address. — Dr. Jacobi, in his opening
address, discussed the subject of cardiac murmurs in
infancy and childhood. He referred to the rarity of
functional murmurs in infants, and reported such a
case occurring in a colored child aged thirteen months.
In this case the murmur, which was a loud systolic
mitral one, could not be accounted for at autopsy.
Dr. Jacobi said that extra-cardial murmurs, mostly
systolic in children, were very infrequent in infants
below two years, because at that early time the heart
was larger in proportion, and less covered by the lungs.
828
MEDICAL RECORD.
[May 12, 1900
Ulcerous endocarditis might not exhibit any murmur,
and the diagnosis of this condition was thereby ren-
dered difficult. Proliferating endocarditis might give
rise to a systolic mitral murmur in the newly born,
which might either last a lifetime, or disappear in
time with the growth of the organ, or by absorption,
or by progressing compensation. Most murmurs
meant organic lesions either in the valves or in the
myocardium; in that respect all ages were alike.
Among other causes of cardiac murmurs in infancy,
aside from the infectious diseases and rheumatism.
Dr. Jacobi mentioned contraction or partial oblitera-
tion of the mitral orifice, or adhesion of the valve;
also persistence of the ductus arteriosus Botalli, and
congenital stenosis of the pulmonary artery, or other
congenital defects.
A Report of Certain 'Cases of Tuberculosis which
were Apparently due to the Nature of the Soil.—
Dr. Richard Cole Newton, of Montclair, N. J., read a
paper on this subject, in which he emphasized the fact
that while sunlight and life in the open air, and pure
milk and a wholesome occupation were necessary and
essential to the alteration of the predisposition, so that
the bacillus of Koch could not gain a foothold in the
human organism, a dry, properly constructed cellar to
one's dwelling, which should be built over a pure,
well-drained, sandy subsoil, was just as essential.
The speaker reported a number of cases in which a
high mortality rate from consumption in certain fam-
ilies was apparently due to the unsanitary condition
of the residence they occupied.
Dr. Leonard Weber, of New York, said he fully
agreed with Dr. Newton regarding the important role
which sanitary conditions played in the development
and spread of pulmonary tuberculosis. E.xamples of
this had frequently come under his observation in
New York, where, in certain tenement-house localities,
the disease was very prevalent.
Dr. N. S. Davis, of Chicago, said there was no ques-
tion that the acquirement of tuberculosis was best
favored by continuous life in poorly ventilated rooms,
which induced imperfect lung exercise. Of course,
the hereditary inclination to the disease was also a
factor, but in its prevention too much importance
could not be placed upon the hygienic surroundings of
the individual.
Dr. Charles L. Minor, of Asheville, N. C, said
that while the epidemic of " tuberculophobia " raging
throughout the country would no doubt react benefi-
cially, there had been no corresponding enthusiasm
in the direction of prophylaxis. The public had be-
come frightened, but not in the right way. The tu-
bercle bacillus was practically ubiquitous, and if
acquirement of tuberculosis depended solely upon that
germ, the human race would long ago have been
exterminated.
Dr. Edward R. Baldwin, of Saranac Lake, said
that the observations made by Dr. Newton had some
bearing upon the bacteriology of tuberculosis. Dr.
Ransom, of England, had made some investigations
which went to show that moisture was an important
factor in the development and longevity of the tuber-
cle bacillus, and he claimed to have demonstrated that
this germ actually grew upon wall-paper in a house
in which the surroundings were very damp. It was
well known. Dr. Baldwin said, that dampness would
preserve the vitality of the bacilli for a long time in
the expectoration.
Dr. Judson Daland, of Philadelphia, said that in
Iceland, where all the factors existed which were re-
garded as favorable to the rapid spread of pulmonary
tuberculosis, i.e., long periods of dampness, wind, and
absence of light, the disease was practically unknown
there until about six years ago, when a few cases of tu-
berculosis were introduced into the island. Since then
the disease had made rapid strides there, and two years
ago one hundred and thirty-four cases were reported.
Dr. E. O. Otis, of Boston, called attention to the
excellent work in the direction of sanitary improve-
ment which was being done by tenement-house reform
committees in New York and Boston.
The Educational and Legislative Control of Tu-
berculosis.— Dr. Charles Denison, of Denver, read
a paper with this title, in which he confined his re-
marks principally to the degenerative results of defi-
cient ventilation, and secondarily to the degenerative
results of defective heredity. In the defective venti-
lation of living-rooms, the author said, we had a uni-
fied, predisposing cause, anterior to the tubercle
bacillus, which would explain alike the origination of
tuberculosis in animals, fowls, and man; this factor
induced deficient pulmonary air and blood circula-
tion, and led to auto-infection. We might reason, as
with few exceptions everybody did, that the bacillus
of tubercle, being the constant accompaniment of the
decaying process in tuberculosis, was consequently
the cause and source of all this evil; but the ver)'
lateness of its appearance showed it to be rather a re-
sult than a cause. Its absence in so many forms of
scrofula, adenoid growths, wasting, and catarrhal con-
ditions which eventually proved tuberculous, showed
that the pretuberculous and perhaps the first stage of
tuberculosis was already established, presumably in
advance of the germ. These conditions were proved
by the tuberculin test to be a part of the real disease
before the microscopic or any other ocular demonstra-
tion of the bacillus was possible. Tuberculosis would
not '"down" in response to any edict against street
expectoration, the disinfection of rooms occupied by
consumptives, or even the slaughtering of tuberculous
cattle, however important these measures of preven-
tion most assuredly were. To show a unified cause,
we must come back to the living-room of a human
being, the meagre size of which, and its deficient
sunlight and air circulation, afforded a sufficiently
marked degree of deficient ventilation to constitute a
glaring fault of our civilization. This seemed to be
the initial cause or starting-point of tuberculosis,
which probably killed more people than did war
and any other one form of disease together. The
speaker said that if law could protect life, as it aimed
to do, by fire-escapes, the necessity of stand-pipes,
the abatement of the smoke nuisance, tiie ventilation
of sewers, and the non-pollution of drinking water, why
should not this subtler and ever-present cause of de-
generation and death, defective ventilation, even in
its slighter degrees, come under its fostering care?
He suggested that an effort should be made to estab-
lish and maintain the equivalent of the following, to
wit: for a living apartment a minimum space of fifteen
hundred cubic feet per individual, and a minimum
ventilation or change of air of two thousand feet per
hour per person. Furthermore, a course for the study
of ventilation should be made a prominent feature of
all advanced schools and colleges.
Dr. Beverley Robinson, of New York, said that
while the building of sanatoria for consumptives
would, no doubt, result in much good, such institu-
tions could do very little toward checking the spread
of the disease so long as the more important factors of
defective ventilation and hygiene were neglected. A
patient was perhaps cured at such a sanatorium, and
then must go back to live under the very conditions
which induced the disease.
Dr. Carroll E. F.dson, of Denver, reported an in-
stance in which the family physician, a man of stand-
ing and reputation, insisted upon the discharge of a
governess when he learned that ten years before she
had spent some time in Colorado on account of some
apical trouble from which she had entirely recovered.
May 12, 1900]
MEDICAL RECORD.
829
Dr. W. F. R. Phillips, of Washington, D. C, said
that the subject of "live" air, and devitalized air, to
which Dr. Denison had referred, had been extensively
studied by Richardson, Mitchell, Billings, and others,
and was still unsettled. Richardson came to the con-
clusion that the devitalization was probably due to
some molecular change which occurred in the oxygen.
The others attributed its injurious effects to increased
temperature and humidity, and to some extent to the
carbon dioxide it contained.
Some Phases of the Tuberculosis Problem in
Colorado. — Dr. Sherman G. Bonney, of Denver, read
a paper on this subject. He stated that there existed
in Colorado at the present time not only an apprecia-
tion of the communicability of tuberculosis and the
necessity for rational preventive measures, but also,
unfortunately, a somewhat unreasoning fear as to the
dangers of direct infection. There had developed an
increasing popular prejudice against ordinary associa-
tion with the consumptive, and a beginning sentiment
against the further importation of individuals afflicted
with the disease. Tire agitation originally conceived
through scientific knowledge applied to public health
\v;"s giving birth to a somewhat ill-proportioned and
ignorant crusade. While the percentage of deaths from
tuberculosis contracted in the State of Colorado had
been progressively increasing during the past four
years, the actual number of cases originating in the
State was but slightly larger, and the total was consid-
erably less. Thus, in 1893, the total number of deaths
from tuberculosis was reported as four hundred and
thirty-five, of which forty-nine were specified as con-
tracted in Colorado, establishing the proportion of
eleven and one-quarter per cent. The next year the
total was three hundred and seventy-seven, a diminu-
tion of fifty-eight, while the number contracted in
Colorado was fifty-one, an increase of but two cases
for the entire year, yet the proportion was published as
being 13.7 per cent., a gain of 2.5 per cent, in the
deaths originating in Colorado for the year. Despite
an increase of fifty thousand in the population of Den-
ver since 1893, the number of cases specified as having
developed in 1898 was but four more than in 1893.
Dr. Bonney said that a factor of no inconsiderable im-
portance in connection with the question was the strong
inherited susceptibility of a portion of the younger
population in Colorado, and such infant cases should
not be recorded as instances of deaths from indigenous
tuberculosis. Another factor was that some residents
might develop an active condition from an infection
previously latent. On the other hand, he said, it must
be remembered that the influx of consumptives in all
stages of the disease, and in every condition of finan-
cial distress, constituted an economic problem not to
be ignored. Many came to the State as a place of last
resort.
Dr. Otis said that last year — which was the first
year in which the Massachusetts State sanatorium was
in operation — sixty-four per cent, of incipient cases of
tuberculosis and thirty per cent, of all cases were dis-
charged as arrested. If other States did as well, the
fears of the people of Colorado would soon be allayed.
Dr. R. H. Babcock, of Chicago, said the statistics
given by Dr. Bonney showed conclusively that the fears
of the people in the State of Colorado were not well
grounded. The increase in the number of deaths from
tuberculosis originating in the State had been insig-
nificant, and could, no doubt, easily be explained on
the grounds of environment, occupation, and heredity.
The population of Denver had largely increased in
recent years, and this was a factor which had favored
an increase in the number of cases of tuberculosis.
Dr. James C. Wilson, of Philadelphia, referred to
the frequency with which apparently hopeless cases of
pulmonary tuberculosis were sent on long journeys in a
fruitless search for health. There was now a growing
knowledge among the profession that very frequently
efficient climatic treatment could be secured at home.
Dr. R. G. Curtin, of Philadelphia, said that Den-
ver would possibly soon cease to be regarded as a de-
sirable locality for tuberculous patients. It largely
owed its popularity to the dry climate, which was being
altered by the extensive irrigation of lawns and trees,
the frequent street sprinkling, the increase in the pop-
ulation, and the number of factories.
Dr. Denison spoke of the prevalence of cases of
tuberculous meningitis in Denver. He attributed the
slight increase in the number of cases of tuberculosis
originating in the State to the fact that many of the
residents had a tuberculous family history.
Dr. James A. Hart, of Colorado Springs, said that
five yeas ago he announced that he had observed but
one case of tuberculosis in his private practice origi-
nating in Colorado Springs. Up to the present time
he had none others to report.
ASSOCIATION OF AMERICAN PHYSICIANS.
Fifteenth Annual Meeting, Heid in Washington, D. C,
Alay I, 2 and j, /goo.
Edward G. Janeway, M.D., ok New York, Presi-
dent.
Second Day — Wednesday, May 2d.
The Organism and Lesion of Actinomycosis. — Dr.
J. H. V\right, of Boston, read this paper, which was
illustrated by stereopticon views of microphotographs
of the diseased organs. The disease, he said, fre-
quently went unrecognized and was much more com-
mon than generally supposed. He considered it as a
subacute or chronic process. He asked what were
the "clubs" or rays, and then answered the question
by saying that they were degenerated filaments. In
the case from which the specimen was obtained, the
lungs, kidneys, liver, and even the abdominal wall
and vertebra had been involved. One picture showed
abscess involving the ventricular wall of the heart.
Diagnosis. — Dr. Wright said that the diagnosis
could be made under the microscope by crushing one
of the rays. It was not necessary to stain the speci-
men. The rays were branched, with dark and light
spots. Staining was necessary to bring out these
spots. He also spoke of the difficulty of obtaining
cultures of the ray fungus, which was due to secondary
infection. The ray fungus was anaerobic.
Dr. J. M. Da Costa said he thought the use of
potassium iodide had an admirable effect upon the
disease and even would cause a cure.
A New Pathogenic Fungus (Sporothrix). — Dr.
L. Hektoen, of Chicago, read this paper, which was
also illustrated by microphotographs. He mentioned
the case of a boy, in whom, after receiving a punc-
tured wound of the finger from an iron nail, several
nodules appeared at the site of infection and later
along the forearm and arm. Cultures were made from
time to time, and with the constant result that sporo-
thrix was present. Dr. Hektoen described the sporo-
thrix as occurring in colonies, with central masses
from which radiated spore-bearing threads. It was
fatal to white rats when injected into the peritoneal
cavity, and caused coagulation necrosis. He said that
he knew of only three cases occurring in man.
Dr. Simon Flexner, of Baltimore, said that when
the sporothrix was inoculated into mice there was an
enlargement of the lymphatic glands, followed by gen-
eral septicaemia.
Dr. Hektoen contradicted this last statement.
830
MEDICAL RECORD.
[May 12, 1900
Some Conclusions Arrived at after a Study of
One Hundred and Ten Cases of Pernicious Anaemia.
— Dr. Richard C. Cabot, of Boston, read this very
interesting paper. In his cases there had been fifty-
seven males and fifty-three females, and only four cases
had followed parturition. Late middle life predis-
posed toward it, as shown by the fact that in eighty-
two of his cases the patients had been over forty years
of age. He thought that pernicious anremia was much
more frequent than the text-books would lead one to
suppose. Some cases had come to him which had
previously been diagnosed as tuberculosis. He
thought that there was very little if any relation be-
tween the menopause and pernicious anaemia. It had
nothing to do with syphilis. Hemorrhage was quite
common, especially of the nose and gums. He spoke
of the striking constancy of the symptoms in almost
all of his cases, even in some of his so-called mild
ones, viz., muscular weakness, dyspnoea, gastro-intes-
tinal disturbance (paro-xysmal diarrhcea). The appe-
tite had been poor in all but three cases, and in these
it had been ravenous. In two-thirds of his cases there
had been a temperature of 99° to 100° F., and even
higher. The urine in fifty-three cases had been nor-
mal, while others had had a trace of albumin with
granular casts. Nervous symptoms had not been con-
stant. Some cases had had myelitis. As to the
blood, the white corpuscles were subnormal; the num-
ber of red corpuscles was 2,500,000. The diameter
of the white corpuscles was greater than normal. The
proportion of lymphocytes was relatively high. Dr.
Cabot said that there was no relationship tjetween the
symptoms and the blood condition. The average du-
ration of this disease was from one to two years. The
longest-lived case he had had was five years. All
treatment, he thought, was hopeless, unless the use of
laxatives would be of service, working along the line
of Hunter's idea, that of gastro-intestinal to.xsmia.
Dr. Cabot thought that arsenic did little if any good
in these cases.
Report of Cases of Pernicious Anaemia with a
Special Reference to the Blood Findings. — Dr.
Frank Billings, of Chicago, read this paper. He
had had nineteen cases, eleven males and eight fe-
males. The average age had been forty-si.x years; the
extremes were twenty-four and sixty-two years. He
could find no exciting cause. His cases were similar
in result to Dr. Cabot's cases.
Clinical Notes on Cases of Pernicious Ansemia.
■ — Dr. Fred. P. Henry, of Philadelphia, reported five
cases, and spok of his theory that the blood of pa-
tients with pernicious anaemia reverted to that of the
cold-blooded animals.
Dr. H. a. Hare, of Philadelphia, thought that per-
nicious ansemia was more common than the books
would lead one t-' think. In his experience, men
from the country district:^ had been more susceptible,
and those in mining districts, especially in the anthra-
cite district Oi i'c nsylvania, were prone to the dis-
ease. He said that he was opposed to the idea of
atrophy of gastric tubules in this disease as an etio-
logical factor, and further, he believed in the use of
arsenic for such cases. W knew a great deal about
the blood in disease, but did not know so much about
it in health. He suggested that work along that line
would show variation in form, etc.
Dr. William H. Thomso:., of New York, spoke of
Hunter's theory of his disease being caused by sup-
puration at the roots of the teeth and in the mouth,
and that swallowing the organisms caused the disease.
Dr. Thomson said he hud a case in which the stomach
washings contained streptococci.
Dr. McPhendron, of 'I'oronto, said he had cured
two cases. He spoke of blood-serum injections and
tlioughtthat some improvement had followed their use.
Dr. S. Weir Mitchell said that all the blood counts
that had been given were merely relative and not ab-
solute. Massage increased the number of red cells,
or rather brought them out of their hiding-places. He
cited his own case as an example.
Dr. Charles G. Stockton, of Buffalo, said that he
had had twelve cases of this disease, and laid stress
upon the difference between the gastric secretions
with hydrochloric acid in pernicious anemia and in
secondary ansemia.
Dr. W. S. Thayer, of Baltimore, thought that one
could not make a diagnosis on the blood count alone.
Dr. J. M. Da Costa spoke of the length of remis-
sions in this disease, which were often very great.
He recalled a case of a man who apparently was well
for eleven months under no treatment whatever. He
also mentioned the case of a sailor treated in hospital
who, when he had begun to improve, had been dis-
charged and had gone on shipboard and worked for
seven months. He had then returned to hospital to
die. Dr. Da Costa spoke of high fever in pernicious
anaemia, and recalled cases that resembled typhoid
fever in their temperature range.
Dr. Herrick, of Chicago, said that the improve-
ment of symptoms was due merely to a relative in-
crease in the red corpuscles and in the percentage of
hsemoglobin.
Dr. Cabot, in closing, answered Dr. Hare by say-
ing that counts of normal blood had been made at the
Massachusetts General Hospital for the last eight
years with negative results.
Proliferation and Phagocytosis. — Dr. F. V. Mal-
LORv, of Boston, read this paper. The efifects of injuri-
ous substances'were manifested, he said, in the follow-
ing way: (i) Degeneration of the cells; (2) exudation
from blood-vessels; (3) proliferation of the cells; and
(4) phagocytosis. He said that the last two were of
importance. He thought that toxins caused prolifera-
tion, i.e., strong toxins caused necrosis and death,
while weak toxins caused proliferation and phagocy-
tosis. He spoke of the micrococcus lanceolatus caus-
ing proliferation ^fibrous exudation) in the lungs and
kidney. The toxins of typhoid and tuberculosis were
mild, and would cause a proliferation of endothelial
cells in the blood-vessels of the intestines, or in the
liver and spleen. Dr. Mallory said that certain toxins
would cause such a great increase of the lymphatic
and plasma cells circulating in blood that they would
pass out into the organ, as, for example, the kidney,
and interfere with its function.
Dr. M'illiam H. Welch, of Baltimore, said that he
objected to the theory that external agents such as tox-
ins would cause cells to multiply. He thought that
the toxins excited necrosis directly, and the finding of
bacteria in the larger cells went to show that the
smaller cells had attacked the larger ones, and not
vice versa.
Cases of Diarrhoea Associated with the Presence
of Strongylus Intestinalis in the Stools.- Dr. W.
S. Thayer, of Baltimore, read this paper. After
spending a short time in giving the history, together
with a short outline of its morphology, he reported two
cases. The first was of special interest from the fact
that the patient had an abscess of the liver due to an
amoeba coli infection. It had also been infected by
infusoria and strongylus intestinalis. Dr. Thayer
said that the diarrhoea was never accompanied by pain.
(.To be concluded.)
Do Not unjustly blame the local anaesthetic for
signs of collapse or fainting when the patient is watch-
ing an operation upon himself. It is better to cover
the patient's eyes even in trivial procedures, and never
to operate upon a standing patient.
May 12, 1900]
MEDICAL RECORD.
831
NEW YORK ACADEMY OF MEDICINE.
Stated Meeting, April jg, igoo.
William H. Thomson, M.D., President.
The Physiology of Internal Secretions. — Prof. W.
H. Howell, of the Johns Hopkins University, read a
paper on this subject. A large number of experi-
menters, he said, had endeavored to prove the anti-
toxin theory of the action of such glands as the thy-
roid, but the accumulated experience of the past few
years had apparently made this theory improbable.
The very gratifying therapeutic results with the ex-
tracts of the thyroid gland had not been paralleled in
experiments with the other gland extracts.
Ovarian Extract. — The value of ovarian extract in
the treatment of amenorrhcea and dysmenorrhoea
seemed to have a rational basis. The hypothesis that
the ovaries produced an internal secretion had received
some support by recent investigation. For example,
experiments had been made upon dogs to determine
the effect upon metabolism. After the performance of
a double ovariotomy no change in metabolism had been
noted for ten weeks, but after that time a decided de-
crease had been observed in the daily consumption of
oxygen. On the other hand, data were available to
show that the administration of ovarian extract had
increased the daily consumption of oxygen. By the
method of grafting more hopeful results were to be
looked for. As to the nature of the specific substance
of the internal secretion, nothing was as yet known.
Testicular Extract. — With regard to the testicles
the evidence that they produce an internal secretion
was less convincing. It had been stated by some in-
vestigators that castration diminished the consump-
tion of oxygen, but, unlike the ovarian extract, it had
not been shown that the testicular extract had the
power of increasing the oxygen consumption.
Thyroid Gland — The parathyroids were minute
bodies adjacent to, or embedded in, the thyroid gland.
Histologically they showed no resemblance to thyroid
tissue. Experimental research indicated that these
bodies had a function of their own resembling, in some
respects, that of the thyroids proper, but differing in
important particulars. Experiments on animals seemed
to show that if both thyroids were removed and the
parathyroids left, the animal would not die, but death
would ensue if both the thyroids and the parathyroids
were extirpated. From physiological experiments
there was little reason to believe that the functions of
the two bodies had anything much in common.
Suprarenal Gland — Schaeffer had suggested that
these glands gave off slowly to the blood an internal
secretion which tended to keep the muscular system
in proper tone, and particularly the musculature of the
circulatory system. It had been shown that the quan-
tity of secretion given off to the blood could be influ-
enced by stimulation of the splanchnic nerve. It had
also been demonstrated conclusively that the adrenal
vein contained more of this secretion than the other
veins of the body. It was exceedingly probable that
the active principle of this internal secretion had been
isolated in the substance known as epinephrin. This
active principle was so easily destroyed in the body
that it was hardly probable that therapeutic results of
much importance would follow its hypodermic use or
its ingestion by the mouth.
Pancreatic Gland — When the duct of the pancreas
is filled with paraffin, an animal showed marked dis-
turbance of nutrition, but beyond a temporary glyco-
suria there was nothing observed. If after the com-
plete removal of the pancreas a small portion was
implanted under the skin of the abdomen, the glyco-
suria failed to appear, or was slight and transitory.
It must be supposed, therefore, that under normal
conditions the pancreas gave off an internal secretion
to the blood, which was in some way a necessity to
secure the normal consumption of sugar. In severe
pancreatic diabetes the glycogen disappeared from the
liver at the time when there was the most sugar in the
urine. Even in the severest form of pancreatic dia-
betes it was easy to increase still further the quantity
of sugar in the urine by puncture of the medulla.
Physiological experiments indicated that pancreatic
diabetes could not be treated successfully by the in-
gestion of pancreatic tissue; on the contrary, it had
been, proved that the transplantation under proper
conditions of pancreatic tissue was successful in ame-
liorating the condition. It was possible that other
glands, like the pituitary body, for example, also manu-
factured internal secretions. This made the subject
of metabolism and nutrition much more complex than
it had hitherto been believed to be.
The Physiological Effects of Extracts of Duct-
less Glands. — Dr. Richard E. Cunningham read
this paper. He objected to the use of the ordinary
desiccated extracts of the ductless glands, on the
ground that there was good reason for believing that
they were mixtures of various substances, and that the
determination of the results from their use must neces-
sarily be very unreliable. Much had been anticipated
from the administration of the extract of the pituitary
body in cases of acromegaly, yet the clinical results
had been disappointing. He had personally been un-
able to observe the remarkable effects on the circula-
tory system from the ingestion of suprarenal extract,
described by several observers. One would expect the
best therapeutic results from the administration of su-
prarenal extract in Addison's disease, yet the cases so
far published had not confirmed this belief. Of twen-
ty-four reported cases that he had collected in which
the suprarenal extract had been administered, not a
single patient could be said to have been cured, though
fourteen had been teni].orarily improved. Ten had
been practically unaffected by the treatment. When
the aqueous extract of the suprarenal gland was intro-
duced into the blood-vessels, it caused a marked fall
in the blood pressure, but if the colloid preparation of
the extract of this gland was injected this lowering
of the blood pressure was not noted.
Thymus Gland. — The thymus gland had been first
introduced to the medical profession as a remedial
agent in connection with the treatment of a case of
pseudo-hypertrophic paralysis. In ten cases of exoph-
thalmic goitre treated by him with dried thymus,
only three could be said to have been even temporarily
improved. The best results from the use of these ex-
tracts had been secured with thyroid extract. If large
doses of the desiccated extract were given, the results
would often be the development of symptoms appar-
ently indicative of poisoning with the proteid bodies
constituting the impurities of the extract. On the
other hand, it would often be found that the same in-
dividual could take rather large doses of iodothyrin
without experiencing any such toxaemia. The iodo-
thyrin did not seem to be nearly so active as the col-
loid, from which it could be easily obtained.
Dr. W. H. Bates said that he understood that the
secretion of the suprarenal gland was stored up in the
muscles, giving them, as it were, latent energy. In
cases of heart disease, a very decided effect on the
heart could be observed when the suprarenal extract
was absorbed through the mucous membrane of the
mouth, or was given hypodermically. This action was
less likely to be observed if the extract was swallowed
and was thus exposed to the gastric juice.
Dr. Cunningham spoke of the parathyroids, and
said that in the dog there were usually two such bod-
ies. The inner one of these was removed with consid-
erable difficulty. In three dogs he had performed the
832
MEDICAL RECORD.
[May 12, 1900
experiment of taking the thyroids and parathyroids
and sewing them in an artificial pocket of membrane.
All three animals had become myxcedematous. One
had been killed at the end of a month, and two had
died in the course of another month. He was sure he
had removed the parathyroids as well as the thyroids,
and yet the animals had survived.
Dr. Howell, in closing, said that Dr. Bates' the-
ory about the storing up of the adrenal secretion in
the muscles was not in accordance with the facts
brought out by experimentation. Undoubtedly the
extract had an effect upon the heart and circulation;
nevertheless this was very temporary. The effect of
injections was certainly not promising so far as direct
physiological experiment was concerned.
SECTION ON MEDICINE.
Stated Meeting, April ij, igoo.
E. Franklin Smith, M.D., CHAIR.^L\N pro tem.
The Iodide Treatment of Aneurism. — Dr. Louis
Faugeres Bishop read this paper. He said that the
immediate effect of this treatment was that the pa-
tients were made more comfortable, the pulsation of
the aneurism became less, and the sac apparently di-
minished in size. This remedy seemed to have an
effect on the sac itself, whereby the development was
less rapid and the tendency to coagulation was in-
creased. The iodide treatment was directed against
the tissue changes which were the original cause of
the disease. Iodide certainly had a greater influence
over tissue metabolism than any other drug. All the
other methods of treatment by inducing coagulation
had the defect that they sought to cure a disease the
causes of which remained active. He had been ac-
customed to begin the treatment by the administration
of ten drops of the saturated solution of iodide of po-
tassium, three times a day, and increasing the dose
one drop each day. The speaker said that he had
seen so many cases of aneurism benefited by the iodide
treatment that he ha^l now great confidence in it.
These remarks were intended chiefly for cases of tho-
racic aneurism.
Report of Three Cases of Thoracic Aneurism in
which Subcutaneous Injections of Gelatin were
Used. — Dr. LEwrs A. Conner made this report, giv-
ing his own experience with the method during the
past year. Briefly the method consisted in injecting
200 c.c. of a 2.5 per cent, solution of gelatin into the
subcutaneous tissues of the thigh, and after the injec-
tion keeping the patient absolutely quiet. These in-
jections should be repeated weekly until fifteen or
twenty had been given. In his own cases the initial
injection had consisted of a two-per-cent. solution and
the subsequent ones of a one-per-cent. solution. The
injections had all been followed by slight local dis-
comfort and rise of temperature. The first case was
one in which rupture took place in the course of the
treatment, and the autopsy had revealed no evidence
of recent clot formation. The second case had been
one of aneurism of the transverse and descending por-
tions of the arch of the aorta. Between May 24th and
July 27th seven injections had been given, and each
injection had been followed by severe pain lasting
often for eight or ten hours. This had been associ-
ated with reddening of the skin, but in no instance
had suppuration occurred. The pain had been equally
severe whether the injection had been given in the
thigh or in the abdominal wall. After the second in-
jection the slight pulsation that had been felt pos-
teriorly disappeared. The patient's cough and the
irritation of the throat disappeared while under
treatment, but the latter had been discontinued be-
cause of the great suffering produced. The third case
was one of aneurism of the transverse portion of the
arch. Three injections had been given, and had
caused local distress without producing any improve-
ment. During the treatment there had been a grad-
ual increase in the size of the aneurism. The great-
est care had been taken in the preparation of the
gelatin solution.
Dr. C. H. Lewis said that he had tried the method
in one case, a patient in Columbus Hospital. There
had been a very large pulsating aneurism of the arch
of the aorta, and extensive erosion of the ribs. The
first gelatin injection had caused a good deal of pain
and some rise of temperature. At the expiration
of a week a second injection had been given, but it
had also been followed by severe pain and by a tem-
perature of 103° F. A few days later the aneurism
had ruptur_ed. Unfortunately an autopsy could not be
obtained.
Rabies in New York City — Dr. Robert J. Wil-
son read a paper with this title. He deplored the
tendency of certain physicians to deny the very exist-
ence of rabies, because this led students and young
physicians to be careless in the treatment of animal
bites. In 1898 there had been eight cases of death
from rabies in the Greater City of New York; in 1899
two cases, and so far in 1900 one case. The disease
might be said to be endemic in the borough of Rich-
mond. Since January i, 1897, the bodies of forty dogs
had been received at the laboratory of the health de-
partment, four coming from one locality. Mild and
superficial cauterization, or the application of antisep-
tics, was worse than useless. The best application
was the actual cautery. Fuming nitric acid was about
as good, but the wound left by it was slower and more
troublesome in healing. Unless the wound was very
insignificant it was better to administer an anaesthetic
in order that the cauterization might be thoroughly
done. Such a procedure conferred protection in about
ninety per cent, of cases. In all suspected cases the
best treatment should be instituted whenever possible,
and if this w^as done it would yield ninety-nine per
cent, of successes. The shortest period for the Pas-
teur treatment was fourteen days, but it was often nec-
essary to extend the treatment over a period of eigh-
teen to twenty-five days. The injections were preferably
given over the abdomen. The first few injections
were quite painful, but it was possible for an individ-
ual who was not of a nervous temperament to take the
treatment and still continue at work. There was ab-
solutely no danger in the treatment itself, but it was
not advisable to send the virus out from a central lab-
oratory.
Dr. H. T. Cronk sent a report of a case of rabies
that he had observed at the Gouverneur Hospital.
Dr. C. H. Lewis presented the report of the case
of rabies which had occurred recently at St. Vin-
cent's Hospital. On March Sth a man, sixty years of
age, had presented himself for treatment for a bite on
the right side of the neck and cheek which he had re-
ceived from a strange St. Bernard dog. This dog had
been found by the man's children, and had appeared
perfectly docile, so that the family had been on the
point of keeping the dog. The man had attempted to
remove a string from the neck of the animal, and in
doing so had pressed upon a partially healed sora;
immediately the animal had sprung upon him and in-
flicted a wound from four to six inches long. The
animal had exhibited thereafter no other signs of dis-
temper or other disease. The dog had been immedi-
ately shot by the police, and his carcass taken away
by the street-cleaning department. The wound had
been irrigated at the hospital with bichloride solution,
cauterized with pure carbolic acid, partially sutured,
and dressed antiseptically. The man had suffered
May 12, 1900]
MEDICAL RECORD,
833
much pain that night, and on his return to the hospital,
on the advice of the surgeons there, he had entered the
hospital. Thirteen days after the bite, the patient
had been discharged with the wound healed. Twenty-
one days later the man had been readmitted, this time
to the medical service of the hospital. For eighteen
days he had worked, and had felt perfectly well. On
April loth, on attempting to drink some w-ater he had
experienced the first difficulty in swallowing. During
the night he became nervous and sleepless, and the
wound began to pain him. The next morning he had
gone to the Pasteur Institute, where he had been told
the preventive treatment would be of no avail. On
readmission to St. Vincent's Hospital, on the same
day, his pulse had been 80, respiration 24, and tem-
perature 98° F. There was a peculiar apprehensive
expression, and he begged to have water taken away,
although the mere sight of it had no effect upon him;
it was only when he was asked to drink it that he ex-
perienced any distress. On the following day the
temperature had kept at about 102° ; the face had been
flushed, and there had been some dyspnoea and a feel-
ing of tightness about the throat and chest. That
night he had become delirious. In the morning his
temperature had been 103°, his pulse 84, and respira-
tion 24, and he had been quite excitable. For the
first time medicinal enemata caused spasm. He
passed into coma and died at 5 p.m. A partial autop-
sy had been secured, making it possible to examine the
medulla, pons, and part of the cord. Nothing distinc-
tive had been discovered from the gross appearance,
but portions of the brain and cord had been taken for
purposes of inoculation.
Dr. L. F. Bishop emphasized the importance of
teaching that there were two forms of hydrophobia, the
rabid and the paralytic. Comparatively few people
seemed to know or realize that a dog might have hydro-
phobia and yet not be rabid, or exhibit the classical
symptoms of rabies.
Dr. Wilson said that while he believed no case had
been reported in which hydrophobia had been commu-
nicated to another by a dog through the saliva alone,
nevertheless it was a well-recognized rule in all Pas-
teur institutes that the utmost care should be taken to
use antiseptics, to cleanse all parts from saliva, and to
take every precaution against possible contamination
of this kind. It was exceedingly important in every
case of dog-bite to inquire where the dog had come
from, and whether the animal was a stray one. If the
latter was the case one should immediately take steps
to find out what had become of the animal. He did
not think human beings were usually infected from
animals suffering from the paralytic form of rabies;
indeed, the paralytic form seemed to be wholly re-
stricted to laboratories.
Dr. Lewis remarked that there was a rule requiring
the police department to see that every animal that
had bitten a person and had been shot should be taken
to the health department for investigation. Had this
been done in the case just reported it might have been
the means of saving the man's life.
Dr. L. a. Conner said that some years ago the as-
sistant pathologist of the New York Hospital had died
shortly after having made a post-mortem examination
on a case of hydrophobia. He had presented in his
last illness a peculiar form of paralysis which had been
considered at the time to be paralytic rabies.
The Good and Bad Effects of Digitalis Used as
a Therapeutic Agent. — Dr. William Henry Porter
read a paper with this title. He said that it was quite
apparent from a perusal of current literature that the
action of digitalis upon the human system was not yet
fully understood; hence he desired to present in this
paper a review of its physiological function and thera-
peutic possibilities. To comprehend thoroughly the
action of any drug its chemical composition must be
fully understood. So far, five glucosides had been
isolated from digitalis, viz., (i) digitalein; (2) digi-
toxin; (3) digitonin; (4) digitalin, and (5) digitin.
They were all oxidizable substances, and yielded as
the result of their oxidation-reduction heat, carbonic
acid, and water. Only four of these glucosides ac-
tively influenced the animal economy, and while three
of these had actions in common, the fourth was abso-
lutely antagonistic to the other three.
Powdered Digitalis — When powdered digitalis was
administered the contained active principles pro-
foundly influenced the action of the heart and the cir-
culation. The three active principles which had a
similar action caused a short and more intense sys-
tole and a prolonged diastole, and at the same time,
by contracting the arterioles, produced a decided rise
in the blood pressure. These circulatory changes were
immediately followed by a marked slowing of the
heart's action- — an effect which was best explained by
the increased resistance in the arteries and the de-
pressing effect of the digitonin upon the cardiac mus-
cle. If the digitalis was continued, the cardiac pulsa-
tion became more frequent and feeble as a result of
the toxic effect of all the active principles of digitalis
on all the involuntary muscles. While these changes
were taking place the continued high arterial tension
deprived the heart of its proper nutrition, so that if
the drug was not withheld, the final result would be
death with the heart in diastole. As a rule, the blood
pressure in the splenic arcade remained normal.
Infusion of Digitalis. — The effect of the infusion
of digitalis is dii'ferent from that of the powder be-
cause two of the active principles, digitoxin and digi-
talin, were almost wholly insoluble in water. The
infusion, therefore, really contained only two active
principles, digitalein and digitonin, whose actions
were antagonistic.
Tincture of Digitalis. — Still another action was
observed from the use of the tincture of digitalis, be-
cause while digitoxin and digitalin were freely soluble
in alcohol, digitalein was only sparingly soluble, and
digitonin not at all.
Fluid Extract of Digitalis. — The fluid extract
more closely resembled the powder in its action, but
it vi'as a more uncertain preparation because there was
no practical method of determining just what propor-
tions of the different ingredients were dissolved out by
the mixture of alcohol and water used in preparing the
extract.
Cumulative Action Dr. Porter said that careful
study failed to discover good evidence that digitalis
was stored up in the system for a time and was then
suddenly liberated and eliminated, thus giving rise to
the well-known phenomena attributed to the so-called
cumulative action of this drug. This action appeared
to be more directly exerted upon the heart, the kid-
neys often acting freely even in spite of the depressed
heart action. The explanations hitherto advanced
seemed to the speaker wholly inadequate. His own
explanation of the occurrence of these symptoms of
digitalis poisoning was, that three factors were at work,
viz., (i) the diminished nutritive supply to the car-
diac muscle, resulting from high arterial tension; {2)
the increased work imposed upon the heart, and (3)
the direct action of digitalis as a powerful muscle poi-
son. He said that there could be but one result of
the continued administration of digitalis, i.e., the de-
generation of the muscular fibres of the auricular and
ventricular walls, particularly of the former. The
heart action was at first slowed to meet the increased
demands made upon it; then, like any other degener-
ated heart, its action became rapid and feeble, and
finally irregular, or it might stop altogether in dias-
tole as a result of some slight exertion, such as sitting
834
MEDICAL RECORD.
[May 12, 1900
up in bed or rising to pass urine. When a reliable
preparation of digitalis was administered continuously
up to the full physiological limit, the heart was inva-
riably damaged, thus explaining the oft-repeated re-
mark that digitalis proved unsatisfactory in perma-
nently alleviating cardiac affections.
Digitalis in Mitral Lesions. — When there was in-
sufficiency or stenosis of the left auriculo-ventricular
orifice, digitalis temporarily improved the condition.
In the case of aortic insufficiency, digitalis caused a
more rapid and eiTectual closure of the incompetent
orifice, and, by the intensified systole, a more thor-
ough emptying of the ventricle. In cases of mitral
stenosis the prolonged diastole and intensified contrac-
tion of the auricle enabled the latter more thoroughly
to fill the ventricle, and the more powerful systolic
contraction drove a larger volume of blood into the
aorta. It was evident, therefore, that in both lesions
of the mitral orifice the administration of digitalis
overcame the pulmonary congestion and the dyspnoea
dependent upon it. But once the normal tension had
been reached and passed, the action of digitalis was
detrimental to all the physiological functions of the
body.
Digitalis in Aortic Lesions. — Dr. Porter said that
there seemed to be no good reason for the employment
of digitalis in cases of aortic insufficiency or aortic
stenosis. In aortic regurgitation the increased sys-
tole certainly could not compensate for the prolonged
diastole, and the longer time during which regurgita-
tion could take place, to say nothing of the injury re-
sulting from increasing the peripheral resistance and
diminishing the nutritive supply of the cardiac muscle.
In aortic stenosis the augmented cardiac systole might,
for a time, force a larger volume of blood into the
aorta, but the increased work thrown upon the heart,
the toxic effect of digitalis on the muscle, and the pro-
gressively diminishing nutrition soon led to degenera-
tion of the heart, and to an aggravation of all the
symptoms. In fatty degeneration, or in any enfeebled
state of the circulation in the heart muscle, digitalis
was contraindicated. In hypertrophy of the heart
digitalis might possibly be of use for a few days at a
time in cutting down the nutritive supply, but it was
too dangerous a remedy to employ for such a purpose.
Digitalis should be given to influence the heart and
circulation only when the arteries were very much re-
laxed, and the pulmonary or systemic veins overfilled.
As soon as the engorgement had been relieved, digi-
talis should be stopped, and more reliable remedies
substituted. • It was true that some of the bad effects
of digitalis could be antidoted by combining it with
nitroglycerin, but such a combination did not prevent
the toxic action of digitalis on the involuntary mus-
cles, and it was at best poor therapeutics.
Action of Digitalis upon the Kidney. — The speaker
then proceeded to discuss at length the physiological
laws governing renal secretion, and in this connection
made the statement that the quantity of water dis-
charged from the kidneys was dependent upon tiie re-
lation of hydraulic pressure within the glomeruli on
the one hand, and in the arterial system throughout
the body on the other hand. The function of the epi-
thelial cells lining the uriniferous tubules was a much
more complex problem. Serum albumin did not exist
in the blood as a single substance; what had been
called serum albumin was now known to be composed
of three or more isomeric forms of the proteid mole-
cule. The speaker said that it had been asserted that
digitalis was not eliminated from the system by the
kidneys in the form of glucosides, and hence the diu-
retic effect of digitalis could not be explained by any
irritative action upon the renal glands. It was not
difficult to show that the chief action of digitalis on
the kidneys could be explained by its power to change
the mechanical workings of the heart and of the circu-
lation. When digitalis was administered continuously
in rapidly increasing doses, owing to the high arterial
tension and the diminished calibre of the renal arte-
ries, the blood was driven through the kidneys so rap-
idly that the effete material was not removed. The
result was first an anemia, and subsequently a toxic
condition usually described as urasmic. In cases of
renal disease in which there was no marked swelling
of the epithelial cells and the exit from the larger
veins remained unimpaired, digitalis simply drove the
blood through the kidneys more rapidly without aug-
menting the hydraulic pressure in the glomeruli, and
consequently in this class of cases digitalis had no
diuretic action, but impaired the nutrition of the kid-
ney and practically aggravated the kidney lesion.
On the other hand, if there was a general venous en-
gorgement, a passive congestion of the kidney, or an
active determination of blood to the kidneys until the
circulation in them had become impeded, the result
was very different. The same was true of all forms of
parenchymatous metamorphosis or degeneration of the
epithelial cells, for here the latter became swollen and
by pressure on the veins outside the Malpighian tufts,
prevented the normal and free escape of blood from
the efferent vessels of the glomeruli. When digitalis
was administered under these conditions, the watery
constituents of the blood flowed off through the capil-
laries of the Malpighian tufts into the uriniferous tu-
bules— in other words, its action here was that of a
true diuretic. Moreover, the improvement of the gen-
eral circulation in this class of cases led to better nu-
trition in the kidney itself, and in this way helped to
cure the parenchymatous lesion and all other lesions
found in this group of cases.
Conclusions.. — The author's conclusions were as
follows: (1) The chemical composition of digitalis
is complex, some of its active principles antagoniz-
ing others; (2) the various preparations of digitalis
differ widely in their composition and action; (3)
the so-called cumulative action of digitalis is due to
its contracting the arterioles and shutting off nutri-
tion ; (4) it is both a useful and a dangerous remedy,
and has a very limited range of usefulness; (5) it
is of use only in lesions of the mitral valve, and
then only for a short time, and should be discontin-
ued as soon as these have been overcome; (7) it is
of value as a diuretic only when there are low arte-
rial tension and engorgement of the kidney ; (8) digi-
talis decreases the excretory action of the normal kid-
ney and impairs its nutritive activity.
Dr. Leonard Weber took exception to the state-
ment in the paper that the infusion of digitalis was of
but little value. His personal experience with it had
been much more satisfactory, provided he used the
fresh Flnglish leaves, made into an infusion of the
strength of half a drachm to six ounces of water. He
had been seldom disappointed with it, and had at-
tained as good results as with the powder. He had
used Squibb's fluid extract for years, and had found it
also an exceedingly useful remedy, being not only re-
liable and effective, but convenient because of the
smallness of the dose. The indications for the use
of digitalis had been laid down very clearly in the
paper, as had also the action of digitalis on the kid-
neys. He had been particularly pleased with the
statement that digitalis was seldom, if ever, indicated
in disease of the left side of the heart. He looked
upon digitalis as one of the most valuable remedies at
at our command.
Dr. L. a. Conner said, concerning the use of digi-
talis in aortic insufficiency, that while the indications
for this drug were much less frequent here than in
some other cardiac lesions, he could not but feel that
it sometimes proved exceedingly beneficial. The
May 12, 1900]
MEDICAL RECORD.
835
theoretical objection thiat it unduly prolonged the pe-
riod of regurgitation did not seem to him of much
weight, for, if this argument was carried to its logical
conclusion, it meant that we should make use of reme-
dies which would increase the rapidity of the heart's
action. It was a question rather of the condition of
the ventricle and of the state of the heart muscle than
a theoretical consideration of the purely mechanical
problems involved.
Dr. Porter, in closing, said that his statements
had not been made from a purely theoretical stand-
point, but had been based on a very large clinical ex-
perience. This had been that, outside of that condi-
tion in which there were decided venous engorgement
and emptiness, so to speak, of the arterial side of the
system in cases of aortic regurgitation, digitalis was
more harmful than useful. The great danger from
digitalis was from the heightening of the arterial ten-
sion in the coronary arteries, with the consequent im-
pairment of the nutrition of the heart. He still be-
lieved that the tincture of digitalis, made from the
fresh leaves, was the most valuable and the most cer-
tain of the preparations of digitalis. It contained the
largest percentage of those constituents which were
most useful in the treatment of cardiac disease.
THE MEDICAL SOCIETY OF THE COUNTY
OF NEW YORK.
Stated Meetmg, April 2j, igoo.
J. Clifton Edgar, M.D., Chairman pro tem.
Tetanus its Nature and Therapy. — Dr. Alexis
V. MoscHcowiTZ read a paper with this title. Tetanus
was one of the diseases known from time immemorial.
It was an acute infectious disease, invariably caused by
the entrance into the body of the organism of Nico-
laier. Different names had been given to this disease,
but they were really varieties of tetanus, giving rise to
differences in symptomatology. Tetanus might follow
the slightest injuries, such as the introduction of a hy-
podermic needle, or from a leech-bite. The diagnosis
was readily made by finding the bacillus of Nicolaier.
Etiology. — It was caused by the lodgment of the
bacillus of Nicolaier, except in the few cases in which
the tetanotoxin or other poison resulting from the action
of the bacilli had been introduced into the system in
laboratory work. The germ was harmless when swal-
lowed, inhaled, or introduced into the rectum.
Symptoms. — The symptoms were always so well
marked that the reader of the paper did not enter
largely into the description of them. Cephalic
tetanus began with paralysis of the muscles supplied
by the facial nerve. Puerpural tetanus might follow
abortions as well as child-birth. It always began
with trismus. Tetanus neonatorum was a disease of the
poorer classes, and the first symptom was inability to
nurse.
Pathological Anatomy.— It was difficult to give
the concise pathological anatomy of tetanus; it was
not fully known. The present knowledge of its patho-
genesis pointed to the cells of the anterior horns as
the seat of changes. Local tetanus occurred regularly
in all cases of experimental tetanus and in muscles
nearest the seat of infection. The seat of origin of
the spasms was in the spinal cord, the toxins being
carried along the nearest nerves. The peripheral
nerves which were connected with the wound were
frequently in a condition of acute, septic, ascending
neuritis.
Prognosis. — The prognosis depended upon two fac-
tors: (i) The period of incubation; (2) the rapidity
of the symptoms showing the progress of the disease.
The prognosis of acute tetanus with a short period of
incubation may be as high as 96 per cent., down to 60
per cent., or a trifle less. During the past ten years
the following cases, taken from the literature, gave
these results: From the use of the subcutaneous
method, 290 cases, of which 173 resulted in recovery;
from the use of the intracerebral method, 48 cases,
in which 23 patients recovered; or a total of 338
cases, of which number 196 patients recovered and 142
died. He separated the cases into the following divi-
sions: (i) Very grave cases, in which, in one or two
hours, the whole body would be involved; (2) grave
cases, in which the tetanic symptoms were continuous,
tonic and clonic convulsions taking place; (3) me-
dium grave cases which developed in the course of a few
hours to six weeks, and in which the symptoms gradu-
ally disappeared; (4) mild cases, which were distin-
guished by the symptoms coming on gradually; (5)
very mild cases, in which there were mild trismus and
mild rigidity of the muscles of the neck; here the
symptoms might last many weeks.
Treatment — Up to the last decade the treatment
was symptomatic. By the efforts of Cattani, Tizzoni,
and others the treatment had been modified. The
rational treatment embraced the following points: (1)
The bacteria should be destroyed at the seat of infec-
tion; (2) the toxins already absorbed should be elim-
inated; (3) an endeavor must be made to render in-
noxious the products absorbed ; (4) the symptoms
induced by the action of the toxins should be over-
come. The offending body should be removed and
the wound disinfected. Saprophytic germs were easily
destroyed. A solution of bichloride, i : 1,000, to which
was added five per cent, of tartaric acid, might be used.
Tincture of iodine was useful. The entire wound
should be cauterized with the actual cautery or nitrate
of silver. Amputation of the injured member might
have to be considered. In endeavoring to eliminate
the toxins already absorbed, it had not yet been defi-
nitely decided through what channels the toxins were
eliminated. He advised the use of diuresis, cathar-
sis, and diaphoresis; these were certainly worthy of
trial on theoretical grounds. Again, a certain quan-
tity of blood might be withdrawn and decinormal
saline solution introduced. The fundamental princi-
ple of treatment was by means of introducing into the
system the serum of animals rendered immune; the
mode of action had not been acceptably explained.
He referred to the failure to diagnosticate tetanus suf-
ficiently early. A patient with tetanic symptoms was
not beginning to have tetanus, but was beginning to
die of tetanus. The toxins should be neutralized;
their effects on the body should be prevented. The
intracerebral injections he thought to be devoid of
danger if used with proper antiseptic and aseptic pre-
cautions, and done slowly enough. Urticaria had
been observed, but it disappeared within a few days.
As to immunizing the patient after infection had taken
place, this involved the introduction of the antitoxin
as a prophylactic measure in all wounds; such oppor-
tunities were seldom offered. To overcome the symp-
toms induced by the action of the toxin, the reflex
irritability of the higher reflex nerve centres, the aim
should be to take such measures as will prevent spasm,
as by the use of certain remedies. Of some value
were opium and morphine, chloral, bromides in full
doses, hyoscyamus, physostigma, etc. The injection
of certain emulsions into the brain substance was re-
ferred to; also the destruction of the toxins circulating
in the system by injections of carbolic-acid solutions.
In closing the speaker stated that by the antitoxin
treatment the mortality had been reduced from ninety
per cent, to about forty per cent. He recommended
that, although the serum was of great value, the other
therapeutic measures should not be neglected.
836
MEDICAL RECORD.
[May 12, 1900
Dr. William H. Park said that the first surgical
point to keep in mind was how extremely local was
the poison of tetanus; the bacilli, and the toxins that
originated from them, were to be found in the small
local wound ; so, if the case was seen early enough,
much of the symptoms could be eliminated. He empha-
sized the importance of cleansing the wound in order
to get rid of both bacteria and the toxins.
Dr. Lambert did not get with the serum treatment
as favorable results as were given in Dr. Moschco-
witz's paper; he was not much encouraged from the
use of the serum. Regarding the method of treat-
ment he did not see chat better results were obtained
when the serum was introduced into the ventricles or
spinal cord than when an intravenous injection was
given. Cases had been reported in which patients
had died from abscess of the brain and not from the
tetanus. The intravenous and subcutaneous methods
should be tried, and he cautioned against injections
into the brain or spinal cord.
Dr. Robert Abbe stated that, from his personal
experience with the antitoxin, he rather favored its use
and would certainly use it again under similar cir-
cumstances. Up to summer before last he had seen
only six cases, and these, with one exception, had been
fatal. Two years ago he had seen two, and last sum-
mer he had seen seven cases. Two cases he had treated
by the subcutaneous method; he had had a small al-
lowance of the serum, and bad results followed. Last
summer he had seven cases which presented unusual
and interesting features; they furnished a valuable
opportunity to see differences in action in wounds in
which the tetanus poison had gained an entrance; the
wounds acted as differently as two surgical wounds
could. Some of the wounds were not ordinary sup-
purative ones but ugly punctures, following pistol
shots, and around the wound, in an area as large as
the hand, there was a lardaceous infiltration; when it
was incised it cut like pork. All wounds should be
thoroughly cleansed, and he preferred the tincture of
iodine for this purpose, wetting a cloth with it. The
intracerebral injections were used only in bad cases;
in five such cases three patients survived. The
method used was that of Kocher; a simple open
wound was made by drilling through the bone with
a common hand-drill, and the antitoxin was injected
with an ordinary hypodermic syringe. An opening as
large as a lead pencil could be made under cocaine
anaesthesia; the proper position was half-way between
the outer angle of the orbit and a point in the middle
of the median line of the skull directly over the audi-
tory meatus. There was no pain or mental change;
the pupils, pulse, respirations, and heart were abso-
lutely unchanged. There was no evidence of later
trouble so far as could be determined. In two cases
the injections were made twice through the same
wound. A practical question that presented itself was
whether we could see any effect from the direct adminis-
tration in this way, either immediately or in the future,
that could be ascribed to the remedy. In some cases
one could not see any striking effects. In some cases
there was some decided benefit, even in those that
were fatal. In one case of puerperal tetanus that was
referred to him, the woman was in an exceedingly bad
condition; intracerebral injection by Kocher's method
was performed, and the patient went thirty-six hours
without spasms; she ultimately died.
Dr. M. W. Ware had often seen the lardaceous ap-
pearance of the wounds described by Dr. Abbe, oc-
curring about the injuries from guns or toy pistols.
Knowing that the germ of tetanus was anaerobic, he
incised three inches away from the wound in patients
who had died from this disease, and he got pure cul-
tures. This taught him that, in these cases of tetanus,
it was better to lay open widely the wounds when first
seen. He deprecated the use of caustics on account
of the eschars that were formed.
Dr. Alexis V. Moschcowitz closed the discussion.
Regarding the remarks of Dr. Park, who had stated
that most of the patients had died after intracerebral
injection from abscess of the brain, as a matter of fact
he had collected all of the cases in which the intra-
cerebral injection had been used, and only one patient
had died, and in this instance the streptococcus albus
was found, showing that it had resulted from improper
cleansing of the skin; that patient probably had gen-'
eral sepsis. Injury to the brain might be done, but
not if care was taken to use a fine needle and to take
enough time.
I^cdtcal %tcms.
Contagious Diseases — Weekly Statement Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending May 5, 1900 :
Tuberculosis
Typhoid fever
Scarlet fever
Measles
Diphtheria ,
Laryngeal diphtheria (croup)
Cerebro-spinal meningitis. . . .
Chicken-pox
Smallpox
164
2
13
32
30
6
Yellow Vision after Snake-Bite — Richard Hil-
bert mentions the various conditions attended with the
phenomenon of colored vision. So far as he is aware,
his is the first report of seeing yellow after snake-bite.
A young girl, walking barefoot in the fields, fell with
a piercing cry that she was bitten on the toe by a
snake. The snake was seen by others. An hour later,
when brought to the office, blood could be squeezed
from the wound near the nail. The limb was 5 cm.
greater in the middle thigh than its fellow, and the
calf 4 cm. The next day there were stiffness and pain,
besides the symptom that all light-colored objects ap-
peared bright yellow. A bluish discoloration of the
skin, extending over the abdomen, required fourteen
days to disappear. It was seven and a half weeks be-
fore the child was well again. It would be interesting
to learn whether in tropical countries, where snake-bite
is more frequent, yellow vision is a common symptom.
— Memorabilien, April 3, 1900.
Notes on a Case Simulating a Perforating Gas-
tric Ulcer. — W. J. Thompson and F. C. Dwyer met
with the case of a young woman, aged twenty-three
years, who some six weeks previously had begun to
suffer from vomiting on taking food, with much dis-
comfort and flatulency. After a meal of bread and
milk she was seized with nausea and epigastric pain,
followed by the vomiting of a reddish fluid. Symp-
toms grew worse in the course of a few hours, with ab-
dominal distention, rapid and weak pulse, fever, etc.,
and a diagnosis of perforation was made. Section of
the abdomen revealed, not a gastric ulcer, as was ex-
pected, but a coil of jejunum intensely inflamed, cov-
ered with flakes of lymph and having on its surface two
patches almost gangrenous, though not yet perforating.
Nine inches of bowel were resected, the Murphy but-
ton being used. Recovery ensued. The lesion was
believed to have resulted from infarction from a mes-
enteric thrombus. — Dublin Journal of Medical Sciences,
April, 1900.
Medical Record
A IP'eekly Jonyiuil of Medicine and Snygery
Vol. 57, No. 20.
Whole No. 1541.
New York, May 19, 1900.
$5.00 Per Annum.
Single Copies, loc.
©KioiwaX Articles.
WHEN SHALL WE OPERATE FOR APPENDI-
CITIS?'
By JOSEPH WIENER, Jr., M.D.,
NEW YORK.
ADJVNCT ATTENDING SURGEON, MOUNT SINAI HOSPITAL.
My object in writing tliis paper is not to add to tiie
already overwhelming mass of literature that has of
late years accumulated on this subject, but rather to
attempt in a feeble way to let a little light on the most
important part of the whole subject-matter, namely,
when shall a given case of appendicitis be submitted
to operation? In spite of the extensive literature on
this subject, perhaps to some e.xtent on account of it,
much uncertainty and diversity of opinion e.xist among-
medical men as to when they should advise an operation
in these cases. I have been led more particularly to
be interested in this subject because I am almost daily
coming in contact with cases of appendicitis that are
sent to the hospital by physicians. Only too many of
these patients have already perforations of the appen-
dix, and not a few have a general peritonitis.
I am no firm believer in the value of statistics, but
the following figures taken from the annual reports of
the Mount Sinai Hospital for the past five years must
give food for reflection:
1694,
i8,s.
1896.
1897.
1808.
Total number of cases of appendicitis .
Number of cases with general perito-
41
7
87
10
91
14
130
149
In one hospital alone we find in five years seventy-
six cases of general peritonitis due to disease of the
appendix, almost every one of which, of course, termi-
nated fatally. It need scarcely be mentioned that had
these seventy-six patients been sent to the hospital
early, the large majority of them would have recovered.
The term " early operation " is a relative one, and
much harm has been done by attempting to lay down
rules as to on which day or at which hour after the
onset of the attack an operation should be performed.
I have known of several cases that were sent to the
hospital on the third or fourth day of disease, some-
times even on the second day, with general peritonitis.
On remonstrating with the physician of these patients
for having delayed so long before sending the pa-
tients in for operation, the reply has generally been ;
" Why, it is only the second or third day of the dis-
ease." This was very true, but it generally cost the
patient his life. Every case must be decided on its
merits — no rule of thumb can be laid down. To wait
for symptoms of perforation or of peritonitis is fatal.
Patients may die, and especially children do die, from
sepsis without any perforation. It is advisable in
children to urge operation even earlier than in adults,
for the child's heart cannot withstand sepsis as well as
an adult's. But there is another important point about
' Read before the Harlem Medical .Association, January S, lyoo.
this term early operation. When did the disease in
the appendix, the appendicitis, actually begin? With
the onset of the first attack of pain, vomiting, fever,
etc. ? Or was there an inflammation going on insidi-
ously long before? The first attack of appendicitis
very often does not mean the beginning of the disease.
There may have been a catarrhal inflammation, or even
an ulceration of the mucous membrane of the appendix
for a long time before the onset of what is generally
taken for the first attack. The acute attack may mean
that the ulcerative process is suddenly increasing, or
that a foreign body (coprolith) is superimposed on a
previously long-present ulcer; or it may mean that the
peritoneum about the appendix is becoming inflamed
(a local peritonitis). If we fail to keep these anatom-
ical facts in mind, we will frequently be disagree-
ably surprised on opening the abdomen early in an
attack (as we suppose) to find a perforation of the ap-
pendix and a general peritonitis. If, on the other
hand, we keep the pathology before us, we will care-
fully examine the history of every case of acute appen-
dicitis for any gastric or intestinal symptoms which,
even though slight, may have previously been present.
We will sometimes even get a history of slight pain at
times in the right iliac region, for months preceding
the first acute attack. In the presence of such a his-
tory, we will be more anxious to operate very soon after
the beginning of the acute attack. For these are just
the cases in which, on opening the peritoneal cavity
on the second or third day, we find a diffuse peritonitis.
Naturally, this is true to even a greater degree in
recurrent attacks. For here we know that a patho-
logical process has been for weeks, or months, or even
years, going on inside the appendix. And we do not
know, we cannot know, how near that process in the
appendix is to perforating. Six hours, twelve hours,
twenty-four hours of an acute attack may bring on a
fatal perforation, and we may then perform an early
operation, so-called, and find to our sorrow that it is a
very late one. Hence it will be wise in a second or
third attack to operate earlier than we would in a pri-
mary attack with the same intensity of symptoms.
There is a class of cases in which the patients have
one attack of moderate severity that keeps them in bed
for a few days only. They then get up and attend to
their work, but they often have pain and discomfort in
the right iliac region with perhaps some gastric dis-
turbance. These cases, though the patients are able to
be up and attend to their affairs, are always dangerous,
and cannot be watched too carefully. They go along
for weeks or even months, and then there suddenly
develops a second attack, which is always a severe one
and often fatal. The disease with them is progressing
continuously though slowly, and finally leads to a sud-
den climax. The following case, in which I operated
a short time ago, serves as a striking example of this
class:
Charles L , aged seventeen years, had his first
attack of appendicitis six months ago. He was in bed
for two weeks with moderate pain and tenderness,
which were relieved by ice-bag and opium. For the
following few months he had pain and discomfort off
and on in the right iliac fossa. For the past six weeks
he was free from pain until two days before his ad-
838
MEDICAL RECORD.
[May 19, 1900
mission to the hospital, when he was seized with severe
general abdominal pain, which soon became localized
to the right side. At the beginning of the attacic he
had a chill lasting ten minutes. He was treated out-
side for forty-eight hours, and entered the hospital
with a pulse of 150 and temperature of 104° F. I de-
cided to operate as soon as I saw the patient, which
was about an hour after his admittance. At the opera-
tion an enormously thickened appendix was found,
gangrenous at its base, where it had sloughed aw-ay
completely from the caecum, and surrounded by foul-
smelling pus. In the pus a small coprolith was found,
and at the tip of the appendix was a second one. The
general peritoneal cavity was not invaded at the opera-
tion; the appendix was removed and the whole wound
packed with gauze. Four hours after the operation the
patient had a second chill lasting ten minutes. The
day following the operation the pulse rate was 120-
142, and the temperature ioo'-io2° F. There was
slight conjunctival icterus and some delirium — in
short, the usual picture of sepsis. Septic paresis of
the intestines developed, and the patient died in forty-
eight hours after the removal of the appendix.
I operated in a somewhat similar case last summer.
A boy, aged seventeen years, had three attacks of ap-
pendicitis during the preceding year and a half. The
attacks were mild in character, and had kept him in
bed only a few days. Between his attacks he had
occasionally had slight pain on the right side. He
entered the hospital two days after the beginning of
the attack, which had been ushered in by vomiting and
pain in the right iliac region. There was general ab-
dominal pain, and the whole abdomen was very rigid.
The diagnosis of appendicitis with general peritonitis
was made. At the operation, offensive purulent fluid
was found in the peritoneal cavity; the appendix was
perforated at its base, not adherent, but the small in-
testines were all matted together, presenting the usual
picture of a general peritonitis, of which the boy died
within twenty-four hours of the operation. Such
cases, of which w^e see only too many at the hospital,
have prompted me to write this paper.
The diagnosis of appendicitis is made from: (i)
The history; (2) the symptoms; (3) the results of ex-
amination— by abdomen, by rectum, by vagina.
As regards the history, we must ascertain first of all
whether there have been previous similar attacks,
whether the patient has had gastric or intestinal symp-
toms which may have been passed by as " indigestion,"
and yet may have been due to trouble in the appendix.
The history of the onset of an acute attack of appendi-
citis is generally one of two kinds. Either there has
been general abdominal pain with or without vomiting
for some hours, with a gradual localization of the pain
to the right iliac fossa — this is the history we most
frequently obtain. Or, on the other hand, the attack
begins with severe pain on the right side, generally ac-
companied by vomiting, but with little or no pain in
other parts of the abdomen. This history is not so
common, and generally speaks for a severe inflamma-
tion.
The syinptoms of appendicitis are sufficiently well
known not to need much dwelling on. I would merely
draw attention to the fact that the symptoms are unfor-
tunately very often no criterion of the intensity or
character of the disease. U'e see very severe cases
with very mild symptoms ; we see mild cases with severe
symptoms. The symptoms of an attack may be en-
tirely masked by the treatment that is being instituted;
particularly is this true of the use of opium or mor-
phine. Too often is operation delayed because the
pain has subsided under the use of opium, and the
patient feels very comfortable, while the pathological
process in the appendix is quietly progressing. Too
much stress cannot be laid on the danger of using
opiates in this treacherous disease. Almost all the
patients that enter the hospital with a general peri-
tonitis have been treated with opium or morphine.
For myself, I firmly believe that if the pain in an
attack of appendicitis, in spite of the use of an ice
bag, is so severe as to necessitate the giving of mor-
phine, then an operation is almost invariably indi-
cated. Pain and local tenderness are two of our most
valuable symptoms in this disease, and we dare not
give drugs that will mask them.
It is a mistake to think that the point of greatest
tenderness is always near the anterior superior spine
of the ilium. True it is that this is generally the
case, because that is the usual location of the appen-
dix. But where the appendix is, there will we find
the greatest tenderness. If the appendix is located
high up near the gall bladder, the greatest tenderness
will be in the hypochondriac region. If it is located
low down in the pelvis, we will elicit great pain by
rectal or vaginal examination. Moreover, it is often
true that the greater the pain, the more severe the dis-
ease. If a case on one day presents but moderate pain
and on the next shows a decided increase, we may
safely deduct therefrom that the inflammation has be-
come just so much more severe. Late in the disease,
however, sepsis may so blunt the sensibilities that
pain is no longer complained of. Perfoiation of the
appendix often causes severe local pain, which after a
few hours is decidedly less but more diffuse, showing
-the beginning of the involvement of the general peri-
toneum.
The examination in cases of appendicitis is of prime
importance. The local symptoms are decidedly more
important than the constitutional ones. In the face of
marked local signs we should operate even if the con-
stitutional symptoms are slight. Conversely, however,
if we have marked constitutional symptoms with but
mild local ones, we should not be too quick to operate,
but should first be certain that we have a case of ap-
pendicitis to deal with. Nevertheless in some of the
worst cases we can feel surprisingly little. This is
due in great part to the rigidity of the rectus abdominis
and oblique muscles of the right side. This rigidity
of the muscles is a very important sign, as it usually
speaks for a severe intra-abdominal inflammation un-
derlying. How often do we cut through such a rigid
abdominal wall and find a perforated appendix! The
following case illustrates what an important indication
for operation right-sided rigidity of the abdominal
muscles is:
Harry K- , thirteen years old, admitted June 15,
1899. He had never had a similar attack. Six days
ago he was struck in the abdomen with a fist. That
evening he had slight general abdominal pain. The
following day he vomited several times. The pain and
tenderness became localized to the umbilical and right
iliac regions. Cathartics were given before he entered
the hospital, and the bowels moved freely. Pain and
tenderness had persisted up to date. The bowels moved
well on the day of admission, when he also vomited
greenish fluid as he had done the day before. The
tongue was moist and coated; there was slight conjunc-
tival icterus. The abdomen was soft on the left side,
but on the right side there was marked muscular rigid-
ity. Owing to this rigidity, nothing could be felt of the
appendix or its surroundings. Rectal examination was
negative. On the day of admission the pulse was 118;
the temperature, 102° F. On the following day, in spite
of the fact that pulse and temperature both dropped to
100, I determined to open the abdomen. I was led to
this conclusion solely by the persistent rigidity of the
abdominal muscles on the right side. I found the
appendix, with a perforation at the tip, behind the
ca?cum, and surrounded by an abscess cavity. The
boy made a prompt recovery.
May 19, 1900]
MEDICAL RECORD.
839-
With the exception of the rigidity of the abdominal
muscles, the abdominal and rectal examinations in the
case were negative. But in the onset of an attack, by
examining the right iliaC fossa carefully, we can usually
feel what we are accustomed to call a " mass.'' This
"mass" only exception ally means an abscess. It usually
means that the appendix is inflamed, that its walls are
thickened, and that there are adhesions around it. We
must not be deceived by feeling the edge of the rectus
muscle, or by fecal masses in the ceecum. Having
made our abdominal examination as thoroughly and as
gently as possible (to avoid rupturing an abscess that
may be present), the next step is to examine by rectum
or by vagina, and if possible by both. Too much
stress cannot be laid on the value of vaginal and rectal
examination in appendicitis. In women the vaginal
examination is of prime importance, but even in men
and children the rectal examination is often invalu-
able. We can often make a diagnosis from the rectal
examination when the abdominal examination yields
no positive result whatever. But it must be borne in
mind that we are not by any means through with our
examination of a case of acute appendicitis when we
have examined the abdomen and the pelvis. All the
organs in the body should be carefully examined. The
lungs may show a beginning consolidation, and we
know that in the initial stage of a pneumonia the ab-
dominal symptoms frequently predominate. Marked
enlargement of the spleen would lead us to suspect
typhoid fever or malaria, both of which diseases some-
times resemble an acute attack of appendicitis. Nat-
urally the examination of the blood and urine would
be immediately made in a doubtful case. Even after
we have examined all the organs in the body there
are still two data that we must ascertain, one of which
is of great value; I refer to the pulse and temperature.
In every case of acute appendicitis there is some in-
crease in the rapidity of the pulse, and generally also
some rise in the temperature. But pulse and tempera-
ture often do not show a corresponding increase.
And what is of the greatest importance, we may have
but slight elevation of pulse and temperature with
grave pathological changes in the appendix.
Granting that we have made the positive diagnosis
of appendicitis, we are at once confronted by the mo-
mentous question: What are we going to do about it?
There is a quite general unanimity of opinion among
surgeons and even among medical men that almost
every case should be operated upon; but w^hen?.
There is the rub. Have we any sign or any symptom,
or any group of signs or of symptoms by which we can
judge in every case when to operate? Unfortunately,
we have not. He would be a skilful diagnostician
indeed who could say, " Here we have a simple catar-
rhal appendicitis," " Here there is a threatened perfo-
ration," "In this case there is a foreign body in the
appendix," and so on. The time may come when we
shall be able to describe the exact pathological process
in the appendix before the operation, but to-day all
our efforts must be centred on the question. Shall we
operate? In deciding this question, on which in so
many cases the life of the patient depends, we must
take everything connected with the case into consider-
ation. The age of the patient, the previous history,
the general physical development, the history of the
attack, the symptoms, and the result of the examina-
tion, all play a role in aiding us to arrive at a correct
conclusion.
In regard to the signs and symptoms that may aid
us, pain, tenderness, vomiting, tympanites, rigidity of
the abdominal muscles, may all be moderate, and yet
we may have a dangerous case before us. As a rule,
not much importance should be attached to the tem-
perature alone, but it should always be carefully meas-
jred, and never by moutli. I had a striking illus-
tration of this recently at the hospital. One afternoon
while I was operating, a patient was admitted with a
pulse of 120 and a temperature of 98.6° F. I exam-
ined the case and found a marked rigidity of the ab-
dominal muscles, and some tympanites. Tenderness
was general, but more marked on the right side. The
pulse was 120, as had been reported. The house sur-
geon suggested that the rapid pulse might be due to
the transportation of the patient to the hospital. How-
ever, the man looked sick, and on inquiry I found that
the temperature that had been reported was mouth
temperature. The rectum showed 102.4° F- I oper-
ated at once and found a perforated appendix, begin-
ning general peritonitis with considerable sero-purulent
fluid in the small pelvis. The case had been treated
with hypodermic injections of morphine for three
days. The man's life hung on a thread for three or
four days after the operation, but he finally made a
complete recovery. Personally, I put more confidence
in tlie rapidity and character of the pulse than in the
temperature. The relation of pulse to temperature is
sometimes of importance. A high temperature with a
rapid pulse always means a severe inflammation, and
with a positive diagnosis of appendicitis should gen-
erally indicate operation. Even more serious perhaps
is a rapid pulse with low temperature. Such a rela-
tionship of pulse to temperature generally points to a
perforation of the appendix without adhesions, and a
consequent general peritonitis. The temperature is
still low because the perforation is recent. If we wait,
the temperature will go up — and so will our patient.
Some surgeons have tried to bind themselves to some
hard-and-fast rule as to when they will advise opera-
tion, but they have few followers in this. True it is
that if the pulse is 120 or more and remains so, we
should operate. But it is a dangerous rule to say that
we should wait until the pulse is so rapid before oper-
ating. In one of the worst cases of appendicitis with
general peritonitis that I operated on, there was a pulse
of only 100. We must take every factor of the case
into consideration. If we have a frightened, neurotic
woman before us, a pulse of 120 is not so serious as a
pulse of no in a phlegmatic man. Then, again, the
whole general condition of the patient must aid us.
Is the tongue dry, is there much rigidity of the abdom-
inal wall, is there tympanites, is the pain severe, is
the tenderness marked, is the facial expression anxious ?
In the face of two of these signs or symptoms being
marked, I would favor an early operation, even if the
pulse was not very rapid, or the temperature high.
The character of the pulse is a condition that is often
overlooked. A small, compressible pulse, especially
if it is irregular, even though it is not yet rapid, is to
my mind a more grave symptom than a rapid, full,
regular pulse. The anxious facial expression some-
times induces us to operate, and we generally find
graver conditions than pulse and temperature would
warrant us in expecting; or we may find complications
that give rise to no symptoms. Not long ago I was
impelled to operate on a woman in whom the symptoms
were not very severe, but the facial expression was
anxious. I found a moderately inflamed appendix
with a tight stricture near its centre, and, to account
for the anxious expression, a retroverted impacted
uterus which gave rise to no symptoms, and which I
was enabled (in Trendelenburg's position) to replace
through the incision I had made for the removal of
the appendix. The condition of the bowels does not
often help us. We find diarrhoea or constipation in
mild as well as in severe cases. The functions of the
bladder sometimes aid us. Dysuria and painful mic-
turition are important symptoms. I recollect a case
in which these two symptoms, together with a small
irregular pulse, led to an early operation, and we found,
an appendix advanced in disease.
840
MEDICAL RECORD.
[May 19, 1900
Again, other surgeons have laid down the rule to
operate on every case of appendicitis as soon as the
diagnosis is made. This would make a malignant dis-
ease of appendicitis, which in very many cases it cer-
tainly is not. To quote from a recent paper of Rich-
ardson: "If in every case we operate as soon as the
diagnosis is made, we may operate at that very time
when the patient's best chance lies in conservatism."
Each case then must be carefully examined, and all
the evidence we can collect must be weighed in the
balance. I have laid down one little rule for myself
that I believe has aided me in saving a few cases, and
that is: "If in doubt, give the patient the benefit of it
by operating."
How is it, then, with a case in which we have made
the diagnosis of acute appendicitis, but in which the
signs and symptoms are not severe enough to warrant
an immediate operation? Here the problem is not so
difficult. We keep the patient in bed, on a liquid
diet. We give no cathartics, we give no opium, we
give no morphine. Only in exceptional cases do we
give enemata. We place a light ice-bag over the
region of the appendix. We have a trained nurse at
the bedside day and night; she counts the pulse every
hour and measures the temperature regularly every
three hours, and whenever there is any increased
rapidity of the pulse. We examine the patient care-
fully three times in twenty-four hours and note the
progress of the case. And just here lies the great
danger in administering opium. We cannot correctly
judge of the intensity of the symptoms if w-e deliber-
ately mask those symptoms by giving narcotics. How
can we tell if the pain has increased, after we have
deadened it with opium? The same is true of the
tenderness. Moreover, we are very apt to have tym-
panites develop if we give opium; and who can differ-
entiate between such a tympanites and that of a
beginning peritonitis? No, let us administer no opi-
um, but rather give nature full sway and allow her, as
the disease progresses, to display her various danger
signals. What are these danger signals? If we find
the pain and the tenderness (for these are two different
things) on the increase; if we find the abdominal wall,
which the day before was soft even on the right side,
becoming rigid, then we advise operation, even though
there has not been much change in the pulse or tem-
perature. If at any time in the course of an attack a
chill manifests itself, immediate operation is impera-
tive. If the pulse, as the disease progresses, does not
show a tendency to become slower, but rather more
rapid, even though the temperature is but slightly
elevated, the appendix should be removed. Persistent
nausea or vomiting is generally associated with obsti-
nate constipation, and means an invohement of the
peritoneum — rarely operation is advisable, even in the
presence of a siow pulse. A rapid pulse with high
temperature early in the disease means pus; we should
operate even though we cannot feel an abscess. There
may be no abscess — the pus may be inside of the ap-
pendix (empyema). In some doubtful cases the pres-
ence of a marked leucocytosis will aid in confirming
our diagnosis of pus. If we feel an abscess forming,
we watch our patient very carefully and, if possible,
wait a few days until firm adhesions form. We must
not expect to get fluctuation, for we very rarely do.
In the following case of an intelligent male nurse, I
diagnosed the beginning formation of an abscess and
waited for firm adhesions:
C. G , aged forty-three years, September 23, 1899.
The first attack began forty-eight hours ago with severe
pain in the umbilical region, which soon became
localized to the right iliac fossa. Pain and tenderness
^yere more severe than at the outset. The patient had
been nauseated since beginning of the attack, but had
not vomited. The bowels were constipated; two ene-
mata given before admission were ineffectual. The
patient felt worse than at any time since the beginning
of the attack. The abdomen was soft except over the
right iliac fossa, where the rectus muscle was tense and
rigid. Rectal examination was negative. Temperature
99.6^ F. ; pulse, 100.
September 24th: Temperature, 100.4' F-; pulse,
80-90.
September 25th: Temperature, ioo.6'^-ioi.2' F. ;
pulse, 97-92.
September 26th: Temperature, 99. 8'^-ioo' F. ; pulse,
68-76.
During this time an abscess was made out, and it
was decided to wait for firm adhesions to form.
October ist: Temperature, 98.6^-99° F. ; pulse, 66-
72. The tenderness had subsided except over a mass
the size of an orange, near the outer wall of the pelvis
on the right side. I now decided to operate. I found
an abscess behind the cascum containing about 100
gm. of fetid pus. Search was then made for the ap-
pendix, which was found with some difficulty. It had
sloughed away completely from the cascum, its base
being gangrenous, and was attached only by its mesen-
teriolum. The wall of the CKCum where the appendix
had been attached was covered by a thick layer of
fibrin. The tip of the appendix was tightly adherent
low down in the pelvis over the iliac vessels. The
perforation had taken place close to the ctecum where
the appendix was gangrenous. The man made an
excellent recovery.
If a large mass is felt per rectum or per vaginam,
immediate operation should be insisted on. A very
sad case I saw recently will prove the correctness
of this statement: A boy was admitted to the hos-
pital at 12:30 P.M. with an appendicitis of three or
four days' standing. Pulse, 100; temperature, 101.2°
F. On rectal examination the house surgeon felt an
abscess low down in the pelvis. One of my colleagues
was to operate on another case at 2 p.m., so the case
was reserved for him. I examined the case shortly
after two o'clock and could detect no abscess per rec-
tum. The boy looked anxious; his pulse in two hours
had jumped from 100 to 140, and when the abdomen
was opened it was found full of pus — the abscess had
ruptured. Tlad the boy been operated on two hours
sooner, his life would have been saved. This case
also emphasizes what was said above concerning the
value of rectal examination. Without it no diagnosis
of abscess could have been made, nor would it have
been suspected, as the pulse was only joo and the
temperature 101.2° F.
During the time that elapses from the onset of the
attack until the time of operation, too much care and
attention cannot be devoted to a case of appendicitis.
The responsibility that rests on the shoulders of the
physician is even greater than that of the surgeon who
performs the operation. For it is well known that,
with modern aseptic technique, the removal of the ap-
pendix is not associated with much danger; provided,
of course, the inflammation is confined to the appendix.
If, on the other hand, the signs and symptoms under
rest in bed, fluid diet, and ice-bag locally, decrease, we
should endeavor to tide the patient over his acute
attack. What shall we do when we have tided him
over the first attack? Shall we advise every person
who has had one attack to have the appendix removed?
Many surgeons and some physicians do so advise.
Unless the attack has been a severe one, I would
not, in every instance, advise the removal of the
appendix after one attack. There are undoubtedly
many cases of catarrhal appendicitis that, with careful
regulation of diet, proper exercise, and mild saline
laxatives, are for years following a first attack entirely
free from symptoms. Such patients should have ap-
propriate treatment, and should not be urged to have
May 19, 1900]
MEDICAL RECORD.
841
the appendix removed. At the same time, I believe it
is but fair to warn them that they are in danger of
having a second attack at any time, and that the
second attack may be much more serious than the first.
Such a patient, who has had one even moderately
severe attack, should not travel in unfrequented places,
or go to any place where he cannot have prompt sur-
gical treatment if the emergency arises. It is for the
intelligent patient to decide in such a case whether he
wishes to have his appendix — his sword of Damocles
— removed. And many such patients will so decide;
especial Ij- as they often have uncomfortable sensations
in the region of the appendix. But such patients
should not be told that the interval operation is en-
tirely free from danger. There is danger in every
administration of an ancesthetic, there is danger in
every operation. True it is, the risk is very small,
especially when compared with the dangers of a second,
more severe attack of the original disease. Should a
patient have had two attacks, I vi'ould in every instance
advise the removal of the appendix. In so advising,
I am well aware that some persons get along very well
even for years after a second attack; for I have myself
seen such cases. But the danger of a third attack is
too great, and it is doubtful if there is ever a restitutio
ad integrum after two attacks of appendicitis. More-
over, the third attack is apt to be more severe than
the previous ones ; nor is any one able to say how near
an appendix that has been twice inflamed is to perfor-
ating. I recently operated on a case that is to the
point, and, moreover, the case proves the falsity of tlie
ground held by some that an interval operation should
be performed only if the appendix can be felt through
the abdominal wall:
Dora H , aged ten years, was admitted to Mount
Sinai Hospital September 23, 1899. The patient had
the first attack four months ago; the attack lasted six
days. The second attack began twelve days ago with
vomiting, and severe pain in the right iliac reg'ion. This
attack lasted seven or eight days, and was more severe
than the first. The patient entered the hospital with
normal temperature and slow pulse. Nothing could
be felt by abdominal examination.
September 26th: Temperature, 98.6^ F. ; pulse, 80.
Operation : The usual incision was made and the colon
readily found, but not the appendix. The hand intro-
duced felt adhesions around the gall bladder. The
incision was enlarged upward, and the gall bladder
was found adherent to the transverse colon and to the
small intestine, forming a densely adherent mass. In
separating the colon from this mass, a very small ab-
scess was broken into. With considerable difficulty
the gall bladder, which was firmly adherent to this
mass, was liberated, and the necrotic appendix was
then felt to the left of the gall bladder and behind the
liver. Owing to the deep location of the appendix
and to the fact that pus had been formed, I did not
deem it safe to attempt the removal of the appendix.
It finally sloughed away completely; there was a slight
fecal discharge for a time, but the recovery was ulti-
mately complete.
This case was technically about as difficult a case of
appendicitis as one could find; the separation of the
adhesions was long and tedious, and had a perforation
taken place during an acute attack, the finding of the
appendix in such an unusual location w^|^M.ve been
even more difficult and dangerous than ipPws. This
case helps to clear up several moot points: (i) It is
dangerous to wait for a third attack. (2) After two
attacks, the appendix should be removed, even though it
cannot be palpated. (3) We cannot tell by the most
careful exaination how far advanced in disease an ap-
pendix is.
Nor is this case an isolated one. We frequently cut
down on an appendix in the interval between attacks,
and are often surprised at the amount of inflammation
we find in and around the appendix, and that too in
cases in which there is little or no pain, temperature
and pulse are normal, and little or nothing can be
felt on careful examination. I had a very striking
illustration of this quite recently in the case of a pa-
tient who had had but one attack of appendicitis:
Miss C , a native of Augusta, Ga., ag^d twenty-
two years, was perfectly well until six months ago.
She was at that time in bed for two weeks with an
attack of appendicitis of moderate severity. Follow-
ing the attack she suffered from loss of appetite, obsti-
nate constipation, and various nervous symptoms, in-
cluding fainting spells. As none of these phenomena
had been present before her attack, and as she also
had slight pain at times in the region of the appendix,
and moreover as I could elicit tenderness on deep
pressure in the right iliac fossa, I concluded that there
was an inflammatory process going on continuously in
the appendix. In spite of the fact that pulse and tem-
perature were normal, I advised the immediate removal
of the appendix. This advice resulted in the hasty
summoning of the patient's parents from Georgia.
Their arrival was followed by a consultation with Dr.
Bull, who agreed with the diagnosis, but who did not
consider the case so urgent as to prevent the patient's
being taken to her home and having the appendix re-
moved there. In this I did not concur, and the result
was that the patient entered Mount Sinai Hospital,
where I removed her appendix by the gridiron opera-
tion. I found an appendix three and a half inches
long with a tight stricture one-quarter of an inch from
its tip and another one half an inch from its base.
The whole organ was moderately congested but not
adherent. On cutting it open I found considerable
brownish, muco-purulent material, and eight distinct
coproliths. These were all situated between the two
strictures. The mucous membrane was extensively
ulcerated, and in places the ulceration had extended
into the muscularis. An acute inflammation might
very well in a few hours have brought about a perfo-
ration. And yet, in spite of the grave pathological
condition that had for months been insidiously devel-
oping in the interior of this appendix, the only sub-
jective symptoms were loss of appetite, constipation,
and very slight pain at times. The only objective
symptom that was present was slight tenderness on
pressure over the appendix.
This case is not an isolated one. Many patients
go about for months and months with such a chronic
process in the appendix; then they develop an acute
attack, and in a very few hours perforation has taken
place. The lesson to be learned from these cases is
obvious. If, after a first acute attack, the patient has
pain (be it ever so slight) repeatedly in the region of
tlie appendix, the removal of the organ should be
strenuously insisted on; and that too in the absence
of all other symptoms, and even in the face of an ab-
solutely normal temperature and pulse rate.
To summarize :
I. Not every case of appendicitis should be oper-
ated on.
II. After a first mild attack, try regulation of diet
and salines.
III. After a first severe attack, remove the appendix.
IV. After two or more even mild attacks, operate.
V. In an acute attack (i) do not give opium or mor-
phine. (2) Operate during an attack, (a) if a chill
manifests itself; (/') if the pain is severe enough to
require morphine; (f) if the pulse is very small, or
rapid, or irregular; (</) if there is persistent vomiting;
(<■) if there is persistent rigidity of the abdominal wall ;
(/) if an abscess can be felt; (g) if the general con-
dition makes it imperative; (/;) if in doubt.
But it must not be supposed that every case comes
MEDICAL RECORD.
[May 19, 1900
under one of these headings, although the great ma-
jority of them will be found to do so.
In conclusion, I would say that I have endeavored
honestly to outline what I believe to be the best plan
of treatment in the most important abdominal disease
we meet with in this country. I have seen many pa-
tients get over a primary attack; I have seen many
recover from a second and a third attack. I have seen
cases free from attacks for years, and then succumb to
a perforative attack. I am well aware of the dangers,
both primary and secondary, of an operation during an
attack. I have seen only too many cases operated on
too late. I know there is a distinct danger in the
interval operation, even though a very small one, and
I recognize the fact that it should not be lightly en-
tered upon. I do believe that if every case was oper-
ated on early, the mortality would be reduced. But I
also believe that by exercising care and discrimination
in our cases we can reduce the mortality just as much,
perhaps more than if we operated on every case, and
■we shall at the same time only be operating on those
cases that need an operation. The grand ideal in the
management of these cases is the hearty co-operation
of the physician and the surgeon, together with that
sine qua non, an intelligent patient. Very often, when
the pros and cons are laid before such a patient he
will unhesitatingly decide on the proper course of
action. May we not hope that in the near future phy-
sician, surgeon, and intelligent patient, working hand-
in-hand, will reduce the awful mortality of this dread
disease — appendicitis !
5 West Eightv-fifth Street.
I. ON A PECULIAR VARIETY OF PATHO-
GENIC STREPTOCOCCI. 2. ON A PECUL-
IAR PROPERTY POSSESSED BY (AT LEAST
SOME OF) THE PATHOGENIC BACTERIA:
PRELIMINARY COMMUNICATION.
By E. LIB.MAN, M.LX,
ASSISTANT PATHOLOGIST, MOUNT SINAI HOSMTAL.
1. This streptococcus was isolated in pure culture
from the mucoid portion of the stools from a case of
acute entero-colitis, in the service of ])r. Koplik.
Besides dilTering in a number of smalkr details from
ordinary streptococci, it possessed a feature not before
described. When grown on glucose-ag.ir, the whole
agar became whitened, although the growth was con-
fined to the surface. The same happened with lactose-
agar, but not with saccharose-agar. A very marked
result was obtained by growing the organism on glu-
cose-agar to which some hydrocele fluid had been
added; the medium became absolutely white, as if it
had been heated or an acid had been added.
Anaerobically, a similar result could be obtained
with the serum medium only. The whitening of the
media seems to depend on the production of an acid
(lactic acid or one closely allied) which precipitates
the albumin of the media. The organism is patho-
genic for mice, causing an acute inflammation of the
gastro-enteric tract.
2. While working on the streptococcus above de-
scribed, I tried to find out whether other bacteria might
not have a similar property. To my surprise I found
that a large number of the pathogenic bacteria can
precipitate serum-albumin in the presence of glucose.
In a general way the result seems to depend upon the
amount of acid produced. Pneumococci are the only
pathogenic organisms hitherto tested which do not
possess this peculiar property. Many bacteria can
also precipitate egg-albumin. Most of them precipi-
tate serum-albumin in the presence of o.i per cent, of
glucose, the amount present in the blood normally.
With lactose, maltose, and saccharose the results are
not so constant.
The saprophytes (T do not include the proteus group
here) which I have thus far tested do not seem to pos-
sess the same property. The growth of most of the
bacteria used in the experiments, including pneumo-
cocci, on a medium consisting of glucose-agar to which
some serum has been added, is far in excess of their
growth on any other medium.
In my complete paper, the question will be touched
upon, of what importance these facts may be in rela-
tion to infections, particularly in diabetics. Likewise
the possibility of differentiation of species will be
referred to.
I desire to express my obligations to Dr. Koplik for
the case upon which these observations are based.
iSo East .Sixtv-fourth Street.
Report of a Case of Gunshot Wound of the Preg-
nant Uterus and Foetus ; Caesarean Section ; Re-
covery— H. L. Nietert reports this case of a woman
nineteen years old. The patient was perfectly well
when last examined, three months after the operation.
The case is a very rare one, a record of only one case
being found in which Caesarean section was performed
for gunshot wound of the uterus. There was no infec-
tion. The skin about the bullet wound contained a
large powder burn, at one side and just below the hole,
giving indications that the weapon had been held near
the body and that the wound had been self-inflicted.
The direction the bullet had taken also pointed to this
fact. The patient finally admitted this to be true. —
Medical Revic7i', April 21, 1900.
A Fatal Case of Congenital Bullous Eruption in
an Infant. — R. H. Kennam says that bullous erup-
tions in the infant occur in two classes. One is pem-
phigus neonatorum. Descriptions of several cases of
this form are epitomized by the author. The other
class is the pemphigoid eruption of hereditary syphilis.
The contents of the bullas tend to become sanguin-
eous, the differential diagnosis from the first class
being made by observing the nature, time of appear-
ance, and position of the buUre, and the associated
cachexia. He finds it difficult to bring his own case
under either of these typical categories, though he does
not doubt that it belongs to one of them. In this
special case the bulla; appeared on the third day of
life, the child dying five days later. Extended refer-
ence is made to the literature of the subject. — Diil>lin
JoKnial oj Ahdiail Sciences, April, 1900.
The Diagnosis of Rabies G. Daddi says that the
best method for ascertaining in a short time (twenty-
four to thirty-six hours) whether a suspected animal
was njad or not, is to make a histological examination
of sections of the brain, cerebellum, spinal marrow,
and intervertebral ganglia. The alterations in hydro-
phobia will consist in destruction of cells, atrophy or
swelling, chromatolysis or vesicular deformation of the
cells, homogeneous swelling and vacuolization of the
protoplasm, granular-fatty or pigmentary degeneration,
or swelling of the protoplasmic and nerve prolonga-
tions, disappearance of these prolongations and of the
nucleus. A special alteration of the nerve ganglia
consists in a destruction of the nerve cells and neofor-
mation of the endothelial cells of the spaces in wliich
the ganglia are situated. Negative results are more
valuable than the positive ones obtained. A normal
nervous system cannot belong to a rabid animal. —
liivista criiica di C/i/iica Medica, April 7, 1900.
May 19, 1900]
MEDICAL RECORD.
843
ASSOCIATION OF AMERICAN PHYSICIANS.
Fifteenth Annual Meeting, licld at Washington, D.
C, May I, 2, and j, igoo.
Edward G. Janeway, M.D., of New York, Presi-
dent.
Third Day — Thursday, May jd.
Case of Filaria with Specimens of the Adult Par-
asite.— Dr. \V. T. Councilman, of Boston, read this
paper. The patient was a native of Barbadoes, and
had had the disease for five years. It was interesting
to note that in this case chyluria was absent.
The Elimination of Deleterious Substances from
Antitoxic Sera Dr. William H. Park, of the board
of health of New York City, read this paper. He said
that antito.xins were of the nature of globulins, and at
first it had been hoped to separate the toxins from
other globulins in the blood that produced the rashes,
but this effort had been unsuccessful. Filtering the
serum had no effect in preventing rashes following
their injection. The sera of dift'erent horses differed
markedly so far as irritating symptoms were con-
cerned. The sera of some horses were far less harm-
ful than others. He thought the only way left was to
select those horses whose sera were non-irritating.
With an increased amount of to.xins in the blood serum
there was also an increase in the globulins.
Dr. George Peabody, of New York, asked if any
decision had been arrived at relating to the idiosyn-
crasy of the toxin, i.e., after a patient had once been
injected with the toxins and a rash followed, would
the rash appear after the second injection.'
Dr. Park said that he had had only one such case,
and in that a second rash had occurred.
Varieties of the Diphtheria Bacillus. — Dr. F. F.
Westbrook, with Drs. Wilson and McDaniel, of the
Minneapolis board of health, read this paper. He
abandoned the old classification of true and pseudo
forms, and divided the bacilli into three groups, viz.,
(1) granular forms, which were metachromatic, there
being seven kinds, numbered by letters from a to g ;
(2) barrel forms, numbered from «' to e' ; and (3) solid
color forms, numbered from a' to g\
Dr. A. C. .\Lr,0TT, of Philadelphia, said that we did
know the normal diphtheria bacillus — in fact, it was
questioned if it was a bacillus. He thought that many
of these forms would change by some slight alteration
in the culture medium.
Dr. Park said that there was no way of telling the
virulence of the organism under the microscope. Some
of the forms described by Dr. Westbrook were consid-
ered in New York to be streptococci and not diphtheria
bacilli.
Dr. Westbrook said that one would be inclined to
agree with Dr. Park, but for the fact that when cultures
of those forms resembling streptococci were injected
into a guinea-pig, death was produced, and after
death the cultures showed a change in form of the
organism.
Presentation of a Case of Addison's Disease un-
der Treatment with Suprarenal Extract. — Dr. W.
W. Johnston, of Washington, D. C, presented this
case, and said that the points of interest were the acute
development of the disease, together with the very
rapid improvement, as shown by gain in weight, under
treatment with suprarenal extract.
Venous Thombosis as a Complication of Cardiac
Disease. — Dr. William H. Welch, of Baltimore, read
this paper and reported four cases that had been under
his supervision. He then reviewed the literature of
twenty-three cases. The first of his own cases was the
most interesting. The patient was a negress, seven-
teen years old, who had entered the hospital with signs
of mitral disease. The right arm became painful and
swollen, and a diagnosis of thrombus was made. The
patient died, and the autopsy showed complete occlu-
sion of the axillary, innominate, and jugular veins.
Cultures taken from different parts of the body were
sterile, except those from the thrombus.
Drs. F. p. Kinnicutt and Hermann Briggs, both
of New York, each recalled a case.
The Nature of the New Tissue in Cirrhosis of
the Liver and its Distribution.— Dr. Simon Flex-
ner, of Philadelphia, read this paper. The new liver
tissue was made up, he said, of elastic tissue and white
fibrous tissue. The pathology was not well under-
stood. By staining and by digesting out the fibrous
tissue, the elastic tissue would be left. In this way it
was possible to demonstrate what part of the new tis-
sue was made up of one or the other forms of the con-
nective tissues.
Cystoma of the Pancreas. — Dr. R. H. Fitz, of
Boston, read this paper. The case was a multilocular
cyst of the pancreas, which had been removed by an
operation. The patient was still living.
Degenerated Echinococcus Cysts of the Pleura.
— Dr. Charles Cary, of Buffalo, reported this case,
and said that the interesting point relating to it was
that the patient had never been out of the United
States. The specimen was on exhibition.
Aneurism of the Aorta with Rupture into the
Superior Vena Cava, Recognized during Life Dr.
Alfred Stengel, of Philadelphia, read this paper and
reported a case. He thought that it was not only use-
less to do a venous section in such cases, but that it
was absolutely dangerous.
Minor Forms of Cardiac Dilatation. — Dr. Bev-
erley KoiUNSON, of New York, read this paper. He
thought that this condition was frequently mistaken
for other ailments. There were several types in which
this condition occurred. The first was the anaemic
girl who had just passed the age of puberty. The
disease might lead to organic change, but generally
the cases were self-limited. The next was the obese
woman between forty and fifty years of age. He said
that such women often had a soft systolic murmur at
the apex. The next type was that of the thin, nervous
woman of about the same age. Dr. Robinson said
that laboring men might not suffer from any valvular
disease, but still might have some dilatation. As to
treatment, he would say that even young girls did well
on digitalis and stomachics.
Graves' Disease without Exophthalmic Goitre.—
Dr. W. H. Tho.mson, of New York, read this paper.
He thought that there were other symptoms besides
the enlarged thyroid gland and exophthalmus by which
one could make a diagnosis of Graves' disease. The
most important symptom, and the one that was gener-
ally first to appear, was tachycardia. The nervous
symptoms were the next in importance, and these
might be either sensory or motor disturbances.
.•\mong them were pains in the eyes, colored spectra,
tinnitus, insomnia, and fear, more marked in the morn-
ing than during the night. Oftentimes the patient
would have shifting pains in the extremities. Dr.
Thomson spoke of the weakness and tremor of the
voice in these cases. The gastric symptoms were very
important. There was persistent vomiting, with ano-
rexia, nausea, and diarrhoea, which was not accom-
panied by pain. There was no mucus in the stools
and no odor to the fjeces. Loss of the hair was often
characteristic. Tremor of the eyelids was the most
constant symptom. Death generally took place by
syncope. He thought diet had a marked effect in
844
MEDICAL RECORD.
[May 19, 1900
causing the disease, and consequently that the disease
had its origin in the gastro-intestinal tract.
Perichondritis of the Larynx in Typhoid Fever,
with Exhibition of a Patient and a Specimen. —
Dr. M. H. Fussell, of Philadelphia, read this paper
and exhibited a patient who had had the disease. It
was necessary to perform a tracheotomy, and the patient
recovered. The tube was taken out later, and the pa-
tient was able to speak very distinctly.
The Attitude of the Physician and Surgeon to
Appendicular Symptoms Complicating Typhoid
Fever. — This paper was read by Dr. H. A. Hare, of
Philadelphia. He spoke of the difficulty in making a
diagnosis in the early stage of typhoid fever, and said
that he had seen cases in consultation that simulated
appendicitis, but in twenty-four hours a typical typhoid
fever had been present. He thought these cases might
be e.xplained by the fact that there really was an ap-
pendicular inflammation present, or that there was a
marked ulceration in the neighborhood of the appen-
di.x.
Observations on Appendicitis. — Dr. Ir.\ Van Gie-
sox, of New York, read this paper. He thought that
the appendix was predisposed to septic attacks because
of its development, and that the attacks were due
merely to mechanical interference. Acute appendi-
citis was not due to an accident, but was the result of
a process of natural selection. He said if the appen-
dix was removed at birth, or a short time after, the
operation would interfere with that of natural selec-
tion. He spoke of the exciting causes of appendicitis
as being of a bacterial origin, and mentioned the
streptococcus, bacillus coli, and pneumococcus as
being the most common ones.
Some Observations on Human Temperature in
Disease. — This paper was read by J)r. Xorman
Bridge, of Los Angeles.
Study of a Mummy Affected with Infantile Par-
alysis— Dr. J. K. Mitchell, of Philadelphia, read
this very interesting paper. The subject was that of
an Egyptian mummy, which had been embalmed about
3700 B.C. That he was an old man was shown by the
worn molars, and the condition of the costal carti-
lages. The left leg was a little shorter than the right.
There was no evidence of fracture, but there was a
thickening of the femur on the left side. Dr. Mitchell
said the pelvis was perfectly formed and there was no
diseased condition of the vertebra. No curvature of
the spine was present. These facts seemed to show
that the subject walked with a high shoe made to coun-
teract the shortening, and that the case was one of an-
terior poliomyelitis.
A New Modified Sphygmograph Dr. Rohert T.
Edes, of Jamaica Plain, Mass., read this paper. He
paid special attention to the arterial tension.
The following papers were read by title: "The
Existence of Bacteria in Normal Tissues," by Dr. G.
J. Adami, for Dr. W. Ford, of Montreal: "Sub-Pec-
toral Abscess," by Dr. J. H. Musser, of Philadelphia;
" Stone in the Kidney and Conditions Stimulating It,"
by Dr. D. D. Stewart, of Philadelphia; "The Circular
Fibres of the Heart (Mitral Sphincter) as a Factor in
Functional Disturbances of the Heart with Mitral In-
sufficiency," by Dr. Morton Prince, of Boston;
"Graves' Disease without Exophthalmic Goitre," by
Dr. D. D. Stewart, of Philadelphia: "Would It Not
Be a Gain to Both Pathology and Practice if a Direct
Interaction between tlie Morbific Agent (Noxa) and
the Reparative Effect were Recognized and the Con-
ception of an Intermediate, so-called Inflammatory
Process Abandoned?" by Dr. Andrew H. Smith, of
New York; "The History of a Case of Circumscribed
Scleroderma," by Dr. S. B. Ward, of Albany; "Clin-
ical Types of Uric-Acid Diathesis," by Dr. J. N. Dan-
forth, of Chicago; " Sarcoma of the Stomach," bv Dr.
George Dock, of .\nn Arbor; "A Case of Multiple
Fibromas of the Nerves w ith Arthritis Deformans," by
Drs. L. Hektoen and R. B. Preble, of Chicago; "Mul-
tiple Myeloma," by Dr. J. H. Wright, of Boston;
"The Urea Content of the Blood in Cases of Nephri-
tis," by Dr. J. S. Thacher.of New York; "A Study of
Twenty-Four Cases of Typhoid Fever with Symptoms
of Peritoneal Infection — I.aparotomy," by Dr. George
B. Shattuck, of Boston, for Drs. George B. Shattuck,
J. Collins Warren, and Fanar Cobb.
AMERICAN SURGICAL ASSOCIATION.
Twenty-first Annual Meeting, Held in Washington,
D. C, Alfly I, 2, and j, igoo.
Second Day — Wednesday, May 2d.
Benign Obstruction of the Pylorus — Dr. Frederick
Kam.merer, of New York, read this paper. He di-
vided the subject into two heads, congenital and ac-
quired. Under the first he considered the acute form,
absolute at birth, and congenital hypertrophy of the
pylorus. Among the most important of the acquired
forms were fibrous stenosis, benign tumors, syphilitic
gummata, gall stones obstructing the pylorus, and
spastic contractions of the pylorus associated with
hyperchlorhydria. In regard to the treatment he em-
phasized the necessity of dietetics and of faithful la-
vage. These failing, surgical measures should be re-
sorted to, dilatation, even up to 40 French, via the
mouth, having been shown to be not only dangerous
but ineffectual . The mortality from this treatment was
about twenty-seven per cent. Of the operative pro-
cedures, he spoke first of resection of the pylorus;
second, of Loreta's operation ; third, of division of the
pyloric adhesions. He said that total pyloric resec-
tion for benign tumors had been abandoned. Divul-
sion was also passing into disuse because of recur-
rence, though it was still used by the English, who
obtained good results in cases of hyperchlorhydria
associated with spasm. Adhesions might be the sole
cause of obstruction, and might be entirely relieved by
breaking down ; but these cases were rare. He de-
scribed one of his own. The speaker then made a
comparison of the two procedures, pyloroplasty and
gastro-enterostomy. The technique of the last had so
improved that the mortality (fifteen per cent.) was
evenly divided, as was shown by recent German statis-
tics. Pyloroplasty was contraindicated by dense adhe-
sions, but this was not so of gastro-enterostomy, which
was here the operation of choice. As to the technique
of the operations, he said that posterior gastro-enter-
ostomy was unquestionably the better. The anterior
union was almost always complicated by a spur, as
well as by serious vomiting. He emphasized the ad-
vantages of Murphy's button over the purse-string
suture, agreeing in this respect with Czerny, and
stated that in placing the button the constriction must
be made very tight. Another advantage of the poste-
rior operation was that complications arising from the
immediate pressure of the jejunum and colon were not
possible. In regard to the immediate and remote re-
sults of these two operations he pointed out that with
the contraction of a dilated stomach, after gastro-en-
terostomy the opening was almost certain to con-
tract, particularly if the purse-string method had been
used. He spoke of biliary regurgitation in this oper-
ation, and of vomiting, and stated that entero-anasto-
mosis often counteracted these and other untoward
symptoms. The speaker advised pyloroplasty when
the pylorus was not seriously involved, because of the
absence of post-operative complications. On the other
hand, this operation was uncertain, particularly in
May 19, 1900]
MEDICAL RECORD.
845
cases of motor insufficiency. In sucli a condition, par-
ticularly with adhesions, posterior gastro-enterostomy,
by means of the Murphy button, was the operation of
choice.
Gastric Dilatation; Gastroptosis — Dr. B. F. Cur-
tis, of New York, read this paper. He began by out-
lining the normal position of the stomach. If the pylo-
rus and lesser curvature were palpable, this one sign
was enough to diagnose disease, for they were normally
far beyond reach. Gastrectasia was more than a sim-
ple enlargement. It involved, just as in kindred con-
ditions of the heart, dilatation and motor insufficiency.
This insufficiency was relative, in proportion between
the pyloric diameter and the stomach walls. The
condition was very rare, except as associated with
malignant disease, benign pyloric stenosis, or gastrop-
tosis causing obstruction at the pylorus. Referring
incidentally to acute dilatation, he said that the eti-
ology was practically unknown. Brown, in 77/,? Lan-
cet, reported a case of a man aged fifty-tive years, who
was seized with intense pain, thirst, suppression of
urine, vomiting, dyspnoea, dizziness, pulse of 40, and
collapse — evidence of epigastric tumor. Operation
revealed a cyst, supposedly pancreatic, w^iich yielded
three pints of green fluid. The autopsy, five hours
later, showed this cyst to be an enormously dilated
stomach. It was interesting to note that this acute
form might possibly be due to trauma of the vagi, for,
experimentally, section of these nerves resulted in
ursemia and gastric disturbances. Speaking of the
symptoms of gastroptosis, he pointed out that it was
invariably associated with the downward displace-
ment of at least one other organ, and very frequently
with a general enteroptosis. As to surgical treatment
of gastroptosis, operation was indicated when medi-
cine failed. The results of gastro-plication were good,
if, at the same time that the stomach was given sup-
port, the neighboring displaced organs were put into
their normal positions. Particularly was this true in
women, who were peculiarly subject to gastroptosis;
in these cases the ligaments of the genitalia should be
shortened. In order that there might not be a disas-
sociation of terms, Dr. Curtis said he preferred to
use the term gastrorrhaphy for this operation. As
to the pathology of gastroptosis one of several con-
ditions might be found, viz. : (i) The cardia was inva-
riably fixed. (2) The lesser curvature might be ver-
tical. (3) There might be descent of the centre of the
organ, the pylorus and cardia being fixed. As to
symptoms, there was almost always a progressive ema-
ciation, along with the usual clinical evidence of dila-
tation. Concluding, he said that since Treves' first
operation, in 1895, ^ number of cases had been re-
ported, with good results; that the outlook was bright
for gastrorrhaphy, provided the accompanying enter-
optosis was coincidentally corrected.
Hour-glass Contraction of Stomach. — Dr. F. S.
Watson, of Boston, read this paper. He spoke shortly
of the different forms of hour-glass contraction and of
the functional and pathological changes associated w ith
them; also of the symptoms and the diagnosis. Re-
ferring to the operation, gastro-anastomosis, for the
relief of this condition, he gave a summary of cases,
of which there had been thirty-five reported. As to
the technique, he spoke of the great influence which
the character of the contraction had on the type of
operation, and mentioned the German method, which
amounted to a lateral anastomosis of the two bulbs.
The speaker then drew attention to an operation he
had devised for the relief of this condition. It con-
sisted in opening the lesser bulb, washing it free of
stomach contents, superimposing it on the greater,
cutting the apposed walls with one stroke of the knife,
and suturing these ; finally, suturing the first wound and
closing the abdomen. In one case the patient was well
on the twenty-first day. A second case he found com-
plicated by very dense adhesions, and autopsy revealed
an undiscovered perforating ulcer at the isthmus of
the bulbs. He concluded by saying that his operation
ofl'ered the following advantages over lateral anas-
tomosis: (1) It avoided the great blood-vessels. (2)
It avoided the stomach contents. (3) The opening
was large and free. He added that gastro-enteros-
tomy was contraindicated in cases of hour-glass con-
traction, because it lost to the patient the very valuable
pyloric mucosa.
Diagnosis of Cancer of Stomach Dr. John C.
Hemmeter, of Baltimore, spoke on this subject. He
said that it seemed reasonable that an early diagnosis
was extremely difficult to reach, chiefly because, as
yet, we knew nothing of the causative factor in neo-
plastic growth. In ninety-nine per cent, of cases of
cancer of the stomach which had been operated on the
patients died of recurrence. In the one per cent,
saved, an early diagnosis was made, that is to say,
the cancer was discovered before subjective symp-
toms of gastric neoplasm had become evident. Czer-
ny, Rindrieisch, and Kraske opposed operating after
the development of these characteristic symptoms. Of
the means at hand to assist in early diagnosis, he
mentioned chemical, microscopical, and physical ex-
amination. The subjective symptoms were of little
value, for reasons stated. Age, likewise, was no longer
thought to be of value. There was undoubtedly a
period of three months — the incipient stage of the can-
cer— which was usually diagnosed as nervous dyspep-
sia or as chronic gastritis. These were very vital
moments. If the case refused to yield to good medical
treatment, despite tlie absence of any subjective carci-
nomatous symptoms, recourse should early be had to
the clinical tests. These he considered as follows:
Absence of hydrochloric acid was valuable; but in
those neoplasms derived from ulceration it was very
generally present. Lactic acid was simply a sign of
stagnation, and was due to carbohydrate fermentation.
Although it was found in eighty-four per cent, of the
cases, it was obviousi" of little yaluCj for no stagna.-
tlon could occur till the growth was too far advanced
for operation. The Oppler-Boas bacillus was present
in fifty-three per cent, of the cases. It was about as
valuable as lactic acid due to stagnation. In regard
to tumors, three-quarters of them were not palpable.
The A--ray test was futile. As to the gastroscope,
German reports gave little hope. It was extremely
dangerous to use. Gastric curettage was the very
latest method of procedure. It was practised with a
weighted soft-rubber tube, run in and out. There was
no hope of seeing carcinomatous architecture, but the
cell nuclei revealed certain changes now thought to
be constant and characteristic. Mitosis was found to
be irregular, one important feature being that the
chromozones were not equally divided between the
poles. If found, this was extremely suggestive. He
said that the future treatment of gastric carcinoma
would not be surgical; when the knowledge of carci-
noma advanced, it would be along the lines of the
biology and chemistry of the neoplastic cells, and,
ultimately, surgery would be discarded for a more sci-
entific mode of treatment.
Adhesions of the Stomach. — Dr. A. T. Cabot, of
Boston, spoke on this subject. He said that adhe-
sions were particularly prone to involve the stomach,
because of the nearness of organs, themselves pecul-
iarly liable to inflammatory change. Of the symptoms,
there were two types — first, those which closely resem-
bled biliary colic, and, second, those in which the at-
tacks simulated chronic dyspepsia. Pain was marked
in all cases, often lancinating, and might girdle or
shoot down the right shoulder. Recognition in mild
cases was as yet impossible; severe cases were usually
MEDICAL RECORD,
[May 19, 1900
operated on for gall stone. Efforts should be made to
diagnose the mild cases, as they often led to a destruc-
tion of the patient's physical power and were almost
always accompanied by nervous hyperassthesia. He
cited a case which came to operation after fifteen years
of medical treatment; a slight kink being removed,
complete cure resulted. He closed by advising an
exploratory laparotomy in such prolonged cases.
Stricture of the (Esophagus following Typhoid
Fever ; Gastrostomy IJr. Frederic S. Dexnis, of
New York, presented a case of gastrostomy, on w-hich
he had operated two years ago. The cardial stenosis
was a sequel' of typhoid, and prior to operation no
food had passed the man's mouth for three months.
His condition was deplorable. He now weighed one
hundred and eighty pounds. He fed himself with
comfort; had no excoriations or pain at the opening,
and was able to do his daily heavy work. This case
was illustrative of the value of gastrostomy.
Cases of Gastro-Enterostomy.— Dr. Fisher, of
New York presented an analysis of several cases of
gastro-enterostomy in which Dr. R. F. Weir had oper-
ated. In order to make such an analysis, it was nec-
essary to watch the cases for years prior to operation,
and for as long after the intervention. Watching
consisted in making frequent analysis of the gastric
contents for hyperacidity, together with observations
on dilatation. He found that in cases of hyperacidity
with dilatation there was a gradual increase of these
objective symptoms, together with the usual subjective
ones, until operation. After intervention in nearly
all cases the hyperacidity was reduced, and the dila-
tation also. Coincidently, the subjective symptoms
were permanently relieved. In regard to the lasting
effect of operation on the objective symptoms, it w'as
probable that the dilatation was much reduced, or en-
tirely negatived, except in cases far advanced, while
the hyperacidity was but changed from a constant to
an intermittent condition.
Hip Dislocations.— Dr. Oscar H. Allis, of Phila-
delphia, spoke (by request) on various hip disloca-
tions, and demonstrated the mechanism of displace-
ment on the Cadaver. Making fast the pelvis to a
table specially constructed for this purpose, he pro-
duced, by manual effort, and without section of cap-
sule or tendons, inward and outward dislocations of
the hip. He spoke of the danger of involving the
sciatic nerve in reducing by Bigelow's method of cir-
cumduction, and mentioned that his method was free
from this objection. He then showed an upward dis-
location and demonstrated an outward displacement,
associated with fracture of tlie shaft, just below the
trochanter. The principle of reduction was the same
in every case: the head of the bone was lifted to a
position opposite the acetabulum, and was supported
there by an assistant, and the thigh was wrung in such
manner as to allow the hand to be used as a fulcrum.
In closing, he said that he wished to be remembered
as having taught that no hip reduction should be at-
tempted until the pelvis was absolutely immobilized.
Under such conditions, and with the exploited tech-
nique, almost any form could be successfully reduced.
Third Day— Thursday, May 3d.
Surgery of the Stomach. — The discussion of this
subject was opened by Dr. W. W. Keen, of Philadel-
phia. He divided the subject into two classes: (i)
treatment of general stomach disease; (2) treatment
of malignant stomach disease. The latter he consid-
ered by far the most important, and confined his atten-
tion to it. Prior to operating on these cases, the sur-
geon met two kinds of medical men: the family phy-
sician and the gastric specialist. The first was too
often baneful ; the second was of the utmost use. He
was of use because through him alone could the sur-
geon reach a diagnosis early enough to hope for suc-
cess. The speaker dwelt on the grave importance of
the first two or three months, and urged that if so
much as a possibility existed of neoplasm, exploratory
incision should early be made. A palpable tumor
contraindicated operation. He closed by saying that
success in the future depended on early operation.
Dr. M. H. Richardson, of Boston, said that he
wished to be put on record as opposing indiscriminate
explorations. They were attended with a certain de-
gree of danger. He felt that exploration was warranted
only in cases of gastric hemorrhage which would not
yield to medical treatment — in cases of gastric perfora-
tion— but urged the danger of laparotomy and the need
of conservatism. He could add nothing to what Dr.
Mayo and others had already said on carcinoma.
With the very valuable assistance of the gastric spe-
cialists, whose skill in early diagnosis surgeons can
never hope to equal, he felt that more lives would be
saved by earl} operation in the future than were now
lost through delay. As to the view taken by Dr. Cur-
tis on the position of the normal stomach, he said he
had been surprised to find in how many cases of ap-
parent perfect health the greater curvature reached be-
low the umbilicus. Nor did he agree with Dr. Curtis
in the extreme rareness of acute dilatation. He ex-
pressed surprise at the statistics of Dr. Hemmeter as
to recurrence in gastric neoplasm (ninety-nine per
cent.), and said that it seemed to him high, though all
his own patients had died. Finally, he said that by
early operating we should get in the future as good
results in gastric neoplasms as in breast and other
superficial forms.
Dr. McGraw said that he wished to show a method
applicable to general intestinal anastomosis, biit par-
ticularly useful in gastro-enterostomy. It was the
elastic ligature. He first used this in 1891, with good
results, but the Murphy button, coming in just at that
moment, caused him to discard the elastic for the
metal connection. Fle now^ felt that this was a mis-
take. A small, round darning-needle was tl readed with
an elastic band, which w^as of greater diameter than
the needle (2-3). The rubber knot he tied with a bit
of thread. These ligatures cut through in about three
days. There could be no leakage, because of occlu-
sion of the needle wound. He closed by saying that
elastic ligature was the safest, the quickest, and best
method of doing gastro-enterostomy.
Dr. Mixter, of Boston, spoke of the case of acute
gastric dilatation to which Dr. Richardson had re-
ferred. The tumor was very large: it reached from
the pelvis to the ribs. A singular factor was the utter
impossibility of passing a stomach tube. Autopsy
showed a kinked oesophagus. The fatal result was
due to making the anastomosis of the stomach to the
ileum. He therefore urged the need of care in tracing
the duodenum to the jejunum, and there joining to the
stomach.
Dr. Allen said that in the \\'est there were two
kinds of gastric specialists, medical and surgical. He
agreed with Dr. Richardson in that exploration was at-
tended with risk, and cited a case to substantiate this
view.
Dr. Ransohoff, of Cincinnati, emphasized the
point that there should be two steps in the more com-
plex gastric operations. This was particularly true
of pylorectomy, in wiiich gastroenterostomy should
precede by perliaps two weeks. This was of value
locally and constitutionally. He noted that the pos-
terior operation seemed to him difficult, as the poste-
rior wall was hard of access.
Dr. C. B. Nancrede, of Ann Arbor, spoke most in-
terestingly on the evil influence of morpiiine used in
post-operative work. In those anastomoses followed
May 19, 1900]
MEDICAL RECORD.
847
by peritonitis, the colon bacillus was constantly the
exciting cause. Experimentally, some animals which
were normally immune to this germ died from septic
infection by it if morphine was given. In the ab-
sence of exact statistics, he felt that in man one-tenth
the fatal dose of bacillus coli communis would kill if
morphine was used. As to the percentage of mortal-
ity (ninety-nine) mentioned by Dr. Hemmeter, he felt
that it was too high. If it was true, the surgeon had
absolutely no right to do anything more radical than
gastro-enterostomy.
Dr. J. E. Moore said that surgery must depend on
medicine for diagnosis. All the means for early diag-
nosis should be exhausted; this takes but a week.
Then laparotomy should be done. He cited a case of
a man aged forty-two years, sick for only three weeks.
There was no vomiting. The only symptoms were
emaciation and absence of hydrochloric acid. He had
pain for ten days only. Operation revealed an inop
erable carcinoma. In closing, he touched on the im-
portance of examining the upper end of the duodenum
in cases in which the bleeding point could not be
found in the stomach.
Dr. S. H. VVeeks, of Portland, Me., continued the
discussion by speaking on the importance of recogniz-
ing that surgical intervention could, at best, be but
palliative now; and he strongly advocated gastro-en-
terostomy. He emphasized the use of catgut in all
buried work. It could be made absolutely sterile by
boiling in juniper oil. He criticised Dr. Watson's
technique in gastro-anastomosis, saying that he felt
the advantages claimed for it were more than counter-
balanced by the additional cut, and advised the ordi-
nary lateral anastomosis.
Dr. L. C. Tiffany, of Baltimore, urged the neces-
sity of early diagnosis. He had seen but one case (at
autopsy) favorable to operation, but recognized that if
all cases of dyspepsia were treated as had been recom-
mended, very many needless operations would be done.
He considered the operation for the relief of gastric
neoplasm still in its infancy, and felt that, before we
could hope to know much about the condition, hun-
dreds of cases must be diagnosed by operation, just as
was done, first, in ovarian disease; second, in appen-
dicitis. We must see the diseased stomach a vast
number of times; then only should we learn.
Dr. F. B. Harrington, of Boston, said thai pyloro-
plasty was not a desirable operation for the help of
immediate conditions.
Dr. Robert F. Weir, of New York, said that in
these gastric cases operation was done to meet one of
four conditions: pain, hemorrhage, gastric dilatation,
and delayed food expulsion. As to technique and
choice of operation, he was much disposed to favor
gastro-enterostomy combined with entero-anastomosis,
because this did away with all untoward symptoms bet-
ter than anything else he had tried. His last eleven
cases had been successful. He referred to Dr. Cabot's
remarks on adhesions, and cited a very complicated
case of his own in which the pylorus had been kinked
by bands, the relief of which proved a very important
factor in the operation. He spoke in favor of the
Murphy button, saying that the cicatrices which had
made Senn's and Abbe's operations obsolete did not
develop after its use. He strongly deprecated the
employment of any technique the chief recommenda-
tion of which was a reduction in the time of operating;
speed was of but little value. In closing, he drew
attention to the importance of using cocaine in ab-
dominal work.
Dr. Rodman asked that the section mi^ht hear from
Dr. .Armstrong, of Montreal.
Dr. Armstrong, in speaking of hemorrhage from
the stomach, divided it into two classes — first, that in
which the blood came from capillaries and small
veins; second, that in which it came from the great
vessels. In this class medical treatment did no good,
and operation was indicated if the hemorrhage recurred
within seventy-two hours. The first hemorrhage was
rarely fatal. He spoke of the necessity of a broad
opening in the anterior gastric wall, and cited a suc-
cessful operation for gastroptosis. He closed by in-
dorsing pyloroplasty.
Dr. L. M. Tiffany, of Baltimore, gave an impor-
tant aid in searching for the bleeding point. It was
to insert the hand and turn the stomach wrong side out.
Here the discussion was closed, and the first volun-
teer paper was read.
The Methods of Closing Abdominal Incisions.—
Dr. M. H. Richardson, of Boston, read this paper.
He placed immediate emphasis on the great advan-
tages of the through-and-through suture over suture en
etage, claiming, first, that it left no blind spaces; sec-
ond, that it was very quickly done. The materials he
indorsed were silk, silver wire, and silkworm gut. Of
two thousand cceliotomies at the Massachusetts General
Hospital which were sutured through and through, and
which healed by primary union, but twelve returned
with recurrence. Buried sutures should be non-ab-
sorbable, for they should add strength to the tissues
in which they lie, and silk was to be preferred. In
closing, he emphasized the point that accurate approx-
imation of the abdominal layers was not necessary for
strong union.
Dr. J. B. Deaver, of Philadelphia, agreed heartily
with Dr. Richardson, and emphasized the need of
carefully dressing the wound.
Dr. Weir said that in New York suturing by layer
was widely in vogue. He spoke of the need of leav-
ing the sutures loose; constriction formed a slough,
which gave a nidus for the skin germs which might
be found in every wound.
Dr. Fowler, of Brooklyn, showed a multiple figure-
of-eight suture, which, starting within, obviated the
" dead spaces " and seemed to combine the best fea-
tures of both types of sutures.
Dr. Freeman, of Denver, objected to unabsorbable
materials on the ground that, if left in place, they could
do no good after a few days.
Dr. Coley, of New York, indorsed Dr. Weir's posi-
tion ; he claimed that catgut could be absolutely steri-
lized, and stated that while prior to the use of rubber
gloves there had been six per cent, of infection in her-
nia cases at the Hospital for the Relief of the Rup-
tured and Crippled, since their introduction there had
been but one infection in the last one hundred and
fifty cases. Catgut had been used in all.
Dr. Mixter, of Boston, spoke of the importance of
the suturing technique, laying stress on two points —
to cut through muscle, and not to tie the sutures too
tight.
Dr. George B. Johnson, of Washington, said he
had used all kinds. He had used the method advised
by Dr. Richardson till a few years ago; now he was
returning to the through-and-through method, feeling
that it was the best.
Dr. Nancrede said that catgut could be made
sterile. He did not think that non-absorbable mate-
rials gave added strength.
Dr. Carson, of St. Louis, had used Dr. Fowler's
cross-suture, and liked it. In a series of experiments
not yet complete a bit of skin was removed from the
wound, and this, together with an end of the catgut
suture, was cultured. The staphylococcus albus (from
the skin) was invariably the only germ found, and that
with considerable constancy. The gut was sterile.
Dr. Ransohoff showed a purse-string suture of the
peritoneum, which seemed of great value in preventing
adhesions, and advised a continuous suture for the
other layers. Thus he would avoid horizontal scars.
MEDICAL RECORD.
[May 19, 1900
Dr. Fowler agreed that the purse-string suture re-
duced the danger of peritoneal adhesions.
Dr. Richardson, in closing, said that he objected
to catgut more because of the difficulty in tying it
than because he feared it would infect. He referred to
the extremely low percentage of hernia in his records,
and spoke of the good effects of gloves and mask. He
ended by urging the use of the through-and-through
method.
Strangulated Hernia through a Traumatic Rup-
ture of the Diaphragm ; Laparotomy ; Recovery. —
This paper was read by Dr. E. W. Walker, of Cin-
cinnati. He spoke first of the extreme rarity of these
cases. In his case there was a severe trauma, the in-
jury being received in the small of the back. When
the patient was seen by him, twenty hours later, his
condition was very desperate. Shock was well ad-
vanced ; dyspnoea was marked ; there was excruciating
pain over the left breast, and cough with bloody ex-
pectoration. Flatus was present, and tympany over
the left lung. The heart was pushed two inches
toward the right. The seventh and eighth right ribs
were fractured. Median incision revealed a great rent
in the diaphragm through which a large mass of bowel
had slipped into the chest cavity. VVith great diffi-
culty this coil, eight inches long, was withdrawn.
The opening admitted three fingers. Closure was
very difficult, and before it was accomplished the pa-
tient grew too weak for it to be continued. It was
accordingly left unfinished, and the operation was
concluded. As to technique, it was of great interest
to consider the choice between the abdominal and the
trans-pleural paths. He preferred the abdominal in-
cision.
Dr. S. J. MiXTER showed specimens of his case
which was of great interest, because of its having re-
sulted from muscular exertion. He found a gangre-
nous mass, and the gut burst during efforts at reduction.
Dr. Freeman, of Denver, advocated the trans-pleu-
ral route because of its greater ease.
Dr. R. Matas, of New Orleans, said that the trans-
pleural route should always be used if a possibility of
strangulation existed. It was less dangerous than the
abdominal, and was preferred by Italian surgeons.
A Case of Sub-Pubic Hernia through the Pelvic
Floor ; Operation — Dr. F. B. Harrington, of Bos-
ton, read this paper. He spoke of the varieties of vesi-
cal hernia, citing some of the causes. His case was
that of a woman aged forty-six years. The symptoms
came on very suddenly, the gravest being acute reten-
tion. When he saw her, she had a tumor eighteen by
eight and one- half inches protruding from the pelvic
floor. Two years before she had been operated on for
fibroid of the left labium majus. Undoubtedly the
present tumor had some relation with a recurrence of
this condition. A vesical sound showed the tumor
mass to be largely composed of bladder, but every at-
tempt at reduction failed. After laparotomy, however,
this was easy. The ovaries and tubes were removed
and the uterine fundus was brought down to cover the
rent in the pelvic wall after reduction. This treat-
ment proved in every respect successful.
A Case of Acute Tuberculosis of the Mesenteric
Glands of the Ileo-Caecal Coil ; Removal ; Perma-
nent Recovery. — This paper was read by Dr. M. H.
Richardson, of Boston. He urged the necessity of
dissecting diseased mesenteric glands, saying that it
seemed as important here as in the neck. The condi-
tion was a common one; the glands were often cheesy
or calcified. He suggested the possibility of a rela-
tionship between such glands and appendicitis. To
show how readily such acute adenitis might be con-
fused with appendicitis, he cited a case which presented
the classical symptoms of appendicitis, but in which
the appendix was normal. A great mass of glands
was found and removed. The operation v,as a perma-
nent success.
Dr. Allen, of Cleveland, recalled a similar case.
Apropos of the relationship which Dr. Richardson
had said might exist between appendicitis and tuber-
culous glands. Dr. Nancrede said that he had been
vainly seeking for many years a tuberculous appendix.
In the absence of Dr. J. W. Elliott, of Boston, his
paper on " Successful Removal of Acutely Inflamed
Tuberculous ^Mesenteric Glands " was read by title.
The society then went into executive session.
Afternoon Session.
In the absence of Dr. De Forrest Willard, of Phila-
delphia, his paper on " Congenital Cystic Tumor of
the Pelvis "' was read by title.
Extirpation of a Very Large Aneurism of the
Renal Artery. — Dr. W. W. Keen, of Philadelphia,
read this paper. Reviewing the history of this condi-
tion, Dr. Keen said that there had been reported but
twelve cases. Three only had been operated upon —
the first by Albert, of Vienna; the second by Hahn, of
Berlin, in 1893; the third having been Dr. Keen's
case. The patient was a woman aged forty-five years.
She had had pain over the gall bladder for four years,
with swelling on the right side of the abdomen. A
vertical incision was made through the right rectus,
and immediately the tumor sprang up to view. He
was uncertain of its character till after its removal,
when it was split; this showed it to be an aneurism.
Dr. Keen spoke of the differential diagnosis; also of
the fact that, presumably because of the small size of the
renal artery in proportion to the size of the aneurism,
pulsation was absent. The tumor was large, 14.5 cm.
in diameter; it weighed 970 gm. In conclusion, he
spoke of the encouraging outlook in this class of
cases. Of the three patients operated on, three lived.
A paper on " Carcinoma of the Rectum,'" by Dr.
John B. Deaver, of Philadelphia, was read by title.
Spontaneous Disappearance of Carcinom.a of the
Lip ; Union following Pathological Fracture of the
Femur due to Secondary Carcinoma. — Dr. Leon-
ard Free.man, of Denver, read this paper. He
described a case having had the characteristic re-
forming crust, which had disappeared entirely after
the removal of a very rough tooth that continually ir-
ritated it. Of the osteoporosis induced by neoplastic
growth. Dr. Freeman said that union took place much
more frequently than was generally supposed. He
showed a striking specimen of this in a firmly united
femur, in which union had taken place despite the
neoplastic growth. Nor was this union composed of
spicules merely, as had been taught.
The remaining papers were read by title, as fol-
lows: "Multiple Coccygeal Fibromata," by Dr. H.
R. Wharton, of Philadelphia; "The Removal of the
Seminal Vesicle," by Dr. N. B. Carson, of St. Louis;
" Complete Absence of the Uterus and Vagina, with
Creation of New Vagina," by Dr. N. B. Carson, of St.
Louis; " A Study of Twenty-F"our Cases of Laparot-
omy for Peritoneal Infection in Typhoid Fever," re-
ported by Drs. George B. Shattuck, J. Collins Warren,
and Farrer Cobb, committee of the Boston Society for
Medical Improvement, presented by Dr. J. Collins
Warren.
Officers Elected President, Dr. Roswell Park, of
Buffalo; First I'icc-Prcsidcnt, Dr. John E. Owens, of
Chicago; Second Vice-President, Dr. Clayton Parkhill,
of Denver; Secretary, Dr. H. L. Burrill, of Boston;
Recorder, Dr. De Forrest Willard,. of Philadelphia;
Treasurer, Dr. George R. Fowler.
The next place of meeting will be Baltimore, Md.,
May 7, 8, and 9, 1901.
May 19, 1900]
MEDICAL RECORD.
THE AMERICAN GYNECOLOGICAL ASSO-
CIATION.
Twenty-Jijtli Annual Meeting, Held at Was/iington,
May I, 2, and 3, igoo.
First Day {continued) — Tuesday, May ist — Morning
Session.
Discussion on Fecal Fistula. — Dr. Dudley said that
in operating for cancer, and in breaking up the adlie-
sions, he had broken the small intestine in two. He
had put in a Murphy button. He could not remove
the uterus, even the rectum being involved, so he
looked upon the case as helpless. The Murphy but-
ton was recovered, having worked down to the rectum
and out through the fistula behind the uterus. The
fistula healed, and the woman recovered.
Dr. Munde said he had understood his friend. Dr.
Noble, to say that fistula was always the result of un-
clean surgery, and while this was generally true, still
sometimes fecal fistula? did occur when the surgery
had been perfectly clean. He had had within a year
three cases of fistula resulting from intentional open-
ing of the intestines to relieve obstruction to the bow-
els tending to general peritonitis following some ab-
dominal operation. In the first case a Murphy-button
operation was performed, as the fistula refused to close
spontaneously. The patient did not survive the sec-
ond operation. In the second case the patient recov-
ered. The woman had fecal fistula through the vagina
following hysterectomy for double intraligamentous
abscesses. This fecal fistula in the vagina closed
spontaneously, but the abdominal fistula was so large
that after two attempts to close by freshening the intes-
tinal suture through the wound it was resected and the
Murphy button applied. In one case of fistula above
the sigmoid in which the gut was adherent the layer
operation gave a cure. In another Szymanowski's
operation was performed, which consisted in paring
the one side of the skin and sliding it under the other
lifted-up side. This gave complete closure of the open
gut. He agreed with Dr. Currier that it was well to
wait in fistula of the small intestine; but with fistula
of the large bow-el the abdomen should be opened.
Dr. Mann was disposed to be very conservative
in his management, giving the fistula a long time to
heal. With the small intestine the condition was
somewhat different; the opening would not heal as well
as one of the large. The farther up the lesion in the
small intestine the less likelihood was there of heal-
ing. The nearer to the stomach the harder was it for
healing to occur; the gastric juices seemed to interfere
with the reparatory process. Therefore it was almost
always necessary to open the abdomen in these fistula
of the small intestine. Further treatment depended
upon the size of the opening; if close to the mesen-
tery, it would be dangerous tO- sew it. If the opening
was large, it could not be sewed for fear of stricture.
In these cases w-e were obliged to resect. In one or
two cases the result had been satisfactory from a plas-
tic operation on the abdomen without opening the ab-
domen and cutting down upon the intestines.
Dr. Peterson described a case of fecal fistula
which had remained open for a year, at which time he
had removed the uterus, hoping to close it from below.
This had failed. Under these conditions it seemed
to him very dangerous to advise patients to undergo
abdominal operations when the fistula was low down.
Dr. I. S. Stone said, in closing, that the deeper fis-
tulae along the sigmoid and the rectum were those
which gave the most trouble. In regard to the claim
of priority made for Lawson Tait an5 Greig Srnjth in
the method he had pursued, he replied that he could
not see how the method was a typical flange suture.
Dr. Munde's method was applicable in a large num-
ber of fistulas in which the sinus was uncontaminated
with fecal matter. In the presence of fecal discharge
his own method had the advantage of dividing off the
fascia and leaving an opening entirely clean.
The Remote Results of Conservative Operations
on the Ovaries and Tubes : An Analysis of Eighty-
five Cases. — Dr. VV. L. Burrage read this paper^
He said he had performed one hundred and thirty-
seven operations on diseased uterine appendages with
the object of preserving one ovary or a portion or por-
tions of one or both ovaries with their tubes, or as
much of the tubes as was reasonably normal in appear-
ance. In eighty-five of these reliable information as
to the present condition could be obtained at least a
year after operation, and the results were included in
the tables accompanying the paper, the cases being
divided into the more severe and the less severe. In
comparing the two it was found that gonorrhoea and
syphilis were more prevalent, and that the symptoms
had resulted more frequently from difficult labors or
abortions among the more severe, and that the tubes
were closed in a majority of the more severe, whereas
they were open in all but one of the less severe.
Pregnancy followed operation in four of the more se-
vere and in all of the less severe. In none of the
cases in which the closed tubes had been opened and
new ostia formed did pregnancy follow operation. In
all of the cases of subsequent pregnancy in both
classes, except two of the less severe, the patients had
had previous pregnancies. Anatomical cure was re-
corded in thirty-three out of fifty-seven cases which
came under observation, and symptomatic cure in sixty
out of eighty-five cases. It was advisable to do con-
servative operations in all cases in which the ovaries
and tubes were not hopelessly diseased in all parts of
their structure, except on patients who were near the
menopause, on patients who had pronounced gonor--
rhcta of long standing, and on the rare cases of malig-
nant disease. With the present methods of performing
resection of the tubes, if both tubes were found closed
subsequent pregnancy was not to be expected. In
severe grades of inflammation of the appendages irre-
spective of causation, if the ostium abdominale of one
tube was patent the prospect of subsequent pregnancy
after the preservation of a portion of the ovary was
about one in four and a quarter, or 23.5 per cent. In
less severe grades of inflammation under similar con-
ditions of tube and ovary, the prospect of subsequent
pregnancy was about one in two and a quarter, or
forty-four per cent. In women who had borne chil-
dren, in both classes, subsequent pregnancy might be
expected in thirty-five per cent., whereas in previously
sterile women it might be looked for in only five per
cent.
Dr. Edwards said that if one thing was more im-
portant, it was the tube rather than the ovary. He
would always leave the tube, for nature did a wonder-
ful amount of repairing. He recalled two cases of
unmarried women, past the age of thirty years, who
married after he had operated, and in both cases the
ovary had been buried down below the cul-de-sac.
Such women should have the benefit of the operation
as much as if they were younger.
Dr. Dudley said that last year he had reported one
hundred and twenty-three cases of such operations and
this year one hundred and thirty-eight without death.
In a case of double pyosalpinx he had taken the tube
off, left the ovary hanging, and brought the uterus up
and split the fundus in two. He was absolutely sure
that the ovary grafted, and to day the patient was men-
struating every twenty-eight days. He had collected
five such cases, and in all of them he was sure the
ovary had grafted. Two of the women were menstru-
ating; in one only five weeks had clasped. He was
of the opinion that the function of menstruation should
850
MEDICAL RECORD.
[May 19, 1900
be conserved, aside from its effects in preventing reflex
disturbances.
Dr. Noble asked why Dr. Dudley cut the ovary
loose from the natural blood supply if his only object
was to retain the influence of the ovary; also if he
put it in the uterus to see if pregnancy would result.
Dr. Dudley replied that it was to try the experi-
ment of bringing about pregnancy that he had planted
the ovary. The woman upon whom he had done the
first operation was pregnant two months afterward.
Dr. Philander A. Harris said he was glad to hear
Dr. Burrage speak as he had. In these cases there
was often no disease in the ovary itself. Aside from
a condition in which there was ovarian abscess, and
the follicle had at the time of rupture involved or in
any way developed abscess, he did not see why we
could judge of a condition which had resulted from
inflammation. The Graafian follicles might be mis-
taken for beginning cystic degeneration. For the past
two years he had scarcely removed an ovary, the only
cases having been those clearly of ovarian abscess,
and he knew that pregnancies had occurred subse-
quently. The personal inferiority a woman felt when
menstruation had ceased was a matter not to be forgot-
ten. It was not the mere matter of having children,
but there was a personal element to be considered.
He was interested to know how many cases of preg-
nancy had occurred in women from whom both tubes
had been amputated close to the uterus.
Dr. H. N. V^ineberg congratulated the writer of the
paper on his excellent clinical report. He was pleased
to see that he did not claim one hundred per cent, of
anatomical cures or one hundred per cent, of clinical
cures. .Speaking in a general way, the class of cases
which in his hands had given the poorest results had
been those in which the lesions had not been so very
severe.
Dr. Mann said he had 'done a great many conserv-
ative operations. One case in point was that of a.woman
operated on, from whom one tube and ovary were en-
tirely removed, and the other tube and ovary were in
bad condition. The tube was opened, and after break-
ing up the adhesions the ovary and tube were left.
The woman married and had had four children, three
girls and one boy, which settled the question of sex in
regard to one ovary.
Dr. J. Riddle Goffe said he had done nearly one
hundred of these conservative operations. His work
had been done very largely through the vaginal inci-
sion, as he very much preferred that route of attack.
When there were large, bulging ovaries, he used the
cautery to resect, and when there was a cystic condi-
tion he used the cautery to burn out the cyst.
Dr. Burrage said he had operated twice on cases
in which there was no symptomatic and anatomical
cure, though there were several other cases in which
operation was required. Here the patients would not
be operated upon. He had used the cautery on many
cystic ovaries after the manner described by I 'r. Goffe.
He had seen no case of pregnancy follow amputation
of both tubes, or when both tubes were closed. He
had had pronounced neurasthenics above the age of
thirty-five years, and it seemed that complete total re-
moval or no operation was indicated. They did not
do well after resections. Careful bacteriological work
in this line was needed in order to determine upon
which cases to operate from the gross appearance.
Few would wish to do an operation when tuberculosis
was pronounced.
Internal Secretion of the Ovary. — Dr. A. W.
JoHXSTOXE, of Cincinnati, read this paper. Retained
secretions, he said, were the causes of nearly all ner-
vous conditions. There was no proof that the ovary
had any other function than the manufacture of eggs.
For fifty years we had known that the ovary was ac-
tive during intra-uterine life, and that it began to ripen
Graafian follicles at the sixth month of gestation ; that
these ripened rather rapidly until after birth ; that dur-
ing infancy the Graafian follicles still ripened occa-
sionally, but not so rapidly as before birth, and per-
sisted in the same ratio up to puberty. At puberty the
follicles ripened more rapidly, but at no time did they
amount to as many as the number of menstruations in
a year. During and after the menopause the Graafian
follicles still continued to ripen. Of all the ovaries
that he had removed after the menopause, he had never
found one that did not possess a small number of
Graafian follicles in an immature state, and he had
frequently found those that had recently ruptured.
The ovary was in no sense a gland. Its epithelium was
arranged for the purpose of being cast out and lost,
and it was not so placed that its secretion, if it had
any, could be absorbed either by ducts or blood-ves-
sels. The adherents of the internal-secretion theory
claimed that it was like the suprarenal, the thymus, or
thyroid gland. This he could state positively was not
correct. The thymus gland was nothing but a larger
lymphatic gland. It did the work of the lymphatic
structures during intra-uterine life. Its lymph vessels
were just the same as those of the axilla or groin.
The thymus gland and suprarenal capsule had no
lymphatics that amounted to much, but a very rich
supply of blood-vessels; each epithelial cell was closely
approximated to a venous radical, thus providing for
a rapid absorption of whatever secretion its cells might
make. So far as we know, these cells were never en-
tirely removed except by a low form of colloid degen-
eration, which material was readily absorbed by the
blood-vessels close to it. But the ovary was a true
duct through which its epithelium when cast out passed
off f/i masse to the outer world. If it was a lack of an
internal secretion that caused the nervous menstrua-
tion disturbances of the menopause, why was it that
the little girl did not have them; why was it that de-
layed menstruation in a child-bearing woman would
produce identically the same symptoms as those of the
menopause? He would lay it down as a rule, that if
a woman's menstruation was delayed for any reason
except pregnancy, she was apt to have symptoms
closely approximating those of the change of life.
Hence he believed that the internal secretion of the
ovary was a myth.
AJtenwon Session.
The Technique, Indications, and Ultimate Re-
sults of Suturing the Round Ligaments to the Vagi-
nal Wall for Retroversions and Flexions of the
Uterus. — Dr. Hiram N. Vineberg, of New York, read
this paper. He deemed it necessary again to describe
the technique in detail, as he had found that the
method had not been correctly understood. The pa-
tient was prepared as she would be for a vaginal hys-
terectomy. He then described the several steps of the
operation in minute detail. When the uterus was un-
usually large and heavy, or when the utero-rectal liga-
ments were put in high tension by anteverting the
uterus, it was wise, according to his experience, to
employ a single uterine fixation suture in addition to
the round-ligament sutures. This suture should not
be placed too high upon the uterine wall, in order to
avoid the possibility of dystocia in the event of preg-
nancy. Any operation on the cervix that might be
called for was now done, and the posterior vaginal
wall or perineum subjected to any plastic operation
that might be deemed necessary. The patient was kept
in bed for twtlve days, when the round-ligament su-
tures could be removed, with the uterine suture if
present. With very few exceptions a curettage pre-
ceded the operation. He had performed anterior and
May ig, 1900]
MEDICAL RECORD.
851
posterior colporrhaphy in fourteen cases, and amputa-
tion of tlie cervix in seventeen cases; trachelorrhaphy
in six cases; Tait's operation for complete laceration
of the perineum in two cases; excision of a vaginal
cyst in two cases ; salpingo-oophorectomy in five cases ;
ovariotorhy in two cases; conservative surgery upon
the tubes and ovaries in twenty-five. Thus, in sixty-
four per cent, some surgical work upon the adnexa
was found necessary. The results showed no mortal-
ity in the fifty-three consecutive cases. He drew at-
tention to the fact that in every instance the peritoneum
was opened and the adnexa were visually inspected.
Convalescence was uneventful in forty-eight cases. In
five cases there were some complications. In only
one case was there an absolute failure, the uterus
being found in retroversion six weeks after the opera-
tion. The indications and contraindications for the
operation were given in detail.
Dr. 'Currier thought that fixation of the uterus_ in
this way merely by suturing the round ligament did
not give much to hold it forward, and thought it could
be done better through the abdomen. His own idea
was to limit this operation to those cases in which
another operation was necessary. As an operation of
election when no other operation was required on the
uterus or perineum, he preferred very much opening
the abdomen, rectifying any difficulty, and then, if
desired, confining the operation to the round liga-
ments, which could be doubled on themselves and
turned two or three different ways.
Dr. Sutton spoke of having seen Dr. Vineberg
carry out the procedure described, and had since re-
peated it with uniformly good results. He expressed
the hope that soon the abdomen would not be opened
so often as now, since these conditions could be at-
tacked through the vagina, and the uterus turned out
and myomectomy or supravaginal hysterectomy done;
and that the various diseases of the ovaries would be
attacked almost exclusively by the vaginal route. He
was the more persuaded that this time would come
since the French and American operators were remov-
ing large fibroids by the vagina after reduction by
morcellement.
Dr. J. W. BovEE stated that as a matter of principle
he had little use for the shortening of the round liga-
ments, stating that in his opinion the Alexander oper-
ation possessed an advantage over the shortening, in-
asmuch as it did not require the opening of the
peritoneal cavity. He thought there was danger in
following these operations of losing track of the fact
that most of the cases of dislocation of the uterus
were due either to injuries to pelvic fascia, or in the
nullipara to abnormal attachment of the ligaments to
the uterus. He thought the point of necessity was to
adjust the ligaments. Constipation and over-disten-
tion of the bladder lessened the efficacy of the short-
ening of the round ligaments.
Second Day — Wednesday, May 2d— Morning Session.
The meeting was called to order at nine o'clock.
The discussion of Dr. Vineberg's paper was con-
tinued.
Dr. J. Riddle Goffe, in answer to Dr. Sutton's
hope that all pelvic work would be done through the
vagina, expressed the belief that he would not have
io wait very long. He had been doing the work for
the last three years, and had taken the position that
no man was justified in doing laparotomy until he had
endeavored to relieve the patient by a vaginal inci-
sion. He had found that disease confined within the
pelvis could be reached just as effectually through the
vagina as through the abdominal incision, and stated
that he had covered through the vagina almost every
condition that existed in the pathological pelvis. In
only one case within the last few years had he been
compelled to resort to laparotomy to complete the
work. He had removed seven fibroid tumors by myo-
mectomy through the vagina. In these cases there
had been retroversion at the same time, which was
relieved by shortening the round ligaments after doing
myomectomy.
Dr. Vineberg, in closing the discussion, said that
he had tried to limit the operation to certain cases
and still thought that the cases might require to be
selected for the vaginal route; that some cases were
best approached from the abdomen. He had fre-
quently removed small fibroids through the vaginal
incision.
A paper entitled "A Comparison of Vaginal and
Abdominal Operations," by Dr. G. Richelot, of Paris,
was read by title.
Demonstrations of Casts Illustrating the Anat-
omy of Pregnancy and Labor, also Models Used
in Gynaecological Teaching Dr. J. Clarence Web-
ster, of Chicago, gave this demonstration. He of-
fered for inspection these casts, which had much value
in teaching. No work of this kind had been done in
America except that done by Dr. William Lusk in
New York two years ago. Many clinical observations
made by Dr. Webster in regard to the topography of
pregnancy had been reproduced in frozen sections.
The series included casts illustrating a vertical mesial
section of the pelvis, in a woman who died of per-
nicious vomiting; another showing the beginning of
the fifth month of pregnancy ; another showing the be-
ginning of the eighth month of pregnancy; a cast of
the amniotic cavity at the beginning of the eighth
month of pregnancy; a cast showing labor in the ad-
vanced second stage; also one with the foetus in situ.
Dr. Mann desired to know whether these models
had been put upon the market, and whether it would
be possible for teachers of gynecology to procure
them.
Dr. Webster replied that he was under the impres-
sion that the Italian moulds had been kept by the
makers, and that he had not had sufficient time to see
whether they could be reproduced.
Dr. Mann suggested that some arrangement be
made by which reproductions could be obtained.
Dr. Buckmaster spoke of a way of reproducing
the method of an operation by paraffin. The cervix
and pelvic floor, or whatever part desired, was cov-
ered with the paraffin, and by placing plaster over this
a perfect cast could be obtained without discomfort to
the patient.
A paper by Dr. E. E. Montgomery, of Philadelphia,
on " Combined Nephrectomy and Ureterectomy " was
read by title.
The Anastomosis of the Ureters with the Intes-
tines: An Historical and Experimental Research.
— Dr. Reuben Peterson, of Chicago, read this paper.
He stated that anastomosis of the ureters with the ex-
perimental work forming the basis of this article was
undertaken with the view of studying the changes re-
sulting from anastomosing the ureter with the intesti-
nal tract, and of determining whether the procedure
could with safety be employed in human beings. The
first part of the article was devoted to an exhaustive
review of the literature; the second part was given to
the description of the author's own experiments, from
which, together with the work of others, general con-
clusions had been drawn. The most striking fact, in
the writer's opinion, yielded by a study of the experi-
mental work was the exceptionally high mortality at-
tending the operation, whether one or both ureters
were implanted in the bowel. Out of sixty dogs oper-
ated on by the various experimenters, when one ureter
was implanted in the intestine thirty-five recovered, a
mortality of sixty-one per cent. Out of sixty-five dogs
852
MEDICAL RECORD.
[May 19, 1900
undergoing bilateral ureteral anastomosis only eight
survived, a mortality of eighty-seven per cent. The
majority of deaths resulted from peritonitis through
a giving-way of the uretero-rectal stitches and the
subsequent escape of the urine into the peritoneal
cavity; or an overwhelming infection of the kidney
ascribed to nephritis or urasmia. The method which
called for the least amount of suturing of the ureter
itself would be found to give the best results. In
none of the cases operated upon was it demonstrated
that the kidney was normal after the corresponding
ureter had been implanted in the rectum. The speaker
then gave a short abstract of the twenty-eight uretero-
intestinal anastomoses in man, showing the primary
mortality of thirty-two per cent, to be high. The sub-
sequent history of the successful cases placed the op-
eration in a still more unfavorable light. His e.xperi-
mental work, covering a period of eighteen months, was
given in detail. Three series of experiments were con-
ducted: (i) Bilateral uretero-intestinal anastomosis;
(2) lateral uretero-intestinal anastomosis; (3) ure-
tero-trigono-intestinal anastomosis. The general con-
clusions were that the primary mortality of the ure-
tero-intestinal anastomosis both in experimental work
on animals and in man was exceedingly high; that all
efforts to prevent ascending renal infection in animals
or in man had proved futile; that it was impossible to
determine the extent.of the infection, and that the op-
eration was unjustifiable either for the purpose of
making the patient more comfortable or for malignant
disease of the bladder.
Dr. Ford, of Utica, referred, in the discussion fol-
lowing, to a case illustrating the toleration of the bowel
for continuous service as a bladder. The case was
that of a young girl with total suppression of urine
lasting over a week. There was no history of stone,
and after six weeks she recovered without nephritis.
She passed all the urine through the bowel, and was
in comparatively good health.
A paper by Dr. George M. Edebohls, of New York,
on "Migrated Ovarian Tumors,'" was read by title, as
was also a paper by Dr. J. \V. Bove'e, of Washington,
D. C, entitled "A Critical Survey of Ureteral Im-
plantation."
The Evolution of My Technique in the Treat-
ment of Fibroid Uterine Tumors. — Dr. Howard A.
Kelly was the author of this paper. He referred to
the fact that it was three years since their fellow-mem-
ber, Dr. Charles P. Noble, had given an admirable his-
torical re'sume' of the evolution of the various meth-
ods of treating the Inbroid uterine tumors, from the
earliest efforts in the fifties down to the perfected
technique of his own work in the Kensington Hospi-
tal for Women. Inasmuch as Dr. Kelly had been
closely connected with the development of this subject
since his first publication in The American Journal of
Obstetrics, January, 18S6, he thought it might be of
more than personal interest to trace his work in the
successive advances up to his present, as he believed,
perfected technique, and he expressed the belief that if
each member would do the same much \aluable and
interesting information would be available. One of
his first operations was an atypical one, performed
September 6, 1884, on a patient who had suffered from
severe bleeding from several sessile fibroid tumors oc-
cupying the lower segment of the uterus. The wound
was closed with a glass drainage tube, through which
the pelvis was repeatedly washed out with weak car-
bolized water for ten days, when it was removed. The
patient recovered with a large ventral hernia, which
she still had ten years later. The next operation was
more radical. In this he adopted in several instances
the treatment advocated by Hegar, consisting in the
control of the vascular supply of the stump by means
of a rubber mass ligature. This plan involved far
less risk to life than the more ideal method of Schro-
der. The author's next advance was described in a
paper entitled " A New Method of Performing Hystero-
Myomectomy," being an address delivered before the
College of Physicians of Philadelphia, January 2,
1889. He there advocated the plan successfully car-
ried out October 10, 1888, of tying off the broad liga-
ment, controlling the circulation from the uterine ves-
sels by means of a temporary rubber ligature; cup-
ping out the stump; turning out the cervical mucosa,
and obliterating the raw cupped surface of the cervical
stump by means of several rows of buried continuous
catgut sutures. Most important of all Dr. Kelly con-
sidered the description of the method of controlling
the uterine vessels, which was detailed, and which was
considered a remarkable advance upon anything which
had preceded. This met the objection to the Hegar
operation by doing away with the rubber ligature, and
was the method practised by the writer since that date.
Dr. Kelly detailed his method briefly in dealing with
very difficult cases, such as large adherent tumors.
There were three ways of dealing with these tumors
and meeting the complications: (i) By median sagit-
tal bisection of the uterus with the tumor; (2) by a
coronal bisection of the uterus in its cervical portion;
(3) by a bisection of the tumor alone. He then stated
that the situation and the relations of the tumor
should be thoroughly studied after the abdomen was
opened before attempting its removal. The principle
of the operation was the same in all cases. The
method of enucleation was to seek first to isolate and
ligate the ovarian vessels of one side; then to expose
the uterine vessels of the same side; then to cut
across the cervix, clamping the opposite uterine ar-
tery, the round ligament, and lastly the ovarian vessels.
The President's Address. — The president. Dr.
George J. Exgelnl\nn\ of Boston, in his address gave
an historical review of the various periods in gyne-
cological progress through which we have passed in
the last twenty-five years. He believed that Robert
Battey, by teaching that the comparatively normal or-
gans could be removed with impunity, opened the way
for the successful surgical procedures of to-day. Our
methods now should be to reduce the morbidity as we
had reduced the mortality. He referred to the work
which the society had done in inquiry, investigation,
and observation, and thought the Transactions might
fairly represent the national contributions to gynae-
cology. The trend of modern medicine was toward
research for cause and prevention. The first step in
prevention was the study of condition and cause. The
main cause of suffering would be found upon the great
waves of a woman's life — puberty, menstruation, labor,
and the menopause. Statistics were given to show
the tremendous susceptibility and almost feverish ac-
tivity of the system in the prepubertal period. Statis-
tical tables with diagrams were used to illustrate the
increased blood tension, temperature, nerve excitabil-
ity, and muscular power before, during, and after the
menopause.
An Appreciation of Kelly's Method of Remov-
ing the Fibroid Uterus by the Abdomen.— Dr. A.
Lapthorn Smith, of Montreal, presented this paper.
Twenty years ago the writer was strongly opposed to
operative treatment of fibroids on account of the high
mortality then prevailing among the best operators.
Ten years ago he became a strong advocate of Apos-
toli's method of electrical treatment, by which he had
cured the hemorrhage permanently in sixty-three out
of a hundred and two cases in ten years. Eight years
ago Price lowered the mortality enough to induce him
to operate in certain cases with the serre-noeud. Baer
further reduced the mortality, and he adopted his
method and operated oftener. Three years ago Kelly
perfected an ideal method which had almost no mor-
May 19, 1900J
MEDICAL RECORD.
853
tality, and which the author had adopted, and to which
he gave the preference over all other treatment in every
patient with fibroid who suffered enough to consult him.
He claimed that he had acted consistently throughout,
being guided by the one test question, " What was the
mortality?" In his last ten successive cases, seven
last year and three this year, all the patients had
recovered. Therefore the operation was now almost
devoid of danger, while it was absolutely effective.
Kelly's method was by far the best, and to it was due,
he believed, his absence of mortality in these ten cases.
The great advantage of Kelly's method was that we
began on the easy side, and after securely tying the
ovarian, round ligament, and uterine arteries, and
separating the bladder, we cut across the cervix and
rolled the tumor out, thus obtaining plenty of room to
tie the arteries from below upward. Another great
advantage of this method was that there was much
less danger of injuring the ureters. This accident
was most likely to happen on the most difficult side;
that is, the side where the tumor filled all the space
between the uterus and the wall of the pelvis. But it
was precisely on this side that the tumor was dragged
away from the ureter while it was being rolled out,
and by the time that it became necessary to cut any-
thing on that side the ureter was at least two inches
away and quite out of danger. Doyen's method had
this advantage on both sides because he pulled the
tumor off the bladder and ureters, and from the first
cut he was getting farther and farther away from the
bladder and ureters. But Doyen's method had the
great objection of opening the vagina and thereby in-
creasing the time of anajsthesia, loss of blood, and
risk of infection, besides the aesthetic one of shorten-
ing the vagina. The author laid even greater stress
than Kelly did upon the importance of feeling for
each individual artery and tying it before cutting it,
and then putting a second ligature on it, as the first
one might loosen after the tension of the tumor had
been removed. He also strongly advised chroniicized
catgut prepared by each operator himself, or else Red
Cross cumol catgut prepared by Johnson, of New
Brunswick, N. J., which he had found reliable. Be-
sides the six primal arteries there were two small ar-
teries which recpiired tying on each side of the cervix.
There was no need of disinfecting the stump beyond
wiping away the little plug of mucus; but the cervix
should be hollowed out so as to make anterior and
posterior flaps, which were securely brought together
before the peritoneum was sewed up. The omentum,
if long enough, should be brought down to meet this
line of suture, thereby preventing the intestine from
sticking to it or to the abdominal incision. The
speaker was opposed to leaving the ovaries and tubes,
although he admitted that in young women so doing
diminished the discomforts of the premature meno-
pause. But in the majority of cases the appendages
were diseased, and we ran the risk of the whole suc-
cess of the operation being marred by leaving in or-
gans which would sooner or later cause more symp-
toms than did the fibroid itself. His experience of
leaving in ovaries or portions of ovaries had been
most unfortunate, having received no thanks for his
conscientious endeavors but a great deal of blame for
having failed to cure the pain, which in the patient's
estimation was much more important than the tumor.
He was also much opposed to myomectomy; the oper-
ation was quite as dangerous as hysterectomy; there
was very seldom any reason for it, as most of the
women who had fibroids were at too advanced an age
to raise children to advantage, or had passed the
child-bearing age altogether. After submitting to
such a serious operation the patient had a right to be
guaranteed against a second or third one for the same
disease. So many women had been disappointed by
these incomplete or so-called conservative operations
that their friends who really could be cured by an
operation hesitated to undergo it. He would make
an exception, of course, in case there was apparently
only a single polypus no matter how large, or a
single pediculated subperitoneal tumor. He held the
opinion that all fibroid uteri should be removed as
soon as discovered, because the woman with a fibroid
was liable not only to the hemorrhage, which might
not be great, but to reflex disturbances of digestion
and circulation. Besides, every day it grew its re-
moval became more dangerous, and tlie chances of its
becoming malignant were greater. He was opposed
to a preliminary curetting because it was unnecessary,
and second, because when done it was seldom done
effectually; having examined immediately after re-
moval a fibroid uterus which had been curetted just
before, he had found only about a twentieth part of
the uterine mucosa removed. He was strongly op-
posed to vaginal morcellement, which was not to be
compared with Kelly's method. It was much more
dangerous, mucii more difficult, and kept the patient
a much longer time under the ana::sthetic. The oper-
ation was carried on in the dark, and the ureters were
frequently wounded, while complications such as ad-
hesions of the vermiform appendix and tears of the
intestines, which were easily dealt with by the abdo-
men, with the patient in the Trendelenburg pos-
ture, were almost impossible to manage when work-
ing from the vagina. Moreover, nearly all women
with fibroids were nulliparous, and the vagina was
consequently narrow ; they were nearly all elderly,
and the passage was consequently inextensible. No
more unsuitable class of patients could therefore be
chosen for this difficult vaginal work. Besides, in
morcellement clamps were used, and these compressed
the nerves in the broad ligament, and a woman who
had been operated upon with clamps took much longer
time to recover than one who had only the arteries
tied. Also, with clamps the peritoneum was left open,
and, worst of all, the air of the hospital was contami-
nated with the sloughing tissue in the vagina. The
author strongly advised the closure of the abdomen
with through-and-through silkworm-gut sutures left in
for three or, better still, four weeks. If they were not
tied too tightly, and the wound was dressed with bo-
racic acid in abundance, the one dressing or at most
two dressings would suffice from the beginning to the
end of the case. Besides, these sutures could be passed
very quickly, thus saving ten minutes in the duration
of the anesthesia.
Intra-Abdominal Amputation of the Uterus ; a
Modification of Hysterectomy. — Dr. F. H. Daven-
port, of Boston, read this paper. He stated that the
indications for hysterectomy were pretty well estab-
lished, and that interest was now centred upon the
technique. He called attention to a modification of
so-called abdominal hysterectomy which he had prac-
tised for about two years. When it was possible in a
young married woman to leave the cervix, he preferred
to do so; hence for suitable cases he chose the ab-
dominal route. He operated by the vagina for cancer
of either the cervix or body. If a patient who was
single or near or past the menopause, with a small or
medium-sized fibroid which was non-adherent, objected
to the scar of the abdominal operation, he operated by
the vagina. On the other hand, in a young married
woman he chose the abdominal route; it was of a good
deal of importance that the vagina be preserved.
VVhen the uterus was to be removed for chronic in-
flammation or its results there was usually concomi-
tant disease of the appendages, and t abdominal
route gave full opportunity for seeing th exar condi-
tion of all the pelvic organs. The essentia, feature
in which his method differed from that usually em-
854
MEDICAL RECORD.
[May 19, 1900
ployed was that the uterine arteries were not ligated.
He then described his method in detail. His results
had been satisfactory.
The papers of Drs. Kelly, Smith, and Davenport
were discussed jointly.
Dr. W. R. Pryor stated that the essence of the
operation was the reduction of the mass by morcelle-
ment to produce a symmetrical tumor. The ovarian
arteries being tied, the anterior wall of the uterus was
split through; traction forceps were applied, and the
intra-ligamentary nodule was seized and taken out of
its bed. The moment the nodule was taken out the
side from which it was taken became symmetrical. If
the nodule was in front it could best be approached by
tilting the tumor forward.
Dr. Gordon said that the continuous suture of which
Dr. Davenport spoke was the one he had followed
since he had been doing hysterectomy. He objected
to the use of chromicized gut as used by Dr. Smith,
for the reason that its absorption required a long time
and sometimes never occurred. He further objected to
Dr. Davenport's continuous suture with silk. He had
used nothing but catgut since 1884, except in the
through-and-through suture of silkworm giit in abdomi-
nal section.
Dr. Mann felt that the trend of sentiment seemed
so decidedly in favor of the method pursued by Dr.
Pryor and Dr. Kelly that he hesitated to mention a
different method which made the operation easier.
In a case in which the tumor was held down in the
pelvis by the broad ligaments he thought that if the
upper part of the broad ligaments was cut first and
then the tissues cut across, the tumor would come up
out of the pelvis and would be more easily gotten out.
Dr. J. M. Baldv referred to a case he had had within
tlie past week, of a fibroid tumor in which the nodule
e-xtended down over the vagina. He was forced to ap-
proach it posteriorly instead of anteriorly as Dr. Kelly
had done. Enucleation was performed similarly to the
method claimed by Doyen. As to cutting down one
side, amputating, and coming up on the other side, he
had done the operation shortly after Dr. Pryor, and
considered it exceedingly dangerous and one to be used
only by the most expert.
Dr. Reynolds considered the principal point in the
method of Dr. Davenport to be that of tying the
uterine artery. The operation was thus made much
simpler.
Dr! Johnstone thought that most of Dr. Kelly's
troubles were of his own making; that when the uterus
was wedged down in the pelvis, and there was danger
of hemorrhage, the arteries should first be tied, thereby
cutting off the blood supply as effectually as a plumber
turned water off from the yard.
Dr. Kelly, in closing, called attention to the fact
that the bisection method was applicable to all inflam-
matory cases. There was no risk to the ureters on the
side if the bladder and the tissues were pushed down.
He considered it safe to cut the uterine arteries and
clamp afterward.
Third Day — Thursday, May jd — Aforning Session.
The discussion of the papers of Drs. F. H. Daven-
port, Howard A. Kelly, and A. Lapthorn Smith was
resumed.
Dr. Smith emphasized the great advantage he had
found in the operation by going down on one side, the
easy side, and coming up on the other. He consid-
ered it important to leave the cervix. He believed
that Doyen's reputed high mortality was due to the
fact that he took out the cervix. He thought the risk
of infection from hemorrhage and the length of opera-
tion were thereby increased. He had reported ten cases
of large fibroids removed in this way, all of which re-
sulted in recovery. He used chromicized catgut which
had been in potassium solution for one hour. In the
cervix this lasted but ten days. He W'ould never
leave any kind of silk in the abdomen. He agreed
with Dr. Gordon that there was nothing like silkworm
gut for closing the abdomen, and with it he had not
had a hernia for four years. He did not concur in Dr.
Baldy's opinion that this operation was made for only
the most expert operators.
Bronchial Disease Not Invariably a Contraindi-
cation for Ether Anaesthesia in Abdominal Surgery.
— In this paper Dr. T. A. Reamv, of Cincinnati, stated
that his personal experience with surgical anaesthesia
covered eight thousand cases; his obstetrical work,
three thousand deliveries. Two thousand of these
were under chloroform anaesthesia. For surgical work
he considered ether in every way preferable as an ances-
thetic. He had. however, never lost a patient under
either ether or chloroform. He considered the preju-
dice against the use of ether in the presence of acute,
subacute, or even chronic bronchitis largely unfounded,
provided proper conditions were observed in its admin-
istration. He insisted that the inhaler must be so con-
structed as to permit reinhalation of the vapor, which
was therefore mixed, from the beginning to the end of
the operation, with carbon dioxide. He objected to most
of the inhalers in use, and presented a simple one of
special form constructed by his nurses, and which an-
swered the purpose perfectly. It was likewise cheap
and clean. The ether was poured on absorbent cotton
in the bottom of the inhaler. No additional ether was
used unless the operation lasted more than forty min-
utes. He began the administration of the anaesthetic
himself. He regarded the assuring words of the sur-
geon to the patient, as the inhalation commenced, as
very important. He insisted upon great care in the
protection of the patient on removal from the operat-
ing-room to her own room, the temperature of which
must be for several hours not below 80° F. He had
witnessed but one case in which pneumonia was prob-
ably produced by ether inhalation. He had seen
bronchitis, both acute and chronic, at once cured as a
result of ether ana-sthesia. In some instances he did
not hesitate to administer it to patients suffering with
severe bronchorrhoea. He would not use ether in the
presence of emphysema. He would not, of course,
employ it when the patient was suffering from Rright's
disease, but he had rarely seen damage to the kidney
follow its administration in properly selected subjects.
Dr. Malcolm McLean, in discussing this paper,
pointed out that the elevation of the temperature of
the room deserved a great deal of consideration. This
he thought was very much overlooked, and he said
that trouble following anaesthesia was often attributable
to the low temperature of the room. The operator felt
comfortable in a temperature of 72" F.. but the patient
under anaesthesia was not in a safe condition. He also
referred to the unnecessary confusion in the etherizing-
room, the result being that the patient required much
more ether. He considered that with the patient in a
secluded place, and without unnecessary intrusion,
one-third of the amount of ether generally used would
place her under full anaesthesia. This had been his
experience for over twenty 3-ears. His rule had been
never to let a person speak to the patient after the
anaesthesia had commenced.
Dr. Philander A. Harris stated that he had had
ether administered to himself quite a number of times,
and so could corroborate the wisdom of remembering
that reference to anything, except just the business of
the ether, should be entirely dispensed with. He con-
sidered this important not only for the patient's feel-
ings, but in consideration of the ease and advantage
with which one could anaesthetize without these dis-
turbing elements.
May 19, 1900]
MEDICAL RECORD.
855
Dr. Reamy, in closing the discussion, said that con-
versation in the room was one of the most damaging
things that could occur. As a rule his patients did
not have the reflex cough, for they were put under the
anesthetic within four to six minutes, in almost every
case. The room must be hot, and the ether must be
given in the operating-room, that the temperature might
be even from beginning to end. The inhaler was not
removed unless the patient developed cyanosis.
A paper entitled "The Treatment of Full-Term
Ectopic Gestation: Should not the Child Receive
More Consideration?" by Dr. Edwin B. Cragin, of
New York, was read by title.
The Relationship between Dysmenorrhoea and
Appendicitis. — Dr. Archibald McLaren, of St. Paul,
read this paper. He considered the influence of pel-
vic and inflammatory conditions on menstruation. In
cases of cystic ovaritis and ovarian abscess he had
seen some particularly satisfactory results follow the
removal of overlooked appendages. In two hun-
dred laparotomies he had had one hundred and fifty-
eight cases in which inflammatory appendages had to
be removed, and the appendix showed indications for
removal in forty per cent. The conclusion drawn from
the histories was that the trouble had originated in the
appendix and spread to the ovary and tube. During
the same time he had operated on seventeen cases of
appendicitis in which there was no evidence of exten-
sion of the inflammation. He did not advocate the re-
moval of the appendix in every case. The speaker
gave the technique of his earlier operations, and stated
that later he had adopted the method of Kelly.
Dr. a. J. C. Skene stated that the relation of appen-
dicitis to dysmenorrhoea was a new idea to him, and he
consequently accepted what had been said by the au-
thor of the paper as being perfectly reliable science.
The paper explained to him certain observations which
he had been unable to account for, i.e., ovarian pain
undoubtedly caused by appendicitis, the pain in the
ovaries being always aggravated at the menstrual pe-
riod, giving rise to the condition known as dysmenor-
rhoea ovarienne. In those cases the ovarian pain had
disappeared when the appendix had been removed.
He considered that the extirpation of the appendix
was better and more quickly accomplished by the use
of the haemostatic forceps, which had the advantage
over other forceps in absolutely and permanently clos-
ing the canal of the appendix and the opening into the
intestine. By this means there was no ligature to be
disposed of, and reopening and establishment of fecal
fistulae were avoided.
Dr. a. Lapthorn Smith's experience coincided
-with that of Dr. McLaren; in nine or ten cases oper-
ated upon for tubal pregnancy or pus tubes he had
found the appendix firmly embedded in the tumor. In
one case of tubal pregnancy the specimen could be
held up by the appendix. The salpingitis communi-
cated from the appendicitis was probably the cause of
the tubal pregnancy. In another case the appendix
could be followed by a probe about an inch deep in a
mass of exudation. He believed that if the plan of
tying the ligature around the appendix and cutting off
was abandoned there would be no fecal fistula. Treat-
ment as in a bullet-wound would be the simplest pro-
cedure. He regarded constipation a strong factor in
the production of infection, bacilli being increased in
number in proportion to the number of days the bowels
were unmoved. The presence of pus tubes in young
women was satisfactorily explained by the appendi-
citis.
Dr. McLaren, in closing the discussion, considered
the point mentioned by Dr. Smith, of young women
having pus tubes, very important. He had seen sev-
eral'young women whose reputation had been smirched
by the very fact that they had pus tubes, when opera-
tion showed appendicitis to be the cause of the suppu-
ration. Such cases were usually confined to the right
side. Out of fifty-nine cases he had removed the ap-
pendix twenty times. Operation did not affect the
mortality. He thought the bullet-wound treatment
safer and more surgical than the removal with the
cautery.
A paper by Dr. Egbert H. Grandin on "Clinical
Data Relating to (<!) Urinary Toxemia; (/') the Oper-
ative Treatment of Uterine Displacements; (c) Ec-
topic Gestation; {d ) Certain Complications of Uterine
Fibroid," was read by title.
A Certain Chart for the Demonstration of Pelvic
Asymmetry from a Very Simple Method of Ex-
ternal Pelvimetry. — Dr. Philander A. Harris, of
Paterson, N. J., demonstrated the use of tiiis chart.
He believed that the best interest of the patient and
physician demanded the study of pelvic measurements.
The instrument employed was exhibited. Dr. Harris
also showed photographs exhibiting the advantages of
employing certain backgrounds in the photography of
pathological specimens.
Dr. E. Van DeWarker said that the shadows
which were troublesome in photography were gotten
rid of by suspending the specimen in water in the
glass tray with the illuminator under it. The effects
secured by this arrangement were exceedingly satis-
factory.
A Contribution to the Management of Face Pres-
entations, with Report of Two Cases.— Dr. Mal-
colm McLean, of New York, read this paper. He
gave in detail a description of his method of dealing
with these faulty presentations. The patient being
under full chloroform anaesthesia, the hand was passed
carefully within the vulva, with the outside hand seiz-
ing the body of the child. In the entire absence of
uterine contraction the chin was pushed away from
the pelvic brim as much as possible, from the point
toward which the chin was pointing in the direction
of the occiput, i.e., pushed obliquely from behind for-
ward. At the same time the fingers of the vaginal
hand were pushed up alongside of the head in one or
other of the oblique diameters of the pelvis, so that
they could reach the sub-occipital portion of the head.
The thumb at the moment steadied the brow, and with
a slight elevated motion imparted to the whole head it
was caused to rotate on its axis as described — the
chin passing upward above the ischiatic notch as the
occiput was drawn down below the pubis. Flexion
could be considerably hastened by pressing down the
occiput by the outside hand as soon as the face was
dislodged from its wrong position. The author de-
tailed cases illustrating the usefulness of the
method.
Dr. C. M. Green had alw'ays believed it was hardly
possible to flex fully the extended head in the pelvis
in the way described. He had never seen a face pre-
sentation with the chin posterior, with the head within
the pelvis, in which he had not succeeded in deliver-
ing with forceps, or in allowing the mother to deliver.
He had often been asked by students whether in these
posterior presentations flexion by the head was not
possible, but had always been obliged to say he had
never tried it because he had succeeded in rotation of
the chin forward by the hand. Everything depended
on the relations between the head and the pelvis; if
the pelvis was sufficiently large, or the disproportion
was not extreme, and the operator was fortunate in
having a small hand, he might accomplish it. He
thought that much more could be accomplished than
was supposed by the use of the hand in the pelvis.
He believed the body should be turned at the same
time to secure success. He thought that many of
these face presentations were due to slight antero-pos-
terior contractions at the brim, and it w«s a question,
856
MEDICAL RECORD.
[May 19, 1900
unless the child seemed very large, whether it was not
wise to let it enter the pelvis.
Dr. R. a. Murray referred to the dictum that when
there was irregular presentation of the child there was
something faulty in the pelvis, and that the child should
always be kept in mind. Examination should be thor-
ough before remedial operation was undertaken. The
mere introduction of the hand to determine the cause
gave means to determine the size of the pelvis and rel-
ative size of the head to the pelvis, and so would be a
guide to remedying these faulty presentations. To wait
for the effective application of the forceps exhausted
the patient, and the child was almost invariably lost
unless it was very small. Schatz's method would be
very good, but for the fact that it had to be applied at
the superior strait. He called attention to the fact
that when the operation was difficult on account of the
head being wedged, and when there was difficulty in
getting the patient under anesthesia, very great aid
could be obtained by putting her either in the knee-
chest position or in Sims' position, in order to take
away the liead from the superior strait.
Dr. Edward Reynolds said that in the treatment
of the presentation of the face posteriorly in the pelvis
the suggestion which he had borne in mind for some
years was that if the ordinary manipulative corrections
of the presentation failed he should expect to render
them easy by symphyseotomy.
Dr. McLean, in closing, emphasized the point that
in these cases the head had the ordinary relation to
the size of the pelvis. This was mentioned because
since the author's first report it had been asserted by
two or three prominent teachers that there must have
been great disproportion between the size of the head
and the size of the pelvis. The proportions were nor-
mal or below the normal relations as regards the width
of the conjugate in the mother. In otiier words, the
conditions were those of the average; he simply took
advantage of the flexible portions of the pelvic passage.
A paper by Dr. E. P. Davis, of Philadelphia, on
"The Pernicious Nausea of Pregnancy, with a Report
of Cases and Autopsy," was read by title.
At the close of the scientific business of the society
the retiring president. Dr. George J. Engelmann,
thanked the members for courteous helpfulness which
had made the duties of the president pleasant and easy.
The newly elected president. Dr. E. Van DeWarker,
of Syracuse, was then introduced.
Other officers elected were: Vice-Presidents, Drs.
Charles Jewett and R. B. Maury; Secretary, Dr. J. Rid-
dle Goffe (re-elected) ; Treasurer, Dr. J. Montgomery
Baldy. The other members of the council were Drs.
M. I). Mann, VV. R. Pryor, S. C. Gordon, and J. T.
Johnson.
The place selected for the meeting in igoi was
Chicago.
AJternoon Session.
The afternoon of the closing day of the meeting was
devoted to anniversary exercises at Marshall Hall, on
the Potomac.
Dr. T. Addis Emmet, of New York, read a paper
entitled " Personal Reminiscences Associated with
the Progress of Gynecology."
"The Status of Gynascology in 1876 and in igoo"
was the subject of a paper by Dr. Alexander J. C.
Skene, of Brooklyn, N. Y.
Dr. James R. Chadwick gave some " Reminiscences
of the Foundation and Early Years of the Society."
The programme was completed on the boat on the
return to Washington, by a paper by Dr. E. Van De
Warker, of Syracuse, N. Y., on " The Personal Factor
in the Work of the American Gynecological Society,"
and a poem entitled "Some Kaleidoscope Pictures in
Rhyme," by Dr. Thaddeus A. Reamy, of Cincinnati.
AMERICAN NEUROLOGICAL ASSOCIATION.
Twenty-sixth Annual Meeting, Held in Washington,
D. C, May i, 2, and j, jgoo.
Second Day — Wednesday, May 2d.
Adiposis Dolorosa. — Dr. F. X. Dercum, of Philadel-
phia, read the report of a case of adiposis dolorosa,
with autopsy. The patient died from fatty degenera-
tion of the heart. There was fatty infiltration of all
of the internal organs and the muscular system. Mi-
croscopical examination revealed interstitial neuritis
of the peripheral nerves, degeneration of the columns
of GoU in the cervico-dorsal region, and unusual pig-
mentation of the cortical cells in the cerebrum. The
pituitary gland was normal. The thyroid structure
was hypertrophied.
Dr. Charles W'. Burr, of Philadelphia, had made
an autopsy in a similar case with practically the same
findings. There was also a new growth affecting the
pituitary body, which was probably the cause of the
hydromyelia.
Dr. Dercum mentioned that marked improvement
resulted from the administration of thyroid extract.
A discussion of the neuron doctrine in its relation-
ship to diseases of the nervous system followed.
The Anatomico-Cytological Relationship of the
Neuron to Disease of the Nervous System.— This
was the title of a paper by Dr. L. F. Barker, of
Baltimore. The paper dealt with the present status
of knowledge of the units in the nervous system. The
history of the neuron doctrine was traced. The con-
ception originated with the pathologists (Ford), was
supported by tiie embryological work of His, and by
histological studies made by Golgi's method. Wal-
deyer, in 1891, collected the evidence in favor of the
view, and gave to the nerve units the name "neu-
rons." The speaker saw in the neuron doctrine nothing
more than the application of the cell doctrine to the
nervous system. Until it was shown that the axis
cylinder of a nerve fibre and its end-ramifications
were integral parts of a single cell, it was impossible
to apply the cell doctrine intelligently to the nervous
system. The "nerve cell "of the books was only a
part of the real nerve cell. The contact theory was
regarded as refuted ; it was not an integral part of the
doctrine of the nerve units or neurons. The retrac-
tion theory had .never had any adequate basis. The
studies of Apathy and Bethe were regarded as ex-
tremely important as bearing upon the intimate rela-
tions which existed between the nerve units; they did
not interfere in any way with the retention of the idea
of the units themselves.
The Pathological Changes in the Neuron in Ner-
vous Disease. — This paper was read by Dr. W. G.
Spiller, of Philadelphia. He regarded the limita-
tion of degeneration to certain systems in some ner-
vous diseases as indicative of alteration of distinct
groups of neurons, and therefore as evidence that dis-
tinct neurons existed. He then discussed the ques-
tions: (i) Whether a neuron was affected in its en-
tirety by disease; and (2) whether the disease of one
neuron had any influence on another neuron with
which it might be functionally related. He attempted
to show that when a neuron was injured in any way it
suffered alteration in all its parts, although in some
cases this alteration might be slight. He took his
illustrations chieHy from his own investigations. He
referred to complete atrophy of the cells of Clarke's
columns from a cervico-thoracic lesion, and spoke of
retrograde atrophy, describing a case of chronic neuri-
tis with changes in the cells of origin and one of facial
palsy of six months' duration, with changes in the fa-
cial nucleus. He described the chromatolysis he* had
found in the nerve cells of the lower part of the cord
May 19, 500]
MEDICAL RECORD.
857
after a hip-joint amputation. Cases were reported to
show that degeneration of the axon did not occur so
promptly as changes in the cell of origin; also two
cases of atrophy of the cortical nerve cells from injury
of their axons. These and other illustrations were
given as evidence that the structure known as a neuron
suffered more or less in its entirety when diseased, and
that this involvement was indicative of the functional
individuality of the structure. Dr. Spiller then dis-
cussed the influence of one neuron upon another. He
said he had been unable to find atrophy of the cells
of the anterior horn of the cord on the side of the
degenerated pyramidal tract in hemiplegia either of
cerebral or spinal origin ; even in the case of compres-
sion of the cervico-thoracic cord in early life, in which
the cells of Clarke's column had disappeared, the cells
of the anterior horns were not distinctly diseased. In
a cr.se of complete paralysis from unilateral internal
hydrocephalus the cells of the anterior horns were not
distinctly affected. In three cats in which the pos-
terior roots had been cut he failed to find alteration
of the motor spinal cells. In the case of unilateral
syringomyelia of the cervical cord, reported previously
by Dr. Dercum and himself, in which the posterior
roots of one side were destroyed, the cells of the an-
terior horns were not seriously affected. Dr. Spiller
therefore did not believe that injury of the central
motor tracts or of the posterior roots had much influ-
ence on the cells of the anterior horns. He referred
to cases to show that disease of the peripheral motor
neuron did not cause degeneration of the central motor
neuron. He said he had never seen involvement of
the lemniscus following degeneration of the posterior
columns, and cited cases to show that two neurons in
connection with one another did not degenerate to the
same degree and with the same rapidity from one le-
sion. He concluded, therefore, that a difference in
structure must exist at the point where these two neu-
rons came together, and that the essential elements of
one neuron were not the same essential elements of
another neuron. A study of pathological changes, he
believed, afforded considerable evidence of the exist-
ence of neurons, and the results obtained in this way
must be harmonized with those derived from anatomi-
cal investigations.
How Far does the Neuron Doctrine Affect Our
Conception of Nervous Disease ? — This was the title
of a paper by Dr. B. Sachs, of New York. He con-
cluded that the nerve force must pass from one unit
to the other, and that the health of the cell body de-
pended in a great measure on the health of the distal
parts. Tlie cell-body was functionally co-ordinate and
dependent upon the entire neuron system. He be-
lieved that the neuron doctrine had aided our concep-
tion of many forms of nervous disease, such as tabes,
amyotrophic lateral sclerosis, multiple neuritis, and
progressive muscular atrophy.
The Physiological Significance of the Size and
Shape of the Neurons. — Dr. H. H. Donaldson, of
Chicago, read a paper with this title.
Dr. J. J. Putnam, of Boston, thought we should
abandon the notion of the cell-body as a storage cen-
tre for memories, etc., as the mechanism acted as a
whole.
Dr. F. W. Langdon, of Cincinnati, said that ana-
tomically the doctrine had helped us to inake order
out of chaos, and had led to better diagnosis and prog-
nosis and possibly to more intelligent treatment.
Dr. Ira Van Gieson, of New York, expressed the
view that the fundamental theory of the neuron could
not be doubted, and required no defence at the present
day. We must depart from morphology and go to
physiology for elucidation. As to the theory of neu-
ron retraction, it must proceed from the deductive
method.
Dr. Charles K. Mills said that as to nomencla-
ture it would be better to adhere to the term nerve cell
or cell body, instead of using confusing terms. The
term neuron had done harm in teaching the new doc-
trine. The facts that had been established must
stand. It seemed to him that the nerve cell was nu-
tritionally and ideo-plastically a unit.
Dr. F. X. Dercum considered theories as good
working hypotheses, and spoke in support of the re-
traction theory.
Dr. Morton Prince, of Boston, thought the differ-
ence of opinion as to the doctrine was the difference
of concept of the neuron theory. It had changed our
views in regard to the interpretation of clinical and
physiological facts. The retraction theory was valu-
able as a working hypothesis.
Dr. Joseph Collins, of New York, opposed the
retraction theory. He believed the neuron doctrine
had aided in the interpretation of many obscure
classes of cases as explained by Dr. Sachs.
Third Day — Tlntrsday, May jd.
Clinical and Anatomical Analysis of Cases of
Diffuse Myelitis — A paper on this subject was read
by Drs. J. J. Putnam and E. \V. Taylor, of Boston.
They expressed the opinion that diffuse myelitis was
a distinct disease with clinical and anatomical char-
acteristics, and reported a case which was associated
with pernicious anemia.
Dr. F. W. Langdon said there were two groups of
pernicious anaemia in which spinal degeneration oc-
curred in the posterior and lateral columns. This did
not occur, however, in every case of pernicious anse-
mia. In one of his cases mucous colitis was present
in conjunction with the spinal degeneration.
Dr. William G. Spiller asked if it was a systemic
degeneration or a degeneration from disseminated foci,
or a posterior root degeneration.
Dr. Putnam replied that it would seem to be a
systemic degeneration. At the present time it was
a matter of uncertainty. The anatomical lesions did
not explain the clinical symptoms.
Section of the Posterior Spinal Roots.— Dr. Mor-
ton Prince, of Boston, read the report of a case in
which section of the posterior spinal roots was per-
formed for the relief of pain caused by neuritis of the
brachial plexus. The operation was followed by ces-
sation of pain in the affected region. Subsequently
Brown-Se'quard paralysis developed, involving the
same area, and pain occurred in other areas as a
result of laminectomy. He thought that one of the
dangers of laminectomy was the possibility of an arti-
ficial blood-clot being formed in the cord.
Central Fissures of the Brain Dr. Burt G.
Wilder, of Ithaca, exhibited the brain and gave a
revised interpretation of the central fissures of the
educated suicide's brain presented to the association
in 1894.
The report was discussed by Drs. Langdon, Donald-
son, Spiller, Meyer, and Mills.
Malaria Presenting the Symptoms of Multiple
Sclerosis, with Necropsy. — Dr. W. G. Spiller re-
ferred briefly to some of the clinical cases of paraly-
sis resulting from malaria, and described the follow-
ing case with the symptoms of multiple sclerosis: A
man of middle age, a sailor, under the care of Dr.
Dercum, was in good health until about 1890. He
then began to have headache, dizziness, and ringing
in the ears. These symptoms lasted until 1895, when
they were controlled by medicine, but they soon re-
turned. In 1892 he had a slight transitory hemi-
plegia of the right side. In 1895 he suddenly lost
power in the left half of his body, but the attack of
paralysis was not accompanied by any loss of con-
858
MEDICAL RECORD.
[May 19, 1900
sciousness and was of short duration. When he came
under observation in i8g6, his sway was decidedly
increased when the Romberg test was made. He was
extremely ataxic in the left lower limb, but not in the
right, and he had a very marked intention tremor on
the left side. He presented a very somnolent appear-
ance. Marked vertical nystagmus was easily elicited.
The speech was scanning. The knee jerk was exag-
gerated on the right side, but was normal on the left,
and ankle clonus was obtained only on the right side.
The man died in 1899 after a severe diarrhoea, prob-
ably of malarial origin, lasting one week. Fever had
been observed only during the last week of the pa-
tient's life. The right crossed pyramidal tract was
slightly sclerotic, and the sclerosis was traced as high
as the left internal capsule. Every capillary of the
central nervous system was filled with the testivo-au-
tumnal form of the malarial parasite containing pig-
ment, and numerous small hemorrhages were found.
The capillaries under low power looked as though they
had been injected with black powder. The symptoms
were those of multiple sclerosis unilateral in type.
This was the only case on record of malaria present-
ing the symptoms of multiple sclerosis in which a
necropsy had been obtained. Some clinical cases had
been reported. The slight unilateral sclerosis, in the
right crossed pyramidal tract was suflficient to prevent
tremor and ataxia such as were observed in the left
limbs. The symptoms of multiple sclerosis were due
to the thrombosis of the capillaries by the parasites
and not to areas of sclerosis. The case showed that
the disseminated sclerosis of malarial origin was a
pseudo-sclerosis.
Dr. Mills said that while malaria was undoubted
in this case, it was questionable whether the ataxia
was due to a toxaemia, as there were numerous hemor-
rhagic lesions of small size. In several cases of ure-
mic hemiplegia gross lesions have been found. The
symptoms were not necessarily attributable to the
toxasmia. He had seen cases in which the symptoms
of tabes were due to malarial poisoning. He referred
to a patient with pseudo-tabes who recovered under
anti-malarial treatment.
Dr. Langdon spoke of a patient with profound coma
and elevation of temperature. Blood examination
showed the presence of malarial organisms, and quin-
ine subcutaneously effected a cure.
Multiple Sclerosis with Autopsy A paper on
this subject with the report of a case was read by Drs.
Charles VV. Eurr and D. J. McCarthy, of Philadel-
phia. The patient presented, during the course of
seven years, the clinical picture of locomotor ataxia;
ataxic paraplegia (combined system disease) ; and
finally spastic paraplegia, without at any time having
the typical symptoms, intention tremor, nystagmus,
scanning speech, etc. The autopsy revealed extensive
degeneration of the cortex with proliferation of the
glia; sharply cut areas of sclerosis in the brain sub-
stance; extensi\e involvement of the pons, medulla,
and spinal cord. None of these lesions produced
secondary degeneration. Microscopically the usual
sclerotic areas of multiple sclerosis were seen: reten-
tion of the axis cylinder in the sclerotic areas with
destruction of the myelin was noted. Around the
blood-vessels a reticular network of nucleated cells
was present, probably due to low-grade irritation of
the blood-vessel walls by the growing glia. The in-
terest in the case lay in the fact that with such exten-
sive involvement of pons and medulla there should be
no bulbar symptoms, and with extensive involvement
of the optic nerves and commissure there should be
so little failure of vision.
Dr. Adolf Meyer, of Worcester, Mass., gave a
demonstration of a few reconstructions of parts of the
nervous system.
Tumor of the Spinal Cord. — This was the title of
a paper by Dr. John Jenks Thomas, of Boston. He
reported two cases of tumor affecting the spinal cord.
The first case was that of a young woman, twenty-one
years of age at the onset of the disease, who during
the course of ten months gradually became paraplegic.
At the time of admission to the hospital the sensory
and motor paralysis and the paralysis of the sphinc-
ters was practically complete, and certainly so at a later
period, and from that time on the patient seemed to
have had no pain. Gradually very marked contrac-
tion developed, and the patient remained in much the
same condition for a period of thirteen years, except
for an outbreak of mental trouble with excitement,
from which she made a good recovery. Death took
place from exhaustion and diffuse nephritis, and
chronic cvstitis. At the autopsy there was found a
tumor of the dura in the mid-dorsal region, which had
completely compressed the cord beneath it. The tu-
mor was an endothelioma. The cord was atrophied
and showed the usual ascending and descending de-
generation of the various tracts. The second case was
one of intramedullary glioma in the cervical region
in a boy of six years. The symptoms developed after
a slight injury, beginning with weakness of the right
hand and arm, the left forearm being congenitally
absent, and with pain in the shoulder, and rotation of
the head to the left. Later the paralysis of the arm
became more marked, and there was diminished elec-
trical irritability of the muscles of the arm, and slight
paresis of the right leg with increased tendon reflexes
in that extremity. Two weeks later, and seven weeks
after the onset of the first symptoms, the patient died
suddenly with symptoms of interference with respira-
tion. The autopsy showed a glioma of the whole of
the cervical enlargement of the cord, into the upper
part of which a large hemorrhage had taken place, and
with another hemorrhage in the lower part of the
growth and in tlie central part of the cord, extending
well down into the thoracic cord. Sudden death from
hemorrhage into the tumor was much rarer in cases of
tumors of the cord than in those of the brain where it
not infrequently occurred, though small hemorrhages
into the cord tumors were frequent. The case was
also unusual because of the rapid course from the time
of the first development of the symptoms, and because
of the youth of the patient.
New Members. — The following-named gentlemen
were elected to membership: Dr. S. E. Jelliffe, of
New York; Dr. J. W. Courtenay, of Boston; Dr.
Llewellys F. Barker, of Baltimore; Dr. Pearce Bailey,
of New York; Dr. Henry M. Hurd, of Baltimore; Dr.
D. J. McCarthy, of Philadelphia.
Election of Officers. — The following officers were
elected for the ensuing year: Ptcsuknt, Dr. G. L.
Walton, of Boston; Vice-Presidents, Drs. Charles W.
Burr, of Philadelphia, and Henry L. Stedman, of Bos-
ton; Council, Drs. K. D. Fisher, of New York, and F.
W. Langdon, of Cincinnati; Secretary and Treasurer,
Dr. G. RL Hammond, of New York.
AMERICAN PEDIATRIC SOCIETY.
T^veljth Annual Meeting, Held at Washington, D. C,
May I, 2, and J, jgoo.
Seconit Day — Wednesday, May 2d.
The Treatment of Hydrocephalus by Craniectomy.
— This paper was by Dr. Edward P. Davis, of Phila-
delphia-. He related the case of an infant six months
old. The mother was previously healthy. Two broth-
ers were not well nourished. The birth was easy
and natural, the child weighing five and one-half
pounds. When six months old it weighed nine and
May 19, 1900]
MEDICAL RECORD.
859
one-half pounds, and was 54 cm. long; chest circum-
ference, ;,4 cm.; cranium, 41 cm. There were no
teeth. The general appearance was that of a case of
intrauterine rachitis. Double inguinal hernia existed.
The child was stupid and showed that there was intra-
cranial pressure. The child was trephined without
trouble, and a sterile silver cannula introduced to draw
off the clear serum. Silkworm gut was left for perma-
nent drainage. The patient collapsed and died. The
speaker questioned whether such operations were justi-
fiable.
Dr. Rotch, who spoke from considerable experi-
ence, declared the operation in itself to be simple and
free from danger. A little fluid should be withdrawn
daily. The results were invariably bad, as tiie opera-
tion was in no way curative. Lumbar puncture was
no better.
Dr. Dorni.\(; mentioned a child aged nine months
from whom two ounces of fluid was drawn by lumbar
puncture. 'I'iie convulsions ceased and the case im-
proved for three weeks, when it passed from observation.
Dr. Koplik spoke of three cases of chronic hydro-
cephalus, one child being two years old, whose anterior
fontanelie was drained. It did w-ell for a time, but
died with stupor and convulsions. In a case of a
child seven months old, with stupid days and nights of
crying, it was subjected to lumbar puncture. From 10
to 20 c.c. of fluid was removed weekly for six weeks.
The temperature tiien rose to 108° F., a peculiar rash
appeared, and the child died in convulsions. Infec-
tion was suggested, but could not be proven, as great
care and antisepsis had been maintained. No tuber-
cles were found at the autopsy.
Dr. Davis preferred direct drainage to puncture.
In one of his cases the child had a head increasing in
size notwithstanding the puncture.
The Nephritis of Influenza in Children. — Dr.
Rowland G. 1''reeman, of New York, read tiiis paper.
He said that nephritis was among the rarer organic
lesions in childhood. In most cases with high tem-
perature there was albumin in the urine, but real
nephritis rarely occurred. Minor mentions four hun-
dred cases of influenza with only one per cent, of
nephritis as a complication. In 55,263 cases in the
German army, only ten patients were noted as having
nephritis. In Lichtenstein's four hundred cases there
were but two with complicating nephritis. The com-
plication was more common in children than in adults.
The literature supplied only seventeen legitimate cases
in both adults and children. Five occurred under the
age of twelve years. Only two of twelve patients died.
The prevailing type was the acute hemorrhagic. The
urine was diminished; blood and albumin Vere pres-
ent. His case was that of a boy aged four years who
had influenza each winter. The temperature was
102.5° F- i he urine was normal on the fifth day, red
on the sixth, scanty and full of blood on the ninth;
casts and epithelium were present. In ten days it was
again normal. The patient passed thirty ounces daily
for weeks, usually of low specific gravity, but on one
occasion 1.050. The child recovered, as was usual in
such cases.
Dr. Fruitnight emphasized the rarity of the affec-
tion. He had examined the urine of fifty-seven chil-
dren with influenza and found albumin in but one.
Dr. Dorning remarked that the condition seemed
to be rare, but it would stimulate physicians to more
careful analysis in all cases. He cited three cases
occurring during the past winter; one in a boy of nine
years, with cedenia of the face and urine showing thirty
per cent, of albumin, with blood and casts ; also a child
four years old in the same family. A third had smoky
urine with fifty per cent, of albumin, and was not yet
well. He advocated baths and laxatives with abun-
dance of water.
Dr. jENNiNfis had had but one case, and that fol-
lowed the double infection of influenza and measles.
The child was six years old, and passed urine of 1.015
specific gravity, containing abundant albumin and
casts. All cleared up in three days. There was
neither dropsy nor languor. The temperature was
102° F. on the second day, but fell rapidly.
Dr. Rotch called attention to the indefiniteness of
the symptoms compared to the lesions. It was not so in
adults. We had few basal notes for conclusions, but
it seemed that interstitial nephritis was usual, while
glomerular nephritis was common in scarlatina. The
diet should always be carefully regulated in order not
to overtax the kidneys, even in simple cases.
Dr. Dorning asked if the amount of albumin deter-
mined the variety, to which Dr. Rotch replied that it
was not known yet. Pathological findings were not
in accord with symptoms.
Dr. Carr cited a case similar to that of Dr. Free-
man, except that the patient also had rupture of the
ear drum. The child showed a sudden liking for su-
gar, and the urine reached a specific gravity of 1.040
with abundant sugar, the albumin disappeariiij::. Of
fifty cases of influenza examined, none presenieii albu-
min.
Dr. Churchill, of Chicago, said that physicians
did not examine the urine enough, and frequently
looked for albumin alone. The infectious diseases of
childhood often led to kidney changes that became
serious lesions late in life. Renal irritation was com-
mon with infectious diseases, and cylindroids then
abounded, with a few casts. He mentioned a patient
with appendicitis who was found to have chronic
parenchymatous nephritis. He had had influenza six
months before. When four years old he had had
measles and suffered ever since from intestinal trou-
bles. The speaker asked which disease led to the
nephritis. Urinary sediments should always be ex-
amined.
Dr. Augustus Caille stated that albumin and blood
casts made the clinical diagnosis. The prognosis was
always good, as children had wonderful recuperative
power in kidney diseases. He instanced a case of a
patient, now well, which he had watched twenty years,
since nephritis of childhood.
Sudden Death from Perforation of Trachea and
Bursting of a Caseous Gland. — Dr. Caille presented
this case. It was that of a girl, four years old, who
was sent to the hospital with a diagnosis of bronchitis.
She was full of life and energy, running about the
ward, when she suddenly complained of pain in the
neck, and soon fell over unconscious. A large
O'Dwyertube was introduced, and the trachea was also
opened without relief. After death, which shortly oc-
curred, there was found a cold abscess the size of a
walnut at the bifurcation of the trachea. Both bronchi
were plugged by its contents. Two similar cases had
been reported 10 the New York Pathological Society.
The patient had no pain nor fever and only a few rales
over the sternum.
Dr. Rotch said he had been endeavoring to get
symptoms of bronchial nodes, but could find few re-
corded. Their presence was serious and modified the
prognosis in all cases of cough. No symptomatology
was in the literature. They were much more difficult
to detect than were mesenteric and cervical glands.
Dr. FreE.man noted the similarity between these
cases and postpharyngeal abscess. He had known
one in the foundling asylum to rupture low and suff'o-
cate the child. He had opened two post-pharyngeal
abscesses, but the patients died later.
Dr. Bl ackader said there were in these cases a
characteristic lack of expansion and slight recession
at the bases of the lungs on deep breathing. A case
he had seen with symptoms of slight bronchitis had
86o
MEDICAL RECORD.
[May 19, 1900
such marked recession that large bronchial glands
were diagnosed. The upper superficial veins were
distended. Large nodes interfered with the entrance
of air, causing slight cyanosis.
Dr. Fruitnight considered elevation of the chin to
the horizontal line absolutely useless so far as produc-
ing a characteristic murmur was concerned.
Dr. West reported several cases, and declared that
the murmurs could be brought out. Three cases
showed clear murmurs that disappeared as the glands
subsided, but reappeared as the glands again enlarged.
Four showed weaker respiratory movement on one side.
The cough in all resembled whooping-cough.
A Congenital Cardiac Malformation with Endo-
carditis and Anuria. — Dr. A. C. Cotton, of Chi-
cago, presented this paper and specimen. The child's
mother had neither syphilitic nor rheumatic history.
The child weighed seven pounds four ounces, and ap-
peared healthy when born, but its respiration was
delayed. Pallor and grayness changed finally to cya-
nosis. The temperature was 102.5'^ F. ; pulse, 160;
respiration, 48. Over the heart was a loud, harsh dias-
tolic murmur. No urine was passed; tlie bladder was
empty. On the third day the child nursed, and was
not restless or irritable. There was no eclampsia.
On the fifth day it died. Numerous subpleural hemor-
rhages were found, but no bronchitis. The heart was
large, especially the left ventricle. The right side
was normal. The size of the heart was 4'j by 5 cm.;
weight, 42 gm. The foramen ovale was normal. The
mitral orifice was small. There were smooth nodules
on the chorda; tendineaa. The anterior segment of the
valve was held by a band-like bridge. There was a
bulging of the wall between the aorta and pulmonary
artery as though they had failed to meet. The begin-
ning of the aorta was wider than usual. In the kid-
neys were uric-acid infarctions. Three hundred cases
of foetal endocarditis showed the left side only affected.
Uric acid might be formed from the nuclei of leuco-
cytes, or be present through imperfect o.xidation. Both
theories added interest to this case.
Dr. Adams asked if the temperature did not indicate
a septic endocarditis. He had found only two cases
of congenital septic endocarditis in the literature. He
considered that there was no direct relation between
the anuria and heart condition. Infarcts were common
in the kidney, and were usually septic, not due to uric
acid. He always used hydrotherapy.
Dr. Cotton mentioned seeing six fatal cases of
anuria, even though the books spoke so lightly of it.
Four of these patients had anomalous hearts, as seen
at tiie autopsy. Two others were recognized as " blue
babies."
Enteric Fever in Childhood. — Dr. A. D. Bl-ivck-
ADER read this paper. It was a careful analysis of
one hundred consecutive cases in private practice and
two in hospitals. All were of children under fifteen
years of age. Four were of infants under two years
old, the youngest thirteen months. This one had early
symptoms like incipient meningitis. It had four or
five loose stools daily, and died after five days. The
Widal reaction was present. The proportion of cases
increased regularly in number with the years of age.
As the disease was comparatively rare, all continued
fevers of remittent type should be carefully investi-
gated. There was no dividing-line where adult and in-
fantile forms differed. Less than fifteen of these cases
were mild. The duration averaged three weeks.
Eighty-three per cent, of the patients had headache,
forty-nine per cent, anorexia; twelve were chilly;
thirty-six had loose stools, and ten had real diarrhoea.
In only four did this require treatment. Twenty-three
had epistaxis. One had a convulsion, but it was at-
tributed to food. Several had subnormal temperature,
one having a rectal temperature of 95^ F. for four
days. Thirty-seven had temperatures of 104° F. or
over. Fifty-five had rose spots. Four had bloody
stools. As a rule the pulse was slow, showing the
effect of toxins on the pneumogastric. Three cases
required catheterizing, and five showed albumin in the
urine. Widal's reaction was tried in forty-three cases,
in three of which it failed. Cold water after Brand
was the regular treatment. Strychnine was the heart
tonic. The great value of baths was shown as a gen-
eral and nerve tonic, not as antipyretic alone. The
duration and temperature of these baths must be as
carefully modified to the case as doses of medicine.
Regularity in baths was necessary for definite elTect.
Dr. Cotton inquired whether laxatives were given
for constipation. He had reported one hundred cases
seen in Chicago. The constipated cases usually had
a high temperature, which fell after an enema of
glycerin and oil.
Dr. Adams said there was no doubt of enteric fever
occurring in patients under one year of age. He had
seen them typical at one year. Twice he had seen in-
sanity follow typhoid in children. The child should
be put in a bath if necessary. It was harmful to put
a child in a bath of very low temperature; 90"^ F. was
enough. He cited a case of a patient who lived on
ice-cream.
Dr. Northrup maintained that it was proven that
children under two years of age were little susceptible
to typhoid. They might acquire it surely, as did a
seven months baby, the sixth case in -one family, or
another infant who was fed milk by and with its sick
father. Typhoid was not an infants' disease. It was
hard to detect. If they really had it, all symptoms
were clear, more so than in adults. Large intestinal
follicles did not indicate typhoid. Most of the doubt-
ful cases were of entero-colitis. The child should be
cooled with water inside and out, but the feet must be
kept hot. Ice-cream might be given, as it was only
iced cornstarch.
Dr. Griffith remarked that too much typhoid was
seen in Philadelphia. It was "the physician's privi-
lege but the city's disgrace." As diarrhoea was not
common he thought the previous speaker's statements
were illogical. Typhoid was difficult to recognize
because many symptoms were so often lacking, but
now the Widal reaction made the diagnosis sure. He
had seen cases in children aged seven months and three
months. All were liable, but still it was rare in the
very young. Children did not bear water so well as
adults; it should not be of lower temperature than 85°
F. Warm bathing was good and should be revived.
Dr. Rotch said all evidence pointed to the possibil-
ity of the occurrence of typhoid; but why emphasize
it? Young and old were affected alike, but the young
in a less pronounced manner. Rose spots were more
common in the young. Cold baths were not necessary.
If the child was wrapped in wet gauze and fanned, it
would lower the temperature.
Dr. Wilson declared that no single series of cases
could settle treatment. There could be no question
that infancy did carry a certain immunity, because few-
were liable to exposure. There were two types of
typhoid in adult and child, and the two were often
reversed. In infancy there were not all the clinical
criteria. Most cases were mild, and hence the prog-
nosis was good. Baths must be used systematically,
but modified from the original Brand method. The
treatment should begin with a bath of 90^' ¥., and each
three hours followed by one a little lower. The child
should be kept in only eight or ten minutes, and soon
came to like it. The bath was not essentially an antipy-
retic. Its regular use modified the nervous symptoms,
secretions, excretions, and general nutrition. Very
cold water was not needed, as there was danger of over
chilling. The superficial area of a child was great in
May 19, 1900]
MEDICAL RECORD.
861
proportion to its resistance. The adult was helped
by the cold shock, but not so the infant.
Dr. Fruitnight cited a case of intercurrent measles
and typhoid. The measles developed about the
twentieth day with a temperature of 105° F., delirium,
and prostration.
Dr. Freeman stated that milk epidemics of typhoid
should show many cases in children, as they were more
likely to drink it.
Dr. Miller commented on the lack of autopsies.
Dr. Dorning reported three cases in children under
a year old. All came to autopsy and presented the
shaven-beard appearance of Peyer's patches, which was
thought characteristic. Physicians should use water
more freely and learn how powerful it was both for
good and for harm. The individual power to react
should be considered. Hot and cold were only com-
parative terms. If one went in a hot-air chamber at
170° F., and had water at 110° F. poured on one's
self, it would seem like ice. Discrimination must be
had with baths, and friction to the surface should be
always employed. He mentioned three patients who
took solid diet without ill results, and seemed to re-
gain health most rapidly.
Dr. Northrup reported that he had made two thou-
sand autopsies on foundlings under two years old,
eleven hundred being those boarded outside of the
hospital. None had shown typhoid lesions. He
wished to encourage a healthy scepticism as to its oc-
currence in children under the age of two years.
Dr. Blackader, in summing up, said that each case
demanded its own treatment. Warm baths had no
tonic effect, nor did sponging, their only result being
antipyretic.
Third Day — Thursday, May 3d.
A Case of Rhachischisis. — Dr. T. M. Rotch, of
Boston, read this paper. The case was that of a girl
three days old. The head was enormous and delivery
was accomplished by forceps. The child was viable.
There was marked caput succedaneura. The occiput
rested on the spine of the upper dorsal vertebra, the
front of the neck bulging forward. There existed a
cleft an inch and a half long in the laminae of the ver-
tebrae. The extremities were normal, also the eyes.
The child could not swallow. Rhachischisis often
occurred with spina bifida; not so here. When the
rhachischisis was total it was often combined with an-
encephalus. Any region might be affected, perhaps
two spots, each including four or five vertebrae. It
was caused by the two portions of cord failing to unite
in the early development. In this case the viscera
were normal.
A Fatal Post-Otitic Cerebral Abscess with
Amnesic Aphasia — This paper was read by Dr. J.
Henry Fruitnight, of New York. He said this case
well illustrated that the extent and gravity of lesions
were not always indicated by grave symptoms. The
laity should therefore be educated to the gravity of
chronic ear troubles, as physicians should themselves
be instructed. In this case the child was twelve years
old. It had otalgia and later otitis media, followed
by an abscess. The pus was let out. The child was
neglected by the mother, who considered the trouble
only a running ear. After the pus had been dis-
charging eighteen months, an acute otitis occurred.
The vomiting, temperature (ioo° F.), headache, and
prostration pointed to mastoid abscess. Operation
was refused. After convulsions set in, operation was
allowed and performed by Dr. Herman Knapp. The
eyes were found normal, and sensibility was normal.
There was no tenderness over the mastoid bone.
Word blindness was marked. Epidural meningitis
was suspected. The bone was opened and the attic
laid bare; all caries was chiselled away. There was
no external pachymeningitis. Both the middle and
posterior fossae were opened. A black spot on the
dura showed where the abscess lay. In three days
there was no word blindness; the next day there was
failure on some words; a day later the patient jumped
out of bed and died suddenly. The third ventricle
and left lateral ventricle contained much pus, with a
zone of softening in the brain around. The abscess
was in the middle temporo-sphenoidal lobe, and had
perforated in two places. The symptoms had indi-
cated meningitis from the beginning, with no charac-
teristics of abscess until the last twenty-four hours.
The thick capsule showed that the abscess had been
of long standing.
Dr. Herman Knapp said that the case was remark-
able and instructive because it was rare to be able to
make a certain diagnosis of abscess, and more rare to
locate it. Word blindness was located in the lower
end of the anterior gyrus, but that was healthy. In
the roof of the tympanum was a dark spot 3 mm. in
diameter, a certain proof of an abscess. One case oc-
curred, having an abscess wall two lines in thickness,
which an aspirator needle would not pierce. Throm-
bosis was more frequent than these cases, and menin-
gitis still more frequent. The speaker cited a case of
right hemianopsia with optic neuritis following long
suppuration from the ear, in which the diagnosis was
made, the abscess located and operated upon with suc-
cess. This was the only one in which the scientific
inferences were correct throughout. The lesson in
prophylaxis was that otorrhcea should never be left
alone; caries will later produce mischief.
Dr. H. D. Chapin said that there was a type of
mastoid disease in which the brain was not aftected,
the pus burrowing in front of the ear. He mentioned
a case with tenderness behind the ears, but no swell-
ing, all of which was relieved by incising the drums.
Dr. W. p. Northrup spoke of a case with pro-
nounced opisthotonos as a beginning symptom. Pneu-
monia was suspected, there having been no discharge
from the ear. All symptoms were relieved by an
operation.
Measurements of Chicago School Children.— This
paper was read by Dr. W. S. Christopher. The
work had been done during the past year and embraced
fifty-six hundred observations. Height and weight
were taken in the usual manner, the weight of the
clothes being found to be 5.8 per cent, of the total
weight. The grip was determined by a special but
accurate dynamometer, which was shown. Vital ca-
pacity was reckoned equal to the amount of air expired
in the spirometer. Hearing was measured by an elec-
trical apparatus. Fatigue and endurance were meas-'
ured on an apparatus in which the middle finger of
the right hand raised seven per cent, of the body weight
every second for a minute and a half. The high-
school pupils from comfortable homes presented better
records than the school whose pupils were of mixed
nationality and inferior housing. The energy as re-
corded on the ergograph showed increasing power of
endurance steadily from the age of six years to twenty,
except for a year or two at puberty. Another ergo-
graphic record showed graphically that endurance fell
from ten to twelve o'clock daily and also from the
second hour of the afternoon session. The first hour
of each session was much the best. This demonstrated
the necessity and advantage of dividing the sessions
by long intermissions. A nervous child with chorea
worked the ergograph for three minutes without appar-
ent fatigue, and only stopped because the record sheet
was exhausted. As this was double what could be
done by a man in health, some interesting inferences
might be made on nerve versus muscle strength. Other
experiments were quoted showing that the energy de-
862
MEDICAL RECORD.
[May 19, 1900
veloped by voluntary eflEort and that by electrical stim-
ulation were the same. It was found that the best
mental development went with the best physical devel-
opment, low mentality being accompanied by low stat-
ure. All the various physical conditions followed
similar lines in the charts. The extremes of stature
in some grades, though few, showed the necessity of
each room being fitted with some adjustable desks.
Endurance was naturally found to increase with
years, the greatest elasticity being in the upper grades.
Vision was counted imperfect at |-f. At six years
there were few damaged. At twelve years thirty-six
per cent, were defective, but at fourteen only twenty-
three per cent, were so found, vision seeming to improve
with the increasing development at that period. School
life therefore did not continuously impair sight. In
considering backward children, we must look to the
brain or cord, and the motor tracts. The existing de-
fects were caused by (a) heredity, (/^) nutrition, (r) in-
fection, and (li) trauma. To remedy the evils as well
as study conditions required the close conference and
discussion of pedagogue, physician, and psychologist.
Dr. Macdonald, of the VVashington board of edu-
cation, gave experiences in measuring twenty thousand
children. It was found that the public were active in
their interest in scientific research in the polar regions,
in rocks and wild animals, but could not readily see
the utility of studying the human species. It was
ideal science versus practical. Boys and girls were
found to diverge at fourteen years, the girls maturing
more rapidly. Observation had been made on three
thousand cases to learn the ability to feel or endure
pain, to learn if the first-born was most acutely sensi-
tive, etc. Thirteen thousand observations showed
clearly that children born in summer did best in every
way. Interesting figures, possibly practical, were ob-
tained abroad, /.e., that twenty per cent, of the aristoc-
racy were blondes. It was interesting to compare the
strength with the vital capacity, or weight with the
same, etc.
Dr. Yale, of New York, presented the practical
application. It was well known that a child grew
"weedy," tall, but not tough — grew beyond his
strength. It was not over-study that the child suffered
from ; it was that he had not the physical strength to
keep up the study. He could not study because he
was ill.
Dr. Fruitxight noted the lack of vigor toward
noon. The school-day should be divided so that the
child was out of doors from 10:30 a.m. until 2 p.M;,
especially in winter.
Dr. Cotton laid stress on the importance to the fu-
ture of all these observations on the developmental
period. He was gratified that so much of this work
emanated from the Pediatric Society. There was a
want of appreciation by the lay public, though they
were keenly alive to commercial investigations.
Dr. Chapin spoke of investigations in one thousand
children at the Juvenile Asylum. Many of these were
committed for petty offences, and all were of poor hered-
ity and surroundings. Many with five stigmata of de-
generation were considered brightest by their teachers.
Dr. Rachford declared that we did not as yet know
what the ergograms meant, muscle or nerve fatigue.
The nervous girl, for instance, did more work than a
strong man, but the tracing was itself like a choreic
action. If brain strain could be measured the energy
of the pupils should be less at the end of the term than
in the beginning. He asked if there was a physical
basis for precocity, and what amount of development
was necessary for sustained work in school. There
should be a physical examination for entrance to
school as well as mental.
Dr. Ware asked if it was to be inferred that chil-
dren had less likelihood of eye strain if they remained
out of school until the eighth year; also if the tracings
for both ends of the school year were alike.
Dr. Yale replied that there was very little differ-
ence. Some lost weight in summer, depending upon
the manner of spending the vacation, whether at home,
at work, or in the country. The observations of teach-
ers varied so greatly that the grade standing was found
the more positive indication of ability. Color blind-
ness in whole or part was found very common.
Epidemic Paralysis in Children. — Dr. Henry D.
Chapin, of New York, read this paper. He said the
prevailing view was that this was a special form of
paralysis due to an infection. The abrupt onset, con-
vulsions, epidemic and endemic outbreaks favored this
view. The symptom complex resembled that of Lan-
dry's paralysis. Some evidences suggested a chemical
change in the blood as in rheumatism, or change in
metabolism not understood. Cold, refrigeration, was
a suggested cause. Paralysis from microbes was not
always confined to the extremities. There were often
groups of cases in one family. The Poughkeepsie
epidemic occurred in July and August. The city was
usually healthy otherwise. There was no paludism.
The speaker saw seven cases and learned of more than
twenty-five in the vicinity. A type was the case of a
child, four years old, taken with vomiting, high fever,
pain in the limbs; temperature, 104° F. ; pulse, 120.
On the fourth day both legs and arms were paralyzed.
All the cases were similar. The blood examination
was negative. A few minute diplococci were found
but might have been due to contamination. The
blood plaques were increased, showing dissolution of
the red elements. The great amount of pain in the
limbs suggested neuritis. One child, two years old,
died in convulsions twenty hours from the onset. The
microscopical examination of the cord showed nothing
especial. There was cloudiness about the anterior
horns, with diplococci and marks of degeneration.
One w^ould hesitate to infer much from these appear-
ances. In all the other cases the patients recovered,
though not all were free from paralysis. Several cases
were of typical anterior poliomyelitis; one child was
still paralyzed. Two forms were evident^ — those with
spinal and those with peripheral lesions. A third set
seemed to include both forms. The epidemic at
Bridgeport was of the same character.
Dr. Griffith narrated two cases that occurred in
the same family without apparent cause. They must
have been infectious. One list of cases of epidemic
paralysis included a scurvy case.
Atresia of the Larynx due to Faulty Intuba-
tion, with Specimen. — This was presented by Dr.
W. P. Xorthrup, of New York. He said that the
causes of retained tube were a faulty tube or a faulty
operator. The specimen of larynx was shown ; it hap-
pened to be the last case seen by the late Dr. O'Dwyer.
The child had snatched the thread and tube out too
quickly for the young operator, and several attempts
were made at reintroduction. Later urgent dyspnoea
demanded tracheotomy. The child died later of pneu-
monia. The larynx showed an hour-glass contraction
below the glottis, caused by a band of new inflamma-
tory tissue where the walls had been abraded by the
frequent introduction of the tube.
Dr. Miller thought the speaker too severe on the
operator, as the most skilful had like troubles.
Dr. Cotton said it would be interesting to know
how many cases there might be with malformed
larynx. He had seen a girl, aged thirteen years, die
with symptoms of diphtheria, at all events of dysp-
ncea. Intubation failed, and after death stenosis was
found and a cul-de-sac in the larynx. The author's
moral was, not every one could intubate.
Three Cases of iSead Nodding and Head Rota-
tion.— This paper was read by Dr. Milton Miller,
May 19, 1900J
MEDICAL RECORD.
863
of Philadelphia. He said that in Budapest fourteen
cases occurred among fifty-two thousand persons in
two years. Seventy-eight were now in the literature.
The term spasm was misleading; head nodding was
more appropriate. He described the case of a negro
male child, five months old. He was breast-fed but
had gastro-inteslinal disorders. His weight at birth
had been eight pounds. The ribs were beaded. He
cut the first lower incisors at nine months. Massage,
baths, and cod-liver oil improved him. The head
nodded ninety times per minute, but ceased during
sleep. There existed vertical and diagonal nystag-
mus. The movements lasted four months, when he
became well. The second case was that of a girl,
aged twelve months, fed upon condensed milk. She
had alternating constipation and diarrhoea. Rickets
was well marked. The head movements had existed
since she was seven months old. She recovered. In
the third case there was no nystagmus, only nodding.
Hygiene and salt baths cured. The cause in these
cases seemed to be gastro-intestinal disturbance. The
second case was aggravated by intercurrent measles.
Of the seventy-eight cases recorded, eleven had con-
vulsions; falls preceded twenty -two; nystagmus of
both eyes existed in forty-three, in one eye in forty-
two; five had strabismus. Twenty-two were examined
with the ophthalmoscope, and twenty-one of them were
found normal. The nodding had been thought due to
uncertain line of sight, and bandaging had been sug-
gested to lessen the habit. The bromides were less
efficient than diet in cure.
Dr. Koplik had had twelve cases investigated. As
a rule nystagmus was more marked in one eye than the
other.
Dr. Lewi had visited the homes of patients and
found that eye strain could not be attributed to their
surroundings. Rachitis was always present.
Dr. Miller, in closing, said in his cases the chil-
dren were living in good rooms and were rachitic.
His view was that the disease was a functional one
due to exhaustion.
Cresoline Poisoning. — Dr. S. S. Adams, of Wash-
ington, described two cases. The first case was that of
a child a year old, who was found in coma, with stridu-
lous breathing and cold clammy sweat. The urine had
been black for twenty-four hours. Recovery was
prompt in the open air. The second case was that
of a baby six months old, said to be dying of bron-
cho-pneumonia. The pupils were dilated; breathing
was stridulous; temperature, 100° F. Pulmonary
cedema was present. The urine was not black. Re-
covery was complete in the open air.
Officers Elected. — President, Dr. Booker, of Balti-
more; Fhst Vice-President, Dr. Frederick A. Packard;
Second Vice-President, Dr. Morse; Treasurer, Dr. J.
Park West; Secretary, Dr. S. S. Adams; Editor and
Recorder, Dr. W. L. Carr; Member of Council, Dr. F.
M. Crandall.
The society adjourned to meet at Niagara Falls on
May 27, 28, and 29, 1901.
AMERICAN DERMATOLOGICAL ASSOCIA-
TION.
Meeting Held at Washington, D. C, May i, 2, and
3, igoo.
First Day— Tuesday, May ist — Mor?iing Session.
President's Address. — The annual address was read
by the president. Dr. Henry W. STELWAGON,of Phil-
adelphia, who said tliat the ultimate aim of physicians,
the diminution of suffering and the cure of disease,
could be attained only by the combined results of the
clinician, the therapeutist, the pathologist, and the
bacteriologist. Bacteriology, especially, played an
important part; and the hereditary receptivity and
family vulnerability, the environment, and the state
of the general health, were factors of moment in many
cases. Dr. Stelwagen spoke of the increased impor-
tance now attached to the teaching of dermatology in
the medical colleges, and also referred to leprosy as
a disease which could be properly handled only by
the national authorities.
Bullous Dermatitis (Dermatitis Herpetiformis?)
in Children — Dr. J. T. Bowen, of Boston, presented
five cases following vaccination. He exhibited photo-
graphs of the cases, in three of which the eruption ap-
peared within two weeks after vaccination, and in at
least four of which there seemed to be reason for the
assumption that the vaccination in some way influ-
enced the appearance of the eruption. The localiza-
tion of the lesions was striking, there being a tendency
to grouping about the mouth, chin, nose, and ears, and
upon the backs of the hands and feet; moreover, the
extensor aspects of the extremities were prominently
aff'ected. The itching was not pronounced. Dr.
Bowen said that our present knowledge of the bullous
dermatoses was such that it was imprudent to draw
deductions from any but a large number of carefully
reported cases.
Dr. George T. Jackson, of New York, read a paper
on "Loss of Hair," which will appear in full in the
Medical Record.
An Unusual Phenomenon of Syphilis : Othaema-
toma. — Dr. Joseph Zeissler, of Chicago, reported a
case in a physician, forty years of age, who had a
small wart-like lesion on his right thumb, which was
removed by excision and cauterization with nitric
acid. The glands of the axilla became much en-
larged, and six weeks afterward a copious roseola
made its appearance. Mercurial injections and inunc-
tions were given. A year later an othematoma ap-
peared on the right auricle. Iodide of potassium was
liberally administered, and the othsematoma promptly
and permanently disappeared. Dr. Zeissler explained
the case on the basis of perichondritis due to syphilis.
Dr. Ravogli, of Cincinnati, referred to two cases
of othasmatoma which he had seen in idiots.
Evening Session.
Case of Brocq's Erythrodermie Pityriasique
en Plaques Disseminees. — This case was reported
by Dr. J. C. White, of Boston. The patient was a
healthy Irishman, with a negative family history, who
twelve years ago noticed red spots of considerable size
on his lower leg, which disappeared in the spring and
reappeared each autumn, invading more and more the
general surface, until the entire surface v.as almost
covered. They showed themselves every year at the
beginning of cold weather, remained unchanged
throughout the winter, and vanished in April. They
had never given rise to any subjective symptoms. On
inspection his face and neck were largely occupied by
bright red areas of irregularly circular outline, varying
in size from one-half inch to two inches in diameter.
They were mostly smooth, not at all elevated even at
the margin, and were not thicker than the normal skin.
Another case was seen about the same time by Dr.
Charles J. White, in a young German aged twenty-six
years. The two cases bore a strong resemblance to
each other in the general appearances, but were far
from identical, the second one covering much larger
individual areas uniformly and being more scaly, as
in Brocq's case. It also lacked the peculiar brownish
tint of the first case.
Dr. Sigjiund Pollitzer said these cases bore very
little resemblance to parakeratosis variegata, or
lichen planus.
864
MEDICAL RECORD.
[May 19, 1900
The Prophylaxis and Control of Leprosy in this
Country. — This paper was read by Dr. Prince A. Mor-
row, of New York. He referred to the growing like-
lihood of contagion from our recently acquired pos-
sessions in the Philippines and Hawaii, and the
necessity for national action in order to prevent the
spread of the disease. He suggested the employment
of skilled experts as quarantine inspectors. He dep-
recated the mediaeval conception of the horror and
virulence of the disease, which was now known to be
no more contagious than tuberculosis. Isolation or
segregation undoubtedly was the most effective means
known to sanitary science for the control of this and
other contagious diseases. Homes or asylums with
suitable hygienic surroundings should be provided by
the national government for the care and maintenance
of lepers. Such asylums should be made comfortable
and attractive, and be arranged with especial adapta-
tion to the requirements and peculiar needs of its in-
mates. In view of the chronicity of the disease, lep-
ers should not be condemned to close confinement
in inactivity, but should be provided with interests,
means of employment, and recreation. As a large pro-
portion of lepers are able to engage in some kind of
industry, such institutions might be made partly or
wholly self-sustaining from the proceeds of these in-
dustries.
The Prevalence of Parasitic Diseases of the
Skin, and Measures Necessary to Limit their
Spread. — This paper was read by Dr. William
Thomas Corlett, of Cleveland. In considering the
class of diseases known as parasitic, the author spoke
of the necessity of enlarging the group, since recent
investigations have demonstrated that other micro-
organisms of the vegetable kingdom, such as the bac-
teria, blastomyces, and actinomyces, were active agents
in producing diseases of the skin. The distinction
that these latter were not limited to the skin, but pro-
duced grave disturbances of the viscera, was held un-
tenable, as instances were recorded of ringworm and
favus attacking the mucous membranes. As to the
frequency of the parasitic dermatoses, the speaker
quoted from the statistics of the American Derma-
tological Association, showing that next to eczema para-
sitic diseases \vere the most common of all diseases of
the skin. Favus was of minor importance, being al-
most wholly an imported disease. The writer had
met with it mainly in Poles and Hungarians, seldom
in persons from Scotland and only once from France.
Tinea versicolor, he held, derived its importance
mainly from the danger of its being mistaken for
more serious affections. Of the greatest importance
among the vegetable parasitic diseases of the skin he
placed the ringworm family. He maintained that the
severity as well as the frequency of ringworm differed
in different countries, being especially prevalent and
more severe in low, tropical countries than in high
northern altitudes. This afforded a striking contrast
to that observed among the animal parasitic diseases,
particularly scabies, which throve best in cold coun-
tries. As an example he mentioned scabies Norve-
gica. In the writer's experience ringworm was mainly
a disease of children and adult males, although all
conditions and ages were liable to become affected.
In children the scalp was the part most frequently at-
tacked, while in men the chin and sides of the bearded
face and crural region were most frequently involved.
He had observed the disease but seldom after middle
life. Pediculosis capitis had been most commonly
encountered in children and women, pediculosis pu-
bis in young men, and pediculosis vestimentorum he
regarded as almost wholly limited to the uncleanly,
and as seen in public clinics was one of the tortures
of old age. As to whether or not parasitic diseases
of the skin were diminishing in frequency in this
country, the speaker again referred to the statistics
of the American Dermatological Association during
the last twenty years, in which it was found that
while there had been a slight decrease in the animal
parasitic diseases there had been an increase in the
number of diseases of the skin due to vegetable para-
sites. He attributed the decrease in the former to
improved hygienic conditions, and especially to the
free bathing establishments in large cities, which en-
couraged frequent ablutions. Among the most potent
factors in increasing the prevalence of vegetable para-
sitic diseases, especially ringworm, he mentioned asy-
lums, schools, barber shops, the roller towel in the
washroom of hotels, and domestic animals. Among
the measures recommended to limit the spread of the
vegetable parasitic disease of the skin, he spoke of
the imperative need of admitting children to asylums,
which oftentimes rendered it impossible to exclude
certain infectious diseases. When isolation was found
impossible, the scalp must be shaved and an imper-
meable dressing worn to prevent the diffusion of the
contagium throughout the apartment. The medical
director should exercise great caution against admit-
ting cases of ringw^orm to asylums. The speaker
strongly urged the exclusion of ringworm from kinder-
gartens and schools. That this might be successfully
carried out he advised that there should be in all com-
munities a medical inspector of schools. Nothing
short of rigid quarantine would succeed in eliminat-
ing the various forms of ringworm. Barber shops
should at least be under the supervision of the board
of health. Minnesota already had a law in force re-
quiring all barbers to obtain a license. No barber
should be allowed to use the same brush, sponge, or
towel on different patrons, without these articles being
first boiled, subjected to dry heat (250° F.),' super-
heated steam, or otherwise disinfected. Absolute al-
cohol, a solution of formaldehyde, fifteen per cent., or
corrosive sublimate (i : 1,000) were among the neces-
sary adjuncts to a barber's outfit. Any disease exist-
ing on the skin or hide of domestic animals, espe-
cially dogs, cows, and horses, should be looked upon
with apprehension, and care exercised by those com-
ing in contact with them.
A Report of Two Cases of Persistent Exfoliation
of the Lips — This paper was read by Dr. Henry
W. Stelwagon, of Philadelphia. The first case was
that of a young woman, aged about eighteen years.
The urine showed considerable deposit of urates.
The condition was limited to the vermilion of the
lips, overstepping neither the mucous portion of the
mouth nor the cutaneous integument. The lips when
free from the scale or crust formation appeared nor-
mal, at times showing scattered points of superficial
abrasion. The first stage in the formation of an exfo-
liating film consisted of a slight, scarcely percept-
ible thickening. In a short time, from two to five
days, the affected parts broke up into plaques by a
cracking of the film, and the edges of the plaques
gradually became everted, and slowly loosened and
detached themselves. If pulled off or forcibly de-
tached, the lips were red, slightly abraded, and some-
what tender. The exfoliative process went on unceas-
ingly. The disease was still persistent, but was no
longer under the reader's care. The second case was
that of a woman aged thirty years. The patient v\as
profoundly neurasthenic. Both lips were to a great
extent involved, although the central parts were most
markedly affected. There was slight seborrhoea capi-
tis in both cases. The reader was inclined to consider
the disease as allied to eczema seborrhoicum.
The Etiology and Pathology of Cutaneous Can-
cer.— Dr. a. Ravogli, of Cincinnati, said that from the
greatest antiquity the clinical conception of cancer
had been an ulcer, especially of the skin and glands,
May 19, 1900]
MEDICAL RECORD.
865
with exuberant growth of granulations, which, when
removed, had a tendency to relapse, gradually spread-
ing and unde rmarasmic conditions causing death.
The true etiology was first given by Billroth, who con-
sidered as carcinoma only those new growths which
resulted from epithelial production, together with an
infiltration in the connective tissues. It was quite
natural that the masses of epithelial cells, crowding
themselves into the midst of the connective tissues,
must produce an irritation which caused a prolifera-
tion of the connective-tissue corpuscles. These cor-
puscles, which had the task of providing for the nu-
trition of the connective-tissue fibres, were greatly
developed in the embryonic stage. In adult life they
were very much smaller, but on account of some in-
flammatory exudation they returned to their embry-
onic stage, increasing in their volume ; their nuclei pro-
liferated, and they increased in quantity, producing hy-
pertrophy of the connective tissues, until they reached
the form of papillary growths. In carcinoma the
presence of sharp epithelial cells, crowding down upon
the delicate structure of the connective-tissue fibres,
caused the connective-tissue corpuscles to take part
in the proliferation; hence carcinoma was a malignant
production consisting of masses of epithelial cells
embedded in a connective-tissue structure, inflamed
and infiltrated.
Second Day — ■ Wednesday, May 2d — Morning Session.
General Discussion — Malignant Diseases of the
Skin. Their Classification and Clinical Features.
— Dr. E. B. Bronson read this paper. The import
of the epithet malignant as applied to disease varied
according to the circumstances under which it was
employed. As most generally used the term implied
a rapid, destructive course, tending to a fatal issue.
It was thus used to designate certain forms or varie-
ties of a disease of a severe and dangerous type, in
contradistinction to other forms of the same disease
that pursued a relatively milder or "benigner" course.
Thus we had malignant and benign forms of syphilis
and tuberculosis. Pernicious cell growths might orig-
inate either in the epithelial structures or in the con-
nective tissue. In the one case the resulting disease
was carcinoma, in the other sarcoma. All known
" malignant " growths pertained to one or the other
of these two diseases. An epithelioma, though in the
common acceptation of the term a skin cancer, was
not necessarily a malignant growth; only potentially
so. A promising field for the study of malignancy in
diseases of the skin and of the conditions relating to
it was found in those diseases that, beginning as an
inflammation or simple perversion of growth, ended
in malignant cancer. The epitheliomas that developed
on old syphilitic lesions, on lupus, or from some
indifferent local irritation of the skin, were common
instances.
Their Etiology and Pathology. — Dr. M. B. Hart-
ZELL discussed this part of the subject. He said that
heredity, age, traumatism, and long-continued slight
irritations had long been considered as predisposing,
in greater or less degree, to the occurrence of cancer.
While heredity was no longer believed to play the
important role formerly attributed to it, yet it was ap-
parently well settled that cancer was apt to occur in
successive generations of some families, due, as was
now believed, not to the inheritance of the disease,
but to an inherited susceptibility. The influence of
age upon the appearance of carcinoma was so very
evident that it was no longer a matter for debate; in
the great majority of cases the patient with cancer was
past forty years of age, the exceptions to this rule
being in most cases examples of rodent ulcer. Rib-
bert produced numerous tumors in the abdomen, uterus.
diaphragm, and pleura of an animal (a rabbit) by al-
lowing free epithelial cells to diffuse through the peri-
toneal cavity. Cancer possessed a considerable num-
ber of features, clinical and pathological, which
suggested the possibility of its being an infection,
although other explanations were not absolutely pre-
cluded. We might regard it fairly well demonstrated
that this neoplasm resulted from a profound and more
or less permanent alteration of the mechanism of cell-
division. This alteration might result from long-
continued irritation of a mechanical or chemical kind.
The immediate causes were therefore multiple. In
cases of xeroderma pigmentosum it might be assumed
that some inborn defect of the skin existed.
Their Treatment.— This paper was by Dr. F.
J. Shepherd, of Montreal. As a surgeon had to
treat all kinds of malignant disease, wherever situated,
excision of the growth and the adjacent lymphatic
channels and glands seemed the most scientific proce-
dure in the majority of cases. He said that all now
believed in the local origin of cancer, and also that
whenever found it should be quickly and completely
removed. The disease being local, only local treat-
ment was curative. Constitutional treatment was of
no avail. There were two forms of local treatment —
removal by knife and removal by caustics. Surgeons
favored the former and dermatologists the latter.
The weak point in the treatment of malignant disease
of the skin by caustics was that it postponed the re-
moval of the neighboring lymphatic tissue and glands.
Dr. Shepherd held that there might be malignant
disease of the glands, and yet they could not be al-
ways felt, as in the axilla and submaxillary region.
Even the microscope failed to detect the disease in
the glands, the cancer cells in the very early stage
being so few and far between. He instanced the
magnificent results of the removal of mammary cancer
by modern methods of very extensive operations. In
Paget's disease of the nipple he advocated removal of
the whole breast. In cancer of the lips, scrotum, pe-
nis, vulva, and wherever the skin was loose, removal
by excision was advocated. Certain malignant ulcera-
tions of the skin he admitted might be successfully
treated by caustics, especially rodent ulcer and the
slow-growing forms of epithelioma situated in regions
somewhat removed from glands, as the nose, forehead,
temples, cheeks, hands, and when the glands were not
early aff^ected. He had successfully employed free
curetting and the after-application of caustics in such
cases. The best caustics were arsenic, chloride of
zinc, and caustic potash. Some held that arsenic had
a selective action, i.e., an inflammation might be pro-
duced which would destroy cancer cells but not nor-
mal tissue. Before employing arsenic the ulceration
should be curetted, or the epidermis over it should be
destroyed by caustic potash. Several other methods
of treatment were alluded to, such as the parenchyma-
tous injections of alcohol, nitrate of silver, or chloride
of zinc, with electrolysis, aniline dyes, and the injec-
tion of toxins. Coler's treatment was more suited to
sarcoma than carcinoma. In sarcoma of the skin early
and complete removal was the best treatment if the
growth was local. When general some cases had been
successfully treated by the injection of a solution of
arsenic. The injection of toxins had not proved suc-
cessful in Dr. Shepherd's hands.
The discussion of the entire subject was partici-
pated in by all the members.
A Case of Naevus-Cancer ; Metastasis; Opera-
tion ; Cure. — Dr. S. Pollitzer, of New York, read
this paper. The patient was thirty years old when a
small, slightly pigmented mole on the back, about an
inch to the left of the eighth dorsal vertebra, began
to ulcerate. During six years of treatment the ulcer
never healed, and finally began to exceed the limits of
866
MEDICAL RECORD.
[May 19, 1900
the original mole. It was then excised, the skin
stitched up, and the wound healed well, producing a
linear scar. Six months later the skin in the neigh-
borhood of the scar became raised, red, and glistening
over an irregular area about two inches in diameter,
and broke down at two points, producing small ulcers.
Soon after tlie patient consulted the speaker. There
was then, in addition to the condition described, a
small, hard, round tumor clearly below the skin, and
an inch and a half from the edge of the red glistening
patch. The patch including the scar and a large ex-
tent of healthy skin were excised. The subcutaneous
tumor was found within the substance of the trapezius
muscle, and the latter was stripped up from its attach-
ment to the spines of the ninth to twelfth dorsal ver-
tebra and cut out to an extent that included the tumor.
Microscopical examination showed the cutis throughout
the red glistening area to be filled with round, oval,
and irregular tracts of cancer cells, without connection
with the surface epithelium. Examination of the tu-
mor in the muscle showed it to be made up of large
nests of cancer-cells separated by dense masses of con-
nective tissue which had replaced the muscle fibres.
Six years had elapsed since the operation, and the
patient was entirely free from any sign of a recur-
rence. Cases of naevus-cancer were usually of such
striking malignancy that the favorable result in this
case, in which a metastatic deposit had already oc-
curred, made it worthy of record.
Syphilitic Lesions of the "Wheal" Type.— Dr.
H. G. Klotz, of New Vork, described an unusual
eruption observed during the early period of second-
ary syphilis, and quoted similar descriptions from
Taylor and Langlebert. The lesions resembled wheals,
except for the absence of itching and other sensory
symptoms, and their long duration. Nevertheless he
believed it justifiable to accept the lesions as wheals,
especially as the conditions found in the wheal of
urticaria by several authors would fully account for
the clinical features. Dr. Klotz called attention to
the want of actual knowledge in regard to angioneu-
rosis, and mentioned a recent paper by Brill ippsoro
which attempted to establish the origin of the so-
called angioneurosis from embolism.
Dr. Joseph Zeissler said he had never had his
attention called to this distinct syphiloderm as an in-
dependent form, but he had seen a case much like that
described by Dr. Klotz.
Dr. J. Hyde, of Chicago, saw no reason why the
introduction of a poison, such as syphilis, into the
system should not bring about a series of changes in
the skin.
Dr. J. Grindon, of St. Louis, said we should ex-
pect, reasoning a priori, to see such eruptions in
syphilis.
Dr. Klotz stated that he was inclined to consider
it a syphilitic eruption, differing from erythema and
similar affections.
Endothelioma of the Skin Developing in the Scar
Tissue of Lupus Vulgaris. — Dr. John A. Fordvce
reported this case. A nodular growtli developed in
the scar tissue following various operative procedures
on the lupus tissue on the forearm. The tumor upon
excision proved microscopically to be an endotheli-
oma, probably starting in the perivascular lymph
spaces surrounding the smaller vessels. It was im-
possible to differentiate the growth in question from
a small-celled epithelioma from the appearance of the
cells alone. Their grouping about the dilated blood
spaces enabled a diagnosis of endothelioma to be
made. Although epitheliomas springing from lupus
tissues had been not infrequently reported, Dr. For-
dyce believed the case in question to be a unique one
in that connection. Several cases of angiosarcoma
were referred to in which tumors were found identical
in structure with the so-called idiopathic pigmented
sarcoma of Kaposi. These growths were histologi-
cally to be differentiated from the true endotheliomas.
Two Cases of Rhinoscleroma. — Dr. C. W. Allen,
of New York, presented by lille, with colored drawings
and photographs, two cases of rhinoscleroma, one of
which had been under his observation since 18S9, the
other for about three months. Both were already
known to literature. In the first case the portion of
the growth involving the centre of the upper lip, gum,
and inferior portions of the nose broke down in a gan-
grenous suppuration, and within the period of a fort-
night was completely thrown off, leaving the bones
denuded. These subsequently became covered over
with a reproduction of the new growth, so that eating,
breathing, sleeping, etc., became more natural, and
life was prolonged after it had been despaired of.
In the case of the man, whose affection had existed
for nineteen years at least, there was enormous enlarge-
ment of the external nose, with dilatation of the nos-
trils, which were also practically occluded. For nine
years a tracheotomy tube had alone made breathing
possible, and the stenosis extended the whole length
of the pharynx, shutting off the posterior nares by
bands and masses of fibrous tissue. Despite the se-
verity of the condition present in both cases, there
had been recent improvement in the general health.
An Unusual Form of Tumor of the Scalp — Dr.
Allen also presented a colored painting, gross speci-
men, and microscopical preparation. The tumor,
which had been of slow growth upon the scalp of a
woman advanced in years, had been widely excised
after the diagnosis of probable carcinoma was made.
The chief clinical feature of the tumor was its extreme
hardness, almost like that of ivory. This was due to
a central encapsulated mass which had undergone hy-
aline or colloid degeneration. Sections made by Dr.
Martin Ware, to whom the reporter was indebted for
a description of the appearances, showed an alveolar
arrangement of polyhedral cells, growing in a very
atypical manner. These cells were arranged about
a central canal indicating that the growth emanated
from glandular structure, either sebaceous or sweat
gland. The cells did not take the hsematoxylin and
eosin stain well, because of the degeneration they had
undergone.
A Case of Xanthoma Tuberculatum Diabetico-
rum, Showing Rapid Disappearance of Lesions
under Anti-Diabetic Regimen and Treatment. — Dr.
S. Sherwell reported and showed some excellent
photographs of a case of this rare and interesting dis-
ease of the skin occurring in the person of a married
woman, aged forty years. She was a somewhat pleth-
oric and robust woman, as was usual in these cases.
The patient was first seen January g, 1900. The dis-
ease being recognized she was put under anti-diabetic
regimen and diet alone until she was shown at a meet-
ing of the New York Dermatological Society on Janu-
ary 23, 1900. A marked improvement had followed
this course in the fortnight's interim. The subjective
glycosuric symptoms had become less, the objective
markedly so, say about twenty per cent, improvement.
She was thereafter continued on strict diet, and some
medication appropriate to the condition, with the re-
sult that in two months the lesions, even the pigmented
stains resulting from the papular and tuberculate
masses, had also disappeared. The amount of sugar,
primarily enormous, was now slight, though always
present. The speaker cited some of the more impor-
tant authors on the subject, as Trok, Robinson, Walker,
James C. Johnston, Toepfer, etc., and agreed with the
opinions of those who had seemed to go into the ques-
tion of etiology and pathology most closely, that it
was an inflammatory disease resembling xanthoma,
rather than a true xanthoma; but still he advocated
May 19, I goo]
MEDICAL RECORD.
867
retention of the name as sufficiently descriptive. Only
somewhat over thirty cases of this peculiar disease had
been so far recorded. Another case of the sort had
been sent by him to Dr. Robinson in the fall of 1890.
Dr. James C. Johnston in another paper gave
findings (histo-pathological) of one or two tumors
excised from the patient's leg.
Blastomycetic Dermatitis and its Relations to
Yaws. — Dr. Isadore Dyer, of New Orleans, read this
paper. In many particulars the case fulfilled the
clinical characteristics of yaws. Dr. Dyer examined
specimens and confirmed the diagnosis of blastomy-
cetic dermatitis. Under the iodide treatment the im-
provement was rapid; the lesions flattened, and the
exudate diminished. Finally mercurial plasters were
applied to all of the lesions, successfully reducing the
granulations. At the present time the face showed a
smooth, glossy area, marked here and there by a
fibrous tab, and with a large, branching, somewhat
keloidal scar in the lower part of the area. Over all
there was a fine linear network of scars, soft but
marked.
Three Cases of Blastomycetic Infection of the
Skin, One of Them Producing a "Tumor" of the
Lower Lip. — These were shown by Drs. F. H. Mont-
gomery and H. T. Rickets.
A Review of the Subject of Blastomycetic Infec-
tion of the Skin, with a Report of Two New Cases.
— Dr. J. N. Hyde, of Chicago, read this paper.
These two papers formed the basis for a general
discussion of the subject of blastomycetes.
A Case of Erythema Elevatum Diutinum (?).
— This was reported by Dr. T. C. Gilchrist, of Bal-
timore, who said that the case did not recall the diag-
nosis of lichen planus, and did not at all resemble
Galloway's case of ringed eruption.
Dr. Hyde said he had seen a case which was al-
most identical with that of Galloway.
AMERICAN LARYNGOLOGICAL ASSO-
CIATION.
Twenty-second Annual Meeting, Held at Was/ttnglon,
D. C, May i, 2, and j, igoo.
Second Day — ■ Wednesday, May 2d.
President, Samuel Johnston, M.D., of Baltimore.
Discussion : The Early Diagnosis and Treatment
of Laryngeal Cancer. — The discussion was opened
by Dr. J. N. Mackenzie, of Baltimore, who spoke on
" Methods of Diagnosis and General Principles of
Treatment." The speaker said he would confine his
remarks to certain phases of the question which were
at the present time more pressing and of immediate
importance. Omitting the matter of a possible cancer
bacillus, there were three methods of arriving at a
diagnosis: (i) The naked-eye appearances combined
with the clinical history; (2) thyrotomy, as affording
a more complete inspection of the parts; (3) micro-
scopical examination of a removed fragment. The
second method was frequently a part of the first.
The latter was the most practical of all, though we
had unfortunately relegated it to a subordinate place.
The removal of a fragment for examination generally
so stimulated the malignant growth that it marked the
beginning of the end. As to the clinical history no
one solitary symptom was of unequivocal value. Many
cases might be positively diagnosticated by this first
method. He asked whether, when reasonable doubt
existed, a piece should be removed for microscopical
examination. In the view of the speaker, he should
answer absolutely in the negative. Under the term
thyrotomy, we might include even a more extensive
division of the cervical tissues than mere laryngo-fis-
sure. This was allowable in cases of reasonable
doubt or when there was failure to define the exact
territory occupied by the disease. Even here it might
be impossible to map out the whole of the affected
area. There might be a diffuse infiltration difficult,
if not impossible, to recognize fully. As to removal
of a piece for microscopical investigation it must be
said that the patients were at once exposed to the dan-
ger of auto-infection or of metastasis. There was also
the danger of stimulation of rapid increase of the neo-
plastic area. The method was unsatisfactory, incon-
clusive, misleading, and often impossible. As to the
nature of the infectious element in cancer we were
still in the dark. It might be a bacillus or inhere in
some peculiar vital characteristic of the cancer cell.
As to treatment, the time would probably come when
the treatment of cancer would be not surgical but
medical. An antitoxin would probably be discovered.
At the present time the only safe procedure was the
total extirpation through healthy tissue of the cancer-
ous mass, together with complete ablation of the
neighboring glands and lymph channels. Surgical
methods in the past had been incomplete, and eradi-
cation had been only partial. It was indeed often
difficult to determine the limits of disease, and the
microscope would show infiltration in areas which to
the eye appeared normal. There was often a diffuse
infiltration or there might be a deep-seated epitheli-
omatous mass which only slowly approached the sur-
face. If the disease approached the middle line, re-
moval of tissue should be early and complete. Such
operations should be undertaken only by surgeons of
skill, and there should be the proper ethical relation
between surgeon and patient, so that the latter should
authorize the former to do whatever seemed most ad-
visable. Under these circumstances the laryngologist
must come to the aid of the general surgeon. The
removal of the lymph structures in the area under con-
sideration was one of the easiest dissections of major
surgery. A low tracheotomy should be done. The
chief danger was the recurrence of the disease in the
cervical lymphatics. In cases seen very early, in which
the growth was small and papillomatous in appear-
ance, circumscribed, not in the median line, and not
especially malignant looking, we might remove one-
half of the larynx. Sometimes growths which seemed
pathologically malignant were clinically benign. If
there was no evidence of malignant infiltration in the
pedicle, we might possibly be justified in removing
simply the growth as it appeared without the more for-
midable operation. But even here there was doubt as
to whether we had completely removed all the ma-
lignant deposit. As to removal of one-half of the
larynx, the remainder was not of especial service so
far as voice production was concerned. Intra-laryn-
geal operations in cases of extensive disease were to
be condemned. Simple thyrotomy with curettage was
not up-to-date surgery, and was a reversion of proce-
dure to the status of fifty years ago. No operation
could be assumed as correct which did not include the
removal of the lymphatics. Success by partial removal
might be explained by a mistake in diagnosis. Many
adenomata had mistakenly been classified as true car-
cinoma.
Methods of Treatment and the Statistical Re-
sults This aspect of the question was discussed by
Dr. D. Bryson Delavan, of New York, who exhib-
ited elaborate statistical tables not included here.
The speaker had made, seven years ago, an earnest
plea for the full reporting of all cases, not only those
which were successful, but those which were not. The
tables presented were a careful compilation of one
hundred and sixty-three cases occurring in the prac-
tice of some eight continental surgeons. No one had
868
MEDICAL RECORD.
[May 19, 1900
been included who had not had at least ten personal
cases. This excluded all American operators. The
current statistics on the subject were faulty because
they were too promiscuous. The cases were confused
and there was a resulting repetition. In some in-
stances the patient had undergone more than one oper-
ation, and so appeared in more than one category.
Finally in the published statistics there was no sharp
line of demarcation between thyrotomy and partial re-
section. Out of the entire number of cases studied
there had been only six per cent, of recoveries, that is,
the patients were alive three years after operation.
The Surgical Procedures. — Dr. J. Solis-Cohen,
of Philadelphia, said that before undertaking opera-
tion permission should be secured from the patient to
do whatever seemed necessary. If the mass was of
such a shape that a section could be punched out
through the whole thickness, thus allowing examina-
tion of the cut surface, this procedure was permissible.
If the growth affected the vocal band, a thyrotomy
might be done and a knife be employed to remove the
circumscribed diseased area. Partial extirpation was
not reliable. In the performance of laryngectomy he
would call attention to the following points: (i) In
order to prevent the entrance of septic matter into the
lungs, we should operate with the head of the patient
in a semi-inverted position. Some material might be
aspirated into the lungs, but this happened with a tra-
cheal tampon, for absolute protection with the latter
device is impossible. (2) Preliminary tracheotomy
should be done, otherwise we may be troubled by the
descent of the trachea. (3) The epiglottis should be
retained if possible. (4) We should shut off all com-
munication of the mouth with the air passages. In
attaching the upper part of the trachea to the skin,
the tube should be slit longitudinally for a short dis-
tance. (5) All dressings should be avoided. No
packing should be allowed, as it caused a constant
desire to swallow. Feeding by enema should be done
and no tube be used per os. (6) The larynx should
be removed from below upward, and after operation
the foot of the bed should be elevated. For the proper
attitude toward the practical problems of these opera-
tions a combination of the laryngological and surgical
minds was needed.
Dr. C. C. Rice, of New York, expressed the convic-
tion that the laryngologist should not turn over these
cases to the general surgeon until the diagnosis was
positively established. It was difficult to make an
early diagnosis. He believed in giving the iodides
and carefully watching the progress of the case before
advising operation.
Dr. Emil Mayer, of New York, called attention to
the fact that cases often diagnosticated as laryngeal
cancer showed the origin of the growth to be in the
oesophagus. He thought that there was a very decided
limit to the extent of applicability of endo-laryngeal
methods.
Dr. W. K. Simpson, of New York, could not advise
total extirpation without a microscopical examination
of a fragment removed for this purpose. No one could
always make a diagnosis from appearances alone. If
the case came to us early and showed an isolated de-
posit, we might use endo-laryngeal methods. In one
of his own cases thus treated the man was alive four
years after operation. In view of his personal expe-
rience, he could not advise total extirpation.
Third Day — Thursday, May jd.
Secondary Hemorrhage after the Use of Supra-
renal Extract.— This paper was read by Dr. F. E.
Hopkins, of Springfield, Mass. He gave the histories
of three cases of posterior exostoses of the septum in
which the extract had been used, and in which second-
ary hemorrhage resulted. The object of the paper was
to give the opinions of various clinicians to whom the
author had written, as to the liability of hemorrhage
under the conditions named. ^ Almost all agreed that
there was considerable danger, and that safety required
the use of intranasal packing after the extract had been
employed. In regard to the remedy causing coryza
after being sprayed into the nose, there seemed to be
an idiosyncrasy in this respect, and it could not be
determined beforehand just who would and who would
not be benefited by this procedure.
Dr. H. L. Swain stated that he had had more hem-
orrhage with cocaine and the extract combined than
with either alone. It should be remembered that the
latter acted on the muscular fibre of the arterioles and
did not lead to the formation of any coagulum. Con-
sequently when the vessel relaxed there was liability
of bleeding.
Dr. J. W. Farlow, of Boston, had had no hemor-
rhage with the extract and had seen some remarkable
cures of coryza follow its use. Yet it might benefit a
patient at one time and cause him much discomfort at
another. This experience had recently been met with
in one of his patients. He had succeeded in remov-
ing headaches from intranasal conditions, sometimes
in a very remarkable way. The question arose in such
cases, how long it was judicious or safe to continue
the use of the remedy.
Dr. A. VV. Watson, of Philadelphia, had seen more
hemorrhage with the use of the extract than without.
He thought that after its use patients should be kept
in the office for half an hour or so. Then if any dan-
gerous degree of vascular relaxation occurred, they
would be under direct control. He had seen acute
coryza follow the intranasal use of the extract, and in
his own person had had under these conditions what
he believed to be a general acute sinusitis lasting ten
days. He had thought that in the latter instance the
solution might have become infected.
Dr. Swain said that if the fresh glands could be
obtained, it was possible to rhake a solution of their
active principles in acetic acid, and that this solution
might be put up in glass tubes and kept indefinitely.
A Case of Ozaena of Probable Sphenoidal Origin.
— This paper was read by Dr. J. \\ . Farlow, of Bos-
ton. His patient was a girl aged twenty-one years,
with a crusty, odorous discharge from the left naris.
There was considerable atrophy of the intranasal
structures, but the discharge seemed to come definitely
from the posterior portion of the naris. The probe
seemed to pass into a cavity which was regarded as
the sphenoidal sinus. Syringing with peroxide of hy-
drogen and an alkaline antiseptic, and later curetting,
practically relieved all the symptoms.
Dr. S. W. Langmaid, of Boston, remarked that the
recent epidemic of influenza would probably cause
much sinus disease. That it did produce much acute
trouble was in accord with his own experience, for he
had recently seen five acute cases in two weeks. If the
influenza attack passed off quickly, trouble in the sinus-
es would not result, but if for any reason the latter be-
came obstructed, inflammation would be very probable.
Dr. A. W. Watson believed that ozaena could occur
independently of atrophy, or there might be crusts
without ozEena. He was inclined to regard true ozaena
as due to sphenoid and posterior ethmoid disease.
He preferred a very weak formalin solution for the
irrigation of these upper and posterior regions.
Dr. Farlow, in closing the discussion, said that it
was always advisable in looking at these cases to have
the patient wait after the nose had been thoroughly
cleared out, for then it would be possible to ascertain
the exact site of discharge.
Bullous Middle Turbinates Dr. J. Payson Clark,
of Boston, read this paper. He reported two cases,
May 19, 1900]
MEDICAL RECORD.
869
both in women, the prominent symptom being head-
ache. The enlarged turbinates were removed without
incident by the cold snare, with complete relief to
symptoms.
Cyst of the Larynx. — Dr. Clark also read this
paper. The mass was situated on the middle of the
right vocal cord and from its hardness suggested a
fibroma. The forceps slipped from its surface at the
first attempt at removal, but it was cut with a laryn-
geal knife, when a fluid escaped showing degenerated
epithelial cells and leucocytes. The firmness was
probably due to the deep situation of the cyst in the
substance of the cord.
Dr. Jonathan Wright, regarding the first paper
of Dr. Clark, said that he was inclined to doubt the
statement which had been made that these bullous
conditions were the result of development from fcjetal
conditions and presented no inflammatory evidences.
He had examined several of these masses and had
found on the convex surface what appeared to be osteo-
blasts, and on the concave what appeared to be osteo-
clasts. The former produced bone while the latter
absorbed it. The conditions met with might be due
to the unequal activity of the two classes of cells be-
neath the embryonal layer of mucosa. It was a strik-
ing fact that most of these cases occurred in women
and after the establishment of puberty.
Fibroma of the Larynx. — This paper was read
by Dr. A. B. Thrasher, of Cincinnati. The patient
was a woman aged fifty-six years, who had complained
of dyspnoea and hoarseness. Her family history was
negative. The posterior and lateral walls of the
larynx seemed to be the seat of some deposit, so that
the true cords appeared pushed in and were defective
in abductor movement. A fragment of the mass was
taken for examination. The report was fibroma. Io-
dide of potassium was given in increasing doses, but
in a week the patient was seen again and was much
worse. After a preliminary tracheotomy with the head
dependent and gauze packing, the larynx was split,
and it was seen that there was a submucous hyper-
trophy extending down to the cartilage. It appeared
to be simply connective tissue. It was removed with
forceps and the patient made a good recovery. The
voice was now rough and hoarse, but audible. Two
similar cases were described. The rarity of the case
consisted in the extensive connective-tissue deposit.
Singular Exhibitions of Partial Paralysis of the
Vocal Cords due to Over-Use of the Telephone —
Dr. C. C. Rice, of New York, read this paper. He
said that he would make its title a query, for he de-
sired to obtain the consensus of opinion as to the pos-
sible effect of over-use of the telephone on the voice.
He had had two cases. The first was a nervous man,
aged forty-five years, who had been accustomed to use
a desk transmitter with his head in a cramped posi-
tion. The cords showed evidence of fatigue of the
thyro-arytenoid muscles, and there was a loss of sus-
taining power in the other outer muscles, for the cords
trembled and the arytenoid cartilages separated imme-
diately after approximating for phonation. The man
was directed to take a rest from business and to use
the telephone with head erect so as to afford perfect
freedom of the cervical muscles. Recovery had been
only partial. The other case was that of a man who
was stout and not at all nervous. On the right side
of the larynx there was fair adduction. The edge was
straight but there was a lack of tension, with an in-
complete view of the cord, which was obscured by the
overhanging and congested parts. By rest and the
assuming of a proper attitude while using the tele-
phone, this patient completely recovered.
Dr. T. A. DeBlois opened the discussion by relat-
ing the case of a man whose head was violently bent
forward as the result of a fall. As a result, a sudden
strain was put upon the muscles of the neck, and he
became hoarse from inability to approximate the cords.
Dr. VV. E. Casselberry mentioned the case of a
clergyman who was accustomed to become very much
excited in his pulpit work, and gradually developed a
similar condition to that seen in the cases mentioned
by Dr. Rice. Rest and the formation of the habit of
more quiet speech greatly improved the condition.
A Case of a Pin in the Larynx for Two Years ;
Removal by Endo-Laryngeal Methods This paper
was read by Dr. A. W. de Roaldes, of New Orleans.
The patient was a young girl in whose larynx a pin
was found situated on the posterior portion, having
pierced the apex of the right arytenoid at its inner
side. Its head was embedded more deeply on the
right side just above the false cord. Forceps was ap-
plied, the left index finger being placed behind the
larynx to steady it. The forceps slipped, but the fin-
ger caught the pin, which was thrown out of the
mouth. In such cases, when the head of the pin was
below, it might at first have passed some way down
the trachea and then have been coughed upward so
that the point engaged. Moreover, the head of the
pin impeded its migration so that it did not move
about in the tissues as a needle would. The Roent-
gen rays might often locate the pin when it was im-
possible to make out its exact position by the mirror.
Another point of interest in this case was a hard
swelling in the neck which was probably due to infec-
tion which had stopped short of suppuration.
A Peculiar Case of Migratory Foreign Body
with X-ray Illustrations. — Dr. D. Braden Kyle,
of Philadelphia, read this paper. The patient was a
woman, who constantly complained of a feeling as if
a foreign body was moving about under the scalp.
She suffered from intense neuralgias, which at times
seemed to focus in the mastoid, and at other times in
the ethmoid or antral regions. In one of these latter
attacks there had been a discharge of purulent mate-
rial from the naris and in the discharge was a piece of
a needle. The symptoms continuing, it was concluded
that still another piece was somew-here in the tissues,
and an .r-ray picture was made, showing a dark line
in the neighborhood of the antrum, though it was im-
possible to tell whether the body was actually in the
antrum or on the bone corresponding to one of its
walls. The antrum was opened and its cavity illumi-
nated, but nothing was found. In a short time a gum-
boil formed which discharged, giving escape to another
piece of the needle. From this time all symptoms
disappeared.
Dr. S. W. Langmaid called attention to the fact
that attempts at swallowing often caused great changes
in the location of foreign bodies in the upper air tract.
Dr. W. K. Simpson commended the trial of forceps
and other instruments upon material similar to the
foreign body before actually attempting the removal
of the latter. He found sharp forceps better than
merely roughened blades.
Dr. Kyle closed the discussion. He stated that
the patient had suffered from an .v-ray burn, and re-
marked that the time of the exposure causing the burn
was not so long as the exposure on previous occasions
when no burn had resulted.
Tracheal Injections in the Treatment of Pulmo-
nary Tuberculosis. — This paper was read by Dr. T.
Morris Murray, of Washington. He gave a short
history of the development of this procedure, and then
mentioned his personal experience with thirteen cases
of pulmonary tuberculosis. In all there was at first a
slight explosive cough, but in all the general effect on
the cough had been good. No spasm had been noted.
The solution used consisted of thyme and eucalyptus
oils in olive oil. His experience had been that cough
and expectoration had both been lessened, while the
870
MEDICAL RECORD.
[May 19, 1900
temperature had fallen and the general condition had
been improved.
Dr. W. E. Casselberry believed that the benefit
from this plan of treatment was confined entirely to
the bronchitic element of the disease. He had no
confidence in its alleged effect upon the general course
of the tuberculosis. It did, however, benefit some of
the symptoms attributable to the mixed infection which
pulmonary tuberculosis presented.
Dr. J. SoLis-CoHEN observed that this was not a
new plan of treatment, as it had been practised forty
years ago. Its greatest benefit was seen in cases of
bronchiectasis.
Correction of Deviations of the Nasal Septum.
— Dr. John O. Roe, of Rochester, read this paper.
It was an exposition of the plan of operation previ-
ously presented by the writer, whereby the septum was
fractured by a fenestrated comminuting forceps. Of
all deviations five per cent, involved the posterior part
of the bony septum, twenty-five per cent, the anterior
cartilaginous part, and from sixty-five to seventy per
cent, the osseo-cartilaginous junction. Other descrip-
tive terms simply referred to varieties and not to loca-
tion. Fpr anterior deviations he advocated a horizon-
tal incision and an oblique bevelled incision, forming
more or less of an angle with the first. By this de-
vice, the flaps would more easily slide by each other.
Surgery of the Turbinal Bodies, with a New
Method of Operating. — This paper was read by Dr.
J. E. BovLAN, of Cincinnati. He advocated the re-
moval of large portions of the turbinates when the
obstruction had resulted from hyperplastic changes.
The obstruction was more apt to be located at either
end of the turbinate. Posterior obstruction was rarely
of a hyperplastic nature. For instruments he used the
saw, snare, and scissors, especially the snare. In this
way he obtained better results than from the cautery.
Dr. W. E. Casselberry used the cautery but was
careful to make deep linear incisions, and in this way
had had no septic or other trouble. He urged caution
in its use on the middle turbinate, care being taken to
confine its action to the lower dependent portion of the
bone, which he never cauterized on its upper surface.
Hemorrhage from a Peritonsillar Abscess. — Dr.
W. F. Chappell, of New York, related this case. His
patient was a young man aged twenty -seven years, who
had had several quinsies, the most recent of which had
been opened by an incision through the posterior pil-
lar. Half an ounce of pus was evacuated. Five days
later there was a severe bleeding. The urine showed
albumin and casts. The bleeding recurred, and the
abscess cavity appeared filled with clots. An incision
was made through the anterior pillar, and the cavity
washed out and packed daily for ten days, at which
time the patient was well. Later a rheumatic attack
came on without cardiac lesions. The condition of
the kidney had continued up to the time of latest ob-
servation. When the cavity was opened for washing
out, the ascending pharyngeal artery could be seen,
but there were no evidences of ulceration. Dr. Chap-
pell had been able to find the records of ten similar
cases. All had occurred in patients in whom the
quinsy had burst spontaneously. In no case had there
been immediate hemorrhage. Of ten cases, eight had
been fatal. In the two recoveries the carotid had been
tied. The lesson from these figures was to open early.
During the different sessions of the association the
following papers were read by title: "Laryngeal Irri-
tation a Cause of Asthmatic Paroxysms," by Dr. W.
L. Glasgow, of St. Louis; " Severe Hemorrhage after
Opei^tions on the Throat and Nose; Report of Five
Cases,'' by Dr. A. A. Bliss, of Philadelphia; "An-
gioma Cysticum of the Nose; Histological Analysis
and Physiologico-Chemical Research of its Contents,"
by Dr. H. L. Wagner, of San Francisco; "Dermoid
Cysts of the Nose," by Dr. H. S. Birkett, of Mon-
treal.
Officers Elected. — Officers for the coming year were
elected as follows: President, Dr. H. L. Swain, of New
Haven, Conn.; First Vice-President, Yix. H. L. Wag-
ner, of San Francisco ; Second Vice-President, Dr. A.
A. Bliss, of Philadelphia; Secretary and Treasu?'er,
Dr. James N. Newcomb, of New York; Librarian, Dr.
J. H. Bryan, of Washington; Member of the Council,
Dr. Samuel Johnston, of Baltimore.
The next meeting will be held at New Haven in
the spring of 1901.
AMERICAN ASSOCIATION OF GENITO-URI-
NARY SURGEONS.
Fourteenth Annual Meeting, Held at Washington,
D. C, May i, 2, and j, igoo.
Secottd Day — Wednesday, Jl{ay 2, igoo.
The Best Method for Obtaining Urine Direct
from the Ureters for Diagnostic Purposes (being
the subject decided upon by the Council for espe-
cial consideration and discussion). — Dr. F. Tilden
Brown, of New York, opened this discussion. He
said that in the majority of all cases presenting he
would offer the statement that the best way to obtain
urine direct from the ureters for diagnostic purposes
was (i) by one which was equally applicable to both
sexes; (2) by one which secured the individual .secre-
tion of each kidney beyond any question of its contam-
ination by the secretion of its fellow-gland, or by other
extraneous material from the lower part of its urinary
tract; (3) by one which effected these requirements
with a minimum amount of discomfort to the patient,
while involving the least possible risk of immediate
or remote harm to the parts involved in the total pro-
cedure; (4) and of least moment in so important
a' matter, by that method which called for the sim-
plest technique. After excluding all cutting opera-
tions for collecting separate urines he proceeded
to discuss the relative merits and demerits of the
Simon-Pawlik-Kelly method, the Harris method, and
the ureteral-cystoscope method. The many details
of this led him to express a decided preference
for the third method, although citing a brief series
of exceptional cases in which this method would
have to give place to that of Kelly or Harris. Dr.
Brown took advantage of this opportunity to make the
first public presentation of his double-barrelled ure-
teral-cystoscope, the advantages of which were summed
up as follows: (i) In favorable cases both ureters
could be catheterized at approximately the same time.
(2) In less favorable cases, after passing one catheter
the second channel could be used to draw the distend-
ing fluid from the bladder, thus giving the organ re-
pose. (3) In still more difficult cases the second bar-
rel could be used for frequent irrigations until fluid of
proper transparency distended the bladder and per-
mitted localization of the ureter, when a catheter, which
has been reposing in the other barrel, could be used to
engage the ureter; by taking hasty advantage of a
momentary clear fluid success may be made of an
otherwise failure. (4) In some cases in which but one
ureter can be catheterized, this double-barrelled in-
strument permitted access to one ureter through one
canal, and urine coming into the bladder from the op-
posite kidney could be collected from that source by
catheter siphonage through the second barrel.
Dr. W. K. Otis, of New York, did not believe that
there was, at the present day, any satisfactory vi'ay of
differentiating urines in all cases, and probably never
would be. In many instances it was impossible to
May 19, 1900]
MEDICAL RECORD.
871
locate the ureteral openings at all, and even when the
opening was localized it was often difficult to gain an
entrance. He referred to the danger of causing an
ascending pyelitis in attempting to catheterize the
ureters when this attempt was made through an in-
fected bladder. In the use of Harris' instrument
much pain was frequently given to the patient. When
the ureter was catheterized through a ureteral cysto-
scope, when the ureter can be catheterized at all, it
seemed to him a most satisfactory method of differen-
tiating urines by catheterizing both ureters; then just
what was coming from each kidney could be discov-
ered; that method was the only satisfactory one yet
devised. So far as the female was concerned, he
thought that Dr. Kelly had solved the problem as
thoroughly as it would iDe solved; but in the male the
conditions were different, and he doubted whether any
simple instrument would ever become popular, i.e., any
instrument with lenses. His reasons for this state-
ment were the difficulty that was experienced from the
size of the instrument, the difficulty of manipulation,
etc., which were likely to do damage and produce
much pain, and, at the same time, it gave a compara-
tively small field of vision. He had always been in
favor of the so-called direct catheterizing cystoscope
of what Dr. Brown calls the convex tube. In the in-
strument he had devised, a metal instrument could be
used, and a metallic sound could be passed as well as
a catheter for sounding the ureters for calculi. His
instrument was identical to the Brennan instrument so
far as the opening was concerned. In all these instru-
ments, as tlie Casper, Nitze, etc., ocular apparatus was
sacrificed to reduce the size of the instrument itself.
Instead of constructing an instrument carrying so many
tubes he had devised a cystoscope with a single tube,
as used in the Leiter instrument; tlie wire was on the
outside of the tube, which took up an exceedingly
small amount of room ; so he got the full-sized field
for catheterizing the ureters, and, at the same time, he
utilized the full size of the ordinary cystoscopic tele-
scope. He obtained exactly the same field as in the
Leiter instrument.
Dr. Malcolm L. Harris, of Chicago, continued the
discussion at the invitation of the association. In
summing up his remarks he stated that catheterization
of the ureters had a field of application which was ab-
solutely distinct, in the sense that no other means at
our disposal accomplished the same end, namely, to
determine tire nature and location of obstruction of
the ureter; to locate the ends of a divided ureter or
act as a guide in certain intra-pelvic operations; for
tapping and draining fluid accumulations in the renal
pelvis ; for therapeutic purposes such as dislodgment
of calculi, irrigation of the renal pelvis, etc. Cathe-
terization of the ureters simply for the purpose of col-
lecting urine for diagnostic purposes had its draw-
backs and limitations, among which might be men-
tioned temporary anuria, due to the presence of the
catheter in the ureter; contamination of the urine with
blood and epithelial cells from the ureter; danger of
infecting a healthy ureter and kidney. This last
point he thought to be of such a serious nature that
catheterization of a healthy ureter, when the bladder
was infected, or the opposite kidney tuberculous, had
been condemned. If this injunction was heeded as it
should be, it would deny the benefits of this diagnostic
aid to a large class of patients. The segregator, like-
wise, had its limitations. There were certain cases
which were not suited for its use. In certain intra-ves-
ical lesions its use must be supplemental to that of the
cystoscope. But for the difiEerential diagnosis of cer-
tain tumors of the abdomen; for determining which
kidney was diseased and the " functional activity " of
each and whether the bladder was infected or not; for
differentiating between certain bladder and kidney
infections, the segregator gave results that were per-
fectly reliable, as had been repeatedly demonstrated
by numerous anatomical findings. Furthermore, in the
infected cases it had the advantage over the ureteral
catheter of being free from the danger of infecting a
healthy kidney.
A Ureter Cystoscope (for Male or Female) Built
on a New Model — Dr. Bransford Lewis, of St.
Louis, demonstrated this instrument, which had the
definite object in view of catheterizing both the male
and female ureters. It consisted of a tube which car-
ried on its upper surface the conducting wires for the
electric light, and within, on its lower surface, a small
tube for guiding the ureteral catheter to the desired
point, i.e., into the ureteral opening. At the ocular
extremity was a handle for controlling the direction of
tlie instrument; at the distal end, contained within the
curved tip, was the electric lamp, of low tension, af-
fording sufficient light for illumination, but generating
hardly any heat; permitting, therefore, the use of the
cystoscope within the empty bladder and without the
complicating presence and often interference of fluid.
The light from the lamp was shed on the adjacent mu-
cous membrane through the glass window sealed in the
roof of the tube just below it. The tip of the cysto-
scope was a hollow cap, attached by a screw, and could
be removed for replacing a burnt-out lamp. This lat-
ter was easily accomplished in the manner made use
of in the Chetwood urethroscope. To facilitate intro-
duction, an obturator was furnished which closed the
distal orifice until it was removed, preventing scraping
of the membrane against the edge of the opening; but,
at the same time, these edges were rounded so that they
could be brought in contact with the membrane within
the bladder, or the instrument, being withdrawn into
the prostatic urethra a certain distance, could be pushed
back into the organ without injury to the surface com-
ing in contact with them. A small silk-web ureteral
catheter completed the instrument. For several years
ureteral catheterization in the female had been iinjait
acco7npli, and to a high degree of satisfaction to the
profession. The Pawlik-Kelly method was in daily
use the world over for both diagnostic and therapeutic
purposes. Yet, if this method could be improved
upon by being made easier or more certain of accom-
plishment, or if the duration of the search for the ure-
teral openings could be shortened, or if the pain so
often suffered by the patients from the preliminary
dilatation of the urethra, or the introduction through
it of a cystoscope sufficiently large to afford a good
view, could be obviated, then these objects should be
accomplished, even though the instruments already in
use had proved of such inestimable value. He be-
lieved that these features, two in number, of fixed in-
ternal heatless illumination and of complete control
over the internal end of a flexible ureteral catheter,
when applied to a tube of proper form, would secure
the advantages mentioned.
Dr. W. T. Belfield, of Chicago, stated that six
years ago or longer he presented an instrument such
as presented by Dr. Lewis; the latter instrument was a
duplicate of his except that it possessed two features
of difference: First, the substitution of a low-tension
cold lamp for that employed in his; second, the pres-
ence of a groove for the conduction of the ureteral
catheter. He found a great difficulty to be overcome
was the heating of the lamp; at the time his instru-
ment was produced the low-tension light was not known.
He hoped soon to be able to produce such an instru-
ment, so perfect in detail that it would do away with
the necessity of such discussions.
Dr. W. K. Otis thought the idea of having the lit-
tle groove for the conduction of the catheter at the bot-
tom of the instrument was an excellent one. He
found that one of the principal difficulties he encoun-
872
MEDICAL RECORD.
[May 19, 1900
tered was the size of the instrument. He thought he
used as large-sized urethral instruments as any one
present; but when it came to using a tube as large as
the one presented, and moving it around to find the
ureteral orifice, the difficulties encountered must be
great; the patient must suffer a great deal of pain,
and if the patient was under the influence of an
anesthetic one was liable to damage the tissues. In
the male he found that it was not easy to find the ure-
teral opening.
Dr. L. Bolton Bangs, of New York, thought the
great difficulty with this instrument was from the
amount of heat produced. He related the experience
of Dr. Howard Kelly, whom he invited to New York
to demonstrate the use of the cystoscope in the male ;
there were many cases in which the straight tube could
not be introduced; the same might be said of short
curved instruments. Three patients were provided for
Dr. Kelly, but on two only was the attempt made to
pass the catheter. In one he succeeded. He failed
in getting the tube in when the attempt was made in
the second case. In the third case it was not at-
tempted. He had not used the straight tube except to
get a view of the deep urethra and the contiguous por-
tion of the neck of the bladder. His own repeated
failures made him decide to go to the dead-house,
where he had bladders opened; there he was surprised
to find that he was unable to locate the ureters except
by inserting carefully the point of a probe. He asked
if others present had experienced the same difficulties.
He could not see the ureters; he thought the position
of them must be guessed at; the swirl caused by the
fluid which gushed out prevented him from finding the
openings. He referred to the case reported by Dr.
Howard Lilienthal, of New York; this patient died of
sepsis from infection; traumatism was produced, and
the patient became infected and died. He had come
to the conclusion that, unless there was some positive
reason for doing otherwise, Harris' segregator was to
be preferred.
Dr. John P. Bryson, of St. Louis, said that his ex-
perience in the use of this instrument had been the
same as that of Dr. Bangs ; he had never been able to
use the straight tube.
Antero-Posterior Subdivision of the Bladder ; An
Important Anomaly. — Dr. Eugene Fuller, of New
York, read this paper.
Radical Treatment for Curvature of the Penis.
— This paper was also read by Dr. Fuller.
Officers Elected. — The following were elected for
the ensuing year, 1900-1901 : Piesident, Dr. Samuel
Alexander, of New York; Vice-President, Dr. W. T.
Belfield, of Chicago; Secretary, Dr. J. R. Hayden, of
New York; Member of Council, Dr. W. N. Wishard, of
Indianapolis.
Members Elected. — The following new members
were elected: Dr. Henry H. Morton, of Brooklyn;
Dr. Charles H. Chetwood, of New York; Dr. Alfred
C. Wood, of Philadelphia.
The next place of meeting will be OJd Point Com-
fort, April 30, May i and 2, 1901.
Third Day — Thursday, May 3d.
The Effects of Ammonio-Formaldehyde Dr.
Edward L. Keyes, Jr., by the courtesy of the associa-
tion, presented this paper, which was founded upon
clinical observations illustrating the effects of this
drug. His conclusions were as follows: (i) Am-
monio-formaldehyde (urotropin) seemed to be a spe-
cific in the treatment of some cases of acute catarrhal
pyelitis, uncomplicated. (2) To prove effective it
might have to be administered in large doses until the
urine was practically clear of bacteria, after which a
smaller dose might suffice. (3) In judging the effects
of the drug, the centrifuj and microscope should be
employed. (4) The dose must not be suflScient to
cause pollikiuria and dysuria by irritation of the neck
of the bladder. (5) The possibility of such an irrita-
tion could be overlooked, even when small doses were
employed. (6) Ammonio-formaldehyde was extremely
serviceable as a prophylactic to the various forms of
urinary septicaemia and urethral chill. (7) Its routine
employment, 'both before and after operation on the
urinary passages, was indicated. (8) The urine con-
taining ammonio-formaldehyde occasionally had an
escharotic effect upon wounds, which might constitute
a contraindication to its employment.
Dr. George Chismore, of San Francisco, consid-
ered this a very valuable agent in controlling bacterial
conditions, but thought that one should be careful to
use Merck's preparation, which was more woolly in
appearance and less clearly crystalline. He thought
that the sudden accession of temperature and the exhi-
bition of certain other symptoms in cases in which ir-
rigations had been used were attributable rather to the
irrigation than to the urotropin (ammonio-formalde-
hyde).
Dr. John P. Bryson said that the experiences re-
corded in the paper agreed so thoroughly with his
own that he had but little to add except to indorse
what had been said. He had seen cases of tubercu-
lous disease in which urotropin had been used alone
result in polyuria ; but as soon as carbonate of creosote
was given in conjunction, relief was obtained. In
some cases the urotropin had to be withdrawn, for it
made the granulations pale and flabby. He referred
to two cases in which there was a certain form of dip-
lococci, which did not yield at all to large doses of
urotropin ; these diplococci persisted in the urifie in
spite of everything done.
Dr. L. Bolton Bangs thought the observations
made in the paper were Vi/orthy of being placed on
record. In order to get the beneficial effects of the
drug the urine must be acid at the kidney. Professor
Morton, of Stevens University, observed the same, that
it was a useful bactericidal weapon if set free in the
acid urine.
Dr. W. F. Glenn, of Nashville, referred to one case
in which gr. viiss. in twenty-four hours could not be
borne on account of the extreme vesical irritation.
He had never seen a single nervous chill arise when
urotropin had been given one week before the time for
operating; large quantities of water should also be
administered. He thought the paper a very valuable
one, and believed that urotropin viould solve the trou-
ble resulting from urinary fever and nerve chills.
Prostatic Deformities due to Loss of Tissue. —
Dr. Ramon Guit^ras, of New York, read a paper with
this title. He related the instance of a Greek who
entered the City Hospital; the interesting features
presented were the absence of the entire lobe of the
left side, and an unnatural lateral curve in the pros-
tatic urethra, due to cicatricial contraction. He also
related an instance of the destruction of one lobe of
the prostate by a tuberculous abscess. This case was
evidently one of tuberculosis of the genitals with an
abscess springing from the cord in the inguinal canal,
with a tuberculous inflammation of the right seminal
vesicle, which had converted the vesicle into an abscess
cavity that had drained down the ejaculatory duct out
of the hole in the prostate made by another abscess in
the ejaculatory duct or in the right lobe of the gland.
The next case cited was one of prostatic abscess, which
was followed by a septic pneumonia and death. There
was another class of patients in whom the prostate had
been almost entirely destroyed, and there remained
simply remnants of the gland tissue along the ejacu-
latory ducts, or along the margin of the gland. Two
cases were recalled in which the ejaculatory ducts
May 19, 1900]
MEDICAL RECORD.
873
could be distinctly felt extending down to a point
where they probably opened into the urethra, and in
which no prostatic tissue could be felt, and another in
which they extended in the same way, but with some
remnant of glandular tissue by their sides. In both
these instances the normal outlines of the gland could
not be detected. He said there were other instances
in which the outlines of the glands could be distinctly
felt, and yet the entire centre of the glands was de-
pressed. These deformities of the prostate usually
resulted from abscesses that had broken into the ure-
thra, and consisted of collapsed sacs surrounded by a
pyogenic membrane, which continued to discharge
pus for a considerable time. Old sinuses were often
found opening into the prostate in autopsies or on the
dissecting-table. Another type of prostatic deformity
had been that produced by a considerable amount of
exudate about the prostate, with resulting cicatricial
contraction which distorted the gland very much by
pressure, and also interfered with the action of the
vesicles; here, too, the circulation was much inter-
fered with, which caused a great deal of discomfort in
the perineum and deep genital regions. The symp-
toms arising from prostatic deformities were generally
those of chronic prostatitis. The treatment of such
cases was usually unsatisfactory.
Prostatic Cancer ; Three Cases with Specimens.
— Dr. E. E. King, of Toronto, thought that the rela-
tive infrequency of primary prostatic cancer justified
him in bringing this subject before the association.
He gave histories of cases and remarked upon them.
His cases did not differ from the general rule of cancer
of the prostate being found in the young, or in those
past the age of fifty years, although just why the ages
between fifteen and fifty should be exempt he did not
know. Most of the cases noted began about one year
before a fatal termination. In the statistics of Tan-
chow, out of 1,904 cancers in the male, he referred to
but 5, or only i in 400. Munn, in 1,286 cases of can-
cer taken from the reports of the Middlesex Hospital
up to 1899, tabulated only 28 cases of cancer of the
male genitalia. Fen wick (Ediidna-gli /ournal, July,
1S99) referred to 50 cases of undoubted primary affec-
tion of the prostate as coming under his personal ob-
servation. He liked the manner in which Fenwick
divided the condition, which he believed to be the cor-
rect one, viz., (i) the hard, malignant growth, resem-
bling scirrhus of the breast; (2) the soft, malignant
growth, which resembled the encephaloid. Fenwick
said the second variety was much rarer than the first,
which was in opposition to the usually accepted belief;
each of his own cases had been of the hard variety.
The speaker concluded by stating that the features
which impressed him in the cases cited were: (i)
The very advanced stage of the disease before being
recognized; (2) the cessation of symptoms on rupture
of the capsule; (3) the non-involvement of the bladder
in either specimen shown; (4) the absence of metas-
tasis in one case, and the metastasis of the kidney
alone in the other.
Dr. L. Bolton B.\ngs was struck with the statement
that primary carcinoma of the prostate was extremely
rare — he supposed it was relatively rare. The occur-
rence every now and then of ordinary prostatic hyper-
trophy with compensatory symptoms in the bladder,
etc., pursuing an unusual course led him to suspect
that the diagnosis of this condition was not always
made.
Dr. Bransford Lewis referred to an early diagnosis
of a case of primary cancer of the prostate occurring
in the City Hospital in St. Louis. That patient had
no symptoms at all previous to ninety days before his
death. He did not even have frequent urinations.
One day before entering the hospital he climbed to the
top of the custom house, which was followed by com-
plete retention of urine. Upon entering the hospital
an attempt to draw the urine failed; various means
were employed, but to no avail. Perineal urethrotomy
was then done, but it was impossible to enter the
bladder, even when strong pressure was used. He
then did a suprapubic cystotomy, when the real con-
ditions of things was noted. There was a prostatic
carcinoma so large that it filled the outlet of the pelvis
and was jammed between the anterior and posterior
walls, so that nothing could be gotten through. This
man was relieved somewhat by continuous drainage,
but died soon after. The pathologist pronounced the
growth to be an adeno-carcinoma. So far as clinical
evidences were concerned, it was short-lived.
Dr. George Chismore thought that cancer of the
prostate was much more common than recorded. He
had seen a number of cases, and he had been led to
look with a great deal of apprehension upon those
cases in which, without ostensible causes, catheteriza-
tion was extremely painful. He had observed two
different forms of the disease^one, in which the scir-
rhus type prevailed, which pursued a very long and
tedious course; the other, in which the cancerous con-
dition was unsuspected almost until the last; all were
characterized by unusual pain and difficulty in attempts
at catheterization. He referred to the case of a man
who was accustomed to use the catheter from his forty-
seventh to his seventieth year of age, in whom almost
all the symptoms of cancer developed within two
weeks preceding his death; this man had rapid ulcera-
tion, with the formation of a urethro-rectal fistula.
The Subjective Symptomatology of Renal and
Ureteral Disease.— Dr. John P. Brvson, of St. Louis,
read this paper. Many clinical observations had been
made by him, and from these he inferred (i) that an
irritation arising in an otherwise healthy urinary tract
in the kidney or its pelvis would create subjective
symptomatology referable to the organ itself, and, if
passing beyond that, radiate toward the centre of
the abdomen along the line of the nerves entering the
hilus of the kidney along with its blood-vessels, cross-
ing over, when severe, to the opposite side, and, espe-
cially when the right kidney was involved, causing vom-
iting. (2) Similar irritations affecting the middle
third of the ureter caused a subjective symptomatology
manifesting itself largely in the distribution of the
genito-crural nerve. (3) Similar irritations affecting
the lower part of the ureter in the neighborhood of the
bladder would manifest themselves chiefly by increased
frequency of urination without tenesmus, provided the
bladder was otherwise free from disease. In all of
these conditions there was a certain amount of tender-
ness on pressure or pain in that portion of the ureter
which was being irritated at the time. Time did not
permit him to detail some cases in which, especially
in tuberculous inflammations more or less localized,
the disease originating in the bladder in the neighbor-
hood of the ureteral orifice travelled up that duct on
that side, creating a subjective symptomatology in the
reverse order to that mentioned. Just how far down
an irritation must travel from the renal pelvis, or how
far up the bladder, before affecting a genito-crural
nerve, it was not possible to state. We might be aided,
however, to a certain extent by anatomical considera-
tions. The chief point in practice was to take advan-
tage, in localizing ureteral disease, of the observation
that in apparent irritation at the upper part of the
ureter, in the kidney and its pelvis, the manifestations
were renal; in the middle portion, genito-crural; in
the lower portion, vesical. This might serve as a
guide for surgical interference in cases of ureteral
disease.
Dr. Arthur T. Cabot, of Boston, referred to cases
in which stone in the pelvis of the kidney gave rise to
symptoms entirely referable to the neck of the blad-
874
MEDICAL RECORD.
[May ig, 1900
der. He cited one case in wliich the symptoms were,
for some time, referred to the neck of the bladder;
the patient subsequently went to Paris and was treated
by Guyon witli injection of nitrate of silver, when a
stone passed down through the ureter and was dis-
charged into the bladder, which was accompanied with
entire relief of symptoms. He was interested in Dr.
Bryson's account of the nervous distribution giving
rise to such variations in the pain.
Dr. Edward L. Keves related the case of an old
gentleman who came to New York with a stone in his
bladder, which was crushed and removed. This pa-
tient was in his "catheter life." He had no cystitis
or prostatic disease. He went home and lived a num-
ber of years, a strong, vigorous man, about sixty-five
years of age, and had no pain except a little renal
colic. Suddenly, while in the bloom of life, he was
attacked with a sharp paroxysm of kidney colic, for
■which he was treated by the ordinary methods em-
ployed in those days; he died from an ordinary anuria.
The autopsy showed one kidney atrophied, with hardly
any kidney substance left. The expulsive force from
his bladder was good. Vesical spasm caused his re-
tention. The wall of his bladder was smooth and not
affected, there being no evidences of cystitis. The
other kidney was blocked or plugged by a calculus
which had caught in the upper end and stayed there.
There was persistent inability to pass urine. This, he
thought, was a curious case.
Dr. W. K. Oris related the case of a woman forty-
six years of age, who was treated for cystitis for years.
She suffered much from irritation and frequency in
urination for about fifteen years. The cystoscopic ex-
amination showed there was no cystitis. Catheteriza-
tion of the ureters showed that the left ureter gave out
pus; the right ureter was shown to be perfectly nor-
mal. The left kidney was cut down upon and was
found to be riddled with abscesses, and there was a
stone that filled the entire pelvis; the kidney was
almost completely destroyed.
Dr. John P. Bryson, in closing the discussion, men-
tioned the instance of a patient who, when there was
the sudden desire to urinate, obtained relief by lying
down; in this case there was no vesical tenesmus;
this latter symptom in connection with bladder lesion
was very important. Before he saw her she had been
under the influence of chloroform for four days. He
stopped the chloroform and watched the symptoms for
a while; she had a constant, unceasing desire to uri-
nate, and a pyuria without any vesical tenesmus. He
cystoscoped the patient and found a pus plug coming
out of the left ureteral orifice. The bladder was fairly
normal. The urethra was then dilated; the left finger
was introduced into the bladder, the right finger was
placed in the left vesico-vaginal fornix, and he then
milked out a mass of material which relieved her
symptoms entirely; she soon became perfectly well.
He thought it was not an uncommon thing for a lesion
to exist at the lower end of the ureter along with renal
lesion of a very serious character, a calculous nephritis
or a nephro-lithiasis.
Acute Abdominal Symptoms Associated with a
Congenital Malformation of a Ureter in a Child. ^
Dr. Charles L. Scudder, of Boston, read a paper on
this subject, illustrating it with numerous drawings.
The blind end of a supernumerary ureter was cited,
which was the ninth reported, the other eight being
found reported in Dr. Bangs' book.
Bacteruria Associated with Congenital Dilatation
of a Ureter. — Dr. George K. Swinburne, of New
York, reported this case. The persistent residual
urine was the particular symptom present. The diver-
ticulum was one and a half inches above and to the
left of the ureteral orifice.
Dr. Arthur T. Cabot told of a case in which
he had done a suprapubic operation and found a stone
in a diverticulum located close to the ureteral ori-
fice. The stone was of good size; the patient grad-
ually died of a pyelonephritis. The autopsy showed
another pocket, exactly corresponding to the one on
the opposite side and also containing a calculus; it
had set up a hydronephrosis behind it.
Dr. George Chismore said he had had the oppor-
tunity of making a post-mortem upon a patient in
whom, for fifteen years, he had been removing stones
by litholapaxy; he first did the suprapubic operation
and cleaned out the bladder thoroughly. He had not
had occasion to operate upon this patient for mora than
a year, he having moved away and died while under
another man's care. He found in the right ureter a
collection of seven stones; in the left ureter, within
the bladder wall, were found five stones small in size.
He also found a thin stone, spoon-shape, behind the
tumor which projected into the bladder wall between
the ureters. The ureters were much dilated.
Dr. John P. Bryson stated that the difficulties in
making a differential diagnosis between calculus or
multiple calculi in the bladder and in the lower end of
the ureters must be very great. He had had some
curious experiences. In one instance the calculus lay
near the end of the right ureter and was fastened there;
he was forced to dilate the ureter in order to get it
out; he there found an old hernia in the muscular
coat, the fibres spreading.
Cases Illustrative of Certain Points of Renal
Surgery. — Dr. Francis S. Watson, of Boston, read
this paper. The cases reported were as follows:
Case I. — Nephrorrhaphy in the fourth month of preg-
nancy. The operation was undertaken in the hope of
avoiding the necessity of inducing premature delivery,
which had already been done in two former pregnan-
cies because of the patient's life being endangered by
persistent vomiting associated with frequent attacks of
renal colic on the right side, which developed in con-
nection with a movable kidney which followed the sec-
ond pregnancy seven years previous to her present
trouble. On the first occasion both vomiting and renal
pain ceased after the premature delivery. But after
the second time vomiting alone was relieved, the pain
persisting, though in a somewhat less degree, until her
present pregnane), when it became very severe and the
vomiting also returned. The patient's life was again
seriously threatened. She stated diat she thought the
vomiting was directly induced by the attacks of pain.
She strongl}' urged that every effort be made to allow
the pregnancy to go on to term. The question was,
how far the mobility of the kidney was responsible for
the pain and vomiting, and whether the chance of re-
lief from a nephropexy was sufficient to justify the risk
incurred by its performance, in addition to that attend-
ing the induction of premature delivery should the
latter be necessitated in case of failure of the former,
and, moreover, with the knowledge from two former
experiences that she would probably be made safe by
emptying the uterus alone, and would be relieved of
the vomiting at any rate. Nephropexy was decided
upon for these reasons: (i) The strong wish -of the
patient not to sacrifice the child; (2) the great prob-
ability that her pain at an-' rate depended upon the
abnormal mobility of the kidney; (3) the chance that
vomiting was in large measure also due to it; (4) be-
cause her condition seemed sufficiently good to enable
her to support the nephropexy. It was accordingly
done, and, while greatly mitigating her pain at once,
did not relieve the vomiting, the continuance of which
became so threatening to her safety that abortion was
done, after which both the vomiting and pain wholly
ceased and her con\alescence was much more satisfac-
torv than after the two preceding pregnancies. It
seemed reasonable to assume that the nephropexy
May 19, 1900]
MEDICAL RECORD.
875
should be credited with the success in that respect,
although it failed to fulfil the expectations with regard
to the matter for which it was primarily undertaken.
The question raised in this case that seemed to the
writer of interest was as to the wisdom of attempting
to avoid sacrificing the life of the foetus by doing
nephropexy under the conditions presented when a
decision was called for.
Case II.— Traumatic rupture of the kidney; nephrot-
omy; suture of the wound to relieve obstruction to out-
flow of the urine by plugging the ureteral orifice with
blood-clots, and to control hemorrhage eight days after
the injury. The case was an example of the develop-
ment of serious symptoms at a relatively remote period
from that of the injury, and showing that an immedi-
ately favorable progress of the case did not necessa-
rily preclude the occurrence of grave danger subse-
quently. The patient was a young man twenty-eight
years of age, who had received no less than five injuries
to the right lumbar or right abdominal regions between
the twelfth year and the present time, the last one
being a violent blow during a fight in which he was
engaged on the night before he was brought to the Bos-
ton City Hospital. There were marked shock, pain,
and tenderness of tiie right kidney, and much blood in
the urine. There was no sign of external violence.
The pain and shock were of short duration. The
hematuria persisted. The general condition gradu-
ally improved. On the seventh day there was sudden
violent renal colic, with cessation of haematuria, and
the appearance of a tumor in the right hypochondrium
and lumbar regions, with great prostration. Twenty-
four hours later he rallied somewhat and nephrotomy
was performed. The kidney had a lacerated wound
an inch and a half long at its upper end, which did
not penetrate the fibrous capsule, but extended from
the surface of the cortex through to the renal pelvis,
which was enormously distended by blood clots and
urine, the former occluding the orifice of the ureter.
The posterior border of the kidney was incised, the
blood-clots were evacuated, the edges of the lacerated
wound refreshed, and the incision, together with the
wound except for a short space to allow drainage, was
sutured with catgut. The hemorrhage was entirely
controlled by the sutures. The hematuria ceased and
the patient made a good recovery, but some months
later renal pain returned, and nephrectomy was done
with satisfactory results by Dr. Paul Thorndike.
Cases III. and IV. — These were cases illustrating
the relief of symptoms simulating renal calculus, no
calculus being found, by incision through the convex
border of the kidney, and confirming the view that
such symptoms were, in many instances, due to sudden
enlargements of the kidney within an unyielding cap-
sule. In both of these cases the capsule was thickened
and adherent to a greater or less degree.
Cases V. and VI. — These were cases of kidneys
fixed in abnormal position by firm adhesions; the kid-
ney in one was hydronephrotic ; in the other it was
structurally normal. Nephrectomy was done in both
cases because of the impossibility of freeing the kid-
neys from adhesions without tearing the renal sub-
stance and the pelvis or ureter, and because, in one
case, of the extensive hydronephrosis as well. One
patient recovered and was entirely restored to health.
The other died of a pneumonia on the thirteenth day
following operation. The symptoms in both were at-
tacks of renal pain on the right side with progressive
frequency and severity.
Case VII. — This was a case serving as an example
of the danger of postponing surgical interference in
some cases of movable kidney, which, in this instance,
resulted in the almost total destruction of the kidney
by intermittent hydronephrosis, which finally became
pyonephrosis. Renal calculus was associated with
this condition. Nephrolithotomy and temporary
drainage resulted in a cure; the wound healed at the
end of three weeks and the pus disappeared from the
urine after six weeks.
Case VIII. — Resection of one-half of the kidney for
tuberculous disease was done, which demonstrated the
very marked general improvement that might follow
even the incomplete removal of a tuberculous area, and
the possible benefits from doing a resection in cases
in which the patient's condition did not seem to war-
rant a nephrectomy.
AMERICAN CLIMATOLOGICAL ASSOCIA-
TION.
Sceiitccnth Annual Meeting, Held at the Arlington
Hotel, Washington, D. C, May i, 2, and j, igoo.
Second Day — Wednesday, May 2d.
The Construction and Management of Small Cot-
tage Sanatoria for Consumptives.— Dr. Arnold C.
Klees, of Chicago, read a paper on this subject, in
which he said that with the opening of the Massachu-
setts State Hospital for Consumptives a new era had
dawned for the treatment of these patients. The ad-
vantages which would accrue from the multiplication
of similar institutions for the home treatment of tuber-
culosis could not be overestimated. Every one agreed
upon the great educational influence which the sana-
torium regime had on the individual, who later became
a missionary in the cause of hygiene, by example and
by teaching spreading broadcast the principles to
which he owed his recovery. Dr. Klebs' paper was
largely devoted to a discussion of the proper construc-
tion of small cottage sanatoria, and he exhibited the
plans for such an institution which he had devised.
The plans embraced three cottages, with a capacity
limited to twenty-five patients. The cottages were
joined by two galleries, so arranged as to admit a
plentiful supply of sunlight and air, and the impor-
tance of these factors was borne in mind in the con-
struction of the cottages.
Dr. Henry P. Loomis, of New York, said that while
the cottage plan of sanatoria was the ideal one, it was
also the most expensive, and could not always be car-
ried out on that account.
Dr. C. F. McGahan, of Aiken, S. C, said that after
a visit to all the principal sanatoria abroad he was
most impressed by that of Walters, at Nordrach, the
capacity of which was limited to forty patients. Wal-
ters claimed that one man could not attend to more
than this number. He visited his patients twice daily
and carried out a very thorough system of management.
Dr. E. O. Otis, of Boston, said that the excellent
results achieved in the Massachusetts sanatorium at
Rutland during the past year had opened the eyes of
the people to the fact that tuberculosis could be cured
right in their own State, and they had become so much
interested in the subject that the construction of a sec-
ond similar institution was under consideration. The
weekly expense of each patient at Rutland was $8.40.
Dr. Carroll E. Edson, of Denver, said that while
large sanatoria were expensive, the general plan of
treatment pursued in such institutions could be carried
out on a small scale in any properly constructed, well-
ventilated house. We might not be able to erect a
sanatorium like those at Rutland or Liberty, but we
could start one, perhaps, in our own back-yard.
Dr. J. Edward Stuebert, of Liberty, said the ques-
tion of expense was always a very important one in
the construction of sanatoria. While the cottage plan
was the costliest, it was no doubt the best. Most of
these patients did not like to be too close to each
876
MEDICAL RECORD.
[May 19, 1900
other, and were annoyed by the coughing, etc. Dr.
Stubbert said that during the past winter the patients
at Liberty took up amateur theatricals as a means of
amusement, with very gratifying results.
Dr. Kdward R. Baldwin said that at Saranac Lake
the expense of each patient was between $7 and $8 per
week. It should be taken into consideration, how-
ever, that Dr. Trudeau received no compensation for
his services in supervising the institution, and a sal-
aried man occupying that position would probably
increase the cost of each patient to about $8.50 per
week. At Saranac the number of cottages had been
gradually increased until one hundred patients could
be accommodated. A larger number than this Dr.
Trudeau considered unwieldy.
Dr. R. C. Newton said that in the lack of sanato-
rium treatment, or instead of it, bands of incipient
cases of tuberculosis might be collected and sent out
into the woods and country on tramping trips under
an intelligent leader.
Dr. Ki.ebs, in closing, said that the plans he had
shown were for an inexpensive sanatorium made up of
three properly constructed cottages.
Some Personal Observations on the Effects of
Intra-Pleural Injections of Nitrogen Gas in Tuber-
culosis Dr. Henry P. Loomis read a paper on this
subject, and gave the following as his conclusions
after about eighteen months' test of this treatment for
pulmonary tuberculosis: (i) That it would have a
permanent place in the treatment of pulmonary tuber-
culosis. (2) He had never seen any bad results or
even unpleasant effects following the injections. (3)
He had seen no patients cured by it. In two cases
there was an apparent arrest of the disease, and in a
number of others there was a disappearance of such
constitutional symptoms as cough, e.xpectoration, and
fever. (4) The local improvement was not so appar-
ent as the constitutional. (5) A marked gain in
weight was found in every case injected. (6) It had
never failed to stop pulmonary hemorrhages, even in
desperate cases.
Dr. Taylor said he had employed the injections of
nitrogen gas in about half a dozen selected cases of
pulmonary tuberculosis, with entirely negative results.
In two of the cases there was a slight temporary im-
provement.
Dr. R. H. Babcock, of Chicago, said he had seen a
number of cases in wliich the use of the gas had been
followed by a decided improvement in the symptoms.
It seemed to give the patients a start in the right direc-
tion.
Dr. Charles Denlson, of Denver, said that if the
sole object of the treatment was to place the affected
lung at rest, he thought that could be attained by the
simple and equally efficient method of strapping the
chest, as described by him in a paper about a year ago.
Dr. Stubbert said he did not believe the injections
of nitrogen gas would do good unless absolute com-
pression of the lung was secured. It was useless in
cases in which there were adhesions which prevented
compression. The operation could best be done under
-r-ray illumination. The speaker said he had seen it
successfully used to check haemoptysis.
Dr. Charles L. Minor, of Asheville, N. C, said
he had seen several cases in which the tuberculous
process was apparently retarded by the injections of
gas.
Stomach Conditions in Early Tuberculosis. — This
paper was read by Dr. Boardman Reed, of Philadel-
phia. The points emphasized might be thus summa-
rized: (i) In early tuberculosis tlie secretion of hy-
drochloric acid in the stomach was very frequently
excessive, the peptic glands being in a condition of
irritability which caused stimulant remedies of the
creosote class to disagree and act injuriously. (2)
Oils tended to depress the secretory function of the
stomach, and in consequence cod-liver oil was likely
to help the cases which the creosote class of drugs
hurt ; but, on the other hand, it hurt the cases in which
the gastric secretion was inactive, the very ones in
which creosote and its congeners often did good. (3)
Therefore it ought to be the rule to ascertain the con-
dition of the secretory function of the stomach before
pushing either class of remedies. (4) When analyses
of the gastric contents could not be made, it was safer
to combine creosote with cod-liver oil, so as to let one
neutralize the other in their influence upon the stom-
ach. (5 ) The motor function was very generally
depressed in tuberculosis and must be restored before
a cure could be brought about. Drugs availed little
in this direction, but diet, exercise, especially in the
open air, faradism, and abdominal massage — except
when hyperchlorhydria complicated — were all valuable
means of effecting the result.
Dr. Howard S. Anders, of Philadelphia, said he
was thoroughly in accord with the statement made by
Dr. Reed, that in the vast majority of cases of early
tuberculosis there w^as hyperchlorhydria. The per-
centage of hydrochloric acid present was very variable.
The motor function of the stomach he had never found
much impaired in these cases.
Subsequent Histories of Patients Apparently
Cured under Administration of Anti-Tubercle
Serum, as an Auxiliary to Climatic Influences. —
This paper was read by Dr. J. Edward Stubbert, of
Liberty. At a meeting in May, 1898, he had read a
paper before the association entitled " Some Statistics
upon Sero-Therapy." The following was the summary
of the cases then reported : Number of cases treated,
eighty-two; expectoration decreased in eightyrtvvo per
cent.; appetite improved in eighty-one per cent.;
weight gained in seventy-eight per cent.; physical
signs improved in seventy-eight per cent. ; temperature
decreased in forty-nine per cent.; bacilli disappeared
in thirteen per cent.; bacilli decreased in thirty-five
per cent ; cough decreased in seventy-nine per cent.;
apparent immunity established in twenty-one percent.;
general improvement in seventy-eight per cent. In
pursuance of investigation and study upon tiiis subject
he now reported a subsequent history of thirty-nine
per cent, of the above cases apparently resulting in
cure, as well as the present condition of fourteen, the
histories of which were not included in the former
paper. These cases were divided into three sections:
first, those patients who had been discharged for three
years; second, those who had been discharged for two
years; third, those who had been discharged for one
year or less, but in those instances when they had
been discharged for less than one year they had been
one winter in their old surroundings. All of those
patients returned had spent a greater or less length of
time in their former environment and work : the speaker
had been able to trace definitely the histories of eleven
per cent, of those discharged three years, seventeen per
cent, of those discharged two years, and ly'i per cent,
of those who had been discharged for one winter, and
all of those had remained in the same condition as
when they were discharged, viz., apparently cured.
Those patients remaining, whose histories had not been
definitely traced, w-ere all known to the writer by gen-
eral repute to be in good condition. Thus practically
it might be stated that in one hundred per cent, of all
cases discharged in the last three years that had re-
ceived this form of treatment, the patients had re-
mained apparently cured. All of these cases but one
were incipient cases; one was a moderately advanced
case. The speaker also reported two arrested cases
in which the bacilli were present at the time of the
discharge, but the diseased area was circumscribed and
there was no special activity present. One of these pa-
May 19, 1900]
MEDICAL RECORD.
377
tients since returning liome had lost the bacilli and
was apparently well, while the second one continued
at hard work, and held her weight, but continued to
expectorate about once in ten days or two weeks. He
also reported one case of pulmonary tuberculosis com-
plicated by tuberculous kerato-iritis, in which the ocular
as well as the pulmonary symptoms had cleared up very
markedly under serum and climatic treatment.
Dr. Klebs referred to the unreliability of statistics
in general, and thought that Dr. Stubbert had given
too much credit to the anti-tubercle serum and too lit-
tle to the excellent regime which was carried out in
the treatment of these patients at Liberty.
The Phlebitis of Advanced Phthisis, with Report
of Cases of Phthisis following Abscess of the Hand.
— Dr. R. G. Curtix, of Philadelphia, read this paper.
Dr. S. Babcock said he had seen three cases of phle-
bitis in tuberculosis.
Dr. Thomas D. Coleman, of Augusta, Ga., also re-
ferred to a case which had recently come under his
observation.
Dr. Anders spoke of the obscure origin of these
venous conditions, of which he had seen two examples
secondary to chronic phthisis. One might regard
them as cases of thrombo-phlebitis, or phlebitis from
within. In the last two cases reported by Dr. Curtin,
in which a phlebitis resulted from an injury to the
hand, which was immediately followed by abscess,
there might have been an inflammation of the vein,
extending from without inward, with subsequent throm-
bosis and softening and the detachment of emboli.
Dr. Norman Bridge, of Los Angeles, Cal., reported
the case of a young man with pulmonary tuberculosis
who developed a phlebitis of both lower extremities;
after giving rise to rather severe symptoms, the swell-
ing in both limbs disappeared, and the patient made a
good recovery. Dr. Bridge said he thought it was im-
possible to say that this complication was, strictly
speaking, tuberculous. This, so far as he knew, had
never been proven.
Dr. Babcock said he thought the phlebitis in these
cases was due to infection, either mixed or otherwise.
Splenic-Myelogenous Leukaemia with Pulmonary
Tuberculosis : Report of a Case. — This paper was
by Drs. Henry L. Elster and William A. Groat, of
Syracuse. They reported a case of splenic-myeloge-
nous leukaemia with pulmonary tuberculosis. The
writers reviewed the literature, and gave a full bibli-
ography showing that the association of pulmonary
tuberculosis with any form of leukaemia was exceed-
ingly rare. There were a few cases on record of
lymphatic leukaemia complicated with tuberculosis.
A thorough study of the cases which were supposed to
have been of the splenic-myelogenous variety showed
that there were only two, and one of these might be
considered to be of the splenic-lymphatic myelogenous
variety with tuberculosis. The case reported was
probably the first of splenic-myelogenous leukjemia
with pulmonary tuberculosis in which the diagnosis
had been confirmed by a differential count of the leu-
cocytes and the demonstration of tubercle bacilli in
the sputum. The patient, who was referred to Dr.
Elster for diagnosis, was a baker, forty years old; his
family history showed a strong tuberculous taint. His
present illness began a number of months before the
advent of continuous symptoms, when the patient com-
plained of great fulness in the abdomen and progres-
sive increase in its size. He became depressed, and
his general condition was also below par. In the
spring of 1899 ^^^ °f ^^^ symptoms increased, and
he grew gradually weaker. His color changed and
became characteristic of leukaemia. In November,
1899, he commenced to cough, and had all of the
symptoms of progressive pulmonary tuberculosis.
Tubercle bacilli were found in the sputum.; the spu-
tum was also blood-streaked. The patient lost
weight regularly; the temperature was usually slightly
above normal, averaging from 100° to 102" F. ; the
pulse was uniformly accelerated. Physical examina-
tion failed to show involvement of the lymphatics.
The spleen almost filled the abdomen; the liver was
also enlarged; the lungs showed positive physical
signs of infiltrating tubercle, disorganization, and cav-
ity formation. The blood examination was character-
istic of splenic-myelogenous leukaemia. The red
corpuscles varied from 3,320,000 to 2,922,000. The
dififerential counts showed an enormous percentage of
myelocytes. The average of these was twenty-six per
cent. At one time the writers found thirty-eight per
cent. There was a marked relative reduction in the
number of lymphocytes, which varied in the counts
from 4.1 per cent, to 7.5 per cent. The eosinophiles
were increased. Many of these were myelocytes and
dwarf cells. There were large numbers of normo-
blasts, or nucleated red corpuscles. The highest
count of leucocytes was 320,000; lowest, 121,500.
They found a gradual and steady decrease in the total
number of leucocytes, but an increase in the percentage
of polymorphonuclear neutrophiles, a decrease in the
number of myelocytes, and an increase in the number
of lymphocytes as the tuberculous process advanced.
The blood at all times retained the characteristics of
splenic-myelogenous leukaemia. The paper contained
besides a full table giving the results of many blood
counts, diagrams which showed the physical signs, and
water-colors reproducing the picture of the blood as it
was found on microscopical examination. The writers
dilated on the interesting changes found in the blood
of leukaemia with added tuberculosis, and also consid-
ered the literature of this subject as well as the efTect
generally of added infection on leuka;mic blood. The
urine showed a marked increase in the excretion of
uric acid. The changes found in the lung in leukemia
were considered in connection with a study of the lit-
erature of the subject. The case reported demonstrated
very clearly the effect which the added tuberculous in-
fection had upon the blood, reducing materially the
number of leucocytes. The physical signs with asso-
ciated laryngeal tuberculosis, the enlargement of the
liver and spleen, the presence of tubercle bacilli in
the sputum, and the changes in the cellular elements
of the blood, with the convincing differential counts,
made the diagnosis of splenic-myelogenous leukaemia
with pulmonary tuberculosis positive.
NEW YORK COUNTY MEDICAL ASSOCIA-
TION.
Stated Meeting, April 16, igoo.
Frederick Holme Wiggin, M.D., President.
The Prevention of Intracranial and Intravenous
Complications in Suppurative Diseases of the Ears.
— Dr. J. H. Woodward read a paper with this title.
He said that in spite of free drainage through the
drum membrane the disease process might spread into
the cranial cavity. To prevent this the conditions
giving rise to it must be removed. In the majority of
cases the objective symptoms would be a reliable
guide. There were six important indications for the
mastoid operation, viz., (i) bulging of Shrapnell's
membrane, or the upper posterior quadrant of the
membrana tympani, and bulging of the inner extremity
of the membrane; (2) persistent tenderness over the
mastoid process; (3) swelling of the soft parts over
the mastoid process; (4) granulations and fistulae in
the external auditory canal ; (5) persistent and relaps-
ing fistuljp behind the auricle; (6) persistent, and
878
MEDICAL RECORD.
[May 19, 1900
especially offensive, otorrhcea. Retention of pus in
the ear could not be regarded too seriously, and when-
ever incision of the drum membrane failed to secure
efficient drainage it was better to open the mastoid
antrum at once than run the risks incident to delay.
Persistent mastoid tenderness or swelling of the soft
parts should be looked upon as an indication for oper-
ation. Fistula; which alternately closed and opened
were especially liable to be followed by sinus throm-
bosis.
Dr. Francis J. Quinlan said that all suppuration
of the middle ear should be regarded with grave mis-
givings. When there was a perforation in Shrap-
nell's membrane there was almost always carious bone
present. No life insurance company of this city to-
day would accept any one having a chronic suppura-
tion of the middle ear above the short process. Any
condition attended by pain over the antrum, pain over
the tip or over the middle plate of the mastoid siiould
be a reason for doing a mastoid operation. U'ith a
little care and attention the antrum could not only be
entered but thrown open to inspection. It was most
important that all of the cells should be laid open.
A practitioner of ordinary intelligence should be pre-
pared to open this cavity and clean it out.
What are the Ultimate Results in Treating Can-
cer of the Uterus ? What is the Best Plan of Treat-
ment?— Prof. Howard A. Kelly, of the Johns Hop-
kins University, Baltimore, read this paper. He said
that from the standpoint of the frequency of this dis-
ease cancer of the uterus was of the first importance,
because Welch had shown that out of 31,482 cases of
primary cancer, 29.5 per cent., or approximately one-
third, were instances of cancer of the uterus. In every
case of cancer of the uterus the entire organ should be
extirpated — an old dictum, but one which he believed
required reiteration in this country even at the present
time. There was a temptation, particularly in the
earlier stages of the disease, to do an amputation of
the cervix or to remove only the body of the uterus.
Speaking on a basis of one hundred and seventy-six
cases of his own, studied most minutely, he found the
exceptions regarding the limitation of the disease so
numerous that they might, for practical purposes, be
reckoned as the rule. In many cases of cancer of the
cervix he had found the disease also in the body, and
in one case it had skipped the body and had developed
in the tubes. With the uterus one should remove the
Fallopian tubes in all cases of cancer of the body. The
next great danger was in the vaginal vault. Cervical
cancer often extended down the vagina under the mu-
cosa without, at first, producing any alteration of color.
The disease should be given a wide berth, therefore,
at the vaginal vault, cutting at least from 2 to 2.5 cm.
away from it. In many cases of cancer of the uterus
attended by pain it would be found that the pain was
not due to the cancer/^/- se, but to an occlusion of the
cervical canal by the growth, and the consequent im-
prisonment of the secretions. In such cases, by boring
through the carcinomatous mass and establishing free
drainage of the uterine cavity, the pain would be com-
pletely relieved. The disease often involved the blad-
der before it had extended very far in any other direc-
tion. In such a case the whole base of the bladder
could be readily cut out and left attached to the cer-
vix. Almost all cases of involvement of the bowel
were associated with considerable involvement later-
ally also. The mode of extension of the disease lat-
erally was a subject upon which surgeons differed
widely, yet the method of treatment must hinge on this
point. He had removed many glands which macro-
scopically appeared to be diseased, yet microscopical
examination had failed to find, in all but a few in-
stances, any evidence of cancerous involvement of
these glands. The operator sliould concentrate his
whole efforts on giving the cervix a wide berth, and if
he did this he need give himself no concern about
the tissues beyond. In all but five per cent, of cases
the disease extended laterally by continuity, and not
by '"jumps." On the question of the risk of inoculat-
ing the fresh tissues with cancer during operation, the
speaker said that implantations of the disease in the
vagina below the site of operation were rare accidents.
The experiments made on animals showed that it was
difficult to inoculate cancer unless aseptically done,
and hence it did not seem probable that implantation
would occur when drainage was used.
Advisability of Operation An opinion which had
gained some ground in the profession was, that the
radical operation was hardly to be recommended be-
cause the disease almost always recurred quickly.
In refutation of this assertion, Dr. Kelly said that out
of sixty-one cases of squamous carcinoma of the cer-
vix, twenty per cent, of the patients were living, and
out of twelve cases sixteen per cent, of the patients
were well. Of thirty cases of adeno-carcinoma of the
body, sixty-three per cent, of the patients remained
well. The fact that seventeen out of thirty-four pa-
tients had remained well for periods varying from
three to six years seemed to him a sufficient argument
in favor of operating in this class of cases.
Mode of Operating. — The old plan of "skinning
out " the uterus was the method most apt to be fol-
lowed by recurrence, and should, therefore, be aban-
doned. It was true that it was possible to distinguish
the ureters in an abdominal operation without the in-
troduction of bougies into them, yet it could not be
denied that without such an artificial guide the opera-
tion was made somewhat more tedious and dangerous.
The disease must be given a wide bertli by ligating far
out in the parametrium. Any operative procedure
based on these principles would give vastly better re-
sults than those hitherto achieved. He had followed
three modes of attack in his endeavors to carry out
these principles. One of these operations consisted
in tying off the ovarian vessels, round ligament, and
uterine artery on both sides, and then cutting in through
the vagina and taking out the uterus through the vagi-
na. Dr. X. O. Werder, of Pittsburg, had greatly modi-
fied the operation. The peritoneum was opened both
anteriorly and posteriorly, and then a wide dissection
of the vagina was done low down. After the uterus
had been separated, the detached peritoneum was
sewed over the top of tiie uterus so that the uterus
was practically extruded from the peritoneal cavity.
After closure of the abdominal wound the vagina was
inverted and the parts were removed.
His Own Method. — Dr. Kelly then described his
own method, which consisted in (i) the removal of all
the tissues down to the point where the infiltration was
deepest, and (2) the concentration of all the energy of
the operator on the most complete removal of this last
segment. A thorough curettage was first done, and
then the vagina was divided on all sides one inch be-
low the diseased area. The vesico-uterine peritoneal
fold was widely opened, as was also the posterior cul-
de-sac. The uterus was then brought out through the
anterior opening. The peritoneum posteriorly was
well protected by gauze packing. The uterus was next
bisected from fundus to cervix with scalpel and scis-
sors; this was attended with very little hemorrhage.
The uterus was next caught by the cervix with two
pair of forceps, and was split again and removed.
The next step was to begin the enucleation on 'the side
which was the less diseased. Up to this point the
operation was very simple. These preliminary steps
secured the maximum of room and mobility. This
operation was, of course, done through the vagina.
It was a question in his mind whether the ligature or
the cautery was better. Much credit was due to Dr.
May 19, 1900]
MEDICAL RECORD.
879
John Byrne for his persistent advocacy of the use of
the actual cautery in advanced cases of carcinoma of
tile uterus.
Dr. Henry C. Coe said that the old method of
skinning out the uterus had certainly given him most
unsatisfactory results. In the majority of cases there
had been a recurrence within two years. He had had
occasion to read a paper on this subject a few weeks
ago, in which he had taken the ground that the opera-
tion of the future would probably be a radical abdom-
inal hysterectomy. Serious as the operation was, this
seemed to be the most scientific method of dealing
witii the disease by any cutting operation. It enabled
one not only to deal with the diseased organ itself,
but with the glands and any suspicious tissue. In his
experience the great difficulty had been to decide at
tiie operation what tissue was infiammatory and what
tissue was involved in the malignant process. He
liad always been a stanch upholder of Dr. Byrne's
method of treating malignant disease of the uterus by
means of the cautery. Such a method seemed to him
very rational, and the ultimate results in the hands of
Dr. Byrne had certainly been very brilliant. He did
not feci sure that cancer of the uterus always extended
into the broad ligaments by continuity. One saw at
times cases in which there was a small nodule of ma-
lignant adenoma of the body of the uterus, yet in spite
of a radical removal by abdominal hysterectomy there
would be early recurrence in the scar. Such a case
was difiicult to explain. He could recall one very
severe case which he had considered most unfavorable
at the time of the operation, yet this patient had lived
five years without any recurrence.
Dr. Egbert H. Grandin spoke of his personal re-
sults in the treatment of cancer of the uterus. He had
analyzed the histories of nearly three thousand women
seen consecutively. The first point was that cancer of
the uterus, in his experience, had been relatively un-
common. There had been forty-eight cases of cancer
of the uterus. Thirty of these had presented an ad-
vanced type of the disease, i.e., the base of the blad-
der, the rectum, and the broad ligaments had been im-
plicated. In such cases he had not been bold enough
to attempt any major operation. These women had all
suffered for a long time from hemorrhages, and had
not reported for examination at an early enough period
to make a radical operation of much value. He had
tested the various routine methods, such as curettage,
cautery, and caustic applications. He was not quite
sure but that in these advanced cases of carcinoma the
less done the better. F.ighteen cases had been suita-
ble for operation. Total hysterectomy had been the
operation of choice in the cases in which the disease
had involved the body of the uterus. Seven of these
twelve cases had been traced, and there had been no
lecurrence. In one case the operation dated back six
years, and in the others from six months to four years
and a half. In six cases in which the portio vaginalis
had been involved the operation selected had been
vaginal hysterectomy, either by clamp or ligature. He
had traced four of these cases, and there had been
recurrence in all but one, that one being a recent ope-
ration. The recurrence had taken place in the vagina
at periods varying from eighteen months to two years.
From his experience he was inclined to believe that
cancer of the uterus was susceptible of cure if seen
early enough and promptly treated by a radical oper-
ation. Vaginal hysterectomy, whether by clamp or
ligature, he thought should be rejected in cases of
cancer of the uterus, for the reason that it was not pos-
sible to do as thorough a resection of the broad liga-
ments by this route as from above. In any event it
was desirable to remove at the same time as much of
the vagina as possible, as this was the site of recur-
rence. In any case of cancer of the uterus, whether of
the body or of the portio vaginalis, a partial operation
should not be thougiit of. Probably in the future a
combination of methods, such as the knife and the cau-
tery, would best enable us to certify against recur-
rence.
Dr. W. R. Prvor said that he did not think the
vaginal operation met properly any of the require-
ments laid down by the reader of the paper of the
evening. He did not look favorably upon Dr. Kelly's
method of performing morcellement by the vaginal
route in cases of cancer of the cervix. The surgeon
should do the most radical operation possible, pro-
X'ided it did not carry with it too high a rate of mor-
tality. Vaginal hysterectomy for cancer was, in his
opinion, a palliative operation merely, and in this
connection it should not be forgotten that the mortal-
ity from it was between five and ten per cent. Vagi-
nal hysterectomy was suitable only for a few selected
cases. His own preference certainly was for the op-
eration through the abdomen, which necessitated no
preliminary procedure for marking out the anatomical
relations, such as Dr. Kelly's clever one of introduc-
ing bougies into ureters. As ever) drop of blood was
precious to these patients, the internal iliac arteries
should be ligated. This ligation could be done with
perfect safety.
Dr. Phineas H. Ingalls, of Hartford, Conn., said
that the majority of cases seen by him had first come
under the observation of practitioners who believed that
irregular hemorrhages occurring in women between the
ages of thirty-five and fifty years were merely an indi-
cation of the approach of the menopause ; hence the
disease was far advanced before coming under his
care. He would like to know in how many of the
cases treated by Dr. Kelly, in which recurrence had
not taken place for five or six years, palpation of the
broad ligament before operation had indicated freedom
from disease. In his experience, operations performed
for cancer of the body had done far better than those
done for cancer of the cervix. He had been impressed
with the fact that a partial operation, as, for example,
by the cautery, had rather aggravated the disease and
hastened the fatal termination more than if the pa-
tients had been let alone.
Dr. Hermann J. Eoi.dt said that cancer of the
uterus must be looked upon as a local disease in the
initial stages; hence, if the diagnosis was made and
the proper treatment instituted at this time, a cure
should result. In his opinion, there was no other
method equal to the cautery for the treatment of that
spot which seemed to be most intimately connected
with the organism. He had personally had but little
experience with the method, but the results obtained
by Byrne and Mackenrodt, and others, left no doubt
on this point. He had treated one hundred and eleven
cases of cancer of the uterus, with a direct mortality
of 5.4 per cent, and a mortality from recurrence of
34.2 per cent. Those patients living with recurrence
constituted 2.7 per cent., those living and free from
recurrence 24.3 per cent. No report had been ob-
tained in 30.6 per cent. After the first year's experi-
ence he had never performed the " shelling out " oper-
ation. The danger of injuring the ureters was very
great.
Dr. George Tucker Harrison subscribed most
heartily to all that Dr. Kelly had said, for he had
preached the true gospel of this disease. It was a
demonstrated fact that cancer of the uterus was a local
disease, and it was certainly susceptible of cure. He
did not consider that statistics of cancer of the uterus
were available until a period of five years had elapsed.
Taking this as the standard, at least fifteen or twenty
per cent, of the patients had been cured, yet the re-
maining eighty per cent., or some of these, should
have been cured, and would have been if the diagno-
88o
MEDICAL RECORD.
[May 19, 1900
sis had been made early enough and appropriate treat-
ment instituted. He had been disappointed with his
own results by the vaginal route.
Dr. Joseph E. Janvrin said that about four years
ago he had read before this association a paper in
which he had reported sixteen cases of cancer of the
uterus beginning, so far as could be judged, in the
cervix. He had operated upon these cases by vaginal
hysterectomy — simply skinning out the uterus. Of
the sixteen cases, twelve at that time dated back three
years or more, and one for twelve years. At that date
four patients had been living and in perfect health.
The remaining four cases dated back at that time, one
four months, two five months, and one twenty-two
months. Two of these patients he knew were living
and well at the present time; two had died within a
year after the operation. This gave a percentage of
37.5 per cent. These cases had been selected as ex-
emplifying the results when the disease began in the
cervix and was, in the majority of cases, confined to
this part. In every instance the diseased condition
of the cervix had been well marked. He had not
tabulated his other cases operated upon prior to four
years ago, but from recollection the ultimate results
had been fully up to the percentage just given. Out
of the thirty cases he was sure over one-third had no
recurrence of the disease. In four of the si-xteen cases
the disease extended down upon the mucous membrane
of the vagina, yet three of these had resulted in a
cure. His experience had been that when the disease
began on the cervix it was more apt to invade, prob-
ably by attrition, the vaginal mucous membrane rather
than to extend down under the mucous membrane.
He thought that vaginal hysterectomy should be con-
fined to cases in which the disease was limited to the
cervix, or to the cervix and mucous membrane only of
the upper part of the vagina, or those in which the
disease having involved these points had also begun
to develop upon the mucous lining of the uterus
itself. To this class might be added cases of adenoma
and carcinoma uteri in their early stages. In all
cases in which there was a suspicion of extension of
the disease beyond these limits, whether into the para-
metrium, the folds of the broad ligament, or the ova-
ries, the combined abdomino-vaginal operation or the
radical operation by the abdomen itself was by all
means the most appropriate if we resort to any radical
operation whatever. As a rule, he had not performed
either abdominal or vaginal hysterectomy in advanced
cases. He had long been of the opinion that the
cases which were operable could be successfully treated
by the abdominal route.
Dr. J. Riddle Goffe said that only in recent years
had accurate and reliable statistics been presented
concerning cancer, and the profession and the public
had been startled by the rapid increase of cancer in
England. Some had refused to accept these statistics,
maintaining that the increase was apparent and not
real. Others, speaking with much authority, insisted
that the disease was not only rapidly increasing, but
that it was developing more and more frequently
among younger subjects. The figures that had been
presented were sadly disappointing, and made him
hesitate to attempt anything. His own experience
led him to think that the vaginal operation was the
only justifiable one in cancer of the uterus, because of
the danger of inoculating fresh tissues with cancer in
other methods of operating. In his opinion, there
seemed to be two serious objections to the operation
presented here this evening by Dr. Kelly. The first
objection was to the method of inverting the uterus,
for the turning of a carcinomatous cervix upward into
the peritoneal cavity seemed to be an excellent way to
encourage inoculation of tiie peritoneal cavity. Again,
he was not in favor of quadrisecting the uterus, for
the less it w^as interfered with the less likelihood of
spreading the disease. He would favor taking out the
whole vagina, if necessary, for the dissection was very
easily performed. The diseased tissue should be shut
up in a little sac of vagina.
Dr. E. E. Tull said that he had a record of twenty
cases of cancer of the uterus upon which he had oper-
ated in hospital practice since 1890. Four patients
were living, and two of them had been operated on in
1890. The operation had been by the vaginal route,
and in all of them the diagnosis had been made posi-
tive by a microscopical examination. From observa-
tion and experience it seemed to him that the vaginal
operation was far from being an easy one. He would
operate upon a fairly advanced case first by the appli-
cation of the cautery, and then, entering the abdomen,
would remove the disease as thoroughly as possible.
Dr. H. X. Vineberg said that although he had
probably seen about twelve tiiousand cases of diseases
of women in dispensary practice, the number of cases
of cancer of the uterus had been exceedingly small,
probably not more than twelve cases. The majority
of these women had borne many children, and had
suffered extensive laceration of the cervix, a point of
interest because of the view held by some that such
lacerations were a prominent cause of cancer. The
cervix was situated in the midst of much connective
tissue rich in lymphatics. These lymphatics acted as
a barrier to the dissemination of the disease upward.
Onlv in those cases in which the disease was limited
to the body had his results been at all encouraging.
He would venture to suggest a modification of Dr.
Kelly's method, viz., the making of a longitudinal in-
cision in the anterior vaginal wall. Through this the
uterus could be anteveried, and there would then be
no need of entering the peritoneal cavity posteriorly.
Dr. Ralph VValdo said that when the disease had
lasted more than six months it was probable that the
tissues had been so much invaded that recurrence
would take place. . His personal preference was for
operating from below, and using ligatures.
Dr. John Byrne, of Brooklyn, said that in 1892 he
had undertaken an analysis of the published statistics
on cancer of the uterus up to date. The trouble had
been in the past that many in the profession had been
disposed to minimize the danger of hysterectomy,
pointing to the exceptionally good statistics of a few
specially skilful operators. In two hundred and
thirty-five cases treated by a number of the leading
operators in Germany, France, and elsewhere, he had
found sixty-three, or twenty-seven per cent., in which
relapses were noted, while nothing was said about the
fate of one hundred and seventy-two cases. Such im-
portant gaps in the records made the task of collecting
honest and trustworthy statistics most disheartening.
Olshausen had reported in 1892 one hundred and
sixty-one cases of hysterectomy for cancer, with only
forty-two patients living at the end of two years. Of
the one hundred and fifty-five who had survived the
operation, only nineteen had been free from recur-
rence. Such statistics as these were worthy of the
most thoughtful consideration. Of late years his own
work had consisted in the free use of the cautery, and
a thorough roasting of the cavity. Exceptionally was
the actual cauterization carried to the fundus. In
circumscribed cancer of the cervix the use of the cau-
tery and a thorough roasting of the cavity were free
from danger, and afl'orded the very best chances for a
cure. He had many cases on his books in which the
patients had lived eight or ten years, or even longer,
free from recurrence. TJie effect of the electro-cautery
knife on the surrounding structures probably explained
the absence of fever and pain after the operation, the
almost complete immunity of the scar tissue from in-
volvement in the event of recurrence, and the compara-
May 19, 1900]
MEDICAL RECORD.
88 r
tive rarity of recurrence. The improved electric ap-
paratus of the present day left no excuse for further
apathy on this important subject.
Dr. Kelly made a few closing remarks.
THE MEDICAL ASSOCIATION OF THE
GREATER CITY OF NEW VORK.
Slated Alating, April g, igoo.
Robert F. Weir, M.D., Chairman.
Difficulties of Intubation. — Dr. Rogers presented
a young girl who illustrated some of the difficulties of
intubation. She was intubated for diphtheria in De-
cember, 1896; tracheotomy was done in February,
1897 ; in May she was re-intubated. She was then in
Wrllard Parker Hospital for a year, during which
time her stenosis remained unchanged. In 1897 she
was transferred to Gouverneur Hospital. A small tube
was then introduced, but the patient coughed it up
and was on the point of being asphyxiated, when a
tracheotomy was done with a penknife. In January,
1898, there was no improvement, and a laryngotomy
was done. Nothing was found but a mass of thick-
ened tissue. A suture was introduced through the
thyroid cartilage to keep the swollen tissues away from
the median line. Infection of the wound followed,
and in April she was discharged, being considered a
hopeless case. There were much excoriation and der-
matitis about the tracheotomy tube, and a great deal
of dense tissue around the larynx. A No. 4 or 5 tube
was introduced, and in October of the same year a
larger tube was placed in. In November, 1898, the
tube was taken out, and she had remained cured ever
since. The interesting point was that from Decem-
ber, i8g6, to October, 1898, she was unable to breathe
through her larynx; then, by wearing a big '^ube in
the larynx, she became cured. She was unable to
phonate until this year. She now breathed with some
dyspnoea at night.
Dr. Rogers also presented the case of a boy who, in
March, coughed out the tube and nearly strangled, a
tracheotomy being performed to prevent asphyxia.
The attempt was made to replace the intubation tube,
but it was again coughed up. In October he was ad
mitted to Gouverneur Hospital, and it was found that
even a uterine probe could not be passed. The at-
tempt was made at dilatation with urethral sounds. A
No. 4 or 5 tube was then introduced and worn for nine
days; then, a No. S or 7 tube was placed in and left
for five weeks, when he was considered cured.
Dr. Rogers presented the third case of a girl who
was intubated at theWillard Parker Hospital in May,
1896, for diphtheria; in July the tube was coughed
up, and she stopped breathing, making it necessary to
perform a tracheotomy ; in October a laryngotomy was
performed. The swollen tissue was excised; there
was no cicatricial tissue, only cedematous tissue; there
was no granulation tissue. The child was no better;
she could not breathe without the tube. Laryngotomy
was again performed in October, 1897. LTntil last
July, a period covering nearly three years, intermit-
tent dilatation was done, but the patient did not breathe
through the larynx. In July the tracheotomy tube was
removed and a large-sized intubation tube — 11 to 13
tube — was placed in and worn for five weeks, when it
was taken out. A cure followed. He closed by
stating that every one of these patients did well by
the insertion of as large a t.ube as could be crowded
into the larynx, to be left there for six weeks, or even
longer.
Pylorectomy ; Gastro-Enterostomy. — Dr. Robert
F. Weir presented this case. The patient, a woman
forty years of age, gave a history of gastric disturb-
ance but not of severe type. Eight or ten months ago
she noticed a swelling in the upper part of her stom-
ach; it increased in size, with some distress in diges-
tion, with vomiting, but there was no hajmatemesis.
The tumor was as large as an orange and fairly mov-
able. An exploratory incision was made to determine
if any adhesions existed or if there was any glandular
involvement. The diagnosis of carcinoma of the
stomach was made, there being a growth of consider-
able extent in the cavity of the stomach. Along
the greater curvature of the stomach, running for a
distance of four or five inches, a mass could be felt in
the walls of this organ, both anteriorly and posteriorly.
A pylorectomy was decided upon and done, seven
inches being removed. This area was clamped. The
stomach wound was closed by means of sutures which
passed through the entire thickness of the mucous
membrane, and two extra layers of sutures turned the
stomach in three-quarters of an inch. A gastro-
enterostomy was then done by means of a Murphy's
button — the duodenum being connected to the pos-
terior wall of the stomach. Recovery was uneventful;
there were no bad symptoms. The stomach was
washed out from the beginning, and fluids were ad-
ministered within the second or third day. She now
ate almost any kind of good food.
Pathology, Diagnosis, and Treatment of Diph-
theria.— The feature of the evening was a discussion
on this subject.
Dr. J. Blake White opened the discussion. He
treated of the throat conditions resembling diphtheria.
There were three distinct exudations: (i) Grayish,
aphthous patches seen in states of debility and in a
deranged state of digestion ; (2) a local non-contagious
condition iibout the glottis, which w^as accompanied by
stridulous breathing, and described under the term
"croup"; (3) the specific, contagious, infectious dis-
ease, which was accompanied by lymph exudation, by
great prostration, and other symptoms, and often
paralytic complications — diphtheria. In making a
differential diagnosis bacteriological evidence of the
disease was of great importance, but should always be
considered in connection with the clinical history.
He cited the instance of a little girl in whom the
clinical diagnosis was diphtheria; the cultures ob-
tained said there was no diphtheria. She was treated
for diphtheria, and a subsequent bacteriological ex-
amination showed the presence of the Klebs-Loeftler
bacilli. The indications for treatment in diphtheria
were naturally those that were present in any condi-
tion of toxffimia, i.e., to sustain, then aid the elTorts of
nature in the struggle to eliminate the principles under
which the patient suffered. Nature fought the disease,
and often a blind man with a club came along; if
he struck the disease, he killed it; if he struck nature
the patient was a sufferer. The speaker, in referring
to the rational methods of treatment, said that among
the vast host of remedies advocated there was no one
that was entitled to superior confidence. The immu-
nizing effect of antitoxin was compared to that follow-
ing the inoculations of smallpox, but he claimed that
they vi'ere in no way identical. In France the anti-
toxin treatment was discredited; also in Moscow.
The Britisli Medical Journal stated that in Paris, with
the use of the antitoxin treatment, there was an in-
crease of diphtheria. The relative value of intuba-
tion was compared with tracheotomy. Intubation
should be practised early to give greater chance of
life. If the obstruction extended below the furthest
reach of the O'Dwyer tube the patient should be
looked upon with superadded anxiety. In conclusion
he remarked that the rational treatment consisted in
the study of each symptom and the idiosyncrasy of
each case.
882
MEDICAL RECORD.
[May 19, 1900
The Heart and Circulation in Diphtheria.— Dr.
Henry Dwight Chapin continued the discussion,
confining his remarks to the various phenomena seen
in connection with the heart in diphtheria. This
organ naturally attracted much attention in the treat-
ment of this disease. The heavy mortality from diph-
theria in severe types was accompanied by failure of
the heart, and death ensued from this cause. Rapid
failure of the heart was especially seen in the septic
type of diphtheria. Here, the throat was covered
with a false membrane, including the tonsils, the
uvula, the palate, and in addition there was marked
involvement of the glands about the neck. The nose
was almost invariably blocked up. This type was ex-
ceedingly depressing to the heart. At the W'illard
Parker Hospital it was found that the septic type of
the disease acted as a powerful depressor of the heart;
of course, here were present the mixed infection, the
Klebs-Loeffler bacilli, the streptococci, and other
germs, which combined their toxins with the original
toxins. In these instances when the heart began to
fail it rarely recovered itself; the pulsation was rapid
and feeble, and the patient developed the type of great
prostration, with pallor and finally stupor and death.
The speaker referred to the grave significance of vom-
iting; if vomiting ensued with a weak pulse death
usually followed; this vomiting might precede or fol-
low failure of the heart. This was not the vomiting
that accompanied over-feeding of the patient. An-
other phenomenon referred to was the distinct slowing
of the pulse, which was regarded as of grave signifi-
cance; this slowing of the pulse might come on be-
fore or after great rapidity. The following cases were
cited to show this retardation of the pulse :
CiSE I. — E. F , eight years of age, died on the
fifth day. The day before death the pulse was 42 and
remained slow; it previously had been 115 to 120.
Case II. — L. M. , about four years old; on the
fourth day the pulse ranged from 128 to 66; next day,
120 to 138. Death followed in three days.
Case III. — G. S , about six years of age, was
in stupor with a pulse of 60; it was regular. The
following day it was 38 and irregular. Death oc-
curred in three days with a pulse of 104.
Case IV. — B. C , aged five years, had a very
rapid heart, which gradually slowed and in a few days
was 28. The patient lived two days thus.
Case V. — A. H , aged thirteen years, had a
pulse of 90; in two days it was 40, remaining so for
three days, when it became 60 to 70. The patient re-
covered.
When the pulse dropped in this way recovery was rare.
The care of these cases consisted in insisting upon the
recumbent position. Dr. Chapin stated that there
seemed to be a direct ratio between the amount and
character of the local inflammation and exudation and
the severity of the constitutional symptoms, especially
the heart. If there was not much membrane, and no
swollen lymphatic glands were present, no matter if
the pulse was rapid and irregular, the case was not so
serious, especially if there were no symptoms of pros-
tration. He believed in the study of the heart in
diphtheria, which was the only disease in which we
must interpret the physical signs by the rational signs.
He had had a mild case of diphtheria, with a rapid
and irregular pulse; the patient improved by getting
up and running about the ward. Whenever we found
that tiie character of the pulse was poor, with evi-
dences of prostration, pallor, vomiting, and stupor, the
condition of the heart must give grave solicitude;
but when there were the same physical signs without
prostration, the significance was not so grave. The
treatment consisted of whiskey, strychnine, and nitro-
glycerin. In cases of slow pulse strychnine in large
doses apparently had no effect whatever; it was' given
hypodermatically. Nothing seemed to steady the
heart in these grave cases. One therapeutic agent
used at the Willard Parker Hospital was morphine in
certain cases. In non-narcotic doses it was a power-
ful heart stimulant. Children were hard to keep
quiet; heart failure sometimes followed when a child'
simply sat up in bed; the children should be kept
quiet, and it could be done with morphine adminis-
tered hypodermatically. This was most efficient. A
child of one or two years of age could stand gr. -^\, to
Yj of morphine hypodermatically.
The Treatment of Diphtheria as Carried Out in
the Willard Parker Hospital.— Dr. John \\inters
Brannax continued the discussion, confining his re-
marks to the above subject. The treatment there did
not differ from that employed in other hospitals or in
private practice except in matters of detail. Unless
there was some opposition antitoxin was given in all
cases; 1,500 to 3,000 or 4,000 units of the strongest
serum obtainable was administered, the dose being
regulated by the severity of the case. If no improve-
ment followed within twenty-four hours the injection
was repeated, and, in some cases, even given a third
time. No cases were admitted to the wards until the
clinical diagnosis had been verified by bacteriological
examination. The naso-pharynx was cleansed by
means of a fountain syringe ; that, he believed, was
the key-note to success. The child was placed on a
table and swathed in sheets; outside of this was placed
a rubber blanket. With the patient upon one side the
nozzle of the syringe was introduced into one nostril,
then into the other, then into the mouth and naso-
pharynx, and all the parts were thoroughly flushed with
decinormal saline solution. The fountain syringe was
elevated three or four feet above the table. If the fauces
were encroached upon, water at a temperature of 120° to
130° F. was used. Irrigation was practised every one,
two, or three hours; if any nasal hemorrhage occurred
it might have to be abandoned for a time. This irriga-
tion prevented further absorption by removing the
false membrane, and by clearing away the discharge;
no attempts were made to do this by the aid of chemi-
cal agents. The speaker laid particular stress upon
the preparation of the patient before the treatment
was begun; the patient should be immobilized first.
The further treatment was chiefly systematic. All
patient were placed upon stimulating diet and kept in
bed until convalescent. Ninety feet of floor space
was allowed for each bed. The temperature of the
room was kept at about 68" or 70° F. Tracheotomy
was rarely necessary, being performed but ten or
twelve times in a year. In some cases gavage was
used, the tube being introduced through the nostril.
For the cardiac weakness whiskey and strychnine were
given, the latter being given with a free hand, a young
child sometimes receiving gr. ,'„ in twenty-four hours;
he had never seen the slightest toxic effect from it.
Broncho-pneumonia and other complications received
the usual treatment. Paralytic sequelae were seldom
seen; they were treated by tonics, massage, and fara-
disni. Recently the use of the suprarenal gland had
been begun; it was spread directly upon the part; it
had also been given internally in powder in five-grain
doses every two hours. No marked effect had been
noticed from its use in the treatment of diphtheria.
Cocaine in operations upon the lower extremities may
be used as a partial anaesthetic by injecting 1-2 cgm.
into the lumbar subarachnoid space. Quincke, Sich-
ard. Bier, Seldowitsch, and Tuffier have employed the
method. Tuffier has operated with success in ankylosis
of the knee, pelvic suppuration, and vaginal hysterec-
tomy.
May 19, 1900]
MEDICAL RECORD.
883
NEW YORK PATHOLOGICAL SOCIETY.
Stated Meeting, March 14, igoo.
Eugene Hodenpyl, M.D., President.
Thrombosis of the Pulmonary Artery; Sudden
Death. — Dr. J. H. Larkin presented specimens from
a man thirty-five years of age, who had given a history
of syphilis and of repeated attacks of goncyrhcea.
The man had entered St. Francis' Hospital about two
weeks ago complaining of difficult and painful urina-
tion. E.xamination showed a stricture at a depth of
four inches, and another in the membranous urethra.
There was also some enlargement of the prostate.
The ne.xt day perineal section had been done. The
patient had done well for four days, and then on at-
tempting to irrigate the bladder with hot saline solu-
tion the man suddenly became cyanotic, complained
of intense pain in the chest and of dyspnoea, and in a
moment was dead. At the autopsy, having in mind
the clinical diagnosis, the lungs and heart were ex-
posed ill situ. On opening the pulmonary artery a
thrombus of large size had been found. The portion
e.xtending into the right ventricle was rounded, show-
ing that this part had slipped down into the ventricle
after having formed higher up.
Fat Embolism of the Pulmonary Artery ; Sud-
den Death. — -Dr. Larkin exhibited specimens and
photographs of this case. The patient, a man aged
thirty-six years, had fallen from his bicycle and in-
jured the right hip. Examination had shown fracture
of the greater trochanter of the femur and impaction
of the neck. For the first few days temporary wooden
splints had been used, and then a plaster spica band-
age had been applied. A day or two after the man
had suddenly experienced severe pain in the chest,
and this had been associated with nausea and feeble
heart action. He had recovered from this- attack of
syncope, and had done well until about one week later,
when there had been another attack similar to the
first one except that it had terminated fatally. The
autopsy had been performed by Dr. Norris and him-
self. The viscera had appeared normal. Having in
mind fat embolism, portions of the viscera were taken,
and stained with osmic acid. In all the branches of
the pulmonary artery, both the smaller capillaries and
the medium-sized vessels, were found accumulations
ot fat globules and thrombi. It was noted at the time
that the lungs were not so oedematous as had been
observed in other cases of fat embolism. The micro-
scopical appearances seemed to leave little doubt re-
garding the correctness of the diagnosis of fat embol-
ism. The fractured femur was also exhibited. At
the time of the autopsy tlie bone had been found rid-
dled with hemorrhages.
Dr. Norris said that fat embolism of the pulmonary
artery was very common after fractures. One observer
had found, in a large series of autopsies, that there
had been some fat embolism in ten per cent, of the
cases. The first attack had been quite mild in the
case reported, and the man had soon recovered from
it. The fact that this had come on twenty-four hours
after changing the dressing made it probable that the
moving of the parts had been the immediate cause of
the embolism. It was difficult to explain the second
attack. Respiration ceased two or three minutes be-
fore the heart stopped beating, which would point
rather to an affection of the blood-vessels supplying
the respiratory centre.
Cystic Degeneration of the Kidneys with Cysts
of the Liver. — Dr. L. A. Conner presented speci-
mens from a woman who had died at the New York
Hospital last December. She was admitted on De-
cember 26, 1899. She was forty-four years of age.
Her family and earlier personal history was unimport-
ant. She had felt " tired " for several months. For
the past six weeks she had been very weak. There was
some dyspnoea on exertion. The urine had a bad
odor. There were no oidema, no lumbar pain, and no
hematuria. On admission, her temperature was 97.8"
F. ; respiration, 32 ; pulse, 106. Physical examina-
tion revealed a tumor mass in the region of the left
kidney and little else besides feeble heart action.
The urine had a specific gravity of i.oii ; it was acid,
turbid, and contained i gm. of albumin to the litre,
much pus, few red cells, and no tubercle bacilli. The
patient grew steadily weaker, became stuporous, and
died three days later.
At the autopsy, the heart showed moderate hyper-
trophy of the left ventricle — its weight was 320 gm.
The heart muscle was rather soft and light colored.
The valves were competent. The coronary arteries
showed a somewhat anomalous distribution. The left
kidney measured 19x8x6 cm., and weighed 686 gm.;
the right kidney measured iS-5X 9.5X7.5 cm., and
weighed 472 gm. The kidneys preserved in general
their usual shape, but owing to the many projecting
cysts their surfaces presented somewhat the appearance
of a bunch of grapes. On section both organs were
seen to be composed chiefiy of a multitude of cysts,
which varied in diameter from i mm. 102.5 cm. They
were most abundant in the peripheral parts.- The
usual topography of the kidneys was entirely lost, and
in only a few places could anything resembling kidney
tissue be recognized. Several of the large cyst cavities
in each kidney contained thick grumous pus. In the
remaining cysts material of two fairly distinct types
was seen: (i) A number of large cysts contained thick,
brown, gelatinous material, which became very firm
by preservation in formalin. (2) Most of the smaller
cysts and some of the large ones contained a thin,
whitish, transparent, gelatinous fluid, which seemed to
be little changed by the formalin. The pelves of the
kidneys were small, and seemed compressed by the
cystic kidney tissue. The ureters and renal vessels ap-
peared normal. The bladder contained purulent urine,
with mucous membrane. The liver was somewhat ir-
regular in outline. The right lobe was prolonged
downward, and was somewhat constricted atone point.
It weighed 1,770 gm. Scattered over the surface of
the liver everywhere and projecting slightly above the
surface were seen many small cysts from 2 to 10 mm.
in diameter. On section of the organ these cysts
were seen scattered throughout, being separated by
normal-looking liver tissue. The cysts as compared
to the liver tissue made up a comparatively small part
of the volume of the organ. A part of the anterior
margin of the right lobe was lighter in color, tougher,
and evidently contained much more fibrous tissue than
did the rest of the liver. In this part the cysts were
especially numerous. The left ovary was 5 cm. in
diameter, and consisted chiefly of a number of good-
sized clear cysts. Microscopical examination of the
kidneys showed the cysts to be lined by a single layer
of cuboidal epithelial cells, and to bear a very close
relation to the uriniferous tubules, and sometimes to
the Malpighian bodies. Between the cysts in many
places areas of much-damaged renal tissue could be
seen. In the liver, in the same way, the cysts could
be seen in process of development from the small gall
ducts.
Dr. Conner said that Ritchie,' of Edinburgh, after a
thorough study of the subject, had drawn the follow-
ing very reasonable conclusions: (i) That in cystic
kidney there was an irritative lesion leading to pro-
liferation of epithelium and also to connective-tissue
changes. There was evidence of it in simple cysts,
in those which occurred in contracting kidneys, but to
' Reports of Laboratory of the Royal College of Physicians,
Edinburgh, vol. iv., 1894.
MEDICAL RECORD.
[May 19, 1900
a much greater degree in the large polycystic kidney.
(2) That in the large polycystic kidney, as in cystic
disease of the mamma, the disease arose in conse-
quence of irritation propagated througii the nervous
system; (4) that this disease of the kidney had no
direct relation to congenital cystic kidney, which was
due to an error in development; (5) that the cysts
were formed from the pre-existing tubules and Mal-
pighian bodies of the kidney, and that they were not
a new formation arising out of persistent embryonic
rudiments; (6) that this cystic disease was related to
and should be studied along with the adenomata; (7)
that cystic kidney was similar in character and in origin
to cystic liver. Continuing, the speaker said that a
number of other writers had concluded that this con-
dition had nothing to do with congenital cystic kid-
ney, and that it should be classed along with the ade-
nomata. It' had been suggested that they should be
called multilocular adeno-cystomata. Ritchie had
tabulated eighty-eight cases, in twenty-one of which
it had been associated with cystic liver, in two with
cystic ovary, in one with cystic uterus, and in one with
cystic thyroid. In all but two cases both kidneys had
been involved. Hypertrophy of the heart had been
noted in twenty-nine out of thirty-nine cases. The
average age was forty-five years, the youngest patient
being twenty-three and the oldest eighty-eight years.
As to sex, there were slightly more males than fe-
males. In three cases the symptoms had existed for
over fifteen years; in seventeen for over one year.
Thirty out of seventy-eight had given some renal
symptoms, such as pain, hitmaturia, and ct-dema. Of
the seventy-two cases, thirty-eight patients died with
symptoms of ura;mic coma, and eight of cerebral hem-
orrhage. The microscope had shown in the kidney
islands of greatly damaged renal tissue between the
cysts, and the cysts themselves bore close relation to
the uriniferous tubules and sometimes to the Malpi-
ghian bodies. In the liver, the close relation to the
small gall ducts was evident.
Dr. E. Hodenpvl said he was very much aston-
ished at the citations made by the last speaker, for it
seemed to him that it had been quite generally ac-
cepted that such kidneys as these were of congenital ori-
gin. He had seen the condition a number of times in the
newly born, and the specimen just presented reminded
him forcibly of a similar one that he had shown to
this society a year or two ago. He saw no reason for
calling these cysts tumors. From the fact that chil-
dren were born with these it seemed reasonable to
look upon them as congenital.
Dr. James Ewing said he had been surprised at the
statements quoted from Ritchie, and he would like to
know more regarding the grounds upon which these
cysts were declared to be tumors. He would like to
know what was the character of the lining of these
cysts. The kidneys just presented seemed to exhibit
much more of the renal tissue than in the cases he had
seen in the newly born.
Dr. Conner replied that cases of congenital cystic
kidney resulted fatally after a comparatively short time,
and, so far as he knew, the condition had not been
traced from early infancy into adult life. Ritchie and
others had found many evidences of tumor formation,
and had given their reasoning in detail. The cysts in
this case had been lined with cuboidal epithelium.
A Case of Perforated Ulcer of the Duodenum. —
Dr. a. J. Lartigau presented a specimen of perfo-
rated duodenal ulcer. The specimen was from a man
sixty-four years of age, who had entered the Roosevelt
Hospital on January 17th complaining of pain in the
ri?ht iliac fossa. One week previously he had been
taken ill with pain in the region of the umbilicus.
On admission, the diagnosis had been made of gen-
eral peritonitis, probably from perforation of the ap-
pendix. When the peritoneal cavity was opened a large
quantity of thin fetid pus had escaped, and the intes-
tine and appendix in that region had been found nor-
mal. Further search had revealed the presence of a
perforation of the bowel, and of adhesions to the liver.
The operation had not been pursued further, and the
man had died eight days afterward. The autopsy had
been made five hours after death, and the anatomical
diagnosis had been purulent peritonitis, chronic dif-
fuse nephritis, and miliary tuberculosis of the lungs,
spleen, and ileum. The duodenum was adherent to
the under surface of the right lobe of the liver. The
duodenal ulcer was unusually large, measuring 3 by 2
cm. As a rule, the pancreas was the protecting bar-
rier, but in this instance the liver had formed the
protecting wall. The microscopical appearance of the
ulcer was similar to that of the ordinary round ulcer
of the stomach.
Dr. J. H. Larkin presented a specimen of perfo-
rated duodenal ulcer taken from a man twenty-eight
years old, who had been ill three days before coming
to hospital. His condition at that time had been very
bad, but an operation had been immediately under-
taken. An extensive peritonitis had been found, and
the peritoneal cavity contained much fetid pus. The
appendix was normal. The perforation had been
found at the site of a small ulcer in the posterior wall
of the duodenum.
Dr. I(Artigau remarked that while these ulcers were
usually circular, the one he had presented was oval.
Most of the duodenal ulcers closely hugged the pylo-
rus, as in both these specimens.
Microscopical Demonstration of " Vaccine Bodies."
— Dr. a. \^'. Williams gave this demonstration. She
said that the principal point of interest in regard to
the so-called " vaccine bodies " was that their nature
had not yet been determined. Most observers, among
them L. and E. Pfeiffer, Guarnieri, von \\'asielewski,
von Sicherer, and Kourloff, considered them micro-
organisms, placing them among the rhizopoda in the
group Sarcodina of the protozoa, and basing their
belief upon the facts that in the fresh tissue they
showed aniceboid movements, that some possessed a
more refractive central spot (nucleus) and showed
evidences of division by fission, that they had been
found in no other disease, and that they could be
accounted for in no other way. On the other hand,
Ferroni and Massari, Salmon, Hiickel, and others
said that these appearances were due to products
of a degeneration, either intra-cellular, proceeding,
as some said, from the nucleus of the epithelial cells,
others from the epithelial cell body — the cenfrosome
perhaps; or extra-cellular, from the leucocytes, the
epithelial cells then taking up the degenerated par-
ticles. Such degeneration, they stated, was probably
specific, and might be produced by an unknown micro-
organism. The specimens under the microscope were
a section from a rabbit's cornea, hardened forty-eight
hours after inoculation with vaccine virus, and one
from an isolated vaccine vesicle on the skin of a calf
six days after inoculation. The section from the cor-
nea was hardened in bichloride of mercury and stained
by Heidenhain's method. The portion under the mi-
croscope showed the edge of the area of inoculation.
Immediately about the point of inoculation the epithe-
lial cells had fallen off, leaving only the lower layers
of epithelium. The vaccine bodies lying, one or two
generally, sometimes more, in the body of the epithe-
lial cell, were stained a more or less homogeneous
brown-black; the bodies of the epithelial cells were
a light yellow, and their nuclei were an irregular faint
gray. The specimen of calf-skin was hardened in
absolute alcohol and stained with hajmatoxylin (Dela-
field's) and eosin. In the field under the microscope
was a sebaceous gland in which the bodies showed
May 19, 1 900]
MEDICAL RECORD.
885
more plainly on account of the large size of the epi-
thelial cells. The vaccine bodies were here stained
a more or less homogeneous purple, the nuclei of the
epithelial cells a darker irregular purple, and their
bodies a light pink. The nuclei of the leucocytes
which were present in moderate numbers about the
gland, and occasionally within it between the epithe-
lial cells, were stained also a dark purple.
A Case of Trichinosis. — Dr. Harlow Brooks re-
ported this case from the fourth medical division of
Bellevue Hospital, in the service of Dr. Lambert.
After eating sausage a man had begun to complain of
malaise and muscular soreness. Microscopical exam-
ination of several sections from his muscles had
showed a myositis, but no trichinae. Subsequently a
large piece of muscle had been excised under cocaine
anesthesia from the junction of the belly of the biceps
muscle with its tendon. From this specimen one
trichina had been found about to become encapsu-
lated. The fffices had been carefully examined, but
no trichinae were found. There had been 18,000 leu-
cocytes and ten per cent, of eosinophiles at the time
of his admission to hospital on February 2d. On Feb-
ruary i2th he had had forty-four percent, of eosino-
philes and a proportionate leucocytosis. The percent-
age of eosinophiles had steadily increased up to a
maximum of eighty-three per cent., and then had slowly
declined. At the present time the percentage of
eosinophiles was fifteen per cent. It had seemed to
him that these eosinophiles differed somewhat from
the cells ordinarily called by this name. They were
possibly a transition form.
Dr. Larticmi said that he had recently had occa-
sion to examine specimens of blood from various cases
of a small epidemic of trichinosis investigated by Dr.
George Blumer, of Albany, N. Y. The percentage of
eosinophiles in none of these cases had been so high
as that just reported. As recovery had taken place
the eosinophilia had declined; at the end of two
months. Dr. Blumer found these cells still increased
in number although much diminished. In many but
not all cases, a decrease in the small mononuclears
was observed. It was worthy of note that some of the
severest cases did not necessarily correspond with the
degree of eosinophilia, some of the mild cases show-
ing a greater increase than the clinically more severe
cases.
Dr. Ewing said that the case reported by Dr.
Brooks gave the highest percentage of eosinophiles
on record. In this connection he would refer to the
possible aid to diagnosis afforded by the increase in
the percentage of eosinophiles. A marked increase
in these cells might furnish grounds for suspecting
trichinosis, but nothing more than this except when
it was associated with an exudative myositis. When
this combination 'was present, one was justified in
making a diagnosis of trichinosis. He had carefully
examined the eosinophile granules in this case, and
had found that many of them were smaller than the
usual type, but reacted alike with staining- agents.
He had been unable to find any evidence that they
were transition forms between eosinophiles and neu-
trophile granules. If there was a transition here, it
was probably between the eosinophile and basophile
granules. The case was exceedingly interesting be-
cause of the influence which a parasite like the tri-
china seemed to have upon the eosinophile cells.
Dr. Lartigau remarked that notwithstanding the
fact that the eosinophilia might be attributed to a num-
ber of diff'erent causes, he regarded a marked increase
in the eosinophiles as extremely suggestive of trichi-
nosis. He knew of several unpublished sporadic
cases in which the diagnosis had been made wholly
by the differential blood count, and subsequently veri-
fied by the finding of the trichinae.
A Case of Chylous Urine and Filaria Sanguinis
Hominis — Dr. M. Nicoll, Jr., reported this case, and
presented the patient, a young man aged nineteen
years, a native of Santa Cruz. Six months ago, with-
out previous symptoms, he had begun to pass creamy
urine. After passing this daily for two months, he
had noted that the urine was pinkish, and then that
there was a momentary retention, relieved by the pas-
sage of a small clot of blood. For the past four
months he had had in the left groin varicose glands,
which gave rise to an appearance resembling a hernia.
The urine was now pink and creamy, and contained
fat cells. He had been unable to detect the filaria in
the urine, though they were probably present. Dr.
Nicoll also exhibited under the microscope the em-
bryonal filaria— the variety found in the blood.
A Case of Solitary Tubercle of the Heart Dr.
E. Dunham reported this case, which occurred in a
person aged twenty-one years, in the service of Dr.
John W. Brannan at Bellevue Hospital. There was
a solitary tubercle about the size of a pea on the inner
surface of the wall of the left auricle, just beneath the
endocardium. There were a miliary tuberculosis in
the lungs, several large tubercles in the brain, and a
solitary tubercle in one of the kidneys. It was rather
difficult to explain the occurrence of the solitary tu-
bercle immediately underneath the endocardium in the
auricle. A number of sections had been made and
examined, and in every one it had been possible to
demonstrate from one to six tubercle bacilli, all within
giant cells.
Dr. Hodenpyl remarked that there were on record
a number of similar cases of solitary tubercle of the
heart.
A Case of Aberrant Suprarenal Body with Pa-
chymeningitis Haemorrhagica Interna Dr. F. C.
Wood reported this case; also a case of aneurism of
the aorta with unusual lesions of the lung, and a case
of tuberculosis with multiple sarcomatosis.
Notes on the Preparation of Hsematoxylin Stain-
ing-Solutions, and on the Technique of Staining.
— Dr. George C. Freeborn read a paper on this sub-
ject, based on personal observation and study in the
laboratory.
Dr. Brooks asked if Dr. Freeborn found that the
acid in the acid eosin injured the clearness of the
hematoxylin stain.
Dr. Freeborn replied that if the precipitated eosin
was washed until the wash-water became tinged, one
could be sure that all of the acid had been removed.
He had never known it to interfere with the harma-
toxylin stain at all.
Dr. Brooks asked if the sections could be left for
a long time in the eosin oil without their over-stain-
ing.
Dr. Freeborn replied that he had left them in as
long as ten days, and had not been able to observe
any detriment from so doing.
Dr. Ewing said that for the last six months he had
tried all the purified eosins he could find in the mar-
ket, yet he had not been able to make a good blood
preparation with any of them. In order to get a good
selective stain for blood he was sure it was necessary
to improve on the ordinary eosins now on the market.
Dr. Freeborn said tfiat the eosin employed by
him had been procured from Grubler, and was known
as "water-soluble eosin." The acid was added until
a precipitate no longer formed. He had not tried the
effect of using an excess of the acid.
Persistent Vomiting. — Iced towels to the epigas-
trium, changed every minute. — Mitchell.
Otorrhoea. — Injections of a two-per-cent. solution of
formalin. — Cipriani.
886
MEDICAL RECORD.
[May 19, 1900
progress of pXetTlcaX Science.
Journal of the American Medical Ass'n, May is, igoo.
Notification and State Supervision of the Tuberculous. —
Joseph Mattesou says that while he shares in the general
recognition of the value of instruction of the people in the
danger of the dissemination of tuberculosis b}' the sputum
of the consumptive, and in the method of disposal or disin-
fection by which this danger may be minimized, he believes
that in spite of the agitation for'State preventive measures
there exists in the mass of the medical profession a strong
if quiet opposition to any radical steps in State interference
with the tuberculous, and that it is based on \\) an under-
lying belief that there is a variance between the infectious-
ness of tuberculosis predicated on scientific experiment
and deduction, and the actual, every-day facts of common
observation ; (2) on the instinctive recoil of reason and hu-
manity at the difficulties and hardships of the progressive
measures which are the logical sequences of the first step ;
(3) on the evidence we have that tuberculosis in man is to
be decreased by increasing vital resistance, discouraging
marriages of tuberculous persons, and improving general
and individual sanitary environment and living.
The Use of Adrenal Substance in the Treatment of Asthma.
— .Solomon Solis-Cohen reports a case of distressing asthma
which failed to yield to all treatment until adrenal substance
was used. Burroughs & Wellcome's tablets, gr. v. each,
were prescribed once, then twice, then three times, daily,
and finally the patient for a time took gr. xc. daily. A
striking improvement shortly became manifest. The con-
stant dyspnoea first appeared, then the paroxysmal noctur-
nal attacks became less frequent and less severe. Recov-
ery was not rapid but was continuous. The author be-
lieves that in cases which are really spasmodic, that is, due
to contraction of the bronchial muscles, the remedy is with-
out good effect and is perhaps capable of bad influence.
But it is of use when the paroxysm is but one other mani-
festation of a congenital fault of structure or of metabolism,
affecting the vasomotor system, and thus permitting the
cardio-vascular balance, and especially the tonicity of the
blood-vessels to be readily overturned b}- exciting causes
which would have but slight effect on other individuals.
The Tenements and Tuberculosis. — S. A. Knopf believes
that the conditions most conducive to the pi'opagation of
tuberculosis, and especially of pulmonary consumption, are
those that prevail in the old-fashioned tenement-houses as
they still exist by the thousand in this and other large cit-
ies. Not only is there a greater number of consumptives
in these tenements than in the same area elsewhere, but
the proportion is actually greater per number of inhab-
itants. The author urges the building of model tenements,
in which with plenty of light and air, perfect ventilation in
all rooms, complete sanitary arrangements, and the ab-
sence of filth, dirt, and sickening odors, consumptives will
have a chance of being cured, and the further spread of
the disease will be checked. Invalids should also be in-
structed as to the precautions to be taken in regard to dis-
infection of the sputum.
Instrument for Use in Phototherapy. — J. W. Kime has de-
vised and is using, in the treatment of cases by means of
concentrated light, a reflector which produces a light equal
in intensity to twenty times that of direct sunlight and
covering an area of twenty-eight .square inches. Concen-
trated light is useful in the treatment of diseases of para-
sitic origin, strong light being very destructive to bacteria.
In tuberculosis of the lungs in its earlier stages, it has some
germicidal influence on the bacilli ; moreover, the blood,
every drop of which passes a number of times through the
area bathed in the powerful light during each treatment,
is without doubt beneficially influenced by the chemical
action of the light upon it. In the treatment of chronic
joint afllection, it has over the apparatus in which high
temperatures alone play a part, the additional advantage
of the beneficial action of the powerful light.
The Influence of High Altitude on Albuminuria. — Edward
C. Hill says that in his experience true renal albuminuria
is comparatively rare in Colorado, this state of aft'airs be-
ing probably chiefly due to atmospheric dryness and rarity,
both of which favor the eliminative action of the lungs and
skin, and thus relieve the kidneys in a corresponding de-
gree. Acute nephritis, though not common, is exception-
ally severe. Amyloid disease is less frequent under pre-
disposing circumstances than text-books would lead us to
infer. Chronic parenchymatous nephritis appears to ter-
minate fatally in about the same time as at lower altitudes.
The chronic interstitial type of the disease is influenced fa-
vorably by the tonic, invigorating qualities of the climate.
Renal tuberculosis is comparatively common. Serious
eclampsia is less common than at lower levels.
Hair and its Anomalies. — Henry Alfred Robbins writes
of the importance attributed to long and flowing locks in
ancient times, of hirsuties, of sudden whitening of the hair
under the influence of shock, terror, or grief, and of the
opposite condition of white hair suddenly turning black.
In regard to alopecia, he mentions the many varying the-
ories held in regard to its causation. The latest opinions
appear to be that it is due to the action of micro-organ-
isms. R. Sabouraud by his experiments has given convinc-
ing proof that the microbacillus is the constant microbian
expression of seborrhoeic infection, causing baldness.
Traimiatic Perforation of the Membrana Tympani.— By
Francis R. Packard.
Etiological Studies on Neuroses of Peripheral Origin. — Bv
H. Gradle.
AVti' York Medical Journal, May 12, igoo.
The Technique of Lumbar Puncture. — In discussing the
special point as to the preferable site for puncture, L. A.
Connor states that the needle should find ready access to
the sub-arachnoid space, that the tapping should be made
at the point least likely to admit of damage to the nervous
structitres of the canal, and that the fluid should be as rich
in sediment as possible. As regards the first requirement,
it may be said that this is sufficiently well met by entrance
through any of the lumbar spaces or through the lumbo-
sacral space. Possible injury to the cord can be excluded
by entering at some point below the third lumbar vertebra.
In adults it is perfectly safe to puncture between the sec-
ond and third vertebrae, but in small children there is some
chance that the cord may be touched. The last require-
ment, that of obtaining fluid richest in sediment, is best
fulfilled by tapping in the lumbo-sacral space. If the punc-
ture is made for purposes of diagnosis, then it seems best
to enter the lumbo-sacral space and to have the patient, if
a child, in the sitting position. With adults, and espe-
cially with those who are delirious or comatose, or who are
greatly prostrated, the difliculties of operating in the erect
position are so great as to render it impracticable. Punc-
ture in the upright position should then, in general, be con-
fined to small children.
General Remarks on the Pathology and Treatment of Stric-
ture of the Urethra. — C. G. Cumston gives in the two articles
the second of which appears in the present issue, a general
review of the subject, though nothing especialh- new is pre-
sented. To render the genito-urinary apparatus antiseptic,
he advises reliance first upon urotropin, then tincture of
eucalyptus and salol in large doses. For local use, he
prefers iodoform, citrate of silver, and cyanide of mercury.
The orifice of the urethra must be carefulh' disinfected be-
fore instrumentation, and for this purpose he advises soap
and water freely, then alcohol, and afterward an antisep-
tic solution.
The Treatment of Hay Fever by Suprarenal Gland. — B.
Douglas commends both the local and internal use of this
remedy. A six-per-cent. solution may be sprayed into the
nose every two hours until the symptoms are controlled.
Internally, gr. v. of the saccharated extract are given every
two hours until some giddiness or palpitation is observed.
or until the vasomotor paralysis in the nose is brought un-
der control. Then the dose should be diminished, though
the remedy should be continued until the hay-fever season
is safely passed. Douglas regards the remedy as almost
a specific for the disease.
Another Case of Typhoid Infection without Intestinal Le-
sions, with Possible Widal Reaction. — W. Ophiils reports
tlie case of a man of twenty-four years, who died in spite
of all remedial measures employed. \A'idal reaction was
positive, but no changes visible to the naked eye were found
in the intestine, and Peyer's patches were distinctly nor-
mal. Reference is made to other similar cases already on
record, and a bibliography of this special topic of typhoid
literature closes the paper.
The Kyphotone or Modified Plaster Jacket Stool for the
Correction of Humpback. — By R. T. Taylor.
Philadelpliia Medical Journal, May 12, igoo.
Remarks to the General Practitioner Regarding the Pes-
sary.— Frank C. Hammond says that before a pessary is
inserted into the vagina one must be certain that a dis-
placement exists. This fact being ascertained, the indi-
cations and contraindications for the employment of a
pessary may be stated to be as follows : (i) All inflam-
mation must be allayed. If there be a metritis, parame-
tritis, perimetritis, vaginitis, salpingitis, or ovaritis, the
presence of a pessary would be so painful as to contraindi-
cate its employment. Inflammation may be overcome by
local tamponade, and the consistent use of the hot douche.
(2) All adhesions must be "broken up " to permit the fun-
dus to be replaced to its normal po.sition. (3) If a tumor
is the cause of the displacement the downward force will
May 1 9, 1900]
MEDICAL RECORD.
be greater than any pessary can counteract, hence the
neoplasm must be removed. (4) By laceration, subinvo-
lution, or other cause, the pelvic floor may be so relaxed
that it will fail to give a pessary the necessary support.
This is a very important point, as too often patients
wearing a pessary are seen with the pelvic floor so badly
lacerated that it fails to support the instrument, hence they
receive no benefits from its employment. The pessary,
when so. strongly condemned, often has been used in those
cases which distinctly contraindicate its employment.
Relation of Diseases of the Nose and Throat to Life Ex-
pectancy.— E. Fletcher Ingals sajfs that very few life in-
surance companies require their physicians to ask an\-
questions regarding aftections of the nose and throat, and
he thinks that less than three out of a hundred persons
examined for life insurance are subjected to any examina-
tion of the air passages. He says that usually examina-
tions of the nose and throat would not aid the life-insur-
ance examiner, but in a limited number of applicants a
thorough examination of these parts would enable him to
reject persons otherwise acceptable, who within one or two
years will develop diseases that very greatly shorten their
expectancy. Such examinations should therefore, beholds,
be made whenever the hereditary or personal history, the
general appearance, or a quick pulse leads the examiner to
suspect the beginning of pulmonary or cardiac disease.
Alarming Hemorrhage Controlled by Haemostatic Forceps
Left on the Vessel.— Wounds of the Femoral Vein Controlled
by Means of Hemostatic Forceps. — Gangrenous Omental Her-
nia with Practically No Constitutional Symptoms. — Amputa-
tion of all the Toes of Both Feet for Dry Gangrene. — Re-
moval of 280 Grains of White Wax from the Male Urinary
Bladder.— By Orville Horwitz.
Pruritus Ani, with Especial Reference to its Local Treat-
ment.-—By Lewis H. Adler, Jr.
Miitter Lectures of the College of PLysicians of Philadel-
phia.— By John B. Roberts.
Intestinal Indigestion and its Consequences. — ]^y William
Henrv Porter.
Scarlatina Miliaris. — By J. P. Crozer Grifhth.
T/:c Lancet, May j, igoo.
Remarks on Vasectomy Relative to Enlarged Prostate and
Bladder Atony. — R. Harrison concludes: (i) That vasec-
tomy has been shown to be specially effectual in the eai-lier
stages of prostatic hypertrophy in producing shrinkage of
the gland and the restoration of the natural process of mic-
turition ; (2) that in cases in which there is evidence to show
that the prostate has in the course of degeneration assumed
the form and structure of a librous growth the conditions
are such, provided the symptoms of obstruction warrant
the adoption of other measuies than catheterism, as to
render some form of prostatectomy preferable to either
vasectomy or castration ; (3) that when as a consequence
of sudden or protracted prostatic obstruction secondary
changes have taken place in the bladder itself, in the form of
sacs, pouches, or trabeculation, the possibility of restoring
its natural function by any means is extremely unlike-
ly. Under such circumstances the induction of shrinkage
of the enlarged gland will do good in afliording a read-
ier access for the catheter and in removing spasm, pain, or
hemorrhage connected with this or other similar process.
The Causes and Treatment of Movable Kidney. — C. M.
Moullin calls attention to the fact that the kidneys are
normally movable organs. He confines his remarks to
those cases in which the kidney fails to re-ascend on tran-
quil expiration when the patient is standing upright and
has driven the kidney as low down as he can by forced in-
spiration. Causes of nephroptosis include tearing or
stretching of the bands of connective tissue which run
through the fat surrounding the kidney, and the relative
displacement of neighboring organs which, packed in
around the kidneys, keep them in proper position. They
are situated in a relatively unprotected position in the ab-
domen, and any sudden pressure, violent movement, or
lowering of intra-abdominal pressure can displace them.
The choice in treatment lies between wearing an abdomi-
nal belt and nephrorrhaphy.
Three Cases of Surgical Interest. — The cases reported by
T. F. Gardner are as follows: (i) Amputation for scirrhus
of the breast in a woman over eighty-two years of age.
The lumjj was first noticed two }'ears previously. The
patient did well, and there had been no recurrence in
nearly two years. (2) Ruptured pyosalpinx complicated
by fibroid tumor of the uterus, abdominal section, hyster-
ectomy ; recover)'. (3) Trephining for threatened cere-
bral abscess ; symptoms of meningitis ; arrest and recov-
ery.
The Effect of Alcohol on the Human Brain.— V. Horsley
traces the effect of alcohol upon the finer nerve elements,
and does not believe in the view so often advanced that
small doses of alcohol such as people take at meals in the
form of wines, etc., are harmless. He believes that from
a scientific standpoint total abstinence must be the only
course in view of the teaching of both truth and common
sense.
Colonial Practitioners and the Public— Presidential address
at the annual meeting of the New Zealand branch of the
British IVIedical Association, by W. Thomas.
Then and Now ; or the Influence of Modern Surgery upon
Medical Practice. — Hunterian oration by F. J. Smith.
Epidemiology of the Plague. — By F. Pearse.
British Medical Journal, May s. igoo.
Secondary Suture of the Brachial Plexus. — William
Thoruburn reports upon a case of comiilcte rupture of the
brachial plexus, in which for the first time suture was ef-
fected a long time after the injury. .Seven months after
an accident by machinery a girl aged sixteen j-ears pre-
sented paralysis of the arm, which was much wasted, and
there was absolute anccsthesia. An hysterical monoplegia
was the only condition which could confuse. In operating
a long incision was made in the posterior triangle of the
neck parallel to and just in front of the trapezius ; the
clavicle was divided and the cervical vessels were held
back with retractors. An irregular cicatricial mass repre-
sented the plexus, which was dissected out as a tense cord
two inches long and three-quarters of an inch thick. After
suturing the ends wound healing took place by first inten-
tion. Feeble though recognizable motion of all muscles
returned with muscular sense and localization.
Treatment of Lupus by the X-Rays. — R. E. Scholefield
presents, with special plate showing lupus of the nose in
various stages of the cure, an account of how the rays were
applied. The results were such as to make the author
wonder whether the rays from the tube might not have
the same effect as the photo-chemical rays of the solar
spectrum emplo\-ed by Finsen. He suggests that if dermal
tuberculosis may thus be cured by concentrated sun- or
.v-rays, why not pulmonary?
The So-Called " Stave of Thumb," or Bennett's Fracture.
— G. T. Beatson refers to Bennett's statement that when
fracture occurs in the metacarpal bone of the right thumb,
this is not "just above the middle," but at the base of the
bone. He relates a case seen sixteen days after the acci-
dent, when crepitus was still thought to be detected. All
supposed sprains of the right thumb should be subjected
to .i-ray investigation, as the fracture is liable to be over-
looked.
Fracture of the Carpal Scaphoid. — Sir William Stokes
says that without the .i-ray no surgeon can form a true
estimate of many osseous lesions. He gives, with special
plate illustration, an instance of the comparatively rare
lesion of carpal scaphoid fracture sustained in falling
twenty-one feet through an elevator shaft. In Dublin only
two cases have been noted. Tlie diagnosis could not have
been made w-ithout the aid of the Roentgen rays.
A Case of Fracture Dislocation of the Spine. — Ashley W.
Mackintosh reports a case in which there was complete de-
struction of the cord in tlie upper lumbar region. A synop-
sis of the case is given, with drawings illustrating the
lesions and areas of total ana?sthesia.
* An Example of the Use of the X-Rays in the Examination
of Enlarged Metatarso-Phalangeal Joints.— By G. H. Rod-
man.
The Therapeutic Value of the X-Rays in Medicine.— By
Edouard Schiff.
Deutsche medicinischc ]VochenscIirift, April 26, igoo.
The Pathology of Bronchial Asthma.— A. Fraenkel dis-
cusses the view held by Curschmann, that most instances
of bronchial asthma have underlying the condition a par-
ticular form of catarrhal affection' known as "bronchiolitis
exudativa, " and which Curschmann believes is a disease
siii generis. He also goes into the question of the presence
of Curschmann 's spirals in asthmatic catarrh. Two fatal
cases have proven correct his former belief that the ana-
tomical findings in the lumen of the bronchi are not always
the same. There exists, however, a bond of union be-
tween them all in the abundant epithelial desquamation.
Clinical Observations upon Excretion of Ammonia by the
Urine.— L. Michaelis says that the previously recognized
causative factors in the increase of ammonia in the urine
under certain pathological conditions can be placed in four
categories, which he goes on to describe. He then enu-
merates a number of clinical conditions in which he has
found a relatively large ammonia loss in the urine.
A Contribution to Physical Therapy.— By Professor Gold-
scheider.
MEDICAL RECORD.
[May 19, 1900
On the Technique of Abdominal and Pleural Puncture.— By
H. Hellendall.
On the Treatment of Obesity (Coucludedj .— By W. Eb-
stein.
Beyliner kliniscJte Woclicnschrift, April 23, igoo.
The Treatment of Naevus and Associated Congenital Vas-
cular Formations. — E. Hollander wannly advocates the
method of hot-air cauterization. Instead of the frequent
and painful cautery punctures, the operation can be done
at one sitting. There is no hemoiThage, so that the blood
in the diseased area is not abstracted from the body. The
cicatrix is a good one, and from its slight extent is hardly
perceptible. Finally the method is applicable to all sur-
faces, even those in cavities. It is contraindicated espe-
cially at subcutaneous sites in which a total capillary sub-
stitution has occurred, and when extirpation otfers a more
speedy result. The technique of the procedure is described.
The Nutrition and Diseases of Nurslings. — A. Baginsky
gives a general review of the vast progress made during
the present century in our conceptions of the matter of in-
fant feeding, and discusses the relative nutritive values of
mother's and cow's milk. He shows the relation of im-
proved feeding to general hygiene, and believes that it is
possible largely to eradicate, by care in this respect, many
of the affectioiis of the mouth, skin, ear, etc., which arise
from neglect in feeding and in hygienic management.
Weather, Duration of Sunshine, and Infectious Diseases. —
J. Ruhemann gives some meteorological statistics for
Berlin, showing that during the period of most sunshine
the amount of contagious disease is the least.
The Plague in the Light of Latest Researches.— By P.
Frosch.
Frcncli Journals.
Researches upon the Semeiological Value of the Toe Re-
flexes.— H. Verger and J. Abadie discuss the Babinski phe-
nomenon in its varied relations and also the antagonistic
refle.x of Schafer. They study the toe reflex in the normal
state and in pathological conditions, and conclude that the
sign is of delicate execution and open to many sources of
error ; it is frequently seen in lesions of the pyramidal
tracts, but is too variable to constitute a symptom of the
first order. It cannot be compared to the epileptoid trepi-
dation of the foot or patella. The antagonistic reflex of
Schafer has no semeiological value as a sign of ceveliral le-
sion. Schafer' s manoeuvre produces an effect of its own
independent of cutaneous excitation. This effect consists
in flexure of the toes in the normal as well as in the patho-
logical state. In cases of reflex hyperexcitabilit)' the effects
of excitation of the skin are felt before those from pinching
the tendon, and Schafer's manoeuvre can cause only exten-
sion of the toes ; but there is no question of antagonistic re-
flex.— Le Prpgrcs Medical, April 2S, 1900.
Early Diagnosis of Madness in the Biting Dog. — V. Babes
refers to his previous writings upon accumulated embry-
onal cells in the region of the central canal and the possi-
bility of making a rapid diagnosis of rabies bv examina-
tion of the bulb of a biting dog. Out of a large number of
examinations of bulbs from dogs dead from all causes, sent
to the author by the veterinary school, he has always been
able to pick out those whose death was due to rabies. Out
of four hundred and eighty-seven cases he has never de-
clared a dog mad which was not shown to be so. He dis-
cusses Van Gehuchten's views and method, and calls upon
antirabic institutes to test the two methods of rapid diag-
nosis and compare them.— Zrt Prcsse Malhalc, April 25,
igoo.
Pulmonary Gangrene after Gastro-Entero-Anastomosis for
Cancer.— J. J. Peyrot and G. Milian report tiie case of a
woman aged fifty-seven years o])crated on by Souligoux
according to his own method for gastro-entero-a'nostoniosis.
On the tenth d^y, after moderate fever, slight signs of
lung implication, pleurisy with slight effusion, fetid breath,
etc., there were sudden tearing pain in the right chest,
dyspncea, cyanosis, and rapidly following death. At the
autopsy gangrene was found, supposed to be due to septic
embolism from the gastric ulceration. This is looked upon
as one of the causes of the high death rate after stomach
ojK-rations. — La Prcsse Meduale, April 25, 1900.
Migratory Abscess becoming Autonomic— H. Morestin
speaks of certain abscesses in Pott's disease which become
isolated from the primary lesion, or shut off in such a way
as to be readily cured. The prognosis in this case is very
different from the majority in which connection with the
bony necrosis still persists. Two typical examples are
cited. One variety of abscess may continue to increase,
the other to grow smaller with atrophying walls and harden-
ing contents.— 6^rr.'<V/<- <lcs Jlopitai<\\ April 19, 1900.
Treatment and Prophylaxis of Gonorrhoea.- Claudio Fermi
thinks we should possess some short, efficacious, painless
treatment capable of warding off complications. He rec-
ommends a bulb syringe filled with 100 or 200 c.c. of per-
manganate solution I ; 200, nitrate of silver 1 : 500, protargol
1 : 500, or ichthyol i : 200, to be caiTied in a metallic box
and the solution to be squirted into the canal and sucked
out again at frequent intervals during the day. — Gazelle
lies Hopllaux, ISIay i, 1900.
Tetanus. — Ch. Dopter gives a clinical and therapeutic
study with symptomatology, prophylaxis, orrhotherapeutic
and other forms of treatment. Only the cases observed
from the beginning are suitable for intracerebral orrhother-
apy. Splanchnic tetanus is excluded by reason of its fatal
outcome and subacute motor tetanus, which carries off its
victim in two or three days. — Gazetic ties Hopilajt.x, April
2S, igoo.
Annals of Surgery, May, igoo.
Report of a Case of Recovery after Ligation of the First
Part of the Right Subclavian Artery for Aneurism of the
Third Portion. — A. E. Halsted reports this case, occurring
in a man aged sixty-three years. He believes that it is
the second case of recovery on record. He regards the
following points as worthy of consideration: (i) The
aneurism involved the entire third portion of the subcla-
vian and encroached slightly upon the second portion,
so that the only rational method of treatment was liga-
tion of the first part. (2) The subclavian vein was found
above the artery throughout its whole course. Owing to
this position of the vein, it was torn while efforts were
made to retract it downward so as to reach the artery exter-
nal to the internal jugular. As a result of this accident,
a considerable amount of time was consumed before the
hemorrhage could be controlled by lateral ligation of the
vein; and (3) the anomalous origin of the right subclavian
and the unusual depth of this vessel were for a time very
confusing. He would strongly recommend preliminary re-
section of the clavicle and a portion of the sternum in all
cases. In his opinion, it makes very little difference
whether the portion of the clavicle which is resected is
restored or not. In the case just reported the patient had
an almost perfect clavicle at the end of six weeks, al-
though the inner third, together with the upper end of the
sternum, had been removed. The ligatures employed in
this case were of formaldehyde catgut. The suggestion of
Souchon, of applying two or three non-contiguous absorb-
able ligatures, should be followed in all cases. The ordi-
nary surgeon's knot is all that is required. The ligatures
should be drawn sufficiently tight to occlude the vessel,
which can be determined by the cessation of pulsation in
the aneurism, and not tight enough to rupture the arterial
wall.
Complete External Dislocation at the Elbow. — R. Winslow
regards this case as belonging to th- "sub-epicondylar "
variety, in which the elbow is flexed to nearly or quite a
right angle and the forearm pronated ; the radius is placed
somewhat anterior to the ulna, and the great sigmoid cav-
ity is placed just below the external epicondyle. Reduc-
tion in this case under anaesthesia could not be accom-
plished, so twenty days after the injury causing the
dislocation a crucial incision was made on the back of the
joint and the parts were thoroughly exposed, the muscles
separated from the external condyle and from the olecranon
process, and a further attempt was made at reduction,
which failed entirely until the triceps muscle was cut quite
across, when the bones were made to resume their natural
relations. The triceps was sutured and the extensive
wound closed except a small ojiening left for drainage on
account of the free oozing which occurred. The triceps
tendon was found displaced to the outer side, and attached
normally to the olecranon process ; the other muscles were
also more or less out of their normal relations, but not
torn. The ulnar nerve was found stretched, and was care-
fully held out of the way with a hook, but it was not in-
jured ; subsequently the little fjnger and the inner side of
the ring-finger remained anaesthetic for some time. Of
course, all the ligaments of the joint were entirely rup-
tured. The radius retained its normal relation to the
ulna, and the functions of pronation and supination wei-e
unimpaired. Four weeks later the limb was in a useful
position with a considerable range of motion, but some
cedema of the parts.
Post-Diphtheritic Stenosis of the Larynx (Retained Intuba-
tion Instrument and Retained Tracheal Cannulae.— The late
J. O'Dwyer stated as the most common causes of obstruc-
tion under the conditions implied in the title, an cedema-
tous, chronically inflamed condition of the subglottic re-
gion, less commonly cicatricial tissue, and exceptionally
granulations from erosion by the tube. He also mentioned
the possibility of a post-diphtheritic paralysis of the laryn-
geal abductor muscles, but regarded this as extremely im-
probable. In the present paper J. Rogers, Jr., states that
the commonest cause of post-diphtherkic stenosis necessi-
tating long-continued intubation is a hypertrophy of the
May 19, 1-900]
MEDICAL RECORD.
88q
subglottic tissues accompanied by a chronic inflammation.
The intubation is in no way the cause of this, as it occurs
irrespective of the operation. Less often there is an ulcer-
ation, with subsequently the formation of a greater or less
amount of cicatricial tissue and contraction. This likewise
is not the result of the intubation except in rare and prac-
tically unavoidable instances. But it certainly may follow a
tracheotomy, and in a larynx already chronically stenosed,
it makes the condition worse but not necessarily more diffi-
cult to cure. Exuberant granulations within the larynx
apparentl}' do not occur with intubation, no matter how
p;olonged. The remedy for these conditions is the use of
a tube as large as can be crowded into the larynx.
Two Cases of CEsophageal Diverticulum, with Remarks. —
M. B. Richardson describes the cases, on both of which he
successfully operated. The number of cases now on rec-
ord is fifty-six. When excision of the pouch is imprac-
ticable or impossible, recourse should be had to gas-
trostomy to prevent starvation and to prolong life. These
pouches are to be regarded as protrusions of the mucosa
through the muscular coat. The primal cause is undoubt-
edly pressure together with the presence of scar tissue or
tissue weakened by unknown causes. A constriction of the
oesophagus is not necessary for their formation, for in all
the cases hitherto reported no stricture has been found.
A Contribution to the Surgery cf the Stomach, Including
Wounds, Gastrostomy, Gastro-Enterostomy, and Gastrectomy.
—By H. B. Delatour.
Dislocation of the Shoulder Complicated by Fracture
through the Anatomical Neck of the Humerus. — By C. B.
Brigham.
Report of a Case of Superficial Bilateral Gangrene with
Asymmetrical Lesions. — By G. K. Wilson.
Report of a Case of Actinomycosis Hominis of the Lungs.
—By J. B. Bullitt.
Tl'.c EdinbiiygJi JSIedical Joiij-nal, May, rgoo.
Some Practical Observations on the Early Diagnosis of
Cancer of the Stomach. — Carstairs Douglas gives detailed
directions as to the diagnosis of this condition. Palpation
is the most reliable method of clinical examination, the
great point in the method termed "dipping" being to take
the abdominal walls by surprise and bring the finger tips
against any sirbjacent hard structure before the muscles
have time to contract. Chemical examination of the stom-
ach contents should be made in doubtful cases; in the
large majority of cases of cancer of the stomach, free hy-
drochloric acid is absent a couple of hours after a test
meal, while in many cases it is found that lactic acid has
taken its place. When there is grave suspicion of malig-
nancy but a positive diagnosis is not possible, a surgeon
'should make an exploratory incision. Even if no tumor is
present, in some inexplicable wa}- the simple making of an
incision produces "some change of government," and the
patient finds that his symptoms are relieved.
On the Mechanism of the Intestinal Movements, and on
Reversal of the Intestine. — I. L. Bunch says that there are
three forms of intestinal movement : first, regular pendu-
lum movements, which take place at the rate of about
twelve a minute and travel along the wall of the intestine
at from 2 to 5 cm. per second ; second, the peristaltic wave,
which travels onl)' from above down and is independent
of connection with the central nervous system ; the third
form is best seen in animals recently killed. It travels .
rapidly, about ninety times as fast as the peristaltic wave,
both in an upward and a downward direction, but it is
seen only when the intestine is in a very excitable condi-
tion. This form of wave e.xplains the antiperistalsis which
is present in certain varieties of intestinal lesion. The
author studies the mechanism of these various movements
and reports various experiments upon animals.
Observation on the Excretion of Nitrogen in Rheumatoid
Arthritis. — William Bain i-eports a ca.se of marked I'heu-
matoid arthritis, in which an analysis of the urine made
for seven days gave the following averages ; Total
quantity of urine, 1,235 c.c. ; urea, 1S.S56 gm. ; uric acid,
0.266 gm. ; phosphoric anhydride, 0.986 gm. ; alloxur
bases, 0.033 g™- ; ammonia, 0.397 gm. ; lactic acid, ab-
sent. There was therefore a diminution in the excretion
of uric acid and phosphoric anhydride. It is stated that in
healthy individuals the excretion of viric acid varies from
0.3 gm. to 1.2 gm. Although the author has examined the
urine of a moderately large number of health)- people he
has never met with an excretion below 0.4 gm. The nor-
mal relationship between the uric acid and alloxur bases
was not disturbed.
Optic Neuritis in Children. — Leslie Buchanan says that
during the few past years he has seen several cases in
which a child, showing no evidence of present bad health,
suffers from atrophj- of the optic nerves ; or again, in which a
child with but slight signs of disease has moderately acute
optic neuritis. It was noticed that almost all such cases
showed more or less marked enlargement of the cervical
glands. LTnless another distinct cause can be found, if
either atrophy or inflammation of both optic nerves be seen
in a child or young person, the presence in the neck of en-
larged glands, even of very moderate size, is an indication
that there may have been, or may be, a meningitis or a
tuberculous growth in the brain.
Points of Practical Interest in Surgical Gynaecology ; I.
Some Points in Gyn2ecological Asepsis.— By H. Macnaugli-
ton Jones.
A Case of Transverse Myelitis, Showing an Abnormality
of the Spinal Cord.— By Walker K. Hunter.
The Clinical Varieties of Visual Aphasia.— By W Elder.
C^orrespoixdence.
OUR LONDON LETTER.
(From Our Special Correspondent.)
RErRESENTATIVE COUNCILLORS AND THE MIDWIVES BILL —
DR. HORTON-SMITH ON TYPHOID — RESISTANCE OF BACTERIA
TO COLD — SIR WILLIAM MAC CORMAC AND MR. TREVES —
MAJOR BABTIE, V.C.
London, April 27, 1500.
The somewhat lively discussion about the midwives bill
continues to occupy our attention. The relation of the cor-
porations, societies, medical council, and our representa-
tives on it is exciting acrimonious remarks. La.st week I
told you how Dr. Glover had found himself at variance
with a rather active committee who had challenged him to
appeal to the constituents, but of course he refuses to con-
sider himself a delegate. Prof. Victor Horsley has now
been cornered by the same committee. It is common
enough to hear these men spoken of as busybodies or as
lacking followers. That is no rare fate for reformers — or
for obstructives either. In this matter it is impossible to
doubt that a large number of practitioners consider their
interests have been betrayed, and it is far from improbable
that an election at this time would displace both these
representatives. I should regret this, for both are earnest
men, anxious to serve the profession, but are removed from
the anxieties and arduous life of the masses, and apparently
neither of them can in thought put himself in the position
of a struggling general practitioner. Both, too, have
friends among the managers of the Obstetrical Society and
hesitate to brand them as dealers in sham diplomas.
The matter was before the parliamentary bills committee
of the British Medical Association, when it was decided
to send a deputation to Sir John Gorst, who has charge of
the bill, to urge amendments. The association, if its mem-
bers were consulted, would repudiate the bill, but the
council and its committee have admitted the principle and
will not find it easy to avoid the consequences of their
error in assuming that they represent the body of members
who decline to follow them.
"There is not tlie smallest difficulty in distinguishing
the typhoid bacillus from what may be called the classical
bacillus coli communis." So said Dr. Horton-Smith in the
first of his Goulstonian lectures on the 20th ult. But I
should qualify this statement, and indeed the lecturer pro-
ceeded to say that we must recognize the fact that the term
bacillus coli refers not to a single microbe, but to a whole
group, some of which very closely resemble the typhoid
bacillus. Then he went on to describe the various tests
by which the diflferentiation can be established. Some of
these are long and tedious, and at any time additional mi-
crobes may be discovered — possibly still more closely re-
sembling the tj-phoid. Thtrefore I repeat I would qualify
the Goulstonian lecturer's statement, and with special em-
phasis I would add that it can be so easy only to the skilled
bacteriologist in a properly equipped laboratory. It may be
granted, as the lecturer holds, that in all cases the bacilli
pass into the blood, for they are very widely distributed to
the viscera. But they are not found in great numbers in
the blood during life. Perhaps the blood is a bad medium
for their growth and soon acquires the power of rapidly
destroying them, so that only those which reach a viscus
escape. If the blood for any reason failed to acquire this
power, the bacilli would develop in it and be found in large
numbers after death. The failure would indeed lead to a
fatal termination. As the bacilli gain entrance to the blood
and circulate to the organs and are to be found in the ex-
cretions, typhoid is no longer to be looked upon as a local
intestinal disease. Dr. Horton-Smith is inclined to regard
it rather as a modified form of septicaemia, inasmuch as in
all cases the bacilli pass into the blood, thence to the vari-
ous organs, producing symptoms of poisoning. But the
890
MEDICAL RECORD.
[May 19, 1900
septicaemia is modified, as there is almost always a defi-
nite, local, primary disease from which secondary dissemi-
nation of the bacilli takes place. Looked at in this way M-e
see why the severity of a case has no relation to the extent
of the intestinal lesion. There may perhaps be some ob-
jections to this view, but at least, I think, it seems about
time to discard the term enteric, for though usually the
starting-point of the disease is a lesion of the intestines,
the microbes speedily pass into the blood. Moreover, in
some cases they gain access to the blood without any ob-
vious intestinal lesion. The infectiousness of the faeces
has been long enough recognized and is often regarded as
the sole source of danger. But it now appears that the
urine may be equally dangerous, and expectoration, if
present in a case, is to be suspected. There is not much
evidence about the sweat, but it would seem that any se-
cretion might convey the microbe. The great point, how-
ever, is the extreme danger of urinary infection. Three
years ago Dr. Horton-Smi"tii was able to report that some-
times the microbe could be found in the urine. Now he
can definitely state that it is present in one out of every
four cases. As a rule it is late in the disease that it ap-
pears, perhaps after convalescence has set in. The dan-
ger, therefore, is increased at the very time it is too often
thought to have passed by. Not uncommonly the mi-
crobes are present in sucli extraordinary numbers that
I c.c. may contain 500,000,000. They are much more easily
detected 'than in the faeces, as they are almost always in
pure culture. They may set up cystitis, but this is not
necessarily so, and there may be no clinical symptoms. ^ It
seems that the urine in these cases is a favorable medium
for their growth. In other cases it is not. Thus, while
in one a few stray bacilli in the bladder speedily produce
enormous numbers, in other cases they perish. The ba-
cilli can be rapidly cleared out of the urine by a few doses
of urotropin, mostly within twenty-four hours, but it is
well to continue the drug for a week. It would seem then
desirable to give the drug in all cases ia order to prevent
infection through the urine — much more difficult to avoid
than in the fsces.
Writing so much about bacteria reminds me that Dr. A.
Macfadyeu and Jlr. S. Rowland lately communicated to
the Royal Society some experiments on the influence of the
temperature of liquid air on these organisms. The mi-
crobes experimented on include the tj-phoid, diphtheria,
anthrax, and several others. The intense cold had no effect
on their vitality. After being exposed to about — igo° C.
for a week no impairment of their vitality could be de-
tected. Cultures grew as well as before. It is wonderful
that such organisms were not injured by the mechanical
strain that must have ensued, to say nothing of the tem-
perature.
Sir W. MacCormac and Mr. Treves are both back in
London. ' A dinner is to be given them to-morrow. Sir
William has been interviewed by a Renter's agent and
talked about the wounds of the different rifles, the .i-rays,
the great value of hospital trains, and the slight loss in
killed compared with battles of the past. On these points
he could speak, but on the eft'ectiveness of artillery fire I
doubt if military men will accept his authority. As to the
adjective admirable applied to the provisions of the gov-
ernment, few of his countrymen will think it appropriate
to the War Office, even if he throws in his own engagement
to help.
Major W. Babtie, R.A.M.C, is awarded the Victoria
Cross for his gallant conduct at Colenso, of which you must
know the particulars.
Rhythmical Tongue Traction in a Case of As-
phyxia of Bulbar Origin. — J. V. Laborde quotes a
case reported by G. Schneider. A patient suffering from
typhoid fever suddenly showed alarming symptoms of
bulbar origin. The face was cyanosed; the conjunc-
tiv.'B were injected, and the pupils enlarged to the
maximum and immobile. There was intense trismus;
the respiration was hoarse, the neck swollen, the jugu-
lars were dilated and pulsating. Loss of consciousness
was almost complete. Rhythmical tractions of the
tongue restored normal conditions. As soon as the
patient became conscious he seized the forceps and
drew his tongue forward with desperate energy, and
continued to make rhythmical tractions for two hours,
until the occasional crises of asphyxia entirely disap-
peared. This he did by instinct and absolutely re-
fused to give up the forceps until respiration was en-
tirely free. — Bulletin tie i'Acadcmie de Mcdecine, March
20, 1900.
|]rtc(UcaT Items.
Contagious Diseases — Weekly Statement. — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending May 12, 1900:
Tuberculosis
Typhoid fever
Scarlet fever
Measles
Diphtheria
Laryngeal diphtheria (croup)
Cerebro-spinal meningitis. . . .
Chicken-po.x
Locating the Antagonism Dr. Virtue writes to
The PLwus as advice to physicians choosing a loca-
tion, that they " shall call on every reputable physi-
cian in the locality as an act of courtesy, and in this
way to find out who will antagonize them in the new
field." In other words, "Will you kindly allow us to
come in ? "
Michael Angelo's Physique and Health — Michael
Angelo is described as having been of middle height
and broad across the shoulders. He was not fat and
his features were marked, his forehead being square.
His nose had been broken in early life by a blow from
a fellow-student, which had caused permanent disfig-
urement. In some of his portraits this is represented;
others give him a good nose of Roman type. He had
been weakly in youth and probably dyspeptic, for
through life he w^as very careful in his diet. He was
accustomed to say : " However rich I may have been,
I have always lived as a poor man." In spite of this
care, however, he suffered late in life from gravel and
stone. It is on record that he had much trouble with
cramp in his legs. His father had attained the age
of ninety-two years, end he himself was only a year,
short of ninety when he died, having retained his fac-
ulties to the last. — Hutchinson's Archives of Surgery.
Alcohol and Hard Work. — In the current number
of a small serial, entitled The Medical Temperance
Re-t-ieii.', is a short paper on the above subject by Dr.
Sims Woodhead. The writer points out that the
greatest amount of work can be done only by com-
pletely abstaining from alcohol, or, in other words,
that alcohol hinders us from accomplishing the maxi-
'mum amount of work of which our bodies and minds
are capable. Now there may be another way of re-
garding this which perhaps might be urged by our
moderate drinkers. We were not created to be beasts
of burden as regards our bodies, nor yet to exercise
our brains until our nerves became shattered. So that
the administration of a little alcohol to those who be-
lieve we should be working every moment of our lives
might be of the greatest service in restraining an out-
put of energy which must undoubtedly be pathological.
Numbers of youths at our universities break down at
a critical period of their lives from sheer overwork,
which tiiey are not sufficiently discouraged to attempt
by their responsible teachers. In the same number is
a short statement on this subject by the late Sir An-
drew Clark, who, curiously enough, was himself a
moderate drinker. He instances an experiment by
Dr. Parkes, of Netley, who set two gangs of men to
work; one gang was liberally supplied with beer, the
other gang being deprived of all alcohol. By the end
of the day the beer gang was left hopelessly behind.
Now, the only inference we can draw from this experi-
ment is that men in a state of intoxication or semi-in-
May 19, 1900]
MEDICAL RECORD.
891
toxication are incapable of hard work. No one denies
that to place gallons of beer beside workingmen is on
a par with placing, say, a quart of Fowler's solution
beside a choreic patient. What we desire is to have
the effect of alcohol tested with the same scrupulous
regard to dosage and conditions as in the case of
toxin, antitoxin, digitalis, or any other similar agent.
Isolation for Consumptives. — When we demand
isolation for cases of tuberculosis, we are, I think,
fanatics; that is, we are driving hard one set of argu-
ments with a blind eye to contingent and conflicting
considerations derived from the other circumstances
which we ignore or to which we are insensible. This
is to be " logical," as the French call it. Would it
have been for the public good to have isolated Henry
Bennet or Andrew Clark in the midst of a beneficial
career, or now on early suspicions to carry off young
people to desert islands, or to banish a bread-winner
on the rather remote chance of consequences which we
are learning successfully to neutralize? — Dr. Chal-
mers, in London Practitioner.
Disappearance of Beri-Beri from the Japanese
Navy. — Dr. Tatsusabaro Yabe, head of the medical
department of the Japanese navy, relates in the Ar-
chives de Medeci>ie Navale how kakke or beri-beri has
to all intents and purposes disappeared from his
branch of the service. Before 1884 the proportion of
men affected during the summer was rarely below
twenty-five per cent., and sometimes it reached forty
per cent. M. Kanebiro Takaki then suggested an
improvement in the food (which was composed mainly
of rice) by the addition of pearl barley, with the result
that from 1885 to 1895 there were only three fatal
cases of beri-beri, all of which occurred during the
war with China, when the supply of rice failed.
Typhoid Fever in South Africa. — The terrible
ravages of typhoid among both troops and civilians
in South Africa is a matter for very serious consid-
eration by the government in the Soudan, 5nd in Cuba
. the same state of matters existed. Typhoid seems to
be the great scourge of our modern armies. The great
desideratum is not to allow it to get a chance so far
as is humanly possible. Once a case or two occurs,
it seems impracticable to arrest its spread where such
crowds are huddled together, lioiling and filtering,
the only remedies for infected water, are neglected, it
is to be feared to an unwarrantable extent. Accord-
ing to a correspondent in the British Medical Journal,
the type of fever differs from that found in England.
Rash is usually absent; the temperature is more of the
continuous type, while diarrhoea is generally in abey-
ance until about the third week, and is then of a mild
character. Notwithstanding, the necropsy shows the
typical lesions. The fever is often extremely pro-
longed and may assume an intermittent character. — •
Medical Magazine.
Smoking among the Young. — The medical officer
for the city of Perth, Scotland, in his annual report
refers to the prevalence of smoking among the young
of his neighborhood, and calls attention to the harm-
fulness of the habit in the following words: "Exces-
sive smoking, while not so common a cause of serious
disease as excessive drinking, is still a sufficiently
powerful factor to cause disturbances in the various
systems of the body. While adults may enjoy the
benefits of the moderate use of tobacco without harm,
smoking to the slightest extent is productive only of
injury to young people by checking their physical and
mental growth. Societies taking an interest in the
welfare of children have given recommendations to
parents how good would result if deterrent nieasurse
were employed, and some people suggest that the fault
lies at the door of the adult members by providing
children with the bad example. The thought of cur-
ing the evil habit among children by asking men to
refrain from smoking requires no comment. Deter-
rent measures have, I fear, little effect, and while I
give credit that the vast majority of parents are op-
posed to their children's smoking, and use what means
they can to prevent it, yet the evil is done when out of
their sight. Legislatures have in some other countries
adopted means to stay the evil, but in Britain nothing
of this nature has as yet been attempted. Municipal
authorities have no legal powers, but there is one way
in which I believe the practice of cigarette smoking
among the youth could be greatly decreased, and it is
a very simple one — viz., a recommendation to all those
having a license to sell tobacco to restrict the sale of
cigarettes unless in such quantities as to put them
beyond the reach of children. Thus, if only sold in
packets, for threepence (six cents) as a minimum, it
is my belief we would have a means of seeing less
cigarette smoking, because it is not in the nature of
children to spend such a sum on any article."
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended May 12,
1900 :
Smallpox — United States.
Cases. Deaths,
Alabama, Mobile April 26th
District of Columbia, Wash-
ington A pril 26th
Florida, Jacksonville . . ..April 26th
Indiana, Evansville April 26th
Indianapolis April 26th
Iowa, Des Moines April ist tc
Ottumwa April 14th
Kansas, Wichita April 26th
Kentucky, Covington April 26th
Le.xineton April 26th
Louisiana, New Orleans ....April 26th
Maryland, Baltimore April 26th
Massachusetts, Chicopee ... April 26th
Michigan, Grand Rapids ...April 26th
Nebraska, Omaha April 21st
New York, New York April 26th
Ohio, Cleveland April 26th
Tennessee, Nashville April 26th
Utah, Ogden , April ist t
Salt Lake City April 26th
Philippines, Manila March 3d
to May 5th 4
to May 5th I
to May 5th I
to May 5th 5
to May 5th 6
3 joth 16
to May 5th 4
to May 5th ... 6
to May 5th I
to May 5th 50
to May 5th 5
to May 5th I
to May 5th 3
to 28th 2
to May 5th 2
to May 5th 7
to May 5th 2
o 30th 2
to May 5th 5
to 24th 9
Smallpox— Foreign.
.\ustria. Prague April 7th to 21st 9
Belgium, Ghent April 14th to 21st
Brazil, Rio de Janeiro .... March 23d to 30th 6
Canada, New Brunswick,
Grand Falls, and St Leon-
ards April 28th Present.
Canada, Province of Ontario.April 18th to May ist 3
Quebec, Bonaven-
ture County May 4th 26
England, Liverpool April 14th to 21st 18
London April 14th to 21st 4
Southampton .-Vpril 14th to 21st 2
France, Lyons April 1st to 14th
Gibraltar April 15th to 22d 2
Greece, Athens April 14th to 21st 2
India, Bombay April 3d to loth
Calcutta March lolh to 17th
Kurrachee April ist to 8th 20
Italy, Milan April 21st to 28th i
Mexico, Vera Cruz April 21st to 28th
Russia, Moscow April ist to 7th 7
Odessa April 7th to 21st 24
Warsaw April ist to 4th
Scotland, Glasgow April 14th to 21st 6
Spain, Corunn'a April 14th to 21st
Straits Settlements, Singa-
pore March loth to 17th
Venezuela, Maracaibo April 7th to 14th i
Yellow Fever.
Brazil, Rio de Janeiro March 23d to 30th
Santos February i8lh to April 8th .
Mexico, Vera Cruz April 21st to 2Sth
India, Bombay.. , April 3d to icth
Calcutta March loth to 17th
Plague— Insular Possessions United States.
Philippines, Manila March 3d to 24th 15
Plague— Foreign.
Arabia. Aden February 21st to April Mlh 119
Egypt, Port Said Ma); 4th Outbreak i
loth
: ported.
Calcutta March loth to 17th
Kurrachee April ist to 8th 47i
892
MEDICAL RECORn.
[May 19, 1900
Medical Record:
A Weekly Journal of jMcdicine and Surgery,
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 51 Fifth Avenue.
New York, May 19, 1900.
CONCERNING THE PLAGUE.
From almost every part of the world the news is being
constantly sent that plague has broken out or is on
the increase. In the East generally, and especially
along the shores of the Red Sea, the disease is spread-
ing with alarming rapidity. In Egypt there has been
a recrudescence. In Manila its inroads are assuming
alarming proportions. It is raging in New Caledo-
nia. In Buenos Ayres there has been an epidemic
since the middle of March. In India the deaths from
plague average about five thousand a week, and it is
computed that since the first outbreak five years ago
the enormous total of two hundred and fifty thousand
persons have perished by its agency. The pest has
made its appearance on shipboard off Cape Town.
There have been one or two cases in San Francisco,
and lastly, according to latest accounts, it seems to
have gained a foothold in Australia. In Sydney,
within the past three months, there is said to have
been nearly two hundred cases, with a mortality of
more than fifty, while Melbourne, Brisbane, Perth, and
Auckland are experiencing visitations of the disease.
The persistency of its stay in Sydney, and its contin-
ued dissemination throughout Australia, are the most
sinister features in connection with the plague so far
as civilized countries are concerned.
There is no doubt that individuals of the white race
are less prone to contract plague than are Asiatics, but
that they enjoy an immunity has now been altogether
disproved. Nor unfortunately, with the experience of
Australia before our eyes, does it appear that good
sanitation is an absolutely sure safeguard against a
plague invasion. When several cases occurred in
Oporto, the filthy condition of that city was regarded
as the cause, and the assertion was confidently made
that in the more or less cleanly towns of Europe out-
side the Iberian peninsula it would be impossible for
the plague to last or spread. This comforting belief
has received a decidedly rough shock, for the sanitary
condition of Sydney is quite equal to that of the aver-
age European town and infinitely better than that of
Oporto. Yet from the latter city the plague was ap-
parently quickly driven out, while in the former and
more healthy place it is every day increasing. The
truth is, so little is known about the plague that it
is an act of unwisdom to dogmatize concerning it in
the slightest degree.
The fact that rats are an important, if not the most
important, factor in disseminating the plague is gradu-
ally being appreciated. Another point to w'hich no-
tice has been drawn of late is the peculiar difficulty
of correctly diagnosing the disease. Professor Simp-
son, referring to this phase of the subject in The
Lancet, April 14th, says: "The difficulty of diagnosis
of plague arises from the several types and forms
which it assumes, and unless the medical man is on
the alert for plague and is fully conversant with the
types the disease may easily at its commencement es-
cape attention. ... A disease which may be mistaken
for yellow fever, gastro-enteritis, typhus fever, diph-
theria, influenza, syphilis, malaria, and parotitis is one
in which diagnosis from clinical symptoms is by no
means easy." The glandular or bubonic, the most
frequent form of the disease, is comparatively easy to
diagnose, its characteristic feature being, as its name
denotes, the appearance of a bubo occurring in most
cases in the region of the thigh or groin, often under
the arm, or in children on the neck. In a few in-
stances, however, the buboes appear on different parts
of th-e body.
The department of health of Berlin has recently is-
sued a circular of instructions in regard to the plague,
dealing especially with its clinical symptoms, which
has been reprinted in Public Health Reports, April
20th. This circular places the number of forms under
which the plague presents itself as three^glandular,
skin, or lung plague. In regard to skin plague it
says: '"'Plague pustules and plague carbuncles are not
frequent as compared with plague buboes. They be-
gin with a spot about the size of a flea-bite or a pea
on some part of the skin. From this very painful
spot there develops a blister filled with cloudy matter.
It then either retains the character of a pustule or the
surrounding tissue becomes hard and thick, later de-
veloping into a deep carbuncle and then into a burn-
ing swelling. Inflamed lymph vessels may convey the
infection to the nearest layer of glands, in which then
a bubo may grow. A bubo may also make its appear-
ance in the neighborhood of a carbuncle." Pneumonic
plague is the most difficult of diagnosis. In some
epidemics it is the most common form and generally
closely resembles an ordinary violent catarrhal or
croupous pneumonia, while on occasions it is ex-
tremely similar to other inflammations of the lungs.
The Berlin circular says: "In all forms of plague the
early appearance of heart weakness is noted, together
with irritation of the stomach and abdomen, extreme
sensitiveness to pressure in the region of the epigas-
trium and the caecum, violent nausea, and later also
the expulsion of black fecal matter. A slight degree
of swelling of the abdomen is the rule; soft swelling
of the spleen and traces of nucleo-alburain and serum-
albumin in the urine, bloody vomit or blood in urine
are less frequent. A diphtheric affection of the ton-
sils is often found in the early stages."
It is needless to say that not only has no specific
been as yet discovered in the treatment of the plague,
but that ordinary curative measures have but little
effect on its course. The therapeutic value of anti-
plague serum has been by no means decisively proven.
May 19, 1900]
MEDICAL RECORD.
893
British physicians who have investigated Yersin's
cases place but little faith in his statistics claiming
favorable results. The following is the report of the
British plague commission treating of Haffkine's anti-
plague inoculation :
"i. Inoculation sensibly diminishes the incidence
of plague attacks on the inoculated population, but
the protection which is afforded against attacks is not
absolute. On the one hand plague has attacked per-
sons who have undergone inoculation as many as four
times in the course of two years previous to their at-
tack. On the other hand, as many as eight per cent.
of the inoculated population may suffer from plague.
Many varying influences have been at work in deter-
mining the rate of attack in different places, and it is
impossible to give a numerical expression for the
measure of protection against attack which inocula-
tion confers.
"2. Inoculation diminishes the death rate among
the inoculated population. This is due not only to
the fact that the rate of attack is diminished, but also
to the fact that the fatality of the attacks is dimin-
ished. Here again no numerical expression for the
amount by which the death rate is diminished can be
given.
"3. Inoculation does not appear to confer any great
degree of protection within the first few days after the
inoculation has been performed. This fact, we may
note in passing, has an important bearing on the risk
of infection which would be incurred by recently inoc-
ulated persons if they were left behind in surround-
ings so plague-infected as to render theiP evacuation
by the uninoculated desirable.
"4. Inoculation confers a protection which certainly
lasts some considerable number of weeks. It is pos-
sible that the protection lasts for a number of months.
The maximum duration of protection can only be
determined by further observation.
" 5. The varying strength of the vaccine employed
has apparently had a great effect upon the results
•which have been obtained from inoculation. There
appears to be a definite quantum of vaccinating mate-
rial which gives the maximum amount of protection,
and provided that this quantum can be injected in one
dose, and provided also that the protection turns out
to be a lasting one, re-inoculation might with advan-
tage be dispensed with. The best results from inocu-
lation will only be obtained after an accurate measure
of standardization has been devised."
This somewhat non-committing report, although cer-
tainly a not enthusiastic eulogy of Haffkine's serum,
nevertheless points to the fact that under certain con-
ditions its use is valuable. Now that plague is preva-
lent in the Philippines and in other parts of Asia with
which this country is in constant communicatiov, it is
essential that every precaution should be taken to keep
out the disease. Rigid quarantine and a wholesale
destruction of rats are measures of the first impor-
tance, while second only to these is the need that
physicians, and especially port health officers and
members of the boards of health, should be able to
diagnose accurately cases of plague. Professor
Simpson makes the following recommendation to
the government of England, which should be equally
applicable to that of the United States, viz., that
under the auspices of the government there should be
instituted a course of instruction on plague, to be at-
tended in batches by the medical officers of the
country.
THE HOSPITAL TREATMENT OF PULMO-
NARY TUBERCULOSIS.
Other things being equal, it may be admitted that
certainly not less good results should be obtained in
the treatment of pulmonary tuberculosis at home than
in institutions. If, however, nursing, care, food, sani-
tary conditions, and the like are open at all to suspi-
cion at home, the chances for the patient are much
better in a well-equipped hospital. How successfu'
may be the results under the latter condition is illus-
trated by Schaper {Be/iiner klhiische Wochenschrift,
1900, No. 12, p. 253), who presents in tabular form the
statistics of the Charite Hospital in Berlin for ten
years, from 1889 to 1899. In the year 1889-go recov-
ery or improvement took place in 45.7 per cent, and
death in 54.2 per cent, of the cases of pulmonary tu-
berculosis, and in the year 1898-99 recovery or im-
provement in 54.8 per cent, and death in 34.3 per
cent, of the cases. These satisfactory results are at-
tributed, among other things, to early diagnosis, to
better care, the more effective medication, and the re-
lation between the hospital and the sanatorium. In
the Institute for Infectious Diseases, which was opened
in 1892-93, recovery or improvement took place in
sixty-one per cent, and death in twenty-three per cent.
of the cases of tuberculosis received during the first
year, and recovery or improvement in sixty-one per
cent, and death in twenty-nine per cent, in 1898-99.
The conclusion to be drawn from these experiences
is that with further improvement in hygienic condi-
tions still better results may be possible and should
be secured. In addition, special institutions will have
to be organized for the care and treatment of incurable
cases of tuberculosis.
The Spitting Nuisance. — At a recent meeting of
the board of health, the section of the sanitary code
relating to spitting in public places was made more
stringent than before, the prohibition being extended
to cover the station platforms and stairs of the ele-
vated railroads, as well as the floors of cars, ferry-
boats, and public buildings. Notices of this prohibi-
tion must be kept posted wherever the prohibition
applies; and janitors of buildings, conductors of cars,
and employees of ferry-boats and on station platforms
are directed to call the attention of all violators of the
ordinance to those notices. A rule has also been
established that in every cigar manufactory and print-
ing-establishment where ten or more persons are em-
ployed, receptacles for spitting, in the proportion of
one receptacle for every two persons, must be provided,
and all such receptacles must be cleaned and disin-
894
MEDICAL RECORD.
[May 19, 1900
fected at least once during each working-day. All
these rules are excellent, and the only objection any
one can have to them is that not the slightest attempt
is ever made to enforce them. Inoffensive citizens
shrinic from calling down curses upon their heads by in-
sisting upon the arrest or ejection from a public vehicle
of a spitter, and the conductors are themselves too
much attached to the habit of expectoration to repre-
hend it in others. The Times of this city says very
justly that "either the spitting provision of the code
is foolishness and should be repealed, or it is as much
the duty of the health department staff to enforce it as
to seize diluted milk or immature veal." And it sug-
gests that the "physicians, sanitary engineers, inspec-
tors, and detailed policemen of the sanitary squad,
constituting the administrative staff of the health de-
partment, set the example not only of respecting the
law, but of enforcing it in the cases of those who do
not. As salaried employees of the city, whose espe-
cial business it is to do whatever will promote or pro-
tect the public health, it is quite within their duties
to aid in enforcing the provisions of the sanitary
code."
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C, May 12, 1900. — Changes in
the medical corps of the United States navy for the
week ending May 12, 1900. May 7th. — Surgeon G.
P. Lumsdon ordered to the Kentucky May 15, 1900.
Assistant Surgeon G. F. Freeman detached from the
Naval Hospital, Washington, D. C, May loth, and
ordered to the Essex. Assistant Surgeon C. H. De-
Lancy detached from the Essex when relieved, and
ordered to the' Naval Hospital, Washington, D. C.
May loth. — Passed Assistant Surgeon S. G. Evans
ordered to the Kentucky May 15, igoo. Passed Assis-
tant Surgeon W. C. Braisted detached from the De-
troit when put out of commission, and ordered home
and to be ready for orders to sea.
The Medical Course at the University of Ha-
vana.— A committee, consisting of Drs. (Jasuso. Me-
nocal, Nunez, and Vildozola, which was appointed
some time ago by General Wood to revise the course
of medical studies at the University of Havana, has
recently made its report. According to this report,
published in the Archivos de la Policliuica of April 29th,
it is recommended that the old system of instruction
be abandoned and that the course pursued in English
and American colleges be followed. The course is
to cover four years, and candidates for admission must
be at least eighteen years old, and must possess the
degree of Bachelor in Letters and Science of the Cu-
ban colleges, or a foreign equivalent recognized in
Cuba. Much opposition developed to the report be-
cause it recommended the Anglo-Saxon system. The
supporters of the Latin system protested, but when it
was shown that the French faculties had made a reor-
ganization on the same basis they accepted the change.
The candidate for the degree of M.D., after having
completed the course and been admitted to examina-
tion, must present a thesis which will be submitted to
a jury of five who will determine whether or not it is
" admissible." If the decision is favorable, the candi-
date will be obliged to sustain the thesis in public.
The course begins in September each year, and clini-
cal study is an essential to graduation.
Philadelphia Hospital.— Dr. H. B. Allyn, formerly
registrar, and Dr. D. Riesman, formerly assistant
pathologist, have been elected physicians to the P4iila-
delphia Hospital, in succession to Drs. Samuel Wolfe
and F. A. Packard, resigned.
Philadelphia County Medical Society At a stated
meeting held May 9th, Dr. William S. Thayer, of
Baltimore, presented a communication entitled "Re-
cent Additions to our Knowledge concerning the Life-
History of the Malarial Parasites."
Dr. Jameson, of Transvaal fame, who has been very
ill, presumably with typhoid fever, is reported to have
entirely recovered. He is said to be going into poli-
tics, and is mentioned as a candidate for one of the
seats in the Cape parliament, representing Kimberley,
in succession to Dr. Frederic Rutherford Harris.
Medical and Chirurgical Faculty of Maryland.
— The next annual meeting of this society will be held
the last Tuesday, Wednesday, and Thursday in April,
1901. The following are the officers for the ensuing
year: President, Dr. Samuel Theobald; Vice-Fiesi-
dents, Drs. Samuel T. Earle, Jr., and J. B. R. Purnell;
Secretary, Dr. J. Williams Lord; Treasurer, Dr. Thom-
as A. Ashby.
Again th*e Fasting-Cure.— A disciple in Philadel-
phia of a medical man who recommends starvation for
the treatment of various diseases, having himself re-
covered from digestive disturbances under such treat-
ment, has been recommending a similar course to
others. To the fact that the method is not infallible
the death of one of the patients has brought a rude
awakening. In this instance, however, death was not
attributed to the system, but to "a cancer or severely
ulcerated condition of the patient's stomach." The
patient had fasted for fifteen days, and is said to have
shown marked improvement. We fear the results in
this case are like those occasionally reported by sur-
geons in which death ensues, although the operation
is successful.
Philadelphia Pediatric Society At a stated meet-
ing held May 8th, Dr. D. J. Milton Miller read a
paper entitled " Brief Notes of a Case of Acute Leu-
kasmia in a Child Eight Months Old." A thorough
examination of the blood could not be made, but the
number of leucocytes was greatly increased, while
the number of red corpuscles was diminished and the
spleen was enlarged. Dr. S. C. Peter reported a case
of facial diplegia due to middle-ear disease. The
patient was a girl fourteen years old, in whom in con-
nection with bilateral otitis media complicating scar-
let fever, first the facial nerve on one side and then
that on the other side was paralyzed. Dr. Alfred
Hand, Jr., reported a case of intussusception in a
four-months-old infant relieved by injection. Some
days after reduction had been effected symptoms of
May 19, 1900]
MEDICAL RECORD.
895
recurrence made their appearance, but these subsided
spontaneously. It was thought that the use of pare-
goric exercised a useful therapeutic influence.
The New York State Medical Association — The
sixteenth annual meeting of the Fifth District Branch
will be held in Wurzler's building, 315 Washington
Street (near City Hall Square), Brooklyn, on Tues-
day, May 22, 1900, under the presidency of Dr. J. C.
Bierwirth, of Brooklyn. The secretary of the branch
is Dr. E. H. Squibb, of Brooklyn. The president's
address will be on " The Necessity and Benefits of
More Completely Organizing the Medical Profes-
sion." The afternoon session will be devoted to a
discussion on " Diabetes Mellitus," to be participated
in by Drs. Heinrich Stern, Egbert la Fevre, Henry
Dwight Chapin, Charles P. Gildersleeve, L. A. VV.
Alleman, Samuel Sherwell, and Jonathan Wright.
The Plague ^Honolulu is once raore^ free port,
as the quarantine was lifted on April 30th The offi-
cial declaration that the plague is at an end is con-
firmed in the lay mind by the fact that rats are return-
ing to Honolulu, as it is a popular belief that the
animals never return to plague-infected places. — From
India it is reported that the epidemic in all the in-
fected places is showing a general decline, but in
Hong Kong it is now increasing. Fifteen thousand
Mohammedan weavers met in Benares on Sunday last
and signed a protest addressed to the Indian govern-
ment against the plague rules, declaring that these
were contrary to the laws of Mohammed. — The plague
is also reported to have reappeared at Alexandria and
several other places in Egypt.
Famine and Cholera in India. — A recent despatch
from Lord Curzon to the Secretary of State for India
in London states that the famine conditions have ma-
terially improved in Madras and Mysore in conse-
quence of the recent rains. In the remainder of the
afl^ected tracts the distress is increasing in intensity,
owing to the want of fodder and water and the in-
creasing heat. The number of persons now in receipt
of relief is 5,617,000. — Regarding cholera, the Bom-
bay correspondent of The London Times says that the
disease continues to rage in the famine camps. There
were four hundred deaths in three days at Mandivee.
So numerous are the cases at Godra that it is impos-
sible to collect the bodies, and they lie for days in
the sun. The people have fled and cannot be induced
to return. A similar state of things prevails at
Broach.
The St. John's Guild.— Mrs. Augustus B. Juil-
liard, who last year presented the second floating hos-
pital to St. John's Guild, has laid the foundation for
a permanent fund by a gift to the guild of $50,000,
the interest of which is to be used toward defraying
the expenses of operating the floating hospital, the
Helen C. Jiiilliard. Mrs. Frederick Elliott Lewis
will build a cottage hospital on the Seaside Hospital
grounds at New Dorp, S. I., in memory of her little
son, Frederick Chandler Lewis. The building, which
will be known as the "Lewis Memorial Cottage of
St. John's Guild," is to be detached from the other
buildings of the group and will be for the care and
treatment of very sick infants. It will contain two
wards for eight babies each, a diet kitchen, labora-
tory, bath, and irrigating-rooms. The hospital will
be completed in time for use this season.
Practitioners' Society of New York The follow-
ing officers were elected for the ensuing year: Fresi-
dent, Dr. A. Alexander Smith; Secretary, Dr. Walter
B. James.
The Medical Society of the State of North Car-
olina will hold its forty-seventh annual meeting at
Tarboro on May 22d, 23d, and 24th, under the presi-
dency of Dr. George VV. Long, of Graham. The sec-
retary is Dr. George VV. Pressby, of Charlotte.
Dr. Georges Apostoli, of Paris, who was for many
years an ardent advocate of the treatment of uterine
fibroids by means of electrolysis, died recently at the
age of fifty-three years. He was a voluminous writer
on electro-therapeutics and was editor of a journal de-
voted to this subject.
The Stickler Memorial Library Ground was
broken on Saturday last for the Stickler Memorial
Library, which Mr. and Mrs. Joseph W. Stickler, of
Orange, N. J., are to erect in memory of their son, the
late Dr. J. W. Stickler, who died suddenly in New
York about a year ago.
The Yale Medical School The Yale University
authorities are negotiating for the purchase of a site
for a new medical school adjacent to the New Haven
Hospital. The land will cost about $75,000. The
building now used as a medical school is not large
enough nor suitable in other ways for the work of the
medical department of Yale, nor is it convenient to
the hospital.
The American Medical Editors' Association will
meet in annual session at Atlantic City on June 4,
1900, the day preceding the meeting of the American
Medical Association. The president of the associa-
tion is Dr. I. N. Love, of St. Louis, and the secretary
Dr. Dillon Brown, of New York. It is reported that
the annual sermon by Dr. George M. Gould will be
omitted this year in deference to the wishes of the
president of the association.
The Dental Society of the State of New York
held its annual meeting at Albany last week. The
following officers were elected for the coming year:
President, Dr. John J. Hart, of New York; Vice-Presi-
dent, Dr. R. H. Holheinz, of Rochester; Recording Sec-
retary, Dr. W. L. White, of Phelps; Treasurer, Dr. G.
W. Stainton, of Buflfalo; Corresponding Secretary, Dr.
Henry D. Hatch, of New York. Drs. William Jarvie.
of Brooklyn, and F. C. VValker, of New York, were
recommended to the board of reg-ents as dental ex-
aminers from the second district, and Drs. S. B. Pal-
mer, of Syracuse, and A. Detter, of Utica, from the
fifth district.
Artificial Immunity against Tuberculosis — Dr.
Tatsusaburo Yabe of the Japanese navy states, in the
introduction of an article on " Immunity against Tu-
896
MEDICAL RECORD.
[May 19, 1900
berculosis," published in the Sei-l-Kiuai Medical Jout-
fiai of March 31, 1900, that he has discovered a means
of effecting this desirable result. In the course of his
studies in the Pasteur Institute of Paris, he has proved,
he says, that Koch's tuberculin is a false toxin pos-
sessing no immunizing properties whatever. He has
himself discovered in tubercle bacilli a substance pos-
sessing bactericidal properties and another which con-
fers antitoxic immunity. By means of progressively
increasing doses of one of these substances or of a
mixture of the two injected into healthy guinea-pigs
he was able to obtain immunity in them against injec-
tions of pure cultures of tubercle bacilli; and the
same injections in the case of tuberculous guinea-pigs
effected a cure, the bacilli disappearing before the tu-
bercles. He asserts, therefore, that it is possible both
to confer immunity against the disease in case of th'"
well and to obtain a cure in those already tuberculous.
St. Luke's Hospital The Rev. George F. Clover,
for many years assistant pastor and superintendent at
St. Luke's Hospital, has been appointed full superin-
tendent in place of the Rev. Dr. George S. Baker,
whose resignation was recently accepted by the board
of managers.
The Michigan State Medical Society.— The thirty-
fifth annual meeting of this society will be held at the
Grand Hotel, Mackinac Island, July nth and 12th.
The annual meeting of the Upper Peninsula Medical
Society will immediately precede that of the State
society, and a joint session of the two will be held to
commemorate the achievements of Dr. Beaumont,
whose celebrated investigations in gastric digestion,
conducted upon Alexis Saint Martin at Mackinac in
1825, the former society will memorialize by an ad-
dress and the erection of a tablet. The address on
medicine will be delivered by Dr. Albert E. Carrier;
that on surgery by Dr. Oliver A. LaCrone; and that
on gynaecology by Dr. Eugene Boise. The subjects
for set discussion will be: in the medical section,
" Diseases of the Stomach " and " Tuberculosis "' ; in
the surgical section, "Appendicitis," " Hysterectomy,"
and " Eclampsia." The president of the society is Dr.
Austin W. Alvord, of Battle Creek, and the secretary
Dr. Collins H. Johnston, of Grand Rapids.
Camden (N. J.) District Medical Society At
the annual meeting held May 9th, the following officers
were elected for the ensuing year: President, Dr. J.
T. Leavitt; F/^-P/w/Vj'c;//, Dr. W. R. Powell ; Secre-
tary, Dr. P. M. Mecray; Treasurer, Dr. E. R. Rams-
dell; Historian, Dr. H. H. Sherk; Reporter, Dr. J. G.
Doron ; Standing Comtnittee, Drs. J. S. Baer, J. E.
Hurff, J. W. Marcy, W. A. Jennings, and \V. A. Wes-
cott; Censors, Drs. Alexander Marcy and Blake; Trus-
tee, Dr. O. B. Gross.
Pathological Society of Philadelphia. — At a stated
meeting held May loth, Drs. W. C. Posey and E. A.
Shumway exhibited specimens from a case of alveolar
sarcoma of the choroid. Drs. A. O. J. Kelly and S.
Flexner presented a specimen probably of carcinoma
of the ileum close to the ileo-caecal valve without
metastasis or evident glandular involvement. Abdom-
inal symptoms had not been marked during life, but
constipation, which had been present, was followed
by symptoms of intestinal obstruction, with marked
retroperistalsis. An operation was undertaken, byt
without a successful result.
Army Surgeons and Bicycles. — All the members
of the German army medical service are required by a
recent regulation to learn to ride the bicycle.
Morphinism among Physicians. — The editor of
The Quarterly Journal oj Inebriety returns to this ques-
tion in a brief note in a recent issue of that journal,
quoting the travelling agent of a large drug house, as
follows: "Within ten years my orders from physi-
cians for morphine have rapidly increased. I have a
number of regular customers who order from two to
five thousand one-fourth-grain and one-half-grain tab-
lets of morphine for hypodermic use every month.
Some of thase physicians buy for their patients, others
clearly use morphine themselves. Many of these doc-
tors have a large practice, and are not known to be
morphine-takers. Other physicians buy very largely of
deodorized tincture of opium and opium pills. In a
small village of five thousand, where seven doctors
practise, one physician bought over five gallons of
tincture of opium every year. In another town where
the practice was limited, large quantities of opium
pills and preparations of codeine were sold to two
physicians. Other narcotics, such as chloral hydrate,
hyoscyamine, and cannabis indica, are called for in
large quantities beyond the natural demand of prac-
tice."
Obituary Notes.— -Dr. Jacob Rick.\baugh, the old-
est practising physician in Chester County, died in
Tredyffrin Township, Pa., on May 6th, at the age of
eighty-five years. He was graduated from Jefferson
Medical College in 1842, and until within a week of
his death was actively engaged in the practice of his
profession. He was also largely engaged in agricul-
ture, being one of the most extensive land-owners in
eastern Chester County. He also took an active in-
terest in political affairs.
Contribution to the Study of Dentigerous Cysts
of the Superior Maxilla and their Relations with
the Maxillary Sinus. — P. Jacques and G. Michel
make the following classification: (i) Cysts of ex-
ternal origin which develop about the roots of the in-
cisors, canines, and sometimes the premolars. These
have a great tendency to develop toward the canine
fossa, separating the two tables of the maxilla. As a
rule, it is the external table which yields, as it is the
thinner; thus the anterior wall of the antrum is bulged
outward. Finally it gives to the finger the character-
istic crackling feel. (2) Cysts of sinus origin. As
a rule, tliese simply pouch inward the wall of the sinus
without actually breaking through, so that there is no
communication between the cavity of the cyst and that
of the antrum. Sometimes, however, such a communi-
cation does actually exist. In the former of the two
conditions extraction of the tooth involved will pro-
vide proper drainage, but in the latter it is necessary
to perform the classical operation for opening and
draining the antrum. — Jict'ue Hebdomadaire de Laryn-
gologie,etc., March 24, 1900.
Medical Record
A Weekly youmal of Medicine and Surgery
Vol. 57, No. 21.
Whole No. 1542.
New York, May 26, 1900.
$5.00 Per Annum.
Single Copies, loc.
REMARKS ON SOME OF THE CONDITIONS
SIMULATING APPENDICITIS AND PERI-
APPENDICULAR INFLAMMATION.'
By E. G. JANEWAY, M.D.,
So much has been written and spoken of appendicitis
in its surgical and medical aspects that interest in this
small portion of our anatomy has never flagged for
any considerable period. It has seemed to me that
no better place than a meeting of this society, in
which there are members who have had a very large
experience with this disease, can be found before
which to present for consideration the subject of con-
ditions which simulate appendicitis and peri-appen-
dicular inflammation. The conditions which I shall
mention in this paper are those which have either
been presented to me for consideration and advice in
consultation and hospital practice, or about which I
have had information from physicians. I prefer to
make this paper, as far as I am concerned, one which
has been drawn from observation in my field of work,
and hope that it will be supplemented by the observa-
tions of those who have had a very large experience in
these conditions.
A doubt whether, or the belief that, appendicitis ex-
isted has arisen in the case of neuralgia affecting the
lower abdominal nerves on the right side in a number
of cases. As a rule, a close scrutiny has enabled the
observer to come to a right conclusion. Yet I have
knowledge of two cases in which an operation was
performed, the appendix found normal, and not re-
moved. In one of these there had been several ante-
cedent attacks. It is probable that to-day the appen-
dix would have been removed at the time, and not al-
lowed to remain as a source of future apprehension.
The cases in this category relate to those neuralgias
whose origin was rather obscure, or, better, so obscure
that it could not be referred to an abnormal condition
of any special organ. There are, however, those
other neuralgic pains reflected over the lower right
abdomen when there is disease of an inflammatory na-
ture above, more especially pneumonia and pleurisy
of the right lung. I have been consulted several times
in cases of this nature, in some of which the idea of
operation for a supposed appendicitis had been enter-
tained. Moreover, as at times, if a physician is called
late, a pleurisy may have supervened on an appendi-
citis wliose inflammatory process has taken an upward
direction, a right decision as to the true origin and
nature of the disease processes may be the occasion
of considerable study. Ordinarily a careful survey of
the history and study of the existing conditions leads
to a correct diagnosis.
Another source of difficulty in the diagnosis is
afforded by conditions of the right kidney. Those
which have come under my own observation have been
renal colic, when somewhat protracted, and especially
' Read at a meeting of the Practitioners' Society, held April
6, igoo.
if associated with fever. Still greater trouble has
been occasioned by those cases in which a retention
of urine constituting hydronephrosis was developed,
as thus a swelling in the right side and some tension
of the abdominal muscles have occurred. Of course,
the members of this society are all aware of the co-
existence of fever in certain cases of renal colic, but
owing to the teaching of certain text-books not a few
physicians are uninformed of this possibility. More-
over, we all know that in certain cases of appendicitis,
owing to the character and direction of the pain, the
opposite error of considering appendicitis renal colic
has been made. Yet so firmly have I known the dread
of appendicitis to influence intelligent medical opin-
ion, that in cases in which the patient was thin, and
without difficulty manipulated, and thus the assurance
was obtained that no exudate or swelling existed in
or about the appendix, an exploratory operation has
been proposed to make assurance doubly sure. The
condition of the urine at the time or later has clinched
the diagnosis.
Intermittent hydronephrosis independent of calcu-
lus has also come under my observation as a source of
possible diagnostic error. Moreover, hydronephrosis
with a displaced right kidney existed in one case
about which I was consulted. Movable kidney has to
my knowledge at times been mistaken for a peri-ap-
pendicular inflammation.
Cholecystitis has, in several cases of which I have
had knowledge, been operated upon with the belief
that the condition was one of peri-appendicular in-
flammation. An operation was necessary for relief of
this condition. The only evil likely to be entailed is
that with healing, owing to the low site of the inci-
sion, considerable dragging pain may be experienced.
For this I was consulted in one case.
Conditions in the intestinal tract at times also have
occasioned the belief that appendicitis existed or that
a peritonitis was occasioned by perforation of the ap-
pendix. In this latter category are the perforations
of ulcers, duodenal, etc., which have been compara-
tively latent in their course. Gastro-intestinal catarrh
with colic coming from some irritant, either undigested
food or toxic agent in the food, has also been mistak-
en for appendicitis. Tuberculous ulcers, with tuber-
culous peritonitis over and about the caecum may give
rise to very great difficulty m decision, and have
been the occasion for exploratory incision for diagno-
sis. So also cancer of the caecum may occasion a
condition which may simulate peri-appendicular in-
flammation. The strangest illustration of this was the
case of a man, whom I had been requested to see in
order to determine whether an indurated mass was of
this or another nature. The hour was fixed for con-
sultation at three o'clock on a certain day. I was
summoned several hours earlier, because the patient
had suddenly gone into collapse. When I arrived
there was no difficulty in determining that perforation
had occurred and that there was free gas in the peri-
toneal cavity. The patient's condition forbade opera-
tion. The history of an illness lasting months made
the diagnosis of carcinoma very probable. An autopsy
showed colloid carcinoma of the cfficum, in which there
was a deep ulcer which had perforated. Fecal im-
MEDICAL RECORD.
[May 26, 1900
paction may at times also simulate peri-appendicular
inflammation, though in my experience the opposite
error may be made of considering the exudate impac-
tion and the obstruction due to the accompanying
local peritonitis as dependent upon some other cause.
There is, however, a class of cases not very frequent
in which there exists an ulceration or narrowing, non-
malignant, of the hepatic flexure of the colon, which
is apt to be attended from time to time by accumpla-
tion of faeces in the caecum and ascending colon, and
also, as the patients are thin, by movable right kid-
ney. As these patients have occasional fever also,
these combined events may give rise to considerable
trouble in diagnosis to one who has not had previous
experience with the individual patient.
In a paper read before the Medical Association of
the State of New York attention was drawn to the fact
that the pain and tenderness occurring in certain cases
of typhoid fever either during the primary attack, or
in a relapse, had led physicians, to my knowledge,
either to propose or to perform the operation for re-
moval of the appendix. This has happened in the
early stage of the disease, when the fever under the
circumstances has been believed to denote the gravity
of the supposed appendix inflammation. That the
appendix may at times be affected in typhoid fever is
also known. A careful survey of the case, including the
history of the method of incipiency of the attack and
a study of the condition of the spleen, of the bowels,
of presence or absence of roseola, of the blood for
Widal's reaction, and a count of the leucocytes will,
together with a careful physical study of the right
iliac region, as a rule, enable the physician to make a
correct diagnosis.
The general aches and pains connected with follic-
ular tonsillitis had led to the removal of the appendix
in a case which I saw afterward for a complication.
The pains in this case were to a considerable degree
complained of in the right iliac region. As an offset
for this I might state that it has happened on two oc-
casions that I have been consulted regarding peritonitis
from perforation of the vermiform appendix when the
disease had been ushered in with follicular tonsillitis.
Abscess of the ovary has been mistaken for inflam-
mation of the appendix. The neighborhood of these
parts readily explains the possibility of a mistaken
conception as to the cause of a local peritonitis. So
also difficulty may arise in deciding whether a given
inflammation in a woman is due to appendicitis or to
salpingitis. Retained menstrual fluid gave rise in
one case to a sapraemia causing chill, fever, and some
pain on the right side of the abdomen, which came
under my observation to decide between a possible
typhoid or appendicitis. The case was that of a
young woman sixteen years of age, who had been
unwell two weeks before, but had felt poorly since
that time. There was some sense of soreness deep in
the right side of the abdomen, more in the pelvis than
over the usual appendix site; there was no exudate
nor distinct swelling to be appreciated at the ordinary
site of the appendix nor back of the cacum ; the leu-
cocyte count was not increased. On the next day a free
discharge of an offensive serous fluid from the vagina
was followed by a disappearance of all tlie symptoms.
At times retro-peritoneal abscesses will simulate
appendicitis or rather the abscess connected with it.
At times patients become hypochondriacal as re-
gards the appendix, and under these circumstances go-
ing to a physician may receive the advice to have the
appendix removed at once, as happened in a case which
came under my observation this week.
These cases sufficiently illustrate the need of care-
ful thought lest we fall into the error of considering
every case with pain and tenderness in the right iliac
fossa as appendicitis.
A CONTRIBUTION TO THE TREATMENT
OF RUPTURE OF THE PARTURIENT
WOMB— WITH A CRITICAL REVIEW OF
THE VAGINAL OPERATION.'
By a. V. WENDEL, M.D.,
NEWARK, N. J.,
SURGEON TO THE ALEXIAN HOSPITAL.
In accordance with the rule of this society requiring
an annual thesis upon one of the surgical emergencies,
some recent experiences have induced the writer to se-
lect rupture of the parturient womb for this evening's
discussion. Rupture of the uterus is justly regarded
as one of the most formidable and fatal accidents to
which the pregnant woman is liable. In this country,
and particularly in our own section, we meet with it
most frequently in the poorer classes who are gener-
ally attended by midwives. This very fact causes the
writer to bring an obstetric emergency before this, a
surgical society, because the midwife sends either for
the family physician or the nearest practitioner. The
practice of operative midwifery is therefore commonly
performed by the general practitioner, and since rup-
ture of the uterus constitutes a surgical complication
of the first magnitude, the outcome of which depends
in no small measure upon the judgment and technical
knowledge commanded by bim who attempts to relieve
the woman, a discussion of the practical points in-
volved and of the appropriate measures to be adopted
must be my apology.
Rupture of the uterus is considered by the text-
books a rare accident, but, as Freund says, one may
not encounter a case in a decade while another may
meet two cases in the same day, as happened to him.
There can be no question, however, that rupture of the
uterus is far more frequent than is generally supposed;
a larger number of those occurring in private practice,
if fatal from hemorrrhage, are reported as post-partum
hemorrhages, and others merely as septic peritonitis
when death results from infection. This statement, as
Fritsch naively remarks, may easily be proven by in-
quiring carefully into the histories of fatal obstetric
cases. Whether the average given by Anufrieff of
eighteen ruptures to four thousand labors, or Bandl's
of one in twelve hundred, or Garrigues' of one in five
thousand deliveries, is correct shall be left to your
own fancy. The writer has examined the annual sta-
tistical reports of New Jersey for the past three years,
without obtaining any information concerning this
matter.
The accoucheur is aware of the causal importance
of contracted pelvis, fcetal malposition, and maldevel-
opmentand cicatricial obstruction of the maternal soft
parts, but cases are being constantly reported in which
women have borne a number of children in as many
normal labors, yet suddenly and without warning rup-
ture of the uterus occurred either during and not sel-
dom even before the occurrence of the next labor.
The predisposition to rupture manifested in such a
manner has been explained by the giving way of scars
formed after the separation of sloughs from the corpus
or cervix uteri following previous accouchements;
atrophic spots in the uterine wall leading either to cir-
cumscribed thinning or sacculation; general uterine
atrophy; placenta prasvia, and chronic interstitial me-
tritis. Indeed, nowhere in nature do we find the de-
fensive dispositions better exhibited than by the fre-
quent abortions resulting from chronic metritis, for if
these pregnancies went to term ruptures would no
doubt be very much more frequent, owing to the dis-
eased state and consequent diminished elasticity and
cohesion of the myometrium.
' Read before the New Jersey Surgical Society, December 5.
1899.
May 26, 1900]
MEDICAL RECORD.
899
It must be remembered, however, that, as Sanger
says, these conditions merely lessen the resistance to
rupture; mechanical factors are absolutely necessary
to cause rupture, and in the majority of instances they
are the sole factors. During normal labor the lower
segment and cervical portion of the uterus are suffi-
ciently dilated to permit foetal extrusion, but if there
should be obstruction of any kind to the progression
of the child, the upper segment continues to retract
until the fcetus is born into the distended and exces-
sively thinned lower segment and neck of the womb.
Unless the woman is delivered by art from her peril-
ous position, rupture of the uterus will certainly occur.
Considering that sixty per cent, of women (often the
flower of child-bearing women) and ninety-two per cent,
of the children are lost even under the best treatment,
we should ever have the possibility of its occurrence
in mind and be prepared to act with decision when
signs of threatened rupture occur.
The recognition of the predisposition to and causes
of rupture can be compassed only by methodical anam-
nesis, pelvimetric and physical examination during
pregnancy and during labor. Rupture will also be-
come rarer the more strictly the law is enforced which
requires the midwife to summon a physician as soon
as she notices difficulty or danger to the patient dur-
ing the progress of labor. There can also be no
doubt that the mortality after uterine rupture will be
lowered the more asepsis in obstetric practice becomes
generalized, because sepsis still constitutes the most
formidable obstacle to reduction of the mortality rate,
and Kroner's statistics show that an infected patient
has but little prospect of recovering even if submitted
to operation. Nevertheless no case should be consid-
ered hopeless, however desperate it may appear, since
cases are reported which appeared hopeless, yet prompt
intervention gave brilliant results.
"The worst cases are allowed to die; if more cases
were operated upon more lives would be saved, but the
whole death rate after operation would be raised." '
There still remain unsettled so very many questions
in the pathology and treatment of ruptured uterus, that
every case, whether fatal or not, should be reported
with the minutest care, because every case presents so
much that is interesting that the time is amply repaid
if it is examined in all its details and compared with
that which is known in order to increase our knowledge
of its nature and draw more correct conclusions as to
treatment. With this object in view the writer begs
to report his own experiences, which are limited to the
three following cases:
Case I. — Primipara; pelvic contraction with mas-
sive bony development; complete rupture of the uter-
us; Porro operation; recovery.
Pelvic diameters: bisiliac 23 cm., bispinous 21 cm.,
bitrochanteric 25 cm., Baudeloque 15.2 cm., oblique
conjugate 9.5 cm., true conjugate 7.5 cm.
Mrs. S , aged thirty-one years, weight one hun-
dred and fifty pounds, robust German peasant. Her last
menstruation occurred January 9, 1897. Pregnancy
passed without unusual incidents. Labor began Octo-
ber 22, 1897, at 5 A.M. ; the membranes broke at 6 a.m.
She was examined by her attending physician some
hours later and he noted that the head had not engaged,
also that the partially dilated cervix was somewhat
swollen. Drs. Ost and Bailey saw the case at 9 a.m.
on the 23d. They found that the pains were not so
powerful as previously; the contraction ring was near
the navel ; the abdominal walls were sensitive to press-
ure; the fcetal dorsum was in front and to the right;
the cervix was swollen but completely dilated, the pre-
senting part above the brim. The child was living.
Drs. Ost and Bailey realized the grave danger of
impending rupture ; perforation and extraction by the
' Greig Smith : " Abdominal Surgery," vol. i., p. 407.
cranioclast was decided upon, and immediately begun
under deep anaesthesia. Notwithstanding the removal
of the entire vault by the craniotomy forceps, they were
unable to deliver the base on account of its massive-
ness and large size. Laparotomy now appeared to
them the proper method of delivery. The writer saw
the case with these gentlemen at 10 a.m. At this time
the patient's general condition was good; pulse, io8;
no fever. The uterus was noticeably movable, but its
contour was not decidedly altered. There was some
emphysematous crackling detected over the hypogas-
tric region extending laterally into both iliac regions.
The contraction ring was obliquely upward from right
to left just below the umbilicus. The catheter
brought away 60 c.c. of clear urine. There was slight
but continuous bleeding from the uterus. There was
no injury of the vagina or portio vaginalis. The
greater portion of the calvarium had been removed;
the head was very movable. On passing the hand
into the uterus a large irregular rent could be felt
in the lower segment, severing in a transverse man-
ner nearly three-fifths of the cervix from the body.
The hand was not passed beyond the uterus. There
was no apparent prolapse of omentum or intestine.
Since laparotomy would be the operation of necessity,
no attempt was made to determine whether the perito-
neal cavity had been opened or not, for fear of carry-
ing infection into the parametrium. The wound in the
uterine wall gaped nearly 5 cm. on the left side.
Twenty minutes later the abdomen was opened in the
middle line. The uterine serosa presented many em-
physematous blebs over its entire aspect; extensive
suggillation of the pelvic subserosum could be seen,
which crepitated on pressure. About 300 c.c. of
blood lay posterior to the uterus, but no active hemor-
rhage was apparent. By passing the hand down into
Douglas' pouch a rent could be felt in the posterior
wall of the uterus involving about 4 cm. of its invest-
ment.
The blood was quickly removed from the belly;
sterilized towels were packed behind the uterus to pro-
tect the intestines; the uterus was incised in the mid-
dle line and the foetus extracted. The placenta, which
was adherent to the rear and upper wall, was not re-
moved. The vesico-uterine plica was next incised,
the bladder separated by blunt dissection, and two fix-
ation needles pushed through the uterus a little below
the level of the lower angle of the tear; an elastic lig-
ature was applied and the uterus amputated from its
remaining attachments. Fixation of the stump in the
lower angle of the wound, drying of the peritoneum,
and closure of the belly completed the operation. Re-
covery was uneventful. The decerebrated foetus meas-
ured 48 cm., and weighed 4,760 gm. No measure-
ments of the head could be made. The photograph of
the uterus was taken after the specimen had been
eleven months in alcohol, which caused much shrink-
age, the result being that the upper limit of the tear
appears in thicker tissue than was really the case. In-
spection of Fig. I shows the tear beginning at c, ex-
tending downward about 4 cm., corresponding to the
peritoneal tear; then the uterine lesion continues ir-
regularly from c\.o b \.o a, that is, to a point a little
anterior to the insertion of the base of the broad liga-
ment; this portion of the tear was entirely subperito-
neal.
Remarks: Beyond doubt this was a typical sponta-
neous rupture according to the teachings of Bandl.
The weakening of the uterine contractions prior to any
operative attempts shows that rupture had probably
already begun ; the rule being for the contraction to
become more and more violent until the uterine fibres
give way, although Fritsch ' claims that the difTerenti-
' ' ' Die Behandlung der U terusruptur ' ' Verhand. d. Deutsch.
Gesell. f. Gyn., vi., p. 8.
goo
MEDICAL RECORD.
[May 26, 1900
ation of rupture threatened from the beginning is by
no means easy, because as soon as the innermost
layers of muscular fibres have separated rupture has
already become actual, and any additional increase of
intra-uterine tension, such as the passage of the liand
into the uterus, the insertion of forceps blades, or press-
ure on the uterine fundus, will result in the more or
less complete and extensive breach of the uterine wall,
the degree of laceration depending on the amount of
uterine energy. The diagnosis of this case was rela-
tively easy, and the question whether the peritoneum
had been opened or not could probably have been de-
termined by simply passing the hand through the tear.
But should this be done as a routine measure? For
the following reasons I would reply with an emphatic
negative: When there has been instrumentation, there
is also infection of the genital tract corresponding to
the extent of the field traversed during the manipula-
tions. You can easily prove this statement for your-
selves by the culture tube and microscope, if you en-
tertain any doubt concerning the accuracy of this state-
ment. We also know that pathogenic organisms may
actually lie at the edge
of a wound, and not-
withstanding primary
union will occur if the
infectious material is
not carried into the
wound by overzealous
handling. You have all
seen proof of this while
attending the cut fingers
of the dirtj'-handed fac-
tory boy. To pass the
hand into the belly in
suspicious cases is to
risk carrying infection
into tissues infiltrated
with blood and therefore
peculiarly susceptible to
progressive infections,
and the question of pre-
venting the spread of
infection is now the most
difficult one. Ludwig' _
asserts that the perito-
neum will not infre-
quently adapt itself to the examining fingers so gently
as to deceive one and give the impression that the peri-
toneum has been perforated when in reality it has not.
Another objection to this method of examination is the
probability of the admission of air to the pelvic connec-
tive tissue. If this complication has not resulted from
the circumstances attending the rupture, we ought not to
induce such a state. Indeed ante-uterine emphysema
or an emphysematous crackling of the abdominal walls
should be sought for, not only because it favors the
invasion and spread of pathogenic micro-organisms,
but also because its presence is an almost pathogno-
monic sign of uterine rupture; the only exception be-
ing its occurrence from decomposition of the fa:tus in
utero. The presence of subperitoneal emphysema is
also an indication for early and radical operation, as
will be seen from the following notes taken from a
paper of Dischler's ° : McClintock's case was fatal
several hours after delivery; Winckel's first case,
forty-six hours post partum ; both patients probably
died from the entrance of air into the venous system.
Paulli's case was fatal eight and one-half hours post
partum; Jolly's, eleven and three-quarter hours after
delivery; Winckel's second case, twelve days after la-
' " Klinische Beitrage zur operativen Therapie der Uterus-
ruptur." Wiener klin. Wochenschrift, 1897, p. 2go.
' " Ueber subperitoneales Emphysem nach Ruptura uteri. "
Archivf. Gynak., Bd. 56, S. I99.
'M-
'\
CU-
bor; Lohlein's first case, eight hours, his second case,
ten days post partum; Bayer's, two days after birth.
All these patients died of sepsis. On the other hand,
in the cases of Leopold, Frank, and Halbertsma, recov-
ery took place after the Porro operation ; of Knauer,'
after abdominal panhysterectomy; but Dischler re-
ports a personal case in which recovery resulted after
gauze packing. Dischler after a careful study of this
condition arrives at the conclusion that subperitoneal
emphysema is a valuable sign of uterine rupture, and
that an emphysematous state of the pelvic connective
tissue is a serious menace to the woman's life for the
reasons which have already been stated, and that radi-
cal methods of surgery — notwithstanding the recovery
in his own case by the gauze treatment — are indicated
whenever it is encountered with uterine rupture.
Irregularity of the uterine quadrant is regarded as
a good sign of uterine rupture but was not present in
this case, as there was no large collection of blood
in the form of hsematoma, and the foetus did not
leave the uterine cavity. The contraction ring was
well marked and characteristic. Mobility of the
uterus was readily de-
monstrated. The Cse-
sarean section was abso-
lutely indicated here on
account of the large
head and the resistance
of the foetal base. Su-
pravaginal amputation
of the uterus was added
because the uterus was
so extensively injured,
and because of the cer-
tainty of rupture in
subsequent labor if
conservation had been
attempted, since the pel-
vic contraction would
remain.
Case II. — Vpara;
complete rupture of the
uterus with partial es-
cape of the foetus into
the abdomen; pelvic
obstruction by dermoid
ovarian tumor; intra-
partal vaginal ovariotomy and vaginal Cassarean sec-
tion ; recovery.
Pelvic diameters: bisiliac 28 cm., bispinous 26.2
cm., bitrochanteric 30.5 cm., Baudeloque 20.3 cm.,
oblique conjugate 14 cm., true conjugate 11.7 cm.
Mrs. K , Jewess, aged forty-three years, weighing
one hundred and fifteen pounds, and wiry; she was
married when seventeen years old. Her first, second,
and third confinements were natural and averaged nine
hours in duration. Her fourth confinement was in 1892;
it lasted thirty-four hours, was followed by fever and
much pelvic distress, but the midwife had not consid-
ered matters serious enough to call a physician, al-
though the patient was confined to bed for five weeks.
Since then and until the last conception occurred, she
has complained of dragging pains, dyspareunia, and
vaginal discharge. Her last menstruation was Novem-
ber 30, 1897. During the last four months of the present
gestation she had to wear an abdominal binder to ob-
tain relief from the distress caused by anteversion of
the gravid uterus. The present labor began at 2 a.m.,
September 9, 1898. A midwife was in attendance.
The membranes broke at 11 a.m., and the pains con-
tinued strong until 4 a.m., September iith, when
the patient complained of feeling weak; the midwife
noticed that the contractions also became feebler and
were separated by longer intervals. She thereupon ad-
• Wiener klin. Wochenschrift, 1897, S. 254.
May 26, 1900]
MEDICAL RECORD.
901
ministered several doses of ergot, which increased the
pains, although she noticed no descent of what she
presumed to be the presenting part. Dr. H. B. Ep-
stein was summoned and arrived at 7 am. He found
the patient weak, with a temperature of 101° F. ; pulse,
100 but feeble; the abdomen was very sensitive but soft
because the abdominal walls were very thin and Habby.
By gentle palpation he found the uterus contracted,
reaching about 3 cm. above the umbilicus. The foe-
tal extremities were palpable in the peritoneal cavity,
but no fcetal movements or heart-sounds were discern-
ible, indagation showed the vagina obstructed in the
upper part By a hard, fi.xed tumor springing apparently
from the rear. The obstruction was so complete that
the finger could not reach the cervix. The doctor
made the diagnosis of complete rupture of the uterus
with partial escape of the fa'tus into the abdominal
cavity; he advised operation, and requested the writer
to see the case with him. We agreed on immediate
abdominal section, but on presenting the decision to
the husband and some of the relatives who were pres-
ent, they would permit only such operative interven-
tion as could be done without cutting the abdominal
wall or removing the uterus. We therefore concluded
to attack the growth from the vagina and then deliver
by the natural passages. Preparations were made for
operation, and additional assistance was summoned.
The catheter brought away about 80 c.c. of clear urine.
The patient was ansesthetized with ether, placed in
the lithotomy position, and the bladder and vagina
were thoroughly irrigated. The labia and vaginal
walls were retracted to expose the neoplasm. An in-
cision was made in the median line about 12 cm. in
length, which bled profusely; the adhesions were
so dense and tough that the scissors were brought into
requisition and applied freely until the pedicle was
reached. Owing to the largeness of the tumor it be-
came necessary to open it; much malodorous material
and hair having been removed, the edges of the cyst
wall were rolled in and sutured to prevent soiling of
the field, and then dissection was continued with the
scissors and fingers until the pedicle was isolated.
During this time 1,200 c.c. of decinormal salt solu-
tion were introduced into the veins of the arm. A
curved clamp was applied to the pedicle and the tu-
mor cut away. The slender pedicle was tied off and
allowed to retract. Many small vessels also required
ligature. Bloody serum, clots, and meconium escaped
from Douglas' pouch, which had been thoroughly
opened during the dissection. The bleeding was now
entirely controlled, and we turned our attention to
the delivery of the foetus. As a result of the low form
of chronic inflammation around the tumor the cervix
had become converted by induration into a hard, un-
unyielding mass; all attempts at dilatation failed.
Delivery was attempted by passing the hand into the
belly through the Douglas incision to ascertain the
feasibility of delivering by version through this chan-
nel, but it could be felt that the foetus was grasped
so tightly about the neck that traction would enlarge
the uterine wound, and besides there was not room
enough to permit the manceuvre successfully. The
fcetus had escaped through a rent in the posterior wall
of the uterus, nothing but the head remaining in utero.
The only alternative remaining was vaginal Caesarean
section. The vaginal fornix was incised in front in
the median line, the bladder separated to the replica,
and several bleeding vessels were ligated. With
heavy scissors the anterior lip of the uterus was split
in the middle line to a distance of 5 cm. from the os
externum. The rear wall, which consisted of a bridge
of tissue intervening between the external os and the
transverse tear in the lower segment (some 6 cm.), was
also split; there was not much bleeding from the cer-
vix on account of the induration, but above hemor-
rhage was decidedly free. The Taylor blades were now
quickly applied and the child was extracted with ease,
the placenta following. The uterus contracted firmly
and all bleeding (above the ordinary) ceased. The
vagina was now thoroughly sponged, then the perito-
neal cavity cleansed with gauze. Another 1,000 c.c.
of decinormal salt solution had been transfused during
this period. The rupture proved to be a large, ragged
transverse tear in the lower segment, .so we attempted
to draw it together with sutures. Slender Pe'an re-
tractors were inserted in such a way as to retract the
uterine and vaginal walls, the uterine flaps also being
drawn divergent by means of slender volsella. Only
two sutures could be placed, but they sufficed to ap-
pose the ruptured surfaces. The Cassarean wounds
were then closed by a few interrupted catgut sutures
excepting the lower portions, which were left open for
the purpose of uterine drainage. Three sutures closed
the anterior wound of the fornix. The incision in
Douglas' pouch was not closed. Gauze w'as passed
into the peritoneal cavity, and the vagina filled loosely
with gauze to absorb the products of drainage from the
peritoneum.
The operation lasted two and three-quarter hours,
the patient leaving the table with a pulse of 156 and a
temperature of 97' F. By warmth and stimulation the
pulse soon fell to 100, but in the evening of Septem-
ber nth it went up to 140 and the temperature to
102.5° F- "^'^^ abdomen was distended and much
pain was complained of. Salines and the ice-bag were
ordered, and by the isth the temperature and pulse
rate had fallen to the normal. 'The gauze had been
changed daily. Five weeks from the operation the
patient was allowed up. She was examined on the
9lh of March, 1899. It was found that the induration
had almost entirely disappeared; the uterus was retro-
fiexed and adherent; the deep antero-posterior scars
could be felt, but otherwise lier condition was good,
and she felt no distress.
The fcetus measured 32 cm. and weighed 2,600 gm.
The suboccipito-bregmatic diameter was 8 cm. ; bi-
parietal, 8.2 cm.; occipito-mental, 13 cm.
Remarks: Several factors contributed to the occur-
rence of rupture: uterine anteversion, the fixed ova-
rian dermoid, and the chronic induration of the cervix
and neighboring soft parts. The uterine anteversion
was certainly a fortunate coincidence, because the
fcetus was directed against the rear wall of the uterus,
and the injury therefore was comparatively innocent as
compared with ruptures occurring in the anterior wall
of the uterus. The anamnesis indicates that the tumor
must have caused the delay and subsequent complaints
in the fourth labor. Pelvic obstruction by ovarian tu-
mor is not a frequent cause of uterine rupture during
labor. McKerron' collected one hundred and eighty-
three instances of prolapsed ovarian tumors complicat-
ing pregnancy, but only three resulted in uterine rup-
ture. The patients all died, KerswilP reported three
instances, two of which were fatal. Hintze's'' case
resulted in recovery after laparotomy, but was compli-
cated by pneumonia and pelvic abscess. Subperitoneal
emphysema could not be detected, neither was undue
mobility present. This case demonstrated in a sur-
prising manner how tightly the foetal neck can be
incarcerated by the uterine woimd. The tumor so
completely blocked the vagina that the cervix could
not be indagated, thus leaving us entirely in the dark
concerning the state of the cervix until the tumor had
been removed. Given a case as related, is it justifia-
ble as a rule to submit the patient to intrapartal vagi-
nal ovariotomy.? The answer should be, no. The
shock resulting from two and three-quarter hours of
' Martin : " Die Krankheiten der Eierstbcke," Bd. i., p. 506.
■ Frommel : " Berichte," Bd. .xi , S. 734.
902
MEDICAL RECORD.
[May 26, 1900
anaesthesia, manipulation, and loss of blood is much
greater than that of a twenty-minute abdominal section.
The general rule should be applied here as in other
surgical emergencies; that is, to relieve the individual
of immediate peril. The deep shock attending uter-
ine rupture is a bar to lengthy operations, although
tills case demonstrated in a superior manner how
much more the patient can endure when her intestines
are not exposed. If I were to meet the same condition
as in Case II. minus uterine rupture, I would follow
the advice of Lohlein' and perform intrapartal ovari-
otomy. The contents of the tumor were so thick that
a trocar could not have emptied it. Abdominal sec-
tion, extraction of the foetus, cleansing of the perito-
neum, supravaginal amputation, and provision for
drainage was the plan settled upon before submitting
the same for approbation to the relatives, and notwith-
standing the successful issue of this case and much
reflection, this plan appears the best, leaving the tumor
unmolested until the patient is better able to stand its
removal.
Case III. — IVpara. Incomplete rupture of the
uterus involving the bladder; escape of the fcetus into
the right broad ligament; vaginal panhysterectomy,
abdominal section for uncontrollable hemorrhage; re-
covery; pelvic measurements normal.
Mrs. G , thirty-five years old, weight one hun-
dred and thirty-five pounds, American. She was sub-
mitted to vaginal section in i8g6 for a mural telean-
giectatic myoma developing in the right side of the
uterus, involving the corpus and upper part of the cer-
vix and bulging into the right broad ligament. The
right uterine and ovarian arteries required ligation on
account of the very free hemorrhage. For this pur-
pose chromicized catgut was employed. The uterine
cavity was not opened during the removal of the tumor,
but the bed of the neoplasm could not be accurately
sutured. A physical examination conducted on August
21, 1897, showed the patient's pelvic organs in a very
satisfactory condition. She menstruated the last time
in April; her gestation passed without abnormal man-
ifestations. Her previous labors averaged twelve
hours in duration. Labor began at 5 p.m., December
19, 1898. Dr. H. F. Cook examined her at 8:30 p.m.,
and found the uterus sinistroverted, the contractions
strong, the os dilating, membranes unbroken, but the
head not engaged in the superior strait on account of
the malposition. The foetal heart was audible on the
left. He placed the patient on the opposite side and
matters appeared to progress favorably. The maternal
pulse was 75 per minute; no fever. At 9 :3o p.m., dur-
ing a contraction the patient complained of fluttering
at the heart, extreme weakness and pain in the right
side; marked facial pallor and drawn features ap-
peared. The pulse became very weak and rapid.
Vaginal examination showed the cervix dilated to
about three inches; the amniotic sack was unbroken,
but instead of the head the foot presented. The doc-
tor's left hand plainly felt the contracting uterus
through the thin abdominal walls, and the f(Etus in
the right iliac region. Realizing at once the true state
of affairs he broke through the membranes, seized the
feet, and delivered a deeply asphyxiated male child.
Much blood began to flow from the uterus. The pla-
centa was removed by the hand. The doctor passed
his hand carefully into the uterus and felt an irregular
gaping tear extending from the middle of the right
side to the right cornu. As the patient complained of
an urgent desire to urinate, the catheter was passed
and brought away a small amount of very bloody urine.
The uterus and vagina were tightly packed with ster-
ile gauze and a tight binder applied around the abdo-
men. It was now 10 p.m.; the pulse was 126, the
' " Erfahrungen iiber vagin.ile Bauchschnitt-Operationen,"
S. 9S.
temperature 98 F. There was no external bleeding,
and after partaking of some hot tea the patient felt
better. The placenta and membranes were now exam-
ined and exhibited but one opening, corresponding to
the opening made by Dr. Cook. The amnion must,
therefore, have enveloped the foetus during its extru-
sion into the broad ligament. At 11 p.m. the puls6
was 136 per minute, the temperature 98° F. ; at 11 :3o
P.M., pulse 142, temperature 98° F. The doctor con-
cluded that hemorrhage was going on in the para-
metrium or peritoneal cavity, and prepared for imme-
diate operation. A little later the narcotized patient
was placed in the lithotomy position. As the writer
commenced the operation, 1,800 c.c. of artificial serum
were thrown into the median basilic vein. After the
gauze was removed from the vagina and uterus, and
the field cleansed, the fornix was incised around the
cervix; the bladder was detached with some difficulty
because the rent in it communicated with the enor-
mous cavity in the broad ligament, and also because
the connective tissue of the paravesical space was so
infiltrated and distorted by liquid and clotting blood
as to render the landmarks very obscure. The hemor-
rhage from the incision was readily checked by strong
downward traction on the uterus by the volsellum at-
tached to the cervix; indeed, after separation of the pos-
terior attachments the uterus could be developed with
amazing ease. The left broad ligament was tied off
with six ligatures of catgut ; on the right side the broad
ligament was so disorganized, and the peritoneal lay-
ers were so distended and distorted by the larger clots,
that I concluded to morcellate the uterus in order not
to include the ureter in the ligature. After this was
done it was seen that no semblance of a broad liga-
ment remained; the uterus was attached merely by
peritoneum and a few shreds on the right side, and
the blood was welling out from the side of the pelvis.
The stump was cut away, and we tried to pick up the
bleeding vessels with clamps, but without success.
After losing twenty minutes in futile attempts because
the oozing and clotting blood obscured the field, the
abdomen was opened in the middle line with the pa-
tient in the Trendelenburg position. The wound re-
tracted to the right; the ovarian and uterine and many
smaller vessels were tied without further trouble.
Clots were turned out, gauze was placed in the crater
of the broad ligament, the end of the gauze led into
the vagina, and finally the belly wall was closed with
suture. The operation lasted fifty-seven minutes.
The pulse numbered 180 beats per minute when the
patient left the table. Altogether 3,000 c.c. of salt
solution had been thrown into her venous system. She
rallied nicely from the shock. The vesical wound
closed on the eighth day. Convalescence was smooth.
The child measured 37 cm., and weighed 2,300 gm.
Biparietal diameter 9.5 cm., sub-occipito-bregmatic
7.9 cm., occipito-mental 13.4 cm.
Remarks: Unfortunately, the portion of the uterus
containing the tear was cast away by an attendant be-
fore I had time to place it in safety, so that we are left
to conjecture the condition of the uterus. However,
it seems most likely that the weak scar in the uterus
permitted a sacculation which gave way during a uter-
ine contraction. The moral learned is, to remove the
uterus whenever accurate suture of the wound is not
possible during conservative myomectomy. An im-
portant and serious feature of this case was the vesical
laceration, because of the great risk of urinary infil-
tration of the parametrium and consequent sepsis.
Bonnaire' reported five cases, all of which were fatal.
The first three cases were treated by vesical drainage
and conservative surgery, and the last two by abdomi-
nal section.
' " Des ruptures vesico-uterines dans le travail de I'accouche-
men* " .\rcli. de Tocologie, iSgi, p. 3gi.
May 26, 1900]
MEDICAL RECORD.
903
The diagnosis of this case was easy. Subperitoneal
emphysema was not present, although the peritoneum
was stripped from its attachments as far up as the
right liidney, probably because the foetus pushed its
amniotic envelope before it and thereby protected the
connective tissue from contact with air. McLean' be-
lieves that this envelopment of the fcetus by the mem-
branes is a not infrequent occurrence, and lays much
stress on the role it plays of preventing septic material
from contaminating the parametrium or peritoneal
cavity.
During a discussion at the Obstetrical and Gyne-
cological Society of Vienna, R. Braun von Fernwald "
expressed some apprehension that in rupture of the
uterus, when the peritoneum, and particularly the lig-
amental peritoneum, is extensively lifted up and torn
from its attachments, vaginal extirpation would meet
with difficulties which would make laparotomy prefer-
able. If vaginal hysterectomy is decided on as the
preferable method, no great amount of time should be
wasted in futile attempts to grasp the divided vessels
with clamps; the abdomen should be opened and the
arteries secured, because these patients as a rule have
lost much blood before the operation and are not able
to stand another serious hemorrhage. The vaginal
operation should be the operation of choice whenever
the prevention or amelioration of sepsis is required by
the removal of the uterus, because of the greater facil-
ity for drainage of the peritoneum afforded through
the vagina. The vesical injury impelled me to select
the vaginal method, although I was aware cf Braun von
Fernwald's statement. I was also aware of Bonnaire's
results with abdominal section for rupture of the uterus
complicated by vesical laceration, and was therefore
prepared to open the abdomen if necessary, because I
believed the removal of the uterus would permit the
urine to flow away from the lacerated and infiltrated
connective-tissue surfaces. Permit me to give you an
outline of Bonnaire's' cases submitted to ventral sec-
tion, (i) A XVIpara was submitted to four fruitless
attempts at delivery by the forceps, being finally de-
livered by version. Bonnaire believes that the for-
ceps caused the injury to the uterus and bladder. The
next day she was operated upon by abdominal section.
The tissues were in such a state that he stitched the
uterus to the parietes and left the wound open so as
to drain the bladder through the abdominal wound.
Death occurred twenty hours later. (2) A primipara
sustained a spontaneous rupture of the uterus involv-
ing the bladder. The abdomen was opened, the fcetus
extracted, and the vesico-uterine wounds were drained
by stitching them into the abdominal wound. As a
result of this experience Bonnaire concluded that su-
pravaginal amputation of the uterus shonld be per-
formed with provision for drainage through an inci-
sion in Douglas' pouch. To my mind this method
does not do away with the worst feature of the case,
which is the danger of allowing decomposing urine to
flow over the lacerated and infiltrated wounds, par-
ticularly when one considers the roundabout manner
proposed of draining the discharges through an open-
ing in Douglas' pouch. After the uterus is removed,
the bladder sinks down and the vesical laceration can
be almost entirely walled off from the general cavity
of the peritoneum and the parametrium. This I have
been able to demonstrate several times when the blad-
der has been injured during hysterectomy. The indi-
cation in these cases is pointed by the wounded blad-
der after the question of hemorrhages has been settled,
for the arrest of hemorrhage is only the milder element
in the mortality rate; Koblank's statistics show that
'"The Palliative Treatment of Rupture of tlie Uterus."
American Journal of Obstetrics, vol. xx.x., p. 47.
• Centralblatt fiir Gynakologie, 1898, p. 21.
3 Op. cit.
more deaths occur from sepsis than from hemorrhage,
after rupture of the uterus. A ruptured bladder re-
quires the freest possible drainage as early as possible
aftet the injury. The infiltrated state of the connec-
tive tissue with blood, and the bruising of the
wounds, dispose the patient to the most violent septic
infections when urine flows over them; the swelling
and distortion render any attempt to suture the blad-
der futile even if it were desirable, so that vaginal
hysterectomy supplies the proper means for dealing
with vesico-uterine rupture, though one must be pre-
pared to do here as elsewhere in vaginal coeliotomy,
that is, to open the abdomen if contingencies arise
which cannot be successfully controlled from below,
and finish the case. Vaginal hysterectomy has, how-
ever, proven itself the operation of election for rup-
tures on the anterior and posterior surfaces of the uter-
us, when the broad ligaments have not been torn up
so extensively as to prevent the spurting vessels being
secured through the vaginal incision. Total escape or
even partial foetal extrusion into the broad ligament
always indicates so severe an injury that one may ex-
pect the landmarks to be so distorted and effaced, the
tissues so torn up and mixed with clots, that only fa-
vorable cases can be finished from below. You may
imagine what difiiculties were encountered in our case,
since eleven vessels on the right side required ligation
after the abdomen was opened. Nevertheless we must
wait for further experience with the vaginal route for
this variety of injury before positive opinions can be
given.
General Considerations.— An accident which not-
withstanding the best treatment results in a loss of
sixty mothers in every hundred instances makes it im-
perative that the question of prevention be given a
prominent position. Dakin' claims that "rupture of
the uterus is almost invariably due to want of attention
on the part of the medical attendant, if he has had an
opportunity of watching the course of the labor from the
beginning." Grandin and Jarman'^ believe that rupture
of the uterus will become rarer " as the benefits of strict-
ly elective surgery become uniformly recognized.'" Its
possibility should be kept constantly in mind, since the
most diverse conditions obtain in the etiology of uter-
ine rupture. For instance, v. Ramdohr' reported two
fatal ruptures following primary inertia. Albers-
Schoenberg' reported a case in which congenital dis'-
location of the left kidney into the cavity of the sa-
crum was the cause of dystocia. Braun v. Fernwald '
averted rupture in an Vlllpara by Cassarean section,
the cause being the incarceration of a retroflexed horn
of a bicornuate uterus. Sacculation was the probable
cause of rupture in Case III. Hirst * saw a case in which
the predisposition to rupture, he believes, was caused
by general obesity. Fundal rupture occurs most fre-
quently before the commencement of labor, and while
not infrequent from external violence, it has occurred
even during sleep.' But in most instances the essen-
tial factor disposing to rupture is over - retraction
of the upper segment of the uterus with consequent
excessive and therefore dangerous thinning of the
lower segment and cervix. The most frequent cause
of this condition is pelvic obstruction, the milder
forms of pelvic contraction predominating. The
latter condition should be sought for in every woman
during pregnancy, or at the beginning of labor if one
fails to see the case earlier. The severer grades of
pelvic contraction are of course readily detected, buf
the diagnosis of milder forms of general contraction
' " Handbook of Midwifery," p. -(92.
"^ " Practical Obstetrics," p. 430.
' American Obstet. and Gyn. Journal, vol. .x. , p. 46.
* Centralblatt fiir Gynak., 1894, p. 1223.
' Monatsch. f. Geburts. u. Gynak.. vol. i.x., p 454.
' " Textbook of Obstetrics," p. 544.
' Dewees : " Diseases of Females," p. 511.
904
MEDICAL RECORD.
[May 26, 19CX)
can be made only by careful external and internal pel-
vimetry, and should always include the manual exam-
ination of the size and consistence of the fcetal head,
the breadth and size of the fontanelles, since a relative
disproportion maybe caused by abnormal development
of the head. During labor the frequency, strength, and
effect of the uterine contractions should also be noted.
If in spite of strong uterine contractions the head fails
to descend, and frequent examinations of the abdomen
prove that the upper segment of the uterus continues to
retract as shown by the ring of Bandl and tension of the
round ligaments during the contractions — particularly
if the ring of Bandl becomes oblique, one or both poles
near the navel and one or both round ligaments remain
tense even between the pains — we may expect rupture
to ensue unless the patient is speedily delivered. In
the selection of methods, the choice will be given to
one which does not increase the already excessive in-
trauterine tension, for in that case rupture will be pre-
cipitated. Prompt and deep chloroform narcosis
should now be employed to stop the uterine contrac-
tions, and thereby retard further thinning until deliv-
ery can be effected.
In mild cases, the head presenting, the forceps may
be applied with the greatest gentleness, but only by a
skilful accoucheur. I have already stated that the
dividing line between threatened and beginning rup-
ture cannot be determined. Is it justifiable, then, to
use the forceps in high degrees of thinning of the
lower segment? Of Koblank's' eighty cases of rup-
ture of the uterus, ten were caused by the forceps and
all ten were fatal. "According to v. Winckel and O.
Schaeffer, the high forceps operation gives the worst
results to the mother, because the thinning of the im-
perilled side is exaggerated and therefore the rupture
is hastened." ' There are, then, two distinct rules ap-
plicable to head presentations with threatening rupture
of the uterus: when thinning of the lower segment is
slight and the round ligaments are tense only during the
contractions, other things being equal, the child should
be delivered by the forceps; but when the ring of
Bandl is very high or very oblique, with one or both
round ligaments tense between the pains, delivery
should be effected by the Csesarean section or craniot-
omy, as the case may require, for, as Fritsch ■' says, in
head presentations the thinning of the lower segment
is apt to be localized in one or other side of the lower
segment, and the practitioner's desperate hope to save
the child by the forceps often sacrifices both lives.
The same holds good Jfor version in head presenta-
tions, the hand being substituted for the forceps. The
rule of action in transverse presentations is simpler,
for when the child is living this fact indicates that
dangerous thinning has not yet occurred, therefore
version may be carefully attempted in deep narcosis.
When the uterus is tetanic and the thinning great the
foetus may be considered dead; version is no longer
the operation chosen, but embryotomy is now consid-
ered the proper procedure.' Malposition of the par-
turient uterus sometimes predisposes to rupture by
directing the fcetus against the opposite wall instead
of into the cervical orifice; it is to be treated by laying
the patient on the opposite side or bandaging the
uterus back, as the case may require. Placenta pre-
via is known to dispose to rupture by softening and
thinning the lower segment at the seat of placental
attachment. Braun v. Fernwald '' believes that when
rupture occurs it generally does so just as the extrem-
ity is pulled down through an insufficiently dilated
cervix, and he advises therefore, in order to avoid this
' " Beitrage zur Lehre von der Uterusruptur," pp. 23 and 46 siy.
•^ //'icf. , 38.
^Verh. d. deutsch. Gesell. f. Gynak., vi., p. S.
■• Fritsch ; O/. ci/., p. g.
' Centralblatt f. Gynak., p. 513.
serious accident, to extract only after the cervix is
thoroughly dilated.
When rupture has become a fact, the motives for
action are to deliver without increasing the injury, to
arrest hemorrhage, and to prevent or limit peritoneal
infection. In head presentations with a living foetus
in utero, the child may perhaps be saved by the
prompt application of the forceps without submitting
the mother to undue risk, providing that she is in good
condition, the os completely dilated, and there exists
no decided pelvic contraction. Ludwig' apprehends
(and the writer's opinion agrees) that even under these
conditions there is much risk of increasing the extent
of the injury or of converting an incomplete into a
complete rupture. \\'hen the head remains in the
uterus and the body has escaped, McLean* argues that
the danger of increasing the size of the laceration no
longer exists, because the intra-uterine tension has
been decidedly diminished by the escape of the foetal
body, and he advises, instead of losing time by at-
tempting to grasp the high and mobile head with the
forceps, if any difficulty is encountered, boldly to ad-
vance the hand (closely applied to the child) into the
uterus, to steady the organ with the other hand, to
grasp a limb, and to rotate and deliver the child. Mc-
Lean has reported a successful case treated after this
fashion, but Ludwig and Koblank claim that with-
drawal of the child through the wound increases the
danger of hemori-hage. Perhaps their statement ap-
plies more correctly when the head has also escaped
and is dragged back again. A dead fcetus would of
course be delivered by perforation and cranioclasty.
Spontaneous rupture with transverse presentation
results almost invariably in ftetal death. Embryoto-
my would therefore take precedence when the fcetus
remained either entirely or in greater part in the uterus.
If rupture occurs during version the operator must
judge by the circumstances of the case whether he
had better continue; in general the child should have
a chance for its life. When the child has escaped en-
tirely into the peritoneal cavity, the conjugate measur-
ing less than 8 cm., abdominal section will be neces-
sary to deliver it. Winter' proposed and carried out
with success the plan of removing the fcetus from the
peritoneal cavity through a very small incision in the
abdomen, and then extirpating the torn uterus by the
vagina. When the true conjugate diameter of the
pelvic inlet measures 8 cm. or more, the writer pro-
poses in such a case to extirpate the uterus by the
vagina, since the primary danger is hemorrhage; then
to grasp the feet and deliver through the natural pas-
sages.' This will obviate the objectionable features
of abdominal section, but will be applicable only to
cases having a true conjugate of 8 cm. or more. If
the soft parts in any case should be similar to those in
Case II., the operator should remember that the vagi-
nal Cresarean section is contraindicated when the true
conjugate measures less than 8 cm.^ The placenta is
generally loose in the uterus or vagina, but it often
escapes into the peritoneal cavity, and in some in-
stances reported much trouble was experienced in
finding it.
After the fcetus and membranes are born the mater-
nal injury will require attention. The ruptured uterus
presents to us a vascular organ frequently infected by
repeated digital examinations and obstetric manipula-
tions, the lacerated parametrium infiltrated with blood,
communicating with the cavity of the uterus and
therefore very liable to infection. If the patient fails
' Wiener klin. Wochensclirift, 1S97, p. 2B9.
'American Journal of Obstetrics, vol, x.nx., p. J\().
'Centralblatt f. Gynak., 1898, p. 509.
■* Diihrssen : " Ueber vaginalen Kaiserschnitt. " .Samml. klin.
Vortrage, N. F., p. 1375.
^ Ibid., No. 232, p. 1366.
May 26, 1900]
MEDICAL RECORD.
90.
to die of hemorrhage, the loss of blood has robbed her
of her best barrier to infection. The requirements of
an ideal procedure will be rapid and certain hemosta-
sis, removal of infected tissues, and free drainage.
The idea of restitutio ad integrum has attracted many
surgeons, and has been advocated enthusiastically by
Freund and Leopold in the form of laparotomy and
suture of the tear. Theoretically nothing can be more
correct, and some brilliant examples of successful re-
sults are reported. Nevertheless, as has been said be-
fore, with a mortality of si.xty per cent, we should exam-
ine into the causes of the same and see what can be
done to reduce it. The practical objection to abdom-
inal section and suture of the wound in the uterus and
parametrium is that the operation is a long one, that
the majority of patients are in deep shock, that the
long anajsthesia and exposure of the intestines and
peritoneum increase still more this shock, and, further,
the woman is left exposed to all the dangers of puer-
peral septicaemia because the case will seldom be
aseptic. This method then would be applicable only
to exceptional cases. To my mind there is another
bad feature which should weigh against its acceptance,
namely, the liability to rupture in subsequent labor.
Subsequent ruptures are reported by Bandl, Wensel,
Battlehner, Deutsch, Green, .\lberts, Diepen, Bizzell,
Rose,' Uittel," and Walter,' and although later
labors have been successfully conducted it seems
illogical again to expose a woman to the serious risk
of rupture. The frequency of puerperal infection
spreading from the uterus with fatal results led
Schultze' and Coe^ to advocate abdominal hysterec-
tomy. Reed " advises the removal of the uterus when
it is much mutilated, .•\bdominal hysterectomy has
never reached the popularity of supravaginal amputa-
tion of the uterus with fixation of the stump in the ab-
dominal wound. The extirpation of the puerperal
uterus by the abdominal route is always a time<on-
suming and sanguinary affair. By the Porro opera-
tion the abdomen can be opened, the foetus extracted,
the uterus removed, and the abdomen closed within
fifteen minutes, as in Case I. The disadvantage of
the Porro operation is sometimes the difficulty of ap-
plying the elastic ligature low enough to get below
the rupture; it may be impossible in very deep tears,
but reports demonstrate that the elevation and con-
striction of the stump usually suffice to close all bleed-
ing vessels. A few instances are reported in which
this failed to control all the bleeding points. Under-
bill ' sutured with catgut the portion of the tear below
his ligature on the cervix, and obtained a good result.
Braun v. Fernwald' was obliged to place deep buried
sutures in the floor of Douglas' pouch to control the
hemorrhage. Ludwig' in a similar predicament re-
sorted with success to gauze tamponade of Douglas'
pouch. Had Case III. been submitted to supra-
vaginal amputation, the elastic ligature would not
have controlled the hemorrhage, because the vessels
had retracted to the side of the pelvis. The Porro
operation avoids the most serious features of abdomi
nal hysterectomy; it will be often performed on ac-
count of the easy technique, and should be the method
of choice by an operator of moderate experience. The
treatment of a ruptured uterus by the tampon is only
less objectionable than leaving the patient to the un-
aided efforts of nature. The arrangement of the mus-
cular layers of the uterus is disposed in such manner
' Koblank : Op. cit. . p. 37.
- Archiv f. Gynak., Bd. 44, p. 396.
■' Frommel's " Berichte," Bd. viii. . .S. 676.
■• Centralblatt f. tlyniik , 18S6, p. 76;.
^ American Journal of Obstetrics, 1S91, p. 5S7.
* Ibid., vol. x.sx., iv. , p. 749.
' Edinburgli Medical Journal, 1S91, p. 206.
' Wiener klin. Woclienschrift, i3g4, p. 34.
^ Ibid., 1897, p, 292.
that as they contract the cervix will be dilated by the
impingement of the uterine contents against it. If
the tampon be of an absorbent nature such as gauze,
retracting fibres will push the mass of gauze against the
the cervix, at the same lime causing a gaping of the
uterine wound (which is usually much the larger aper-
ture), and the contents of the gauze will be squeezed
into the belly. So the only remarkable feature about
a case treated by the gauze packing or gauze drainage
is recovery of the patient, for gauze drains only until
its meshes are filled with fibrin, and this fibrinous de-
position occurs as rapidly as the gauze is packed in.
Dangerous hemorrhage occurs from the vessels out-
side of the uterus over which the gauze tampon has no
control; the bleeding often ceases for several hours
after rupture on account of the cardiac depression,
only to recur with a fatal issue; thus the tampon gives
a false sense of security. The occurrence of secondary
hemorrhage is illustrated by a case of Gessner's,' in
which the rupture was not detected until the fifth day
after labor; during urination fatal hemorrhage oc-
curred, and the autopsy revealed a rupture in the left
lower segment of the uterus with a large subperitoneal
hematoma extending to the kidney. Dole'ris and
Bonus" also report an instance of rupture of the uterus
with sudden death on the fourth day from hemorrhage;
these cases were untreated, but Koblank,' Freund,'
Loin,' and Winckel'' report deaths of tamponed patients
from hemorrhage, respectively on the seventh, ninth,
third, and thirteenth days after delivery. As a result
we are forced to conclude that there is no real safety
from hemorrhage unless the torn arteries are secured
by ligature. To the question then of " What shall we
do when a case is seen six hours after rupture and
no evidence of internal bleeding is apparent?" pro-
pounded by a learned writer, the most rational answer
would be — operate, whether the tampon has been used
or not. Backer' charges the tampon with increasing
the size of the laceration ; Fritsch and Chrobak * blame
it for changing incomplete into complete ruptures.
After a study of these clinical reports it becomes evi-
dent why the trend of opinion is increasing in favor
of surgical intervention in all cases. The uterine
tampon has, however, a definite place in our armamen-
tarium as a temporary dressing to prevent prolapse of
intestines or to retain them within the belly after re-
position of prolapsed coils, pending the arrival of the
operator or during transportation of the patient to a
hospital.
To obviate the uncertainty of the uterine tampon
and the risks of abdominal section, obstetricians have
attempted to close the rupture and ligate the bleeding
vessels from the vagina. Thus Green" advises draw-
ing down the uterus with volsella after, thorough ex-
posure of the parts and applying sutures directly to
the bleeding parts. Cholmogoroff '" succeeded in su-
turing a bad laceration of the uterine lower segment
by the vaginal route. The patient was a IVpara,
bleeding profusely after a breech birth ; the rupture
was 10 cm. in length, situated about 3 cm. above the
external os in the anterior wall of the uterus; the
bladder was not injured. The placenta was removed
from the abdominal cavity through the uterine wound.
The cervix was steadied with volsella; the torn edges
were trimmed evenly with scissors and closed with inter-
' Zeitschrift f. Geburts. u. Crynak. , Bd. 37, p. 162.
'Gaz. hebdomadaire de med. et de chir., 1896, p. 249.
^ Op. i-it. , p. 22.
■•Zeitschrift f. Geb. und. Gyn., Bd. 23, p. 474.
^Clinique Bru.xelles, tome iii., p. 177.
^ " Berichte und Studien," Bd. i., p. 138.
■■ Centralblatt f. Gynak., 1S97, p. 139.
* Verhandl. der deutsch. Gesellschaft f. Gynak. , Bd. vi.
' American Journal of Obstetrics, vol. .w.-i., p. 41.
•" " Zur Behandlung der kompleten Uterusruptur." Zcitschr.
f. Geburts. u. Gyn., Bd. 31, p. Sq.
9o6
MEDICAL RECORD.
[May 26, 1900
rupted sutures, with the exception of one corner which
was left open for drainage by a strip of gauze. She
recovered. Cholmogoroff believes that uterine rup-
tures can be sutured from below, providing the tear is
below the contraction ring. In Case II. suture of the
rupture was relatively easy because the Cassarean in-
cisions permitted the approach with needles and nee-
dle-holder, but otherwise it would have been impossi-
ble. Vaginal suture will be limited to a very few
favorable cases, as the objections to leaving a torn
uterus in the woman obtain, and more particularly be-
cause bleeding vessels may be overlooked. Indeed,
even after opening the abdomen one cannot always see
where the bleeding vessels are located without open-
ing up the pelvic serosa.
I have already mentioned that the extirpation of
the puerperal uterus from the abdomen is always a
lengthy and bloody operation, attended with much risk
of ureteral injury, because of the great vascularity in-
■ cident to gestation. It was on this account removed
only when extensively mutilated or septic, but recent
experiences with the extirpation of the gravid and
puerperal cancerous uterus by the vaginal route have
demonstrated the extreme ease and rapidity with which
the freshly delivered uterus can be removed; further,
that as strong downward traction on the cervix is ex-
erted its vascular apparatus becomes so attenuated by
the traction that for the time being hemorrhage almost
entirely ceases. It was at first feared that the volume
of the puerperal uterus would be so great as to render
extirpation difficult unless the organ was niorcellated,
but the experiences of Fritsch,' Chrobak," Seiffart,'
Winter,' Iwanoff,' Solowij," and Diihrssen' have de-
monstrated with positiveness the ease and rapidity of
the vaginal operation.
Immediately and for several hours after delivery
the uterus is very soft, compressible, and withal so
loosely attached, owing to the softened condition of the
ligaments, that the organ can be drawn out to the vul-
var orifice, a corresponding diminution of its trans-
verse diameter occurring. Fritsch concludes that vagi-
nal extirpation is peculiarly adapted to the treatment
of ruptured uterus, because after the abdomen is
opened one frequently sees only a small opening in
the peritoneum, whereas in the parametrium there is a
large cavity, and he claims that when hemorrhage is
severe after the child has been delivered by the natu-
ral passages, vaginal hysterectomy will give better re-
sults than the abdominal operation. Iwanoff arrives
at the same conclusion after removing a ruptured
uterus per vaginam. Winter believes vaginal hyster-
ectomy preferable to abdominal extirpation or conser-
vative treatment in all cases of complete uterine rup-
ture. Johannosky* and Solowij are not so favorably
impressed by the vaginal operation, because they can-
not overlook the field of operation. The writer's ex-
perience with Case III. and the reported cases in the
literature have convinced him that the vaginal opera-
tion for rupture of the uterus, like the vaginal opera-
tion for other pathological conditions, has its limita-
tions, and is not applicable to all cases and conditions
without discrimination. Partial or total escape of the
child from the uterus results in such extensive dis-
placement of the pelvic and abdominal structures
' " Vaginale Totalextirpation eines carcinomatosen Uterus am
Ende der Schwangerschaft." Centralblatt f. Gynak., 1898, p. i.
' Verhandl. der deutsch. Gesell. f. Gyn., vi.
3 Centralblatt f. Gynak., 1S98, p. 121.
■* Ibid. , p. 509.
' " Totale vaginale Extirpation einer wahrend der Geburt
rupturirten Gebarmutter." Centralblatt f. Gynak., 18S9. p. i.
^ " Totale.\tirpation der Gebarmutter per Vaginam oder per
Laparotomiam bei Gebarmutterzerreissung wahrend der Geburt."
Centralblatt f. Gynak., 1S99, p. 345.
'Volkmann's Samml. klin. Vortr.. N. F., p. 1385.
* " Zur Uterusruptur." Prager med. Wochenschrift, 1894,
p. 28.
that the damage done to the ureters or intestines may
demand abdominal section as a supplement. For an-
terior and posterior ruptures vaginal hysterectomy has
proven itself an ideal procedure, and in the light of
my own experience I will add that it is the operation
fiar exccllc7iie when the rupture is complicated by vesi-
cal laceration, also in those utero-vaginal lacerations
which occur from neglected transverse presentations,
and in all cases attended with septic endometritis.
Another commendation is that it may be performed if
need be without general ansesthesia, as in Iwanoff's
case.
Technique of the Vaginal Operation. — The pa-
tient is prepared for abdominal section and vaginal
hysterectomy, narcotized with ether, and placed in the
lithotomy position. The catheter is passed, the urine
withdrawn into a glass and inspected for blood. If
the patient is undelivered, the true conjugate diameter
will be measured again.
I shall suppose the case to be one in which the foetus
has escaped into the peritoneal cavity through a rupture
in the anterior wall of the uterus, the placenta remain-
ing in the uterus, with a conjugate diameter of the
pelvis of 8 cm.
The placenta is removed from the uterus and all
blood quickly swabbed away from the field. The la-
bia and vaginal walls are drawn apart with broad re-
tractors. The cervix is grasped on each side with a
strong volsellum forceps and drawn down to the vaginal
orifice; then with strong scissors the fornix is incised
all around the cervix. Douglas' pouch is opened by
blunt dissection, the retro-uterine ligaments are sev-
ered, the bladder' and the plica are opened, the uterus
is retroverted, the ligaments are tied off from above
downward, and then the uterus is cut away. The hand
is passed into the wound and all tears of the peritoneum
are followed up and examined for incarcerated intestinal
loops, which if found are gently loosened, drawn down
into the vagina, and inspected for injury before being
returned into the abdominal cavity. The foetus is
grasped by the feet and delivered; if the intestines
give much trouble by prolapsing before the child,
Diihrssen advises delivery in the Trendelenburg posi-
tion. The peritoneal cavity is now cleansed of clots,
amniotic fluid, and meconium, and gauze inserted for
drainage. Saline transfusions should be administered
with a free hand during the operation to replace the
lost blood and combat shock. The after-treatment is
that of an ordinary hysterectomy.
It will by this time be noted that the writer has
not laid the stress which the text-books do on the differ-
entiation of complete from incomplete tears. After all,
this distinction is not of so much importance, for we
have seen that in Case III., of subperitoneal rupture,
the patient would have died of hemorrhage if the bleed-
ing vessels had not been ligated, and Paschen" lost a
case of incomplete rupture from pelvic abscess four
weeks after the occurrence. On the other hand, in
many cases of complete rupture the patients recover.
Of main importance is the determination whether in-
fectious material has entered the abdominal cavity or
not; it seems to me that the thermometer is the more
reliable guide, for Kroner found that all of his patients
who had fever either before or during the period of
rupture died of septic infection.
' When vesical rupture complicates the uterine lesion, accord-
ing to Diihrssen it happens that trouble may be experienced in
detaching the bladder. Diihrssen, therefore, advises that the
rear Avail of the uterus be split to the fundus, the uterus re-
troverted and drawn out through the rear wound in the fornix,
and the separation completed from above downward. Diihrssen
st.ated that the neglect to split the opposite wall of the uterus
caused Winter so much difficulty that he was obliged to morcel-
late the retroverted uterus before he succeeded in detaching the
bladder ; this entails much loss of time.
^Centralblatt f. Gynak., iSyi, p. 915.
May 26, 1900]
MEDICAL RECORD.
907
When intestines prolapse into the uterine cavity or
the child escapes into the belly, the question of peri-
toneal laceration will be easily solved, but when de-
livery has been effected by the natural passages, even
if the hand is passed througii the uterine tear the un-
torn peritoneum o;ten adapts itself so gently to the
lingers that intestiial coils may be felt with deceiving
accuracy, and undue force would rupture the delicate
serosa. The writer agrees with those who regard
every diagnosticated uterine rupture as an indication
for operation; reasoning that if a woman subject to
this calamity does not die of primary, she may die of
secondary, hemorrhage, and that if she is fortunate
enough to escape death from hemorrhage she will be
still more fortunate if she escapes death by sepsis.
I believe that prompt and radical surgical interven-
tion presents the only solution to the question of re-
ducing the mortality of uterine rupture, and the vagi-
nal operation appears to answer both requirements,
but should be supplemented if need be by abdominal
section. Rupture of the uterus will always be a se-
rious affair, and while the general rule enunciated
holds good, the practitioner should not forget that his
attitude must be modified by circumstances. To oper-
ate on a patient in collapse would only hasten death,
but to transfuse several thousand cubic centimetres of
decinormal salt solution into her veins will promptly
revive her and give the surgeon time to remove her
uterus and close the bleeding vessels. Neither should
commencing peritonitis be regarded in any other
light than as a peremptory command for immediate
operation and provision for the very freest drainage, as
patients not infrequently recover under the most ad-
verse circumstances. Thus Reussing' reported an in-
stance of rupture in which the fcetus remained in the
abdominal cavity for three days before its removal
by cceliotomy, but the patient recovered. What is
known as conservative surgery should be avoided un-
less the relatives of the patient expressly forbid the
radical procedures. If a conservative operation is
performed one must be prepared for long suppurations
and pelvic abscess ; and if pregnancy occurs subse-
quently the practitioner will be called upon to choose
either the Cesarean section at term or to induce
premature labor earlier in pregnancy. Should the
undelivered patient be dying or just dead, the physi-
cian will e.xamine for foetal movements and heart
sounds; if the child is living the post-mortem Cassa-
rean section should be performed. Kendall '" reports
two instances. The first child was born alive but
died soon after; the second child was still alive a
year later.
Resume. — I. In threatened uterine rupture the
woman is to be delivered at once by the method which
does not increase the excessive intra-uterine tension.
II. After rupture occurs, delivery by the natural
passages is permissible only if the uterine injury is
not aggravated thereby.
in. If the true conjugate diameter of the pelvic in-
let measures less than 8 cm. a completely intra-peri-
toneal foetus should be delivered by abdominal section.
IV. But if the conjugate measures 8 cm. or more,
the uterus should be removed by vaginsl hysterectomy
and the child delivered by the feet through the natural
passages.
V. If life is detected in the child after the mother's
death, the post-mortem section should be performed.
VI. The uterine tamponade is useful only as a
dressing to prevent intestinal prolapse or to retain re-
posited loops of intestine within the abdomen until the
case can be submitted to operation.
' Centralblatt f. Gynak., 1895, p. 41.
'"Two Cases of Rupture of the Uterus; Post-mortem
C.'esarean Section, etc." Virginia Medical Semi-monthly, vol.
iii., p. 591,
VII. Conservative surgery exposes the woman to
the serious risk of subsequent rupture, and should
therefore not be elected unless expressly commanded
by the patient or immediate relatives.
VIII. Vaginal suture is open to the objection that
bleeding arteries in the parametrium are apt to be
overlooked.
IX. When laparotomy becomes necessary for the
birth of the fcetus, the uterus is to be removed by su-
pra-vaginal amputation, with the extra- or intra-perito-
neal treatment of the stump, according to the exigen-
cies of the case or ability of the practitioner.
X. Vaginal hysterectomy is the elective procedure
in all cases, but should be supplemented by abdomi-
nal section whenever necessary.
LOSS OF HAIR; A CLINICAL STUDY
FOUNDED ON THREE HUNDRED PRI-
VATE CASES.'
By GEORGE THOMAS JACKSON, M.D.,
OF COLUMBIA
In 1892 the subject of loss of hair was discussed by
this association, following the reading of a paper upon
the subject by Dr. George T. Elliot. In 1893 I pub-
lished in The American Medical and Surgical Bulletin'
a clinical study of one hundred private cases of loss
of hair. Both Dr. Elliot and I maintained the same
proposition, namely, that a disease of the scalp vari-
ously called seborrhcea, pityriasis, dandruff, sebor-
rhceal eczema, or dermatitis was the cause of a great
majority of the cases. In the present study I have
not endeavored to touch upon any pathological or bac-
teriological question, but have simply tried to find
out what my clinical experience teaches. I have
chosen the term loss of hair rather than alopecia so
that it would be readily understood that baldness was
not present in every case. Most of the patients who
consult us are losing their hair, and have not lost it.
Of the three hundred cases, a study of which forms
the basis of this paper, one hundred and fifty-eight
occurred in men, and one hundred and forty-two in
women.
In this paper I have made no account of the nation-
ality of the patients, as naturally the vast majority of
them were natives of this country.
Condition: Married, 38 men and 61 women, or 99
in all. Single, 97 men and 60 women, or 157 in all.
Widowed, i man and 7 women, or 8 in all. Not re-
corded, 36.
Occupations — of the men : Actor, 2 ; architect, 3 ;
banker, i; bookkeeper, i; bookbinder, 1; broker, 9 ;
butcher, 2 ; clergyman, 2 ; clerk, 20; commercial trav-
el ler, 1 ; dentist, 2 ; electrician, i ; engraver, 2 ; farmer,
2 ; grocer, i ; gymnast, i ; hotelkeeper, i ; lawyer, 8 ;
lecturer, i; librarian,!; manufacturer, 2 ; mechanic,
4; merchant, 8; musician, i; physician, 40; printer,
i; student, 13; tailor, i; teacher, 4; telegrapher, 1;
waiter, i; not stated, 21. Of the women: Artist, 2;
clerk, I ; domestic, i ; dressmaker, 1 ; glover, i ; house-
keeper, 56 ; musician, 2 ; nurse, 3 ; physician, i ; proof-
reader, I ; reporter, i ; student, 1 ; teacher, 4; unstated,
67.
Age at beginning: From ten to twenty years, 27
men and 24 women, or 51 in all. From twenty to
thirty years, 97 men and 50 women, or 147 in all.
From thirty to forty years, 31 men and 36 women, or
' Read before the American Dermatological Association, May
I, 1900.
* Amer. Med. and Surg. Bull., 1893, vol. vi., p. 1047.
9o8
MEDICAL RECORD.
[May 26, 1900
67 in all. From forty to fifty years, 3 men and 17
women, or 20 in all. Over fifty years, 19 women.
The largest number of cases in any one year was
20 cases in tlie twenty-sixth year. The next largest
was 18 in the twenty-second year. It is notable that
12 cases began under sixteen years of age.
Regions affected: General thinning, 21 men and 80
women. Crown, 56 men and 21 women. Crown and
forehead, iS men and 3 women. Crown and temples,
16 men and 2 women. Temples and forehead, 24
men and 8 women. Occiput, i woman. The tonsure
was formed in 19 men and 3 women.
Diseases of the scalp and hair, as probable causal
factors in the production of the loss of hair: Atrophia
pilorum propria, 13 cases; atrophy of the scalp, 6
cases; canities, 9 cases; dandruff, 2 18 cases; dryness
and heat of scalp, 6 cases; hyperemia of scalp, i case;
hyperidrosis capitis, 10 cases; keratosis capitis, i case;
seborrhoea oleosa, 6 cases; erysipelas, i case.
General diseases as probable complicating factors:
Anaemia, 15 cases; chorea, i case; constipation, alone
7 cases; with and without dyspepsia, 39 cases; gall
stones, I case; gonorrhoea, 2 cases; gout, i case; hypo-
chondria, I case; inebriety, 3 cases; insomnia, 2 cases;
invalidism, chronic, I case; malaria, 10 cases; malnu-
trition, 1 case; menopause, 8 cases; neuralgia, 3 cases;
nervousness, n cases; neurasthenia, 5 cases; obesity,
1 case; overstudy, 2 cases; over-training, i case; poor
circulation, i case; spermatorrhoea (?), i case; ure-
thritis chronica, i case; uterine disorders, 4 cases.
Family history : A history of baldness in the family
was found in 132 of the 300 cases, as follows: Father
only, 27 men and 6 women; father and paternal
uncles, 13 men; father and paternal cousins, i man;
father and paternal grandfather, 2 men ; father, paternal
grandfather, and brother, i man ; father and brother,
17 men; father, brother, and maternal aunt, i woman;
f atlier and mother, 4 men and 6 women ; father, mother,
and brother, 2 men and 4 women ; father, niother, and
maternal grandfather, i man and i woman ; father and
sister, i woman; father and maternal aunt, i woman.
Paternal uncle and brother, 2 men; paternal uncle, 3
men ; paternal uncle, maternal grandfather, and uncle,
I man; paternal grandfather and cousins, i woman.
Mother only, 3 men and 13 women; mother and ma-
ternal grandfather, i man and i woman; mother and
maternal grandmother, 2 women ; mother and maternal
aunt, 5 women; niother and paternal uncle, i man;
mother and sister, i woman; mother and brother, i
man and i woman. Maternal uncle, 3 men; mater-
nal uncle and brother, i man; maternal aunt, i wo-
man; maternal grandmother, i woman. Brother, 8
men; brother and sister, i woman. Sister, i v.'oman.
What inferences can be drawn from these statistics?
1. It would seem at first glance that loss of hair was
more common in men than in women, as 158 is to 142.
But I feel sure that the proportion is not altogether
correct, because it is well known that women value a
good head of hair much more than do men. They
will do everything in their power to save their hair.
Men either regard the loss of their hair as inevitable,
or will not take the time or trouble even to try to save
their hair. It is therefore probable that the statistics
represent fairly well the prevalence of loss of hair
among women; but that they inadequately represent
the prevalence of loss of hair among men, which is
doubtless greater than they show. It can, then, be
fairly inferred that loss of hair is much more frequent
among men than among women, which is the general
impression without the aid of statistics.
2. It would seem at first glance that the unmarried
state is specially bad for the hair, as we find that there
are 157 unmarried men and women to 99 married.
But when we note that the number of the unmarried
women (61) and of the married (60) is practically
the same, while the bachelors outnumber the married
men by 59, or are nearly three times as many, we sus-
pect that our first inference is a little lame. The rea-
son why the number of bachelors is so far in excess of
that of the married men is found in the expression I
hear so often from them: " I would not mind growing
bald if I were married." When a man marries, grows
old, and has resting upon him the task of winning a
living for himself and his children, his personal ap-
pearance usually is a matter of secondary importance,
and he bears the loss of his hair with equanimity.
A woman, no matter how old she may be, nor how
heavy her cares, still studies her personal appearance,
and glories in her hair, or mourns its waning luxuri-
ance. The correct inference, then, should be drawn
from the statistics of the women, and that is, that
neither the married nor the single state has any influ-
ence in the production of baldness.
3. We now come to the question : W'hzX influence
does occupation have in causing loss of hair.' My
statistics show a great variety of occupations among
those who are losing their hair. Two facts come out
prominently, namely: (i) The great majority of my
patients lead indoor lives. The 67 women put down
as having no occupation belong to the leisure class of
unmarried women, and are housed most of the time.
(2) Nearly all of my patients belong to the intellec-
tual class. That 13?; per cent, of them are physi-
cians does not necessarily mean that physicians are
specially prone to loss of hair, any more than because
18-,; per cent, of them are housekeepers means that
that occupation specially tends to loss of hair. And
yet perhaps it does in both cases. The life of the
physician and the housekeeper is alike in that their
work is never done, and in that worry and nerve strain
are constant elements. If we add together the actors,
architects, bankers, brokers, housekeepers, lawyers,
manufacturers, merchants, nurses, physicians, students,
teachers, and telegraphers, all of which can fairly be
regarded as occupations in which the elements of
worry and nerve strain enter largely, we have 155, or
more than one-half of our cases, subject to these influ-
ences. It may, then, be fairly inferred than an intel-
lectual, indoor life, specially when coupled with worry
and nerve strain, is a predisposing, if not a determin-
ing cause of baldness,
4. Without doubt my statistics show that the major-
ity of the cases of loss of hair begin before the thirtieth
year of age, sixty-six per cent. Further, more cases
begin in the decade between the twentieth and thirtieth
years than in any other decade, the largest number in
any one year being 20 in the twenty-sixth year. It
would seem, then, that if one passes the thirtieth year
of age without showing signs of incipient baldness,
the chances for keeping the hair intact are very much
increased. This would seem to apply specially to
men, though here again comes in the fact that married
men care less about their hair than do single men.
Here again, also, the figures in regard to the women
are probably most to be depended upon, and we can
infer that loss of hair occurs with rapidly decreasing
frequency in the decades after thirty years, as repre-
sented by 36, 17, and 9.
5. My statistics show that loss of hair in women
most often takes the form of a general thinning, wiiile
in men the whole top of the head is most often affected.
The receding temple is very common in men, excep-
tional in women. Though not brought out in my sta-
tistics, I would say that I have come to regard the
receding temple as a family trait, ha\ing often found
it so in talking with patients. The tonsure was
formed in only 19 of my male and 3 of my female
patients. That the top of the head was so much more
often affected in men than in women is doubtless due
to the well-known difference in the make-up of the
May 26, 1900]
MEDICAL RECORD.
909
scalp in the two sexes, the woman preserving tlie in-
fantile fatty cushion under the scalp much longer than
the man. If you put your hand on the head of a man
you will usually find the scalp close down on the skull,
while under the scalp of a woman you will feel a more
or less thick layer between it and the skull.
6. As to the causes of loss of hair, apart from acute
febrile diseases causing defluvium capillorum, which
are not included in this study, we have predisposing
and exciting causes. I believe that my statistics show
that the great predisposing cause is heredity. We
find that out of the 300 cases 132 have a well-marked
family history of loss of hair. Without doubt in many
of the cases of baldness in ancestors dandruff has
played an important part. Still in a great many other
diseases heredity is recognized as a predisposing
factor, and it cannot be lightly set aside in the etiol-
ogy of alopecia. I believe that in some families the
hair falls at an early age without any discoverable
cause in the scalp itself. The, to me, most interesting
fact brought out both by my former statistics and the
ones now before you is that the hereditary tendency to
loss of hair runs in sex. So far as I know I am the
first to draw the attention of the profession to this. If
you study my figures you will find that when the father
and father's family only show a tendency to loss of
hair, there are 75 men and 21 women; while when
the mother and mother's family only are concerned,
there are 18 men and 32 women. When it was the
father only who was bald, there are 27 men and 6
women; while when it was the mother only who was
bald, there are 3 men and 13 women.
It seems to me that it is a fair inference to draw
from the above that heredity is a factor of marked in-
fluence, a strong predisposing cause of loss of hair at
least, if not in many instances the actual cause of
baldness.
A glance over the list of complicating diseases
noted in 122 cases shows us that they are all disorders
that affect the general nutrition of the body. It is
recognized that the hair sympathizes with the general
nutrition of the body, falling out after fevers and the
like. There does not seem to be any reason why it
shoidd not suffer in anosmia, 15 cases; dyspepsia, 30
cases; malaria, 10 cases; neurasthenia, 16 cases; and
we see that it does. Therefore it can be stated as
another conclusion that all diseases of lowered nutri-
tion are predisposing, and at times determining,
causes of loss of hair.
As exciting causes of loss of hair we find in ninety
per cent, of all the cases some disease of the scalp or
hair itself. In 218 cases, or 72 J3 per cent., there was
dandruff. I use this term to include both pityriasis
and seborrhcea sicca, both forms of seborrhceal derma-
titis, so called. In Dr. Elliot's statistics the propor-
tion of dandruff cases was even greater, 88| per cent.
There is, therefore, no doubt that dandruff' is found in
connection with loss of hair in the majority of cases.
It is a matter of common experience that dandruff may
be present in large amount for years and the hair es-
cape all damage. It does, however, antedate the loss
of hair so often that it must be regarded as the most
active exciting cause of alopecia.
I would state my belief in regard to the etiology of
alopecia as follows: In a small minority of cases it is
due to heredity alone ; that heredity or any debilitating
disease predisposes to loss of hair; that dandruff in
some form is the exciting cause in the great majority
of cases; that atrophic processes in the scalp, hyperi-
drosis and keratosis and a few other diseases may
cause loss of hair in exceptional instances. Or, to
state it differently, I believe that while it is possible
for one without a family tendency to loss of hair to
have dandruff for years without losing his hair, the
same disease affecting one coming of a family the
members of which lose their hair early is very sure to
cause alopecia unless the dandruff is held in check
by treatment. The important part played by dandruff
in the production of alopecia is shown by the fact that
if we can cure the dandruff the loss of hair is checked,
unless the scalp has been too much damaged by the
atrophic processes to which it gives rise. If the dan-
druff relapses the fall of hair will begin again.
Treatment — On looking over my notes I find that
I was able to follow only about a third of my cases
long enough to draw conclusions in regard to the
effects of treatment. Many of my patients were seen
but once in consultation with other physicians. In
others the calvities had gone too far for any hope of
making the hair grow. But enough of them were fol-
lowed sufficiently long, and from a number of them
I have heard more or less directly as to the results of
treatment to enable me to form quite definite ideas in
regard to what may be expected from treatment.
If there is absolute baldness, and the scalp is atro-
phied and bound down, there is little use in trying to
treat the case. All such a patient can do is to en-
deavor to stay the evil day by keeping his scalp in as
good a condition as possible by hygiene, massage, and
applying remedies for the dandruff if it is present.
What the latter are will appear later. It is possible
to stimulate the dying hairs for a time into a stronger
grovi'th, but ultimately calvities is inevitable.
I have had positive results in checking the fall of
hair and increasing its amount by using precipitated
sulphur 10 per cent, in a good cold cream with or
without either salicylic acid, three to five per cent., or
extract of jaborandi, a drachm to the ounce. These
are my favorite remedies. The ointment proposed by
Dr. Bronson, composed of ammoniated mercury gr.
XX., calomel gr. xl., in an ounce of vaseline, has also
done good service in some cases. In a few cases re-
sorcin in solution and in increasing strength has
proved helpful. On the other hand, naphthol and
cantharides have proved perfect failures; resorcin has
failed as often as it has helped; and my favorite sul-
phur preparations have failed about one-third times as
often as they have been successful.
Medicated ointments and lotions are useful for
overcoming the dandruff. I believe that there is no
permanent cure for that disease, because it is parasitic,
and the scalp once having been infected is all the
more liable to reinfection. Therefore I am in the
habit of telling my patients that they must expect re-
lapses, and have their remedies constantly at hand so
as to apply them as soon as the dandruff reappears.
For stimulating the growtli of the hair I believe that
there is only one remedy worthy of the' name, and that
is massage. For this a skilled professional is best,
but a great deal can be done by the patient pinching
up the scalp between the ends of the extended fingers
of both hands for five minutes night and morning.
Massage must not be used until the dandruff is
checked.
To state it clearly, my treatment for the ordinary
case of loss of hair with dandruff is as follows: I first
attend to the general condition of the patient. The
patient is given one of the sulphur preparations and
is directed to use it once a day for three days, and
then to w-ash the hair and scalp. Immediately after
the hair is dried, the ointment is again applied and
repeated every other day for ten days. The scalp is
again washed and the ointment continued twice or
three times a week until the dandruff is controlled, the
washing being repeated from time to time. When the
scalp is in good condition massage is ordered. If the
patient will not use an ointment I order a lotion of
resorcin, at first three and afterward five and ten per
cent, strength, to be used morning and night. If the
sulphur is used in the form of what my druggist calls
9IO
MEDICAL RECORD.
[May 26, 1900
"sulphur cream" it is not at all objectionable, and
being used but twice a week or so, it is not so much
trouble as it is to use a lotion twice daily. For a
case of loss of hair without any apparent trouble witli
the scalp I rely mostly upon massage, using the sul-
phur preparation occasionally to keep the scalp a lit-
tle oily.
Prognosis — The prognosis is bad when calvities is
already present. A bad family history as to the hair
is a bad element in prognosis. The longer the dan-
druff has lasted the worse is the prognosis. It is less
easy to help a man than a woman. The best progno-
sis is founded upon the patient being a woman without
a history of baldness on the maternal side, the loss of
hair not being of long standing.
14 E.^ST Thirtv-First Street.
CELLULAR SPECIFICITY AND ITS BEAR-
INGS ON NEOPLASMS.
By B. H. BUXTON, M.D.,
The question of the specificity of cells could not arise
so long as their origin remained obscure; that is to
say, until about 1840, when Schleiden for the vegeta-
ble, and Schwann for the animal kingdom, demon-
strated that cells cannot arise rtt- /lozv.as had been sup-
posed, but only from pre-existing cells, and Virchow,
applying their discoveries to pathological processes,
formulated the axiom, '• Omnis cellula e cellula." Ac-
cording to Virchow, the sole agents in regenerative and
neoplastic processes are the connective-tissue cells,
which, assuming embryological characteristics by a
kind of atavistic change, are then enabled to differen-
tiate themselves and form various tissues, of connect-
ive or epithelial types, according to circumstances.
These views were generally adopted and held good
until 1865, when Thiersch, after an exhaustive study of
epitheliomas of the skin, arrived at the conclusion that
the epithelial elements in these tumors are derived
solely from the epidermis; the connective tissue tak-
ing no part in their development. Waldeyer followed
suit in 1867 and 1872 with extended observations on
epithelial, principally glandular, tumors, in two hun-
dred of which he found that new-formed epithelial
masses were always in connection with pre-existing
epithelium, and there was no evidence whatever that
the development of these masses proceeded from the
connective-tissue cells.
Re'mak had already maintained that from the mo-
ment the germinal layers are fully formed there can be
no metaplastic interchange between the cells compos-
ing them, but beyond this he did not go, and it was not
until the publication of Thiersch's and Waldeyer's
researches that the theory of cellular specificity was
generally adopted. From this time the idea rapidly
developed, and has been carried to what appear absurd
lengths by Bard, whose first article on the subject ap-
peared in 1886. Bard starts with the ovum as the most
complex cell, from which less and less complex cells
arise by a process of what he calls de'doublement, in
which the cells resulting from division are of unequal
value — as opposed to simple multiplication, in which
they are of equal value. He supposes the first divi-
sion of the ovum to be such a dedoubling, giving rise
to two less complex transitory cells of unequal value,
which continue to increase by a simple multiplication
until there is another dedoubling process, so that cells
become less and less complex as they recede from the
ovum; the finished tissue consisting of simple cells
which can reproduce their own species only by a proc-
ess of multiplication, and are unable to take on the
properties of other species by metaplastic interchange.
He expands Virchow's axiom into "Omnis cellula e
cellula ejusdem generis," and draws up a scheme for a
histogenetic tree in which the branches increase by
dichotomic division, the nodal points representing the
dedoublings and the final twigs the various species of
cells.
Bard gets along swimmingly until he has to account
for the appearance of ova and spermatozoa in the newly
formed organism, which carries him into a maelstrom
of speculation where no one can follow, for he has to
assume that there are cells which have been derived
direct from the ovum by simple multiplication and
have never passed through stages of dedoubling. This
not only contradicts his own view that the first divi-
sion of the ovum is a dedoubling — a matter of little
moment — but is utterly opposed to all that is known
of the histogenesis of ova and spermatozoa. That they
arise by dift'erentiation of the columnar mesothelium
of the peritoneum is a fact which cannot be disputed,
and there is no evidence w-hatever to show that they
are set aside from the beginning of things to fulfil their
special functions.
Bard's ideas are evidently too simple for the Ger-
man mind to grasp, so Hansemann, basing his belief
in cellular specificity chiefly on the fact that each type
of cell has certain mitotic characteristics peculiar to
itself, elaborates a more complicated theory. He sup-
poses that the ovum is a complex cell containing a
large number of what he calls plasmas, each plasma
having a potentiality of forming a certain type of cell.
On repeated division each cell contains all the plas-
mas, but in unequal quantities, so that one particular
plasma, Haupt or chief plasma, is developed in each
cell at the expense of the other Xeben or secondary
plasmas. No metaplastic interchange can take place
except between cells whose Hauptplasma is similar.
Supposing the ovum to contain equal quantities of
three plasmas, 6a, 6/', 6^,- on division one resulting
cell may contain 4*7, 3/', 3<\ and the other 21?, 3/', ^c.
In the first case, therefore, the chief plasma would be
a, and the secondary ones /' and f, and this inequality
would go on increasing as the cells receded from the
ovum. By this method he is able to explain the for-
mation of new ova by supposing a gradual re-equaliza-
tion of the plasmas; this re-equalization being the sole
function of the ovum.
Both Bard and Hansemann maintain that the func-
tion of a cell is strictly limited by its origin; for ex-
ample, certain cells are predestined to form fat, others
bone, and yet others fibrous tissue, and between these
there can be no interchange of functions. The same,
in their opinion, holds good for the different kinds of
epithelium. Facts, however, hardly justify these con-
clusions; it seems more probable that the function of
a cell depends more on itsenvironment than its origin,
and that, except when the function is already of a
highly complicated nature, cells may vary both func-
tionally and morphologically within very wide limits
if there is a change in their environment. Lubarsch
says: "Such already differentiated cells always pro-
duce like offspring under like conditions, but only
then."
All cells form certain derived products which must
not be confounded with their products of excretion.
The former may be called synthetical, and the latter
analytical, products. The synthetical products maybe
(i) intracellular, as those of striated muscle or nerve
cells, and contribute to the activities of tlie organism;
or (2) extracellular, as those of connective tissue or
epithelium, and contribute to the support of the organ-
ism.
I. Striated muscle and nerve cells, both functionally
and structurally, have reached a very high degree of
organization. No instance of metaplastic interchange
between themselves or between them and any other
May 26, 1900]
MEDICAL RECORD.
9ir
group of cells has ever been observed, and they may
safely be considered to constitute distinct species.
Death is the only result of a change in their environ-
ment, so that their power of reproduction and tumor
formation is practically ;///.
II. In this group the synthetical products, after be-
ing formed, are removed from the cell and contribute
in various ways to the support of the organism. It
may be at once conceded that there are apparent ex-
ceptions to this rule as in the cells of the sebaceous
glands and epidermis, but in these cases the cells them-
selves die and are cast ol'f with their contained prod-
ucts, so that, as far as the living organism is concerned,
the latter may be regarded as extracellular. In other
instances, the formation -of synthetical products is re-
duced to a minimum, as in the lining cells of ducts
and vessels.
The cells forming this group may be subdivided
into A, the epithelial, in which the synthetical prod-
ucts on being separated from the cell are removed to
a distance, and H, the connective tissue in which they
remain practically /// situ.
A. The epithelial sub-group may be classified ac-
cording to its morphological and functional proper-
ties :
Morfhological. Functional.
1. Stratified. Defence — external influences.
2. Columnar. Transmission or absorption.
3. Flattened. Defence — internal influences.
4. Cubical or spherical. Specialized secretions.
The functions of the first two classes are simple, and
the cells manifest a comparatively low grade of organi-
zation in their capability of proliferation and regenera-
tion, of metaplastic interchange, and formation of neo-
plasms if there is any change in their environment.
Their capability of regeneration is too well-known to
be dilated upon, but it may be mentioned that Hanse-
mann, Bizzozero, and other recent investigators main-
tain that in the normal adult organism mitoses can be
observed in some tissues; in epithelial principally
those communicating more or less directly with the ex-
terior, as the epidermis with its hair follicles and seba-
ceous glands, mucous membranes of the intestinal and
respiratory tracts, the epithelial recesses of the uterus,
etc., and finally the ducts of glands, all of which can
undergo physiological regeneration, irstitiitio ad in-
tegnnii. Such mitoses are scarcely to be found in the
more complicated glands, with the exception of the
mammary and testicular, and when present indicate
considerable proliferative power.
Metaplastic interchange between the first two classes
may take place physiologically. Examples of this are
monotremes, marsupials, and edentates, in which the
teeth are absent or rudimentary, so that the task of mas-
tication falls to the lot of the stomach, the epithelium
of which takes on the functions and structures of the
epidermis, even to the formation of keratohyalin, as
shown by Ernst and Posner, the latter of whom re-
marks that keratinization is not a monopoly of the
epiblastas had been hitherto supposed. Huxley com-
pares the stomach of edentates with that of gramini-
vorous birds, which is also lined with stratified keratin-
izing epithelium, but in his day the minute anatomy
had not yet been fully studied. In the above instances
the unusual environment necessitating increased de-
fence is evidently the cause of the structural changes.
In the domain of pathology Virchow was the first to
point out the change to flattened stratified epithelium,
which often occurs along the track of the tracheotomy
cannula; a similar change having been also observed
in the nasal passages in ozajna, in chronic endome-
tritis, and in inversion of the uterus. To these it may
be objected that the change has been brought about by
progressive invasion of the epidermis from without,
rather than by metaplasia, but such objections can have
no weight in the cases reported by Ernst, Siegert,
Gruenwald, Ohloff and others, of primary keratinizing
epitheliomas arising in the bronchi and gall bladder.
Here the natural conclusion is that, in consequence
of long-continued irritation from foreign bodies, the
epithelium has to assume the defensive and changes
its character accordingly. Such occurrences may be
relatively frequent, but except when there was subse-
quent tumor formation would be liable to remain unno-
ticed.
That metaplastic interchange can take place between
columnar and stratified epithelium seems certain, and
they cannot therefore be regarded as distinct species^
although they may be of widely different origin.
As regards neoplastic formation, it is astonishing
how closely the cells of tumors derived from these two
classes often resemble those of the parent tissue, al-
though malignancy may already be pronounced, show-
ing that their power of proliferation is great, even in
the adult though not very highly differentiated condi-
tion. As examples may be quoted keratinizing epithe-
liomas of the skin, malignant adenomas of the rectum,
and tubular carcinomas of the liver arising from the
gall ducts.
A very generally accepted hypothesis, first mooted
by Weigert, for the etiology of tumors is that of a dis-
turbance of balance within the organism. Certain tis-
sues become weakened and are unable to maintain their
normal physiological resistance to the encroachments
of other neighboring tissues which have retained their
vigor. The functions of the cells under consideration
being simple, they are less liable to regressive changes
than certain others; any possible relative weakening
of their neighbors constituting a change of environ-
ment for them, of which they are able to take advantage
by virtue of their proliferative capabilities. This is
in reality a regenerative effort, but, not being con-
trolled by the normal resistance, it proceeds lawlessly
and gives rise to a structurally atypical growth. The
flat single epithelium lining the vessels and the large
serous cavities appears to be more highly differenti-
ated, and yet more so are the secreting cells of the true
glands, in which latter the conditions are favorable for
specialization. Being for the most part deeply situated,
they have, from the earliest ages, been protected
against changes in their environment, and have there-
fore been enabled to devote all their energies toward
providing materials for the support of the body, in
which process they have reached a high level of organi-
zation. As already remarked, in the adult normal
state mitotic figures can rarely be observed in them,
showing that their capabilities of proliferation and re-
generation are comparatively slight. In organs com-
posed of such cells there can never be a restitutio ad
iiitegnim on loss of substance, although there may be,
and usually is, a compensatory hypertrophy of the re-
maining parts. If, for instance, a lobe of the liver be
removed, although the organ may regain its normal
size, the lost lobe is not regenerated, but the individ-
ual microscopic lobules of the remaining lobes, being
stimulated to unusual activity, increase in volume,
though not in number, as shown by Meister.
Metaplastic interchange is unknown among the se-
creting cells of deep-seated organs; like muscle and
nerve cells they are to be considered as constituting
distinct species. Primary carcinomas of compound
glands almost always arise from the ducts and not from
the specific secreting epithelium. In the pancreas they
start, as a rule, at the head, in which the ducts are most
numerous, and in the liver, in which their origin can
be traced, it is usually found to be in the gall bladder
or bile ducts. The small multiple adenomas found in
cirrhosed livers or kidneys are probably more in the
nature of localized compensating hypertrophies thaa
true tumors.
912
MEDICAL RECORD.
[May 26, 1900
Siegenbeck von Heukelom describes three cases of
adeno-carcinoma of the liver with cirrhosis, numerous
small nodules up to the size of a cherry being scat-
tered throughout the organ; a condition, the "cirrho-
sis carcinomatosis " of Perls, occasionally observed
though by no means frequent. Von Heukelom is un-
able to account for the combination, but it seems
probable, as suggested by Orth, that "compensating
hypertrophic patches from some unknown cause may
overstep the limits of hypertrophy, and by a typical
growth lead to the formation of malignant tumors.'"
The glands arising from the epidermis are more ex-
posed to external iniiuences than the deep-seated ones,
and their secreting cells have not become so highly
specialized. Sebaceous glands can apparently become
formed de novo, and Fabre Domergues maintains that
remains of sweat glands on a denuded surface can as-
sist in the regeneration of the epidermis by becoming
transformed into stratified epithelium. Tumors, both
benign and malignant, arising from these glands are
by no means infrequent.
In the mammary glands, which are probably modi-
fied sebaceous glands, mitoses are frequent in the cells
of the acini, even in the adult state. The necessity
for proliferative power in these cells is obvious, and
the frequency of mammary tumors may not only be
ascribed to this, but also to the fact that the mamma is
both phylo and ontogenetically the last of the organs
to attain its full functional activity, so that, its stabil-
ity being naturally less than in older organs, a disturb-
ance of balance between its epithelial and connect-
ive-tissue elements can more easily occur. Among
domesticated animals, statistics of carcinoma in sev-
enty-eight cases, collected by Casper, show about eigh-
teen per cent, both in dogs and horses, including both
sexes, to be mammary; no other organ giving such a
high percentage. On the other hand, McFadyean
m.iintains that mammary carcinomas in animals are
relatively uncommon, and in sixty-four cases only
quotes five or eight per cent, among horses and dogs,
while in the cow, so far as he is aware, there is no
authentic case on record. Still even eight per cent.,
including both sexes, is a high percentage, and seems
to indicate that among domesticated animals, as in the
human species, malignant tumors are more likely to
arise in the female breast than in other organs.
B. Connective Tissue: The second sub-group com-
prises the connective-tissue cells, whose different kinds
of synthetical products assist in building up the en-
doskeleton and— following Mark — may be called sus-
tentative. It is not, however, quite determined in
what way the intercellular substances are formed by
the cells, although it is certain that the presence of
the latter is essential to their development and con-
tinued existence.
Acording to Goette, the primary mesenchymal sub-
stance is formed by transfusion from the entodermal
canal, and is destitute of cells. Later on cells become
detached from the mesothelium, and by amoiboid move-
ments penetrate into the mesenchymal Huid; further
differentiation being influenced by them, but the act-
ual changes occurring altogether outside of the cells.
It may be taken for granted, then, that the secretions
of the cells so act upon preformed undifferentiated in-
tercellular substance as to cause it to assume various
characteristics, and the question then arises: " Is the
character of the secretion of a mesenchymal cell de-
pendent on its inherent specificity, in which case there
can be no metaplastic interchange between the differ-
ent kinds, as maintained by Bard and Hansemann; or
is it merely dependent on the cell's environment, so
that with a change of the latter the cell can alter the
nature of its products? "
Those mesenchymal cells which are purely sustenta-
tive will alone be considered here. Some have taken
on other functions, as the fat cells which form a re-
serve fund, the involuntary muscle cells which con-
tribute to the activities of the organism, and the lymph
and blood cells. The mesenchymal fluid at first is
probably only a serous effusion (Minot) either derived
primarily from the entodermal canal, as already men-
tioned, or, as Hertwig maintains, from the cells of the
middle germ layers — the mesothelium — and later by
transfusion from the immature blood-vessels which
penetrate it in every direction; mucin being the first
product added to it by its own contained cells. In the
resulting gelatinous tissue, the cells are no longer
able to wander freely, but become fixed; assuming a
stellate form with branching anastomosing processes.
Mucoid tissue then is oedema plus mucin, as main-
tained by Koster and Kickhefel, and in the embryo is
the first stage in the differentiation of connective tis-
sue. In the lower vertebrates mucoid tissue persists
in places throughout life, but in the higher is purely
embryonic, except in pathological conditions. As the
walls of the blood-vessels reach a higher stage of
organization, the serous effusion becomes relatively
less; the intercellular substance condenses and under
the influence of the cellular products assumes by de-
grees its various adult forms. Of the three kinds of
sustentative connective tissue, cartilaginous, fibrillar,
and osseous, the former is both phylo- and ontogenet-
ically the oldest, being found in invertebrates, and ap-
pearing before either of the others in vertebrate em-
bryos.
Schmiedeberg has studied the constitution of carti-
lage, and finds the matrix to consist of a meshwork of
fibrils, identical witli those of fibrillar connective tis-
sue and bone, the interstices of which are filled with
chondrin, which by long-continued maceration in potash
can be dissolved out, leaving the form of the carti-
lage intact. The synthetical products, therefore, of
cartilage cells act on the intercellular substance,
mucus plus serum, in precisely the same way that those
of fibrillar or osseous connective tissue act, viz., by
transforming it into gelatinous fibres or collagen.
But in addition there is formation of chondrin, and
Schmiedeberg has isolated from this substance an acid,
freely soluble in water, which he calls chondroitin
sulphuric acid. If a solution of this be added to gela-
tin, a precipitate is formed which is identical with
chondrin; the same occurring, though not so readily,
with egg albumen and serum albumin. \\'e may infer
from this that the cartilage cell secretes the acid in
order to give stability to the matrix by the formation
of chondrin.
Cartilage may be considered as the first crude at-
tempt at the formation of an endoskeleton. In the life
history of animals, as the necessity for increased sup-
port in certain places arises, there is first a massing
together of the mesenchymal cells, which become so
closely packed that the blood-vessels are to a great
extent excluded. Further support is then attained by
the production of gelatinous fibres and chondrin, which
afford a certain amount of stability and flexibility com-
bined. There is, however, no provision for the en-
trance of vessels, and the way in which cartilage cells
obtain nourishment is somewhat obscure, though there
can be little doubt that it is the chondrin which in
some way or other enables them to carry on their exist-
ence in the absence of blood-vessels. However this
may be, formation of cartilage seems to be favored by
a deficiency of vascular supply. In the course of de-
velopment the structures affording stability and flexi-
bility become separated, cartilage is supplanted by
osseous and fibrillar connective tissue, and in the higher
vertebrates remains only in isolated patches, where it
can be utilized as pads or for keeping tubes open, for
which purposes it is admirably adapted. But it must
not be forgotten that the cells of these three tissues
May 26, 1900]
MEDICAL RECORD.
913
have one property in common; that of secreting a sub-
stance— possibly in the nature of an unorganized fer-
ment— which can change the mesenchymal Huid into
gelatinous fibres, other secretions being secondary and
depending on the environment of the cell. Where sup-
port is needed and vessels are few, there may be depo-
sition of chondrin; where rigidity is needed and ves-
sels are plentiful, there may be calcification ; and where
flexibility is the main requisite, there may be forma-
tion of elastic fibres. It would, therefore, not be sur-
prising to find the connective-tissue cells capable of
changing their secondary secretions in order to adapt
themselves to a change of environment whether occur-
ring physiologically or pathologically.
Physiologically, in the formation of the shaft of a
long bone, for example, we find the bone being formed
by the action of connective-tissue cells which remain
in the osseous tissue as bone cells. As the bone in-
creases in size, the necessity for lightness arises, and
the centre becomes hollowed out by absorption of the
calcified matrix, setting free the bone cells, which
again take on the functions of fibrillar connective-tis-
sue cells and form lymphadenoid tissue, which can
be regarded only as fibrillar connective tissue, in which
the fibres are reduced to a minimum and the lympli
spaces enormously distended.
As an instance of metaplasia in cartilage, the his-
tory of Meckel's cartilage is instructive. To quote
Minot: "The lower portions of the cartilage ossify
metaplastically, and the bony part is incorporated in
the permanent mandible, but the rest of the cartilage
atrophies and entirely disappears except a small por-
tion of the end next the malleus, which becomes
changed into fibrillar tissue, and remains as the liga-
mentum internum maxillae inferioris." Minot explains
elsewhere, that by metaplastic ossification he means a
direct conversion of the cartilage cells into bone cells,
which here occurs, although in ossification generally
the cartilage cells are destroyed in the process. Here,
then, we have connective-tissue cells developing a car-
tilaginous bar, one end of which is further converted
into bone, while the other end becomes a variety of
fibrillar connective tissue; the change taking place
metaplastically in both places, obviously on account
of the cells adapting their secondary synthetical prod-
ucts to perform functions indicated by their environ-
ment.
Pathologically, metaplastic interchange often occurs
between the different kinds of sustentative tissues.
In experiments on rabbits Ribbert transplanted pieces
of periosteum into intermuscular connective tissue
and other places. He found they would frequently
take root and grow up to a certain point, after which
regressive changes occurred, and they were resorbed.
Cartilage was always produced first, after which was
ofcasionally some attempt at osteoid formation.
Birch- Hirschfeld, also working on rabbits, rubbed
up early embryos in which there was not yet any dif-
ferentiation of the connective tissues, and injected
them into various organs and tissues — principally
under the capsule of the liver. His experiments
were mostly failures, save when growth cartilage was
the only tissue produced. He argues from this in
favor of the specificity of cartilage cells, holding that
the cells predestined to form cartilage alone survived,
but it seems much more probable that, in his cases
and also those of Ribbert, the cells, finding nour-
ishment scarce in their new situation, secreted chon-
droitin sulphuric acid, so that by fixing serous effusion
from the surrounding tissues in the form of chondrin
they were enabled to continue their existence for a
time by drawing supplies from a distance.
In callus formation, cartilage is formed from the
periosteum, especially, as Bonome points out, "just
at the seat of fracture where circulatory disturbances
are greatest, while further away the osteoblasts change
directly into bone corpuscles without passing through
the intermediate chondroblast stage."
Warren Coleman, in reporting a case of osteosis of
the cutis occurring in the foot, refers it to metaplasia
of the connective tissue, comparing it to the osseous
formation in rider's bone, and in myositis ossificans.
Rider's bone, however, according to Berthier, arises
from torn-off pieces of the periosteum, and he was able
to produce it experimentally on rabbits by cutting out
the insertions of the adductor muscles, together with
small fragments of the periosteum, which were then
dragged off by the contracting muscles and formed
foci of ossification. As an argument in favor of meta-
plasia rider's bone would, therefore, be ruled out by
strict adherents of cellular specificity, but in myositis
ossificans, as shown by Mays and Caen, foci of ossifi-
cation occur for the most part in the intermuscular
connective tissues quite unconnected with the perios-
teum.
According to the " disturbance-of-balance " theory
for the causation of connective-tissue tumors, it would
naturally be supposed that where loss of normal re-
sistance is slight and sharply localized the cells would
proliferate slowly, and be able to attain their normal
life cycle; elaborating their synthetical products as
usual, and forming the benign so-called adult con-
nective-tissue tumors.
If the loss of resistance be considerable, the cells
by virtue of their proliferative power multiply in or-
der to fill up the breaches, but their increase being
met by little or none of the usual counteracting in-
fluence, they continue to multiply rapidly and law-
lessly, no time being allowed them to attain functional
activities. It is not necessary to suppose that the
cells themselves assume embryological characters.
The conditions — plenty of elbow-room — existing in
the early embryo are reproduced to a greater or less
extent, and the cells conduct themselves according to
their environment. It is evident, therefore, that the
cells which take part in the formation of the three
varieties of sustentative tissue cannot be considered
as distinct species. According to their environment
they can produce any one of these tissues, proving, by
their power of multiplication whenever a chance is
given them, that they have not reached a very high
degree of organization. The differentiation of the
sustentative tissues appears to lie more in the inter-
cellular substances than in the cells themselves.
BlIiLIOGR.^PHY.
Bard : Archives de Physiologie, 1SS6 ; La Semaine Me'dicale,
1894-
Birch-Hirschfeld : Ziegler's Beitrage, iSgg.
Bizzozero ; Virchow's Archiv, vol. ex.
Berthier; Osteomes musculaires. Arch. me'd. exp. , 1894.
Bonome; Virchow's Archiv, vol. c.
Caen; Myositis ossificans. Deutsche- Zeitsch. ftir Chir. ,
vol. .\xxi.
Casper ; Ergebnisse der Pathologic (Lubarsch), 189^, p. 794.
Coleman: Journal of Cutaneous Diseases, 1894.
Ernst ; Ziegler's Beitrage, vol. xx.
Fabre Domergues ; Les cancers epitheliaux, 1898.
Gotte ; Cited by Minot, Human Embryology, p. 207.
Griinwald ; Miinchener med, Wochenschrift, 1889.
Ilansemann ; Spezificitat der Zelle,- 1893.
Von Henkelom ; Ziegler's Beitrage, 1894.
Huxley; Anatomy of Vertebrates, 1872.
Kickhefel ; Virchow's Archiv, vol. cxxix.
Koster ; Niederrheinische Gesellschaft, iSSl.
I.ubarsch ; Geschtilste and Infektionskrankheiten, 1899, p. 238.
MacFadyean ; Practitioner, April, 1S99.
Mark ; Trans, of Hertwig's Entwickelungsgeschichte, 1899.
Mays ; Myositis ossificans, Virchow's Archiv, t878.
Meister ; Rekreation der Leber. Ziegler's Beitrage, 1894.
Minot: Human Embryology. 1892.
Ohloff ; Epithelmetaplasie, Greifsvvald, 1S91.
Orth ; Cited by Lubarsch, Geschwulste, etc. , 1899.
Posner : Schleimhautverhornung. Virchow's Archiv, 1S89.
Ribbert ; Archiv fur Entwickelungsmechanik, vol. vi.
Schmiedeberg : Archiv exp. Pathologic, 1891.
914
MEDICAL RECORD.
[May 26, 1900
Siegert ; " Histogenese des primaren Lungenkrebs.
chow's Archiv, vol. cxxxiv.
Thiersch: Der Epithelkrebs, 1865.
Waldeyer ; Virchow's Archiv, 1S67 and 1S72.
Weigert : Virchow's Archiv, vol. Ixx.
NOTE ON THE TREATMENT OF CHRONIC
HEART DISEASE BY THE ARTIFICIAL
NAUHEIM BATHS.'
By ABRAHAM MAYER, M.D..
NEW YORK.
The balneo-therapeutics of chronic disease of the
heart as practised at Bad Nauheim originated with
Professor Beneke, of Marburg, physician at Bad Nau-
heim, in the year 1859. Beneke observed that in
treating chronic articular rheumatism with the car-
bonic-acid mineral waters of Nauheim, patients suffer-
ing from valvular lesions of the heart were not only
vastly benefited, but in many cases the improvement
became permanent; that relapses were the exception,
not the rule. About this time Beneke began the treat-
ment of chronic valvular disease by the use of car-
bonic-acid mineral baths and drinking-waters in a
more systematic manner, finding that the results ob-
tained were so extraordinary that other therapeutic
measures could not be compared with them.
Of course he found that new connective-tissue for-
mation about the valves or contractions produced ste-
nosis, especially when the result of an infectious en-
docarditis could not be overcome, but the general
condition of such patients was vastly relieved, and
cyanosis and cedema disappeared. About thirteen
years later, in 1872, Beneke published a history of
one hundred and one cases of disease of the heart
principally the result of an endocarditis, showing that
the benefits derived from these carbonic-acid mineral
baths were beyond question. Later Groedel, the
Schott brothers. Bode, Graeupner, and others not only
verified these observations but systematized the meth-
ods, and introduced a series of exercises framed, to
replace Oertel's Terrainkur, which exercises were for
the purpose of increasing the lumen of the arterial
vessels, filling the arteries with more blood, and thus
relieving passive congestion. So that to-day, in the
treatment of chronic diseases of the heart, we have no
therapeutic measures so potent as the Nauheim baths
and exercises.
Until within two years ago the writer had frequent
occasion to send patients suffering from chronic dis-
ease of the heart to Bad Nauheim for treatment as
prescribed there by the Schott brothers, the elabora-
tors of this therapeutic measure. The Schotls have
always claimed that similar results could be obtained
from baths artificially prepared so as to resemble the
Nauheim waters, 'and, if they were carried out on the
same principles, a journey to Germany would be en-
tirely unnecessary. Not considering the expense of
such a trip, a great many patients afflicted with heart
troubles cannot stand the debilitating effects of an
ocean voyage. It occurred to me that if the Nauheim
baths and system of .e.xercises could be carried out
here these drawbacks would be obviated.
Various methods may be employed for the produc-
tion of a carbonic-acid effervescent bath. The action
of hydrochloric acid on bicarbonate of sodium is a
simple way for generating the gas. Used in conjunc-
tion with the saline mixture (described below) in vary-
ing proportions, the degree of effervescence may be
regulated by the quantity of acid and alkali employed,
so that a mild, medium, or strong ebullition results.
The mild bath is prepared by adding three-quarters of
' Read before the Metropolitan Medical Society, January 23,
J 000.
a pound of hydrochloric acid to one-half pound of bi-
carbonate of sodium; the medium, by doubling these
quantities; the strong bath by the action of three
pounds of hydrochloric acid on two pounds of bicar-
bonate of sodium. The procedure is as follows: A
given quantity of the saline mixture is dissolved in
thirty gallons of water, 4 or 5^ warmer than the bath
calls for. Bicarbonate of sodium is now added and
thoroughly mixed with the saline solution. The hy-
drochloric acid, contained in a stoppered bottle, is
placed at the bottom of the tub, the stopper is re-
moved, and the acid is slowly distributed throughout
the lower layer of water. In this way rapid efferves-
cence takes place, and the bath is ready in a few
minutes.
Or the acid sulphate of sodium (or potassium) and
bicarbonate of sodium may be used with great advan-
tage. The acid sulphate of sodium is fused into suit-
able cakes weighing about two ounces. Six or eight
of such cakes are placed on tinfoil strips or in saucers
at the bottom of the tub containing the saline solution
of proper strength and temperature, and two pounds of
bicarbonate of sodium added. Effervescence begins
at once, and the patient is immediately immersed in
the bath, his head only being above the level of the
water, properly supported by a cross-piece of web-
bing. The strips of tinfoil protect the porcelain or
wooden tub from any deleterious effect. It is wise to
distribute the cakes on the bottom of the bath in such
a way that two each will correspond to the shoulders,
buttocks, and feet of the patient. Fused cakes of the
acid sulphate of sodium or potassium may be pro-
cured in the shops, and produce with the bicarbonate
of sodium an ideal effervescence.
The employment of liquid carbonic acid gas may be
mentioned here. Unless used in conjunction with a
suitable apparatus this method may prove dangerous
on account of the poisonous nature of the gas when
inhaled.
I use the following mixture for preparing the saline
bath: Sodium chloride (sea salt), 30 lbs.; potassium
chloride, 10 oz.; calcium chloride (granular), 30 oz. ;
magnesium chloride, 8 oz. These ingredients are
thoroughly mixed and kept in a moisture-proof tin
box till required for use. It is advisable to begin
with a weak saline solution, three pounds of the abo\e
mixture in thirty gallons of water, and increase grad-
ually until five pounds of the mixture in the same
quantity of water is used. The latter strength closely
resembles the Nauheim Spring No. VII., called the
Grosser Sprudel, the strongest of the waters there.
The temperature of the bath should be 95° at first,
which is gradually reduced in each succeeding bath
till a temperature of 85 F. is recorded. The duration
of the first bath must not exceed five minutes. As the
strength of the bath is gradually increased and the
temperature diminished, so the period of immersion
is lengthened until the limit of fifteen to twenty min-
utes is reached. Following the usage at Nauheim it
is necessary to omit the baths every second or third
day. The number of baths necessary varies with each
individual case; usually a course of treatment extend-
ing over several months is required. During the past
year, 1899. twenty-eight patients with chronic diseases
of the heart have been treated by me with these arti-
ficial Nauheim baths. The results obtained have been
so gratifying that I can without hesitancy claim that
the therapeutic infiuences of these baths are identical
with the natural ones.
The baths in Nauheim consist of various saline
thermal waters impregnated with natural carbonic acid
gas. In some of the bathrooms these waters enter a
specially designed wooden tub in a continuous flow,
and leave by an overflow pipe, so that during the en-
tire immersion bubbles of carbonic acid gas are con-
May 26, 1900]
MEDICAL RECORD.
9'5
stantly rising to the surface and adiiere with great
tenacity to the body.
The effects of the Nauheim baths, as given by
Schott, Thome, and others, are " to lower the fre-
quency and increase the force of the action of the
heart, to cause a recession of cardiac dulness of con-
siderable amount, and to induce a sense of rt'fresh-
ment and invigoration which is shortly followed by an
agreeable inclination to avail one's self of rest in the
recumbent position." The effect of the immersion in
the artificial bath is exactly similar. One of the ef-
fects noticed is sometimes a slight oppression for the
first few seconds, a diminution of pulse beat amounting
to ten or twenty pulsations at the end of two minutes,
which continues for the next ten minutes. In an in-
dividual case of a boy seven years of age, suffering
from mitral insufficiency with considerable enlarge-
ment, the pulse was reduced in frequency from go to
70 at the end of two minutes, with a further reduction
to 64 at the end of ten minutes; so that in ten min-
lites the pulse ran down from 90 to 64. This subse-
quently rose a few beats at the end of another ten
minutes. The dyspnoea, which in this case was very
striking, was entirely relieved while the patient was
in the bath. Such effects last for some hours after
the bath, the pulse rate being only slightly raised by
the e-xertion of dressing.
In order to verify the observations of Schott, Thorne,
and others, and to prove that the effect of the artificial
bath was identical with the natural one, the writer
submitted to a test bath in the presence of Drs. J.
Kaufman and M. S. Kakels, who were asked to wit-
ness it, make the physical examination, and record the
observations. The temperature of the bath was 92°
F. The saline solution contained three pounds of the
saline mixture in thirty gallons of water. Carbonic
acid gas was equal to 900 c.c. to the litre. The bath
was taken December 17, 1899,31 4:20 p.m. The pulse
in sitting position before entering the bath was 76.
Immediately after entering the bath a sense of oppres-
sion was experienced, which lasted about a minute
during which time the writer was forced to take very
deep inspirations. After two minutes' immersion the
pulse was 65 and a sense of glow came over the en-
tire body. At the end of three minutes the pulse was
62 and the whole body was covered with bubbles of
gas. After ten minutes the pulse was still 62 and a
sense of exhilaration was felt. Then arising from the
bath and getting a brisk rub while enclosed in a warm
bath robe, I rested ten minutes in the recumbent posi-
tion. The pulse then taken was 64. Dressing lei-
surely, the pulse rose to 68 and remained so for sev-
eral hours. The most astonishing feature of the bath
was the effect on the area of cardiac dulness. Before
immersion a careful physical examination of the heart
and liver was made, and the area of cardiac dulness
and liver was carefully outlined on the chest and ab-
domen. These areas being normal, it was doubted
whether any diminution would take place after the
bath. Nevertheless, the area of cardiac dulness de-
creased nearly half an inch ; over the liver a somewhat
larger diminution was observed.
As said before, there is produced a momentary effect
of oppression in breathing which causes one to breathe
deeply and slowly, and which is followed by a reduced
and more rhythmic inspiratory and expiratory move-
ment. As Thorne justly remarks: '"The carrying
power of the peripheral vessels is increased and a sense
of warmth in the extremities and on the surface of the
body is experienced. The general arterial capacity,
systemic and pulmonary, is increased, and without the
loss of blood the relief of a general bleeding is
afforded to an overloaded and laboring heart." In
neurasthenics, and in patients suffering from a scanty
flow of urine, it was also noticed that a series of baths
caused increased diuresis. These baths through their
action on the heart, and lessening its burden, indirectly
relieve the deep-seated organs, and consequently cause
them to resume a general normal functional condition.
The mineral and gaseous constituents of the water
produce a cutaneous excitation and thereby leflexly
the above effects are produced. Schott supposes that
from the surface of the body by imbibition into the
superficial layers of the skin an influence is transmit-
ted to the central nervous system which is centrifugally
reflected to the ' vasomotor system and the ganglia
which control the action of the heart. That the nerve
centres are influenced is attested by improvements
noticed in patients suffering from neurasthenia, anaa-
mia, etc., nearly all of whom showed decided amelio-
ration of their symptoms. There is no doubt, accord-
ing to my observations of the invigorating influences
which these baths exert on the heart and circulation,
of the improvements observed, lasting for three or
four months after a series of immersions. Excepting
in cases of arteriosclerosis and advanced cardiac de-
generation due to myocarditis, benefits may be ex-
pected in all cases of chronic heart disease.
The therapeutic influences of the baths are aug-
mented by a system of exercises, the results of which
are nearly as efficacious and which can be employed
in conjunction with the baths, or independently espe-
cially in obese or bedridden patients. Schott calls
these exercises " Wiederstands-Gymnastik," or resist-
ance gymnastics. They consist of regulated move-
ments of the entire voluntary muscular system, which
are resisted by an expert attendant in such a way as
slightly to oppose the muscular action without arrest-
ing it. These exercises, originating w'ith the Schott
brothers, have been carefully studied by Thorne, Lau-
der Brunton, Morrison, Gibson, and others. Without
going into details of these various resistant move-
ments, it will be sufiicient to state here that the
operator must be thoroughly conversant with the ac-
tions of the different groups of muscles; the patient
must be carefully observed during the manoeuvres,
which must be at once suspended on the slightest
symptom of circulatory or respiratory interference.
The results of the exercises are similar to those of the
baths; that is, a correction of circulatory disturbances
and strengthening of a diseased and weakened heart.
The changes which attend these graduated exercises
are disappearance of cardiac irregularity, palpitation,
and uneasiness, better filling of the arterial system,
reduction of the frequency of the pulse, increased en-
ergy of the heart, and absence of all respiratory dis-
tress. The increased capacity of the blood-vessels
enables the heart to contract in such a manner as to
empty its cavities with each beat. The e.xercises
taught in a scientific manner by the physician to his
patient can be successfully carried out by him at
home without an attendant. We can readily see that
these measures can be utilized and are within the reach
of every sufferer from chronic disease of the heart.
This paper has not been written for the purpose of
presenting a statistical report of cases, and so I have
refrained from burdening you with histories.
In considering the treatment of chronic heart dis-
ease we must consider that there is a loss of the equi-
librium normally existing throughout the circulation.
This loss of normal relation produces a tendency to a
diminished amount of blood in the arteries and an
excessive amount in the veins, from which there re-
sults a liability to the accumulation of fluid in the sys-
tem. In consequence of these disturbances all the
great functions are interfered with. Venous stasis
results with its pernicious effects on all the important
organs; lungs, stomach, liver, kidneys, and the nervous
system, all suffer from the disturbed circulatory condi-
tion. These results are again reflected on the blood
9i6
MEDICAL RECORD.
[May 26, 1900
and through it on the heart, and hence a continuous
circle of vicious influences is kept up.
Of all methods of treating chronic diseases of the
heart — and by treating I mean relieving not only the
circulatory disturbances but the concomitant effects
on the different organs of the body — I am convinced
that the artificial Nauheim baths, like the natural ones,
together with the resisting exercises, are the most effi-
cacious and lasting therapeutic remedy yet devised.
40 East Sixtieth Street,
Remarks on Facial Paralysis with Special Ref-
erence to Treatment T. Sydney Short states that
researches tend to show that in Bell's paralysis, in
some cases at least, the lesion is a real parenchymatous
inflammation of the nerve structure itself, and not
due to pressure alone. Pain seems to be more fre-
quently absent than present. The writer divides the
treatment into local, general, and electrical. He be-
lieves counter-irritation to be of great value early in
the condition. Potassium iodide is usually given.
Galvanism is the most valuable treatment. Short also
describes the "face crutch." — The Birmingham Medi-
cal Review, April, 1900.
The Therapeutic Uses of Yeast Elsie Reed
Mitchell reviews Landau's work on this subject, then
giving her own experiences. Out of eight cases of
leucorrhcea treated by local applications of yeast, one
was entirely unaffected. This was a syphilitic and
the discharge was not of local origin. Five cases were
still under treatment or passed from under observa-
tion, markedly improved, one of these being of known
gonorrhoeal origin. Two cases were cured, with re-
lapses under peculiarly unfavorable circumstances,
possibly a reinfection. One case was cured with a
relapse after four months. The writer has observed
no unpleasant after-effects. Brewers' yeast was used
when it could be obtained: when it was not to be
had, compressed yeast gave apparently similar clin-
ical results. A quarter of a cake of " Fleischmann's "
was dissolved in half a cupful of water mixed with
about a teaspoonful of either flour or sugar. — The
Wovian's Medical Journal, April, 1900.
The Motor Innervation of the Palate From the
prolonged observation of a child who presented total
loss of power on the right side of the palate and
larynx, and who was operated on for a left tubercu-
lous otorrhcea by the radical method, Brindel comes
to the conclusion that the motor innervation of the
palate is through the vago-spinal nerve. He expresses
the hope that the statement which appears in even the
most recent treatises, that the innervation is through
the facial, will speedily be corrected. — Rcvuc Ilehdo-
madaire de Laryngologie, etc., March 3, 1900.
On the Administration of Anaesthetics to Chil-
dren— VV. I. McCardie and C. F. Marshall consider
the main physiological differences between the child
and the adult which concern the induction of anaes-
thesia, and lay stress upon the fact that the adminis-
tration of anresthetics, especially chloroform, is by no
means so free from danger in childhood as is gener-
ally supposed. They also consider the question of
the best anaesthetics to employ in the various opera-
tions performed on children. Chloroform is never
free from danger, and it is better to use, as a routine
anfEsthetic, ether, A. C. E. mixture, or a mixture of
two parts of ether to one of chloroform. Nitrous oxide
followed by ether may be given to the older children.
Nitrous oxide alone has been used by one of the au-
thors successfully in operations lasting from five to
ten minutes. It should never be followed by chloro-
form. Local anaesthesia is inapplicable to children
owing to the great difficulty in keeping them quiet
and overcoming terror. — Trealtnent, April, 1900.
The Mosquitos of the City of Grosseto. — Fran-
cesco Testi made a study of more than five hundred
mosquitos collected chiefly in the city of Grosseto.
He found that while the variety Culex was most
abundant in all houses where there had been cases of
malaria, the Anopheles was so rare that only eigh-
teen were found to four hundred and forty-nine Culex.
The fact is a curious one, in view of the importance
attributed to the Anopheles in the dissemination of
malaria. The author does not draw any conclusions
therefrom, but merely mentions the fact as such. The
Anopheles is more apt to be found in the country
than in the city, and the persons suffering from ma-
laria may have become infected out-of-doors, espe-
cially toward the evening hours. — Giornale Medico del
Regie Esercito, March 31, 1900.
A Case of Meningism from Helminthiasis.— C.
A. Annaratone reports the case of a patient who died
apparently of meningitis. No abnormality was found
in the meninges or brain, but in the stomach w'as a
mass of ascarides lumbricoides. Chanson has found
that by injecting the juice of ascarides obtained from
horses and pigs into guinea-pigs, death was produced.
The author believes that in the reaction against the
too great importance which used to be attributed to
intestinal worms as a cause of disease, their real pow-
ers of injury by the production of intoxication has laeen
overlooked or underrated. The subject deserves
study. — Giornale Medico del Regio Esercito, March 31,
1900.
Facial Hyperidrosis of Nervous Origin. — E. Rug-
giero reports the case of a young sailor, aged tvienty
years, whose face is constantly covered with perspira-
tion, both summer and winter, day and night. There
are no symptoms of hemicrania, facial neuralgia, ceph-
alalgia, disturbance of facial muscles, of cutaneous or
olfactory sensation. The chief seat of the disturb-
ance is the tip of the nose, where in freezing weather
the perspiration freezes. The author believes the
trouble to be of nervous origin, probably in the ante-
rior horns of the cervical spinal marrow, the lesion
involving the fibres which the trigeminal receives
from Gasser's ganglion. The prognosis in this case
is bad, as the disorder has already lasted seven years.
Local remedies have had no effect, and nothing can
be hoped from the use of electricity. It might be
useful to resect the nerves distributed to the affected
region, the naso-lobular nerves of Chaussier. — Annali
di Medicina Navale, March, 1900.
Adherent Pericardium. — H. W. Rogers reports
the case of a colored woman, about tw'enty-five years of
age, who was brought to the hospital suffering from in-
tense dyspnoea, with physical signs of delirium cordis
and a pulse which was rapid, irregular, and arrhythmic.
The right heart was much dilated and extended over
to the right side of the sternum, passing beyond at
least two fingers' breadth. The left heart did not
show any very marked degree of enlargement. There
was a murmur heard with greatest intensity at the
apex, presystolic in time and of a musical intonation.
A diagnosis was made of mitral stenosis with a pre-
systolic murmur and excessive dilatation of the right
heart. The necropsy revealed extensive adhesions
between the layers of the pericardium and a band of
adhesion extending over both ventricles, and also at-
tached to the apex down to the diaphragm. There
was no pulsus paradoxus.— C/t'r'i'/rt'"^ J'^nrnal oj Medi-
cine, March, 1900.
May 26, 1900]
MEDICAL RECORD.
917
Medical Record:
A Weekly Journal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
PUDLISHERS
WM. WOOD &. CO., 51 Fifth Avenue.
New York, May 26, 1900.
MEDICAL LEGISL;\TI0N IN NEW YORK
STATE.
The last legislature passed several amendments to the
public health law; but none of them was so impor-
tant as the entire recasting of Article XI. The
amendment is the result of several years' agitation and
several failures . to secure satisfactory legislation.
There have been three boards of pharmacy, one in
New York, one in Erie, and one whose provinc.e was
the remainder of the State. The new rule provides
for a single board for the whole State.
The State is divided into three sections. The east-
ern (New York) comprises New York, Kings, Queens,
Nassau, Suffolk, Richmond, and Westchester counties;
the western (Erie) section takes in the counties of Erie,
Niagara, Orleans, Genesee, Wyoming, Allegany, Cat-
taraugus, and Chautauqua; and the middle (Albany)
section comprises the other counties in the State.
The members of the board, to the number of fifteen,
are to be elected every June, five from each section,
and they must be licensed pharmacists, one from each
section to go out of office every year. The maximum
term is five years. For the eastern section two mem-
bers are to be elected from the IVIanhattan Pharmaceu-
tical Association, two by the Kings County Pharma-
ceutical Society, and one by the New York German
Apothecaries' Society. The members for the western
section are to be elected at a meeting of the licensed
pharmacists and druggists residing in such section,
called by the Erie County Pharmaceutical Associa-
tion, and those for the middle section are to be elected
at the annual meeting of the State Pharmaceutical As-
sociation, at which meeting all licensed pharmacists
and druggists residing therein are entitled to vote.
The State board is to meet in January annually in
Albany, and elect a president and a secretary, who
shall also be treasurer. The board fixes the salaries
of the secretary of the State board and the secretaries
of the branches for the eastern, western, and middle
sections. After the organization of the State board,
the members of the State board from the respective
sections shall organize branches therein and elect a
chairman and secretary and treasurer. Each member
of the State board shall receive $5 for each day actu-
ally engaged as a member of such board, or one of its
branches, provided that no member shall receive more
than $150 in any one year, together with his necessary
expenses.
The State board is empowered to regulate the prac-
tice of pharmacy, the sale of poisons, the character
and standard of drugs and medicines dispensed in the
State ; to employ inspectors of pharmacy ; to examine
all applicants for license or registration, and to issue
two grades of licenses to be known respectively as
that of " licensed druggist " and " licensed pharmacist,"
and one grade of certificates as " registered appren-
tice"; except that, in New York Cily, a license for
the grade of " licensed druggist" shall not be issued;
to investigate and prosecute violations of law govern-
ing the practice of pharmacy and sale of poisons; to
require the annual registration of every pharmacy,
store, dispensary, or place where drugs are dispensed
or sold, and to charge a fee of $2 therefor; and to
revoke for cause any license issued. Existing licenses
are continued, and as regards the issuing of licenses
the law does not take effect until the end of the year.
After next January ist, any person who hplds a cer-
tificate of registration granted upon examination as an
"assistant pharmacist" from any legally constituted
board of pharmacy of the State, the same not having
been revoked, may apply to the State board, surrender-
ing such certificate, accompanied by a fee of $1 and an
affidavit that he or she has had three years' practical
experience in the compounding, dispensing, and retail-
ing of drugs, medicines, or poisons, and may be grant-
ed a license as a "licensed druggist," entitled to prac-
tise outside of New York City.
Any person holding a certificate of registration as a
" pharmacist " granted upon examination by any legally
constituted board of pharmacy of the State may be
granted by the State board a license to practise as a
"licensed pharmacist" anywhere within the State,
upon the payment of $1 fee. Provision is made for
the registration of apprentice pharmacists for a fee of
50 cents.
Otherwise no person shall be granted a license as
a " licensed druggist " who has not had three years'
practical experience in the business and passed an ex-
amination, and the fee is $5. To be licensed as a
pharmacist a person must have four years' experience
and have passed an examination. The fee is $10.
The bill very properly prohibits the sale of the
usual domestic remedies by country stores, and pro-
vides that they can be dealt in only by regularly
licensed dealers. A provision for the proper labelling
of poisons is also incorporated. The State board is
empowered to regulate the hours of labor of employees
in drug stores and pharmacies in New York City,
which shall not exceed one hundred and thirty-six
hours in two consecutive weeks.
Another amendment to the public health law pro-
vides that the commissioners of quarantine, at the port
of New York, shall pay all salaries of persons appoint-
ed by them from money appropriated by the State.
They shall collect from the owners, agents, or con-
signees of vessels all bills for the care and mainten-
ance of persons detained in quarantine, and shall
have power to enforce such payment by process of law
against the vessel upon which such detained persons
9i8
MEDICAL RECORD.
[May 26, 1900
have arrived, or against the agents, or owners, or con-
signees of such vessels, and, in case of an emergency
arising, the quarantine commissioners shall, upon the
certificate of the health officer that such an emergency
really exists, use all means conducive to the protection
of the public health, except when such emergency calls
for the expenditure of money beyond such amount as
may be in the hands of the commissioners, when such
expenditure may be made only by and with the ap-
proval of the attorney-general and controller. The
health officer is also directed to inquire relative to the
plague and all other infectious diseases on board in-
coming ships; and he is required to keep the depart-
ment of health of the city of New York informed of
the number of cases of quarantinable diseases and the
character of the same held at quarantine, and he may
receive any vessel or merchandise sent to him by the
health authorities of New York which in his opinion
is dangerous to the public health.
The commissioners of statutory revision offered a
bill amending, generally, the public health law, but
it did not pass; neither did proposed amendments
relative to imperfect licenses of physicians and sur-
geons, and relative to the practice of dentistry.
A charter was granted to the New York State Medi-
cal Association for the purpose of the cultivation and
advancement of the science of medicine, the promo-
tion of public health, and the establishment of a death
benefit fund for the dependents of its members. It
may hold property to the amount of $100,000. The
incorporators are: D. Ayres, J. C. Bierworth, L. J.
Brooks, J. D. Bryant, H. D. Didama, C. E. Denison,
E. D. Ferguson, J. M. Farrington, C.-E. Fritz, C. H.
Glidden, G. W. Goler, J. \V. S. Gouley, E. E. Harris,
N. H. Henry, J. G. Hunt, F. \V. Higgins, W. E. John-
son, E. M. Lyon, E. M. Moore, D. C. Moriarta, M. C.
O'Brien, T. D. L. Rochester, B. T. Smelzer, E. H.
Squibb, W. H. Thornton, M. W. Townsend, T. A.
Wales, and F. \V. Wiggin. An unsuccessful attempt
was made to exempt from taxation the property of cer-
tain medical societies situated in cities of the first
class.
A law was passed providing tliat pharmacists and
drug clerks shall not work to exceed one hundred and
thirty-six hours in any two weeks; and that an em-
ployee shall have at least one full day off in two con-
secutive weeks. Several amendments to the charter
of New York, relative to pharmacists and druggists,
were not passed because what they proposed seemed
to be covered in the amendment to the public health
law, first noted above.
The code of civil procedure was amended so as to
include malpractice, along with slander, assault, etc.,
in the limitation of actions to two years. An unsuc-
cessful attempt was made to amend the same code,
relative to disclosures by physicians and surgeons, by
making an exception that in any action heretofore or
hereafter brought by a person authorized to practise
physic or surgery, or by his legal representatives, for
the value of any professional services alleged to have
been rendered or performed for such patient, the
plaintiff in such action or any other physician or
surgeon assisting him in the performance of such ser-
vices may testify concerning the same, so far as may
be necessary to prove the performance or the value
thereof; provided, that the court in its discretion may
exclude any testimony tending to disgrace the pa-
tient. The medical profession successfully opposed
the bill regulating the practice of midwifery in the
city of New York.
A law was passed providing that whenever the board
of health in Buffalo shall declare that rabies is preva-
lent in the city, or in the vicinity thereof, the commis-
sioner of public health shall prepare ordinances pre-
scribing the conditions under which dogs may be kept,
brought, or allowed to be within the city, and provid-
ing for the destruction of dogs suffering from rabies
and to prevent the spread of the disease, with penal-
ties for their violation. An unsuccessful attempt was
made to amend the charter of New York City relative
to the sale of lymph and antitoxin; also to give the
State board of health unlimited power to designate
the style of boxes or bottles in which poisons shall be
put up; also to repeal the school law relative to in-
struction in hygiene and narcotics; also to require
that no person, association, corporation, or company
shall sell, offer for sale, or dispose of within this State
any proprietary or patent medicine or tonic, snuff,
tobacco, or headache, catarrh, or hay-fever remedy
containing cocaine.
A bill for the protection and improvement of the
purity of the waters of the State, and conferring addi-
tional powers on the State board of health, did not
pass; neither did a bill allowing New York City to
spend unlimited amounts for the sanitary protection
of its water supply.
A law was passed establishing a State hospital, in
some suitable location in the Adirondacks, for the
treatment of incipient pulmonary tuberculosis. The
city of New York was authorized to accept the real and
personal property of the Brooklyn Homceopathic Hos-
pital. The authorities of New York City were author-
ized to change certain leases to the Mt. Sinai Hospi-
tal. The city of Buffalo was authorized to issue
$50,000 in bonds to erect a quarantine hospital; and
Lockport, $5,000 for a city hospital. Bills calling for
the establishment of a State hospital for crippled
children, and for New York City hospitals for pul-
monary tuberculosis and contagious eye diseases, did
not pass.
REPORT OF THE ELMIRA STATE REFORM-
ATORY.
The 1899 report of this institution provides much
instructive and interesting reading. It appears that
the gross number of inmates who had been upon the
books from September, 1S98, to September, 1899, was
2,035, of which number 556 have been received dur-
ing that period and 651 discharged, producing a daily
average of 1,474.6. Xo transfers to State prisons have
been made, but with the exception of fourteen per
cent, who were specially paroled invalids, etc., of the
651 discharged 425 were sent out on regular parole to
work at trades taught them at the Reformatory. The
health of the inmates is stated by the physician on the
May 26, 1900]
MEDICAL RECORD.
919
whole not to have been so good during the past six
years as in the preceding twenty years, but the in-
crease in the death rate is attributed to overcrowding.
The remedy for this state of things suggested by the
board of management is a reduction of the population
to 1,200. A large amount of attention is paid to
gymnastic training, including Turkish baths and mas-
sage, with, it would appear, most satisfactory results.
Personal instruction is also given in elementary physi-
ology and the hygienic care of the body. In the phy-
sician's report attention is drawn to the fact that tu-
berculous disease appears as the largest single cause
of admission to the hospital and as the greatest factor
of mortality. The reason suggested for the prevalence
of this disease is that at the present time the hospital
has inadequate accommodations except for those in
whom the disease is well marked and progressive, but
that an unrecognized case, or a person in the incipient
stage, may so infect a cell that it becomes a menace to
the health of succeeding occupants. During the pe-
riod covered by the report forty men were transferred
to the Matteawan State Asylum for the Insane, and
for the first time since 1894 there were two cases of
suicide.
SIR WILLIAM MACCORMAC ON THE SOUTH
AFRICAN WAR.
Sir William MacCormac, like Mr. Treves, has been
making public the result of his experiences in South
Africa. His opinions as to everything connected w-ith
the medical arrangements were in a high degree lau-
datory; he nevertheless permitted himself to criticise,
although in words much less pungent than used by his
professional brother, the hampering interference of
certain ladies ignorant of hospitals and nursing, and
whose inexperience rendered their services ineffective
for good. Hospital trains were referred to by him in
the most favorable manner, and as in some instances
they were enabled to go on to the field of battle itself,
the fact may be easily understood that by their aid
the removal of the wounded to the base hospitals was
facilitated to an extent not known in any previous
war.
There has been an altogether universal consen-
sus of opinion among surgeons serving in the
present campaign with regard to the humaneness of
the Mauser and Lee-Metford bullets. Sir William,
who has several times drawn attention to this matter
in his letters to the London Lancet, reverts to the subject
at some considerable length in an account published in
the New York Sun of May 13th, a part of which reads
as follows: " Speaking generally he found the wounds
intiicted by the Mauser and Lee-Metford to be very
similar and both much less fatal than the larger pro-
jectiles used in former wars. As many as ninety-six
per cent, of the cases in the general base hospitals
recovered and were discharged, a very large proportion
being able to return to duty at the front." He says:
" One finds case after case convalescent after a bullet
has traversed the lung and in many cases both lungs.
The heart and peticardium have so often been found
to lie in the track of the bullet that it seems probable
that these, highly vulnerable structures must in sev-
eral instances have been actually pierced." Sir Wil-
liam expresses himself as by no means in favor of
laparotomy, as he feels sure that the mere fact of a
Mauser or Lee-Metford rifle bullet traversing the ab-
domen is of itself no sufficient indication of the ne-
cessity for abdominal exploration or operation.
It is satisfactory to notice that notwithstanding the
many charges made by both British and Boers as to
the alleged use by the former of Dum-dum bullets, and
by the latter of explosive or soft-nosed bullets, Sir
William declares that he never came across a wound
caused by a Dum-dum bullet, and tha the saw no evi-
dence of the use of explosive bullets, although it was
reported on good authority that some of the wounds
had been caused by them. With respect to inocula-
tion against enteric fever, which was largely practised
by British troops before proceeding to South Africa,
the distinguished surgeon says: "No decided opinion
can yet be given on this point, since there are not suffi-
cient data for statistics. The observations made seem
to show that those inoculated are less apt to take the
disease, or if they are attacked they have it in a milder
form; but the question is ^\\\\ sub jiidke." Whether
the lyddite shells were so destructive to life as the
British assert, or whether they were, in accordance
with the testimony of the Boers, comparatively innoc-
uous, is a point that has not been made clear. At
any rate it has been conclusively shown in our war
with Spain, and on a larger scale in the South Afri-
can campaign, that even within the past twenty 3'ears
the conditions of warfare have greatly changed for the
better, and indeed that, contrary to general prognosti-
cations, modern weapons have been mainly responsible
for this state of things.
^ctus of tTxe "SMccIi.
A Correction. — Dr. Paul F. Mimde' writes: "Per-
mit me to correct an error in the discussion on fecal
fistula at the last meeting of the American Gyneco-
logical Society, published in the Medical Record of
May 19th. Your reporter makes me say that I ' agree
with Dr. Currier that it was well to wait in fistula of
the small intestine ; but with fistula of the large bowel
the abdomen should be opened.' (Italics are mine.)
Now, I said exactly the opposite, for in my experience
fistulas of the large intestine, especially when near or
in the pelvic cavity, show a great disposition to con-
tract and in time heal spontaneously; whereas fistula
of the small bowel usually require operation, either, if
small, by trimming and uniting the edges and adja-
cent peritoneal coat, or, if large, by free opening of
the abdomen and enterorrhaphy or Murphy button.
The point is of sufficient practical importance to war-
rant my wishing to be correctly reported in the matter.
I may add that this tendency to spontaneous closure
of fistulae of the large intestine was first impressed on
me by three cases of gunshot wound of the ascending
and descending colon and of the upper pelvic part of
920
MEDICAL RECORD.
[May 26, 1900
the rectum which I saw in the Austro-Prussian war
of 1866, and which I described in a letter to the Bos-
ton Medical and Surgical Journal, January, 1867, under
the title of ' Gunshot Wounds of the Pelvic Viscera.' "
Post-Graduate Medical School. — Dr. Charles War-
renne Allen has been elected adjunct professor of skin
diseases.
Philadelphia Polyclinic Dr. James Thorington
has been elected to a new chair of diseases of the eye,
created by the trustees.
Gloucester County (N. J.) Medical Society.— At
a meeting held at V\'oodbury on May 17th Dr. Judson
Daland, of Philadelphia, read a paper on "Aneurism,"
and Dr. G. Betton Massey one on "Mercurial Cata-
phoresis."
The New York Eye and Ear Hospital. — A two-
story addition to the New York Eye and Ear Hospital
will soon be erected on the lot 311 East Thirteenth
Street, in the rear of the present buildings of that in-
stitution at the northeast corner of Second Avenue and
Thirteenth Street.
College of Physicians of Philadelphia — At a
stated meeting of the section on general medicine,
held May 14th, Dr. F. Savary Pearce exhibited a case
of hysterical monoplegia cured by suggestion. The
patient was a colored woman who presented at first
paralysis upon one side of the body, with improve-
ment in the condition in the lower extremity, while
that in the upper disappeared in the sequence of hyp-
notic suggestion and applications of static electricity.
A similar attack had occurred on a previous occasion.
Dr. William G. Spiller exhibited a case of unilateral
progressive ascending paralysis, with exaggerated
scapulo-humeral reflex (v. Bechterew), occurring in
a man who presented symptoms of spastic hemi-
paresis, with fibrillary tremor, of several years' devel-
opment. Dr. Spiller exhibited also a case of pseudo-
rhizomelic spondylosis, occurring in a man in whom
the apparent rigidity of the spine was due to muscular
pain. He exhibited further a man who presented
brachial palsy following a fracture of the arm, to-
gether with atrophy of the thenar eminence and the
interossei muscles, the latter being found on careful
inquiry to have been an antecedent condition and not
related to the accident. Dr. A. A. Eshner presented
a communication upon "Angina Pectoris," in which
he deprecated the use of the terms true and false, pre-
ferring rather those of mild and severe, contending
that the two sets of cases are essentially of the same
nature, though differing in degree, both clinically and
pathologically. He reported a case in a man thirty
years old, in which typical paroxysms of angina pec-
toris occurred in the absence of demonstrable organic
disease related to the heart. Dr. M. H. Fussell ex-
hibited a case of myxa-df ma with complications. The
patient was a boy eighteen years old, exhibiting
marked dementia of gradual development, together
with excessive accumulations of fat upon the abdomi-
nal wall, and to whom thyroid extract had been as-
siduously administered in large doses without note-
worthy therapeutic effect. Doubt was expressed as to
the exact nature of the disease, the symptoms of which
did not wholly conform with those of myxoedema. Dr.
Walter I. Pennock read a paper entitled "An Unusual
Influence of Strychnine in Diseases of the Kidneys,"
reporting two cases in which the administration of
strychnine in full doses induced symptoms closely
simulating those of uraemia.
The Cholera is spreading rapidly in India. A des-
patch to a London paper from Hyderabad says that
in one division no fewer than forty-five famine camps
have been attacked by the pestilence. The most viru-
lent type is at Gujerat, where many thousands have
perished. In the Godhra camp alone there have been
thousandsof victims. An appalling loss of life seems
inevitable.
A Man with a Quiver Full. — A French Canadian
living in a Rhode Island town was recently presented
by his third wife with his forty-first child. His first
wife gave birth to several pairs of twins, and his
second presented him with three sets of triplets.
Thirty-six of the children are living and many of
them have families of their own. Eight of the grand-
children also are parents.
China a Field for Women Physicians — At the
graduating exercises of the VVoman's Medical College
of Pennsylvania, the Chinese minister, Wu Ting
Fang, delivered an address to the graduates in which
he advised them to seek their fortunes in China. In
that country, he said, there are about two hundred
million women, but the number of woman physicians
is very small. Midwives there are, but few or no
women with medical knowledge and training, and the
speaker said he was sure women doctors would receive
a welcome and good treatment in China. Twenty-six
women received diplomas.
Bureau of Information for the Members of the
American Medical Association Passing through
Philadelphia. — The directors of the Philadelphia
County Medical Society will establish a bureau of
information for the benefit of physicians on the \\ay
to Atlantic City, at the College of Physicians of
Philadelphia, northeast corner of Thirteenth and
Locust streets. This bureau will be open from 10 a.m.
until 5 P.M. daily except Sunday, from Monday, June
4th, to Monday, June nth. Physicians are invited to
make free use of the bureau, where they may obtain
full information relative to the situation of the various
hospitals, medical colleges, and other scientific insti-
tutions of Philadelphia, and the time of operations
and clinics at the different hospitals throughout the
city.
Testimonial to Dr. Jacobi.— On Wednesday of
last week the Woman's Health Protective Association
of New York presented to Dr. A. Jacobi a set of reso-
lutions of esteem and congratulations on the recent
celebration of his seventieth birthday. After the con-
gratulations and wishes for many more years of useful-
ness and honor, the resolutions spoke of Dr. Jacobi's
wise counsel to the association, and aid in enforcing
May 26, 1900]
MEDICAL RECORD.
921
the health laws of the city, and also of his services as
. a public benefactor, and his devotion to children.
The resolutions were handsomely bound in pamphlet
form, and were presented with an appropriate address
by Mrs. Esther Herman, vice-president of the associa-
tion.
The New York Polyclinic— Drs. Francis J. Quin-
lan and R. C. Myles have been elected professors of
laryngology and rhinology in this school.
The New York County Medical Association has
become a part of the New York State Medical Associ-
ation under the new charter of the State society.
A New Investigation of Yellow Fever The
Liverpool School of Tropical Medicine is soon to
send a commission to Brazil to study yellow fever.
A Large Dose of Electricity. — An electrician in
Mount Vernon, N. Y., recently received a discharge of
1,040 volts, and though badly burned and made in-
sensible was not otherwise seriously injured.
Trinity Hospital, Varick street, was closed Tuesday
for the first time since its foundation, twenty-seven
years ago. It will reopen October 15th, after exten-
sive alterations, in charge of trained nurses, instead
of the Anglican Sisters of St. Mary, headed by Sister
Eleanor, who has been in charge of it since its incep-
tion.
St. John's Hospital, Brooklyn, will, it is said,
soon be taken from the list of city hospitals and be-
come a private institution to be under control of the
Episcopal Church Charity Foundation. The reason
for this change is said to be that Comptroller Coler's
recent cutting down of appropriations to institutions
of the sort has greatly impaired the working efficiency
of the hospital.
Formalin as a Milk Preservative It is reported
from Chicago that the health department of that city
has decided that the use of formalin as a preservative of
milk must be stopped. Experiments have been made
proving to the satisfaction of the health officers that
formalin is poisonous. Kittens fed on milk preserved
with this substance died in a few days, while other
kittens from the same litter fed on ordinary fresh milk
grew plump and fat. Guinea-pigs were also experi-
mented on with the same result.
The Section on Materia Medica of the Ameri-
can Medical Association. — The troubles of the Amer-
ican Medical Association are perennial. For years
the annual quarrel surged around the permanent secre-
tary, and now, no sooner has the permanent secretary
been unseated and removed from the scene of conflict,
than clouds gather round the section on materia med-
ica. The American drug manufacturers are alarmed
by a report that the section is to be captured by mem-
bers of the American Medical Association who are on
the side of German chemical houses, and who will turn
the work of the section into an advertising bureau for
foreign drugs. The medical press is urged to raise
its voice to thwart this nefarious scheme. But surely
this alarm must be without foundation in fact. The
American firms seem to have forgotten that every mem-
ber of the American Medical Association is an avowed
upholder of the code of ethics, and no one whose life
is regulated by this moral law could descend so far
as to bamboozle his fellows in this unprincipled
manner.
Yellow Fever is reported epidemic in San Salva-
dor, the capital of the Central American republic of
Salvador. In a communication from the United
States consul there, dated April nth, it is stated that
eighteen cases were in the pest-house and twenty
known cases were being treated in their homes. The
mortality had been very considerable and many per-
sons were leaving the city on account of the disease,
which had appeared at a much earlier period than
usual. No foreigner had so far been attacked, the
disease being confined to natives of Central America.
The Plague is reported to have spread to nearly
every seaport town in Australia and to. have invaded
many places in the interior. In Sydney there have
been one hundred and forty-two cases and forty-nine
deaths up to April 25th.— The board of health of San
Francisco has adopted a resolution declaring that the
plague exists in that city. Surgeon-General Wyman
of the Marine-Hospital service states that March 8th
Surgeon Kinyoun reported that a suspicious case had
been fatal in Chinatown, and on March nth he found
the plague bacillus. On April 27th another case oc-
curred, verified by bacteriological examination and so
reported on May 2d. On May 13th there were two
cases from plague. On May i6th another case was
reported. There have been six cases, and so far as
known the disease has appeared only among the Chi-
nese. Four marine-hospital surgeons, in addition to
those already there, have been ordered to San Fran-
cisco. A large supply of Haffkine's serum has been
sent, and an endeavor will be made to vaccinate all
the Chinese in the city. The timid health officials of
Texas have taken alarm and have declared a rigid
quarantine against freight and passengers from San
Francisco. — It is reported from Tokio that Kitasato
has discovered a second plague bacillus which is
thought to explain the fact that the Yersin serum has
had such different effects in different cases. Kitasato
is preparing a new serum from which he hopes to ob-
tain more satisfactory results.
Home of the Kings County Medical Society. —
On Saturday last the new library building of the Med-
ical Society of the County of Kings, on Bedford Ave-
nue, Brooklyn, was dedicated in the presence of many
of the members of the society and guests from other
cities. The building, of colonial design, is fifty-nine
by eighty-five feet, three stories in height, and fireproof
in construction. Entering the building, one steps into
a foyer from which three doorways lead into the main
auditorium, which will seat about four hundred.
Opening from the foyer are a reception room, a wom-
en's room, and a cloakroom. The library is on the sec-
ond floor and the third story is devoted to the apart-
ments for the librarian and custodian of the building,
storage rooms, and two large section rooms, which
922
MEDICAL RECORD.
[May 26, 1900
may be used separately or in conjunction. Dr.
Lewis S. Pilclier, president of the society, presided.
After a prayer by the Rev. Dr. A. J. Lyman, addresses
were made by Drs. G. M. Gould, James R. Chadwick,
and A. Jacobi. Dr. William Maddren, chairman of
the building committee, transferred the building to
the trustees, and the building was then accepted with
brief remarks by Dr. Frank E. West, chairman of the
board of trustees, and Dr. Pilcher in behalf of the
society. After a benediction by the Rev. John P.
Chidwick, United States navy, there was a reception
to the women present from 5 to 6 p.m. In the even-
ing a dinner in honor of the occasion and for the en-
tertainment of the invited guests was held at the Farm-
house, Prospect Park. Dr. Pilcher was toastmaster,
and among the speakers were the Rev. A. J. Lyman
and Drs. Abraham Jacobi, William Browning, Fair-
bairn, McLean, and J. H. Hunt.
Navy Department, Bureau of Medicine of Surgery,
Washington, D. C, May 12, 1900. — Changes in the
medical corps of the United States navy for the week
ending May 19, 1900. May 17th (changes by cable
from Asiatic station). — Assistant Surgeon J. C.
Thompson detached from the Bennington and ordered
to naval hospital, Mare Island, Cal., for treatment.
Assistant Surgeon E. O. Huntington detached from
the Newark and ordered to the Bennington.
The New Hampshire Medical Society. — The one
hundred and ninth annual meeting of this society will
be held on Thursday and Friday, May 31st and June
I St, at Concord, under the presidency of Dr. Charles
R. Walker, of Concord. The secretary is Dr. Gran-
ville P. Conn, of Concord. The annual meeting of
the alumni of Dartmouth Medical College will be
held on May 31st, and the first annual meeting of the
New- Hampshire Association of Military Surgeons will
also be held on the same day.
A School of Instruction for Health Officers. — The
second annual school of instruction for health officers,
conducted by the Vermont State board of health, was
held on Tuesday, Wednesday, and Thursday of this
week in Burlington. The object of the annual ses-
sions of this school of instruction is to have a confer-
ence and discussion between the officers of health of
the State as to the latest and most efficient means at
command for preserving the health of the citizen and
of communities, and it is believed that this is the most
practical way of accomplishing the purpose.
Prof. Wilhelm Conrad Roentgen will be awarded
the Barnard medal, in conmiemoration of his discovery
of the -r-rays, at the commencement of Columbia Uni-
versity on June 13th. The award will be made on the
recommendation of the National Academy of Sciences.
The medal is of gold and was, established by the pro-
visions of the will of former President A. P. Barnard,
of Columbia University, and endowed by him. It is
awarded every five years " to such person, if any,
whether a citizen of the LTnited States or any other
country, as shall within the five years next preceding
have made such discovery in physical or astronomical
science to purposes beneficial to the human race, as
in the judgment of the National Academy of Sciences ■
of the United States shall be esteemed most worthy
of such honor." The award of 1895, which was the
first, was made jointly to Lord Rayleigh and Prof.
William Ramsay.
Acting Assistant Surgeons in the Army.— .A bill
is before Congress granting to all acting assistant
surgeons of the army of the United States the same
rights and privileges as regards leaves of absence,
quarters, and commutation, and all other rights, priv-
ileges, allowances, and emoluments (except pay, which
shall be, except as otherwise stipulated, at the rate of
Si 50 per month) as commissioned officers of the army
of the grade of first lieutenant, mounted. The bill
provides also for back pay, rank, etc., for acting as-
sistant surgeons \\\\o served during the Spanish war
and who were dropped for illness or disability, and
also enacts that those who have served for one year or
more shall be commissioned assistant surgeons of vol-
unteers with the rank of first lieutenant, mounted, sub-
ject to honorable discharge whenever their services are
no longer needed.
Obituary Notes.— Dr. William R. Ramsey died
at Norristown, Pa., on May 13th, from some disease
of the throat, at the age of sixty-eight years. He was
a student and subsequently an assistant of the late Dr.
William Corson. He was assistant surgeon in the
United States army during the Civil War, and was in
charge of the field hospital at the battle of Gettysburg.
Subsequently he practised medicine at Hazleton and
Norristown.
Dr. Coleman F. Leaming died at Cape May Court
House, N. J., on May 13th, at the age of eighty-two
years. Early in life he engaged in mercantile pur-
suits, but at the age of twenty-one he began the study
of medicine and was graduated after three years, set-
tling in New York and practising there for some time.
Later he returned to his native place, where he ac-
quired a fortune from business enterprises.
Dr. Charles S. Collixs, of this city, died on May
20th from the effects of an overdose of chloral. He
was a graduate of the College of Physicians and Sur-
geons in 18S4.
Dr. Sherrard R. Tabb, of the United States Ma-
rine-Hospital service, stationed in Savannah, disap-
peared on April 30th, and his body was found on May
loth in a dense thicket near the Bonaventure ceme-
tery. He had committed suicide by means of chloro-
form. He was born in Virginia in 1869 and was a
graduate of the medical department of the University
of Virginia in the class of 1802.
The Frequency of Goitre at Different Ages. —
Lucien Mayet presents the results of the tabulation of
over thirteen thousand cases of goitre, occurring in
those parts of France where the affection is endemic,
with a view especially to determine the age at which
the disease is most frequently encountered. This age
was found to be, for both sexes together, between forty-
six and fifty years. In men the greatest number was
in those from twenty -one to twenty-five years, and in
women between the ages of forty-six and fifty. — Lyon
MeJicd/, April 15, 1900.
May 26, 1900]
MEDICAL RECORD.
923
gtrogtcss of ||!XetXical J>ciencc.
Jou7-nal of the American Medical Ass' n. May ig. iqoo.
A Case of Hysterical Hip-Joint. — J. L. Porter reports a
case of this nature occurring in a girl aged eleven years,
who stood with the right thigh flexed and rotated outward
and only the toes touching the floor. In walking, the same
position was maintained, the weight being carried on the
toes, but the flexion increased each time the weight was
borne by the right leg. On inspection the affected hip and
leg seemed perfectly normal, there being no swelling. The
length of the two legs was the same, but the circumference
of the right thigh was one-half inch greater than that of
the left one. The latter was easily flexed, rotated, and put
through the normal motions, but as soon as any motion
was attempted in the affected leg a resistance was felt. If
the leg was forcibly flexed and suddenly released, it as-
sumed extension without any evidence of pain. If the
forcible flexion was continued until all resistance was over-
come, the thigh went up into normal flexion on the trunk
and could be rotated freely. Though she covered lier face
with her arms and cried a little, she did not shed tears or
give indications of pain. The thigh was forcibly flexed on
the pelvis several times, and if flexion was maintained un-
til she found that resistance was useless, it ceased. No
acute symptoms whatever followed the forcible manipula-
tions. The foregoing examination, together with the ab-
sence of any objective indication of intra- or para-articular
disease, such as swelling, thickening of the tissues, or local
elevation of temperature, gave the findings on which a
diagnosis of hysterical hip-joint was made.
Vesico-Rectal Anastomosis, with Special Reference to the
Treatment of Exstrophy of the Bladder. — J. Frank believes
that from the careful histological and bacteriological ex-
amination which was conducted in a number of the cases
experimentally operated on by him, it appears beyond a
doubt that vesico-rectal anastomosis may be performed on
a dog without leading to an infection of the kidnevs. In
two instances both the histological and bacteriological ex-
aminations showed a total absence of infection, and one of
these cases was that of a dog killed six months after the
operation. If the results on dogs, which naturally cannot
be kept under the best hygienic conditions and in which no
after-treatment could be instituted, furnished results like
the above, it is not unreasonable to expect far better ter-
minations in the human patient when after-treatment such
as washing out the bladder could be commanded. The
advantages of vesico-rectal anastomosis may be summa-
rized as follows : (i) Simplicity and shortness of time re-
quired for the operation ; (2) no danger of ureteral con-
striction by the bowel scar, nor sloughing of an implanted
trigone, as in Maydl's operation; (3) comparatively little
danger of infection ; (4) it is applicable not only in ex-
strophy of the bladder but also in other pathological con-
ditions of that organ rendering life a burden.
Use of Opium in Infancy, seen in Adult Life. — T. D.
Crothers states that the use of opium and its alkaloids in
infancy creates a diathesis or predisposition to its use in
later life. Acting as they do on the most unstable organ-
isms, the brain cells and centres, they not only retard but
prevent healthy physiological growth. Another point
which must be remembered is the concealed danger from
opium drugging in infancy. If only neurosis is present, if
defects of growth and function exist, opium will of neces-
sity increase this condition. Ansemia, exhaustion, and
perversion of organic activity follow. If some temporary
state is present, opium, by covering up the pain signal, is
not curative but may be destructive in many ways not
easily recognized until later in life. No one can tell
whether this danger begins with the first dose or only after
a succession of doses.
Antitoxin and Intubation, with a Report of One Hundred
Cases. — B. R. Shurly gives the following summary of re-
sults : number of operations, 100 ; recoveries, 69 ; deaths,
31 ; mortality under three 5-ears, 49 per cent. ; mortality
over three years, 19 per cent. ; complicating measles, 8
cases, 5 deaths. Age of patients operated on : One to two
years, 16, of whom 9 recovered, 56.25 per cent. ; two to
three years, 23. with 11 recoveries, 47 per cent. ; three to
four years, 20, of whom 16 recovered. So per cent. ; four
to five years, 15, of whom 12 recovered. So per cent. ; five
to six years, 11, with 10 recoveries, 90. g per cent. ; six to
eight years, 10, of whom 7 recovered, 70 per cent. ; eight to
twelve years, 5, of whom 4 recovered. So per cent. ; num-
ber of doses of antitoxin, 160. Eighty-five per cent, of the
cases occurred on streets that were not paved.
Eustachian Catheterization. — S. O. Richey makes a plea
for the greater use of the Eustachian catheter, claiming
that it is far superior in its action to either politzerization
or the method of Valsalva. An astringent or antiseptic
solution may be blown through it into the tube, later into
the cavity. It dilutes the secretion it reaches, destroys
germs more or less, and its astringency increases the cali-
bre of the tube, acting antiphlogistically. Secretions can
also be withdrawn from the lube by suction. The two
methods above alluded to are in the opinion of the writer a
frequent cause of extension of inflammation from the mid-
dle ear to the mastoid antrum. For the catheter, the small
hand-bulb of the a'tomizer is preferable to the large, un-
wieldy Politzer bag.
Abdominal Surgery ; Five Interesting Cases— Pancreatic
Cyst, Hepatic Calculi, Fecal Fistula, Combined Appendectomy
and Nephrorrhaphy.— By F. \V. McCrae.
Cleft Palate ; A New Urano-Staphylorrhapy.— By A. H.
Ferguson.
Bubonic Plague in San Francisco. — Hy W. H. Kellogg.
Philadelphia Medical Joiiriial, May ig. /goo.
Common Colds ; their Cause, Prevention, and Treatment. —
D. H. Bergey finds absolute immunity from colds quite
rare. Specific micro-organisms have not been demon-
strated, hence it is probable that micro-organisms com-
monly found are the cause, anatomical differences in tissue
giving the various inflammations encountered. Constitu-
tional conditions render one portion more vulnerable than
another and act in influencing location. Con.stitutional
symptoms indicate that large quantities of the poisons
generated /;/ -loco are absorbed into the circulation. One
person in a family may infect the whole household, and a
subject of chronic catarrh must be looked upon as a source
of danger, and as such should be excluded from public
schools. Mouth washes are discussed and therapy is sug-
gested.
Rupture of the Plantaris Muscle. — John H. Gibbon reports
the case of a man aged thirty-eight years who while play-
ing tennis was suddenly seized with a .sharp pain in the
calf. As soon as the diagnosis was made, a firm bandage
was applied from the toes to the knee. In a month the
function was re-established. The writer suspects, in severe
cases, a laceration of the deeper calf-muscles.
A Case of Chronic Pneumonia.— M. S. Councill reports a
case of unusual persistence, extending over a period of
about twelve months in a child of two years. Tuberculosis
was excluded. The writer thinks such cases will be found
to be more frequent wlien all means of diagnosis are
brought to bear upon them.
Miitter Lectures of the College of Physicians of Philadelphia.
— By J. B. Roberts.
Intestinal Indigestion and its Consequences. — By \V. H.
Porter.
Gastric Analysis. — By A. P. Francine.
AV'Ti' Vofh Medical Journal, May ig, igoo.
The Genesis of Antitoxins. — J. D. Lisle states that antitox-
ins are the result of cell stimulation. The question is. How
does the cell produce the antitoxin? — admitting, for the
time, that the antitoxin is the product of the cell. If a
cell, when properly stimulated, will produce an antitoxin,
the question naturally arises, How or what is the process?
A cell receives a stimulus; now, what does the cell do?
According to the theory of Ehrlich, the protoplasm of each
living cell is divided into a number of groups, and each
group is susceptible to a dift'erent stimulus. Among these
groups there is one or more which, when .stimulated by a
to.xin, begins an internal molecular change that results in
the production of the antitoxin. If the impression of the
stimulus upon the cell is only slight, the effect is only
molecular rearrangement and nothing is excreted ; this is
called vaccination, and accounts for cellular resistance ;
but if the stimulus is increased or is caused by another
class of toxins, the process of molecular change goeston,
and an antitoxin is poured into the circulation as fast as it
is made. Ehrlich has given to these groups of hypothetical
elements the name of "side chain," a term borrowed from
modern organic chemistrj-, and which contributes nothing
toward solving the mystery of the function of the cell in its
production of the antitoxin.
Trachoma. — N. B. Jenkins gives a general description of
this aft'ection. In speaking of treatment he says that per-
fect rest will usually give relief to trachomatous eyes.
This may be had by instillations of atropine, together with
protection of both e)-es from light and u.se by bandages,
cataract shields, etc., put on as after a major operation on
the eyeball. Before bandaging, a weak iodoform oint-
ment may be put in the eyes and on the lids. At night
these blinds are removed and the patient is kept in an ab-
solutely dark room. No ray of light should enter the eyes.
Uncomplicated trachoma may, in time, be cured by this
treatment. Proper glasses, in the writer's limited obser-
924
MEDICAL RECORD.
[May 26, 1900
vation, cure simple trachoma without other treatment, but
if there is much organic destruction, of course they can
have little if any curative effect.
Cystitis. — H. H. Morton concludes a lengthy article with
observations on treatment. For acute cystitis, he believes
that the only application which can be used without harm
is nitrate of silver beginning with four grains to the ounce,
twentj'di-opsof this solution being deposited every seconder
third day in the posterior urethra, from. which point it flows
back into the bladder. The indication for its u.se is painful
and frequent micturition, provided the bladder is capable of
emptying itself. For chronic cystitis, the indications to be
met are : { i ) To remove any source of local irritation with-
in the bladder or any obstacle to its evacuation ; (2) to re-
move the urine from the bladder and keep it empty; (3)
to destroy micro-organisms or check their growth, and re-
move pus and fermentation products from the bladder.
Study of the Blood in Cancer of the Stomach.— W. Osier
and T. McCrae come to the following conclusions: (i) In
a doubtful case a blood count below 1,000,000 red blood
corpuscles is strongly in favor of pernicious anjemia. (2)
While nucleated red blood corpuscles are present in all
very severe anaemias, megaloblasts rarely if ever occur in
cancer of the stomach. (3) Neither an increase in the leu-
cocytes nor special variations in the forms appear to be of
any moment in the diagnosis of cancer of the stomach.
(4) The presence or absence of digestion leucocj-tosis is
too uncertain to be of much assistance in diagnosis.
" .Sstivo-Autumnal Fever " in New Orleans, Summer and
Autumn, 1899. — By II. A. Veazie.
Physical Training in School and Home. — By H. S. Pettit.
Medical Xcii's, May 79, ]goo.
The Status of Gynaecology in 1876 and 1900. — Alexander
J. C. Skene says that in 1S76 gynaecology may be said to
have graduated with honors and to have taken a well-
merited position among the grand divisions of the profes-
sion. The author describes the condition of knowledge at
that time, in respect to various uterine diseases. There
were few actual specialists or experts in the branch.
Thei-e were only three journals and one society exclusively
gynaecological in 1876; now they e.xist in every town, and
the books have multiplied from three hundred to one thou-
sand. All that was obscure then in regard to inflammation
of the uterus twenty-five years ago has now been cleared
away ; equally strong lines and high light may be used in
sketching the present status of uterine displacements.
There has been extraordinary advancement in the knowl-
edge of neoplasms, great improvement in ovariotomy, and
knowledge of diseases of the urinary organs. Many other
advances are mentioned by the author, but are too numer-
ous to find place in an abstract.
The Treatment of Suppurative Otitis Media in Young
Children. — George L. Richards, in clironic cases, syringes
the car with warm sterile water or with a solution of bi-
chloride I ; 1,000, dries the canal, and inspects the ear. If
there is much destruction of the tympanic membrane he
applies peroxide of hydrogen on a cotton pledget, as long
as there is any exudation of gas, and after again drying
the parts applies on a cotton pledget a saturated solution
of boracic aoid in from forty to ninety per cent, alcohol.
He then dusts the ear lightly with powdered boracic acid,
and lightly stops the ear with a narrow wick of antiseptic
gauze which must reach the 1)ottom of the canal. Careful
instruction is given the mother as to home treatment.
Fibroid Tumor of Uterus ; Enteroptosis ; Retroversion ;
Ruptured Perineum ; Operations; Recovery. — By Matthew D.
Mann.
The Pharmacopceia of igoo. — By Horatio C. Wood.
Boston Medical and Sti7-gical Journal, May 77, iqoo.
A Case of Pernicious Vomiting of Pregnancy. — E. L.
Tworably reports a fatal case which illustrates that dis-
placements and faulty positions of the pregnant uterus
which delay its rising out of the pelvic cavity and press
upon the cervix are more often the causes of excessive
vomiting than has been generally supposed. If all meas-
ures of replacement of the uterus and correction of the
faulty position fail in the early months of pregnancy, we
should not trust to nature and time to effect a cure, but
should proceed to empty the uterus by surgical means.
Indication for emptying the uterus are; (i) Inability to
retain any food taken by the mouth ; (2) intolerance of
rectal enemata ; (3) more or less albuminuria ; (4) pro-
gressive emaciation ; (5) constant headache ; (6) frequent
and feeble pulse ; (7) a certain apathy on the part of the
patient.
Bicornate Uterus with Twin Pregnancy ; Abortion from
Ona Horn. — diaries H. Winn reports a case in wliich the
salient features are; (i) An abortion witli twins some
years ago, in which one foetus was macerated and tlie other
not. (2) A second twin pregnancy, both horns being occu-
pied. Abortion of one foetus was complete, as shown by
foul, decomposing tissue removed by a vigorous curetting,
and the immediate relief of septic conditions which fol-
lowed. (3) The demonstration of the bicornate condition
by the facts mentioned, and by the finding of a contracted
horn on the left side of the pregnant uterus. (4) The
probability of superfoetation. (5) The tolerance of the
pregnant utei-us to adverse influences is shown by the per-
sistence of pregnancy, in spite of catheters, abortion, sep-
sis, curetting, intra-uterine douches, and iodoform gauze
intra-uterine packing.
A Study of the Nature and Significance of the Symptoms
in Disorders of the Stomach. — Henry F. Hewes states that
the results of his investigations have been (i) to show that
there are certain sj-mptoms which are common to all affec-
tions of the stomach, and that they frequently form the
whole symptomatology of cases with distinctl}' opposite
causes, as in cases of hyperacidity and hypoacidity : (2) to
show what symptoms are the manifestation of this habit.
The author considers the habit as the manifestation of the
organ working to perform its function under untoward
conditions. Hyperaesthesia of the stomach would explain
the functional cases to some extent, but it does not ex-
plain the hypoacidity cases.
A Case of Pernicious Vomiting of Pregnancy. — H. S.
Knight reports a case in which vomiting was so excessive
and so continuous that it seemed as if the end must be
fatal. The vomiting was found to be due to anteflexion of
the neck of the uterus. Packing the vagina and the use of
the ball pessary were not entirely satisfactory, but the
insertion of a small soft-rubber pessary, which raised the
uterus and also gave an opportunity for the cervix to
straighten itself, was followed liy the best results. There
vi^as gradual cessation of the vomiting, with return of sleep.
The patient is now on a generous diet, and everything
promises well.
The Question of Supernumerary Fallopian Tubes ; with
Specimens of Fallopian Tubes with Supernumerary Ostia.—
By Agnes C. Victor.
The Ideal Ration for an Army in the Tropics. — By Edward
L. JIunson.
Berliner klinische ]\'oelieiischiift, April jo, igoo.
The Struggle against Tuberculosis as a Universal Disease.
— W. Winternitz makes a plea for the systematic use of
hydrotherapy in the treatment of tuberculosis. He finds
as the great characteristics of this disease a weakening of
the circulation and a condition of ana;mia. He claims for
this mode of therapy that it strengthens the heart action,
increases vascular and tissue tone, and calls forth an active
or collateral hypei'cemia in the affected organ, re-establishes
the normal relations in and about the organs involved, and
strengthens the entire organism, especially innervation
and circulation. Haemoptysis, hectic fever, and night
sweats are all benefited. The remainder of the article is
devoted to an explanation of methods of application.
What Chances Have We to Eradicate rnfectious Diseases,
Especially Tuberculosis ? — 1 >. 1 liinitz traces the various steps
whicli luive kd up to ii\w present knowledge concerning
immunity and the preparation of the various therapeutic
serums. He finds great encouragement in the progress
made, and believes that we shall some day succeed in ob-
taining an antitoxin which will combat tuberculous ravages.
He calls attention to the fact that it has been found that
under some circumstances it is possible to use the serum of
an immunized animal fir human being for purposes of
further immunization in others.
The Occurrence of Peculiar Crystals in the Bones of Rachitic
Children Treated with Suprarenal Substance. — By Stoeltzner
and Salge.
Observations on the Demonstration by the Roentgen Rays
of Bone Structure.— By J. Wolff.
French Journals.
Post-partum Hemorrhages Cured by Simple Drainage and
followed by a Psychosis. — C. Zalackas says we can admit
a post-puerperal psycliusis ; tliat the ])sychoses following
gynaecological operations are very exceptional, and when
they exist we usually have to do with women predisposed
or already affected with insanity. There is no connection
between the psychoses and the operative procedure.
Psychic troubles can be produced as well after any other
operation as after ovarian castration. The operation never
of itself produces madness. There exists a psychic state
before operation, called phobia, which may persist after
the operation. In psychoses at precocious menopause a
certain predisposition is at work. The fear of mental per-
turbation should not deter one from ojierating when the
indications are clearly present. — Le Progres Mc'dical,
May 5, lyoo.
May 26, I goo]
MEDICAL RECORD.
925
Infantile Typhoid Fever of the Exanthematic Forms.— E.
Weill and Ch. Lesieur report upon a remarkable frequency
of typhoid in children presenting an abundance of rosy
spots. The}- find that classic cases with few spots have
marked or intense intestinal symptoms, and that the
prognosis is often grave. Slight fever with few spots and
intestinal symptoms slightly marked has a good prognosis.
Intense fever with abundant spots and marked intestinal
symptoms has a very grave prognosis. Purely exanthe-
matic typhoid, such as exemplified in the cases now stud-
ied, with very abundant rosy spots, intestinal symptoms
slight or almost nil, has an extremely benign prognosis. —
Gasette Hebdomadaire de Midecine et de Chiriirgie, Jlay
6, I goo.
Bathing in the Tjrphoid Fever of Childhood. — E. Ausset
finds a series of cases in children more severe than the adult
form. He never finds at autopsj' in an infant tj-phoid which
has escaped recognition during life. In forty-five cases
there were four before the fifth year, twenty-nine between
five and twelve years, and twelve between the twelfth and
fifteenth years, with two deaths in each series. The author
believes in systematic bathing from the very onset. The
temperature should be regulated for each case. The
younger the child the less cold is the bath. It is unneces-
sary to give baths as cold as the pure Brand method calls
for. — Journal de Medecine de Paris, !May 6, 1900.
Note on Two Cases of Cutaneous Manifestations in the
Course of Infectious Diseases of the Digestive Tube. — P. En-
gelbach found in the recent epidemic of typhoid fever at
Havre that severe eruptive phenomena were frequent. He
cites an instance of scarlatiniform generalized eruption in
typhoid with cardiac complications followed by death, and
a case of enteritis with similar eruption and death in the
course of convalescence. He does not look upon the ery-
thema as belonging to the tj-phoid process, but as a sec-
ondary infection. — La Revue Mediea/e de Xormandie,
May 10, 1900.
The Permanent Sound in the Treatment of Urinary Infec-
tion.— Felix Gu)-on discusses, with temperature chart illus-
trations, the use of the catheter a demeure in prostatic and
urethral hemoiThages attended with infection. It con-
stitutes the method of choice of bladder drainage in
febrile cases. In a study of fifty cases we find forty-two
cases and eight deaths or twenty per cent, mortality. The
decline of fever is, as a rule, rapid. The instrument must
be carefully managed and watched to get the best results,
but this is not a contraindication to its employment. — La
J'resse Medicate, May 5, 1900.
The Treatment of Large Rectal or Ano-Rectal Prolapse by
Excision of the Rectal Mucous Membrane.^Professor De-
lorme concludes that ablation of the rectal mucous mem-
brane, reserved hitherto for the treatment of prolapse pure-
ly mucous, is equally applicable to prolapse of the second
group, in which all the tunics of the intestine participate
in the rectal protrusion, whether or not there be invagina-
tion.— Le Bulleiin JMedical, May 9, 1900.
The Praciiiiotier, May, igoo.
The Distinguishing Features of Rheumatoid Arthritis, Gout,
and Rheumatism. — Arthur P. Luif believes many cases of
rheumatoid arthritis are diagnosed as rheumatism or gout.
Chronic rheumatism of the joints is a comparatively rare
affection. It may not manifest itself as an arthritis at all.
A rough clinical test is to ascertain the effect of treatment
with salicylate of sodium. By rheumatoid arthritis the writer
means the same as arthritis deformans or polyarthritis de-
formans, or rheumatic gout. The latter term is confusing.
It occurs most often in females, while gout occurs mostly
in males. It occurs among the poor and ill nourished.
There is little pain at first, but some aching in the joint,
and the onset is very insidious. He accepts neither the
uric-acid nor the lactic-acid theory. In a great number of
cases it is an infective disease, due to a settlement of mi-
cro-organisms in the affected joints, in which they produce
a toxin, which passing into the circulation is responsible
for the nervous symptoms. In children it is often second-
ary to scarlatina, rheumatic fever, and acute septic ton-
sillitis. In adults it also follows ulcerative disease of the
tonsils or of the gastro-intestinal tract. Rheumatism cer-
tainly predisposes to rheuinatoid arthritis.
Some Clinical Varieties of Osteo-Arthritis. — A. E. Garrod
finds it an open question whether we have here a single
morbid process. In young patients a rapid course may
cause widespread deformity. In older subjects the progress
is much more gp-adual. The more acute cases of early life
may be further subdivided into the fusiform and crippling
varieties, the former being the more common. The verte-
bral column is usually involved early, and stift'ness of the
neck is a common sjTirptom. The crippling variety is usu-
ally met with in early adult life and shows little tendency
to be restrained by treatment. In nodular cases no marked
degree of repair is possible. The fusiform variety is bene-
ficially influenced by attention to certain points : persever-
ance in treatment ; rigid dietary is injurious ; drug medica-
tion should be tonic, and not depressant. Mineral baths
often prove most helpful.
Osteo-Arthritis or Rheumatoid Arthritis ; its Pathology and
Treatment. — G. A. Bannatyne thinks more care should be
exercised in differentiation. There arc three types; (i)
An acute polyarticular disease ; (2) a chronic polyarticular
disease of primary and secondaiy forms ; (3) a monarticu-
lar disease. These are not all one disease. There is no
connection between the acute polyarticular and the monar-
ticular affection, or between the latter and the chronic
polyarticular condition. The conditions under which the
difl:erent forms occur are treated at length. The pathology
is entered into, and treatment appropriate to the various
conditions is laid down, with indications for baths, etc.
Mechanical and Traumatic Arthritis. — W. A. Lane em-
ploys the term mechanical or traumatic arthritis to cover
all the pathological changes known as rheumatoid arthritis.
True rheumatoid arthritis resembles in no manner the
pathological condition to which the same term is still al-
most universally applied. A series of excellent drawings
shows modifications of bone at joint regions due to occupa-
tion, injury, etc.
The Varied Forms of Osteo-Arthritis, with Illustrative
Cases. — By William Armstrong.
The Treatment of Osteo-Arthritis at ALx-les-Bains. — By
H. Forestier.
Arc/lives of Otology, vol. .x.xix.. A'o. r, /goo.
Suppurative Disease of the Temporal Bone. — S. M. Bur-
nett reports a series of cases, the paper being of special
intei^st from what the author observes concerning diseases
of the temporal bone in the negro. He had previously
stated his belief that the affection of the middle ear, known
as sclerosis or drj- cataiTh, was much less common among
the negroes than among the whites. This referred partic-
ularly to the adult. Furthermore, his added experience
has shown him that suppurative diseases of the temporal
bone are also very uncommon among negro adults. He
has never seen a case of mastoiditis in an adult negro.
This is by no means the case, however, with the negro in
infancy and childhood. Negro children are very subject
to diseases of the bones, particularly in the form usually
called "tuberculous." Not only this, but suppurative dis-
ease of the bones when once established is very difficult to-
eradicate, and relapses are frequent. The negro child is
almost without exception badly nourished, and nearly al-
ways " scrofulous. " It would not perhaps be safe to say
that in every case this means tuberculosis in a demon-
strable form in some organ, though few autopsies show its
absence, but the power of resistance is much reduced and
recuperation sluggish. Whether all cases of temporal-bone
suppuration in these children start in the middle-ear in-
flammation is doubtful. There seems at an)- rate to be a
strong predisposition among them to take on suppurative
disease in these bones on slight provocation.
Facial Paralysis as a Complication of Acute Otitis Media. —
W. R. JIurray has .seen this complication twice in two
hundred and fifty-eight cases of this form of ear trouble.
He says that during its passage through the Fallopian
canal the anatomical position of the nerve accounts for the
somewhat unusual complication of facial paralysis attend-
ing an otitis media, and, when present in an acute catar-
rhal case, is due to the direct extension of the inflamma-
tory process to the nerve sheath, which, lying within the
unyielding bony walls of the Fallopian canal, may be sub-
jected to sufficient pressure, from the swelling attending a
slight inflammation of the nerve sheath, to interfere, partly
or completel)-, with the functions of the nerve, and is prob-
ably due to some abnorhiality of the bony structure sur-
rounding the nerve, probabl)' in the neighborhood of the
fenestra ovalis, in the internal wall of the tympanum,
where the canal turns from its horizontal course and
passes downward to its exit at the stylo-mastoid foramen.
Excessive Hemorrhage following the Removal of a Myxo:-
Fibroma from the Ear.— C. R. Dufour has recently met
with an experience of this kind, his patient being a woman
aged fift)- years. The tumor protruded in a polypoid form
and was surrounded with the wire snare, but the latter
could not cut through, so the growth was removed by tor-
sion. Severe arterial hemorrhage followed, which hot
water did not control but which was entirely checked by
compression of the carotid. Release of pressure was fol-
lowed by immediate recurrence of the bleeding, so under
anaesthesia the meatus was packed with gauze, which
stopped all further trouble. The gauze was removed with-
out incident in four days.
The Rinne and Gelle Tests.— G. Briihl comes to the fol-
lowing conclusions : (i) 1£ the Rinne test is positive, then
Gelle is also unexceptionally positive, and the impaired
926
MEDICAL RECORD.
[May 26, 1900
hearing is due to nervous affections. (2) If the Rinne test
is negative absolutely and totally or up to c', the Gelle test
is unexceptionally negative, and the impaired hearing is
due to a stapes ankylosis. (3) If the Rhine test is nega-
tive below or up to the c limit, and positive above it. then
the Gelle test decides whether a stapes ankylosis exists or
not.
GTotrrjcspornTencc.
OUR LONDON LETTER.
(From our Special Correspondent.)
DINNER TO RETURNED CIVIL SURGEONS — MR. TREVES AND
THE PLAGUES OF SOUTH AFRIC.\ — CAUSE OF SCURVY— CYSTS
OF THE BREAST— CIRRHOSIS OF THE LIVER — ST.\TUE TO
HUXLEY — SIR BATTY TUKE — DEATH OF PROF. VINER ELLIS.
London, May 4, iqoo.
Lord Rosebery presided at the dinner to Sir William
MacCormac and Mr. Treves. In commending their work
in South Africa he extended his praise to the army medical
service which has so completely done its diity in the cam-
paign. As the only department which has been on all
hands pronounced perfect the Royal Army Medical Corps
has justified its position and its profession. Lord Rose-
bery's eulogy of the service will do much good, and it was
indorsed by both the distinguished guests. Sir William
JIacCormac spoke of the war as one of the happiest things
that could have happened in view of the way it has brought
out the noblest part of the national character and consoli-
dated the power of the empire to put an end to the most
corrupt oligarchy. Mr. Treves confined his remai-ts to
more professional topics, but in speaking of amateur
nurses he put his foot in it, and the screaming sisterhood
are seeking revenge. He is a bold man and refuses to re-
tract, but he has expressed to an interviewer his amaze-
ment at the misunderstanding of his remarks. It is true
he said there were two plagues in Africa — the flies and
these women. The women were those who went out ap-
parently in search of a novel excitement — society butter-
flies, who knew nothing and cared nothing for real nursing,
and only hindered the surgeons in their duties. I hear
army men declaring what he said is too true, and it needed
some one out of the army to say it. Sir A. Milner had
• spoken, but it seems these women could not take a hint, so
Mr. Treves has translated it into vigorous denunciation.
T/ie T/mt-s ma.de an extraordinary blunder by attributing
the perfection of the Royal Army Medical Corps to Sir
William MacCormac and Mr. Treves. Those gentlemen
accordingly at once wrote a joint letter to T/if Times dis-
claiming any share of the credit, as they went to South
Africa only after the Royal Army Medical Corps had
completed all its arrangements, and could therefore only
testify to the efficiency of those arrangements. That let-
ter in 'Tile Times will be appreciated by their army breth-
ren and by the public. Its prompt appearance does justice
to the writers' sense of right.
That scurvy is caused by lack of fresh vegetables and
may be prevented by lime-juice is still, I believe, generally
thought to be an indisputable fact. Even when the precise
manner in which the result is brought about is disputed,
the fact has been admitted for more than a generation.
Still here and there doubts have been expressed, chiefly on
account of the impossibility of reconciling some outbreaks
with the theory, which may yet have to be greatly modified
or discarded. A communication has been made to the
Royal Society by Mr. Frederick G. Jackson and Dr.
Vaughan Harley, detailing an investigation into this mat-
ter which points to the conclusion that ptomain poisoning
is the cause of scurv)^ The sug.?estion is not novel, but
it is now founded on a careful research. A number of
monkeys were kept under the same circumstances on a
strictly regulated diet. In one group fed c 1 boiled rice
and maize with fresh meat mixed in it, the .■ lost weight
and diarrhoea was produced. The diet was probably in-
sufficient, and monkeys are not carnivorous. In another
group on exactly the same diet, except that the meat was
tainted instead of fresh, the same wasting occurred, but
the diarrhoea became bloody, in some cases the motions
just before death consisting principally of blood and mucus.
Further, five out of the eight monkeys in this group devel-
oped spongy gums, in some ulceration occurring. A third
group of five, dieted in the same manner, except that an
apple or banana was added daily, showed similar eftects
but not so intense. Four had blood and mucus in the
stools, and two of them spongy and bleeding gums. Thus
it would seem that the vegetable only restrained but did
not prevent the symptoms of scurvy. The facts of Arctic
ex])editions are in agreement with the conclusion that veg-
etable food or lime-juice is not alone able to prevent
scurvy when the meat is tainted. Therefore the condition
of the diet generally must be considered, and most of all
the state of preserved meat, whether tinned or salted.
The blood of two of the scorbutic monkeys was analyzed,
and that of a healthy monkey, and these analyses were
compared with those recorded in cases of human scurvy.
The results supported the conclusion that the two diseases
corresponded.
A paper on cysts of the breast comes opportunely after
the Lettsoraian' lectures of Sir W. M. Banks on cancer of
that organ. At the Medical Society the relative frequency,
diagnosis, and treatment of such cysts was considered by
Mr. Bryant. This communication was a sequel to one he
read before the same society in iSg6. From an analysis of
two hundred and fort}--two consecutive cases seen by him
in the last ten years he was brought to the following con-
clusions : ( I) Simple cysts are more common than is gener-
ally believed ; (2) they are chiefly found at the period of
life in which cancer is met with : (3) they are amenable to
treatment without the sacrifice of the gland ; (4) there is no
reason to believe that women who have these cysts are more
liable than others to cancer. Separating the cases proved
by operation to be correctly diagnosed, Mr. Bryant was
able to report that of every four cases which simulated
cancer one proved to be cystic. He then showed how
safely these cysts may be dealt with either by simply lay-
ing them open and plugging with iodoform gauze after de-
stroying the inner surface with carbolic acid or solution of
iodine ; or by dissecting the cyst from the gland, when in-
tracystic growths can be seen attached to its walls. In his
cases permanent recovery has always followed. But should
the cyst be found to contain solid cancerous or sarcomatous
growth he would remove the whole gland, and, indeed,
had done so on two occasions, the cases being classed as
solid tumors. If one in four cases simulating cancer turned
out to be cvstic, Mr. Bryant thought that eliminating cases
with clear indications of cancer it might be that half the
remaining doubtful cases would be cystic. Such an in-
ference may well give pause to the practitioners who would
regard every lump in the breast as cancer. An explora-
tory incision would make the diagnosis clear. Mr. Bryant
admitted that the figures had somewhat surprised him,
particularly as they were of consecutive cases. Cysts were
generally thought rather uncommon, but these figures dis-
proved that.
Some remarks were made by fellows on the difficulties of
diagnosis, and one said he thought innocent tumors were
even more common than Mr. Bryant's statistics showed,
but these were of course restricted to cysts.
At the same meeting Dr. Campbell Pope read a paper
on "Twenty-four Years' Death Certificates in General
Practice." His figures pointed to the prevalence of respira-
tory diseases in the district, situated in West London, the
slight fatality of infections diseases, and the frequency of
cancer, Further, influenza was not verj- fatal, and the in-
fantile death rate was high. In the absence of statistics
from other general practices in the district it seems to me
difficult to assign a proper value to these.
When a question arises as to the condition of the liver in
a given case, I am reminded of a remark once made by
Addison. After careful palpation, percussion, and consid-
eration in a consultation on an obscure case, that able ob-
server said; "We feel, and feel, and give a guess." The
difficulties of diagnosis remain jnuch the same, and the
clinical history of hepatic disease has not kept pace with
the progress of our knowledge of other maladies. Still
some points have been made clearer and others are being
elucidated. They were well treated by Dr. Cheadle m his
recent Lumleian lectures on "Some Cirrhosesof the Liver."
He has for a long time taken great interest in this subject,
and was able to enforce his views from extensive expe-
rience. I need only mention one or two practical points to
show the value of his lectures. The advent of ascites is
.so often regarded as the beginning of the end that practi-
tioners will be glad to learn that Dr. Cheadle has not found
it so surely and rapidly fatal as many suppose. In the
contracted, atrophic form of cirrhosis, due to alcohol, he
admits the full gravity of the symptom and thinks that to
these cases is to be attributed the hopeless prognosis gen-
erally entertained. On the other hand, in hj'pertrophic
and syphilitic ca,ses the advent of ascites is less serious.
The cirrhosis is of course incurable, but in itself of little
consequence, only important by the pressure it produces.
Therefore a certain degree may persist for a long time
without precipitating the end. Another point relates to
treatment. Dr. Cheadle is a thoroughgoing advocate of
early and repeated paracentesis, and some of the cases he
related were very convincing as to the value of this prac-
tice. Everyone will admit that the indication is to get rid
of the fluid, and most will subscribe to the doctrine — the
sooner the better. But many, perhaps too many, cling to
the hope that diuretics or cathartics may suffice. The
futility of the former has tocroften been experienced, and
the latter Dr. Cheadle finds do not often reduce the ascites,
though they do reduce the patient's strength. He there-
May 26, 1900]
MEDICAL RECORD.
927
fore deprecates the postponement of paracentesis until the
vital powers are exhausted, and would repeat the operation
as it may be called for until the fluid ceases to accumulate.
On Saturday the Prince of Wales unveiled the statue of
the late Professor Huxley in the Natural History Museum.
He referred to the fact that he had fifteen years ago un-
veiled a similar statue of Darwin.
It seems that Sir Batty Tuke will have a walk-over for
the vacant Scottish University seat.
An outbreak of typhoid at Leeds is causing some anx-
iety.
It seems like going back for a generation to record the
death of George X^iner Ellis, the professor of anatomy and
author of the " Demonstrations." He died on the 25th ult.
at the advanced age of eighty-eight years. He retired as
long ago as 1S77 to his country house, where he died. The
beautiful colored plates he issued in his "Illustrations "
were drawn from his own dissections.
THE MEDICAL ASPECTS OF THE SOUTH
AFRICAN V/AR.
(From our Special Correspondent.)
Lord Roberts' Genuine Success in occupying Brandfort, and
his more qualified successes both to the north and the south-
east of his halting-place at Bloemfontein, all of which have
taken place since I last wrote, may be of more significance
than they appear. But few prisoners have been taken, and
there is no evidence that the Boers have lost more than a
dozen lives, while their guns and provisions have been
safely removed and all attempts at cutting off their retreat
upon their main army have failed. But, on the other
hand, the fertile country from which they have been ousted
is the best 'corn land in .South Africa, a consideration to
both sides now that the immense importance of cavalry in
this war is recognized, while the onward march of the Brit-
ish is sure to lead, as it did previously, to desertions from
the Boer commandos.
The Total British Casualties, according to a War Office re-
turn published on April 21st, amounted to just about fif-
teen thousand men, this total being exclusive of sick and
wounded actually in hospital at the time of publication of
the return. No official return has been made by the Pre-
torian government of the Boer losses, and the reason of
this is probably the apprehension of the Boer leaders lest
appreciation of the risks should prevent some of the burgh-
ers from joining the flag ; but as a matter of fact it is com-
mon knowledge that the Boers have not lost anything like
so many men as the English. Sir William MacCormachas
said, after walking round the trenches of Colenso, that the
place was practically impregnable. At the battle of Co-
lenso there were eleven hundred and forty British casual-
ties, while the Boer losses, if the figures of Mr. Fischer,
the secretary of the Free State, are received as accurate,
amounted to five killed and twenty-five wounded.
Rain and Dust Storms are causing the British troops
much discomfort and .some sickness. There are now con-
siderable diff'erences in temperature during the twenty-four
hours, for the night temperature falls very low, while the
torrents of rain occasionally swamp out the tent-dweller.
The rain storms are usually preceded by a wind which
sweeps up with it the dust of the veldt to deposit it in a
fine layer over everything and into everything. This dust
makes the mucous membranes of nose and mouth and
pharynx sore, causes sore throat with headache and fever-
ish symptoms, and, in the opinion of some, is responsible
for diarrhoea. The lull in fighting is enabling the base
hospitals to get empty of their patients. Most of those
sent down to the base are suffering from enteric fever, but
the number is not very great when the size of the British
army is considered. It will be interesting to see if any
proofs can be obtained that the dust storms are followed
with any regularity by enteric symptoms.
The Boer Prisoners at Simonstown are still suffering from
enteric fever. The number of cases is great and the mor-
tality considerable. A special hospital has been estab-
lished at Simonstown for their treatment, and every com-
fort and even luxury compatible with their condition is pro-
vided by the British government. The Boers must have
brought the disease down with them from their trenches,
which were in a terribly fetid and unsanitary condition,
for there was no enteric fever at Simonstown previous to
their arrival, and none of the British transports has put
in from England with the disease on board.
Moral Support. — I referred in my last letter to the value
of the moral support which Sir William MacCormac has
been able to givetoihe Royal Army Medical Corps during
their campaign, and a striking illustration of my meaning
has been furnished by Sir William MacCormac himself, who
has thus summarized his opinion of the department :
"The professional surgical effectiveness shown by the
oiScers of the Royal Army Medical Corps during my inti-
mate connection with them, while they have struggled with
difficulties of location, transit, want of water, and a hun-
dred and one other impediments never experienced in a
civil hospital in peace, is, in my opinion, of a very satisfac-
tory character, and everything has been done which one
could possibly suggest under the varving circumstances
for the comfort and skilful treatment of the wounded. The
rapidity and completeness with which large field hospitals
were conveyed by road or rail, unpacked and re-erected,
reflect great credit upon the organizing powers of the offi-
cers and the effective carrying out of their orders by the
hard-working and patient non-commissioned officers and
men of the corps under them."
Such a testimonial from the president of the Royal Col-
lege of Surgeons of England will be of great value to the
corps. Hitherto even when praised (which seldom oc-
curred) the praise was alwavs bestowed with somewhat
doubting accents, for the commendation had to come from
men with no expert knowledge whatever of the work of the
military surgeon. In the South African campaign Sir Wil-
liam MacCormac, and in no less degree such civilian sur-
geons as Mr. Treves and Mr. Watson Cheyne, are vouch-
ing and will vouch for the standard of the scientific work,
and will thus enable the commander-in-chief to understand
the merits of the corps. Sir William MacCormac, who, by
the way, is a strong and sensible man, quite unlikely to
bespatter with praise undeserving objects for the sake of
making himself agreeable, describes the work of the nurs-
ing sisters also in terms for which they will be grateful.
"The work of the army nursing sisters," he says, "has
been admirable and endless. As soon as one batch of seri-
ous cases from the front was comfortably settled and a
partial rest seemed possible, another batch arrived. The
untiring energy and patience shown by these ladies under
great diflficulties and stress have been beyond praise."
Tbe " Maine." — The American hospital ship Maine is
now nearly due again at Cape Town. Lady Randolph
Churchill, who has acted as chairman of the American
ladies' committee, has published a statement explaining
why only male nurses have been engaged for the second
voyage.
"Our sisters," she says, "were not ' lady volunteers, ' but
skilled professionals, having received the same training
and receiving the same salaries as the male nurses from
the Mills schools, the whole nursing staff having been sent
to us by Mrs. Whitelaw Reid. In reference to the sisters,
nothing could exceed their excellent work, and if we are
parting with them, our decision casts no reflection on their
efficiency. It has been found that the nursing staff was
too large for the number of patients we could take on board,
and for the class of cases which hospital ships, practically
three daj-s' journey from the front, necessarily received.
There is no doubt that a wounded or sick man at death's
door prefers a woman to nurse him ; one before whom he
need not fear to break down, one whose gentle touch no
man can replace. But the bulk of our patients were men
able to do a good deal for themselves, who, if given the
choice of equally good men or women nurses, would prefer
the former. Under these circumstances, and added to
them the fact of the cramped accommodation and want of
privacy the ship affords for women, it has been thought
advisable to dispense with their services."
Lady Randolph Churchill's explanation was probably
due to the feeling that the public, reading Mr. Treves'
estimate of the value of amateur nurses, and hearing that
the Maine was going out on its second errand of mercy
with only male nurses, might jump to the conclusion that
the women who had nursed on the Maine were exactly the
incompetent ladies of fashion whose actions had been so
criticised. I do not know if any one has had this errone-
ous idea, but I do know that the patients on board the
Maine were excellently looked after in every way.
Firing on the Red Cross. — Sir William Thompson, who is
head surgeon with the Irish Hospital, has publicly stated,
in reference to the oft-repeated allegation against the
Boers that they fire on ambulances and hospitals, that
when this occurs it may well be an accident ; for the Red
Cross markings are not made the proper size to be visible
at the present long ranges, and can be seen only at a dis-
tance of six hundred yards or so.
METHYL BLUE AND METHYLENE BLUE.
To THE Editor of the Medical Record.
Sir : In the Medical Record for April 2S, 1900, in Dr.
Willy Meyer's article on "Bot*ini's Operation for the Cure
of Prostatic Hypertrophy," he mentions his use of methyl
blue in two- to three-grain do.ses three times daily, com-
bined with quinine in eight-grain doses. He must mean
methylene blue, which is used in cystitis, pyelitis, malaria,
rheumatism, and carcinoma. Methyl blue, on the con-
928
MEDICAL RECORD.
[May 26, 1900
trar\-, is never used internalh-, but is dusted on the throat
in diphtheria in a two-per-cent. mixture with sugar powder.
Jlethylene bhie with sodium hydrate is changed to a vio-
let color ; meth\-l blue with sodium hydrate (NaOH) is
changed to a reddish-brown.
Ciiari.es Teubner, M.D.
2387 Howard Street, S.an Francisco, Cai..
May 4, 1900.
Dr. Baruch is entitled to great credit for his efforts in be-
half of public baths, but he was in no wise reponsible for
the acts of 1S92 and 1895, nor, I am satisfied, would he
claim to be so.
All of the experiment with rain and spray bathing were
made about the same time — 1S90-1S91 — and by many peo-
ple at different dates. It is not strange that I did not learn
of Dr. Baruch's, for I did not know of him or meet him
until 1S95. Goodwin Brown.
LYMPHATIC INVOLVEMENT IN CANCER OF
THE STOMACH.
Sir : In the issue of the Medical Record for May 5, 1900,
is an abstract of a paper on "Malignant Diseases of the
Stomach and Pylorus," which I read before the American
Surgical Association, in which I am made to sa}- that
Ivmphatic involvement, so called, is now known to be a
simple septic glandular enlargement — the relation between
the abdominal glands and the carcinoma being utterl)- dif-
ferent from that which exists between the breast and
axilla ; and that abdominal adenitis is, therefore, of lit-
tle importance.
AVhat I did say was: "Lymphatic infection is a still
more serious complication because, if palpable glandular
malignanc}' can be established, it is altogether probable
that the involvement has passed bej-ond reach. In twenty-
eight cases of non-malignant dilatations of the stomach
from various causes which I have operated upon, in more
than half enlarged glands could be palpated, due to an ac-
companying chronic gastritis. This may be, and fre-
quently is, true of cancer of the stomach, the enlarged
glands being the result of septic complications. The
modern operation for the removal of the glands with car-
citioma of the breast suggests a similar glandular extirpa-
tion in radical operations on the stomach. Linder does not
believe this feasible. In twenty-eight recurrences after
extirpation, fifteen were local, twelve distant, and only one
involved the glands. An investigation leads to the belief
that glandular infection in cancer of the stomach is not
uniform, many such cases die without such involvement,
and that a moderate enlargement may be septic. Should
the)- become infected their situation renders radical re-
moval practically impossible."
As involvement of the lymphatics takes place in at least
two-thirds of the cases of cancer of the stomach, I feel that
the statement should be corrected, and more especially
when I consider the large circulation of your journal.
W. J. Mavo, M.D.
Rochester, Min-n.
PEROXIDE OF HYDROGEN AS A LOCAL
AN.-ESTHETIC.
To THE Editor of the Medical Record.
Sir : I have not seen anywhere peroxide of hydrogen
spoken of as a local antesthetic, and as it has proved very
satisfactory in luy hands I venture to mention it in your
paper. Injected under the epidermis it produces imme-
diate and complete aasesthesia of the whole skin. I have
used it for over a year, in opening abscesses, cutting off
redundant tissue in in-growing toe-nails, opening the
pleural cavity, and in one case the abdominal cavity. I do
not think any absorption takes place, as the intercellular
inflation from the gas generated seems to produce such
pressure that the skin cuts like frozen tissue.
H. E. Kendai.i., M.D.
Svdnev, Nova Scotia, May 4, 1900.
PRIORITY IN THE PUBLIC-BATH QUESTION.
To THE Editor of the Medical Record.
Sir: In reply to the editorial in the Medical Record of
May I2th, permit me to say that a careful reading of my
article will show that I made only two claims — first, that
so far as I knew the Lunacy Commission were the first
(iSgi) to introduce spray bathing into institutions for the
insane ; second, that I was the author of the first general
State legislation (1S92) providing for the erection and
maintenance of free public baths and making their erection
mandatory (1895). Dr. Baruch did not secure me as a
coadjutor. The first act was passed in 1S92 — three years
before I knew Dr. Baruch. In 1S95, at his request I met
him and subsequently invited him to appear with me be-
fore a legislative committee, but he was unable to do so.
gleuicxus and Notices.
Practical Text-Book of Midwieerv for Nurses and
Students. By Robert Jardine, M.D. Edin., M.R.C.S.
Eng., F.F.P. and S. Glasg. ; Physician to the Glasgow
Maternit)- Hospital, Glasgow. With thirty-six illustra-
tions. 245 pages. New York : The Macmillan Com-
pany. Edinburgh: William F. Clay. 1S99.
Thls volume treats of midwifery in a simple, direct waj-
especially adapted for beginners. The descriptions are
clear and concise, and technical terms are avoided as much
as possible. The actual duties of nurses are well described
and the procedures for asepsis particularly insisted upon.
The author does not claim to have written for practitioners,
but merely for those who are their assistants, and he has
succeeded admirably in his task of pointing out what they
should observe and what the probable meanings of the more
evident symptoms are,
A Mancal of Sirgical Treatment. By W. Watson
Chevne, M.B., F.R.C.S.. F.R.S., etc.. and F. F. Burg-
hard, M.D. and M.S., Lond., F.R.C.S. Vol. II,: The
Treatment of the Surgical Affections of the Tissues, in-
cluding the Skin and Subcutaneous Tissues, the Nails,
ttie Lymphatic Vessels and Glands, the Fascia?, Bursae,
Muscles, Tendons and Tendon Sheaths, Nerves, Veins
and Arteries, Deformities. Philadelphia and New
York : Lea Brothers & Co. 1900.
The second section of this commendable work is now be-
fore us, and we find that the promise of the first volume is
well maintained. The book is especially strong from the
practical point of view, and contains many useful hints,
often upon minor details, care for which contributes so
much to surgical success. As the title indicates, the sub-
ject of treatment recei\-es a very large share of attention,
and most of the illustrations bear upon this part of the
subject. The deformities, congenital and acquired, of the
hand and foot occupy considerable space in the first part
of this volume, and make a very concise and readable sec-
tion uponorthopa.'dic surgery. Under the division devoted
to the surgical affections of the tissues, among other mat-
ters, the subject of the treatment of many of the minor
surgical conditions, especially of the extremities, receives
attention, and adds much to the interest and value of the
book. Pathology does not receive much consideration
either in text or in illustrations. It is good advice which
tells us to make the curved incision in front of the knee,
when removing a bursa, with the curve up instead of
down, so as to keep the cicatrix out of the way when the
patient kneels later. The chapter upon di.seases of the
tendons and their sheaths is satisfactory and complete, but
there is no noteworthy departure from generally under-
stood and accepted principles. We do not think it neces-
sar)- to suture a ruptured quadriceps-femoris tendon with
silver wire, because it is not logical to depend on strength
of suture material to maintain apposition against a pull,
when we know that sutures which exert tension upon liv-
ing tissues will cut through. The authors have not had
satisfactory permanent results with nen-e stretching for
sciatica and allied conditions, and with this experience our
own coincides. The last part of this volume is devoted to
diseases of the blood-vessels, the treatment of aneurism of
cour.se receiving most attention. A short description of the
older methods, some non-operative, is followed by a very
comi)leIe discussion of the later procedures. The authors'
materials of preference for ligatures are thick chromicized
catgut and kangaroo tendon, these substances having the
advantage of slow absorbability. The illustrations in this
part of the book are clear and useful, and the index has
evidently been very carefully made. The introduction of
so much advertising matter at the end of the volume is
offensive to those who are fond of a well-made book.
Experiments on Animals. By Stephen Paget ; with an
Introduction by Lord Lister. ^London : T. Fisher
Unwin. New York : William Wood & Co. 1900.
There could not be a fairer or more convincing statement
of what animal e.xperimentation has done for the progress
of medicine than is to be found between the covers of this
May 26, 1900]
MEDICAL RECORD.
929
volume. Its appearance is opportune, and a United States
Senator who has been persistently advocating a certain ill-
advised and thoughtless bill should have a presentation
copy. The tirst part of the book is devoted to a description
of what the older investigators have accomplished for phys-
iology by experiments upon animals, and contifins much
of historical interest The main part of the book contains
an exceedingly accurate, interesting, and concise descrip-
tion of therestiltsof bacteriological and pathological inves-
tigation of the various infectious diseases, in which, of
course, experiments upon animals have figured largely.
We do not think that even the most confirmed "antivivisec-
tionist " could be so bigoted or wrong-headed as to read
the chapters upon diphtheria, or tetanus, or the plague,
among others, and still continue to deny the usefulness and
propriety of our use of animals in this connection. The
book is a timelj' one, and we have seldom seen a work on
a scientific subject so well written.
NoRDRACH AT HoME. By JosEPH J. S. LuCAS. Bristol ;
J. W. Arrowsmith.
This little sixt5--page brochure gives the hygienic open-air
or "sanitorium" treatment of consumption adapted to Eng-
lish home life. The simple directions, if followed, wovild
go far toward diminishing the spread of the disease while
contributing to the patient's comfort and cure.
Essentials of Physical Diagnosis op the Thorax. By
Arthur M. Corwin, A.M., M.D. Third edition, revised
and enlarged.
This work, though revised and enlarged, still remains a
book essentially adapted, to the use of the student, and as
such, without doubt, will continue to be appreciated. It
successively deals with : I. Topography and Landmarks of
the Chest : II. Methods of Physical Diagnosis ; III. Phys-
ical Signs in Diseases of the Chest ; IV.. Diseases of the
Pericardium, Heart, and Great Vessels. The various sub-
jects are, as far as practicable, presented in a tabulated
form, thereby increasing its value as a handy book of ref-
erence and a useful guide to the intelligent examination of
the thoracic cavity and its contents.
The Rise and Development of the Liquefactio.n of
Gases. By Willett L. Hardin, Ph.D., Harrison
Senior Fellow in Chemistry in the University of Pennsyl-
vania. New York ; The Macmillan Company. 1899.
The work is a very timely one, considering the general in-
terest which has recently been aroused by the liquefaction
of hydrogen. The worker in this field has found his litera-
ture rather scattered, and will welcome a book bringing to-
gether foreign investigations and discoveries, as well as
those with which he may be more familiar. This small
volume of two hundred and fifty pages gives a rather com-
plete account of methods now in use, while enough of the
theoretical aspects of liquefaction have been included to
enable the layman to grasp the subject intelligently. It
is the references to scientific works which make the book
most valuable to one already up in the general subject,
while the style is one which will appeal to the popular
reader. The work is illustrated with a number of draw-
ings.
Te.\t-Book of the Embryology of Invertedratks. By
Dr. E. Karschelt, Professor of Zoology and Compara-
tive Anatomy in the University of Marburg, and Dr.
K. Heider, Professor of Zoology in the University of
Berlin. Translated from the German by Matilua Ber-
nard. Revised and edited with additional notes by
Martin F. Woodward, Demonstrator of Zoology, Ro5'al
College of Science. Vol. II., 374 pages, and Vol. III.,
441 pages. London : Swan, Sonnenschein & Co. New
York; The Macmillan Company. iSgg.
These volumes follow the one translated by Professors
Mark and Woodworth, who were obliged to abandon the
work in favor of the pre.sent translator and editor. Vol. II.
deals with the embryology of phoronidea, bryozoa ecto-
procta, brachiopoda, entoprocta, Crustacea, and palseo-
straca ; Vol. III. is devoted to arachnida, pentastomidse,
pantopoda, tardigrada, onychophora, myriapoda, and in-
secta. Although a work of such scope and abounding in
such minute details would naturallj- appeal more strongly
to the special stvident, the general reader cannot fail to be
impressed with the amount of erudition displayed, as well
as by the clear and orderly arrangement of the subject-
matter. Each chapter is richly illustrated, and is followed
by an exhaustive bibliography. To those who are familiar
with the difficulties attending the translation of a German
book abounding in such ponderous scientific terms as a
work on comparative embryology, it must be evident that
the present volumes are singularly free from idioms and
obscure sentences. The English edition will be invaluable
to special students.
The Urine and Clinical Chemistry of the Gastric
Contents, the Co.mmo.n Poisons, and Milk. By J. W.
Holland, M.D. Forty-one illustrations. Sixth edition,
revised and enlarged.
In view of the fact that the above work has reached its
sixth edition but little need be said of its merits. Origin-
ally intended for the student, its present form is such as to
render it of value to the general practitioner as well. It is
divided into the following chapters ; I. Examination of the
Urine; II. Examination of the Gastric Contents ; III. Ex-
amination of Common Poisons ; IV. Study of Normal Milk,
and Milk Examination. For convenience the more impor-
tant matter is printed in large type. The text is clear and
concise, and the microscopical drawings are well repro-
duced.
Loveliness. By Elizabeth Stuart Phelps. Boston:
Houghton, Miffiin & Co. 1S99.
This is a charming tale which will, however, pervert none
of those who believe that vivisection in the hands of the
humane and scientific investigator has proved and ever will
prove an inestimable boon to mankind. The story tells how
Loveliness, the pet dog of a little invalid girl,' is stolen,
bringing the child to death's door. The dog is finally recov-
ered by her father in a somewhat dramatic fashion' at the
very moment it is about to suffer vivisection in the medical
college of which he himself is one of the professors. Carried
home in triumph, it is the means of restoring its young mis-
tress to health. Had the author in her task gone one step
further and actually depicted her canine hero suffering va-
rious tortures without the boon of an aesthetic, we would
have heartily concurred with her in condemning such an
act as one of unnecessary cruelty. Let us be mindful, how-
ever, that but for vivisection many branches of medical
science would to-day be but in an embry<mic state, and
countless lives be sacrificed through ignorance of the func-
tions governing that intricate and wonderful mechanism,
the human body.
A Text-Book of Embryology for Students of Medi-
cine.. By John Clement Heisler, M. D., Professor of
Anatomy in the Medico-Chirurgical College, Philadel-
jihia. With 190 illustrations, 26 of them in colors. Pp.
405. Philadelphia: W. B. Saunders. 1S99.
This volume is a worthy companion of the others in this
well-known series. The author has succeeded in present-
ing a subject which has always been the bete iivirc of med-
ical students in an unusually clear and interesting way,
though necessarily much condensed. The introductory
chapter deals with ovulation and fertilization. We note on
page 33 the surpassing statement that if the ovum "in-
stead of passing into the tube drops into the abdominal
cavity and is fertilized there, it undergoes partial or com-
plete development /;; situ ; this condition is known as
extra-uterine pregnancy or ectopic gestation. " Chapters
II. and HI., on segmentation of the ovum and the germ
layers, are followed by a chapter on the beginning differ-
entiation of the embryo. The two succeeding chapters, on
the foetal membranes and the decidute, are beautifully
illustrated by colored plates. Chapters VIII. to XVIII.,
inclusive, take up the development of the various systems
of the body, beginning with the connective tissues and
lymphatics, and concluding with the skeleton. A tabu-
lated chronology of developments is appended. The index
is unusually full and accurate. While a work which deals
largely with dry anatomical details does not admit of criti-
cism from a literary point of view, it maj- be said that the
author's style is lucid and pleasing. Each sentence is so
clearly expressed that there is no chance of misunderstand-
ing its meaning. The illustrations are excellent ; in fact,
the book is in every way worthy of commendation.
LTeber Gangran bei Diabetes Mellitus. Von Dr. Fritz
Grossman, in Berlin. 8vo, 134 pages. Berlin: August
Hirschwald. igoo.
In this excellent monograph the author considers the vari-
ous theories as to the cause of gangrene and trophic dis-
turbances in diabetes mellitus ; his conclusions are that
these are due either to arteriosclerosis (thrombo.sis) result-
ing from the abnormal products, such as acetone, lactic acid,
butyric and oxybutyric acids, which are present in the
blood of diabetics, or due to inflammatory processes in-
duced by bacteria whose virulence has been increased by
the hyperglycemia acting on tissues whose resistance has
been lessened \>y the diabetes mellitus. The author has
also fully discussed the relation of neive degeneration to
the arteriosclerosis and to the trophic disturbances and
gangrene ; he rightfully concludes that the nerve degen-
erations are not the cause of these pathological states, but
are in themselves only a manifestation of a diminished
nutrition of the nervous system, resulting from the arterio-
sclerosis. In the chapter on treatment the author advocates
the use of local anajsthesia when operating on diabetic
930
MEDICAL RECORD.
[May 26, 1900
patients, and also the employment of "digital" compres-
sion for temporary hecmostasis during an amputation. In
view of the frequent association of arteriosclerosis with
the gangrene he prefers to amputate at a high level. The
monograph contains a critical review of cases of diabetic
gangrene reported in literature, and also a report of the
author's experimental investigations concerning the action
of bacteria on diabetic tissues.
Letter-, Woud-, and Mind-Blindness. By J.ames Hin-
SHELWOOD, M.A., M. D., Surgeon to the Glasgow Eye In-
firmary. London : H. K. Lewis. 1900.
The f.ubject-matter here presented is largely made up of
papers published by the author in 7 he Lancet, and covers
a field which has hitherto had not very much attention in
English literature. There are five chapters. The First,
"Visual Memory," is strictly new. A case is given of par-
tial mind-blindness with dysle.xia — a peculiar form of word-
blindness. Word- without letter-blindness, and letter-
without word-blindness are also considered.
Leaders in Typhoid Fever. By E. B. Nash, M.D., au-
thor of "Leaders in Homoeopathic Therapeutics." Phil-
adelphia : Boericke & Tafel. 1900.
In this little monograph of one hundred and thirty-five
oages, are given, without the description, merely the leading
indications in treatment. The remedies are grouped accord-
ing to stages of the disease. The author believes that no
hemorrhage should occur under proper treatment ; he has
.seen but one case in fifteen years, since he has learned how
to use the remedies. He thinks hunting after something
better than the "superb homoeopathic therapeutics" for
typhoid is time wasted. The type is large, so that the
amount of reading matter is quite limited.
Healthy Exercise. By Robert H. Greene, M.D. New
York : Harper & Brothers. 1900.
This is an excellent little manual for the laity, setting
forth the necessity of exercise as a means of preserving
health. It is divided into three parts — the first dealing in
a general way with the theory of exercise and bathing, the
second discussing the choice of an exercise according to
the age and physical condition of the person, and the third
describing briefly the manner of carrying out' the dift'erent
forms of e.xercise. The description of the respiratory and
abdominal exercises in Part III. is supplemented by some
useful outline sketches. The book is full of sound advice,
and the general adoption of the author's suggestions would
go far to reduce the physician's income.
DrsE.vsES OF Women : A Treatise on the Principles and
Practise of Gvn.ecology. For Students and Practi-
tioners. By E. C. Dudley, A.M., M.D., Professor of
Gynaecology. Northwestern University Medical School ;
Gynaecologist to St. Luke's Hospital, Chicago, etc. Sec-
ond edition, revised and enlarged. With 453 illustra-
tions, of which 47 are in colors, and 8 full-page plates in
colors and monochrome. Pp. 719. Philadelphia and
New York ; Lea Brothers & Co.
The appearance of a second edition of this work within a
little over a year after the first is a proof both of the suc-
cessful reception it has met, and of the energy and pro-
gressive ness of the author. As we have already pointed
out the many e.xcellent features of the book, we need only
indicate the changes which have been made. Part VI.,
including four chapters, is new. It includes the disorders
of menstruation and sterility, which the author, though
properly regarding them as symptoms, has seen fit to con-
sider under separate headings — to the detriment of the
book in our opinion. The same grouping of subjects, "not
by the more common regional method, but so far as possi-
ble from the standpoint of pathological and etiological
sequence," is still maintained. Apropos of this we may
add that not a few practical teachers have not found it such
a decided advance on the old " regional method. " Certainly
there seems no sufficient reason for the close juxtaposition
of tumors, tubal pregnancy, and malformations in Part
III. We had rather hoped that the subject of inflamma-
tion of the uterus might have been retouched and rendered
a little less confusing. We are less pleased with the
author's handling of Part II. than with any other portion
of the book. Since he is an avowed exponent of the school
of gynecology represented by the Woman's Hospital, it
would be unfair to comment too severely on the unusual
amount of space devoted to plastic operations on the cervix,
as compared with others which would seem to the ordinary
reader to be equally if not more important. Dr. Dudley is
a loyal follower of Dr. Emmet, as well as a brilliant
alumnus of the institution which he adorns. A table of
illustrations is much to be desired, if for no other purpose
than to call attention to the numerous original drawings,
of which we would mention especially figures 412 to 416,
representing the various steps of the author's ingenious
operation for anteflexion. In dwelling upon a few minor
defects of this excellent work, we seek only to emphasize
the fact that, while original, it is not yet a perfect text-book
for the student. That it is a distinct addition to the litera-
ture ot gj-nsecology no one can deny. We heartily con-
gratulate Dr. Dudlej' on its continued popularity.
The Principles of Treatment and their Applic.\tion in
Practical Medicine. By J. Mitchell Bruce. M.A.,
M.D., F.R.C.P., Physician and Lecturer on the Princi-
ples and Practice of Medicine, Charing Cross Hospital ;
Consulting Physician to the Hospital "for Consumption,
Brompton ; Examiner in Medicine, University of Cam-
bridge. Adapted to the LTnited States Pharmacopoeia by
E. OuiN Thornton, M.D., Demonstrator of Therapeu-
tics, Pharmacy, and Materia Medica, Jefl:erson Medical
College, Philadelphia. Philadelphia and New York:
Lea Brothers '& Co. 1900.
There are two distinct parts to this work, which may be
called the theoretical and the practical. The first part
deals with tlie general indications for treatment, based
upon the etiology, pathology, and symptomatology of the
disease, and modified by the age and sex of the patient,
and also with the means and art of treatment. In the sec-
ond part the author furnishes special illustrations of the
principles of treatment, previously outlined, applied to dis-
eases of the circulatory, respiratory, and digestive sj'Stems
(the latter including the urinary), to a few cerebral affec-
tions, neuritis, and typhoid fever. The first part should be
read through and pondered especially by young physicians
just starting on their life work, with a good supply of
knowledge but a lack of ability to apply it; the second
part will serve as a work of reference and a gTiide, for older
practitioners as well as the }-oung, to the management of
any of the maladies here discussed. The work is one that
can be commended without reservation to young practi-
tioners especially, and it may also be read with interest
and profit by those of long and varied experience.
A System of Medicine, by Many Writers. Edited by
Thom.\s Clifford Allbutt, M.A., M.D.. LL.D., D.S.C.,
F.R.C.P., F.R.S . F.L.S., F.S.A., Regius Professor of
Physic in the University of Cambridge, Fellow of Gon-
ville and Caius College. Honorarj- Fellow Royal College
of Physicians of Ireland. Volume IX. New York; The
Macmillan Company. 1900.
This, the final volume of Allbutt' s excellent System, con
tains a presentation of mental diseases and the dermatoses,
together with the concluding portion of diseases of the
nervous system, and an appendix to malarial fever show-
ing the part plaj-ed by the mosquito in the spread of this
affection. There is also a general index to the entire
work, which will probably provoke to more profanity than
anything of the kind attempted in the past century. We
have repeatedly noted the confusion of volumes in this
work, the number of the volume on the book seldom agree-
ing with that on the title-page. The same confusion is
carried through the general index. This volume is called
ix., both on the back and on the title-page, yet all the ref-
erences in the general index to the articles in it are to
volume viii. — and so with the references to all the other
volumes. The inde.x is. furthermore, wretchedly incom-
plete. One's fault-finding must, however, cease with the
index, for the two treatises on diseases of the skin and
mental maladies are deserving of naught but praise. The
list of writers contains the names of nearly all the best
known dermatologists and alienists in Great Britain and
Ireland, and almost without exception they have handled
their subjects in a most acceptable manner. The supple-
mentary article on malaria is written by Dr. Patrick Man-
son.
A Case of Flat Condyloma of the Vocal Cords —
Domenico Tanturri Fu Vincenzo reports a case, a
study of which justifies the following conclusions:
Among the manifestations of syphilis of the larynx
maybe included Hat condyloma; this maybe the first
manifestation of the second stage. Its structure is the
same as that of condyloma of the mucous membrane
of the upper passages. The affection most likely to
obscure the diagnosis is primary laryngeal tubercu-
losis. Specific treatment is valuable in clearing the
diagnosis. The symptoms of the lesion are a con-
stant dysphonia, and sometimes a laryngeal stenosis.
The prognosis is good, these growths usually yielding
to antisyphilitic treatment. — Gioriiale Inteniazionale
delle Scienze Medic/ie. February 28 th.
May 26, 1900]
MEDICAL RECORD.
931
J>xivoicat J'UODCStions.
Perforating Typhoid Ulcer. — The incision should
be made on the right side, the ulcer inverted without
cutting away its edges, the abdomen flushed, and a
drain inserted. — J. E. Platt.
Cancer of the Rectum.— Do not operate radically
if the patient is very weak; if there are metastases; if
the mass is firmly anchored in the pelvis; if glandular
infection passes beyond the reach of the finger; and
if acute obstruction arises. — liocHENEGc;.
Adhesive Perigastritis of the pyloric region with
symptoms of ulcerative stenosis was successfully treated
by gastro-enterostomy. This is the rational method
in the vast majority of cases. — VVestph.\len and Pick,
Deutsche tueJ. Wochensch., No. 52, 1899.
Neuralgia. — Successful resection of the perineal
branch of the internal pudic nerve for severe urethro-
cystitis, is accomplished by cutting down upon the
internal pudic at its point of passage through the small
sacro-sciatic notch. — Rochet, Report of French Asso-
ciation of Urology.
Anthrax. — Make a ring of dough about the pustule
about 4 cm. deep, and fill the centre with lye made
from equal parts of wood ashes and lime; leave on
for four hours. The best results are obtained by early
and complete excision, but this is not always possible
to carry out. — Andreu y Pahi, Gaceta Aled. Cata-
lana.
Post-Puerperal Psoitis is to be thought of after
severe labor when fever is associated with marked pain
in the iliac fossa, especially on extending the leg, and
a tumor is made out. It must not be confounded with
renal affection, perinephritic phlegmon, abscess by
congestion, and especially appendicitis with abscess.
The best possible drainage is the proper treatment. —
Walter C. Wood.
Secondary Hemorrhage will be less likely to occur
if just before closing the abdomen the operator care-
fully inspects all ligatures and raw surfaces and takes
a final look at any portion of the omentum which has
been adherent or ligated. If the table be lowered to
the horizontal position and a clean sponge be intro-
duced into Douglas' pouch for a few minutes, the
stain noted after removal will be an index of the
amount of oozing. — M. A. Crockett, "Gynaecology."
Operation in Gastric Ulcer should be done (i) in
all cases of perforation at the very earliest possible
moment — also in subphrenic abscess; (2) in cases
of hemorrhage ia) when there is continual oozing of
blood, especially if the stomach be dilated, and {/') in
cases of repeated severe hemorrhage; (3) in cases in
which there is severe pain and vomiting unaffected by
treatment, and which is producing progressive emaci-
ation; (4) in case of dilatation of the stomach from
contraction within or from adhesions outside the stom-
ach. BiDWELL.
Operations for Ascites. — In the ascites of cirrhosis
the liver may be exposed by an abdominal incision
and the adjacent surfaces of the liver and diaphragm
scraped by means of the finger or a sponge. — Drum-
MOND.
A ligature may be passed through the edge of the
liver, the omentum, and the cut parietal peritoneum.
The omentum can be brought up between the liver and
diaphragm by tying the three sutures together. — Rol-
LESTON. ,
Suprapubic drainage is necessary when there is a
large amount of fluid present and when there has been
a rapid reaccumulation of fluid after tapping. — Swain,
Bristol Medico-Chinir'^ical Jotirnal, March.
Carbuncles are best treated by extirpation, which is
no more painful than incision. — RtJSHTON Parker.
Pylorectomy will give better results as time goes
on, especially if performed early when the patient's
strength is retained. — Richardson.
Stammering in a boy aged thirteen years was cured'
by temporary craniectomy for depression due to lack
of cranial development. — Jonnesco.
Before Operating' it sliould be discovered whether
the patient gives any history of malaria. This may
save anxiety when the temperature suddenly goes up
afterward.
Cancer of the Tongue — The danger of sepsis,
which is the chief cause of mortality after operation,
can be lessened by thoroughly cleansing the mouth
and teeth for several days before operation. — Chevne.
Chancroids should be washed twice a day for fifteen
minutes with a two-per-cent. creolin solution at a tem-
perature of 100° to 108' F. ; after drying they should
be dusted with salol and a bandage applied. — Grime-
perte.
Needles are best kept in a saturated solution o(
washing-soda. Lysol is good, but the color hides the
needles. Albolene is also a good medium, as is like-
wise absolute alcohol containing calcium chloride. —
Dawbarn.
Cyst of the Breast — There is little evidence that
general cystic disease of the breast degenerates into
cancer. The cysts which occasionally develop at the
menopause during the process of involution need not
be interfered with. — W. T. Bull.
Vaginal Antepartum Douches should be employed
only if there is any purulent or putrid discharge, such
as caused by gonorrhcea or cancer ; and if any opera-
tion is to be performed in which the hand or instru-
ments have to be introduced into the uterus. — Jar-
dine.
Laminectomy should not require more than half an
hour's time, diminishing shock. Sepsis is the only
danger. There should be a single median incision.
Operation^ should not be done till the shock of the
accident has passed, and not at all if the cord is
known to be completely crushed or divided. — J. C.
Munro.
Cancer of the Breast. — The disease is more fre-
quent in the upper and outer quadrant. Medullary
cancer is far more apt to recur than scirrhous.^WAR-
REN.
The pectoral fascia must invariably be removed, and
if the whole great pectoral is not taken away, at least
a superficial layer must be dissected off. — Chevne.
It seems impossible to doubt that in certain in-
stances oophorectomy causes the cancer to disappear.
It may be of value as a palliative operation. — Stan-
ley Boyd.
The supraclavicular region should almost invariably
be cleared out. — Halsted.
A mask should be worn by the operator to prevent
wound infection from the mouth and nose. — Ht;EBE-
NER.
Rubber gloves are the only effective kind for sur-
geons' use. The hands must be as carefully steril-
ized as though the gloves were not to be worn. — Lock-
ETT.
932
MEDICAL RECORD.
[May 26, 1900
Society ^Icports.
THE PRACTITIONERS' SOCIETY.
One Hiiudn'd and Fijty-fijth Regular Meeting, Held on
Friday, April 6, igoo.
A. Alexander Smith, M.D., President, in the
Chair.
Two Cases of Hypertrophy of the Spleen of Diffi-
cult Explanation. — These were presented by Dr.
Andrew H. Smith.
Case I. — ^Male, aged t\vent7-'sl:!rycars, was admitted
to the Presbyterian Hospital on November 28. 1899.
His family history was negative. When the patient
was eleven years old he had an attack of typhoid
fever. Ten years ago he had an irregular fever which
lasted for ten or twelve days; at that time he had no
chills, but he was greatly prostrated with nausea and
vomiting. He was treated at a hospital in Savannah,
Ga., and cured by the administration of quinine. He
had never had a similar attack since. Six years ago
he had an attack of rheumatism which lasted two
months; during this attack he suffered much from
palpitation of the heart and dyspncea. He was only a
moderate user of alcohol, and denied syphilis. About
a year ago the patient began to have a sense of op-
pression over the chest, with slight dyspncea on exer-
tion. He also had rheumatic pains in the joints.
These continued with more or less intensity for four
months. He also had some cough and several slight
ha;moptyses, and lost considerable strength but no
flesh. His appetite was poor ; the bowels were regular.
He paid a visit to his home in Sweden, and returned
to this country two months ago, slightly improved.
Examination showed a man of large frame, well nour-
ished but somewhat anasmic. The lungs were normal.
The heart's action was regular; the apex impulse was
in the fifth intercostal space, three and one-half inches
to the left of the median line. Over the third right
space was heard a faint systolic and a louder diastolic
murmur, the latter being transmitted up and down the
sternum and heard loudest over the third right space
at the sternal margin. The pulmonary second sound
was somewhat accentuated. The liver was percussed
from the fifth space to the free margin of the ribs; its
edge could not be felt. The spleen was enormously en-
larged, being percussed as low as the umbilicus; its
surface was distinctly felt, but its edge could not be
made out. The pulse was soft and regular. The
urine was negative. An examination of (lie blood on
December 5th showed sixty-five per cent, of haemoglo-
bin; red cells, 4,396,000; leucocytes, 7,000; there
was marked relative lymphocytosis. On December
6th a blood culture was made with negative results.
Case II. — J. H , male, aged twenty-five years;
a native of the United States; a cook by occupation.
He was admitted to the Presbyterian Hospital on
October 17, 1899. His mother had died of cancer of
the breast; the other members of his family were alive
and well. There was no history of leukemia. The
patient stated that he had always had a sallow, yel-
lowish color, and had never been very robust. As a
boy, while living on the Delaware River, he had re-
peated attacks of chills and fever, recurring every
summer until he was seventeen years of age, when he
went to sea ; this was eight years ago. Fourteen
years ago he first knew of any trouble with his spleen.
At that time he had an attack of intestinal obstruction,
and was very ill for two weeks, recovering without
operation. For some time after that his abdomen
was increased in size, but gradually it resumed its
normal dimensions. Two years later he had typhoid
fever and was ill for two months. Three years after
that he had a second attack of typhoid fever, which
was treated at the German Hospital in this city. The
following year he had an attack of what was pro-
nounced to be '■ typho-malarial fever." Six years
ago, while in Australia, he had scurvy; at that time
his teeth became so loose that he could easily have
pulled them out. He recovered, however, but some
months later an ulcer formed on his leg which failed
to heal until his return to America, three years ago;
recently this ulcer broke out again. Four years ago
he had pneumonia at Bellevue Hospital. During the
past five or six years, whenever the patient visited his
home on the Delaware River he had repeated attacks
of chills and fever, the last one about a year ago.
The patient denies venereal disease. He had at times
used alcohol to e.xcess, but drinks infrequently. He
had never had any vomiting to speak of, nor hemor-
rhages from the mucous membranes; he had never no-
ticed any glandular enlargements. Examination showed
the impulse of the apex of the heart to be in the fourth
space, two and one-half inches from the median line.
The heart's action was regular. There was a blowing
systolic murmur, heard at the apex and upward along
the left sternal margin to the pulmonic area. There
was also a loud systolic murmur heard over the aortic
area. The area of cardiac dulness was apparently not
increased. The lungs were normal. The liver was
percussed from the fifth space to an inch and one-half
below the free margin, where its edge was felt. It
was tender to the touch. The spleen was very much
enlarged, extending about an inch to the right of the
umbilicus, and three inches below that point it was
distinctly felt. Its surface was smooth, hard, and not
tender. The organ was so large that it could be
grasped between the two hands. The abdomen was
prominent over the splenic region; otherwise it was
normal. While the patient was in the hospital he had
an attack of acute pleurisy, without effusion, from
which he made an uneventful recovery. A blood
count, made on October 24th, showed 3,056,000 red
cells and 17,000 leucocytes, with thirty-eight per cent,
of haemoglobin. The blood was carefully examined
for malarial organisms, but none was found. The
urine was negative throughout. On February 14,
1900, the patient was readmitted to the hospital for
an attack of lobar pneumonia. Three days later an
examination of his iDlood showed 4,120,000 red cells,
17,000 leucocytes, and forty-five per cent, of haemo-
globin. He made an uneventful recovery from his
pneumonia.
In both of the preceding cases. Dr. Smith said, the
point to which he desired to direct particular attention
was the enormous chronic enlargement of the spleen,
to which no adequate cause could be assigned.
Dr. George L. Peabody said that in the second
case shown by Dr. Smith the enlarged spleen was
probably attributable to chronic malarial infection, of
which disease the patient gave a history dating back
many years. He also gave a history of having had three
attacks of typhoid fever, and it was possible that one or
more of these were really malaria instead of typhoid.
Dr. E. G. Janewav said he thought the second pa-
tient siiown by Dr. Smith could be put down as one of
the old-fashioned ague cases. In the first case he did
not care to venture a positive opinion as to the cause
of the enlarged spleen. There was possibly some ob-
struction to the portal circulation, without dropsy.
The possibility of a cirrhosis of tiie liver, with ir-
regular manifestations, should always be borne
in mind, and further developments awaited. The
speaker said he had frequently seen cases of supposed
pseudo-leukasmia at Bellevue Hospital turn out to be
cases of cirrhosis of the liver, in spite of the fact that
the patients absolutely denied an alcoholic habit.
May 26, 1900]
MEDICAL RECORD.
933
Dr. Beverley Robinson expressed the opinion that
the use of the microscope could not be relied upon in
the diagnosis of chronic malaria, nor, in many in-
stances, could the usual anti-malarial remedies be
depended upon.
A Case of Heart Disease with Some Unusual
Features This case was presented by Dr. J. W.
Brannan. a. J , a colored boy, aged sixteen
years, was admitted to Bellevue Hospital on March
21, igoo. His father died of pneumonia; his mother
was alive and well. His sister and grandmother had
suffered from rheumatism. According to the statement
made by the boy's aunt, he had been a healthy baby,
but at the age of five years he had had an attack of
acute articular rheumatism, and again two years later.
In both of these attacks his heart was affected, and
since his second attack he had always suffered more
or less from dyspnoea, with cardiac pain and palpita-
tion. Five years ago he had an attack of dizziness
and fell to the floor, but did not lose consciousness.
He was put to bed and remained there for five weeks.
His present illness began about March ist. He had
a severe cough, with muco-purulent expectoration and
pains in the chest. No blood was raised. His ankles
and knees became swollen, painful, and tender, and
he was unable to walk. His dyspnoea at times be-
came so severe that he could not breathe comfortably
in the recumbent position. No ascites was found.
On examination the heart apex was difficult to locate.
Its impulse was made out with the greatest distinct-
ness in the fifth space in the nipple line, two and
three-quarter inches from the mid-line of the sternum.
It varied in force. The impulse at the base was
stronger than at the apex. Over the whole precor-
dium there was a systolic thrill, with its maximum in-
tensity in the second left intercostal space. Over this
same area was also heard a loud, long, rough systolic
murmur, with its maximum intensity in the second
left space, close to the sternum. The murmur was
heard with great distinctness over the entire chest in
front and behind, most distinctly on the left side.
The heart's action was rapid and irregular. The sec-
ond aortic sound was absent and the second pulmonic
accentuated. The left border of the heart was three
inches outside the median line; its upper border was
at the third rib; the right border was three-quarters
of an inch to the right of the edge of the sternum.
Examination on April ist showed the apex impulse
to be fairly well localized in the fifth space, two and
three-quarter inches from the median line. The
heart's action was more regular and the dyspnoea had
disappeared. The murmur was heard as at the first
examination, with its maximum intensity in the second
space to the left of the sternum. There were marked
pulsation coincident with the murmur and thrills in
the second and third left spaces. The murmur was
heard loudest posteriorly higher up than usual, about
the level of the spine of the scapula. It was also ap-
parently transmitted into the great vessels of the neck
and axilla. The patient had been up and about the
ward during the past few days doing light work. Dr.
Brannan said he was in doubt as to the nature of the
cardiac lesion in this case. The possibility of a pul-
monary lesion had been considered, but in the ab-
sence of any signs of venous congestion and the fact
that the patient had not been a "blue baby," that
diagnosis was rather doubtful. On the other hand, it
was the right side of the heart that was mostly en-
larged. The aortic second sound was lost, or at all
events was very indistinct. The pulmonary second
sound was markedly accentuated. There was nothing
abnormal in the sphygmographic tracings. They
certainly did not indicate stenosis of the aortic orifice.
There was no change in the murmur when the patient
was in a recumbent position, nor when the lung was
inflated and fixed or held in the position of complete
expiration. The possibility of aneurism of the de-
scending portion of the arch of the aorta and pressing
upon the pulmonary artery had been suggested. The
similarity of the sphygmographic tracings in the two
radials was opposed to this diagnosis.
Dr. Peabody said the case presented by Dr. Bran-
nan was certainly an unusual one. The murmur was
a very loud one, with its point of maximum intensity
over the pulmonary area. The fact should be borne
in mind that the loudness of a murmur was not always
an indication of its seriousness. Dr. Peabody said
he was inclined to think that the murmur in this case
was a mitral one. The absence of certain symptoms
which one would expect to find in a pulmonary cardiac
lesion should be taken into consideration in making
the diagnosis.
Dr. Janeway said that a case of this kind would
require repeated examinations before a definite opin-
ion as to the nature of the cardiac lesion could be ar-
rived at. The right ventricle did not appear to be
particularly enlarged. Mitral stenosis, in rare in-
stances, gave rise to some of the phenomena observed
in this case, or possibly its unusual features were due
to some anatomical abnormality. The speaker said
that some years ago he saw a boy who had a loud
heart murmur which was abnormally situated. At
the autopsy it was found that the aorta sprang from
the right ventricle and the pulmonary artery from the
left. He said he did not think the case shown by Dr.
Brannan was one of mitral insufficiency, because the
murmur was so loud above and less distinct in the
area where it was usually heard when the mitral
valves were insufficient.
Dr. Andrew H. Smith said he agreed with Dr.
Janeway that Dr. Brannan's case required more pro-
longed study before an explanation of its unusual
phenomena could be given. The speaker said he was
struck by the fact that the murmur could be heard
very distinctly posteriorly and along the dorsal spine.
He was inclined to believe that the case was one of
mitral regurgitation, and that the thrill and the un-
usual location of the sounds were the result of some
abnormality existing in the auricle by which the back-
ward current from the ventricle was made to form an
eddy.
Dr. Robinson said that, in considering a case of
this kind, the symptoms and general condition of the
patient should be borne in mind. The diagnosis
probably lay between mitral stenosis and mitral
regurgitation, as it was highly improbable that a
pulmonary lesion was the cause of the murmur. That
the location of the bruit would not always enable us
to distinguish positively between a mitral stenosis and
regurgitation was proven by the late Dr. J. West
Roosevelt in a paper on this subject which was based
upon the post-mortem records at Roosevelt Hospital.
In obscure cases like the one shown by Dr. Brannan,
repeated examinations might perhaps enable us to
make out the cause of the trouble, but our diagnosis
could only be verified on the post-mortem table.
A Case of Bullet-Wound of the Brain.— This case
was presented by Dr. Robert Abbe. The patient
was a man forty years old, who was shot in the head
sixteen years ago. The missile, which was a small
rifle bullet, entered the forehead near the hair-line an
inch to the left of the centre, and became embedded
in the brain. The bullet gave rise to no trouble until
four years ago, when the man had an epileptic convul-
sion which was repeated in six months and gradually
came more frequently. Now it recurred every two
weeks. An ;i-ray picture was taken, which located
the bullet in the brain, about one-third the distance
between the frontal and occipital bones, and about
an inch and one-quarter below the vertex. Dr. Abbe
934
MEDICAL RECORD.
[May 26, 1900
said he intended to operate on this patient, as the con-
vulsions were possibly due to pressure from an indu-
rated scar or to the presence of bony spicules. The
bullet was a small one and probably could be re-
moved.
Dr. Charles L. Dana said he had seen a number
of cases like the one shown by Dr. Abbe, and in one
instance he had had an opportunity to examine the
brain after death. It was not particularly rare to
have epilepsy develop some years after the receipt of
an injury of the brain. In the case which the speaker
had in mind the patient developed generalized epilep-
tic attacks and subsequently died of alcoholism. The
brain showed a certain amount of cortical cellular
degeneration, such as was seen in degenerative epi-
lepsy. This cellular degeneration was usually at the
bottom of the epilepsy, and it continued whether
operation was done or not. In the case shown by Dr.
Abbe the convulsions set in so long after the acci-
dent that an operation could hardly be expected to do
much good. At the same time, it could be done with
comparative safety.
Dr. Janeway said the man admitted having had
syphilis twenty years ago.
Dr. H. M. Biggs said that some time ago he per-
formed an autopsy on a man who had committed sui-
cide. In addition to the bullet which had caused his
death, an old, encysted bullet was found in the frontal
lobe of the brain, and it was afterward learned from
the man's relatives that he had made an attempt at
suicide by shooting himself in the head ten years be-
fore. The bullet had apparently remained embedded
there for ten years without giving rise to any symp-
toms.
Dr. Abbe said that if any improvement would re-
sult from the operation in the case he had shown, he
thought it would be due more to the removal of scar
tissue, cortical adhesions, or cyst, or, probably, of
osteophytes, than from the removal of the bullet itself.
The speaker recited cases of severe epilepsy which he
had relieved for varying periods by the release of ad-
hesions.
Remarks on Some of the Conditions Simulating
Appendicitis and Peri-Appendicular Inflammation.
— This paper was read by Dr. E. G. Janeway (see
p. 897).
Dr. Robert F. Weir said that surgeons were well
aware of the difficulties occasionally encountered in
the diagnosis of appendicitis. Many of the rarer
conditions simulating this disease could be recog-
nized only after much study and observation, and not
infrequently an exploratory incision was necessary in
order to clear up the diagnosis. Probably three of
the most common conditions which were mistaken for
appendicitis were those associated with a displaced
kidney, or with perforation of the gall bladder, or with
perforation of the stomach or duodenum. The speaker
said he had recently collected fifty-one cases of duo-
denal perforation, three-fourths of which had been
regarded as cases of appendicitis and operated on as
such.
Dr. Joseph D. Bryant said that a mistaken diag-
nosis of appendicitis was probably often due to the
fact that the anatomical relationship of the appendix
toother contiguous organs was an uncertain one: it
was not always found in one particular region. Hence,
any derangement of that appendage might easily be
confounded with a diseased condition of the ovary, or
kidney, or gall bladder, and viic veisa. The speaker
recalled the case of a man who suffered from neural-
gia, associated with symptoms of gastric and intes-
tinal trouble due to the excessive use of alcohol;
his neuralgic pain simulated appendicitis, and he
was twice operated on under the supposition that he was
suffering from that disease, and subsequently he was
refused operation at two hospitals where he applied for
relief from the same trouble. Dr. Bryant said that an-
other case which came under his observation was that of
a girl aged seventeen years, with an hysterical tendency,
who complained of excessive pain in the region of the
appendix. There was a slight increase of temperature
and a small tumor could be made out. An operation
cured her, but it also revealed the fact that she had no
appendix at all, the usual site of the appendix being
occupied by a small elevation, scarcely half an inch in
height. He said he had seen cases of perforation of
the stomach and duodenum which were regarded as
examples of appendicitis. In one instance of the
former there was a perforation, and the escape into
the peritoneal cavity of gastric contents had set up an
extensive circumscribed peritonitis, which after much
suffering gave rise to the formation of an abscess
pointing to the left of the median line and just above
the umbilicus, when the patient came to his attentioi .
A free incision at that point permitted the discharge
of the collection and established a diagnosis through
the presence of gastric juice a few hours later. This
patient made a prompt and complete recovery. A
perforation at the posterior surface of the duodenum,
complicating a pronounced and long-extended alco-
holic debauch, was mistaken for an attack of acute ap-
pendicitis with perforation, in an instance coming
beneath his observation. Another source of error in
the diagnosis of pathological conditions in the appen-
dicular region lay in confounding the fibrous exudation
of chronic appendicitis with malignant disease of the
cascum. Such a case was recently reported at the
New York Surgical Society. A similar one not long
since came under the speaker's observation. The
patient was supposed to have appendicitis. The sur-
geon upon opening the abdomen found a large mass
which he then regarded as inoperable sarcoma of the
cfficum, whereupon he abandoned the operation and
closed the wound. Subsequently the patient came
under the speaker's care, who found a large, compact
tumor composed of fibrous exudate, from the centre of
which the appendix was removed and submitted to Dr.
Dunham for microscopical examination. The walls of
the appendix were greatly thickened from chronic in-
flammation. No evidence of perforation or ulceration
was noted. After removal of the appendix, the exu-
dation was rapidly and completely absorbed, and the
patient had remained entirely well since the operation.
Another case, presumptively of the same character, had
lately come to his attention. There was slight eleva-
tion of temperature, attended with the presence of a
large fibrinous deposit involving the cascum, and other
manifestations indicative of chronic fibrous appendi-
citis. The abdomen was opened and revealed peri-
toneal surfaces which were perfectly smooth, present-
ing no evidence of any inflammatory action except at
one point about the size of a head of a pin, to which
omentum was adherent; also numerous enlarged mes-
enteric glands were found. The new formation was
extensive and fixed to the deep underlying bony tis-
sues. It was highly vascular, presenting other physi-
cal characteristics of inoperable sarcoma, which the
tumor was considered to be, and the wound was closed.
Subsequently the growth began to diminish in size and
finally disappeared entirely. Not infrequently in the
current medical literature of the day apparently simi-
lar examples were noted, for which excision of the cae-
cum was practised, when possibly the removal of the
appendix might have sufficed.
Dr. Walter B. James said he had often been im-
pressed with the fact that although in the majority of
cases of appendicitis the diagnosis was easy, yet in
a certain number of cases the true state of affairs re-
mained in doubt in spite of the most careful observa-
tion. In some instances an absolute diagnosis was
May 26, 1900]
MEDICAL RECORD.
935
impossible. Such an example recently came under
his observation. The patient was a physician, the
house surgeon in one of the hospitals in this city, who
developed an agonizing pain in the right iliac region.
He had a sharp chill, followed by a rising tempera-
ture, and in the course of a few hours there was in-
tense tenderness over the lower abdomen. The symp-
toms were typical of a ruptured gangrenous appendix,
with the rapid effusion of serum into the lower peri-
toneal cavity. He was operated on four or five hours
later; the appendix was found to be inflamed, but
there were no evidences of peritonitis, no rupture, and
no fluid in the peritoneal cavity.
Dr. William T. Bull said that he could recall
quite a number of instances in which a wrong diagnosis
of appendicitis had been made by both physician and
surgeon — cases of right-sided pleurisy and pneumonia
and inflammations of the gall bladder. In order to
avoid such errors, one or two factors should be borne
in mind. In arriving at a diagnosis of appendicitis,
considerable weight should be attached to the presence
of an actual inflammatory exudate in the appendical
region. If this could not be detected, and there was
simply local tenderness in the iliac region, with some
fever, Dr. Bull said he was rather disposed to wait.
In certain doubtful cases, the use of an ancesthetic was
of the greatest service, both to the physician and to the
surgeon, in order to overcome the muscular rigidity
which often existed. In more than one instance this had
helped him to clear up the diagnosis. With reference
to chronic cases of appendicitis, Dr. Bull said he had
no doubt that many errors had been made. Still, the
fact should be borne in mind that in operating for
chronic appendicitis an appendix might be removed
which was apparently perfectly healthy, and which still
might have been the seat of disease. Many such at-
tacks cleared up and left a fairly normal appendix;
yet its removal might be desirable on account of the
repeated attacks which it had given rise to. The rec-
ognition of chronic appendicitis by palpation. Dr.
Bull said, seemed to him a rather uncertain procedure,
in spite of the fact that some surgeons had made the
assertion that they could feel such an appendix dis-
tinctly. The speaker said he had often found that
what he supposed to be the thickened appendix
proved, upon operation, to be the edge of the psoas
muscle, or a thickened mesentery or wall of the colon.
The diagnosis of chronic appendicitis by palpation
had been strongly insisted upon by some rather per-
sistent writers on this subject, and one writer had
found the condition very frequently associated with
floating kidney. Dr. Bull said he had good reason to
believe that in many of these cases the diagnosis
rested upon a false bottom. He had seen a number
of cases in which small neoplasms of the ileocascal
region were confused with appendicitis; such were
very difficult to recognize. This was also true of
cases in which peritonitis had already set in. It
might be due to a perforating appendicitis, or to a
perforation of the stomach, duodenum, or gall bladder,
and an exploratory incision was necessary to reveal
its starting-point.
Dr. Peabody said he did not think that cases of
abdominal neuralgia, to which reference had been
made, were often confused with appendicitis. The
intermittence of the symptoms in neuralgia was far
more marked than in cases of appendicitis; besides,
the thermometer would help clear up the diagnosis.
Dr. Peabody said he had seen a number of cases of
typhoid fever which had been operated on for sup-
posed appendicitis. In those cases, the wound inter-
fered materially with the hydrotherapeutic treatment
of the fever. In one case, the speaker said, he mis-
took a ruptured gall bladder, with tenderness, pain,
and fever, for appendicitis. An operation revealed the
true state of affairs. In any case of supposed acute
appendicitis, in which an exudate or some foreign
mass could be felt, we were not likely to go far astray
by advising an exploratory operation.
Dr. Robinson said he had seen a certain number
of cases of supposed appendicitis, both in children
and adults, with localized pain in the appendical re-
gion, with a certain amount of fever, and perhaps more
or less resistance in that region, in which the patients
recovered without operative interference, and the true
nature of the lesion was therefore left in doubt. On
the other hand, there were undoubted cases of appen-
dicitis which resulted in recovery without operation,
and the general practitioner was often placed in a very
uncertain state of mind as to whether the gravity of
the case demanded the aid of a surgeon or not.
Dr. Abbe said that his most troublesome cases of
doubtful appendicitis had been in women, in whom
the question of ovarian or tubal trouble became a fac-
tor. In a number of such cases in which he had oper-
ated, he found that the inflamed appendix had attached
itself to the pelvic organs, and thus helped to confuse
the diagnosis. He said he had very rarely been able
to palpate the appendix- in cases of chronic appendi-
citis. What he regarded as the appendix had usually
proved to be the border of the external oblique mus-
cle. Although the gross appearance of the appendix
in cases of chronic latent appendicitis might be fairly
normal, its interior would almost invariably be found
to be diseased. This, the speaker said, he had proved
by distending and hardening hundreds of such speci-
mens in alcohol, and then, upon section, the diseased
condition of the interior could be plainly made out
(see Medical Record, July 10, 1897). After a very
severe, or even a fairly severe, attack of appendicitis,
the lumen of the tube might become entirely obliter-
ated by the hypertrophy of the mucosa, and adhesion
of its inflamed and denuded lining. No future attacks
would occur. This explained the occasional sponta-
neous cures after one severe attack. It was so rare to
have this occur, however, that much stress should not
be laid upon it.
Dr. Peabody said that on one occasion, at a meet-
ing of this society, during a discussion of this subject,
the late Dr. ■ • related at length the history of a very
severe attack of what was probably appendicitis — al-
though it occurred long before that name was given to
the disease — which he passed through while a student
at Harvard twenty years previously. After his death
Dr. Peabody made an autopsy and failed to find any
trace of the appendix, not even a fibrous cord. It had
probably been destroyed by the inflammatory process
years before.
Dr. Biggs said that one was impressed very much
by the frequency with which evidence of disease in
the appendix was met with at autopsy. Sometimes
very extensive changes in the appendix were observed
in cases in which the patient had given no history of
ever having had trouble in that region.
Dr. a. H. Smith said he recently saw a patient
with right-sided pneumonia, who complained of a
great deal of pain and tenderness in the region of the
appendix, although his trouble was clearly confined to
the lungs. He also recalled a similar case which he
saw some years ago. That patient complained of pain
in the right side of the abdomen, and gave a history
of having eaten a heavy, indigestible meal and after-
ward exposed himself to the cold: all the symptoms
pointed to the abdomen as the seat of the trouble, but
shortly afterward he developed a right-sided pneumo-
nia which proved fatal. It was a recognized fact. Dr.
Smith said,' that the pain of pneumonia might be re-
ferred to a region distant from the seat of the trouble.
Dr. Weir said he wished to corroborate the state-
ments made by Drs. Bull and Abbe with reference to
936
MEDICAL RECORD.
[May 26, 1900
the unreliability of palpating the appendix in cases of
chronic appendicitis. When the appendix was en-
larged it could at times be felt, but an appendix of the
ordinary size could not always be palpated satisfac-
torily; at least that had been his experience.
Dr. Bryant said he wished to add his evidence to
the confirmation of the statement just made by Dr.
Weir. The speaker said that in probably one-half
the cases in which he had been called upon to operate
he had been unable to locate the appendix correctly,
as proved by the operation. In many cases in which
he thought he had located the organ, it proved to be
something else that he had felt; in one case it was the
psoas muscle.
Dr. F. p. Kinnicutt expressed the belief that often-
times in these cases the induration which was palpaWe,
and which was regarded as an inflammatory exudate,
was in reality the resistance due to the rigidity of the
muscles. The speaker said he entirely agreed with
the previous speakers regarding the unreliability of
palpating the appendix in cases of chronic appendi-
citis. The case reported by Dr. James was supposed
to be one of chronic appendicitis, the patient having
had six or seven attacks during the past two years: in
spite of this, frequent examinations made during this
period failed to elicit any positive signs of an enlarged
appendix. Operation demonstrated the existence of a
chronic appendicitis.
Dr. Janeway, in closing, said it had not been his
intention, in his paper, to speak of all the conditions
which might be or which had been mistaken for ap-
pendicitis. He mainly wished to emphasize the fact
that the diagnosis of appendicitis was often jumped
at too quickly, and too much import placed upon the
pain, tenderness, and muscular rigidity. He said he
agreed with the previous speakers that, as a rule, the
appendix was not palpable with certainty in chronic
appendicitis.
Ulcdicat Items.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended May 19,
1900 :
-United States.
Cases. Deaths.
Alabama, Mobile May 5th to 12th 2
Indiana, Evansville May 5th to 12th 2
Kansas, Wichita May 5th to 12th 4
Kentucky, Covington May slh to 12th 2
Louisiana, New Orleans May 5th to 12th 57
Maine, Portland May 5th to 12th i
Massachusetts, Chicopec — May 5th to 12th
Michigan, Detroit May 5th to 12th 2
Nebraska. Omaha May 5th to 12th 6
Ohio, Cleveland May sth to 12th 19
Pennsylvania, Pittsburg May 5th to 12th 2
South Carolina, Greenville. .May 5th to 12th 3
Utah, Salt Lake City May 5th to 12th 2
Washington, Tacoma April 28th to May 5th i
Wyoming, Sweet Water Co.. May 4th 6
Uintah Co May 4th 4
Smallpox— Foreign.
.April 22d to 28th 16
.April 22d to 28th I
.April ist to 30th 8
.April 28th to May 12th 3
3.Nlay 4th to nth 5
. March 24th to April 7th 6
April 22d to 28th 9
.April 22d to 28th 6
.April j8th to May 5th 5
.April 14th to 21st
.April 22d to 29th T
.April 22d to 28th 8
.April roth to 17th
.March 25th
.April 8th to 15th 12
.March 22d to April 7th
.April 14th to 2ist
.March 24th to 11st 134
.April 28th to May 5th
.April 1st to 2Qth 57
April 28th to May 5th
.April 13d to 28th
Austria, Prague
Belgium. Antwerp...,
Canada, Manitoba
Winnipeg
Quebec.Bonaventi
China, Hong Kong...
England, Liverpool..
Southarapto
France. Lyons
Gibraltar
Greece, Athens
India, Bombay
Calcutta
Ku trachea
Italy, Rome
Russia, Moscow April 7th to 21st
Odessa April 22d to 28th
St. Petersburg.' April 14th to 21st
Warsaw April 14th to 21st
Scotland, Glasgow April 22d to 28th
Spain, Valencia April 22d to 28th
Yellow Fever.
Cuba, Havana May 7th
Mexico, Vera Cruz April 28th to May 5th . .
Cases. Deaths.
abia, Oman
dia. Bombay April loth to 17th. .
Calcutta March i8th to 24th
Plague.
h loth Present.
Egypt, Alexandria May 9th
India, Bombay April lolh to 17th
Calcutta. March i8th to 24th.
Kurrachee April 8th to 15th
Japan, Formosa, Tamsui . . . March 24th to 31st
Osaka April 13th
New Caledonia, Noumea . . . December 17th to April 4th 123
Reported.
480
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RADICAL CURE OF EPITHELIAL CANCER
BY ARSENIC.
BV C. TkUXECEK, M.D.,
PRAGUE, AUSTRIA.
Arsenious acid is one of tlie oldest remedies used in
the treatment of epitlielial cancer. This fact alone
would not justify the conclusion that it is a specific
in this disease, for nearly the whole materia medica
has been used at various times, and often with appar-
ent success, in its treatment. But considering the ease
with which certain kinds of cancer are cured by ar-
senic, it is almost certain that some cases of epitiie-
lioma have been cured by arsenious acid. As it is
not within the scope of this article to enter into the
history of this department of medicine and surgery, it
will suffice to say that arsenic has been repeatedly rec-
ommended for this special disease. Various have been
the reasons why it has failed of universal adoption,
and has fallen into disuse. In some cases the diagno-
sis of cancer cured by arsenical treatment was not
convincing, and in other cases there was a prejudice
against the treatment, more or less justified by its
many failures. A third reason appears to consist in
the fact that the different varieties of epithelial cancer
have not been sufficiently taken into account. For
although the arsenical preparations, such as the paste
made by the Brothers Come, contained many useless
substances and altogether too much arsenic, still they
did cure some varieties of cancer. They also de-
stroyed normal tissue, a disadvantage which they
shared with all methods.
Within the past ten years experiments have again
been made with arsenic as a remedy against cancer.
Lassar claims a rapid cure in several cases of cancer-
ous ulcers by the internal administration of Fowler's
solution, but they were merely small ulcers which had
never been operated upon. Since in other analogous
cases this method was a total failure, it cannot be said
to have greatly enriched our knowledge of the thera-
peutics of cancer. A real step in advance, however,
was made by Hue, who injected an aqueous solution
of arsenic into the midst of the cancerous masses (0.20
gm. arsenious acid, 100 gm. distilled water [gr. iiil to
^•3 '''§])• His method, however, has not become
widely known, partly because he brought forward no
proof of its value, and partly because it is of such
difficult application. Von Esmarch used arsenious
acid in the treatment of cancer some time before the
authors mentioned above, and according to Momburg'
he used a mi.xture of 0.25 gm. (gr. iv-t), 0.25 gm. mor-
phine, 2 gm. (gr. .XXX.) calomel, 12 gm. ( 3 iii.) gum
arable; the result is not given. The treatment of
Felix* consists in the application of a paste, one-half
zinc chloride, the other half mostly of indifferent sub-
stances, but containing arsenic. This method is a
combination of ancient arsenical treatment and of
treatment by simple caustics, that is to say, chemical
* " Des caustiques dans le traitement du cancer." Brussels,
1S92, Maiiceaux. publisher.
agents capable of destroying any part of the body,
whether normal or diseased. It scarcely deserves
mention, since the same effects are more rapidly and
easily attained by operation, but the author claims
that in his experience relapses do not occur.
With the exception of the above-mentioned rare
modes of treatment, which never became general, ar-
senic fell into absolute disuse as a remedy against
cancer. It was, however, given internally to improve
the general condition of patients suffering from can-
cer. The experiments of Billroth and von Esmarch
in this line are well known, yet these authorities state
that they have never seen a single case of cancer cured
by arsenic.
In 1897, together with m.y collaborator. Dr. 8.
Cerny, I published a work'^ in which I tried to show
that under certain conditions arsenious acid gives a
constant reaction with cancerous tissue, and that by
its aid we may radically cure some varieties of epithe-
lioma. Since that time the method has been tried in
several clinics and hospitals, and with good success
to judge by the reports published.'' *
I will first give a detailed description of the method
itself, and then the indications, and, after having de-
scribed two typical cases in which a cure was obtained,
will briefiy describe the mechanism of the cure of can-
cer by means of arsenious acid.
I.
"S, Acid, arsenics, pulver i gm. (gr. .w. )
Alcohol, ethyl, absol. ,
Aq. destillat aa 75 gm. ( 3 ii. 3 ivss.)
M. S. tor external use.
The remedy as prescribed in the works quoted above
is a mixture of arsenious acid (As.OJ and of 75 gm.
of ethylic alcohol (C„H,,0) with an equal amount of
distilled water. It is applied as follows: The ulcer
is cleansed and dried; we must not be afraid of caus-
ing a slight How of blood; indeed, it may even be
necessary to scrape and denude a portion of the neo-
plastic tissue. The arsenical mixture is then stirred
and spread with a brush over the whole surface of the
tumor. Without covering it, it is left to dry, and if
at the end of five minutes the patient feels no pain,
another layer of the mixture may be spread over the
cancer. No dressing is placed upon it.
The patient sometimes has pain after the applica-
tion, but not of an unbearable nature. The next day,
or perhaps not until the day after that, the neoplasm
will be found to be covered with an eschar (especially
in the denuded or scraped portions), which is not re-
moved, but treated daily with the preparation of ar-
senic. Acute oedema of surrounding parts may be
caused by the application, in which case the treatment
is suspended until the ctdema has completely disap-
peared, after which the remedy is used in lessened
amount. The crust, thin and yellowish at first, be-
comes gradually brow-n, and finally black. The first
day its base is firmly adherent to the subjacent tissue,
and its removal would bring away a large amount of
cancer substance. By degrees it thickens and invades
the whole surface of the neoplasm. After a while its
edges become less adherent and begin to be detached;
the fissure thus formed becomes daily more marked, and
938
MEDICAL RECORD.
[June 2, 1900
a greenish f.uid oozes out from the edges of the ulcer.
Treatment is continued regularly until the eschar is
freely movable, non-adherent to the subjacent tissue,
and is easily removed, or falls of itself. This eschar
is of variable thickness, is hard in consistency, and is
essentially formed of cancerous tissue which has mor-
tified under the influence of arsenic. The scab being
removed, another application of the arsenical mixture
is made to the bottom of the ulcer, but only once. If by
the ne.xt day I find merely a yellowish crust which can
be easily removed without causing any hemorrhage, I
may be sure that no cancerous tissue remains in the
wound. If, on the other hand, there is a dark crust
adherent to the subjacent tissue, the treatment is con-
tinued until the last cancerous cell has disappeared.
During the course of the treatment, as the eschar
thickens, the amount of arsenic should be increased.
Instead of the i : 150 solution used in the beginning,
a 1:100 or even a 1:80 is used, according to this
formula:
1^ Acid, arsenics, pulver i gm. (gr. xv.)
Alcohol, rethyl. abs.,
Aq. destill aa 40 gm. ( 3 i. 3 ii,V)
M. S. For external use.
When no vestige of cancerous tissue remains, the
neoplastic ulcer is transformed into a granulating
wound, covered with a fine whitish membrane, and
possessing no induration anywhere. It should now
be treated as an ordinary suppurating surface which
is beginning to be covered with granulations. For
the stimulation of the regenerating tissues an oint-
ment consisting of one part boric acid to ten parts
vaseline should be applied, especially to the edges of
the wound. Even when every vestige of cancer seems
to have disappeared, it is well to make assurance
doubly sure by occasionally making a light applica-
tion of the 1:150 mixture until a cure is attained.
When the neoplasm has been entirely destroyed, the
applications no longer produce a black, adherent crust,
and the alcohol contained in the remedy merely helps
to cleanse the wound.
For superficial, non-ulcerating cancers, in which
mere surface applications give no result because the
remedy does not destroy normal epithelial and epi-
dermal cells, we should proceed as follows: if the
integument is very thin and adherent to the tumor, it
will usually be all-sufficient to scarify slightly the ad-
herent portion, and to apply the remedy in such a way
that some of the arsenic will penetrate to the cancer-
ous tissue. If the skin has not yet been invaded by
the neoplasm, it will be found best to excise a small
cutaneous flap with the scissors, and then to make an
application of the remedy, leaving it as usual without
dressing. The applications are repeated daily, and
after three or four of them we see the tumor diminish
in size and become dried. Treatment is continued up
to complete cicatrization. The same method of pro-
cedure is indicated in the case of the cancerous nod-
ules sometimes found under the adjacent skin during
treatment or subsequent to the cure of a neoplastic
ulcer.
Instead of using a brush, we may, if we prefer, fix
a pledget of wadding on forceps, or wrap cotton around
a probe, as I did in an undoubted case of cancer of the
larynx, in which cure was obtained and has been
maintained for two years. However, although the use
of hair brushes is not in strict accordance with the
laws of modern surgery and of asepsis, it must be ac-
knowledged that a brush distributes the solution more
regularly than anything else and possesses the advan-
tage of not irritating the granulating tissue.
II.
The curability of cancer by the above-described
method depends in part upon the stage of develop-
ment of the neoplasm, and in part upon its location.
In regard to the first, a necessary condition is that the
ganglia be not indurated; in regard to the second, the
tumor must be where it can be reached by the medic-
ament. This can be done in the case of all non-relaps-
ing cancers of the skin, no matter what their extent;
cancers of the external auditory meatus, of the lips
and the buccal mucous membrane wherever it can be
reached, and cancerous lesions of the larynx in an
early stage.
In order to specify more exactly the indications for
this treatment we will compare the results which it
has given with those given by operation.
With the exception of incurable cancers, such as
those of the pancreas for instance, we may from a
therapeutic point of view divide malignant neoplasms
into three groups: The first, and by far the largest,
those in which an operation constitutes the only
method of relieving the patient, although in truth a
permanent cure is the exception rather than the rule
(for instance, cancers of the stomach, and all cancer-
ous lesions accompanied by infiltrations of the gan-
glia) ; the second, those in which the method described
above is the only one applicable,' as, for example,
large cancers of the skin whose extirpation would
leave an enormous wound, some neoplastic lesions of
the head where a bloody operation would necessitate
too extensive impairment and might even risk the pa-
tient's life; finally the third, those in which either
method might be used with probable success, and in
which the choice may be left to the patient or to the
physician. This last group is worthy of a closer
study.
In cases in which either procedure is capable of
giving good results, and in which we are certain that
there is no induration of the ganglia, the method un-
der discussion seems preferable for the following rea-
sons: during the course of treatment we can always
ascertain whether any cancerous tissue remains in the
wound, a thing which is almost impossible during sur-
gical intervention, owing to the fact that the operative
field is hidden by the flow of blood; again, auto-inoc-
ulation, which is of easy occurrence during operation,
cannot take place when we apply the arsenical mix-
ture, and finally, the latter does not destroy neighbor-
ing healthy tissues, whereas operative intervention al-
ways does to some extent. This method should be
used, whenever possible, in the treatment of cancer of
the face, especially of the eyelids, nose, ears, lips, in
which surgical measures, even when successful, usu-
ally cause frightful deformity. I must not be un-
derstood as saying that it is not indicated for other
parts of the body, for the prognosis does not seem to
be less favorable than in regard to lesions of the lower
lip. The great advantage of this procedure, as I have
already said, consists in the fact that it destroys every
vestige of cancerous tissue without injury to normal
tissues. Moreover, in no case have I ever been obliged
to apply a ligature, for the cancer was always elimi-
nated without loss of blood, although several of the
patients before treatment had had hemorrhages that
were diflicult to arrest. This is certainly an impor-
tant advantage.
Cancers of the nipple can be successfully treated by
arsenic, and the cure, according to my experience, is
permanent. The same may be said for some cases of
cancer of the mammary gland, but at present I am
unable to give exact statistics. As to neoplasms of
the internal organs and of all those accompanied by
induration of the ganglia, they are best treated by surgi-
cal measures. The same statement applies to relapsed
cancers, which I have often succeeded in curing,
as we shall see later in the report of a case, yet in
regard to which I have not had a sufficient number of
cases to establish absolute conclusions.
June 2, 1900]
MEDICAL RECORD.
939
As to the action of arsenious acid upon tiie organ-
ism, it has been «//, even when the lesion was situated
in the mouth, and when treatment extended over sev-
eral months. It may therefore be used in all cases
and for as long a time as necessary, without fear of
arsenical intoxication. All investigators have recog-
nized this advantage possessed by this treatment.
From, what has been said, it is evident that the pro-
cedure is especially indicated in the treatment of
cancer in its early stages. The therapeutic value of
the method may appear to be somewhat limited, but
I would call attention to the fact that every cancer
has an early stage, and that uncertain diagnosis, and,
more frequently still, fear of operation, are what usu-
ally aggravate the lesion and cause it to become invet-
erate. With the possession of a harmless method of
treatment, it is to be hoped that cancers with indurated
ganglia (that might have been cured in the early
stages) will become rare exceptions. Taken in the
beginning, a cancer is amenable to treatment by ar-
senic, and when we find an ulcer we need no longer
resort to expectant treatment, as was the case when an
operation was the only treatment possible to recom-
mend. This is one reason why the argument that a
radical cure can be more quickly obtained by opera-
tion falls to the ground. This would be an incontest-
able fact if the physician was able to make a positive
diagnosis at once, or if the patient was willing to submit
immediately to an operation. But very frequently even
surgeons advise patients having a small ulcer on the
lower lip, for instance, to wait awhile, and should the
ulcer not heal after some simple antiseptic treatment
to have it removed. But by the proper application of
our remedy we are enabled to ascertain at once whether
vv-e have to do with cancer or not, and in the time usu-
ally devoted to expectant treatment, before operation
is resolved on, we have cured the cancer by arsenic.
If, on the other hand, we are dealing simply with a
non-cancerous ulcer, no characteristic eschar is formed,
and the ulcer heals of itself.
This method is the only one possible in patients
suffering from diabetes, haemophilia, etc., in whom even
a slight operation might cause dangerous or even fatal
hemorrhage.
As to the duration of treatment, it would appear
that the greater the ulceration the more rapidly the
remedy acts. Moreover, in cases in which the cancer-
ous tissue has the characteristics of embryonal tissue,
its action is more prompt than in cancroids, in which
the cells are corneous. This is the reason why the
remedy sometimes acts very slowly upon the superfi-
cial layers of a tumor, but when the first eschar, com-
posed of horny cells, has been detached, acts more
quickly upon the layers formed of young cells. Small
cancerous ulcers which have not been operated upon
require three or four weeks for a complete cure, while
extensive cancers take much longer; but the physician
as a rule does not need to see the patient more than
twice or even once a week. On the other days the
patient himself applies the solution, and goes on with
the daily routine of life as usual. The cure of can-
cers situated in parts of the body where subcutane-
ously there is a hard base is much easier, for bone
and cartilage are so resistant to the invasion of can-
cerous granulations that the process extends superfi-
cially rather than deeply, which permits of thorough
applications of the remedy, even in inveterate cases.
In some cases no opinion can be given as to the prob-
able duration of treatment, unless we can tell the
depth to which the neoplasm penetrates, for the deeper
it goes the more difficult the treatment, and the longer
will it last.
This method is, moreover, of value in cases in which
the patient absolutely refuses operation, in spite of the
fact that it would undoubtedly effect a cure; examples
of this condition are described by Hermet and Cou-
raux, in which non-operative treatment, no matter what
its duration, was preferred to surgical measures.
III.
Having described the method of application of the
medicament, and the indications for its use, I will,
to make the treatment more comprehensible, give
the history of two cases in which it effected a cure.
The first case was one of relatively benign cancer of
the face, which had never been operated upon; the
second, one of cancer of the lower lip, which had re-
turned after a radical operation, and in which the can-
cerous masses were found deeply situated in the lip,
having either penetrated it in the form of bundles and,
finding little resistance in the soft tissues, having
grown there with rapidity, or begun there after auto-
inoculation in the depths of the wound, following
operation.
The patient, a woman seventy-seven years old, had
never been seriously ill, and had never had syphilis.
Until the present illness she had never observed any
abnormality in the part of the face where the cancer
is situated. Eleven years ago a small pimple appeared
on the cheek and increased progressively until it had
reached the dimensions seen in Fig. i, from a photo-
graph taken before treatment. Microscopical examina-
tion showed cancroid.
On March 6, 1898, I began treatment. I cleansed
the ulcer with boric acid, freshened a small portion, ap-
plied the mixture i : 150, and left it without dressing.
The next day a black crust appeared on the scraped
portion, and was painted over with the mixture
daily. After the third application cedema of the
neighboring parts obliged me to suspend treatment for
two days. Ten days later moderate pressure on the
crust forced out a purulent fluid from the edges, a sign
that it was beginning to be detached; on the fouith
day thereafter detachment was complete. In the
wound, which was treated every other day with the
940
MEDICAL RECORD.
[June 2, 1900
1:150 solution, another eschar formed ^nd was de-
tached in three weeks, leaving only the debris of can-
cerous tissue. These having been destroyed by ar-
was made, and in addition the right submaxillary gan-
glia were removed. A year ago a new excrescence
formed, the growth of which was more rapid than the
first, and which gradually invaded the whole middle
third of the lip. In this condition he came under my
care the i8th of December, 1898. In the inside of the
lip were indurations connected with the tumor. The
lymphatic ganglia were not indurated. Microscopi-
cal examination showed carcinoma simplex (not can-
croid).
On December i8th I began treatment. The tumor
was nowhere ulcerated, and I had to freshen it, which
I did, removing a small portion of the epithelium with
the forceps. The day after the arsenic was applied,
the characteristic eschar was formed, and I removed
a portion of it to use in the microscopical examina-
tions which I describe below. Under daily treatments
the eschar grew to such an extent that on one side it
overlapped the tumor. This phenomenon frequently
occurs, especiallv in cancers in which there is much
stroma, and physicians who have not had much expe-
rience in this method are easily deceived by it and
think that the tumor has increased in size under the
influence of the treatment. This is seen in a work pub-
lished from the clinic cf Prof. Bruns,"^ of Tiibingen.
After the spontaneous detachment of the eschar, which
occurred after eight days of treatment, there was found
a dark red tissue, which upon contact w ith the air be-
came black; the following day it had the aspect of the
characteristic eschar, and under daily treatment with
the i:So solution grew to the extent shown in the
photograph (Fig. 4). It was firmly adherent by its
base to the subjacent tissues, and five weeks later it
began to become detached. It was only three weeks
after this, however, that it could be removed, and even
then not entirely, a small, pimple-shaped, adherent
senic, the wound was treated as an ordinary granulat-
ing surface, but treatment in general was prolonged
because of my finding three nodules in the vicinity of
the lesion. I pierced these with a pincette a hameaux,
and applied tlie mixture. After three treatments they
were dried and transformed into an eschar which
heale.d in the usual way.
The treatment lasted more than three months, partly
because toward the last I saw the patient only once a
week. As we can see by the photograph of the patient
taken after treatment, it is impossible even to tell
where the cancer was situated. The result of a suc-
cessful bloody operation would not have been so good,
for there would have remained a deformity of tiie nose.
The patient is cured, and no change has occurred in
the cicatrized portion of the face. It is eighteen
months since the treatment ended.
Similar cancers in other parts of the body where
bone or cartilage form a hard base are more easily
cured, and the prognosis is good even in moderate
cases. We must always ascertain whether there is
any induration in the vicinity of the ulcer, and more-
over the granulating wound itself should often be
treated with the arsenic so that not the smallest cancer-
ous tissue may remain within it. European medical
literature" "■ contains many reports of cancers cured by
this method, and there is a consensus of opinion that
it is the best form of treatment for cancer of the face.
The second case is that of a man aged forty-nine
years, who has never been ill, and has never had syph-
ilis; until the beginning of the present trouble he
never noticed anything abnormal on his lower lip.
Three years ago a fissure on the lip was followed by
a small excrescence, which kept increasing in size; to
get rid of it he had it removed in the Bohemian surgi-
cal clinic of Prof. Mayde in Prague. Judging from
the cicatrix, which is still visible, a cuneiform excision
portion having to be left /// situ. Antiseptic treat-
ment of the wound and arsenic applications to the
debris of the eschar succeeded in five days more in
June 2, 1900]
MEDICAL RECORD.
94T
completely loosening the eschar, and cicatrization was
perfect on March 20, 1899. As we can see in the
illustration (Fig. 5) the cure is more complete than
agent is the arsenious acid, which constitutes the es-
sential element of the remedy. The presence of alco-
hol is not absolutely necessary, for I have cured a case
of cancroid by a simple mixture of water and arseni-
ous acid. The pain following the application was
less than when the alcoholic mixture was used. In the
case of encephaloid (medullary) cancer, alcohol plays
an important part by determining dehydration of the
neoplastic tissues, and it would therefore be a mistake
to leave it out.
The first symptom after application of the remedy
is the flow of a liquid so irritating to the surrounding
parts that if it is very abundant these will have to be
protected by means of borated vaseline. In the en-
cephaloid forms this flow may last for several days,
and when it stops reddish or purplish spots appear on
the surface treated: when they come in contact with
the air, they are changed to a black crust. For the
arsenic to act it appears to be necessary that the can-
cerous tissue should lose some of its water. The wa-
ter remaining in the mortified tissue simply evaporates
as from dead matter in which arsenic prevents putre-
faction, and a true mummification is the result. A
microscopical examination of the crusts which have
separated of themselves shows merely a necrosis of
cancerous cells; we see a granular mass in the midst
of which may still be distinguished infiltration and
thrombosis of the vessels, with hemorrhages; we also
see in the midst of this debris nuclei similar to those
of cancer cells.
For a better study of the processes I cut out small
fragments of crusts which had formed as the result of
several applications of the remedy, and which had not
yet become detached. The preparations, of which I
present drawings, are from a fragment of the cancer
of tlie lower lip which I have described in detail — a
would have been the case after a bloody operation, for
although a third of the lip was affected both superfi-
cially and deeply, scarcely a trace remains.
In cases like this it is of the greatest importance to
leave the eschar in place until it is entirely detached;
even when it is of large size, only the free portions
must be removed, and while this is being done, care
must be taken not to pull or tear the parts adherent to
the crust, for if the crust is pulled off forcibly, por-
tions of the cancer usually remain in the depths of the
wound and grow there, it being especially difficult to
apply the treatment to them. Those beginning to use
this treatment would best commence with cases of the
first class, in which a slight mistake would not be dan-
gerous to the patient.
In the medical literature of the subject I have been
able to find only two cases of cancer of the lower lip
cured by this method. The first, in which the cure
has been maintained for more than a year, was seen in
the surgical clinic of Professor F^slar of the faculty of
Montpellier,"' and the second in the surgical clinic
of Toulouse.'"" I would add that for relief of the pain
which is occasionally caused by the application of the
remedy, some have recommended the addition of or-
thoform to the original prescription,'''' while others
combine the treatment with the internal administra-
tion of Fowler's solution of arsenic."' This I do only
in cases in which the cancer is situated in some part
of the body where arsenic might be absorbed, and I
administer it for a few days before beginning treat-
ment. Bv this means the organism gradually becomes
accustomed to arsenic, and its absorption later will
not injure the patient.
IV.
The mechanism of the cure of cancer by the above-
described method remains to be explained. The chief
Fig. 5.
fragment removed after the first arsenical application;
and from a crust produced by four applications in an-
other case of cancer of the lower lip which I cured fif-
94'
MEDICAL RECORD.
[June 2, 1900
teen months ago, and in which there has been no
relapse.
The preparation made from the crust caused by one
application of arsenic upon the cancer previously de-
^^■?*^->,':
surfaces. But in no case have I been able to cause
the formation of the characteristic adherent crust, even
when the mixture contained ten times the amount of
arsenic, and was made with absolute alcohol. Violent
inflammation of the
II-
/
#
^
M
^iSSC^
&'
Fig. 6.— Section of Scab, afte
four applications of arsenic on epithelioma of the I
pushing through the scab.
npha
scribed, will be seen to be torn. This is due partly
to a mechanical cause, partly to lesions of the cancer-
ous stroma, especially its increase in size. The cells
have the appearance of being in hyaline degeneration.
They are increased in size, their outlines are pale,
and the nuclei present no visible alteration. There
are, moreover, lacuna between the cells of the stroma,
near which is found a small-cell infiltration and even
hemorrhages infiltrating the cancerous tissue. These
cells, and more especially their nuclei, have under-
gone no change.
An examination of the crust from cancer of the
lower lip, produced by four applications of the rem-
edy, shows that this crust consists of a lamella covered
with a thin layer of lymphatic exudate, and that it is
composed exclusively of cancer cells possessing the
same characteristics as those in an actively develop-
ing neoplasm. These cells show no sign of degenera-
tion; their nuclei appear to be normal, and stain as
usual. In one portion of the preparation the crust is
torn by the lymphatic infiltrate. In the interior
part of the crust the cells are either isolated or
disposed in rows, but always interrupted by lacunae
filled with the lymphatic infiltrate and a few red
corpuscles. Here the cancer cells show various
degrees of necrosis. As a rule the nucleus becomes
paler, swells, and finally disappears, so that we find
here and there a mass of cells with well-marked
outlines but without nuclei. Farther along outlines
of the cells have also disappeared, and there re-
mains merely a granular mass formed not only of
cancerous tissue but of the exudate and blood as
well.
It was not possible to ascertain when the arsenic
had becoine fixed in the tissues, because there is
no characteristic arsenic reaction that can be seen
under the microscope: with our ordinary chemical
methods the red blood cells give nearly the same
reaction as arsenic.
From all these microscopical examinations we
find that the cancer cells are directly mortified by
the arsenic without the production of any visible
phenomenon, while the action upon the stroma
causes degeneration of its cells and a small-celled
infiltration in its vicinity. Gaston and Haury, who
have especially studied this question, state that the
more abundant the infiltration, the better the action of
the remedy and the more prompt the cure.
In order to understand the mechanism of the action
of arsenious acid, I have made a number of experi-
ments, applying the remedy to various wounds, to epi-
thelium of the mouth and nose, and to suppurating
tissues has fol-
lowed, but not the
black, adherent es-
char. This is in
harmony with t h e
results obtained by
■ Einz, who has never
yet succeeded i n
.,.; causing a combina-
»"■' tion of albumin with
arsenious acid.
Such also has been
my experience with
albumin, or rather
with the protoplasm
of normal cells,
ratiun whether of epithelial
or connective tissue.
As to cancer, everything leads us to believe that arsenic
enters into combination with some substance contained
in the protoplasm. At least, in all cases in which the
application of arsenic caused an inflammation of normal
tissues, the same application caused in cancer the for-
mation of a black and adherent crust. Moreover, this
crust cannot be removed from the rest of the cancerous
tissue without causing a wound and abundant hemor-
rhage, while it separates of itself from normal tissue
without hemorrhage. The formation of crusts always
ceases after a certain time, no matter whether the ap-
plications are continued or not. Finally, the applica-
tion to the surface of the arsenic which is contained
in the remedy as a powder determines mortification of
the cancerous tissue, even to the depth of 2 to 3 cm.
(0.8 to 1.2 inches), which proves that arsenious acid
penetrates into the cancerous tissue probably in the
form of a soluble combination. If repeated applica-
tions are made to one special portion of an ulcer, the
mortification of the whole cancer follows; as was
Vl*s
/,.
'^
^^^-
Fig. 7. -Section of the internal portion of the same scab.
shown in the description of treatment of cancer of the
lower lip, given above. But on account of the ab-
sence of direct proof, the theory that arsenic enters
into combination with one or several substances of
the cancerous protoplasm remains an hypothesis await-
ing confirmation.
To conclude, the mechanism of the cure of cancer
June 2, I goo]
MEDICAL RECORD.
943
by the application of the hydro-alcoholic mixture of
arsenious acid may be explained as follows:
1. The cancer cells are first of all dehydrated by
the alcohol, and then their protoplasm coagulates in
the presence of arsenic.
2. The cells of cancerous connective tissue — can-
cerous stroma — degenerate, and provoke a serous exu-
dation, which in its turn determines alterations in the
cells mummified by the arsenic.
3. In the surrounding healthy tissues a circumscribed
inflammation is set up by the remedy, which always
goes on to suppuration, and by means of which the
neoplasm is first cut off" from the circulation, and is
finally eliminated from the organism as a foreign
body.
lilliLIOGRArHY.
1. Aus der chirurgischen Klinik der Universitat Kiel : Die
Radicalheilung des Epitlieliall;rehses nacVi Ceiny-Trunecel:.
Therapie der Gegenwart, April, 1809.
2. S. Cerny, C. Trunefek : Radikalni lefene rakaviny Rozni.
Prague; 1S97. In Svo. Otto, publisher (en Tcheque).
3. Cerny-TruneCek : Guerison radicale du cancer epithelial.
Semaine medicale, iSgy, pp. 161-4; and same journal, 1S99,
pp. 97-100.
4. C. Trune!5ek : Radicalheilung des Epithelialkrebses mit
Arsenik. Rheinisch-therapeutische Wochenschrift, 1900, Nos. i
and 2.
5. Besnier : Rapport sur le prix Barbier. Bulletin de I'Aca-
demie de Medecine de Paris, October 31, iSgS.
6. Cicatrisation d'un epithelioma ulcere de la face, par la
me'thode de Cerny-Trunefek. Semaine medicale, iSgS, No. 14.
7. Application de la methode de Cerny-TruneSek a la gue-
rison de r epithelioma de la face. Bulletin de la Societe fran-
(jaise de dermatologie, June, iSgS, p. 267.
S. Hermet : Cicatrisation d'un epithelioma ulcere de la
face par la methode de Cerny-TruneCek. Semaine medicale,
1S9S, No. 14, p. no.
g. Courteau.-v : Application de la methode de Cerny-Trunefek
k la guerison de I'epithclioma de la face. Bulletin de la Societe
de dermatologie de Paris, June, iSgS, p. 267.
10. Voron : Epithelioma de la face guerit par I'acide arse'-
nieu.K. Lyon medical, iSgS, No. 22, pp. 163, 164.
11. Monserret : Cancroide de la face traite avec succes par
des applications d'acide arsenieux. Nouveau Montpellier medi-
cal, April 9, 1S9S.
12. Finatelle ; Traitement des ulcerations cancereuses par des
badigeonnage d'acide arsenieux. Loire medicale, .June, iSg8,
No. 6.
13. Piasesky : Tratamentul cancerulin epitelial prin metoda
Cerny-Trune&k (enRoumain). Revista de chirurgie, .August,
1S9S, Bucarest.
14. Ginestous (de la clinique ophthalmologique de la faculte
de Bordeaux) : De la valeur du traitement du cancer par I'acide
arsenieux en solution hydroalcoolique (methode de Cerny-
TruneCek). Gazette medicale de Bordeaux, August 21 and 28,
i8g3. Compte rendu dans le Bulletin medical, September 4,
i8g8.
15. Ducci : Due casi di carcinoma epiteliale guariti col tratta-
mento Cerny-Trunefek (in Italian). Pitigliano, 189S. In Svo.
Osvaldo Paggi, publisher.
16. Doiry : Cancer epithelial et methode de Cerny-Trunecek.
Echo medical du Nord, i8g8. No. 48, pp. 5S4, 5S5.
17. Costinin : Traitement des tumeurs malignes du nez, etc.,
par I'acide arsenieux (methode Cerny-Trunefek). Revue hebdo-
niadaire de rhinologie, etc., 189S, p. 38.
iS. Gaston et Flaury : Epithelioma de la face gueri par la
methode de Cerny- Truneiiek. Semaine medicale, iSgS, No. 57,
p. 462.
19. Cosma : Un travail roumain sur 8 cas gueris ; compte
rendu fran9ais. Traitement du cancer epithelial suivant la
methode de CernyTrunei!ek ; Archives orientales de medecine
et de chirurgie, Paris, March, iSgg.
20. Pascal ; Contribution a I'etude du traitement du cancer
par la methode de Cerny-Trune&k. These de la faculte de
medecine de Montpellier, i8g8.
21. Steuermann : Reflecti asupra un nou tratament al canceru-
liu epithelial. These de la faculte de medecine de Tassy (Rou-
manie) ; compte rendu franfais dans les Archives orientales de
medecine et de chirurgie, Paris, February, 1899.
22. Robillard : La methode de Cerny-Trunei!ek ; ses resultats
et ses indications. These de la faculte de medecine de Paris,
1S99; Svo. Jouve and Boyer, publishers. Report in Gazette
hebdomadaire de medecine et de chirurgie, September 3, 1899.
Concours medical de Paris, September 30, 1S99.
23. Honsell : Ueber die Behandlung des Krebses nach Cerny-
TruneJek. Beitrage zur klin. Chirurgie, 1S9S.
24. Veanbreau : Epithelioma de la levre inferieure traite et
gueri par le procede de Cerny-Trunefek, Presse medicale de
Paris, October 10, 1898, No. 75.
25. Boue : Traitement des epitheliomas de la peau par la
methode Cerny-Trune&k. These de la faculte de medecine de
Toulouse, 1899. Cite d'apres la these Robillard de Paris.
26. Ginestous : L'arsenic et I'orthoforme dans le t'raitement
du cancer epithelial. Gazette medicale de Bordeaux, iSgS, No.
15. pp. 174, I75.
27. Panyrek : Lecene shoubrych nadorfl. Lekarske roshledy,
October, 1S9S (en Tcheque).
CYSTIC
TUMORS OF THE
EPIDIDYMIS.'
TESTIS AND
By JAMES B. BULLITT, M.D.,
Cysts of this character are usually spoken of as en-
cysted hydroceles; but the above classification is be-
lieved to be more correct and therefore preferable.
Before coming to the subject proper of this paper it
will be useful to review briefly the various forms of
hydrocele with the help of the accompanying diagrams.
It will be borne in mind that the testis at an early
period of fcetal life is placed at the back part of the
abdominal ca.vity behind the peritoneum, in front of
and a little below the kidney. Its descent into the
scrotum takes place gradually during the progress of
/
^
fcetal growth through the agency of the gubernaculum
testis, reaching the scrotum in ordinary development
by the eighth month. The pouch of peritoneum ex-
tending from the peritoneum proper into the bottom
of the scrotum is termed the processus vaginalis; this
is blind at its lower extremity, open and continuous
at its upper extremity with the parietal peritoneum of
the abdominal cavity. The testicle finally comes to
occupy a position at the lower and back part of the
scrotum, the epididymis being placed to its outer side
and the vas deferens to the inner side. It will be
borne in mind that the testicle is not completely in-
vested by the peritoneal coat of the processus vagina-
lis, but that it lies really outside of the peritoneal
prolongation, and is only partially invested by it, just
as the kidney lies behind the peritoneum and is only
partially covered by it. Just before birth the upper
part of the pouch, the processus vaginalis, usually be-
comes closed, and this obliteration extends ordinarily
from the site of the internal ring to within a short dis-
tance of the testis. The peritoneal process surround-
ing' the testis is in this way entirely cut off from tht
general peritoneal cavity and is termed the tunica
vaginalis.
The ordinary form of hydrocele consists in the dis-
tention with serous fluid of this space enclosed by the
tunica vaginalis, and represented by Fig. 2. It is
contended by some authors that it is incorrect to
speak of the cavity of the tunica vaginalis, or of the
pleural cavity, or of the peritoneal cavity, as these
' Read before the Falls City Medical Society, Louisville, Ky. ,
in March, iqOQ
944
MEDICAL RECORD.
[June 2, 1900
cavities do not exist, the serous surfaces normally
lying in contact. Such contention, however, seems
somewhat hypercritical; certainly for purposes of
^
convenience it is desirable to speak of all three as
cavities. We know that a rubber bag with a capacity
of four quarts has its walls lying against each other in
apposition when empty, and it might be just as fairly
contended that it would be improper to speak of the
cavity of a four-quart rubber bag.
In Fig. 4, the cavity of the tunica vaginalis is seen
in its normal relation to the testis and epididymis, its
serous lining membrane being indicated by the single
light line. Throughout these diagrams the single
light line will indicate the tunica vaginalis on the one
hand and the abdominal parietal peritoneum on the
other. We observe, therefore, that the ordinary hy-
drocele is a simple distention of the cavity of the tunica
vaginalis with serous fluid.
Fig. I represents the congenital variety of hydrocele.
The cavity of the tunica vaginalis is again distended
with serous fluid, but it connects with the general ab-
dominal cavity through failure to close of the funicular
process, which is that portion of the processus vagi-
nalis lying between the testicle and the internal ab-
dominal ring. This communicating opening is here
represented as very wide, but in reality it is usually
very small, from the size of a goose-quill to a straw.
The infantile variety of hydrocele is represented by
Fig. 3. It will be observed that the cavity of the
tunica vaginalis is distended with fluid and connects
with the open funicular process, the latter being closed
The funicular process is closed at its lower end toward
the testis, but remains open above in communication
with the abdominal cavity. This condition is termed
by some authors congenital hydrocele of the cord, or
congenital funicular hydrocele, and is the form which
not infrequently accompanies undescended testicle.
Fig. 5 represents the rare form of hydrocele known
as bilocular. It will be observed that there is a sec-
ond cavity communicating by means of a small open-
ing with the cavity of the tunica vaginalis, and that
both of these cavities are lined with the serous mem-
brane characteristic of the tunica vaginalis. This
second cavity may occupy the position of the funicu-
lar hydrocele. In still rarer instances the bilocular
form of hydrocele may be intra-abdominal; in such
event the second arm maybe either intra-peritoneal or
extra-peritoneal.
Fig. 7 shows the first of these varieties. The tunica
vaginalis and funicular process are distended and con-
nect through the internal abdominal ring with the in-
tra-abdominal arm. The peritoneum covers this pouch
in the same way that it is carried ahead of and covers
an advancing inguinal hernia, so that if an incision
were made above Poupart's ligament into this pouch
ofiE at its upper end from the abdominal cavity. This
closure generally is at the external abdominal ring,
although it may be at the internal abdominal ring, or
between these two.
Fig. 4 represents the converse of this condition.
two layers of peritoneum would have to be divided
before the pouch could be reached.
Fig. 6 represents the intra-abdominal and extra-
peritoneal variety. The advancing arm of the hydro-
cele has pushed the peritoneum before it and bears
about the same relation to it as the urinary bladder
does.
This brings us to the consideration of the subject
proper of this paper, namely, encysted hydrocele, or,
more properly, cystic tumors of the testis and epidid-
ymis.
Encysted hydrocele of the cord will occupy us only
for a moment. Fig. 8 represents an encysted hydro-
cele of the cord due to the distention with fluid of an
unobliterated portion of the funicular process. It will
be observed that it is lined with the same serous coat
which lines the tunica vaginalis.
Fig. 9 represents another variety of encysted funicu-
lar hydrocele which has had its origin in another way,
either as the result of the extravasation of blood into
the cellular tissue of the cord after a strain, the re-
sulting fluid afterward becoming encysted and its
coloring matter absorbed ; or it is possible for a funic-
ular hydrocele situated low down to have its origin
by the distention of a tubule of the organ of Giraldes,
of which we will have occasion to speak further along.
The cystic tumors having their origin in or near the
epididymis are of much greater frequency, and hence
much more importance, than the cystic tumor? of the
testis proper. These latter are in fact very rare ; in
them the fluid is described as " encysted between the
tunica albuginea and the inner surface of the visceral
tunica vaginalis." ' The language of this description
' Jacobson, and White and Martii..
June 2, 1900]
MEDICAL RECORD.
945
would apparently indicate that such cysts have no
wall or sac proper, but consist of really free fluid lying
between the tunica albuginea and the visceral tunica
vaginalis, these two tunics supplying the cyst walls in
the same way that the visceral and parietal pleura
furnish the enclosing walls of an encysted empyema.
On the other hand, some of these testicular cysts cer-
tainly lie beneath the tunica albuginea, as shown in
the illustration in Jacobson, p. 202, and representL-d
by diagram i^i- The cyst here was supposed to have
resulted from an interstitial hemorrhage into the
tunica albuginea as a result of puncture of the testis
by tapping with a needle some years before. The
testicular cysts are usually situated in front of the
testicle, are small in size, and are very hard in con-
sistence, owing to the intra-cystic tension due to the
resistance of their surroundings. This peculiarity of
these cysts would seem to indicate that most of them,
at least, have more than the tunica vaginalis as a wall
on one side. This tunica yields readily, as is attested
by the large size which the ordinary form of the
hydrocele attains; and further by the ease with which
the tunica vaginalis can be displaced and pushed to
one side by the cystic tumors of the epididymis. If
this tunic ordinarily formed part of the wall of such
cysts, therefore, it would scarcely be expected that the
cystic contents would exist under such pressure; and
there would further be no reason, in so far as limita-
tion by pressure is concerned, why such cysts might
not attain a respectably large size, instead of remain-
ing very small, as they practically always do. The
conclusion is therefore reached that cysts in this situa-
tion in all probability have other coverings and are
not, properly speaking, encysted collections of fluid.
Cysts of the epididymis are much more important
clinically, on account both of their greater frequency
and greater size. All such tumors are provided with
proper walls of their own, and therefore are not prop-
erly described as "encysted hydroceles." According
to Jacobson, they are conveniently divided into two
classes: (i) Small subserous cysts, usually appear-
ing external to the epididymis, unimportant clinically,
and very rarely containing spermatozoa. After the
age of forty about two-thirds of the testicles examined
have shown these small cysts from the size of a pin's
head to that of a pea, projecting upon the convex free
surface of the head of the epididymis, and more rarely
upon its body or near its tail. They are usually mul-
tiple, four or five in number; sometimes they are
pedunculated and may become one source of the loose
bodies sometimes found in the tunica vaginalis. The
contained fluid is usually clear and limpid, sometimes
turbid; it rarely contains spermatozoa. They pos-
sibly develop from remnants of fcetal structures, but
more probably are involution cysts originating in the
tissue of the epididymis but becoming subserous. (2)
Larger cysts, originating within the tissue of the epi-
didymis, and therefore important clinically and often
containing spermatozoa.
These cysts are usually single, but may be multiple
or multilocular. The contained fluid maybe perfectly
clear, but is frequently milky from the spermatozoa
contained. In size they vary from that of a hazelnut
to that of a goose egg, or even an ostrich egg, contain-
ing on an average not more than two or three ounces
of fluid. They are represented diagrammatically by
Figs. 10, ir, and 12. Fig. 10 shows the tumor origi-
nating about the head of the epididymis, small and
extra-vaginal. As the cyst grew and developed the
vaginal tunic was pushed before it, and it remained out-
side of it. 1 possess a pathological specimen of such a
cyst. It was removed by Dr. \V. C. Dugan,and kind-
ly entrusted to me for preservation. In its removal
the operation was made entirely outside of the tunica
vaginalis, which was accidentally opened, however, in
one place. Fig. 11 represents a similar extra-vaginal
cyst having its origin near the tail of the epididymis
and pushing its way between the testicle and the tunica
vaginalis. Another pathological specimen in my pos-
session is of this nature. It was removed by the writer
from a man at the City Hospital during last summer's
service. It is much larger than the other specimen,
about the size of a goose egg. These two cases illus-
trated very well the different relations which these
cysts can bear to the testicle proper. In the ordinary
intra-vaginal hydrocele the testicle is situated at the
lower and back part of the tumor. In the ordinary
epididymal cysts the testicle is immediately beneath
the cyst, the cyst being unmistakably superimposed on
the testicle. This was the case with the smaller of
the specimens. But if the cyst has its growth from
the tail of the epididymis, and attains a large size,
almost the exact relations of ordinary hydrocele are
presented; the testicle appears at the lower and
posterior aspect of the tumor, and the latter may as-
sume the even, pyriform shape and appearance charac-
teristic of intravaginal hydrocele. Such was the case
with the larger specimen. Indeed, the diagnosis was
not made until the incision showed that the fluid was
contained in a sac outside of the tunica vaginalis.
Unquestionably cysts of this kind have often been
/«?.
operated on as ordinary hydroceles, the true condition
never being recognized.
Fig. 12 represents another possible relation of these
cysts to the tunica vaginalis. The cyst has its own
proper wall but projects into the cavity of the tunica
vaginalis.
These larger cysts are believed to originate in
several ways: (i) as a retention cyst due to dilata-
tion of a seminal tubule, and the final severance of
connection of the dilated portion, just as other reten-
tion cysts are formed. (2) Morris' states they may
also occur as a new formation in the connective tissue
consequent upon the rupture of a seminal tubule and
the escape of some drops of seminal fluid. (3) The
cyst may originate in certain foetal relics, as follows:
((?) The parepididymis, or organ of Giralde's, a little
body which lies in front of the cord immediately above
the head of the epididymis, and beneath the upper
part of the tunica vaginalis. The tubules constitut-
ing this organ are the relics of the urinary part of the
Wolflian body, as the tubules of the parovarium, or
organ of Rosenmueller in the female, are of the sexual
part. Cysts having this origin, therefore, would be
analogous to the parovarian cysts of the female. It
will be remembered that parovarian cysts in the female
usually contain a clear and limpid fluid of low specific
gravity. (/') Vestiges of the duct of Mueller. In the
female this duct forms the Fallopian tube, the uterus,
and vagina. Abortive in the male, its remains are to
be found constantly in the hydatid of Morgagni, and
sometimes it can be traced from the globus major be-
' White and Martin, p. 926.
946
MEDICAL RECORD.
[June 2, 1900
tween the testis and epididymis to tlie globus minor,
reappearing again as the sinus pocularis in the pros-
tatic urethra. The hydatid of Morgagni is normally
cystic, and by its growth may develop into a good-
sized cyst. Owing to its pedunculation it would be of
the variety represented by Fig. 8 of the diagrams. (()
The vas aberrans of Haller, which is a diverticulum
of, or a convoluted cxcal tube opening into, the vas
deferens close to the tail of the epididymis. This
structure, usually single, is a part of the remains of
one of the tubes of the Wolffian body, still connecting
with the representative of the excretory duct of that
body, the vas deferens. This is the probable origin
of the larger of these cysts above mentioned, which
had its chief attachment, and hence origin, in the tail
of the epididymis.
As has been stated, in a large proportion of these
larger cysts spermatozoa are found in the fluid. Sev-
eral theories have been advanced to explain their pres-
ence. A communication may remain unobliterated
between the fcetal remains and the seminal tubule, as
has been proven to exist between the vas aberrans and
the vas deferens.
The fact that seminal fluid is generally not found
in these cysts when they are small suggests the prob-
ability that the semen gains entrance by the rupture
of a seminal tubule as a result of the distention from
the larger growths.
These cystic tumors are very slow in developing.
What has been said of their characteristics and illus-
trated by these diagrams gives the clew to diagnosis.
The small cysts in any event are recognized with
difficulty; and in some of the largest cysts the differ-
entiation from ordinary hydrocele will scarcely be
made without incision or puncture. If the trocar is
used the character of the fluid may be determinative.
Many of these cysts cause so little discomfort that
relief is scarcely demanded. Simple evacuation may
produce a cure; or evacuation with injection of iodine
or carbolic acid may be practised. But, best of all,
the scrotum should be opened and the cyst dissected
out.
HEALTH CONDITIONS IN THE HAWAIIAN
ISLANDS.
Bv CHARLES E. DAVIS, M.D.,
The Hawaiian islands are in an ideal location, being
just inside the tropics. There is never danger of frost
(except upon the mountain tops), and as they lie in
the line of the trade winds extremes of heat are un-
known; although the humidity, at times, is quite
unbearable.
The group consists of eight inhabited and four un-
inhabited islands, lying between parallels 18° 50' and
23° 5' north latitude, and meridians 154° 40' and
161° 50' west from Greenwich. A straight line drawn,
connecting the two most distant points on the islands,
would measure about four hundred miles. Honolulu,
the chief seaport town, is situated twenty-one hundred
miles from San Francisco and forty-eight hundred
miles from Hong Kong.
1 flat
Hawaii 4,210
Maui 7()'j
Oahu 600
Kauai 590
Molokai 270
Lauai 150
Niihau 97
Kahoolaue 63
Total 6,740
Acres. Height in feet.
2,000,000 13,800
400,000 10,032
360,000 4,030
350,000 4,800
200,000 3,000
100,000 3,000
70,000 800
30,000 1,450
The accompanying table gives the area and highest
elevation of the eight inhabited islands. The four
others are small and unimportant. All these islands
are of volcanic and coral origin. Upon the largest
of the group, Hawaii, stands Mauna Loa, the greatest
active volcano in the world. Upon the island of Oahu,
where is situated Honolulu, the United States troops
were, and still are, located at Camp McKinley. Here
are to be found no less than seven extinct craters.
The city lies at the foot of one crater (Punch Bowl),
and the camp at the base of another (Diamond Head),
and are four miles apart. These craters are distinctly
defined. The cones have been built up of successive
layers of lava. Eruptions occurring at intervals give
to the sides of these mountains a stratified appearance,
which is easily confounded with a like appearance
produced by water.
None of the seven craters on Oahu has been active
within the memory of man. LTpo,-, the island of Ha-
waii, Mauna Loa, or Great Mountain, is at present
active, and a few weeks ago threatened, in its immense
flow of lava, to destroy much valuable coffee and sugar
land on the "koua " or southwest side.
The soil of the islands is very fertile, and is com-
posed of volcanic lava, disintegrated by atmospheric
agencies. The climate and rank vegetation favor
the decomposition of lava and rapid formation of soil.
The "coral insect" or animal — Professor Agassiz
calls it a species of jell}' fish — by its industry has
added acres to the territory that fringes the shores of
these islands.
The mountainous character of this country gives
a great variety of temperature. Torrid heat can be
found at times in some spots sheltered from the
trade winds; frost and snow- exist upon the tops of
the highest mountains. The invalid in search of a
change of climate has but to travel a few miles to
find any temperature the physician may prescribe.
The air, coming over so many thousand miles of sea,
is remarkably pure. The average temperature is about
74° F. In observations made by Prof. A. B. Lyons
from 6 A.M. to 2 p.m. and 9 p.m. each day throughout
the year, for seven years, the minimum in Honolulu
has been 54", the maximum 90°. These islands lie in
the track of the Japanese gulf stream called " Kuro-
shiwo," which has much to do in preventing extremes
of heat and cold. The contrast between the windward
and leeward sides of the island is very marked. The
eastern sides are windy, rainy, and heavily wooded,
while the western coast possesses a warm, dry climate,
with scanty vegetation.
Trade winds blow constantly from the northeast for
nine months of the year, and have an average velocity
of twenty miles an hour, keeping the temperature cool
and invigorating. During the rainy season, the wind
often shifts to the south, bringing intense humidity.
The natives call this the "koua" or sick wind; it
often lasts twelve or fourteen days and is very un-
healthful and depressing, also blighting temporarily
the vegetation near the shores.
The ethnological problem exhibited in these group
of islands, though a complex one, has never, from Ihti
first, been diflicult of solution. It is but another dem-
onstration of the old hypothesis, "the survival of the
fittest," where the unconquered Anglo-Saxon rules
every other people with whom he mingles. The ac-
companying census enumeration shows, for the year
1896, a total population of 109,020 souls, made up
from the representatives of ten different people, and
no less than six different races: native Hawaiians,
31,019; part native, 8,485 ; Hawaiian-born foreigners,
13,733; Americans, 2,266; British, 1,538; German,
912; French, 75; Portuguese, 8,232; Norwegians,
216; Chinese, 19,382 ; Japanese, 22,329; Polynesian,
409; other nationalities, 424 ; total, 109,020.
June 2, 1900]
MEDICAL RECORD.
947
Added to this already cosmopolitan population is
found a combination, or mixture of white and dark
blood, which, of frequent occurrence, is found to pos-
sess in the offspring in a marked degree the color of
the dark parent, with the tastes, ambition, and often
the refinement of the white parent. Of this cosmo-
politan population, it is especially to be noticed that
only 3,804 persons can properly be classed as Anglo-
Saxons, and that the curious fact exists, explained
only by the indomitable courage and persistence of the
race, that these 3,804 Anglo-Saxons, constituting as
they do but a small fraction of the population, have
taken in their hands the control of affairs, political
and governmental. That this should be the racial
condition that would finally be established has never
been a question of much speculation, since the time
that the great natural resources of the islands became
known and tempted with the promise of wealth the
adventurous Briton and the practical American.
The preceding enumeration shows a large population
of Chinese and Japanese. This element never has, and
probably never will, seriously figure in the political
history of these islands, since' nearly all were brought
here from their native countries by the Anglo-Saxon,
who had already acquired possession of the richest
portions of the islands. They were brought, too, under
the contract labor system, by which they were little
better than the white man's slave, whose lot it is to
bear the heat and burden of the day.
The Portuguese, of whom there are more than eight
thousand, are a quiet, unobtrusive people, content to
live simply and work industriously for their day's
wage. Very few Portuguese are progressive and inde-
pendent enough to establish their own business. They
segregate in the parts of the city that are given up al-
most exclusively to them. They marry young (seldom
outside their own people), raise large families, and
are not, to any marked degree, assimilated by any
other race. The native Hawaiian is undoubtedly of
Malay-Polynesian origin. This philologists have es-
tablished through a study of the language, which they
declare to be directly derived from that spoken by the
Polynesians. They probably emigrated to these isl-
ands in canoes via Samoa. Their skin is dark, re-
sembling that of a half-white in the States. Their
hair is raven black, very luxuriant, and straight or
slightly waving. Their faces are broad, noses rather
flat, and lips thick. They are of moderate height.
When in 1778 Captain Cook discovered, explored,
and named the islands after an Englishman, the Earl
of Sandwich, he estimated the population at 400,000,
which, most likely, was too great. In 1828, when the
missionaries arrived, 120,000 was the estimate. To-
day the natives number about 31,000. They are be-
coming extinct as a race, and a few more generations
will see the last of them and of the Hawaiian lan-
guage. However, no small fraction is by inter-mar-
riage becoming assimilated by the white races, espe-
cially the Anglo-Saxon, that have settled here. Under
the rule of Kamehameha I., who consolidated all the
petty chiefs of the eight islands under one monar-
chical government, they were warlike and prosperous.
But with the advent of the white man the extinction
began. They are immoral, and because of improper
medical attention (a necessity which they do not un-
derstand) they are diseased. Syphilis and leprosy
have made sad inroads on their general health and
fertility. The missionaries reduced their language to
a written form, which was gratefully received and
quickly acquired. Many of the natives show an apti-
tude for languages, and usually acquire English, and
often Japanese and Chinese, in addition to their own.
An interesting item to notice is, that there is no word
for virtue — and for their omission the people are pay-
ing the penalty.
The health problem in the Hawaiian islands is al-
most as serious a question for the United States to
deal with as it is in Cuba or Porto Rico. In some
respects it is greater, in proportion to the population;
the conditions existing in the two large cities (Hono-
lulu and Hilo) are identical with that which con-
fronted the military commanders of Santiago and Ha-
vana. If, added to the general unsanitary condition
of these two cities, there should be placed in them a
certain number of reconcentrados, starving and af-
flicted with all kinds of diseases, the problem here
presented would be the same. That some radical ac-
tion must be taken at once is most apparent to any
one who has had anything to do with matters pertain-
ing to public health, or who has given the subject a
moment's consideration.
Honolulu offers the best example of life in these
islands from a health point of view, because it is the
largest city, and said by the inhabitants to be the
healthiest. It is located, as mentioned above, on the
island of Oahu, which is about thirty miles long, with
many hills and mountains, rising to the height of sev-
eral thousand feet, between which are many fertile
vales and plains. But, owing to its general formation,
the coast lines are most available for habitation and
cultivation. It is on one of the level tracts of land,
between the mountains and the sea, that Honolulu is
situated. In early days the plain was the remnant of
a lava-flow, or perhaps the bottom of an extinct crater,
with the side fallen out. It is within the memory of
the earliest inhabitants when it was nothing but beach
sand and lava-dust. The subsoil is black sand, very
porous, and quickly absorbs all fluids cast upon it.
The general drainage is bad, because of the fact that
the hills rise somewhat abruptly from the sea, leaving
a great tract of land but a few feet above sea-level.
The transformation of Honolulu from grass huts and
cocoa-palms to modern houses, parks, and streets has
been very rapid. Good roadways of coral blocks have
been laid; palaces and fine public buildings have
been constructed, also mansions large and small, ele-
gant detached houses, modern schools, churches, and
museums. Tram-cars, water-works, and electric lights
are enjoyed. Parks filled with beautiful tropical fo-
liage dot the city here and there. Streets and drive-
ways are nicely shaded with royal and cocoanut palms.
And yet, with all this seeming love and beauty and
show of intelligence and refinement, Honolulu might
almost be considered filthy, and a spot full of danger
to its inhabitants. In what might otherwise be the
garden city of the world, certain classes have disre-
garded the laws of nature and hygiene, and actually
defiled their own habitations.
The chief part of the city trade is carried on in a
space of about half a mile square, closely built,
densely populated, and largely made up of one'- and
two-story houses, the sort usually found in tropical
countries. Of late years, modern stone and brick
structures are taking their places. In this part of the
city, Chinese, Japanese, and some natives are found
in great numbers; they generally live and sleep in
one room, and the small yards in the rear of their
houses are entirely taken up with cesspool and vault.
On one or two of the principal streets it is impossible
for pedestrians to travel without being met everywhere
by the most obnoxious odors. No part of this city
has had a sewerage system until the present time,
when one is being constructed through the main thor-
oughfares. If the history of other cities repeats itself
here, it will be some years before this comes into gen-
eral use. At present, all refuse matter is disposed of
in cesspools. In many cases they are properly built
and regularly pumped out by scavengers, but in the
majority of cases they consist of holes in the ground,
with wooden boxes sunk into them. In many cases
948
MEDICAL RECORD.
[June 2, 1900
refuse is cast upon the ground to decay and rot in thie
tropical sun.
This condition of affairs has continued for the past
fifty years. The city is honeycombed with cesspools
and privy vaults. The outlying districts, which are
not so closely built, have added to this the pestilen-
tial nuisance of rice, taro, and banana patches which
are constantly flooded with water. Interspersed here
and there will be seen duck-ponds and pig-styes; so
that from any height overlooking the city the picture
is not unlike Venice with its many canals. These
pools of stagnant water, added to the lakes and la-
goons in the public parks, are favorable breeding-
grounds for all kinds of disease, especially in this
climate. We are told by those who make the subject
a study, that a waterlogged tract of land, between
mountain and sea, is the best place for the propaga-
tion of malaria. Add to these conditions lava-dust,
of which the atmosphere is full and which. at times
covers everything in clouds, and is so fine that it pene-
trates one's clothing; a water supply which is partly
artesian, and partly collected from mountain streams,
(admittedly so full of decomposed vegetable matter
that it is the rule to boil it before it is drunk) ; an
even temperature which seldom falls below 72° F.,
with sunshine and rain almost daily during the winter
or wet season; with very little attempt at street clean-
ing— and we have the conditions which are bound to
breed disease wherever they exist.
In this city of thirty thousand inhabitants of mi.xed
races, the death rate is thirty-five per thousand, or
thereabouts. Typhoid fever has been constantly on
the increase, and is always endemic. Pernicious
tropical malaria is a common complaint, while rheu-
matism, catarrh, and bronchitis are very prevalent.
The climatic conditions are especially bad for those
suffering from rheumatism or lung diseases. The
death rate is steadily increasing, as the incomplete
records of the board of health show. The causes of
death have not been carefully recorded, and, until the
last few months, interments were made without permits.
The mortality is greatest among the natives. Venereal
diseases in the worst forms prevail among the lower
classes.
One cannot better illustrate the effect of the condi-
tions in Honolulu, than to recall the recent epidemic
of typhoid fever and malaria which prevailed among
the United States troops stationed there. To be sure,
they lived in tents, and had to contend with the hard-
ships of camp-life, but had not the disease been there
they would not have been so afflicted. Now that these
islands have been annexed, the people who live there
should look at these conditions as they exist, fairly
and squarely, and let the United States government
know just how badly they need some active health
work done. '
The island government is doing all it can to im-
prove the sanitary conditions, but necessarily has
many local influences to contend with, as well as na-
tive prejudice, which leads the inhabitants to conceal
their sickness. Late reports from Honolulu show the
above statement to be true among the Chinese, who
evade the authorities, and will not report cases of bu-
bonic plague, fearing cremation.'
The question of leprosy alone is international, now
that we have adopted twelve hundred lepers in these
islands, with many more in Porto Rico and the Phil-
ippines. Some national health legislation must be
the result, and this disease must be properly segre-
gated and treated in a more complete way. New
schools, workhouses, and hospitals should be con-
structed on the island of Molokai, for these afflicted
people to live, work, and be treated in. At present
no attempt at classification of cases and treatment on
Molokai is made. To be sure the Hawaiian govern-
ment, through the board of health, with Mr. \V. O.
Smith, its efficient president, has gone further than
any other in the segregation of lepers, and much credit
is due them, but this disease being now more than
ever a possible factor in the diseases of the United
States, it becomes a national question, and one of the
greatest importance. A local government will take ,
years to do, in a health and sanitary way, whaj a proper
health commission, not of the country, could accom-
plish in much less time.
For Honolulu I should heartily recommend the
completion, as soon as possible, of the sewerage sys-
tem, the filling of all stagnant pools, rice, taro, and
banana patches; putting an end to the breeding of
ducks and pigs in the city limits. Then with the sea-
bathing and many natural advantages it would become
the garden city of the world.
In conclusion, I should like to add a word in favor
of a national health department, with a representative
in the Cabinet. I am led to believe that medical so-
cieties throughout the United States will make a strong
effort in this direction, as the necessity for such a
department is daily growing more apparent.
THE ASSOCIATION OF CHRONIC APPEN-
DICITIS WITH DISEASE OF THE RIGHT
ADNEXA.
Bv HIRAM N. VINEBERG, M.D.,
ATTENDING GYN.ECOLOGIST TO ST. MARK'S HOSPITAL, MOUNT SINAI HOSPI-
TAL OITDOOR DEPARTMENT, ETC.
Considerable has already been written upon the dif-
ferential diagnosis between appendicitis in women
and disease of the right adnexa. The writer himself,
in a short paper in the Medical Record, December
21, 1896, drew attention to the close similarity in the
clinical picture between acute catarrhal salpingitis
and acute catarrhal appendicitis, and related some
cases in which the differentiation was wellnigh im-
possible. But in this communication he desires to
draw attention to the not infrequent association of the
two diseases in the same patient.
Every operator who has to deal with abdom.inal and
pelvic lesions encounters every now and then in cases
of marked disease of the right adnexa a thickened and
inflamed appendix adherent to tlie pelvic mass. Such
appendices usually show unmistakable signs that they
have become involved secondarily to the tubal dis-
ease. They are as a rule considerably enlarged
through thickening of the wall of the peritoneal cov-
ering, with thickening also of the meso-appendix.
They usually lie in the midst of an exudate covering
the pyosalpinx, or an ovarian abscess, or ruptured tu-
bal sac. Such a complication seldom gives rise to
any characteristic sign or symptom by which it may
be suspected prior to operation. It derives its im-
portance chiefly from a technical consideration when,
as is the custom nowadays with many operators, to
attack tubal and ovarian diseases through the vaginal
route. In such a procedure of course the secondarily
affected appendix would probably be overlooked, and
doubtless would interfere with a satisfactory return to
good health.
Within the past few years in my laparotomy cases
I must have met with over a dozen presenting the
foregoing complication, and of course removed the
diseased appendix together with the diseased pelvic
structures.
One case' last summer was particularly instructive
in this connection. The woman had a large pelvic
haematocele as a result of a ruptured tubal sac some
' Published in full in The American Gynaecological and Ob-
stetrical Journal, January, iqoo.
June 2, 1900]
MEDICAL RECORD.
949
weeks previous. As the collection of blood was very
accessible through an incision in the posterior va-
ginal vault, the temptation was strong to adopt that
plan of procedure. But the case presented some fea-
tures which it was thought demanded an abdominal
incision. These proved to be an intraligamentous
cyst of the left ovary independent of the ha^matocele.
Lying buried in a deep exudate in the upper surface
of the hjematocele was found a very much thickened
appendix, the size of one's thumb. Both it and the
intraligamentous cyst were removed. The hemato-
cele was then evacuated by a free incision in the pos-
terior vaginal vault. The patient made a good recov-
ery from the operation, and has enjoyed the very best
health since. Further comment is unnecessary.
The object of this paper, however, is not to dwell at
any length upon those cases just referred to, in which, in
the presence of marked right adnexal disease, there is
a secondarily diseased appendix lying in contiguity to
the former; it is rather to call attention to those puz-
zling cases in which the patient suffers from symp-
toms vaguely referred to the right lower half of the
abdomen, and in which the diagnosis vacillates be-
tween chronic catarrhal appendicitis and a mild form
of salpingo-oophoritis. These cases in reality show
an association of the two affections in the same pa-
tient. The operation will disclose a thickened, in-
flamed right tube, with some inflammatory changes in
the ovary, and an appendix showing more or less dis-
ease. At one time the changes will be most marked
in the appendix, at another they will be found most
pronounced in the right tube or right ovary. It is not
always easy to trace the causal relation of the two in-
fections. In many of the cases I have operated upon
the distance between the appendix and the tube was
too great to assume an extension by contiguity of the
inflammatory process from one to the other. In some
cases, however, there was general relaxation of the
abdominal supports, so that the right kidney was found
moderately prolapsed and the uterus in more or less
retroversion, with the adnexa hanging rather low in
the pelvic cavity. Whether the prolapsed kidney and
the appendicitis stood in the relation of cause and
effect, as maintained by Edebohls,' I am unable to
say. I am rather inclined to the view that the same
factor — relaxation of the abdominal supports — must
be looked upon as contributing equally to the changes
in the different organs in the abdominal and pelvic
cavities. The subject, however, requires for its eluci-
dation much more extensive investigation than has
as yet been accorded to it. The profession owes a
debt of gratitude to Edebohls for having called atten-
tion to it, and for having stimulated observation and
thought in this direction by his publications.
As already hinted, the symptoms from which these
patients suffer are rather vague. But there is one fea-
ture which stands out rather prominently, and that is,
the subjective symptoms and general debility are out
of all proportion to the physical signs found. There
may be and there usually is indefinite tenderness over
the appendicular region, but I must confess that I
have seldom been able to determine by palpation the
slight changes that are usually found in these forms of
chronic appendicitis. I have relied more upon ten-
derness and pain than upon my ability to detect by
palpation a constriction of the appendix or moderate
adhesions or an inflammation of the peritoneal cover-
ing. On bimanual examination the right tube is found
decidedly tender and more or less thickened, and the
ovary is usually slightly enlarged and moderately pro-
lapsed. The symptoms usually set in insidiously.
The patient cannot tell just when she began to suffer
from pain in the right side of the lower abdomen.
' Centralblattfiir Gynakologie, 189S. pp. 10S4-1090 ; Mf.uicai,
Record, iSgg, pp. 341-345-
During the subsequent course of her ailment she may
or may not have had one or more acute attacks which
at one time may have been diagnosticated as appendi-
citis, at another as right-side salpingitis or oophoritis
or as pelvic peritonitis. In other cases again there
may be an entire absence of any acute attacks. Pain
and ill health may be the only prominent symptoms
present, and at no time will there have been observed
any elevation of temperature or any marked change in
the pulse rate.
These patients are sometimes operated upon for
supposed appendicitis, and the removed appendix
shows some slight lesion. But the pain continues, and
a second laparotomy reveals a diseased right tube or
ovary, which is excised and the patient is cured.'
Such an experience must cause the operator very much
chagrin, to say nothing of the mental agony and phys-
ical suffering which a patient endures who has to un-
dergo a second laparotomy shortly after having been
subjected to the first. To avoid such a pitfall one
should adopt the rule always to investigate the condi-
tion of the right adnexa when operating for appendi-
citis in female subjects, be they married or single."
The youth of the patient should not throw us off our
guard, as the following case will illustrate:
Case I. — Chronic catarrhal appendicitis, adherent
tube and ovary; operation; recovery. Miss S., aged
sixteen years. The menses were established in her
twelfth year; they were regular and attended with only
moderate pain. She had been well until a year ago,
when she had an acute attack of pain in the right side
of the abdomen which kept her in bed for a day or two.
She had another attack of a more severe nature while
in the country during the past summer. The physician
there diagnosticated right-sided oophoritis. The pain,
with variable severity, continued until her return to
the city, when she consulted her family physician, who
made the diagnosis of appendicitis. He kindly re-
ferred her to me, and on examination I found decided
tenderness over the appendicular region, but could not
with certainty palpate the appendix. Bimanual exami-
nation was made with a finger in the rectum. Consid-
erable tenderness was detected over the right adnexa,
and they seemed adherent. She was operated upon
November 30, 1898, by an oblique incision over the
usual appendicular site. The appendix was found
after considerable search behind the cascum and
pointing downward into the pelvic cavity. It was
very firmly and extensively adherent, the distal end
lying in a sheath of exudate. After excising the ap-
pendix, I introduced two fingers through the incision
and explored the right side of the pelvic cavity. The
right ovary was found moderately enlarged and adher-
ent. The adhesions were gently broken up and the
ovary brought up into its normal position. The ab-
dominal wound was closed with tier sutures. Recov-
ery was uneventful. The patient has remained free
from pain since the operation.
In the majority of cases presenting the complex
phenomena outlined in this paper, the more desirable
and prudent course to pursue is to open the abdomen
in the median line, when the appendix, uterus and its
' .See case reported by Dr. R. F. Weir, in a paper entitled,
"An Improved Operation for Acute Appendicitis," in the Medi-
cal News, February 17, 1900.
- I learned this lesson from an unpleasant experience some five
years ago. I had operated upon a woman twenty- four years of age,
for acute appendicitis. The appendix was swollen and contained
pus. The operation passed off smoothly and the patient made an
apparently good recovery. She was up out of bed at the end of
two weeks, .-'l couple of days after getting up she was seized
with pelvic pain and developed fever. A small pelvic abscess
was detected, and being incised through the vagina, convales-
cence was soon established which now was permanent. I had no
doubt afterward that at the time of operation the patient had
some trouble with the right adnexa which should have been in-
vestigated then.
950
MEDICAL RECORD.
[June 2, 1900
adnexa can be treated surgically if their condition re-
quires it. No better illustration can be offered of the
wisdom of such a plan of procedure than is presented
by the following case:
Case II. — Median laparotomy; excision of appen-
dix; suture of round ligaments to abdominal wall: ex-
cision and puncture of cysts in both ovaries. Mrs.
W , twenty-five years of age, married eighteen
months, gave birth to a child eight and a half months
ago. She has been ailing ever since the confinement,
which seemed to be perfectly normal. Before this she
had enjoyed excellent health. She resides in a West-
ern town. The physician who attended her last writes
that she consulted him November 18, 1899 : " She was
suffering from pain in the right side of the abdomen,
backache, dragging pelvic pains, and from profuse
leucorrhcea. I found the cecal, ascending colon,
right inguinal and hypogastric regions extremely ten-
der, almost painful. The epigastric region was tender
to painfulness on percussion. The endometrium was
exquisitely tender. Temperature was normal. I gave
her three local treatments, and advised recumbent po-
sition and hot douches. On December 15th she
aborted. The products of conception were less than
two months (not over). After this accident she kept
her bed eight days and her distress almost disap-
peared. After being on her feet distress returned,
disabling her almost." Her husband took her then to
a large city in the vicinity and consulted two of the
most- prominent operators there. One diagnosticated
appendicitis, the other inflammation of the right
ovary. Both urged immediate operation. The dia-
metrically opposed opinion of these two surgeons
unsettled the man's confidence and placed him in a
quandary. He then came on here with his wife and
was referred to me. She is a tall, slender, delicate-
looking W'oman, with rather pale mucous membranes.
She complains of constant backache, pain across the
hypogastrium and over the abdomen in general. The
pain is most severe in the right inguinal region and
extends down the right thigh, which, she says, feels
numb. She suffers from general debility, loss of flesh
(having lost fifteen pounds in weight since the birth
of her child), loss of appetite, constipation, and sleep-
lessness. For weeks past she tells me she has been
unable to go to sleep without an opiate. The abdo-
men is very lax. There is marked tenderness over
the cascal region and along the course of the ascend-
ing and transverse colon. The appendix is readily
palpated, is markedly tender, but no decided thicken-
ing is detected. The kidneys are not found prolapsed.
The uterus is large, succulent, tender, and in fair po-
sition. A thick, tenacious discharge fills the cervical
canal. The right ovary is considerably enlarged, pro-
lapsed, and very tender. The left ovary does not seem
to be enlarged. Urine withdrawn by catheter showed
a moderate amount of albumin, but no casts. I learned
she was excreting it in very small quantity. I declined
to express an opinion as yet, and advised her entering
a private sanatorium to be under observation and treat-
ment. Under suitable regimen the kidneys soon acted
normally. On the first day she passed only 700 c.c.
urine, on the second 1,100 c.c, on the third day 1,450
c.c, and from this on the amount and quality were
normal.
At my second examination the uterus was found in
complete retroversion, in which position it was found
at every subsequent daily examination during the week
prior to the operation. The abdominal pain and ten-
derness persisted in spite of rest in bed and appro-
priate treatment. I concluded I had to deal with a
case of chronic appendicitis, associated with subinvo-
lution and retroversion of the uterus and cystic degen-
eration of the right ovary.
On February 4, 1900, I performed median laparot-
omy, having first dilated and curetted the uterus. The
right ovary contained a cyst the size of an almond,
which was excised and the wound in the ovary sutured
with catgut. A similar-sized cyst was found in the
left ovary, which was treated in the same way. The
uterus lay in complete retroversion. It was brought
forward and held in position by suturing the round
ligaments to the fascia of the rectus muscle. A search
was now made for the appendix. It was readily found
in the usual position, covered with a few membranous
adhesions, and the peritoneal covering was highly in-
fected. Appendectomy was done in the customary
manner. The appendix on being slit open presented
an erosion, the size of a five-cent piece, of the mucosa.
The abdominal wound was closed with tier sutures.
Recovery from the operation was perfectly normal.
The patient is making a rapid and satisfactory con-
valescence. She is free from pain, has a good appe-
tite, sleeps well, and has gained three and one-half
pounds in the first week after getting up from bed.
It may be argued that the appendix would be diffi-
cult of access by a median laparotomy, especially when
it was extensively and firmly adherent. Such, how-
ever, has not been my experience in the class of cases
under consideration. As a rule the appendices in
these cases are but slightly adherent, and are very
easily reached by a median incision. Still, if on ex-
amination prior to operation a firm adhesion of the
appendix is suspected, then the Battle-Kammerer in-
cision through the sheath of the right rectus muscle,
with traction of the muscle toward the median line,
may be adopted. This incision gives ready access to
most of the situations which a diseased appendix may
adopt, while it permits at the same time with moder-
ate ease the examination and surgical treatment of the
right adnexa. I have at times been able to investi-
gate through it the condition of the uterus, and even
of the left adnexa. When I am morally certain be-
forehand that disease of the appendix exists, I usually
adopt this incision. It seems to me to be preferable
to the rather complicated incisions recently recom-
mended ' to accomplish the purpose of investigating
the condition of the right adnexa when operating for
appendicitis in female subjects.
Of course cases of appendicitis are sometimes en-
countered in which neither of the two foregoing in-
cisions will be applicable. I merely make this state-
ment so as not to be understood as advocating certain
incisions for all varieties of appendicitis. A few
weeks ago I operated upon a woman in whom I could
feel an enlarged appendix lying firmly attached to the
side of the ileum. I made an oblique incision directly
over the mass, and found the appendix firmly adherent
to the iliac wall, lying to the outer part and behind the
cjecum. It was embedded in a mass in the centre of
which was about two ounces of pus. After having lo-
cated the position of the appendix, and before attempt-
ing its removal, I enlarged the incision downward so
as to bring within reach the right adnexa. I found
the right ovary converted into a cyst the size of a
hen's egg, and removed it. Then after walling off the
intestines as well as possible, I proceeded with the
removal of the appendix. While enucleating it from
its bed of exudate some pus (about two ounces) ap-
peared, which was quickly mopped up. The abdomen
was closed with tier sutures save a small area where
a gauze strip passed down to the abscess cavity. This
was removed in three days, and the patient made a
perfectly normal recovery, leaving for her home in a
neighboring town fifteen days after the operation.
Nowadays the question is frequently asked, When
' See papers by Dr. Robert F. Weir (The Medical News, Feb-
ruary 17, igoo), Dr. Willy Meyer (The Journal of the American
Medical Association, February 17, 1900), and Dr. George R.
Fowler (The Medical News, March 3, 1900).
June 2, 1900]
MEDICAL RECORD.
951
doing a laparotomy for pelvic lesions, do you always
search for the appendix and remove it, be it diseased
or not? The question no doubt would be differently
answered by different gynecologists. My own prac-
tice is based on the principle never to remove a tissue
unless its removal is indicated by disease. Whenever
it is feasible in the performance of a laparotomy for
other conditions than appendicitis, I search for the
appendix for the purpose of investigation, but do not
excise it unless it shows some pathological change.
Personally I do not feel justified in subjecting my pa-
tient to the additional risk, be it never so slight, of
removing a healthy appendix for the reason that at
some future date it may become diseased. Of course,
this is a matter of mere personal sentiment. I have
said when it is feasible, for no operator, I take it,
would be so foolhardy as to waste any time over the
search for the appendix unless there were good rea-
sons for so doing, after a very difficult and tedious
operation on the pelvic viscera. Moreover, in these
cases such a search is as a rule unnecessary, for if the
appendix is at all involved it is generally found ad-
herent to the diseased pelvic structures, and comes
under the operator's hands without his having to look
for it.
Two Unusual Cases of Annular Syphilides in
Negroes. — T. Caspar Gilchrist's first case had ringed
and gyrate lesions over the face, axillary region, and
inner surfaces of the thighs. Near the chin were
three rings one within another. In the second case
the face and neck were chiefly affected. The chancre
had existed six months previously. In doubtful cases
ringworm and erythema multiforme have to be ex-
cluded. In the latter the backs of the hands will be
coincidently affected and the margin will not be raised,
firm, or indurated. Annular syphilis may occur as
late as the third or fourth year. In one case mentioned
it was as late as the tenth year. This form seems
much more prevalent in the negro race. The writer
agrees with Crocker that it belongs in the papulo-
squamous group. An article on the '' Anomalies of
Syphilis," in the current number of the American
Jotinial of Dermatology and Genito- Urinary Diseases,
shows illustrations of an almost identical case. — Mary-
land Aledieal Journal, April, 1900.
The Effect of Strong Heat in Pruritus. — Edmund
Andrews recommends applications as hot as caij be
borne for the relief of obstinate itching, especially
pruritus of the anus and adjoining regions — perineum
and scrotum or vulva. Hot water has been used in
anal pruritus, but with imperfect success, because of
the difficulty of applying strong heat thoroughly to
the deep sulcus in which the anus lies. The water
must be as hot as can be borne without blistering. A
large dish of it must beat hand, and two or three com-
presses placed in it. The patient taking a crouching
position picks up one compress and instantly presses
it against the anus. In a moment or two it will be
partly cooled. He then drops it into the dish and
immediately uses another, thus keeping up a constant
and very strong heat until the itching ceases. One
such treatment, the author says, will often make the
patient perfectly comfortable for twelve or twenty-four
hours. — The Clinical Review, May, 1900.
Nearly Complete Occlusion of the Trachea by a
Tumor Originating in the Cicatrix of an Old Tra-
cheotomy.— Bayer's patient was tracheotomized in his
fourth year for croup. In his twenty-third year he
contracted an initial specific lesion, and in the next
few years received irregular treatment. At the age of
thirty years he suffered from difficult breathing, which
became noisy in both inspiration and expiration. Ex-
amination sliowed the subglottic space obstructed by
a sort of membranous diaphragm, perforated a little to
the right side of the median line by a small orifice.
Closer examination showed that the supposed dia-
phragm was in reality a mass of granulation tissue.
Surgical intervention was refused, but the patient was
placed on appropriate treatment, and massage was
given both internally and externally over the site
corresponding to the tumor. The tracheal occlusion
gradually disappeared, and a complete cure resulted.
Tracheal occlusions in general arise from a tumor in
the trachea proper, from deformities in its walls, from
cicatrices or pressure by neighboring organs, or from
the presence of horizontal fibrous partitions inserted
on the inside of the normal wall of the tube and de
veloping their surface in a plane at right angles to its
axis. — Jievue Hcbdomadaire de Laryngologie, etc., March
10, 1900.
Acute Serous Meningitis and Sero-Purulent
Meningitis due to Streptococci — P. Nobecourt and
M. Delestre note two cases which were seen in an
epidemic of broncho-pneumonia, and which were both
fatal. The first patient, a boy three and one-half years
old, was brought to the hospital for diarrhcea and for
cough. Nine days after the appearance of meningitic
symptoms he died. Liquid from cerebro-spinal punc-
ture gave pure cultures of streptococcus. The lungs
showed the ravages of broncho-pneumonia. There
was a diffuse oedematous congestion of the meninges
of the convexity of the hemispheres. No tuberculosis
was present. The cerebro-spinal liquid was clear
and limpid. The second case also showed the lesions
of broncho-pneumonia. The cranial meninges were
distended by a cloudy liquid, rich in leucocytes.
Bacteriological examination of the cerebro-spinal
liquid showed the streptococcus analogous to that
seen in the first case. So the same micro-organism
can sometimes cause a serous, sometimes a sero-puru-
lent, inflammation in the meninges. — Annales de
Mcdecine ct de Chirurgic Injantiles, April 15, igoo.
On the Relationships between Anaesthetics and
Insanity. — G. H. Savage states that an anaesthetic
may cause insanity. As to the advantage of one anaes-
thetic over another, the writer has had no experience
of special danger from any one. Various forms of
insanity have been observed in this connection. An
anaesthetic may relieve for a time in a few maniacal
cases. It may be given to the insane with impunity,
as a rule, when operations or examinations are neces-
sary. But there is danger that it may lead to a fresh
attack of insanity if it is given to patients who have
had previous attacks of insanity, and to those who are
subject to recurrent insanity of any form. — The Clini-
cal Joicrnal, April 11, 1900.
A Plea for Examination of the Male Genitalia
in Obscure Cases. — Ferd. C. Valentine says that
whenever a woman with manifestations of nervous dis-
ease comes to the general practitioner or the neurolo-
gist, the latter at once proceeds to establish or elimi-
nate the presence of a genital affection as a possible
cause of the ailment for which advice is desired. The
same rule does not hold in the case of a male patient,
but the author thinks it might do so with great benefit
in many cases. The symptoms may not at all point
to the genito-urinary apparatus, and yet the cause of
them may well reside in that part. There are many
pains and symptoms simulating disturbances of the
gastric, motor, sensory, and circulatory systems which
are evolved and maintained solely by a genito-urinary
disease. As regards exploration for urethral stric-
ture, which is only one of the many affections of the
genito-urinary system that may find expression in
952
MEDICAL RECORD.
[June 2, 1900
symptoms in distant parts, Valentine cautions against
the giving of an opinion after tlie simple passage of a
metal sound or even of a metal bougie-a-boule. He
advises the use of a soft-rubber bougie-a-boule, even
two numbers smaller than the rigid instrument em-
ployed, and says that only when this is whipped out
of the urethra and encounters none of the characteris-
tic impingement, can the urethra be pronounced clear.
Besides instrumental and visual exploration of the
urethra, and tactile interrogation of its adnexa, an ex-
amination of the urine will oftentimes give important
clews not only to the character but also to the site of
a urethral disease. — The Cleveland Medical Gazette,
May, 1900.
Functional Relation between the Thyroid and
the Parathyroid Glands.— Gustav Lusena thus sums
up the results of his experimentation: While in some
cases the theory that the removal of the thyroid and
parathyroid apparatus accelerates the process of nutri-
tive exchange, and increases the gravity and rapid
course of the cachexia is quite true, the theory cannot
be upheld which would attribute all the symptoms
which occur after parathyroidectomy and thyro-para-
thyroidectomy to an increased or diminished rapid-
ity in the metabolic processes. — La Riforma Mediea,
March 28 and 29, 1900.
The Bacteriology of Influenza. — Arnaldo Cantani
believes it to be highly improbable that the bacillus
of influenza should be met with in the mouths of
healthy individuals. Even in those suiTering from
chronic catarrh it is found only after a superadded
acute and typical attack of influenza. Once intro-
duced, its persistence is remarkable, and is shown in
frequent relapses. The specific nature of the bacillus
is indisputable. As a result of experimentation, it
would appear that the intoxication produced by this
disease is due to a poison contained in the bodies of
the micro-organism. There are clinical affections
which exactly simulate influenza, but are due to other
bacteria. These and the typical bacteria are best
found in the sputum and in the nasaJ secretions. —
La Riforma Aledica, April 6, 7, 9, 1900.
Malarial Neuritis. — E. Sacquepee and Charles Dop-
ter give a description of twenty-two cases culled from
medical literature and three from their own practice, of
polyneuritides absolutely referable to malarial infec-
tion and to no other cause. In one case the sensory
nerves of the legs and arms were affected, the pain be-
ing of an excruciating nature. The patient died, and
the cubital and external popliteal nerves were subjected
to a minute examination. Not a single fibre was found
in a normal condition ; the chief lesion was a breaking
up of the myelin into small droplets, with a varicose
and moniliform condition. The fibres were, in fact,
almost totally destroyed. In a second case, lancinat-
ing pains of the thigh, and finally of the w^hole leg and
the arms, returned at intervals, but were benefited and
finally cured by quinine, electricity, massage, and tepid
douches. In tiie third case paralytic, painful, and
trophic phenomena occurred from time to time; quin-
ine, antipyrin, faradization, and occasionally morphine,
were given in treatment, and the patient's condition
was greatly improved. Some muscular atrophy re-
mained.— Revue de Mcdeeiiie, April 10, 1900.
Epilepsy: Artificial Trepanning.— G. Jacquin re-
ports the following case of a man thirt3-seven years
old: The patient never had convulsions in childhood.
There was no history of alcoholism or syphilis; no
venereal excess. The patient had an attack of typhoid
fever when eighteen years of age ; it was severe and
attended by delirium, and lasted four months. Three
months later the first convulsions appeared. In Octo-
ber, 1S97, he fell into the fire and received a severe
burn on the head which amounted to a veritable tre-
panning. A sequestrum was formed and thrown off.
For a time after the accident the epileptic attacks were
less frequent, but gradually the frequency increased
till they occurred as often as before the accident.
This case goes to prove with other examples that tre-
panning sometimes secures a temporary amelioration,
but never a perfect cure of the affection. — Archives de
Neurologic, April, 1900.
Cutaneous Grafts : Strips Taken from an Ampu-
tated Leg and Grafted with Success Nine Hours
after Amputation. — Alfred L. Dupraz cites the case
of a man suffering from an extensive wound of the
hand. On this wound, which had been protected with
adhesive plaster since the day before, the writer grafted,
according to Thiersch's method, strips of skin taken
from a leg amputated nine hours previously. The
strips of skin had been preserved in sterilized serum.
The grafts took with great success.— .^;r///rw Provin-
ciales de Chirurgie, April i, jgoo.
Note on the Etiology of Subscapular Friction;
Role of Pleurisy M. Pe're' declares that physiological
subscapular friction does not exist. Subscapular fric-
tion is the result of the approach of the two osseous
surfaces — subscapular and costal. This condition can
take place in the event of an exostosis, in callus follow-
ing a fracture, in an exaggerated protrusion in front of
the spinal border and of the inferior angle of the
scapula, in the denudation of the osseous parts follow-
ing atrophy of the scapular muscles, or in an abnor-
mal projection following pleurisy, scoliosis, etc. In
these conditions, when the movements of the scapula on
the thorax are too extensive or too frequent, a serous
bursa maybe interposed between the two bones and by
its inflammation reproduce the friction by substituting
its rugous walls for the two bony surfaces. — Archives
Proviiuiales de Chirurgie, April i, 1900.
The Diazo Reaction in Consumptives Applying
for Sanatorium Treatment. — Hermann Lorentz pro-
poses the use of the diazo reaction in order to deter-
mine whether a given individual with pulmonary
tuberculosis will probably be benefited by sanatorium
treatment. During the past year he has applied this
test several times in the case of each of the patients
in one division of the Halila Sanatorium, and presents
a table of the results obtained in the fifty-four ex-
aminations. The only deaths that occurred were
among those who presented the diazo reaction. All
those who did not present this reaction on admission,
with the exception of three, were improved during
their stay in the sanatorium. Of the three exceptions,
in two the diazo reaction subsequently appeared, and
the third patient left the institution. The appearance
of this reaction in marked degree was always followed
by a rapid destruction of the lungs, but it was inde-
pendent of the number of bacilli and of the presence
of fever. The writer regards the diazo reaction as a
valuable aid to prognosis, its presence being of bad
omen; but its absence does not indicate an absolutely
favorable course, as the condition may grow worse
after a time, and then the diazo reaction will probably
appear. — Finska Lakaresdltskapets Liandlingar, March,
1900.
The Treatment of the Stump of the Umbilical Cord.
— F. Ahlfeld protests against the statement of Martin,
that the successful treatment of the stump of the um-
bilical cord is as yet " a consummation devoutly to be
wished," and refers to the method (fully described in
the second edition of his "Text-Book") that has been
employed with most favorable result in far over a thou-
sand cases treated at the " Marburger Anstalt." He
June 2, 1900]
MEDICAL RECORD.
953
gives a brief description of the method, and states that
they have not had a single case of umbilical disease
since a number of years. He does not approve of the
methods suggested by Martin. — Centralblatt Jiir Gynd-
kologic, March 31, 1900.
A Case of Congenital Hemeralopia — W. Koster
reports a case of congenital perinuclear cataract in
which the opacity was so even and so nearly trans-
parent that the patient had almost normal acuity of
vision in a strong light, but at dusk, or when the illu-
mination was dim, was nearly completely blind. —
Weekblad van het Nederlandsch Tijdschrijt voor Gcnccs-
ktinde, March 31, 1900.
Pregnancy and Birth after Hysterocolpocleisis
Menge cites an instance in which pregnancy occurred
after hysterocolpocleisis had been performed on a
woman, aged thirty-five years, who had borne seven
children. Examination upon her admission to the
" Universitats-Frauenklinik," Leipsic, revealed the
'presence of a large vesico-cervico-vaginal fistula. She
stood the operations well, but less than three years
later again became pregnant. Menge gives a very
complete report of the case, which is certainly quite
interesting. — Cetitralblatt Jiir Gyndkologie, March 31,
igoo.
Contribution to the Knowledge of the Neutrali-
zation of Poisons. — Ernst v. Czyhlarz and Julius
Donath, in their researches regarding the power of
some organs to neutralize poison, found, among others,
that by tightly bandaging the hind-legs of guinea-pigs
as far above the knee as possible, they could with im-
punity inject into the leg thus ligated quantities of
strychnine sufficiently large to have caused certain
death within two to five minutes in other animals of
the same weight. They conclude from this that the
poison was neutralized by the subcutaneous cellular
tissue, the musculature, and the blood and lymphatic
fluid contained in the same. — Centralb/att fiir innere
Medicin, March 31, 1900.
Treatment of Ozaena with Normal Horse Serum.
— Pedro Borrds y Torres reports the results of hypo-
dermic injections of normal horse serum in eight cases
of ozffina. The results were of three kinds; (1) Gen-
eral symptoms, fever, joint pains, etc., such as com-
monly follow injections of the various therapeutic sera
and organic extracts ; (2) local symptoms at the site
of injection, pain, swelling, and sometimes a morbil-
liform eruption ; (3) symptoms on the part of the nasal
mucous membrane, greater circulatory activity marked
by turgescence and an increased secretion. After four
or five injections the crusts were expelled and the odor
was no longer perceptible, either objectively or sub-
jectively. This amelioration, however, continued only
so long as the injections were repeated at regular in-
tervals, and the dose was not reduced. No change at
all was produced in the atrophied mucous membrane
by this increased secretion. The initial dose of the
serum was 5 c.c, gradually increased to 15 c.c. The
injections were repeated every other day, or twice a
week, according to the individual tolerance. — Gaceia
Medica Catalana, March 31, igoo.
Variety in the Diet of Typhoid Fever — Andrew
H. Smith states that considerable experience has
shown him that quite a variety of fluid and semi-fluid
food may be given in cases of typhoid, even in the ear-
liest stage, not only without danger, but with decided
benefit. The aim should be to give the minimum of food
that will sustain the patient, not the maximum amount
that he can take. "Starvation fever" is often abol-
ished by administration of a more nutritious semi-solid
food. A good diet list is : Milk, broths, soft-boiled
eggs, junket, custard, the soft part of raw oysters, milk
toast, scraped chicken, scraped beef, chicken and rice
boiled to a jelly, sago, tapioca, cornstarch, animal jel-
lies. The efl'ect should be carefully watched.— /«/<?/•-
national Medical Alagazhte, April, 1900.
Hysterogenous Tympanum.— M. Ricard reports a
case of pain and partial deafness in the left ear of a
young girl aged seventeen. The instillation of a few
drops of cocaine caused an hysterical attack, taking the
form of suffocation, vertigo, and loss of consciousness.
Water used in the place of cocaine produced the same
effect. Repeated applications of warm water finally
brought about a cure. — Revue Bebdomadaire de Laryn-
gologie, April 15, 1900.
Intestinal Antisepsis in Typhoid Fever James
M. Anders believes that the principal indication for
the use of intestinal antiseptics is the meteorism which
owes its origin to decomposable material in the prima
via. They have a mitigating sphere of usefulness.
They exercise a mitigating influence upon the diar-
rhoea when present. The bowel antiseptic employed
by the writer is salol. The powdered form is best.
Turpentine is to be preferred when marked distention
of the bowel is present. When intestinal irrigation is
used, the writer employs salicylic acid or mercuric
chloride. — International Medical Magazine, April, 1900.
On Carcinoma in Cattle. — Leo Loeb sums up the
results of observations on this subject as follows: (i)
In 1899 one case of carcinoma in fifty thousand was
found in cattle. (2) The most frequent place for its
occurrence is at the inner canthus of the eye. (3) The
female sex predominated. All cows with carcinoma
were, however, from six to fifteen years old, while the
majority of steers are usually killed when young.
This fact must betaken into consideration in this con-
nection. (4) All animals with carcinoma were much
emaciated. (5) There was constant absence of metas-
tases in the deeper lymph glands or other organs, al-
though the metastases in the retromaxillary lymph
gland very often attain a great size.^ — Medicine, April,
1900.
The Plantar or Toe Reflex Horatio C. Wood, in
the examination of a number of adult sufferers from
various diseases involving the pyramidal motor tract,
has not been able to verify Collier's statements in re-
gard to the plantar reflex, i.e., that there are two dis-
tinct forms, one in the normal adult, the other in
children, and that in certain diseases in the adult
there is a reversion of the form, so that it is possible
to make a diagnosis as to the seat, or even within cer-
tain limits the nature, of the disease by studying the
toe reflex. In children the author has several times
found the adult reflex. In short, the result of his study
has been to indicate that the condition of the toe re-
flexes cannot be relied upon as a basis of diagnosis. —
University Medical AJagazine, April, 1900.
Meteorismus in Abdominal Typhus and its Treat-
ment.—W. E. Tschernow bases a report upon one hun-
dred and twenty-eight cases. When meteorism is pro-
nounced, the bowel must be emptied. Injections with
water, or water and glycerin, or glycerin alone, may
be employed, or a mixture of asafetida water and tur-
pentine oil. When the diaphragm is elevated by me-
teorism and the lungs are pressed upon and the heart is
displaced, we may be forced to puncture the abdomen
in patients who present lung complications. This
procedure is not difficult when the stomach or large
intestine is to be punctured, but in meteorismus of the
small intestine puncture succeeds only when the dis-
tended loop of gut is prominent behind the abdominal
walls. Meteorismus is produced by an increased gas
954
MEDICAL RECORD.
[June 2, igoo
production in the intestine, or caused by atony and
paresis of the intestinal walls from local auto-intoxi-
cation of the neuro-inotor apparatus of the intestine
by products of abnormal fermentation. — Kiinisch-thera-
pciitische Wochcnschrijt, April 15 and 22, 1900.
Traumatism in the Pathogenesis of Syringomye-
lia.— Vincenzo Cito quotes a number of cases of this
disease following injuries received by falls, blows, etc.
He believes that the traumatism is the chief etiologi-
cal factor, and that it produces hemorrhagic foci which
Minor divides into two varieties, local and localized,
the former situated at the seat of the lesion and dis-
tinctly circumscribed, the latter characterized by an
accumulation of pure blood in the form of a central
haematomyelia or simply by central softening with or
without blood. In the majority of cases these foci are
the starting-point for the formation of the cavities,
surrounded by a ring of newly formed nerve tissue. —
Gr Incurabili, March, 1900.
The Treatment of Infantile Spastic Paralysis —
A. Codevilla reports a number of cases in which trans-
plantation and plastic operations on tendons have
succeeded in overcoming spastic contractions of hands
or feet. In the majority of cases of infantile spinal
paralysis, the vicious position and the deformity are
chiefly due to the lack of equilibrium between the
forces which move the articulation. Some muscles
are paralyzed and others relatively normal, so that
with each voluntary or reflex movement some muscles
contract while their antagonists are inert. This gives
rise to the vicious position or the deformity, and it is
only rational to suppose that a cure may be obtained
by a better distribution of force. This can be done
by musculo-tendinous transplantation, with stretching
or shortening of certain tendons in order to obtain a
passive equilibrium in the normal position. No rules
can be given as to the operation, for the conditions
vary in each case.^ — Rivista Critica di Clinica Aledica,
April 21, 1900.
The Diagnosis of Chlorosis and Chloro-Anaemia.
— Alfred Stengel says that the prominence of certain
symptoms, as cardiac palpitation, or cough due to
vascular disturbance, frequently interferes with the
diagnosis of chloro-ansmia. More often still mis-
takes occur when the clinical manifestations are a
little obscure. We must not expect to find the green-
ish pallor of the books in every case. Our ten-
dency nowadays is to pay too much attention to the
blood examination; its importance is great, but there
is danger in relying too much upon this one method
of investigation. We must take into consideration
the history and the clinical course' of the case. We
should be especially careful in pronouncing cases with
unusual and atypical symptoms chlorotic. Chloro-
anaemia is simply a form of secondary anamia present-
ing an unusual blood picture. It is most frequent in
the early stages of phthisis, carcinoma, and secondary
syphilis, and may be met with very characteristically
in post-hemorrhagic aneemia. — University Medical Mag-
azine, April, 1900.
Pyelophlebitis and Hepatic Cirrhosis. — Attilio
Colpi thus concludes a study of two cases: (i) We
may have a cirrhosis secondary to thrombosis of the
portal vein. (2) Its characteristics will show that the
thrombosis is primary, and not secondary to cirrhosis
of the liver. (3) The thrombus is of gradual, not
sudden, formation. (4) The formation of interaci-
nous connective tissue is secondary to thrombosis of
the portal vein. As a result of the gradual diminution
of the blood supply to the liver, the function of the
hepatic cells is abolished, and we have atrophy and
destruction of the cells, the compensatory circulation
in the internal branches of the portal vein not being
sufficiently powerful to nourish them. (5) The pres-
sure of the congested blood further contributes to de-
struction of the hepatic cells. — La Rijonna Medica,
April 10, II, 12, and 13, 1900;
The Rudimentary Ophthalmoscopic Stigmata of
Acquired Syphilis. — A. Antonelli writes of the fre-
quent presence of vestiges of neuritis of the optic
nerve, retinitis, chorio-retinitis, or simple chorio-
retinal pigmentary dystrophy in thee)'esof syphilitics,
in addition to the classical lesions of the fundus of the
eye. These stigmata are essentially the same in ac-
quired and in congenital syphilis, but in the former
they are usually associated with a true papillitis or le-
sions of the fundus, which is not the case in heredi-
tary syphilis. An ophthalmoscopic examination may
sometimes clear a doubtful diagnosis in general paral-
ysis or tabes or other diseases in which syphilis is the
unrecognized cause. — Gl'Inatrabili, March, 1900.
Appendicular Pleurisy. — M. Dieulafoy describdfe
this affection, which is secondary to appendicitis, the
pleura becoming infected by propagation through the
adhesions and lymphatics. The infective agents may
or may not perforate the diaphragm. The pleurisy
occurs a few days after the onset of the appendicitis,
at about the time when the symptoms of the latter are
beginning to subside, and is almost without exception
a pleurisy of the right side. There may be very slight
dry pleurisy, or pleurisy with effusion, but as a rule
there is extensive effusion, the fluid being fetid and
putrid. Prognosis is bad. Surgical intervention
should be prompt, and when peritoneum and pleura
are both infected may have to consist of the operation
for empyema and laparotomy. Prophylaxis is the only
rational treatment, and will consist of early appen-
dectomy.— Bulletin de fAcademie de Medecine, April
10, 1900.
Yellow Fever is a Preventable Disease. — Antonio
Matienzo says that, although the situation and climate
of Tampico offer the most f-avorable conditions for
the reproduction and development of the germ of yel-
low fever, and although there have been visitations
there at various times, yet the disease has not become
endemic. He reports briefly the nine cases occurring
in that city from April 10 to October 13, 1899, and
recounts the sanitary measures taken in each case to
prevent the spread of the disease. From his study of
these cases he concludes that yellow fever, like small-
pox, diphtheria, scarlatina, etc., is an avoidable dis-
ease. The prophylactic hygiene of the affection con-
sists in isolation and the most thorough and scientific
disinfection in addition to general sanitary measures,
such as a pure water supply, subsoil drainage, sewer-
age, the drying up of pools and marshes, and the pro-
tection of river lands from overflow. — Boktin del Con-
sejo Superior de Saluhridad (Mexico), No. 8, 1900.
Prevention and Treatment of Pelvic Inflamma-
tory Diseases in the Female by the General Prac-
titioner.—K. R. Kime believes that fifty per cent, of
pelvic inflammations are due to infection after abor-
tion or labor, twenty-five per cent, to gonorrhoeal in-
fection, and the remainder to various causes, such as
rheumatic diathesis, chilling during menstruation,
venereal excesses, and uncleanliness in minor gynae-
cological manipulations. He makes a plea for greater
cleanliness in what are ordinarily considered matters
of minor importance, and gives minute directions for
the various emergencies of the puerperal period, post-
abortion week, etc. He lays the greatest possible
stress upon the necessity of uterine and alimentary
drainage. -^Annals oj Gynecology and Pediatry, April,
igoo.
June 2, 1900]
MEDICAL RECORD.
955
Medical Record:
A Weekly Journal of Medicine and SiiTgcrj'.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD &. CO., 51 Fifth Avenue.
New York, June 2, 1900.
THE CARE OF THE CONSUMPTIVE POOR.
The opinion is rapidly gaining ground in this and in
other countries that steps should be taken to provide
proper accommodation and treatment for those persons
suffering from pulmonary tuberculosis whose means
will not allow them to live under the conditions best
calculated to cure or arrest the progress of that dis-
ease. Attention is also being drawn to the fact that
the consumptive individual is a source of more or less
danger to those in the immediate neighborhood, and
that therefore his isolation will be to the best inter-
ests of the community at large and the only effectual
method of successfully preventing the spread of the
malady. In order to bring this niuch-to-be-desired
state of affairs to pass, sanatoria on a very large scale
must be erected within a convenient distance of cities.
However, much money will be required for the accom-
plishment of the scheme, which will certainly not be
forthcoming in sufficient quantities from private or
public charity. Consequently it is argued that it is
incumbent on the State to act in loco parentis, and that
the people should be taxed for the benefit of their
poor brethren.
Ur. Howard S. Anders read a paper on this subject
at the joint meeting of the Philadelphia County Medi-
cal Society and the Pennsylvania Society for the Pre-
vention of Tuberculosis, held on January 10, 1900, in
which he said: "In the evolution of the care of con-
sumptives, State aid is truly an opportune, just, and
consummate factor. First the private pay sanatorium;
then the hospital for poor consumptives maintained by
voluntary contributions; and now the public hospitals
and sanatoria for advanced and incipient cases re-
spectively. England has accommodation for about
five thousand poor cases supported by charity only,
leaving about seventy thousand cases more unpro-
vided for. Germany has about fifty sanatoria, but
mostly for pay cases of tuberculosis, although many
more for the poor are in process of installation by the
government and by private enterprise separately and
co-operatively. The Swedish parliament recently
voted 850,000 kroner for a sanatorium for Soulli
Sweden; and 2,200,000 kroner given by the people to
King Oscar has been turned over by him for sanatoria
in northern and central Sweden."
The striking success of the sanatorium treatment
of consumption has been so decisively demon sti ate tl
that it would be needless to dwell upon tl it part of
the question. There can be also no doubt that the
indigent require this description of treatment to a
much greater extent than the well-to-do, and have the
right to expect it. Dr. Edward O. Otis, in a paper
read at the meeting referred to above, said : " If it is
the duty of the city, as most cities so consider it, to
provide for the care and treatment of its injured and
sick poor suffering from other diseases, it is equally
its duty to provide for the equally worthy poor con-
sumptive. It is his misfortune to have this fearful
disease, not his crime or personal election. He sees
a neighbor with appendicitis taken to a perfectly ap-
pointed hospital and operated upon by the most skil-
ful surgeon, or another with pneumonia receiving like
care and skill; but for him the city neither will nor
ought to open the doors of its general hospitals, and •
he must either drag out his life in wretchedness, or as
a last resort go to the almshouse. And further, there
is the added reason why he should be provided for,
because his disease is a communicable one and he is
endangering others."
The question of treating the poor consumptive in a
manner satisfactory to himself and to others is one
beset with difficulties on all sides. It is manifest
that the matter is too large to be undertaken by indi-
vidual effort, and that if anything is to be done the
State must take it in hand. It has been pointed out
in the Medical Record many times that the inroads
of consumption might be very greatly checked in cities
by municipalities insisting that the poor are housed in
sanitary healthy dwellings. By all means build sana-
toria for the poor consumptives, but at the same time
strike at the root of the evil. The following words,
written by Dr. Clifford Allbutt, in The Fractitioner,
January, 1899, are very much to the point: " Are we
to hope that consumption, like smallpox, may become
a tale of the past? If so, like smallpox it must be
banished by preventive means. Is there any prospect
of such a consummation? Undoubtedly there is, and
while we are perfecting our means of cure, let us not
rest until these perfect means are no longer wanted.
Tuberculosis has fallen into the class of infectious
diseases, and must be resisted by the methods appli-
cable to infectious diseases. These are to seek for an
antidote and to abolish the immediate cause."
REPORT OF THE CHIEF SURGEON OF THE
DEPARTMENT OF MATANZAS AND SANTA
CLARA.
The fact that Cuba, and particularly its towns, at the
time of the American invasion were in the most de-
plorable sanitary condition is a well-worn story. The
first portion of the report referred to above gives a
detailed account of the successful efforts made by the
medical department in Matanzas to place the military
camps in that province in a satisfactory hygienic
state. It is stated that yellow fever would appear
to be practically abolished among the troops, and the
only diseases that occasioned any anxiety were the
venereal affections. In a total strength of 1,121 at
the time of the publication of the report there were in
956
MEDICAL RECORD.
[June 2, 1900
Matanzas 150 sick, or a percentage of 13.3; of these
70 were venereal in character, or a percentage of 6.2,
leaving a sick report of -j.i per cent, of other diseases.
The most serious problem affecting the commissary
department, according to the chief surgeon, is that
relating to the supply of ice for troops serving in the
tropics. It is pointed out that civilization and sani-
tation have demonstrated that ice has long since ceased
to be a luxury and become a necessity, consequently
in the modern days of ice machines there is no excuse
for the absence of this article in all of our garrisons.
The present system of purchasing from outside parties,
except in transient cases, is expensive, uncertain, and
in every way undesirable. Ice plants of sufficient ca-
pacity should be located in certain localities which
will be distributing-points for the smaller garrisons.
The public charitable institutions, which in this
department, as in the other provinces of the island,
were found to be in an incredibly filthy condition, were
placed under the supervision of the medical depart-
ment, and were thoroughly cleansed and reorganized,
greatly to the benefit of their inmates. The latter por-
tion of the report is chiefly devoted to a consideration
of the work of the sanitary department, and demon-
strates the good efifect of prompt and vigorous meas-
ures. The statement is made that the sanitary condi-
tion of Matanzas and Santa Clara — when the report
was issued — was excellent. The death rate had de-
creased and starvation and yellow fever were absent.
Nevertheless attention is drawn to the fact that the
present methods of sanitation are but the forerunners
of what remains to be done, and that unless a perma-
nent, scientific, economic, and efficient system be es-
tablished, the work already done will in great part
bear little more than temporary fruit.
Chief Surgeon Ives concludes his report: " I would
state that since my association with this command,
which dated from December 3, 1898, the health of the
troops has been excellent. Prior to embarking for
Cuba the sanitary conditions in all camps of the di-
vision with which I had the good fortune to serve were
everything that could be expected, thereby resulting
in as healthy and fine appearing a body of men as
then existed in the army. It would not be inappro-
priate to state that the condition of almost perfect
health in this command and its freedom from typhoid
is the natural sequence of military sanitation, syste-
matically and thoroughly applied. . . . The health of
the command compares favorably with that of any in
the division. All medical and line officers seem
keenly alive to the importance of the sanitary situa-
tion, and are working diligently to prevent infection,
and the fact of the absence of all traces of such indi-
cates that up to the present time at least their efforts
have been eminently successful."
All evidence points to a hopeful anticipation that,
under the vigorous leadership of Governor Wood,
aided by the earnest co-operation of the medical and
sanitary departments, Cuba, instead of as in times
past being a hotbed of disease and looked upon as the
white man's grave of this part of the globe, may be-
come an altogether desirable place of residence, pos-
sibly a health resort.
^ctDs at X\xz 'Wiztk.
Dr. Harry Warren Lincoln has been appointed
gastrologist to the Bushwick and East Brooklyn Dis-
pensary.
Nu Sigma Nu. — The third annual banquet of the
XI. Chapter of the Nu Sigma Nu medical fraternity
of the University and Bellevue Hospital Medical Col-
lege was held Thursday evening. May 24, igoo, at the
Hotel Belvedere.
American Proctological Society — The following
officers were elected at the meeting of the American
Proctological Society at Washington, May 6, 1900:
President, Dr. James P. Tuttle, of New V'ork; Vice-
Frcsiiient, Dr. Thomas Charles Martin, of Cleveland.
Ohio; Secretary, T)\.Wi\\\2im M. Beach, of Pittsburg,
Pa. ; Executive Council, Drs. S. T. Earle, Jr., of Balti-
more, Md., A. B. Cooke, of Nashville, Tenn., and J.
R. Pennington, of Chicago, 111.
The Fifteenth Annual Conference of State and
Provincial Boards of Health of North America was
held at the Hotel Dennis, Atlantic City, N. J.,
on June i and 2, 1900. The set discussion was on
school hygiene. The officers of the conference for
1900 are: President, Dr. U. O. B. Wingate, of Mil-
waukee, Wis.; Vice-President, Dr. Charles O. Probst,
of Columbus, Ohio; Treasurer, Dr. J. A. Egan, of
Springfield, 111.; Secretary, Dr. J. N. Hurty, of In-
dianapolis, Ind.
National Confederation of State Medical Examin-
ing and Licensing Boards — The tenth annual meeting
of this confederation will be held in the Hotel Tray-
more, Atlantic City, N. J., on Monday, June 4, 1900.
Members and ex-members of State medical examining-
boards, physicians, and educators who are interested
in the cause of higher medical education are invited
to attend. Every State or Territorial board whose duty
it is to examine or license physicians intending to
practise in the jurisdiction of the board, by whatso-
ever name it may be called, is urged to affiliate with
the National Confederation, if it has not already done
so. The officers for 1899-1900 are: President, Dr. J.
N. McCormack, of Bowling Green, Ky. ; Vice-Presi-
dents, Drs. N. R. Coleman, of Columbus, Ohio, and B.
F. Crummer, of Omaha, Neb. ; Secretary-Treasurer,
Dr. A. Walter Suiter, of Herkimer, N. Y.
The Roentgen Society of the United Status. —
There has been organized a Roentgen Society of the
United States, with the American X-Ray Journal, St.
Louis, Mo., as the official organ. This society is the
only one of its kind in America. It is national in
character, and is represented by physicians, surgeons,
dentists, and radiographers in the several States. The
constitution is similar to those of the Roentgen socie-
ties in Europe. The annual dues are $5. The first
regular meeting will be held in December, 1900, in
New York. Many papers have been promised by emi-
nent men abroad and here, and a very successful
scientific meeting is looked for. There will be an exhi-
bition of .v-ray and electro-therapeutic apparatus, radio-
June 2, 1900]
MEDICAL RECORD.
957
graphs, etc., during the meeting of the society. The
chairman of the committee of arrangements is Dr.
Monnel, of New York. The society will be repre-
sented at the International Congress of Medical Elec-
trology and Radiology, in Paris, France, by Dr. Price,
of Cleveland, Ohio. The secretary of the society is J.
Rudis-Jici'nsky, of Cedar Rapids, Iowa. The presi-
dent is Dr. Heber Robarts, of St. Louis.
The Delaware County (Pa.) Medical Society-
celebrated its fiftieth anniversary at Media on May
27 th, and the event was made the occasion of a gift to
Dr. William B. Ulrich of a silver loving-cup in recog-
nition of his fifty years spent in the practice of medi-
cine.
Asociated Health Authorities of Pennsylvania.
— At the meeting held at Mechanicsburg on May 23d
and 24th, Prof. A. J. Beitzel, of Mechanicsburg, read
a paper on "School Hygiene." Miss Dora Keen, of
Philadelphia, presented a communication on "The
Medical Inspection of Schools." Dr. Benjamin Lee,
of Philadelphia, read a paper entitled " Recent State
Legislation for the Protection of the Health and
Lives of School Children." Mr. C. Herbert Obreiter,
of Lancaster Township, presented a communication
entitled " The Rural Director as a Health-Officer."
Dr. A. C. Abbott, of Philadelphia, read a paper on
" General Hygiene." Mr. Moritz G. Lippert, of
Phoenixville, advocated State inspection of commer-
cial dairies and herds. Dr. H. B. Bashore read a
paper on " Rural Hygiene." Dr. R. S. Maison, of
C^hester, spoke upon "Township Supervision." Mr.
W. H. Allen, of Philadelphia, discussed measures cal-
culated to render State health protection effective.
Pathological Society of Philadelphia. — At a
stated meeting held May 24th, Dr. A. A. Eshner pre-
sented the heart and the brain from a case of rupture
of an aortic leaflet and cerebral hemorrhage, with
right hemiplegia and aphasia, and he pointed out tlie
difficulty of diagnosis especially from cerebral em-
bolism. Dr. L. Pearson and M. P. Ravenel reported
a case of pneumonomycosis due to the aspergillus
fumigatus. The specimens were obtained from a calf
thought possibly to be tuberculous, but not reacting
to tuberculin, and the lungs presented an appearance
of mixed emphysema and condensation, with peculiar
hemorrhage-like lesions of varying size. Cover-slip
preparations disclosed a fungous growth, which cul-
ture proved to be the aspergillus fumigatus. Dr.
Joseph McFarland exhibited cultures and tissue prep-
arations showing plague bacilli. Dr. A. O. J. Kelly
presented a communication on "Papillomatous Epi-
thelioma of the Pelvis of the Kidney," adding the re-
port of one case to the few already on record. Dr.
Simon Flexner made some remarks on " The Nature of
the New Tissue in Cirrhosis of the Liver and its Dis-
tribution," detailing the employment of various
stains, showing that all of the connective tissues take
part in the hyperplasia. Drs. E. P. Davis and H.
F. Harris reported a case of chorio-epithelioma witii-
out uterine lesion, the patient having been a multi-
parous woman in the third month of pregnancy, in
whom it became necessary to empty the uterus for the
relief of pernicious vomiting. The woman failed,
however, to recover, and post-mortem examination
disclosed neoplasms in the brain, liver, kidney, lungs,
and elsewhere, which on histological examination were
found to be chorio-epitheliomata. The uterus was
free from disease.
A Long Hospital Service.— Dr. John Cameron,
who lately resigned, on account of advanced age, his
position of physician to the Royal Southern Hospital,
Liverpool, had been actively connected with the insti-
tution for fifty-two years.
The University of Edinburgh Dr. John Wyllie
has been appointed to the chair of practice of physic
in the University of Edinburgh, rendered vacant by
the death of Sir Thomas Grainger Stewart. Dr.
Wyllie is fifty-six years of age, and has been a mem-
ber of the medical profession for thirty-five years.
Smallpox in Hudson River Towns.— Several
cases of smallpox have recently been discovered in
North Tarrytown and other places in that vicinity.
The houses where the disease exists have been quar-
antined, and all the children in the school at North
Tarrytown have been revaccinated.
Havana Temporarily Free from Yellow Fever. —
A report to the surgeon-general of the army from
Major W. C. Gorgas, chief sanitary officer of Havana,
states that there were no deaths from yellow fever in that
city during April. This was the first month without
a death from the disease since May, 1899, and the
only one during the last ten years, with two excep-
tions, February and May, 1899. The total number of
deaths during the month was four hundred and eighty-
two.
Philadelphia County Medical Society At a stated
meeting held May 23d, Dr. L. J. Hammond exhibited
a new growth of undetermined nature removed from the
abdominal wall of a woman. Dr. H. W. Cattell made
a demonstration of lantern slides prepared from fresh
specimens, with an exhibition of some pathological
specimens preserved by Kayserling's method. Dr. J.
P. Crozer Griffith read a paper entitled " Percentage
and Laboratory Feeding of Infants in Health and
Disease," in which he pointed out by means of illustra-
tive cases the great advantage of methods of scientific
precision in the artificial nourishment of infants. Dr.
Lewis S. Somers presented a communication entitled
"The Use of Adrenal Extract in Hay Fever," report-
ing the results obtained in some twenty cases. Al-
though the drug exhibited marked local effects, little
benefit was observed from its administration by the
stomach.
The International Congress of the Medical Press
will meet in Paris on July 26th, 27th, and 28th.
The two chief subjects proposed for discussion are : ( 1 )
The advisability of founding an international associa-
tion of the medical press and the conditions on which
such an association should exist; and (2) the appli-
cation of the principle of the protection of literary
property to medical literature. Other questions
958
MEDICAL RECORD.
Qune 2, 1900
which have been suggested for discussion are: the
unification of medical technical terms; the extension
to members of the medical press of certain privileges
accorded to members of the political press; a better
understanding as to what constitutes a legitimate quo-
tation; the principle which should govern exchanges
of papers; the representation of medical papers in
foreign countries; and the part of the medical press
in the organization and preparation of medical con-
gresses. The committee on organization consists of :
President, Professor Cornil ; vice-presidents, Drs.
Lucas-Championniere and Laborde; treasurer, Dr.
Cezilly; and general secretary. Dr. R. Blondel, 8 Rue
Castellane. All publishers, proprietors, editors, and
members of the staffs of medical journals are eligible
for membership in the congress upon the payment of
a fee of 25 francs ($5). The families of members and
medical men and medical students may also attend as
spectators on payment of an entrance fee of 10 francs
($2). They may participate in the fetes and recep-
tions, but cannot take part in the discussions of the
congress, nor can they vote on any question before
the meeting.
Dr. John B. Walker has been appointed visiting
surgeon to Bellevue Hospital, second division, vice
Dr. F. H. Markoe resigned.
New York State Hospital for the Care of Crip-
pled and Deformed Children, — In an editorial note
on "Medical Legislation in New York State" in the
issue of May 26th, it was inadvertently stated that
the bill calling for the establishment of the above-
named institution failed to pass. The bill not only
passed but was signed by the governor, as was noted
in these columns at the time.
Yellow Fever among American Troops. — Five
cases of yellow fever have broken out at Santa Clara
among men of the Second Cavalry who are married to
Cuban women and who live out of the barracks. There
are only two cases in the province of Havana, and
there is not one in the city.
How to Free a Town from Mosquitos. — At a
meeting of the Societh, Medico-Fisica Universitaria of
Sassari, on March 23d, Dr. C. Fermi gave an account
of certain experiments made in Sassari, in conjunc-
tion with Dr. Lumbau and Dr. Cossu-Rocca, with the
object of freeing the town from mosquitos. He was
able to discover all their breeding-places in different
parts of the city, in drains, cisterns, puddles, etc. The
method adopted was the destruction of the larvae by
means of petroleum placed in the breeding-grounds
twice a month. The mosquitos were destroyed in
shops by means of chlorine, and in houses by means
of other culicides, such as a mixture of pyrethrum,
chrysanthemum flowers, valerian, and calamus aro-
maticus, or the "zanjoline" of Celli and Casagrandi.
The results obtained were so satisfactory that Dr.
Fermi concludes from them that it is always possible
to free a town from mosquitos unless the condi-
tions are exceptionally unfavorable — as, if it be situ-
ated in the midst of a swamp. He estimates the ex-
pense of freeing a town of fifty thousand inhabitants at
1,000 to 1,500 lire ($200 to $300) a year. This includes
the wages of the staff required to carry out the measures
prescribed. — British Medical Journal, May 12, 1900.
A Martial Medical Man. — A troop of Westchester
County cavalry has been organized in Mount Vernon,
N. Y., and Dr. Edward F. Brush of that city has been
elected captain. Dr. Brush, who is a graduate of Belle-
vue in 1875, was formerly mayor of Mount Vernon.
The Plague is reported again in Brazil, several
cases having been discovered during the past week in
Rio de Janeiro. A case has occurred at Durban in
the person of an East Indian employed in the army
transport service. — The first death of a white man at
Manila from bubonic plague occurred on May 21st.
The victim was a government teamster. Seven
natives have died since the outbreak of the plague at
Quiapo Market. — In San Francisco the house-to-house
inspection of Chinatown was continued by the inspec-
tors of the board of health during the first part of the
week, but no case of bubonic plague was discovered.
The United States circuit court has issued an order
restraining the health officials from inoculating the
Chinese. The Colorado State board of health has es-
tablished a quarantine against California. — In Sydney,
N. S. W., there have been two hundred and forty-seven
cases of plague since the beginning of the epidemic,
eighty-nine of which have resulted fatally. — The dis-
ease has appeared again in Osaka, Japan.
Navy Department, Bureau of Medicine of Sur-
gery, Washington, D. C, May 12, 1900. — Changes in
the medical corps of the United States navy for the
week ending May 26, 1900. May 21st. — Medical
Director T. C. Walton detached from duty at the
naval laboratory, Brooklyn, N. Y., and from other
duty May 20th, and ordered home to wait orders
and retirement May 31st, at sixty-two years of age.
Passed Assistant Surgeon W. C. Braisted, orders to
the Alayflower revoked; when the Detroit is placed
out of commission detached and ordered home and di-
rected to hold himself in readiness for orders to sea.
Passed Assistant Surgeon G. T. Smith detached from
the naval laboratory and department of instruction,
Brooklyn, N. Y., June 14th, and ordered to the May-
flower, June 15th. May 22d. — Passed Assistant Sur-
geon G. D. Costigan detached from the Boston navy
yard May 29th, and ordered to temporary duty on the
Pensacola, and then to the Asiatic station via the
Gaelic. Assistant Surgeon E. Davis detached from the
naval hospital, Brooklyn, N. Y., May 29th, and ordered
to temporary duty on the Pensacola, and then to the
Asiatic station via the Gaelic. Assistant Surgeon J.
T. Kennedy detached from the Independence June 4th,
and ordered to the Asiatic station via the Gaelic.
May 24th. — Assistant Surgeon T. M. Lippett detached
from the Oregon and ordered to the Ncivark. May
2ist. — Pharmacist S. W. Douglas detached from the
Wabash and ordered to the Key West naval station
for such duty as may be assigned as relief of Phar-
macist I. N. Hurd. Pharmacist I. N. Hurd, upon re-
porting of relief, detached from the Key West naval
station and ordered to the Wabash.
June 2, 1900]
MEDICAL RECORD.
959
Obituary Notes. — Dr. J. S. R. Hazzard, of Spring-
field, Ohio, died suddenly on May 26tli, at the a^^e of
seventy-four years. He was one of the foremost men in
the State for years, and a raiser of fine stock. Delaware
was his native State. He was a graduate of the medi-
cal department of the Western Reserve University.
Dr. John MacDonald, a surgeon in the employ of
the American Line, died at Philadelphia on May 21st
from pneumonia. He was born in India of Scotch
parents in 1835, and studied medicine in London.
For the past eighteen years he had been a steamship
surgeon, and for four years was on the Wacs/and, on
which vessel he died.
Dr. John L. Leprohon, of Montreal, died in that
city on May 23d. He was a veteran of the Civil War
and a founder of Hancock Post, G.A.R. He was a
graduate in medicine of McGill University in 1843.
Dr. Horace B. Scott, United States navy, retired,
died at Wallingford, Conn., May 29th, aged forty-three
years. He was graduated at Trinity College in 1878,
and later from the Jefferson Medical School. For
several years he was a surgeon in the United States
navy until his health failed, when he was retired.
FESSENDEN NOTT OTIS, M.D., NEW YORK.
Dr. Fessenden N. Oris died on Thursday, May 24th,
in New Orleans, at the age of seventy-five years. He
was born in Ballston Spa, N. Y., on March 6, 1825,
and was graduated in arts from Union College. His
medical degree was conferred by the New York Medi-
cal College in 1852, and in 1876 he received the
honorary M.D. from the College of Physicians and
Surgeons in this city. After serving a year at Black-
well's Island Hospital he passed some years as sur-
geon on vessels of the United States and Pacific Mail
steamship companies, and was later superintending
surgeon on shore of the Pacific Mail Company. In
1862 he was appointed a police surgeon, and was presi-
dent of the medical board of the police department
for several years. In 1862 he was appointed lecturer
on diseases of the genito-urinary organs at the Col-
lege of Physicians and Surgeons, and clinical pro-
fessor in the same branch in 187 1. He was also con-
nected at various times with many dispensaries and
hospitals in New York City.
Early in his medical career Dr. Otis turned his
attention to diseases of the genito-urinary system, and
his labors and teachings contributed much to the ad-
vancement of this specialty. His views regarding the
normal calibre of the male urethra were thought ex-
travagant at the time they were first propounded, and
he was obliged to defend them stoutly in many rather
heated discussions before medical societies and in
the medical press. He was the inventor of many
urethral instruments, especially dilating instruments,
and was the author of many papers and works on
genito-urinary diseases and syphilis. He also wrote
several works on the tropics and the Panama Rail-
road, and before graduating in medicine published a
book of instruction in drawing.
Ten years ago Dr. Otis resigned his medical posi-
tions and retired from practice, travelling for a long
time in Japan and the Far East. He never lost his
interest in medicine, however, and used frequently,
while in New Orleans, to attend the clinical lectures
at the Charity Hospital in that city.
grogress at ||XcxUcal Science.
New York Medical Journal, May 26, igoo.
Report of a Case of Haematuria due to Renal Carcinoma ;
with Endovesical Photographs.— F. Beirhoff reports tlie case
of a woman, aged fifty years, who had passed blouil in the
urine at intervals for over a year. Cystoscopy showed no
changes in the vesical mucosa. The right ureteral orifice
was occluded by a blood clot which protruded for about i
cm. into the bladder. The left ureter was normal, and was
seen to discharge clear urine actively. The lower left por-
tion of the bladder was seen to be occupied by a large blood
clot, which prevented proper maumulation for ureter cath-
eterism before another irrigation to discharge the clot could
be made. In view of the fact that the patient had a second
time become comatose, and that catheterization of the ure-
ters was not an absolute necessity here, this procedure was
omitted, and a diagnosis of right unilateral haematuria of
renal origin, probably due to renal tumor, was made. The
patient was, in view of her extremely critical condition, at
once replaced in bed, and a course of active stimulation
continued. Later, nephrectomy was performed by Pro-
fessor Gebhard, the right kidney and as much of the ureter
as could be reached being removed. The kidney was
found to be carcinomatous. The subsequent history of the
case was uneventful, the urine being for two days slightly
tinged with blood, due to the discharge of the vesical and
ureteral clots, after which it remained free.
On the Dietetics of the Convalescent Stage of Fevers. — A.
Rupp believes that density of food is one of the chief con-
ditions that deternjiue its digestibility. Therefore weak
stomachs and lazy intestines should not be burdened with
foods that are impervious to the juices of the digestive
canal. To quote Hutchinson: "The intestines demand a
certain amount of insoluble residue " — and they get it —
"to act as ballast and serve as a stimulus to peristalsis."
All this does not militate against allowing convalescents
puddings and gelatins and creams. The absorption and
digestibility of the.se luxuries can be favored by sipping
water, plain or carbonated, as they are eaten. Sometimes,
from nervous causes or from the lack of having something
to do, the stomach will give rise to insomnia, or to distress
and uneasiness and even nausea. Such cases must be
studied individually and treated accordingly. A cup of
milk, diluted or undiluted, with or without lime-water, or
a crust of bread, and even cold water sipped, may give re-
lief.
A Study of the Application of the Galvano-Cautery in the
Nose. — B. Douglass believes that the cautery is a destruc-
tive element even more powerful than the knife ; that it
destroys physiological tissue as completely as if it were re-
moved from the body ; that its effects extend, unlike those
of the knife, to a region beyond its limit of application ;
that it is subject to all the dangers of surgical accident
which come from using the knife, with the single exception
of hemorrhage ; and that, besides the ordinary surgical
dangers, it has special dangers of its own — that is, it may
furnish a nutrient pabulum for bacterial growths. Used in
the hands of a novice it is capable of producing a subse-
quent atrophic condition worse than the original disease.
Its present method of use by linear cauterization is, to say
the least, theoretically incorrect, but in special and selected
cases, used by a proper method and in the hands of a care-
ful operator, it will give better results than cutting methods.
The General Characteristics of Ray Fungi and their Rela-
tion to Certain Bacteria. — L. Hektoen reviews the literature
on this question, stating that Olsen regards most bacteria
as adaptation forms and not as true independent species.
They are in reality imperfect and imperfectly known fungi.
The ray fungi are genuine mycelial fungi which pass by
various stages into bacilli, and the tuberculomyces (the
name, according to the new view, of the bacillus tubercu-
losis) is a ray fungus or streptothrix becaa-se it has
branches. Allusion is also made to the branching of diph-
theria, glanders, and other bacilli. An extensive bibliog-
raphy is appended.
Treatment of Anal Chancroids.— The plan commended by
M. A. H. Thelberg consists of the following steps : general
anaesthesia, dilatation of the sphincter, cauterization of the
chancroid with the Paquelin cautery, rubbing orthoform
into the wound, and the insertion into the bowel of a good-
sized rubber drainage tube wound about with iodoform
gauze and dusted with orthoform. The usual dressing
with T-bandage is then applied. The bowels are controlled
for three days, then moved with magnesia, an enema of
olive oil and castor oil in equal parts being given at the
same time. A cleansing enema follows the catharsis, and
a ten-per-cent. iodoform suppository is introduced. Results
have been excellent in eleven cases.
Physical Training in School and Home.— By H. S. Pettit.
960
MEDICAL RECORD.
[June 2, I goo
The Instruction of the Hospital Corps of the United States
Army.— By W. H. Wilson.
A Summer Plaster-of-Paris Jacket for Pott's Disease. -Bv
R. T. Taylor and S. H. McKim.
Septicaemia among Young Chickens. — By L. F. Rettger.
Joiiinal of American Medical Association, May 36, rgoo.
Medicine as a Business Proposition. — G. Frank Lydston
discusses the business side of medical practice and shows
some of the reasons why the average medical man is not as
prosperous financially as he ought to be. Among other
drawbacks, he devotes much space to the "inconsistencies
and absurdities of ethics," concerning which he says;
"There was once a time when it appeared a goodly thing
for the chosen few to g^t together, like the ' three tailors of
Tooley Street,' and, after establishing to their own satis-
faction the fact that they were indeed ' the people. ' formu-
late rules for the guidance of the many. These rules were
called ' ethics. ' And the profession has been wrestling with
its ethics ever since, trying to determine what it was all
about, anyhow. The ethical garment of half a century ago
no longer tits — it is frayed and fringed and baggy at the
knees : full many a patch has been sewed on it, in individ-
ual attempts to make it iit from year to year, until it is now.
like the Irishman's hat, respectable by age and sentimental
association only. And the public, the ever practical and
heartless public, has also wondered what 'twas all about,
and exhibits little sympathy for a profession which, while
drivelling of ethics, has 'strained at gnats and swallowed
camels.'" He says that the present sj'stem of ethics is not
only hypocritical, but somewhat confusing. "The young
man on the threshold of medicine doesn't know 'where he
is at. ' He is confronted by the un\yitten law that only
celebrated men and quacks may advertise. Small fry, who
haven't the ear of the newspapers nor a chance for a col-
lege position, are tacitl)^ ordered to keep their hands off.
And the young fellow watches the career of the big man,
who hides every other man's light under his own bushel,
and marvels much. " Other obstacles in the way of suc-
cess of any but the favored few are the hospital and dis-
pensary evils and the superabundance of medical colleges.
Experiments and Observations in Scarlet Fever. — W. K.
Jaques discusses the investigations which have been made
in Chicago regarding the oupposed germ of scarlet fever,
and concludes that the "crescent" of Wynkoop and the
"diplococcus " of Class are merely different forms of the
same germ. He thinks the symptoms in the disease are
caused by the multiplication of the germs themselves and
their irritating presence, and not, as in diphtheria, by any
toxins they may produce. He says in this respect the scar-
let-fever germ resembles the typhoid bacillus. He pur-
poses making experiments in the production of artificial
immunity after the following method whenever an oppor-
tunity presents itself: "Raise a small bleb by means of a
fly-blister ; with a hypodermic needle inoculate the serum
without breaking the blister, if possible. If the patient is
susceptible, the germs ought to multiply in this serum, and
before passing into the blood they would have to get
through the barrier of inflamed capillaries filled with leu-
cocytes. In this manner their entrance would be slow and
the blood coivid gradually take up the products of germ
multiplication in the serum, while the cells would be stim-
ulated to the production of a defensive antigermin."
Carcinoma in Early Life. — Walter L. Bierring reports
eight cases of cancer occurring in patients aged respect-
ively twenty-three, twenty-six, twenty-seven, twenty-
eight, thirty, thirty-two, thirty-four, and thirty-five years.
He says the disease in early life is becoming more fre-
quent, though whether it keeps pace with the general in-
crease in carcinoma he thinks it will be difl^cult to deter-
mine. He reviews the several etiological theories of the
cause of malignant new growths, but brings forward noth-
ing of importance which might contribute to a solution of
the problem.
Chronic Constipation a Symptom Resulting from a Disor-
dered State of the Sympathetic Nervous System ; its Cause
and Cure. — By Charles E, Stewart.
Report of a Unique Case of Appendicitis, with Some Re-
marks on Treatment. — By James T. Jelks.
Pathology of Criminal Abortion. — By Maximilian Herzog.
Complete Occlusion of the Bowel. — By Dwight E. Cone.
Distilled Water as Food.— By Ephraim Cutter.
Quinine Amblyopia. — By M. Caplan.
Philaddfiliia Medical Journal, ^Tay 26, rgoo.
Syphilis. — S. H. Friend treats of the special pathology
and advocates reclining rest-treatment in the constitutional
stage. He concludes: (i) That without regard to the
system, organ, or tissues affected, and irrespective of the
period of syphilitic infection, all syphilitic lesions begm in
the arteries. The truth of this special pathology is demon-
strated by a study of the symptomatology of syphilis.
There are few symptoms of the disease which cannot be
explained b)* (a) an acute change in the arterial wall caused
by the infection, (/') by a chronic change in the arterial
wall or a destruction of the artery, a sequel of the syphilitic
infection, (e) by a relapse of the syphilitic infectioncausing
changes in the arterial walls and destruction of the artery.
A study of the pathological phenomena of the disease shows
that almost every phase of those phenomena, including the
formation of connective tissue, gumma, and the virulent
infectiousness of the blood, is explained by the disease in
the walls of the arteries. (2) That (a) the special pathol-
ogy of syphilis is in a disease of the arterial walls ; (/') that
this disease of the arterial walls bears the same relation to
syphilis as does the disease of Peyer's glands of the intes-
tine to typhoid fever ; the disease of the skin to smallpox ;
the formation of a fal.se membrane to diphtheria, etc. The
foregoing special pathology demands that reclining rest be
made a routine treatment during the constitutional stage.
Clinical Notes on a Case of Paranoia.— A. W. Ferris re-
lates an interesting history of a medical man who, having
strong neurotic heredity and history of eccentric childhood,
after a life of early dissipation became extravagant, ac-
quired exalted and egotistic religious delusions, and
claimed to be "the second coming of Christ," carrying out
his ideas by producing voluminous "Scriptures," seeking
followers, etc. He finally had systematized delusions of
persecution, with occasional outcrops of hypochondriasis,
and a possible capacity for homicide.
Rickets. — J. L. Morse gives, with pictures, an account of
the skeletal changes : rosary thorax, enlargement of the
epiphyses, and deformities of the long bones, bow-legs,
knock-knees ; weakness of the spine, pot-belly, feebleness
of leg-muscles, increased nervous irritability ; changes in
the skin, glandular system, respiratory tract, circulatory
system, enlargement of the spleen, etc. He finds the
causes to be dietetic and hygienic. The prognosis is good
as to life, and treatment must be along the lines of dietetics
and hygiene.
Friedrich's Disease, with the Report of a Fatal Case. — F.
S. Pearce and J. M. Swan relate the history of a girl, aged
nineteen years, first seen in 1^95, when knee jerk was still
present. Six months later, in iSg6, it had entirely disap-
peared, and nystagmus, at first absent, appeared the fol-
lowing year. At no time were there pains in the joints or
muscles, and the athetoid movements first noted in the
hands subsequently appeared in the neck. There was no
post-mortem obtainable.
The Hospitals for the Insane and Study of Mental Dis-
eases.— By Stewart Paton.
Mutter Lectures of the College of Physicians of Philadel-
phia.—By J. B. Roberts,
Intestinal Indigestion and its Consequences. — By W. H.
Porter.
Boslon Medical and Surgical fournal. May 24, /goo.
On Ischaemic Paralysis and Contracture of Muscles. — Au-
gustus Charles Bernays says that the only t)peration or
tlierajieutic measure that .suggests itself to his mind as
promising any real benefit in this condition is the excision
of a transverse section of the radius and ulna. The piece
to be resected should be from 2 to 4 cm. in length, and both
long bones would be shortened just that much. The con-
tracted muscles and their tendons could then possibly ex-
ert a greater play upon the wrist and fingers. It is clear
that the muscular tissue in the forearm would not be in-
creased by this operation, as, indeed, it cannot be by any
possible surgical proceeding. The effect of the operation
would be to give such remnants of contractile substance as
may be in existence a chance to exercise theii« power to a
greater advantage. The functions of the fingers would
thus be more or less improved, and the usefulness of the
crippled hand increased.
The Ideal Rations for an Army in the Tropics. — By Ed-
ward L. .Munson.
Some Thoughts on Medical Education. — By Frederick C.
Shattuck.
Medical A'e7Cis, May 26, /goo.
Cystitis Papillomatosa. — Frederic Bierhoff reports three
cases of tliis ati'cctinn, which occurs in women as a form of
chronic cystitis, its symptoms being frequency of urination,
accompanied by more or less pain and tenesmus, the urine
passed being clear or turbid. Its seat is at the trigone,
which it usually covers, and it may extend over into the
urethra, from which at times it appears to start. Its villi
or papillfc spring from an inflamed base, and are discrete.
To diagnose the condition, the ureteral cystoscope is
armed with a ureter-catheter and inserted into the blad-
der, so that the window lies directly over and close to the
June 2, 1900]
MEDICAL RECORD.
961
. inflamed area : the catheter is then gently laid diagonally
upon this surface, or is passed over the surface at an angle.
It will at once sink into the mass of papillas, or pass be-
tween them, and the individual papillae will stand out dis-
tinctly as discrete, rosy-red tongues against the deeper
color of the catheter.
Organotherapy in Tabes and Other Nervous Diseases. —
Martin A. H. Thelberg reports two cases in which the ad-
ministration of spermin had undoubted beneficial effect
where other medication had failed. In the first case, after
si.x injections, incontinence, bladder and rectal pains dis-
appeared, and general tone, well-being, and cheer im-
proved considerably. After twelve injections had been
given, ptosis and oculo-motor symptoms were cured. In
the second case, one of paralysis agitans, the frequent in-
somnia, which in this patient seemed to be caused by auto-
intoxication from gastro-intestinal disturbances, is usually
relieved by a single injection of i c.c. spermin given hypo-
dermically. The stumbling gait is also gratefully afifected.
Medicinal and Non-Medicinal Remedies, with Points on
Hydrotherapy, Diet, and Massage in Certain Diseases At-
tended with High Temperature. — By Chark'S E. Page.
A New Method for Retroperitoneal Drainage of Pyosalpinx,
with a Report of Five Cases. — By Leon F. Garrigues.
Inaugural Address. — By Edward D. Fisher.
British Medical JoKfJial, May 12 and rg, igoo.
Remarks on Plague in the Lower Animals. — Frank G.
Clemow considers the acquisition of the plague hy mon-
keys under natural and artificial conditions ; then, after
eliminating mammals and bats, which have never been
known to suiTer, he takes up the important question of
plague in rodents, especially rats, and their sources of in-
fection— from grain, flesh of other animals, rags, insects —
the mode of their infection, and the way they transfer it to
man. Then the study of rats on shipboard and their infec-
tion under artificial conditions is taken up. Infection in
mice, squirrels, guinea-pigs, porcupines, marmots, and
rabbits is then studied. In conclusion, it maj- be asserted,
the author says, that the following animals are liable to
contract plague under natural conditions : monkeys, rats,
mice, bandicoots, squirrels, and marmots. Of these, rats
suffer far the most fi'equently, and are, of all animals, the
most important agents in the spread of the disease. Mice
are less susceptible, but appear, in some instances, to have
suffered considerably, and may have been agents in spread-
ing the infection. Monkeys, bandicoots, and squirrels have
on rare occasions suffered from plague, but there is noth-
ing to show that they have ever aided to any extent in trans-
mitting the disease to man. Marmots undoubtedly spread
a disease allied to plague in Transbaikalia, and possibly in
Mongolia. The evidence in regard to cats, dogs, and
jackals is far from conclusive, but there is no reason to be-
lieve that these animals play any great part in spreading
plague. The same is true of pigs, sheep, and goats.
Horses and cows do not appear to have ever contracted
plague under natural conditions, and may be disregarded
as active agents in spreading it. Birds are equally im-
mune to the di.sease, and there is no evidence to show that
either birds or reptiles or fishes have ever aided in multi-
plying and diffusing the infection. Insects, on the other
hand, are probably agents of considerable importance in
the spread of plague.
Small-Bore Rifle Bullet Wounds and the "Humanity" of
the Present War. — C. T. Dent finds that the great majority
of wounds in the present war are inflicted by rifle bullets.
Septic wounds, shell and shrapnel wounds, wounds from
small-bore arms, skin wounds, injuries of long bones,
wounds of joints and of the spinal column are considered.
In conclusion he sa5-s : "I dread lest the good surgical re-
sults be not ascribed fully enough to their proper cause.
We know tlie fearful mortality brought about by over-
crowding and by bad hygienic surroundings in the Cri-
mean War, and, for that matter, in the Franco-German,
Russo-Turkish, and other later wars. This campaign has
already shown that these preventable disasters have been
traced to their true source. Air, air, pure sunlight and air,
have done more, much more, for our wounded in this war
than seems generally to be acknowledged. I dread lest the
Army Medical Department, commended and patted on the
back as it has been and is, may relax its efforts to improve
further. If so, a terrible awakening is in store for us when
we next have to face the hideous horrors of war amid un-
favorable surroundings. But if we look on our present
experience just as an indication that we are working in the
right direction, then at least the medical profession may
feel that it is doing — not that it has done — its best to con-
tribute to the humanity of war."
Injuries of the Bladder Occurring in the Course of Gynse-
cological Operations. — J. W. Cousins gives a case in which
there was recovery after sloughing of the bladder walls and
free discharge of urine tln-ough the abdominal wound. In
rupture or wound of the bladder, he finds that success of
imrnediate treatment depends (i) upon the complete disin-
fection of the seat of injury, and (2) upon the accuracy
with which the stitches are inserted. It is .sometimes an
important question to decide whether the abdomen can be
safely closed without any provision for drainage. This
must be determined by the .severity of the injury, the state
of the urine, and the condition of the peritoneal cavity.
Surely, if other organs can be injured and the abdominal
wound closed, there can 1)e no reason why bladder injuries
should not admit of the same treatment. In his case, how-
ever, it appears highly probable that the introduction of
a glass drainage tube was a fortunate precaution, and ma-
terially aided in saving the life of the patient by establish-
ing a channel for the direct escape of the urine. On the
other hand, if the abdomen had been completely closed at
the time of the operation, the rupture would have been fol-
lowed by the accumulation of septic fluid within the pelvis,
which would have very probably terminated in fatal sep-
ticaemia.
Herpes Progenitalis from a Diagnostic Point of View.—
Arthur Cooper says it must be remembered that herpes is
one of the most sensitive of lesions, and that nothing
resents ill treatment more^promptly or more actively. One
of the commonest causes for irregularity is the course of
herpes in balanoposthitis. A polyc'yclic outline of the edge
of the ulcer can often be made out with the aid of a lens.
A case is cited in which herpes was present at the time of
infection with syphilis ; a condition in which the latter may
readily be overlooked. The following points may be found
useful to keep in mind in any doubtful case in which sores
are present on or near the genital organs : (i) The chances
of irregular herpes should always be considered ; {2) the
lesion or lesions, and also the inguinal glands, should be
closely and repeatedly examined until the diagnosis be-
comes clear ; in the mean time (3) do not apply irritants,
and (4) do not give mercury.
An Account of Some Researches into the Nature and Ac-
tion of Snake Venom. — R. H, Elliot first considers the source
of immunity when cobra venom is taken by the mouth, and
quotes Profes.sor Eraser's paper, " Filling in Some of the
Gaps Suggested." A series of experiments are represented
by tables. In a further communication the protective
properties of serums and the nature of certain immunities
and protections will be taken up.
Case of Suppuration in the Mastoid with Optic Neuritis on
the Same Side : Operation : Recovery. — By J. Preston Max-
well.
Abstract of the Report of a Committee on the Medico-Legal
Relations of the X-Rays.— By J. William White.
Case of Septic Thrombo-Phlebitis Treated by Injections of
Streptococcus Antitoxin. — By R. B. Mahon.
Accidents and Injuries Caused by Lightning. — By Oscar
Dunscombe-Honiball.
Removal of a Glass Penholder from the Abdomen. — By T.
T. S. Harrison.
CEsophageal Feeding in Bulbar Paralysis. — By H. S. Ren-
shaw.
Haffkine Antiplague Vaccine. — By S. Mallannah.
Notes on Ocular Leprosy. — By Arthur Neve.
Milk Poisoning in Malta. — By T. Zammit.
Beri-beri. — By Francis Clark.
T/it' Lance/, May rs, igoo.
A Case of Ruptured Liver; Successful Operation on a
Pulseless Patient. — T. Carwardine reports the case of a man
aged twenty-five years, upon whom a heavy case of glass
weighing half a ton had fallen, cruidiing him against a
wall. He was operated on about three hours later. Mul-
tiple intravenous injection of saline fluid were made. The
abdomen was opened above the umbilicus. It was full of
blood. There was no free gas or odor ; the spleen was in-
tact, but the liver was felt to be lacerated. The right rec-
tus was therefore cut across — it was pale from ansemia and
did not bleed — and a large quantity of clot was turned out
of the abdominal cavity. The wliole hand could now be
passed into a laceration of the liver which extended right
across the under surface from about the position of the gall-
bladder—which was not to be seen— to the posterior part,
dividing the liver almost in twain and leaving the upper
part of the capsule floating freely on the blood-clot. The
remainder of the right lobe appeared to be badly smashed
and could not be defined owing to its crushed condition.
The clots and fragments were removed. Then, as suturing
was quite out of the question, three long pieces of iodoform
gauze were packed in the laceration and a fourth piece be-
low, comprising three and three-quarter yards of gauze
several folds thick. In addition a sponge-cloth was packed
below and to the left of the liver. The abdominal wound
962
MEDICAL RECORD.
[June 2, 1900
was approximated and nearly two pints of saline fluid were
poured into the peritoneal cavity. The duration of the
operation was very short and the patient had severe dysp-
noea afterward and was restless, thirsty, and sick. He re-
mained pulseless for thirty hours, after which the pulse
became perceptible and gradually improved, and the dress-
ings were found to be bile-stained. On the following morn-
ing the patient was much better and deliberately sat up
and asked for the paper to read the war news. Subse-
quently the discharge was copious, bile-stained, and smelt
strongly ammoniacal, like urine. The gauze was removed
at the end of a week and a temporary drain was estab-
lished in the right loin. The patient went to the convales-
cent home two months after the injury and returned look-
ing fat and strong with the wound securely healed. The
author is able to find recorded only three previous success-
ful cases where a primary operation has been done in cases
in which the patient was severely injured and collapse
followed quickly.
A Study of the Heart Wall in Diphtheria, Rheumatic
Fever, and Chorea. — F. J. Poynton states that the poison
of diphtheria appears to destroy the muscle fibres far more
than does that of rheumatism. This is a warning not to
raise dilatation of the heart — a clinical entity so definite
and well recognized — into the position of a primary disease,
for if this be done it is natural enough to consider that the
greater the dilatation the greater the danger. Yet the
truth of this, even for any one disease, is only approxi-
mate, for all diseases vary in their virulence and individual
effects, and those that attack the cardiac wall may damage
the muscle fibre at one time far more than at another. A
poison acting upon the myocardium with .great virulence
will, it is clear, cause such an impairment of the heart's
force that death must occur before there is marked dilata-
tion, an occurrence not infrequent in diphtheria. It is
probable that in rheumatism also this question of greater
or less virulence is an important one. Though the extent
of the cardiac dilatation must necessarily be a sign of very
great significance, it is in these myocardial affections that
the paramount importance of the symptoms becomes ap-
parent ; for these symptoms are an index of the muscle
failure. In this principle probably lies the explanation of
some of those more obscure cases of cardiac rheumatism —
cases in which, without evidence of valvular or pericardial
disease, there remain unaccountable breatlilessness, prje-
cordial pain, and other indications of cardiac inadequacy.
Finally, from the theoretical stan'dpoint the changes in the
cardiac wall and in acute rheumatism are of interest be-
cause their nature and complexity are decided evidence in
favor of rheumatic fever being due to a microbic infection.
Mastoid Disease, Acute Otitis Media, and Pyasmia Occur-
ring in an Epileptic as a Result of Injury. — R. A. Wilson's
patient was a managed thirty-seven years, who was beaten
about the head with an earthenware chamber utensil in the
hands of another patient in a frenzy of acute maniacal de-
lirium. For several years after, the patient complained of
pain over the right mastoid process, and eventually a dis-
charge made its appearance from that ear. Symptoms
gradually ensued as indicated in the title, and death finally
resulted. Several circumstances in the case strike one as
being peculiar : (i) The fact that the disease commenced in
the mastoid portion and spread to the middle ear, instead
of vice versa ; (2) the long period of latency during which
the only symptoms were deep-seated pain and slight deaf-
ness ; (3) the rapid progress to a fatal termination when
once the process had spread to the tympanum ; and (4) the
limitation of the disease to the mastoid and tympanic cav-
ity, and the non-implication of the membranes and lateral
sinus, although the ultimate cause of death was pytemia.
Intestinal Obstruction Due to Gall Stones. — A woman aged
eighty years, seen by E. W. Palin, was suddenly seized
with symptoms of acute intestinal obstruction which per-
sisted in spite of treatment until the sixth day, when com-
plete relief followed the passage of a gall stone measuring
a little over one inch in diameter by three-quarters of an
inch in thickness, nearly round, and well saturated with
fecal material. Several smaller stones were passed but
unfortunately they were lost. There had never at any
time in the patient's life been any symptoms pointing defi-
nitely to any gall-bladder trouble, but she passed through
a very similar attack of obstruction some five or six years
ago. Though the obstruction was complete for at least six
days, her condition never became serious.
Ptosis of the Liver and the Floating Lobe. — Under the
foregoing title, F. Treves describes respectively the sink-
ing down of the liver in the abdominal cavity and the pro-
jection downward of a portion of the right lobe in the form
of a large tongue-like appendage. The condition was first
described by Cantani in 1S65. Treves describes the mode
of prolapse, symptoms, detailing in full methods of ab-
dominal examination, etc. He finds the floating lobe to
be commonly associated with a distended gall-bladder con-
taining gall stones. The operative treatment of ptosis
consists in fixing the organ in place by various schemes of
suturing. For the floating lobe, we may either excise, su-
ture the lobe to the anterior abdominal wall, or treat the
associated distention of the gall bkiddur by cholecystotomy.
Remarks on the Diagnosis and Prognosis in One Hundred
Cases of Double Optic Neuritis with Headache. — By R. T.
Williamson and F. Roberts.
Summer Diarrhoea with Special Reference to Causation
and Prevention. — The first Milroy lecture. By F. J. Waldo.
Note on Simultaneous Excision of Both Mammse with
Axillary Glands for Cancer. — By H. Snow.
A Mishap with Carbolic Acid. — By H. L. Johnston.
Berliner klinische ]\'ochenschrifi. May 7, igoo.
The Pathology of Chronic Fibrinous Bronchitis. — H. Strauss
narrates the history of a man aged fifty-eight years, whose
sputa presented numerous tube-like bodies which under the
microscope were found to be made up largely of the so-
called Charcot-Leyden crystals. The sputa were brought
up with a cough unlike that of bronchial asthma, inasmuch
as it lacked the characteristic inspiratory whistling sound,
though in the intervals between the coughing spells the
man suffered from dyspnoea. The masses containing the
crystals were found to be of a fibrinous nature.
The Treatment of Infected Wounds with Hydrogen Perox-
ide.— Von Bruns believes that the effect of this agent is
partly chemical and partly physical. The nascent oxygen
has a stimulating effect on the tissues, and the foamy con-
dition produced tends to loosen up all particles of necrotic
material. The actual germicidal effect of the remedy is a
very weak one.
Resection of the Rectum. — A case of this nature is de-
scribed by W. Levy, who discusses the general surgical
technique under the headings of skin incision and splitting
of the sacrum, isolation of the tumor for the removal of
which the operation is planned, resection of the bowel, and
subsequent suturing and after-treatment.
Observations on the Demonstration by Means of the Roent-
gen Rays of the Architectural Structure of Bone. — By J.
Wolff.
Examination of the Acid Secretion of the Stomach. — Bv
S. Talma.
// Policlinico, May i, igoo.
A Case of Diabetes Insipidus in an Infant of Two Months.
— Olimpio Cozzolino reports a case in which the amount of
urine passed daily was over a litre. There was nothing in
the familj' history to account for the condition. Treatment
consisted of an equal mixture of tincture of valerian and
ethereal tincture of the chloride of iron, gtt. v.-x. being
given three times a day, and a spoonful of coffee in Scott's
Emulsion in the morning. The child recovered. Cases of
this disease are extremely rare in young children. Hered-
ity is usually a chief etiological factor, and nervous taints,
such as hysteria and peripheric neuritis, traumatism, falls,
shocks, acute and chronic infective diseases, and gastro-
intestinal catarrh, have all been considered to exercise an
influence in the production of diabetes insipidus in chil-
dren. The author agrees with Heidenheim, that in certain
cases there is merely exaggerated but still normal activity
of the emunctories of water, very little solid matters being
e.xcrctcd.
New Method of Treatment by the Intravenous Injection of
Metallic Iodine. — L. M. Spolverini, giving the results of his
experimentation upon animals, says that injections of the
strong solution of iodine proved entirely innocuous, even
12 c.c. producing no symptoms of poisoning, either imme-
diate or remote, and no symptoms of irritation in the cir-
culating blood. Animals subjected to this treatment all
increased in weight. No thrombus was fovind in the blood-
vessels, and blood taken from human veins and directly
from an animal's heart showed no tendency to coagulate
when mixed with the solutions used in the injections.
Auscultation of the First Heart Sound 'in Relation to the
Tracings of Ventricular Pressure. — By Balderino Bocci and
Adamo Moscucci.
Extra-Pulmonary Absorption of Gas. — By C. Bernabei and
Dr. Liotta.
Malaria in Grosseto in 1899. — By B. Gosio.
Hydrocele. — Under infiltration-anEesthesia the up-
per portion of the sac is cut into and the testicle
turned out, the tunica vaginalis stripped off and
turned inside out. Stitches are passed to prevent the
testicle from re-entering the sac. It is replaced within
the scrotum, and the wound sutured. — Winkelmann.
June 2, 1900]
MEDICAL RECORD.
963
Ol^orrcspondciice.
OUR LONDON LETTER.
(From Our Special Correspondenl.)
MR. TREVES' ADDRESS ON HIS EXPERIENCE IN SOUTH AFRICA
— VICTOR HORSLEY ON THE EFFECT OF ALCOHOL ON THE
URAIN — CONFERENCE AT MANCHESTER — LONDON UNIVERSITY
— SIR BATTY TUKE, M.P. — VROFESSOR WYLLIE — DEATH OF
DAVIES-COLLEY.
London, May 11, igoo.
If you had visited the Medico-Chi. ou Tuesday evening
you would certainly have thought at first that you had
strayed into the wrong meeting. The usually staid and
digiiified Royal Medical and Chirurgical Society — to give
it the full official title— exhibited as many signs of anima-
tion as any of its more lively sisters. Instead of a spansely
scattered audience listening to an abstruse paper, there
was a crowded room, every seat occupied and standing-
room only to be had in a crush. There must have been
some three hundred fellows present, and they all seemed
cheerful and happy as if they were really enjoying them-
selves. They had turned out to greet the civil surgeons
just home from the war, for it had been announcecl that
these gentlemen would attend and speak. Naturally a full
meeting was anticipated, but it was hardly .supposed pos-
•sible for such a number to put in an appearance, and the
returned surgeons could not but be gratified at the friendly
reception of their colleagues. Mr. Treves would no doubt
be specially pleased that his own profession quite under-
stood his recent utterance about the "plague of women" in
South Africa. He really only put in forcible, if rather
rough phrase, what Sir A. Milner had stated more diplo-
matically and what had been said in all directions by those
-who knew the facts. Of course some cried out as if they
were hurt, and for a few days the female party was against
Mr. Treves. But the tide seems to have turned, and I have
"heard ladies express delight that he had denounced the
society seekers of excitement.
To return to the meeting. Mr. Treves brought no sta-
tistics. It is too soon for them. AVe shall get figures in
plenty later on and also lessons in military surgery. . Mean-
time it is interesting to listen to the impressions of one who
was present and well qualified to form opinions. Many
were curious to hear what Mr. Treves would say about
abdominal wounds. He did not advocate interference ; he
pointed out the difficulties of carrying out abdominal sec-
tions under the circumstances of warfare. It is impossible
for the surgeon to spend adequate time over one operation
when many wounded men are waiting for his attention.
Neither can the ordinary precautions and skilled nursing
be at his disposal on the field or in the hospital after a
battle. Then the modern rifle gives the wounded a better
■chance. The small bullet does not carry the clothing into
the wound ; hence this is mostly aseptic and soon heals, a
fact frequently observed in this war as to wounds in all
parts, while there have been most remarkable recoveries
from those of the abdomen, some of which were related by
Mr. Treves. The most dangerous of these are those which
"traverse the abdomen from side to side, but Jlr. Treves has
himself recorded some marvellous cases of the kind in
which recovery took place though nothing was done. He
mentioned the circumstances which should, in his opinion,
deter from interference — such as the time after the wound,
a long transport, retained bullet, wounds involving liver
and right kidney, as they usually resulted in recovery, as
did also those below the umbilicus. As to the mortality
of abdominal wounds by the Mauser bullet he hazarded
the guess that sixty per cent, of the wounded have recov-
ered. This, as I just now intimated, is only a rough esti-
mate or an impression. If it should eventually prove to be
nearly correct it would show a great fall from the mortality
met with in previous wars, and confirm the view of niili-
-tary surgeons generally that wounds from modern rifles are
less dangerous than from older weapons. A great many
other points were touched by Mr. Treves, who was accorded
a vote of thanks for his interesting address.
At the next meeting Mr. Dent will give an account of his
experience in the war, and Sir W. MacCormac also will
probably speak.
Professor Horsley delivered the second Lees and Raper
lecture at St. James' Hall on the 27th ult. This lecture-
ship has been established as a memorial of the late Dr. F.
R. Lees and Mr. J. H. Raper. The former of these was
perhaps the most learned advocate of the temperance cause,
a retiring scholar whose writings were everywhere re-
spected ; the latter was an eloquent and enthusiastic plat-
form worker in the same cause. Mr. Horsley opened his
lecture with a warning that the emotions excited by trage-
dies and poverty brought about by alcohol must not warp
the judgment in considering the scientific aspects of the
subject. He then proceeded to expound what is known as
to the effects of alcohol on the brain. He explained and
illustrated with lantern slides the structure and functions
of the cerebrum and cerebellum, directing the attention of
his audience particularly to the arrangement of the sensory
and motor areas. The relation of the cerebrum to the
cerebellum was then considered. The effect of small
quantities of alcohol on the centres for voluntary move-
ments and for co-ordination led to the necessity of explain-
ing that the perceptive and associated centres work as a
whole. A demonstration of the way in which the " reaction
time" is measured was then given, and Kraepelin's re-
searches were quoted as showing that after a small dose of
alcohol it was slightly shortened at first, then it was very
speedily lengthened, and continued so as long as the alco-
hol remained in the system. So far as to the simple reac-
tion period, but when we come to the complex reaction (in
which there is an association of ideas) , there is no prelim-
inary quickening but the slowing begins at once. Kraepe-
lin had himself been deceived at first as to the complex
reaction, for he thought he could add and subtract figures
more quickly, but when he proceeded to measure on the
recording drum the exact time he was astonished to find
the reverse was the case ; all his mental operations were
really impeded from the first by even small or dietetic
doses. Much the same deceptive feeling is produced by
other drugs. Mr. Horsley proceeded to explain the effect
on voluntary movements, and then stated the structural
changes produced on nerve cells. These and other points
were considered in the light of the most recent researches,
and the lecturer concluded that the common notion that
moderate doses, such as people take with meals, have no
deleterious eff^ect, cannot be maintained, and from a scien-
tific standpoint the plain teaching is total abstinence.
The three direct representatives in the medical council
attended the medical conference at Manchester and ex-
pounded their views. There were fifty delegates of medi-
cal associations at the meeting, and they represented about
four thousand members. The conference extended over
three days, and some pious resolutions were carried. I am
afraid all three direct representatives have lost influence
over the midwives bill, which was one of the subjects dis-
cussed. The outcry for an increase in the number of direct
representatives in the council is useless. One or two more
could do nothing, and no one expects a larger increase —
scarcely any one hopes for that.
The London University, having safely effected its flit-
ting to South Kensington, held its first presentation of de-
grees in its new home on Wednesday. The Prince of
Wales was present on the occasion.
.Sir J. Batty Tuke took his seat in the House of Commons
on Tuesday as the new representative of the universities
of St. Andrews and Edinburgh.
Dr. John Wyllie has been appointed successor to Sir
Grainger Stewart in the chair of medicine of Edinburgh
University.
Mr. Davies-Colley resigned his appointments at Guy's
Hospital, where he had steadily worked for above thirty
years, about Christmas last. He was in feeble health — in
fact he knew himself that he w-as the subject of mortal dis-
ease, but he finished his work up to the Christmas vaca-
tion, and then went home, to return to the hospital no
more. He died on the 6th inst. in his fifty-seventh year.
He was a Cambridge graduate in arts and medicine,
F.B.C.S., and had filled examiner.ships and other offices at
his college and his university. But his life-work was at
Guy's. He edited several volumes of the Reports, to which
he contributed some papers as he did also to the medical
journals and society transactions. When it became known
that his illness would be fatal he received an address from
a great number of Guy's men who had been his pupils, ex-
pressing their gratitude for his teaching and example and
their regret that his health compelled him to retire. Few
men at Guy's would be so much missed.
OUR PARIS LETTER.
(From our Special Correspondent.)
THE INTERNATIONAL MEDICAL CONGRESS IN PARIS.
Pakis, May iS, 1900.
The Thirteenth International Medical Congress is to be
held in Paris from the 2d to the gth of August, 1900. The
fact of its taking place during the exhibition will certainly
tend to draw a large number of American medical men
than would have been otherwise the case. It may be of
interest to the reader to have a synopsis of what will hap-
pen during this congress, as well as sundry details as to
the method of being inscribed, the advantages accruing
therefrom, and the subjects chosen for discussion. A few
rem^ks will be added on the hospitals to be visited and
the arrangements made bv the French government for fur-
964
MEDICAL RECORD.
[June 2, 1900
nishing information and for lodging visitors. The prices
to be paid will also be hinted at.
The president of the congress is Dr. Lannelongue, well
known for his works on infantile surgery, the use of
craniectomy, and the treatment of chronic abscesses in
Pott's disease. On calling at the headquarters of the
congress, I saw Pr. Lannelongue as well as Dr. Chauffard,
tlie general secretary of the congress, who gave me in
great part the information which follows.
The first steps in the organization of the congress were
taken long ago, and consisted in sending out circulars and
invitations to a great number of phj-sicians and surgeons,
and also to different governments and scientific bodies.
Five different classes were established under the following
titles : biology, medical science, surgery, obstetrics and
gynaecology ; lastlj-, public medicine. Each class is di-
vided into sections, of which there are in all twenty-four.
It was, of course, a hard task to find the place to locate
them in special halls in the space of a week. The general
assemblies will be held in the grand amphitheatre of the
Sorbonne : as to the sections, they will be held at the
Faculty of Medicine, the Law Faculty, the School of Phar-
macv, the College of France, the Sorbonne, the Pasteur
Institute, the Assistance Publique amphitheatre, and the
Val de Grace, a military hospital. All these buildings are
near each other, so that it will be easy for a member of the
congress to go from one to the other. The ophthalmologi-
cal section will attend the H6tel Dieu ; that of dermatology
will, of course, hold its meetings at the St. Louis Hospital.
I shall now describe the method used for each member of
the congress, how he is classified, and what paper he re-
ceives on writing for admission. This can be done either
directly by writing to the general secretary. Dr. Chauffard.
21 Rue del'Ecole de Medecine, and enclosing a postal order
for 25 francs, or else through a foreign committee, the
president of which is Dr. Osier, of Baltimore, for America.
Suppose an American physician to have written for admis-
sion. In a month he will receive a receipt for his 25 francs
on stamped paper, a membership card, and a railway ticket
to be used on arriving in France. On crossing the frontier
this ticket is to be stamped by the railway officials, and the
price of one single ticket paid. On leaving, this ticket,
which must have been countersigned in Paris at the Ecole
de Medecine, serves as a free pass, but the same route
must be followed without any stop-over. All this is indi-
cated in a special circular printed in five languages. The
applicant, moreover, receives the definite programme, the
insignia to be worn, and invitations to the first and second
general meetings. There is also sent a prospectus indicat-
ing a certain number of agencies, who will see to furnish-
ing apartments or lodgings to the members of the congress.
I notice on this prospectus that the " Agence Desroches " will
receive the visitors at the station, conduct them to a hotel,
and give them all the requisite information. The first day
will be 20 francs, including room, lights, attendance, and
first breakfast ; the other days 10 francs ; the last day 1 5
francs, including the ride to the station. One should
notify the Agence, Rue du Faubourg Montmartre 21, of
the day of one's arrival and send the first day's price, I'.t:,
20 francs. The Agence des Voyages Pratiques, 9 Rue de
Rome, undertakes the same thing for 6 fr. 50 c. up. There
is also the Agence des Voyages Modernes, Rue de I'fechelle
I : the Agence Lubin, Boulevard Haussmann 36 ; the
Societe Frangaise des Voyages Ducherain, 20 Rue de
Grammont. One of these agencies should be written to at
least a month in advance. For medical men travelling by
themselves I must mention the fact that about eight hun-
dred beds in the dormitories of the'public schools will be put
at their disposal. The price will be 5 fr. 50 c. for bed, at-
tendance, and first breakfast. One should write to the
office of the Medical Congress, 21 Rue de I'ficole de Mede-
cine.
On arriving in Paris, the member should go as_ soon as
possible to the ficole de Medecine, 21 Rue de I'Ecole de
Medecine, and show his card to the porter. The latter will
direct him to a secretary speaking English, who will stamp
his railway ticket, give him his personal card, write down
his address, and give him the special invitations. There
will be a night festival in the gardens of the Luxembourg,
and official receptions by the President of the Republic
and by the President of the Council. As souvenirs of the
congress there will be the insignia, which are to be made
by Vernon, a well-known engraver, and the volumes dis-
tributed gratis to the members of the congress.
On leaving Paris the visiting physician will be able to
use his railway ticket without any extra charge. Of course
luggage over-weight will undoubtedly be charged for.
During his sojourn in Paris the medical man will have a
variety of hospitals to choose from, each one being in some
way specialized. St. Louis will interest dermatologists on
account of its wonderful museum ; Necker and Beranjon
have two genito-urinary services under the direction of
(niyon and Bazy. At the Hotel Dieu Dieulafoy is pro-
fessor of clinical medicine. Potain is at the Charite.
Ferrier, professor of surger\', has a service at La Pitie.
Finally the physician should not fail to visit the newly
constructed Boucicaut Hospital, where he will be able to
see the latest type of hospital erected in France, and visit
what is considered the best specimen of a maternity in this
country.
LETTER FROi\[ THE FALKLAND ISLANDS.
(From our Special Correspondent.)
The health of the colony of the Falkland Islands is most
satisfactory. The death rate from preventable diseases has
not exceeded that of former years, there being an entire
immunity from contagious diseases, grippe, variola, diph-
theria, typhus fever, etc. A few cases of scarlet fever
simplex of an exceedingly mild form occurred recently,
which has been stamped out. The climate is hostile to all
diseases of a contagious or infectious nature. Tropical dis-
eases could not e.xist for a single hour, the climate being
too cold and bracing, and the strong westerly and southerly
winds, with the amount of iodine in the air, would prove a,
sovereign prophylactic against their incursion.
The presence of tuberculosis, whether attacking the
mesenteric glands, joints, or in the insidious form of phthi-
sis, is met with, which is not to be wondered at considering
the numbers of waifs and strays that elect to take up their
abode in these islands. Notwithstanding this drawback,
the climate and highly nitrogenized food successfully com-
bat them, there being an entire absence of want or destitu-
tion of any sort. The humblest laborer receives at least
6 s. per day, and some of the above-mentioned diseases no
doubt have been superinduced bj- living too highly, and
over-indulgence in intoxicants. The large number of
cases of drowning is not surprising considering the low
temperature of the water, the ice zone being not far dis-
tant, and the sinuosity of the kelp, which entwines itself
around the legs and arms of the swimmer, and with wav-
ing motion brings him beneath the surface.
The absence of specific disease is remarkable considering
the number of blue-jackets and marines who for five
months each year visit our shores. This fact speaks well
for the medical officers in charge, or for the highly moral
and respectable class of men in the navy. A few cases of
tertiary or secondary syphilis have been under my treat-
ment, but only one case of primary.
The usual diseases of childhood occur, such as urticaria,
varicella, fevers, and convulsions, the latter the result of
dentition or intestinal worms.
The Falkland Islands colony, when any other statistical
test is applied, is phenomenally comfortable and thriving.
But for the natural decay that comes with age, and a few
deaths by accident, the Falklands might almost lay
claim to being the islands of the immortals. The deaths
■ number twenty-four in a population of some two thousand,
but when fatal accidents to new-comers from drowning and
shooting and other exceptional causes are taken into ac-
count, the rate is whittled down half-way to zero. The
rate of infant mortality is little more than a fourth of the
English average. It is impossible to find conditions more
favorable to vigor of body and length of days. It would
surprise many physicians at home to see how that dread
malady phthisis is warded oft', and I believe in many in-
stances completely buft'eted by the health-giving qualities
of these islands. Let it not be thought that disease and
pain are unknown. A chronic intractable rheumatism is apt
to twinge the back in the form of lumbago, or the knee or
elbow joints ; but the bane of the islands is chronic indiges-
tion. Pyrosis (or water-brash) is continually reminding the
inhabitants that they are mortal, and yet the fault is their
own ; the source of mischief lies in the enormous quantities
of coffee and tea consumed in the strongest forms, the indi-
gestible character of the bread they eat, and the ignorance
of most of the women of the rudimentary laws of cooking.
Tested by exports and in comparison with the number of
inhabitants, the prosperity of the Falkland Islands is un-
excelled by any of Her Majesty's possessions, and repre-
sents the sum of /'bs per capita in produce unaided by
manufactures. The well-being of the inhabitant is further
evidenced by the fact that the sum per head of the popula-
tion deposited iu the Government Savings Bank averaged
;^22. In the balance of loss and gain, the islanders with a
small portion of sunshine and warmth, but without phthisis
or crime,, and ;^22 per head in bank, are certainly happy
among colonists.
Ethyl Chloride is sprayed upon the inside of a
thick Esniarch inhaler and administered. As soon as
the patient is insensible to a pin's stick ether is sub-
stituted. The advantages are rapid anesthetization,
less disagreeable after-effects, and simplicity. — J. P.
TUTTLE.
June 2, 1900]
MEDICAL RECORD.
965
©Xinical gcpavtmcnt.
PLACENTA PR.-EVIA AND TWINS.
By ANTHONY BASSLER, M.U.,
The following case occurred in the practice of Dr.
Albert T. Swan, and by virtue of its rarity and success-
ful issue is worthy of recording:
Mrs. C , aged thirty-five years, mother of eight
children, i.e., four normal births ; a placenta prajvia par-
tialis five years ago, delivered by Dr. H. J. Garrigues;
a breech, uncomplicated, two years ago, and the pres-
ent instance.
The mother could not give a definite account of the
beginning of the last pregnancy because at the third
month she had a flow lasting several days which she
supposed to be menstruation. The history to the
present period is uninteresting. Two weeks before
delivery, while doing housework she had a slight hem-
orrhage from the vulva lasting about five hours; con-
fident that she would have no return of the hemorrhage,
the household duties were resumed. On February
25th she was awakened in the morning by profuse
hemorrhage. Within a short time the diagnosis of
placenta pravia was made, and inasmuch as the uterus
reached to within three inches of the ensiform carti-
lage full term was supposed to have been reached, and
the vagina was tamponed to control the hemorrhage
and excite labor pains. On the follovi'ing day the
tamponade was removed and a fresh packing done.
No more bleeding had taken place. This was done
for two days longer; as no pains were set up, and in-
fection of the placental site was feared, and as no
safety to the mother could exist so long as pregnancy
continued, forcible delivery was advised.
On examination under chloroform the uterus was
found to be quite globular in shape. High on the left
side a hard body was felt which was supposed to be a
breech; being fearful of placental separation the head
was not sought for in the pelvis. On vaginal exami-
nation the cervix was high and was lengthened. The
external os was flaccid; the upper end of the cervix
would barely admit two fingers, and was very firm.
The entire lower uterine segment had a soft boggy
feel, and internal ballottement could not be gotten.
The cervix was dilated manually by Dr. Swan and my-
self; as it gave way to the force the placenta bulged
down into its cavity and the bleeding increased. This
bleeding was effectively controlled by pledgets of cot-
ton wrung out in very hot bichloride solution pressed
against the protruding mass. Care was exercised in
dilating the cervix so as not to detach the placenta.
Only the tips of the fingers were employed in over-
coming the contraction above. When the cervix was
fully ciliated, diagnosis of placental site was made as
occupying the right lower segment. A small portion of
the placenta was felt on the left side. The flat hand
was then passed upward on the left side between the
placenta and uterus. About four inches above, the mar-
gin of the placenta was passed. Continuing upward
between the membranes and uterine wall, about an inch
beyond this margin, the amniotic sac was broken into
and the hand passed into its cavity. During this time,
as a precaution against alarming hemorrhage care was
taken to keep the forearm to the right so as not to peel
up the placenta. A child's head was seized, brought
to the left side of the uterus, and delivered through
the rent in the sac. After delivery the flow of blood
was profuse. Quickly the hand and forearm were re-
introduced and the second child was delivered in the
same way. The placenta and its membranes were then
removed. Although the uterus had retracted, the sub-
sequent hemorrhage, not yielding to hot douches and
acetic acid, compelled packing with gauze.
The mother made a rapid recovery, and excepting a
slight rise of temperature on the third day (probably
from absorption of stagnant lochia at the placental
site) she ceased to be of interest. The children were
about fifteen inches long and were attaclied to a single
large flat placenta.
The first case of placenta previa and twins was re-
ported by Dr. H. R. Storer.' The woman was dead
when first seen by him, and laparotomy was done in the
interest of the children. Two placentas and separate
membranes were found. Dr. C. E. Quinn' reported a
case in which pains were induced and the first child was
expelled in its sac, the hemorrhage being very slight.
Dr. Collingwood Fenwick '' reported a case having two
placentae and two membranes. Dr. H. O. Nicholson''
reported a fatal case, the mother living six hours after
delivery.
Obstetricians differ as to the rarity of this condition.
Among Dr. Trask's two hundred and fifty-three cases
of placenta praevia, gathered from every source,'' there
was only one such case, and that foreign. Angus puts it
as occurring once in 44,500 cases. Barnes states that
it is not so common. Winckel states that multiple preg-
nancy predisposes to placenta prcevia, the accident
being relatively four times more frequent in plural
than in single pregnancy. If Lusk's book be taken as
a standard, we might conclude as follows: (1) Pla-
centa praivia with single child occurs once in nine
hundred cases; (2) in about every eighty labors one
pair of twins are born; (3) by comparing these ratios
we should expect to find twins with placenta prsevia
once in seventy-two thousand cases.
THE LIFE OF A PLASTER-OF-PARIS JACKET."
By homer GIBNEY, M.D.,
I PURPOSE giving the history of several cases of the
very many of Pott's disease seen at Dr. V. P. Gibney's
clinic, orthopaidic department Vanderbilt Clinic, at
the Hospital for Ruptured and Crippled, dispensary
service, and those seen at our office, which, of cgurse,
are private cases; many of which in these various
places came under my personal hand. The cases re-
ported by Dr. Stokes are ones with which I am more
or less familiar, and I know much care is always given
to these individual cases as they present, and to 'this
I think is due the fact that our jackets wear so well ;
and that, when we get an early case, apply a comfort-
able snug splint, thus absolutely fixing the spine, we
are gratified to find on its removal all of the acute
symptoms have disappeared, no psoas contraction, and
no evidence of active disease.
There are many contributing causes to the lon-
gevity of a plaster-of-Paris jacket. I may be par-
doned if I mention a few of the most prominent points
which, if conscientiously adhered to, carry it to a " ripe
old age."
First, the plaster must be carefully bought; that is,
dental plaster, smooth and without grit; secondly,
the bandages must be well or rather loosely rolled;
and thirdly, the meshes of the crinoline must be w-ell
filled with the plaster. Each successive turn of the
bandage must also be carefully and vigorously rubbed
' Boston Medical and Surgical Journal, 1S56-57, pp. 347-349.
* Medical and Surgical Reporter of Philadelphia, September
12, 1874. p. 128.
^British Medical Journal, January 20, igoo, p. 140.
* British Medical Journal, February 17, 1900, p. 3S0.
* Trans. American Medical Association, 1S55.
" Read before the Orthopredic Section of the New York Academy
of Medicine, November 17, 1S99.
966
MEDICAL RECORD.
[June 2, 1900
in. I believe one cannot pay too close attention to
these apparently minor details to insure a perfectly
fitting splint, a lasting support with the maximum com-
fort.
I have three cases pertinent to the life of a plaster-
of-Paris jacket. Briefly:
Case I. — A boy four years old, first seen in 1891.
Symptoms present were abdominal pains and a disin-
clination to walk. He had been treated expectantly
by some homceopathic doctor, a diagnosis not having
been made. His family history was good; the
hygienic surroundings were excellent, and there was
no definite history of treatment. The consultation
with their regular family doctor resulted in a diag-
nosis of caries of the spine — the prominence being at
the mid and lower dorsal vertebrae. A Taylor brace
was applied and worn with considerable discomfort;
a large psoas abscess developed; the boy became much
emaciated, and he was said to have developed a pulmo-
nary tuberculosis. His parents were advised to take
him at once to the country. Before this was done the
abscess was carefully aspirated, but as its contents
was thick, cheesy pus the field around was cleaned
and an incision made, and the sac evacuated. Pro-
longed suppuration reduced him to an alarming point
of emaciation. It was, however, thought best to apply
a solid or permanent jacket. This was accordingly
done; the bony prominences were protected, a fenes-
tra being cut to dress the abscess. This jacket was
worn for two months, when his general health was so
much improved that it became necessary to change it.
The deformity had not increased; there were no ex-
coriations; the back and skin were in good condition.
A new one was immediately applied. His condition
remained good, and this jacket was worn for a year,
when a new one was applied. His deformity re-
mained the same, as shown by the tracing, which was
taken with a lead tape, familiar to all those who have
to do with spinal cases. His back showed no exco-
riations from the plaster, and the abscess instead of
producing constitutional disturbances had, to a very
large extent, given him no trouble.
Two months ago a new jacket was applied, and he
went again to the country and continues to improve.
Case 11. — A boy six years old (caries of dorsal
spine), was seen first in 1895. He had a fairly good
family history. His personal history was fair, and
the hygienic conditions and surroundings were excel-
lent. The symptoms present were grunting respira-
tion, attitude over-erect, unsteadiness of gait, and
considerable abdominal pains. The kyphosis was
most prominent at the tenth dorsal vertebra;. In this
case, as in the previous one, a Taylor brace was ap-
plied, and this was followed by a Knight spinal. Both
of these, however, failed to give him the desired sup-
port and consequent relief. His general health began
to fail. A solid, perma-
nent jacket was applied,
and he w'as sent to the
country. All of his
symptoms rapidly cleared
up; he gained in flesh,
and it was necessary at
the expiration of three
months to reapply a new
jacket, which was worn for
eleven months. This was
cut down ; there were no
abrasions and but slight
excoriations, and the usual
tracing revealed no appre-
ciable increase in the de-
formity. A new jacket
was applied less than two
months ago. He runs and
romps with other boys, and
his general health remains
excellent.
Case III. — Woman,
twenty-seven years old.
No definite history could
be given. Following
childbirth she had per-
sistently severe pains
through the lumbar spine
and over the lower abdo-
men. Her family and per-
sonal history was good,
and she was surrounded by
best hygienic conditions.
Her attitude was normal,
the gait a little cautious
and unsteady. She was exquisitely tender over the
third and fourth lumbar spines. A snugly fitting, solid
jacket, grasping the pelvis firmly, was applied, and she
went to her home in Massachusetts the following day.
She did not again appear at the oflice for a year, when
she reported that within a month nearly all of her
symptoms had disappeared and that for several months
she had been absolutely free from.all pain and discom-
fort. The jacket was cut down; the body was found
to have no excoriations, in fact to be in excellent con-
dition. There was no pain on concussion and no
evidence of active disease. The spine was fairly flex-
ible except at the point where tenderness and slight
prominence were first noticed. A light steel spinal
assistant was applied, and she was sent home cured.
These then are but three of the very many spinal
cases which I have had the privilege of seeing in Dr.
Gibney's practice, and in which we have applied the
solid plaster jacket with most beneficial results. Just
how long the solid jacket will live is difficult to say.
I can but emphasize the cardinal point — careful
attention to the minor details.
June 2, 1900]
MEDICAL RECORD.
967
We have about discarded the swing or upright posi-
tion in applying the jackets. Especially is this true
in the cases of children when the deformity is in the
lower dorsal and lumbar regions, we having adopted a
slight modification of Goldthwait's frame, which ap-
paratus is shown by the illustrations.
Two uprights on which the shoulders and hips may
rest are placed at a short distance from each other on a
table or board. Two untempered steel rods one-fourth
to one-half inch in breadth are easily shaped to hug
closely the deformity or prominence. The child is
then held by two assistants, at the arms and thighs, in
position on these vaselined rods, which fit into grooves
in the uprights; the assistant at either end employing
slight traction.
The bandages are thus rapidly applied, and as the
plaster is setting or hardening the rods are carefully
withdrawn, the spaces and unevennesses are smoothed,
and the jacket is trimmed out with a sharp knife under
the axillaj and over the hips, the edges being smoothed
and bevelled. It is possible thus to make a most
effective light support.
For many years we have promoted cleanliness and
thus added to the age and efficiency of our solid
jackets by putting a long strip six inches wide of linen
or gauze ne.xt to the skin before the building-up proc-
ess of the jacket begins. Then we carefully instruct
mothers and nurses to move this back and forth under
the jacket, first saturating one end with alcohol, thus
giving the child practically an alcohol bath everyday.
^crcietxj ^lepovts.
NEW YORK ACADEMY OF MEDICINE.
Statc-if Meeting, May j, igoo.
W. H. Katzenbach, M.D., Vice-President, in the
Chair.
Remarks on Hyperchlorhydria. — Dr. Max Ein-
HORN read this paper. He said that at one time it
had been considered proper to treat almost all cases
of dyspepsia by giving hydrochloric acid, under the
supposition that the gastric juice was always deficient,
but later observation had shown that sometimes the
secretion of hydrochloric acid in these cases was actu-
ally greater than normal. Still later it had been dis-
covered that digestion sometimes went on in the stom-
ach when it should not do so, i.e., when the stomach
was empty. The present paper dealt only with those
cases in which there was e-xcessive acidity. Accord-
ing to his own experience, more than half of the cases
of impaired stomach digestion were examples of hy-
perchlorhydria. Among farmers and others leading
a life comparatively free from mental strain, the per-
centage would probably be much less than among his
patients, who had been, for the most part, men in ac-
tive business in the city.
Symptomatology Persons suffering from hyper-
chlorhydria were usually well nourished, and com-
plained of uncomfortable sensations about one hour
after meals. Some of them felt well except after their
heaviest meal. Some complained of a burning sensa-
tion in the pit of the stomach, or sometimes of water
brash. A smaller group complained not only of water
brash but of slight regurgitation of food. The burn-
ing sensation might be present along the course of the
oesophagus rather than in the stomach alone. These
were the common symptoms, but they did not include
all. Some of these patients complained of dizziness,
or of a feeling of apprehension, or of severe headache,
coming on perhaps without any distress in the stom-
ach, at about the same time after taking food. In the
more exceptional cases the symptoms might be vague,
and might even simulate to some extent those of an-
gina pectoris. A characteristic feature of all these
different types of cases was that they experienced relief
with the ingestion of food, and about ninety per cent,
of the cases exhibiting these symptoms would be
found to be instances of hyperchlorhydria. The ap-
petite was usually good, and sometimes a hungry feel-
ing was experienced about one hour after meals.
Thirst was not increased. About two-thirds of these
patients suffered from an obstinate constipation which
was dependent upon an abnormal condition of the
stomach. Sometimes there was a diarrhoea of similar
origin, and the fact that it arose in this way was well
shown by the ease with which it was controlled by the
administration of an alkali. He was of the opinion
that if the symptoms were reasonably distinct no ex-
amination of the gastric contents was demanded, but
the fact should not be lost sight of that hyperchlor-
hydria sometimes existed without giving rise to the
usual symptoms.
Pathology — Opportunities for post-mortem study
were naturally very rare in this disorder. In one case
in which death had resulted from a pneumonia, ex-
amination, both macroscopical and microscopical, had
faileci to show any abnormality of the gastric mucous
membrane, not even an ulcer. Most physicians now
agreed that hyperchlorhydria was a functional dis-
ease.
Etiology. — As had been already stated, the disease
was especially common among those subjected to
much mental worry or anxiety, such as men in active
business, or ladies too much occupied with social
functions. Tobacco and alcohol were also prominent
factors. As ulcer of the stomach was quite commonly
associated with hyperchlorhydria, some had supposed
that it was a cause of this affection. This could
hardly be the case, because it was well known that
gastric ulcers developed in cases not exhibiting hyper-
chlorhydria. Probably all that could be said on this
point was, that hyperchlorhydria made it easy for such
ulcers to develop. When these conditions coexisted,
it might be impossible correctly to diagnose the pres-
ence of the ulcer except by the persistence of the
symptoms in spite of appropriate treatment.
Treatment. — As a rule, cases of hyperchlorhydria
responded promptly to treatment. Some physicians
excluded all starchy foods for the reason that the ex-
cessive acidity interfered with the digestive action.
He did not indorse this plan, and believed that most
physicians had given up exclusive diets in these cases.
As it had been found that an exclusive diet of meat
stimulated and increased the flow of gastric juice, it
had been recommended to exclude meats. His own
practice was to try and strike the happy medium be-
tween these extremes, believing that exclusive diets
were harmful. The diet which he usually arranged
for those suffering from hyperchlorhydria comprised
tender meats, not too highly seasoned, plenty of milk,
water, and sugar. He directed that they should avoid
acids, and should restrict the quantity of the starchy
foods, particularly potatoes. The great point, after
all, was to make them take their food in small quan-
tities and at shorter intervals. These frequent meals
in themselves gave relief, as the ingestion of food took
up the acid, forming with it an acid albumin. Recent
experiments seemed to show that sugar, as such,
tended to diminish the acidity. Fats, especially butter,
also decreased the acidity. The medicinal treatment
consisted in administering alkalies at the time of
maximum acidity, i.e., about two hours after meals.
One or two teaspoonfuls of bicarbonate of sodium would
be found useful for this purpose, or, if the patients
were constipated, bicarbonate of sodium and calcined
968
MEDICAL RECORD.
[June 2, 1900
magnesia, or rhubarb, soda, and magnesia, could be
administered with advantage. He had also found the
greatest benefit from the use of the bromides. Wash-
ing out of the stomach was not essential in these cases
because there was no impairment of the motor func-
tion of this organ. The internal application to the
stomach of either the faradic or the galvanic current
would be found beneficial, as would also spraying into
the stomach a solution of nitrate of silver.
The Occurrence of Mould in the Stomach — Dr.
Einhorn also read a report on this subject. He said
that in all of his cases the microscopical picture had
been the same. Dr. E. K. Dunham had examined the
pellicles in the fresh condition. He had been unable
to make them grow on the usual culture media, but
had been more successful in growing them on bread.
The species of mould had not been definitely deter-
mined from the fresh specimens — it might be an as-
pergillus or a penicillium. He had found these
moulds more particularly in two groups of cases, viz.,
(i) cases of hyperchlorhydria, and (2) cases of gas-
tralgia. It was reasonable to expect some benefit
from the use of the gastric douche, or the spray of ni-
trate-of-silver solution.
Stated Meeting, May 77, I goo.
William H. Thomson, M.D., President.
Poisonous Snakes and Snake Poison, with Demon-
strations.— Dr. Gustav Langmann read a paper on
this subject. He said that snakes had two raised pa-
latal teeth, both running almost parallel. The pointed
hooks upon the back were used for hooking the prey.
They had a very dilatable mouth, through which the
prey was gradually drawn down into the oesophagus.
The innocent teeth extended backward. In the row
of teeth of the upper jaw, the poison was concentrated
into one powerful tooth, the poison fang; sometimes
there were two or three teeth at this point. The
fangs stood immovable on erection, and folded like
a pocket-knife when at rest. The arrangement of the
teeth would aid in discovering if the snake-bite was
harmless or not; but snakes did not always leave the
imprints of their teeth. The poison gland was situ-
ated behind the eye, and was under the influence of
the masseter muscle. The secretion was thrown into
a groove in the mucous membrane at the base of the
fang. The king-cobra was the largest of all poisonous
snakes, measuring often fourteen feet, and enjoyed at-
tacking and pursuing men.
Poison Apparatus — The poison glands were trian-
gular in shape, and this was supposed to be character-
istic of all poisonous snakes. The glands were the
homologues of the parotid glands. These animals
could retain their secretion at will, sometimes keeping
it for months. The poison was not odorless, and there
was a specific smell for every species; the odor might
be called " mousy." Fresh poison under the micro-
scope showed epithelial cells and adenoid masses. It
had been supposed until quite recently that the action
of the poison was due to very virulent bacteria con-
tained in the secretion. The cultures in different
media gave entirely negative results.
Active Constituent of the Poison. — The first chem-
ical examination was made with the viperida;, and the
active principle extracted was called viperine. Dr.
Weir Mitchell, in 1883, published the results of his
investigations: he found two albuminoids — one dia-
lyzable and coagulable by heat, the other not; these he
considered the active principles of the poison. There
had really been no definite analysis of the poison
made as yet, but there was quite reasonable assurance
that the active principles were albuminoses. These
albuminoses were peptones of rather recent date; they
were the same as what was called propeptone, the in-
termediary stage in the changing of albumin to pep-
tone. They were products by hydrolysis; they decom-
posed, took up certain constituents of the water, and
so became more soluble and approached the peptones.
It was important to know the different ways in which
the albuminoses were changed, artificially by super-
heated steam, or by the gastric juice, or by pancreatic
digestion, or by the living cells; these latter might be
cells from the living organism or from the plant or
bacteria. He asked what was the origin of the al-
buminoses. They were from the same albumin which
had been worked out by superheated steam, by bacilli,
or by gastric digestion, but they were entirely differ-
ent; the toxins created in this way were different and
could not be compared at all with each other. Differ-
ent poisons had a different percentage of peptone and
globulin. Gastric action had no influence on the
snake poison, but the action of the bile had. A dried
poison mixed in glycerin was as active as the fresh
poison, even after the lapse of twenty years. Putrefac-
tion would destroy it after a time. Alcohol rendered
it inert for a time only.
Physical Effects. — Peptone caused some local
oedema, with convulsions, and ended by paralyzing
the respiratory centres. Globulin, on the contrary,
excited local reaction with hemorrhages around the
points of injection. Experience showed that the in-
tensity of the hemorrhages and the paralysis corre-
sponded with the hydrolysis of the albuminoses. In-
stant death was due to thrombosis.
Symptomatology. — The effect of the cobra bite was
first shown by a scratch on the skin, which gave a
burning pain with cedema; then appeared vertigo, fol-
lowed by weakness of the limbs, paraplegia,, ptosis,
paralysis of the tongue and epiglottis, and inability to
speak. The saliva dribbled from the open mouth.
The paralysis was general, and the patient lay motion-
less. The pulse was weak, and continued after respi-
ration had ceased. The respirations were slow and
labored. The pupils were contracted. Slight convul-
sions sometimes occurred before the end. Absorption
was exceedingly rapid, as experiments had shown,
which were made by injecting the poison into the tail
of a rat and amputating the tail after one minute,
death following in a short time. If patients did not
die from paralysis they recovered quickly. The bite
of a rattlesnake caused more pronounced local dis-
turbances. There were hemorrhagic disturbances and
bloody exudations of all mucous membranes. Within
thirteen minutes constitutional disturbances devel-
oped. There was a marked fall in the blood pressure.
After a temporary increase of reflexes, tetanus and par-
esis supervened, and paraplegia of the lower extremi-
ties ending in complete paralysis followed. Patients
died within twelve hours. If they recovered from the
paralysis, septic fever might develop. An authentic
case was instanced of a draughtsman in the National
Museum at Washington, who was bitten by a snake on
the index finger. After several weeks he recovered.
He was bitten about the 2d of June. Swelling and
inflammation of that finger occurred every year about
the 2d of June, resulting invariably in the loss of the
nail. It was only after ten years that this curious
phenomenon ceased ; he was then supposed to have
been cured by the South American plant micania
guaco. In autopsies the serous membranes were
shown to have ecchymoses throughout, especially the
peritoneum. The blood was liquid and did not clot
even after a long time. The cobra bite gave symp-
toms analogous to those of acute bulbar paralysis in
its most acute type.
The Pathological Effects.— No description of the
pathological effects upon the central nervous system
had ever been publislied which could be considered
June 2, 1900]
MEDICAL RECORD.
969
valuable. There were certainly pronounced effects
upon the central nervous S3'stem and the medulla.
Fresh poison added to the blood in a test tube caused
the blood corpuscles to swell and lose their hrtnio-
globin. There was no change produced in the ha;mo-
globin. In the tissues diapedesis soon set in, and in
a few hours after the injection one-half the normal
blood corpuscles could be counted. The coagulabil-
ity of the blood was influenced. Another important
effect was the loss of the germicidal property of the
blood plasma. Briefly summarized, it might be stated
that if the patient died within a few minutes, he died
from general thrombosis; if within twenty-four hours,
from paralysis of the respiratory centres, and, later,
from general paralysis; if after days or weeks, he
might die from sepsis.
Prognosis The prognosis was not bad. VVeir
Mitchell once gave the mortality from the bite of the
cobra as twenty-five percent.; at another time he gave
it as not more than twelve per cent. In Australia the
mortality was said to be about seven per cent.
Treatment. — The object in the treatment of snake-
bites was (i) to prevent the absorption of the poison;
(2) to destroy or neutralize its effects; (3) to acceler-
ate its elimination ; (4) the treatment of the symptoms.
If the limb could not be immediately amputated, the
ligature should be employed. This should be tied as
tightly as possible and in several places; for instance,
if the finger was bitten, the ligature should be applied
to the finger, the wrist, and the elbow. Sucking the
wound with the lips or with glass cups was a doubtful
measure; if employed, it should be preceded by free
scarification of the tissues. Many drugs were consid-
ered by the speaker, including permanganate of potas-
sium, hypochlorite of lime, ammonia, alcohol, etc.
Often alcohol was given to such an extent for snake-
bites that patients died from acute alcoholism; in
many cases it was difficult to tell whether the snake-
poison or the alcohol caused the patient's death.
There were few chances of neutralizing the poison in
loco. Since the kidneys were attacked it was doubtful
if such measures should be employed as would in-
crease their activity. Diaphoretics gave dubious re-
sults. It had been experimentally shown that, when
morphine was administered hypodermically, much
of it was eliminated by the stomach — in fact, by re-
peated washings more than one-half the quantity in-
jected might be recovered. The same was the case
with snake venom. Experiments showed that when
animals' stomachs were washed out, after they had re-
ceived a lethal dose of the poison, they lived; the
control animals died. The fluid washed out of the
stomach produced death when injected into other ani-
mals. In the snake-dance, in India, after the per-
formance the performer received large doses of an
emetic; then the whole crowd stood around watching
the performer empty his stomach. The speaker con-
sidered remedies that were supposed to be specifics in
snake poisoning, such as strychnine. This drug was
repeated until tetanic symptoms appeared; enormous
doses of it were given, especially in Australia. It
could not be relied upon as a specific. It was noted
that an artificial tetanus brought on by strychnine was
stopped by the snake poison.
Antivenene Serum. — It had been found that cer-
tain animals were immune to snake poison. In the
tropics this was regarded as caused by their activ-
ity. Poisonous snakes were immune against their own
poison; this was ascribed to their own internal secre-
tions. Antivenene he considered to be the only relia-
ble antidote to combat the effects of snake poison.
Full protection was afforded if from 5 to 20 c.c. was
injected within one and half hours after thfi receipt of
the bite. This antivenene had been used with suc-
cess in the West Indies, the East Indies, and Africa.
It was an open question whether the action of anti-
venene was chemical or physiological. Dr. Langmann
thought it was chemical. He discussed the relation
of toxin and antitoxin in detail.
The treatment was thus summed up. The ligature
should be used, and followed by deep scarification.
Antivenene and solution of calcium hypochlorite (i :
60) should be injected. Stimulation with ammonia or
alcohol was necessary. Hypodermoclysis of normal
saline solution and artificial respiration maybe called
for. The victim should be encouraged to counteract
the depression.
Demonstration of the Snakes Every human being
had an aversion to snakes which could be overcome
by will-power. There were about seven varieties of
rattlesnakes. They were quite abundant in the East-
ern States. Only a few years ago a man was bitten
by one on the Palisades. These snakes, as a rule,
were of a timid and retiring disposition, and were not
aggressive, as they were reputed to be. If attacked
they would stand and defend themselves. Dr. Lang-
mann then showed how to handle these snakes. He
removed them from the cage by means of a hooked
stick. The snakes clung to it, being afraid to fall.
Then, dropping them on a level surface, the stick was
placed just back of the head, holding them down
firmly, and the neck was grasped with the finger and
thumb. The rattles were not an indication of the age
of the snake; they got a new rattle with each shed-
ding. The doctor showed, and handled, the diamond-
backed rattler, the tiger, the moccasin, the copperhead,
and others. The moccasin snake, when excited, would
strike the floor with the tail, and the sound produced
was very similar to that produced by the rattlesnake.
Sometimes this snake was more dreaded than all others.
Negroes were particularly afraid of them. The Pali-
sades were still full of the prettiest of all snakes,
the copperhead. Three years ago, sixty-nine copper-
heads were caught there.
Mode of Collecting the Snake Poison. — Dr. Lang-
mann took a glass funnel, over the open end of which
was stretched a piece of chamois skin; this was thrust
into a cylinder. The snake being held as demon-
strated, its head was brought close to the chamois and
its fangs were deeply buried in it, the venom entering
the cylinder by drops. To facilitate its passage the
doctor pressed the poison glands with his fingers.
Demonstration of Rabbits Killed by Snake
Venom. — One rabbit was shown which was killed by
the intravenous injection of venom and which died in
three minutes. On examination the peritoneum had a
perfectly normal look and was not at all hypersmic.
The right auricle was- filled with blood-clot. There
were no hemorrhages. A second rabbit was then
poisoned by the hypodermic injection. Here there
were numerous hemorrhages. A third rabbit was
shown in which there were numerous hemorrhages all
over the peritoneum.
Anatomy of the Poison Apparatus.— Dr. S. Pul-
LiTZER said that all vipers were distinguished by having
a short superior maxillary bone which articulated with
the lacrymal bone. Vipers brought forth their young
alive. These two characteristics all species of vipers
had in common. They were all poisonous, and were
widely distributed, especially in the temperate and
tropical zones, except in Europe, Australia, and New
Zealand. Some vipers had a peculiar pit known- as
the"laureal pit." In 1866-67 a scientific study of
this pit was undertaken. It was a depression on the
side of the face on a line between the lower jaw and
the margin of the orbit. This was called by some
"the sixth sense." The function of it has been left to
conjecture, but it was thought to be connected with
the elaboration of the poison; also, that it enabled
the poison gland to get oxygen. At the bottom of the
97°
MEDICAL RECORD.
[June 2, 1900
pit was found a delicate membrane which was invari-
bly ruptured in attempts to dissect it off; it closed off
an entire cavity whicJi was lined with epidermis,
which made it evident that it communicated with the
outside skin and had an outlet. Serial sections were
made, and the outlet was found near the margin of
the eye. The speaker thought it was purely some
kind of sense organ. He thought it migiu be an ac-
cessory organ of hearing, for a rudimentary cochlea and
semicircular canals were found. There was no exter-
nal opening or tympanum or external ear in any snake.
Findings in Nerve Cells after Poisoning. — Dr.
P. Bailey presented a paper on this subject, based on
experiments with rabbits.
Kabbit No. i. Snake poison ; rapid action. Cells
showing changes were confined to the anterior horn of
the spinal cord. Most of these cells were normal. A
small number of cells presented in their chromatic
elements modifications which probably evidenced the
early stages of a beginning acute degeneration ; /.<'., an
increase in the granularity of the chromophilic bodies,
and a fraying out at their edges, with some distinct
loss in chromatic substance. The cyto-reticulum was
normal. The nucleus might be normal or there might
be an intensification of the surrounding membrane and
a thickening of the strands of the nucleo-reticulum.
A few cells were found in which there was much
greater loss of chromatin, the cell bodies appearing
extremely pale and no distinct chromophilic bodies
being present.
Rabbit No. 2. Snake poison; long action. The
character of the changes was the same as in the pre-
ceding, but more advanced and involving a much
greater number of cells. Changes were found in the
cells of the cortex, cerebellum, olfactory lobe (mitral
cells), basal ganglia, medullary nuclei, anterior horn,
and spinal ganglia. The cells showing the most
marked changes were the anterior-horn cells, the
Purkinje cells, and the mitral cells of the olfactory
lobe. The changes were those of later stages of de-
generation.
Rabbit No. 3. Heloderma poison; rapid action.
The changes were almost identical with those found
in ral)bit No. i.
Technique: The material was placed in a fcur-per-
cent. alcoholic solution of formalin for twenty four
hours, then passed through graded alcohols. Sections
were cut in celloidin and stained by Held's modifica-
tion of the Nissl method, i.e., erythrosin-methylene blue.
Dr. J. EwiNG also presented a paper on this topic.
The changes in the ganglion cells of a rabbit, in which
moccasin-snake poison was injected, were found by
Nissl's stain to be of a somewhat specific type and of
the most extreme grade. The general appearance of
the cells was that of total disintegration of chromatin
bodies without marked loss of the amount of the chro-
matin substance. The outlines of tiie Nissl bodies
were completely obscured, the substance having been
redeposited in finely granular form ail over the cell
body and even in the pericellular lymph space. In
the majority of the large stichocromes neither formed
bodies nor reticulum could be distinguished. It was
evident that the lesions extended much deeper than the
chromatic substance, affecting the underlying cyto-
reticulum, which was granular, disintegrated, and in
some places completely destroj'ed. The nuclei were
very opaque and the nucleoli often diminished in size
and subdivided. The dendrites were very irregular,
shrunken, or detached. These changes constituted a
true acute degeneration of the cell in contradistinction
to the simple disturbance of chromatic substance,
which might be entirely physiological. He thought
that the changes he had found in the rabbit were the
most violent of all the conditions included in his ex-
perience with ganglion-cell degeneration.
SECTION ON GYNAECOLOGY.
Stated Aleetuig, April 26, igoo.
J. Riddle Goffe, M.D., Chairman.
The Prevention of Dystocia due to Foetal and Pel
vie Disproportion — Dr. Edward A. Ayers read a
paper on this topic. He said that in multiparte one
had as an aid to prognosis the previous history of la-
bors. Inquiry should be made as to the size of the
children previously born, the size of the caput or other
evidence of head moulding, the character of the pains,
and whether or not assistance had been required. Up
to the age of thirty-five years it w'as safe to assume that
with each successive labor the child would be a little
larger, and that after that age there would be a steady
decrease in size. Some notion of the probable char-
acter of the pelvis might be surmised from a consider-
ation of the size of the mother's bones generally. A
stout woman was apt to have a less roomy pelvis than
onenot so fleshy. Large external pelvic measurements
accompanied a heavy bony framework. When a wo-
man had a satisfactory delivery history, careful inter-
nal measurements were not demanded. Measurements
of the pelvic outlet were not generally taken, and this
omission occasionally led the physician into trouble.
The width of the pubic arch should always be consid-
ered. In cases of contraction of the true conjugate
the child's head usually lay quite high. The varia-
tions of the head diameters were not so great as in the
pelvis, but the determination of them should not be
neglected. The speaker said that with sufficient expe-
rience very accurate opinions could be formed of the
probability of obstruction occurring during labor, by
examining during pregnancy with a view of determin-
ing the amount of resistance to the engagement of the
fcetal head. This tentative engagement of the fcetal
head would show in cases of marked contraction of
the inlet a sudden and decided resistance as the head
was forced down. If, on the other hand, the pelvis was
roomy, the head could be forced down some distance,
and its descent would then be checked gradually in-
stead of suddenly.
Induction of Labor. — The chief and almost the only
objection to tiie induction of premature labor was the
danger of death of the infant from prematurity. This
transferred tiie danger, to some extent, from the
mother to the child. The question was really whether
the prognosis for the child was better or worse if de-
livery was effected two or three weeks before full term
by an easy labor, or at full term after a difficult labor.
The best means of inducing labor were: (i) The use
of the sterile, solid, flexible bougie, which should be
tapering and not blunt; (2) the small liarnes' bag used
only to excite contractions; (3) the tampon. All of
these measures should be preceded by a full dose of
castor oil.
Indications for Premature Delivery with Special
Reference to Eclampsia ; the True Toxaemia of
Pregnancy — Dr. S. Marx read this paper. He said
that clinical experience showed that eclampsia was
closely allied to renal inadequacy, and that the surest
way to health was by the restoration of this function.
The treatment must be early and timely. It was not
sufficient to determine the presence of albumin and
casts in the urine of the pregnant woman; the quantity
of urea excreted daily must be estimated, for upon tiiis
must largely depend the question of the advisability
of active interference. Five per cent, of all pregnant
women had albuminuria, yet he had never known urje-
mic symptoms to ari.se when sufficient urea was ex-
creted. For a woman otherwise healthy, the daily
quantity of urea excreted should be about five hundred
grains. The majority of albuminurias were simply
danger signals; on the other hand, the absence of al-
June 2, 1900]
MEDICAL RECORD.
971
buminuria, in the face of certain symptoms, meant
nothing as regards safety. In some of the most des-
perate cases of eclampsia neither albumin nor casts
were present in the urine. Progressive diminution of
urea excretion, with or without albuminuria, was a
special indication for interference.
' Induction of Labor. — He was utterly sceptical as
to the frequent occurrence of a truly contracted pelvis
in this country. Most obstructed labors were the re-
sult of a disproportion between the ftetal and maternal
parts. No matter how narrow the pelvis, as deter-
mined by the pelvimeter, a child could be delivered
with assistance, provided it was small enough. The
indication for the induction of premature labor was
not to be found in the old-fashioned tables found in
the text-books on obstetrics. All pregnant women
should be subjected to a thorough pelvimetric exami-
nation because this instrument gave a clew to pelvic
distortions and contractions. With one or two fingers
in the vagina the other hand pressed the fcetal head
down into the pelvis. The ease with which the head
engaged at the brim determined whether or not prem-
ature labor should be induced. Small and even fair-
sized foetuses had been delivered through pelves whose
diameters were far from normal, and in persons in
whom there was reason for suspecting that major oper-
ations would be demanded. When once it was found
that the head could not be made to engage, the time
for interference was at hand. The pelvimeter should
be used for purposes of comparison only.
Ths- Treatment of Tumors Complicating Preg-
nancy Dr. Brooks H. Wells read this paper.
Speaking of cancer, he stated that about forty per
cent, of the children were born dead, and almost all of
the others were feeble. Under these circumstances the
child deserved only secondary consideration. In can-
cer of the cervix in a pregnant woman, operation was
urgently demanded, and when circumstances were fa-
vorable vaginal hysterectomy should be performed
while the uterus was still small. During the sixth
month, or later, the viability of the child must be con-
sidered. If the case was first seen at term, and the
disease was in the very early stage, the cervix might
dilate satisfactorily, but there would probably be cer-
vical lacerations. When the cancer involved the vul-
va, vagina, or rectum, the mass should be removed, if
small; if more advanced, operation by the abdominal
route gave the best results. The chance of becoming
pregnant was less than when fibroids were present, yet
when pregnancy did occur it was well known that the
fibroids were prone to take on a much more rapid
growth. Interstitial tumors grew the most rapidly,
particularly where the uterine wall was much thickened.
Subperitoneal tumors did not grow so rapidly, and if
near the fundus were not of so much importance. In
general, the higher the situation of the tumor and the
more it approached the subperitoneal type, the less the
danger. The most serious cases were those in which
the fibroid occupied the pelvic cavity. It should be
borne in mind, however, that the fibroids predisposed
to abortion. Inflammation and sloughing of the tu-
mor from injuries received during labor were very
common, and constituted a grave danger. The mortal-
ity in labors complicated by fibroids had been, in the
past, almost fifty per cent., and nearly as much for the
child. During the early months of pregnancy myo-
mectomy was indicated, and could often be done with-
out interrupting pregnancy. P"or interstitial tumors of
the fundus of the uterus, supravaginal hysterectomy
should be done. Inversion occasionally followed de-
livery with tumors of the fundus. If the fibroid tu-
mor obstructed labor and was in the anterior wall, it
could sometimes be pushed out of the way while the
patient was in the knee-chest position. Tumors of the
cervix must be enucleated when possible, as even when
they were very small enucleation was less dangerous
than forcible delivery. A fibroid polyp, detected first
after labor, should still be removed, as it was apt to
slough and give rise to sepsis. To be successful these
operations must be done early as a matter of election.
Cysts or solid tumors of the ovary might also compli-
cate labor. Large cysts were not likely to block the
pelvis, but they caused much discomfort, and were
particularly liable to rotation and twisting off of their
pedicles. The dangers incident to delivery by ver-
sion, forceps, puncture, twisting of the pedicle, intes-
tinal occlusion, septic infection, and peritonitis were
so great that the records showed a mortality here also
of nearly fifty per cent. When seen early in pregnan-
cy, an abdominal section, preferably by an intermus-
cular incision, with removal of the cysts, gave the best
results. After the fifth month, if the tumor was not
large or impacted, it was allowable to wait until the
child was viable. At term, if the cyst was small, the
child might be driven past it, or the tumor might be
drawn above the brim. If the cyst was not impacted,
and labor was progressing well, operation should be
deferred until after the birth of the child. With an
impacted cyst, puncture and delivery by version or
forceps would seem proper, but the mortality was so
great that it was rarely justifiable. Supravaginal hys-
terectomy was a better method. Labor might also be
obstructed by enchondromata, cysts of the pelvis, hy-
datid cysts, displaced kidneys, and the muscle mass
which sometimes resulted from ventral fixation of the
uterus. His experience had been that during preg-
nancy abdominal operations in general weie well
borne. . All unnecessary hemorrhage should be avoid-
ed, and particular care should be taken to secure per-
fect asepsis.
When was it Proper to Interfere in Apparently-
Difficult or Delayed Delivery, Especially in Primi-
parae ? — Dr. Malcolm MlLkan read a paper with
this title. He emphasized the fact that the great dif-
ference between first labors and subsequent ones was
to be found in the different condition of the soft parts.
If surgical interference was attempted before the soft
tissues had properly relaxed and dilated, great and
unnecessary damage would be done to the mother.
This was a very common error, and a notable example
of meddlesome midwifery. If the presenting part was
high up and movable, and the pelvic measurements
were within normal limits, interference should be with-
held. If the soft parts of the mother, once thoroughly
relaxed and moistened with mucus, became hot and
dry, the indications for interference w^ere plain.
Dr. E. a. Tucker emphasized the necessity for be-
ing cautious in considering deductions from the first
labor regarding the character of subsequent labors.
In a case presenting suspicious symptoms of uraemia,
the daily quantity of urea should be estimated at short
intervals during pregnancy. He had recently urged
primiparre to do considerable walking during the last
month or six weeks of pregnancy, in order to facilitate
the engagement of the head. Such exercise did no
harm, and he felt convinced that it accomplished much
good in the way of facilitating engagement of the head.
A substitute for the walking was the use of systematic
exercise in bed— raising and lowering the body so as
to exert abdominal pressure. Occasionally one wculd
meet with primiparai in whom the parts did not relax
or become moist, even after many hours; here, of
course, interference was demanded, and should be
given, if possible, even before the vagina became hot
and dry.
Dr. Egbert H. Grandin said that he was a believer
in pelvimetry, and thought it would be better for wo-
mankind if all practitioners were taught and drilled
in its use. Pelvimetry was valuable because it taught
that, on the part of the woman, there might not be
972
MEDICAL RECORD,
[June 2, 1900
sufficient room, and hence impressed upon the attend-
ing physician the necessity for determining positively
at the proper time whether or not one should interfere.
He believed there was such a thing as an average nor-
mal pelvis, and yet through such a pelvis one woman
would not be able to bring a child into the world,
while another woman could do so, simply because one
child was smaller than the other. If the presenting
part would engage under suprapubic pressure, the
chances were all in favor of the mother being able to
deliver herself, but when the fcttal parts would not
enter the pelvic inlet interference was at once de-
manded. Such interference should be as rapid as
possible without injuring the maternal parts. He was
sorry that Dr. Ayers advocated the use of the sterile
bougie as a means of inducing labor, as it was a most
uncertain and tedious method, and there was always
risk of rupturing the membranes. If this accident
should occur, one method of elective version was
placed beyond our reach. Personally, he thought the
best method was to use the tamponade of sterile gauze
to excite dilatation, and then to complete this process
manually.
Urinary Examinations in Pregnancy. — The time-
honored teaching that the practitioner should make a
perfunctory examination of the urine for albumin in
the latter months of pregnancy should be relegated to
oblivion. Some of the worst and most sudden cases
of toxaemia that he had seen had been those in which
there had been absolutely no albumin in the urine,
and in which, the physician not having had his atten-
tion concentrated upon the quantity of urea and on
renal insufficiency, the woman had suddenly, passed
into the condition of eclampsia.
Treatment of the Toxaemia. — He had recently
looked over his records for the past twenty years, and
had been struck with the large number of cases of tox-
jemia he had seen, and the high mortality that had
attended the use of all of the approved methods of
treatment. Of late years, in cases under his immedi-
ate supervision, just as soon as there had been evi-
dence of urinary insufficiency, both as regards the to-
tal quantity of urine and of urea, he had not waited
for cephalalgia and disturbance of vision, but had
promptly emptied the uterus, because he felt that this
meant the greatest good to the greatest number. He
could not emphasize too forcibly the importance of
making the treatment of this toxaemia of pregnancy a
prophylactic one.
Dr. G. H. Ballerav said that he had seen a good
many women go through labor safely and well in spite
of the large quantity of albumin in the urine; on the
other hand, he had seen them succumb to eclampsia
when there had been little or no albumin. He
agreed with Dr. Marx that absolute pelvic contraction
was rare. The indications of the pelvimeter should be
looked upon as entirely relative. Pelvimetry was very
much like measuring the outside of a man's house; it
did not show positively whether or not the man could
pass through a doorway in that house into one of the
rooms.
Dr. F. H. Stuart said that the papers just pre-
sented had distinguished clearly two sets of conditions
— those under the physician's control and those be-
yond his control. Examination of the pelvis by means
of instruments, in his opinion, was fallacious; the
digital examination by the experienced physician
often afforded more reliable information. He would
indorse most heartily the recommendation made by
Dr. Tucker, that the patientshould be directed to walk
and to exercise the abdominal muscles systematically
and freely toward the close of pregnancy. Delay in
labor was often owing to a faulty position, and this
could have been avoided by preliminary efforts at se-
curing proper head moulding.
Dr. Ayers said that the suggestions about walking
in the later months were excellent, but required some
modification, for the discussion had included both en-
gagement of the head and the avoidance or relief of
toxffimia, and if such exercises were not restricted one
might walk from one danger into another.
Restricted Diet. — Dr. Marx said that he had made
use of the restricted diet treatment for women in whom
it was feared that labor would be difficult because of
the large size of the child. It was certainly possible
to accomplish a good deal in this direction by restrict-
ing the starches and sweets, and limiting the ingestion
of water. At one time he had endeavored to improve
upon this by administering the thyroid extract, but the
women had returned to him complaining that they did
not " feel life " so strongly as before. This diminution
in the fatal movements had been so marked as to
compel him to abandon this mode of treatment. In
closing, he would say once niore that it was not albu-
min but urea that killed.
AMERICAN
CLIMATOLOGICAL ASSOCIA-
TION.
Seventeenth Annual Meeting, Held at Washington,
D. C, May i, 2, anit j, igoo.
( Concluded from page Syj. )
Third Day — Thursday, May 3d.
The Value of the Tuberculin Test in the Diagnosis
of Pulmonary Tuberculosis. — Dr. J. M. Anders, of
Philadelphia, read a paper on this subject, in which
he said that among those who have made use of tuber-
culin there was a remarkable unanimity of opinion as
to its value for purposes of diagnosis. The question
of dosage was vitally important, and he said he favored
a medium-sized initial dose, which would obviate the
disadvantages arising from the necessity of repeated
injections, as was generally the case when small com-
mencing doses were used. Recent and extensive
clinical testing of Koch's method in widely separated
parts of the world, by competent observers, had re-
sulted in a practically unanimous verdict, which em-
phasized its superior value as an aid to diagnosis of
incipient cases on the one hand, and in no smaller
degree its apparent harmlessness on the other.
Dr. J. W. Brannan, of New York, said he was
somewhat uncertain as to what was considered a re-
action after the use of tuberculin. In a number of
joint cases of doubtful origin in which the tuberculin
was used for diagnostic purposes, the injections were
followed by a rise of temperature and an increased
pulse rate, but no tenderness or other local signs
about the joint. The speaker asked whether in such
a case it could be claimed that the patient had reacted
to the tuberculin test.
Dr. Charles E. Quimby, of New York, said that
in cases of pulmonary tuberculosis the injection of a
very small dose of tuberculin would sometimes pro-
duce an obvious increase in the rales heard over the
suspected area, even when it did not produce an evi-
dent rise of temperature. The speaker said he usually
started with a dose of half a milligram.
Dr. Charles Denison, of Denver, in discussing
the question as to what constituted a tuberculin reac-
tion, said he thought that sufficient weight was not at-
tached to the local reaction in the affected lung.
After such an injection, there was usually an
elevation of the pitch, and a peculiar, harsh broncho-
vesicular sound which was diagnostic, and which
could not be detected previously.
Dr. H. L. Taylor, of St. Paul, said he wished to
protest against the statement made by Dr. Anders
June 2, 1900]
MEDICAL RECORD.
973
that tuberculin should not be used as a therapeutic
agent. The speaker said he was thoroughly con-
vinced that much good could be done by the judicious
use of tuberculin in a therapeutic way.
Dr. Arnold C. Klebs, of Chicago, said he had
frequently seen local changes in the lung produced by
the use of tuberculin. Still, in looking for a reaction,
the temperature must be our main guide. In his own
practice he had adopted the following rule: The tem-
perature of the patient was taken at frequent intervals
for a week previous to injection : this was averaged, and
if, after the injection, there was a rise of 2° F. above
this average, it was regarded as constituting a reaction.
Of course there were variations to this rule. Further-
more, different preparations of tuberculin gave differ-
ent reactions, and there was no absolute standard to
go by. The speaker said he usually began with a
dose of one-tenth milligram, repeated, if necessary,
after two or three days, and increased up to one or
two milligrams if the previous ones are negative.
Dr. E. O. Otis, of Boston, said that in the course
of his experiments with tuberculin in cases of cervical
adenitis, the results of which were published last year,
he found that the reaction occurred in a certain num-
ber of cases of syphilis. As to what constituted a
tuberculin reaction. Dr. Otis said that in addition to
the increased temperature he would expect to get
malaise and general depression. In the syphilitic
cases which reacted, he had no reason to suspect any
latent tuberculous focus.
Dr. Edward R. Baldwin, of Saranac Lake, said he
thought that tuberculin was rarely needed in the diag-
nosis of tuberculosis of either the lungs or joints.
It should be used only as a last resort, when the older
methods of diagnosis had failed.
The Hydriatic Treatment of Tuberculosis. — Dr.
J. H. Kellogg, of Battle Creek, Mich., read a paper
on this subject, in which he said he considered it re-
markable that such an old and valuable remedy in
the treatment of tuberculosis as water should have been
so much neglected. Upon the application of cold
water to the body there was an awakening of all tlie
vital functions, which exerted a marked influence on the
circulation of the blood. Instead of the rather too
vigorous application of cold water by means of ablu-
tion or the use of a sprinkling-pot, as was done in
some institutions in Europe, Dr. Kellogg preferred dry
friction of the skin followed by the application of
cold water by means of the hand, accompanied by
vigorous rubbing of the skin. The temperature of the
water should be 60^ F., gradually lowered as the pa-
tient became accustomed to the applications. Dr.
Kellogg also demonstrated a rapid and simple method
of applying a cold pack to tlie chest.
Dr. Charles L. I\Iixor, of .\sheville, referred to the
importance of simplifying hydrotherapeutic methods
of treatment, so that they could be easily and quickly
taken advantage of by the physician in his general
practice.
Dr. R. H. Babcock, of Chicago, said that while he
regarded hydropathy as a valuable adjunct to the gen-
eral treatment of tuberculosis, he objected to the
statement made by the author which implied that a
certain number of his patients were cured in conse-
quence of this method of treatment.
Petroleum in the Treatment of Phthisis. — Dr.
William Duffield Robinson, of Philadelphia, read
a short paper in which he recommended a refined pre-
paration of the oleum petrolatum of the United States
Pharmacopceia as a valuable remedy in the treatment
of pulmonary tul)erculosis.
Stamina: with Special Reference to the Con-
sumption of Fat Food for its Maintenance as a
Preventive of Tuberculosis. — Dr. A. N. Bell, of
Brooklyn, read a paper with this title. He said that
after a somewhat extended observation and careful
study of the relations of tuberculosis to food, he had
come to the conclusion that, other conditions being
equal, tuberculous diseases were prevalent in the in-
verse ratio to the use of fat of some kind as an article
of diet.
In persons on the verge of pulmonary consump-
tion, inability to digest fat food was one of the
most prominent symptoms. They were afflicted with
dyspepsia, of the kind in which an acid stomach was
predominant — that kind of dyspepsia which was the
common effect of the excessive and too exclusive use
of farinaceous food; insomuch as, in some cases, to
have created a loathing of fat food in every form.
Nevertheless, in medical practice generally, this con-
dition was an indication for the use of fat food. Cod-
liver oil, emulsified or otherwise, was almost universal-
ly the first remedy resorted to, and the most persistently
urged. Butter or bacon was the most digestible of all
fat foods. Fat was the needful thing to energize both
digestion and nutrition, and that form of it which was
the most acceptable was the best.
Dr. Judson Daland, of Philadelphia, said that
tuberculosis had appeared in Iceland in recent years.
It was supposed that it had been introduced from Den-
mark.
The Blood Changes in High Altitudes Dr. S.
E. Solly, of Colorado Springs, made a few remarks
on this subject. He stated that during the past year
he had done considerable work in connection with ex-
aminations of the blood. Perhaps the most interest-
ing part of this work was that done upon twenty-five
college students in Colorado Springs. They were all
healthy, as far as could be ascertained. The blood-
count was almost always high in young men at uni-
versities, and it was higher than the average in those
whom he had selected for his experiments. It was
noticed that in those students who had always lived
in that altitude, the blood-count and haemoglobin did
not average quite so high as in those who were there
for a comparatively short time — two years or less.
There was also an intermediate class between these
two extremes. Dr. Solly said that his findings rather
argued in favor of the theory that while the blood-
count and haemoglobin were higher in those altitudes
than at the sea level, there was a loss rather than a
gain by long-continued residence there.
Dr. Daland, in reply to a question as to whether
the peripheral blood was always a good index of the
character of the blood throughout the body, said he
thought there was no question but that the peripheral
circulation was often greatly modified by external
conditions, such as friction, for example, and that the
blood in that region varied at times from that in the
deeper vessels. Still, for experimental purposes we
could secure it only from the peripheral vessels, and
we must abide by the results.
A Case of Endocarditis. — Dr. Harold Williams,
of Boston, briefly reported a case of mural endocar-
ditis with the findings at the autopsy by Dr. T. Leary.
This case was chiefly remarkable because of the
unusual group of pathological lesions, and because of
the absence of murmur in spite of the fact of exten-
sive mitral disease. The absence of pain was another
unusual feature.
Dr. R. C. Newton narrated the history of a case of
malignant endocarditis which had recently come un-
der his observation, in which the physical signs were
very obscure. There was an entire absence of pain.
The patient lived about six months after the onset of
his symptoms, and died of exhaustion.
Dr. N. S. Davis, Jr., of Chicago, reported a case
of what lie regarded as malignant endocarditis, with
recovery.
Dr. J. W. Br ANNAN said it was well known that
974
MEDICAL RECORD.
[June 2, 1900
the presence or absence of a murmur, or the character
of the murmur, could not always be relied upon to in-
dicate the anatomical conditions we had to deal with
in cases of heart disease.
The president, Dr. Jacobi, said there were cases of
endocarditis in which the murmur disappeared, or in
which there was no murmur. In malignant endocar-
ditis there might be extensive changes and deposits
without a murmur. When, however, the deposits were
along the edge of the valves, we had a murmur. The
speaker reported a case of malignant endocarditis, of
gonorrhoeal origin, with recovery.
Dr. Babcock said that although a cardial murmur
might be regarded as a very valuable guide-post,
pointing out the direction in which we were to search,
it was comparatively unimportant in the actual diag-
nosis of valvular disease. We must chiefly rely upon
the secondary physical signs in determining the
nature of the lesion. Theoretically, it seemed that
the presence or absence of a valvular murmur de-
pended largely upon the size of the orifice through
which the blood passed. The entire subject, however,
was still involved in obscurity.
Exercises Suitable for Children Suffering from
Heart Disease Dr. J. Madison Taylor, of Phila-
delphia, read a paper on this subject. He began by
alluding to the fact that a fair number of cases of
heart disease were met with among people who had
lived a long and arduous life, in whom the cardiac
disability was recognized in very early years and pro-
nounced by competent clinicians to be most danger-
ous. Dr. Taylor said that in carefully selected in-
stances, the use of regulated activities afforded much
relief to many of the distressing symptoms which ac-
companied and followed disordered conditions of the
heart. The term " exercise,*' as he employed it,
should be clearly kept in mind as being a normal use of
the bodily parts— not merely of the muscular system,
as it was usually understood, but particularly the in-
ter-relation of the viscera and their mutual co-opera-
tion. The first and most important item was that the
individual should learn to sit, stand, and move in
proper attitudes, for only thus could this symmetrical
activity of the various parts be maintained. The next
was to secure and practise full flexibility of the mov-
able joints and skeletal tissues. An invaluable form
of exercise was the act of breathing correctly, which
should be taught, enforced, and practised. After out-
lining certain forms of exercise more fully. Dr. Taylor
related his experience in adapting these measures to
children, showing what remarkable results were some-
times brought about by movements which would seem
to be of the simplest sort. Among these he mentioned
readjustment of the muscles of the trunk and limbs,
also stretching, both active and passive, and the cau-
tious use of massage and baths. Most of the move-
ments should be begun in the recumbent posture, and
all should be followed by long periods of rest, lying
down. Each individual case must be carefully studied,
and the rules governing it should be formulated from
watchful experience.
Dr. Jacobi said that in the treatment of acute car-
diac disease he knew of nothing better than absolute
rest. In addition to this, we should stimulate the
peripheral circulation and relieve the heart by mas-
sage and passive movements, or applications of cold
water or alcohol to the skin. The skin normally con-
tained an immense quantity of blood, and if there was
no peripheral circulation the heart would suffer.
A Case of Cardiac Aneurism, with Thrombosis
of the Left Coronary Artery — Dr. Judson Daland,
of Philadelphia, reported this case. The patient was
a man over fifty years of age, with an old history of
syphilis, who died suddenly. The autopsy showed an
aneurism of the left ventricle, with extensive fibroid
degeneration of the wall of that cavity and the intra-
ventricular septum. There was also a thrombosis of
the left coronary artery.
Officers Elected. — The following officers were
elected for the ensuing year: President, Dr. R. H.
Babcock, of Chicago; Vke-Fresidcnts, Drs. A. C.
Peale, of Washington, D. C, and S. W. Langmaid, of
Boston; Secretary and Treasurer^ Dr. Guy Hinsdale,
of Philadelphia; Member oj Council, Dr. A. Jacobi, of
New York.
Catarrhal Laryngitis. —
"S, Ammon. et potass, tartrat gr. ^
Liq. ammon. cit. (Br. ) ni x.
Elix. aromat HI v.
Aquoe q.s. ad 3 i.
M. S. Every four hours for a child of two or three years.
— AsHBY AND Wright.
Croup. —
'S, Chloral gr. Ixxv.
Potass, brom gr. xlv.
Amnion, brom gr. xxx.
Aq. cinnamomi § ij .
M. .S. Teaspoonful for child of seven years. Repeat in
twenty minutes if not relieved. Decrease for younger children.
— Joseph Holt.
Creolin Pills.—
I^ Creolin 6 gm.
Spt. vini rect. dil i gm.
Ext. glycyrrhiz^,
Pulv. glycyrrhizse aa 6 gm.
Gum. tragacanth i gm.
M. ft. pil. div. No. c.
For use in intestinal fermentations, infectious dis-
eases, etc. — Spoeth.
Diuretic. —
R Salicylate of sodium and theobromine aa 5 gm.
Syrup of orange-peel 25 gm.
Distilled water 60 gm.
M. S. Dessertspoonful every two or three hours.
— Journ. dt Med. de Paris, March 25th.
Acute Colic, when non-surgical :
IJ Chloroformi 7-5
Tinct. opii camph 5°-
01 . cajuputi 2-
Acacix pulv. ,
Syrupi aa q s. ad 100.
M. ft. emuls. S. Dessertspoonful in water every two or
three hours.
— William Pepper.
Chloro-anaemia. —
l\ Arteniisin o.ooi mgm.
Quassin. crystal o.ooi mgm.
Ferri protoxalat o. 10 cgm.
M. ft. pil. No. i. S. Take four daily.
This is said to bring rapidly back appetite and a good
color.
Rebellious Intermittent Fever.—
If (Juinin.v sulphat 4- gm.
Ferri et potassii tartrat 10. gm.
Acidi arsenosi .... o. 10 cgm.
Aqu.-e destil 300. gm.
M. S. The day following the fever a teaspoonful every
hour ; subsequently ever)' three hours.
— Baccelli.
Rheumatism. — Alkalies should always be pre-
scribed along with the salicylates, and the one to be
preferred is some potassium salt, the bicarbonate or
the citrate. These remedies should be continued for
two or three weeks after the joint symptoms iia\e sub-
sided. Iodide of potassium and sodium are often useful
in the symmetrical type, in which the same joints on
each side are affected. With regard to diet, meats and
June 2, 1900]
MEDICAL RECORD.
975
meat teas are contraindicated. Milk may disagree,
and this may be overcome by adding to it a little salt.
A temporary vegetable diet is useful. In the com-
mencement the less food the better. — William Ewart.
After-Pains.— A hot meal may be better than medi-
cine. For the instant, relief of exhaustingly severe
pains a piece of tissue paper is saturated with five or
six drops of amyl nitrite and stuffed into a tuo-
drachm vial, and the patient inhales this whenever she
feels the pains coming on. — Winterburn.
Dysentery. — Free gentle purgation is kept up with
I^ Sodii sulphat j i.
Aq. fceniculi 3 iv.
giving as much as is required for the effect of produc-
ing bloodless stools. — VV. J. Buchanan.
Grippe
1} Sodii benzoat 20 gm.
Tinct. aconiti gtt. ix.
Syr. polygal* 100 gm.
Aq. IJul q.s. ad 300 c.c.
M. S. Dessertspoonful three times a day in hot infusion.
Grippe with Circulatory Asthenia and Arterial
Hypotension. — Daily intestinal lavage, after which
5 c.c. of the following can be injected:
• I^ Caffein.x',
Sodii benzoat aa 10 gm.
Aquae bul ad 100 c.c.
— Grasset.
Gonorrhoea •
R Methylene blue gr. i.
Oil of nutmeg gtt. i.
Oil of sandalwood gtt. ij.
In capsules. Give four daily.
—O'Neill.
Phthisis. —
R Tannin 6
Spt. vini rect 20
Glycerini 60
Eli.\. Garus (Fr.) 30
Aq. destil 1 60
M. S. Teaspoonful three times a day.
— Derscheid.
Grippe in Children. —
I^ Tinct. aconiti gtt. v-.\.
Sodii benzoat 1-3 gm.
Syr. lactucarii 5-10 gm.
Syr. aurant. flor 20 gm.
Mucil. acac 120 gm.
M. S. Dessertspoonful every two hours.
— P£rier.
Or,
I{ Antipyrin r gm.
Aqure laurocerasi 2 "
Syr. tolu 40 "
Aq. destillat 60 "
M. S. In three or four doses during the day.
— COMBY.
Obstipation. —
1} Mydrarg. corrosiv O. I
Strychnin, sulphat 0.05
Aquae destil 30.
E.\t. cascarx sagrada fl 120.
Glycerin ad 250.
M. S. One to three teaspoonfuls daily.
— R. C. Fisher.
Anaemia. — Give iron in hot solution.
Bronchitis. — Potass, iod. 0.3 in a tablespoonful of
water half an hour before meals will give relief in
three or four days; given after meals in a larger quan-
tity of water it is said to have much less effect.
To Abort a Cold. — Give a nasal douche with a
pink solution of permanganate of potassium. Place a
plug of cotton in each nostril, soak with the solution,
and leave in place for an hour. — Ma.\ Nass.auer.
In Nursing Women Opium, morphine, atropine,
hyoscyamus, colchicuin, arsenic, cocaine, chloral, and
salts of lead should not be given, and digitalis, ergot,
and antipyrin should be withheld when they produce
untoward effects. — Marifan.
Pertussis. — The following is to be applied to the
pharynx:
I{ Acid, phenic. cryst 1.50 gm.
Glycerini purl 10
Syr. tolutani 5 "
M. S. E.Kternal use.
— GUIDA.
Cervical Metritis
1} Tinct. iod.,
Glycerin (neutral) aa p.se.
Apply every second day. then every third, and finally once
a week. At the same time inject daily for ten or fifteen days with :
I^ lodi bi-sublimat o. 50 cgm.
Potass, iodidi i.o gm.
Aq. bull 1 ,000
^Cariere.
Pruritus Scroti. —
I^ H ydrarg. chlor. corros o. 50 cgm.
Spt. vini rectif. ,
Aquie chamomil aa 25 gm.
Chloroformi gtt. v.
Aqu.TS camphoriE loo gm.
M. S. Apply.
— Leistikoff.
Gout.—
If Lithii benzoatis 3 iiss.
Sodii phosphatis 3 v.
Tinct. colchici sem 3 iiss.
AquK cinnamomi ad 5 iv.
M. S. Dessertspoonful two or three times daily.
— Butler.
Snake Bite. —
R Selaginella apus (snake moss) 3 ss.
Macerate in an ounce of sweet milk and give at once. Alio
apply some of the moss to the wound.
— Rawley White, of Virginia.
Ulcerating Blepharitis. — Epilation, followed by
washing for ten minutes morning and night with the
following solution, diluted with three times its volume
of tepid water:
Ti Hydrarg. oxycyanid 0.30 cgm.
Sodii chloridi 3. gm.
Aq. destil 500.
Touch daily with a crayon of blue pyoctanin. — Cop-
pez.
Convulsions in Children. ^ — Hot or tepid bath or
mustard bath if the child seems to have been chilled.
To prevent, recurrence give:
If Potass, brom.,
Sodii brom..
Amnion, brom . . .aa o. 20 cgm.
Syr. codein 5- g™.
Syr. auranti flor 30-
Aqua; lOQ. "
If the child cannot swallow, give a rectal injection
with
If Musk 0.20 cgm.
Chloral hydrate 0.30 cgm.
Camphor I gm.
Yellow of egg 10 gm.
Water 100 gm.
J. Simon.
Parasitic Blepharitis. —
If Bals. peruv 2 parts.
Lanolin 4
01. amygdal. dulc 2 "
M. S. Applv to the margins of the partly closed lids and
leave on for a half-hour or more.
— Roehlmann.
976
MEDICAL RECORD.
[June 2, 1900
|]actUcaI Jtcms.
How Frozen Meat Deteriorates Meats frozen and
kept in cold storage for long periods do not undergo
organic changes in the ordinary sense— that is, they
do not putrefy, soften, or smell bad, but they certainly
do deteriorate in some intangible way. After a cer-
tain time frozen meat loses some life-principle essen-
tial to its nourishing quality. Such meat lacks flavor;
it is not well digested or assimilated. Its savorless
condition cannot be remedied or successfully disguised
by the use of sauces and condiments. Those who eat
cold-storage food for any length of time develop diar-
rhoeal disorders, lose in weight, and would eventually
starve to death unless a change of diet was made.
The same reasoning applies to tinned fruits and vege-
tables. They should not be used after a certain period
has ebpsed. Especially should people be warned
against using stale eggs and old milk and cream.
Milk and cream are kept for days, rancid butter is
washed and treated chemically, but all food, and espe-
cially cold-storage food, is damaged by long keeping,
and will not nourish the body properly. There is the
greatest abundance of food, but it does not satisfy. —
Sanitary Record.
The Home of Genius in Great Britain.— Accord-
ing to Mr. Jonathan Hutchinson, the home of genius
in Great Britain is in the vicinity of Shakespeare's
birthplace. In Tlie Home Uiihersity he has written a
short article in support of this point, showing that
within a radius of fifteen miles of Coventry were born
Shakespeare, George Fox; Butler, the author of Hudi-
bras; George Eliot, and Walter Savage Landor. Mr.
Hutchinson suggests that the cause for this may be
some surviving strain of Italian descent in the district,
and further remarks that others have directed atten-
tion to the fact that it was here in the very centre of
England that the Romanized Britons were less dis-
turbed than elsewhere. It seems exceedingly probable
that what we call genius is seldom or never produced
by races of men only recently civilized, but that it oc-
curs in those who in some degree trace their descent
to the other stocks. The features of many European
men of genius suggest .some admi.xture of Semitic
blood, and during the three hundred and sixty years
of the Roman occupation it must have been that many
Italians settled in England and subsequently left their
descendants.
Medical Students in Paris. — The annual report
on the attendance at the Faculty of Medicine of Paris
has been published. There were inscribed at the
Faculty for the year 1898-99, 4,315 students, of whom
4,122 were candidates for the diploma of " docteur en
niedecine," or of "officier de santtf," an inferior quali-
fication now abolished except for a few students who
began their studies under the previous law of the stu-
dents; 3,542 were French and 570 foreigners. There
were 3,983 men and 1,229 women. The diplomas of
" docteur en niedecine " given were 671 in number; of
"officier de sante," 13; of midwife. 48; and of sur-
geon-dentist, 68. The statistics show that 180 stu-
dents less than in 1897 were inscribed, but it must be
remembered that this includes the names of 160 struck
from the rolls for not having been present during the
past five years. Among the foreigners were 180 Rus-
sians, 79 Roumanians, 26 Germans, 25 Greeks, 24
West Indians, 21 Swiss, 12 Spanish-Americans. Most
of the women were foreigners — 100 out of 129 — of
whom 9 1 were Russian, 5 were Roumanian, 2 Ger-
man, and I Swiss. The individual examinations were
9,119, passed before 34 professors and 36 professeurs
agre'ges. The number of candidates refused was i,-
591, or 17.4 per cent., a rather high percentage of the
671 diplomas given; 79 were bestowed on foreigners
and did not admit to practice in France. ^ — Paris letter
to Tlicrapeuiic Gazette.
The Age of Medical Graduates in Japan — A
Japanese paper, the //// Shinipo, finds reason for la-
mentation in the fact that whereas medical students
in Europe graduate at twenty-two or twenty-three years
of age, in Japan the age is over twenty-six. The pa-
per in question points out that Japanese mature and
age earlier than Europe, and that as the period of use-
fulness in life in Japan is considered to be over at
fifty, the period of active practice is short. In Europe
a man is usually at his best at fifty, and even at sixty,
seventy, and over grave and reverent seniors are not
looked upon as uselessly barring the way of ambitious
juniors. — Jotirnal of Tropical Medicine.
Dental Anomalies. — .Among anomalies of the teeth
are macrodontism, microdontism. projecting teeth,
badly placed or misplaced teeth, double row of teeth,
or teeth which are striated transversely or longitudi-
nally. Caries of the teeth and Hutchinson's teeth are
due to neglect or disease. The latter, however, may
often be considered as a stigma of degeneration.
Then there is a retardation of the first and second
dentition. — Petersen's "Dental Diseases."
While the Medical Record is pleased to receive all new pub-
lications whicli may be sent to it, and an acknowledgment will be
promptly made 0/ their receipt under this heading, it must be with
the distinct tinder standing that its necessities are such that it can-
not be considered under obligation to notice or review any publica-
tion received by it which in the judgment of its editor will not be
of interest to its readers.
The OrHTH.\LMic P.\tient. I!y Percy Fridenberg, M.D.
l2mo, 304 pages. The Macmillan Company, New York.
Chemistry and Physics. By Martin Rockwell Gallaudet.
l2mo. 374 pages. Lea Brothers & Company, Philadelphia and
New York.
Medicine and the Mind. By Stacy B. Collins, M.D.,
translated by Dr. Maurice de Fleuiy. 8vo, 373 pages. Downey
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Metropolitan Water Board. Svo, 250 pages. Wright
& Potter Printing Company, Boston, Mass.
Electric Medicine and Surgery. By John V. Stevens,
M.D. Svo, 520 pages. Scudder Brothers Co., Cincinnati, Ohio.
International Clinics. By Henry W. Cattell, ^^D. Svo,
315 pages. J. B. Lippincott Company, Philadelphia, I'a.
International Conthiisutions to Medical Literatiire.
"Festschrift" in honor of Abraham Jacobi, JLD., to com-
memorate the seventieth anniversary of his birth. Svo, 496
pages. The Knickerbocker Press, New York.
Neurom.\ and Neuro-Fihromatosis. By .Me.\is Thomson.
Folio, 168 pages. TurnbuU & Spears, Edinburgh.
Golden Rules of Ophthalmic Practice. By Gustavus
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Guide Pratique d'Electroth^rapie Gyn£cologique.
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Medical Record
A Weekly yournal of Medicine and Surgery
Vol. 57, No. 23.
Whole No. 1544.
New York, June 9, 1900.
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CHOLECYSTECTOMY FOR GALL STONE"' '
By C. L. GIBSON, M.D.,
ATTENDING SURGEON ST. LUKE's AND CITV HOSPITALS.
The gall bladder was first removed in man by Lan-
genbuch " in 1882 ; the operation proved a success
both from the standpoint of technique and curative
effect. This new " radical "method of treating cho-
lelithiasis was for the most part unfavorably received
at first. In later years its value was more generally
recognized, but not along the line of usefulness
planned for it by its originator, as most surgeons pre-
ferred to reserve it for secondary operations. It was
also long after this advanced method was formulated,
that even simple operations for gall stones became
fairly common, and for some time it was lost to sight
in the study of the advantages of cholecystotomy in
one or two stages.
As a primary operation for the relief of gall stones
it has never come into vogue, although it has always
had individual champions. The script
of the operation is essentially German,
both by origin and practice.
In English-speaking countries the
operation has generally been rejected or
ignored. Certain French surgeons have
used it with success, but have failed
materially to increase its popularity
among their colleagues.
According to a recent observation of
Wolynzew,^ the operation has been per-
formed only six times in Russia.
It may fairly be stated that in this ii,, i-
country the operation as a primary or
optional measure is of great rarity. In the few in-
stances that have been brought to the writer's notice
the operation generally consisted in the removal of an
atrophic calculi-containing bladder, usually buried in
adhesions and subjected to such laceration in its search
and the evacuation of its contents as hardly to leave
any other choice than removal. The records of the
New York Surgical Society contain only two cases out
of the abundant material presented at its meetings for
the last ten years, and they were of the character just
described.
Cholecystectomy the writer believes has a far wider
field of usefulness than would be indicated by the
above. He finds also that certain operators of very
great experience have become converted to its value
with increased opportunities for its performance.
The operation has commended itself to the writer
in two cases in which he employed it, although in
each case the condition to be dealt with was quite
different.
' Read at the meeting of the New York Clinical Society,
March 23, 1900.
' " Chirurgie der Leber u. Gallenblase. " Deutsche Chirurgie,
Lieferung 45 c.
^ Centralblatt fiir Chirurgie, I900, p. 230.
The history of the patients is as follows:
Case I. — Mrs. R. F , aged twenty-two years,
admitted to St. Luke's Hospital June 3, 1899. Three
months previously she submitted to double oophorec-
tomy at another institution. Since this operation she
has had occasional uterine hemorrhages. She gives
no history of symptoms referable to previous stomach,
kidney, or liver trouble, except that she thinks she has
been " bilious" for a few days before this attack. The
bowels have been constipated.
Present illness: On the morning of June 2, she
woke up with severe pain referred to either side of
the upper abdomen and in the back. She had a dis-
tinct chill lasting twenty minutes. There was con-
tinuance of pain throughout the day. She began to
vomit in the evening. To-day her pain continues but
is confined to the right side.
On admission the temperature was 103° F. ; pulse
120, of good quality and force. The face was flushed,
but not presenting a picture of severe trouble. Exami-
nation showed a moderate amount of general abdomi-
nal distention. The muscles on the right side were
very rigid. There was general tenderness over the
entire right half of the abdomen, very marked and al-
lowing of only superficial palpation, which yielded
ase I. Unopened Distended Gall Bladder. (One-half actual size.)
no information. Percussion was also without result.
Vaginal examination was negative. The diagnosis
was not made. She was originally admitted as a case
of appendicitis, but it was believed that in the pres-
ence of the physical signs, together with the short
history, the only possible form would be the extremely
virulent type without limiting adhesions and general
peritonitis; such a condition, in view of the absence
of severe constitutional symptoms, was held to be
highly improbable. Therefore operation was deferred.
The next day there was a general remission of all
symptoms. Palpation could be made more thor-
oughly, but still revealed nothing. The next day (the
third in the hospital) she had a temperature of 100''
F., and pulse of 100, rather small and jerky, and she
looked bad. Fearing to delay any longer, operation
was decided on. Under ether, palpation still remained
negative. The incision was planned as an explora-
tory operation, being situated midway between the
appendix and gall bladder; it being believed that one
of these two structures was the site of mischief. The
finger detected nothing in the cffical region, and at
first nothing above, but on enlarging the wound
slightly upward there were found to be some soft
vascular adhesions from the omentum and abdominal
978
MEDICAL RECORD.
[June 9, 1900
wall, which having been penetrated revealed a large,
elongated gall bladder lying parallel with but not
coming below the edge of the liver; it was directed
toward the right. It was felt to be full of stones.
With a further enlarging of the wound along the edge
t ;v.-. J. -Case I. Section of Gall Bladder, showing Stones in s.
of the rectus to the free border of the ribs, the entire
biliary apparatus was exposed and found to be free
except the gall bladder. This was surrounded by
acute inflammatory adhesions. Aspiration of the fluid
showed purulent contents. Removal of the gall blad-
der was performed with great ease by gentle blunt dis-
section after the cellular line between it and the liver
had been entered. Holding up the fundus the cystic
duct was easily exposed, ligated, and the gall bladder
cut away. The stump of the cystic duct was further
closed by a suture. Gauze packing of the pocket left
by the removal of the gall bladder. Closure of the
abdomen except at one angle for drainage.
- The patient experienced no shock after the opera-
tion. Reaction was manifested by a temperature of
105° F. twelve hours after operation, after which con-
valescence was uneventful. The gauze was gradually
removed. There was never any leakage, and the pa-
tient was discharged in a month with a firm wound and
fully restored to health, which condition has since
been maintained.
Case II. — Miss M. E. T , aged forty-nine years;
admitted to St. Luke's Hospital June 6, 1899. She
has always been well except for the last two or three
years. She has been troubled with palpitation of the
heart and shortness of breath.
Present illness: Five months ago she began to feel
a dull pain in the liver region, more marked when she
lay on that side, also several attacks of sharp shooting
pains, but lasting only a few minutes. Some two
months ago she became jaundiced within twenty-four
hours without any accompanying attack of pain. The
urine became dark and the stools clay-colored the
next day. She thinks there have been times when
the jaundice has faded, only to return in a few hours,
never entirely disappearing. She has lost sixty
pounds of flesh.
Examination showed the patient to be very poorly
nourished. The skin, mucous membranes, and con-
junctivae were of a deep yellow color. The skin in
several places showed ecchymoses and petechia;. The
tongue was thickly coated. The liver flatness began
in the sixth space; the edge of the liver could not be
felt.
Operation, June 10, 1899. An incision was made
six inches long, parallel to and just below the free bor-
der of the ribs. The gall bladder was found to be
the size of a crab-apple, well up under the liver. A
stone was found in the cystic duct and a larger one
in the upper portion of the common duct. This latter
was opened and both stones were removed; a dress-
ing forceps was passed to the duodenum without ob-
struction, and a flexible bougie into the duodenum.
The incision in the common duct was sutured with
some difficulty and not entirely satisfactorily. There
remained the gall bladder to be dealt with. As it
could not be satisfactorily drained owing to its inac-
cessible position, it was removed by the free use of
the scissors; some hemorrhage occurred, but not to
any alarming extent />fr Ji?, although all the operative
field oozed freely throughout the operation. Packing
of gall-bladder wound was done, with
drainage of the site of the common-
duct incision by a glass tube through
which a rubber tube passed. The
greater part of the incision was closed.
The patient did not rally well from
the operation and required free stimu-
lation. There was considerable bloody
discharge on the dressing on the next
day, June i ith.
June 1 2th : There was some discharge
of bile on the dressings, still bloody ; the
'■ jaundice was markedly improved, stools
were yellow. She was still very weak.
June 14th: There was less bile but still a bloody
discharge. Jaundice was decreasing; general weak-
ness was increasing.
June 15th : Her condition was steadily getting worse.
Bloody discharge continued. Fearing the weakness to
be due to continued bleeding, the entire wound was
reopened without an anaesthetic. An enormous hasma-
toma was evacuated from the abdominal muscles.
There was some oozing from the surface of the liver
and other points, but no actual bleeding point was
found. The patient collapsed rather suddenly, dying
an hour later. No post-mortem was made. Death
was due to exhaustion in a feeble subject, especially
caused by continued oozing due to the icteric condi-
tion.
Briefly summarized, Case I. was that of a young
patient with a chronic cholecystitis and the formation
of large and numerous stones in the gall bladder,
coming under observation during an acute exacerba-
tion of cholecystitis. Cholecystectomy without open-
ing of the gall bladder was early and speedily per-
formed, all steps of the operation being accurately
controlled by direct inspection. There was unevent-
ful convalescence with entire restoration of health.
Case II. was that of an elderly woman, with intense
and chronic jaundice, a small atrophic gall bladder
with stones, and impaction of calculi in the cystic and
common ducts. Choledochotomy was performed with
evacuation of stones, and demonstration of freedom
from further obstruction ; cholecystectomy as the most
rational means of dealing with the gall bladder situ-
ated out of reach under the liver. There was tempo-
rary benefit with restoration of biliary physiology.
Death occurred by gradual exhaustion, chiefly deter-
mined by capillary hemorrhage due to jaundice. The
cholecystectomy was not an essential if any feature in
the fatal result.
The gall bladder was removed in the first case as
a matter of expediency. In so doing the writer was
influenced by the following considerations: (i) Avoid-
ance of a long-continued drainage and its attendant
annoyances. The cholecystitis was intense and of
long standing, and drainage to be effective must neces-
sarily be maintained for a long time. (2) Avoidance
June 9, 1900]
MEDICAL RECORD.
979
of a possible biliary or mucous fistula when the long-
continued drainage was stopped, insming a radical
cure, which result can only be obtained with certainty
by this method. (3) The avoidance of further dis-
turbances, chiefly attacks of pain due to adhesions
from neighboring tissues. Such disturbances were
pretty sure to follow the acute inflammatory condition
of the adjacent structures. (4) Because the operation
presented no technical difficulties and could be easily
and safely performed. Hence, given the above ad-
vantages it became the operation of choice.
In Case II. the sole indication was the difificulty or
inadvisability of any attempt to deal with the gall
bladder in any other way.
The foundation of these indications, the writer be-
lieves, is to be found in the following reasons. Other
things being equal so far as safety and a restoration
of the normal anatomy and physiology are concerned,
a short convalescence unaccompanied by the discom-
forts attending the long-continued escape of bile, is to
be preferred. The writer believes that in properly
selected cases and properly performed the operation is
as safe as cholecystotomy. In Case I. there was only
the gall bladder to be dealt with, and the freedom of
the rest of the extra-hepatic biliary passages was veri-
fied with unusual ease and freedom. The gall bladder
was shelled out of its inflammatory bed with great
ease — much more easily than the ordinary pus tube
is removed. The structures at its junction with the
cystic duct were all in plain sight, and the ligation and
closure of the cystic duct were done with a perfect
sense of their surety and efi'ectiveness.
The avoidance of a biliary or mucous fistula was
hereby guaranteed. It is a well-known maxim that
if the bile ducts are free a sinus after drainage of the
gall bladder closes readily. There are exceptions to
the rule even if these conditions are fulfilled, and the
proportion of fistulae that require secondary opera-
tions, such as suture of the gall bladder or a second-
ary cholecystectomy, or some such ingenious expedi-
ents, is not inconsiderable. And there is a still larger
number that close spontaneously but not for many
months. Such a condition may not assume much im-
portance to the surgeon, but to a nervous, hypochon-
driacal, self-observant person in the so-called higher
walks of life it is a matter of the greatest importance,
and the possibility of anticipating it is well worthy of
consideration.
The insuring of a radical cure: Does a cholecystec-
tomy insure a radical cure any more than does a prop-
erly conducted cholecystotomy with continuance of
drainage till a return to the normal? It is the
writer's belief that it does, because it is a radical cure;
the focus of disease is at once abolished. It is, how-
ever, conceded that a cholecystotomy almost invari-
ably does the same thing, but it is not a certainty.
The impossibility of a positive cure in every case will
be appreciated if one considers the pathological proc-
esses. Gall stones are the products of disease of
the biliary passages and not its cause. The prin-
cipal symptom of gall-stone disease is pain. Pain
may be and usually is the result of inflammation of
the gall bladder. The pain due to this inflammation
is increased by the added complication of stones.
Without inflammation of the gall bladder there is
practically no pain, provided the stones are in a
state of rest. "One in ten persons," says Kehr, "has
gall stones; but ninety-five per cent, of persons hav-
ing gall stones have no decided inconvenience from
their presence." In reviewing the histories of a large
number of patients after cholecystotomy, one is im-
pressed with the scant evidence of actual re-formation
of stones in the gall bladder. Further operations have
not infrequently been necessary; but the stones have
almost always been found in the ducts, from which they
should have been removed at the time of the cholecys-
totomy. On occasions they have been found again in
the gall bladder; but with an evident etiology, as in
cases of Kehr and Homans, in which they had formed
upon a nucleus of a silk stitch that had worked into
the gall bladder. This circumstance would certainly
show that the cholecystitis was not cured or the biliary
salts would not have been deposited.
There is, however, a condition which is not uncom-
mon after cholecystotomy, if one follows the cases,
and it is the symptom that gives rise to the belief that
the stones have re-formed, because of the recurrence of
the prominent symptom — pain. It is due to the renewal
of the cholecystitis, which, again to quote Kehr, " is a
recurring condition, in which the succeeding attacks
are of a much more pronounced character than appen-
dicitis." To say that once for all this condition can
be cured by one course of drainage, when especially
there is a continued source of infection from the in-
testinal canal at hand, is to make an assertion that is
contrary to all probabilities and cannot be substanti-
ated by the usual course of analogous processes in the
human economy. It is the recognition of this patho-
logical basis of the symptoms that gives us the right
to undertake more radical, — that is, curative measures.
The avoidance of disturbances other than those
whose manifestations take place within the interior
of the biliary passages. By this phrase the writer has
in mind the very severe disturbances from adhesions
formed by the gall bladder with neighboring organs.
They are of very varied character, and not infre-
quently give rise to masses which so closely simulate
a new growth as to make the recognition of their na-
ture difficult, even after the abdomen is opened. They
generally give rise to intense pain, and may provoke
physiological disturbances of the organs to which they
adhere. By some the pain of gall-stone disease is
attributed more to these adhesions than to internal dis-
turbances of the biliary tracts. The abdomen has not
infrequently been opened without any evidences of stone
formation being found at any point; but the break-
ing down of adhesions, either necessary to the search
or intentional in purpose, has frequently given relief
to the symptoms. This pain- and symptom-producing
element, the writer believes, is a prominent source of
the disturbances both before and after evacuation and
drainage of the gall bladder; by any operation short
of removal of the source of irritation, the condition is
likely to exacerbations notwithstanding prolonged
periods of latency. It is the writer's belief that this
element of the pathological sequelae of gall stone,
though perfectly well known, has not been sufficiently
appreciated. It is destined in the future, he believes,
to be judged an important factor in the indications for
seeking a radical cure.
The ease and safety with which the gall bladder can
be removed in a given case are indications for its re-
moval. This point the writer would particularly em-
phasize, as also the converse, that when for various
reasons the operator believes the conditions are par-
ticularly difficult, and therefore attended with risk, the
operation should be rejected, except under certain con-
ditions when removal of the gall bladder is indicated
because no other operation will approach it in effec-
tiveness and safety. Such were the conditions in
Case II., the atrophic gall bladder being situated en-
tirely under the liver and therefore entirely unsuited
to the normal process of drainage. Every case must
be a law unto itself, and the operator must exercise
his best judgment according as he finds the situation
and according to his self-estimate of his capacity for
successfully handling it. The writer therefore repudi-
ates the operation as a routine measure, just as in like
manner he would reject the operation of cholecystotomy.
A good many objections have been raised against
gSo
MEDICAL RECORD.
[June g, 1900
cholecystectomy, and they are in great part perfectly
justifiable if the operation is considered as a routine
measure and not from what the writer believes to be its
proper sphere. It is claimed that it has no advantages
over the simpler and safer operation of cholecystot-
omy. Perfectly true in some instances; but that it
has some very great advantages in general the writer
believes he has demonstrated. The testimony of oth-
ers bear out this statement.
In Duplay and Reclus' : " To-day cholecystectomy
can and must be considered not only as a physiological
operation, but also as a very rational intervention.
The merits of cholecystectomy are therefore no longer
in doubt." Kehr, in one of his most recent commu-
nications, and supported by an experience of nearly
one hundred cholecystectomies, says: " " Cholecystot-
omy is not a radical operation, the reservoir so dis-
posed to stone formation being left behind. With
a recurrence of the inflammatory process, and when
obliteration of the cystic duct results, the disturb-
ances return de novo. Such a result has occurred- in
about six per cent, of the cholecystotomies, and for
this reason I have more frequently resorted to extir-
pation in the last two years, now that I have acquired
the necessary perfection of technique for its perform-
ance. I have never observed any recurrence of trou-
ble after a cholecystectomy. ... A cholecystectomy
may be a severe operation; but not infrequently it is
easier to do than a cholecystotomy. In one case the
total time of the operation, reckoned from the first cut
in the abdominal wall to the last suture taken in clos-
ing it, was only fifteen minutes." Attention is called
to the great importance of this statement because it
represents the views of the most experienced operator
in gall-stone surgery, writing at a time when he had
four hundred and thirty-three operations to his credit,
of them "nearly one hundred cholecystectomies," and
because it marks his conversion to an operation which
only three years before he had performed only upon
certain restricted indications. In his book ' published
at that time, his experience was based on two hundred
and six laparotomies for gall stones, only twenty of
these being cholecystectomies. So that while he has
doubled his total experience, his operations for the
removal of the gall bladder have increased fivefold.
He said then (page 65): ". . . . Total extirpation
of the gall bladder is generally only indicated when
there is generalized disease of the gall bladder, fis-
tula;, carcinomatous infiltration, calcareous degenera-
tion or obliteration of the cystic duct." His last re-
port on the mortality of his cases of cholecystectomy
was 3-|- per cent.
If space allowed, the changes of views of other in-
dividual operators due to increased experience might
be offered: certainly we have in the radical change of
opinion experienced by Kehr sufficient evidence in
favor of the operation.
Still another objection sometimes advanced is ''that
the operation is more dangerous than cholecystotomy."
This objection is granted by the writer; but he does
not believe that it holds true if the cases are chosen
with discretion. The procedure in its early days was
damaged by some reports of cases, the unfortunate re-
sults of which were loudly proclaimed as definite rea-
sons for the rejection of the method. Investigation of
these cases shows that, for the greater part, the blame
is not to be placed on the operation, but on the ope-
rators who chose to disregard Langenbuch's warning
that a sine qua non of success depended on the absolute
demonstration of the patency of all the ducts.
The operation is also objected to, " because, if
' " Traite de Chirurgie," vol. vi., iSgS.
' Sammlung klin. Vortrage, No. 225.
' Kehr: " Chirurgische Behandlung der Gallensteinkrankheit, "
Berlin, i8q6.
stones should recur in the common duct, there would
no longer be a guide to the duct." The writer is pre-
pared neither to admit nor to deny that the presence
of a gall bladder is necessary to find the common duct
when it is the site of an obstruction of a size sufficient
to cause it and demanding interference. He believes
that only on theoretical grounds can this objection be
supported. Langenbuch denies that obstruction can
result from stones formed in the biliary ducts outside
of the gall bladder. He points out that the two varie-
ties of stone differ markedly in their chemical compo-
sition and in other respects. The gall-bladder stones,
he believes, are mainly composed of cholesterin de-
posits and may attain a large size, while the stones
formed in the hepatic duct are chiefly composed of
bilirubin, and seldom if ever attain a size that makes
them a danger.
The operation is also objected to, "because it de-
prives the body of an organ of more or less physio-
logical importance. This objection can be dismissed
pretty summarily by putting the burden of proof on
the objectors to demonstrate that the gall bladder ful-
fils any useful function. As has been well said, it
is " a structure of little value but of great importance."
Comparative anatomy seems to treat the gall bladder
rather as a joke: certain varieties of the animal king-
dom have it, others have not; certain subdivisions of
a given species are afflicted with it, while other mem-
bers of the same group get along without it. The ele-
phant has no gall bladder. Dogs, according to the
most recent observations,' appear to resent the loss of a
gall bladder, by setting up a compensatory hypertrophy
of the cystic duct which replaces the lost organ. The
reservoir function of the gall bladder must be con-
sidered as a physiological fairy tale; normally of the
capacity of a detni-tasse, it cannot very efficiently store
up much of the 600-900 c.c. of bile excreted daily.
There remains to be mentioned an additional indi-
cation for the performance of cholecystectomy which
is destined to increase its future sphere of usefulness.
The influence of chronic irritation in the production
of malignant disease has long been recognized, but
its practical application to prophylaxis is still little
appreciated and still less practised. There are abun-
dant statistics on the association of cancer of the gall
bladder with gall stones. In all probability the cases
of malignant disease of the gall bladder, not preceded
by gall-stone formation, are the exception. It is there-
fore right, the writer believes, to remove the gall blad-
der which is endangered by its condition of chronic
irritation.
It may be noted that throughout these indications
for cholecystectomy it has been compared only with
cholecystotomy. It may be asked why ideal chole-
cystotomy should not sometimes compete with cholecys-
tectomy. This operation the writer now absolutely
rejects, although he performed it with marked success
six years ago, the patient remaining well while under
observation (two years). With a greater experience
and a clearer appreciation of biliary pathology he
would no more venture to repeat the procedure than
he would suture the incision made in an acute abscess.
A gall bladder containing stones is a diseased organ,
and the removal of the products of disease in no way
influences the underlying pathological condition.
The scope of this paper forbids the consideration of
the indications for cholecystectomy for conditions other
than cholecystitis with or without cholelithiasis. Such
details may be advantageously studied from the ac-
companying table taken from Kehr. It has been re-
produced here in full that the reader may properly
appreciate what an important part the operation of
cholecystectomy performs in the treatment of the sev-
eral varieties of biliary affections.
' G. N. de Voogt : Centralblatt fUr Chirurgie, 1898, page 1097.
June 9, 1900]
MEDICAL RECORD.
'. Stones in the bladder wh
walls are little if at all di^eas
Cystic duct parent. Content:
gall bladder, clear bile.
I. Stones in the previously in-
flamed gall bladder. Cystic duct
temporarily patent. Adhi
between gall bladder,
IV. Acute cholecystitis in a
tively healthy bladder. A large
stone is usually impacted ir
neck. Fluid cloudy or purul
Walls thickened.
V. Acute cholecystitis in an i
phic, frequently inflamed blad-
der. Cystic duct obliterated
Diffuse adhesions. A li 1 1 1 1
muco-purulent fluid.
VI. Dropsy of the gall bladder,
Cystic duct blocked by stone, 01
obliterated. Contents clear and
sterile. Walls thin as paper.
VII. Empyeraaof the gall bladdi
Pus in the gall bladder. Stone
in the cystic duct. Adhesi
The disease is either {a) th.
suit of an acute serous chole-
cystitis, or {i>) begins as an acute
empyema.
Carcinoma of the gall blad-
with stones, without involve-
E of the portal glands.
IX. Acute obstruction of
duct by stone.
X. Chronic obstruction of
duct by stone. Stone in t
supraduodenal portion.
XI. Chronic obstruction of co:
men duct by stone. Stone 1
pacted in the duodenal papilla
^nic obstruction of th<
duct by a tumor situ-
the pancreas or duo-
or oblitrration of tht
duct.
Symptoms almost constantly wanting (late
stage). Now and then gastric pains (ter
porary closure of the cystic duct). I*
passage of stones, no enlargement of live
Ls under I., frequently severe colic, di
kinking of cystic duct, from distention of
gall bladder, causing vomiting and pain
pressure. Intervals may be entirely free
from disturbances.
*ain is frequently provoked by a c
position {sitting up). Otherwise ;
: of
Gall-bladder tumor. Riedel's lobe. Jaun
dice infrequent. Severe pains (stomach)
Prominence of upper abdomen. Marked
tenderness on pressure. General condit
not markedly affected if degree of infect
is slight, but greatly so if severe. (Ac
cholecystitis, with cholangitis. Circu
scribed peritonitis (peri-cholecystitis). May
or not have fever. Swelling of liver only
if cholangitis.
No tumor is felt because the gall bladder is
high up under the liver. Pain as in IV.
More frequent changes in the manifesta-
tions. Jaundice rare ; if present, due to
inflammation. No passage of stones.
Symptoms may be lacking. Tumor is
that patient notices. Gastric pain fre-
quent. No passage of stones, no jaundice,
no enlargement of liver. Occasionally
Riedel's tongue-shaped lobule.
In the beginning symptoms as in IV., later
fever may be wanting. Symptoms as in
VI. Tumor is usually smaller than VI.
Constipation.
Palpation negative. Occasionally sligh
tenderness in the gall bladder region (bi
manual examination). Often mistaken for
gastric ulcer, intestinal colic, floating kid-
ney, hernia of the linea alba
As above, during the colic tumor of the gall
bladder is noticeable if the inflammation of
the gall bladder continues
IS in II. Patient's conditii
edly from its long continua
may cause stenosis of pylo
sense of oppression.
Diagnosis is easy. Possible to mistake it foi
appendicitis. The diagnosis must demon
strate that the tumor felt is the gall bladder
(Form, mobility, tenseness, etc.) Usually
constipation. If the cholecystitis ends
'th the expulsion of stone, obstruction of
I suffers mark-
re. Adh<
iS, obst
the
duct follows
Operation is surely indicated if
there are frequent relapses.
The best one is cholecystec-
As in II., cholecystectomy is the
best operation.
sides; the stone still remains.
For the cholecystitis, cholecys-
totomj; and drainage is the
operation of choice.
At first only disturbances of digestion. No
jaundice. If the gall bladder and portal
glands become involved, then jaundice.
Tumor of marked hardness and
ness. Later cachexia.
Marked jaundice, colic, vom
-'er (chill). Remission
iting. Usually
of symptoms
Passage of stones.
Jaundice may be wanting. Varies, Stools
now brown, now gray. Frequently inter-
mittent fever. Pain is generally present,
but may be entirely wanting.
)iagnosis difficult owing to negative palpa-
tion. Careful attention to the history is
of the greatest help. With severe consti-
tutional symptoms, purulent cholecystitis,
without appreciable tumor, and without
pronounced colic, has been mistaken for
malaria, typhoid, and sepsis.
Diagnosis easy. Bear in mind the possi-
bility of mistaking it for floating kidi
The tumor (if no adhesions) is especially
movable laterally, can be pushed backward,
but immediately comes up again. Little
tenderness on pressure. Dropsy of ar
atrophic bladder causes no tumor. Diag-
nosis then as in V. not easy.
An exploratory puncture must not be per-
formed. Otherwise as in VI. With im-
plication of the peritoneum, the picture ol
peritoneal irritation becomes most promi-
nent. If perforation, symptoms of perfora-
tive peritonitis. In the beginning the
tumor of the empyemic bladder very pain-
ful. Later the pain may subside, or even
fully disappear.
Little pain. At first diagnosis very difficult,
usually made only with appearance of
jaundice. With involvement of the portal
glands (ascites) diagnosis becomes easy,
Gall bladder usually cannot be felt. Liv
more or less enlarged. Tenderness 1
pressure, more in the middle line. Splei
Cholecystectomy is the best
treatment. Internal treatment
is useless. Cholecystotomy in
two stages, and deep drainage,
frequently impossible.
Jo use unless early cholecystec-
tomy with resection of liver.
.s in X., jaundice i
to vary.
isually intense, less apt
Internal treatment. Morphii
hot applications. Ope
only exceptionally required
(drainage of the hepatic duct).
Choledochotomy with appropri-
ate treatment of the conditions
present in the gall bladder.
Possibility of choledocho-duoden-
ostomy. If after three months,
medical treatment (Carlsbad)
unavailing, operation is neces-
Marked and unvarying jaundice coi
increasing. Stools always clay
Usually absence of fever. Litt]
Expectant treatment,
cystenterostomy.
Chole-
In conclusion the writer would express his belief
that cholecystectomy as a means of treating cholecys-
titis anti cholelithiasis is called for under the fol-
lowing conditions:
In all cases of cholecystitis with or without stones,
acute or chronic, provided that the gall bladder and
gall ducts can be properly explored, and that the con-
ditions promise an easy removal of the gall bladder.
It is to be borne in mind, that the more distended the
gall bladder, the more likely is its separation from the
liver to be easy. And provided that the common and
cystic ducts (sometimes also the hepatic) are demon-
strated to be free from stone, and that in addition to
stone there is no other obstruction of the lumen of the
common duct such as a tumor, benign or malignant,
of the pancreas.
The operation is also recommended even when its
performance is difficult or possibly entails a slightly
greater risk in a limited class of cases — that is, when
it is the only satisfactory way to deal with the gall
bladder (as illustrated in Case II.), and as a prophy-
lactic measure against malignant disease in the pres-
ence of long-standing irritation.
If these various limitations receive a strict inter-
pretation, the number of cholecystectomies that are
justified by the above indications will be compara-
tively restricted, and the operation will be done only
under circumstances that permit of its greatest useful-
ness with a minimum of risk.
48 West Forty-ninth Street.
Precautions Taken to Keep the Plague of Women
from the Hospitals of South Africa. — Surgeon-Gen-
eral Jameson, speaking a few days ago at a medical
meeting in London, and referring to the "plague of
women " of which Mr. Treves had complained as in-
festing the hospitals of South Africa, said that already
Mr. Treves' remarks had borne fruit, for he was in-
formed that the engineers had encircled with barbed
wires the hospital containing cases of enteric fever.
MEDICAL RECORD.
[June 9, 1900
ACUTE SUPPURATIVE FOLLICULTITS OF
THE SCALP.
By WILLIAM S. GOTTIIEIL, M.D.,
The inflammatory affections of the hair follicles form
one of the most unsatisfactory chapters in dermatology.
Their nature, varieties, classification, and nomencla-
ture are still matters of dispute. Examining two or
three of the more prominent te.xt-books, I find that
Hyde, under the caption of " alopecia follicularis,"
mentions a whole series of interesting and important
affections of the hairy parts, which he admits have
not as yet been distinctly differentiated from each
other, nor the series from all others. Crocker men-
tions follicular disease of the scalp, but maintains
that it is always secondary to eczematous disease
of that organ. Lesser barely refers to folliculitis
and perifolliculitis of the scalp, or sycosis capil-
litii, saying that it is of extremely rare occurrence.
Follicular intlammations of the scalp similar to
the ordinary folliculitis, or non-parasitic sycosis so
common on the bearded face, have been described
by several authors under an astounding variety of
names. Thus we have the folliculite destructive s.
epilatoria of Quinquaud; the folliculite et perifol-
liculite de'calvante of Krocq; the alopecie cicatri-
sante innomine'e of Besnier; the acne de'calvante
of Lailler; the ulerythema sycosiformc of Unna;
the dermatitis perifollicularis atrophicans of Sack;
the conglomerate pustular perifolliculitis of Leloir;
the folliculitis exulcerans of Lukasiewicz; and the
bacillogenous sycosis of Tomassoli. And even this
by no means exhausts the list.
There can be no doubt at all that several dis-
tinct affections, all characterized by a follicular or
perifollicular inflammation of the hair sacks, and
leading, with or without suppuration, to loss of
hair and atrophic changes in the tissues of the
scalp, are included in this list. The analysis and
classification of these cases is a task that must
await a wider experience and more exact records.
Certain prominent characteristics, however, are no-
ticeable in all of them. The affections are all chronic,
with a duration extending over months and years ; they
affect localized or isolated areas of the scalp; and
they are rarely frankly suppurative, the inflammatory
process being subacute and the resultant atrophy being
due to interstitial absorption of tissue.
I have had occasion during the last year to observe
two cases of follicular inflammation of the scalp which
differ in many essential characteristics from those re-
corded by the authorities mentioned above. In both
the process was acute, lasting only a few weeks; the
entire scalp was involved, every single hair being
affected at about the same time ; suppuration was
frank, occurring in all the hair follicles; and there
was no resultant atrophy of the hair papillee or other
structures of the scalp, and, although I have been un-
able to find any cases resembling it in its essential
features, I have no doubt that the affection occurs oc-
casionally, more especially among the foreign-born
and less cleanly of our population, and that other in-
stances will be recognized when attention has been
called to the disease.
One only of the two cases above referred to was ob-
served with care during its entire course. It was re-
ferred to me through the kindness of Dr. George Les-
ser of this city, and was under observation from
February i8th of this year until the present time (De-
cember 15, 1899). Its history is typical, and is de-
tailed below. The other case occurred in a child aged
six years, also of Russian parentage ; the process was
similar, though not so acute, and the patient disap-
peared from observation after a few visits to the dis-
pensary.
History: L G , aged sixteen years, Febru-
ary 18, 1899. The patient is a well-grown girl, appa-
rently in robust health. She has menstruated for two
years, regularly until three months ago; since which
time, without any other symptoms, she has been
amenorrhoeic. Her past history is entirely negative.
So far as the surface of her body, other than the scalp,
is concerned, the only abnormality is a scar on her
left loin, due to a burn received in childhood, and
which is occasionally irritated and made sore by the
corsets that she wears. Seven months ago a blister
June 9, 1900]
MEDICAL RECORD.
983
appeared on the scar, followed, when it broke, by some
suppuration, but which healed promptly under a sim-
ple vaseline dressing. She states that this lesion oc-
casionally becomes chafed and opens, as she terms it,
and that then there is some discharge from it. Her
scalp has always been covered with an abundant
growth of fairly coarse black hair, and, until the
present affection appeared, she has never had any
trouble with it. Some three weeks before, and at a
time when the scar on the loin was irritated and
discharging, she noticed a painful, pinhead-sized
blister among the hair at the front of the scalp.
It grew bigger, and filled up with matter, finally
rupturing, and when the crust that formed came
away it carried the hair shafts with it. After the
blister had ruptured, the process was entirely pain-
less ; and the patient did not know that the hair had
fallen until she accidentally discovered, in the
looking-glass, the red bald spot of the exact size of
the pre-existent crust. While this process was
going on with the first lesion, a few other small
blisters appeared on the back of the head, which
were hard and very painful, so that she could not
rest on her back in bed. The patient cannot report
concerning the appearance of these lesions, since
she could not see them ; but they were undoubtedly
similar to the first one, and, like it, left reddened
and hairless areas of skin behind them.
Dr. Lesser first saw the case at this time, and
reports that there was then a bald, reddened, de-
pressed, tender, bean-size, and apparently cicatricial
area on the scalp near the frontal margin of the hair,
a few similar lesions were on the vertex and back of
the head, together with a number of tender and in-
durated nodules over which the hair was tightly
matted with secretion. Treatment with various
ointments and applications did not stop the prog-
ress of the affection. New nodules began to ap-
pear with frequency, and the older ones commenced
to suppurate.
As it was impossible to treat the scalp effectively
in the condition in which it was, and as the patient
refused to have her hair cut off, she was sent to a well-
known specialist for diagnosis and treatment. The
diagnosis made was apparently pediculosis, and an
application was ordered to be used for twenty-four
hours, with the warning not to go near a fire or light
while employing it. Inquiry showed that this appli-
cation was the customary mixture of vaseline, kero-
sene, and olive oil, with a small amount of balsam of
Peru. This she used for one day; and she claims
that it burned her so terribly that she lay awake
screaming with pain the whole night. Emollient ap-
plications were thereupon ordered by the attending
physician, with some relief from the pain.
Meantime new nodules appeared continuously, until
the whole scalp was involved. From time to time the
older crusts would become detached without pain ; the
entire hair of the affected area coming with them, and
bald spots being left behind. The patient felt very
bad; she was feverish, and lost her appetite. Her
sleep was much disturbed; and during this whole
period the only position in which she could rest in
iDcd was prone upon her abdomen, with her face upon
the pillow.
On February 21 st I examined her carefully. She
looked pale, depressed, and anxious; but was otherwise
in fair health and well nourished. Her scalp was cov-
ered with an abundant growth of thick, bushy, black
hair. Near the head this was firmly matted down by
dried secretion, ointment, and debris. There was no
trace of pediculi or their ova. Scattered all over the
scalp were hairless, pea to quarter-dollar sized, red-
dened, slightly depressed, and moderately tender areas ;
most of the rest of the scalp was invisible, being cov-
ered with the matted and crusted hair. In the few
places where the scalp was visible, it was covered with
minute red papules, papulo-pustules, and pustules,
each one pierced in its centre by a hair. A number
of minute pustules were also visible on the redder, ten-
derer, and more recent bald spots. Removal of the
crusts was excessively painful; but, once loosened
from their adhesion to the scalp, they were readily
taken off, and in each case the entire bundle of hair
growing from the affected area was removed with them.
The entire scalp was cedematous and excessively pain-
ful; the cervical lymphatic glands were moderately
swollen. She was ordered to apply cloths thoroughly
soaked in two-per-cent. salicylic-acid oil to the scalp,
and, after softening, to try to remove the crusts with
warm water and soap.
On February 26th I noted that the patient had been
unable to remove the crusts on account of the pain.
More or less extensive suppuration was going on under
many of them ; and at various places, some of them
already denuded, deeper abscesses had formed, which
were evacuated. As it was impossible to treat the
scalp, or even examine it properly, she was directed
to cut the hair off as close to the skin as possible.
March ist: On this date I took a negative of the
patient's head (Fig. i). All the surface of the scalp
not already denuded was covered with closely adherent
crusts containing bundles of matted-down hair. Re-
moval of these crusts was still intensely painful ; but
I succeeded in persuading her to allow me to displace
several of them. In every case all the hair came out
with the crust, leaving a reddened, slightly moist, and
depressed scalp behind. Even where the adherent
material had been softened by the applications em-
ployed, the hairs came out on removing the de'bris;
the shafts seemed to lie entirely loose in the follicles.
But few new pustules had appeared lately; probably
because all the hair follicles had been or were involved.
From February 2 1 St to date I made a number of
careful microscopical examinations of the hair shafts
984
MEDICAL RECORD.
[June 9, 1900
and crusts. The hairs were always normal, not fra)'ed,
and contained no fungus. The crusts and scales con-
sisted of masses of epithelium and fat, with detritus
and various bacteria, but with neither mycelium nor
spores. As suppuration was in active progress under
all the crusts, and as at each examination a number of
larger pus collections had to be opened, I proposed
the anesthetization of the patient and a thorough
cleansing of the scalp. This, however, the patient re-
fused; and she was, therefore, ordered to wash the
scalp as thoroughly as possible every day with warm
water and tar soap, and to apply cloths thoroughly
soaked in carron oil.
On March 13th I noted that the patient's condition
was about the same. A few new pustules had occa-
sionally appeared, and many of the older crusts had
been removed, so that the scalp was now about two-
thirds denuded of hair. The older bald areas were
less red and tender, and the crusts were now more
readily removed. There were a few boggy, infiltrated
areas of pus collection, which were freely incised.
Careful examination revealed the presence of a num-
ber of minute, colorless lanugo hairs springing up over
the oldest denuded areas. There was no other grow-
ing hair upon the scalp; only detached hair matted in
the still adherent crusts. She was placed upon a three-
per-cent. xeroform-olive-oil suspension in the place of
the carron oil.
March 31st: The patient claimed to have got great
relief from the last application. She could now, for
the first time in many weeks, sleep upon her back,
and rest her head upon the pillow. A new crop of
minute pustules had, however, appeared upon the de-
nuded and partially lanugo-covered occipito-cervical
region of the scalp. They presented in exquisite form
the original lesion of the disease, being pin-point to
pin-head sized, seated on inflamed bases, and pierced
each in its centre by a delicate lanugo hair. It was
evidently a recrudescence, or, rather, a renewed infec-
tion of hair follicles that had already been involved,
and gave me an excellent opportunity to study the dis-
ease in its various stages. The pustules increased in
size, and finally ruptured, extruding the lanugo hair
of the follicle in the pus. But the lesions were iso-
lated and discrete; and, as there were no long hairs to
be matted together and retain the pus, they ran a short
course and gave the patient little trouble. The ac-
companying illustration shows the condition of the
head at this time.
On April 14th I noted that the patient was now
quite comfortable; almost all the crusts were gone;
and of her original stiff black hair not a trace re-
mained, save the few loose bundles that were still held
in the crusts. The older lesions were now white and
covered with thin, fluffy lanugo hair of very light
color. No new lesions had appeared. The xeroform
oil was continued.
I saw the patient from time to time during the next
two months. No fresh lesions appeared ; all the crusts
came off; the denuded areas whitened ; and finally the
whole bald scalp began to be covered with an abun-
dant growth of lanugo hair, which in its older portions
was already getting longer, stiffer, and darker. All
treatment save vigorous cleansing and brushing of the
scalp was stopped; a good prognosis as to the restora-
tion of the hair was given, and the patient was dis-
charged.
I sent for her on December ist of this year, and the
accompanying illustration from a photograph (Fig. 3 )
will give an idea of the condition of her hair. Her
scalp was normal, and her hair as abundant as it was
before she was attacked by the malady. It was, how-
ever, thinner, somewhat lighter in shade, and more
curly than was the original pilous covering.
Apparently, then, the case was one of acute general
suppurative folliculitis of the hair sacks of the scalp.
It is possible that infection occurred from the lesion
on the loin; and also that the kerosene applied during
its early stages hastened its spread. But its acuteness
and generalization, and its superficiality, as shown by
the fact that, though apparently all the hair follicles
were involved, and every hair shaft detached, the
papillEE were not destroyed, and permanent baldness
did not result, combine to form a picture that differs
essentially from the foUiculitides of the scalp described
by the authors mentioned in the beginingof this paper.
THE EFFECT OF SUMMER HEAT UPON
THE PUBLIC HEALTH.'
By henry DWIGHT CHAPIN, M.D.,
The effect of climatic changes upon the public health
is a subject of great interest and importance. When
certain conditions are known to be approaching, it is
the duty and privilege of preventive medicine to indi-
cate plainly where the dangers lie, and what may be
done in an endeavor to obviate them. The depressing
effects of continuous heat may be shown most on the
nervous and digestive systems, and the extremes of
life are especially vulnerable. With reference to the
gastro-intestinal tract, not only does great and con-
tinous heat depress the digestive power and hence
make for disease, but the food supplies also depreciate
from the influence of heat, and fermentation has fre-
quently begun before the nutriment is ingested.
A glance at the summer death rate from gastro-
intestinal diseases, in comparison with the winter rate,
is suggestive in this connection. Four summer
months are compared with four winter months during
the past five years in the following tables, which will
be preceded by a statement of the mean temperature
and mean humidity of the summer months:
Mean Tempekatire (F
^HE.).
Mean Hi-midity.
June.
July.
Aug.
Sept.
June.
July.
Aug.
Sept.
iSqS
72.80'
72.50°
75.60°
70.80°
71
7S
64
63
iSqb
69.80
76.80
76.10
67.20
6q
72
6q
74
I8q7
67.40
75-90
73.20
66.90
6q
71
6q
65
I8,q8
71.10
76.00
75-30
70.20
73
80
78
6q
1899
74.10
76.20
75.11
66.10
68
6b
75
64
Deaths from Gastritis.
Gastro-Enter.t.s, and
Enteritis.
Deaths from Diarrh<ea,
Under Five Years.
June.
July.
Aug.
Sept
June.
July.
Aug.
Sept.
112
I4S
116
75
150
344
313
301
318
391
223
260
24S
304
221
179
176
203
244
210
281
363
220
157
176
1,084
880
914
834
608
564
446
650
643
276
441
245
319
461
187
1896
1897
l8g8
Totals
605
1,667
1,256
1,012
1,197
4,320
2,579
1.653
Nov.
Dec.
Jan.
Feb.
51
Nov
Dec,
Jan.
34
54
44
41
35
49
34
57
61
3S
41
36
38
43
42
47
60
4b
30
39
56
56
50
50
31
26
20
59
54
43
41
23
25
15
226
26-)
245
240
182
152
161
29
36
42
23
34
164
I am indebted to Dr. Tracy for access to the board
of health records.
' Read before the Medical Society of the County of New York,
May 23, igoo.
June 9, 1900]
MEDICAL RECORD.
9^5
A glance at these tables shows the enormous in-
crease of the summer mortality from gastro-intestinal
diseases over the corresponding winter months. It is
especially noticeable in the deaths from diarrhoea, in
children under five years. One encouraging feature,
however, will be seen — that there is a certain diminu-
tion in the death rate at this period during the past
five years. This is doubtless due to the improved
sanitary condition of the city, with a stricter supervi-
sion of the food supply, especially milk. There has
also been a certain improvement in drainage, sewer-
age, and the ventilation of dwellings.
It has long been recognized by sanitarians that the
death rate among infants, and especially the preva-
lence of diarrhoeal diseases among them, are sensitive
tests of the general sanitary condition of the com-
munity.
One of the greatest dangers during the heated term
consists in sunstroke. The following table shows the
deaths from this cause during the past five years, dur-
ing the four summer months:
Deaths from Sunstroke.
June.
July. August.
September.
1895
45
5
3
So
4 1 i3
13
1896
30
28
75
10
725
2
46
5
6
l8g3
2S3
Totals
133
147
-96
272
In looking over the records of the board of health,
the most fatal recent years from sunstroke are 1892,
iSg6, and 189S. The deaths from sunstroke during
1896 reached the enormous number of 765; of this
total 671 occurred in one week, and 52 during the
weeks immediately before and after, making a total of
723 during the three weeks covering the extreme heated
period. If we take the day when the greatest number
of deaths occurred as a culminating point of the period
of extreme heat in each case, including in each period
all days when the temperature rose to 90^ F. or more,
we find that the culmination in 1892 was on the fifth
day, and in 1896 on the eighth day. The greatest
number of deaths in any one day was 350 in 1892 and
386 in 1896. The noticeable increase in the number
of deaths began on the second day in 1892 and on the
fifth day in 1896. Whether this postponement of the
fatal effect of extreme heat has been due to a difTer-
ence in other meteorological conditions than heat
alone, or whether it is due to an improved sanitary
condition of the city, rendering the population more
vigorous and more capable of resisting The morbific
effects of heat, cannot be positively determined.
The year 1898 was an exceptional one in that the
vast majority of deaths from sunstroke, 253, occurred
in September.
A most depressing influence, where there is a con-
tinuance of great heat and humidity, is the coexist-
ence of hot days and hot nights. If the nights are so
warm that sleep is interfered with, there is little op-
portunity for recuperation from the exhaustion of the
day.
Depression of the nervous system by heat is appar-
ent in lassitude and a general vulnerability to disease.
In two nervous affections, the death rate is actually
higher in summer than in winter. Thus, during the
four summer months of this period, there have been
1,399 deaths from meningitis reported, while during
the months of November, December, January, and
February of the same period, there were only 1,040
deaths from meningitis. Probably a certain number
of cases of meningitis reported were, however, spurious
hydrocephalus following infantile diarrhcea. During
the five years there were 781 deaths reported from con-
vulsions, while during the winter months the number
reached only 737.
In looking up the deaths from alcoholism, there
have been fewer reported in summer than in winter,
460 being the number for the summer months, against
525 for the four winter months of these five years. It
is well known, however, that alcoholism is a common
predisposing cause of death in sunstroke.
The actual increase of sickness in any community
due to summer heat is hard to estimate; everything
possible, however, that preventive medicine can sug-
gest should be employed to obviate the deleterious
effects of heat. A consideration of this subject must
include in its scope an oversight of the city, the house
and the life and habits of the people. The responsi-
bility of the city is to be doubly watchful in the inter-
ests of public health; the streets must be kept scrupu-
lously clean, all garbage and decaying animal and
vegetable matter must be promptly removed and de-
stroyed. Perishable food-stuffs, particularly cow's
milk, require the greatest watching and regulation
As hinted above, the work of the board of health in
this connection has already borne fruit.
With reference to milk, while a minimum pro-
portion of cream is now called for by law, there
should be a certain standard of freshness as well.
The number of bacteria found in each cubic centi-
metre of milk bears a direct ratio to the age of the
milk, as well as the proportion of lactic acid. What
is needed is a better regulation of the city's milk sup-
ply at its source, viz., the dairy farm. A committee
of this society is now at work on this problem and
hopes to be able to secure a fresher and cleaner milk
for all desiring it.
A very efficient way in which the city can modify
the deleterious effects of the heated term is by plant-
ing trees and furnishing small parks and breathing-
places. In the Fol>ii!ar Scicm'i Monthly for February,
1899, Dr. Stephen Smith shows how trees are of the
greatest utility in modifying and equalizing climatic
conditions. He calls attention to the fact that an
average temperature of the air of 54° F. is best
adapted to public health, as at that temperature the
decomposition of animal and vegetable matter is
slight and normal temperature is most easily main-
tained. Every degree of temperature above or below
this point requires an action of the heat-regulating
power to maintain a proper equilibrium.
In a densely populated city, the summer heat is
conserved and reflected by the stone and asphalt of
the street as well as by the bricks and mortar of build-
ings. Even during the night, the stones, by retaining
their heat, prevent any appreciable fall of temperature.
Here is where the modifying effects of trees can be
most beneficial. As trees maintain an average mean
temperature of 54° F. in all seasons, it is easy to see
what a constant cooling influence they possess in an
atmosphere of 90°. Add to this the constant ex-
halation from the leaves of watery vapor, that has
been absorbed from the moisture in the soil and from
the surrounding air, and the cooling effect is much
enhanced. This takes place most actively during the
heated portion of the day when it is most needed.
A general purification of the air is not the least
benefit to be derived from vegetation, as carbonic acid
is absorbed and oxygen given out, just the reverse of
what takes place in the animal economy. The purify-
ing and cooling influence of trees placed uniformly
through the city would have a marked influence on the
public health in summer. The Tree Planting Asso-
ciation of New York has proven that various species
of trees are adapted to our soil, and with a little care
can be made to thrive. It seems, however, that in a
matter that concerns not only the health but the
986
MEDICAI- RECORD.
[June 9, 1900
beauty of the town, the city itself should be respon-
sible for a uniform and continuous effort. If our
thoroughfares were lined with shade-trees, the sum-
mer heat would not be so intolerable and unhealthful.
The construction of the underground road through
upper Broadway will injure the life of the beautiful
rows of trees now planted in that thoroughfare. It is
much to be hoped that not only in the interests of
beauty, but of public health as well, efficient steps
may be taken to preserve the life of these trees. New
York is bare enough without sacrificing any vegetation
in a satisfactory state of growth.
With reference to the domicile, the proper efforts
must be made in the line of extra cleanliness. Food
of all kinds must be removed when the meal is ended
and all decaying refuse be not allowed to accumulate.
Sometimes by keeping rooms closed during the heat of
the day, and thoroughly aired at night, a certain equali-
zation of temperature will result.
With reference to individual hygiene much may be
accomplished by a proper observance of the laws of
health, especially with reference to eating and drink-
ing. Doctors must especially protest against the in-
discriminate use of alcoholic liquors during a pro-
longed hot spell. Eating to excess of nitrogenous
food and rich and "made-up" dishes is also injuri-
ous. Overfatigue during the heat of the day should
also be discouraged. The temperature of the body
may often be satisfactorily lowered by a tepid bath,
the effects of which will often remain longer than
when a cold bath is used.
With reference to food, extra care must be taken
that it is fresh, as a slight spoiling is most disastrous
to the consumer. This is particularly true with refer-
ence to the universal food, cow's milk. It is esti-
mated that there are 146,600 children under the age
of three years in the boroughs of Manhattan and
Bronx, or 6.72 per cent, of the whole population.
This immense number subsists principally upon milk.
Recent studies show that if cow's milk can be properly
cooled it will keep a considerable time, and is much
better than relying too largely upon superheating.
Here is where the subject of ice comes properly under
the physician's notice. Any difficulty in the free pro-
curing of ice by the poor during the heated months,
whether from a natural scarcity of this article or from
a cornering of this staple by commercial greed, is a
public calamity.
In 1896, during the heated term the death rate among
little children rose to such an alarming state that the
board of health requested the city authorities to dis-
tribute ice freely among the poor. This was done
during the heated term, and doubtless resulted in a
great saving of life. The streets were likewise flushed
at this time.
SEASICKNESS AND WHAT TO DO WITH IT.
By HERMAN PARTSCH, M.D.,
" Repetition is the law of impression," said the Rev.
Robert Mackenzie, and that explains why I have not
yet succeeded in impressing the susceptible seagoing
passenger with an understanding of the theory that ex-
plains and the method that succeeds in reducing sea-
sickness to a minimum of about one-tenth of what it
may otherwise be. No drugs nor any extraordinary
procedures are involved. It is a little matter of sim-
ple instruction, which, when repeated to the point of
impression, is likely to result in action and do some
good. I must therefore repeat the effort, though the
words may not be the same. But, first, may I be al-
lowed to account for my position as a self-constituted
instructor on this subject?
The first two and one-half years of my professional
career were spent as medical officer on various ocean
steamships. In April, 1S86, the Medical Society of the
State of California awarded me a prize for an essay on
" Motions in the Etiology of Seasickness." This was
published in the Pacific Medical and Surgical/otirnal,
November, 1886. In 1890, a Boston firm published
for me a book of one hundred and ninety-six pages on
seasickness. Tiie undertaking, I suspect, may have
proven fatal to the firm's existence, as I have heard
neither of the firm nor the book for six or seven years.
Also in 1890 I issued a little pamphlet for the instruc-
tion of susceptible passengers in regard to seasickness.
My efforts on this subject received the hearty and un
solicited approval of Dr. L. C. Lane, president of
Cooper Medical College, who was competent to judge
by virtue of four years of experience of his own at sea.
Approval came also from many other good sources,
and, besides, from the four principal steamship com-
panies operating from San Francisco.
By means, then, of the following instructions, un-
derstood and based on the brief explanations that are
thrown in and also to be understood by the person who
is managing his own case, or conducting the case of
another, the worst degree of seasickness can easily be
replaced by a condition of comparative comfort under
the circumstances.
Make no other preparation calculated to avoid sea-
sickness. Continue in your usual ways. A steamer
chair will prove a desirable convenience if the voyage
is to be long and the weather happens to be good.
Get on board a half-hour before sailing, get your
cabin and small luggage arranged to suit you, and
have nothing to do but take care of yourself after the
ship starts.
Shoes should be warm, comfortable, and easily put
off or on. Besides being comfortable, have all cloth-
ing as convenient as practicable for dressing and un-
dressing.
Rooms amidship are preferable. Avoid the extreme
ends of the ship. Good facilities for ventilation are
very necessary.
Strive to have the air inside of the room about as
good as outside, even when you are in it ; do at least
the best you can under the circumstances toward this
end. Two sufiiciently large openings to the room are
necessary. Good, clean, fresh air is of the greatest
importance to the susceptible passenger. There is no
danger from draughts. Second-hand air is a factor in
the causation of seasickness.
Weather and condition of health permitting, stay on
deck much of the time, in a steamer chair, in a semi-re-
cumbent position, comfortably covered and eyes closed.
Anywhere on ship, in berth or chair, keep the eyes
closed during the daytime, with exceptions of short
duration, until immunity from optical vertigo is ac-
quired. Thus you will exclude' optical vertigo, by
which are meant that dizziness and nausea which are
often consequent on the continued observation of un-
usual relations among our environs, and between them
and ourselves.
Whenever the slightest sensation of illness is felt,
lie down at once and close the eyes. Use only one
pillow, or if quite sick, or it seems likely that you will
be, have the head even below the level of the body,
with no pillow for a while. I have seen the pillow
make all the difference between great misery and
almost absolute comfort.
Steamship motion can be analyzed into twenty-six
different factors. It is therefore very complicated
and, of course, incomprehensible at first. The many
variations occur to the passenger unawares. His ani-
mal mechanism cannot adjust itself to them, because
he cannot at first foreknow them. The case becomes
much like that of going up or down stairs in the dark
June 9, 1900]
MEDICAL RECORD.
987
and finding one step more or less than was expected.
The variations not IJeing adjusted to, because not fore-
known, violence of some kind is the result. The dis-
turbances occur in a continued series, each very slight,
but the series results in an accumulated sum of vio-
lence which we call seasickness.
What is first disturbed in the animal mechanism is
the vaso-nervous system, that which controls the cir-
culation of the blood, and, as a result, the circulation
itself must of course be disturbed. The first impor-
tant result is a relaxation of the blood-vessels in the
abdominal cavity; these vessels having much less out-
side support than those that traverse muscular tissue.
The second effect is the gravitation of blood into
the relaxed vessels, thus permitting the occurrence of
a deficiency in the brain. One result of this defi-
ciency in the brain is the sensation called nausea.
This mechanical deficiency of blood in the brain, with
its corresponding sensation (nausea), is to be avoided
when observed to be approaching, and corrected when
already present, by lying down with the head no higher
than the body. If the patient does not promptly lie
down, retching will take place. Retching is nature's
method of flooding the brain with blood, by squeezing
the contents of the abdominal cavity in such a manner
as to force upward some of the excess of blood con-
tained in its relaxed vessels. The regurgitation of
food or fluids from the stomach is merely incidental,
and not essential. The stomach has nothing to do
with seasickness except to be incidentally and acci-
dentally implicated.
By the time a patient has been seasick two or three
days, and his forces have regardless of his consent
been heavily drawn upon by many hours of retching.
and having meanwhile, of course, not profited by any-
thing swallowed, he will be suffering from poverty of
blood. The sense of hunger will be obscured by the
nausea.
Even while lying down, a susceptible passenger will
not escape seasickness if his blood becomes impover-
ished in respect of nutritive material; and, having
been seasick, he cannot recover while his blood re-
mains so impoverished. To prevent seasickness one
must keep his blood saturated with nutritive material.
To recover from seasickness one must saturate his
blood with nutritive material. For this purpose one
must eat, and if unable to eat enough at a time, he
must eat oftener. To eat seven times a day is about
right; the three regular meals, ten to fifteen minutes
before rising, half-way between meals, and at bedtime.
Always eat and drink at least ten minutes before
rising in the morning. It matters little what it is,
provided only it is what you want. Porter or stout is
good, so are hard sour apples. At sea we may find
ourselves liking and longing for things that we hardly
ever think of on shore. Whatever you really want,
that is the best thing to take; and porter or stout is
always good, whether you want it or not.
Whatever is taken before rising must be so conven-
iently available as not to require the patient to raise
his head. In case of porter or stout, the glass must
be dispensed with and the liquid taken directly from
the bottle.
When one is already seasick, those liquid foods are
best which require least digestion, are most rapidly
absorbed, and yield the quickest returns — beer, ale,
porter, stout, broths, soups, meat extracts. These can-
not all be prescribed with success; they should only
be suggested — then the patient will choose which he
wants, and the stomach will agree on the choice. The
sicker the patjent the oftener he must eat and the less
at a time, and when he feels a repugnance to all other
foods, porter or stout taken without raising the head,
directly from the bottle, a mouthful at a time, at about
five-minute intervals, ^Vill prove a great success.
A woman taking care of herself will not generally
attend to these details, but will suffer instead. But if
she have the help of another who will promptly attend
to each detail at the right time without stopping to ask
the patient's consent, the scheme works beautifully.
If you are able to be up and about and are regularly
going to meals, then always lie down immediately after
eating, about fifteen minutes at least. At table do not
wait, but begin eating at once on something, or delay
going to table until the rush is over, or stipulate with
your waiter for immediate attention. When done, do
not wait, but go directly to your berth or elsewhere
and lie down.
Whenever there appears the slightest sensation of
hunger, or nausea, or any indescribable sense of dis-
comfort about the stomach, or in the head, eat and lie
down.
The worst case of seasick retching will easily be
made comparatively comfortable in thirty minutes or
less, by lying down without a pillow, closing the eyes,
and taking a pint of porter or stout in six doses at
five-minute intervals. Another food for such an emer-
gency, but not so good as stout, is made by mixing
well the yolks of two raw fresh eggs with an equal
bulk of good brandy. Give a teaspoonful at ten-min-
ute intervals. If you do not feel quite well with a pil-
low, remove it, and you will feel better. This is very
important.
Retching occurs in paroxysms at intervals more or
less regular. The best time to take the malt beverage,
or any other food, is just after a paroxysm of retching.
Should it be taken before and thrown up, then take
another dose immediately after the paroxysm. That
will stay down, because the next paroxysm will not
occur under ten to fifteen minutes, and by that time
the patient has had the benefit of the dose, or several
doses, and should not retch at all. So after casting
up an entire meal it is proper to go and straightway
eat another, which is not likely to come up.
All necessary edibles are, I believe, supplied by the
steamer steward ; but on short voyages it may be more
convenient to have one's own variety of such things
for extra use in one's cabin. In so providing one
should bear in mind the presence of rats on some
steamers.
Avoid all needless expenditure of mental or muscu-
lar energy. Talking, reading, and listening are done
at the expense of power, which the patient may not
have to spare, and should be reduced to a minimum
by the susceptible at sea.
When the patient is eating too little to keep the
bowel well filled, constipation will be only apparent.
He must not expect to discharge much cargo when he
is taking little in. Respond promptly to the calls of
nature. On long voyages when the patient has begun
to eat fairly and the bowel is well filled, and real con-
stipation is present, it will be better to resort to instru-
mental means for relief daily by using an enema of
glycerin ; twenty drops, more or less, will be sufficient.
Do not mix it with water or anything else. The use
of purgative or laxative medicines is attended with too
much additional and general violence.
Seasickness is sometimes accompanied by severe
headache or by much mental uneasiness. If these do
not yield to the treatment already prescribed, then
bromide of sodium may be given in a dose of half a
teaspoonful of the dry powder in a little water; repeat
the dose in an hour if necessary. The bromide of
sodium may be used with the patient's food as salt
(which it much resembles in appearance and taste),
but only while the necessity for it continues. Should
there be any doubt about its necessity, do not use the
bromide at all.
If these directions are promptly, fully, and faithfully
executed, the passenger will be able to endure a sea
MEDICAL RECORD,
[June 9, 1900
voyage of any length with not more than a tenth of the
illness that he might otherwise suffer, and this mini-
mum of discomfort can be without retching. I have
promised to get people of known susceptibility across
without retching, and have fulfilled my promises.
95 Hicks Street.
Diagnosis of Raynaud's Disease. — Adolf Calmann
reports a number of cases which he holds confirm the
opinion that the Raynaud symptom complex may oc-
cur without demonstrable anatomical disease of the
central nervous system, and add to the number of
cases in which the Raynaud manifestations are only
symptoms of an affection of the central nervous or-
gans, especially of the spinal cord. They afford no
grounds for considering a disease of the peripheral
nerves as the cause of symmetrical gangrene, equally
little for hysteria. The author says, however, that
those who assume an immaterial trouble of nervous
nature in all of the Raynaud cases far overshoot the
mark. Opposed to such a partial opinion are a not
inconsiderable number of observations which demon-
strate in vivo or by obduction an anatomically devel-
oped disease process to be the cause of the local
asphyxia and its sequelEE. — The Alienist and Nenrolo-
gist, April, 1900.
Sprains. — S. H. Huntington holds that in the treat-
ment of sprains our first object should be to check
hemorrhage from the torn vessels and to limit the
extent of the injury to what has already occurred.
This is best accomplished by firm, even pressure, ob-
tained by strapping the sprained joint with strips of
adhesive plaster. If properly applied in sprains of the
ankle, the pain is immediately relieved and the patient
can walk at once. If the conformation of the sprained
joint forbids the use of the plaster straps, apply firm
pressure by means of an unyielding muslin (not rub-
ber) bandage, first carefully padding all hollows. A
thorough douching of the parts with very hot water
may precede the application of the dressings. Pas-
sive motion of the sprained joint should begin as
early as the second or third day. If motion is made
only in the direction and to the extent that the joint
is naturally capable of, there is no possibility of
stretching or displacing injured parts, and the forma-
tion of adhesions will be prevented. — Yaie MeJical
Journal, May, 1900.
Pancreatic Digestion from the Standpoint of the
Comparative Anatomy of the Bile and Pancreatic
Ducts in Mammals. — B. K. Rachford says that cer-
tain anatomical conditions have been developed in
the carnivora which have the effect of so slowing the
rate of passage of food through the duodenum that
the time of exposure of foodstuffs in the duodenum of
these animals to the action of bile and pancreatic
juice is greater than in the herbivora. From these
facts one would infer that it is of physiological impor-
tance that the fats and proteids should be retarded in
their passage through the duodenum in order that they
may be longer acted upon by the bile and pancreatic
juice while the food yet contains combined acid, and
before it reaches the alkaline succus entericus of the
jejunum and ileum. This physiological inference
finds support in laboratory experiments made by the
author. — -Medicine, May, igoo.
The Pulmonary Complications of Typhoid Fever.
— C. E. Edson calls attention to the extra-intestinal
growth of the bacillus of typhoid, and to the fact that
the care of a patient in this disease includes care of
the whole man and not merely of his abdomen. Bron-
chitis has been found in fifty-four per cent, of Edson's
cases. Ulcerations are frequently seen in the upper
trachea. Bronchitis may assume a mild or severe
form, often masking at first the true nature of the mal-
ady. Pneumonia is the most common thoracic com-
plication. It occurs about the second week, rarely
before. It may be lobular or assume the true croup-
ous form. Pleurisy, dry or with effusion, may occur
at the outset of typhoid, but with the greatest rarity,
and it is a very infrequent complication at any stage
of the disease. Abscess, gangrene, and infarction are
all rare complications and secondary to others, such
as pneumonia or infected areas of hypostatic conges-
tion. Small areas of infarction are generally over-
looked or confounded with patches of hypostasis.
(Edema of the lungs must be considered as a circula-
tory complication from failing heart rather than a truly
pulmonary disorder. A tuberculosis may be implanted
upon an unresolved patch of pneumonia, or an old
tuberculous infection, latent and never yet active, and
may find in the lowered vitality of the convalescent its
opportunity to spread. Both these conditions, how-
ever, partake more of the character of sequelte than of
true complications. The possibility of the supposed
typhoid preceding a rapid general tuberculosis having
been not typhoid at all, but tuberculous fever, must
be borne in mind. — Colorado Medical Journal, April,
1900.
Hepatism and Neuropathy. — R. Massalongo says
that chronic diseases of the liver are sometimes, but
only exceptionally, accompanied by disturbances of
the central or peripheral innervation. Acute or
chronic diseases of the liver do not cause such dis-
turbances more than do affections of other organs.
The phenomena of auto-intoxication in the human
organism are very complex; the symptomatology of
the lesions of an organ is never exclusive nor inde-
pendent; local diseases in the strict sense of the term
do not exist. There is too great a tendency to special-
ize, to create new morbid entities, and to carry labora-
tory data with too much enthusiasm to the bedside of
the patient. — Rivista Critica di Clinica Medica, April
28, 1900.
Cystitis Caused by the Bacillus Pyocyaneus.—
Thomas R. Brown cites the investigations leading up
to the accredited belief that the pyocyaneus may be
pathogenic as well as saprophytic. He relates an in-
stance of cystitis in a woman after operation for pel-
vic adhesions caused by this bacillus as shown by cul-
tures. This is the first case in the author's knowledge
in which this cause has been definitely proven. The
urine left over night showed a green color, thought to
be due to the fact that it contained sufficient albumin
to act as a culture medium for the bacterial growth. —
Maryland Aledicaljournal, May, 1900.
The Etiology of Tumors Antonio Carini says
that the origin of tumors is one of the most widely
discussed subjects at the present day. The theory of
a parasitic origin is the one most generally accepted.
From the author's experimental and historical re-
searches he reaches the following conclusions: In
tumors extirpated during life under aseptic conditions,
he has never succeeded in isolating blastomycetes,
even when a histological examination had determined
the presence of Russell's bodies (blastomycetes of
Sanfelice). By the inoculation of a pure culture of
blastomycetes he never obtained true neoplasms. The
blastomycetic nature of the Sanfelice bodies (fuchsin
corpuscles of Russell) is doubtful. These bodies are
not constant in tumors, and are found in other patho-
logical processes in tuberculous organs and in normal
organs. The bodies found in tumors, and described
as parasites, as a rule do not take the specific color-
ing of blastomycetes. — II Policlinico, April 15, 1900.
June Q, 1900]
MEDICAL RECORD.
989
AMERICAN MEDICAL ASSOCIATION.
Fijty-frst Annual Meeting, Held in Atlantic City, N. /.,
on June 2, 6, J, and 8, /goo.
William \V. Keen, M.D., of Philadelphia,
President.
GENERAL SESSIONS.
J^irst Day — Tuesday, June §th.
The meeting was called to order at 10:45 a-^'- '"
the Marine Hall, Young's Pier, by the president, Dr.
William VV. Keen, of Philadelphia; and the session
was opened with prayer by the Rev. Frederick J.
Stanley.
Dr. Keen was then presented with a gavel, sent by
the profession of Canton, O., his native city.
Addresses of Welcome. — Acting-Governor John-
son, of New Jersey, delivered an address of welcome.
He referred to the absence of Governor Voorhees on a
sea voyage by saying that his excellency was " half
seas over," and, hence, unable to be present. The
very fact of his being away at this time in search of
health was but another proof that there was a power
even above that of the chief executive of the State, i.e.,
the authority of the family physician. As a matter of
seniority, the State of New Jersey had a right to en-
tertain this large representative medical body, for his-
tory told us that the first medical society was organ-
ized in New Jersey in 1766. He had been informed
that the minutes of that society were still in the pos-
session of the Medical Society of New Jersey. After
adverting to the many advances in medical science
during the present century, the speaker bade the asso-
ciation a hearty welcome.
Hon. L. P. Story, mayor of Atlantic City, also
welcomed the association in a few well-chosen words.
The President's Address.— W. W. Keen, M.D.,
LL.D., of Philadelphia, made an address, of which
the following is an abstract: He commenced his re-
marks by congratulating the association on its great
prosperity, as evidenced, among other things, by a
membership of about nine thousand physicians.
While this number was truly a large one, when one
considered that there are over one hundred thou-
sand regular physicians in these United States it
seemed strange and anomalous that the association
should comprise less than one in ten.
Rush Monument Committee. — With reference to
the Rush monument fund, he said that as he had been
called upon to till the vacancy on the committee left
by the resignation of Dr. Albert C. Gihon, he had ap--
pointed Dr. James C. Wilson, feeling that it was ap-
propriate to select for this place one who was a physi-
cian rather than a surgeon, and who was also from Dr.
Rush's native city. The committee had actually in
hand a little over $11,000 — a sum too large to go
backward, and not enough to go forward. Probably
several thousands of dollars were still in the hands of
various State organizations, which had been pledged
to this fund.
The Anti-Vivisection Bill On the subject of anti-
vivisection, the president said that he had been so
deeply impressed with the tremendous harm that would
be done if the "anti-vivisection bill," or Senate PJill
No. 34, were allowed to pass, that he had deemed it
his duty to send out letters to the president and secre-
tary of every State medical society in the country, to
prominent members in the profession, and to a large
number of other influential men, urging them to arouse
a public sentiment against the bill. He was proud to
be able to bear public testimony to the enthusiasm
and unanimity with which the profession in every part
of tiie country had responded. He believed this ac-
tion had exerted an enduring influence on senators and
representatives in establishing and confirming their
judgment against the inhumanity of any such bill.
A hearing had been granted, before the sub-committee
in Washington, to both the friends and opponents of
the bill. Among the latter was a noble array of speak-
ers, counting among them such names as Drs. William
H. Welch, Henry P. Bowditch, H. A. Hare, William
Osier, Mary Putnam Jacobi, Howard A. Kelly, Sur-
geon-General George M. Sternberg, together with
Bishop Lawrence, of Massachusetts, and others. It
was encouraging to note that this effort had not been
in vain, the present committee having so far changed
its views that it was probable the bill would slumber
in committee or be reported negatively. One of the
most telling and forceful of the communications in
opposition to the bill was a letter addressed to the
chairman of the commi'ttee on the District of Colum-
bia by President Eliot, of Harvard College. It was
worthy of note that President Eliot takes the ground
that it is the anti-vivisectionists who are inhumane and
cruel to the last degree, because they would condemn
both man and animals to suffering and death by im-
peding the progress of medical science.
Members of the Association by Invitation Dr.
Keen called particular attention to the desirability of
limiting the "members by invitation " more strictly
than had been done in the past. For instance, it had
been the custom, in most of the sections, to invite
medical men of distinction, not members of the asso-
ciation, to read papers before the sections. Some of
these persons had even been openly hostile to the as-
sociation, yet year after year had had these courtesies
extended to them. It seemed just and right that this
loose practice should cease, for membership in the
association was open to every American, and any one
who did not choose to avail himself of the privileges
and advantages of membership by joining the associ-
ation should be debarred from them.
A Section on Pathology and Bacteriology. — In
view of the importance of pathology and bacteriology,
he had ventured to ask a number of gentlemen to act
as a provisional and unofficial committee to organize
such a section, under the chairmanship of Dr. Ludwig
Hektoen, of Chicago, feeling sure that the association
would give its official sanction at the proper time.
Annual Exhibit. — The annual exhibit was an im-
portant financial aid to the local committee. As yet
there were no rules or regulations to govern the con-
duct of this important business. He therefore urged
the establishment of a permanent committee, or one
member of the previous year's committee to be re-
tained, so as to give greater stability and uniformity
of management.
Publication of Papers. — The speaker advised, in
connection with the vexed question of publishing the
Transactions, that only the more important papers
should be printed in full, the example of the British
Medical Journal, in publishing only abstracts of the
less important communications, being worthy of emu-
lation.
Endowment of Medical Schools. — The remainder
of the address was taken up with a thoughtful and
earnest review of the needs of our medical schools,
and the reasons why they should be liberally en-
dowed. Dr. Keen said that the tide of charity in the
United States had reached a remarkable height,
amounting, in 1899, to the enormous sum of nearly
$80,000,000, yet only a small portion of this had been
bestowed upon medical schools. In his opinion, the
chief cause for this discrimination against the medical
99°
MEDICAL RECORD.
[June 9, 1900
schools was to be found in the vicious method by
which these schools were formerly conducted — i.e.,
practically as joint-stock companies. But that day
had happily passed. As a consequence of the broad-
ening and lengthening of the medical course of study,
the cost of medical education had enormously in-
creased, yet it was not practicable to increase the
students' fees, and the latter were entirely inadequate
to meet modern demands. President Eliot, of Har-
vard, very rightly says: "There is no branch of edu-
cation which more needs endowment. Medical edu-
cation is very expensive, because it has become, in the
main, individual instruction." He was not one of
those, however, who believed that the day of the di-
dactic lecture had passed, for, in the language of Presi-
dent Faunce, of Brown University, " never shall we be
able to do without the personality of the teacher,
flaming with enthusiasm for knowledge, pressing up
the heights himself and helping the student on."
One or two such men in every school made a good
faculty. But the great difference between the modern
method of teaching medicine and the older method
consisted in laboratory instruction and clinical in-
struction, both of which must be individual. In the
modern, fully equipped medical school no less than
thirteen laboratories were needed, viz., (i) the dissec-
tion room, or anatomical laboratory; (2) the labora-
tory of histology; (3) the laboratory of embryology;
(4) the physiological laboratory; (5) the laboratory
of chemistry; (6) the laboratory of physiological
chemistry; (7) the laboratory of pharmacy; (8) the
laboratory of pharmacology; (9) the laboratory of
practical obstetrics, where obstetric operations may
be taught; (10) a laboratory for instruction in surgi-
cal operations; (n) a laboratory of morbid anatomy;
(12) a laboratory of bacteriology; (13) a laboratory
of hygiene. The laboratory in the last few years had
done much for humanity; it had discovered the cause
of tuberculosis, tetanus, cholera, typhoid fever, and a
host of other diseases; it had shown us how to avoid
all danger from trichina; it had shown us how to
banish erysipelas, pyaemia, and tetanus from our hos-
pitals, and reduce our death rates after operation from
fifty or thirty-three per cent, to ten per cent., five per
cent., one per cent., or even lower; it had given us a
scientific instead of a guess-work hygiene; it had
pointed out the role of the mosquito in malaria, of
the rat in the bubonic plague, and of the fly in typhoid
fever; it had limited the spread of diphtheria; it
would, in time, enable us to conquer other implacable
enemies of the human race — and yet, there were those
who would stay this God-given hand of help ! An-
other reason for the increased expense of medical
education was the lengthening of the curriculum.
When he was a student, the course of study consisted
of two sessions, of about nineteen weeks each, or
thirty-eight weeks in all ; now it was, as a rule, made
up of four sessions of thirty-two weeks each, or a total
of one hundred and twenty-eight weeks. Comparing
the endowments of theological and medical schools it
is found that in 1898 five theological schools reported
endowments of from $850,000 to $1,369,000 each, yet
in 1899 there were only eight thousand students of
theology for whom this enormous endowment was pro-
vided, as against twenty-four thousand students of
medicine — in other words, each theological student
had the income of an endowment of §2,250 provided
for his aid, while each medical student had only the
income from $83.
Grants for Research Dr. Keen, in closing his
address, said that while the first object of the asso-
ciation should be to place itself on a strong financial
basis, he hoped it W'ould before long assume a rank
second only to the British Medical Association, and
that it would set a fruitful example by giving each
year "scientific grants in aid of research." To a
profession which gave so freely of its own life-blood
surely the public could aff'ord reasonably to endow
its schools; it would be returned to the community
tenfold, and more devoted, self-sacrificing men and
women they never could have.
Report of the Treasurer — Dr. H. P. Newman, of
Chicago, presented the report. He stated that the
total disbursements for the past year had been $57,-
874.75, and that on January i, 1900, there had been
a cash balance of $13,556.38, the total assets amount-
ing to $27,396.86.
Report of the Secretary. — Dr. George H. Sim-
mons gave a detailed report of the work of his office.
He said that he had supplied every regular medical
college in this country with copies of the Code of
Ethics, with the request that a copy be placed in the
hands of every graduate in medicine. Among other
interesting features of the report was the announce-
ment that the Honolulu Medical Society, having six-
teen members, had applied for admission to the Amer-
ican Medical Association.
.'SECTION OX PRACTICE OF MEDICINE.
First Day — Tuesday, June ^th.
The chairman. Dr. George Dock, of Ann Arbor,
Mich., in his opening address discussed the difficul-
ties of modern medicine due to the numerous advances
which had taken place in methods of accuracy, and to
new discoveries. He said that medicine, as a study,
was becoming more difficult. He referred to an ab-
surd superabundance of medical schools in the United
States. The laboratory expert should be selected with
as much care by the practitioner as was the operating
surgeon, and his recompense should be more carefully
made. The profession had a weight of guilt in the
matter of the great prevalence of mercantile concerns
putting forth their cure-all wares, which called for
correction.
A System of Personal Biological Examinations of
the Condition of Adequate Medical and Scientific
Conduct of Life. — Dr. GEtiROE M. Gould, of Phila-
delphia, advocated the establishment and systematiza-
tion of a series of periodical scientific personal exami-
nations, tests, and measurements of the human body
throughout life, having in view the discovery of the
early symptoms of disease now often passing unno-
ticed— the symptoms of the symptom — as well as the
functional abnormalities that finally led to organic
disease. To the methods of the anthropometric, psy-
chophysical, and physiological laboratories should be
added those of the specialist and general physician, to
determine morbid tendencies and to preserve a general
biological picture or epitome of the individual life.
He described the possible methods of carrying out the
plan, and the function of the physician in the sug-
gested work. He also alluded to the connection with
life-insurance problems, with public sanitation and
hygiene, with governmental, military, and civil-ser-
vice examinations, and with the hygienic and educa-
tional work of schools, colleges, and universities, and
the relation of the same to the specialist and general
physician. The speaker made a plea for a living
anthropology, with a system of records carried through-
out life, starting with the data of inheritance. Some-
thing similar to the Bertillon system should be made
the basis of the first and of all subsequent examina-
tions. The pathological element had been sadly neg-
lected in all previous anthropological study. The
physician's case-books would furnish the most valu-
able data if they could be utilized for this purpose.
With this view histories should be made scientific
and preserved for future study.
June 9, 1900]
MEDICAL RECORD.
991
The Hospital Clinical Laboratory. — This was the
title of a paper presented by Dr. C. N. B. Camac, of
New York, who spoke of the value of bedside exami-
nations carried out by especially appointed internes
for this service. The reader reviewed the work of
European laboratories, and discussed the importance
of proper record-taking in connection with ward lab-
oratory work. The clinical laboratory contributed
only certain elements which, taken in conjunction
with clinical data, led to the correct diagnosis. No
one instrument of precision by itself alone was suffi-
cient. All contributed to the end in view. The first
laboratory was established at Breslau in 1825. The
time had come when all the data since then piled up
by scientific investigation of this kind should be sup-
plemented by the practical hospital and ward clinical
laboratory. Here methods determined upon in ana-
tomical, physiological, chemical, bacteriological, and
pathological laboratories could be applied and carried
out. Photographs of thoroughly equipped workshops
of this kind were shown by the speaker. He had es-
tablished such laboratories in the Johns Hopkins and
Bellevue hospitals in i8g6, and similar ones would
shortly be established at .St. Luke's Hospital. The
apparatus was simple and readily brought to the bed-
side. One of the objections was the expense of mi-
croscope and cabinet, in which poisonous reagents
were locked away from the patients. The cost was
from $30 to $50 per year for maintenance, and the
original outlay need not exceed S300.
On Blood Examination and its Value to the
General Physician. — This paper was read by Dr. M.
H. FussELL, of Philadelphia, who showed simple ap-
paratus to be carried in a bag and used at the bedside.
In discussing both papers Dr. Osler said that ap-
paratus for bedside examinations were as essential
to-day as was the knife to the surgeon. Proper diag-
nosis by the aid of simple equipment would lead to
proper treatment. When his time came to fall, tiie
speaker said, he preferred to fall into the hands of the
man with his microscope with him in a bag for bed-
side use.
Dysentery Dr. Simon Flexner, of Philadel-
phia, spoke upon this subject, and described experi-
ments carried out in Manila by a body of young men
sent out by the Johns Hopkins Hospital. It was
a mistake to suppose that tropical dysentery was of
one single kind. There were different groups of or-
ganisms to which the disease had been attributed.
Many still believed that the bacillus coli communis
was the cause. Pyogenic cocci were supposed by others
to be causative in their action. There was a protozoon
which was now believed to be active in tropical dys-
entery, the amceba coli. This form of dysentery was
not distinct on this point alone, but in its pathologi-
cal anatomy as well. The studies referred to were
made for the most part on American soldiers, in both
acute and chronic cases. The acute stage often at-
tracted little attention. Here the amoeba were com-
monly found. In other cases the amcebae did not occur
or were few in number. In some very acute forms
bacilli were often found, not normally present in the
intestines, and showing peculiar reaction. When the
acute form became chronic, the ulcers were superficial
and were not undermined, and the danger of stricture
was not so great as in tropical dysentery. Immunizing
experiments in the laboratory showed that small ani-
mals could be rendered immune with the products of
these micro-organisms. The speaker thought that the
bacillus found was the same as that reported as being
observed in the dysentery of Japan, and that it was in-
timately concerned with the acute dysentery of the
tropics. Army surgeons in Manila now distinguished
an "infectious" in distinction from the tropical form
of dysentery.
Notes on Tropical Dysentery. — This was the title
of remarks by Dr. J. H. Musser, of Philadelphia,
who related the case of a patient who had come from
Porto Rico and .was treated in the Philadelphia Hos-
pital. There were marked emaciation and extensive
pigmentation of the skin, with numerous boils upon the
surface of the body. The symptoms were those of
colitis and proctitis. The stools were free from fresh
blood, and mucus was absent or but sparingly present.
Purpura was a striking feature, with signs of scorbutus,
which latter might have been the diagnosis made, were
it not for the microscopical examinations. In aggluti-
nation methods the speaker thought we had a means of
obtaining an accurate estimate of the affection.
Dr. Osler said he had formed the impression that
the amceba would have to take a back seat since Dr.
Flexner had reported his findings in connection with
the bacillus he had described. He believed the dis-
ease was separate and distinct from that of the
tropics, and thought it might be the same form as that
which occurred in this country in epidemics seen in
jails, hospitals, etc.
Dr. Briggs mentioned a patient who had come
from Cuba, whose history was substantially that de-
scribed by Dr. Musser for his own case, but here the
Widal reaction occurred. In a second case it did not.
Dr. Hunter, of Minneapolis, spoke of cases from
Manila, in one of which amcebse were found. In a
second case in which they were not found the symp-
toms were mild while the patient was at rest, but se-
vere under exertion.
Dr. Woodhull, of the regular army, recently sta-
tioned at Manila, spoke of the service to medicine at
large, as well as to the army, rendered by Dr. Flexner
and others who went to Manila to carry out these in-
vestigations. He found that many patients had to be
sent to a colder climate before they began to show
signs of improvement.
Dr. Murphy, of Missouri, said that in Kansas City
he had studied three cases of amcebic dysentery. Ex-
pectorated pus showed that a liver abscess had per-
forated the lungs in one instance. He desired to call
attention to the occurrence of the disease in northern
latitudes.
Dr. Vaughan, of Ann Arbor, spoke of epidemic
bloody flux occurring as far north as Michigan.
Nothing more than the colon bacillus had been found
in these cases, and he was inclined to think the latter
the cause of this particular form of the affection.
Strychnine hypodermatically acted well in conditions
of severe collapse and' depression. Dr. Wilson, of
Pennsylvania, referred to a case in which the tongue
was denuded and appeared sandpapered throughout.
The temperature was at times subnormal and never
elevated. Emaciation was progressive till death, but
there was never any pain. Treatment and dietetics
were futile.
Dr. Flexner, in closing, gave credit to Dr. Wood-
hull for furthering the investigations in Manila by
giving full opportunity to prosecute them. Every
acute outbreak should be examined bacteriologically,
and the blood should likewise be examined. The mi-
cro-organism he described was closely allied to the
typhoid bacillus, but it could be distinguished. Ty-
phoid blood had no effect upon it. Liver complica-
tions in the form he studied were extremely rare.
Serum Therapy in Croupous Pneumonia. — Dr. J.
C. Wilson, of Philadelphia, discussed this question
together with the bacteriology of the affection. He
said that in direct infection by way of the air passages
there was an exudate and a toxaemia. The more abun-
dant the exudate the greater was the toxaemia. After
brief historical considerations and reference to theoret-
ical points he mentioned intricate problems which had
to be solved in the laboratory. Experiments he found
gg:
MEDICAL RECORD.
[June 9, 1900
to be encouraging tor the serum therapy. An analysis
of eighteen cases treated with serum placed in the speak-
er's hands by Dr. McFarlane,o£ Philadelphia, showed
that antipneumococcic serum gave results which were
encouraging. In some cases the serum acted in pre-
venting general septicaemia. The clinical histories
and records of blood examination were given. Other
treatment was not excluded. The pneumococcus was
present in fourteen examinations. The dosage of se-
rum varied from 22 c.c. to 460 c.c. It was employed
timidly at first, and more boldly later on. Recent
serum gave better results than old, and the results
showed a general improvement in most cases. There
were four deaths. The duration of the disease was from
five to fourteen days. The small number of cases did
not permit of definite conclusions.
Dr. a. O. J. Kelly, of Philadelphia, in discussing
this paper reported a case showing consolidation of
the right lower lobe, in which the antipneumococcic
serum was given. The patient died, and the autopsy
showed conditions which would probably not have
been cured by any treatment.
Dr. Rochester, of Buffalo, referred to a trial upon
another patient of serum obtained by blistering the
skin of a convalescent from pneumonia. There was
slight improvement.
Dr. Newton, of New Jersey, inquired as to the
mode of preparation of the serum.
Dr. McFarlane, of Philadelphia, answered that it
was obtained by administration of living cultures of
the pneumococcus to horses, and described the method
minutely.
Influence of Sea Air and Sea-Water Baths on
Disease. — This paper was read by Dr. W. Blair
Stewart, of Atlantic City, N. J. He described the
essential differences between sea and land breezes,
considering particularly the absence of pollen, dust,
miasm, germs, etc., and the presence of ozone, iodine,
and moisture. He alluded to the peculiar loca-
tion of Atlantic City with reference to sea air and
tidewater, and its action on neurasthenics, convales-
cents, tuberculosis, rheumatism, etc. Other subjects
discussed were: sea water, its composition, and its
temperature at Atlantic City; the surf bath, its time,
limitations, physiological action, and its use and abuse,
naming particular contraindications and indications in
disease. Hot and cold sea-water baths were described,
with their use in rheumatism, gout, neurasthenia, etc.,
and their physiological action. Particular stress was
laid on the action of sea water in cases of tuberculosis
and neurasthenia, and in convalescence.
SECTION ON SURGERY AND ANATOMY.
J^irsi Day — Tuesday, June ^Ih.
The section was called to order by the president.
Dr. H. O. Walker, of Detroit, Mich., at 3 p.m. His
address was as follows:
A Retrospect of Surgery of the Stomach He
spoke of the great advances which had been made
since the pioneer work of Billroth, twenty-five years
ago. Stomach lesions, he said, might be classed un-
der two heads, the benign and the malignant. In con-
sidering the relief of these conditions, he emphasized
the fact that beyond peradventure the posterior opera-
tion in gastro-enterostomy was the operation of choice,
except when the pylorus was bound down by extensive
adhesions. In gastroptosis he felt that the shortening
of the ligaments was of very questionable value. He
spoke of the very great difliculty of 'early diagnosis,
and hoped that much help would come to the surgeon
from the gastric specialist. To the medical man, it
was of little importance to determine the exact seat of
the lesion; to the surgeon it was of the utmost impor-
tance, for upon the location depended the character
and the prognosis of operation. As to technique he
had used Senn's plates, Murphy's buttons, and the
various sutures, and had found them all about equal.
The cause of death was usually shock or sepsis, or
hemorrhage. In regard to the last, it was important
to ligate and cut, rather than to use the knife first and
then suture afterward. Gastrectomy could hardly, as
yet, be considered as established, but he pointed out
that physiologically at least it was doubtless feasible,
because the stomach being already gravely diseased,
its function practically at an end, the patient had
now habituated himself to digesting with the un-
aided gut. He cited many experiments on dogs in
which buttons as well as other methods of anastomo-
sis were used, but the animals, habituated to the use
of their normal stomachs, were unable to recover from
their sudden loss and died within forty-eight hours.
In conclusion he said: (i) Non-perforating gastric
ulcer must be operated on if medical treatment failed,
and posterior gastro-enterostomy was usually the best
operation for these cases. (2) Perforating ulcer must
always be operated upon early. (3) Benign tumors
called for surgical intervention if producing pyloric
stenosis. (4) Pylorectomy was indicated in the case
of small movable growths; posterior gastro-enteros-
tomy, if the growth was large. (5) In case of hour-
glass contractions, posterior gastro-enterostomy or
gastro-anastomosis should be done. (6) Exploratory
Cttliotomy was justifiable in all questionable cases.
Non-Perforating Gastric Ulcer with and without
Hemorrhage. — Dr. W. L. Rod.man, of Philadelphia,
read this paper. In Germany, gastric ulcer was said
to occur in five per cent, of all cases. While it was pos-
sible that this was excessive, there seemed little doubt
that the condition was far more common than gener-
ally supposed. He said that the best statistics were
furnished by Welsh, of Johns Hopkins, from a total of
seven hundred and ninety-three cases. These showed
the lesser curvature, posterior wall, and pylorus to be the
areas involved, three and a half times as often as else-
where. Also, they showed that one in five was mul-
tiple, and that this multiplicity might reach as high
as thirty-five. Cicatrices were very common and were
frequently seen to be merging into malignancy, while
hyperchlorhydria, which was denied by Ewald, was
shown by Welsh to be a very constant factor. The
etiology was unquestionably in very close relationship
with anaemia, it having been overlooked that the oc-
cupations commonly supposed to predispose to this
disease were invariably accompanied by profound
blood changes. Particularly of interest was the state-
ment that ulcer was relatively more common between
the ages of forty and sixty years than at any other pe-
riod. Of the symptoms, pain, severe and boring, in-
fluenced by food, localized, was the most characteris-
tic. Vomiting was not so important, but if occurring
two hours after eating, and particularly if accompa-
nied by hyperchlorhydria, it was of diagnostic signifi-
cance. Ha:matemesis was a variable quantity, the
color depending entirely on the amount of hemor-
rhage. It was the cause of death in from three to five
per cent, of all cases. The treatment should always
at first be medical : three-fourths of all cases thus re-
sulted in cure in from three to five weeks. The re-
maining one-fourth were conceded by even the most
conservative to fall within the realm of surgery. As
to the character of the operation, the first question
was, " Should the ulcer be excised?" Were it not
that there was a mortality of fifteen per cent., this
would be the operation of choice. Adhesions fre-
quently contraindicated it. Pylorectomy or gastro-
enterostomy might be done, though both might fail to
cure. Again, there might be a multiple ulceration.
Here gastro-enterostomy should be done, and prefer-
ably by Murphy's button.
June 9, 1900]
MEDICAL RECORD.
993
Dr. Fenton B. Turck, of Chicago, opened the dis-
cussion. He dwelt on the indications for operation,
and spolie particularly of those cases rendered ob-
scure by pyloric spasm, and absence of tumor. The
condition of gastric myasthenia was frequently mis-
interpreted, and still a third was an hypertrophy of
the gastric glands accompanied by degeneration and
atrophy of the walls. The diagnosis of perple.xing
conditions was greatly aided by the passage into the
duodenum of a pyloric sound. A beautiful .v-ray
photograph was exhibited showing such a sound in
position and outlining with great clearness the greater
curvature. The contraindications to operation were
not limited to so-called inoperable cases; heart and
lungs were factors frequently overlooked. Circula-
tory disturbances often aggravated the existing auto-
intoxication, and so killed, while kidney insufficiency
was another very important factor. Important points
in the technique mentioned were rapidity; the use of
the rubber dam in isolating the operation area, and
the avoidance of tugging at the viscera during their
manipulation. For this last reason he deprecated
posterior gastro-enterostomy. He closed by urging
the importance of technique and the ante- and post-
operation care of the patient.
A New Method of Elevating the Glottis during
Anaesthesia and after Certain Cervical Operations.—
Dr. CHRISTI.4N Fencer, of Chicago, spoke on this
subject. He said that the method consisted in mak-
ing a median longitudinal incision over the hyoid,
and passing beneath it a strong silk suture. In cases
of bony ankylosis of the inferior maxilla this method
was of great value to the anaesthetist, while as a post-
operative procedure in cases in which the upper hyoid
attachments had been cut away, this suture, tied to the
dressing, held the epiglottis well open and prevented
the inhalation of foreign particles and consequent
pneumonia.
Diagnosis and Treatment of Cholelithiasis.— Dr.
W. J. Means, of Columbus, Ohio, read this paper.
He spoke of the need of early diagnosis and of the
very important complications involving intestinal and
hepatic changes. Of twenty cases, ten had been oper-
ated on, of which all had resulted in recovery; ten had
been treated medically, of which number three had been
fatal. The average age was fifty years. Fourteen of
the patients were females, and six males. The number
of calculi ranged from one to two hundred and thirty.
Sixteen patients had a history of recurrent attacks,
while typhoid had preceded the attack in four. Rig-
ors had been observed in four cases, vomiting in
fifteen; jaundice in thirteen, coming within twenty-
four to thirty-six hours. Hepatic enlargement was
present in eight. Tenderness and rigidity were
marked in all. Pain likewise was a constant factor,
but of very variable intensity. In fifteen the stools
were white. Considering some of these factors in de-
tail, he stated that pain frequently radiated toward the
stomach on up to the right shoulder, two hours after
eating. Nausea was usually more severe than in ap-
pendicitis. Jaundice he considered important, and
carefully differentiated the two forms. Cholangitis
was a frequent cause of jaundice. Of great impor-
tance was the fact that women in the fourth decade of
life were the most frequent victims. The treatment was
medical and surgical. The first should be employed
only in the way of proplylaxis, for the mortality of
medical treatment after the deposition of the stones
was very high. On the contrary, the surgical inter-
vention was free from danger, and if, as was often the
case, the function of the ducts was re-established, the
cure was permanent. Early operation here was as nec-
essary as in appendicitis.
Cholecystectomy, vs^ith Special Reference to the
Removal of the Mucous Membrane of the Bladder
in Certain Cases as a Substitute for it. — Dr. W. J.
Mayo, of Rochester, Minn., read this paper. He said
that trauma, phlegmon, gangrene, and malignancy were
the chief indications for total ablation of the bladder.
Trauma was very rare. In gangrene, two courses
were open — first, excision of the sac; second, drainage.
Cases of obstruction of the cystic duct were frequent.
Here a permanent fistula discharging mucus often fol-
lowed cholecystostomy. This condition could easily
be cured — he had done it in seven cases — by the en-
tire removal of the mucous membrane. He would
also use this method in preference to cholecytostomy
in cases of chronic catarrh of the lining membrane,
for it was the secretion of these cells which was at
the root of the evil. In closing, he outlined the tech-
nique of the denudation.
The Importance of Early Operation for Biliary
Calculi Dr. M. H. Richardson, of Boston, read
this paper. Gall stones, he said, must be removed as
soon as diagnosed. There was a close analogy be-
tween this condition and appendicitis. The earlier
the operation, the greater the success. There was
slightly more danger in the early operation than in
the interval appendectomy, but this was largely due to
the greater average age of the patients. In speaking
of the chronic cases he dwelt on the influence of cholte-
mia in lowering the vitality and often causing death.
He cited his thirteen fatal cases, all but one of which
were chronic, many extending over a period of twelve
years. The most frequent complications were acute
infection of the gall bladder and appendicitis. The
indications for operation consisted in finding faceted
stones in the stools, non-faceted stones so found con-
traindicating operation. Repeated attacks with or
without finding stones pointed to operation. Quies-
cence no more contraindicated operation that it did in
appendicitis. Repeated attacks of tenderness and per-
sistent pain over the gall bladder were among the most
valuable indications.
Dr. John VVyeth, of New York, on being asked to
open the discussion, said that he agreed so perfectly
with the spirit of the paper that he would not discuss
it.
Dr. Mynter, of Buffalo, said that he believed the
haematogenous theory of jaundice to be exploded. He
thought the colon bacillus was the constant cause, and
that all jaundice was due either to inflammatory or
other obstruction of the ducts. In regard to Dr.
Richardson, whom he congratulated on presenting his
fatal cases, he said that all his own early-stage cases
had resulted in recovery; not so the late. He urged
that continual pain and intermittent tenderness over
the gall bladder were almost pathognomonic.
E)r. Nicholas .Sen.v, of Chicago, recommended the
use of the .v-ray. He deprecated the operation of Dr.
Mayo because it seemed to him to call for two stages,
and spoke of the danger of leaving bits of mucous
membrane behind. He recommended a splitting of
the peritoneum from the fundus to the point of ob-
struction, and a removal of the tissues beneath.
Again, he protested that gall-stone operations were
becoming deplorably frequent, and urged conserva-
tism.
Dr. Grey, of Jersey City, cited a case in which the
appendix had become involved by an acute exacerba-
tion of a chronic cholelithiasis.
Dr. H. O. Marcy, of Boston, emphasized the need
of ablation of the bladder in many cases, and of the
crying need of early operation.
Dr. J. B. Deaver, of Philadelphia, said that perfo-
ration-peritonitis was the most fearful condition the
surgeon could be called upon to treat, whether it be
caused by appendix or gall bladder. He strongly crit-
icised Dr. Senn and supported Dr. Richardson. There
must be early operation. Further, the a--ray was use-
994
MEDICAL RECORD.
[June 9, 1900
less in diagnosing cholelithiasis, though it had a place
in the kindred kidney lesion.
Dr. Wyman, o£ Detroit, urged the simplicity and
the value of cholecystostomy, which relieved the chol-
asmia.
Dr. Merrill Ricketts, of Cincinnati, advocated
early intervention. Contracted gall-bladder work was
one of the most fearful undertakings in the surgical
line.
Dr. Ochsner, of Chicago, said that almost all fatal
cases were due to procrastination — the early opera-
tions being invariably successful.
Dr. Bevan, of Chicago, said that in 16.5 per cent,
of all dissecting-room cases there were gall stones.
Of all patients over sixty years of age twenty-five per
cent, were found to be in this condition. Thus they
must often give no symptoms.
Dr. John Spmmers, of Nebraska, spoke of the use
of Murphy's button in anastomosing the common bile
duct and the duodenum; of the need of introducing
the finger into the foramen of U'inslow, and of a modi-
fication which rendered the use of the button easy in
these cases.
Dr. Means, in closing, said that he supported the
old classification of jaundice. He did not agree with
Senn in his conservatism nor in the use of the .r-ray.
Jaundice led the practitioner into grave error because
the surgeon had placed too much weight on this fac-
tor. He felt that stones almost always produced pro-
dromata.
Dr. Mavo said that Dr. Senn had misunderstood
the spirit of his operation. It did not call for a
double operation, but was useful, first, for those cases
in which a permanent fistula had established itself,
and, second, in case of a mucopurulent discharge be-
ing a prominent factor at the time of the primary op-
eration. He said that all who had worked on the
stomach would realize how easily mucous membranes
parted from the other layers, and that this was equally
true in the case of the gall bladder.
Dr. Richardson applied to the gall bladder, though
to a less marked degree, the rules which governed our
treatment of the appendix. He thought Senn's con-
servatism good, but said that it should not go too far.
He admitted that stones might exist without symptoms,
but felt that dissecting-room findings were a pernicious
argument against the modern operation.
SECTION ON OI'.STF.TKICS .\M) DISEASES OF
WOMEN.
First Day — Tuesday, June jfk.
Chairman's Address The meeting was called to
order by the chairman. Dr. VV. E. B. Davis, of Bir-
mingham, Ala., who then read his address. After
expressing his pleasure at the honor conferred upon
him in selecting him to preside over the deliberations
of the Section on Obstetrics and Diseases of Women,
he said he believed he could say without fear of con-
tradiction that the members of this section had done
most for the advancement of gynecology. He re-
ferred to the illustrious work of Sims and McDowell,
and in the words of another said "that the outcome of
the labors of these two men in beneficent results had
no parallel in medicine.'' Reference was made to the
effort of the late Dr. Parvin to have a combination of
the chairs of obstetrics and gynecology. He believed
there was every reason why the gynecologists should
be the teachers of obstetrics; that nothing short of the
attainments of the gynecologist could make the chair
complete. He believed we could learn a lesson from
Austria and Germany in having large maternities for
teaching purposes. He believed the exalted position
which gynecology occupied in this country owed much
to the medical journals devoted to this department,
and to the national special societies of limited mem-
bership whose transactions had gained world-wide
reputation. The development of gynecology had been
attended with many errors, but with so many earnest
workers only time was required to correct these. For
the vaginal section he believed too much had been
claimed, although believing it to have a wide field.
Peri-tubal and peri-ovarian abscesses of large size,
from whatever cause, he believed should be drained
by this route, and later abdominal section be done if
necessary. Puerperal inflammation occurring in the
first month or six weeks after delivery, at term or pre-
maturely, should also be dealt with by vaginal in-
cision. A good percentage of such patients would be
cured, and some he stated would bear children. Cases
of pelvic inflammation should be operated on without
waiting for pus formation. His experience in cases
without pus had not been large, but the results had
been exceedingly satisfactory. In cancer of the uterus,
when the disease had passed beyond the uterus, he
advocated palliative operations rather than radical
ones. He was gratified to note the increasing popu-
larity of the round-ligament operation for retro-dis-
placements of the uterus. Much honor was due to
Pawlik, Kelly, and others for their work in exploring
the bladder and kidney; and particularly for the
method popularized by Kelly, but he thought it carry-
ing refinement too far when attempts were made to
treat pus in the kidney through the ureter. The sur-
gery of the bladder he believed to be little advanced
beyond the surgery of Marion Sims' operation in 1878.
In the closure of the abdominal wound he employed a
method combining the tier sutures with absorbable
material and the interrupted through-and-throiigh su-
tures with unabsorbable material. He used inter-
rupted sutures of silkworm gut uniting aponeurosis,
recti muscles, and peritoneum, securing the sutures by
means of very small silver tubes corresponding in
length to the thickness of the skin and subcutaneous
fat through which the ends of each suture are passed
and then through a perforated shot. The suture should
be superficial or subcuticular.
The Angiotribe in Vaginal Coeliotomy. — This pa-
per was read by Dr. Carstens, of Detroit, Mich. He
called attention to the point that Battey had origi-
nally removed the ovaries through the posterior cul-
de-sac. With the increased knowledge of extensive
pelvic lesions, the abdominal route was chosen, while
later the removal of the uterus and all the pelvic or-
gans by the vagina was practised, but on account of
the tendency to conservatism the abdominal route was
generally selected at present. He said that the vag-
inal route was preferable if thorough work could be
done, which was the case in selected cases, but the
great trouble in removing a single ovary and small
ovarian tumors or diseased tubes by the vagina con-
sisted in the difficulty of applying a ligature and con-
trolling the hemorrhage. In the angiotribe, however,
we had an instrument which enabled us to make use
of the vaginal route in many cases in which it could
not previously have been done. The angiotribe was,
therefore, one of the most valuable instruments ever
devised in abdominal surgery, as it enabled us to
operate with less danger, and with decidedly shorter
convalescence.
Angiotripsy. — Dr. Huofl M. Taylor, of Rich-
mond, Va., said his experience sustained the advan-
tages claimed for the angiotribe. In selected cases
he thought it was a Safe substitute for forceps and
ligature. It was very easy to apply, and this should
commend it to those who have not served a long ap-
prenticeship in the use of the ligature. He was im-
pressed by the commonly observed fact that post-oper-
ative shock was markedly diminished in the cases in
June 9, 1900]
MEDICAL RECORD.
995
which he had used Ihe angiotribe, and he thought this
was equally true as to the intensity and duration of
post-operative pain. Convalescence seemed to be es-
tablished at an earlier date and to progress more rap-
idly. In only one instance did he fail to secure com-
plete hcemostasis by means of the angiotribe. This
occurred in resecting a section of badly infected omen-
tum which had wrapped up a necrotic appendix. In
all he had used the angiotribe in fifteen cases, all of
which were suprapubic sections. He had not used
it when operating by the vaginal route. This was
largely due to the fact that he had had but a limited
experience in working through the vagina. The en-
couraging reports from so many, he thought, warranted
the conclusion that the angiotribe would find a large
field of usefulness through the vaginal route. A ma-
jority of his cases were very simple in character;
about one-half were uncomplicated hysterectomies,
while the others were types of cystomas. In only one
instance were there post-operative symptoms which
suggested the occurrence of hemorrhage. This case
was a large unilocular ovarian cystoma with e.xtensive
bowel adhesions. He had had no opportunity to use
the angiotribe in septic cases, but it seemed especially
desirable to avoid the use of the ligature in existing
or threatening septic conditions.
Improved Technique in Major and Minor Sur-
gery of the Female Generative Organs. — Dr.
Henry P. Newman, of Chicago, read this paper. He
said that under the favorable conditions in which op-
erations were now done it must not be forgotten that
in handling the organs or tissues of the body we were
dealing with living substances of different degrees
of resisting-power, and that the success of the manoeu-
vres depended largely upon the amount of delicacy,
dexterity, and expedition that was used. A cervical
operation, to be successful, must at the same time, in
inflammatory conditions, remove all adventitious tis-
sue from the organ, and in deformities of imperfect
development remodel the organ to as nearly normal
outlines as possible, giving ample lumen to the canal
and establishing proper menstrual and intermenstrual
function. To accomplish these ends the speaker did
tracheloplasty, which consisted in clean removal of
a more or less wedge-shaped plug of the diseased tis-
sues from the centre of the cervix by the use of a
right-angled knife, especially designed to make the
flap, and a pair of curved scissors. In perineal work
to restore contour, stability, and function to the pelvic
floor, the author recommended the Harris method with
a slight modification, of shortening, the torn or
stretched fibres of the levator ani muscle. In rectal
and urethral work for hemorrhoids, fistulsE, etc., the
best results could be obtained by clean dissecting out
of these lesions and approximating mucous membrane
and cut surfaces with catgut or some less yielding
suture material. In vaginal section and vaginal hys-
terectomy the ligature and the angiotribe had re-
placed the retention forceps. Dr. New'man was the
first to introduce the angiotribe into America. He
designed his model for use in abdominal and vaginal
work, and his experience had upheld his confidence
in its advantages.
Dr. J. W. BovEE, of Washington, D. C, was glad
to hear such good reports from the use of this instru-
ment, which seemed to him more like a plumber's in-
strument than a surgeon's. He could not see why
cases should have a shorter period of convalescence
which were operated on with the angiotribe than those
operated on with gauze. He had not had a case of
vaginal hysterectomy in which the patient had been
in bed longer than two weeks, and he did not believe
the use of the angiotribe shortened the length of time.
He thought it was only necessary to refer to the
French and German literature to learn of a number of
deaths in cases in which the angiotribe had been used.
He did not think as much of the broad ligament could
be removed with the angiotribe as with scissors and
ligature. He also believed that hemorrhage was best
controlled by ligation of the internal iliacs.
Dr. W. E. Ashton, of Philadelphia, believed that
the use of the angiotribe would be more extensively
resorted to within the next year by all those who fa-
miliarized themselves with its use. He had had little
experience with it, because the major portion of his
work was by the abdominal route. In reference to the
question of lacerations of the cervix he believed it
a great mistake to do trachelorrhaphy and curettage,
and that rather amputation should be done, when the
patient not only recovered but went on to child-bearing.
In the discussion of the papers of Drs. Carstens, Tay-
lor, and Newman, Dr. VVathen, of Louisville, said
that much of the objection to operation on the uterus
was the result of multiplicity of technique, three to
four large retractors — posteriorly, anteriorly, and lat-
erally— generally being used. For the last two years
he had performed no operation in the vagina, or done
hysterectomy for cancer, in which he had ever used
more than one retractor, and generally none at all;
with few exceptions he believed them absolutely use-
less. He had not used the angiotribe himself, but
had examined it carefully and recognized that there
was a field for its use. He objected to the statement
that there was much work done per vaginam by the
use of the angiotribe which would otherwise have to
be done by the abdominal route. He could not con-
ceive of any instance in which as much could not be
accomplished per vaginam by the use of the clamp as
with the angiotribe.
Dr. J. Riddle Goffe had had some little experience
with the angiotribe, and wished to say a word for it.
In order to test the efficiency of it in critical cases he-
had selected two cases of advanced cancer upon which
to try it. He found that even in cancerous tissue the
instrument controlled hemorrhage. In a recent case
he had used it when he resected the rectum through
the vagina, and the result was very satisfactory. In
hemorrhoids he had secured perfect hamostasis. He
had reduced the time of application from two minutes
to a minute and a half.
Dr. Carstens, in closing the discussion, said he-
did not care about the size of the instrument if it did
the work better than a smaller one. In answer to the
man who had spoken of his principles, he said that in
the case of an ophthalmologist, he thought, if a pa-
tient had an eye dislocated to the extent of three
inches the ophthalmologist would take it uut, and
that it would be good surgery too. He did not claim
that the ovary should be taken out unless it caused
pain and trouble. He adapted his methods to the
conditions, and did not remove every uterus and every
ovary, nor use the angiotribe all the time. He thought
he had been meek and humble in his declarations; he
had said the angiotribe was good for certain cases of
vaginal hysterectomy. He did not believe it was
good in cancer of the uterus. In that condition he
used clamps, getting away as much as possible of the
broad ligament.
Dr. Newman, in closing, said that in regard to-
operation upon the cervix he did not state in his
paper that he did trachelorrhaphy, but tracheloplasty.
In answer to Dr. McMurtrie he stated that the advan-
tages of the angiotribe were expedition, complete hae-
mostasis, doing away with the ligature or doing away
with foreign bodies, which had been the aim of all
surgery; it also did away with the massing of tissue.
The lineal stump left was another advantage claimed.
Like Dr. Carstens he used the angiotribe when indi-
cated, and had found it very useful when applied in.
controlling hemorrhage.
996
MEDICAL RECORD.
[June 9, 1900
Dr. G. B. Massey, of Philadelphia, took exception to
the statement of Dr. Carstensthat prolapse of the ovary
in a young girl was incurable, that nothing but re-
moval of the tube and ovary was proper. He thought
that if the ophthalmologist went on that plan the re-
sult to the patient would be very bad.
Dr. McAIurtrie asked what advantages were claimed
for the angiotribe, and to what degree it was superior
to the present methods of controlling hemorrhage.
Dr. Porter asked that the gentleman who had rec-
ommended the angiotribe would state how long it
should be applied, and how many pounds' pressure
was required.
Dr. Boldt, of New York, did not believe the angio-
tribe in the least superior to the ligature, with which
he felt more secure than in the use of the angiotribe.
Dr. John C. Da Costa, of Philadelphia, said he
was like the Irishman — that the proper way to do a
vaginal hysterectomy was by the abdominal route. He
did not think ligature on cancerous tissue was good
surgery ; when all of the diseased tissue could not be
removed he thought it better to leave the patient
alone. He agreed with Dr. Ashton that trachelor-
rhaphy was often done in mistake for amputation.
Myomectomy per Vaginam — Dr. J. Riddle
GoFFE, of New York, said in this paper that myo-
mectomy was preferable to hysterectomy, and vaginal
myomectomy was preferable to abdominal myomec-
tomy in all cases in which it could be employed. He
believed the scope of vaginal myomectomy much
wider than it was usually thought to be. A report of
cases was given illustrating the author's principles.
Myofibroma Uteri Dr. H. J. Boldt, of New
York, read this paper. He said that the greater num-
ber of solid neoplasms of the uterus were fioro-myo-
mata. Tumors consisting only of fibrous connective
tissue (fibroids) or only of muscle (myoma) were rare.
The original site of such neoplasms, the writer stated,
was, strictly speaking, interstitial, and they subse-
quently grew in the direction of least resistance. The
histogenesis of fibromyomata was still a disputed
point. His own studies led him to believe with -Ros-
ger that they arose from the muscularis of the capil-
laries. This, too, would explain why in the earliest
stages we found many mixed tumors from a histologi-
cal standpoint. In the matter of treatment the author
stated that if by any measure adopted a symptomatic
cure could be secured, it should be done in preference
to a radical operation. It must not be forgotten, how-
ever, that there were instances, although rare, in which
nothing but undelayed operations should be advised;
they had been mentioned among the degenerations of
serious character. The position in life of the patient
must be considered, because a woman of the laboring
class could not observe the rules laid down for those
in better circumstances. No specific had been discov-
ered to check the size of the growth, stop bleeding or
the pain. In his observations of the influence of
thyroid extract, recommended by Shober and Polk in
this country, he had noted three instances of improve-
ment; but with regard to the size of the tumor it must
be remembered that this extract had the effect of di-
minishing the amount of adipose tissue in the abdomi-
nal walls. Among the remedies for local use consid-
ered palliative, the speaker believed electricity had a
limited field.
Arrhythmia Cordis Complicating Fibromata
Uteri. — Dr. J. Wesley Bovee, of Washington. D. C,
in this paper reported a case successfully operated
upon. The arrhythmia was probably of nervous ori-
gin, as the pulse was regular during anaesthesia and
arrhythmic again during convalescence. He classi-
fied the etiological and pathological conditions into
(i) nervous and cerebral; (2) neurotic and psychic;
(3) reflex; (4) toxic; (5) critical arrhythmia of acute
diseases; (6) arrhythmias of cardiopathies. He men-
tioned several cases demonstrating the wide variance
in results from cardiac arrhythmia depending upon
the pathological cause. His conclusions were: (i)
Arrhythmia cordis was not yet well understood. (2)
As a complication of fibromata uteri it was exceed-
ingly rare. (3) It had a serious import, the degree of
which depended upon the condition causing it. (4)
Its presence as a complication of conditions requiring
surgical operations necessitated a careful inquify into
its cause before operation was done. (5) It was a
contraindication of more or less influence in all cases
for surgical operation. (6) If not due to severe path-
ological lesions other than those for which operation
was to be done, its presence did not necessitate prohi-
bition of operation, but lent additional doubt as to the
patient's recovery.
The papers of Drs. Goffe, Boldt, and Bove'e were
discussed jointly.
Dr. Porter, of New York, said that the field for
myomectomy in the larger tumors was much more
limited than in the small. He adhered very closely
to a limit as regards the age of the patient. He be-
lieved the operation should be done with due consid-
eration of possible malignant development, and in
patients of the age of forty its use should be limited.
The operation in its technique he regarded as very
simple; the location of the tumor must help in the
selection of an anterior or posterior incision. He
preferred the Alexander operation for replacing the
uterus to the antero-fixation suggested by Dr. Goffe.
When there was difficulty in removing the growth from
below on account of its size, abdominal operation was
advocated in a large percentage of cases.
Dr. Wiggin spoke in support of incision along the
anterior vaginal wall in operations through the vagina,
as it facilitated operations in which it was necessary
to get at the ovarian vessels. In reference to a re-
mark by Dr. Porter as to the necessity of abdominal
hysterectomy when the tumor was of large dimensions,
he recalled one case in which the patient would have
died had this been resorted to.
' Dr. Carstens regarded myomectomy as described
by Goffe as excellent and in selected cases applicable:
in a great many cases it could not be done; some
fibroids were not encapsulated; they were really myo-
mas and went all through the uterine tissues. The
younger the woman the more inclined was he to do a
myomectomy, and the more advanced the age the more
he favored hysterectomy, whether abdominal or vag-
inal.
Dr. Joseph Price, of Philadelphia, thought nothing
was more important than that there should be a con-
sensus of opinion concerning methods of operation.
He thought the retrograde changes in fibroids very
common. After the age of thirty years he thought the
mental state very marked in a woman carrying a
fibroid; after operation it was greatly improved. He
did not think the lower route could be used by every
one, owing to the lack of facilities in some locations.
Dr. Zi.vke admitted that the operation per vaginam
could be done most dexterously by such a man as
Dr. Goffe, but in view of that ease he thought how
much more easily it might be done through the ab-
dominal wall. He did not believe that the method of
Dr. Goffe would ever be practised largely in this coun-
try or abroad. He was sorry that Dr. Boldt still found
a place for electricity.
Dr. Wathen believed the conditions in each case
must be considered in deciding upon the abdominal or
vaginal route. The expertness of the operator must
also be regarded. He believed it better to begin the
operation in either way indicated by the operator's
judgment, and be prepared to complete it by any other
method demanded.
June 9, 1900]
MEDICAL RECORD.
997
Dr. C. p. Noble, of Philadelphia, preferred the ab-
dominal route in general, on account of the greater
facility in reaching the field of operation, the greater
certainty of asepsis, and the greater control of hem-
orrhage. To the objection to the abdominal route on
account of hernia, he said that those who worked from
above seldom saw hernia;. In all cases in which it
was possible in young women he did myomectomy;
in older women, hysterectomy.
Dr. G. Betton Massey, of Philadelphia, expressed
the feeling that physicians should guard against pro-
fessionalism. If they were prejudiced in favor of
one method of treatment, patients coming to them
did not get what they paid for, and if paying nothing
they did not get what the medical profession should
give to these patients free. He had noticed this pro-
fessionalism in regard to the use of electricity. The
absence of this professionalism was very marked in
the treatment of doctors' own families, for he had
treated a large number of the wives and daughters of
physicians. He thought the word infection should be
used in connection with fibroids rather than the word
degeneration.
Dr. Goffe in closing said he did not mean to imply
that his method was the only way; but that it was one
way. He would do laparotomy in large fibroid tumors.
He insisted on the danger of hernia from the abdomi-
nal route. He believed that Dr. Noble did not see all
the cases of hernia, nor did any operator; the patient
usually going to another surgeon. He admitted in
reply to one criticism that he might not get out all the
tumor ; but if the larger part was taken out, as much as
possible had been done to prevent development.
Dr. Boldt said in closing that he had given elec-
tricity only a limited field as a palliative measure. To
say it had no field indicated a want of careful obser-
vation. He believed that a certain indefinite number
of interstitial myomata would be symptomatically
cured by electricity. He stated that the cases of sub-
mucous fibromyomata which were lodged in the pelvis,
when it was possible to split the cul-de-sac from side
to side, were the cases in which vaginal operation was
indicated. Interstitial fibromyomata he did not be-
lieve indicated vaginal operation.
SECTION ON PEDIATRICS.
First Day — Tuesday, Jiuie ^th.
Address of Chairman. — Dr. Edwin Rosenthal,
of Philadelphia, called the section to order. He said
that pediatrics had become a most important branch
of medicine. The most frequent diseases that we had
to consider were diphtheria and typhoid fever. In
speaking of antitoxins he said that the original anti-
toxin was a patented preparation. Those preparations
now in use, however, were not. He never gave less
than 1,500 units for an initial dose, but in cases of
laryngeal diphtheria he gave 2,000 units. In speaking
of typhoid fever, Dr. Rosenthal mentioned the three
methods of treatment, viz., the antiseptic method, the
Woodbridge method, and the antipyretic method.
Etiology of Idiocy and Imbecility. — Dr. Martin
W. Barr, of Ehvyn, Pa., read this paper. He said
that, judging from his experience of the last fifteen
years, the etiology of idiocy was threefold, viz., hered-
ity, malnutrition, and accidents. In speaking of
heredity. Dr. Barr considered mental and physical de-
fects. He said malnutrition was predisposed to by
the use of drugs, vicious habits, etc. He then re-
ferred to weak-mindedness in certain families among
the nobility of Europe. Dr. Barr had a case of insan-
ity which could be traced clearly through seven gen-
erations. Out of three thousand and forty cases, nine-
teen per cent, were imbeciles, five per cent, were
insane, and seven per cent, were due to intermarriage.
The so-called Mongolian type constituted about ten
per cent, of the cases of idiocy. Tuberculosis and
epilepsy were mentioned.
Physiological Training of the Feeble-Minded. —
Dr. S. J. Fort, of Ellicott City, Md., presented this
paper. He said a feeble-minded person was one in
whom certain things were lacking that were necessary
for association with people in general. He then
spoke of the so-called ''moral imbecile," and he con-
sidered a child that was six years old and unable to
talk as feeble-minded. In conclusion, he thought that
the institution was not only the best place for such
cases, but that it was absolutely essential for their ad-
vancement.
A Study of the Circulation in the Feeble-Minded.
— Dr. J. Madison Taylor and Dr. F. Savary Pearce,
of Philadelphia, presented this paper, which was read
by Dr. Taylor. It was based upon observation of nine
hundred and fifty-five cases. Cardiac and vascular
changes were more common in males. Presystolic
murmurs at the apex were the most common organic
changes, there being one case that had an aortic mur-
mur. The circulatory changes he thought were very
interesting in that all of the cases involved a loss of
tone. Dr. Taylor thought that these conditions were
due to a toxcemia acting on the neurons.
Infantile Cerebral Palsies Dr. A. C. Cotton, of
Chicago, read this paper. He considered anything
that impaired the function of the brain as palsies.
He had collected the histories of twenty-five cases,
and found that females were more often affected, and
that diplegia was the most common form (seven out
of the twenty-five cases), and that dysphasia was the
rule. He exhibited some very interesting photo-
graphs.
Dr. William M. Leszynsky, of New York, opened
the discussion. He did not agree with Dr. Fort in the
institutional treatment of feeble-minded children. He
thought that " home treatment " would be as beneficial
as any. In considering Dr. Cotton's paper, Dr. Les-
zynsky thought that every case of epilepsy should be
examined for infantile cerebral palsy.
Dr. J. P. Crozer Griffith, of Philadelphia, said
that he thought tremor, as a post-cerebral symptom,
was rare, while choreiform movements were quite
common.
Dr. Taylor said that years ago he had thought, as
Dr. Leszynsky did, that home treatment for feeble-
minded children was the best thing for them, but now
he knew that institutional treatment was the only right
way to handle these cases.
Dr. Cotton, in closing the discussion, said that he
strongly favored institutional treatment, and, in pass-
ing, mentioned the case of a child who became self-
supporting by such treatment and training.
SECTION ON MATERIA MEDICA AND THERA-
PEUTICS.
Leon Solomon, M.D., Chairman.
First Day — Tuesday, June ^th.
Chairman's Address. — Dr. L. Solomon, of Louis-
ville, the chairman, expressed the opinion that the
greater precision in the knowledge of the use of medic-
inal agents within recent years was gradually over-
coming the therapeutic nihilism so prevalent a decade
ago. This branch represented the highest aim of all
medicine, and was the culmination of all of the re-
searches of the other departments. After outlining
the past history of the section and the plans for the
future, he gave a review of the progress in this de-
partment for the past year. Particular attention was.
998
MEDICAL RECORD.
[June 9, 1900
devoted to the subject of serum therapy. Natural,
passive immunity was discussed at length. Ehrlich's
side-chain theory offered the best explanation of im-
munity. The various tissues of the body had different
side-chain combinations — as an example, tetanus toxin
in an emulsion of fresh brain became much atten-
uated. The diphtheria antitoxin neutralized all of the
side chains. Other antitoxic serums failed because they
failed to neutralize all of the side chains. No serum
over six months old should be dispensed. The teta-
nus antitoxic serum fulfilled all the requisites of an
antitoxin, and would be of undoubted service if we
could diagnose the disease at its inception, as in the
case of diphtheria. In discussing the antipneumococ-
cus serum he pointed out that inasmuch as the pneu-
mococci circulated in the blood, the phagocytic power
of the leucocytes furnished the chief means of attack.
The function of the antipneumococcus serum, there-
fore, was to stimulate the leucocytes. This agent thus
far did not hold a fixed place in our armamentarium.
The tuberculins could neutralize only a few of the
many toxins of the bacillus tuberculosis, and their ac-
tion was therefore limited. The antirabic serum of
Tizzoni had not been a success. The toxins of bacil-
lus prodigiosus and of bacillus erysipelatis gave good
promise. In closing he spoke very forcibly of the
slanderous rumors derogatory to the officers of this
section that had been circulated throughout the coun-
try.
Dr. a. M. Lyons, of Detroit, outlined the policy of
the American Pharmaceutical Association, of which
he was a delegate. He advised a censorship over all of
the papers and advertisements in the medical journals.
Treatment of Acute Alcoholism by Large Doses
of Digitalis ; A Clinical Study Based on Cases in
the Alcoholic Wards of Bellevue Hospital. — Dr.
Henry P. Loom is, of New York, read this paper.
He said that this agent was largely employed for this
purpose in England. One observer reports seventy suc-
cessful cases. It was generally agreed that there was
a great tolerance of this agent in acute alcoholism.
He administered it in ten cases. There were two
deaths, only one of which could in any way be attrib-
uted to the drug. One-half ounce of the tincture
was given every four hours for three doses; if this
was not effectual he waited six hours and repeated the
procedure. The effects observed were a better pulse,
the skin became warm, the temperature fell, and the
patient went to sleep. Recovery was much more
rapid than with any other treatment. The speaker,
however, cautioned against the indiscriminate use of
such large doses, and thought they should be given
only to robust young people. If after three doses the
narcotic eft'ect was not evident, it was better to desist.
Dr. O. T. Osborn, of New Haven, said that the
vessels of the stomach in cases of acute alcoholism
were in a state of vasodilatation, and, therefore, ab-
sorption from the stomach was very slight. This was
the reason why such large doses of so powerful an
agent produced so little effect.
Some Dangers from the Use of Narcotics in
Young Persons. — This paper Svas read by Dr. T. D.
Crothers, of Hartford, Conn. He said that when
opiates were administered to some people for a lim-
ited period a diathesis was established which cropped
out late in life if the subject was given opium again.
The patient often did not know that the drug was ad-
ministered before. In some individuals a repugnance
was established with the first administration, which
continued ever after. When opium did not cause
nausea and disagreeable after-effects there was a pre-
disposition toward the habit. A child born of a wom-
an who was addicted to its use was irritable, and this
irritability was often only overcome by the use of
opium.
Dr. W. B. Hill spoke of the possibility of the cells
being stimulated to produce a kind of antitoxin to neu-
tralize the effect of the opium toxin, and thought that
when the opium was discontinued the cells continued
to produce the antitoxin, thus creating a demand or
craving for the toxin.
Dr. J. N. Upshur, of Richmond, Va., deprecated
the advice of college professors to students to use
morphine for all pains. The students should be
taught the responsibility of using narcotics.
Dr. Crothers in closing pointed out the difference
between the opium and morphine habits, and said that
both alcohol and opium habits were often the result of
a psychosis inherited or acquired.
Therapeutic Progress — Dr. I. Tracy Melvin, of
Saguache, Colo., read this paper. He spoke of the
uselessness of the knowledge of an accurate descrip-
tion of medicinal plants as far as the physician was
concerned. The active principle was all that he
needed. The Galenical preparations of the crude
drug were too uncertain to be of any scientific value.
The effects of soil, climate, and variety were so great
that it was impossible that any two samples of a crude
drug should possess the same effect. They often va-
ried as much as three hundred per cent, in their per-
centage of alkaloids. He believed that the alkaloid
should be prescribed in preference to the crude drug
preparations.
Dr. N. S. Davis said that the physiological effects
of many drugs could not be got from the use of their
alkaloids. He believed in a proper combination of
medicinal agents in many cases, and that the effect
was really more simple than if a single agent was pre-
scribed for each symptom.
Dr. F. Woodbury, of Philadelphia, believed that
the scientific attitude toward all new remedies was
that of scepticism until their value was clearly deter-
mined.
Plea ior Greater Simplicity in Therapeutics. —
Dr. L. Faugeres Pishop, of New York, read this
paper. He said that a small number of drugs well
understood tended to clearness of thought and definite-
ness of purpose in therapeutic measures. Often a sin-
gle ingredient of a complicated mixture caused inju-
rious effects which were attributed to the course of the
disease. He would advise young men to use a few
drugs which they knew well, and to rely on hygiene
for the rest of the treatment. He strongly protested
against the use of proprietary combinations, the ingre-
dients of which could not be varied and in many cases
were not even known definitely.
Dietetic Treatment of Diabetes. — This paper was
read by Dr. N. S. Davis, Jr., of Chicago. He said
that in mild cases patients would cease to pass sugar
when the sugars and most of the starches were with-
held from the dietary. In cases of moderate sever-
ity improvement would take place as soon as both
sugar and starches were entirely stopped. The sugar
would not disappear from the urine in severe cases
under this regimen. Even the amount of albumin in-
gested must be limited. The carbohydrates should
not be stopped at once. It was wise to do this gradu-
ally. Very rarely could any diabetic patient take more
than three and one-half ounces of carbohydrates in
twenty-four hours. Fats should be taken liberally.
Meat, milk, and eggs were the staple articles of food
for most diabetics. In ordinary cases of patients who
had improved sufficiently to take regular food again, a
day of fasting should be observed about once a week,
when the patient should return to the diabetic regimen.
Coma Diabeticum and its Treatment. — This paper
was read by Dr. Heinrich Stern, of New York. In
an analysis by the author of the number of deaths in
Manhattan and the Bronx for the past year, there were
two hundred and six cases of death in which diabetes
June 9, 1900]
MEDICAL RECORD.
999
was the cause. Sixty cases terminated in coma. He
did not believe that it was true diabeiic coma, how-
ever. There were two forms of diabetic coma — the
true, and the pseudo-diabetic or coma due to an inter-
current affection. In true diabetic coma there was a
regular dyspncea, without any apparent cause, present
in the lungs. Cyanosis was rare. The pulse was
weak and the temperature low. After the onset the
quantity of urine became much less; it generally con-
tained albumin; glucose was absent in sixty per cent,
of the cases examined by the writer. Before the coma
occurred there was sometimes a diminished alkales-
cence of the blood. In some cases casts were found.
When these were present they were absolutely diagnos-
tic of diabetic coma. They w-ere short, smooth, and
broad, and of a pale hyaline appearance. There was
no reliable symptom to warn one of the approach of
coma. Usually death occurred in twenty-four hours.
As a preventive alkalies in large doses afforded the
best results. When coma occurred they were useless.
Two cases were reported by the writer in which he
saved the patient's life by the use of precipitated cal-
cium carbonate. It was administered per rectum.
GENERAL SESSIOX.S.
Sccc/iii Day — Wednesday, June 6tli.
Address on Surgery Dr. W. L. Rodman, of
Philadelphia, delivered this address, taking for his
subject " Gastric Hemorrhage."
Gastric hemorrhage of whatever nature was, until
recently, looked upon as strictly a medical affection,
and was treated upon the same general principles as
those which underlay that of many other internal hem-
orrhages. This was still true of many cases of gas-
trorrhagia, but not of others which were treated by
a combination of medical and surgical means, and of
others still which should be met by prompt operative
procedure. Ha;matemesis, he said, might result from
ulcer of the stomach, duodenal ulcer, gastric carci-
noma, cirrhosis of the liver, vicarious menstruation,
post-operative ha;matemesis, purpura hajmorrhagica,
miliary aneurisms, aneurisms of the aorta and other
vessels, leukaemia, typhoid, yellow, and other infec-
tious fevers, valvular disease of the heart, and various
kinds of traumatism. Gastric ulcer was the most
common disease of the stomach producing hemorrhage
■ — occurring in five per cent, of the entire population,
according to Ewald and others. Hemorrhage occurred
in at least fifty per cent, of all cases of gastric ulcer,
and many authorities estimated it as present in eighty
per cent. It was, too, fatal in eight per cent, of the
cases in which it occurred, according to the conserva-
tive estimate of Leube, and it was indirectly fatal in
a much greater number of cases by anaemia and its
remote consequences. The character and amount of
the ejected blood, however, would usually give prompt
and positive evidence of its source and the cause un-
derlying it. Bleeding in carcinoma was rarely so free
as in ulcer; the amount of blood lost being small in
quantity, and of the characteristic coffee-grounds ap-
pearance. It did not resemble pure blood, as it did
in ulcer even though mixed with food. The presence
of hydrochloric acid in the ejected matter was as char-
acteristic of vdcer as its absence and the presence of
lactic acid were of carcinoma. Ulcer was more fre-
quent in women under the age of forty, whereas carci-
noma occurred more commonly in men past middle
life. Formerly the treatment of hemorrhage from gas-
tric ulcer was uniformly by ice, astringents, and opium,
combined, of course, with rest. This should properly
be the treatment still for the first hemorrhage in all
cases; for the second, possibly; but not for subse-
quent ones — for recurring hemorrhage, like appendi-
citis, would sooner or later prove fatal, and should,
like that affection, be treated radically; and to carry
the parallelism further, the best time to operate was
between attacks. With two hemorrhages coming close
together we might assume that as in appendicitis there
would be a third attack, and if anything was to be at-
tempted surgically it should be done when the patient
was in fairly good condition, and not in the collapse
of hemorrhage. The speaker said that better results
would be secured by judicious interference than by
the policy of inaction hitherto invariably followed,
though he would not be understood as advocating in-
terference in every case. Up to a certain point there
was substantial agreement between physicians and sur-
geons, and, indeed, the idea of arresting hemorrhage
from gastric ulcer by surgical means occurred to a
physician and a surgeon at the same time. The re-
sults of operations for chronic hemorrhage were most
encouraging. There had been thirty-one operations
for frequently recurring, or what might be called
chronic, hemorrhage, with six deaths, or a mortality
of 19.3 per cent. Mr. Robson had reported one hun-
dred and eighty-eight operations for gastric ulcer (non-
hemorrhagic and non-perforating) with a mortality of
16.4 per cent., which was about the same percentage
found by Heydenreich, Tricomi, and others. The
good showing now made for recurring hemorrhage
would be still better when physicians generally recog-
nized that if delayed operations were justifiable, early
ones w-ere better, and should, therefore, be encouraged
at a time when the chances of success were corre-
spondingly brighter. While hemorrhage per sc as a
symptom of gastric carcinoma had not yet. Dr. Rod-
man said, led to an operation, he thought that in cer-
tain cases it might be either so free or of such fre-
quent recurrence as to make one desirable. Resection
would be the best procedure, but gastro-enterostomy
would not only arrest the bleeding, but usually delay
the inevitable end, and bring about a decided ameli-
oration of all the distressing symptoms. Indicated as
it often was in advanced carcinoma without hemor-
rhage, the presence of the latter as a symptom should
be an additional reason for surgical intervention.
Hemorrhage into the stomach was a frequent symptom
in cirrhosis of the liver. The diagnosis of cirrhosis
could be made in only one-third of the cases at the
time of the first hemorrhage. A study of Preble's
cases along with those collected by Savariaud showed
the possibility of an unexpected and fatal gastric hem-
orrhage in the course of cirrhosis of the liver. Sev-
eral of the cases reported as having been operated
upon for diffused or capillary hemorrhage complicat-
ing ulcer were really, the speaker held, instances of
venous hemorrhage into the stomach on account of an
obstructed portal circulation due to cirrhosis. It was
quite certain that operation for gastric hemorrhage in
cirrhosis had a less promising future than the same
procedure in bleeding ulcer; for in the former there
was, in addition, that general hemorrhagic tendency that
made bleeding from any situation most difficult to
arrest. No operation had as yet been deliberately per-
formed in cases in which the diagnosis of cirrhosis
had been made, although some of the cases reported
and operated as hemorrhagic ulcers might have been
instances of cirrhosis.
Vicarious Menstruation. — There was a more or less
general belief that vicarious menstruation might mani-
fest itself in the way of ha;matemesis. If this did hap-
pen, one would naturally think that it should do so in
young women whose ovaries and tubes had been re-
moved, or in women submitted to hysterectomy, the
appendages being left, and who could not therefore
menstruate in the natural way. The speaker said he
had written to fifty prominent gynaecologists and sur-
geons to learn if they had seen, and if so bow fre-
MEDICAL RECORD.
[June 9, 1900
quently, instances of vicarious menstruation showing
itself by h^ematemesis following removal of the appen-
dages, uterus, or both. Nearly all answered, and only
two reported (each a single case) affirmatively. Many
of the writers expressed a positive conviction that vi-
carious menstruation did not occur.
Post-operative Haematemesis is rare. Mayo Rob-
son, in his Hunterian Lectures, states that he has
encountered it in seven cases of his own, two being
fatal, and refers to a similar experience of Eiselberg,
who reported to the Surgical Society in Berlin the
details of six cases. It is significant that nearly all
of the cases reported by Robson and Eiselberg were
instances of operations on the intestines, omentum,
and structures adjacent to the stomach. Robson stated
that in si.x of the cases the omentum was ligated, and
in another it was probably contused. He also said
that " in an experiment on an animal multiple hemor-
rhages into the stomach followed twisting of the omen-
tum." The-speaker gave details of four experiments
upon dogs to determine whether it was possible to
cause hemorrhage into the stomach by rapid and se-
vere traumatism not applied to the stomach itself.
In none of the experiments was any hemorrhage noted.
He also wrote to fifty surgeons, of whom only nine
replied that they had seen operative hrematemesis.
He made particular inquiries as to the frequency of
heematemesis after hernia operations as Robson and
Eiselberg had both seen it. Of the fifty surgeons
written to, only two had encountered it, and one of
the cases was a strangulated hernia with general
peritonitis. The other was a case operated upon for
ventral hernia, and in which death occurred from
a demonstrated duodenal ulcer. In more than a
hundred herniotomies — strangulated and non-strang-
ulated cases — Dr. Rodman himself had never en-
countered gastric hemorrhage. The sum total of all
the hernia operations done by -these fifty surgeons
was undoubtedly many thousands, and \et but two
cases of post-operative hajmatemesis were reported,
and each was satisfactorily explained — one patient
dying of general peritonitis foUow-ing strangulated
hernia, the other from a duodenal ulcer demonstrated
at autopsy. All of the cases seen by Robson and
Eiselberg followed intra-abdominal operations, such
being also the case with all post-operative hseniate-
meses reported by American surgeons, excepting
two cases in which nephrorrhaphy had been done. In
doing nephrorrhaphy, the peritoneum migiit, in the first
place, be incautiously opened by the most careful op-
erator, and secondly there was always a considerable
amount of traumatism necessary to force the kidney
into the lumbar incision. It is not, therefore, difficult
to understand how a hematoma might easily be pro-
duced by the great abdominal pressure oftentimes nec-
essary to bring the kidney into view, and how, further-
more, this extravasation might occasionally cause
saprsemia, septicemia, or peritonitis, according to cir-
cumstances. All septic conditions favored disinte-
gration of the blood corpuscles, and predisposed to
hemorrhage from mucous surfaces. The gastric mu-
cosa was particularly liable to congestion, in condi-
tions of sepsis, both on account of the marked ten-
dency of the thin and more or less disintegrated blood
to settle in the internal organs, and on account of the
vomiting and retching so frequently present. This
would give, the speaker said, a satisfactory explana-
tion of the rare hK;matemeses following abdominal
operations. The experiments upon dogs had shown
that even violent traumatism to the omentum, intes-
tines, spleen, pancreas, and liver did not produce
immediate hemorrhage into the stomach; and it did
not seem unreasonable to suppose that delayed hx-
matemesis would usually depend upon disintegration
of the blood due to sepsis.
Oration on State Medicine : Typhoid Fever among
American Soldiers. — Dr. Victor C. Vaughan,
of Ann Arbor, Mich., delivered this address,
presenting therein some of the more important con-
clusions reached after a study of typhoid fever
among the American soldiers in 1898. He said that
in August of that year a board, consisting of Major
Walter Reed. U.S.A., Major E. O. Shakespeare, U.S. V.,
and himself, was appointed at the request of the
surgeon-general of the United States army for the
purpose of ascertaining the causes of the existence
and spread of typhoid fever in the national encamp-
ments, and of suggesting means for its abatement.
After completing the tour of inspection, this board
spent about eighteen months in going over the medi-
cal records of the various commands. The first con-
clusion arrived at was that every regiment in the
United States service in i8g8 developed one or more
cases of typhoid fever, statements to the contrary not-
withstanding. More than ninety per cent, of the vol-
unteer regiments developed this disease within eight
weeks after assembling in the State encampments,
and most of the regular regiments — probably all —
developed it in less than that time. Typhoid fever
was so widely distributed in this country that one or
more cases were likely to appear in any regiment
within eight weeks after assembling. U'hen war with
Spain was proclaimed, the total strength of the stand-
ing army of the United States was twenty-seven thou-
sand, scattered in about one hundred military garri-
sons, and with no epidemic at any post. Typhoid
fever not only appeared in every regiment in the ser-
vice, but became epidemic in the small as well as in
the large encampments. There was abundant proof
that the prevalence of typhoid fever among- these
troops was not due to geographical location. The
chance of infected men being found in each regiment
was shown by the following figures: In New York
City, which is unusually free from typhoid fever, it
was calculated that there were 3,986 cases of this
disease in 1897. As at least four-fifths of the cases
occurred in those of military age — eighteen to forty-
five years — there were among this class in New York
City 3,188 cases. Assuming the population to be
2,000,000, and that the number of persons of military
age was one-half of the population, it followed that if
these people were divided up into regiments of 1,300
each, they would have furnished 769 commands. If
the estimated 3, 18S cases of typhoid fever had been
evenly divided among these regiments, each command
would have contained at least four persons who, in all
probability, would develop typhoid fever during the
year. Another point, which the speaker substantiated
by quotations from military authors, was that typhoid
fever usually appeared in military expeditions within
eight weeks after assembly. As many intelligent
medical officers still clung to the old miasmatic theory
of typhoid fever, it was worthy of note that this inves-
tigation brought out no fact more prominently than
the demonstration that locality was not responsible
for the epidemics. Neither was any support found for
the pathogenic theory. Translated into terms of mod-
ern medicine, this theory was founded on the belief
that the colon germ might undergo a ripening process
by means of which its virulence was so increased and
altered that it might be converted into the typhoid
bacillus, or, at least, might become the active agent
in the causation of typhoid fever. Moreover, all the
known facts of experimental bacteriology were at vari-
ance with this theory. This investigation also made
it clear that there was no ground for the belief that
simple diarrhoea might develop into typhoid fever, or
predispose to it — indeed, the men who had simple
diarrhtea did not, as a rule, subsequently develop
typhoid fever. Typhoid fever was disseminated by
June 9, 1900]
MEDICAL RECORD.
lOOI
the transference of the excretions of an infected indi-
vidual to the alimentary canals of others. It was
more likely to become epidemic in camps than in
civil life, because of the greater difficulty of dispos-
ing of the excretions from the human body. Alore
than this, a man infected with typhoid fever might
scatter the infection in every latrine of a regiment
before the disease was recognized in himself. As it
was probable that typhoid bacilli were eliminated from
the bowels as soon as infection began, it was reason-
able to assume that throughout the entire period of
incubation an individual might be a source of danger
to others. If this was true, the only way in which
typhoid fever could be with certainty prevented in
armies was by the complete disinfection of the stools
of all, both the sick and the well. Camp pollution
was the greatest sin committed by the troops in 1898.
Some commands were also unwisely located, as, for
example, at Chickamauga, where certain regiments
were so placed that they received the drainage of
other regimental camps. In some instances the space
allotted the regiments was inadequate, and many com-
mands were allowed to remain on one site too long.
The placing of the regiments in unsanitary positions
was done by the superior line officers, sometimes in
the face of protests from the medical oifi.cers. As the
medical officer could only recommend, the line officer
having the authority to command, it did seem right
that the line officers should at least know enough of
this subject to be able to recognize the importance of
reasonable requests and recommendations made by
medical officers. It also seemed proper and expe-
dient that greater authority should be given medical
officers in matters relating to the hygiene of camps.
A significant statement made by Dr. Vaughan was
that, in a general way, the number of cases of typhoid
fever in the different camps varied with the method of
disposing of excretions. Thus, during a part of the
stay of the First Division of the Seventh Army Corps
at Miami, and during the entire period of its encamp-
ment at Jacksonville, water carriage was employed for
the disposal of fecal matter. In the Second Division
the tub system was employed, and by it the fecal mat-
ter was scattered all through the camp. In the Third
division regulation pits were used. The number of
cases of typhoid fever was smallest in the First Di-
vision and greatest in the Second Division. The tub
system should be condemned, and the regulation pit
system was far from satisfactory, particularly in hot
weather. He was convinced that if epidemics of ty-
phoid fever were to be prevented, some other method
of disposing of fecal matter in camps occupied for a
week or longer must be resorted to. The board of
inspection recommended that in permanent camps,
where water carriage could not be secured, all fecal
matter should be disinfected, and then carted away
from camp. Galvanized iron troughs containing milk
of lime should be used for the reception of the fecal
matter, and their contents should be removed daily by
means of the portable odorless evacuator. The inves-
tigation showed that infected water was not an impor-
tant factor in the spread of typhoid in the camps in
1898. The greater prevalence of typhoid fever in the
Third Army Corps was attributed to the fact that the
camp-sites furnished many wet-weather springs, thus
favoring infection. These undoubtedly served as
carriers of the infection, either by mechanically
transporting adherent and infected fecal matter, or
by the men swallowing the typhoid bacilli and void-
ing them afterward with the encrement. It was more
than likely that the men transported infected material
on their persons or in their clothing, and personal
contact was undoubtedly one of the means by which
the infection was spread. Blankets and tentage be-
came soiled with typhoid discharges, and in this way
the disease was carried by the command wherever it
went. It was probable also that the infection was
disseminated to some extent through the air in the
form of dust. Men inhaled the fine dust from the
roads, or it was deposited on their food and was then
eaten. It w^s true that complete desiccation soon
destroyed the typhoid germ, but dust was not always
completely desiccated. It should be borne in mind
that a badly infected command did not lose the in-
fection by simply changing location, though such a
step was desirable. Even an ocean voyage did not
relieve an infected command of its infection, as was
well shown in the case of infected regiments going
from Chickamauga to Porto Rico. Except in cases,
of most urgent military necessity, one command should
not be located on a site recently vacated by another,
and the fact that a command expected to change its
location did not justify a neglect of proper policing
of the ground up to the very moment of vacating it.
In some of the encampments the tents were too close
together, and there were too many men in each tent.
Malaria was not found to be a prevalent disease
among the troops that remained in the United States,
and the malaria that did exist in the camps in this
country yielded readily to quinine. The continued
fever that prevailed among the soldiers in this country
in 1898 was typhoid fever. What was designated as
a distinct disease under the name of " Chickamauga
fever " had the typical temperature curve of typhoid
fever and the death rate of that disease; the fever
was not arrested by quinine, and in cases coming to
autopsy the characteristic lesions of typhoid fever
were found. While the investigations of the board
showed that coincident infection with malaria and
typhoid fever might occur, the resulting complex of
symptoms did not seem to be sufficiently well defined
and uniform to be recognized as a separate disease.
About one-fifth of the soldiers in the national encamp-
ments in the United States in 1898 developed typhoid
fever. Of the 9,660 cases of probable typhoid studied
at Chickamauga, 4,068, or a little less than half, were
diagnosed by army surgeons as typhoid fever. Of
these 9,660 cases, 713 resulted fatally, giving a death
rate of 7.38 per cent. It was probable that when a
command was thoroughly saturated with typhoid, one-
third to one-quarter of the men would be found sus-
ceptible to the disease. In military practice typhoid
fever was often an intermittent disease. No support
was found for the belief that errors in diet, with con-
sequent gastric and intestinal catarrh, induced typhoid
fever or predisposed to it. More than eighty per cent,
of the men who developed typhoid fever had no pre- •
ceding intestinal disorder. The deaths from typhoid
fever were more than eighty per cent, of the total mor-
tality. The shortest period of incubation in typhoid
was probably something under eight days. One who
had lived in a camp in which typhoid fever was prev-
alent was liable to develop this disease any time within
eight weeks after leaving such a camp. The proof of
this last statement was to be found in the history of
the Fifth Pennsvlvania.
Change in Name of Section.— The name of the
Section on State Medicine was changed to Section of
Hygiene and Sanitary Science.
A New Section Formed. — In accordance with the
suggestion of the president, the association formally
authorized the establishment of the Section on Path-
ology and Bacteriology.
A Permanent Committee on Exhibit.— Acting upon
another timely suggestion in the president's address,
it was voted to establish a permanent committee on
exhibit, composed of five members, electing each year
a chairman residing at the place selected for the next
annual meeting of the association.
Report of the Board of Trustees. — This report
MEDICAL RECORD.
[June 9, 1900
showed the total receipts for the year 1899 to have
been the largest in the history of the association, i.e.,
$109,115.33. The total expenses of the /('/(■/v/i?/ were
$77,641.01, and of the treasurer's office §15,968.39,
making the total disbursements $93,609.40.
American Medical Association Medal. — Dr.
George M. Gould, of Philadelphia, presented the re-
port of the committee having this matter in charge. He
stated that the committee had carefully examined the
six essays submitted, and had unanimously voted to
award the prize to Dr. A. L. Benedict, of Buffalo, N. Y.,
for the essay entitled, " Quantitative Tests for Proteo-
lysis." The gold medal was of about the diameter of
a United States twenty-dollar coin, and about twice as
thick, and was of handsome design.
The Senn Medal. — Dr. W. L. Rodman reported
for this committee that this prize had been awarded
to the author of an essay entitled " Exstrophy of the
Bladder," and requested President Keen to break the
seal and announce the name. This was done, and the
author was found to be Dr. F. Gregory Connell, of Chi-
cago. Dr. Keen, in presenting the medal to Dr. Con-
nel, took occasion to thank him for the high standard
of excellence which characterized this important con-
tribution to surgery.
Rush Monument Fund Dr. James C. Wilson, of
Philadelphia, reported that the contributions for the
year amounted to $938.20, making the total fund at
the present time $11,330.05. Drs. Billings, Bulkley,
and Rodman were added to the committee.
New Officers. — The nominating committee se-
lected the following officers to serve the association
the coming year: President, Dr. C. A. L. Reed, of
Ohio; First Vice-President, Dr. A. W. Calhoun, of
Georgia; Second Vice-President, Col. Alfred A. Wood-
hull, U.S.A.; Third Vice-President, Dr. Philip Mar-
vel, of New Jersey; Fourth Vice-President, Dr. W. E.
Quine, of Illinois; Treasurer, Dr. H. P. Newman, of
Illinois; Secretary and Editor, Dr. George H. Simmons,
of Illinois; Trustees, Drs. M. F. Porter, of Indiana,
E. Fletcher Ingals, of Illinois, W. L. Rodman, of Penn-
sylvania, and J. A. Matthews, of Kentucky.
Dr. John A. Wveth, of New York, was mentioned
as the one who is to deliver the oration on Surgery
next year, and Dr. N. S. Davis, Jr., of Illinois, for the
oration on State Medicine.
SECTION ON PRACTICE OF MEDICINE.
Second Day — Wednesday, June 6th.
Pseudo or Modified Smallpox. — Dr. T. J. Hap-
PEL, of Trenton, Tenn., read this paper, in which he
reviewed the salient points in the course of a normal
case of variola vera, giving data to show that it could
be prevented by vaccination. The clinical history of
pseudo-variola was given, showing absence of a pus-
tular stage and of secondary fever often occurring in
those successfully vaccinated; the vesicles desiccat-
ing without crusting or scabbing, and not being fol-
lowed by pitting. Vaccination seemed to give no
protection, and in some instances vaccination was suc-
cessful after the disease had run its course. The re-
port was based upon an epidemic extending to about
three hundred patients, mostly negroes; white pa-
tients seemed to suffer more. The eruption was unat-
tended by itching. There were no swelling and no
mortality. The disease ran such a mild course that
it was preferred to vaccination, the early backache
and headache being i.he chief subjective symptoms.
There were no complications nor sequels, and no
medicines were administered.
Dr. VValsh, of New York, thought the observation
valuable as showing a connecting link between variola
and varicella, observers now coming to acknowledge
the connection between these extremes.
Dr. James, of Missouri, said that in Missouri they
had had an exaggerated form of the same affection,
which he thought was mild or modified or discrete
smallpox. There had been over three thousand cases
of a mild form of variola often mistaken for chick-
en pox.
Dr. Chapman, of Ohio, said that for a year or two
an epidemic of this disease had existed; a third of the
adult population of a region being sick at the same
time. Vaccination had been practised in infancy in
almost all cases. He had found vaccination success-
ful, and in this he took exception to Dr. Happel's
views. The disease was not varicella, which was not
an adult disease. He had seen a number of deaths.
Health officers should vaccinate and isolate and stamp
out this affection just as though it were more virulent.
It was smallpox.
Dr. Corlett, of Ohio, said dift'erent epidemics dif-
fered in virulency. In Cleveland a number of cases
had proven fatal. The distinction between variola
and varicella could usually be made readily. Vacci-
nation was the only safeguard.
Dr. Woodward, of Ohio, spoke of one hundred and
twenty-five cases with one death. Vaccination seemed
to protect; the one vaccinated in one family escaping,
and seven others not vaccinated contracting it. Some
epidemics were as mild as chickenpox.
Dr. Stewart, of Philadelphia, said that the evi-
dence presented did not show that the epidemic was
either variola, or varioloid, or varicella. He thought
it might be some exanthem.
Dr. McCormack, of Kentucky, offered a resolution
expressing the sense of the section that the epidemic
described was one of modified variola. The cases he
had seen coming from Tennessee were variola. ■
The resolution was declared out of order, and this
decision was loudly applauded.
Yellow Fever : Its Nature and its Cause. — Dr.
Eugene Wasdin, surgeon in the United States Ma-
rine-Hospital service, went over the natural history of
the disease, describing its endemic presence in some
Southern cities and in inter-tropical countries; its epi-
demic invasion of more temperate climes, and its dis-
appearance from these regions with the cessation of
the epidemic at the advent of frost. Tiie clinical fea-
tures marking the disease as an entity and distinguish-
ing it at certain stages were described. The varia-
tions of temperature giving the three characteristic
stages furnished the chief distinctive feature of the
affection. The organisms at different times charged
with being causative had been shown by Sternberg to
be without sufficient evidence to support them. There
was at present sufficient evidence to establish the
claims made for the bacillus icteroides discovered by
Sanarelli. It was found in half the cases, and was
pathogenic to animals when introduced experiment-
ally into the blood. It explained the natural peculi-
arities of the disease, satisfactorily explained its clin-
ical phenomena, and fulfilled the demands of modern
bacteriology to warrant its acceptance as the true and
proved cause of the disease. It attenuated rapidly in
cold and lost its virulence at a temperature below
zero, explaining the disappearance of epidemic dis-
ease at the onset of frost. It was first colonized
in the respiratory tract, giving the first paroxysm. In-
vasion of the blood gave the second, and septicity the
third stage. Domestic animals were susceptible. Re-
crudescence might be attributed at times to them.
America had furnished the proofs and the scientific
explanation of Sanarelli's important discovery.
Dr. Flexner, of Philadelphia, said Sanarelli had
done much in the discovery, in the bodies of subjects
dead of yellow fever, of a hitherto undescribed organ-
ism. He did not know that all the conclusions ar-
rived at by the reader could be accepted, but the ob-
June 9, 1900]
MEDICAL RECORD.
1003
servations opened the way for further experimentation
and confirmation. The mode of invasion must still
be regarded in the light of hypothesis.
Dr. Gerry, of Boston, asked whether one who had
had yellow fever was really immune. This was not
true for variola.
Dr. Wasdin said in closing that he felt convinced
that further investigation would prove the value of
Sanarelli's bacillus. Animals reacted to small amounts
and were not overwhelmed by large quantities of the
bacillus, so that the e.vperiments approximated a natu-
ral process. The conditions required by Koch, Stern-
berg, and others were fulfilled in the animal inocula-
tions, so that they must be accepted. Black vomit
and characteristic changes were present to prove the
truth of the specific nature of the bacillus icteroides.
He did not believe absolute immunity was conferred by
one attack.
Resolutions of regret at the death of Dr. Whitaker,
of Cincinnati, were offered by Dr. Osier and accepted
by the section.
In opening a symposium on malaria the secretary
read a paper presented by Dr. Jesse W. Lazear,
U.S.A., of Havana, Cuba, with the following title:
Pathology of Malarial Fevers ; Structure of the
Parasites and Changes in the Tissues. — The meth-
ods of preparation of the blood and staining with
methylene blue, the Romanowsky method and its
modifications, were first given. The cycles of devel-
opment of the parasites were described. The structure
of gameti or sexually ripe parasites was given, togetiier
with the formation of crescentic bodies.
The Etiology of Malaria, with Especial Refer-
ence to Mosquitos. — This paper was read by Dr. VV.
S. Thayer, of Baltimore. He described experiments
carried on along the eastern shore of Maryland, where
malaria prevailed, and where mosquitos abounded.
One variety of mosquito, the Culex, abounded in
high regions where there was no malaria. Another
variety, the Anopheles, on the other hand, was found
where the disease prevailed. It had been proved
that the malarial parasite possessed an extracor-
poreal cycle which took place in the mosquito just
as was the case in birds. A single bite would trans-
mit the disease, and when fed upon the parasites the
mosquito would transmit the particular form (quotid-
ian, tertian, or quartan) with which it had been orig-
inally fed. The speaker believed that mosquitos
acquired the parasite exclusively from man. While
there might be other methods of transmission by mos-
quito bites, this was the only one proven. It is high-
ly probable that where .\nopheles abounded malaria
would prevail. In prophylaxis the mosquitos must be
killed in their larval stage. Patients should be treated,
in relapses, under mosquito netting.
The Structural and Other Differences between the
Several Mosquitos of North America. — Dr. L. O.
Howard, of the Department of .\griculture, gave a
screen demonstration showing the differentiation be-
tween the Culex and the Anopheles, the latter being
the transmitters of malaria. They were to be distin-
guished in the larval stage in their mode of develop-
ment, and when fully developed. The wings of the
Anopheles were spotted; those of the Culex were
plain ; the " feelers " protruding from the head of the
Culex were much shorter than those of the Anopheles.
The singing note of the Anopheles was not so high as
that of the Culex ; this was well appreciated by collect-
ing a number of each variety in a jar and listening to
their buzzing when the jar was tapped upon.
Inoculation of Malarial Fever through the Agency
of the Mosquito.— Dr. A. E. Woldert, of Philadel-
phia, read this paper. The natural order, general
species, and modes of identification and of distin-
guishing the male from the female mosquito were
given, based upon sections, dissections, and gross
study. He said that the Culex pungens was not ca-
pable of inoculating a human being with malaria, but
the reasons for this were not known. The different
species of Anopheles, however, did transmit the dis-
ease. The Anopheles maculipennis or claviger was of
doubtful occurrence here, and there was no example
in any museum. The speaker went over the cultiva-
tion of zygotes of proteosoma in the dapple-winged
mosquito as described by Ross. He also discussed
the etiology of malaria based upon studies made in
the South.
SECTION ON SURGERY,
Second Day — Wednesday, June 6th.
Colostomy for Permanent Fecal Fistula.— Dr.
John A. VVyeth, of New York, read this paper. He
laid particular emphasis on the desirability of form-
ing an artificial sigmoid. It was the natural store-
house of the rectum, and its presence, in great meas-
ure, did away with the fifteen-minute dejections and
the tenesmus so distressing in the older form of opera-
tion. The technique of the operation, which was in
part suggested by his former assistant. Dr. Bodine, was
as follows: As much as ten inches of the sigmoid and
descending colon was dragged into the wound, and two
running sutures, four inches long, were passed from
the enterostomy site down the bowel wall. Traction
was made on the lower gut, so that there might be no
slack whatsoever to the rectum. The knuckle was
held in place by sutures- — he believed these to be pref-
erable to the glass rod.
Present Status of the Murphy Button, and Re-
port of 1,620 Cases. — Dr. J. E. Murphy, of Chicago,
presented this paper. Just eight years ago he used
the button on the first human case. He cited many
statistics showing the infiuenceof the button in lower-
ing the mortality of all anastomotic work. In detail,
he considered then as follows: Entero-enterostomy,
which formerly yielded a mortality of from fifty to
one hundred per cent., now showed a mortality of but
19.7 per cent. This seemed to Dr. Murphy to demon-
strate the great value of his button in gangrenous her-
nia when the mortality reached the ebb-figure of
fourteen per cent. It was for the operation of chole-
cystenterostomy that the button was first devised.
Prior to its introduction there had been but eleven
cases recorded. While formerly he recommended it
in every gall-bladder case, he would now restrict
its use to conditions in which there was permanent
obstruction to the common duct. The mortality was
14.7 per cent. Gastro-enterostomy and uretero-enter-
ostomy presented very favorable statistics. Review-
ing the history of gut approximation, he spoke of the
early efforts of the French, as far back as 1802, and
said that Senn's classic paper in t888 gave a tremen-
dous impetus to bowel surgery. In the eight years
during which the button had been used, the following
conclusions regarding it had been reached: (i) It ap-
proximated without suture. (2) The time of operation
was much shortened. (3) The union was ideal. (4)
There was no contraction of the scar. (5) The physi-
ological function of the gut was not interrupted at any
time. There were two great classes of objections to
the use of the button: (i) The opening might be oc-
cluded by food or other particles, prior to the slough-
ing of its attachment. (2) There might be prolonged
retention of the button in the gut or abdominal cavity.
Botli these matters were of small moment, there having
been but three fatal cases, in the 1,620 considered,
traceable to such causes. It was of little consequence
whether the button was passed or. not. The portions of
the canal in which it had been found retained were
I004
MEDICAL RECORD.
[June 9, 1900
enumerated as follows, in the stomach, 22 times;
colon, 5 times; ileum, 2 times; jejunum, i time: cae-
cum, 2 times; rectum, 4 times.
The Treatment of Obstinate Constipation Based
on New Points in the Anatomy and Histology of
the Rectum and Colon — Dk. J. R. Pennington, of
Chicago, read this paper. He spoke of the great vari-
ability of the position of the sigmoid which, when dis-
tended, frequently extended to the right iliac fossa.
Numerous paraffin casts, both of the adult and of the
child, together with a series of charts, fully supported
this statement. They also illustrated the depth to
which Heuston's valves frequently indented this por-
tion of the great intestine. Of the histological anat-
omy of these valves he spoke at length and showed the
numerous epithelial glands which found a foothold
within their walls. These valves seemed to him to be
very potent factors in the etiology of chronic constipa-
tion, when, their epithelium diseased and their tissues
sclerosed and thickened, they presented firm barriers
to the passage of fecal matter. The speaker showed
a specially contrived chair for the examination and
operation of rectal cases, and a contrivance whereby
a clamp could be attached to a portion of the offend-
ing valve by means of a sigmoidscope. In time the
portion bitten upon sloughed away and was thus re-
moved without fear of hemorrhage.
Dr. Tuttle, of New Vork, opened the discussion.
He wished to say, in support of Dr. Murphy, that he
recalled five cases in which the button l^d not been
recovered, in all of which no ill effects had resulted.
He emphasized the necessity of using Dr. Wyeth's
operation only in those cases in which a permanent
anus was to be established. Colostomy for transient
conditions called for as much slack in the rectum as
could possibly be obtained, and, furthermore, a fistula
once established bj- Wyeth's method was exceedingly
difficult to close. Indeed, in those cases in which re-
section of the spur was necessary, statistics showed a
mortality of thirty-one per cent. But for a permanent
anus Wyeth's operation was ideal, particularly when
combined with one of the modern methods of making
a new sphincter. He recommended a rectangular in-
cision through the oblique muscles, and the carrying
of the gut between the skin and the e.xternal oblique
to an opening just below Poupart's ligament. Over
the collapsed gut, and upon the firm surface of the ab-
dominal wall, a truss pad could be applied with such
success that the patient could not pass even gas with-
out lifting the pad. By a union of these .methods a
patient could be made absolutely comfortable. He
differed from Wyeth in that he always used the glass
rod, rarely introducing a suture, for he believed that
the suture alone was very apt to yield and allow pro-
lapse, which was a frequent cause of death.
Repair After Resection of the Intestine Dr. W.
A. Evans, of Chicago, read this paper. It consisted
of a discussion of the histological characteristics of
the scars in end-to-end anastomoses by the use of
Murphy buttons and other methods. Dr. Evans dwelt
on the rarity of strictures after such anastomoses, and
said that if they were destined to appear, it would be
before the tenth month. In those few cases in which
stricture had been studied in the small gut, it had
been found to be composed exclusively of circular
fibres. He cited at length the histological arrange-
' ment of the gut elements. In intestinal scars the
amount of cicatricial tissue was small; the fibres were
very generally in one direction only, and bridged the
wound. The important factor was, that they never
ran circularly. There was a law that governed the
direction of the fibres of scar tissue: they always ran
in the direction of greatest tension. Of the small
number of strictures which had been found in the
lesser gut, the great majority were due to tuberculous
lesions. Strictures due to other causes, however, were
common in the greater gut, in the oesophagus, and in
the urethra. Why ? Probably because there w as in
these passages a lack of the longitudinal tension
which was ever acting in the lesser gut. He advised
the approximation of the deeper coats as well as of
the serous, believing that a union so produced must
be stronger. The Czerny-Lembert suture often re-
sulted in the formation of a diaphragm which might
produce obstruction, but we should not forget that
these valves were physiological, at least in the lower
gut. Concluding, he said that his investigations
showed that the scar formation in these cases was so
light and so harmless as in no case to contraindicate
end-to-end anastomosis.
Dr. Wiggin, of New York, opened the discussion.
He said that he cordially agreed with Dr. Evans as
to the infrequency of scars in end-to-end anastomoses.
He had watched patients for many years on whom
he had operated when these procedures were still in
their infanc)'. Years ago he had experimented on
animals, using both the button and Monsel's suture.
In some which were killed from one to nine months
later, he had experienced the utmost diff.culty in dis-
covering the point of union. He strongly advised the
use of horsehair in the Monsel operation, because of
its elasticity; This factor obviated the danger of the
stitches cutting through. He no longer invaginated
the intestine, preferring to pass through and through,
from inside to inside. This seemed undoubtedly the
safest procedure.
Dr. Ev.\ns, in closing, said that much needless stress
had been laid on scar formation after the button oper-
ation, but he now felt that this danger was much
exaggerated.
Appendicitis : Colitis as an Etiological Factor,
and the Operation of Removing the Appendix in
All Cases Operated on. — Dr, Miles S, Porier, of
Fort Wayne, Ind,, read this paper. His special aim
was to draw attention to the etiological relationship
existing between constipation, colitis, and appendici-
tis. He cited a number of cases in which the appen-
dicitis had been ushered in by an acute colitis, in
many of which cases chronic constipation had long
been a symptom. The second part of his paper treated
of the important question whether or not incision and
drainage, without removal of the appendix, was the
operation of choice. He agreed that the appendix
should be removed in a great majority of cases, but
advocated a simple incision, with drainage, when speed
was demanded and shock particularly to be avoided.
Of two hundred and two cases thus treated, recurrence
had been found in but thirteen per cent. In conclu-
sion he said that no operator could do appendectomy
in every case without raising the percentage of mor-
tality.
Appendiceal Fistulae. — This paper was read by
Dr. J. B. Deaver, of Philadelphia. He spoke of the
unfortunate frequency of this condition; important
because of its sequela;. Fecal fistula> should be con-
sidered under two heads: the external, which might
be simple or fecal, and the internal. The simple ex-
ternal fistula was readily cured by the removal of the
gauze left by accident in the wound. Those fistulsE
which discharged fceces were either in direct connec-
tion with a loop of the bowel or CKCum, or connected
with the intestine via the lumen of the appendix. Pus
was not essential to the formation of a fistula; micro-
organisms were important, while drainage tubes often
caused it to persist. Speaking of internal fistula;, he
strenuously objected to the view that a happy outcome
of an appendicitis was to have the pus cavity evacuate
into the gut, and deplored the lack of surgical inter-
vention which made such a condition possible. He
tabulated the etiology of fistula as follows: (i) Ab-
June 9, 1900]
MEDICAL RECORD.
1005
scess formation ; (2) migration of bacillus coli com-
munis; (3) separation of the appendix; (4) the use
of too many sutures; (5) the prolonged use of the
drainage tube; (6) pressure necrosis. He continued
by urging the abolition of those factors, which could
largely be accomplished by immediate action. The
treatment of fistulfe was largely dietetic. They should
not be frequently washed out, but left severely alone.
In closing, he summarized as follows: (i) Fistula
was one of the most important sequelae of appendi-
citis. (2) Some cases closed spontaneously. (3)
When they produced marked symptoms they should
be operated on. (4) They should be avoided by early
•operation. (5) Fistula; were generally curable by
dietetics. (6) They did not always occur soon after
the operation, but might come late in the convales-
cence.
Dr. Senn, of Chicago, opened the discussion. He
said that operation should be considered as a preven-
tive and as a curative measure. Both the immediate
and the remote causes should be removed. Ho felt
that Dr. Deaver was an extremist, who, while he had
done incalculable good, had probably wrought greater
harm. Fortunate it was that Dr. Deaver did not teach.
He advanced the expectant treatment; eighty per cent.
of cases so governed resulted in recovery. FistuLx' op-
erations were extremely dangerous. He urged the sub-
peritoneal method of enucleation. Lastly, he urged
the section to beware of operating in those cases in
which one had reason to suspect that the abscess had
opened internally.
Dr. Mordecai Price, of Philadelphia, was glad to
take Dr. Deaver's side. He opposed Dr. Senn's view
very strongly, and felt that he had treated the very
class of cases to which Senn referred. But twice in
one hundred and twenty-five cases had he operated
without pus, and he had yet to repent in a single case.
His method was, not to close the head of the bowel if
it was badly broken through. He simply opened the
pus cavity, washed it out, and broke down adhesions.
The most important part of his technique he felt to be
the placing of the ruptured colon deep in the wound,
and the use of gauze dressing. He operated on every-
thing that would leave the table alive. He disagreed
with Porter's statement that appendicitis was common
in children, having found it most frequent after the
age of twenty-one.
Dr. Dawharn, of New York, regretted the futility
of the discussion, which he felt would be repeated
for the next twenty-five years without show of prog-
ress. At least that long would the archaic side per-
sist which opposed early operation. He called par-
ticular attention to the prevention of fistula;, believing
them to be due, in almost all cases, to faulty tech-
nique. In those cases in which the c^cum was gan-
grenous, he cut away the appendix, and, without wait-
ing to invaginate the stump, cast a purse-string suture
about the gangrenous area and quickly inverted this,
together with the stump, into the copious lumen of the
cjECum. This procedure, repeated at all points of
weakness in the gut, precluded the possibility of fis-
tulfe.
Dr. Hamilton, of Columbus, said that no sweeping
rules could be established. He criticised Dr. Price's
method of breaking down adhesions and washing, be-
lieving it to be permissible in very infected cases
only. Fistula; usually yielded to medical treatment.
He referred to what Dr. Senn had said as to the fre-
quent posterior position of the abscess, and advocated
a backward draining through the loin.
Dr. Mynter, of Buffalo, was first, last, and at all
times with Dr. Deaver. He was surprised at Dr. Senn's
point of view. He should have said that eighty per
cent, of the cases end in recovery in spite of medical
treatment. He thought incision and drainage the
proper course in most cases after the sixth day. He
found that fistula; healed in most cases without inter-
vention, and noted that, should operation be necessary.
Dr. Deaver's method of curettage would not cure.
End-to-end anastomosis was necessary.
Dr. Keen, of Philadelphia, said that, like the poor,
we have appendicitis always with us. The two impor-
tant questions were:. (1) Should we operate coinci-
dent with diagnosing? (2) Should the appendix al-
ways be removed? He felt that we should not try to
practise surgery by aphorisms. Dr. Deaver, he was
sure, in spite of his theoretical assertions, did not
operate in every case. He urged a conservative course :
no case should be allowed to pass beyond the second
attack. He pointed out that the section was making
surgical standards for the country, and feared that evil
would result from its taking a too radical stand. In
general, operation was best. In general, removal was
best. Fistulae healed, as a rule, spontaneously. This
failing, he advocated excision of the tract, invagina-
tion of the stump, and gauze dressing in the wound.
Dr. McCrae, of Atlanta, Ga., urged the removal of
the appendix. Otherwise seventy-five per cent, either
recurred or had fistula. He criticised very emphati-
cally Dr. Price's suggestion that the abdominal cavity
should be washed out, as very dangerous to life. He
used the purse-string suture for closing fistuls.
Dr. Murphy congratulated Dr. Deaver on his point
of view. Granted that eighty per cent, resulted in re-
covery when medically treated ; was there any opera-
tion with a mortality of twenty per cent, of which sur-
geons spoke with pride? He used to operate on all
cases. Now, however, those already moribund he
left to the physician who caused them. Diagnosis
should be made within the first twenty-four hours. In
these early cases the mortality of one per cent, was
due entirely to fulminating cases which had perfo-
rated.
Dr. W. H. Walthen, of Louisville, advocated the
conservative course.
Dr. Grey, of Jersey City, said he had had seven fatal
cases out of one hundred and seventy-five. This ex-
perience had taught him to operate early and to ex-
cise the appendix.
Dr. Hall, of Cincinnati, felt that the discussion
should not be closed without protesting against the
advice of Dr. ^Murphy, who leaves the moribund
cases in the hands of those who allowed them to fall
into that state. Simple incision might here save a life.
Dr. Boldt, of New York, agreed with Dr. Murphy
in every detail.
Dr. Fenger, of Chicago, urged the conservative
treatment, agreeing with Dr. Senn.
Dr. \V. E. AsHTON,of Philadelphia, agreed with Dr.
Deaver, for no one could foretell the pathological
changes which come so quickly in the appendix.
Dr. La Place, of Philadelphia, said that in every
fatal case there had been a moment when operation
was indicated. Either the physician or the surgeon
was directly responsible for this death. He felt that
we should have to turn to the physiological chemist,
who might one day reach a method of determining
conditions by an analysis of the relationship between
the effects on the heart and temperature of the toxins
of the different germs causing the disease, thus reach-
ing an early diagnosis.
Dr. Ochsner, of Chicago, made special reference
to the Importance of maintaining absolute rest for the
bowel until the omental and other adhesions had be-
come firmly fixed. To this end he would forbid all
food by mouth and all cathartics.
Dr. Porter said, in closing, that incision and
drainage were sometimes absolutely necessary. He
criticised Price's method of irrigation very keenly.
He would also try to save the moribund cases.
ioo6
MEDICAL RECORD.
[June 9, 1900
Dr. Deaver said that if he looked tired he only
showed what he felt. It was distressing in this ad-
vanced age to listen to those who opposed the radical
view. He was glad and proud to be an extremist in
so good a cause. He claimed but two points: (i)
that the diagnosis could be made early; (2) that this
once established, the appendix should come out.
Officers Elected. — The officeh chosen at the close
of the meeting were : Chairman, Dr. A. J. Ochsner, of
Chicago; Secretary, Dr. Martin B. Tinker, of Phila-
delphia.
\To b.' concluded.)
THE MEDICAL SOCIETY OF THE COUNTY
OF NEW YORK.
Stated Meeting, May 28, jgoo.
George B. Fowler, M.D., Chairman.
Dr. William E. Bullard resigned the secretaryship
of the society on account, of absence from the city.
Dr. J. V. D. Young, the assistant secretary, was ap-
pointed to the position of secretary for the remainder
of the year.
The Governor and his Staff : Being a Glance at
the Personnel of a Modern Hospital, and a Plea
for a Permanent Resident Staff. — Dr. Thomas J.
HiLLis read a paper with this title. He dwelt prin-
cipally upon the incompetency of the internes, ridi-
culing the hospital governor and his staff, but he failed
to offer any remedies for the alleged evils.
Infantile Amaurotic Family Idiocy. — Dr. John
Claiborne read this paper. In 1881 Tay, of England,
described a case of symmetrical changes in the macula
lutea. The child held itself upright with difficulty.
Intellectual development was very backward. At the
first examination the optic disc was normal, but at the
macula there was a white, more or less round, area in
the centre of which was a brown spot. The picture
was similar to that seen in embolism of the central
artery of the retina. Tay at first thought it was a con-
genital change. Five months later he noticed the
optic disc was atrophied. Three months later he ob-
served three other cases in the same family. In all
the ophthalmoscopic picture was the same, and all
these persons died before the end of the second year
of the disease. Between the years 1885 and 1886 the
same ophthalmoscopic picture was described by Mag-
nus, Knapp, and others. In 1887 Dr. Sachs reported
a case which impressed him as being one of idiocy;
this was particularly interesting on account of the
changes observed in the cortical cells. The family
character of the affection was suggested to him after
observing four cases in two families. Kingden, of
England, published a case and showed a picture which
eye surgeons said belonged to the disease which Sachs
had elucidated. In 1S98 Sachs reviewed the subject,
tabulating twenty-nine cases. The speaker's analysis
was based on ten cases. Six cases observed tallied
nearly with those of Sachs. At birth and for days and
weeks after the children were apparently normal : at
the age of nine months they ceased to take any inter-
est in their surroundings. The eyes seemed to roll
about; they could not hold up their heads; there were
purposeless movements of the head and body; there
was a great tendency to sleeplessness. The children
either fell forward or slipped down on their backs
when the parents attempted to make them sit in the
lap. The children slid backward more often than for-
ward. The appearance of the fingers suggested the
notion of athetosis. He laid stress on the fact that
somnolence was more marked than idiocy. In one
case he observed distinct hydrocephalus. There was
weakness of the extremities which seemed to increase
slowly until diplegia appeared. The electric excita-
bility of the nerves and muscles, as a rule, was normal,
although Koplik reported the reaction to the farad ic
current to be slightly diminished. By the end of a
year these children were totally blind; the optic nerve
was dead and idiocy was pronounced; at the end of
two years marasmus usually closed the scene. He
did not agree with Sachs that the change in the mac-
ula was the most striking symptom; idiocy was the
most striking. Yet the existence of the macular
changes was necessary to establish the diagnosis. In
January, 1898, Chamberlain referred to the case of D.
D , a female, aged eleven months, upon whom the
diagnosis was made and treatment carried out for dou-
ble ophthalmoplegia completa of the third nerve. The
mother was healthy, but the father was tuberculous.
There was no consanguinity. The child was carried
to the ninth month and delivered normally. Nine
months after birth the mother noticed that the ^eft eye
turned outward and the upper lid drooped. Three
weeks later Dr. Chamberlain saw that the right eye
turned outward and the lid drooped. Both pupils were
moderately dilated. Both optic discs were normal.
The child was given mercury by inunction, and the
patient was brought again to the doctor a trifle less
than four months after the first visit. After the use
of the inunctions the lids elevated and the eyes be-
came straighter. Then there developed great somno-
lency and nervous movements of the head and body.
In each eye were marked areas, more or less round,
in the centre of each macula lutea, showing as
cherry-red points. The intelligence of the child di-
minished. Amaurotic idiocy was diagnosed and an
unfavorable prognosis given. The doctor left the city
for six months. On his return. May 5, 1899, the' child
died with symptoms that pointed to tumor of the brain.
There was found a tuberculous tumor of the tubercula
quadrigeniina the size of a hickory-nut, and various
organs were affected.
Dr. Pooly related a case of a child eight* months
of age. Soon after birth the eyes began to twitch and
move constantly. Within three months, however, this
improved. The intelligence was very backward. There
was great restlessness. There was constant nystagmus.
The pupils were contracted. There was a cherry-red
spot in each eye. The optic disc was yellowish-white.
Carter was the first to point out the fact that the vic-
tims of this disease were children of Hebrew origin.
Sachs corroborated this view. It had been suggested
that blood-relationship, trauma at child-birth, etc.,
might lie at the bottom of the affair. Sachs' and
Tay's cases lent considerable color to this view. The
speaker's own case showed very conclusively that the
disease was associated with tuberculous tumor of the
tubercula quadrigeniina, with tuberculous deposits in
the bronchial glands, the liver, the spleen, and the
kidneys; in short, a general tuberculosis. Similar
changes were found in the central nervous system.
He failed to find grounds for the statement that syphi-
lis might lie at the root of the trouble. So far as he
was aware no one had suggested tuberculosis as a pos-
sible cause. Similarly hereditary spastic paralysis
had been mentioned. The fundus picture tended to
settle the diagnosis. He thought it was only just to
regard the matter as yet siih jiidice. Many doubted
that the marasmus of tuberculosis was a factor. Path-
ologically we were directed to the central nervous sys-
tem. According to Sachs the external configuration
of the brain exhibited a distinct picture of a lower or-
der of development. He thought it was a question
whether these changes were to be considered as pri-
mary degenerations or due to an arrest in develop-
ment. In the speaker's opinion they were due to an
arrest of development in the central nervous system,
which invariablv led to a fatal termination. The
June 9, 1900]
MEDICAL RECORD.
1007
clinical features were rather clearly outlined, and he
thought a name should be applied to the disease which
indicated clinical features. The name " infantile cere-
bra! degeneration " was not satisfactory. Sachs sug-
gested the name "amaurotic family idiocy." In view
of the blindness that follows, amaurotic was distinc-
tive and correct. A better name he thought would be
" infantile amaurotic family idiocy." The disease, in
a large number of instances, occurred in more than
one member of a family. Among twenty-seven of
Sachs' cases seventeen occurred in families in which
there had been other cases. Tay recorded three cases
in the same family. The definition of the condition
of idiocy should be one thing when applied to adults
and another when applied to infants. Idiocy, when
applied to adults, was a mental condition character-
ized by more or less complete abolition of intelli-
gence and moral faculties. Among infants there must
be some modification either in the direction of excess or
in diminution of instinctive and physical reflexes. In
1895 Sachs tabulated twenty-eight cases. At the Van-
d^vbilt Clinic seven cases were seen. Five of these
the speaker had seen. The disease was not so rare as
it was supposed to be. All cases brought to the Van-
derbilt Clinic were Polish-Jew in origin. In studying
this disease certain features had been grouped which
were distinctive. Children at birth w^ere apparently
healthy and remained so for several months. Then the
parents noticed that the children were sleepless and
could not hold themselves erect on the lap; they fell
forward or backward. Purposeless movements of the
head, body, and legs were noted, which increased as the
disease progressed. There was found in the macula
of each eye a picture strongly resembling embolism of
the central artery of the retina. Around the central
artery there was a grayish-white area the edges of which
were not sharply outlined ; in the centre of each macula
there was a cherry-red spot in blonds, but slightly dif-
ferent in color in brunettes. The disc was normal at
first but later became atrophied. Nystagmus, hypera-
cusis, double third-nerve paralysis, etc., were concomi-
tants. A fatal termination occurred before the end of
the second year. The majority of cases occurred in
children of Hebrew parentage, though a number did
occur among those of Polish-Hebrew blood. A num-
ber of cases had been shown among members of the
same family. The macroscopical and microscopical
examination directed attention to the central nervous
system. The brain seemed to be in an arrest of de-
velopment. The microscopical examination showed
changes in the pyramidal cells; changes were also
found in the retina and in the spinal cord. It was reas-
onable to regard the alterations that occurred in the
central nervous system as due to an arrest of develop-
ment. The etiology of the disease was not established.
From the findings in the case he reported, in which
there was found a tuberculous tumor in the tubercula
quadrigemina, tuberculosis might be considered a
causal agent.
Dr. Hen'rv Koplik said he had had experience
with eight cases, and that very little had been added
to the clinical picture that was described by Tay.
These cases came under observation for blindness.
He agreed that it was not the ocular symptoms but the
other symptoms that were the most striking. Tlie
mother brought the child with the story that she
noticed the baby was stupid and could not hold its
head up, could not sit up; but the doctor noticed noth-
ing. The clinician then had the child taken to the
oculist. In one case the child cried incessantly, and
the physician in charge thought the child had an ordi-
nary colic. The mother called attention to the fact
that the child did not notice anything; that he could
not sit up, that he did not play. This was a case of
amaurotic idiocy. On the other hand, cases that were
well marked did not show changes in the macula lutea.
Dr. Sachs called attention to those cases which seemed
to develop very late. The speaker had seen three such
cases. In regard to the tuberculous element, there
were no marked cases of tuberculous meningitis in
which the changes in the fundus resembled those seen
in amaurotic idiocy; the fundus examination often con-
firmed the diagnosis of meningitis. He did not think
tuberculosis was a causal element in these cases; it
might be accidental complication.
Dr. William Hirsch said that two years ago he
published the findings in an autopsy on one case in
which he could prove that the disease was not con-
fined to the cortical cells; but he could prove exclu-
sively that the entire nervous system was affected in a
somewhat typical manner. In i8g8 specimens were
obtained that showed that all' the nerve cells of the
spinal cord, in the anterior as well as the posterior
horns, all the nerve cells of the pons, the medulla,
the optic thalamus, the corpus striatum, and all the
cells of the cortex had the same typical changes. The
changes that took place in the cells were such that they
were immensely enlarged ; they were not only enlarged
but showed very marked changes in the nasal bodies;
the nucleus was invariably displaced, and in a great
many cases it was pushed entirely out of the cell.
This enormous increase and enlargement of all the
nerve cells of the spinal cord gave an appearance as if
there was an increase in the cells in vast numbers. In
a great many instances these cells appeared as large
white masses without any configuration at all, and
often the nucleus belonging to one cell was found in
other sections. The same changes described in the
spinal cord and brain took place in the cells of the
retina, and so gave the picture on the retina of a
white rounded area with a red spot in the centre.
Besides these changes there were absolutely no other
alterations. The internal organs were found to be
perfectly normal. The blood-vessels and other parts
of the nervous system were also perfectly normal; so
syphilis and tuberculosis and other diseases of this
kind could be excluded. There was a theory that, in
these instances, there was an intoxication of some
kind; the reason for this theory was that there was an
affection of all the nerve cells, and nothing else but
nerve cells. The anatomical picture of the nerve
cells resembled the picture which was to be seen in
experimental poisoning. This was offered as a theory
as yet to be substantiated. Children were never born,
he said, with changes in the macula lutea. There
was no one special part affected, but the entire nerv-
ous system was involved. We had to deal, not with
an arrest of development, but with an acquired dis-
ease. He considered tuberculosis to be but an acci-
dental complication.
The Effect of Summer -Heat upon the Public
Health. — Dr. Henry Dwight Chapin read this paper
(see page 984).
Dr. Abraham Jacoki said there was one part of the
subject that he wished to allude to, and one that he
believed Dr. Chapin had meant to avoid. Certainly
commercial enterprises should not be debarred ; but,
when commercial enterprise went so far as to endanger
public health and destroy lives, then it was a danger
to the community and should be interfered with.
When commercial enterprise killed thousands of chil-
dren and adults, it should not be considered legiti-
mate, and should be interfered with. Here the doctors
should be politicians, they should be statesmen, or
else they could not be good citizens. It was true that
our professional duties prevented us from taking part
in the primaries, but doctors should raise their voices
in protest when any obstacle is placed in the way of
pure milk and plenty of ice reaching the poor of this
great city.
looS
MEDICAL RECORD.
[June 9, 1900
THE NEW YORK PATHOLOGICAL SOCIETY.
Special Aleciing, March 2g, igoo.
Eugene Hodenpyl, M.D., President.
A Case of Epithelioma of the (Esophagus with
Stenosis of the Trachea and Suffocation. — Ur. J.
H. Larkin presented specimens removed from a man,
sixty-three years of age, who had always been in ex-
cellent health up to five days before operation. At
that time he had experienced a slight dyspnoea at
Irrst, and this had increased rapidly until at the time
of his admission he was deeply cyanosed. Tracheot-
omy had been done immediately. On opening the
trachea and endeavoring to pass in a tube, some diffi-
culty had been encountered. A small tube had been
passed without giving him much relief. On the fol-
lowing day the tube had caused so much distress that
it had had to be removed. The man only lived forty-
eight hours after the tracheotomy. At the autopsy all
•of the abdominal viscera had been found normal, and
the lungs also with the exception of a slight cedema.
About three inches above the cardiac end of the
oesophagus was a small, slightly raised area which,
on microscopical examination, showed epithelioma.
High up in the trachea, and about one inch below
the tracheotomy wound, and about one inch and a half
above the bifurcation of the bronchi, was a marked
:Stenosis of the trachea. The cause of this was a tra-
•cheal lymph node which had enlarged and grown
through the tracheal rings and had occluded the tra-
•chea at that point. Microscopical examination had
shown this to be a metastatic epithelioma of the
lymph node. On account of the pressure on, and
erosion of, the tracheal rings a secondary suppurative
process had taken place in the lymph node. Death
had resulted from slow asphyxia and cedema of the
lungs.
Osteocarcinoma of the Breast. — Dr. Larkin also
presented a tumor which had been removed from a
woman of middle age by Dr. Kammerer. Five months
ago she had first noticed a slight enlargement of the
breast. At the time of the operation the growth was
-supposed to be carcinoma, but after its removal it was
found exceedingly difficult to cut into the tumor.
Further examination showed the tumor to be a well-
circumscribed growth, and to have a limiting wall.
At the periphery it was somewhat spongy, but toward
the centre was a large and somewhat grayish elastic
area which was undoubtedly cartilage. In the centre
were nodules made up of true bone. Microscopical
examination showed at the periphery a typical picture
of carcinoma, but the carcinomatous element dimin-
ished as one proceeded toward the centre. In the
latter location were bone and cartilage. A search
through the literature showed that few tumors of this
kind iiad been reported. The speaker said that cases
of calcification of tumors of the breast had been re-
ported in Virchow's Archiv for i-^j"}- Osteosarco-
mata of the breast had also been described, but very
few osteocarcinomata had been reported. Coen, of
Boulogne, had reported a case almost identical with
the one just described. In that case the woman was
forty-five years of age, and the clinical history had
presented nothing unusual. A case of osteochondro-
carcinoma had been reported by Hacke. Lesser had
also reported a similar case, as had Leon, of Paris.
Astley Cooper, in his book on " Diseases of the
Breast," also reported such a case, but there was some
doubt about the correctness of the diagnosis. Dr.
Larkin raised the question as to whether this tumor
had been at first an osteochondroma, or a combined
growth of carcinoma with a secondary metaplasia of
the stroma into osteoid tissue. As in the periphery
metaplastic changes could be seen in the alveoli, it
seemed to him reasonable to look upon this tumor as
having been first a carcinoma, and that secondarily
there had been a metaplasia of the fibrous tissue, result-
ing first in cartilage, and ultimately in bone.
Dr. Lartigau said that pathologists had hesitated
to accept the belief that true osteoid tumors of the
breast existed primarily as such. The tendency was
to regard these neoformations as ossifying enchondro-
mata. A study of the literature showed that enchon-
dromata were very common in the mamma of bitches.
A Case of Actinomycosis. — Dr. F. S. Mandlebaum
exhibited under the microscope a section from a case
of actinomycosis removed from a woman of thirty-four
years, a Russian, who had been admitted to hospital
on January 25, 1900, with a history dating back five
months, and beginning with the development of two
localized points of tenderness on the back to the right
of the spine. Three months after the onset of pain,
small sw-ellings without redness had appeared at these
points. Three weeks later, or five weeks before ad-
mission, these had been excised, and in one week a
swelling had appeared in the right axilla and above
the clavicle on the same side. On admission, these
tumors had been the size of a small apple, and tender
and painful, but the skin had not apparently been in-
volved. Near the right scapula was a discharging
sinus, and two inches below this another sinus. The
entire supraclavicular triangle was occupied by a
mass, in places fluctuating. Physical examination of
the chest showed anteriorly dulness over the first right
interspace, with exaggerated breathing, and posteriorly
marked dulness and tenderness on percussion from the
apex downward to the spine of the scapula. Over this
vocal fremitus was increased. The woman was
emaciated and was six months pregnant. One week
after admission abscesses in the neck and axilla had
been incised, and a large quantity of pus, streaked with
blood and containing numerous small, yellowish par-
ticles, had been evacuated. She had received iodide
of potassium internally, and had improved consider-
ably while in the hospital. Dr. Mandlebaum said
that he had taken small drops of the pus and fixed
them in five-per-cent. formalin solution. The small
pieces were then hardened in alcohol, embedded
in celloidin, and sections made. The microscope
showed these small particles to be actinomyces. He
had stained them with many different stains, and had
found that the best results were obtained with Plant's
stain. This consists in staining the section for ten to
fifteen minutes in a solution of carbol-fuchsin ; then
washing in water; transferring to a saturated alcoholic
solution of picric acid for five minutes; decolorizing
in fifty-per-cent. alcohol for fifteen minutes, and finally
passing through absolute alcohol, oil of cloves, and
into balsam. With the Gram method in only one in-
stance had he been able to demonstrate the clubbing,
although this was brought out well by following with
eosin. The teeth and mouth were normal, and the
primary focus was supposed to have been somewhere
in the chest.
Haematoma of the Right Suprarenal and Rup-
ture into the Peritoneum in a Child of Ten Days,
with a Patent Foramen Ovale, Patulous Ductus
Arteriosus, and Stenosis Isthmi Aortae. — Dr.
Charles Norris reported this case. The child had
been brought to Bellevue Hospital with no further
history tiian that it had been blue since birth. It had
died very suddenly a few minutes after entering the
hospital. On autopsy, the abdominal cavity had been
found filled with blood, and the intestines all matted
together by fairly firm adhesions. On the superior
surface of the suprarenal, represented by a more or
less organized blood-clot of a considerable size, was
an opening two inches in diametfer, through which the
blood had escaped into the abdominal cavity. On
June 9, 1900]
MEDICAL RECORD.
1009
examining the foramen ovale it had been found near!}'
closed. The ductus arteriosus as it entered the aorta
presented a funnel-shaped opening. The speaker said
that haematoniata of the suprarenal were rarely as large
as the one just presented. This was the second case
of the kind that he had met with. He had been able to
find only one or two instances reported in the literature
in which rupture had taken place into the peritoneal
cavity. One observer had reported twenty-six cases
in which there had been small hemorrhages into the
suprarenal in a series of over one hundred autopsies
on still-born infants. In two of the cases the hemor-
rhage had started in the cortex. The blood more com-
monly escaped into the perinephritic tissues. It was
more often met with after pelvic than podalic presen-
tations, and after difficult labor.
Dr. Larkin said that having had an opportunity of
examining a number of still-born children he had met
with four or five such hcematomata. His experience
confirmed what had been said about their being more
frequent after difficult labors, and with pelvic presen-
tations. He had never before seen one rupture into
the peritoneum, but had seen the blood escape behind
the peritoneum, and had dissected out the latter down
as far as the bladder.
Dr. E. Hodenpvl presented several specimens, as
follows:
A Portion of the (Esophagus Showing Varicose
Dilatation of the Veins. — This specimen had been
taken from a man who was suffering from cirrhosis of
the liver, and who died of a profuse gastro-intestinal
hemorrhage. The oesophagus in the fresh state
showed a number of very large and tortuous veins in
the lower portion, at least one of which was ruptured.
Preble, of Chicago, had found that in about eighty
cases of fatal hemorrhage occurring in the course of
cirrhosis of the liver, the bleeding arose from the
varicose veins in the lower two-thirds of the oesoph-
agus. This accident occurred in atrophic cirrhosis
rather than when the liver was of normal size or en-
larged. Attention was called to the fact that the
venous circulation of the oesophagus was part of the
systemic circulation, while that of the cardiac end of
the stomach belonged to the portal system, and that
there was a poor collateral circulation between the
two. There might also be a negative pressure on the
oesophageal veins during expiration.
Pneumothorax — The next specimen had been taken
from the gripman of a car who had been suddenly
seized with severe pain in the right chest while at his
work. He had been hurriedly removed to a hospital,
and examination had revealed the presence of air in
the right pleural cavity. He had died in a few hours.
In spite of the man's excellent physique the autopsy
showed quite advanced tuberculosis of both lungs,
and the kidneys were studded with miliary tubercles.
There was also a moderate tuberculous enteritis. The
liver was found forced almost entirely below the free
border of the ribs, and the diaphragm bulged down-
ward. On puncture of the diaphragm below a water
level, a considerable quantity of air escaped. The
right lung was forced into the bottom of the pleural
cavity against the vertebral column. This lung was
entirely free from adhesions, although the pleura over
the posterior portion of the apex was markedly thick-
ened. The opening was so minute as to be discover-
able only after forcing air through the bronchi.
A Tuberculous Appendix. — The third specimen
had been taken from a man who had died of pulmon-
ary tuberculosis with quite marked tuberculosis of the
intestine. The latter was very markedly dilated, and
it was so dark as to suggest gangrene. There were
two constrictions in it. The miliary tubercles could
be distinctly seen through the serosa. In tuberculosis
of the appendix, as well as in typhoid ulceration of
the appendix, the speaker said, it was worthy of note
that the usual symptoms of appendicitis were not
present.
Primary Carcinoma of the Pancreas with Second-
ary Carcinomatous Nodules in the Liver.— The
speci.mens from this case had been taken from a per-
son who had suft'ered but slightly, and had been ill
only a few weeks. He w^as an alcoholic subject who
had presented but few symptoms, but had died shortly
after entering the hospital. At the autopsy immense
deposits of fat were found throughout the body. Oc-
cupying the head of the pancreas was a large carci-
nomatous mass. The liver was studded with carcino-
matous nodules. Examination of the heart showed
dilatation of the right side of this organ and incom-
petence of the tricuspid valve.
Two Cases of Multiple Spurious Diverticula of
the Intestine. — The specimens from two cases of this
kind were exhibited. In the first, the duodenum and
upper portion of the jejunum was the seat of a number
of thin-walled cysts varying in size from that of a pea
to that of an egg. The second specimen was from a
case of papilloma of the peritoneal cavit)'. There
were strictured areas in various parts of the colon,
and seventy-nine diverticula were found in the intes-
tine, principally in the lower end of the colon. Roth,
in 1872, had described five cases of diverticula of the
duodenum, in all of which the diverticula had been
small and not over three in number. In 1894, an
article on this subject had been published in Vir-
chow's Aixhiv by Edel. Here the cases had been di-
vided into two classes — congenital and acquired.
Meckel's diverticulum alone constituted the first
class. All three coats were present in the congenital
form, whereas the muscular coat was missing in the
acquired variety. The most common situation for
these false diverticula was in the colon; next in order
of frequency, and usually along the attached border,
came the duodenum. The number of these diverticula
varied from one up to two hundred or more. As a
rule, they were small. The cause of the condition
seemed to be a separation of the fibres of the muscu-
lar coat, so that, in one sense, they might be regarded
as herniae of the mucous membrane into the serosa.
The pressure of scybalous masses, the presence of gall
stones, circumscribed or diffuse peritonitis, constipa-
tion, and carcinoma were all causes. It had been
noted that these diverticula were almost always found
empty at autopsy.
Hypertrophic Tuberculosis of the Intestine. —
Dr. a. J. L.\rtigau read a paper on this subject. He
said that very few cases of hypertrophic tuberculosis
had been studied outside of the ileo-caecal region.
In 1888 Hacker had reported a tuberculosis of the
ileo-ca;cal region simulating a tumor mass, and lead-
ing to operation. The new formation proved to be
tuberculous. In 1893, twenty-one cases had been
collected. In almost all of these cases the clinical
diagnosis had been carcinoma. The amount of re-
duction of the intestinal lumen was quite variable,
and was not in proportion to the increase in the size
of the intestinal wall. The author then reported a
case of this affection. According to the clinical his-
tory there had been brown pigmentation of the skin
without vomiting, and slightly failing health. The
bronzing was most marked on the exposed surfaces.
The left adrenal gland was enlarged and soft, and
contained a small cavity filled with brownish fluid.
The right adrenal gland was also enlarged, and
showed a dift'use tuberculous lesion. The retroperi-
toneal and mesenteric glands were enlarged and cas-
eous. The mucous membrane of the duodenum and
jejunum was normal, while that of the ileum showed
thickening, increasing from above downward. In the
lower two or three feet of the ileum the lumen was re-
MEDICAL RECORD.
[June 9, 1900
duced to about one-third. The Cfficum was thickened,
and its walls measured 1.5 cm. The thickening in
the colon was noticeable, but diminished until it be-
came normal at the sigmoid. Tubercle bacilli were
found in great numbers throughout the intestinal
wall. Small round-cell infiltration was present in the
submucosa. This case was undoubtedly one of pri-
mary tuberculosis of the intestine in an adult.
S/ated Meeting, April 11, jgoo.
Eugene Hodenpyl, M.D., President.
A Pronounced Case of Arterio-Sclerosis. — Dr. D.
H. McAlpin, Jr., presented specimens from a patient
who had been admitted to hospital on March 19th suf-
fering from dyspncea and pain in the epigastrium. He
was fifty-four years of age, and had been a sailor until
a short time ago, when he had been compelled to give
up this occupation because of shortness of breath.
His past history was not a good one, having had syph-
ilis and gonorrhoea, and having been accustomed to
indulge in alcoholics to excess. Ten years previously
he had fallen from a height and had fractured his
clavicle. The present illness had begun with pain in
the stomach and continued vomiting, shortness of
breath, and some cough. Shortly after admission he
had become delirious and had remained so until
death. A few hours before death there had been com-
plete suppression of urine. His temperature had
ranged between 100° and 102° F. ; the pulse had been
80, and the respirations between 28 and 40. There
had been signs of consolidation of the lungs, and the
apex of the heart was at the sixth interspace, to the
left of the nipple line. There was a murmur heard
indicating aortic insufficiency. The diagnosis had been
chronic endocarditis and nephritis, pneumonia or pos-
sibly infarctions of the lungs, and arterio-sclerosis.
At the autopsy, on opening the chest the heart had
been found greatly enlarged. It weighed nearly fifty
ounces. All of its cavities were greatly distended,
and contained large, dark clots, and the coronary ves-
sels stood out very prominently but were not tortuous.
On opening the heart, several thrombi were found at
the apex of the left ventricle, and a number of thrombi
were attached behind the columnai carna;. The mi-
tral orifice admitted four fingers, yet the valve cur-
tains were greatly enlarged and appeared to be per-
fectly competent. The aortic orifice was very large,
and the curtains of the valve were also very large and
free. There was calcification of the aorta beyond the
aortic valve, but no visible disease of the curtains.
The walls were considerable hypertrophied, and the
cavities greatly dilated. On the right side there ap-
peared to be no disease of the valves. The foramen
ovale was patent. The liver was about normal in
size, and on section it showed a distinctly nutmeg
character. There was an immense amount of passive
congestion in the central zone of the lobule. The
small hepatic arteries and hepatic veins were very thick
and easily seen. The kidneys were of the charac-
teristic stony hardness of the cardiac kidney. The
small arteries were very prominent. The lungs exhib-
ited areas which were firm, more or less granular, and
of a gray color. The vessel walls were greatly thick-
ened. The same uniform thickening of the vessels
was observed in the brain.
A Case of Perforation of the Stomach by a
Toothpick. — Dr. Mc.\lpin also presented the case of
a man, aged fifty years, a chronic alcoholic. Four
months before admission he had been hit in the epi-
gastrium with a base-ball. Two months later his abdo-
men had begun to swell, and he had then begun to lose
flesh very perceptibly. His temperature on admission
had been 100° F., but had quickly fallen to normal.
The abdomen had been found distended with fluid;
the heart was normal; the lungs were the seat of em-
physema. On February 15th he had been so much
better that he had left the hospital for the day, and
had not returned until March loth. At that time he
had been jaundiced and feverish, and his urine showed
hyaline and granular casts. He had died on March
14th, three hours after one gallon of dark, foul-smell-
ing fluid had been removed from his abdomen. This
fluid contained a variety of germs and leucocytes. At
the autopsy, the intestines had been found greatly dis-
tended and heavily coated with fibrin, and the omentum
hemorrhagic and drawn over the liver. The starting-
point of the peritonitis had been traced to a point
underneath the liver. On separating the adhesions
here, a cavity one and a half inches in diameter had
been laid open. This cavity was formed by the stom-
ach and the liver. It contained dark greenish, vis-
cid pus. In this cavity, sticking into the stomach,
was a piece of a wooden toothpick, one inch in length.
The opening through which the wooden spicula had
entered the peritoneal cavity could not be found, evi-
dently having closed by muscular contraction as soon
as the wood had passed.
A Specimen of Uterine Mole. — Dr. F. R. Bailey
presented this specimen, whicii had been removed
from a colored woman, about fifty-five years of age.
She had been married about five years, and had had
no children and no miscarriages. Her last menstrua-
tion had been on July t;, 1899. On November 29th
she had had a severe hemorrhage, and on February
I, igoo, she had had what she called a miscarriage,
i.e., a discharge of a foetus of five or six weeks em-
bedded in a mass of tissue, for the most part pla-
cental.
The Duration of Life of Typhoid Bacilli in Ice.
— Dr. W. H. Park said that he had been making
some experiments on the duration of life of typhoid
bacilli in ice. He had been led to do this because
of some statements made recently by Dr. Sedgw ick as
to the rapidity with which death occurred. He had ex-
perimented with twenty cultures. They had been made
from twenty-four-hour agar cultures, one loop of each
culture being put in a separate lot of 300 c.c. of fil-
tered Croton water. The average number of bacilli
in the water of the twenty lots was 2,500,000 in i c.c.
At the end of three days' freezing the average number
w'as 1,089,000; at the end of one week, 361,000; at
the end of two weeks, 203,000; at the end of three
weeks, 10,000; at the end of four weeks, 4,000; at the
end of five weeks, 3,000; at the end of seven weeks,
2,000; at the end of nine weeks, 127. Three of the
cultures had become sterile at this time. In general,
then, it might be said that at the end of nine weeks
the ice from a certain proportion of the cultures was
sterile and the living bacilli from all the cultures
were greatly reduced in number.
Dr. T. M. Prudden asked if any cultures older
than twenty-four hours had been tested. He asked
this because he thought it not improbable that at this
age the bacilli were more vulnerable than older ones.
Dr. Park replied that the cultures differed greatly
as to the lapse of time since they were obtained from
the case. Of some interest was the fact that in thirty
specimens of ice taken at random neither colon nor
typhoid bacilli had been found, though the ice was
the ordinary ice found in the market.
Dr. a. J. Lartioau said that last year he had had
occasion to investigate the ice supply of the city of
Albany. From one specimen he had obtained an
organism which responded to all of the culture tests
for the typhoid bacillus. Unfortunately this speci-
men had been destroyed before it could be tested with
typhoid serum. There was every reason to believe
that this ice was over three months old. He had tested
June 9, 1900]
MEDICAL RECORD.
pure cultures of typhoid bacilli at various tempera-
tures. At the end of twenty-four hours nearly fifty
per cent, had been destroyed — in some specimens a
still higher percentage were killed — and at the end
of ten to eighteen days practically all had been de-
stroyed (ninety-seven to ninety-eight per cent.). The
water used was the Hudson River water. He had
also tested the viability of the bacilli in water just
above the freezing-point, and had found this tempera-
ture about as effective as when the water had been
frozen. Alternate freezing and thawing had been
somewhat more destructive to the life of the bacilli.
A Peculiar Streptococcus. — Dr. E. Libman pre-
sented a streptococcus which had been isolated from
the stools of a child suffering acute entero-colitis. The
stools had been placed in sugar bouillon for twenty-
four hours, and this had yielded a pure culture of this
organism. This streptococcus was peculiar especially
in one respect. In its growth on lactose agar and
glucose agar it made the medium white, which it did
not do in its growth on the other preparations of agar.
The peculiar action was found to be due to a precipi-
tation of the albumin in the medium by the acid
formed by the splitting up of the sugar. The organ-
ism was pathogenic for mice.
Sarcoma of the Small Intestine with Special
Reference to Cases Resembling Appendicitis. — Dr.
E. Libman said that he had seen four cases of intes-
tinal sarcoma, notwithstanding the comparative rarity
of the disease. Compared to carcinoma of the intes-
tine sarcoma was uncommon. Sarcomata had their
seat by preference in the small intestine. They might
occur at any age, cases having been recorded from the
age of five days up to seventy years. In a series of
thirty-four cases he had found twenty-one males and
thirteen females. These sarcomata might be single
or multiple, and might be localized or diffused. The
lymphosarcomata were the most common. In most
cases the growth was confined to the mucosa and mus-
cularis. The latter was early intiitrated and para-
lyzed, and the intestine was then dieted by the faeces.
Spindle-celled sarcomata had very few metastases. In
intestinal sarcomata the superficial nodes were not
usually involved. The growth showed a marked ten-
dency to extension to the pelvis, or to the formation
of metastases there. Ulceration was very common,
and might result in perforation, or in exposure of the
vessels. The vena cava, bile ducts, pancreatic ducts,
or the ureters might be obstructed by the growth. An
important point was the frequency of the association
of lymphosarcoma with tuberculosis. If the sarcoma
was in the small intestine, there was very early a
marked affection of the whole system, with but few
local symptoms. At first, there were pain in the ab-
domen, loss of appetite, nausea, and vomiting, and the
abdomen was distended. A tumor was found in most
of the cases. The duration of the disease was from
a few weeks to one year and a quarter, though most
patients succumbed in nine months. The first case
was that of a boy who had had pain in the abdomen
to the right of and below the umbilicus. In a few
days the abdomen had become distended; then the
pain had increased and the constipation had been
obstinate. The operation had been done on October
I St by the late Dr. Van Arsdale. It had revealed a
large growth in the duodenum, encircling the gut and
projecting into its lumen, and there were nodules in
the mesentery, omentum, spleen, pancreas, and liver.
The tumor was a lymphosarcoma beginning in the sub-
mucosa. The case had been sent to the hospital as
one of appendicitis. The second case was that of a boy
three and a half years old, and the symptoms were of
eight days' standing. On the right side of the abdomen
was an irregular-shaped mass. On January jth an
operation had been done by Dr. Gerster. This had
shown a thickening of the peritoneum and omentum, and
the intestine was infiltrated with new growth. The pa-
tient died in twenty-four hours. The autopsy showed
the main tumor mass to be situated in the beginning
of the ileum. Mesentery, omentum, intra-abdominal
lymphatics, spleen, gall bladder, pancreas, and bron-
chial lymph nodes were also infiltrated. The left
adrenal was almost replaced by a new growth. The
microscope showed it to be a lymphosarcoma. The
third case was that of a boy aged eighteen years, and
the illness had begun with an attack of pain and vom-
iting. The pulse was rapid, small, and weak; the ab-
domen hard and tympanitic. It was thought to be a
case of perforation of the appendix. The patient was
almost moribund, so an infusion was given, but he
died shortly afterward. Near the duodenum was found
a perforation the result of an infiltration by a new
growth. The latter was white and soft on section.
Microscopical examination showed the growth to be
lymphosarcoma. The fourth case was that of a man
forty-two years of age, who came with a history of two
weeks of irregular abdominal pain. Four days before
admission there had been violent and diffuse abdomi-
nal pain. There was an irregular, hard, and sensitive
tumor in the hypogastric region, especially on the right
side. The operation was done lay Dr. Brewer, and
revealed a very large hemorrhagic tumor springing
from the ileum about 70 cm. from the valve. The
patient died three days later from acute peritonitis.
The tumor measured 15 by 13 cm. It had begun in
the submucosa and reached to the mucosa. Micro-
scopical examination showed the growth to be a spin-
dle-cell sarcoma. This clinically resembled a subacute
appendicitis.
Dr. Harlow Brooks said that he had seen only
one case of this kind, occurring in a stoker on an
ocean steamer. He had felt slightly ill on reaching
port, and had gone to St. Vincent's Hospital, where
he died three days later. The autopsy had shown a
very extensive involvement of the small intestine, and
some involvement of the liver.
Notes on Acid Intoxications. — Drs. C. A. Herter
and A. J. Wake.man presented a paper on this subject,
which was read by Dr. Herter.
Treatment of Epilepsy in its Incipiency. — W. P.
Spratling concludes as follows: (i) Make an early
differentiation of the type of epilepsy from which the
patient is suffering. (2) If it be reflex epilepsy, or if
the child be suffering from epileptic phenomena, the
chances of cure are much greater than if the case be
one of genuine epilepsy. (3) If genuine epilepsy be
present we are in a position to give a much more accu-
rate prognosis as to the ultimate outcome and to apply
better principles in the treatment of the case. (4)
Remove as far as possible parental sympathy from the
treatment of the child, for if allowed to assert its way
this usually does more harm to the child than good.
(S) Endeavor to keep from the young epileptic the
many patent nostrums that, when taken by him, only
aggravate the disease by first masking the true symp-
toms of the same; second, by destroying or impairing
the functions of the gastro-intestinal tract. (6) If the
seizures are localized and a given part of the body is
chiefly involved at the time of convulsive phenomena,
and suffers therefore exhaustion or partial paralysis as
the result of same, apply physical means for its correc-
tion as soon as possible, for it will only be by these
means that such a difficulty can be overcome. (7)
We must learn to place great value on little things in
studying the etiology and treatment of this obstinate
malady, as, for instance, the occurrence of capillary
hemorrhages in the brain. — Buffalo Medical Journal,
June, 1900.
MEDICAL RECORD.
[June 9, 1900
Medical Record:
A Weekly Joitriial of Medicine and Surgery,
GEORGE E. SHRADY, A.M., M.D., Editor.
PrBLISHERS
WM. WOOD & CO., 51 Fifth Avenue.
New York, June 9, 1900.
THE SIGNIFICANCE OF THE DIAZO REAC-
TION IN CASES OF TUBERCULOSIS.
Although the property of diazo bodies to 3ield strik-
ing color reactions with organic substances had bean
noted previously, Ehrlich was the first, nearly twenty
years ago, to apply this principle practically in clini-
cal diagnosis. It was found that this diazo reaction
was yielded by the urine only in disease and not in
health, and then only in connection with certain dis-
eases and under certain conditions. It is rarely pres-
ent in cases of chronic visceral disease, but it is with
especial frequency a concomitant of typhoid fever and
of measles. It does not occur, as a rule, in cases of
uncomplicated diphtheria and pneumonia, and its
presence under such conditions is rather of grave
prognostic omen. The reaction has been found to be
of considerable diagnostic significance in cases of
tuberculosis, and in cases of pulmonary tuberculosis
it is of grave prognostic significance. It is not de-
pendent upon fever, as it has been marked in cases
without fever.
The reaction consists in the development of a rose
or a red color when urine and the test agent are
shaken together. Two test solutions are prepared and
should always be fresh, one consisting of 0.5-per-cent.
solution of sulphanilic acid in a five-per-cent. solution
of hydrochloric acid, and the other of a 0.5-per-cent.
solution of sodium nitrite. When used, one part of
the latter is added to forty-nine parts of the former.
To equal parts of urine and this mi.xture is added am-
monia in the proportion of 1 to 10, and the whole is
agitated.
Michaelis (^Berliner klinische Wocheiisr/iri//, 1900,
No. 13), who has devoted special attention to the
test for the past five years at the clinic of Profes-
sor Leyden in Berlin, speaks most highly of its diag-
nostic and prognostic utility, particularly in cases of
tuberculosis. The occurrence of the reaction is inde-
pendent of fever, of the number of tubercle bacilli
present in and the amount of the sputum, but often a
parallelism is observed among all of these. The reac-
tion cannot be obtained, as a rule, in mild cases, al-
though it does appear when acute complicating infec-
tions supervene that do not themselves give rise to the
reaction, such as pleurisy, pneumonia, and influenza.
When the reaction is marked in cases of incipient
tuberculosis, the disease must be considered serious
and the prognosis grave. On the other hand, in ad-
vanced cases even with cavities, when the reaction is
absent the course of the disease appears to be station-
ary or slow. The reaction may disappear after it has
been pronounced and the condition of the patient has
improved, but usually subsequent aggravation takes
place. The administration of preparations containing
tannic acid or gallic acid interferes with the develop-
ment of the reaction, but without influencing the
prognosis. Among 167 cases of pulmonary tubercu-
losis in which the diazo reaction was studied it was
found present in 1 1 1 patients and absent in 56. Of
the latter 5 patients were discharged cured, 43 im-
proved, 5 not cured, and 3 died ; while of the former
none was cured, 15 improved, 3 were transferred, 13
were not cured, and 80 died.
THE PUBLIC-HOLIDAY QUESTION.
Every worker, be it with brain or hand, requires occa-
sionally a change. Indeed a break in the monotony
of every-day existence and a cessation, however brief,
from toil and worry are absolutely essential to the
health of those who live under the high-pressure con-
ditions of this twentieth-century age. Time was when
civilized life was not so strenuous as now, and when,
in the opinion of many, the manner in w-hich men
passed through their earthly pilgrimage was more in
accordance vvith the laws of nature and the rules of
common sense. But even in the far-back days the
necessity of a periodical term of intermission from
labor was clearly recognized, and thus it came about
that — putting aside the religious aspect of the ques-
tion— the Mosaic law appointed for the Jews one day
of rest in seven. The strain placed upon the mental
and physical resources by the e-xigencies of our pres-
ent-time mode of living have rendered more frequent
and more lengthened intervals of relaxation indispen-
sable.
These remarks apply with especial force to brain
workers, and if such a course be not pursued a com-
plete collapse of the vital powers must be the inevit-
able result. However, it is not only those who use
their brains to an excessive degree who stand in need
of recreation from time to time, but also those unfor-
tunates who are cooped within the four walls of a fac-
tory or store, or condemned to sit upon an office stool
ten hours in the day throughout the week, and who in
too many instances earn scarcely enough to keep them-
selves and family from the grip of want. These are
the people who are really deserving of the most sym-
pathy and for whose benefit public holidays were
mainly instituted. The presumable object, then, of
a holiday is to recuperate exhausted energies and to
relieve the sameness of ordinary daily life, and the
outcome anticipated is that it will fit a person better
to fulfil his duties. In fact a holiday may be rightly
designated as a requisite safety valve.
In the case of public holidays there is a serious
doubt if this result is often attained. Rather than be-
ing utilized as a means of gaining health they are, it
is to be feared, more frequently made the excuse for
June 9, 1900]
MEDICAL RECORD.
indulging in disgraceful orgies, with the consequence
that instead of being invigorated by his outing the
worker returns to his appointed task with aching head
and impaired digestion, a sadder if not a wiser man.
Of course among the young of this class released from
grinding toil on such rare occasions some exuberance
may be forgiven, but when this superfluity of animal
spirits is caused by an over-indulgence in strong
drinks and takes the forms of obscenity and of objec-
tionable horseplay, the questions may be fairly asked
whether public holidays are an undeniable good or
whether they are as beneficial as their founders ex-
pected to that grade of workers for whose especial
behalf they were instituted. It must not be supposed
that in saying this there is any intention to rail against
public holidays; it is only against their abuse that a
protest is made. With the advance of education, with
a wider knowledge of sanitary laws, and above all
with the creation of better homes, will come a more
intelligent understanding of the advantages to be de-
rived from spending the public holidays in a rational
and healthful manner.
nishing a careless pupil of limited experience the
defendant fulfilled its contract obligation to the plain-
tiff, and if it did not, and injury resulted from the
breach of contract, to award the adequate compensa-
tion for such injury.
In the following trial before Judge Leventritt, the
jury failed to agree, one man standing out for the hos-
pital upon the grounds that there had been no contract
made, but, as before stated, the supreme court on May
i2th decided for the plaintiff with damages. This
ruling appears to be a perfectly sound one. The mere
fact of accepting money for services rendered implies
in itself that a contract has been entered into, carrying
with it pecuniary obligations for a breach thereof. If
the hospital had been purely and solely a charitable
institution no suit could have been brought against it,
for the simple reason that, only a moral obligation
being involved, and money not entering into the ques-
tion, it would be impossible to make a contract incur-
ring pecuniary responsibility. While sympathizing
with St. Vincent's Hospital for the loss it has sus-
tained, we cannot but think it is well that the matter of
liability of pay hospitals should be established.
DECISION IN THE CASE OF WARD VS. ST.
VINCENT'S HOSPITAL.
On May 12th ult., in the supreme court, before Jus-
tice Gildersleeve, the suit of Ward t's. St. Vincent's
Hospital resulted in a verdict for the plaintiff with
damages of $10,000. This case has been noticed edi-
torially in the Medical Record (August 12, 1899,
and again on December 23, 1899), but as the matter
is one of the very greatest interest to the medical pro-
fession, and as by the verdict a precedent has been
established, it may be as well to run over briefly the
leading facts. In February, 1894, Miss Ward entered
St. Vincent's Hospital as a pay patient in order to
have an operation performed. The sister in charge, at
Miss Ward's request, agreed to provide a skilled nurse
at $3 a day, which charge was additional to that asked
for the room. While she was still under the influence
of ether an unsheathed hot-water bottle was applied to
Miss Ward's leg, injuring that member to such an ex-
tent that she has been more or less lame since. After
this accident had occurred the discovery was made
that the person who laid on the bottle was not a
trained nurse, but a pupil in the defendant's training-
school.
An action was brought against the hospital for large
damages. In the first trial Justice Cohen decided that
a hospital was not liable for damages sustained through
negligence of its servants. The appellate division of
the supreme court reversed this decision, taking the
common-sense view that if a charity hospital takes in
paying patients, furnishing them with private rooms
and nurses, it enters into an express contract, and for
any breach of that contract the sufferer thereby is en-
titled to the same damages as though the action had
been for negligence pure and simple, and is entitled
to an adequate compensation for injuries. The per-
son furnished as a nurse in Miss Ward's case not
being trained, it was for the jury to say whether in fur-
Yellow Fever in Manila ? — The Boston Medical
and Surgical Journal states that there have been only
three months in the past ten years in which there were
no deaths from yellow fever in Manila. Our esteemed
contemporary has been misinformed, for whatever
drawbacks there may be to a residence in Manila, the
prevalence of yellow fever is certainly not one of
them.
The Pan-American Medical Congress. — The inter-
national executive commission of the Pan-American
Medical Congress announces that the third meeting
of that body will be held in Havana, Cuba, on the
25th, 27th, 28th, and 29th of December, 1900. The
original intention was to hold the congress at Cara-
cas, Venezuela, in December, 1899, but on account of
the disturbed political conditions in that country the
medical profession there first advised that the meeting
be postponed to December of this year, and now have
requested that some other country be selected. Ow-
ing to the lack of adequate hotel accommodation in
Havana, it has been suggested that an entire hotel be
reserved for the foreign visitors, especially those from
this country and Canada, of whom it is believed many
will be in attendance. The second congress of Cuban
physicians, which was to have been held this year, will
probably be postponed to some time in 1902.
Inspection of the City Hospitals. — The grand jury
on May 23d made a tour of inspection of Bellevue
Hospital, the Morgue, the City Hospital, the New
York City Training-School for Nurses, the County
Penitentiary, the Workhouse, the Almshouse, and the
other public institutions on Blackwell's and Randall's
islands. " Without a single exception," the report
says, " the various buildings, outhouses, and offices
I0I4
MEDICAL RECORD.
[June 9, 1900
connected with all these institutions were found to be
in an exceedingly good condition. In the hospitals,
the patients appeared to be well cared for, and the
sanitary conditions of the hospitals were as nearly
perfect as modern appliances could make them."
The grand jurors also visited the Harlem Hospital
and Dispensary, and found less to praise there. They
report that the dispensary is absolutely unfitted for
the use to which it is put, and that the hospital ac-
commodations are inadequate to the great demands
made upon them. In concluding their report, the
grand jurors "congratulate the people of the city of
New York upon the admirable way in which the inter-
ests and welfare of the poor and unfortunate of this
great city are protected."
The Associated Physicians of Long Island. — The
spring meeting of the " Associated Physicians of Long
Island" will be held June i6th at Northport, L. I.
The association will be the guests at dinner of the
Northport Yacht Club and the village of Northport.
Omega Upsilon Phi. — The annual banquet of the
Epsilon chapter, at the University and Bellevue Hos-
pital Medical College, of the Omega Upsilon Phi
Medical Fraternity, was held May 28th at the Hotel
Marlborough.
The Maine Medical Association. — The forty-eighth
annual meeting of this association will be held at
Portland, Me., on Wednesday, Thursday, and Friday,
June 13th, 14th, and 15th, under the presidency of
Dr. B. T. Sanborn, of Augusta. The annual oration
will be delivered by Dr. J. Collins Warren, of Boston,
the subject being " The Etiology of Cancer."
The Medical Club of Philadelphia gives a recep-
tion at the Hotel Bellevue on Saturday evening, June
9th, in honor of Drs. Abraham Jacobi, of New York,
Alonzo Garcelon, of Maine, George H. Simmons, edi-
tor of the Journal oj the American Medical Associa-
tion, James Morrison Bodine, of Louisville, Frank
Billings, of Chicago, and the president-elect of the
American Medical Association.
The American Academy of Medicine. — At the
annual meeting of this society, held at Atlantic City
on June 2d and 4th, the following officers were elected
to serve for the ensuing year: President, Dr. Samuel
D. Risley, of Philadelphia ; Vice-Presidents, Drs. C.
M. McCulver, of Albany, N. Y., Rosa Engell, of Chi-
cago, 111., G. G. Grafif, of San Juan, Porto Rico,
Charles T. McClintock, of Detroit, Mich.; Secretary
and Treasurer, Dr. Charles Mclntyre, of Easton, Pa.;
Assistant Secretary, Dr. Alexander R. Craig, of Co-
lumbia, Pa.
A Chicago Diploma Mill, known variously as the
Metropolitan Medical College, the Independent Medi-
cal College, and the National Law School, was raided
on Monday by agents of the Post-Office Department,
and four of the " professors " were arrested. The
charge was that of using the mails to defraud. The
diplomas of medicine or law were sold at prices vary-
ing from $2> to $200, according to the amount that
could be squeezed out of the candidate in each indi-
vidual case. The mill was grinding out "physi-
cians" at the rate of ten or twelve a day. The diplo-
mas contained an array of names of the learned men
who constituted the faculty, but all the signatures
were made by two young women who were employed
for their ability to vary their handwriting to fit each
name.
The Electrocution of Germs. — It is reported that
a Viennese dentist has discovered a means of killing
bacteria in a human body by a current of electricity
so weak as to be barely perceptible.
An Ambulance Makes Patients An ambulance
racing at high speed, early one evening last week, ran
into a crowd of people who did not hear the gong, and
knocked a number of them down. Two were so
severely injured as to require the attention of the sur-
geon of the ambulance that ran over them.
Attack on a Dispensary. — A mob recently attacked
a Chicago dispensary and nearly demolished the build-
ing before the rioters were dispersed by the police.
The disturbance was caused by a story being circu-
lated to the effect that the physicians had carried a
neighbor's child into the dispensary and were cutting
him to pieces for medical purposes. After the dis-
turbance the missing child was found. The rioters
were mostly ignorant Bohemians and Lithuanians who
had been worked up to a high pitch of excitement by
stories of dissections at dead of night and experiments
upon kidnapped children.
The Beth Israel Hospital. — The ceremony of lay-
ing the corner-stone of the new Beth Israel Hospital,
at the corner of Cherry and Jefferson streets, took
place last week. The programme of exercises con-
sisted of an opening prayer and address by the Rev.
Dr. Bernard Drachman; the laying of the corner-stone
by Harris Cohen, president of the Beth Israel Hospi-
tal; a dedicatory prayer by the Rev. Dr. G. Gottheil;
and addresses by Kaufman Mandell, Abraham Nelson,
the Rev. Samuel Schulman, the Rev. Dr. H. Pereira
Mendes, Randolph Guggenheimer, John W. Keller,
Isidor Straus, Dr. Abraham Jacobi, the Rev. L. Zins-
ler, and the Rev. Philip Jaches. The hospital build-
ing is to be seventy-eight by one hundred and twelve
feet on the ground, five stories high, in the Renais-
sance style of architecture, and is to be of steel and
buff brick, with trimmings of Vermont marble and
terra cotta. It will be completed by January ist next,
and will contain one hundred beds.
The American Association for the Advancement of
Science, which includes many of the most important
non-medical scientific societies in America, will meet
in this city during the last week in June. The gen-
eral meetings will be held at Columbia University.
On Saturday afternoon, June 23d, the annual meeting
of the association council will be held at the Hotel
Majestic, and a second meeting will be held early on
Monday morning in Schermerhorn Hall, Columbia
University. The general meeting will be opened on
Monday by President G. K. Gilbert, of Washington,
D. C, vvho will introduce Prof. Robert Simpson
June 9, 1900]
MEDICAL RECORD.
1015
Woodward, of Columbia, the president-elect. Gover-
nor Roosevelt will then deliver the address of welcome,
and President Seth Low, of Columbia, will follow
him. Dr. Woodward will then reply for the associa-
tion. A general session will again be held on Tues-
day evening in the American Museum of Natural His-
tory, at which President Gilbert will deliver his retiring
address, after which a general reception will be held
for the members of the association and invited guests.
General sessions will be held on every succeeding
morning during the week at 11 o'clock, and on Thurs-
day evening the general committee will meet at the
Hotel Majestic for the election of officers and the de-
termination of the time and place of the next conven-
tion.
Succi, the Italian Faster, has been declared to be
insane and is now under confinement in an asylum.
The Plague. — Six new cases of bubonic plague and
two deaths were reported in Cairo on June 4th. In
San Francisco a case is reported from time to time,
and the quarantine of Chinatown is still maintained.
In Sydney, N. S. W.,the disease is believed to be well
under control.
Cape May County (N. J.) Medical Society At
a stated meeting held at Cape May on June ist. the fol-
lowing officers were elected : President, Dr. A. L.
Leach ; Vice-President, Dr. J. S. Douglas, of Tuckahoe ;
Treasurer, Dr. Randolph Marshall, of Tuckahoe; Sec-
retary, Dr. C. B. Corson, of Seaville.
Association of Baltimore and Ohio Railway Sur-
geons.— At the annual meeting of this association,
held at Atlantic City on June 2d, the following officers
were elected: President, Dr. R. B. Short, of Union
Mills, Ind. ; First Vice-President, Dr. F. J. Evans, of
Chester, Pa.; Second Vice-President, Dr. J. W. Hays,
of Albion, Ind. ; Secretary and Treasurer, Dr. G. A.
Davis, of Summit, W. Va. ; Assistant Secretary, Dr.
W. A. Bailey, of Leisenring, Pa.; Executive Commit-
tee, Drs. John E. Russell, of Mount Vernon, Ohio,
and W. W. Weaver, of Philadelphia.
The Association of Military Surgeons of the
United States met in their ninth annual session at
the Academy of Medicine in this city on May 31st
and June ist and 2d, under the presidency of Col.
Charles H. Alden, of the Army Medical Corps. The
address of welcome was made by Dr. Albert H. Briggs,
of Buffalo, major and surgeon of the Sixty-fifth New
York Regiment. Dr. Alden, in the presidential ad-
dress, suggested the advisability of the publication of
a medico-military journal under the auspices of the
association. Such a publication, he said, could be
made self-supporting, and could be made a magazine
for the permanent preservation of many facts that had
been gathered by army surgeons during the wars in
Cuba and in the Philippines. On motion of Dr.
Daly, of Pittsburg, a committee was appointed to take
steps toward the establishment of such a journal.
The award of the gold medal offered by Dr. Eno
Sanders, of St. Louis, for the best essay on "military
surgery " was made to Capt. W. C. Borden, assistant
surgeon United States army. Among those present
were Major Narciso del Rio, surgeon in the Mexican
army and delegate from the government of Mexico,
and Colonel-Surgeon W. McWatters, of the British
army. The following officers were elected: President,
Brig.-Gen. A. J. Stone, of Minnesota; First Vice-Pres-
ident, Medical Inspector John G. Wise, of Washington,
D. C. ; Second Vice-President, J. F. Calef, of Connecti-
cut; &(7-?/'a^:)', Col! Charles Adams, of Illinois; Treas-
urer, Lieut. Herbert A. Arnold, of Pennsylvania. St.
Paul, Minn., was selected as the next place of meet-
ing, and it was recommended that the meeting for
1902 be held in San Francisco. A motion was made
and adopted that all e.\-surgeons of the Civil War,
both Federals and Confederates, be eligible for mem-
bership in the association.
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C. — Changes in the medical
corps of the United States navy for the week ending
June 2, 1900. May 2d. — Assistant Surgeon W. H.
Barber detached from the Alliance when placed out of
commission, and ordered to duty at the naval hospi-
tal. New York. May 31st. — Assistant Surgeon C. N.
Fisk commissioned assistant surgeon from May 15,
1900. Surgeon O. D. Norton detached from the Mo-
nadnock and ordered to the Bennington. Assistant
Surgeon J. S. Taylor detached from the New Orleans
and ordered to the Culgoa. Assistant Surgeon F. J.
Grow detached from the Richmond and ordered to the
Monadnock.
Obituary Notes.— Dr. Truman W. Miller died at
his home in Chicago on June ist, of sequela; of influ-
enza. He was born in Seneca, N. Y., March 2, 1840.
He attended Hobart College, and later studied at the
Geneva Medical College, where he received his de-
gree in 1863. He was connected with the United
States army medical staff during the Civil War, and
became post-examining surgeon at Chicago in 1864.
From 1877 to 1886 he was surgeon in charge of the
Marine Hospital at Chicago, and was for six years
surgeon at the Cook County Hospital. He was pro-
fessor of general and genito-urinary surgery at the
Chicago Policlinic, and was surgeon to several hospi-
tals and railways.
Dr. Joseph Davis Osborne, of Newark, died in that
city on June 2d, at the age of sixty-seven years. He
was born in Morris County, N. J., and was graduated
from the College of Physicians and Surgeons in this
city in the class of 1859, subsequently studying under
Dr. Abram Coles, of Newark. He was a surgeon in
the Fourth New Jersey Volunteers during the Civil
War. A widow and two daughters-survive him.
Dr. Theodore Menges, a well-known dentist in
Chicago, is dead as the result of an operation for ap-
pendicitis. Dr. Menges was secretary of the faculty
of the Northwestern University Dental School.
Dr. Gerald C. Hopkins died at Philadelphia on
May 27th at the age of thirty-six years. He was
graduated from the medical department of the Univer-
sity of Pennsylvania in 1886.
Dr. Eowm O. Shakespeare died at Philadelphia
on June ist, of angina pectoris, at the age of fifty-four
ioi6
MEDICAL RECORD.
[June 9, 1900
years. He was born at Dover, Del., where he ob-
tained his preliminary education. He subsequently
entered Dickinson College and received the degree of
bachelor of arts in 1867, and of master of arts in
1870. He was graduated from the medical depart-
ment of the University of Pennsylvania in 1869. In
1885 he was commissioned by President Cleveland to
investigate the cholera in India, and he devoted a year
to the study. His report, a voluminous one, was pub-
lished in 1889. In 1898 he was appointed a brigade
surgeon with the rank of major of volunteers, and at
the time of his death he was a member of a commis-
sion appointed by the surgeon-general to investigate
the causes of typhoid fever in the army.
^voQtcss 0f l^tXcxlical Science.
A't.'7i> Yo-k Medical Journal, Jttne 3. igoo.
On a Little-Known Method of Treatment of Furunculosis. —
G. Langmann believes that the growth of boils as com-
monly seen is the result of a trophoneurotic disturbance.
He advocates for purposes of treatment the galvanic cur-
rent, describing his method in the following words : "The
cathode, exhibiting more intense reaction upon the tissue,
is placed upon the furuncle, the anode somewhere in the
neighborhood, and a current of about two to five milliam-
peres is applied for from five to ten minutes. As a rule,
one sitting daily is sufficient. The intensity of the curi-ent
ought to vary both with the stage of development of the
boil (the earlier stages being more sensitive) and with in-
dividual sensitiveness. Whoever has no galvanometer on
his battery may regulate the current according to the sen-
sations of the patient ; the feeling of a lively sting, enter-
ing, as it were, the centre of the boil, just enough to be
tolerated, indicates about the proper strength of the cur-
rent."
Microbes —What Are They ? — H. G. Graham details a se-
ries of experiments undertaken upon the lower forms of life
in order to determine the nature of microbes. He comes
to the conclusion that bacteria are low forms of life de-
rived from the protozoa, and that in turn they are also ele-
mentary forms of higher organisms. Protozoa are con-
stantly being taken into the body, and the possible fact of
their becoming virulent is conditioned on two things: (i)
whether they will by their own motile powers penetrate the
walls of the alimentary tract and so reach tissue beyond ;
(2) whether they will adapt themselves to a new and ever-
changing environment that gradually becomes more and
more toxic for the host.
The Diseases of the Blood in their Relation to Surgery
and their Treatment. — G. C. Van Schaick makes a plea for
the systematic examination of the blood in all cases requir-
ing surgical intervention in which the nature of the pa-
tient's malady does not require immediate operation. If
a condition of anffimia is found, the patient should first be
brought up to a proper blood condition. He thinks it is
generally possible to do this by the administration of a cer-
tain organic preparation of iron now on tlie market.
A Case of Mediastinal Growth with Subsequent Tubercu-
lous Disorganization Mistaken for Aneurism of the Arch of
the Aorta. — This case is reported by F. Griffith. His pa-
tient was a woman aged seventy years. The nature of the
case is sufficiently indicated in the title. The author dis-
cusses the question of differential diagnosis between the
two conditions suggested therein.
.SIstivo-Autumnal Fever in New Orleans, Simimer and Au-
tumn, 1899. — By H. A. Veazie.
Some Desultory Remarks concerning Diphtheria. — By J. W.
Jervey.
Philaiiclpliia Medical foiirnal. June .?, igoo.
Asthma. — Richard B. Faulkner defines asthma as a con-
dition of spasm of the bronchial tubes with bronchial and
peribronchial hypera;mia, approaching or amounting to
inflammation, accompanied by rales upon both inspiration
and expiration, with great difficulty in breathing. A sec-
ond form exists as an aft'ectiou of the vagus, either at its
root or at some remote part of its course, or of the fibres of
other nerves that connect with the vagus, without apparent
bronchial lesion or other lesion. In the treatment of the
' paroxysm he advises counter-irritation over the course of
the vagus, and also the use of strychnine. For the gen-
eral condition and to prevent a return of the paroxysms he
advises exercises adapted to the physique of the patient.
To prevent the return -of the paroxysms, other important
indications are : (i) Removal of all exciting causes ; (2)
removal of all toxic influences, rheumatic, gouty, renal,
malarial, irritating plants (ragweed, goldenrod, ailanthus,
honeysuckle) , irritating dust (hay, feathers, Chinese mat-
ting, ipecac), irritating animal odors (horses, dogs, cats,
rabbits) , acid fumes, the atmosphere of close, warm rooms ;
(3) restoration of general good physiological conditions of
digestion, respiration, circulation, nervous system, cutane-
ous surface ; (4) .removal of reflex irritations, nasal, rectal,
uterine; (5) relief of bronchial hyperaemia, bronchitis ; (6)
repair of emphysema ; (7) climatic suggestions.
Prognosis in Fractures. — Clinton B. Herrick insists upon
the importance, in every case of fracture, of making the
patient acquainted with the exact state of affairs at the out-
set, and also aware of the complications, in order that a
perfect understanding may exist and the possibilities of cen-
suring the surgeon may be eliminated. He hold that frac-
tures should take their place with the more serious, rather
than be classed as simple injuries, for if so regarded an in-
creased degree of diligence will be accorded, results will
be improved, and the odium of failure will be removed.
He refers to the various complications and sequelae that
may occur, from slight atrophy even to death, and says that
the surgeon should in every instance give a guarded prog-
nosis to the end that the patient and his friends may under-
stand the uncertainty of a positive result, and the surgeon
preserve his reputation against distrust, censure, and mal-
practice suits. Especially should the surgeon refrain from
saying to the patient that his leg or his arm will be just as
good as ever, for that cannot Ije and will not be.
Siphonage of the Partitioned Bladder for the Individual
Kidney Urines. — By Andrew J. iJownes.
Diagrams of the Genito-Urinary Tract, with a Table for
Keeping Records. — By Ramon GuitOras.
The Hospitals for the Insane and the Study of Mental
Diseases. — By Stewart Paton.
The Registration of Tuberculosis. — By Lawrence F. Flick.
The Boston Medical and Surgical Journal, May^i, igoo.
Some Advances in Medical Instruction. — President C. W.
Eliot of Harvard, in an article entitled "The Inductive
Jlethod Applied to Medicine." says that education in gen-
eral comprehends just three things : accurate observation,
the foundation of all ; an exact record, and the exactly lim-
ited inference from recorded facts. The lecture sj-stem in
medicine has been greatly modified, and is now- mi.xed with
question and answer, with conference, and with the writing
of themes and theses. Another improvement should be
made at once in preparatory medical education, and that
is, a study of animal life. We have found out that dis-
eases are pretty well mi.xed up between animals and man ;
we know that the sources of some diseases that afflict hu-
man beings are to be found in animals, and that some dis-
eases are transmitted through animals to man ; and also we
know happily that we can get treatment for some human
diseases out of animals. We should do well to secure to
the medical student a comparative study of medicine in
other animals as well as in man.
William J. Councilman, speaking of "The Course in
Pathology at the Harvaid Jledical School," says that cer-
tain things which seem evident have been brought out in
this course: (i) That the mind of the student must be
active and not passive ; that he can acquire knowledge only
by his own powers of observation and deduction ; he can-
not acquire it by being told things. (2) That teaching
should be individual as far as possible ; that the central
idea should be to give opportunities to the student, and to
assist him in the effort which he himself makes. (3) That
medical education should not be directed solely to teach-
ing the medical art, but education in its true sense, the de-
velopment of the individual, must not be lost sight of.
Discussing "The Case System in Aledicine." W. B. Can-
non speaks of the practicability of the method ; its value
from the point of view of the medical student ; and what
.seems to the author its place in a medical curriculum. As
to the first point, in the past two years he and other in-
structors have used printed records of cases as centres of
interest in the study of medicine, and there has not been
the slightest difficulty in applying the plan. As to its
value, it arouses much enthusiasm in the students ; teaches
them the judgment of clinical data, the estimation of the
value of evidence, fixes symptoms in the mind by their
vivid presentation, and gives the students a training in
being required to adapt them.selves to actual difficulties in
practice. The place in the curriculum of the study of case
histories is in the central position between the scientific
work of the first two years of training which provides prin-
ciples and theories, and the practical work of dealing with
actual problems.
June 9, 1900]
MEDICAL RECORD.
1017
Giving "A Personal Experience in the Teaching of Sur-
gery," Herbert L. Burrell thoroughly indorses Mr. Can-
non's suggestion of the case method of teaching systematic
medicine. In surgery he considers it imperative. There
is a tendency for surgeons to work more with their hands
than with their heads — which is fraught with danger to the
true advancement of surgery on a secure scientihc basis.
The "case-method" system and sectional teaching will
counteract this danger and will oblige students to use their
brains. The advance of teaching in the first and second
years has been along the lines of concentration and se-
quence. The advance of teaching in the third and fourth
years should be along the same lines, plus electives and co-
ordination of teaching subjects. The students are taught
in their case-taking and section work continually to go
back to the foundation principles of anatomy, physiology,
and pathology, in interpreting clinical phenomena. This
will make a race of physicians whose knowledge is drawn
from known scientific facts, and not mechanical operators,
or "up-to-date," "last-remedy" practitioners.
A. H. Wentworth answers the objections made to "sec-
tion teaching " and considei'S its advantages. Its chief aim
should be to oblige the students to do most of the work.
They should learn systematic methods of physical exami-
nation, and should be required to state the results of their
examinations. They ought to be able to make provisional
diagnoses and to give their reasons for the same. The in-
structors should correct and criticise, and the entire section
should take part in the discussion. One of the best ways
for gaining a clear idea of a subject is to try and explain it
to some one else. It stimulates ideas and teaches accuracy
and clearness in description. The students take the great-
est interest in the work and improve with wonderful
rapidity.
Journal of the Ainej'icaii Medical Ass'/i, June 2, /goo.
Removal of the Cervical Sympathetic in Glaucoma and
Optic-Nerve Atrophy. — James Moores Ball reports several
cases of this operation and discusses its technique. From
a study of the cases of sympathectomy made by Jonnesco
and others, and from the observation of his own cases, he
reaches the conclusions that excision of the superior cervical
ganglion is a valuable procedure in glaucoma, more so in
glaucoma simplex than in inflammatory glaucoma. In in
flammatory glaucoma, when iridectomy has been done
without benefit, this operation should be tried. Incases of
absolute glaucoma with pain, sympathectomy is to be tried
before any operation on the eyeball. In simple optic-nerve
atrophy, the operation may possibly be beneficial if done
before vision is entirely lost. In unilateral glaucoma ex-
cision of the sympathetic ganglion is to be done only on
the corresponding side. In the hands of a careful operator,
excision of the superior and middle ganglia is a safe opera-
tion, but removal of the inferior ganglion can be done
safely only by the most skilful surgeons. The fact that
glaucoma is improved by sympathectomy and the finding
of pathological changes in the excised ganglia suggest that
this affection is due either to a permanent irritation of the
cervical sympathetic, or to an irritation located elsewhere
and transmitted by means of this nerve.
Intralaryngeal InsufQation for the Relief of Acute Surgical
Pneumothorax. — Rudolph Matas refers to the danger of
opening the pleural cavity and thereby inducing acute col-
lapse of the lung, and reviews the methods which have been
employed to counteract the disastrous effects of acute
pneumothorax so brought about. The most effective of
these procedures, he says, is artificial inflation of the lungs
and the rhythmical maintenance of artificial respiration by
a tube inserted in the glottis and directly connected with
the bellows of an air-pump. The idea of insufflation of
the lungs is an old one, the author says, although its ap-
plication for the maintenance of the pulmonary function
in thoracic operation is an essentially modern and very re-
cent conception. The article is a continued one.
Gastro-enterostomy for Carcinoma of the Pylorus.— J. Henry
Barbat reports a case of this operation performed on a
woman forty-five years old. She had a tumor at the
pylorus which was found at the time of the operation to be
so extensively bound by adhesions to neighboring parts as
to make removal impossible. The author then resorted at
once to a gastro-enterostomy. The result was brilliantlv
successful, the patient being, at the time of the report, able
to eat and digest large quantities of food. Before the oper-
ation the woman weighed eighty-three pounds, and six
weeks later her weight was one hundred and one pounds,
and was constantly increasing.
Functionally Good Results in Treatment of Fractures as
Viewed by Skiagraph and Photograph. — By B. N. Torrey.
Tuberculosis in Colorado. Methods of Dissemination and
Measures for its Restriction. — By G. E. Tyler.
Medicine as a Business Proposition. — By G. Frank Lyd-
ston.
Regulation of Practice of Medicine.— By John I. Dille.
The Doctor in the Public Schools.— By G. W. Hiett.
Intubation of the Larynx. — By Charles J. Whalen.
Medical Xeii.'s, June 2, igoo.
The Sanatorium Treatment of Incipient Pulmonary Tuber-
culosis and its Results. — E. L. Trudeau describes his method
of combined climatic and sanatorium treatment. A study
of the gross results in the twelve hundred patients admitted
during the past fifteen years shows the result to be as fol-
lows : Twenty-three per cent, were discharged as apparently
cured ; fifty-six per cent, were discharged with the disease
arrested or much improved ; nineteen per cent, were dis-
charged stationary or unimproved ; two per cent, died in
the institution. Of the eleven hundred and seventy-six
patients discharged alive, about one-half are still living,
and one-half of this number have been heard from as being
perfectly well. The permanency of the recoveries depends
necessarily a good deal on the environment to which the
patient returns. A laborious life and indoor occupation are
more likely to bring a relapse than a good climate and out-
door exercise. The education which the patients receive
at the sanatorium as to the nature of their disease and the
methods of combating it is of the utmost value to them-
selves and to others.
Stump Pregnancy. — John C. Morfit describes a case, which
convinced him that it was a variety of extra-uterine preg-
nancy that has never before been met with, which occurred
in the remains of a tube, the proximal end of which he had
not entirely removed. The absence of the ovary and most
of the tube on the right side, the occlusion by ligature of
the stump, the presence of a normal ovary and tube on the
left side, and a large corpus luteum being present in the
only ovary, led to but one possible conclusion. The ferti-
lized ovum came from the left side, passed through the left
tube and the uterine cavity up into the remains of the tube
on the right side, where it began to develop, and finally
ruptured the tube into the abdomen. This upsets the view
that ectopic pregnancy is due to some mechanical or inflam-
matory hindrance to the normal downward passage of the
fertilized ovum. The author believes that the ovum can
travel in any direction before anchoring itself preparatory
to development.
Hip-Joint Amputation. — William D. Hamilton describes
five cases in which Wyeth's bloodless method of hip-joint
amputation was used. Three of the operations were done
by the writer, with one death and two recoveries. The
other two patients were operated upon by Dr. Charles Ham-
ilton, and both recovered. Of the last two, one had had a
thigh amputation done by the writer, with early recurrence.
There is no doubt as to the great value of Wyeth's blood-
less method when it is applicable. A well-appointed hos-
pital is the proper place for its performance. Then, too,
shock can be more successfully combated in case it should
occur.
The State of New York and the Pathology of Insanity. —
By P. M. Wise.
The Prevention of Scarlet Fever. — By Floyd M. Crandall.
Treatment of Membranous Colitis. — By W. H. Thomson.
The Lancet, May ig and 2b, /goo.
Chronic Abscess of the Pericardium. — D. Hunter's patient
was a man who was insane and had been a hard drinker.
The clinical features of the case presented nothing out of
the ordinary. Cardiac symptoms were feeble, with irregu-
lar and intermittent heart action without murmurs. Grad-
ual asthenia supervened, and he died from cardiac failure.
An attempt to open the pericardium at autopsy showed
that much thickening exLsted and that the pericardial lay-
ers were firmly adherent. Continuing the incision round
to the left side, a cavity was opened and some thick,
creamy, greenish-yellow pus exuded. The heart and peri-
cardium were removed en masse, and were found to weigh
530 gm. On dissection the cavity above mentioned was
found to be over the wall of the left ventricle and to con-
tain about four ounces of pus. The walls were thickened
and lined with a definite pyogenic membrane. There
was a smaller cavity over the left auricle containing thin
ichorous pus, also with thick and velvety walls. The re-
mainder of the pericardium showed considerable thicken-
ing, with complete firm adhesion between its layers. The
wall of the left ventricle was hypertrophied, and the myo-
cardium generally was of good color and consistence. The
mitral orifice admitted the tips of two fingers only, and the
tricuspid orifice was .somewhat dilated, but there was no
structural valvular disease. The base of the aorta showed
two small atheromatous patches.
A Clinical Study of the Causes of the First Sound of the
Heart. — A. Morrison conchides that the impulse given to
the blood by the muscular action of the heart gives rise in
it and in the vibratory structures containing it to vibra-
tions of a certain quality which result in that tone which is
ioi8
MEDICAL RECORD.
[June 9, 1900
synchronous with cardiac systole and usually called the
first sound of the heart, and 'that the largest share in this
result must be attributed to vibrations in the blood itself,
to produce which at a normal rate valvular support 0f the
vibrating blood columns is necessary. The study of some
congenital cardiac malformations especially appears to sup-
port this conclusion, because with considerable parietal de-
fects and bruits caused by such the sounds of the heart
may be well heard so long as the division of the blood is
fairly maintained by the valves.
A Fatty Tiunor of the Ascending Colon ; Enterectomy ; Re-
covery.— The case reported by J. Bland-Sutton was that of
a man aged fortj--four years. He suffered from symptoms
of intestinal obstruction, and on examination a sense of
resistance could be made out between the caecum and the
umbilicus. A continuance of the symptoms led to coeliot-
omy. Two inches below the ileo-cascal valve, a tumor was
found in the colon, over which an incision was made. This
mass was ovoid, one pole being embedded between the mus-
cular and mucous coats ; the remaining two-thirds of the
tumor, covered with mucosa, projected into the lumen of
the ascending colon. It proved to be a lobulated lipoma
weighing two ounces.
Congenital Word Blindness. — J. H. Wood gives the histo-
ries of four cases, two occurring in his own practice. Both
patients were brought to him by medical attendants who
suspected that difficult)' in learning to read might be due
to some cerebral cause. AVood regards the difficulty in
these cases as due to some congenital defect in the visual
memory centre for words and letters. Learning to read is
a process of two stages: (i) the storing up in the visual
memory of the individual letters of the alphabet : (2) the
gradual acquirement and storage of the memory of words.
This special function is localized in the angular and supra-
marginal gyri on the left side o^the brain in right-handed
people.
A Case of Multiple Papilloma of the Vaginal Surface of
the Cervix Uteri. — J. Oliver records the case, the patient
being a woman who had had two children, but had been a
widow for ten years, being at the time of operation fort\"-
one years old. The growth originated on the left half of
the cervix, about three-eighths of an inch from the os.
There was no evidence of surrounding infiltration. Two
other smaller similar masses were also discovered. To in-
clude the bases of all three, a wedge-shaped piece was
taken from the left half of the cervix and the edges of the
incision were brought together with deep catgut sutures.
Recovery was without incident.
The Incubation Period of the Plague. — From a study of
various outbreaks of the plague, F. G. Clemow concludes
that infection from inoculation, as iu making an autopsy,
has a regular incubation period of from two to three days.
Under general circumstances the period runs from ten to
twelve days, varying according to the mode of infection.
In studying this question a distinction must be made be-
tween the time of exposure to infection and the onset of the
disease, and the period between the reception of the bacil-
lus into the tissues and the onset of the disease.
Simultaneous Excision of Both Mammae for Cancer. — A case
of this nature is reported by G. P. Newbolt, the patient
being a woman aged sixty-four years, with mitral trouble
and albuminuria. In spite of these handicaps, the surgical
result was a successful one.
The Wounded in the Present War. — An address delivered
by Sir William MacCormac before the Royal Medical and
Chirurgical Society.
Some Cases Showing the Use of "Gas and Oxygen" as
an Anaesthetic in Certain Ophthalmic Operations. — By W. J.
McCardie.
On the Inefficiency of the Board-of-Trade Tests for the
Detection of Color Blindness. — By F. W. Edridge-Green.
Lecture on the Operative Treatment in Simple Fracture. —
Delivered at Guy's Hospital by W. Arbuthuot Lane.
The After-Hisory of Forty-One Cases Treated by Operation
for Destructive Hip-Joint Disease. — By A. E. Barker.
Summer Diarrhoea with Special Relation to Causation and
Prevention. — Second Milroy lecture by F. J. Waldo.
Summer Diarrhoea with Special Relation to Causation and
Prevention. — Third Milroy lecture, by F. J. Waldo.
A Case of Incomplete Development of the Third and
Fourth Ribs.— By F. B. Jefferiss.
Malaria and the Malarial Parasite. — By P. Manson ; a
clinical lecture.
The Modem Treatment of Diabetes Mellitus.— By R.
Saundby.
The Standardization of Anti-Venomous Serum.— By W.
Myers.
Plague Contracted from the Bite of a Rat.— By J. Bell.
Berliner klinische Wochejtschrift, May 14, igoo.
The Reflex Irritability of the Nasal Mucosa in Relation to
Narcosis. — F. Bruck attacks the plan devised by Rosenberg,
whereby the nasal mucosa is cocainized previous to chloro-
form inhalation. He asks ; (i) Are the cocainized por-
tions of the interior of the nose completely aneesthetized?
(2) Does such a plan of local anaesthesia reach the entire
nasal interior? To both of these questions he returns an
emphatic " no. " He believes that if the mouth is kept open
and the tongue well forward during chloroform narcosis,
there is a minimum of danger of failure of either heart or
respiration, from reflex influences. Theoretically these
should be abrogated by the local anaesthesia in the nose ;
practically, according to Bruck, this procedure renders the
administration of chloroform more difficult.
Diagnostic EmplojTnent of Upper Bronchoscopy in Pulmo-
nary Carcinoma. — G. Kilian records a case of ha-moptysis
in which the usual methods of chest examination located
some trouble in the right lung. Its exact nature could not
be made out. An .r-ray picture confirmed the location, but
bronchoscopy enabled the observer to see the exact bron-
chial tube from which the bleeding proceeded. Kilian was
able to study the ramifications of the bronchial tree, and
makes some obseiTations on the anatomical relations of
the pulmonary interior.
Fundamental Views on Pathogenesis. — Fr. Martins reviews
the changing views as to the pathogenesis of disease which
have been ctirrent during the present century, paying spe-
cial attention to Virchow's theory of cellular pathology.
The Origin and Secretion of Oxalic Acid. — By E. Salkow-
ski.
Deutsche medicinische Wocheiischrift, JMay 10, igoo.
The Diagnostic Significance of the Digestion of Carbohy-
drates in Gastric Hyperacidity. — L. Schiiler says the defini-
tion nf hvperacidity is not yet settled. For the diagnosis
of this disease the qualitative examination of total acidity
or that of free hydrochloric acid is not enough. There are
cases of low total acidity with the clinical symptoms of hy-
peracidity. For this purpose it is necessary to inquire into
the duration of the amylolytic stage of digestion, the quan-
tity of the stomach contents after a test meal, and the spe-
cific gravity of the filtered digested fluid. The amylolytic
stage is very much shortened in hyperacidity, and hence
we will find large quantities of amidolin (proven by the
action of Lugol's solution) ; the quantity of the stomach
contents after the test meal is increased — about 200 c.c,
while the normal amount is 150 c.c. — due to the hypersecre-
tion of the stomach cells ; the specific gi^avity is therefore
low — 1. 1 10. Taking into consideration all those points, we
are able to make a diagnosis even in so-called latent cases
of gastric hyperacidity.
The Relation of Epileptic Convulsions and the Excretion
of Urea.— By Dr. Garo.
Acute Dilatation of the Heart and Cor Bovimen. — By Dr.
Hoffman.
Deutsche med. Wochenschrift. May ij and 24, igoo.
The Blood Pressure in Neuropathic Children. — Paul Heim
discusses the various apparatus for testing blood pressure,
and favors the use of Gartner's "tonometer " as giving
the most accurate and constant results. But the physi-
ological variations in the blood pressure cannot be ob-
tained ; the scale does not even read off the average, but
merely the maximum, pressure at the height of the sys-
tolic pulse, and this finally is increased during the respira-
tory phase. For comparison with neuropathic children
Heim examined about twenty-five normal children. These
children were physically in no wise similar, but only such
were chosen as were free from fever, nephritis, heart
lesions, or icterus. He observed, even in normal children,
that the first result obtained was always 10-20 mm. higher
than succeeding ones, when taken from the same finger
after a pause of about a quarter of an hour. Only after
two, three, or at most four tests was a constant value ob-
served, which varied between 80 and 90 mm. ; as extremes
he found twice a pressure of 75 mm., and in four instances
95 mm. He does not agree with Fraenkel that this differ-
ence between the first and subsequent tests is due to paral-
ysis of the arterial muscle, as the variation is too great, but
ascribes the heightened pressure to psychical influence, i.e.,
excitation. Contrarj' to his expectations this variation was
not so marked in neuropathic as in normal children. Only
such children were classified as neuropathic who, without
discoverable physical cause, complained of headache,
stitches in the sides, loss of appetite, nausea, vomiting,
dizziness, fainting-spells, cramps, or became easily fatigued
at school. Anaemic children, children with defective re-
fraction or other discoverable cause, were excluded. Neu-
ropathic children are always in physical excitation, and
this condition causes increased blood pressure, the same as
it frequentl)' causes pulse acceleration. Heim does not be-
June 9, 1900]
MEDICAL RECORD.
1019
lieve that there is any relation between the height of the
blood pressure and the severity of the affection ; the usual
tension was between 130 and 150 mm. Nor is it possible
to make a differential diagnosis of the different neuroses
by measuring the arterial pressure, /. c. , we cannot say that
hysteria causes a higher tension than neurasthenia or vice
versa. He believes, however, that blood-pressure meas-
urement is of considerable value in the diagnosis of neuro-
ses in general, in differentiating neuropathic children from
the non-neuropathic when suffering from similar symptoms.
Contribution to the Study of Kraurosis VuIveb. — Ph. Yung
discusses the various theories and gives the resume of four
cases of this disease. The appearance of the skin is as
follows : it is white and dry, occasionally covered by thick,
rough epidermis ; the neighboring cutis is shiny, pale red-
dish-gray in color, covered by white spots and occasionally
coursed by varicosed arterioles ; sebaceous glands of the
pudendal folds are very sparse. Except mild atrophy and
atonicity, the remainder of the outer genitalia shows no
constant changes. Histologically, connective tissue is very-
much atrophied and often presents a small-cell infiltration ;
the rete Malpighii is very thin ; papillae are small or en-
tirely obliterated ; in severe cases glands are more or less
completely obliterated ; no changes in the nerves. Elastic
fibres are almost entirely absent. In the neighboring cutis
there are sometimes hypertrophy and enlargement of the
stratum coenium, rete Malpighii, and papillfe, as well as
small-celled infiltration of the papillae and horny layer.
The atrophy follows the hypertrophic stage. Anatomi-
cally, kraurosis is the result of " chronic dermatitis. " As to
the symptoms, in severe cases, there is a feeling of tension
and rigidity, which sometimes entirely prevents coitus.
There is also local pruritus and burning on urination.
Some cases, however, are entirely symptomless and are
discovered only accidentally; The disease may occur at
all ages. Bacteriological examination is negative. In six
of the sixty cases reported, carcinoma vulvae was also pres-
ent, the malignant di.sease probabl)' finding its starting-
point in the chronic inflammation present. The best pro-
cedure is excision and removal of the diseased areas. In
only one case did a relapse take place. Those cases com-
plicated by cancer naturally give a bad prognosis.
A Case of Glanders. — Zandy describes a case which oc-
curred in a j'oung man twenty-five years old. He was
brought to the hospital with the history of having been sick
fourteen days, suffering from headaches and weakness.
There were no chills. The abdomen was tympanitic and
distended, the spleen somewhat enlarged and palpable ;
there was no gurgling or abdominal pain. There was a
doughy swelling in the left upper part of the face, partly
covered with a number of small (size of millet seeds)
whitish-yellow vesicles upon a bluish-red base. A number
of red blotches and nodules were found on the upper arm
and chest. Fetor from the mouth was present. His tem-
perature was 39.5° C, pulse 156, respiration 40. The sen-
sorium was free. The cedema of the face and hypersemic
nodules on the arm increased in area. The right lower
arm now showed a diffuse swelling. The urine contained
albumin and casts. No micro-organisms were found in the
blood. Though the picture was not typical ( no muscular
abscesses, no typical exanthem, no nasal lesion) , glanders
was diagnosed by exclusion. The patient died after an
illness of about three weeks. On the day before death cul-
tures were made on glycerin-agar and on potato of the
contents of the pustules, and animal inoculations were also
carried out. All these showed the pathogenic glanders
bacillus.
Three Cases of Fatal Parenchymatous Gastric Hemorrhage.
— Reichard reports three cases of fatal parenchymatous
bleeding from the stomach without discoverable anatomi-
cal lesion. In the first case, that of a man aged fifty-six
years wath a history of long-standing jaundice and pro-
nounced icterus, indicating occlusion of the common bile
duct, no obstruction could be found at the operation,
though the bile channels were dilated. A cholecyst-
enterostomy was performed. On the sixth day the patient
passed a large quantity of fluid and clotted blood from the
bowels, and died on the eighth day after operation. Rei-
chard concedes that jaundice may have been an etiological
factor. In the other two cases there was no jaundice. The
patients were transferred to the surgical department on
account of uncontrollable hsematemesis with progressive
anaemia. At the autopsy no lesion was found to explain
the hemorrhage.
Contribution to the Pathology of the Blood. — Lipowski
gives the history of a patient dying from an acute perni-
cious anaemia of toxic origin. There were continued hem-
orrhages from the gums and pharynx, as well as from the
vagina. Examination of the blood showed slight poikilo-
cytosis, no micro- or macrocytes, no nucleated erythrocytes ;
number of erythrocytes, 2,115,000; hamoglobin, eighteen
per cent. Death took place after two weeks. The specific
toxin was not discovered. He cites another case of pro-
gressive anaemia in which its pernicious character was de-
termined rather by the marked continued decrease of haemo-
globin and erythrocytes, the fever, subcutaneous hemor-
rhages, and changes in the background of the eye, than by
the characteristic histological data derived from the blood
examination.
Gastro-enterostomy, Gastrostomy, and their Relation to
Gastro-enterostomosis Externa.— By O. Witzel and C. Hof-
mann.
Occupation Poisoning and Accident-Insurance Laws.— By
L. Lewin.
Further Clinical Studies on Aspirin. — By Heem and
Liesau.
French foiirnah.
A New Treatment for Alopecia Areata.— Scheffer finds
that pilocarpine acts not only in increasing transpiration
but produces also marked and persistent vaso-dilatation
which increases the nutrition of the hair bulb. He em-
ploys the nitrate in solution of one-half per cent, mixed
with I : r,ooo bichloride of mercury, by intradermic injec-
tion. Before injecting the plaque is rubbed with ninety
per cent, alcohol. The syringe is filled three-quarters full
by drawing in first ^ c.c. of the mercurial solution, then ]{
c.c. of the pilocarpine solution, and finally % c.c. of the
mercurial solution. This makes the proper proportion.
The injections are made just beneath the skin in as hori-
zontal a manner as possible, i cm. apart, and repeated
every four or five days. A patch the size of a dollar re-
quires about twelve injections. After four or five sittings
the hair begins to grow. In sixty cases treated over a
period of three years there was no instance of failure. The
extension of the plaque is at once arrested and new ones
do not form. — La Mcilcciiii: JModerne, May 19, igoo.
Clinical Pneumography. — E Hirtz and G. Brouardel, in a
study based upon extensive observations, describe normal
pneumography, and that in the course of chronic pulmo-
nary tuberculosis, and point out its importance in the early
diagnosis of the latter. The subject is one which has hith-
erto received little attention excepting at the hands of one
of the present writers. Many tracings from the same sub-
ject are required for approximately correct results. It is
found that while the tracing for each normal respiration
presents four lines, that from the onset of tuberculosis
shows but three. This pneumographic fo'rmula of chronic
tuberculosis persists in all periods and is not found in other
pneumopathies. — La Presse MediiaU, May ig, igoo.
Post-Operative Spontaneous Evisceration. — G. Chavannaz
describes as a complication of laparotomy the spontaneous
expulsion of a portion of the abdominal viscera through
the various layers of the abdominal incision or alongside
of the cicatrix. The paper is based on twenty-four cases
of this rare accident, three of which are unpublished. In
one instance of rupture of the cicatrix there was syncope.
The treatment is preventive and curative. A well-applied
bandage at first and caution against strain, etc., may act
as preventive measures. Infection and shock are two ele-
ments to combat. In treatment alcohol, heat, caffeine, and
artificial serum are precious resources. — Le BitlUtiii Uledi-
cal. May ig, igoo.
Pediatrics, May /j, igoo.
The Present State of Our Knowledge of the Action of the
Various Therapeutic Serums. — Antonio Fanoni reviews the
development of orrhi itherapy and strives to answer the ques-
tion. " Are all these worthy of the confidence of the unbiassed
practitioner? " Pane's serum he has employed with marked
success in pneumonia in children. Maragliano's serum
against tuberculosis has much in its favor. This latest ex-
pression of the ars cur audi, " serum therapy," is gradually
forcing itself upon us, 'and in thejinterests of humanit)' it is
hoped there will soon be complete victory for its advocates.
A Case of Amnesia. — P. F. Barbour relates the case of a
girl aged four j-ears and three months, found in a stupor
with apparent paralysis of the right upper and lower ex-
tremity. Memory was lost and not regained for several
weeks. The writer looked upon the case as one of func-
tional derangement of the intellectual centres such as may
be produced by an interference with the nutrition of the
frontal lobes, or with the general circulation in the brain,
resulting most probably from an auto-toxsemia arising from
the intestinal tract.
A Case of Peliosis Rheumatica Caused by Traumatism.^
Louis Fischer differentiates peliosis from simple purpura
by the fever, swelling, and tenderness in the joints plus
subcutaneous hemorrhages. Cardiac lesions do not com-
plicate the condition. A case of a boy of nine j'ears is re-
lated, coming on after bicycle riding to excess, from which
the writer feels justified in calling it peliosis rheumatica
traumatica. The illustration does not do justice to the
case.
I020
MEDICAL RECORD.
[June 9, 1900
^jcxrintTs and |T[oticjes.
Helen Keller Souvenir, Volta Bureau, Washington,
D.C.
This handsomely prepared and illustrated volume com-
memorates the Harvard final examination for admission to
Radcliffe College in June, 1S99, of Miss Keller, a deaf girl
who passed with distinction. This account of her instruc-
tion, with methods pursued, is circulated by the Volta
bureau for the increase and diffusion of knowledge relat-
ing to the deaf, and as such is of the greatest interest to
all instructors of deaf children and to those engaged in
educational pursuits in general.
Indigestion — Its Causes .and Cure. By John H. Cl.\rke,
Fellow of the British Homoeopathic Society, etc. Amer-
ican edition, revised and enlarged from the fifth English
edition. Philadelphia : Boericke & Tafel. igoo.
Little alteration has been made in this American edition,
since only a year has elapsed from the time of output of
the last English. The work is very brief, but touches
upon the various forms of faulty digestion and enumerates
the homceopathic remedies.
A Digest of E.xternal Therapeutics, with Numerous
Formulee. Arranged for reference by Egbert Guernsey
Rankin, A.M., M.D., physician to the Metropolitan Hos-
pital, New York. Second edition, revised and enlarged.
New York ; Boericke & Runyon Company. 1900.
The necessity for a new edition on March ist speaks in it-
self for the reception this work has received. The authori-
ties quoted are almost without exception old-school writers.
Pepper, Allbutt, the Twentieth Century Practice, Bangs,
Hardaway, Unna, Allen, Ingals, Roosa, Jacobi, et al.
The work might have been written, selected, compiled,
and arranged, and may be read by one of the regular quite
as well as by one of the homoeopathic school of medicine.
A Handbook for Nurses. By J. K. Watson, M.D. Edin. ,
late hou.se surgeon Esse.x and Colchester Hospital.
American edition, under the supervision of A. A. Ste-
vens, A.M., M.D., professor of pathology in the Woman's
Medical College of Pennsylvania. Philadelphia; W. B.
Saunders. 1900.
The excellent judgment displayed by the author in giving
the essentials without trying to instruct nurses too deeply
in the science of medicine has made an American edition
of his work a thing to be desired, and the supervision has
been in such hands as to give confidence that the work in
its present form will be found most useful. The scheme of
marginal subheadings has husbanded much space put to
good use in making the reading-matter compact.
Plea for a Simpler Life, and Fads of an Old Physician.
By George I. Keith, M.D., LL.D., F.R.C.P.E. Lon-
don : Adam & Charles Black. 1900.
This is an interesting and suggestive account of the author's
long experience in the dietary treatment of many of the com-
moner diseases. He maintains that most of the latter owe
their origin to excessive feeding, and advises extreme absti-
nence, especially in regard to red meats. Although con-
fessedly an extremist, the majority of his arguments are
eminently sound and will appeal to the good sense of prac-
titioners generally. His style is charming and he has very
winning ways in presenting his subject.
Mr. Sinai Hospital Reports; Volume I., fur iSyS. Ed-
ited for the medical board by Paul F. Munde, M.D.,
LL.D. iSgg.
The institution publishing this work is to be congratulated
upon its most interesting first volume. The more modern
method of publishing articles upon the hospital experiences
by the various chiefs of staff has been followed, and in so
doing the board has given the medical public a far more
interesting work and one much more apt to be read than
if it were simply a mass of statistics. Among the notewor-
thy articles on medical subjects are those on typhoid fever,
lobar pneumonia, and Widal reaction ; from the surgical
side. Dr. Gerster's general report, as well as numerous and
thorough articles on special subjects. It is a most instruc-
tive and valuable collection.
Proceedings ok the Pathological Society of Philadel-
phia. New Series, Vol. HI., No. 4. February, 1900.
The chief article of interest in this little pamphlet is the
symposium on typhoid fever, discussed by Miisser, Flex-
ner, Ashton, and McFarland. General tuberculosis and
the method of staining the sporozoa of malaria are treated
by Hand and Woldert respectively, and Lloyd describes a
case of hsematomyelia.
Diseases of the Stomach, their Special Pathology, Diag-
nosis, and Treatment, with Sections on Anatomy, Physi-
ology, Chemical and Microscopical Examination of the
Gastric Contents, Dietetics, Surgery of the Stomach, etc.
By John C. Hemmeter, M.D. Second enlarged and re-
vised edition. Philadelphia: P. Blakiston's Son & Com-
pany. 1900.
This edition of Hemmeter's work on " Diseases of the Stom-
ach " contains much new and important material. The fol-
lowing articles have been added : Hypertrophic stenosis
of the pylorus, obstruction of the orifices, the use and abuse
of rest and exercise in the treatment of digestive diseases.
Part of the chapter on motor insufficienc)-, electro-diaphany,
hemorrhage from the stomach, and the articles on gastrop-
tosis and enteroptosis have been entirely rewritten. The
present edition will undoubtedly gain as many friends as
the first edition.
Skin Diseases : their Description, Etiology, Diagnosis, and
Treatment according to the Law of the Similars. By M.
E. Douglass, M.D,, lecturer on dermatology in the
Southern Homoeopathic Medical College of Baltimore.
Philadelphia : Boericke & Tafel. 1900.
The author states that he has been prompted to prepare
this work by a conviction of the existence of an urgent de-
mand for a work which should embody the advances re-
cently made and set forth the distinctive characters of his
school's therapeutics. He believes that in this department
more than in any other we will find Hahnemann's rule, to
treat the totality of the symptoms complained of by the
patient, the only method by which we may cure our pa-
tient. The author states quite freely what those whom he
is pleased to call "allopaths" advise in the various affec-
tions, and at times he makes statements concerning their
views which carry one back toward the dark ages of der-
matology. L'nfortunately he does not give the source fi-om
which he derives his knowledge of old-school methods,
there being no bibliographical references. Nor are there
any acknowledgments concerning the source of the pic-
tures, almost if not all of which are borrowed, with the ex-
ception perhaps of a print of eczema opposite page 165,
which shows nothing of any value to the student and does
not grace the book. The statement is made concerning
impetigo contagiosa that pediculi capitis are rarely present,
and the lymph which is poured out is said to be "splastic. "
After the statement that "the old school rely " on external
measures, the author gives a list of twenty-five remedies
for internal use from which the student is left to choose one
or more, at times being guided by what the child may state
as to the particular kind of irritation it feels at the time of
his visit. In trying to learn dermatology the homoeopathic
student has as much right as any other to the best instruc-
tion he can get. There are plenty of good works on the
subject. The therapy he can acquire after he has mastered
diagnosis.
Transactions of the American Laryngological Associ-
ation FOR 1899. New York : D. Appleton & Company.
1900.
This bound volume of Transactions is very neatly printed,
and the papers are of the usual high order of excellence
and interest. Henry Swain, of New Haven, is the secre-
tary, to whom credit is probably due.
New, Old, and Forgotten Remedies. Papers by Many
Writers. Collected and arranged and edited by E. P.
Anshutz. Philadelphia ; Boericke & Tafel. 1900.
This collection is intended to answer the question, "Where
can the literature or description of such and such a drug be
found? " The work represents much searching of old jour-
nal files and many hours spent on considering what to re-
ject. The compiler deserves no little credit for the amount
of careful work bestowed. The reader will find, at times,
hidden among chaff, many grains of wisdom. The writ-
ings concern chiefly nature-given remedies rather than
laboratory products.
The International Text-Book of Surgery. By Amer-
can and British Authors. Edited by J. Collins War-
ren, M.D., LL.D., etc., and A. Pearce Gould, M.S.,
F.R.C.S., etc. Volume I. General and Operative Sur-
gery. With 458 illustrations in the text, and 9 full-page
plates in colors. Philadelphia : W. B. Saunders, igoo.
In this volume there are twenty-eight chapters, some au-
thors having written several, and there are many illustra-
tions. The subjects usually discussed under the head of
general surgery, or the principles of surgery, occupy the
first few hundred pages, and we find here bacteriology, in-
flammation, infection and its causes, the pathology of the
blood, and various general and local diseases which are of
surgical significance. There is much information which
makes the book especially useful as a work of reference.
June 9, 1900]
MEDICAL RECORD.
1021
but there will be few occasions upon which it will be neces-
sary to do much memorizing by the medical student in
these days of "compends." The chapter upon the technic
of aseptic surgery is capital and contains all that is neces-
sary for the novice or the expert, and the illustrations rep
resenting amputations and excisions are very satisfactory.
A good diagram in this department of surgery often serves
a better purpose than much text. The warning in regard
to cocaine cannot be too often repeated. The chapter on
"Tumors" is not as satisfactory as it might be. The de-
scriptions are rather too brief, and the illustrations are not
specially commendable. The subject of fractures and dis-
locations, we think, forms the most satisfactory section of
the book, and here we iind excellent explanatory illustra-
tions. Cranial surgery, including fractures, is considered
in a separate chapter, and is followed by one on the special
surgery of the vertebral column and spinal cord. An at-
tempt to suture a wound of the heart is advised in all cases
in which there is time, but such cases are necessarily rare.
The diseases of blood-vessels are disposed of in a rather
short chapter, which includes treatment in a general way.
Anatomie Clinique des Centres Nerveux. Par Dr.
Grasset. Paris ; J. B. Bailliere et Fils. igoo.
A MOST useful little book for every physician to read.
After a short introduction on the neuron, and its groupings
and connections, the author proceeds to discuss the special
anatomy of the nervous mechanism of general motion and
sensibility ; secondly, of the special senses ; thirdly, of
speech ; and, finally, of circulation, respiration, and diges-
tion. In a comparatively small space the author has suc-
ceeded in clearly stating the most recent ideas as to centre,
localization, and the paths of nervous impulses in the brain
and spinal cord. The book will be of especial interest to
the general physician who has not the time to devote to the
more extensive works on this subject.
The Anatomy of the Brain. By R. W. Whitehead, M.D.
New York : The F. A. Davis Company, igoo.
This book is intended as a text-book for students, and cer-
tainly fulfils the aim of the author. In clear, concise lan-
guage he has described this complex portion of anatomy ;
by tracing only those fibres whose course is definitely
known and omitting minutiae of those tracts that are still
sub jiidice as regards their exact relations and distribution,
he has been enabled to present the subject in a compara-
tively small space. Its terseness, completeness, and com-
pactness recommend it strongl)- to those for whose use it
has been written. The illustrations are numerous and good.
OUR LONDON LETTER.
(From Our Special Correspondent.)
COMING EVENTS IN MEDICAL COUNCIL — MEDICAL SOCIETIES —
BRITISH MEDICAL ASSOCIATION^GALL STONES — PNEUMOTHO-
RAX IN HEALTHY PERSONS — ACUTE ENCEPHALITIS — CHANGES
IN THE BLOOD IN DISEASE.
London, May 11, igoo.
Next week the Medical Council meets, and we shall have
more dreary talk on many disputed projects. The mid-
wives bill must, of course, be one, as the council cannot
permit all their representations to be ignored without a
protest, as the government asked for them, and the pro-
moters of the bill have misrepresented their recommenda-
tions in the House.
We are also to have next week the conversazione of the
Medical Society and the oration by Dr. Fowler. The Clin-
ical, too, will hold its annual meeting, and the Medico-Chi
will give us another evening on "The Wounded in the
War," by Mr. Dent and Sir W. MacCormac. There will
be an exhibition of specimens, bullets, etc. Lantern slides
will be employed.
The conference at Manchester, of which I gave you some
particulars last week, has given rise to some uneasy sensa-
tions. These seem to centre round the resolution to at-
tempt to reform the British Medical Association and to
open the campaign at Ipswich in July. If the reformers
can only get a hearing we may expect a lively time. But
the little clique which rules the association has never been
at a loss to stifle unwelcome discussion, and is likely to
make a strategic movement in an unexpected direction.
At the Clinical Society on Friday the chief interest was
centred in .some cases of gall stones. These concretions
always excite interest on account of the excessive pain they
sometimes give rise to and the slight symptoms in other
cases. Thus in one case the diagnosis is evident and
in another obscure. Besides, the secondary effects vary
greatly and fresh difficulty arises. Mr. Battle related
three cases. In one, a girl aged fourteen years had had
severe attacks of abdominal pain with nausea and head-
aches. The pain was not well localized, but referred to the
umbilicus and again to the left lumbar region. There were
blood and albumin in the urine, but no casts. An .r-ray
examination was negative. A lumbar incision was made
and the left kidney explored, but nothing was found.
After convalescence another severe attack of the old pain
occurred and an abdominal exploration was made. A gall
stone was found in the cystic duct, the removal of which
cured the patient, who continues well. Another of Mr.
Battle's cases was of a girl aged sixteen years. The gall
bladder could be felt, very hard as if contracted on some
large stones. It contained none, but its wall was very
thick. A stone was found in the common duct and ex-
tracted with a good result. The third case was that of a
woman aged forty-nine years, who had had attacks of pain
and vomiting extending over eighteen years. She had
passed gall stones. She had jaundice ; stones were found
in the gall bladder and ducts and were removed through
incisions, and the patient did well.
Mr. Bland-Sutton related a case in which on operation
the stone was detected in the wall of the duodenum, im-
pacted in the terminal segment of the common duct. It
could not be moved in either direction, so the wall of the
duodenum was incised and the papillte were exposed, when
the concretion could be seen at the orifice, and on nicking
the edges it was extracted. The incision into the duodenum
was sutured in two layers. The patient did well.
Dr. Weber said his house surgeon was palpating a large
gall bladder when it disappeared under his fingers, and
the stools, previously clayey, became colored. That seemed
a case of distention with bile, but in another case when the
bladder diminished suddenly a hard lump was felt, which
proved to be a stone.
Mr. Symonds made some interesting remarks on the
cases and mentioned others. He discussed the necessity
of suturing the duct when it was incised, as if that could be
dispensed with it would much facilitate operation.
Mr. Bland-Sutton, in his reply, said he had operated on
a number of cases without suturing the duct since he re-
ported one in the Transactions, vol. xxv. Though it was
thought "risky" then, he never felt the least temptation to
put in a suture — he merely drained.
Those curious cases of pneumothorax which now and
then come on suddenly in healthy persons were the subject
of some conversation at the society. Dr. Parkes Weber hav-
ing related one at length and Dr. Percy Kidd another more
briefly. All the recorded cases seem to have been in males
and were probably caused by the bursting of an emphyse-
matous bulla. A minute tuberculous nodtile had also been
found to open a communication between the air passages
and pleura in a person who had given no previous signs of
tubercle. Dr. West had such a case, but this cause must
be rare, for in cases of sudden pneumothorax in healthy
persons, recovery almost always takes place spontaneously.
Drs. Prickett and Batten read details of a case of acute
encephalitis following influenza in a lad aged nine years.
On the fourth day of the influenza he became paralytic and
aphasic, passed into coma, and died in sevent)'-two hours.
The adjourned discussion at the Pathological Society on
changes in the blood in disease was not so interesting nor
yet so severely scientific as the earlier debate. Neverthe-
less there were many points deserving of consideration.
Professor Wright, of Netley, resumed the debate. He
did not think much of enumeration of red or white cells, and
asked if, after all, there were an)' diseases in which exami-
nation of the blood by current methods helped the diagnosis
or prognosis. He thought the coagulability of the blood the
most important point to estimate, and that we should watch
whether the condition we wish to produce is brought about
by our treatment. In aneurism it was wished to increase
the coagulability, and starvation diet has been used. But
in starvation the coagulability goes down and after a good
meal goes up. In phthisis also the coagulability is reduced.
Eating acid fruits reduces it to the extent sometimes of
" serous hemorrhages " — urticaria. Lime salts increase it,
and the professor has shown that they may be used for this
purpose, and that decrease of them means diminution of
coagulability. The investigation of the agglutinins is a
promising field. In Malta fever slow development of ag-
glutinins had been noticed as occurring in the more pro-
longed cases, and if after this fever or typhoid the agglu-
tinin kept high a relapse was not likely to occur, but if low
a relapse was probable.
Dr. Lorrain Smith confined his remarks to ansemia, on
which he has made laborious researches. In anaemia from
hemorrhage he finds there is a loss of oxygen capacity, i.e.,
of hasmoglobin. It was not so in chlorosis. Many symp-
toms he finds due to increase of the volume of blood, and
treatment should be directed to reducing it.
Dr. J. H. Drysdale said the red and white cells varied
independently of each other, and protested against the com-
I022
MEDICAL RECORD.
[June 9, 1900
mon practice of comparative measurements. Percentages
were useless. Blood from the periphery differed from that
from the centre. Advance must come from clinicians rather
than biologists.
Dr. William Hunter could not indorse Professor Wright's
remarks on estimation of the corpuscles. Coagulation he
admitted to be important, but so were other factors. He
demonstrated by the lantern some of the changes he had
investigated.
Dr. A. Whitfield said he had worked at the blood from
the morphological standpoint, and he gave the results of
his researches. He also referred to the work of Justus, who
found that mercury given to syphilitics caused a sudden
fall in hfemoglobin, followed by a steady rise to normal as
the drug took effect. The fall did not occur in health)- sub-
jects, so perhaps might serve as an aid to diagnosis. The
statements of Justus had been confirmed by all who had
experimentally investigated them.
Some one has suggested nutritive enemata. I say no.
A nutritive enema can be given only to an intelligent pa-
tient, who knows why it is given and tries his or her utmost
to retain it. M. D.
THE FEEDING OF INTUBATION CASES.
Sir : Here is a difficulty ; your patient coughs so much,
the regurgitation is so great, that but little nourishment is
retained ; add to this the usual dislike for medicine, and
it seems almost insurmountable. First, try this method,
which, I think, when practicable, is always the best ;
Lay the child on its back with the head hanging over the
nurse's knee, or, if it is in bed, let the head hang over a
pillow ; then feed slowly with a spoon or medicine dropper ;
do not use a feeding-bottle unless the child has always used
one, otherwise the nurse will first have to teach the child
how to nurse from one, and time in those cases is always
an object.
The purpose of feeding in this manner is simply this :
The intubation tube is, of course, a foreign body, and the
child in the act of swallowing cannot entirely close the epi-
glottis ; hence the coughing, choking, and regurgitation
caused by the fluids getting into the trachea. When the
head is kept at a certain angle the food passes more directly
into the oesophagus. Now this method, "although very
good, is not always successful ; the choking and regurgita-
tion may continue, and premature coughing up of the tube
is a danger to be looked out for.
We have another resource — feeding by gavage. This
method is really a life-saving one, but I hold it should be
a last resource. A feeding-tube is used, which is similar
to the tube used in giving enemata. Get a small rubber or
glass funnel. Attach to it a piece of rubber tubing about
four inches long, then a piece of glass tubing three inches
long, and then the catheter. A rubber catheter. No. 7, is a
good size unless the child is very young ; then a smaller
one may be used. The child is wrapped securely in a sheet
and placed on its back on a table. Pass the catheter through
the right or left nostril into the oesophagus, at the same
time pinching the tube so as to exclude as much air as
possible. This is not so difficult as it seems, if the child
is held firmly and not allowed to struggle. Practice has
proved that it is better to pass the tube through the nasal
passage into the oesophagus than through the mouth.
When the tube is passed through the mouth a gag has to
be used, and the patient is likely to cough and struggle
more. Do not pass the tube too slowly ; remember how
sensitive the parts are, and the tube causes a great deal of
irritation, and passing it slowly only means prolonging the
trouble.
Insert about eight inches of the catheter. The milk is
used warm. Medicine may be given at the same time.
When the fluid has passed below the glass tubing, pinch
the catheter and withdraw it. The pinching prevents the
small quantity of milk that has remained in the tube from
dripping as it is withdrawn, and prevents further irrita-
tion.
Now it can be readily understood that this is not a pleas-
ant operation for the patient, although I have seen children
fed in this manner without the slightest resistance. The
strongest argument in its favor is that it prevents the pos-
sibility of the fluid getting into the trachea and later on
causing bronchial pneumonia ; against it is the resistance
of the patient and consequent exhaustion. Its use in pri-
vate practice might be questioned, so for those reasons,
unless it is a question of starvation, I advise other means
being tried.
Never keep to any rule in those cases. Feed the child
the way it takes it best. Every patient is a "law unto
himself. " There are children who have held the intubation
tube for months, and were able to eat and drink as well as
if the tube was not there. The patient is often able to
swallow solid food when drinking is impossible. This is
easily explained : dry particles of food cannot get into the
trachea as readily as fluids.
THE SALE OF PATENT MEDICINES.
Sir : Cannot some way be suggested for the concerted
action of the medical profession against "patent medi-
cines"? Their sale and the harm that they do are increas-
ing every )-ear, and, except for a feeble protest now and
then from our superior medical periodicals, not a particle
of resistance is attempted to the great inroads they are
making upon the health of our citizens. It would be folly
to introduce a bill into the legislature of any State govern-
ing the sale of patent medicines until the people are awak-
ened to its necessity, and who is there to advise and ad-
monish the people except the medical profession? As a
profession should we not do all in our power to protect the
public's health? Yet how many of your readers ever take
the trouble to warn their patients of the dangers to be
encountered in taking patent medicines, or any medicines,
without the advice of a competent physician? Many physi-
cians, I doubt not, laugh and joke and make light of patent
medicines. Perhaps they think their levity will teach the
absurdity of using them, but they are slighting their re-
sponsibilities when they let pass an opportunity to explain
the innumerable dangers always risked by taking any
drug, even a diarrhoea mixture, without being so advised
by a physician.
The people of the State of New York, by their laws duly
enacted at the capital and enforced at no little expense, de-
mand to-day a thorough education in all the principles un-
derlying the science and art of medicine and surgery before
they grant a license to treat and prescribe for a patient, and
if the same people knew the serious dangers of patent medi-
cines would they not demand the laws and gladly expend
as much from their treasury to prohibit the sale of such
articles? If the public's attention was drawn to the fact
that the laws protect them from ignorant doctors, but do
not protect them from poisonous drugs or fraudulent medi-
cines, would they not act, and act at once?
If as much ink as has lately been used by members of
the profession in Pennsylvania in a controversy over
whether the medical student should receive any credit for
subjects pursued in an academic college, were used by
these gentlemen in as able arguments for the protection
of the public from the ignorant administration of drugs by
means of patent medicines or by the drug clerks, much
would be accomplished for the public safety.
Again, the profession would do the public and itself bet-
ter service would it devote a little more exertion toward
the regulating of the prescribing of drugs and medicines
and a little less toward regulating the free dispensing of
professional services.
The law at present upon the statutes of the State of New
York, controlling the sale of poisonous drugs, even if en-
forced, is of little value. If a man has a pain, no matter
where, or a cough, or trouble with his bowels or his kid-
neys, or in fact any trouble whatsoever with his bodily
functions, he needs but to be able to go to the drug store,
and his wants will be attended to by either the patent
medicine bottle or some "just the thing" from the drug-
gist's own bottles. Indeed a man confined to his bed may
often receive treatment from a druggist by a friend's de-
scribing his ailment. What he receives may not be the
direct cause of his death, and yet the delay in seeking pro-
fessional aid may put him beyond the chance of recovery,
and, furthermore, may have given him so many more
hours in which to infect other people with typhoid or some
other disease.
Since so much advertising is done in the interest of pat-
ent medicines, would it not be well to advertise more
widely the ruin of health they may cause, and the dangers
they exert in possibly inculcating opium, alcohol, or some
other habit? A prize for the best article setting forth the
dangers of using any drug, without first being advised by
a physician, would call forth a number of publishable
articles, which could be inserted in the newspapers and
magazines. The medical .societies could take this matter
in hand and by systematic pamphleteering make such
attacks as would demand attention from the jjublic and
result sooner or later in legislative action.
A suggestion which may be far from feasible, and yet
may lead to some one offering a better idea, is this : Let a
law be passed prohibiting the sale of any drug or combi-
nation of drugs for internal or external use, by any one
whatsoever, except upon a written demand of a registered
physician, a book of registered physicians to be kept by
all druggists. The patent-medicine manufacturers would
June 9, 1900]
MEDICAL RECORD.
1023
expend millions to defeat such a bill ! Yes, but we are not
afraid of the fight, when we are in the right. The drug-
gists would combine against the passage of such a bill !
Yes, probably. The people would say the profession was
trying to form a trust ! No, for the working of such a law
would prove the contrary. The drug stores might each
have a doctor, who would write for any drug desired !
Well, he must be registered, and not many men so well
educated as to have passed the necessary examinations
would sell their services for dishonorable purposes ; and if
the drug stores kept proficient doctors behind their count-
ers it would be a step forward at least. Prescriptions
would be for sale at every drug store, all written and
signed ! Again, an educated, honorable man would not
dare, or care to, sell a batch of prescriptions for indiscrimi-
nate distribution, and the law might be framed to forestall
such an evasion.
One result that might accrue would be the customary
practice for families, or even a houseful of boarders, hotels,
etc., to have visiting physicians at a yearly rate, who
would call regularly, practise prophylaxis, and advise upon
all topics of health and hygiene. They would at times
advise this or that member of the household to be exam-
ined by the oculist, aurist, the gyngecologist, or some
other specialist. The specialties would be more popular,
and the specialists would in consequence be more ad-
vanced. During severe illness the consultants would be
more frequently called to the bedside. All headache pow-
ders, cathartics, etc., the family physicians would prescribe
as needed, and no extra charge would be made. As the
result of such a law, we would not take a prescription into
a shop one quarter of which is given up to a soda-water
and ice-cream counter, another quarter to toilet articles,
and the shelves on both sides crowded with patent medi-
cines. Pharmacy would become a much higher and more
dignified profession than it is to-day, and the drug shop
would be a much more respectable institution.
John Joseph Nutt, B.L., M.D.
San Diego, Cal.
institutions and are used for the purpose of public batli-
ing.
I do not write this with the desire to prop up any claims
of priority which Mr. Brown may have made, but simply
in justice to the very efiicient aid he gave me in this then
experimental work.
J. B. Ransom,
Physician to CliJiton Prison.
Dannemora, N. Y., May 21, 1900.
RAIN BATHS.
To THE Editor op the Medical Record.
Sir : In the issue of the Medic.\l Record of May 12,
1900, I notice an editorial under the title of "An Absurd
Claim and a Unique E.xhibit," referring to spray or rain
baths. Regarding the claims of Dr. Baruch or Mr. Good-
win Brown as to priority in the establishment of public
baths I know nothing, but as perhaps pertinent to the
subject I wish to make the following statement :
Soon after taking charge of the medical department of
Clinton Prison, New York, in May, iSSg, I became con-
vinced that the only proper method for bathing a large
number of persons was by means of the spra}' or rain bath,
of which at that time I practically knew nothing. The
idea was suggested to me by the necessity of preventing
contamination from one person to another from tub bath-
ing, especially when there was venereal disease ; and also
a necessity for a form of bath which would bring on rapid
reaction, the circulation of confined men usually being of
low pressure and altogether sluggish. I immediately be-
gan investigating the subject and agitating the necessity
of constructing a bath-house in connection with this insti-
tution. Early in the year 1891 an appropriation of $18,500
was obtained from the legislature for the construction of a
bath-house in connection with Clinton Prison. No sooner,
however, did I attempt to introduce my ideas of spray and
rain baths than I met with determined opposition on the
part of some concerned in the construction of the building.
I could find no precedent to fortify my position, but for-
tunately for my cause I accidentally mentioned the subject
to Mr. Goodwin Brown, who was then acting in the capac-
ity of pardon clerk to Governor Hill. He immediately in-
dorsed my idea as a feasible one, and stated that he'was
a warm advocate of this method for public baths. He gave
me his earnest support in the matter, and the result was
that a bath-house was constructed on the Roman plan of
architecture and fitted up with nine rain baths and fifty in-
dividual sprays. The water for the sprays is driven with
a pressure of eighty-seven pounds, and very finely subdi-
vided ; the spray rosette is large, giving a wide radius to
the jet, and is attached to a flexible hose. The water is
heated to any desired temperature by means of heaters at-
tached to the water-supply pipe. The water used in bath-
ing and all debris are washed down inclines to well-trapped
sewers.
The bath proved to be a great success, and so far as I
am able to learn is the first spray bath put into operation
in connection with a public institution in this country. It
attracted considerable attention, and many persons in-
spected it and approved the principle. Now I am aware
that many similar baths are in operation in connection with
To THE Editor of the Medical Record.
Sir : The articles on bathing recently appearing in the
Medical Record, as to priority of public baths, whether
shower or tub, might well be extended and thus put on
record some other facts than have yet been published.
The Charity Organization in October, 1893, opened its lodg-
ing-house at 516 West Twenty-eighth Street, and largely
because of ray personal insistence the baths were spray
baths. We required also a system of disinfecting clothing,
and determined upon constructing something quite differ-
ent from any apparatus then to be seen. With the com-
petent help in planning given me by our plumber, a hot-air
chamber constructed after the manner of the cold-storage
places (which gave me the idea) was put in and econom-
ically maintained at a temperature of 240' F. or more.
All clothing was taken at the time the bather took it off and
placed by him in netted bags designed for the purpose, and
then the bags were hung on an elevated railway and pushed
into the hot-air chamber, swinging perfectly free in the air.
The clothing, after remaining there for at least two and
one-half hours, was freed from vermin and vermin eggs.
To our minds no public baths are complete without such
an arrangement for disinfecting the clothing. Our system
of dry heat has been copied in several places outside the
city, and has been always found satisfactory. It destroys
all visible animal life. Two attempts to copy our system
with modifications have been tried in this city, and have
both proved dismal failures because of the introduction of
steam into the process, thus wrinkling the clothing, be-
cause it is in those places (quarantine and department of
charities) subjected to steam while under pressure. The
result, besides the wrinkles, is to warm the eggs into life,
and a worse condition than before obtains in forty-eight
hours. With the dry heat, however, this is all avoided,
and the bather is not only clean after his bath, but has a
chance to remain so by putting on clothing that is also
clean.
This is written more to place on record facts that may
hereafter be of importance, than to claim any priority for
any one. Wickes Washburn.
May 26, igoo.
^XccUcal Items.
sterilizing Water by Ozone — In a method of ster-
ilization of water by means of ozone described by Dr.
Weyl, of Berlin, at the German scientific conference
in 1899, water is pumped to the top of a tower and
allowed to flow freely over stones, meeting as it falls
a current of air charged with ozone. The process ap-
pears to be likewise effective in purifying peat and bog
water, the solution of the iron of humic acid being
decomposed and oxidized, and the brown color disap-
pearing in consequence. The method, it is said, can
be advantageously used in connection with filter beds.
— Appleton's Popular Science Monthly.
Losses at Mafeking. — An official report from Ma-
feking as to tlie total casualties during the siege shows
the following losses: Officers, 5 killed, 15 wounded,
I missing; non-commissioned officers and privates, 51
killed, 103 wounded, and 25 missing. Of these 15
died from disease and 5 were accidentally wounded.
Of Kaffirs 25 were killed and 58 wounded. Non-com-
batants, 4 killed, 5 wounded, and 32 died from disease.
Among the natives 54 were killed and 117 wounded.
The Baratongs had 128 killed and 122 wounded.
Military Surgery in the Boer Army.— The Ber-
lin correspondent of The Lancet says that Professor
von Esmarch has permitted the Miinchener medicinische
Wochenschrijt to publish letters written by a former
assistant, who is now medical officer to an ambulance
with the Boer forces. Most of the wounds treated
I024
MEDICAL RECORD.
[June 9, 1900
were caused by the Lee-Metford rifle. Simple wounds
of the soft parts healed ver}' well without suppuration
except when the shot had been fired from a short dis-
tance. This seldom happened in fighting, but some
Boers shot themselves wilfully with their own rifles to
avoid military service. In these cases the wound of
ingress was very small as in all other wounds of the
soft parts; the wound of exit, however, was very large
and the muscles were lacerated. It was an interesting
fact, not from a surgical but from a psychological
standpoint, that these accidents happened always
a day before a battle was expected. Soldiers with
wounds of the extremities continued to fight and were
even able to ride to the dressing-tent without support.
The majority of the Boers, however, when slightly
wounded, seized the opportunity to withdraw from the
battlefield. Dr. Kiittner, another of the German sur-
geons at Jacobsdahl, in a letter addressed to Professor
Bruns, of Tiibingen, confirmed the opinion of the lat-
ter that the prognosis of the wounds inflicted by mod-
ern rifle bullets was good, and that conservative treat-
ment was advisable. VVounds of the skull and brain
were usually very serious and often required operative
treatment, while wounds of the thorax healed very
well. As to wounds of the abdomen, their prognosis
was better than was supposed. A good many of them
healed under expectant treatment without laparotomy,
an experience in accord with that of MacCormac
and Watson Cheyne. The results were not improved
by laparotomy. Wounds of the liver were not ob-
served at all, as the wounded died on the battlefield.
Wounds of the kidney were more frequent and of a
better prognosis. In a postscript the state of the
wounded in General Cronje's laager after his sur-
render at Paardeberg is described. Owing to the
want of surgical aid, the wounded had been ten days
without dressings. The wounds were covered with
tobacco leaf, and nearly all were septic. Many opera-
tions were, therefore, necessary, and there were many
deaths from septicjemia and tetanus.
Number of Registered Physicians in the United
States. — The actual number of registered physicians
in the United States, according to the most recent
count, shows an average for the whole of about one to
647 inhabitants, but the proportion in the States varies
greatly. California appears to be the State which is
most liberally supplied, the proportion there being one
physician to 420 inhabitants, while in Iowa nearly the
same conditions prevail. On the other hand, in North
and South Dakota and New Mexico the proportion was
respectively one to 1,285, 1,296, and 1,391 inhabitants.
Cremation in the United States. — Within the past
twenty years the custom of cremating the bodies of the
dead has obtained a considerable foothold in the
United States, and several crematories have been
built in different parts of the country. The first cre-
matory was built by Dr. Julius T. Le Moyne, at Wash-
ington, I'a., in 1876, and was used for tlie disposal of
his own remains. From that time to the present much
has been written in America in relation to this safe
and rational method of disposal. No more establish-
ments for incineration were erected till 1884, but from
1884 to the present time twenty-six crematories have
been established. In some instances laws have been
enacted favoring the practice and placing it under
proper restrictions. That the public sentiment in
favor of incineration is steadily increasing is shown
by the rapidly augmenting number of bodies sub-
mitted to this method of disposal. The following list
furnished by Mr. Louis Lange, of New York City,
shows the rapid progress which has been made in the
establishment of crematories in the United States and
in the number of persons whose remains have been in-
cinerated in these since their introduction in 1876.
In the eight years, 1876 to 1883, only twenty-five
bodies had been disposed of in this manner, and all
these were treated in the crematory built by Dr. Le
Moyne at Washington, Pa. From that time the an-
nual number increased to 1,699 in 1898, with a total
of 8,885 i" ^'1 ^P '^o '^'^^ close of 1898, and at the
present date the number has probably reached ten
thousand. — " Public Hygiene and State Medicine in
the United States," by Samuel W. Abbott.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended June 2,
1900:
Cases. Deaths.
Smallpox — United States.
District of Columbia, Wash-
ington May i2th to igth 5 x
Colorado, Archuleta Lo May 19th 2
Arapahoe May 19th 2
Boulder Co May 19th i
Otero Co .May 19th 3
Pueblo Co May 19th 2
San Miguel Co. .. .May igth i
Illinois, Cairo May 12th to 26th 4
Indiana, Evansville May 19th to 26th 1
Indianapolis May 12th to 19th 7
Kansas, Wichita May igth to 26th 7
Kentucky, Covington May 12th to 26th S
Louisiana, New Orleans May 12th to 26th 78 33
Shreveport May 19th to 26th 3
Massachusetts, Fall River... May 19th to 26th i
Lowell May 19th to 26th 2
Michigan, Detroit May 12th to 19th 3
Grand Rapids .... May 12th to 19th 5 i
Minnesota, Minneapolis April 28th to May 3d 54 3
New Mexico, Capitan May 7th to 21st 11
New York, New York May 19th to 26th 4
Ohio, Cleveland May 19th to 26th 32
Oregon, Portland May 17th i
South Carolina, Greenville. .May 12th to 19th 2
Utah, Salt Lake City May 12th to 26th 5
Virginia. Petersburg April 26th to May 26th 2
Washington, Tacoma May 12th to 19th j
Wisconsin, Deer Co May 22d 8
Douglass Co May 22d 8 '
Eau Claire Co. . .May 22d 10
Kewaunee Co ...May 22d 6
Pierce Co May 22d i
St. Croix Co. . . May 22d 70 I
W'aupaca Co May 22d 3 i
Wyoming, Cheyenne May 19th 3
RockCreek.... May 19th 2
Sweetwater Co 7
Green River May igth i8
Evanston . . May igth 6
Aspen May igth 1
Tunnel May 19th 13
Smallpox— Foreign.
Austria, Prague April 28th to May 12th 9
Belgium. Antwerp May 5th to i2ih 6
Brazil, Rio de Janeiro ., March 31st to April 13th 14 11
Canada, Ontario, Collings-
wood ... May 16th . .
Sault Ste. Maria.... May 16th P;
Winnepeg May 12th to 26th 1
China, Hong Kong April 7th to 21st
Egypt, Cairo April 1st to May 6th
England, Liverpool May 5th to 12th T
London April 28th to May 12th 1
Southampton Ma>; 12th to i8th
France, Lyons April 21st to May 12th
Germany May 5th to 12th 2
Gibraltar April 28th to May 13th 4
Greece, Athens May 5th to 12th 3
India, Bombay April 17th to May 1st
Calcutta March 24th to April 7th
Kurrachee April 15th to 2gth 45
Madras April 7th to 27th
Italy, Leghorn May 5th to 12th I
Mexico, Chihuahua May 12th to 19th
Vera Cruz Majr 12th to igth 4
Russia, Odessa April 28th to May 12th 15
St. Petersburg April 28th to May 5th 15
Warsaw April 22d to May 5th
Scotland, Glasgow May nth to i8tn 27
Sprain, Corunna May sth to 12th
Madrid April 21st to May 5th
Valencia May 12th to igth x
Straits Settlements, Singa-
pore April ist to 2ist
Brazil. Rio de Ja.
Colombia, Panan
Cuba, Cienfuego:
Yellow Fever.
.March 31st to April 13th 47
. May 15th to 22d 7
.May 26th 5
• Santa Clara Barracks.
India, Bombay April 17th to May ist ...
Calcutta March 24th to April 7th .
Madras April 7th to 13th
Japan, Osaka and Hiogo . . .April 21st to 28th
Plague.
China, Hong Kong April 7th to 21st
India, Bombay April 17th to May 1st . . .
Calcutta March 24th to 31st . . . .
Kurrachee April i6th to 2gth
Japan, Osaka. April Sth to May 14th . . .
Sbidzuoka May 7th
Medical Record
A IVeekly younial of Medicine and Surgery
Vol. 57, No. 24.
Whole No. 1545.
New York, June 16, 1900.
$5.00 Per Annum.
Single Copies, loc.
©rxflitral Articles.
THE OCCURRENCE OF MOULD IN THE
STOMACH AND ITS PROBABLE SIGNIFI-
CANCE.*
By max EINHORN, M.D..
The part which micro-organisms (bacteria and mould
fungi) play in the occurrence of pathological processes
in the stomach has been variously interpreted by
authors. Most clinicians ascribe no special signifi-
cance to them. Others, however, assign them a promi-
nent place; thus, for example, Talma' maintains that
the fermentation of carbohydrates induced by micro-
organisms is the cause of hyperchlorhydria; others,
again, place stress not so much upon the variety of
these microbes as upon their ultimate number. Among
these authors Naunyn" may be especially cited.
The mould fungus, as such, has been but little men-
tioned in the domain of gastric alTections. In the fol-
lowing I shall give the different data which I have
found in the literature:
Leube' writes as follows: "Usually yeast and
mould fungi, sarcinae, and the most diverse forms of
bacteria are found. Inasmuch as all these fungi do
not e.xert any direct deleterious influence upon the
gastric mucous membrane, and as their presence in
the diseased stomach docs not materially interfere
with a cure, the occurrence of fungi in the gastric con-
tents must be regarded as rather accidental than as
a symptom of certain pathological processes in the
stomach. On the other hand, in very rare instances
micro-organisms appear to be capable of exciting in-
flammation and ulceration of the stomach; but up to
now so few observations from an anatomical stand-
point have been made upon gastritis mycotica that it
would be better to refrain from the exposition of a
clinical picture and from a diagnosis of this condi-
tion."
De Bary* frequently examined the gastric contents
for micro-organisms in seventeen patients suffering
from gastric troubles, and found : thread fungi, oidium
lactis (cases i,8); other forms, undetermined (cases
I, 3) ; mucor mycelia (cases 3, 4) ; leptothrix buccalis
(cases 14, 17). In general, he determined that the
thrush fungi and mould fungi are more infrequent.
Naunyn says: "I would mention the occurrence of
mould fungi in the stomach, which 1 have found in
two cases; one observation I made three years ago,
the patient being a woman about forty years old with
moderate dyspeptic disturbances and considerable in-
crease in the width and depth of the stomach. After
lavage had been performed twice the patient withdrew
from treatment. The mould fungi, which were present
profusely the first time, could be found only with diffi-
culty in the wash-water the second time. The other
case came under my observation about a year ago.
Unfortunately I have not any notes in regard to it, and
* Read before the American Gastro-Enterological Association on
May I, igoo, at Washington. D. C.
can only state that, if I recollect rightly, the mould
fungi disappeared from the stomach contents after a
single lavage, and that here no considerable mechan-
ical gastrical insufficiency was present."
Boas'* makes the following remarks relating to this
subject: "Among the sprout fungi, the yeast fungi
(at least in small quantity) are to be regarded as a nor-
mal constituent. The thrush fungus (oidium seu sac-
charomyces albicans), usually originating in the buc-
cal cavity, is also occasionally met with. Furthermore,
mould fungi (mucor forms) are found in small num-
ber, these being likewise of no essential pathogno-
monic significance."
The following pathological anatomical data found
in Klebs' "Handbuch"'' are also of interest: "A
different condition prevailed in a mycosis of the stom-
ach which was first observed by E. v. Wahl ( Virch.
Arch., Bd. 21), then by Recklinghausen ( Virch. Arch.,
Bd. 30), since here the fungi penetrated into the ducts
of the mucous glands. In the first case there were
found, especially in the pyloric portion, numerous
foci of the size of pin-heads, pustular nodules, partly
of yellow and partly of red color, which occupied the
glandular layer and extended to the submucosa; and
in the second case there were in the fundus similar
but somewhat larger foci with central necrosis. In
this case the fungi were present both in the glandular
tubercles as well as here and there in the tissue be-
tween them, so that they connected the ends of the
tubes with one another. ... In both instances the
same variety of fungi was present, consisting of sev-
eral fine threads, only rarely or not at all segmented,
together with fine, minute granules occasionally ar-
ranged in rows in the form of a rosary — forms which
therefore belong to the leptothrix group." Klebs
attributes the necrosis to the proliferation of these
fungi.
Eichhorst' expresses himself in a similar manner:
"Oidium albicans does not frequently occur in the
stomach. Reisz has described an instance in a girl
eighteen years old. The mucous membrane was found
to be covered with whitish, semiglobular granules up
to a pin-head size, which at some points in the fundus
ventriculi had coalesced into larger patches. Micro-
scopically, the cylindrical epithelia were destroyed in
some places, the mucous membrane being infiltrated
by an abundance of round cells, but nowhere was there
any entrance of the fungi into the blood-vessels. Be-
sides the stomach, thrush fungi were found in the
oesophagus. Rudnew has found penicillium glaucum
in a woman who died from cholera, in the vicinity of
the pylorus the fungi had penetrated abundantly into
two small tumors. Naunyn also observed in two in-
stances mould fungi in the stomach contents. Kund-
rat recently described, in the case of a man with favus
universalis, the presence of favus colonies upon the
mucous membrane of the stomach and colon, which
had led to a croupous diphtheritic inflammation and
to the formation of ulcers."
Grawitz" has succeeded by injections of aspergillus
colonies into the blood-vessels in producing mycotic
diseases of the kidney and liver. As regards the be-
havior of the fungi in the stomach, nothing, however,
is mentioned in this work.
I026
MEDICAL RECORD.
[June 1 6, 1900
In all the literature cited, with the exception of the
pathological anatomical data, the scant references to
mould fungi in the stomach relate to the findings of
microscopical examinations. Mould itself, recog-
nizable by macroscopic examination, has, according
to my knowledge, not as yet been observed clinically
in the stomach. At any rate, no mention of this oc-
curs in the literature. I have had occasion to observe
several cases of mould formation in the stomach, and
it seems to me worth the while to discuss the subject
somewhat more fully. In the cases under my observa-
tion there were found in the wash-water of the empty
stomach small, sometimes blackish-gray, and some-
times brownish-green flakes (2 to 5 mm. in diameter;
see P"ig. i) in varying number (four to fifty and more).
The microscopical e.^amination showed that these floc-
culi consisted entirely of spores and mycelia and
scarcely anything else. Similar flocculi were found
in the same patients in the gastric contents after a test
meal, and the microscope showed the same picture as
in the flocculi from the empty stomach.
Sometimes these blackish-gray masses are embedded
in mucus. We then note besides these fungus colo-
nies mucous corpuscles and numerous epithelial cells.
This indicates an intimate connection between the
fungus colonies and the surface of the mucous mem-
brane. The former must adhere quite closely to the
latter and perhaps even proliferate into the epithelial
layer. This firm adhesion must be assumed for the
following reasons: If the fungi were only an acci-
dental admixture of the ingesta, that is introduced
with the latter and then carried further onward, with-
out there being any fungus proliferation, then they
would be encountered only in the gastric contents
after meals, but not in the fasting state of the patient,
that is, when no food is found. As a matter of fact,
however, in the cases referred to these flocculi occur
in large number, pwincipally in the empty stomaah.
Are these mould fungi, present in the stomach, still
in a living condition, or are they destroyed by the ac-
tion of the gastric juice? In answer to this question
it can be said that the mould colonies retain their full
vitality and are capable of further development. If
the flocculi are placed in some water or in the filtrate
of the gastric contents of the patient it is soon noticed
that there is a formation of whitish-gray clouds which
are connected with the flocculi, and under the micro-
scope we find spore colonies and mycelia very similar
in character to the original mould.
After these introductory remarks permit me to de-
scribe in detail a few of the cases that have come under
my observation.
Case I. — Hyperchlorhydria, with periodical contin-
uous gastro-succorrhoea; October, _ 1899. William
R , thirty-eight years old, has suffered for four
years with periodical vomiting of from two to four days'
duration. While at first the attacks of vomiting oc-
curred about once in four or five months, they in-
creased to such an extent in the third year of the dis-
ease that they appeared every three to four weeks.
Since then the patient has no longer felt well during
the interval between the attacks, being constantly
troubled, about two hours after meals, with intense
heartburn and gastric pains; constipation was also
present in a marked degree. The patient had lost
about thirty pounds in weight. At this time he first
came under my treatment. A careful examination
showed the presence of hyperchlorhydria with contin-
uous gastro-succorrhoea occurring periodically. He
was placed upon proper diet and treated with sodium
bromide and alkalies. During ten months he re-
mained free from the attacks of vomiting, after which
they recurred in the same manner as previously. The
patient consulted me again during such an attack.
Status prKsens: The patient appears well-nour-
ished, but somewhat pale; nothing abnormal can be
discovered in the thoracic organs; the gastric region
is somewhat sensitive to pressure; the knee phenome-
non is present; the urine is free from albumin and su-
gar. In the fasting state about 60 c.c. of gastric juice
mixed with some bile is found. During the following
irrigation of the stomach small greenish flakes in con-
siderable number (about twenty to thirty) are observed
in the wash-water. I first thought that these were
small mucous flakes which had absorbed biliary color-
ing-matter, but the microscopical examination showed
that this was not the case, but that the shreds consisted
entirely of round spores and mycelia (Figs. 2 and 3).
Case II. — Hyperchlorhydria; February 18, 1900.
T. M , twenty-two years old, had suffered for six
years with digestive disturbances; he was troubled
with frequent belching; the tongue was always coated,
and he often had a bad taste in the mouth in the morn-
FiG. J.— A (Ire
Wra. R ),
crystals are vi<
nisli Pellicle iourid in the Wash-water ot the Moi
In the fasting condition. Mycelia, free spores, ani
ible. X 240.
the Stomach (of
ing. One-half to two hours after meals a feeling of
burning frequently appeared in the pit of the stomach,
and the patient had a sensation as if he had swallowed
a foreign body. He also often experienced a raw feel-
June 1 6, 1900]
MEDICAL RECORD.
1027
Ing in the throat, with repeated hawking. The bowels
were always regular; the appetite was good; there
was no loss in weight.
Status praisens: The patient is of vigorous build
and well nourished ; the tongue is covered with a
Fig 1 — Same as t g 2 h fc.hly magnihed
greenish-gray coating; the thoracic organs show nor-
mal conditions; in the abdomen nothing abnormal can
be discovered; the knee phenomenon is intact; the
urine is free from sugar and albumin.
Examination of the stomach one hour after the test
breakfast shows: HCl -(-, acidity 76; free HCl, 56.
The chyme contains small greenish flakes similar to
parsley, in small number (about four such shreds on
the filter). Macroscopically these presented the ap-
pearance of being either small particles of green vege-
tables or mucous flocculi whicli had taken up biliary
coloring-matter. Microscopical examination showed,
however, that these flakes represented mould fungi
colonies, consisting of spores and mycelia (Fig. 4).
The patient was examined on the following morning
in the fasting state ; the stomach contained no ingesta,
but a slight quantity (20 c.c.) of gastric juice. After
lavage was performed the wash- water contained a con-
siderable number (fifty to sixty) of the above-described
greenish flakes; there was a small quantity of mucus.
The patient was treated with bicarbonate of sodium
and with gastric irrigation, in connection with a spray
of silver nitrate. His condition improved, that is, the
subjective symptoms diminished, and about fourteen
days after commencing treatment the irrigating-fluid
contained either no greenish flakes or only a scanty
number. A small amount of yellowish-brown mucus,
however, is almost always present in the wash-water,
and in this epithelial cells and spores (probably from
fungi) can be demonstrated.
Case III. — Hyperchlorhydria; March 15, 1900.
George D , forty-eight years old, had always en-
joyed good health until about a year ago, when he be-
gan to suffer with digestive disturbances. At first the
pains appeared some time after eating, and later they
were now and then accompanied by vomiting. The
appetite at the beginning was undisturbed, later im-
paired; the bowels were sluggish ; frequently there was
a sour taste in the mouth. During the course of the
disease the patient had lost forty-five pounds in weight,
and felt weak and restless.
Status praesens : The patient is of vigorous build,
but appears pale and debilitated; the tongue is
markedly coated ; the thoracic organs are normal; ex-
amination of the abdomen discloses a slight sensitive-
ness to pressure in the gastric region, the presence of
splashing sounds, which can be produced down to the
navel, and the absence of any tumor. The knee re-
flexes are present; the urine contains neither sugar
nor albumin.
Examination of the stomach one hour after the test
breakfast shows: HCl +, acidity 104; free HCl, 80.
In the fasting state the stomach is found empty. In
the irrigating-water numerous mould flocculi are pres-
ent, as determined microscopically.
The patient was treated for several days with gastric
lavage and alkalies; in addition he was placed on a
light diet, with frequent meals. His condition im-
proved; the pains diminished; the vomiting ceased,
and he began to gain in weight. After three weeks'
treatment no mould pellicle can be discovered in the
stomach.
Case IV. — Gastritis glandularis chronica and gas-
tric erosions; January 12, 1900. Leopold C ,
twenty-nine years old, has been troubled for two
years with dyspeptic symptoms, a feeling of pressure,
and slight pains in the gastric region one-half hour
after meals, frequent eructations and slight constipa-
tion. The patient has kept up a strict diet during this
time, and has lost twenty pounds in weight, while the
disturbances remained unchanged.
Status prffisens: The patient appears pale; the mu-
cous membrane of the lips and cheeks is anaemic; the
tongue is only slightly coated; the thoracic organs are
normal; palpation of the abdomen elicits a slight sen-
sitiveness to pressure in the epigastric region.
Examination of the stomach one hour after the test
breakfast shows: HCl -f, acidity 24; a considerable
quantity of mucus and two blackish-green flakes, which
on microscopical examination are found to consist of
spores and mould fungi. In the fasting state the
stomach is found empty; the wash-water contains,
however, an abundance of these mould floccules
(twenty to thirty) (Fig. 5) and, besides, four small
pieces of mucous membrane. The same finding was
repeatedly determined, with the exception that after
longer treatment, which consisted of gastric irrigation
and spraying with silver-nitrate solutions, the mucous
Fig. 4.— a Blackish Pellicle found in the Gastnc Contents (of T. M )
after a Test Breakfast. Numerous spores, mycelia, a few crystals, starch
granules, and epithelial cells are visible. X 140.
fragments and also the mould Soccules appeared in
lesser numbers.
The patient felt batter, was more vigorous, and ex-
I028
MEDICAL RECORD.
[June 1 6, 1900
perienced fewer disturbances. He is, however, not yet
entirely free from his pains.
Aside from the above-described observations I have
found mould in the stomach in two other instances:
Fig. 5.— a Blackish Pellicle found
C ), in the fasting condition.
cr>-stals, epithelial cells, and several algx
Wash-water of the Stomach IL.
spore-colonies, mycelia, a few
in one there was a decided hyperchlorhydria; in the
other an atony of the stomach, with quite normal
chemical processes and gastralgias. Both patients
were not long under observation, so that I am not
sufficiently informed as to the subsequent course of the
cases.
That the grayish-green or grayish-black flakes, which
were found, represented mould pellicles, was estab-
FlG. 6.-0c. 2. Obj. -f, oil.Le
lished beyond doubt by the microscopical examina-
tion. An extremely large number of •spores and
mycelia was always observed. In all my cases the mi-
croscopical picture was the same, and it can therefore
be assumed that the mould fungi present belonged to
one and the same species. In order to determine the
latter point I gave a few of these greenish shreds to
Dr. E. K. Dunham, and insert his report:
"New York University, Carnegie Laboratory, |
"New York, April 27, 1900. )'
"Dear Doctor Einhorn: The specimen from
stomach contents which you sent me for examination
contained small particles of a dirty yellowish or green-
ish color. Under the microscope these particles con-
tained granular material of indefinite character, from
which mycelial threads projected into the surrounding
liquid. The latter contained numerous round bodies
which were considered to be the spores of some mould,
but no signs of any fructification could be detected
upon the mycelium. Attempts to cultivate the myce-
lium upon agar-agar, gelatin, milk-sugar, bouillon, and
upon acidulated media yielded no fruiting mould.
The original material was finally distributed over
sterilized bread. Upon this medium, colonies of an
aspergillus, a penicillium, and one colony of a mucor
were obtained without difficulty. The penicillium ap-
peared to be the
common penicil-
lium glaucum.
The colonies of as-
pergillus were also
green in color.
Only the asexual
spore- formation
came under observa-
tion.
" I attach very
little value to these
observations, b e -
cause bread cultures
were not made until
at least a week had
elapsed after the
material was re-
ceived from you.
There was a chance
that the growths obtained were due to contamination
of the material distributed upon the bread.
■' 1 enclose tliree drawings made from the original
material with the aid of a camera lucida (Figs. 6, 7, 8).
" Yours very truly,
" Edward K. Dunham."
At this place I beg to express my indebtedness to
Dr. E. K. Dunham as well as to Dr. Goldhorn for
their labor.
If now we return to our cases in which mould fungi
were frequently found in the stomach, the question
comes up, What significance have these mould fungi
in gastric pathology? Although isolated fungi may
exist in the stomach for a short time without any detri-
ment, they do not find in the normal organ favorable
soil for further development. They are intimately
mixed with the chyme and
are carried onward, living
or dead, through the py- | f- — I 1 1 — |
lorus. Entire colonies of Scale, 0.05 mm. Each
fungi which are macrosco- division = o.oi mm.
pically perceptible are
probably never to be found
in the normal stomach.
Any considerable growth of
mould would be possible
only if a colony of the
fungi had infested a fold
of the surface of the gas-
tric mucous membrane and
had become so firmly ad-
herent that they were not
carried along with the on-
ward passage of the chyme.
Under these circumstances
a fungus colony may grow
undisturbed, and considerable areas of the gastric
mucosa may become covered with mould. In the
above-described cases such a condition must have pre-
vailed. In lavage of the stomach the inflowing current
June 1 6, 1900]
MEDICAL RECORD.
1029
of water exerts considerable force and tears many
mould islets from their bases, so that they then appear
in the wash-water.
It is scarcely conceivable that such a mould coating
of certain zones of the gastric mucosa can be unat-
tended with disturbances of the functions of the organ.
Conditions of irritation as well as inflammatory proc-
esses might be e-xpected a priori hom the mechanical
action of the mould.
After these theoretical conclusions it would be
profitable to analyze more closely the cases that have
been described, and to elucidate whether the mould
formation was in a causative relationship to the symp-
toms of the disease. The decision of this question is,
however, very difficult, htC3L\isQ post hoc is not always
the (rgo propter hoc. I have met with the mould for-
mation particularly in two groups of gastric affections:
first, in cases of intense hyperchlorhydria (occasionally
attended with hypersecretion and vomiting) ; and, sec-
ond, in gastralgia with normal or reduced gastric
secretion. It cannot be denied that in many of these
cases the mould flakes became smaller in number or
disappeared after gastric lavage followed by spraying
with a one to two per mille solution of nitrate of sil-
ver. In connection with this a subjective improve-
ment could be observed in the condition of the patient.
Yet it cannot be said with certainty that the mould
produced the existing pathological process in the stom-
ach ; for we find cases analogous in every respect with-
out the presence of mould fungi. Notwithstanding
this, it appears plausible that these mould fungi are
connected to a certain extent with the above-mentioned
abnormal conditions; and even if they are not the
cause of these, they undoubtedly increase their severity.
The occurrence of mould in the stomach in large
masses must, therefore, be considered of itnportance
from a therapeutic standpoint; hence it must be our
endeavor to free the stomach from them as soon as
possible. This is best done by irrigation of the
stomach in the fasting state of the patient. This acts
in a purely mechanical manner, since the mould flakes
are removed with the water. The use of the gastric
douche might also have a favorable influence in this
direction. Following this the application of an anti-
septic solution of silver nitrate with a spray appears
likewise of some utility. Aside from the therapeutic
measures just described, tiie treatment of these cases
must be directed in accordance with the special dis-
ease present.
BIBI.IOGRAPHV.
1. Talma : Von der Gahrung der Kohlehydrate im Magen.
Zeitschr. f. klin. Medicin, 1S98, Bd. 35, p. 542.
2. B. Naunyn : Ueber das Verhaltniss der Magengahrungen.
Deutsch. Arch. f. klin. Med-, vol. xxxi.
3. W. V. Leube ; Specielle Diagnose innerer Krankheiten,
Leipzig, 1895. vol. i., p. 256.
4. l)e Bary : Beitrag zur Kenntniss der niederen Organismen
im Mageninhalt. Arch. f. exper. Path, und Therapie, vol. xx.,
p. 243.
5. J. Boas. Magenkrankheiten. Theili., p. 218.
6. E. Klebs ; Handbuch der patholog. Anatomie, vol. i. , p.
201, Berlin. 1S69.
7. Eichhorst . Handbuch der spec. Pathol, und Therapie, I S90,
vol. ii.. pp. 170. 171.
8 1'. Grawitz Ueber Schimmelvegetationen im menschlichen
Organismus. Virch. Arch., vol. Ixxxi,, p. 355.
DIFFUSE SEPTIC PERITONITIS AND THE
ELEVATED HEAD AND TRUNK POSTURE.
A REPORT OF THREE ADDITIONAL CON-
SECUTIVE CASES OF RECOVERY.
By GEORGE RYERSON FOWLER, M.D.,
NEW YORK,
YORK POLYCLINIC ; SURGEON TO
Prostatectomy. — In lateral lobe enlargements, in
perineal urethrotomy, a crescentic incision is made an-
terior to the rectum and well around it, the rectum
being drawn backward and the prostate capsule in-
cised. The prostate is drawn down into the wound by
means of the finger and enucleation made with the
finger of the other hand and scissors. The wound is
packed, leaving in the bladder a large tube from the
perineal wound for six days. — Freyer.
The following is presented as an addendum to the re-
port of nine consecutive cases of recovery of diffuse
septic peritonitis published in the Medical Record
for April 14th, thus making twelve consecutive cases in
which recovery has taken place under the combined
treatment of cleansing the neighborhood of the original
focus with hydrogen peroxide, through flushing of the
abdomen with decinormal saline solution at 110° F.,
deep pelvic drainage, and the elevated head and trunk
posture to facilitate the passage of fluids from the in-
testinal and diaphragmatic areas to the pelvic portion
of the peritoneum. The special object to be accom-
plished by this posture, namely, that of removing the
fluids from the dangerous areas mentioned to the com-
paratively safe region of the pelvis, together with the
anatomical and physiological reasoning upon which
this is based, are fully set forth in the article referred
to.
Case X. — March 15, 1900; Methodist Episcopal
Hospital; female, aged seven years. The patient was
admitted and operated upon on the tenth day of an at-
tack of acute appendicitis. The expression was anx-
ious. There were extreme abdominal distention and
tenderness, with persistent vomiting. The conditions
were believed to be complicated with intestinal obstruc-
tion of mechanical origin. A median incision was
made, the operation revealed the small intestines
deeply reddened and matted together with exudate ; as
these were separated large quantities of sero-purulent
material flooded the peritoneal cavity. The appendix
was gangrenous and perforated. It was excised ; the
primary focus was cleansed with partially neutralized
hydrogen peroxide (diluted with equal parts of a satu-
rated solution of sodium bicarbonate). The intestines
were separated, cleared of lymph deposits wherever
these were easily separable, and the peritoneal cavity
was repeatedly flushed with large quantities of deci-
normal saline solution. A glass drainage tube was
placed in the pelvis and led out of the lower angle of
the incision.
After-treatment consisted of elevation of the head of
the bed fifteen inches above the horizontal ; an enema
of saline solution every two hours. Vomiting ceased;
flatus passed freely; the distention subsided. The
glass drainage tube was removed on the sixth day, and
substituted, on account of a reaccumulation in the pel-
vis, by one of rubber, which was finally removed on
the fourteenth day. The head of the bed was lowered
at the end of the second week. Recovery resulted.
Case XI. — March 17, 1900; German Hospital;
male, aged twenty-three years; perforative peritonitis
of appendicular origin. The operation showed a large
quantity of sero-purulent fluid; the peritoneum was
deeply reddened, and extensive deposits of fibrino-
plastic material were scattered over the entire area of
the small intestine. The appendix was excised; the
original septic focus was cleansed with partially neu-
tralized peroxide-of-hydrogen solution; the lymph
deposits were removed where easily detachable; the
peritoneal cavity was flushed with decinormal saline
solution at 110° F. ; a glass drain was inserted in the
pelvis.
After-treatment: The head of bed was elevated fif-
teen inches; stimulation with strychnine and caffeine;
an enema of decinormal saline solution was given
every two hours; fluids were administered by mouth
I030
MEDICAL RECORD.
[June 1 6, 1900
ad libitum. No vomiting occurred after the patient
was placed in bed. Flatus passed freely after six
hours. The glass drain was forced out by an act of
coughing at the end of twenty-four hours; it was not
replaced. The elevated head and trunk position was
maintained for six days. Staphylococcus was found
in culture. Recovery resulted.
Case XII. — April 5, 1900; Methodist Episcopal
Hospital; male, aged sixty-six years; perforative peri-
tonitis of appendicular origin. Upon admission the
patient presented the characteristic picture of dififuse
septic peritonitis. Upon opening the abdomen, a
quantity of sero-purulent fluid escaped from the peri-
toneal cavity. The intestinal coils were greatly dis- ^
tended, deeply reddened and mottled, and coated here
and there with patches of fibrino-plastic exudate. It
was with difficulty that spontaneous eventration through
the abdominal wound was prevented. The appendix
was perforated. Excision of the appendix was done;
the original septic focus was cleansed with partially
neutralized hydrogen dioxide; the peritoneal cavity
was systematically flushed with decinormal saline solu-
tion. A quantity of the latter was permitted to remain
in the cavity for the purpose of favoring peritoneal
leucocytosis and immunity. A small supplementary
opening was made through the abdominal wall in the
left linea semilunaris, and through this a large and
closely fitting glass drainage tube was passed to the
bottom of the pelvis. The original operation wound
was closed.
After-treatment : Elevation of the head of the bed
eighteen inches ; stimulation by strychnine and caffeine ;
aspiration of drainage tube every four hours; enemata
of decinormal saline solution. Nausea and vomiting
ceased at once; normal peristalsis was re-established
and flatus expelled within twelve hours; a movement
of the bowels was obtained by simple enema on the
morning of the third day. The rigidity of the abdom-
inal wall was replaced by the normal relaxed con-
dition, and the peritonitic facies disappeared. The
glass drain was removed on the fourth day, and its
place supplied by a narrow gauze strip. Recovery
ensued.
The following case is offered in addition. Espe-
cial points of interest present themselves in the case,
for the reason that the abdominal symptoms absolutely
disappeared, while a general septico-pyaemia persisted,
which finally resulted in septic meningitis, from which
the patient died on the thirteenth day following the
operation. I am greatly indebted to Dr. H. A. Hen-
riques, of Morristown, N. J., who, although not previ-
ously in attendance, assumed the care of the patient
at my request, upon the supervention of the meningeal
complication.
April 14, 1900; L. D— — •, aged fourteen years, of
Morristown, N. J.; perforative appendicitis; third day
of the disease. The patient presented the typical ap-
pearances of diffuse septic peritonitis, i.e., anxious
facial expression, purplish-red hue of surface (vaso-
motor paralysis), extreme distention, and rigid abdom-
inal walls (barrel-shaped abdomen). There was par-
alysis of peristalsis. The stomach was absolutely
intolerant; vomiting of brownish-green matter took
place. The pulse was 160; temperature, 104° F. Ab-
dominal section revealed deeply reddened coils of in-
testine floating about in a large amount of foul-smell-
ing sero-purulent fluid with flakes of lymph; fibrino-
plastic patches were present upon the intestinal serous
surfaces. The appendix was gangrenous and perfo-
rated. Excision of the appendix was done; the
region of the original focus of infection was cleansed
with hydrogen dioxide undiluted, about twelve ounces
being used. Considerable of the hydrogen-dioxide so-
lution necessarily invaded the general peritoneal cav-
ity. Forcible flushing was done with decinormal saline
solution at 110° F. A large glass drainage tube was
inserted to the bottom of the pelvis.
After-treatment: Elevated head and trunk posture;
the glass drainage tube was aspirated every three
hours until the third day, when it was removed, and a
rubber drainage tube and a strip of iodoform gauze
were substituted. Stimulation was effected by caffeine
and strychnine. A saline enema was given every three
hours; fluids ad libitutn. The nausea and vomiting
ceased at once. The bowels moved spontaneously
three times within the first twelve hours, accompanied
by the expulsion of large quantities of gas; the dis-
tention promptly diminished. The morale rapidly im-
proved. The extensive general septic conditions which
existed prior to the operation, however, persisted, al-
though the abdominal symptoms rapidly subsided, save
the occurrence of a small and well-vialled-off secondary
abscess in the left iliac region, which was evacuated
by an incision in the left linea semilunaris on the
ninth day. On the eleventh day symptoms of cerebral
meningitis developed, with intolerance of light, vom-
iting, high fever, delirium, the temperature finally
reaching 107.5° ^-'^ there was stiffness of the neck
due to contractions of the posterior muscles; alternate
contraction and dilatation of the pupils occurred.
The patient became comatose and remained so for
forty-eight hours preceding the final lethal exit, which
took place on the thirteenth day following the opera-
tion.
A word as to the method of flushing pursued in the
last case: I believe, in spite of the assertion of Bode'
to the contrary, that eventration or disembowelling
adds increased risks to the operative procedure, and
should be avoided, if possible. Heretofore the diffi-
culty of reaching every portion of the peritoneal cavity
with the irrigating-fluid and with the intestines /;/ situ
has been almost insurmountable. In the last case, I
adopted an expedient for overcoming this difficulty by
means of the following improvised means: The outlet
tube of a large douche bag was cut away, and through
the hole thus left in the bottom of the bag an ordinary
curved and flanged abdominal glass drainage tube of
large size was passed from inside the bag. The tube
was then passed into the remoter portions of the peri-
toneal cavity at first, and. the bag being filled with
the decinormal saline solution, the solution was forced
from the bag by rolling the latter upon itself from
above downward, the fluid rushing rapidly and forcibly
from the end of the glass tube as this was moved about
first in the region of the spleen and liver, and subse-
quently between the coils of intestine and about the
root of the mesentery. Quantities of sero-purulent
material, with flakes of lymph, were thus brought to
the surface and flowed out of the operation wound with
the returning fluid. The pelvic cavity was then flushed
in a like manner, and finally a rapid washing away of
what de'bris had been deposited about the wound itself
followed. The bag was filled and then emptied again
and again, until about eight gallons of the decinormal
saline solution was used.
Finally, I desire to state that, in spite of the fact
that the elevated head and trunk posture should, theo-
retically, throw additional work upon the heart in these
desperate cases, this has not constituted a valid objec-
tion to its employment, in my experience. In case the
patient fails to respond to the stimulation employed
after the operation, however, there would be no
objection to placing the bed in the horizontal posi-
tion, or even elevating the foot of the bed during the
first few hours, providing thorough cleansing of the
peritoneal cavity had been done. Absorption of the
relatively clean saline solution from the diaphragmatic
and intestinal areas will do no harm, and may be of
service in assisting the stimulation of the patient. A
' Centralblatt flir Chirurgie, No. 2, 1900.
June i6, 1900]
MEDICAL RECORD.
1031
further argument in this connection is found in the
fact that the presence of the saline solution in the
peritoneal cavity favors a large local leucocytosis,
which, according to the experiments of Durham and
Issaeff,' results in a peritoneal immunity against path-
ogenic bacteria for a certain length of time. Unless
persistent and progressive failure of the circulation is
observed in spite of strychnine and caffeine stimulation
combined with whiskey and saline enemas, however,
it is better to place the patient in the elevated head
and trunk posture from the commencement, since, in
addition to its principal advantage, this posture se-
cures early cessation of vomiting and the prompt expul-
sion of flatus.
DISEASE OF THE THORACIC DIVISION OF
THE SYMPATHETIC CHAIN.'
By JOSEPH FRAENKEL, M.D.,
The physiology, pathology, and symptomatology of
the sympathetic nervous system are admittedly still
obscure. Undoubtedly some have found herein an
inviting field for speculation, and others a not less
welcome excuse for hasty and harsh criticism of at-
tempts to elucidate the subject.
For centuries much ingenuity and labor have been
spent upon this question by earnest investigators; but
the results are so far very meagre indeed. The sum
total of facts concerning the sympathetic nervous sys-
tem that has been admitted into the text-books as per-
manent scientific acquisition is small. Most of the
text-books refer to the sympathetic only incidentally
and meagrely. In all, the familiar symptom groups
of destruction or irritation of the cervical division of
the sympathetic are described, with their bearing on
the diagnosis and localization of disease of the ner-
vous system. This last point is, however, often not so
fully considered as it deserves to be.
Recently, affection of the abdominal division of the
sympathetic chain has frequently been called upon to
explain more or less obscure pathological states.
The discussion concerning the role that the abdomi-
nal sympathetic may play in the causation of Addi-
son's disease, diabetes, colica mucosa, and similar
obscure conditions is not yet settled.
Apparently the least is known about the thoracic
part of the chain. It is known that from this part the
great splanchnic nerve takes its origin, but the exact
roots from which this nerve arises have not been
definitely ascertained. Some writers (Quain, Gegen-
bauer) assign the origin to the fourth, fifth, or sixth
dorsal, down to the ninth or tenth dorsal ; others (Lan-
dois) to the sixth cervical down to the fifth dorsal
ganglia. Further, it has been proven by experiments
that lesion of the great splanchnic nerve may lead to
death of the animal, through anaemia of the oblongata;
the animal bleeding into its own blood-vessels as it
were (Landois).
From a clinical standpoint, the only reference to
the thoracic sympathetic to be found in the literature
is in the first edition of Oppenheim's text-book, page
814, which reads: "In a very obscure case of abscess
formation near the thoracic vertebral column, there
was in life a unilateral oedema, which occupied the
whole corresponding side."
The writer recently had the opportunity of observing
a case, in many respects singular and remarkable, but
' Byron Robinson : 'Annals of Surgery, vol xxxi., No. 2, p.
223.
* Read before the New York Neurological Society, March 6,
I goo.
particularly valuable as a contribution to the subject
in question :
Mrs. B , thirty-seven years old, married, was
first seen July 25, 1898. She complained of head-
ache, irregular sleep, pain in the upper part of the
thorax of the left side and in the precordial region,
and finally of attacks to be described more fully below.
Her father died at the age of fifty-two years from
Bright's disease; her mother is eighty years old and in
good health, excepting occasional attacks of senile
bronchitis. The other members of the patient's fam-
ily, two sisters and two brothers, personally known to
the writer, are in good health; all, as well as the pa-
tient herself, are somewhat undersized. Concerning
the other branches of the patient's family, nothing
definite is ascertainable.
Mrs. B was of temperate habits, rather reti-
cent and quiet. When six years old, she fell from a
second-story window, without apparent immediate or
remote consequences. Menstruation began at the age
of thirteen and had always been normal. The patient
married at the age of twenty-three, against the wishes
of her family, a man who shortly afterward began to
ill-treat her, and who subsequently developed general
paresis. Soon after her marriage, the patient claims
to have "gone into a general decline,'" which the then
attending physician called " uterine displacement and
ansemia." Rest and treatment were followed by ab-
solute cure after two months, and she remained well
until the onset of the present disease, ten days pre-
vious to my first examination, i.e., up to July 15, 1898.
The patient claims to have been free from venereal
disease; she never had been pregnant; she states
further that she was more or less nervous all her life,
"as most women are," but emphatically denies ever
having had what people call " hysterics." This latter
statement is corroborated by the patient's sister.
The present disease developed without attributable
cause, out of vague symptoms of general nervousness
and irritability. These symptoms were unheeded, un-
til a nocturnal attack frightened the patient and her
family. About ten days previous to the date of her
first visit, the patient awoke at midnight with a pecul-
iar pain in the left upper extremity. This was soon
followed by painful contraction of the muscles of this
extremity, and later by contraction of the muscles of
the left lower extremity. Then the right lower and
finally the right upper extremities became painfully
contracted. According to the patient's description,
the hands assumed, during the spasm, the position
characteristic of tetany.
The attack lasted about from three to six minutes,
and terminated in a short laughing-spell; the patient
felt exhausted and soon went to sleep again. Alto-
gether three seizures of this type occurred during two
weeks. Apparently there was nothing like an aura
preceding these attacks. Furthermore the patient
complained of headache, but of a different kind from
those to which she had been subject during the
greater part of her life. The latter headaches were
apparently of a migrainous nature, coming once in six
weeks, preceded by a general feeling of malaise that
enabled the patient to foretell the attack, and most of
the time accompanied by nausea and vomiting. These
headaches were all over the skull, and of a throbbing
character. During the few months preceding the ill-
ness which I am describing, this type of headache dis-
appeared, and its place was taken by a more constant
feeling of dull ache, with an occasional sharp parass-
thesia on the top of the head (clavus — according to
description). She has occasionally some paresthesia
of her throat; not distinctly a globus, though. The
patient was nervous, depressed, and sleepless. She
arose tired and claimed to be practically ailing all
day ; " if it's not one thing it's another." The appetite
I032
MEDICAL RECORD.
[June 1 6, 1900
was whimsical, and occasionally attacks of uncontrol-
lable vomiting occurred. Every autumn the patient
used to cough for about two weeks, and she has a
slight cough now. There were no haemoptyses at any
time; the bowels were and had always been regular.
Micturition was normal. Menstruation was regular,
copious, of three days' duration. There was no leu-
corrhoea. There were no subjective complaints of
vision, although for some time she suspected that her
headache might be caused by some ocular defect, and
she was fitted with glasses.
Examination: The patient is of short stature, but
otherwise well-built, without somatic signs of degen-
eracy. She is well nourished. The skin is of good
color and free from scars. The hair is dark, streaked
considerably with gray. The teeth are good. The
pulse is 72, of normal qualities; respiration, 16; tem-
perature, 98 '3° F. The tongue is clean, of normal
shape and volume. Percussion and auscultation of
thoracic organs, as well as percussion and palpation of
abdominal and pelvic organs, reveal no noteworthy
findings. Examination of urine and sputum is nega-
tive. Vision, hearing, smell, and taste are normal.
The cranial nerves are normal. Motility and
co-ordination of upper and lower extremities are
undisturbed. Erb, Chvostek, or Trousseau phenom-
ena could not be elicited. Scattered areas of anal-
gesia and hypalgesia could be made out on the left
side of the body, and a few areas of hypalgesia on the
right side. Reflexes: chin and tendon reflexes of up-
per extremities were absent; patellar and Achilles
jerks were present and fairly lively ; interscapular and
upper abdominal absent; lower abdominal and plan-
tar present; pharyngeal reflex diminished ; conjuncti-
val and pupillary reflexes present.
The objective findings justified only one diagnosis;
that is, hysteria. Accordingly this diagnosis was
given to the patient and her family — although with very
little satisfaction. It is the conviction of the writer
that the simple clinical diagnosis, "hysteria," is often
extremely unsatisfactory, as long as an organic point
of exit is not detectable or there is not at least a
sufficiently evident etiological factor upon which to
rest an understanding of the condition. The therapy
that the patient was advised to follow was, therefore,
symptomatic and general only. She was advised to
spend more time out-of-doors, to abstain from stimu-
lants, to have a cold sponge bath daily, to avoid emo-
tional excitement; and finally she was given a pre-
scription for a mixture of bromide and valerian, to
be taken internally.
After four weeks the patient returned, reporting
slight improvement — in so far as only two other at-
tacks had occurred since the last visit. Still she had
many complaints. The search for the etiology was
this time as futile as before, and thinking a premature
menopause possibly at the bottom of the mischief, the
valerian-bromide mixture was replaced by a mixture
of bromide and ovarian extract.
On the 23d of September, the patient reported that
she had been free from well-defined seizures, but that
she was in general worse. Twitching and pain in the
whole left side of the body were more or less constant,
with considerable headache; sharp pain on the top of
the head and over the left eye. This eye and the left
side of face were swollen considerably on various oc-
casions. Sleep was disturbed, and she was tired in
the morning. She complained of pain around the
heart, frequent and severe, and of " fainting-like feel-
ings around the heart," with tingling and formication
in the left upper extremity. Objective examination
was as above.
Very little change occurred in the patient's condi-
tion until April, 1899; that is, nine months after the
onset of the disease. She had called at my office
from time to time, complaining constantly, and putting
stress at one time upon the one and at another time
upon several of the above-mentioned symptoms. The
chief complaints were headaches, disturbed sleep, at-
tacks of vomiting, pain in cardiac region, and attacks
of stiffness in the left upper extremity. A variety of
therapeutic procedures in vogue for these troubles
were tried, but all in vain.
On April 17, 1899, the writer was summoned to the
patient's house. She then was in bed, and stated that
she had become very ill during the last few days.
She was much prostrated and complained about every-
thing in general, and in particular about considerable
weakness, absolute loss of sleep during the last two
nights, and very severe pain around the upper left
thorax. The appetite and digestion were fair; the
bowels moved; she passed urine; she had no cough.
Temperature was 99' F. ; respiration. 28; pulse allo-
rhythmic (counting in the first sixth of a minute 20,
in the second sixth of a minute 14, and in the third
sixth 12), averaging about 130 beats in a minute,
otherwise of normal qualities. Physical examination
was absolutely negative, excepting for the above-men-
tioned sensory disturbances. The family was told
that all this might be but an aggravation of her origi-
nal disease, although the slight elevation of the tem-
perature, the peculiar behavior of the pulse, and the
localized thoracic pain, and particularly the perma-
nence of these symptoms, did not exactly fit into the
picture, but were on the other hand so vague as not
to permit of more definite interpretation. She was
given some indifferent acid mixture, and assured that
she would soon feel better, and she was encouraged to
get out of bed soon. Thirty-six hours after that, it
became necessary to see the patient at midnight, be-
cause she was reported to have become very much
w-orse. She then stated that she did not have a min-
ute's sleep during the preceding four days, and that
she was suff'ering indescribable agony. Temperature
was 103° F. ; pulse, 120, of good qualities; respira-
tion, 32. The tongue was slightly coated; the bowels
were constipated. Urine was passed, and a specimen
examined showed an excess of phosphates, but was
otherwise negative. Percussion and auscultation of
thoracic organs were negative; the heart, however,
was pushed upward, and at the base a loud systolic
murmur was heard. Astonished at this finding, con-
siderable attention was paid to it, and its existence
established beyond a doubt. It was thought that the
cardiac murmur was in all probability due to the me-
chanical displacement of the heart by the distended
stomach, but nevertheless the fever and the murmur
seemed to call for salicylic acid; so this was pre-
scribed. Further physical examination revealed con-
siderable gaseous distention of the stomach.
Of the reflexes present, the patellar reflexes were
somewhat weaker than on former examinations. Sen-
sibility was as above. The patient evinced consider-
able weakness in standing or walking, but there was
no actual motor paralysis.
To the family the findings of this evening were re-
ported, and the view expressed that a definite diagno-
sis could not be made, and that all these symptoms
occasionally occur in the course of a severe hysteria.
The next morning the patient looked very mucii
brighter and reported that, "After the first powder"
(gr. X. of salicylate of sodium) "I slept all night."
Thorough physical examination was absolutely nega-
tive. No trace of a heart murmur was audible; the
bowels moved; the pains subsided. She was left in
charge of the' nurse and advised to continue taking
her medicine. By the evening the clinical picture
had undergone a most remarkable transformation.
The patient was in a state of acute collapse. She
was pale, covered with perspiration, the features
June 1 6, 1900]
MEDICAL RECORD.
1033
were pinched, and in an aphonic voice she said, " I am
very mucli better." The head was drawn to the left
side; considerable tachypncea, enormous tympanitic
distention of the abdomen, and weakness of lower ex-
tremities were present. Temperature, 100^ F. ; pulse,
120. The nurse reported that the patient had voided
involuntarily but small quantities of dark, badly
smelling urine, and that she had vomited a few times
some fluid intermixed with small black particles, not
of fecal odor. The nurse was certain that consider-
able flatus had passed. A thorough examination could
not be made, and the patient was given some cardiac
stimulants. This remarkable change could not plaus-
ibly be explained to the family as being a continua-
tion of the original disorder, as it was very difficult to
familiarize them with the differential details between
a genuine and a hysterical or dynamic ileus.
The necessity of getting surgical advice was con-
sidered, but before the final decision was reached the
patient died.
Dr. Van Gieson, to whom I am indebted for the fol-
lowing notes of the post-mortem examination, was
asked to perform the autopsy. I said to him that
clinically the case presented the picture of a grave hys-
teria, and that the autopsy might reveal a severe or-
ganic lesion of the sympathetic chain, on account of
the severity and fatality of the case.
Autopsy : Body of a woman, apparently thirty to
thirty-three years old. About one-third of the hair
over the frontal region had turned gray. The re-
mainder of the black hair was only sparsely streaked
with gray. External inspection of the body disclosed
no abnormalities. The body was fairly well nour-
ished, even plump. The diaphragm on the right side
stands at the fifth rib, on the left side at the fourth in-
tercostal space. The pleural cavities contain no fluid.
The pericardial sac is normal. It contains about two
ounces of clear limpid fluid. The heart is normal.
The muscle is firm and the valves are normal. The
left lung has on its posterior surface near the apex a
thin pellicle of fresh fibrin about 3 cm. long and i
to \% cm. wide. The substance of the lung is nor-
mal, excepting a slight degree of cedema and a moder-
ate amount of emphysema. The right lung is in a
similar condition. The pellicle of fresh fibrin on the
posterior surface near the apex is a trifle less exten-
sive. The bronchial glands and bronchi are normal,
likewise the arch of the aorta, thoracic aorta, and
oesophagus.
The four upper thoracic sympathetic ganglia of the
left side and the intervening trunk are buried in a
mass of purulent material from beneath the parietal
pleura. The right inferior cervical ganglion is also
surrounded by purulent material. The details of this
involvement of the sympathetic are as follows : On
the left side, the subpleural purulent mass is centred
about the second intercostal space and its posterior
terminus. From this point the purulent mass extends
for a slight distance upward, for a greater distance
downward, and also laterally along the second inter-
costal space (see diagram). In its lateral course the
pus collection occupies about the posterior quarter of
the second intercostal space, burrowing under the pa-
rietal pleura, and elevating it above the surface of the
ribs, as a tense bulging, yellowish, opalescent mem-
brane, of about the size of a pea. When the elevated
pleura over the second space was cut, thick yellowish-
white pus flowed out. The pus collection extends
downward to the lower border of the fourth rib. It
does not, however, in the downward extension, reach
out under the pleura, along the ribs or intercostal
spaces, but is confined to the left lateral surfaces of
the vertebral bodies. The inferior tongue of the pus
collection lies in the angle made by the junction of the
ribs with the vertebral column, and partially fills up
this space. The pus lies beneath the pleura and has
stripped the membranes up from the bodies of the
vertebrae to a point above one-quarter of the circum-
ference of the bodies. The upper tongue of the pus
collection occupies the same position with respect to
the vertebral bodies and extends to the upper margin
of the first rib. The depth of this abscess is on the
average about y2 cm. There were no evidences of a
recent reactive inflammation in the neighborhood.
Thus it can be seen that a portion of the left thoracic
sympathetic chain is buried in this flattened, linear,
subpleural abscess. Indeed it seemed impossible to
dissect out the sympathetic chain, as it passed through
the abscess. Above the abscess, the inferior cervical
and the first thoracic ganglion were free and distinct;
below the pus mass, the fourth thoracic node, and the
remainder of the chain down to the great splanchnic
cord and semilunar ganglion, were free and normal;
Fig. I.— Interior of Thoracic Cavity, Showing Involvement of Sympathetic
by Collections of Pus in Inferior Cervical and Upper Thoracic Ganglia.
but the intervening segment was left hidden in the
pus collection and thickened pleura, and hardened en
masse. On the right side the thoracic chains and its
nodes seemed from macroscopic inspection to be per-
fectly normal, yet when the inferior cervical was cut
across a drop of pus oozed out from the region imme-
diately surrounding the capsule. Apparently this
thin layer of pus, enveloping the capsule of the right
stellate ganglion, had ploughed its way downward,
along the cervical cord, from some source in the neck,
for the pus showed no track of communication with
the abscess of the opposite side, and section of the
cord above the inferior cervical ganglion still exuded
scanty traces of pus. Unfortunately, just as we were
about to trace out the cervical sympathetic, to deter-
mine the source and extension of this thin layer of
pus enveloping the inferior cervical node, we were
forbidden to continue the examination. The autopsy
occurred at a private house, and the examination of
the sympathetic was deferred until the organs could
be studied first. The abdominal viscera are in gen-
eral normal, and while attentively examined do not
need individualized description for each organ. The
general peritoneum is smooth, lustrous, and perfectly
I034
MEDICAL RECORD.
[June 1 6, 1900
normal. There are positively no naked-eye evidences
of peritonitis, neither is there any collection of fluid
in the pelvic or abdominal cavities.
The hollow viscera with smooth muscle w^alls, such
as the stomach, intestine, and bladder, uniformly ex-
hibit a long, flabby condition and are seemingly dis-
tended a moderate degree, as, for instance, especially
the stomach and bladder. The liver, spleen, supra-
renal capsules, pancreas, mesenteric lymph nodes,
uterus, ovaries, and vagina seemed normal. The dia-
phragm has its natural arch, and the large abdominal
vessels are normal. Volvulus was looked for but not
found. The lumbar sympathetic cord was e.\amined
in detail on either side, and found normal. The left
aortico-renal plexus was also partially dissected out on
the right side, as well as a sympathetic trunk enter-
ing the left suprarenal capsule.
The semilunar ganglia are normal except that the
one on the right side has attached to the middle of
its upper surface a small, yellowish, cheesy nodule,
about 2 mm. in diameter. Just above, and to the
right of the right external iliac artery, apparently one
of the deep inguinal lymph nodes is swollen and
cheesy. Further examination was not permitted.
Anatomical diagnosis: Subpleural abscess involv-
ing the left second and third thoracic sympathetic
ganglia and thin capsule of pus enveloping the left
inferior cervical ganglion; localized apical acute
fibrinous pleurisy ; pulmonary oedema. The thin pel-
licle of fibrinous exudate under the apex of each lung
seems plainly secondary to the contact of those surfaces
to the pus collections on either side involving the sym-
pathetic.
Microscopical examination: The right inferior cer-
vical ganglion is surrounded by a zone of leucocytes
about 1-2 mm. thick, which shows very plainly to
the naked eye. Many of these leucocytes show vari-
ous stages of degeneration and disintegration, and
throughout the zone are great numbers of cocci of two
kinds: one, the predominant form, apparently staphy-
lococci, is grouped in clusters, while the other, seem-
ingly streptococci, are arranged in chains or linear
series. A number of bacilli are also present, resem-
bling morphologically the colon bacillus. This zone
of pus cells runs out in thin strings or stouter cords
and gets into the fat tissues surrounding the ganglion.
Bundles of nerve fibres, branches of the ganglion, are
also surrounded by envelopes of pus cells, extending
often some little distance from the ganglion itself.
Thus the zone of pus cells e.xtends out among the
branches of the node, and along the main trunk of the
cervical chain. The substance of the ganglia, how-
ever, is not infiltrated by the pus cells or bacteria,
nor have they even penetrated into the outer layer of
the capsule. The ganglion cells are not destroyed or
diminished in number; on the other hand, they are
normal as to arrangement and distribution. The in-
ternal structure of many -of these cells, however, is
abnormal. These cells, composing probably fifteen to
twenty per cent, of the entire number, seem plainly
degenerated; their central portions are bereft of gran-
ules, and remain clear after staining with Nissl's re-
agent, although the periphery still retains a number of
plaques, one or two rows in thickness. The nucleus
of such cells has an eccentric position, although its
internal structure appears unchanged. The pigment
contents of the cells do not seem abnormal in amount.
The semilunar ganglia and second and third right
lumbar nodes have also been examined, with the result
of disclosing only a very few cells indeed of the de-
generated variety mentioned above. Not over two or
three can be found in a section.
We have, on the one hand, an array of symptoms
which individually and collectively are often compo-
nents of the clinical picture, hysteria. The general
morale, the headache, the disturbed sleep, the vomit-
ing, precordial pain, the hemianassthesia, the contrac-
tures, the fugitive oedema, and finally the tympanites
and pseudo-ileus, are known to be occasionally con-
stituents of hysteria. The occurrence of hyperpyrexia
and a fatal issue in pure and genuine hysteria is de-
batable. There are just as many authoritative voices
in favor as against the first, and concerning the latter
it may be stated that fatal hysteria is not altogether
an unheard-of thing. It is true that I have been able
to collect only about fourteen cases of fatal hysteria
from the literature, and that none stood a thorough
critical test. However, I have in my own experience
seen two cases of death in hysterical patients under
similar conditions to the above-described case. At
any rate it seems to me that hysteria was the only
possible clinical diagnosis that could be made of
this case.
On the other hand, the anatomical findings are at
first sight rather bewildering. Unfortunately, the
anatomical examination could not be made so exhaus-
tive and thorough as the importance of the case seems
to have called for. But it is safe to assume that neither
the brain nor the cord could very well be called upon
to explain our clinical picture. To me at least it is
unknown that a lesion of brain or cord could produce
this kaleidoscopic symptomatology, except a severe
injury to the cord. Still even so, the symptoms would
naturally have been more stable, and finally in the
given case such a supposition is entirely out of the
question.
We have then practically a cold abscess of the rib,
which accidentally involved the thoracic division of
the left sympathetic, as an anatomical basis for the
described symptoms, and have to answer, with these
facts at hand, the following questions:
(i) Are the last scenes of the clinical picture neces-
sarily a continuation of the first act, or mere expres-
sions of the accidental localization of the given ana-
tomical lesion, and in no connection with the original
symptoms for which the patient sought relief?
(2) Supposing the above clinical picture to be a
continuous one, is there any causal relationship be-
tween the clinical symptoms and the gross anatomical
findings?
In the present state of our knowledge of the anat-
omy and pathogenesis of hysteria, and the anatomy
and physiology of the sympathetic, it would seem very
dangerous to attempt to answer these questions with-
out thorough and extensive study, which, however,
must be postponed for another occasion. For the
present, it is best to accept the verdict of the Roman
judges, " n. 1.," noii liquet.
Nephritis in Chickenpox. — Hans Haenel says that
nephritis as a complication of varicella is not so
very rare. Henoch was the first to observe these cases.
The affection is usually of a mild character, very sel-
dom fatal. It seems that the complication of varicella
with nephritis depends greatly on the character of cer-
tain epidemics, as the author observed six cases of
varicella, three of which were complicated with renal
disease. One of the cases was of unusual character,
and is therefore worth mentioning. A child one
year old, recovering from an attack of pertussis and
broncho-pneumonia, was affected with high fever,
which lasted for eight days. The physical examina-
tion was negative. On the second day the examina-
tion of the urine showed quite an amount of albumin,
hyalin and granular casts, and red blood corpuscles.
On the tenth day there was a new rise of temperature,
which was followed by a scanty but characteristic vari-
cella eruption. The author is of the opinion that the
June 1 6, I goo]
MEDICAL RECORD.
1035
primary nephritis was one of tlie prodromal symptoms
and is inclined to think that the abortive eruption was
due to the early elimination of the poison through the
kidneys. — Centralblatt /iir iiiiiere Medicin, May 19,
1900.
Some Points in Connection with the Etiology
and Treatment of Diabetes Mellitus. — Alexander
W. Beck says that while nothing is as yet definitely
known, it seems highly probable that in many cases
diabetes is due to bacterial influence. This is based
on: (i) The non-existence of uniform lesions after
death; (2) the occurrence of the disease between cer-
tain ages; (3) the occurrence of the disease in more
than one member of the family at the same time; (4)
the occurrence of the disease in certain races, and its
endemic form in certain countries. Nine cases are
cited as treated upon the theory of bacterial origin.
The bromide of gold and arsenic is well thought of,
but the chloride of gold and sodium proved a pro-
nounced failure. — InternatioJial Medical Magazine,
May, 1900.
Unusual Condition of the Skin and Kidneys fol-
lowing an Operation for Appendicitis W. G. Tay-
lor reports a case in which the removal of the dis-
eased appendix was followed by severe pain in the
incision. Two subsequent operations by removing an
adhesion attached to the under surface of the scar in-
volving the omentum relieved the pain, but nutritional
disturbances followed, and finally the kidneys, skin,
and bowels show^ed evidence of disturbed function.
The specific gravity of the urine went as high as i.ioo;
this the author considered due to glycogen. It is
probable that as a result of shock to the organic ner-
vous system the digestive tract suffered first, and no
doubt primarily the liver. The stomach undertook to
eliminate the imperfectly absorbed food stuffs, causing
anore.xia and irritability. Amenorrhcea and obstinate
constipation were additional means of retention, but
finally skin, kidneys, and bowels came to the rescue,
and the patient recovered, although she is not in per-
fect health. — Buffalo Medical Journal, May, 1900.
Rupture of the (Esophagus Caused by Vomiting.
— Bowles and G. R. Turner recently reported to the
Royal Medical and Chirurgical Society the case of a
woman aged si.xty-two, who after purging herself with
aloes and rhubarb became sick on taking some milk
and then took a tumblerful of salt and water to " clear
the stomach." The vomiting caused by the latter was
follow^ed by epigastric pain and collapse. There were
retraction and some rigidity of the upper abdomen,
vomiting having ceased on the occurrence of the col-
lapse. She was partially quieted by morphine, but as
she threw off the effects of the opiate her distress and
pain returned and emphysema of the neck set in.
Death came twenty-two hours after the attack. Au-
topsy showed, . one and one-half inches above the
diaphragm, a longitudinal rupture of the oesophagus
five-eighths of an inch long, with thin edges and no
peeling of the mucous membrane. The authors ana-
lyzed the literature of the subject, having been able to
find on record the histories of some sixteen similar
cases. — Journal oj Laryngology, May, 1900.
Some Illustrations of the Clinical Significance
and Importance of Decubitus. — J. O. Affleck de-
scribes the various postures characteristic of diseases
of the respiratory, circulatory, alimentary, and nervous
systems, a study of decubitus being most valuable to
diagnosis. Even in fevers, he says, it is a good sign
to find the patient lying on his side, particularly if
that attitude is assumed spontaneously, testifying as
it does to a fair measure of muscular strength; while
on the contrary, when the patient lies on his back and
tends to sink down low in the bed, it is regarded as an
evidence of great debility, and often of evil omen.
One serious accompaniment and result of this latter
posture is the condition known as hypostatic conges-
tion of the lungs. Taking the hint from this, it is
often excellent practice in attending a case of long-
lasting fever or debilitating disease, to have the patient
occasionally moved round on one or the other side,
so as to prevent blood stasis in the posterior parts of
the lungs. — Tlic Scottish Medical and Surgical Journal,
March, 1900.
Comparative Anatomy of the Pharynx in Ver-
tebrates— C. Chauveau studies the development of
the pharynx among branchial vertebrates, cyclostomes,
elasmobranchiates, teleosteans, batrachians, reptiles,
crocodiles, birds, and mammals. His study is of spe-
cial interest as showing that the human embryo in its
various stages of development successively presents
practically all the varieties of pharynx enumerated as
occurring in the various lower orders above mentioned.
— Annates des Maladies de f Oreille, etc., April, 1900.
Case of a Peculiar Form of Dwarfed Growth. —
John Thompson reports the case of a little girl aged
four years, whose height was only twenty-eight and one-
half inches, her weight twenty pounds and seven ounces.
The body was well nourished and fairly normal, and the
child was in good proportion. Intelligence was good.
The administration of thyrocol caused slightly in-
creased growth for ten months, after which it ceased
to have effect. The child suffered from seizures the
nature of which w^as obscure, but which finally proved
fatal. At the autopsy the only abnormal conditions
discoverable were great congestion of the brain, and
the persistence of a greatly enlarged but otherwise
healthy thymus gland. — The Scottish Medical and Sur-
gical Journal, March, 1900.
Salol in the Treatment of Smallpox.— Charles
Begg found that the administration of this drug kept
the patient free from all sense of irritation without
the slightest desire to scratch. This prevented e.x-
haustion from sleepless nights and drain to the system
from weeping vesicles and pustules torn by scratch-
ing, and avoided danger to the eyes from soiled fin-
gers. Secondly, all the vesicles terminated as vesi-
cles, and the stage of maturation was absent except in
a few isolated vesicles. The author has not observed
any evil effects from a daily dose of 3 i. continued for
long periods, and the slight mental depression some-
times caused at first quickly passes off with discontin-
uance of the drug. — The Scottish Medical and Surgical
Journal, March, 1900.
Disturbances of the Sympathetic System in Lo-
bar Pneumonia J. Eason, out of fifty-four cases of
lobar pneumonia, found twenty-four patients with une-
qual pupils, the inequality being due to unusual dila-
tation of one pupil. Twenty-one of these had the
large pupil on the side on which the signs of pneu-
monia were detected. The author suggests that the
condition of the pupils may be explained by the irri-
tation which the pneumonia causes to that part of the
sympathetic system which is known to act as the dilator
of the pupil. These fibres are said to pass from the
first, second, and third dorsal nerves to the inferior
cervical ganglion, and in their course must be inti-
mately related to the lung at its uppermost part. This
would explain why apical pneumonias appear spe-
cially liable to cause inequality of the pupils. There
are other indications that the sympathetic in this re-
gion is irritated in pneumonia, as the flushing and
pallor of the face, and in some cases a distinct though
not very great protrusion of the eyeball. — 7lie Scottisk
Medical and Surgical Journal, April, 1900.
1036
MEDICAL RECORD.
[June 16, 1900
Medical Record:
A IVei'kly Journal of Mi-dicinc and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Fl'KLISHERS
WM. WOOD & CO., 51 Fifth Avenue.
New York, June 16, 1900.
THE ANTI-VIVISECTION BILL.
The question as to the need or morality of tliat form
of investigation known as vivisection has been the
cause of more acrimonious discussion during the past
twenty years in Great Britain, and within the past
four or five years in this country, than of any other
subject connected with experimental research. The
men who experimented on animals and those who
agreed with these methods of gaining knowledge have
been characterized as inhuman, " without bowels of
mercy," and maligned and slandered in every pos-
sible way. In Great Britain the anti-vivisectionists
have been so far successful as to obtain the passing
of an act restricting the practice of vivisection, which
has, however, by no means had the eflfect of quench-
ing the ardor of workers in this branch of medical
science, although undoubtedly it has caused delay,
annoyance, and loss of time.
In the United States during the past three years
the opponents of vivisection have been busy, and
have, as is well known, introduced into Congress,
from the District of Columbia, a bill during that pe-
riod under the sponsorship of Senator Gallinger, with
the object of placing obstacles in the way of experi-
mental animal research. However, scientific men in
this country, judging that they had been supine in the
matter long enough, and fearing from the favorable
consideration accorded to the bill by the committee
on the District of Columbia, that it might be allowed
to slip through without the true bearings of the ques-
tion being clearly understood, prevailed upon the
committee to give to advocates and opponents of the
"anti-vivisection" bill a public hearing.
At this meeting, which took place on P'ebruary 21st,
friends and enemies of the bill presented their views,
and speaking without prejudice it may be asserted
that the vivisectionists had distinctly the best of the
argument. Of the statements made, those of Profes-
sor Welch, of Professor Bowditch, and of Dr. D. E.
Salmon were perhaps the most instructive. Dr. Welch
defined the situation and the attitude of the majority
of scientific men in regard to it accurately when he
said: "However much the advocates of the bill may
assert that its enactment will not interfere with the
proper uses of experimentation upon animals, and is
designed only to check abuses, it is to be noted that
the main part of their argument is an attack upon the
practically unanimous opinion of well-informed scien-
tific and medical men that experimentation upon ani-
mals is essential to the advancement of physiology
and medicine, and has conferred inestimable benefits
upon mankind. Nor is it surprising that anti-vivisec-
tionists should cling tenaciously to this position, inde-
fensible as it has become, for it is apparent that those
who are convinced of the great value of experiments
upon animals to science and humanity will hesitate
long before approving any legislation likely to check
the progress of scientific and practical medicine."
And, again, he points out that there is no need for
additional legislation restricting the practice of ani-
mal experimentation in the District of Columbia.
The existing law permits only "properly conducted
scientific experiments or investigations, which experi-
ments shall be performed only under the authority of
the faculty of some regularly incorporated medical
college, university, or scientific society." The result
of this discussion was that on March gth an amended
bill was printed for the committee, the only important
changes in which are that cold-blooded animals are
excluded, two classes of special certificates are omit-
ted, and a freer hand is given in the selection of anaes-
thetics. Some of the restrictions are made more severe,
and the most obnoxious features, in the eyes of its
opponents, are unaltered.
President Eliot, of Harvard Li^niversity^ writes on
the new bill and on the subject of the restriction of
vivisection generally as follows: "This bill is a slight
improvement on its predecessor, but is still very ob-
jectionable. I beg leave to state very briefly the ob-
jections to all such legislation: (i) To interfere with
or retard the progress of medical discovery is an inhu-
man thing. Within fifteen years medical research has
made rapid progress, almost exclusively through the
use of the lower animals, and what such research has
done for the diagnosis and treatment of diphtheria it
can probably do in time for tuberculosis, erysipelas,
cerebro-spinal meningitis, and cancer, to name only
four horrible scourges of mankind which are known
to be of germ origin. (2) The human race makes use
of animals without the smallest compunction as arti-
cles of food and as laborers. It kills them, confines
them, gelds them, and interferes in all manner of ways
with their natural lives. The liberty we take with the
animal creation in using utterly insignificant members
of them for scientific researches is infinitesimal com-
pared with the other liberties taken by iisor the people
who cry out against the infliction of any suffering on
animals on behalf of mankind. It is of course pos-
sible to legislate against an improper use of vivisec-
tion. For instance, it should not be allowed in sec-
ondary schools or before college classes for purposes
of demonstration only; but any attempt to interfere
with the necessary processes of medical investigation
is, in my judgment, in the highest degree inexpedient
and is fundamentally inhuman." In respect to Senate
Bill 34 its most serious defect is that it delegates
to men who are ignorant of medicine and science au-
thority to arbitrarily dictate concerning these matters.
It places in the hands of two laymen who constitute
the maioritv of the District commissioners the dutv
June i6, 1900]
MEDICAL RECORD.
1037
of deciding whether certain experiments upon animals
shall be undertaken in the District of Columbia.
There are other clauses of the bill which are unneces-
sar}', but the one just referred to must strike any un-
prejudiced individual as absurd.
In regard to the stand now being made against
vivisection, the fact should be remembered that all
scientific progress has ever been obtained in the teeth
of bitter and unreasoning opposition, and it could not
be expected that a method which so powerfully ap-
peals to the popular imagination and lends itself so
easily to the creation of distorted views should escape
the common fate. The public at large have in the
nature of things no accurate knowledge of the manner
in which experiments on animals are carried out, and
consequently the imagination runs riot and pictures to
itself the scientific laboratory as the scene of the most
grewsome happenings. The belief is widespread —
and this fallacy is unfortunately fostered and encour-
aged by many educated but prejudiced persons — that in
in all, or at any rate the majority of instances in which
animals are experimented upon torture is inflicted
upon them. Any one who is intimately conversant
with the subject knows well that such is not the
case, and that while there is no doubt that vivi-
section has at times been abused, and perhaps on oc-
casions is abused now, in the United States it is in-
variably conducted upon as humane lines as possible.
Of course no scientific man would contend that even
under existing conditions and as aided by anaesthetics
pain is not sometimes inflicted upon animals under-
going operation for experimental purposes. But at-
tention maybe drawn to these facts: First, that no
animal feels pain as man does — the higher the organi-
zation the greater the capacity for feeling pain ; and
secondly, that it is only pain given needlessly and
uselessly that is cruel. Pain given for beneficent rea-
sons cannot be termed cruelty. There is yet another
point in the plea for vivisection which does not ap-
pear to be appreciated at its full worth by the oppo-
nents of the method; that is, the benefits which
have accrued to the human race from experimental
animal research. It would not be too much to say
that almost every discovery of permanent value in
medicine and surgery had its origin in experimental
investigation. Charles Darwin some years ago made
use of these words: " I am fully convinced that physi-
ology can progress only by the aid of experiments on
living animals. I cannot think of any one step which
has been made in physiology without that aid."
There has been no proof that vivisection has been
abused in this country, and therefore it would seem
that more restrictive vivisection regulations than at
present exist would be both unnecessary and tiresome.
Sir Michael Foster, in a letter written to Professor
Hodge, of Clark University, in 1890, expresses him-
self as follows: " I have always said, and always shall
say, that the necessity of a restrictive law has never
been shown. The English commission failed to de-
monstrate any abuse such as could justify the measures
adopted, and from what I know of America and Amer-
icans I am confident that no such laws are needed
with you. Indeed my objections to the act as a poli-
tician are quite as strong as my objections as a physi-
ologist; the act is stamped with that mark of bad
statesmanship, meddlesomeness." This will probably
be the opinion of the majority of medical and scien-
tific men.
OUR REPORT OF THE AMERICAN MEDI-
CAL ASSOCIATION.
We take a commendable pride in referring our readers
to our exhaustive report of the meeting cf the Ameri-
can Medical Association. Although we reported the
proceedings in full up to the date of going to press,
there was not an hour's delay in the delivery of the
journal. Aside from the accuracy of the report, the
time of its presentation is a matter for gratification.
Without attempting to make any invidious compari-
sons, we feel warranted in stating that the Medical
Record stands alone in this respect, so far as the
timely publication of the proceedings is concerned.
We regret to notice that several of our contemporaries
that pride themselves on being rivals in this method
of journalism have been quite behindhand in this
respect. One, from which we might naturally expect
the most, as being the official organ of the association,
has no report at all for the last week, save that of the
president's address, which, of course, was furnished in
advance. Another journal, in order to make a fuller
report, delayed its edition, which, of course, is not
prompt journalism as understood in this age. Still
another journal had no mention at all. We say this
much only in plea for modern, progressive journalism
based on fair business principles, which consists in
giving the most news up to the latest date of going to
press, and not delaying the publication for mere con-
venience of what is mistakenly called generous rivalry
in journalistic enterprise.
NEW THEORIES OF PLAGUE PROPAG.\TION.
The apparently mysterious manner in which the bu-
bonic plague spreads itself to distant and widely sep-
arated localities gives becoming interest to any new
theories explaining such methods of propagation.
When it is considered that much of what is now
known concerning the character of the scourge has
been learned since 1894, wfien the specific bacillus
was discovered by Kitasato, the profession can con-
gratulate itself that very much has been accomplished
in solving many of the apparent problems which
attached themselves to propagating qualities of this
direful scourge. The isolation of the plague microbe
was the first step in this direction. Then followed the
various experiments by numerous observers, in con-
nection with inoculation tests and the more minute
and careful examination of autopsical lesions as bear-
ing upon their relations with symptoms and the way
in which the disease spreads in accordance with the
modern views of pathology.
So far it may be definitely stated that the plague
bacillus is the specific cause of the disease. This has
been abundantly proved by the usual bacteriological
1038
MEDICAL RECORD.
[June 16, 1900
methods of isolation of the micro-organism, its culti-
vation, its inoculation into animals, the transmission
of the bacillus through their bodies, and its final re-
covery from the dead victims. The latest theories
of the propagation of the disease are quite ex-
haustively presented in the work of Dr. Jose Verdes
Montenegro,' of Madrid, who in connection with other
important studies of the disease has summarized his
experience with the Oporto epidemic.
The rat is acknowledged to be a chief factor in the
dissemination of the disease, as this animal is pecu-
liarly liable to infection through the intestinal canal
and is notoriously migratory in his habits. Monte-
negro asserts that the plague is simply a disease of
rats which infects man. According to the observa-
tions of Simon, the epidemic among rats follows a
course analogous to that in man. After a period dur-
ing which the cases are not very frequent the plague
becomes suddenly very severe with a consequently in-
creased mortality. Thus it happens that before the
disease attacks man large numbers of dead rodents are
found in the houses and streets of a threatened district.
This was the case in Mandvi, where the street arabs
amused themselves by using the dead animals as mis-
siles in play.
Curiously enough Simon has discovered that preced-
ing the rat in initiative causative influences comes the
rat flea, which appears to have the real credit of start-
ing the humble bacillus in its ambitious tendencies
for better company. Simon says that a healthy rat
has very few fleas on it, but the sick animal becomes
very soon covered with them. The insects become
gorged with bacilli and transfer the disease not_ only
from one rat to another, but also to man.
While this very ingenious theory might explain
quite satisfactorily why some sporadic cases appear in
widely separated localities, it does not seem capable
of accounting for the actual explosion of an epidemic
which is evidently due to the varied conditions of
human infection. It must be admitted with all our
recent knowledge on the subject of propagation of the
disease gained by those who have had large experience
with the plague, that we have not yet arrived at safe or
definite conclusions upon the subject. Whether or
not the disease is contagious or infectious, whether
or not it depends upon soil or house contamination,
we certainly know one thing — that an epidemic when
once started burns like 5 devouring fire madly reach-
ing for available fuel. The epidemic influence, what-
ever it may be, gives the virulence of the disease a
new force and a new purpose. If we rule out the lat-
ter condition and confine ourselves to the study of iso-
lated cases, the conclusion seems almost irresistible
that the real danger of directly communicating the
disease from person to person is very much exaggerated.
It does not appear to be distinctly contagious in the
sense in which that term is now used. There is great
' " Bubonic Plague : Its Course, Symptoms and Means of Pre-
vention and Treatment," by Dr. Jose Verdes Montenegro,
Ex-interne Central University of Medicine and Professor at
Municipal Micrographical Laboratory, Madrid. Translated by
W. Munro, M.D., Medical Ofticer St. Kitts, W. I. New York ;
William Wood and Company. I900.
probability, however, that it is markedly infectious
under certain circumstances of careless contact. This
is most frequently manifest in cases of autopsy in
which the operator becomes infected through accidental
wounds coming in contact with the blood and secre-
tions of the corpse. Two of Kitasato's assistants ac-
quired plague that way. The experiences in the
Vienna laboratory, still fresh in the minds of medical
men, were on parallel lines. It is quite assuring to
know, however, that physicians, nurses, and tinder-
takers who come most in contact with plague cases
are seldom stricken when proper aseptic precautions
are taken. The danger appears more in the direction
of actual contact, actual and direct transmission of
virus, than by any other means. But a most ready
means of transmission of the disease is by house in-
fection, which by many high authorities is considered
to be the underlying and controlling factor in all wide-
spreading epidemics.
Regarding human infection the same laws govern as
in similar communicable diseases. With plague the
most direct avenue of infection appears to be by inoc-
ulation or by the transference of the germ to the naso-
pharyngeal mucus. Next in order come wound infec-
tion, contact with articles of soiled clothing, utensils
of sick-room, sputum or dejections generally, and, last
and perhaps least of all, constantly breathing the air of
the sick-chamber. It is by no means proven that the
intestine can be infected as in typhoid, as numerous
experiments on animals have proved the negative side
of this question.
^ems of the "tliSlcck
Sir John William Moore. — Among the recipients of
knighthood conferred in honor of Queen Victoria's
birthday is Dr. John William Moore, president of the
Royal College of Physicians of Ireland, and editor of
the Dublin Journal of Medical Science. Her Majesty's
advisers might have searched the United Kingdom
over without finding among the members of the medi-
cal profession one more worthy of this honor.
Dr. Pilcher a Doctor of Lavi^s. — Among the June
honors from the colleges may be especially noted the
degree of LL.D. conferred by Dickinson College upon
Dr. Lewis Stephen Pilcher, of New York, the editor
of the Annals of Surgery. Such an honor to a distin-
guished American surgeon is particularly appropriate
upon the part of an institution of which Benjamin
Rush was one of the founders and for many years an
active trustee.
Thirteenth International Medical Congress.— Dr.
Henry Barton Jacobs, secretary of the American Na-
tional Committee, writes that, according to instruc-
tions from Dr. A. Chauffard, secretary-general of the
Thirteenth International Medical Congress, no sub-
scriptions to the congress will be received after the
15th of July, and the name of no subscriber will ap-
pear in the official programme whose subscription is
not received before the isth of June. The publica-
tions of the Congress will consist of seventeen vol-
June 1 6, 1900]
MEDICAL RECORD.
1039
limes, one of which will be sent gratuitously to each
subscriber; that is, the volume containing the papers
of the section under which he has inscribed himself.
The other sixteen volumes may be purchased at a
price of 4 francs per volume, or 45 francs for the
series.
Dr. John V.' Shoemaker, surgeon-general of the
Pennsylvania National Guard, and acting president
of the trustees of the Medico-Chirurgical College of
Philadelphia, has been appointed a director in the
Department of Charities and Correction of Philadel-
phia.
The Lucien Moss Home for Incurables of the
Jewish Hospital, at Philadelphia, was formally dedi-
cated on June loth. The building, which cost $50,-
000, is an exceedingly fine fire-proof structure. It is
forty-eight by one hundred and thirty-four feet in size,
and constructed of stone, brick, and terra-cotta, with
a roof of slate.
University of Pennsylvania, Medical Depart-
ment.— Dr. J. William White has been elected Rhea
Barton professor of surgery and Dr. Edward Martin
and Charles H. Frazier clinical professors of surgery.
Dr. Richard M. Pearce has been elected demonstrator
of pathology, and Drs. William F. Hendrickson and
Frederick H. Howard assistant demonstrators of path-
ology.
Tuberculosis Declared Infectious. — The board of
health of Trenton, N. J., has placed pulmonary tuber-
culosis on the list of infectious diseases which must
be reported by the physician in charge. The latter
is allowed thirty days in which to make this report,
failing in which he is liable to fine or imprisonment.
When reporting existing or suspected cases the physi-
cian must forward sputum in receptacles which are to
be furnished by the board of health, in order that in
case there is any doubt cultures can be made. Hos-
pitals are not exempted from the general provisions.
After the death of a tuberculous patient the bedding,
clothing, and other articles which may have become
infected must, if possible, be destroyed by fire.
The International Congress of Obstetrics and
Gynaecology is unfortunate. The third congress, held
last summer in Amsterdam, was boycotted by German
gynaecologists who had taken umbrage at some action
of the estimable Dutch gentleman who presided over
the deliberations of the assembly. The fourth con-
gress, it has been announced, will be held in London
in 1902, under the presidency of Professor Simpson,
of Edinburgh, and now we learn from The Hospiia/ th&t
the past and present teachers of gynaecology and ob-
stetrics in the metropolitan medical schools now prac-
tising in London have decided with quite an interest-
ing unanimity to boycott this congress. "This they
do in sorrow, as a protest, not against the distin-
guished professor, but against the manner and source
of the invitation. . . . That an international congress
should be held in London and should be ' bossed ' by
the non-elect was too much to be borne." In view of
the present disjointed condition of the medical pro-
fession, our contemporary remarks, " it is somewhat in-
structive to note the sort of thing which is capable of
producing an absolutely unanimous action in any
group among its members, an action so unanimous
in this case that the letter in which the boycott was
announced was, we believe, signed by every member
of the set."
A Study of Alcoholism in Germany The Prus-
sian minister of education, Dr. Studt, has recently
ordered the government bureau of statistics to collect
material regarding the effects upon the nation of the
abuse of alcoholic beverages.
Smallpox is reported from several places in Massa-
chusetts, near Westport and New Bedford. The board
of health of the latter has ordered all the local mill
managers to exercise caution in giving employment
to help from Fall River and Westport.
A Temperance Congress. — The World's Temper-
ance Congress has been in session in London this
week under the presidency of the Archbishop of Can-
terbury. The archbishop delivered an address at the
opening of the congress on Monday, and on Thurs-
day entertained the members of the Congress at a
garden party at Lambeth Palace. The lord mayor, A.
J. Newton, gave a reception to the delegates on Fri-
day. A leading feature of the programme was a
grand cosmopolitan temperance meeting, over which
the Earl of Carlisle presided. Many Americans took
part in the deliberations and discussions of the con-
gress.
The Philippine Association of Acting Assistant
Surgeons, U.S.A. — The first annual meeting and ban-
quet of this association was held at the Paris Cafe,
Manila, on May 1st. The toastmaster was Dr. Harry
Morell. This association was formed on April 28th
on board the United States steamer Grant, on which
seventeen of the members of the society came over
to the Philippines to administer relief to the sick
and wounded soldiers. The following were elected
officers of the association : President, Dr. H. W. Beal ;
Vice-President, Dr. H. Morell ; Corresponding Secretary,
Dr. R. M. Inglish; Recorder, Dr. H. M. Stromberger.
Members—T)x%. F. M. Baker, L. P. Bell, H. P. Belt,
C. R. Byars, J. A. Collie, C. L. Hodgkins,' L. P.
Howell, G. L. Marcion, J. N. Merreck, J. L. Norris,
C. R. Ohliger, J. J. Reilly, E. R. Rockhill, W. H.
Spiller, S. A. Springwater, R. M. Thornburgh, E. M.
Trook, and C. E. Ward. It is the intention of the
association to enroll as members all the acting assist-
ant surgeons in the Philippine Islands and hold a
meeting and banquet on Dewey Day every year in the
future.
An Incident of the Tuberculosis Congress. — The
following amusing tale regarding the congress for the
study of tuberculosis, held recently in Naples, is re-
lated in The Practitioner. The members of the con-
gress '■ were expected to wear a badge, besides carry-
ing a little token showing them to be entitled to all
the privileges of membership. Both the badge and
the token were described as works of art which mem-
I040
MEDICAL RECORD.
[June 1 6, 1900
bers would be proud to display. But nothing seems
to have been said as to any official costume. The
dress-coat is recognized in Italy as a kind of ceremo-
nial vestment which must be worn on solemn occa-
sions. It may easily be imagined, therefore, that
when a considerable number of foreign members pre-
sented themselves without having on the regulation
garment, the native mind suffered a serious shock.
The ' undressed ' strangers were refused admission,
and when they attempted to assert what they consid-
ered their rights, they were promptly ejected by the
arm of the civil power in the form of policemen. So
hot was the fray that the police called firemen as aux-
iliaries! Thereupon the excluded ones retired to a
neighboring hostelry bearing the suggestive name of
Gambrinus; here, under the inspiration of the beery
genus loci, they drew up a formal protest against the
injustice and indignity to which they had been sub-
jected."
Navy Department, Bureau of Medicine and Sur-
gery, Washington, D. C— Changes in the medical
corps of the United States navy for the week ending
June 9, 1900. June 2A. — Passed Assistant Surgeon
A. M. D. McCormick detached from the Montgomery
and ordered to the Chicago. Assistant Surgeon J. R.
Whiting detached from the Chicago and ordered to the
Montgomery. June 6th. — Passed Assistant Surgeon
W. C. Braisted ordered to the Massachusetts immedi-
ately. Passed Assistant Surgeon L. L. von Wede-
kind detached from the Richmond and ordered to the
Indiana immediately. Pharmacist S. V\'. Douglass or-
dered to additional duty on the Massasoit.
The American Electro-Therapeutic Association.
—The tenth annual meeting of this society will be
held at the Academy of Medicine in this city on
September 25, 26, and 27, 1900, under the presidency
of Dr. Walter H. White, of Boston. The chair-
man of the committee of arrangements is Dr. Robert
Newman, 148 West Seventy-third Street, New York.
The secretary of the association is Dr. George E. Bill,
25s North Street, Harrisburg, Pa. The subjects an-
nounced for set discussion are " Electricity in Gynae-
cology and the Present Reluctance of Gynecologists
to Use. Electricity," and "Electricity in Tuberculosis
and the Present Modes of Treatment."
The Late Dr. Landon Carter Gray — "The mem-
bers of the New York Neurological Society wish to
record their profound sorrow at the untimely death of
Dr. Landon Carter Gray. As one of the earliest mem-
bers of the society, he was ever zealous in its behalf,
and during many years of his activity added much to
the interests of its meetings. His work was charac-
terized by care and thoroughness in preparation; his
thoughts were soberly presented in the light of a large
clinical experience, and his conclusions were those of
a sound thinker. In every line he wrote, and in
every word he spoke, there was evidence of broad cul-
ture and refinement. He was a kind friend to many,
disposed to help those who sought his counsel, and
was always ready to allow for honest differences of
opinion.
" Whereas, The members of this society have sus-
tained a severe loss in the death of their honored
friend and colleague; be it
"Resolved, That this acknowledgment of Dr. Gray's
estimable qualities be recorded in the minutes of the
society, and that a copy of these resolutions be sent
to the New York Medical Record,' the New York
Medical Journal, and the Medical News."
B. Sachs, M.D., C. L. Dana, M.D., Frederick
Peterson, M.D.
Dr. Edmund C. Wendt, of this city, recently gave
a reception at the Hotel Cap, Paris, in honor of the
United States commissioners to the Exposition.
Turkish Medical Students in Trouble The stu-
dents in the military medical school of Stamboul
recently rebelled against the system of supervision to
which they are subject. Ninety of them have been
arrested, and will be brought before court-martial.
Dr. John Wyllie, who was recently appointed to
the chair of medicine at the University of Edinburgh,
left vacant by the death of Sir Thomas Grainger Stew-
art, is said to have been the only one of the numerous
candidates who did not back up his application with
a stack of testimonials.
Another Testimonial to Dr. Jacobi. — The dinner
of the Section on Diseases of Children of the Ameri-
can Medical Association, which was held at the Hotel
St. Charles, Atlantic City, on Tuesday evening, June
5th, was made the occasion for the presentation to Dr.
A. Jacobi of a. handsome loving-cup and engrossed
testimonial from the section.
Obituary Notes. — Dr. James T. Whittaker, of
Cincinnati, died at his home in that city on June sth
of cancer of the intestine. He was graduated in med-
icine from the University of Pennsylvania in i866,
and from the Medical College of Ohio in 1867. Dur-
ing the civil war he served for a time as a private in
the army, and later as acting assistant surgeon in the
navy. After graduation he studied for a time in Ber-
lin and then began the practice of medicine in Cin-
cinnati. He was professor of theory and practice of
medicine in the Ohio Medical College, and was at-
tending physician to the Good Samaritan Hospital
and to the Cincinnati Hospital. Dr. Whittaker's con-
tributions to the literature of medicine were numerous
and important.
Dr. Melancthon Storrs, of Hartford, Conn., died
in that city on June 9th, from a septicrtmia contracted
during an operation. He was a graduate of the Yale
Medical School in 1853. During the Civil War he
served as brigade surgeon on the staff of Gen. Edward
Harland, and at the close of the war took up practice
in Hartford. He was a member of many local. State,
and national medical societies.
Dr. Paul Gibier, of this city, was killed in a runa-
way accident near the medical institute of which he
was the head, at Suffern, N. Y., on June 9th. He was
born in France on October 9, 185 1, and was gradu-
ated in medicine from the University of Paris in
1884. He was for several years an assistant at the
June 1 6, 1900]
MEDICAL RECORD.
1041
Pasteur Institute. His first public work was the
study of cholera and of Ferran's preventive inocula-
tions in Spain, and in 1888 he was sent by the French
government to Havana to make a study of yellow
fever. On his way home he spent some time in this
city, and a year later returned here to reside perma-
nently, opening a small hospital for the preventive
treatment of rabies. Later he built a large sanato-
rium in the upper part of the city, but a few years
ago moved the institution to Suffern. He was a
chevalier of the Legion of Honor.
Dr. Robert Locke, of Chicago, committed suicide
in the Occidental Hotel, San Francisco, on June 9th.
He was a graduate of the Rush Medical College.
Some time ago he was sent to the Philippines as a
government press censor, but ill health forced him to
return, and it was shortly after his arrival that he
shot himself.
Dr. G. R. Chambers, a dentist in Vineland, N. J.,
died on June 4th, of apoplexy. He was sixty years
old.
Dr. Valerius Idelson died recently at Bern, Switz-
erland. Dr. Idelson was an expatriated Russian, and
was for many years a contributor to American and
European journals of reviews of Russian medical pub-
lications.
^rogt-jcss of l^tXcdical J«cience.
AVtc/ yo7-k Ulediial Journal, June g, igoo.
The Treatment of the Opium Habit by the Bromide Method. —
A. Church says that the purpose of tliis plan of treatment
is to stupefy the patient utterly for a number of days, dur-
ing which time the opium is rapidly withdrawn and the
physical disturbance secondary to its withdrawal is recov-
ered from. The drug should be given only in the daytime,
gr. cxx. of sodium bromide in half a tumbler of water
ever)' two hours, until an ounce is given in the first day.
The second day a smaller amount is given in the same
way, and this may be sufficient, or it may be necessary to
continue the doses in the same way on the third day.
Three deaths occurring in twelve cases, although in each
instance attributable only remotely to the bromide, and oc-
curring when the bromide had been used in e.xtraordinary
doses, doses that can no longer be advised, show that the
plan of treatment is very far from being simple and with-
out danger.
.aistivo-Autumnal Fever in New Orleans, Summer and Au-
tumn, 1899. — H. A. Veazie concludes a series of articles, the
object of which has been to prove that the fever outbreak
in question was malarial in nature and had nothing at all
to do with yellow fever. The articles are of interest chiefly
from their bearing on various sanitary questions concern-
ing the locality in which the fever occurred.
Ethylic Bromide as an Ansesthetic for Short Operations. —
This agent is commended by P. F. Sondern, who gives a
brief description of its effects and of the proper method of
administration. Nothing new is presented.
Abstract of President's Address Delivered at the Fifty-first
Annual Meeting of the American Medical Association, Held
at Atlantic City, June 5-8, 1900.— By W. W. Keen.
The Collection, Preservation, and Transportation of Clinical
Material for Laboratory Examination. — By S. Hart.
Some New Traction Apparatus for Hip Disease, Pott's Dis-
ease, etc.— By R. T. Taylor.
Journal of the American Medical Ass' n, June g. igoo.
Neurasthenia and the Rest Cure. — Frederick A. McGrew
distinguishes three varieties of neurasthenia — develop-
mental, overstimulation, and developmental plus over-
stimulation neurasthenia. In some individuals asthenia
is a prevailing factor from the cradle to the grave. The
developmental neurasthenic is usually a wom.an of healthy
appearance who complains of chronic fatigue. This pa-
tient needs exercise, not rest. In the class of overstimu-
lation neurasthenia belong individuals, 'mostly men in
middle life, whose baneful habits end in exhaustion of
their inherited nervous vitality. The rest cure is here the
treatment par excellence, combined with massage, etc.
The developmental and over.stimulation elements may be
combined, either predominating. The degree of nerve
strain necessary to precipitate an attack is in inverse ra-
tio to the degree of developmental weakness. In those
cases in which loss of weight, dyspepsia, headache, neu-
ralgia, and other symptoms indicating a failure of nutri-
tion accompany a history of recent nervous overstrain, the
rest cure is the best thing, preliminary to sub.sequent treat-
ment, to develop nerve vitalit)' as indicated above under
the first class. On the other hand, with patients who have
succumbed to a slight overtaxation of the nervous system,
the overstimulation element may be disregarded alto-
gether, and treatment for the development of nerve force
instituted at once ; it is with this class that a sea-voyage
or a sojourn among the mountains proves most beneficial.
Improved Methods and Details in the Care of Patients
during Surgical Operations. — T. H. Turck gives methods of
preventing infection from the skin with hands, instru-
ments, sponges, etc. : of preventing the skin from becom-
ing contaminated, by the use of an improved laparotomy
sheet made from thin rubber dam fitted close to the body.
A similar arrangement for shutting off the peritoneal cav-
ity is figured. A thin rubber cylinder is employed to pro-
tect against leakage around a drainage tube inserted within
it. Another device is a thin rubber hot-water bag placed
within a gauze pad to apply heat to the viscera ; a temper-
ature of 4S' C. is that found most useful. Hot rubber
sponge pads are figured, and hot-water-coil slippers for
application to the foot-soles especially in preventing shock.
Intralaryngeal InsufQation. — Rudolph Matas gives details
of a procedure for the relief of acute surgical pneumo-
thorax. He concludes his article with a history of pulmo-
nary insufflation as applied to the surgery of the chest,
presenting drawings of bellows, insuflSating-tubes, etc.
The features of the apparatus presented by the writer are
that the original O'Dwyer cannula is modified so as to be
used as a respirator, tampon cannula, anaesthetizer, tractor
of the larynx and tongue, insufflator, and as an aspirator.
In total extirpation of the tongue, etc., the value of an ap-
paratus which will permit of easy respiration while the
larynx is securely plugged, can be readily appreciated.
Address of Chairman, Section on Practice, American Medi-
cal Association. — By George Dock.
President's Address, American Medical Association. — By
W. W. Keen.
Typhoid Fever among American Soldiers in 1898. — By V.
C. Vaughan.
Philadelphia Medical Journal, June 9, igoo.
Criticism in Medicine. — George Dock finds a discouraging
fact in the waning influence which medicine has over the
layman. While the science is becoming more candid and
more accurate, the grossest delusions flourish and the ridic-
ulous claims of half-crazed brains find believers by thou-
sands. This is an age of little respect for authority.
Healthy scepticism can do no harm, and it is well to re-
member that with all our great advances there are still
about us some relics of medisevalism. It is often impossi-
ble to distinguish the wares of the professor of chemistry
or pharmacology from those of the modern seekers after
the philosopher's stone. Commercialism is largely le-
sponsible. He fears tliat false prophets will last long into
the twentieth century.
Conclusions Reached after a Study of Typhoid Fever among
the American Soldiers in 1898. — By Victor C. Vaughan.
Gastric Ulcer : Non-Perforating Hemorrhage. — By William
L. Rodman.
The Endowment of Medical Colleges.— By W. W. Keen.
Gastric Hemorrhage.— By W. L. Rodman.
The Boston Medical and Surgical Journal, [une 7, igoo.
A New Intra-Abdominal Method for Retroverted Uteri. —
George W. Kaan says that in all cases of retroverted uteri
the round ligaments, with the peritoneal covering, are
elongated, and his method consists simply in puckering
them upon a gathering string, and so shortening them that
the uterus is brought into normal position. He picks up
the round ligament and peritoneum together with a double
hook, about midway between the cornu of the uterus and
the internal abdominal ring, then passes a suture of silk
subperitoneall)' from the uterus as far outward along the
round ligament as seems necessary. The tissue is puck-
ered along this suture, the two ends of which are then tied
together with moderate traction. To avoid its cutting
through, the silk used is of medium size, and is passed into
the tissue of the fundus at its point of entrance, and through
ligamentous tissue at its exit. The strain on this stitch,
however, is not nearly so great as upon the stitches of a
ventral suspension, which drags the uterus out of position.
I042
MEDICAL RECORD.
[June 1 6, 1900
Report of Cases in which the Bacillus Aerogenes Capsu-
latus was Found. — Joseph H. Pratt and Frank T. Fulton
report five cases and draw the follow! ngconcUtsions : Only
one of the cases was a pure infection with the gas bacillus,
but this case shows what marked pyogenic properties the
gas bacillus may possess. In these cases the organism
appeared to gain entry into the tissues from the gastro-
intestinal tract. In two, infection was probably referable
to dirt containing the gas bacillus which gained access into
the body through wounds of the skin. The bacillus is
shown to be easily destroyed by cold. The lesions pro-
duced by it on a muscle tissue are remarkable. This was
shown in two cases of emphysematous gangrene reported
by Dr. Thorndike. In some places the tnuscle fibres were
broken into small pieces — the appearance being that of
debris thrown about by an explosion. In other places de-
generation and digestion of the muscle fibres appeared to
have taken place.
New Nasal Scissors for the Removal of the Lower Tur-
binate.— Carolus M. Cobb de.scribes scissors which are
more convenient to use than the turbinate saw, and leave
a cleaner cut. The fault with most nasal scissors is that
the blades are not firm enough to cut through the body of
the turbinate ; the blades either slip by each other, or one
is not able to put force enough on the handles to make the
points cut anything more than the mucous membrane.
The blades of this instrument are short, and the whole so
strong that the blades will cut through any part of the
lower' turbinate. The shape of the instrument allows the
operator to reach any part of the lower turbinate that can
be reached by the saw or by any other instrument except
the cold wire snare.
Clinical Report of Cases of Infection due to the Bacillus
Aerogenes Capsulatus of Welch. — Paul Thorndike describes
four cases which were, clinically speaking, cases of malig-
nant oedema ; in two of these the bacillus present was not
the Koch bacillus, although similar to it. Dr. Post con-
siders that the symptoms of malignant oedema may be
caused by other spore -bearing, gas-producing organisms
equally well as by the bacillus known as that of malignant
oedema. The lesson deduced by the author from the cases
reported is to operate as early as possible, but operate even
after the time when the whole of the diseased tissue could
have been removed by earlier operation.
Chairman's Address before the Section on Practice of Medi-
cine.— By George Dock.
The Endowment of Medical Colleges. — By \V. W. Keen.
Gastric Hemorrhage. — By W. L. Rodman.
The Lancet, June 2. igoo.
Preventive Inoculation against Typhoid Fever. — A. G. R.
Foulerton describes the different steps which have led up
to the introduction of inoculative measures, and gives some
figures indicative of results thus far obtained. In regard
to the length of the protective period he says that if we
accept the persistence of the agglutinative power as an
indication of the persistence of immunity, the protective
effect lasts for two j'ears. The immediate effects of inocu-
lation are often unpleasant, but they are only temporary.
The symptoms following the inoculation have been as fol-
lows. Toward the evening more or less severe constitu-
tional symptoms may set in ; thus there have been severe
frontal headache, slight shivering, and in one case actual
rigors and nausea, accompanied sometimes by vomiting.
A tendency to syncope is sometimes present ; it occurs
within between four and six hours after the inoculation
and very soon passes off, but is quite sufficient to render
it necessary that the recumbent position for some hours
should in every case be insisted on. All these constitu-
tional symptoms, except perhaps a little headache, have
invariably disappeared by the next morning — that is to
say, within about eighteen hours of the inoculation. The
patient feels fairly well except for the local reaction which
now begins to make itself felt at the site of inoculation.
The local reaction results in a firm and painful (edema of
the subcutaneous tissue with redness of the skin over it
extending for about two inches round the puncture made
by the syringe ; there may also be redness of the skin ex-
tending for some little distance along the line of the lym-
phatics. Shooting pains may be present which radiate
from the puncture in the flank principally upward toward
the pectoral region. The inguinal glands are enlarged and
tender. By the following morning all the signs of local
inflammation will have disappeared in nearly every case,
and the completeness of the disappearance of what is some-
times a very intense local reaction in the short space of
time is very striking. The only remaining effects of the
inoculation felt by the patient are a general feeling of tired-
ness and a sensation of bruising and stiffness about the
site of inoculation, although no trace of redness or oedema
is now perceptible nor is there any tenderness on pressure.
Removal of a Foreign Body from the Ear.— J. G. Ma-
caskie's patient was a school-boy who had pushed into the
ear the india-rubber attached to a pencil. Owing to its
flat surface and the depth to which it had gone, it was im-
possible to remove it bj- either forceps or syringing. Ma-
caskie therefore teased out a small piece of twine, and giv-
ing it a good coating of some adhesive material, packed it
against the rubber, surrounding the whole with cotton
wool. It was allowed to dry for twenty-four hours. Then
gentle traction on the string easily removed the whole
mass.
Intestinal Obstruction due to Persistent Meckel's Divertic-
ulum; Successful Laparotomy. — By F. Fawcett and R. F.
Jowers. The patient was a girl aged eleven years, with
evidences of intestinal obstruction referred to intussuscep-
tion. Abdominal section showed several coils of small gut
tightly nipped by a thin cord which came from the extrem-
ity of a IVIeckel's diverticulum, which was again attached
to the bowel, forming a ring through which the strangu-
lated coils liad slipped. Recovery was uneventful.
A Contribution to the Statistics of Rheumatic Fever and
its Complications. — W. C. Bosenquet analyzes four hundred
and fifty cases of rheumatic fever treated in the course of
eight years at the Charing Cross Hospital. Statistics are
given as to age, sex, heredity, occupations, season, onset,
duration, location, complications, causes of death, and treat-
ment.
On Operations for Cancer in the Aged. — E. H. Freeland
records the case of a spinster aged eighty-two years, who
underwent an operation for cancer of the mamma. Imme-
diate surgical results were successful, and the patient lived
about eighteen months, dying of sudden heart failure.
The .growth had not recurred.
Note on the Passage of a Calculus of Exceptional Size
through the Right Ureter and the Urethra of a Man of
about Fifty Years of Age. — By J, A. Cunningham.
The Use of Massage in Recent Fractures and Common In-
juries.— A clinical lecture by W. H. Bennett.
A Case of Two Aneurisms of the Transverse Arch of the
Aorta. — By G. J. Arnold.
Primary Syphilitic Chancres. — A clinical lecture by Jona-
than Hutchinson.
British Medical Journal. JMay 26 and /une 2. igoo.
The Treatment of Puerperal Eclampsia by Diuretic Infu-
sions.— Roljert Jardine treats these cases on the principle
of toxic elimination ; he believes that the renal activity
should be stimulated immediately during the actual attack,
and considers saline infusions of sodium chloride and po-
tassium bicarbonate or sodium acetate the best means of
producing early diuresis. The fits should be controlled by
chloroform, chloral, or the bromides, or if the pulse be quick
and tense ten or fifteen minims of tincture of veratrum
viride .should be given hypodermically. Free catharsis is
produced by administering four to six tablespoonfuls of
magnesium sulphate in water, using a tube if necessary.
The skin should be kept active by steam or hot pack. The
most important part of the treatment is the subcutaneous
infusion under the breasts, into the abdominal wall or ax-
illa of a hot (104' F.) saline solution containing half a
drachm each of .sodium chloride and of potassium bicarbo-
nate to the pint of water. Of twenty-two cases treated, in
twelve this solution was employed, while in the last ten
cases he used a drachm each of sodium chloride and sodium
acetate to the pint. One to three pints were infused at a
time, repeated as indicated. Seventeen patients recov-
ered : one of the five died from perforating duodenal ulcer.
In all cases the urine was increased in quantity, and the
percentage of urea and uric acid rose. Of the twenty-three
children, ten were alive and thirteen dead. Of the ten
full-time children all were saved except two on whoni
craniotomy was performed. In two cases in which urine
was obtained from the new-born it contained albumin in
considerable quantity.
The Treatment of Smallpox by Salol. — J. Biernacki and
P. N. Jones discuss the suggestion made by Charles Begg
that salol will arrest the development of the rash iia the
vesicular stage. A score of cases were subjected to this
treatment. AH but eight had been vaccinated, so that
modification of the process aside from salol was to be
looked for. Their conclusions based upon the eight cases
are that salol may practically avert general pustulation,
and even Iiave a partial abortive effect when given after
maturation has commenced. The influence of the treat-
ment on maturation is, however, not constant in degree,
and in one case was almost ;///. Short of an abortive effect,
it almost invariably hinders pustulation, so that the pus-
tules form tardily, the process being imperfect in a much
higher proportion than usual. The cutaneous inflamma-
tion is slight, and irritation commonly absent even in con-
fluent cases. There is generally an entire absence of
unpleasant odor. Scarring is inconsiderable and often
June i6, 1900]
MEDICAL RECORD.
1043
absent, the scabs scaling ofiE with great rapidity. The
most remarkable eii'ect of the treatment is its effect on the
secondary fever, which, if not absent altogether, is as a
rule of little importance. These results appear to resem-
ble, but exceed, those obtained by the red-light treatment.
On the whole, the statement is justified that salol affords
a means of treating smallpox superior to the methods in
vogue.
A Case of Puerperal Septicaemia ; Treatment by Antistrep-
toccus Serum; Recovery. — Harcourt Gervis reports the case
of a woman suffering from puerperal sepsis, seen by liim
on the sixth day after delivery. There were a slight oft'en-
sive discharge, some tymphanites, and diarrhcea. Injec-
tions of 10 c.c. of antistreptococcic serum were made morn-
ing and evening for six days, until the temperature of
105.5° F. and ijulse of 144 fell to 99° F. and pulse 8S re-
spectively. The uterus, at first irrigated with i ; 4,000 bi-
chloride solution, was subsequently washed out with a
1 : 2,000 solution of chinosol. An apparent relapse or rein-
fection occurred a week later with high temperature, and
serum was again injected and the uterus scraped ; but a
subsequent parametritis explained the symptoms. Gervis
believes that septic absorption was stopped after the sixth
day, and that the further injections were unnecessarv, and
that curetting should not have been performed. He in-
jected in all 170 c.c. of seriJm, and concludes that antitoxin
is harmless ; that no one should be satisfied, when treating
a case of puerperal fever, unless, in addition to the ordi-
nary methods of treatment, he also employs antistrepto-
coccic serum.
Chronic Brass Poisoning. — ^William Murray gives the clin-
ical picture of an aft'ection seen in metal manufacturing
centres which is apt to puzzle a stranger. Symptoms may
come on only after years of brass polishing. The first in-
dication is usually anasmia. A green line on the teeth may
be seen very early. Later on subcutaneous fat gradually
diminishes and progressive emaciation supervenes. Dys-
pepsia, gastralgia, catarrh, itching skin eruptions, etc.,
are among the symptoms. E.xcessive debility and nervous-
ness are among the features of the early stages. Whether
it is the copper or the zinc of the alloy which poisons has
not been definiteh^ a.scertained. Phosphorus has been
found to act beneficially. Milk diet and change of occupa-
tion are advi.sed.
Remarks on the Pathology of Acute Yellow Atrophy of the
Liver. — J. W. Findlay gives with pathological illustrations
clinical notes of a case of acute yellow atrophy in a girl
aged fifteen years. Distinct evidences of proliferation and -
division of the hepatic cells were noted in the peripheral
parts of the lobule, and such proliferation is considered a
forerunner, not of degeneration but of regeneration of the
proper hepatic tissue. Fattj' degeneration of the hepatic
cell is considered the primary lesion and connective tissue
increase secondary. Some of the writer's pathological
conclusions differ from those of other observers quoted.
Hsematometra in Right Horn of an Undeveloped Double
Uterus, Successfully Treated by Abdominal Section. — Bv F.
W. N. Haultain.
A Clinical Lecture on Puerperal Inguinal Parametritis ; or
the Common Kind of Pelvic Cellulitis. — By G. E. Herman.
A Case of Uterus Bicornis Accidentally Discovered after
the Patient's Fourth Pregnancy. — By C. Hubert Roberts.
Two Cases of Extirpation of the Uterus for Excessive Hy-
pertrophy and Prolapse. — By T, Arthur Helme.
A Case of Enteric Fever of Three Months' Duration. — Bv
William Murrell.
A Case of Rigid Os Uteri Treated with Cocaine. — By E.
F. Clowes.
Case of Bromoform Poisoning ; Recovery. — By T. Brown
Darling.
On Vaginal Hysterectomy for Uterine Prolapse. — By R. C.
Chichen.
Two Cases of Bromoform Poisoning; Recovery. — Bv C. E.
Stokes.
A Clinical Lecture on a Case of Cholecystotomy. — By James
Swain.
Chronic Eczema Cured by an Abscess. — By P. A. Long-
hurst.
The Radical Cure of Femoral Hernia. — By T. E. Gordon.
Infectiousness of Acute Rheumatism. — By C. W. Lanson.
Berliner klinische Woclienschrift, ?\'o. si. May 21, igoo.
Treatment with Hetol. — C. A. Ewald gives his experience
with this remedy, which is the commercial name of cinna-
mate of sodium. Twenty-five cases of pulmonary tubercu-
losis were placed upon a course of treatment therewith.
Of these, eleven patients were during the whole period free
from fever, ten had long afebrile intervals, while in only
four did the fever persist. None of the cases had cavities
when the administration was begun, though all but twu
showed bacilli in the sputa. The remainder of the article
goes into the details of the cases and cannot be analyzed
here. Ewald believes that the remedy is deserving of a
further trial, but he is unwilling to accept, (m the basis of
results thus far attained, the sweeping claims of Landerer
and others who have been its advocates.
Are Special Divisions for Tuberculous Patients Necessary
in General Hospitals? — This question is answered in the
affirmative by E. Aron, though he does not take the ex-
treme views of some of the latter-day sanitarians.
Haemolysine. — By P. Ehrlich and J. Morgenroth.
F)-ench Joui-nals.
The So-Called Pernicious Dysenteric Fever. — S. Kanellis.
and J. Cardamatis, having observed many cases, conclude
(i) that pernicious dysenteric fever is not an especial or
essential morbid entity. (2) A similar form does not re-
sult primarily from paludal miasm, that is to say, this ele-
ment cannot produce essential dysenteroid catarrh. (3)
In case of complication of dy.senteric paludal miasm the
products of one of the causes cannot influence those of the
other excepting by the debility of the organism which both
bring about. Each one of the nosological entities evolute
in the same organism independently of the effects of the
other, each progressing in the nosological camp on its own
account. (4) These two nosological entities do not .oppose
each other nor join forces, and when they follow out their
evolution in the same organism the one does not the less
predispose the soil for the establishment or for the renais-
sance of the other disease after the debility of the organism,
which it produces. (5) Dysenteric fever, called pernicious,
should be erased from the list of malarial fevers, since it
does not exist with th(? nosological properties which ai-e
attributed to it. It should be referred to as paludism,
complicated with dysenteric catarrh,— /,<• Progres Medi-
cal, May 19, 1900.
Hypertrophic Alcoholic Cirrhosis with Diabetes. — A. Gil-
bert and P. Lereboullet report two observations which
seem to belong to the class of indurated and indolent hy-
pertroijhy of the liver in alcoholics affected with diabetes.
In one case intemperate habits were persisted in ; little
treatment was carried out, and the cirrhosis ended in death
with hypothermic coma without the disappearance of sugar
from the urine. In the second case treatment was di-
rected toward the cirrhosis, and the glycosuria disappeared
coincidently with marked improvement in the hepatic
symptoms. It is thought that in both cases the evolution
showed the dependence of the diabetes upon the hyper-
trophic cirrhosis, and the liver disease seemed to govern
the evolution of the diabetes instead of causing the sugar
to disappear as is the case in atrophic cirrhosis. — Gazette
Hetulomadaire de Medecine et de C/tiriirgie, May 20, 1900.
Traumatic Bilateral Cowperitis in a Bicyclist. — E. Ozenne
records an instance of this affection due to falling forward
upon the point of the saddle. There was burning in the
canal on urinating and perineal discomfort for the rest of
the day. The following day there was painful tumefac-
tion on either side of the canal. The Cowper glands could
be made out behind the bulb in the membranous portion,
especially on combined rectal and perineal touch, or rather
ano-perineal touch with the thumb and index of one hand.
The swelling was firm and olslong along the canal. Sim-
ple treatment and rest brought about prompt relief. The
glands were still to be felt at the end of six weeks. — Jour-
nal de Medecine de Paris, May 27, iqoo.
Syphilis of the Liver. — P. Hutinel in his course on inter-
nal pathology states that hepatic lesions are among the
most frequent and the most severe manifestations of vis-
ceral sj'philis, both hereditary and acquired. The lesions
are diffuse or gummous with small infiltrations. Small
nodules are generally associated with diffuse infiltrations.
Diffuse lesions are found in infancy, while in the adult
sclerous lesions are found about the vessels, especially the
hepatic artery. Recent lesions disappear under treatment,
but it is diflScult to bring back normal vitality to a liver
which has been the seat of old filjrous lesions. — La Tribune
Medieale. May 23, 1900.
The Plague in Australia and South America. — Netter re-
views the history of the plague in these countries. He
finds that the first cases usually escape recognition. The
period between their occurrence and the official recogni-
tion of the presence of the plague varies from one to sev-
eral months. At times the exact time of first invasion
cannot be determined. Early bacteriological researches are
insisted upon. Even when prophylactic measures have
not been taken epidemics have remained limited in extent.
An extensive development can occur only in insalubrious
localities or quarters. — La Presse Medieale, May 26. 1900.
Repose and Exercise in Cardiac Disease. — H. Vaquez cau-
tions against a too exclusive drug medication in heart dis-
ease. He does not pretend to claim that exercise can be
1044
MEDICAL RECORD.
[June 1 6, 1900
set up as a systematic treatment for all cardiac affections,
but applied to particular forms and individual cases it may
render great service, and this is in some instances so con-
siderable that physicians cannot longer afford to ignore it
as one of the curative measures. The theory and technique
are discussed. — La Prcsse Mcdicale, May 23, 1900.
Ulcero-Membranous Anginas. — Bonnus and Deguy give a
number of observations upon an angina showing fusiform
bacilli and spirals. The first may exist al6ne, the spirals
being merely associate forms. These cases must be recog-
nized so that rational therapy can be established. Anti-
septic applications, tincture of iodine, phenosalyl, and chlor-
ate of potassium are recommended with frequent gargling,
and ox)-genated water renders good service. — Journal dcs
Piaticicns, May ig, lyoo.
Psoriasis Treated by Full Baths Containing Oil of Cade. —
Balzer and Mousseaux olf'er a new method of applying oil
of cade. A soap emulsion is made with one part of green
soap and two parts of water. To 100 gm. of oil of cade is
added enough of this emulsion to make 250 c.c. to be
added to each bath. The results have been about the same
as after other forms of active treatment, but it is considered
more agreeable for the patient, who continues at his occu-
pation.— /ouriia/ di'S l'ial!cu'iis,'Sia.y 2(>, igoo.
Acute Blennorrhagic Aortitis and Endocarditis. — Bodier
and Laroche call attention to an attenuated form of endo-
carditis* in gonorrhcea, giving the liLstory of a case with aor-
titis. Modifications in the volume of the aorta ma)' at times
be qviite rapid. Salicylates and revulsives are recom-
mended. These cases should be recognized early b)? daily
examinations of the heart in the cour.se of gonorrhoea. —
Ca:t//i' di-s Hopitaux. Jlay 22, 1900.
Treatment in Strangulated Hernia. — Pauchet says that
taxis should not be attempted ; most deaths after operation
are to be attributed to preceding attempts at reduction.
Directions for operating are given, and the steps to be taken
wlien gangrene is present. Radical cure in various forms
of hernia is described. Opium must never be given after
abdominal operations. — Journal de Medecine de Paris,
Jlay 20. 1900.
Acute Spinal Perimeningitis. — A. Delearde discusses the
inflammation of the cellulo-adipose tissues which envel-
op the dura mater of the cord and separate it from the
vertebrae. Historical considerations, etiology, pathology,
and treatment are discussed, and a case is reported. The
abscess should be opened by incision of the vertebral lam
ina:. — Ga:clle Hcbdomadaire de Mi'dc'ciite, yi&y 27, 1900.
Digitalis in Heart Disease. — Professor Potain considers the
indications and contraindications of this drug, which is a
very useful and powerful remedy without possessing any
succedaneum. It should be employed with great caution,
.since in too strong or too long-continued dose it may prove
injurious. — Le Bulletin Medical, May 26, 1900.
American Journal of /lie Medical Sciences, fuiie, iqoo.
A Contribution to the Pathology of Chronic Hyperplastic
Tuberculosis of the Ceecum, Based upon the Study of Two
Cases, in One of which Carcinoma of the Csecum Coexisted.
— T. R. Crowder contributes an elaborate article in which
the subject of caecal tuberculosis is carefully studied. He
says that a review of the clinical histories and the post-
mortem findings proves that with active, destructive, and
disseminated tuberculosis of the intestine there is usually
found in the lungs a similarly active process, while in cases
of localized chronic caecum tuberculosis there is quite as
frequently found a latent healed or healing pulmonary
involvement. In primary tuberculosis of the caecum the
general conditions would be much the same as in that con-
tracted from a healing pulmonary lesion. The clinical his-
tory seems often to point to such a primary infection, but
even when the physical examination fails to show any
involvement of the lung there is found post mortem an old
lesion. On account of this slight involvement, or the ina-
bility to demonstrate clinically any at all when the tumor
is first noticed, many authors have concluded that the pul-
monary aff^ection is secondary. Opposed to this view are
two facts : the extreme rarity of localized CEecum tubercu-
losis with no lung findings, and the extreme frequency of
slight ancient pulmonary involvement. Even when a
patient with a tuberculous cfecal tumor has died of a later
pulmonary tuberculosis there has been found evidence of
an old latent or healed preceding process which may have
given rise to the caecal trouble.
Permanent Non-Progressive Ataxia, with a Clinical Report of
Three Cases. — Sanger Brown presented these cases, which
showed the common features of a more or less severe,
acute, and probably infectious illness of varying duration
and character, resulting in profound general muscular
ataxia showing itself conspicuously in the muscles con-
cerned in articulate speech. In none was there any lasting
impairment of special sense or of general sensation. The
ataxia in all was essentiallv stationarv. Experiments on
the lower animals, studies in embryology, clinical and
post-mortem observations on the human subject, have
abundantly demonstrated definite relations between the
neurons of the cerebellum and those of other parts of the
nervous system, both sensory and motor. Assuming that
the cerebellum exercises a predominating influence upon
the co-ordination of voluntary muscular movements, then
it would not be unreasonable to assume in the cases cited
that one effect of the primary disease had been to injure
permanently those parts of the organ subserving this func-
tion, or, what would amount to the same thing, a consider-
able number of the neuron processes connecting it with
other parts of the nervous system.
A Fifth Case of Family Periodic Paralysis. — L. M. Crafts
reports the case of a man aged thirty-five years, under
observation for a period of seven years. He regards this
rare neurosis as due to same form of auto-intoxication,
though the poison has never been isolated. The poison,
whatever it may be, seems to be developed only at intervals
and not constantly. It seems to result from over-exertion
and gastro-intestinal disturbances, but it is unknown why
these causes evolve the poison in certain individuals. All
of the cases have presented a massive muscular supply.
In the present case, a muscular snip from the inner portion
of the right gastrocnemius shows a distinct increase in the
fibrous tissue and moderate hypertrophy and vacuolation
of the fibres.
The Surgical Anatomy of Congenital Dislocation of the
Hip Joint. — Bv Edward H. Nichols and Edward H. Brad-
ford.
A Critical Summary of Recent Literature on Plasma Cells
and Mast Cells. — By Herbert U. Williams.
The Pathological Anatomy of the Cord in Paralysis Agi-
tans and Senility. — By Charles L. Dana.
Embryonal Renal Adenosarcoma. — By Maximilian Herzog
and Denslow Lewis.
On the Spinal-Cord Changes in Paralysis Agitans.— By
Max Nonne.
Tlie Medical C hronicle. May, igoo.
Widely Conducted Cardiac Murmurs. — E. M. Brockbank
reports twenty-four cases of heart disease in which the
murmurs were heard in unusual situations. The only ex-
planation which suggests itself to him is that the sound
was carried along the aorta and large vessels, and trans-
mitted to the surface over the liver, spleen, and kidneys
by the intervening tissues, and over the upper part of the
chest by the resonant qualities of the thorax. There was
no pulmonary consolidation. The author has never met
with these widely conducted murmurs in health, in anae-
mia, or in any case without a cardiac lesion. As a means
of cardiac diagnosis their value is doubtful, but it is pos-
sible that they may indicate an abnormal condition of the
aortic or anterior cusp of the mitral valve, which is thrown
into vibration during ventricular systole and the passage
of a column of blood — with which it is in contact — into the
aorta. Their occurrence must be remembered in examining
cases of supposed aneurism, or obstruction of the thoracic
or abdominal aorta.
Immunity to Diphtheritic Infection, and Reinfection after
the Use of Antitoxin. — R. \V. Marsden reports several cases
\*hich seem to demonstrate that immunity after an attack
of diphtheria may have quite ceased to exist at the expira-
tion of three weeks, when that attack has been terminated
by the injection of antitoxin. It is interesting to note that
in each instance the second attack was practically a reca-
pitulation of the first, i.e., was of an exactly similar type.
The author does not incline to believe that the period of
immunity is proportionate to the dose of antitoxin admin-
istered, or at least, he holds that a consideration of the
doses administered warrants the conclusion that the con-
nection cannot be a very close one. For his own guidance,
he has decided that -during convalescence from an attack
of diphtheria, the reinjection of antitoxin must be immedi-
ately performed upon the supervention of "croupiness " or
signs of early laryngeal stridor.
Two Cases of Intestinal Obstruction due to Peritoneal
Bands. — J. E. Piatt describes two cases, and remarks that
the most frequent causes of peritoneal bands are appendic-
ular trouble and pelvic peritonitis. Obstruction from com-
pression of the gut under the band, as in the first case, is
the most common way in which the lumen of the bowel is
interfered with in these cases. Less frequently the obstruc-
tion is due to traction of the baud upon a loop of bowel, as
in the second case. The course of the disease is usually
rapid, the average duration of life in ca.ses not subjected
to operation being five days, according to Treves. Treat-
ment must be conducted on the lines for acute intestinal
obstruction generally, for in only a few cases will it be
possible to diagnose the exact cause of obstruction.
A Case of Pneumothorax Complicating Whooping-Cough. —
Francis Villy reports a case in a child aged three years.
June 1 6, 1900]
MEDICAL RECORD.
1045
who had just previously suffered from faucial diphtheria,
whooping-cough, measles, and otitis media. There were
no pressure signs in the chest, but a slight difference was
perceptible in the percussion noted at the two bases of the
lungs behind, and the child's general condition was so
serious that aspiration was performed. A considerable
quantity of gas was evacuated, but no pus was found.
The immediate relief did not appear to be very great, but
the child steadily improved, and finally recovered.
The Enucleation of Interstitial Fibro-Myomata by Cervico-
Vaginal Hysterotomy. — By Louis Dartigues.
Medicine, June, igoo.
Ether Anesthesia from a Medical Standpoint. — Louis Fau-
geres Bishop thinks that as a rule more ether is given than
is necessary. If a patient be put thoroughly under in the
early part of an operation, very little additional ether is
required to keep him under for a considerable length of
time. There is great danger of doing insidious damage to
a patient by having him at some stage during an operation
too profoundly an£esthet1zed. Such an occurrence upon the
nervous system is like what might be produced by a blow
upon the abdomen or a condition of shock. Many of the
ultimate bad results of ether mi,ght be accounted for by
such an interference with innervation of different parts of the
body, such as the kidneys. The management of the tongue
is often a source of much worry. So long as the air enters
and leaves the chest with freedom the tongue can be let
alone. If it gives trouble, lifting the angles of the jaw in
the usual way is sufficient in most cases. Nausea may be
to a large extent avoided by regulating the ahajsthesia so
that it is never too deep.
Maternal Impressions. — James G. Ki^rnan gives an ac-
count of the early beliefs and superstitions in regard to
maternal impressions, and illustrates his article with photo-
graphs of monstrosities supposed to have been due to men-
tal shock, but really due to arrested development. • Pro-
found shock, destitution, and want of food act on the
mother and may influence the f(£tus deleteriously. Hence
the significance of the fact that of ninety-two children born
in Paris during the siege of 1870-71, si.xty-four had slight
physical or mental anomalies ; the remaining twenty-eight
were all weakl)-. Not only do poverty and want produce
anaemia and malnutrition of the fcjetus, but profoundshock
disturbs the whole bodily metabolism. The nutrition of
the mother may thereby be so disturbed as to result in a
partial toxaemia, which would tend to check or disturb the
healthy development of the fcetus in utero. In this way a
nexus of cause and effect can be traced, but facts which
can be thus explained give no support to the view of ma-
ternal impressions popularly entertained.
Rumination and Periodic and Habitual Vomiting. — Fenton
B. Turck says that rumination is characterized by return
of food without nausea or effort through the oesophagus
into the mouth, to be rechewed and reswallowed. This
occurs not only without distress, but is accompanied often
by a peculiar enjoj-ment. Peripheral irritation of the va-
gus nerve should be looked for in every case, and should
be corrected by both local and general treatment. Periodic
vomiting is a symptomatic disorder characterized by regu-
lar recurring cycles of vomiting, or the more or less con-
stant rejection of food. Nervous vomiting may be divided,
for description, into three classes: (i) cerebral, spinal, or
central vomiting ; (2) hysterical or neurasthenic ; (3) that
caused by irritations of various parts of the body.
The Repair of Old Traumatic Nasal Deformities.— By J.
Homer Coulter.
Talmudic and Jewish Medicine.— By Lawrence Irwell.
Archivio per le Scienze Medic he, vol. .x.xiv.. No. /, /goo.
The Pathogenesis of Periodic Hamoglobinuria.- Ettore
Chiaruttini says that there are tliree stages in the produc-
tion of hsemoglobinuria :' (I) Alteration of the blood (pre-
existing) ; (2) alteration of circulation (paroxysmal) ; (3)
kidney lesion (usually only functional). The blood changes
may aft'ect the corpuscles or the plasma. The globules be-
come in part disintegrated, and the haemoglobin escapes.
The alteration in the plasma consists of a power to cause
dissociation of the haemoglobin from the corpuscles. The
circulatory changes are produced by vasomotor disturb-
ances and induce paroxysms by causing hasmoglobinfemia.
The kidney lesion consists of a temporarj' loss of the prop-
erty possessed by the epithelium of the convoluted tubules
of decomposing the haemoglobin and separating the iron.
This kidney lesion is essential to the appearance of haemo-
globin in the urine.
The Alterations Caused by Rachitis in the Metabolic Proc-
esses of the Epiphyseal Cartilages.— V. Grandis and C. Mai-
nini, from experimentation, deduce the theorv that the
growth of bones is caused by a fixation of the circulating
lime by means of the phosphorus accumulated in the carti-
lage cells. In rachitis the cells do not prepare and do not
elaborate the phosphorated products. This gives a scien-
tific basis to the well-known clinical fact of the good effects
of phosphorus in the treatment of rickets. In a case stud-
ied carefully by the authors, the rachitis was without doubt
due to a quantitative and qualitative alteration in the dis-
tribution of the phusjjhorus in the cartilage, the amount of
lime salts being certainly equal to that of normal conditions.
The Chemical Phenomena Occurring in the Epiphyseal
Cartilages during the Period of Growth of the Bone. — By V.
Grandis and C. Mainini.
The Physiology of the Spleen.— By Angelo Pugliese and
Tullio Luzzati.
©orrcspoutlcucc.
THE MEDICAL ASPECT OF THE SOUTH
AFRICAN WAR.
(From our Special Correspondent.)
Since I last wrote the war has come almost certainly to a
close, while winter has definitely set in. Lord Roberts is
virtually in possession of all the Orange Free State (which
he has formally annexed to the British Crown) , and of the
two chief cities of the Transvaal. The change of tempera-
ture has exerted a marked influence upon the soldiers.
The sick rate has gone up, and there is a considerable in-
crease in the number suffering from pneumonia and
dysentery. On the other hand, the tremendous activity
shown by Lord Roberts in the field has not tired his troops
in the least, those who have had to march hardest showing
the cleanest bills of health. In fact, throughout the war it
has been noted that inactivity has been followed by disease.
The Plight of Mafeking.— On May iSth, as all the world
knows, Mafeking was relieved. The little town, so near
the Boer capital and so far from the British base, seemed
doomed, but some admirable marching on the part of com-
bined forces from the north and the south drove the invest-
ing troops away just in time. There is no need for me to
e.xpatiate upon the heroic nature of Baden-Powell's defence
of Mafeking. Everything possible to be said has been said
twice over, but the total casualties incurred by the garrison
prove the nature of the struggle they endured. Among the
combatants 22 officers were killed, wounded, or missing
out of a total of 44, and 190 men out of a total of 970. The
total casualties among the non combatants, black and
white, brought the list of injured up to 924, a figure which
sufficiently indicates the persistent nature of the shelling
and "sniping" to which the inhabitants of Mafeking were
subjected during their seven months' siege. There were
60 deaths among adults of disease, and a great many
native children perished, but on the whole, the health of
Mafeking, when it was relieved, was found to be better
than had been anticipated. The investment of the place
was never so clo.se as that of Ladysmith, so that there was
not the same trouble about water supply, and enteric fever
was not so rife, while the natives were occasionally able to
drive cattle into the town through the Boer lines and thus
replenish the stock pots a little. Still Mafeking was on
starvation rations when Captain Mahon entered it, and
even on that scale of diet could not have held out more
than another three weeks or so.
Inoculation against Typhoid Fever is on its trial in this
war, and when the figures are published (as in the inter-
ests of science they should be) medical opinion ought to be
able to declare itself for or against the process. Inocula-
tion was practised on the outgoing British transports to the
considerable discomfort of the men, and it is admitted that
in a striking proportion of cases it has pi'oved an entire
failure as a measure of protection under the circumstances
of camp life. All the fever that has prostrated the British
soldiers during the South African campaign is not typhoid
fever, malaria and typho-malaria having accounted for
long sick lists, but there is no doubt that a good many who
were presumably protected by inoculation liave succumbed
to genuine enteric fever. Full notes have been kept of all
deaths in the hospitals, so that interesting statistics may
be looked for.
The British War Office has approved of pay at the rate
oi £1 per day being given to civilian medical practitioners
in temporary military employ who are not receiving either
fixed or capitation rates of pay from the army fund.
The Princess Christian Hospital, which has been presented
to the Natal government by Jlr. Alfred Mosely, is now
open. The building is situated at Pinetown Bridge, a
healthy spot fifteen miles from Durban amidst fine scenery,
and contains two hundred beds together with the most
complete fittings necessary for a military hospital. The
beds are all occupied already, and Mr. Mosel}' has under-
taken to bear at his own expense for four months the
whole cost of the establishment, which cost is estimated at;
;/[25,ooo. This is truly practical patriotism
1046
MEDICAL RECORD.
[June 16, 1900
The Death Rate in Bloemfontein, especiall)' among the
sick in the hospitals, is ominously high. This is a great
disappointment to medical authorities, for the pretty town
was regarded as a model place to have the sick during the
great march northward. But Bloemfontein is forty-six
hundred feet above the sea-level, and this altitude causes
a diurnal variation of temperature that tells heavily upon
sick men. For the future the sick will be sent farther
south, as all lines of communication are now quite safe as
far as the British are concerned.
Dr. William Davies, son of Dr. Ebenezer Davies, the
medical officer of health of Swansea, who was imprisoned
owing to his supposed connection with the Jameson raid,
was in charge of the medical stores with the Mafeking
relief column.
By the request of the principal medical officer at Bloem-
fontein the Langman Hospital, which, as your readers may
remember, consisted originally of one hundred beds, has
been converted into one of one hundred and fifty beds, the
necessary additional equipment having been provided b)'
Mr. Langman.
Wearing the End. — The war is believed to be practically
over. I .shall send you information concerning the sani-
tary condition of Johannesburg and Pretoria when Lord
Roberts enters those towns, as well as a note upon the
plight of the three thousand prisoners whose stay in the
latter city has been so prolonged and by many accounts so
uncomfortable. These will be the last medical aspects of
the war, accuratelj^ speaking, though the submission of the
Boers in their capital will not preclude the possibility of
prolonged guerilla warfare.
LETTER FROM NEW ZEALAND.
(From our Special Correspondent.)
A PL.'VGUE SCARE — THE PLAGUE IN SYDNEY — SUKGEKY IN
AUCKLAND.
Auckland, May 12, igoo.
DuRLNi; the last month w-e have been suffering from a
plague scare. Your readers may possibly have learned
that the plague has been in Sydney, New South Wales, for
more than two months. Now the whole of New Zealand is
in constant connection with Sydney, which is only eleven
or twelve hundred miles distant. The mail steamers from
San Francisco go on to Sydney from Auckland, and having
delivered the mails foi Australia, and received those for
New Zealand, America, and Europe, return to Auckland
and there receive the outward mails. Besides these, there
is, or rather was, a regular weekly service of steamers.
All this in addition to sailing-vessels. When the plague
appeared in New Caledonia and Sydney, the usual precau-
tion of subjecting all vessels arriving from those parts to
quarantine until they received pratique was adopted.
Later on, seeing that the whole of Australia was liable to
be infected by travellers overland from Sydney, the whole
continent was declared infected. In Auckland the muni-
cipal authorities were at last stirred up from their usual
lethargic condition, and sanitary measures were taken
which had been neglected for years. The harbor board
offered a reward of sixpence a head for rats caught about
the wharves. The city council offered a penny a head
(two cents) for rats caught on shore ; poison was distrib-
uted gratis, and so carelessly that the wonder is that hu-
man beings were not poisoned. His excellency the gov-
ernor, the Earl of Ranfurly, went about the slums in
Auckland, and very usefully employed himself in poling
up the mayor and council. We don'tthink quite so much
of earls as you do in the States, because we are more used
to them ; but still an earl who is also governor has a good
deal of influence.
Then came the news that some man on the Queen's
wuarf had caught a rat, and that this rat, or the fleas that
infested him, had the plague bacillus. Then the harbor
board went mad, shut up the man and two of his mates in
one of the landing-sheds, barricaded the wharf, and would
not allow any one to visit the men or that part of the wharf
where they were confined. Meanwhile the premier, Mr.
Seddon, a most energetic individual, came up ])ost-haste
from Wellington, and he went off his head too. He even
went so far as to inform the city council that if they did
overstep the law in their zeal to suppress nuisances, he
would introduce an indemnity act in the next session of
Parliament to protect them from the consequences ! You
ought to bless your stars that your ancestors instituted a
supreme court that can protect you against the vagaries
of ministers with a majority in both houses of the legisla-
ture. We have no such protection.
Last of all, a boy was bitten by a rat. He grew feverish
and the wound did not heal kindly. The medical man who
was attending thought it a case of blood poisoning, and ad-
vised that he should be sent to the Auckland Hospital.
There he was put in the smallpox ward (which has never
had a smallpox case in it) , and he was isolated — after the
New Zealand fashion. A young lady who has just taken
her degrees in the New Zealand L^niversity, and of course
never saw a case of plague nor probably of typhus in her
life, volunteered to attend him. Cultures were taken from
his blood ; the plague bacillus was found ; it was wired all
over the world that a case of plague, but a raild one, had
appeared in Auckland. A number of people were inocu-
lated with Hafl^kine's serum, and the scare became in-
tense. One lady whose children were all at boarding-
schools in Auckland took the first boat from the town she
resided in, rushed up to the schools with cabs, had the
children's luggage bundled in anyhow, and started off for
the country forthwith. Trade was seriously interfered
with. A boot and shoe manufacturer, who had nearly
completed a large order for the South, received a telegram
peremptorily telling him to send nothing until further or-
ders. Even loads of timber were countermanded, as they
would have to be fumigated at a cost of nearly two dollars
a ton.
Some days elapsed ; the boy did not die, but seemed get-
ting better. Fortunately, just at this point a physician
arrived on a visit who had seen plague on a large scale in
India. In conjunction with the staff of the hospital he ex-
amined the patient, and unhesitatingly affirmed that it was
not a case of plague at all ! Then there were rage and fury
on the part of the trading classes, and indeed of all classes.
Who was responsible for pronouncing the case plague?
Well, the medical superintendent of the hospital, who had
also been just made by the premier a sanitary commis-
sioner with extraordinary powers, had undoubtedly wired
up to the colonial secretary that it was a case of plague.
He had to resign his hospital appointment, instead of get-
ting the six months' leave he had applied for in' order to
fulfil his duties as a sanitary commissioner. As an illus-
tration of the despotic powers assumed by Mr. Seddon, I
may just remark that there is no such person as a sanitary
commissioner known to our law ; he is entirely the creation
of Mr. Seddon.
I asked in an article published in the principal daily pa-
per for particulars as to the culture experiments adopted,
whether there were any control cultures, how many, and
of what kind. To these impertinent inquiries I of .course
got no answer.
However, as the plague still continues in Sydney, no
precautions are omitted. We have a Maori population of
about forty thousand, and if the plague once got among
them it would carry off thousands. They live in the most
unsanitary conditions possible ; they are accustomed to eat
dried shark's flesh and other fish dried in such a way that
they are most offensive to the smell of Europeans ; they
delight in maize soaked in water until it becomes putrid,
absolutely putrid ; and they crowd together in huts at
night, sleeping on the floor, men and women and children
all together, in an atmosphere that would suffocate a Euro-
pean. For their sakes we must keep out the plague if pos-
sible. Then we have four thousand of the lowest class of
Chinese, living as Chinese always do.
It seems probable that we shall have the plague sooner
or later, as it shows no signs of abating m Sydney, al-
though winter has commenced. With proper care, how-
ever, it may be kept sporadic, as it has been in Sydney.
There, in nine weeks there were only one hundred and
fifty-three cases and forty-nine deaths, which in a city of
about four hundred and fifty thousand inhabitants can
hardly be called an epidemic. Sydney is the oldest town
in Australia, having been founded in 17S0 (or thereabouts)
as a convict settlement. The older streets are very nar-
row, and there are some horrible slums in those parts of
the city near the wharves. The government is resuming
the control of the wharves, and has shut up several of
them. It is estimated that this step, which is quite unnec-
essary, and merely the result of the scare, will cost the
colony of New South Wales betvveen two and three mil-
lions sterling.
There is nothing new here except the plague scare. I
paid a couple of visits to the Auckland Hospital lately, and
saw .some very jiretty operations by Mr. Hope Lewis, who
is one of the honorary visiting surgeons — a tenotomy, an
Alexander, an amputation of the hip joint, a hysterec-
tomy, and an ovariotomy. The hip-joint case was the first
amputation of the kind I have .seen done since I served in
the Crimea. We had five cases there and all ended fa-
tally. The ovariotomy was i-eally a funny case. It was a
dermoid cyst, and when the incision was made to admit
the trocar, out shot hundreds of little white spherical bod-
ies, exactly the size and shape of sugar-coated pills ; out
they came with every movement of the cyst, and ran out
on the floor and rolled about in a really ludicrous way.
There were a number of masses of hair as well. Mr. Hope
Lewis is an excellent operator and making a name for him-
self by his laparotomies and other operations. His style
reminds one of the late Sir William Ferguson, of King's
College, London.
June 1 6, 1900]
MEDICAL RECORD.
1047
OUR LONDON LETTER.
(From Our Special Correspondent.)
queen's BIRTHD.'iY HONORS — MEETING OK MEDICAL COUNCIL
— THE MEDICO-CHI. ON WOUNDS IN THE WAR — THE ORA-
TION AT THE MEDICAL SOCIETY^ — EXCISION OF THE c;as-
SERIAN GANGLION — FIRST SOUND OF THE HEART — PATH-
OLOGICAL society's LABORATORY MEETING — DEATHS.
Lo.*JDO.v, May 25, igoo.
We have been celebrating; the Queen's birthday yesterday
(24th) with more than usual enthusiasm, making the occa-
sion a demonstration of patriotism as well as loyalty. The
list of honors conferred on this occasion is long enough, but
the medical profession scarcely gets its share. No baro-
netcy i.s given us, but there are four knighthoods, viz.. Dr.
Hector Cameron, President of the Glasgow Faculty, Dr. J.
\V. Moore, P.R.C.P.I., Dr. W. B. Berry, Speaker of the late
House of Assembly, and Dr. D. P. Ross, surgeon-general
of British Guiana. There are also three medals for services
in India.
The General Medical Council met for its sixty-ninth ses-
sion on Tuesday, and is still sitting with much work yet to
do. With its oppressive cost and its inability to find time
for all its work, why should the president persist in giving
a lengthy address? There is no need to tell the members
what they have to do. A good programme would suffice.
Details of what has been done and told in all the journals
are equally unnecessary, and laudation of outgoing coun-
cillors would be best omitted.
Two new members put in an appearance, viz.. Sir H.
Beevor, vice Mr. Brudenell Carter, for the Society of Apoth-
ecaries, and Mr. W. R. Power for the Crown in succession
to the late lamented Sir R. Thorne. Dr. Leech is absent
from illness, and Sir W. Thomson is in South Africa. Re-
ports of committees and formal business occupied most of
the first day. In the evening the president of the Royal
College of Physicians and Mrs. Church gave a reception
as they also did on the following evening.
On Wednesday the midwives bill monopolized the major
part of the time. The report of the committee was dis-
cussed with some animation, but other points managed to
force their way into the speeches. The committee accepted
the suggestion of the lord president of the council that the
central board could frame a rule requiring the midwife to
send for a registered practitioner in case of abnormality,
but Mr. Horsley, who was on the committee, had dissented
from this point in the report and divided the council upon
it. The report, however, was adopted, and so far as the
council is concerned the midwife will do as she pleases.
The question of personation of registered practitioners
came on. It seems the public prosecutor does not consider
such personation criminal in the sense that he is bound to
prosecute. Counsel's opinion is to be obtained, and the
question will then be considered, perhaps to-morrow. The
proposed conjoint board for London, the appointment of
a solicitor, and resolutions forwarded about the mode of
appointing councillors received the usual attention. Yes-
terday renal cases occupied the council. The Medico-Chi.
gave another evening (Tuesday, the 22d) to the subject of
the wounded in the present war.
Mr. C. T. Dent, of St. George's Hospital, told of his ex-
perience in this campaign. He thought tent hospitals bet-
ter than wood or iron in a climate like that of South Africa,
for they permitted of practically open-air treatment. If
chilling was avoided, only good resulted. Churches and
schools were very ill adajjted for hospitals. He entered
into various particulars as to different wounds, but, of
course, admitted that there is much more to be learned be-
fore positive conclusions can be formulated on many points.
Sir William MacCormac also gave some details of his
experience, though he admitted he had said all he wished
to say in his letters to 'T/ie Lance/. He exhibited a one-
hundred-pound shell presented to him by the officers of the
Royal Artillery, and a smaller one was also shown, said to
be the first fired into the English lines at the battle of
Colenso.
Major W. Dick, of Netley, made some remarks on the
wounds after the men returned. There had been many
injuries of the musculo-spiral nerve. He thought small-
bore bullets more often deflected than supposed and gave
instances. He thought, too, the successful issue of abdom-
inal wounds was favored by their having been inflicted on
men when starving.
You will naturally take it for granted that there was an
unusually large assembly to hear the returned surgeons
and welcome them back. In fact, with such a subject as
the war and exhibits of bullets, shells, etc., with lantern
slides and other attractions this session, the Medico-Chi.
bids fair to become quite popular — a change which will be
welcomed by many.
On Monday evening the Medical Society gave its annual
conversazione. There was a full assembly of fellows and
their friends, and everything passed off successfully. The
oration was delivered by Dr. Kingston Fowler, who took
for his subject "Science and Medicine in the Eighteenth
Century." Sir W. Gairdner was present and proposed the
vote of thanks (cordially carried) , contrasting m a few
words Cullen and Brown, and remarking that the eigh-
teenth century was one of revolution, the nineteenth one of
evolution.
At the last ordinary meeting for the session held on the
preceding Monday evening, Mr. Hutchinson, Jr., read a
paper on excision of the Gasserian ganglion for epileptiform
neuralgia of the fifth nerve, in which he detailed the cases
in which he had performed this operation. He thought the
Hartley-Krause method the only practicable one of expos-
ing the ganglion. In all his cases the neuralgia had lasted
five years, but he thought it would be justifiable to operate
after two or three j-ears or before the patient was worn out
by pain and treatment. If the pain was confined to one
branch, a full removal of that branch would suffice ; but
when it alfected two divisions and had an epileptiform
character, excision of the ganglion would be necessary and,
if the patient were running down, might be undertaken
after one year.
Dr. A. Morison read a paper on "The First Sound of the
Heart, Considered from a Clinical Point of View." His
study led him to attribute the largest share in producing
the sound to "vibrations in the blood itself, to produce
which at a normal rate valvular support of the vibrating
blood columns is necessary." Thus he would seem to take
a view between that of Quain on the one hand and Leared
on the other. Of course this was objected to. Indeed, the
first sound seems to be a perennial source of controversy.
Dr. Sanson! insisted on tension and could not believe the
blood had much to do with the sounds ; while Dr. Robert
Maguire held by Quain's view. He said the first sound
was produced by one column of blood against another, or
one bubbling through another, and asked if murmurs might
not be due to the same thing modified. I pass the question
on to physicists and physiologists instead of following this
debate further.
Lord Lister presided at the laboratory meeting of the
Pathological Society on the 15th, which was held at King's
College. Professor Crookshank said he had lately found
in healthy field rats the flagellate protozoa which he de-
scribed fourteen years ago in sewer rats, and which were
then thought to indicate disease. A similar protozoon is
found in equines and camels.
Dr. Dean described an apparatus for the cultivation of
the tetanus bacillus ; Messrs. Hewlett and Rowland their
plan of measuring a volume of serum for diagnostic pur-
poses.
Dr. MacFadyen described experiments on the. virus of
African horse sickness, which point to the possibility of
bacilli being so minute as to pass through Chamberland's
filters. At any rate, the fluid which so passed killed the
horses experimented on. It has been asserted that the
bacillus of bovine pleuropneumonia will pass through such
filters.
Drs. Bullock and Hunter made a preliminary communica-
tion on a hasmol}'tic poison in pyocyanic toxin and an anti-
haemolytic body in the serum of immune animals.
Dr. G. Newman had tested the inoculability of twenty-
nine species of animals with tubercle. Guinea-pigs could
always be inoculated with the tubercle of mammals, never
with that of birds. In fishes and reptiles he had not found
a bacillus which answered the tests for tubercle. In birds,
tubercle attacks the abdominal viscera, rarely the lungs.
In cattle, the serous membranes are the most frequently
attacked.
Dr. Hewlett demonstrated the indol-like reaction given
by cultures of the diphtheria and of the pseudo-diphtheria
bacillus.
Dr. Drysdale gave an account of research on the bacillus
capsulatus aerogenes to which post-mortem emphysema is
attributed.
Mr. Pryce Jones exhibited three varieties of streptothrix
from rum, horse dung, and drinking-water.
The late Dr. George Bird, who died on the fourth inst. at
the advanced age of eighty-three years, was a very note-
worthy man, the friend and adviser of a considerable num-
ber of "men of light and leading." Sir R. Burton dedi-
cated to him a volume of his "Arabian Nights," and many
other marks of the appreciation of his worth by great think-
ers fell to his lot. It is said that Ringer's "Therapeutics "
owes any literary grace it pos.sesses to his revision. He
was always attached to athletics and even took up the bi-
cycle in his old age.
Capt. W. F. Hopkins, M.D., who went from Australia
with the contingent and performed prodigies of valor at
Rensburg, where the officer in charge declared if any one
deserved the V. C. he did, has died of typhoid.
Captain Dowse, R.A.M.C, has also died at Bloemfon-
tein. He had the medal for service in the Chitral expedi-
tion.
1048
MEDICAL RECORD.
[June 1 6, 1900
Society |lcpoi-ts.
AMERICAN MEDICAL ASSOCIATION.
Fijty-vrst Amiual Meeting, Held in Atlantic City, N. /.,
on June j, 6, 7, ana 8, igoo.
(ConUKued front page loob.)
SECTION OX OBSTETRICS AXD DISE.^SES OF
WOMEN.
Second Day — Wednesday, June 6t/:.
Parturition as a Factor in Gynaecic Practice — Dr.
JoHX M. DvFF. of Pittsburg, read this paper. He
said that to convince gynecologists that parturition
was the principal factor in producing morbidity call-
ing for their interference, no other argument was
needed than the statistics of their own practice. He
felt justified in saying that considerably over fifty per
cent, of all gynecological cases could be charged to
parturition. He believed that a rigid enforcement of
the rules of obstetric practice as laid down by the best
teachers of to-day would eliminate more than fifty per
cent, of the gynaecic cases resulting from parturition,
if we e.xcept those resulting from abortion. In proof
of this he referred to records of cases in maternity
hospitals. The author declared that the day of anti-
septic midwifery was past. To-day its principles
were not only directly harmful, but a neglect of asep-
sis, with a dependence upon antiseptics to right
wrongs, was not only unscientific but cruel and mur-
derous. The true antiseptics were stated to be the
normal and healthy secretions of the body, and espe-
cially that greatest of all germicides, the blood.
Hence the necessity of due attention to the secretions
and to the condition of the blood previous to the on-
set of latjor. In instituting aseptic precautions before
labor the douching of the vagina with antiseptics was
declared to be harmful in a healthy woman; and in
an unhealthy vagina with pernicious secretions it was
not effective. When necessary to cleanse the vagina,
it should be prepared as carefully as for vaginal hys-
terectomy. The vulva should undergo the most care-
ful cleansing possible. One cause of infection through
putrefaction was a failure to remove all placental tissue
and membranes, and in this connection he emphati-
cally called attention to placenta succenturiata and
placenta spuria, which he believed to be frequently the
direct cause of sepsis which could not be accounted
for. On five occasions he had found spurious pla-
centa. The author still believed his previously pub-
lished opinion, that "the routine practice of admin-
istering ergot after the third stage of labor" was
pernicious and frequently the cause of the woman
coming into the gynecologist's hands. The too early
resumption of household cares after labor he consid--
ered accountable for many malpositions with their
concomitant disorders.
In conclusion it was stated that by a rational mid-
wifery such as suggested, with careful asepsis and
proper and timely repair of lacerations, salpingitis,
ovarian abscess, and endometritis would be less fre-
quent, and prolapsus uteri, vesicocele, and rectocele,
with all their accompanying phenomena, would be
comparatively rare.
Dr. Mordecai Price, of Philadelphia, opened the
discussion of Dr. Duff's paper by heartily indorsing
the author's views upon the antiseptic treatment of
puerperal conditions. The cases thrown into his
hands, of puerperal fever, or fever following the puer-
peral state, in nine cases out of ten had been caused
wholly an J entirely by the unnecessary and dangerous
use of antiseptics. He thought that the profession had
been so imbued with the old idea of antisepsis that
such papers as this were required to correct the past
teaching.
Dr. L. H. Dvxxixg, of Indianapolis, indorsed the
paper of Dr. Duft' most heartily. He thought that Dr.
Price had perhaps stated the matter a little too strongly,
though he had seen some of the results indicated, from
intra-uterine douches. He considered of great impor-
tance the matter of displacement due to subinvolution,
which could readily be corrected if the obstetrician
would follow the cases after delivery. He agreed that
every case of laceration should be attended to at once
unless there were strong contraindications. He did
not believe in the immediate repair of laceration of
the cervix, but did believe that when there was reason
to suspect such laceration the case ought to be exam-
ined in six weeks and repaired if the necessity- was
present. Otherwise there was the possibility of sub-
involution of the uterus and of the ligaments, result-
ing in displacement, endometritis, chronic congestion
of the pelvic organs, and chronic invalidism. He
emphasized the point that the care of the woman de-
livered should not end until the cervix had been
attended to and involution completed.
Dr. Joseph Price, of Philadelphia, said the prac-
tice of midwifery in private and public cases differed
greatly, and that there was not the enthusiasm in ob-
stetrics that there was a few years ago. With Parvin
died the last obstetrician in America. He deplored
the general use of the family syringe in private prac-
tice. The indiscriminate use of the curette in many
cases was simply guesswork : often the finger would
bring away that which had not bten detected by the
curette. He believed that nothing was more impor-
tant than the fact that at the present time we have no
enthusiastic specialists in obstetrics. Too often an
obstetrician sought the position of teaching obstetrics,
but practised gynecology.
Dr. Ritter. of Kansas City, said that Dr. Duff's
paper had the genuine ring, and, as Dr. Price had
said, enthusiasm in obstetrics w-as on the wane. He
also thought that there was too great a tendency to use
the syringe. He believed that if more attention was
paid to the alimentary canal the patients would be in
a better condition. He also agreed with the essayist
that too often strong germicidal remedies were used.
Of more importance was thorough cleanliness in the
practice of obstetrics.
Dr. Miller, of Syracuse, thought that in treating
puerperal fever the source of infection should first be
ascertained. This infection was sometimes carried by
the physician, who might at the same time be in at-
tendance upon a pus case which was due to the more
virulent infection, and if the field was sufficiently
large there would be great development of the septic
poison with serious danger to the patient. If due to
sapremia the curette and irrigation would do good by
washing away the products. The specific treatment
was indicated by a recognition of the source of infec-
tion.
Dr. Tuttle believed that if the cases of disease
due to parturition were ruled out, there would be few
women complaining of abdominal trouble. He thought
the matter must be regarded from a preventive stand-
point, and that it resolved itself into two stages: (1)
the preparation of the patient before delivery, which
should be as careful as that for abdominal section or
vaginal hysterectomy; (21 that which was perhaps
more important than the first — careful investigation of
the parts immediately at the close of labor.
Dr. Zinke, of Cincinnati, did not doubt that the
majority present knew how to prevent sepsis during
and after labor; when and when not to curette, and
when and when not to use a dull or sharp curette.
The trouble he believed lay elsewhere: the obstetri-
cian of the present day did not hold the position be
June 1 6, 1900]
MEDICAL RECORD.
1049
should because it did not pay to be a specialist of
obstetrics, and the cause of this was in the fact that
when graduating a man thought he knew all about
obstetrics. He appreciated the remark of Dr. Price
because he held the chair of obstetrics, and was bound
to practise- gynaecology to make it possible for him to
pay his debts. In his opinion the chair of obstetrics
ought to be endowed. He thought obstetrics could
be thoroughly taught even if the obstetrician found
time to do gynecological work. The attempt to es-
tablish maternities for teaching-purposes had been
frustrated, and to teach obstetrics thoroughly and to
practise this department as it should be practised, due
consideration must be given to all these things. Dr.
Zinke thought an obstetrician should not be blamed
for not limiting himself to the position which he oc-
cupied and for practising something else which he
understood just as well, simply because it did not
seem right to some. For himself he would like to
practise obstetrics and nothing else, but he would
have to starve if he depended upon the practice of
obstetrics alone.
Dr. Duff, in closing the discussion, said the sub-
ject of obstetrics had not been a popular one; that
he made his living out of gynaecology, and taught
obstetrics incidentally. That obstetrics did not pay
financially he believed to be the fault of the profes-
sion. With reference to sepsis he thought we were
coming to the day when consideration would be given,
not to septic infection, but rather to the prevention of
sepsis in obstetrics. He expressed the hope that the
spirit engendered by 'this discussion might aid in the
obstetric physician becoming popular.
The Causal Relation Intra-Abdominal Diseases
Bear to Nervous Disturbances Recognized by Gy-
naecologists, Ignored by Neurologists Dr. Henrv
O. M.ARCV, of Boston, in this paper considered the
importance of the physiological function of reflex
action of nervous centres in health, the normal rela-
tionship of afferent fibres, nerve centre, and efferent
fibres. Motor impulses were spoken of; also inhibi-
tory nervfe centres, and automatic action. The deep
reflexes were believed to be of little value. Certain
groups of symptoms were shown to be indicative of
local lesions. These were considered in relation to
their bearing on the reproductive organs of woman in
health and in disease. A careful knowledge of the
pathological reflexes of the first were stated to be im-
portant in proper differentiation of organic lesions of
pelvic structures.
The Principal Obstetrical Advance during the
Last Half-Century Dr. A. H. Halberst.\dt, of
Pottsville, Pa., in this paper declared the standstill
in obstetrics to be due to so much attention being
given to gynaecology through the fascination of ab-
dominal surgery. He said that little advance had
been made in obstetrics since the death of Hodge and
Meigs. Asepsis and anaesthesia he considered to be
the only advances made during the last half-century,
and these he stated did not apply to obstetrics more
than to medicine and surgery. Symphyseotomy he
considered as fleeting, and gave a brief report of two
cases.
Neuroses due to Auto-Intoxication from Faulty
Menstruation. — Dr. Arthur Johnstone, of Cincin-
nati, read this paper. He spoke of the repair or the
cure of an inflammation of the pelvis as doing much
to regulate menstruation; and stated that with this
regulation came the relief, of headaches, migraines,
neuralgias, and all the other nervous symptoms to
which we were so thoroughly accustomed. This re-
lief he believed to be sometimes caused by the re-
moval of the scar tissue; but this scar tissue could not
by any means cause the general systemic disturbance
present in most of these cases. Relief came gradually,
and each successive menstruation was better; still, per-
fect relief did not come for six months or a year,
which proved that the relief was due to the drainage
of accumulated poisons from the system by a perfect
menstruation. The majority of nervous symptoms in
gyneecological subjects he believed to be due to re-
tained excretions which defective menstruation had
failed to eliminate. Another great cause of neuroses
was the intestinal infection accompanying nearly all
these cases. The main thing to remember was that
the bad cases belonged to gouty families, and for their
relief reference was made to Haig and Rachford on
the leucomain poisons. Elimination was the keynote
of their work. Exercise was stated to be only another
form of elimination.
Traumatisms and Malformation of the Female
Generative Apparatus as the Cause of Insanity
Dr. George H. Noble, of Atlanta, Ga., based this
paper upon his personal observation, and many re-
plies received from alienists and gynecologists of the
United States relative to the subject. He stated: (i)
that traumatisms and malformations of the female geni-
tal apparatus were indirect or exciting causes of insan-
ity; (2) that heredity did not necessarily play a part as
a cause, but was found in a large percentage of cases;
(3) that many operations had been done with satisfac-
tion and uniformly good results: (4) that no special
form of insanity followed the above conditions. Some
institutions made a practice of examining women in-
mates for the above-mentioned conditions, and were
giving much attention to the gynatcological side of
the question with much satisfaction.
The Third Element in the Equation between
Pelvic and Abdominal Disease in Women and Dis-
turbance in the Nervous System. — Dr. H. A. To.m-
LixsoN, superintendent of St. Peter State Hospital,
St. Peter, Minn., read a paper on this subject. He
said that menstrual disorder and pelvic diseases were
quite commonly associated with the different neuroses
and psychoses, but in his experience they bore no ap-
parent causal relation to the nervous disturbance, nor
was the intensity of the nervous disturbance in pro-
portion to the gravity of the physical disease; but, on
the contrary, the most grave pelvic disease, even
among the neurotic and insane, existed without dis-
turbance in the nervous system and frequently without
physical symptoms. In cases in which the insanity
or chronic nervous disease had existed for more than
a year, or the patient had a defective ner\ous organi-
zation, it was stated that treatment of the disease of
the generative organs was practically without effect
upon the insanity or neurosis, and in such cases oper-
ative interference resulting in the establishment of an
artificial menopause almost invariably hastened the
onset of the dementia. Operative interference the au-
thor believed was called for in the treatment of pel-
vic disease among the insane for the same reasons
that would determine the necessity for such treatment
among the sane; i.e., the reasons were purely surgical.
In order to know the probable curative effect on in-
sanity of treatment of diseased generative organs, it
was considered important to know the family and per-
sonal history of the patient with regard to the pres-
ence or absence of evidence of unstable or defective
nervous organization, the length of time the condition
had existed, and to what extent the general health of
the woman was affected by the pelvic disease inde-
pendently of the insanity or nervous disease.
Pelvic Disease as a Factor in the Insanity of
Females, and Surgery as a Factor of Cure. — Dr.
E. C. Carpenter, of Columbus, O., read this paper.
He said that from the data at hand we seemed to
be justified in the conclusion that pelvic disease
was a factor in the cause, and that surgerj- was a fac-
tor in the cure, of the insane condition. The ques-
1050
MEDICAL RECORD.
[June 1 6, 1900
tion confronting us now was, what estimate may be
placed upon them as factors. As such he believed
both had their limitations. The established law of
multiplicity and complexity of cause admitted few ex-
ceptions in singleness of cause. He thought it impor-
tant to take the broadest view in the consideration of
the etiology in insanity. The specialist, the speaker
said, was too prone to infer that the organ of his spe-
cialty must be the source of all other pathological
conditions, when the lesions, the remote symptoms,
might be but consequential to general conditions. In
the consideration of cause in the insanity of women
he stated that heredity, predisposition, puberty, the
puerperal and the climateric periods were especially
to be borne in mind. In the general physical exami-
nation pelvic disease should always besought for, and
when found to exist it should be eradicated. No
physician, in his opinion, should consent to the com-
mitment of a woman for insanity until the existing
pelvic disease was removed; except under absolute
necessity from the mental condition. He further be-
lieved that upon entrance into our asylums every fe-
male should be examined by a conscientious special-
ist, and if she was found diseased operation should
be urged. In the absence of pelvic disease operative
procedure should be approached with our best judg-
ment. He thought it questionable whether medical
knowledge and experience would justify operating on
the defective classes, women at puberty, idiopathic
epileptics, those in the preclimacteric years, and those
whose insanity was not over two years in duration.
All our asylums, it was stated, had representatives in
them from these classes, who had not only not been
benefited but made worse by operation. This list he
believed it would be at least instructive to place in
parallel with those benefited, in passing judgment on
any case to be operated. Reference was made to a
class which might be regarded as non-diseased but
operable — the hysterical, those especially disturbed
at the catamenia, and those in the post-climacteric
years. From the first two the author considered that
some of our most brilliant recoveries have come by
the employment of surgery alone. Operation in the
post-climacteric period, he believed, might hasten
senility, but was not likely to do much absolute harm.
Interrelation of Gynaecology and Neurology in
Practice. — Dr. C. H. Hughes, of St. Louis, Mo., read
this paper. He stated that advances made in bio-neu-
rological discovery gave us just warrant for the state-
ment that, with a proper understanding of this subject,
there ought to be one opinion respecting the interre-
lation of neurology and gynaecology in practice; there
should be but one method of therapeutic procedure
among both gyna;cologists and neurologists, i.e., to
treat the whole organism and every damaged part for
the best results. The omnipresence of the nervous
system throughout the organism, with its afferent and
efferent communications, as could be witnessed, for
instance, in the interrelations of the vagus nerve and
the brain and the abdominal and thoracic viscera; the
relations of hysteria, a cortex lesion, to its varying sub-
cortical and peripheral abnormalities of functions; the
proven interrelations of pelvic and cerebral states as
shown in the various phases of erotic life and evolu-
tion; the neurophysiological and neuropathological
changes, both central and peripheral, of thecatamenial
stages, and the menopause in women — were dealt with.
It was shown that these alterations beginning in the
governing nervous system, and affecting active and re-
active influences, revealed to us in a clinical sympto-
matology largely nervous, but also in grave pathologi-
cal changes of uterine structure, admonished us that we
have a patient to treat as well as a part, a case in which
the knowledge of more than one specialist is often
demanded in treatment. Woman, the author said, had
both a gynsecic and a neurocerebral function and
sphere of physiological and pathological influence,
and often deserved when ill both neurological and
gynaecological attention at the same time. The gynae-
cologist, if he treated her all over as she deserved,
should be much of a neurologist, and the neurologist
should be much of a gynaecologist.
Tubo-Ovarian Adhesions : their Reflexes Dr.
A. L. Beahan, of Canandaigua, N. Y., called atten-
tion to the simulation of hysteria by conditions re-
sulting from simple inflammatory forms of adhesions
between tubes and ovaries. Differential diagnosis of
this border-line disease was shown to be paralleled by
insanity caused from structural changes in the appen-
dages; the former consigning the patient to chronic
invalidism, misnamed neurasthenia or hysteria, the
latter excluding from society if not ostracizing from
home. The author emphasized the fact that tubo-
ovarian adhesions occurring in the early years of a
woman's life might, by reflex as well as by direct
effects, give in insidious ways obscure nervous symp-
toms, and a great error would be made if from a lack
of a discriminating diagnosis this disturbance was
characterized as one in which systemic forces alone
were at fault instead of local ones. It was claimed
that a clean removal of both appendages cured the pa-
tient, and a nervous wreck became a healthy, happy,
useful being.
Gall Stones and Diseases of the Gall Bladder,
and Nervous Symptoms Resulting Therefrom. —
Dr. Edwin Ricketts, of Cincinnati, read this paper.
He said that clinically speaking there were recognized
by operators marked nervous manifestations of a most
detrimental kind, but that just how these were caused
had so far not been satisfactorily explained'. The
contents of the gall bladder, with or without gall
stones, might become infected by the bacillus coli
communis or a pyogenic streptococcus entering the
biliary passages from the duodenum or through the
blood of the portal vein. He advocated the removal
of gall stones as soon as diagnosed. Distended gall
bladders that failed to empty themselves by well-
selected internal medication and with massage through
the abdominal wall, he believed should be drained by
means of cholecystotomy. The views of the author
were based upon an experience of forty-six cases.
■The foregoing papers were discussed together.
Dr. Porter, of New York, in opening the discus-
sion said that to him the most interesting fact demon-
strated by the papers was that physicians must not
attempt as gynaecologists to deal with this most im-
portant subject alone, but must combine with the neu-
rologist, which unfortunately was too infrequently
done. In his opinion, by operation the patient was
sometimes put into a worse condition than before.
He believed that in connection with the asylums for
the insane there should be consulting gynaecologists.
Dr. G. E. Shoemaker, of Philadelphia, thought that
Dr. Hughes struck the point at issue when he stated
that the gynaecologist and the neurologist should have
the same view-point. He stated that there was one
central standpoint of truth, and if all could get the
same training and look at the problem from the same
point the problems would be solved. Reference vi'as
made to a friend who was at the head of a great insti-
tution for the insane, who was strongly opposed to
gynaecological work for the insane, and he stated that
large numbers came into the institution who showed
depraved nutrition. They were fed to the highest
point. Many were helped and not a few cured. It
was shown that the gynaecologist treated cases show-
ing definite disease and profound nervous disease in
the same way.
Dr. Eastman, of Indianapolis, referred to the re-
markable increase of cancer and insanity as the two
June i6, 1900]
MEDICAL RECORD.
105 1
important subjects confronting the medical profession
to-day. From the discussion he thought it appeared as
if the old practitioner, who looked through the whole
system, was again to come to the front; but " to plough
deep, means in no sense to turn a wide furrow." Two
specialists working along these lines would, in his
opinion, secure the best results.
Dr. I. S. Stoxe, of Washington, said he was re-
minded of a discussion along these lines some years
ago, when several papers were read before the Ameri-
can Medical Association on insanity due to pelvic
disease, which resulted in inquiries being made of
every insane asylum in the United States as to exami-
nations. He claimed credit for the gynaecologists in
starting this inquiry.
Dr. Benjamin, of Camden, referred to his success
in the treatment of patients in whom there was no
clear indication of lesion, with those medicines which
were used in neurological cases, and through this
means there had been a reduction of ovariotomy.
Dr. Zinke, of Cincinnati, said he was reminded by
the discussion of to-day of that held in Denver at
a previous meeting of the American Medical Associa-
tion, and a comparison showed the wonderful progress
that had been made: peace prevailed to-day where
then all was war. He wished to contribute his share
of compliments due Dr. Hughes. He cited two cases,
one in which he had removed two pus tubes and in
which the wound healed perfectly and the woman left
the hospital sane, but within a short time symptoms
of insanity developed and she was placed in an insane
asylum for eighteen ' months. The doctor was con-
demned. The other case he saw w-ithin two months
thereafter, in which also there were pus tubes, and in
this case he urged operation, notwithstanding the
result in the first. Comparisons were made by the
family and operation refused. In exactly two weeks
afterward this patient was insane without operation.
She was not right to-day, while the other had recov-
ered perfectly. He regretted that he could not agree
with Dr. Ricketts in everything he said. He had
seen patients who had been the victims of gall stones
for years, recover without operative interference and
he did not believe it was right to operate as soon as
the diagnosis of gall stones was made.
Dr. Carstens believed that if it was simply consid-
ered that healthy ovaries and healthy tubes would not
produce insanity, and that the same organs diseased
would produce all kinds of disturbances in the ali-
mentary canal and interfere with the process of diges-
tion, the function of the kidney, and the elimination
of effete material — which effete material would lower
the nutrition of the nerves — it would be easily seen
that there was a tendency to the increase of insanity
from this source. If it was considered, too, that the
pathological condition at the nerve periphery pro-
duced a process of irritation and, if the process of
irritation continued for a long time, we might remove
the nerves but the pathological condition became
permanent, the wisdom of early removal of the re-
flex cause would be apparent. He believed great pre-
caution should be used not to promise the patient too
much from operation. He defended Dr. Ricketts by
saying that if pus tubes ought to be removed, also gall
stones when diagnosed should be removed.
Dr. Baldv, of Philadelphia, thought the whole sub-
ject resolved itself into the two questions : Will pelvic
or gynajcological troubles cause insanity; and, if so,
will operation cure? After due consideration he was
convinced that gynaecological troubles did not cause
insanity. So convinced of that was he, that the sug-
gestion that every insane woman should undergo a
physical examination, and operation be done if a le-
sion was found, appeared to him a preposterous one
and entirely indefensible. Many healthy married
women had lesions which in no way caused symptoms,
and the only argument in favor of operation was for
the removal of symptoms.
Dr. Palmer Dudley, of New York, said that he
did not discuss the subject from the standpoint of
the neurologist, but from his experience he believed
that if neurologists would look over the statistics of
cases in women they would find, aside from heredity
when they could trace a direct line of insanity, that
the majority of cases under their care were puerperal,
i.e., having puerperal fever as a starting-point. There-
fore he agreed with the neurologists that insanity was
directly produced by pelvic trouble.
Dr. Hughes, in closing the discussion of his paper,
referred to the matter of promising too much from oper-
ation, and stated that he was very guarded in his
prognosis.
Dr. Carpenter, in closing, said his position, in giv-
ing to the insane the same advantages as to the sane
woman, was unchanged, because the minutest part of
the disease was so serious a question even when only
a probable element that he thought the patient should
undergo operation for the removal of the cause.
Dr. Marcv, in closing, referred to a consultation
between the distinguished Brodie and Watson, the re-
sult of which was the opinion that it was good medi-
cal practice to remove the cause of irritation if pos-
sible, and then trust that the irritation itself would
cease; and it would appear from the discussion that
in this century we w^ere not very much w'iser than
those celebrated men of the earlier time. Gynaecolo-
gists and the neurologists were one in removing the
cause of irritation and in trusting to God for a better
result.
SECTION ON PEDIATRICS.
Second Day — Wednesday, June 6th.
Demonstration of Home Milk Modifier. — Dr. A. L.
Sherman, of New York City, exhibited this apparatus,
which consisted of a glass jar showing seven panels,
with lip, capable of holding sixteen ounces. One of
the panels presented an ounce graduation, while the
other six had different formulas for modifying cow's
milk. He said that the physician should decide what
formula was to be used, and ignore the others. The
food should be compounded for the period of twenty-
four hours. The apparatus is called "the materna."
Causation and Relative Frequency of Typhlitis,
Perityphilitis, and Appendicitis in Infancy and
Childhood. — Dr. Joseph N. Byrne, of New York,
presented this paper. He said that typhlitis was
generally due to primary conditions, while perityph-
litis was always secondary. The advancement in
bacteriology and pathology during the past twenty
years forced us to abandon our former theories. He
spoke of the relative position of the appendix, it often
being directed toward the spleen, but it might be, and
often was, directed downward.
Milk Supply and Control at the Kaiserin Fried-
rich Hospital. — This interesting paper, by Drs. Adolf
Baginsky and Paul Sommerfield, of Berlin, was read
by Dr. Louis Fischer, of New York. The control of
the milk supply in general necessarily began with the
care and the arrangement of the cow stables. They
were built of brick, iron, and cement, and were two
stories in height, and the walls were finished with
glazed brick. The building was 30 metres long, 11
metres wide, and 4 metres high. The lower story was
divided into two compartments, while the second story
was one open room. The ground floor was raised at
one end slightly in order that it could be flushed eas-
ily. The cows stood in stalls that were called " feeding-
tables," which were made of cement. The mangers
I052
MEDICAL RECORD.
[June 1 6, 1900
were of glazed bricks. Each animal had a separate
stand, and it was raised 2.7 cm. with a sloping floor.
The water supply was automatic. Sawdust was used
in the stalls. The cows were of Holland breed. All
of them were injected with tuberculin and were under
the constant care of a veterinary surgeon. The animals
were fed in two ways, viz., dry feeding and wet feed-
ing. Those that were dry-fed produced the milk used
for infant feeding. Swill was entirely forbidden. It
had been noted that cows fed on the products of dis-
tillation of potatoes and corn soon suffered from
diarrhoea, and the milk had a certain toxic effect
upon the child. The principal dry food-stuffs used
were clover, residue of breweries, wheat, and the bran of
rye. When it was necessary to stimulate the appetite,
small quantities of dry cut bagasse, or sugar-cane
stalks, were given. The wet or moist feedings used were
turnips, rye, bran, and hay. The stables were cleaned
before each milking, and the men were obliged to wash
their hands as well as the udders. This did away with
milking-machines. The milk was removed immedi-
ately. Milking was done three times a day. By the
immediate removal of the milk to the dairy, where it
was filtered, sterilized, and cooled, the danger of in-
fection was reduced to a very small point. It was
found that the bacilli of potatoes and hay were the
most difficult to destroy, and the warm milk easily ab-
sorbing fumes would become infected. Thus the milk
would be affected by the perspiration from the cow,
and so would have a repulsive taste. In filtering the
milk, linen cloths were used. These were readily
boiled and cleaned, which was a simple and inexpen-
sive method. The milk for house use was cooked in
copper vessels and packed in ice-boxes. Milk for
children was mixed with oatmeal gruel, and after
sterilization was bottled and cooled to 10° C. The
milk was transported in galvanized tin cans. Sterili-
zation was performed by the Soxhlet method in what
is called a Henneberg sterilizer. This held two
hundred and sixty-four bottles. The paper closed by
mentioning some of the different modified milks.
Infant Feeding — Dr. Alexander McAllister, of
Camden, N. J., read this paper. He said that the
generations yet unborn were more or less influenced
by the methods of infant feeding. The mother's milk
would go farther to solve this question than any chemi-
cal combination. The infant's food was strictly an
animal food and not a vegetable one. We could not
improve upon nature's method. He then spoke of
young married society women, who for social or other
reasons would not nurse their young. Dr. McAllister
mentioned, in passing, the well-known pictures of
" fat babies " seen in certain advertisements of '" infant
foods." Babies fed naturally were in a better condi-
tion to resist disease, while the artificially fed infants
were exposed to constant dangers. The milk from the
time of milking to the place of feeding was in- con-
stant danger of being infected. Pasteurization and
sterilization were used, but not in every home. He
spoke of the importance of partial breast-feeding, and
thought that even one breast-feeding in twenty-four
hours would be very beneficial. Young mothers, who
had little milk, should be treated for it, and everything
possible should be done to increase the flow. Food
for the mother was very important, such as cow's milk
and other fats. He referred to galactagogues, with
diet, and thought in this way many lives migiit be
saved. In considering the different modified milks,
he said that there should be an excess of proteids in
water, but one had to keep in mind the needs of the
individual case.
Infant Feeding ; Accidents and Incidents Dr.
William P. Northrup, of New York, read this paper.
He spoke of the responsibility of the physician in such
cases. In regard to modified cow's milk he said there
was a greater responsibility upon those who persisted
in using a fixed formula. He cited a case of a female
child that had a fair start in life. When she was
three days old, modified milk was given. At the age
of nine months she had bleeding of the gums. One
eye was seen to be black and blue, and then swelling
of the ankles and knees was noticed together with
paresis of the lower extremities. Later she had blood
in the urine. The patient was put on orange juice
and other anti-scorbutic treatment, but the child did
not improve as much as she should have done. When
she was two years old she had typical rachitis. Dr.
Northrup advised, in closing, to begin with a formula
and increase the amounts rapidly. Sick children
could not stand as much proteid as could well chil-
dren.
Dr. H. D. Chapin, of New York, said that in ster-
ilizing milk a chemical change took place. When
modified milk first came into use it was thought that
the question of the percentage of fats and proteids was
solved. It was not solved. The less manipulation of
the milk the better. When an emulsion such as milk
was once broken up it could never be restored in as
perfect a form. Dr. Chapin said that the milk should
be bottled at the farm and then sent on its journey.
He said that when milk was bottled in cylindrical
vessels and cooled to a temperature of 50° F., nine-
tenths of the butter fat rises to the top of the bottle.
He said that there was nothing so variable as cream, the
percentage of fat varying with the layers. Dr. Chapin
exhibited a small dipper which held one ounce, to be
used to take the cream off of the top instead of using
a siphon drawing from the bottom. He showed a
chart relating to what was called the " deep-setting pro-
cess of milk," and its relation to fats. Mother's milk
varies from day to day. Dr. Chapin spoke of the im-
portance of watching the stools, and said that gruels
were of service because of their dextrinizing power.
When a gruel was thoroughly dextrinized, the solution
would separate into two layers.
Dr. Victor C. Vaughan w^as the next speaker. He
agreed with Dr. Chapin as to the value of sterilization
of milk. Sterilization changed the proteid into a nu-
cleo-albumin at high temperature. There was no
change at the temperature of 158° F., but when heated
two degrees higiier nucleo-albumin was formed. ^ He
spoke of the bacillus coli communis in milk, and said
that while we were able to kill the bacilli we had no
control over their toxins. Dr. Vaughan mentioned a
case of a child who was poisoned by the parents' allow-
ing the milk to stand for three hours at summer
heat.
Dr. W. L. Stowell, of New York, said that modi-
fied feeding was ideal, but did not work practically.
He mentioned some cases of scorbutus, and said that
children would digest an amount of casein. He
thought the main difficulty in artificial feeding was
that the milk was not modified rapidly enough for the
growing child.
Dr. a. Jacob! said that if any person present thought
he could lay out any routine feeding, that person had
found by the papers read that he was mistaken. He
had taught for years that milk should be diluted with
cereals. He said milk once separated could never be
made milk again. Nine to ten per cent, of breast-fed
children had fat in their stools. He said that nature
was more generous than doctors.
Dr. J. P. Crozer Griffith, of Philadelphia, said
that he believed in sterilized milk.
Dr. Koplik, of New York, said that the whole prob-
lem was still unsettled. He believed the day would
never come when a clean milk could be procured.
Dr. Northrup said that he had learned of a new
mixture, that of "milk and brains," and this he
thought was the secret of Dr. Jacob i's success.
June 1 6, 1900]
MEDICAL RECORD.
1053
Demonstration of Specimen of a Fatal Foetal
Ichthyosis, with Complete Pathological and Bac-
teriological Examinations. — Dr. A. S. Daniel, of
New York, exhibited this specimen. The maternal
history was negative with the exception of severe grief
over the loss of her previous child. She was de-
livered b)' a midwife, the head presenting. The pa-
ternal history was also negative as far as syphilis was
concerned. The child passed urine and meconium at
birth. During its life the child's body was rigid
and cold. After death the temperature was 103° F.
Necropsy showed an absence of the panniculus adipo-
sus, and the heart was normal. There were a few
small areas of emphysema in the lungs. The liver
was congested and showed granular degeneration of
the liver cells. A meningeal hemorrhage was also
present. Dr. Daniel then reviewed the histories of
these cases, and found that only forty-two cases had
been reported.
Gastro-Intestinal Hemorrhage in the New-Born.
— Dr. Edward H. Small, of Pittsburg, Pa., read this
paper. He had had a case of a female child, born at
full term, who began to vomit blood about the third
day. A little later she had a tarry movement, and
then she passed clots of blood. She died on the eigh-
teenth day, treatment being of no avail. Dr. Small
said that the following causes had been ascribed to this
accident: sepsis, syphilis, respiratory disturbances,
malformation of the heart, conditions of the blood,
haemophilia, worms, ulcerations in the gastro-intes-
tinal tract, and delayed labor. These cases were more
common in hospitals. This fact, he said, suggested
that this disease was of the character of an infection.
Diplococci resembling that of pneumonia and strep-
tococci had been described.
Clinical Significance of Stools in Diarrhoea of
Infants Dr. William E. Darnall, of Atlantic
City, N. J., read this very interesting paper. He
spoke of the importance of examining the stool and
napkins of the child and not depending upon the
mother's statement. The usual history of these cases
was as follows: The child became cross and irritable,
■which was soon followed by an attack of acute indi-
gestion and colic. The mother would feed the child
-every time it cried, thus increasing the symptom.
Green stools were the rule, the so-called spinage-
green stool; sometimes they were pea-green in color;
others were brown and muddy in character. These he
thought were due to bile. Some stools were loose and
watery. He spoke of the stools with more or less
mucus, due to some colitis or proctitis present. In
these cases the rectum was often relaxed. The " con-
stipated stool," so-called, he thought was due to a de-
ficiency of fat in the child's diet. The serous dis-
charges were often important. The treatment of these
cases consisted of elimination, disinfection, and feed-
ing. All food was to be withdrawn for twenty-four
hours, and only cold water given that had been boiled,
or barley water. He prescribed 3 ss. of aromatic syrup
of rhubarb, or salol gr. y^ t.i.d. Dover's power in grain
doses was also of great benefit in cases with an exces-
sive number of stools. Hot applications over the ab-
domen were often of service. In cases of mucous
stools, high rectal irrigations of warm water or saline
solution were very serviceable as well as soothing and
comforting to the patient.
Shall Children be Kept from Measles and Ex-
anthemata Usually Incident to Children ?— Dr. C.
F. \VAHRER,of Fort Madison, Iowa, read this paper.
He said that one of the axioms in medicine was '" If
a child did not have a disease, it could not die from
that disease." He thought that preventive medicine
was better than a cure. VVe had quarantine regula-
tions for consumption and cerebro-spinal meningitis.
Scarlatina was the most dreaded of these diseases, for
there was no way of foretelling its complications,
which sometimes disfigured the patient for life. The
same was true of diphtheria. The mortality of mea-
sles in some epidemics was very great, more espe-
cially among adults. There were mild epidemics of
measles, and why should not all children be exposed
to the disease?
Rbtheln : a Distinct Affection Apart from Mea-
sles and Scarlatina, and its Differentiation from
these Exanthemata — Dr. Henry Koplik, of New
York, presented this paper. He said that some ob-
servers doubted that rotheln was a distinct disease.
It was most often mistaken for measles. He said that
rotheln was not a disease of the mucous membrane.
He had never seen coryza and cough in this disease,
as it occurred in measles. The slight cough present
was due to an infection of the mucous membrane and
tonsils as in la grippe. Children rarely complained
of sore throats, but adults did. The temperature was
practically normal. He said a typical case might run
its course without fever. He had seen one case of
rotheln with desquamation. He paid especial atten-
tion to the recent enlargement of lymphatic nodules in
the groin and axillae.
Clinical and Pathological Study of the Rash of
Scarlet Fever — Dr. Jay F. Schaumberg, of Phila-
delphia, read this paper. He said that the eruption
in scarlatina was an infectious dermatitis, and that it
varied with the patient. The different colors pro-
duced were known as redness, raspberry, and boiled-
lobster appearance. In some cases there was a blu-
ish color, due to venous congestion. The punctate
spots were due to inflammation around the hair folli-
cles, and sometimes they were* so enlarged as to
produce roughness, which was spoken of as "nutmeg
feel." Sudamina were due to droplets of sweat. He
exhibited a photograph showing marked sudamina
over the mons veneris. Vesicles were often present,
but not much larger than pin-points, and oftentimes
they were microscopical. He said that the vesicles
were directly proportional to the intensity of the dis-
ease. The skin was infiltrated with eosinophiles, and
these seemed to stimulate the cells in the corium to
multiply. Several karyokinetic figures were shown
in microphotographs.
Dr. Wahrer said that what was wanted was a clini-
cal study of the disease.
Dr. Griffith said that he would not be willing to
expose his children to measles. The mortality was
as large as that of scarlatina and diphtheria together.
He said that desquamation in rotheln did occur. Ten
years ago his attention had been called to a case of
measles with enlarged cervical glands and no disease
of the scalp.
Dr. Louis Fischer spoke of the complications of
measles. Last winter he had cases with otitis media
and emphysema, and one case of vaginitis following
measles and lasting for several months.
Foetal and Infantile Typhoid. — This paper was
read by Dr. John Lovett Morse, of Boston. He
said he would not consider the cases reported before
the typhoid bacillus was discovered. By experiments
on animals he found that the bacilli could pass from
the mother to the child; also that they were found in
the amniotic fluid. He referred to foetal typhoid,
which had entrance through the blood, and called it
a septicremia; he also spoke of infantile typhoid and
the serum reaction.
SECTION ON MATERIA MEDICA AND THERA-
PEUTICS.
Scrond Day, Wednesday, June 6th.
Discussion on Diabetes. — Dr. O. T. Osborne, of
New Haven, differentiated between true diabetes and
I054
MEDICAL RECORD.
[June 1 6, 1900
glycosuria. In all cases some malfunction of the pan-
creas was at the bottom of it.
Dr. J. M. Allen said that in seven personal cases
of diabetes in which an autopsy was made he found
a chronic inflammatory process in the duodenum in
each of them. The value of opium consisted in its
quieting effect on the bowel. Intestinal antiseptics
were to be used in all cases.
Dr. Brower, of Chicago, related the history of a
case that w-as due to colon infection, with recovery.
Dr. Bartley, of Brooklyn, pointed out that the cop-
per test was useless for determining small quantities
of sugar in the urine. When albumin was not present,
the bismuth test was the best that we possessed.
Dr. Solomon believed that we might educate pa-
tients to consume large amounts of fats. A certain
percentage of alcohol was often beneficial. The dis-
cussion was continued by Drs. Lyons, of Detroit, and
Zwisohn, of New York.
Dr. Stern stated that for the past ten years in New-
York City there were eighteen hundred and seventy-
six deaths from this cause; fifty per cent, of these
cases were in women. In some patients an absolute
milk diet afforded the best results. In most cases of
diabetic coma o.xybutyric acid was present. The most
frequent cause of oxybutyric acid was fat meat. The
color tests for sugar in the urine were unreliable.
Gastro-Intestinal Remedies in Typhoid Fever —
Dr. I. M. Anders, of Philadelphia, presented this
paper. The importance of careful feeding and cool
baths in the prevention of complications could not be
said to be overestimated. From two to three quarts
of water should be administered daily. This was best
given between the feedings. If hydrochloric acid was
given after the feeding, there was less likelihood of
indigestion. The stools should always be examined
both microscopically and macroscopically whenever
any complication arose. Errors in diet and digestion
were generally the cause of fresh symptoms. Intesti-
nal antiseptics controlled meteorism, diarrhoea, etc.
They had no effect on the bacillus typhosus. Calo-
mel should be given for the first few days, or even as
late as the second week if necessary. Salol gr. iii.
every three hours was his favorite drug. In tym-
panites due to ulceration of the colon turpentine in
small doses was often useful. The so-called specific
or Woodbridge treatment was entirely useless in the
control of the disease. Intestinal irrigation was often
beneficial for tlie diarrhoea that occurred late in the
disease. In many cases of delayed convalescence a
saline would cause rapid and permanent reduction of
the temperature.
Dr. F.WILL, of Chicago, said that the type of the
disease had changed in the last ten ^ears. Much of
our success was due to hydrotherapy. He employed
saline enemas of one pint several times daily with
much success. Guaiacol was given internally.
Dr. T. F. Reilly, of New York, called attention to
the value of fair-sized doses of strychnine in the man-
agement of the constipation during the decline of the
fever.
Dr. W. B. Hill, of Milwaukee, believed that we
feed too often. Flushing of the colon with cold sa-
line solution lowered the temperature better than the
external application of cold water.
Dr. F. VVoodrury, of Philadelphia, pointed out that
all water that was given to the patient should be ster-
ilized.
Dr. Anders in closing said that the urine should
be watched if large doses of salol were administered.
The salol prevented complications, but had no effect
on relapses. The intestinal antiseptics prevented the
multiplication of other germs and rendered the stools
less offensive. An absolute milk diet was best in
most cases.
Brief Note on Ointments and Some of their
Medicinal Applications ; the latraliptic Method of
Treatment. — Dr. Frank Woodbury, of Philadelphia,
read this paper. He described the various classes
of ointments. If warmed, many of them could be used
in a nebulizer and sprayed over the cavities of the
body. The value of inunctions of cacao butter and
cod-liver oil in overcoming the denutrition of ty-
phoid fever and of diabetes w-as pointed out. Poi-
sons might be transmitted by the skin as well as
medicines. Most of the ointment bases in present
use contained various toxic agents, as a result of the
micro-organisms contained in them. Lard was gener-
ally septic. In order to overcome this ointments
should be dispensed in collapsible tubes similar to
those containing artists' colors. This w-ould also pre-
vent the carrying of infection, and was an economical
way of using an ointment.
Idiosyncrasy against Mercury; a Case of Ery-
thema Mercuriale Dr. A. Bernheim, of Philadel-
phia, presented this history of a case of erythema mer-
curiale, due to the ingestion of a small amount of
mercury. There was a history of four such attacks in
the same patient, following at each time the use of the
drug.
The Unbroken Skin as an Absorbing Medium.
—This paper was read by Dr. Thomas F. Reilly, of
New York. He said that a medicinal agent to be
absorbed by the unbroken skin either must become
volatile during its application, or be incorporated in
a fatty base and applied with friction. Occlusion was
an absolute requirement in the case of volatile sub-
stances. Most of the absorption occurred in the crypts
of the sebaceous glands. The effect was much slower,
about one-fourth as intense, and continued longer than
when the same agent w-as administered by the mouth.
A large number of medicinal agents, which w-hen given
by mouth were intolerable to many patients, could be
administered in this way with scarcely any unpleasant
effects. The literature mentioned the following medic-
inal agents as having been successfully employed for
their constitutional effects when applied in this man-
ner: Mercury, iodine and iodides, salicylic acid and
some salicylates, guaiacol, creosote, iodoform, turpen-
tine, carbolic acid, pilocarpine, croton and cod-liver
oils, metallic silver, quinine, digitalis, and bella-
donna.
Dr. Remington, of Philadelphia, said that cacao
butter was one of the best bases that we possessed. It
was practically sterile and could be softened if mixed
with a small quantity of any fixed oil. For inunction
purposes he placed oleic acid at the head of the list.
The great advantage of cacao butter was that it was
solid at 94° F., and fluid at 98 F.
Dr. Solomon called attention to the fact that some
drugs w^ere readily absorbed no matter \vhat the oint-
ment base might be. Ichthyol was cited as an exam-
ple of this class.
The paper was further discussed by Drs. Rotter of
Harris'iurg, Lyon of Detroit, VVheatly, 'Reamy, and
E. B:ardman-Reed of Philadelphia.
The Metric System. — Dr. F. G. Wheatley, of
North Abington, Mass., in this paper set forth the
many advantages that would arise from the general
use of this system.
Dr. Bartley, of Brooklyn, said that if the prescrip-
tions were written only in terms of grams and milli-
grams much confusion would be avoided.
Report of Cases Illustrating the Value of Rectal
Injections of Salt Solution in Hemorrhage. — Dr.
T. B. Greenley, of Meadow Lawn, Ky., presented
this report. Tlie histories of several such cases were
reported in which the procedure was a life-saving
measure. From one to two quarts of decinormal salt
solution was employed.
June 1 6, 1900]
MEDICAL RECORD.
1055
Preventive Treatment of Migraine — Dr. E. \y.
Mitchell, of Cincinnati, Ohio, discussed in this pa-
per the various theories that had been advanced to
explain the cause of this affection. The theor\- of
auto-intoxication had the most adherents. The paraxan-
thin theory had not been verified. He believed in an
absolute withdrawal of all red meats. These attacks
could generally be prevented by the use of the follow-
ing mixture, to be taken each morning before break-
fast: Sodii sulph. and sodii phosph., of each "ii-;
sodii salicylas, gr. x. ; tr. nux vom., TTliii; water, ; iv.
This was best administered in seltzer or Vichy.
Dr. a. L. Benedict, of Buffalo, said that as a gen-
eral rule the amount of hydrochloric acid was very
much diminished in the gastric secretions of these
patients. He advised that it should be administered
as a routine treatment.
Dr. I. N. Upshur, of Richmond, thought that the
disease was in almost every case due to nerve strain.
It was caused by dietetic disturbances in only a very
small percentage of the cases. In many of these cases
during an attack the fa;ces were clay-colored, and this
was due to disturbances in the liver. Full doses of
sodium phosphate in hot water on an empty stomach
for several days had given him the best results.
Dr. J.M. Allen stated that in many of tiiese cases
in which he had performed autopsies there was a
chronic ulceration of the common bile duct, which,
when inflamed, penned up the secretions in the gall
bladder, and then they were diffused throughout the
system.
Dr. Bartley pointed out that Haig, in his work on
this subject, confused xanthin with uric acid, and that
many of his conclusions were faulty.
The paper was further discussed by Drs. Yasnall,
of Washington, and H. Stern, of New York.
Dr. Mitchell, in closing, said that the white meats
w'ere less likely to cause fermentation than the red
meats, and therefore were to be preferred.
The Role of Drugs in the Management of Con-
sumption.— Dr. S. Solis-Cohen. of Philadel;)hia, pre-
sented a paper with this title. He said that tuberculo-
sis was a curable disease. Drugs played a secondary
part in its management. In the pretuberculous stage ni-
troglycerin was a valuable agent, causing the blood to
penetrate to the utmost recesses of the lungs and thus
to favor nutrition. AH the tonics and good hygiene were
to be employed during this stage. The building up of
nutrition was the broad principle of cure, and should
be pursued throughout the whole course of the disease.
Digitalis was very valuable in cases in childhood and
also in the florid or galloping variety, and in the
bronchopneumonias occurring in chronic tuberculo-
sis. Iodine and iodoform v.ere the most useful drugs
to influence the local condition. He began with
doses of iodoform gr. ss. three times a day in pill
form. This was gradually increased until in three
months the patient was taking gr. v. t.i.d. As an in-
halation both the iodide of ethyl and niyrtol had given
very satisfactory results. Myrtol if given internally
was one of the best agents for the control of the bron-
chial inflammatory conditions accompanying the dis-
ease. Formaldehyde by inhalation acted well in the
laryngeal form. Calcium chloride given in dose of gr.
XV. every two hours continuously for three or four days
would stop persistent haemoptysis. It should not be
continued for more than five days. Hydrastine hydro-
chlorate was also useful. Ergot was useless for this
purpose. Camphoric acid and atropine usually would
control the night sweats.
Importance of Early Recognition of Tuberculosis.
— This paper was read by Dr. A. M. Holmes, of Den-
ver, Col. He divided the disease into three stages:
(i) The pretuberculous stage, in which there was no
lesion but a susceptibility; (2) early incipiency — a
lesion or tuberculous infection being established, but
bacilli not being present in secretions or excreta; (3)
when a well-established lesion was present and bacilli
appeared in the sputa. Among the early suspicious
symptoms might be mentioned a rapid and variable
pulse. Pleuritic friction sounds were generally of tu-
berculous origin. The cog-wheel respiration was a
very suspicious sign. This was heard most plainly
toward the end of inspiration, and was accentuated if
a strong heart action was present. Subnormal tem-
perature in the morning was another early sign.
Dr. William H. Thomson, of New York, said that
tuberculosis was either simple or complicated. In the
lungs it was always of the latter sort. The disease
would have no antitoxin because it was unlike the other
infections in that nature did not tend to limit its
growth. Birch-Hirschfeld was quoted as having
found it present in seventy-eight per cent, of four
thousand autopsies. In the lungs the constant move-
ment in respiration was a great hindrance to its cure.
The specific effect of the tubercle bacillus was emaci-
ation. By this was meant a loss of fat in every tissue
except the nervo«s system. The facial expression
and contour of the consumptive was the result of this
emaciation. As therapeutic agents iodoform and
arsenic ranked foremost. He administered creosotal
in doses of gr. xx. every two or three hours. There
was no drug that would act so well in the septic cases
as fresh air. Cod-liver oil was generally ordered when
the stomach tolerated it.
Dr. I. N. Upshur said that the stomach was to be
preserved at all hazards. Hygiene was to be relied
on, and few drugs should be given.
Dr. Cohen, in closing, emphasized the point that
the patient's vital resistance was the key to the whole
situation, and everything possible should be devoted
to the increasing of this resistance.
Heart Tonics.— Dr. I. N. Upshur, of Richmond,
Va., discussed this subject. He said that digitalis
was an unsatisfactory and uncertain remedy because
its action could not be controlled. The same was true
to a less degree of convallaria. Sparteine was of great
service in weak and flabby hearts. Strophanthus was
very much superior to digitalis. It was more prompt
in its action and more permanent in its effects.
When combined with strychnine it was a most valuable
agent in fevers and weak states of the system. Atro-
pine was of especial value in cases of cardiac insuf-
ficiency accompanied by bronchorrhoea. Caffeine
was of considerable service when the kidneys were
affected. Strychnine was cur most valuable and reli-
able heart tonic. If given before chloroform anaes-
thesia it prevented cardiac failure. It was invaluable
in the case of a weak heart from any cause. Nitro-
glycerin was not a heart tonic. It was contraindicated
in weak states of the system, and especially in surgical
shock. It was a motor depressant, and its too free use
was fruitful of harm. In the late stages of typhoid,
opium seemed to have a true tonic effect on the heart.
Cactus grandiflorus was useful in cases of rapid heart
due to tobacco poisoning.
Dr. Oarlock, of Little Falls, N. Y., said that most
of our therapy in heart diseases should be directed to
the condition of the blood rather than to the heart itself.
Dr. Melvin, of Saguache, Colo., said he had em-
ployed cactus grandiflorus either alone or with stro-
phanthus in various forms of cardiac disease, and was
well pleased with its action. He gave the fluid ex
tract every four hours in doses of TTl ix.
Dr. Heinrich Stern said that adonidin was one
of the safest and surest of cardiac tonics that we pos-
sessed. It was of especial value when nephritis was
present.
Classification of Medicines Based on the Time
Required to Produce their Effects. — Dr. William
IC56
MEDICAL RECORD.
[June 1 6, 1900
H. Thomson, of New York, read this paper. He said
that the vagueness of terms used to designate medici-
nal agents was the cause of much of the therapeutic
scepticism of the present day. The classification
should be founded on fundamental distinctions. He
distinguished two general classes : (i) Functional or
symptom medicines, these had no effect on struc-
ture. (2) Nutritive medicines; these should not
produce symptoms no matter how long they were
employed, and they affected structure solely. He
outlined how the classification could be carried out
in the case of the commoner drugs, and spoke of the
different actions of large and small doses of the same
drug.
GENERAL SESSIONS.
Third Day— Thursday, June Jth.
Oration on Medicine. — Dr. John A. Wither-
SPOON, of Nashville, Tenn., delivered this oration.
He first paid his respects, in a witty and pointed man-
ner, to the manufacturing chemists and their commer-
cial allies, who were so fond of deluging the profes-
sion with their products, and, at the same time, giving
" instruction " to the doctor concerning the use of these
products, and incidentally as to the best way for him
to practise the healing-art. A strong plea was made
for the establishment of a national department of
health, and the advantages which would accrue to the
whole nation from such an arrangement were clearly
pointed out. The speaker then went on to sound a
note of warning against the present tendency of physi-
cians to give indiscriminately the preparations of
opium. Too often, he said, the degeneracy produced
by this insidious drug was transmitted to the offspring
of the unfortunate victims. The " hypodermic shot"
was too often given for a stomach-ache when a dose
of oil was what was needed, or it was given month
after month to relieve painful menstruation, until the
brilliant eye of the young and healthy woman gave
way to the dull expressionless eye and the muddy skin
of the morphine habitue'. The same was true of co-
caine, and its careless and indiscriminate use in minor
surgery and elsewhere. In approaching the subject of
the useless multiplication of books and authors, the
speaker declared that he did so with trepidation, and
that he felt like taking off his shoes, for he knew he
was standing on " holy ground." Many books and
papers were written merely to satisfy the personal am-
bition of their authors. There was a prevailing ten-
dency, amounting almost to a mania, among young
men to rush into print and appear as ■" authorities."
He did not mean that young men should stay in the
rear, but he did contend that they should print their
views, not in books, but in the medical journals —
those great educators of our busy profession. In con-
clusion, the speaker averred that when the regal robes
ci ethical medicine should have been made aseptic,
and should have been cleansed from their present
pollution, we might be justified in exclaiming:
" Sound the loud timbrels o'er Egypt's dark sea. '
Jehovah has triumphed ; the people are free."
Military Education and Sanitary Knowledge —
■On motion of Dr. Tuckerman, of Ohio, the following
resolution was adopted :
" Resohid, That the national legislative committee,
in conjunction with the special committee on reor-
ganization of the army and navy medical corps,
cause to be drafted a bill providing for adequate in-
struction in hygiene and sanitation in the national
military and naval academies, such bill to be perfected
at the next meeting of the joint national legislative
.committee of the American Medical Association and
affiliated societies, and to be pushed through Congress
as speedily as possible."
A Grant for Scientific Research.— In accordance
with the suggestion in the president's address, the
trustees were requested to set aside the sum of $500
annually for the encouragement of scientific re-
search, this sum to be increased in the future if the
finances of the association warranted such a course.
The manner of expending this sum was left to the
committee on scientific research, and it was directed
that the money be distributed in sums not to exceed
$50 or $100 to any one individual.
Fourth Day — Friday, June 8th.
This was only a short session for the transaction of
routine business.
After the usual votes of thanks, the association ad-
journed at 1 1 130 A.M., to meet in St. Paul, Minn., on
the first Tuesday in June, igoi.
The total number registered at this meeting of the
association was 2,030.
SECTION" ON PRACTICE OF MEDICINE.
Third Day — Thursday, June Jth.
Malaria and Mosquitos. — In discussing the paper
upon malaria Dr. Thayer said the commonest mos-
quito was not capable of transmitting malaria. Those
of one genus only did so, and these only when they
were themselves infected. They could take in the
poison from a case of relapse and transmit it in regions
previously free from malaria. As to transmission by
the gastro-intestinal tract, there was little evidence in
favor of it.
Dr. Edwards, of Philadelphia, said that getting rid
of ground-water and using rain-water or that from deep
wells had seemed to do away with malaria in certain
regions of North Carolina.
Dr. Howard said the Anopheles had been found at
an elevation of one thousand feet, but it was usually
found lower.
Dr. VVoldert said that the mosquito remained in-
fective for two to three weeks after tjiting a subject of
malaria. Hemoglobinuria was due to the malaria as
a rule and not to the quinine administered.
Dr. ISuRNS, of Arkansas, reported on sixteen cases
of malaria showing ha;moglobinuria, more than half of
the patients having died without quinine having been
given. He gave quinine in one case, and although
hajmoglobinuria came on the man recovered, and since
then he had used quinine freely. He thought that
quinine might often save life in these cases. He ob-
jected to the term post-malarial hemoglobinuria.
Prolonged Fevers of Obscure Origin. — Dr. Rob-
ert B. Preble, of Chicago, in this paper confined his
remarks to cryptogenic sepsis, leaving aside a great
number of obscure fevers due to a wide range of causes,
and these were termed " obscure " only because of their
occurrence in unusual locations or because of being
obscured in their symptomatology and course. The
reactions recently introduced (Widal, diazo, etc.),
more careful examinations of the blood, exclusion of
the malarial parasites, etc., had done much to aid in
the proper recognition of such confusing conditions.
A wide range of diseases were included in this sepsis,
such as malignant heart disease, purpura, etc. In
treatment the strength must be supported, and anti-
streptococcic serum, salt solution, etc., used.
Dr. Bishop, of New York, said there was a class of
cases usually referred to as blood-poisoning. He
thought some of the cases were really typhoid, as
another speaker had suggested. The blood should
alwavs be examined to exclude the latter.
June 1 6, 1900]
MEDICAL RECORD.
1057
Dr. Davis, of Chicago, thought the .explanation
made a certain class of cases much clearer. In ob-
scure fever of septic origin we must watch for endo-
carditis just as in rheumatism.
Dr. Preble said he did not exclude a diagnosis be-
cause of the absence of the VVidal reaction. He did
not suggest doing away witli terms of convenience, but
students should be instructed that these conditions were
but different manifestations of similar processes.
Pathology of Rheumatism This paper was read
by Dr. David Riesman, of Philadelphia.
Some Thoughts on Rheumatism and Prevention
of Heart Complications. — Dr. James J. Walsh, of
New York, read this paper. He said that rheumatism
was regarded as an infectious disease, probably a mild
pyemia, and was self-limited. Dampness was a sec-
ondary cause. The contagiousness seemed estab-
lished. That rheumatism was not a simple disease
was shown by the multiplicity of organisms giving a
series of similar affections closely associated. The
simple form was due to a diplococcus, in rapidly fatal
cases to an anaerobic bacillus in all probability. The
uric-acid theory has been practically abandoned.
More than half the endocarditis was due to rheumatism.
There was no specific, and no drug treatment lessened
the liability to the involvement of other joints or of
the heart. The salicylates alleviated symptoms bet-
ter than any drugs previously recommended, and were
less objectionable. For heart complications nothing
equalled rest in bed. These were not complications,
but integral parts of the general infectious process.
The Relation of Chorea and Rheumatism. — Dr.
C. W. Burr, of Philadelphia, read this paper. He
said there was frequently a history of rheumatic fever
or less frequently of " growing pains " preceding Saint
Vitus' dance. Chorea less often occurred during an
actual outbreak of rheumatism. Valvular heart dis-
ease was frequent.
The speaker did not think the coincidence of rheu-
matism and chorea was of sufficiently frequent occur-
rence to show that the one had more than a predispos-
ing influence over the other.
The Heart in Rheumatism. — This paper was read
by Dr. De Lancey Rochester, of Buffalo. He
looked upon rheumatism as an infectious disease in-
volving the heart in a large percentage of cases. The
younger the patient the greater the liability to endocar-
dial involvement. Pericarditis because of its variety
was to be looked upon as a complication, more severe
in effects as a rule than was endocarditis. The myo-
cardium became involved in the presence of both in-
flammatory processes, but was more pronounced in
pericarditis. The occurrence of endocarditis or of
pericarditis did not contraindicate treatment by the
salicylates.
Pathogenesis and Clinical Features of Arthritis
Deformans. — Dr. A. O. J. Kelly, of Philadelphia,
read this paper. He thought that of all the names
suggested, the one here employed was to be preferred.
The pathogenesis excluded gout and rheumatism,
though these might precede or complicate. Only two
theories were worthy of present serious consideration,
i.e., the neural or nervous and the infectious or bacte-
rial. The arguments advanced in support of each
were reviewed. He believed the disease to be an in-
fectious tropho-neurosis, and not a disease of spinal
origin or the result of peripheral neuritis. It occurred
after known infectious processes.
Dr. J. M. Anders, of Philadelphia, said he had ob-
served a heart murmur disappear in chorea following
rheumatism, and did not think such murmurs always in-
dicative of endocarditis. Acute articular rheumatism
as a primary affection was rare. It was common after
infectious diseases and in convalescence from scarla-
tina. Osteomyelitis must not be confounded with
acute articular rheumatism, or the results would be-
disastrous. The bones here became enlarged, and
side-to-side pressure directly over or above or below
the joint elicited tenderness and pain in the early
stages. It was often monarticular, but might involve
more than one joint. In septic ostitis the symptoms
were more severe, but sweats were less profuse. Salicy-
lates did not relieve the pain. Alkalies combined
with salicylates tended to obviate heart complica-
tions.
Dr. C. G. Stockton, of Buffalo, said that we had
not reached a point where we could say that rheuma-
tism depended upon one single infection, as was the
case in scarlatina. Arthritis deformans was an entity.
By neuro-trophic infection was undoubtedly meant
that neuro-trophic changes predisposed certain tissues
to infection. This was a tenable belief. So-called
diatheses might likewise predispose to infection at
certain points. There were climatic influences which
surely had an effect. Little could be at present posi-
tively affirmed.
Dr. L. F. Bishop, of New York, said he felt more
clear in his mind than some speakers as to classifica-
tion. There were disorders of the chemistry of the
body and of nutrition which had an influence outside
of infection on which acute articular rheumatism de-
pended. Gout was a disorder of the chemistry of the
body. Trophic disturbances accounted for some
affections. Arthritis deformans might come on after
shock, grief, etc. He did not look upon chorea and
rheumatism as the same disease.
Dr. H. B. Favill, of Chicago, believed with Dr.
Bishop that there was a chemical foundation. He
thought, however, that we must wipe off the slate and
begin the study of rheumatism anew. On one side
there was a toxic relation, on the other infection, but
he could not define his views more closely. Chorea
did not result from rheumatism, bi.it occurred in those
in whom rheumatism was prone to develop.
Dr. McCaskey said that the use of the term rheu-
matism should be strictly limited to the clinical pic-
ture we all recognized, and the designation rheumatic
dropped in speaking of other affections. In arthritis
deformans cataphoresis with a solution of iodide of
potassium had given him satisfactory relief of symp-
toms. Antiseptics could be used in the same way.
Dr. Solis-Cohen said arthritis deformans must be
still further separated into several classes. He thought
"toxic" tropho-neurosis was more appropriate than
the term " infectious." Then all would agree. He
referred to the tincture of the chloride of iron in
treating acute rheumatism, especially combined with
salicylates and alkalies, as means of preventing heart
complications.
Dr. Riesman said that we had agreed that rheuma-
tism was " several diseases." Polyarthritis would be
found to be due to one organism, and one alone.
Dr. Walsh said that endocarditis always occurred
in the left heart. The blood flowing here came direct
from the lungs. If the organism was aerobic, this lo-
cation might be accounted for. Choreic children had
usually had rheumatism previously, and that is why
they had it subsequently.
Dr. Rochester said that rest in bed for six to
eight weeks, often between blankets, was necessary in
every case of acute articular rheumatism. He advised
milk diet, occasional doses of Rochelle salts, and sali-
cylates in large doses at intervals of two or three hours
day and night. It did not affect the heart. He had
given 2 gm. of salicylate of sodium every three hours
for several days. Oil of wintergreen disturbed the
stomach more. Iron was of the utmost importance, es-
pecially the pyrophosphate •_■ gm. to i gm., or HI xx.-
XXX. of tincture of the chloride.
Dr. Kelly referred to different forms of arthritis
1058
MEDICAL RECORD.
[June 1 6, 1900
deformans. Superheated air or steam over long pe-
riods of time had been of much benefit. The salicy-
late of strontium had givesi good results.
In What Relation does Occupation Stand to Tu-
berculosis ? — In this paper, read by Dr. W. Freuden-
THAL, of New York, the predisposition of tailors,
sewing-women, printers, and others to tuberculosis
was pointed out. The speaker gave the statistics of
others and the results obtained in analyzing fifteen
hundred cases. He found that in many instances the
primary lesion of tuberculosis was not to be looked
for in the lungs, but in the upper respiratory tract,
especially the retropharynx.
Diagnosis and Treatment of the Prebacillary Stage
of Tuberculosis. — Dr. J. M. Anders, of Philadel-
phia, read this paper. He thought there was reason-
able certainty about accurate diagnosis before bacilli
showed themselves in the sputum. He employed with
this aim .v-rays and the tuberculin test, and carefully
studies the anamnesis, looking out for symptoms and
physical signs in cases presenting unusual onset. It
was possible for the bacilli to remain encapsulated
until inroads had been made by the disease. He ad-
vocated early pre-bacillary treatment, and recognized
the superiority of hygienic and climatic conditions in
these early stages.
Rest in Pulmonary Tuberculosis. — Dr. Carroll
E. Edsox, of Denver, in this paper showed the impor-
tance of securing proper rest, many advising exercise
in the early stages, especially to the disadvantage of
the patient. There were indications in the pathology
of the disease for rest, and while physicians followed
them as they applied to articular and laryngeal tuber-
culosis, they ignored them when the lungs were in
question. There were also physiological reasons why
phthisical patients should do well under this plan of
management. This was especially true as applied to
those who sought high altitudes such as those of Colo-
rado, and there was abundance of clinical proof to
substantiate the claim.
Pulmonary Tuberculosis. — Dr. C. P. Ameler, of
Asheville, X. C, read a paper showing the present
condition of one hundred and six patients treated in
1898, upon whose cases he had reported to the section
at the last meeting. Of the cases then reported ap-
parently cured under serum therapy reports had been
received showing that they continued for the most part
in the same highly satisfactory condition. Tabulated
data arranged for comparison with the previous re-
port were presented. Serum therapy was highly
praised.
Tuberculosis of the Lungs. — Dr. A. F. Lemke, of
Chicago, read a report upon special cases treated by
the Murphy method, with nitrogen compression, giv-
ing the rationale of the method, considering the pa-
thology, and presenting the results of his experiments
on dogs. The average quantity of nitrogen which
could be introduced into the pleural cavity without
injurious effects was 120 cubic inches. Healthy lung
tissue could be compressed for a year, and retained
its capacity to expand. He found intra-pleural injec-
tions curative, and there was no evidence that fresh
tubercle could develop in a compressed lung.
Silver-Injection Treatment of Pulmonary Con-
sumption.— Dr. Thomas Mays, of Philadelphia, who
read this paper, said he believed that primary changes
in pulmonary tuberculosis did not reside in the lungs,
but in the nervous system. Basing his treatment upon
this view the reader had employed nitrate of silver
injections to cause irritation over the tract of the vagi
in the region of the neck. The counter-irritation
stimulated to vital resistance the vagi throughout their
ramifications, modifying lung conditions. In a period
of a year and a half in which he had employed the
method the results had been good, and more than half
the patients so treated were now, at the end of eighteen
months, practically well.
Dr. Vaughan, of Ann Arbor, thought that out-of-
door treatment was not sufficiently utilized, in the East
especially.
Dr. Rochester spoke of dissemination of phthisis
by sewing-women having the disease, who worked in
close quarters and had a habit of wetting the thread
in the mouth. The naso-pharynx as well as the mouth
was a good culture-ground for the bacilli. It was im-
portant to watch the temperature. It was probable that
in health there was a normal curve of variation.
Hence temperature observations must be made care-
fully. The sanatorium treatment was the very best,
with rest out-of-doors. The individual should be
treated.
Dr. Solis-Cohem said that there was a disease pres-
ent before the tubercle bacillus gained entrance to the
tissues. Treatment must vary with the stage. The
first point was nutrition, but in all cases we must in-
dividualize. The temperature of the atmosphere had
more influence upon the patient's temperature in
phthisis than in almost any other disease.
Dr. Knopf, of New York, had found that laun-
dresses who sorted dirty linen, and rag sorters were
more prone to consumption than others. Prolonged
rest on the back produced hypostatic congestion, so
we must alternate it with exercise in well-regulated
stages. He gave as little creosote as possible. Coun-
ter-irritants were of value. The tenements of the poor
must first of all be improved before sanatoria are es-
tablished to counteract their evil eft'ects. The State
should contribute to the care of the consumptive poor
close to their homes. Climate was not a specific.
Consumption was a social disease.
Dr. Xewtox, of New Jersey, related a case in which
there was an evening temperature in anaemia, tubercu-
losis being suspected.
Fourth Day — Friday, June 8th.
The Relative Importance of Valvular and Mus-
cular Lesions in Diseases of the Heart. — This paper
was read by Dr. S. Solis-Cohen, of Philadelphia.
He said that in the great majority of cases of chronic
disease of the heart, the exact site and nature of the
valvular lesion, while always to be taken into consid-
eration in treatment, were of less importance thera-
peutically and prognostically than the state of the car-
diac muscle. The most important exception to this
general rule was in the case of mitral stenosis with
great narrowing. Aconite was often in use in this
condition to reduce the excessive muscular effort, not
only in the absence of hypertrophy in cases of com-
pensation, but even when compensatory hypertrophy
had not become sufficient. In many cases in which
no evidence of valvular lesion could be detected dur-
ing life, and in some of which slight valvular altera-
tions, in others normal valves were demonstrable after
death, there existed rational signs of cardiac incom-
petence which were due to diseases of the cardiac
muscle. In the absence of valvular lesions, intermit-
tence or irregularities of the pulse, disturbance of rate
or rhythm by slight causes, and recurrent pain referred
to the precordium, in non-hysterical and non-neuras-
thenic subjects, were the principal local symptoms.
There was usually impurity or weakness of the first
sound of the heart, with approximation of the two
sounds in quality or relative accentuation of the sec-
ond sound; later embryocardia and gallop rhythm
might develop. Gout, syphilis, alcohol and tobacco,
tea and coffee, sexual excesses, mental strain, and
physical overwork were among the chief provocatives
of disease of the myocardium. Among the acute in-
June 1 6, 1900]
MEDICAL RECORD.
1059
fections, influenza was a frequent cause of cardiac-
muscle disease.
Diagnosis. — Other than the general diagnosis of
disease of the myocardium, there was not yet sufficient
knowledge of clinical signs to permit accurate recog-
nition of the lesion. The differentiation between
neurasthenia of the heart and disease of the myocar-
dium might be difficult. The chief importance of the
subject lay in the avoidance of error^ — (i) in the prog-
nosis and treatment of valvular disease, which might
be over-treated or under-treated through failure to esti-
mate properly the condition of the muscle; (2) in the
recognition of serious lesions of the muscular structure
of the heart in cases that had been supposed to be nor-
mal because of the absence of valvular murmurs; (3)
in the distinction between organic and muscular
lesions and functional disturbances, and in the reali-
zation of the fact that the latter might lead to the
former.
Treatment. — In treatment, judicious regulation of
diet, rest and exercise, avoidance of exciting causes
and excesses of any kind, the good functional condi-
tion of the skin and eliminative organs were of the
first importance. Warm, saline, carbonated baths and,
in some cases, gentle massage and resistance exercises
carefully adapted to the individual case, were of great
benefit. Nitroglycerin was the most useful single
agent of the materia medica. Strychnine, digitalis,
adonis, cactus, strophanthus, and sparteine had useful-
ness in individual cases. Venesection should be
made promptly in cardiac failure.
Clinical Study of Myocarditis. — Dr. Louis F.
Bishop, of New York, said he believed the importance
of recognizing myocardial lesions to be very great, as
it had a decided bearing on prognosis in many affec-
tions. The myocardium w'as as important as the peri-
and endocardium. The symptoms here gave us more
aid than did the physical signs, but in many instances
we must carefully differentiate from "nervous heart."
A study of a series of cases which he referred to showed
the relation of irregularity of rhythm to disease of the
muscle.
Plea for More Rational Prognosis in Cardiac
Affections. — This paper was read by Dr. J. J. Mor-
RissEV, of New York, and was based upon the study of
two hundred and fifty-five cases. He said that accu-
rate prognosis necessitated a complete diagnosis.
This should not be based solely upon the physical
signs present, which were frequently deceptive and
limited in character, but upon a consideration of the
cardiac efficiency, of the presence of hypertrophy, and of
the condition of organs far removed from the tlioracic
cavity. We should obtain as accurate a history of
causation and duration as possible. A gloomy prog-
nosis should not be given upon the simple fact of mur-
mur alone; the condition of the cardiac walls should
be considered, the probable duration, the presence of
dilatation or hypertrophy, and the occupation and tem-
perament of the patient. There was no means of recog-
nizing the strength of the individual heart except by
its power of resistance to the effects of alcohol, tobacco,
disease, occupation, and exposure. As AUbutt says:
"Give your prognosis on the best suppositions, treat
your patient on the worst." Prognosis based on the
presence of a murmur was unjust and demonstrated in-
capacity upon the part of the physician. We wished to
be just to the applicant, and at the same time to do our
duty toward the insurance company. The fact that a
man had a murmur at the apex, of which he was entire-
ly unconscious, whose heart was doing its work thor-
oughly despite the existence of the lesion, whose occu-
pation was not of an adversely laborious character,
who had passed that period of life when acute rheu-
matic infection was liable to stimulate into fresh and
renewed activity the latent inflammatory products of
an endocarditis, should be factors in recommending a
policy commensurate with the degree of cardiac ineffi-
ciency. A presystolic murmur did not always indicate
mitral stenosis. From the standpoint of longevity
aortic stenosis was a favorable lesion. The speaker
differed from authors who stated that it appeared for
the most part after middle life. He found it between
the ages of thirty and fifty as part of general athero-
matous changes, but it was more frequently present
without such pathological manifestations than had
been suspected. A young man between the ages of
eighteen and twenty-five should not be informed that
he had heart disease because some hypertrophy had
been discovered, with no complication, the result in
most instances of active exercise. The patient should
return for further examination, as the condition might
then have entirely changed.
Diagnosis of Diabetes. — Dr. J. B. Herrick, of
Chicago, read this paper. He said that the detection
of sugar was always the final test, but there were rarer
manifestations which, if taken in time, would not only
lead to proper diagnosis, but would permit of early
proper treatment. Among such symptoms were neural-
gias, neuritis, dry mouth, skin affections, impotence,
psychical disturbances, angina, dyspnoea, somnolence,
and irritability. The failure to detect or confirm dia-
betes was due to error in examination; to the fact that
the urine was not examined or sugar was not present
at the time of examination. Insurance companies
should change their rule which required examination for
sugar only when the specific gravity was above 1.015,
since sugar was not infrequently found below i.oio.
The variety of diabetes present should be studied.
Mortality from Diabetes Mellitus in the City of
New York during the Decade 1889-99. — Dr.
Heinrich Stern, of New York, read this paper, in
which he drew deductions from statistics furnished by
the city's bureau. In 1867, 931 deaths from diabetes
occurred in females, a much larger proportion than
that given in previous records. Tables by years were
presented. For the eleven years the deaths by months
scarcely varied; the limits being 190 and 134, show-
ing that temperature, sunshine, etc., had but little in-
fluence on mortality. The increase in October was
because the city was then most fully populated. The
mortality in negroes was low.
Cutaneous Diseases Accompanying Diabetes Dr.
M. B. Hartzell, of Philadelphia, read this paper.
He said the importance of recognition of the relation-
ship between skin manifestations and general condi-
tions applied to many other aflections besides diabetes.
This was from both a diagnostic and therapeutic stand-
point. In diabetes the skin was dry, the hair lustre-
less, the nails were brittle. Papular lesions might
occur upon the arms. Eczema, beginning as a pru-
ritus, especially about the genitals and anus, was one
of the commonest forms. The prepuce might become
thickened and fissured. Acne cachecticorum was often
due to glycosuria, just as was furunculosis. Papillo-
matosis diabeticorum occurred as an inflamed patch
upon the back of the hand. Gangrene might be moist
or dry. Bronzing of the skin and xanthoma were char-
acteristic features. Some affections might be pre-
vented by proper bathing to remove all deposited sugar
from the surface.
Dr. Solis-Cohen said that every case of glycosuria
was not diabetes, although most cases were. It fre-
quently followed influenza. Bilateral sciatica should
make one suspect true diabetes.
Dr. Walsh said that tuberculous and nephritic sub-
jects often died of unrecognized diabetes.
Dr. Morrissey said the same factors acting to pro-
duce the sugar produced the lessened sexual function.
In examining a series of one hundred tuberculous sub-
jects, he found sugar present in thirty per cent. In
io6o
MEDICAL RECORD.
[June 1 6, 1900
another series of fifty patients ten per cent, sliowed
sugar.
Dr. Wahral, of Iowa, made a plea for the patient.
Molecular changes in the nervous system should receive
attention. Strict dieting was vigorously denounced as
torturing the patient without good results.
Dr. Russell, of Philadelphia, thought fixed diet
rules should not be laid down.
Dr. Osborne, of Connecticut, said that fifty per
cent, of cases showed pancreatic disease. The other
fifty per cent, occurred in a variety of affections, thy-
roid disease, etc. If we took away carbohydrates, we
should slowly substitute fats.
Dr. Herrick spoke of obesity in regard to its pre-
disposing to diabetes. He had never seen bilateral
sciatica in diabetes, though he had been on the look-
out for it for years. Too vigorous enforcement of diet
was not advisable. All authors mentioned its dangers.
Dr. Stern said his statistics showed a large propor-
tion of diabetes in the poor. The name diabetes mel-
litus was inappropriate. There were a pre-diabetic and
a post-diabetic stage. Anti-diabetic diet was utilized
only experimentally to determine the proper diet for
each subject.
Exophthalmic Goitre. — Dr. O. T. Osborne, of
New Haven, in this paper said that the name was 4I
misnomer. He suggested that of Graves' thyroid dis-
ease. The cause of its frequency in women was the
increased activity of the gland called forth by the nor-
mal sexual function, and the consequent susceptibility
to permanent irritation. The relationship of the gland
to the symptoms of the disease w^as discussed in rela-
tion to hypersecretion. Thyroid feeding, when it in-
creased the symptoms in obscure cases, pointed to im-
pending Graves' disease. Eighty per cent, of cases
occurred in women. In treatment, those things which
tended to diminish secretion and quiet the circulation
did good, i.e., strophanthus, with mental and physical
rest. In an active case thyroid feeding would tend to
do harm. Thynius-gland treatment at times did good.
A portion of the gland should be removed if there were
pressure symptoms. Ordinarily it was not justifiable
to operate.
Dr. Herrick said that many patients suffered long
before they presented marked symptoms, often giving
signs of neurasthenia, or even of incipient tuberculosis.
Dr. Solis-Cohen thought experience showed mental
and physical rest to be the most important factor.
There was weight in favor of thymus feeding. The
symptoms might spontaneously recede or disappear.
Digitalis was to be used only wh*i the particular heart
showed its employment to be indicated. Hydrobro-
mate of hyoscine, gr. ^'tt. for a maximum dose, and
picrotoxin up to gr. ,'^ every three or four hours, did
good.
Dr. Osborne said it was a functional disturbance
and not a disease at all. We must look to the emo-
tional or psychic side of the individual for a cause of
the hypersecretion.
Lesions of the Cauda Equina and Conus Medul-
laris — Dr. Bertram W. Sippv, of Chicago, desig-
nated by the term conus medullaris that portion of the
spinal cord at the lower end of the lumbar enlarge-
ment. He found that lesions here situated were char-
acterized by well-marked disturbances, both sensory
and motor. By means of diagrams he illustrated
impairment of sensation in symmetrical distribution
involving the perineum and the anal and scrotal
regions. There might be loss of ^exual power. That
which chiefly characterized caudal disease was pain.
The absence of pain indicated the conus affection.
Movable Kidney from the Standpoint of the
General Practitioner. — Dr. A. Marcy, Jr., of River-
ton, N. J., read this paper. He said that the disease
was very frequent. All women who complained of
reflex nervous symptoms, digestive disorders, hysteria,
etc., and especially those of light weight, should be
examined for movable kidney. Thin patients could
be examined in the erect posture, the examiner stand-
ing behind and using one hand for either kidney. In
stout subjects both hands should be used, the physi-
cian being seated at the patient's side. If necessary
an aneesthetic could be given. A distended gall blad-
der or other organ must not be mistaken. Suitable
cases should come to operation.
Dr. Cleveland, of Cincinnati, said that movable
kidney was a general abdominal condition associated
with enteroptosis and gastroptosis. He doubted the
advantages of operation. There might be no painful
symptoms.
Dr. Am Ende said that the first thing to do was to
put away the corset.
Dr. Marcy replied that some patients were comfort-
able only when the corset was worn.
Antiseptic Treatment of Diphtheria — This paper
was read by Dr. D. Benjamin, of Camden, N. J. He
said that statistics should be collected by an expert
paid by the association. He had tabulated forty thou-
sand cases of diphtheria. The success of germicidal
treatment depended upon the thoroughness of applica-
tion. For twenty years he had used local antiseptic
treatment, chiefly tincture of iron chloride, and had
not lost one per cent, by death. He gave tincture of
iron coincidently in frequent doses.
Observations on Direct Antiseptic Treatment of
Infectious Diseases — Dr. C. Am Ende read this
paper. He found that direct antisepsis gave gratify-
ing results in diphtheria, as well as in a number of
other infectious diseases. A pre-membranous stage
could be detected, and medication could be applied
early and prophylaxis thus be extended to others.
Antiseptics modified the bacilli so that the microscope
showed them changed. He used quinine with an ex-
cess of muriatic acid.
The Climatology of Arizona This was described
in a paper by Dr. William Duffield, of Phcenix,
Ariz.
The Clinical Examination of the Blood. — This
paper was read by Dr. R. L. Watkins, of New York.
Certain Clinical Features of Influenza Recently
Epidemic. — Dr. H. S. Anders, of Philadelphia, read
a paper based on personal observations alone. Spe-
cial features, as conjunctivitis, otitis media, laryngitis,
purulent bronchitis, influence of previous affections
on special features, complications, bradycardia during
convalescence, antecedent and associated meteorolog-
ical conditions and their bearing on symptomatology,
were all discussed.
The section then adjourned.
SECTION ON SURGERY AND ANATOMY
Tliiril Day — Thursday, June Jth.
Treatment of Hernia in Children. — Dr. A. J.
Ochsner, of Chicago, read this paper. In consider-
ing the predisposing causes he laid particular stress
on the descent of the testicle, and of congenital weak-
ness of the abdominal walls. Long mesenteries he
considered a questionable etiological factor. Among
the exciting causes he mentioned: (i) Abnormal in-
tra-abdominal pressure; (2) constipation ; (3) phimo-
sis; (4) coughing. These factors were, directly 01
indirectly, remote results of bad nourishment and evil
hygiene. Hernia was, in support of this statement,
by far more frequent among the children of the poor
than among those of wealthy parentage. Another very
interesting etiological factor was the nationality of the
child, the lesion being particularly prevalent among
the Jews. He suggested that here close intermarriage
June 1 6, 1900]
MEDICAL RECORD.
1061
might be the cause, and believed that this subject
would reward careful investigation. Hernise in the
young tended to spontaneous cure. At birth, one child
out of every twenty-one was ruptured ; at thirteen years
of age there was but one in every seventy-seven. This
spoke for itself. He felt that because of this, less
than five per cent, of hernise in adult life were con-
genital. He by no means insisted on early operation
in childhood hernia; on the contrary, only acute con-
ditions should lead to it. Intelligent medical treat-
ment, however, was of the utmost importance, and in
this connection he detailed some of the most impor-
tant points. Posture was considered among the first.
He recommended that the patient should be kept in
a bed the foot of which had been elevated. The con-
stipation, the coughing, the malnutrition were each to
receive the most careful attention. A tru.ss should be
worn at night as well as by day, unless the recum-
bency kept the hernia reduced. Special attention
should be given to the prevention of gaseous intra-
abdominal pressure by the most careful feeding. In
conclusion, he said that operation was indicated only
under the following conditions: (i) Strangulation,
(2) irreducibility, {3) abdominal hyperdistention, (4)
irreducible hydrocele.
Treatmeat of Ventral Hernia. — Dr. M. M. John-
sox, of Hartford, Conn., read this paper. He spoke
first of the etiology, and cited the following factors:
(i) prolonged use of drainage tubes; (2) healing by
secondary intention ; (3) division of motor and trophic
nerves.
The speaker, after advising the avoidance of these,
entered into minute detail of the technique of his
operation, in the course of which he emphasized the
desirability of (i) electrical incision; (2) silver wire;
(3) kangaroo tendon. These were to be removed at
the end of ten days.
Cure of Inguinal Hernia in Men. — Dr. H. O.
Marcy, of Boston, read this paper. He spoke of the
great safety of the modern operation, saying that scarce
a decade had passed since it was fraught with the
greatest danger. He felt the cause of hernia to be
rather a failure in the development about the internal
ring than any influence of the infundibular process.
He urged that the wound should be made wide enough
to permit of easy removal of cord and sac. In clos-
ing the sac, he recommended a suture rather than a
ligature, citing a case in which the latter had slipped,
with a fatal result. Especially he emphasized: (i)
that danger vi'as hypothetical; (2) that suture material
should be absorbable; (3) that dissection should be
free; (4) that the canal should be reconstructed; (5)
that the wound should be sealed without drainage.
In closing he thanked the section for their generous
recognition of his services toward devising the modern
operation.
Dr. De Garmo, of New York, urged the crying
need of curing children. He paid high tribute to
the ceaseless work of Dr. Marcy, who had been the
father of the modern operation. He said that very
frequently the immediate cause of hernia in infants
was constipation. Operation he did not consider in-
dicated before the fifth year of age, for earlier in life
the hernia could generally be cured by a truss. He
disagreed with Dr. Ochsner in that he thought that no
ruptured child should be confined in bed, every one
realizing how badly children did when so confined.
In repairing ventral hernias, the layers should be
most carefully appro.ximated, and, in thin cases at least,
relaxation sutures were distinctly indicated.
Dr. Fergusson, of Chicago, felt that he voiced the
sentiment of the section when he said that whatever
progress had been madejby Bassini and Halsted in
the treatment of hernia had been due to the untiring
efforts of Dr. Marcy. He cited an interesting ana-
tomical point bearing on the relative infrequency of
indirect inguinal hernia in women, viz., that in the
female the internal oblique reaches three-quarters up
Poupart's ligament, while in the male it involves but
half the same area.
Dr. W. J. Mayo, of Rochester, Minn., praised Dr.
Ochsner's conservative treatment. He felt that the
great value of the so-called Bassini operation was that
the scar was divided. This principle he would apply
to umbilical hernias.
Dr. M.\Rcy again thanked the section for their
recognition. He felt that the hernia question was
settled, and expressed a wish that the three million
ruptured citizens of the United States — the truss-
bearing army — might all be operated upon.
External Drainage of Superficial Lung Cavities,
with Report of Two Successful Cases.— Dr. W. L.
Wills, of Los Angeles, Cal., read this paper. He
drew attention to the vast interest which Western sur-
geons took in pulmonic surgery, because it was to the
West that the great tuberculous population trended.
He could see no reason why these cases should
not be operated on, and strongly indorsed external
drainage, citing two successful cases, as follows:
The first one was that of a ranchman, of fine phy-
sique originally, at the time of operation dying of
sepsis from the absorption of pus in a large cavity in
the left lung. The speaker was disappointed, on re-
secting a rib, to be unable to locate the focus. This
was due to delay caused by the very critical condition
of the patient after the opening of the chest wall.
Two days later, however, during a fit of coughing,
there was a great discharge of very foul pus exter-
nally. The patient progressed to complete recovery.
The second case differed from the first in that no
internal drainage — via a bronchus — existed. That
gravity drainage by external incision was indicated
in these pulmonic-cavity cases seemed strongly sup-
ported by the immediate and permanent fall of tem-
perature after its establishment. The speaker closed
by suggesting that the free use of bichloride of mer-
cury in solution as strong as i : 4,000, for irrigating
these cases, was of very probable importance. Sin-
gularly, it did not seem to cause ptyalism.
In discussing this paper, Dr. Murphy, of Chicago,
spoke of the importance of external drainage for the
chest. In order, however, to accomplish it success-
fully, there must be pleuritic adhesions over the area
to be operated on. VVhen these were absent, he recom-
mended internal drainage by gaseous compression of
the lung. He advocated the admission of air to the
pleural cavity through a hypodermic needle. He dep-
recated the use of the cautery in lung surgery, and
urged that a sharp knife was free from danger.
Dr. Wills, in closing, spoke of the beneficence of
the California climate, and said that it had an im-
portant bearing on these cases. He recommended
the generous use of i : 4,000 bichloride.
Surgical Errors in Skiagraphy. — Dr. Carl Beck,
of New York, read this paper. He felt that careful
study of skiagraphs would enable us to make more
general use of them. Many errors, indeed most er-
rors, were due to a faulty interpretation. In the ex-
tremities, for instance, the arrangement of the carpus
and of the tarsus were such as, in many positions, to
cause a shadow to be cast from one bone to the other.
Projection was an important factor in causing error.
In fractures special thought should be given to the
whereabouts of the epiphysis, which, particularly in
children and often in the adult, gave a skiagraphic
line of apparent breakage. In closing. Dr. Beck
aptly said that it was extremely unwise to allow pa-
tients to examine united fractures with the rays, for
a good functional union thus seen appeared often dis-
tressingly crude.
io62
MEDICAL RECORD.
[June 1 6, 1900
Diagnosis of Calculous Diseases of Kidney, Ure-
ters, and Bladder by the Roentgen Method. — This
paper was presented by Dr. C. L. Leonard, of Phila-
delphia. He spoke of the great advances which had
been made in the diagnosis of these conditions by
bacteriology, by cystoscopy, by urinalysis, segrega-
tion, and sedimentation. Ureteral catheterization, the
sound being wax-tipped, after the suggestion of Kelly,
the recurrence of attacks, and the proper interpretation
of pain — all had a very useful end. He wished to
bring before the section the latest, and perhaps the
most important factor of use in the diagnosis of this
obscure condition. When properly used, the Roent-
gen ray was almost absolute — would probably be abso-
lute when technical errors had been eliminated. His
last twenty cases of affirmative diagnosis had been
correct. The work had been equally successful in
negative diagnosis, and this often in the face of emi-
nent clinical opposition. The .r-ray admitted of very
early diagnosis, an advantage which could not be over-
estimated. He cited cases in which, because of the
presence of albumin and casts, diagnoses of nephritis
had been made. In closing, he said that because of
the .T-ray exploratory incisions could now be avoided.
Treatment of Injuries of the Ureter — Dr. B. B.
Davis, of Omaha, Neb., read this paper. He said that
ureteral injuries had been much more frequent than
was generally supposed, and cited cases to prove this
fact. Before the possibility of anastomosing the cut
ureter w-as shown to exist, there was open to the sur-
geon but one of three very unsatisfactory procedures:
he was obliged either to perform nephrectomy, to stitch
the ureter to the skin, or to ligate its proximal end.
The result of the first was never an enviable one; the
second left the patient in a pitiable plight, while the
atrophy which was supposed to follow the third was
by no means constant. So much advance had recently
been made, however, that none of these procedures
was justifiable. He then described a method of an-
astomosis which seemed to him better and simpler than
V^an Hook's. Implantation into the bladder, that
viscus having been freed from its attachments to a
sufficient extent — after Kelly's method — to reach the
proximal end of the ureter without tension, or uretero-
ureteral anastomosis, seemed to him to offer a happy
solution of the problem. In support of this statement
he said: (i) The normal channel was thus preserved.
(2) There could be no fistulae. (3) Stenosis W'as not
probable. (4) There was no leakage. (5) Cicatricial
contraction gave no trouble.
Dr. Kelly, of Baltimore, said that Dr. Leonard was
doing the finest work of any one in the world with the
.r-ray. He had recently failed to locate a stone with
his wax-tipped sound, and Dr. Leonard had found it
for him. He therefore heartily welcomed so valuable
an aid to diagnosis. He demonstrated his cartridge-
like instrument for uretero-ureteral anastomosis.
Dr. Bevan, of Chicago, also congratulated Dr.
Leonard. He spoke of the very great value of the
.v-ray in urinary calculus and cited a case in which
very small stones were located by its aid.
Dr. Bouve classified uretero-ureteral anastomoses
as follows: (i) end-to-end; (2) end-in-end; {3) lat-
eral of Van Hooke; (4) lateral, as is ordinarily done
with gut; this last had been done twenty-one times.
Cysto-ureteral anastomosis was the next best. He be-
lieved there was a great future for sigmoido-ureteral
anastomosis, which operation had been done eighty
times.
Dr. VVinslow, of Baltimore, spoke of the anatomy
of the renal pelvis. It was not, as usually described,
a dilated pouch within the kidney, but consisted of a
series of tubes which frequently persisted well beyond
the organ. If in one of these a calculus lodged, as
was frequently the case, it might be seen how Dr.
Kelly's wax-tipped sound would fail and the .v-ray be
of incalculable use.
Dr. Beck, of New York, said that the .r-rays had not
yet been fully appreciated. He spoke of the great
need of making at least four or five plates in order
properly to correlate the distances.
Dr. Somers, of Nebraska, emphasized the value of
Kelly's operation of lifting the bladder to meet the
too short ureter.
Dr. Carpenter, of San Francisco, reported a suc-
cessful case of uretero-cystostomy. He showed a but-
ton for this purpose.
Dr. Leonard, in closing, said that by careful tech-
nique even uric-acid calculi could invariably be de-
tected by the .r-ray. This technique consisted in using
for the ray a tube of such low vacuum that one could
just see the muscular outlines. Formerly the rays
were altogether too penetrating.
Exstrophy of Bladder, with Exhibition of Case.
— Dr. Morgan Vance, of Louisville, presented this
paper. He detailed the technique of the operation,
which was plastic in character, and which was repeated
in more than five stages, over a period of two years.
The case had been a peculiarly evil one, had required
a vast amount of patience, and had yielded a very
brilliant success. The patient was a young man nine-
teen years old, and he had been enabled to enter busi-
ness life successfully.
Dr. Willard, of Philadelphia, gave his heartiest
congratulations to Dr. Vance. He said that an inward
turning of the flaps is responsible for many failures;
likewise a deposition of urinary salts. He recom-
mended the use of the upper sigmoid or colon as a
reservoir. He spoke of the desirability of transplant-
ing the vesico-ureteral valve in these cases, to avoid
infection.
Dr. Kelly, of Baltimore, said he had tried in vain
to obtain a cure in these cases by a loosening of the
sacro-iliac joints. He now shelled out the bladder
far enough to meet the divided ureter; this failing, he
urged the use of the colon for a reservoir.
Dr. Herzel, of Chicago, urged the use of the colon.
He said that few cases of infection had resulted.
Dr. Connell, of Chicago, supported the use of the
upper colon, thus doing away with the use of a rubber
reservoir.
Dr. Vance, in closing, said that his was a very ex-
aggerated case, and that he thought all cases could be
cured by his technique.
Surgical Asepsis of the Urethra and Bladder. —
Dr. Ferd. C. Valeniine, of New York, demonstrated
a new device, called the auto-irrigator, made of steri-
lizable rubber. The instrument occupied a space five
inches long, three inches wide, and two inches thick
in the instrument bag. It weighed about six ounces.
The device had a capacity of 1,500 c.c. (about three
pints). Its purposes were: (i) Urethral and intra-
vesical irrigations before and after operative ingres-
sions, preventing urethral fever; (2) an aid to the
treatment of gonorrhoea in such cases as could not be
irrigated in the physician's office twice daily; (3) as
near an approach as was possible to aseptic catheter-
ism in prostatic enlargements. The author appended
to his paper a resume of the treatment of gonorrhoea,
the diet to be observed, and advocated the prevention
of gonorrhoea by self-irrigation after suspicious coitus.
These explicit directions were worded especially for
those practitioners whose experience in genito-urinary
diseases was not large. In closing he showed the old
methods of irrigation to be incomplete and faulty.
Treatment of Prostatic Hypertrophy ^This paper
was presented by Dr. Parker Syms, of New York.
He dwelt interestingly on the very great prevalence of
this condition. In considering the symptoms he spoke
of the almost invariable prominence of dribbling, due
June 1 6, 1900]
MEDICAL RECORD.
1063
to the dilated bladder, and of the frequency of mictu-
rition. Almost invariably a chronic cystitis was
present, which, from time to time, was provoked to
acute exacerbation. Formerly, indeed until very re-
cently, catheter life was the ultimate and unhappy
ending of these cases. Now, however, two alternates
had come into the field: (i ) prostatectomy, and (2)
prostatotomy, or Bottini's operation. Dr. Syms made
only a passing allusion to the latter, saying that he
felt that for certain cases it had a brilliant future. Of
the former, he spoke at length, devoting most of his
considerations to a new and interesting technique.
That the death rate was high in this operation he
could not deny, but he was convinced that this was
due very largely to the extreme physical and mental
depression present in almost all cases operated on.
For this reason the operation should not be undertaken
as a last resort, but practised rather at the inception of
the hypertrophy, or, at any rate, just as soon as the
habitual use of the catheter became necessary. Phys-
iological old age, however, contraindicated operation.
Of technique he spoke as follows: In 1898 he advo-
cated the perineal route, crowding down the prostate
through a suprapubic incision. Now, however, he had
given up opening the abdomen, using by preference a
small opening in the membranous urethra. Through
this, and into the bladder, he introduced a rubber
bulb, tied to the end of a soft catheter. After intro-
duction, the bag was filled with water and the tube
was clamped. Traction on this simple device readily
drew the prostate into the perineal wound.
Dr. Thayer, of Clifton Springs, New York, said
that cystitis was always of bacterial origin, and was
characterized by a loss of tissue. As to Dr. Valen-
tine's method of irrigation, he had nothing to offer but
praise. It was impossible properly to disinfect the
canal by any other method.
Dr. Glenn, of Alabama, thought Dr. Valentine
over-enthusiastic. He did not feel it necessary to irri-
gate before instrumentation except in pus cases.
Dr. Young, of Baltimore, had been greatly inter-
ested in Dr. Syms' paper. Nevertheless, he felt that
the Bottini operation was the better because the me-
dian lobe only of the prostate was the area usually
involved.
Dr. Chesmore, of Philadelphia, was pleased with
Dr. Syms' method of pulling down the prostate, and
especially advocated the abolition of the suprapubic
incision.
Dr. Beck, of New York, supported Dr. Valentine.
Too much care could not be given to antisepsis.
Dr. Robbins, of Detroit, said that of all drugs he
considered terotropin to be the most valuable. He
thought Dr. Valentine's auto-irrigator no better than
an ordinary syringe.
Dr. Eastman spoke of the value of potassium bi-
chromate in gonorrhoea, used hot, often, copiously, and
under pressure. He preferred a blunt syringe to the
auto-irrigator.
Dr. Grey, of Jersey City, testified to the value of
enucleation, although he supported the suprapubic
incision. He suggested the stretching of the sphinc-
ter ani in order that pressure might be brought upon
the prostate through the rectum.
Dr. Guiteras, of New York, said that washing in-
variably did good even if it was but with sterile water.
The patient should not irrigate himself, unless with an
absolutely bland solution, if obstruction was present.
He considered the auto-irrigator as incomparably su-
perior to the syringe. He congratulated Dr. Syms on
his very able paper. Prostatic surgery was still in its
infancy. Enucleation should not be thought of if the
kidneys were damaged or in the face of arterioscle-
rosis. Touch was very necessary in the determination
of mid-lobe enlargement. The vesical side of the
prostate often differed very markedly from the rectal.
Enucleation was suitable only in the greatly enlarged
glands, whereas Bottini's operation was to be chosen
in the slighter cases. The mortality should not be above
five per cent. Enucleation, however, would for many
years probably give a death rate of twenty per cent.
Dr. Valentine said, in closing, that Bottini's opera-
tion had been made much simpler by the introduction
of an incisor with cystoscopic attachment. He de-
fended the auto-irrigator.
Dr. Svms pointed out that his device was to be in-
serted through the membranous urethra, not through
the penile part.
Fourth Day — Friday, June 8th.
Treatment of Tuberculous Knee Joint. — Dr. Wis
ner R. Townsend, of New York, presented this paper.
He divided the topic into constitutional and local treat-
ment. The first, of the gravest import, was generally
neglected. Diet, climate, rest, and creosote he spoke
of in turn. The second involved — (i) rest of the
joint; (2) correction of the deformity; (3) removal of
diseased bone; (4) treatment of complications. Of
the varied means of getting rest, the Thomas knee
splint v.as doubtless one of the best, particularly if
combined with a rubber footpiece. Again, the dress-
ing must be snug, else a great deal of deformity might
take place beneath it. As to the correction of de-
formity, he mentioned (i) weight; (2) traction; (3)
force, with or without an anjesthetic — in no case vio-
lent. He absolutely excluded brisement force'. (4)
Tenotomy; (5) osteotomy or osteoclasis; (6) excision;
(7) amputation. Decalcified bone must be early and
thoroughly removed. Septic knees demanded a very
thorough draining, this often leading to happy results.
Cold abscesses in the region of the knee must be
treated as though fulminating, for at any moment they
might become septic. The local treatment of sinuses
by drugs was negative; they often took two or three
years to heal. Dr. Townsend closed by saying how
promising was the outlook in tuberculous knee-joint
cases.
Dr. Barton, of Philadelphia, agreed w-ith Dr.
Townsend. He suggested the total extirpation of cold
abscesses.
Dr. Ochsler, of Chicago, said that he lived amid a
great tuberculous-knee-joint population. He empha-
sized the absolute need of good hygiene.
Dr. Bullett, of Louisville, said that the protective
treatment had given far better results than the opera-
tive.
Dr. Sullivan, of Chicago, said that early diagnosis
was very necessary, and rarely attained.
Dr. Townsend said, in closing, that he emphatically
indorsed evacuation ; that the involvement of the lower
epiphyseal cartilage often resulted in nine inches of
shortening.
Fractures of the Patella — Dr. J. M. Barton, of
Philadelphia, read this paper. He spoke of the un-
satisfactory results of the expectant treatment. Out of
seven hundred and eleven cases operated on by Amer-
ican surgeons there had been but three fatal cases.
The necessity of operation was caused by a falling of
the pre-patellar membrane between the fragments. He
urged that in uniting them, heavy silver wire be used,
and that the ligature should pass well into the bone
substance. He spoke of the need of strict asepsis and
of the importance of removing all blood clots. Post-
operative rest should not be over three weeks, when
gentle motion should begin.
Operative Treatment for Unreduced and Irre-
ducible Dislocations Dr. A. D. Bevan, of Chicago,
read this paper. He cited cases and showed skia-
graphs of three elbow dislocations, four dorsal of the
io64
MEDICAL RECORD.
[June 1 6, 1900
hip, and one of the astragalus. He urged the open
method — free incision and no drainage. This, com-
bined with an intelligent use of the .T-ray, presented
the modern surgical treatment of these deformities.
He concluded as follows: (i) Operation was justifi-
able if asepsis was perfect. (2) Dislocation was fre-
quently complicated by fracture. (3) The best inci-
sion for the elbow was a double lateral. (4) No
drainage was to be used. (5) The elbow should be
dressed in semi-fle.xion, with the hand in pronation.
(6) Passive motion should begin early. (7) The
mortality was less than five per cent. (8) The patient
should be warned of this danger.
Dr. Blake, of Chicago, agreed with Dr. Barton in
all respects. He felt that the patella might unite as
did any other bone.
Dr. Tinker, of Philadelphia, spoke of aluminum
bronze as specially useful in bone work. It was first
used in Germany in 1895. It was to a considerable
degree absorbed, due to the aluminum being acted on
by the plasma salts. Thus all sharp edges were worn
away, making the tissues very tolerant of it.
Dr. Ochsler recommended a transverse incision,
and said that the knee should be well elevated after
the operation. He allowed the patient to walk three
weeks after the operation.
Dr. McF.\rland, of Pittsburg, spoke strongly
against operating. It was very well for the great joint
cavities to be opened by men trained in the rules of
absolute asepsis. But to him it seemed a very unwise
procedure in the hands of the average surgeon.
Dr. Barton, in closing, said that he wished to lay
stress on the use of rubber gloves and on the penetra-
tion of the bone tissue by the suture.
Dr. Bevan, in closing, said that, singularly enough,
he did not support tiie open operation in fractured pa-
tella. It seemed incompatible with the tenor of his
paper, but he begged to make the knee joint his one
exception.
Report of Five Cases of Tetanus Treated with
Antitetanic Serum — Dr. J. D. Blake, of Baltimore,
read this paper. He spoke of the rapidly growing im-
portance of serum therapy. He urged the giving of
large doses of the serum, and cited his last five con-
secutive cases, all of which had resulted in recovery.
Dr. Whit.more, of New York, stated that nine cases
had been experimented upon at Roosevelt Hospital
last summer. These had been trephined and inocu-
lated sub durani. Seven patients had died.
Two Cases of Growths in Frontal Sinuses. — Dr.
VV. D. Hamilton, of Columbus, presented this paper.
He said that these growths were often osteomata; that
the diagnosis was rarely established till the deformity
was marked, and that because of the septic nature of
the area they yielded a mortality of thirty-three per cent.
Occasionally, because of the proximity of the brain,
pressure symptoms developed early, particularly in the
eye. He cited two cases of successful removal, and
spoke of the need of an early diagnosis of malignancy.
Dr. Dawbarn, of New York, said that this early
diagnosis could often be very easily and surely made.
For years he had been in the habit of thrusting the
blunt end of a sewing-needle against the questionable
area. Very early in the malignant process the hard
parts of the bone are absorbed, and this blunt instru-
ment would readily penetrate it long before there was
any external evidence of disease. A second point es-
tablished by Dr. Dawbarn was that the technique of
crushing a passage through to the nasal cavity from
above was open to severe criticism. As was shown .
by him long ago, in Wood's "Reference Handbook,"
by bending a probe at a particular angle the natural
passages could be passed through from above down-
ward, thus avoiding unnecessary and prejudicial crush-
ing of the bone.
Laminectomy for Diseases and Injuries of the
Cord. — Dr. Samuel Lloyd, of New York, read this
paper. He had recently operated on fifteen cases of
Pott's disease, making a total of one hundred and
thirty. • This operation was not dangerous /</• se, but
at best offered little hope; it was absolutely hope-
less if the anterior portion of the spine was diseased.
If the disease was strictly localized posteriorly, an
early diagnosis having been made, there was ground for
hope. The lower the region of involvement, the bet-
ter. He considered that the myelitis was generally
due to the pressure from accumulated de'bris rather
than to granulation tissue. The operation was hope-
less if this change was well established. In Pott's
disease, operation was rarely indicated after the incep-
tion of paralysis, because of the probable establish-
ment, by that time, of pulmonary or other foci. Tu-
mors gave a fifty-per-cent. mortality, but this was due
rather to their being usually malignant than to a fatal
outcome of the operation. Fractures in the cervical
region yielded a very small percentage of recovery
The type of fracture was also a factor. Most vital of
all was the consideration of elapsed time. He gave
the following indications for operation: (i) If the
cord destruction was incomplete; (2) when the lesion
was incomplete but was extending; (3) when recov-
ery, almost complete, was interrupted by callus for-
mation. In closing, he advocated operation as a
desperate chance.
Dr. Dawbarn said that he rose to emphasize rather
than to criticise. This emphasis was particularly di-
rected to the crying need of early operation. He cited
two cases — the first that of a woman who fell four
stories, sustained a fracture, presented the typical symp-
toms, and was operated on by him within two hours.
The result, after enucleation of a large blood clot and
the removal of a good-sized bony fragment, was per-
fect recovery. In the second case, under the advice of
certain nerve specialists, the patient refused operation
until myelitis was well established. Although the op-
eration was helpful to the patient, the paraplegia had
been permanent.
Dr. Hough, of Massachusetts, cited a favorable
early operation.
Dr. Lloyd, in closing, said that the operation
should not cease till the normal pulsation had re-
turned in the cord. Its membranes should be un-
hesitatingly opened if necessary.
Operations for Injury of the Median and Ulnar
Nerves. — Dr. B. B. Eads, of Chicago, read this paper.
He cited a number of interesting cases of neurorrhaphy,
emphasizing these points: (1) the need of a wide in-
cision; (2) asepsis; (3) the evil effects of tension;
(4) use of a relaxation splint.
Results of Surgery in the Aged.^This paper was
read by Dr. J. P. Tuttle, of New York. He wished
to establish the point that old people stood operation
well. His data were gathered from 168 operations
on patients over fifty years of age, and 133 in which
the average age was sixty-nine years. The anaesthetic
used in 226 senile cases was: ether, 183; chloroform,
13; cocaine, 30. The mortality from operative causes
was less than two per cent. Albumin was not a con-
traindication, nor were hyaline casts. He argued that
because patients were aged, ipso Jacio the constitution
was good and the resisting-power high.
Dr. Dawbarn spoke of the development of a sec-
ond childhood in disease, as well as in intellect. Mi-
crobic infection was a very important factor in the
aged. They possessed but little bactericidal power.
Dr. Hart, of China, said that aged Chinese stood
operation very well.
Sarcoma of Colon, with Report of a Case — Dr.
C. Van Zwalenmeri;. of Riverside, Cal., read this
paper. He said there was but little analogy between
June 1 6, 1900]
MEDICAL RECORD.
1065
sarcoma and carcinoma of the alimentary canal. Sar-
coma was rare. He then detailed the technique of
his operation, which embraced the resection of gut
and the exsection of a large sarcomatous nodule from
the belly of a child five years of age. The Murphy
button did not reappear for six months, but this did
no damage. In summarizing fifteen cases he said that
the age limits were between one and fifty-two years.
Nine cases were in males, five in females; five were
below ten years of age. The small gut was affected
ten times. Nine patients recovered. Sarcoma was
more common than was generally supposed. Stenosis
rarely accompanied it, dilatation being the rule.
SECTION ON OBSTETRICS AND DISEASES OF
WOMEN.
Third Day — Thursday, June Jth.
Aseptic Minor Gynaecology. — Dr. Augustin H.
GoELET, of New York, presented a paper on this sub-
ject in which he made an earnest plea for cleanliness
in ordinary gynaecological examinations, laying stress
upon the necessity for thoroughly sterilizing the hands
and instruments. He outlined the method of arrang-
ing the examining-table, exhibiting a new clinical air-
cushion. He described in detail the manner of wash-
ing the hands and cleansing instruments, for which
purpose he used an antiseptic soap, which by actual
bacteriological tests he had found would destroy all
infecting germs. The advantages of a suitable reser-
voir and irrigating apparatus were specified, atid an
outline of the method of irrigation of the vagina for
securing asepsis was given. As a lubricant for the
examining finger and speculum he had abandoned all
forms of grease because it was difficult to remove from
the hands and genitals. To meet the requirements for
aseptic gynecological examinations and minor opera-
tions in private houses he exhibited an aseptic gynae-
cological emergency case made under his directions,
containing all instruments needed, and in addition
a clinical air-cushion and portable irrigating-reservoir
with vulva-shield and nozzle, and leg-holder.
Dr. John M. Duff, in discussion of this paper,
thought it was directed rather to the general practi-
tioner. He emphasized the importance of thoroughly
cleansing the vulva, laying greater stress upon this
than upon the cleansing of the vagina because of the
germicidal nature of the normal secretions of the
vagina. The sterilization of the cervix was also im-
portant.
Dr. L. H. Dunning, of Indianapolis, thought that
if the essayist carried out the technique in routine
practice, much valuable time would be consumed.
His own method in private practice was to have the
nurse prepare the tampons and instruct the patient to
make herself ready by douching, so that upon his ar-
rival at the house everything would be ready.
Dr. J. W. BovEE, of Washington, thought it impos-
sible to sterilize the hands in five minutes' scrubbing
with antiseptic soap or with anything else; though the
cultures might be negative, the hands were not sterile.
For this reason he advocated the use of rubber gloves.
He agreed with Dr. Dunn that the vaginal secretion
was usually able to take care of the vagina. He was
of the same opinion as Dr. Dunning, that if the elabo-
rate technique was gone through, sufficient time would
not be left for the calls on a busy man.
Dr. W. H. Humiston, of Cleveland, did not regard
it necessary to go through all this detail in order to
insure a proper amount of care and asepsis. He
thought Dr. Duff correct in thinking the danger of
infection was not so great from the vaginal secretions
as from the vulva. He had met with hundreds of
cases which, if properly treated aseptically while the
condition was simple, would not have been converted
into infected ones by wrong treatment. He quoted a
case which he had been asked to explain. The pa-
tient had been treated by a general practitioner for a
leucorrhoeal discharge and difficulty in menstruation.
The practitioner finally curetted her, as she got no
better under other treatment. The result was a firmly
fixed uterus, with the development of chill. Office
work he thought should be limited to examinations,
and further treatment for a chronic case should be
carried on in the hospital.
Dr. Porter, of Indiana, thought that in the cleans-
ing of the vagina or of any part harm was often done
with a stiff brush; a few microbes he did not fear
would do much damage in the presence of an intact
covering. He had made it a rule to invite his nurses
or assistants to speak of any lapses which might occur
in carrying out his technique.
Dr. Goelet, in closing, said one thing which he
had learned was the necessity for such a paper as this.
The portable reservoir he had intended particularly
for such work as examinations at the patient's house,
for ordinary curettings, and for minor work when
washing out the uterus. He recognized the difficulty
of making the hands free from germs, but after scrub-
bing his hands with the antiseptic soap mentioned
bacteriological tests had shown them to be absolutely
sterile. He thought no man should complain of the
time required for washing the hands in ordinary office
work, and that a patient would appreciate the care
taken. Five minutes he considered a sufficient length
of time to give to this cleansing of the hands.
Dr. Engelmann, of Boston, chairman of the nomi-
nating committee, announced that Dr. H. P. New-
man, of Chicago, had been nominated for chairman
of the section, and Dr. C. S. Bonifield for secretary.
Technique of Vaginal Extirpation for Cancer of
the Uterus. — Dr. R. B. Hall, of Cincinnati, read a
paper by this title, in which he emphasized the neces-
sity for careful preparation of the patient in vaginal
hysterectomy. He advocated the extreme lithotomy
position. The anaesthetic should be chloroform un-
less the drug was contraindicated. Should the case
be far advanced with great sloughing, or one of epi-
thelioma with a large mass of cancerous tissue, the
operation might be done in two stages. The author
preferred the ligature to the clamp. The technique
was described.
Combined Abdominal and Vaginal versus Vagi-
nal Hysterectomy for Carcinoma — Dr. John B.
Deaver, of Philadelphia, in this paper said that the
choice of route for hysterectomy must be selected for
each case. He gave a concise resumr of the reasons
for the selection of each, with their advantages. He
performed abdominal hysterectomy for the great ma-
jority of cases of uterine carcinoma, though granting
that there were cases in which the vaginal operation
might be better. He knew of no condition indicating
vaginal hysterectomy which possibly could not be bet-
ter dealt with by the abdominal route. He reviewed
the anatomy of the lymphatic glands and their con-
necting channels involved in the morbid process of
the uterus. In late carcinoma or even in the early
stage of rapidly advancing disease, involvement of the
broad ligament rendered worse than useless any opera-
tion short of total extirpation. The weak spot of
vaginal hysterectomy, he stated, had always been the
danger of injury to the ureters; though there was dan-
ger in either route, he believed there seemed to be less
by the abdominal. He did not believe catheterization
of the ureters an essential part of vaginal hysterec-
tomy. There was also greater danger of hemorrhage
in vaginal hysterectomy for carcinoma of the uterus,
although this was liable to occur in either operation.
The better command of the field of operation secured
by the abdominal route aided in the placing of liga-
io66
MEDICAL RECORD.
[June i6, 1900
tures, and thus lessened the liability of hemorrhage.
Another disadvantage of the vaginal route was the
liability of the intestines to come in contact with fin-
gers, instruments, and ligatures, which, having tra-
versed the vagina in cases of carcinoma, were never
sterile. Supra-vaginal drainage should be employed
when drainage was needed in abdominal hysterectomy.
Vaginal hysterectomies called for gauze drainage in
all cases. Vaginal hysterectomy he considered applic-
able only in those cases in which the carcinomatous
process was strictly confined to the vaginal portion of
the cervi.x, the cervical or the uterine canal, and when
the uterus was freely movable.
The Importance of Early Recognition of Cancer
of the Uterus. — Dr. W. H. Hcmiston read this pa-
per. He emphasized the importance of the early rec-
ognition by the general practitioner of malignant
d'isease of the uterus. Immediate and complete oper-
ation should be insisted upon. The epitheliomatous
variety he stated to be comparatively slow to give rise
to metastasis and offered the best chances against re-
currence after operation. The modes of recurrence
were specified as follows: (i) Metastasis; (2) incom-
plete removal of infected areas; (3) by infection or
direct implantation of malignant cells in previously
healtiiy tissue at the time of operation. The principal
import of the paper was summarized as follows : (1)
Early differentiation of malignant growths of the cer-
vix; (2) careful consideration of importance of lym-
phatic vessels and glands in their capacity of drains
of different portions of the uterus; (3) abdominal
section with complete removal of these special groups
of lymphatics alone offered, in suitable cases, chance
against a recurrence.
Treatment of Cancer of the Uterus Dr. Wil-
liam R. Pryor, of New York, read this paper. He
quoted statistics to show that of all cases of cancer
which came to the operator, but ten per cent, admitted
of operation; that of these, 11.5 per cent, were fatal,
and in the remaining but twenty per cent, resulted
favorably after five years. He expressed his personal
belief that all cases of clinical cancer occurred within
five years, and that vaginal hysterectomy met none of
the requirements of a successful operation. The oper-
ation of high amputation by means of the cautery gave
few better results than abdominal hysterectomy, and
was the operation for the ocasional operator to apply.
He insisted upon the analogy of cancer in other parts
of the body with cancer of the uterus, and stated that
the anatomical requirements of successful operation
were that the ovaries, uterus, broad ligaments, lym-
phatic glands, and upper third of the vagina should
be removed; that this removal should be done in a
bloodless field and in such a way as to prevent soiling
of the field of operation by the cancer cells and me-
chanical forcing of the cancer cells into the absorb-
ents. He advocated the application of the cautery by
the vagina to seal the mouths of the absorbents, after
which the abdomen was opened, the internal iliac ar-
teries were ligated, and all tissues removed in which
cancer was liable to occur. He quoted ninety-eight
cases operated on by the Rumpf-Reis-Clark operation,
by progressive ligation, and by ligation of the internal
iliac arteries, showing a mortality of only 11.5 per
cent. He insisted upon the abandonment of vaginal
hysterectomy for cancer and the adoption of more
radical work through the abdomen, stating that al-
though not sufficient time had elapsed to show the
remote results, observation demonstrated that by this
method not more than one-half as many cases recurred
in the first year as by the vaginal method.
Dr. H. J. BoLDT, of New York, opened the dis-
cussion of papers on cancer of the uterus. He re-
garded the early diagnosis of cancer of the supravagi-
nal portion of the uterus as most difficult. As to pro-
phylaxis, it should be borne in mind that there was
no form of disease which led to malignant disease as
often as long-continued inflammatory conditions of the
mucosa. He thought Dr. Hall's technique a most
beautiful one, but questioned how many patients re-
mained free from the disease after a time. The age
of the patient was an important factor. He thought
that the clamp must be used in an improper way if it
could be said that as much broad ligament could be
taken off with the ligature as with the clamp. Cases
in which the broad ligaments had become infiltrated
were better if not operated upon. The ultimate re-
sults so far as vaginal hysterectomy was concerned
were not satisfactory. As to abdominal hysterectomy,
his experience was too limited, and, as Dr. Pryor had
said, experience /// toto was too limited to admit of
forming a positive opinion.
Dr. J. M. Baldy. of Philadelphia, said it was the
practical aspect of the subject which appealed to him.
In technique he agreed with Drs. Pryor and Deaver,
that when a major operation was to be done the ab-
dominal route was the one of choice. In the practi-
cal question of how many patients got well he did not
consider it fair to consider the picked cases as was
sometimes done. He believed that cancer of the fun-
dus and cancer of the cervix gave very different results
from operation; he did not know of a single case of
cancer of the cervix in which he had been able to
make a diagnosis clinically by hemorrhage and pain,
upon which he had operated, in which the patient was
alive to-day. On the other hand, of the cases of fun-
dal cancer all the patients were well except four or
five who had died at operation. He had done thir-
teen or fourteen operations in the eastern section of
the State. The practical question was, by what means
relief could be given. He thought that the curette
used repeatedly, with scissors and knife, offered more
advantages for the relief of the patients than operation
in the cervical cases.
Dr. J. B. Massey, of Philadelphia, said that as long
as the medical profession advised that cancer should
not be touched until it became imperative, the limita-
tions of surgical work would be very great. He called
attention to a surgical method — though not surgical in
the sense of being limited to the knife — a method of
using the salts of mercury by electrolysis to destroy
the cancer at once as thoroughly as the knife would
do it. By the diffusion of the oxy-chloride of mer-
cury a zone of sterilization was produced extending
from one-half to one inch beyond the limits where the
cancer was destroyed. Another advantage claimed was
that the method was bloodless. He had used it upon
four patients, of whom two were now living — one at
the end of six years and one at the end of six months.
The two who were not living had been temporarily
benefited. In these the application was made daily
for several months, controlling the hemorrhage and
the odor. Both patients had been previously operated
upon by the knife.
Dr. J. H. Carstens, of Detroit, urged that an honest
survey be taken of all the cases of cancer of the breast
operated upon with removal of the axillary glands
and the glands beneath the clavicle, and a note be
made of how many of these patients were alive to-day,
three years after operation, without recurrence. His ex-
perience was that in all recurrence had taken place, and
nearly all the patients had died, with rare exceptions.
If all the glands in cancer of the breast could not be
removed, he questioned how it was possible to remove
all the glands in the abdomen in the soft tissues, and
when it was sometimes necessary to work around the
aorta. He was willing to predict that tlie gentlemen
who practised abdominal hysterectomy would have as
many recurrences in five years as the men who did
vaginal hysterectomy. He had limited his operations,
June 1 6, 1900]
MEDICAL RECORD.
1067
and indorsed the statement of Dr. Baldy that he could
give his patients longer life by repeated curettings.
Concerning electrolysis, he thought if cancer was due
to a germ and electricity was a germicide, and if Dr.
Massey could tell them of a method of killing the
germs /'/ toto, all should be under everlasting grati-
tude to him. He advised the greater use of the cu-
rette and microscope in the early stages.
Dr. Joseph Price thought that the point made by
Dr. Baldy in regard to the malignancy of the upper
and lower part of the uterus was the experience of
many specialists. In the child-bearing woman ma-
lignancy occurred in the cervix and rarely in the fun-
dus. In the desperate cases, those far advanced, with
everything involved, he thought the curette and cau-
tery, as Sims advised many years ago, offered the best
results. With reference to the glands he observed
that Dr. Humiston found three sets of glands, and Dr.
Deaver, a very fine anatomist and excellent surgeon,
found only two. He thought they would have to rec-
oncile their differences between them. He felt that
the general surgeons were neglecting their department
and were too prone to take up the speciality of the
gynaecologist.
Dr. Goelet emphasized three points in connection
with the subject: (1) Early diagnosis. He thought
the family practitioner could not be impressed too
strongly with the importance of the early diagnosis of
these cases. One case had been sent to him as one
of cancer, which proved to be senile endometritis.
(2) If a positive diagnosis of cancer was made, some-
thing should be done to relieve the condition. He
cited a case in which he had advised operation, three
years ago. A year later the daughter of the patient
asked him to operate, and the excuse given for de-
clining operation was that their family physician had
advised tliem to wait. (3) If the cancer had attacked
the body of the uterus the abdominal route should be
insisted upon, which offered a better opportunity for
more thorough work. He wished to place himself on
record as being decidedly in favor of the abdominal
route in these cases. He thought Dr. Humiston's
diagrammatic illustration of the lymph channels one
of the strongest arguments in favor of this route.
Dr. Byrne, of New York, agreed with Drs. Baldy
and Boldt that what concerned the profession and the
community most was the question of how many lives
could be saved by operation for cancer of the uterus.
He denied the legitimacy according to statistics of
hysterectomy for cancer of the cervix in any case; in
his opinion there was no case of malignant disease
with adeno-carcinomata of the fundus for which hys-
terectomy was justifiable, according to the records.
The primary mortality, he had observed, had increased
from fourteen per cent, in 1892 to twenty and a frac-
tion. For cancer of the cervix he advocated exsec-
tion, carefully and smoothly and thoroughly, of the
diseased part with the heated knife, and deep cauteri-
zation of the cavity left by its removal. These pa-
tients he predicted would live from fifteen to twenty
years. He knew of several instances in point. He
hoped the day was coming when hysterectomy for can-
cer of the cervix uteri would cease to be popular in
the profession. He believed the pendulum was swing-
ing in the right direction, and felt that the reaction
could not come too soon.
Dr. Phillips said he had been expecting to hear
the converse side of the picture; it had been his for-
tune to see within the last six months several cases of
complete hysterectomy which he believed were not for
cancer of the uterus, but in which the condition w'as
simple chronic erosion. He had seen many amputa-
tions of the cervix in cases which he was thoroughly
convinced were never cancerous. Some of the diag-
noses had been made by the general surgeon, the most
by the general practitioner, and a few were made by
the gynajcologist. He thought the general practi-
tioner in every case before advising operation should
have a thorough examination made by a microscopist.
Dr. Bonikield thought the general practitioner had
been pretty well educated, and that rather the people
should be taught to apply for relief early to the spe-
cialist. He thought, as Dr. Baldy had said, that the
question was a practical one, and that until the friends
who advised this radical operation of removing all
glands in the abdomen and pelvis could prove by stat-
istics their success, the majority of gynecologists
would continue to do the milder operations which re-
lieved the symptoms and which seemed to offer about
as good results.
Dr. Engelmann said he had never ventured to pub-
lish his results in this direction. It had been his
experience to find improvement for a time, and then
recurrence followed. He believed that an acknowl-
edgment was due Dr. Byrne for his work. Our re-
sults showed the juttice and correctness of his reports.
He said that the position which gynaecologists now
held on the subject was about the same as that of a
quarter of a century ago — removal in the early stages,
which would give relief for a time, freedom from pain,
hemorrhage, and discharge, and then a rapid passing
away.
Dr. p. F. H.'Vrris, of Paterson, N. J., called atten-
tion to the pre-existing leucorrhcea as an aid to early
diagnosis. He thought it a mistake to wait for the
appearance of blood.
Dr. J. G. Clark, of Philadelphia, stated that
twenty-two years ago Froyne performed the first ab-
dominal hysterectomy for cancer of the uterus, and
quoted his present experience as of interest. He said
that at times his confidence in his own operation had
been shaken. He had tried all plans and all forms
of local treatment, and was going back to the radical
operation as being the best yet advised; but, like all
others, he thought operative treatment at best very in-
efficient, and that it was necessary to have some other
thing to look to for radical cure. In the early stage
he performed a radical operation; in the more ad-
vanced stage he did vaginal hysterectomy, or simple
curettage and cauterization.
Dr. Clark was glad to find Dr. Pryor advocating the
radical operation from above. He felt that a com-
bined method was advisable — first from above, and
then the continuation by a very clever modification by
Werder of Pittsburg.
Dr. Bov^e said he was in favor of the abdominal
route in operating for cancer of the uterus. He agreed
with Dr. Clark as to the efficiency of the operation
modified by Dr. Werder, one advantage of which was the
avoidance of the contamination of raw surfaces by can-
cerous tissue. He had done fourteen operations with-
out one primary loss, with one from recurrence; at
least the patient had died of that which the family
physician did not think cancer, but which Dr. Bove'e
thought from the description was. He believed that
when the bladder had become involved it was too late
to do any radical procedure.
Dr. a. J. DowNES, of Philadelphia, referred to the
electro-haemostatic forceps modified after the method
of Dr. Skene, with which he had been working with
the view of having tfiem control hemorrhage in thirty
seconds. On the heated blade of these forceps a drop
of water would boil in fifteen seconds. He had oper-
ated five times during the past winter.
Dr. Hall, in closing, agreed with the gentlemen
who said we should conserve human life. He had
always believed that in certain selected cases vaginal
hysterectomy was the operation to be performed. He
preferred the ligature to the clamp because it gave an
opportunity to close the peritoneum, and thus pre-
io68
MEDICAL RECORD.
[June 1 6, 1900
vented infection and the subsequent possibility of an
intestinal obstruction, which those gentlemen using
the clamp and a large quantity of gauze must admit
was not an imaginary danger. He admitted that he
occasionally did the combined operation. Cautery
and curettage he believed should be done when cure
was not possible. He recorded two patients living
from four to six years after operation when the epithe-
lioma had been entirely destroyed. The unfortunate
fact that recurrence occurred in nearly all these cases
made him hesitate to perform the radical operation.
Dr. Deaver said that with the involvement of the
broad ligaments the radical operation promised noth-
ing, and advised in those cases the use of the cautery
and curette. He recommended early operation and
removal of the glands before involvement.
Dr. Humiston said it was necessary in all cases of
chronic disease of the uterus to examine carefully all
tissue removed. If malignant disease of the cervix
was found, he did vaginal hysterectomy; if malignant
disease of the fundus, abdominal hysterectomy.
Resection of the Ureter. — Dr. Howard A. Kelly,
of Baltimore, read a paper upon this subject. He
specified cases in which the ureter was most liable to
injury, with the character of the injuries received.
The best methods of treatment of an injured ureter
were considered, and the instruments needed were de-
scribed. An essential point in the method of treat-
ment was pulling up the bladder to reach the ureter,
making a blunt dissection and holding it there with-
out suspending the bladder to the psoas muscle. In
anastomosing the ureter to the bladder he followed one
of two plans: either bringing the ureter just to the
vesical opening, or inserting it well into the bladder.
He described a pair of alligator forceps which spread
only at the jaws and which was pushed through the
bladder. At the end of the forceps there was a long
guide which prevented injury of the ureter when
stretched. The forceps was practically that of Sanger,
to which he had simply added the feature of the guide.
Acute Senile Endometritis.— Dr. L. H. Dunning,
of Indianapolis, gave a detailed history of two cases
upon which he performed hysterectomy. The cases
were both in women sixty-three years of age, in whom
the menopause had occurred many years previously.
The clinical history in its main features was identical
in both cases. The women had been well until a short
time (one and three months) previous to examination.
There had been no uterine discharge. At the begin-
ning, the discharge was described as thin and irritat-
ing. Shortly it became sanguineous and offensive.
Pain appeared in the pelvic region. General lassitude
and rapidly growing ill-health followed. There were
backache, bearing-down pains, and some vesical dis-
turbance. The skin was dry and sallow. This was
marked in the case of longest duration. In this case
the general appearance suggested cancer. The uterus
in one case was in normal position, in the other retro-
verted. A diseased tube and ovary could be palpated
in one. The external os was patulous and the internal
OS permitted the easy passage of a uterine sound.
There was senile vaginitis in both. Hysterectomy
was done in both cases. Both uterine cavities were
distended by a foul-smelling, sanguino-purulent fluid.
A microscopical examination of both uteri was made,
and the findings were reported. Microphotographs of
sections were also presented. The author presented
the following conclusions : (i) The lesion found in
both uteri was an acute inflammatory process. It
might properly be denominated acute senile endome-
tritis. (2) The characteristic pathological features of
the inflammation were: (a) a thickened endometrium,
the free surface of which was devoid of its epithelial
layer; (/>) increased vascularity with peculiar arrange-
ment of small blood-vessels; (c) round-cell infiltration ;
(//) diminished glandular elements ; while a few glands
were to be distinctly seen, in many of them the epithe-
lium was desquamating and their lumen was filled with
granular debris; they might be said to be functionless
glands; ((') degeneration of the coats of the arteries of
the muscular layer of the organ ; in one specimen (No.
2) this degenerative process was distinctly hyaline;
(/) in not one section examined from various parts of
the organ could there be found any increase of con-
nective tissue. (3) In one case the acute inflamma-
tion seemed to have developed without any preceding
chronic inflammation. In the other case the acute
attack might have been an acute exacerbation of a
chronic inflammation. (4) The mucosa of both the
cervix and body were involved in the inflammation,
but it was more marked in both cases in the body of
the uterus. (5) In the more acute case the small
round-cell infiltration extended into the deeper muscu-
lar tissue, though the inflammation was more marked
in the mucosa. (6) In both cases one uterine ap-
pendage was diseased; in one the ovary was cystic, in
the other one ovary was cystic and the Fallopian tube
was inflamed. In this case there were slight recent
peritoneal adhesions. (7) The microscopical appear-
ances in these cases bore but slight resemblance to
those found in cases of interstitial endometritis. (8)
In one case there was marked retroversion of the
uterus, in the other the uterus was in normal position,
and in neither case was there marked stenosis of the
internal os, yet there was a considerable accumulation
of fluid within the uterine cavity. (9) The presence
of diseased appendages in both cases and of pelvic peri-
tonitis (mild) in one would indicate that the inflam-
mation was prone to extend beyond the limits of the
uterus, and if such extension was demonstrable by
combined examination an extirpation of the uterus
and appendages was indicated.
Inflammation of the Fallopian Tube, with Spe-
cial Reference to Specific Origin.— Dr. J. R. Guth-
rie, of Dubuque, read a paper on this subject. He
referred to the fact that authorities diftered widely as
to the importance of the gonococcus as an etiological
factor in tubal disease. A latent gleet in the male
might be the cause of a fresh infection in the mucous
membrane of the vagina. Only a few germs might be
present, yet their development was incredibly rapid
and they had a wonderful grasp on life. The speaker
believed that in order to establish the existence of the
gonococcus frequent careful examinations should be
made before stating positively whether or not it was
present. Failure to do this was often the cause of
pronouncing tubal disease to be due to some other in-
fection. The sources of infection were by the douche,
unclean instruments, and careless examinations. The
disease reached the tubes by extension. He advo-
cated the appointment of a committee to investigate
the eff'ects of gonorrhceal infection in the female.
Tuberculous Peritonitis.— Dr. A. H. Cordier, of
Kansas City, read this paper. He said that there
were many demonstrable truths in surgery and medi-
cine, and other facts plainly to be seen, yet no satis-
factory explanation of the manifested phenomena had
been discovered. Many explanations had been given
of how an incision into the peritoneum cured a tuber-
culous peritonitis, yet not one had been accepted. He
hoped, therefore, that he might be pardoned for ad-
vancing another theory which to him was new. He
was disposed to believe that an explanation of how
these patients were cured by a surgical procedure
might be found in the production of a special antitoxin
within the peritoneum owing to some unknown func-
tion of that organ. In no other way could he under-
stand how a similar process in the pleura as a compli-
cation could be cured by a laparotomy. The bacilli
present were killed, ceased to multiply, or were held
June 1 6, 1900]
MEDICAL RECORD.
1069
in abeyance in the recurrent cases. The liandling of
the peritoneum and its contents at the time of opera-
tion stimulated that great organ to an increased activ-
ity in the production of an antituberculous toxin.
A Plea for the More Frequent Avoidance of Ex-
section of the Ovaries in Connection with the
Removal of Diseased Tubes — Dr. Philander A.
Harris, of Paterson, N. J., read a paper with this
title, in which he laid special stress upon the fact that
the Fallopian tubes, when once infected by suppura-
tion, so persistently harbored it that they became the
natural habitats of pelvic suppuration. The ovaries
should be regarded as the contiguous and compara-
tively unwilling participants in these suppurations.
The ovaries generally recovered from the effects of in-
flammation when the adjacent suppurating structures
had been cured. The author claimed that the good
results which had followed removal of the tubes and
ovaries for tubal suppurations could in most cases be
secured without sacrificing menstruation, thus not en-
tirely depriving such patients of the possibility of
conception. The reader had observed one case of
pregnancy following the removal of both tubes.
Appendicitis Opsrations in Young Women and
Girls. — Dr. Joseph Price, of Philadelphia, in a paper
with this title, said that for a number of years his expe-
rience in appendicitis had differed from that of many
operators in that he had found the trouble to occur
sixteen times in the male to once in the female; now
the proportion in his practice was about even. It
seemed to the author that young surgeons were more
prone to the disease than any other class of medical
men. He was satisfied that the error of treating ap-
pendicitis for typhoid fever was more common in the
case of females than in that of males, the cause of this
being that the pain and tenderness were at a lower
level in the female than in the male. He believed
that if it was made a practice to operate when the
trouble was first recognized, without the delay of a
day for consultation and for medical treatment, deaths
would be few in number.
( To be concluded.)
AMERICAN ORTHOPEDIC ASSOCIATION.
Fourteenth Annual Meeting, Held in Washington,
D. C, May /, 2, and j, /goo.
Harry M. Sherman, M.D., of San Francisco,
President.
First Day — Tuesday, May ist.
A Simple and Efficient Treatment of Calcaneus
Paralyticus in Young Children. — Dr. V. P. Gibnev,
of New York, read this paper. He said that all or-
thopedic surgeons knew that the reverse catch was
very prone to get out of repair. His experience had
taught him that long-continued position contributed
to the shortening of the paralyzed muscle. The treat-
ment which he recommended consisted in the applica-
tion of plaster of Paris with the part in complete ex-
tension, and changing the plaster every three or four
months. Four cases were reported as evidence of the
good effects of this treatment. He had not tried wa-
ter-glass or leather splints on young children.
Dr. L. a. Weigel, of Rochester, spoke of the dan-
ger of producing excoriation in some cases of com-
plete paralysis associated with much trophic disturb-
ance, and instanced a case in which he had found it
impossible to use any form of dressing without the
danger of gangrenous ulceration occurring.
Dr. John Ridlon, of Chicago, pointed out that the
treatment advocated in the paper was not new, as for
many years the late Hugh Owen Thomas had treated
his cases in this manner, and had claimed that it was
entirely possible to get a return of function in all
muscles that were not really paralyzed, if they were
but retained in a position of relaxation. His ap-
paratus for accomplishing this was, however, quite
clumsy.
Dr. H. p. H. Galloway, of Toronto, felt that val-
gus would occur quite frequently after the shortening
of the tendo Achillis. There seemed to be a class of
cases in which the shortening of the tendo Achillis
would cause either supination or pronation according
to the direction the foot happened to be given.
Dr. a. B. Judson, of New York, said that he had
abolished the joint at the ankle to make the apparatus
more durable. The first effect of such an apparatus
was to carry the weight of the body from the anterior
part of the foot, by virtue of the strength of the mus-
cles acting on the tendo Achillis, to the anterior side
of the upper part of the shin. By these means, in
cases of extreme calcaneus the gait could be made
absolutely perfect.
Dr. Gieney, in closing, said that his experience had
taught him to place very little reliance on the electri-
cal examinations of the muscles in young children.
He had not claimed to be presenting anything novel,
but had simply advocated a simple method by which
a permanently good result could be secured. His
cases had presented the clinical appearance of paraly-
sis, and without an electrical examination he was will-
ing to have them go on record as poliomyelitis.
A Final Report on the Use of Pure Carbolic
Acid in the Treatment of Tuberculous and Puru-
lent Diseases of Joints and Bones. — Dr. A. M.
Phelps, of New York, made this report. His prac-
tice had been to lay open abscess cavities, divide the
capsule about two-thirds of its extent, and pull out the
head of the bone. The joint was then irrigated freely
with bichloride 1:1,000, after which pure carbolic
acid was poured in and allowed to remain just one
minute. This application was followed by irrigation
first with strong alcohol, and then with a two-per-cent.
solution of carbolic acid. He then inserted the
largest possible glass drain that the joint would ad-
mit, and put the patient in bed with a weight and
extension apparatus. In the last eighteen months he
had operated on seventy cases, and had performed
twenty excisions, whereas he would have ordinarily
done fifty. In fifteen cases the head of the bone had
been found separated from the neck, and lying as a
sequestrum in the joint. In forty cases the capsule
had ruptured anteriorly into the muscles. On an av-
erage, all of the cases requiring excision or extensive
bone operations had been discharged from hospital at
the end of three weeks.
Dr. Robert W. Lovett, of Boston, said that at the
Children's Hospital the surgeons had endeavored to
prevent the formation of these abscesses by putting
the children to bed whenever there was a painful con-
dition of the joint or deformity due to irritative mus-
cular action, and they had learned to attach consider-
able importance to this as a preventive treatment.
When an abscess occurred, it was the practice to
open it up freely and drain, after irrigating the cavity
with corrosive-sublimate solution.
The Movements of the Normal Spine in Relation
to Scoliosis. — Dr. Robert W. Lovett, of Boston, pre-
sented in this paper the results of an elaborate study of
this subject. He said that at present there was no sat-
isfactory theory to account for the mechanism of scolio-
sis, and particularly the rotation. A large number of
theories had been propounded, and the fact that they
had not been generally accepted had led to the study on
which this paper was based. The text-books on anat-
omy usually described four movements of the spine.
1070
MEDICAL RECORD,
[June 16, 1900
viz., (i) flexion; (2) extension; (3) lateral flexion;
(4) torsion. He had fo'jnd that in side-bending in
the flexed position a type of torsion was got in which
the bodies of the vertebra; rotated toward the convexity
of the lateral curve. In extension the rotation was
more limited to the upper part of the spine than in
flexion, and was the reverse of that seen in flexion.
The construction of the spine being very complex, the
next step in the present investigation had been to
study, with the aid of the professor of mechanics of
Harvard College, the action of a flexible beam or rod.
The vertebral column apparently followed the behavior
of a flexible rod — a matter well understood by stu-
dents of mechanics. It was found, however, that one
could not entirely leave out of account the articular
processes. Apparently in side-bending in the ex-
tended position the articular processes merely served
to accentuate what the column would do if they were
not present. In the flexed position they appeared not
to exert any influence. The author's conclusions were :
{i) Scoliosis was a deformity that must always be
acquired in the flexed position; (2) reverse rotation
was possible on the ground of side-flexion occurring
in the extended position; (3) extension exercises
should be cultivated in the treatment of lateral curva-
ture, and even forcible correction done in the extended
position; (4) symmetrical exercises seemed much safer
than the complex unilateral ones; (5) probably a safe
and efficient method consisted in throwing the spine
into positions which would bring the articular processes
into play, and reversing the rotation acquired in the
flexed position.
On Some of the Problems Involved in the Treat-
ment of Lateral Curvature of the Spine. — Dr.
Newton M. Shaffer, of New York, presented this
paper, but spoke of only one of the problems. He
said that clinical experience had taught him what Dr.
Lovett had concluded from his mechanical studies,
i.e., that the treatment should be carried on in the
extended position. He indicated the best directions
in which to make pressure, by diagrams on the black-
board.
The Relation of Deformity of the Pelvis to Lat-
eral Curvature of the Spine. — Dr. H. P. H.
Galloway, of Toronto, read this paper. He said that
the theory which considered the superincumbent
weight the chief etiological factor in lateral curvature
of the spine had been the one most generally ac-
cepted. In a faulty attitude, habitually assumed in
a growing child, the conditions were ripe for this su-
perincumbent weight to become a determining factor
in the production of lateral curvature. His own ob-
servation had convinced him that the primary me-
chanical fault had received but scant consideration.
Many writers had looked upon distortion of the pelvis
as the effect of the lateral curvature, but his own be-
lief was that cause and effect had here been con-
founded. It was not uncommon to meet with a sa-
crum the base of which was an incline. As the
vertebral column was built upon this slanting foun-
dation, the column must lean to one side, and this led
the person to endeavor to restore the balance of the
body. To his mind it was more logical to look for
the faulty construction in the foundation than in the
superstructure. It was unreasonable to suppose that
the stable foundation, or pelvis, should fall a prey to
faulty mechanical conditions belonging to the flexible
vertebral column resting upon it.
Spasmodic Lateral Curvature of the Spine — Dr.
Arthur J. Gillette, of St. Paul, gave in this paper
a record of a number of cases of hysterical curvature
of the spine that had come under his observation.
The Results of my Observations in Lateral Cur-
vature of the Spine, Clinically, Mechanically, and
Pathologically Dr. B. M. Phelps read a paper
with this title, in whic'i he gave the results of an
autopsy held on a patient with lateral curvature, dying
at the workhouse of natural causes. The subject was
a man about forty-five years of age, who had had a
lateral curvature as far back as he could remember.
There was extreme lateral curvature with rotation.
The superficial layer of muscles was found in fairly
good condition. Upon the side of the concavity the
muscles were in fairly good condition, but upon the
side of the convexity they were atrophied, and had
undergone fatty degeneration. The quadratus lum-
borum and other deeper muscles were entirely de-
stroyed by fatty degeneration and atrophy on the side
of convexity, and on the concave side degeneration
was present, but was not so far advanced. This con-
dition of the muscles extended throughout the whole
region of curvature. The intervertebral cartilages on
the side of the concavity were completely destroyed.
His conclusion was, that it was utterly futile to expect
to cure a lateral curvature of the spine after bone
changes had taken place. The most that could be
hoped for from treatment was to prevent an increase
of the curve. He was of the opinion that all of the
machines for forcible correction now in use were of
but little value.
Dr. E. H. Bradford, of Boston, said that while he
agreed entirely with Dr. Phelps regarding the pathol-
ogy, he could not accept the doctrine that there was
no stage of lateral curvature in which treatment would
benefit. There were certainly some cases in growing
children which were benefited by treatment.
Dr. Wek.el said that he had time and again seen
patients with muscles as rigid as a bar of iron, in
which absolute relaxation had been secured by forcible
correction. This was certainly an improvement.
Dr. N. M. Shaffer said that if there was any one
thing clear in his mind it was that lateral curvature
was dependent primarily not on bone changes, but on
changes in the muscles.
Dr. H. Augustus Wilson, of Philadelpliia. sug-
gested the possibility that asymmetrical hip action in
apparently normal subjects might result in lateral cur-
vature. In a number of cases he had found such ac-
tion present, although the hips were apparently normal
in other respects.
Dr. Phelps replied that in the early stages of mild
cases of lateral curvature a very decided physiological
curve was added. This latter curve could be cured,
but in proportion as a curve developed in the dorsal
region there was distortion of rib, and these patients
could not be cured. It was not necessary to do myot-
omy in young children; nevertheless at the present
time he was cutting more than one-third of all the
cases of lateral curvature coming under his care. He
did not believe any of the cases began in the muscles
except those originating in a poliomyelitis.
Dr. a. B. Judson complimented Dr. Lovett on his
ingenious and convincing model demonstrating the
prevention of rotation by extension and its promotion
by flexion of the spine. The speaker said that about
1876 he had himself advocated, and in one case prac-
tised, the application of a spinal brace for the produc-
tion of extreme lordosis in cases of lateral curvature,
on the ground that, as in rotation the anterior part of
the column was affected by deviation from the median,
just as it was affected by caries in Pott's disease, it
was good practice to shift the weight of the body from
the anterior to the posterior part of the column. If
he had looked ahead as far and as keenly as had Dr.
Lovett, he would have entertained a more favorable
opinion regarding this method of treatment, which he
now believed promised great advantages.
Anterior Support Supplementing the Taylor
Brace in Pott's Disease. — Dr. George B. Packard,
of Denver, read a paper on this subject. He said
June 1 6, 1900]
MEDICAL RECORD,
1071
that plaster of Paris would be frequently the most
satisfactory method of treatment were it not for the
lack of adjustability. In the mid-dorsal region, in
which there was apt to be the most deformity, the an-
terior support was of decided advantage. The sinking
forward of the upper dorsal spine in these cases car-
ried the ribs forward. The front piece could be made
to extend higher than the apron.
A Suspension Pressure Chair for Scoliosis. — Dr.
Phil. Hoffmann, of St. Louis, described this simple
and inexpensive apparatus. It was the pressure chair
that had been described by Dr. Bradford, with the lat-
eral steel bars prolonged upward to the height of four
and a half feet, and meeting overhead in the form of
an arch, to which was attached an apparatus with com-
pound pulleys. It was intended to be used only as
an accessory to proper gymnastic exercises and other
treatment.
A Brace for Cervical and High Dorsal Spondy-
litis.— Di. Hoffmann also exhibited this apparatus,
which belonged to the cuirass type.
Results of Treatment of Congenital Dislocation
of the Hip. — Dr. E. H. Bradford, of Boston, pre-
sented this communication. It had been shown in
recent years, he said, that congenital dislocation of
the hip could be reduced, or apparently reduced, both
by operative and by the bloodless method, and that
relapses occurred after both methods. It had also
been shown that both methods lacked precision. A
specimen was presented illustrating the results of both
methods. According to his study of this subject, one
cause of failure in these cases was the covering of the
acetabulum with what he called "the hymen of the
acetabulum." By exposing this, and incising it
deeply, and then retracting the parts, it would be
found that there was usually a fairly deep acetabu-
lum. He had operated about forty times by the blood-
less method, and in only one case had there been no
relapse. There were definite surgical conditions
which were difficult to meet. If they could be met,
a cure would usually result; if not, relapse would al-
most certainly occur. He had seen a few cases in
which relapse had occurred after a year. He had en-
deavored to make the results more permanent by su-
turing the capsule. In his later operations he had
made a straight incision from the greater trochanter
to two or three inches below, or just above, the inser-
tion of the gluteus maximus muscle. At the upper
end the incision curved slightly upward between the
tensor vaginae femoris and the gluteus medius. He
first exposed the lesser trochanter, and with the peri-
osteal elevator pressed up the insertion of the psoas
and iliacus muscles. He next opened the capsule by
a transverse incision anteriorly and posteriorly, and
inserted the finger into the acetabulum. After reduc-
tion the parts were kept immobilized for three or four
weeks, and if then the head did not seem to be firm,
he cut down and sewed it in. He felt that he could
not operate successfully on patients over six years of
age.
Dr. Gibney remarked that the suturing of the cap-
sule, so as to make the results more lasting, seemed
to him a capital idea.
Dr. Ridlon thought it was more important to con-
trol flexion than abduction. If the patient was young,
and the head and neck were fairly well developed, it
was possible to replace the bone by the bloodless
method and retain it. This statement presupposed
that very considerable abduction was maintained per-
manently, together with absolute control of both active
and passive flexion.
Dr. Harry M. Sherman said that he had tried
suturing in one or two instances, but had found it
very inaccurate because he had to do it without the
guidance of sight. He believed that the position of
the head between the two lateral halves of the pocket
made it as stable as if sutures had been used.
Dr. Galloway said that in one of his cases, a
double dislocation treated by the bloodless method,
apparently a perfect cure had been obtained.
A New Back Brace for Pott's Disease Dr. John
Dane, of Boston, exhibited this brace. The object of
the device was to combine the advantages of a plaster-
of-Paris jacket with those of an antero-posterior brace.
The two pad-plates were held by an arm which could
be removed to facilitate fitting the pads to the child.
There was a cross-piece very high up on the back, and
straps passed around under the arms. The usual apron
was dispensed with, thus giving the wearer a much
better opportunity for deep thoracic breathing.
Tendon Transplantation in the Treatment of
Paralytic Deformities.— Dr. W. R. Townsend, of
New York, read this paper. He said that only dur-
ing the past five years had tendon transplantation at-
tracted much attention in cases of paralytic deformi-
ties. There were many patients suffering from drop-
wrist whose deformities could be entirely done away
with and the function more or less restored if this
operation was done. Several cases were described,
including one of his own — a case of equinus and drop-
wrist. In this case the tendon was shortened by
lapping one portion over the other. The method of
fastening was that recommended by Dr. Goldtlnvait,
and already reported to the association.
A Report of a Tendon Transplantation for Par-
alytic Club-Foot. — Dr. L. Porter, of Chicago, re-
ported this case. The case was one of paralysis of
the anterior and posterior muscles of the leg from po-
liomyelitis. All the muscles of the gastrocnemius
group were paralyzed. The extensor proprius pol-
licis and the peroneus longus were intact.
Dr. Joel E. Goldthwait, of Boston, said that if
tendons were to be transplanted, the more direct the
route the better the result. He would certainly prefer
the route taken by Dr. Townsend in going directly
through the interosseus membrane, because in cases
in which the anterior tendons had been carried around
the leg and made posterior tendons, the result had not
been very good.
Dr. Weigel said that in certain cases complete
division of the tendon seemed an absolute necessity,
particularly when the condition was the result of in-
jury.
Dr. E. H. Bradford said that he had endeavored
to avoid complete division by doing a myotomy, di-
viding the intermuscular septa, and over-correcting the
hand. In that way the power of the muscle had been
retained, and yet the contracted tissues had been over-
come.
A Case of Tuberculosis of the Astragalus with
Ankylosis and Subsequent Amputation. — Dr. V. P.
Gibney reported this case. At first the case had
seemed to be one of synovial tuberculosis, but it had
gradually extended to the bone, and had involved the
latter and the joint. A girl, aged sixteen years, had
sprained her ankle. It had been treated at first by
plaster of Paris, and subsequently by splint and
crutches. She had kept up the latter treatment for
about twelve years. A few weeks ago she had ap-
peared at his clinic, with what seemed to be a typical
example of tuberculosis of the astragalus. About
eleven weeks ago he had made an incision over the
astragalus, and had then found a mass of granulation
tissue which the pathologist reported to be filled with
tubercle bacilli. The surface of the bone was some-
what eroded, but the body was apparently intact. He
had removed the astragalus and the surrounding tis-
sues for about one-eighth of an inch in every direction.
After a short time she had developed an abscess, and,
after consultation, the knee had been amputated. The
1072
MEDICAL RECORD.
[June 16, 1900
specimen showed an eroded condition of the inner
facets of the malleoli, the rest of the bone being ap-
parently normal. The astragalus was also exhibited.
( To l,c Continued )
^cdical Items.
Contagious Diseases — Weekly Statement — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending June 9, igoo:
Tuberculosis
Typhoid fever
Scarlet fever
Measles
Diphtheria
Laryngeal diphtheria (croup)
Cerebro-spinal meningitis. . . .
Chicijen-pox
Smallpo.x
lOI
419
294
7
139
4
Inoculation of Typhus Fever .\ Russian physi-
cian, Dr. Mochutkovski, has inoculated himself with the
blood of a typhus patient. After feeling no ill effects
for seventeen days he had a severe rigor on the eigh-
teenth day, with fever, delirium, and a comatose con-
dition lasting for a fortnight. The rash appeared on
the fifteenth day of the disease and desquamation be-
gan eleven days later, he being convalescent on the
twenty-third day after the initial rigor. This interest-
ing experiment appears to prove that the virus in ty-
phus fever resides in the blood. It should, however,
be mentioned that Dr. Mochutkovski had previously
attempted to inoculate himself with the blood of
typhus-fever patients no less than seven times. — The
Lancet.
The Nails in Insanity.— That acute diseases fre-
quently involve defective nutrition of the nails, so that
their occurrence at a previous date, which may be aj>
proximately estimated, is often indicated by transverse
lines, is a well-known fact. According to Dr. Marco
{Gazetta Medica Lonibarda) X\\\s, occurs with special
frequency and regularity in the periodic psychoses
known as alternating or cyclic insanity, folic circulaire,
etc. "In patients so affected the periodic changes in
the general and psychical condition are so counter-
signed on the nails in the form of grooves and ridges
that a simple examination of the fingers will enable
one in most cases to estimate the frequency and rela-
tive duration of the attacks. In some cases, espe-
cially cyclic forms, where the periods are frequent,
short, and regular, the nails assume a characteristic
aspect resembling in the richness of concentrically
arranged dystrophic strias the ridged shells of certain
molluscs." — Medical Magazine.
The Failure of the Filters in South Africa
The Hospital, referring to the large death list of the
British troops in South Africa, and especially to the
mortality from typhoid fever, remarks that it is doubt-
less due to a polluted water-supply, and speaking of
the filters says: "Much of the knowledge which has
been gained in recent years about filtration has tended
to throw doubt upon the power of ordinary filters to
produce a safe and drinkable water. Indeed a sort of
despair has seized upon scientific men upon this sub-
ject. We are, however, by no means sure that the last
word has been said upon the purification of water by
mechanical and perhaps chemical means. Bacteriolo-
gists have set up so high a standard as to have con-
demned off-hand all the old-fashioned filters, and have
given us instead some very beautiful and perfect ar-
rangements, which, however, clog up directly with
Soulli African mud. But we are beginning to appre-
ciate the biology of the subject, and to understand
what a very tender organism the typhoid bacillus
really is, and it is on the cards that some better way
of getting rid of these microbes may be devised than
the apparently simple but really very difficult method
of straining them out."
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon -general of the United States Marine-
Hospital service during the week ended June 9,
1900 :
Cases. Deaths.
Smallpox— Un
Colorado, Logan Co
Me:
I Co .. May 25th ,
District of Columbia. Wash-
ington
Florida. Jacksonville
Illinois. Chicago. . . .
indianapoli;
, Des Mo
Kansas, Wichita
Kentucky, Covington
Louisiana, Caddo .
Orleans..
:tts, Kail River
Lovk-ell ...
Grand Kapids
Chippewa Co .
Duluth
May
.May
.May
May
.May
-May
.May
26th to June
26th to June
26th to June
19th to June
ist to 31st..,
2Uh tojune
26th to June
26th .
He
epin
Houston Co. .„
Jasper
Meeker
Minneapolis. . . .
Northfield
;Co
St. Paul
Sheldon
Waverly
Wright Co
Ohio, Cleveland
Dayton . ,
Portsmouth . . . ,
Pennsylvania, Pittsburg.,..
South Carolina. Greenville.
Utah. Salt Lake City
Wyoming, Aspen
Rock Springs. . .
.Mav
.May
.May
.May
'May
.May
May
May
.May
.May
.May
.May
.May
.May
.May
.May
.May
.May
.May
.May
38
26th to Ju
26th to June 2d .
26th tojune 2d .
19th to June 2d .
.5lht0 2cth
15th to 29th
15th to 2Qlh
i5lh to 2Cith
j'sth lo 2qth
15th to 29th... .
15th to 29th
15th to 2Qth
15th to 2. th 7
15th to 29th 8
15th to 29th 4
15th to 2gth 4
1 5th to 29th 3
26th to June 2d 2*4
26th to June 2d I
26th to June 2d i
26th to June 2d 3
19th tc June 2d 4
26th to June 2d ij
igth to 26th 6
19th to 26th 8
-Foreign.
Austria. Prague
Belgium, Antwerp ,
Brazil. Bahia. . . .,
Canada, Winnipeg
Egypt. Cairo
England, Liverpool.
.May 1 2th to 19th 3
.May 12th to loth. . 2
• April 2ist lo May sth .. 1
May 1st to 30th 16
. May 6th to 1 3th
.May i2th to 19th.
Mex
London May 12th to igth 3
Southampton . May 12th to 19th x
France, Lyons May isth to igth 5
St. Etienne May ist to isth 4 i
Greece, Athens May 12th to igth 2 i
India. Bombay May 1st to Sth 33
Calcutta April 7th to 14th . 31
Kurrachec April 2Qth to May 6th 16 14
Madras April 28th to Ma'y 4th i
:o. Vera Cruz May i6lh to 23d 6 4
Kussia, Moscow .. May 5th to 12th 9 3
Odessa May 12th to igth 11 2
•St. Petersburg May 5th to i2lh 216 g
Warsaw May 5th to 12th i
Scotland. Glasgow May i8th to 25ih 30 i
Straits Settlements, Singa-
pore April 7th to 14th 7
Uruguay, Montevideo April 1st to 8th x
Yellow Fever.
Colombia, Barranquilla May 5th to 12th 1 i
Panama May 22d to 29th 3 i
Cuba, Cienfuegos May i6th to 23d i*
Havana May i6th to 23d i
Mexico, Vera Cruz May igth to 26th 22 6"
* Santa Clara Barracks.
Cholera.
India. Bombay May ist to Sth 28
Calcutta April 7th to 14th . .. 113
Madras April 28th to May 4th.... i
Plagub— United States.
California, San Francisco. . . March Sth to June Sth Reported present.
Plague— Foreign.
Arabia, Aden April 7th to 28th 266
Australia, Sydney April 28th to May 5th 38 10
China. Hong Kong April 22d to 28th , 33 28
Egypt, Alexandria May Sth to nth 5 2
Port Said May 3d to 5th 8 3
India, Bombay May ist to Sth 340
Calcutta April 7th to 14th . 465
Kurrachee April 2Qth to May 6th 319 173
Japan, Osaka and Hiogo.. ..May 7th to 13th . . 8
Kurdistan April 2d to 17th 158 12a
Turkey May 2gth 1
Medical Record
A IVeekly yournal of Medicine and Surgery
Vol. 57, No. 25.
Whole No. 1546.
New York, June 23, 1900.
$5.00 Per Annum.
Single Copies, loc.
A MEMORIAL ADDRESS UPON Dr. FESS EN-
DEN NOTT OTIS.'
By T. GAILLARD THOMAS, M.D.,
No man ever passes through life, who, if a careful,
candid, and unprejudiced study were made of his char-
acter and career, would not furnish a lesson of greater
or less moment for humanity. If he has achieved
great results, profit would accrue from a consideration
of the qualities and methods which secured him fame
and fortune. If he has passed through his existence
a sluggard and a dolt, the suggestion of avoidance
would reward the biographer. If he has been a crim-
inal and a malefactor, the interest of the investigator
would grow in proportion to the depth of infamy to
which his subject has sunk, and the brilliancy of the
exhortation which could be based upon his depravity.
But to give to this consideration of individual ca-
reers the universal interest which I claim for them, it
should be made with fairness, justice, fearlessness, and
honesty; the investigator spurning the absurd maxim,
" De mortuis, nil nisi bonum," and making truth the
pivot of his work.
You have met together to-night to listen to the un-
varnished and impartial account of one of our col-
leagues, whose life and character were such that I
dare to tell the truth of both, holding up before them
the mirror, showing you an honest reflection, and tell-
ing you a simple tale based upon an intimate ac-
quaintance of nearly half a century.
In the year 1852, I was a member of the resident
staff of Bellevue Hospital. One of the amusements
of this staff on summer afternoons was to row upon the
East River in the staunch yawl of the warden, and
one day we called upon the resident staff of Black-
well's Island Hospital, which was then under the
charge of the brilliant and lamented Dr. Kelly, who
just after the time of which I speak was lost at sea,
upon a voyage to Europe for the purpose of perfecting
himself in the study of venereal diseases, of which he
intended to make a specialty. To one of Dr. Kelly's
staff I was particularly attracted by his kindly, genial
manner, his simple, unostentatious ways, and his
striking appearance. He was nearly six feet in
height, of dark, almost swarthy complexion, with a
head large and somewhat Websterian in shape. Meet-
ing him casually, one might have supposed him to
belong to one of the so-called " Latin races," from his
raven-black hair and huge black moustache, which en-
tirely shrouded his mouth and gave to his face a stern-
ness of expression which ludicrously belied the gentle
nature of the man.
I recall the fact that before the two staffs, strangers
to each other up to this time, had conversed very long.
Dr. Kelly arose, and, pointing to a fine life-size oil
portrait of himself, told us that it had just come from
the hands of the framer, and descanted upon its mer-
' Delivered before the New York Academy of Medicine, June
7, igoo.
its, its accuracy as a likeness, and the great pleasure
which he experienced in its having been painted by a
member of his staff, bowing as he went on to the dark
and striking-looking man of whom I have just spoken.
From that day to the day of his death an intimate
friendship existed between this man and myself, a
per,iod of forty-eight years. From this statement you
may judge of the fulness of the knowledge from which
I speak to-night. I shall endeavor in dealing with
my theme to make candor and impartiality go hand-
in-hand with knowledge.
Fessenden Nott Otis, the subject of this memorial
address, was born at Ballston Springs, Saratoga County,
N. Y., May 6, 1825. The family from which he was
descended settled in New York State prior to the
American Revolution, and is a branch of the Otis
family which came from England toward the close
of the seventeenth century, and settled at Hingham,
Mass. Oran Gray Otis, the father of Dr. Otis, was
one of the early graduates of llnion College, Sche-
nectady, N. Y. He became prominent as a law-
yer, advocate, and legislator, although dying at the
age of forty-one years. He was selected to deliver
the oration on the one hundredth anniversary of the
birthday of Washington, before the joint legislative
bodies of the State of New York, at Albany, in the
year 1836. On the maternal side Dr. Otis was de-
scended from anotlier well-known New England fam-
ily of English origin ; his father having married Lucy,
daughter of David Kingman, a leading citizen and
shipping merchant of Bridgewater, Mass.
Dr. Otis began the study of medicine in 1848, and
came to New York City, matriculating in the medical
department of the New York University; also enter-
ing the office of Dr. John Whittaker, demonstrator of
anatomy, as a private student. Subsequently he left
the university with Dr. Whittaker, who had received
an appointment to the chair of anatomy in the New
York Medical College, just then organized. In 1852
he was graduated from that college, receiving the
competitive gold medal for his graduating thesis, as
well as prizes in the departments of physiology and
practice.
Immediately after his graduation, he was appointed
one of the resident assistant physicians of Charity
Hospital. At the close of this service he received an
appointment as surgeon in the United States Mail
Steamship Company, the service of which covered that
portion of the route between New York and the Isth-
mus of Panama. Subsequently he continued in this
and the Pacific Mail service up to 1859, when he left
the ocean and settled in the practice of his profession
in New Vork City in i860.
In January, 1862, he was appointed to a lectureship
in the College of Physicians and Surgeons, New York,
which he continued to fill until 187 1, when he suc-
ceeded to the clinical professorship of the department
of genito-urinary and venereal diseases. This chair
he occupied until his resignation from it, on account
of failing health, in 1890, when he received the degree
of professor emeritus. In 1861 he was elected a fel-
low of the New York Academy of Medicine, and sub-
sequently was made a member of the New York County
Medical Society, and also of the New York State
I074
MEDICAL RECORD.
[June 23, 1900
Medical Society, the British Medical Association, and
the Society of American Genito-Urinary Surgeons.
He had also became a member of the medical board
of Charity Hospital, and was attending surgeon at
Blackwell's Island Hospital for over ten years.
Dr. Otis' career of professional activity extended
over a period of exactly thirty years. During this
time he labored as a practitioner, as an operative sur-
geon in his speciality, the genito-urinary organs of the
male; as a lecturer; and as a steady contributor to
medical literature. An enumeration of the most im-
portant of his contributions makes his industry quite
apparent.
In 1883, "Practical Lessons on Syphilis and the
Genito-Urinary Diseases," a work of six hundred
pages, was published; and this was followed by "The
Pliysiological Pathology of Syphilis," in book form.
Soon after the following brochures were published-
"The Limitation of the Contagious Stage of Syph-
ilis, Especially in its Relations to Marriage " ; " Some
Important Points in the Treatment of Deep Urethral
Stricture " ; " Temporary Overstrain of the Bladder,
Producing Localized Atony and Chronic Retention
of the Urine;" " Re'sume' of the Experience of Seven-
teen Years in the Operation of Dilating Urethrot-
omy"; "The Perfected Evacuator in the Operation
of Lithotrity " ; "Reflex Irritations and Neuroses,
Caused by Stricture of the Urethra in the Female";
"The Radical Cure of Urethral Stricture," a work of
three hundred pages. For him who has not written
for publication, the enumeration of an author's works
may signify little; for him who has done so, it will
carry home a meaning which will appeal to his memory.
In the course of his practice, and in order to carry
out his special surgical procedures most completely.
Dr. Otis invented various instruments of precision,
which came into very general use. A case containing
these was ordered, in 1889, by the surgeon-general for
every post of the army of the United States. I re-
member quite well the peculiar pleasure which the
inventor experienced from this act on the part of the
medical executive.
In this most wonderful era of the world's history;
this age in which progress, advancement, and develop-
ment in all things are startling the minds of men by
their exuberant growth; this magic age in which the
science of medicine is rapidly being elevated into the
position of one of the bulwarks of society and one of
the mainstays of civilization — it is most difficult for
one, strive he ever so hard, to score for himself more
than a mediocre success; and most happy should be
the man who succeeds in writing his name among
those whose works shall live after him and be recog-
nized as deeds which will prove of lasting good to his
fellow-men. This claim can honestly and fairly be
made for the subject of this memoir; for he has so
decidedly left the imprint of his labors upon the whole
subject of urethral pathology and treatment that it
would be idle to dispute his claim. So long as the
God-given art of surgery lives, its history will be im-
possible without reference to his name and acknowl-
edgment of his contributions to it as a science and as
an art.
In some of the views advanced by Dr. Otis in his
public teachings he was opposed by leading authori-
ties at home and abroad. This resulted in much spir-
ited discussion in the various medical societies and
journals, and also in the publication of the last work
mentioned in this enumeration. This was soon after
republished in London. Previous to this publication.
Dr. Otis, by invitation of Prof. Berkeley Hill, had ad-
dressed the profession from Professor Hill's chair in
the University Medical College of London, and had
also presented his advanced views at the meeting of
the British Medical Association at Edinburgh, in 1875.
Now that the laborer is at rest, it becomes a matter
of deep interest for those who stood near him during
his life and watched his eitorts, to inquire into the
forces and methods which crowned them.
Where and how shall we class Fessenden Nott Otis
among the workers in our calling? Among the bril-
liant geniuses, like Marion Sims, who like a meteor
swept athwart the dark field of gynaecological surgery,
flooding it with light? No. Shall we place him
among the deep thinkers, the profound philosophers,
like John W. Draper? No. He was not in any re-
spect a quick, brilliant, striking man. He belonged
to an entirely different class; to the class which holds
within itself the greatest number of men who have
lifted up humanity and advanced civilization; that
class occupied by men who are slow of thought, delib-
erate of speech, and cautious of action; the class to
which belong George Washington and Ulysses S.
Grant. I count upon you not to do me the injustice
of supposing that I am in any way comparing the sub-
ject of my essay with either of these great men. The
class is large and it is comprehensive. From my
standpoint, there are men in all positions of life who
belong to the same class as those whom I have men-
tioned. As we look back upon our comrades of col-
lege life, we will recall them as belonging to three
classes: First, the thoughtless, giddy youths, whose
aim was pleasure and whose lives were froth; second,
the talented, brilliant, witty, fascinating fellows, who
gave great promise for the future, and who held among
their number the " first-honor man " and those of
lesser note; and third, the quiet, slow, well-balanced
fellows, who, while not in the front ranks of college
scholarship and college honors, always held positions
of dignity; men of reserved force who took life gravely,
avoided scrapes, and plodded on through the college
career, the real bone and sinew of the class. To this
class of men we all look back as that which has fur-
nished the largest number of those of our classmates
who have shed lustre upon their alma mater, gained
honor for their own names, and accomplished worthy
deeds for society. To this class belonged Fessenden
Nott Otis. What he accomplished in his profession
was attained by careful, devoted thought, devotion to
details, strict and unbiassed examination of results,
and honest regard for truth.
Upon his reading a paper before a European soci-
ety, a man eminent in the specialty to which both be-
longed rose against it with uVidue warmth and uncalled-
for severity. He appeared to feel that the slow-talk-
ing man who was opposed to him would readily fall
before his flowing, flowery logic, and leave him undis-
puted victor upon a stricken field. A friend w-ho was
present described the encounter to me as a signal ex-
hibition of methods between the brilliant and rather
superficial man, and the deep, thoughtful, slow-mov-
ing one, whose staying powers wear out only after long
conflict. Success on that occasion undoubtedly rested
with the subject of this memorial and added largely
to his then growing reputation.
But Dr. Otis presented other bright and attractive
sides to his character, apart from that connected with
his profession. He was an artist by nature, and to a
certain extent by practice; for he always kept in
touch with artists and with art, even to the end of
his life. A mutual friend, the late W. H. Beard, once
said to me in discussing his character and career:
"The gain of your profession in attracting Otis was
the loss of mine. Had he followed his natural bent,
as in my judgment he should have done, he would
have made an artist of merit and distinction, perhaps
even of renown." An accident received in early life
to a certain extent modified the course of his career.
At this time and owing to this fact, perhaps, he de-
voted himself to landscape drawing and perspective.
June 23, 1900]
MEDICAL RECORD.
1075
with such success as to result in the subsequent pub-
lication, through the house of D. Appleton & Co., New
York, of several books on these subjects. Their ex-
cellence and his reputation as a lecturer and teacher
were recognized by the faculty of Union College in
the presentation to him of the honorary degree of
Master of Arts in 1849. And thus it was that on my
first introduction to him in 1852, when he was twenty-
eight years of age, I heard Dr. Kelly allude with en-
thusiasm to a life-size portrait in oil, painted by him.
It is quite evident that when Otis in due course
came to the parting of the roads, one of which led to the
temple of /Esculapius and other to that of art, he con-
sidered the course which would be his path in life
with all that coolness, caution, and judgment which
always characterized him, and decided definitely.
Nevertheless, he loved art to the day of his death, and
always kept in affectionate touch with it. Among his
most intimate friends were artists of world-wide fame,
such as Church, Beard, Winslow, Eastman Johnson,
Bristol, and many others. But it was not only, or es-
pecially, the well-known and distirguished devotees
of art that he cultivated. He was to my certain
knowledge the medical adviser and counsellor of a
host of poor students, who in time of need sought his
guidance and aid, and sure am I that they never
sought him in vain. In many an artist's humble
home his loss will be deeply felt, and from many a
studio prayers from grateful lips have ascended to
heaven in his behalf.
In 1849 he published two volumes, entitled "Les-
sons in Drawing," and " Studies of Animals and
Landscapes" ; and later he put forth a brilliantly il-
lustrated work upon " Tropical Journeyings." In i86o
he published an illustrated " History of the Panama
Railroad, and its Commercial Connections."
But I have kept back for you the most charming
phase of his character, the loveliest feature of his na-
ture, until the close of this address. A few words
only, as I tell those of you who did not know him
well, of his social, genial, humorous personality, and
his gentle and affectionate nature. His friendships
were tenacious and lasting, and his enjoyment of the
society of his friends almost childlike. Fond of a
good joke, he was an effective raconteur, and he had
one virtue rarely seen in such men : he enjoyed the
jokes told by others. I cannot refrain from telling
you how deeply he enjoyed the following incident.
Some years ago a dinner was given at the old Delmon -
ico's restaurant to an eminent English burgeon, by
some physicians of New York, and for a part of the
evening I had the honor of sitting next to the guest of '
the occasion. For some reason I found it very diffi-
cult to interest him in my conversation, and, growing
desperate, I pointed Otis out to him and said, " I
have just returned from London, and on a visit of
exploration I saw in a hostelry in the ' Seven Dials,'
a portrait of that man in a picture hanging there which
represented him standing not ten feet from Queen
Victoria." Had I set off a bomb under his chair I
could not have aroused the attention of this true Eng-
lishman more effectually. He was eager for an ex-
planation, and evidently suspected me of insanity, or
worse. You are all aware of the fact that when the
British ship Resohih-, which England sent out to search
for Sir John Franklin in the Arctic Ocean, and which
was lost, was recovered and returned with honors by
the United States, Otis, in full naval uniform, and
with a huge sword hanging by his side, was acting in
the capacity of secretary to Commander Hartstene of
our navy. The queen and the prince consort came
on board to receive the ship, as Commander Hartstene
delivered her to the English government. This strik-
ing scene was committed to canvas, and large engrav-
ings of it were struck ofiE. It was one of these that I
had seen hanging in a saloon in the questionable pre-
cincts of the " Seven Dials," and which represented
Otis and the queen within ten feet of each other.
After this the Englishman was eager to be presented
to the enviable American, and to Otis' astonishment,
I soon placed him in my seat and gave him my place
of entertainer. The Englishman's extreme warmth
and delight in knowing him, and' his great desire to
cultivate his acquaintance, amused him ever afterward,
and was the subject of much merriment.
In his own home he was the soul of hospitality, and
many of his friends will recall with pleasure the hours
spent with him in his cottage upon the magnificent
bluffs of Montauk Point, overlooking at once an end-
less expanse of ocean and hundreds of acres of pas-
ture land, which recalled the prairies of Colorado.
Here, surrounded by wife and children, and free from
the cares of an arduous practice, the guest saw his
true nature face to face, and learned to comprehend
the charm of character which made for him in his
three-score years and fifteen such a host of friends.
Brilliancy, wit, and eloquence make men rich in ad-
mirers; simplicity of nature, sincerity, and kindliness
produce, in their place, friends.
Dr. Otis was for many years a member of the New
York Century Association, to which he was very deeply
attached; of the New York University Club; the New
York Medical and Surgical Society ; a member in per-
petuity of the New York Metropolitan Museum of
Art; medical examiner and honorary member of the
New York Artist Fund Society; and a life member of
the New England Society.
For the last nine years of his life, failing health
caused him to spend his winters in milder climates
than that of New York, and he sought health in South-
ern California, Jamaica, Thomasville, Tallahassee, and
New Orleans. He even tried lengthy journeys to In-
dia and Japan. On my last meeting with him I urged
him to write a guide-book to the best winter resorts
for invalids; but with a smile he rejected the propo-
sal, saying: "Too late, too late, I am up to no more
work." Then came to my mind the lines of Whittier,
" Of all sad words of tongue or pen,
The saddest are these, it might have been."
Such a work from such a man would have filled an
important place as an aid to the physician of our day;
for his dicta would have been freighted with a plenti-
tude of practical knowledge.
His last winter was spent in New Orleans, w'here, in
the early part of April, he was attacked by double
pneumonia. During his convalescence a carbuncle
appeared, and in his already debilitated state of health
resulted fatally on May 24, 1900.
He leaves a widow, two daughters, and a son to
mourn his loss. To them his death was a dire calam-
ity, but to him it was not so. He fell like ripened
fruit indue season, and as it is allotted to all men
once to die, what happier ending could have come to
any man than that which took our colleague from us?
His career was one of honor and usefulness; his hour
had fully come; no task was left unfinished, no de-
mand of duty unfilled.
As we draw the pall over the quiet face which we
shall look upon no more, we murmur, "A fitting exit
for a true and noble man."
Snake Bite in India, on the recommendation of
Major Lyons, is to be treated as follows: Bind a
string or handkerchief as close as possible to the
wound on the proximal side. Wash with a fresh so-
lution of hypochlorite of lime diluted to i : 60. Inject
a dose of antivenomous serum into the subcutaneous
cellular tissue of the flank.
1076
MEDICAL RECORD.
[June 23, 1900
A NEW PLAN FOR WASHING THE BLAD-
DER, WITH A DESCRIPTION OF APPA-
RATUS.
. By WILLIAM F. FLUHRER, M.D.,
ATTENDING SURGEON TO WOINT SINAI AND BELLEVUE HOSPITALS, NEW
In the general practice of washing the bladder, the
repeated filling and emptying of the organ is apt to
excite contractions and limit the duration of the pro-
' cedure. If, to avoid inducing bladder spasm, the
irrigation is made more gently, it is mechanically
less efficient.
For the most thorough washing of the bladder, in
the writer's opinion, two conditions must be realized:
First, the bladder must be held in a state of compara-
tive rest in any given capacity of contents, during the
procedure, and, second, while the bladder is thus at
rest, the liquid it contains must be more or less agi-
tated. If the washing can be practised while the
bladder is at rest, spasm of the organ can be avoided;
the procedure can be prolonged, and the probability
of disinfecting a foul bladder correspondingly in-
creased. Ordinarily, the antiseptic impression made
upon the bladder is brief. If it is lengthened by in-
creasing the strength of the antiseptic, it is with the
chance of causing irritation. If, however, the condi-
tions allow a lengthening of the period of antisepsis
without increasing its intensity, irritation may be
avoided and a more thorough disinfection attained
without subtracting from the energy of the bladder. A
thorough freeing of the bladder of its foul contents,
and a prolonged extension of the period of disinfec-
tion without undue irritation, brings into view the
possibility of accomplishing the complete cleansing
and disinfection in a few prolonged sittings rather
than spreading many, perhaps ineffectual efforts over
weeks and months, with the attendant risks.
According to the first proposition, not only should
the bladder be washed while at rest, but in varying
degrees of capacity of contents from a state of very
small contents to that of full capacity and distention.
It is understood that the gross impurities are best re-
moved when tlie bladder has only a small amount of
contents; but it should also be appreciated that for
its thorough cleansing the bladder should be washed
while filled sufficiently to smooth out its folds and
expose all pouches and depressions to the action
of the irrigant. To suppose that a trabeculated
bladder with all its numerous pouches can be
cleaned by simply a repeated filling and emptying
of liquid contents is unreasonable. Such a blad-
der should be washed while held at comparative
rest in different capacities of contents from partial
to full distention.
Over-distention, unless for the special purpose
of increasing the absolute capacity of the bladder,
is to be avoided. Straining the bladder by over-
pressure upon its wall is apt to excite spasm and
limit the washing procedure, and is consequently
to be avoided. The reaction of the bladder to in-
ternal pressure is a cliaracteristic special to the
individual and is best determined by a gauge con-
nected with the bladder. This consideration also
has its application to a dilated and insensitive
bladder.
That the liquid contents of the bladder should
be agitated during the procedure of washing will
be conceded. Apart from the mechanical washing
of the bladder, the disinfection of its wall is best
accomplished while it is held at comparative rest
and the contained liquid is made to circulate with-
in it. liy this means the whole disinfectant energy
of the irrigant is utilized. It should be remem-
bered that the time element is an important factor
in disinfection.
In the usual procedure of washing, care is taken,
very properly, not to have the end of the catheter
project far into the cavity of the bhidder, for the
collapsing organ striking against the catheter
may be irritated and thrown into spasm. In the
washing according to the plan of the writer, this
restriction to the position of the end of the catheter
is remrtved, except while emptying the bladder.
Indeed, when the bladder contains considerable
liquid it is an advantage to have a free length of
catheter in its cavity, for then the loose end takes
different positions and the currents of agitated liquid
take dilTerent directions.
To carry out the foregoing ideas, the writer has
striven to contrive an apparatus, after many changes
in design, that will give the surgeon complete com-
mand over the irrigation of the bladder, and that shall
at the same time be simple in construction and opera-
tion, inexpensive, and easily cleaned.
The apparatus comprises a main and secondary re-
servoir with a distributing or washing apparatus. The
smaller, or graduated measuring-reservoir, contains
about eight ounces, and is mounted only high enough
above the bladder to make the attached gauge opera-
tive. The main reservoir, which should contain a
large amount of irrigant, should be at a higher level
than the upper level of the smaller or measuring-
reservoir, for it is convenient to be able to fill the lat-
ter from the former through simple gravity. The
main reservoir is connected with the washing-appara-
tus proper through rubber tubing which is attached at
the intake (n). To the bottom of the measuring-reser-
voir is attached by a rubber coupling a glass tube
June 23, 1900]
MEDICAL RECORD.
1077
about twenty inches long, of three-sixteenths of an inch
bore. This tube is to serve as a gauge upon the
bladder. The lower end of this glass tube or gauge
is attached by a rubber tubing to the washing-appara-
tus at the branch tube from the trap. This form of
gauge and its attachment were adopted after using
mercurial and other gauges attached to the wasliing-
apparatus itself. The washing-apparatus proper con-
sists of two glass bulbs with tubular glass extensions,
which for controlling the circulation or distribution
of the irrigant connect with properly attached rubber
tubings. The flow of liquid is checked and controlled
in its distribution by pinch-cocks, the glass construc-
tion being so designed as to bring these pinch-cocks
under the easiest manipulation. The glass bulbs ex-
pose the charge of irrigant to convenient inspection.
The larger glass bulb creates a partial dead water
•when the apparatus is in action, allowing clots and
coarse particles, grit, etc., to fall into the trap con-
structed on its lower side. This trap communicates
through a branched tube with a pipe leading to the
sewer, and also with the gauge and measuring reser-
voir.
Attached to what may be called the distal end of
the bulb is a common rubber bulb. This rubber bulb
is the means by which the irrigant may be pumped to
determined points of distribution, and also serves as
an agitator to give motion to the contents of the blad-
der. It is an injector and aspirator, and by
its suction, controlled by the hand, the blad-
der contents can be withdrawn with gentle-
ness. Attached to the distal end of the
rubber bulb is another and smaller glass
bulb terminating in a bent short glass tube
which by means of rubber tubing communi-
cates with the sewer. This smaller glass
bulb serves as a tell-tale to indicate when
charging the apparatus that the unseen con-
tents of the rubber bulb are clean. There are there-
fore two courses to the sewer, one through the trap
and the other through the distal end of the apparatus.
The rubber coupling and small glass tube at the
proximal or bladder end of the apparatus are to facili-
tate ready attachment to a soft-rubber catheter. It is
premised that only a soft catheter of simple construc-
tion should ever be used in washing the bladder.
The apparatus is brought into action by expelling its
contained air and filling with the irrigant. This is
done by opening pinch-cocks 2 and 5, while at the
same time holding the distal end of the apparatus up-
ward. Any imprisoned bubble of air can by appro-
priate handling be driven toward the sewer. The
connection with the catheter should be so managed as
to avoid pumping any air into the bladder. Perhaps
this is best done by allowing some urine to flow
through the proximal end of the apparatus down
through the trap. The ingress and exit of the bladder
liquid are controlled by a pinch-cock upon the catheter,
or upon its rubber coupling. For the first emptying
of the bladder, it is advisable that the eye of the
catheter should be just within the bladder cavity.
The urine in the blader is siphoned into the sewer
through the trap by opening the catheter pinch-cock
and cock No. 4. If any air is caugiit in the appara-
tus, it is driven out for good. The surgeon now has
it in his power to introduce a definite quantity of
irrigant into the bladder, it being practically empty-
He will probably, however, by compression of the
rubber bulb, throw some of the charge in the appara-
tus into the bladder and by releasing the compression
withdraw it, repeating the manoeuvre. He has thus
stirred up any residuum, slightly cleansed the blad-
der, and correspondingly fouled the charge in the ap-
paratus. He now replaces the foul charge in the
apparatus by a clean one; opening pinch-cocks 2 and
4 or 2 and 5, for that purpose. The apparatus has
been thus flushed from the reservoir of supply, and a
new charge of pure irrigant stands ready to be shifted
back and forth, in communication with the bladder
and with any degree of force of agitation.
A definite amount of irrigant may be sent into the
bladder by first transferring a definite amount from
the main reservoir to the measuring reservoir, either
by opening direct communication with the main reser-
voir or through the medium of the forcing rubber
bulb. In the same way it may be injected into the
bladder from the measuring-reservoir, either by the
force of gravity, at low pressure, or by means of the
rubber bulb with any degree of pressure. To operate
the gauge, the liquid is drawn off from the measuring-
reservoir into the sewer till its level in the gauge is
near the presumed level in the bladder; then the
bladder level or pressure can be exactly taken by
opening the catheter and gauge pinch-cocks. Vice
versa, the amount of liquid withdrawn from the blad-
der can be definitely known by forcing it into the
measuring-reservoir before directing it into the sewer.
It will be seen that some study and a little practice
will be required for the surgeon to develop the full
capabilities of the apparatus. In manipulating the
rubber bulb, injecting and withdrawing liquid,
through delicacy of touch quite a knowledge may be
gained of the sensitiveness of the bladder. The pa-
FlG. 2.— Rubber Forcing; N- Bulb. Glass connections.
tient can feel a forcible churning of contained con-
tents and may complain of the force of the agitation.
The least force necessary to clean the bladder should
be used. Sometimes there is a diminishing sensitive-
ness as the washing proceeds and the bladder is
cleansed. The sensitiveness of the bladder wall, as
it is drawn by aspiration against the eye of the
catheter, may be well observed. The surgeon has
control over the eye of the catheter to prevent its ob-
struction. Perhaps the bladder wall persistently
blocks the eye of the catheter; then it is easy to shift
the position of the catheter eye, by allowing the par-
tially collapsed rubber bulb to fill by opening pinch-
cock No. 2, then injecting more liquid into the
bladder and pushing the catheter further into its
cavity. Many little features that need not be de-
scribed, that will be met with in practice, can with
little thought be easily dealt with.
Having freed the bladder, while containing a small
amount of liquid, of its principal impurities, a larger,
definite amount of irrigant may be introduced, and by
means of the rubber bulb the contents of the bladder
can be kept in motion and mingled with the charge in
the apparatus. By constantly renewing this charge and
repeating the commingling, the bladder contents,
without being materially varied in quantity, are con-
stantly approximated in quality to the purity of the
irrigant fed to the apparatus. The smaller reservoir
may be used to inject a different liquid from that con-
tained in the main reservoir, the washing-apparatus
serving quite simply as a manageable means for dis-
tribution.
The washing-apparatus is thrown out of use by first
emptying the smaller reservoir and gauge through the
trap. The connecting rubber pipe is then detached
from the lower end of the gauge. A little suction is
made by opening and closing pinch-cock No. 5, at the
I078
MEDICAL RECORD.
[June
1900
distal end of the apparatus. The apparatus is discon-
nected from the catheter and is thus freed without
spilling any liquid.
Finally, the apparatus is cleaned by connecting its
proximal or catheter end with the hydrant and allow-
ing a stream of hot water to course through it and the
attached pipes by opening the different pinch-cocks.
If desired, although to the writer it has seemed un-
necessary, the apparatus may be taken apart and dis-
infected. It can be readily reassembled.
CERUMINOUS AND EPITHELIAL IMPAC-
TIONS IN THE EXTERNAL AUDITORY
CANAL.'
By SAMUEL KOHX, M.D.,
I.MPACTED cerumen in the external ear, to the mind of
the general practitioner, is a condition at once simple
and benign; the diagnosis is usually made by him
from the subjective symptoms alone, without recourse
to local or any other examination; we cannot wonder,
therefore, if, with this mistaken idea of the positive
harmlessness of the affection in mind, he accords the
treatment and the sequela; scant attention. Be it un-
derstood that these prefatory remarks do not refer to
otologists or to those physicians who are versed in
otology; but so many cases of all forms of aural dis-
ease, and of this affection in particular, are treated,
for a time at least, by the general practitioner, that it
is a matter of moment to direct the attention of the
profession to the great importance of aural affections
in general, and of the greater importance of treating
them properly in their incipiency.
No pretence to an exhaustive treatment of the sub-
ject-matter is made for this paper, its object being
mainly to throw light upon conditions in the external
auditory canal, whose power for ill to the organism is
much underestimated. This can best be accomplished
by considering the subject under the following head-
ings: Frequency, classification, causation, dangers,
symptoms, diagnosis, prognosis, treatment.
Frequency. — In ear clinics, the frequency of the
affection has been shown statistically to be from ten
to twelve per cent, of all cases (Roosa, Burkner).
This is a large proportion, but I am convinced, from
my personal experience, that in a general practice the
percentage of cases is relatively even larger than this,
because accumulated cerumen may for a long time
cause no noticeable symptoms, and the patients do
not, therefore, come under observation. The number
of persons who are found upon examination to have
accumulations of cerumen in one or both ears, but
who consider their ears perfectly "clean," is surpris-
ingly large; the percentage of cerumen inspissatum
will in my opinion amount to fifteen per cent, of all
cases of ear disease.
Classification and Causation — The variety of aural
plug most frequently met is that consisting of the
more or less thoroughly inspissated secretion of the
ceruminous and sebaceous glands of the integument
lining the external auditory canal. It is caused
either by an individual tendency to hypersecretion of
the glandular elements of the skin, or by a sudden
bend or narrowing in the canal obstructing the out-
flow or evaporation of the secretion ; or both causes
may be at work in the same case.
The fresh accumulation of secretion is light yellow-
ish in color and so soft that it exercises no pressure on
the surrounding tissue; even though it entirely fills the
canal it usually does not markedly reduce audition.
In time the watery constituents evaporate, the plug
' Read before the Metropolitan Medical Society at the meeting
of Tuesday, March 27, igoo.
shrinks somewhat, receding from the walls of the
canal and from the drum; this slight air space about
the plug accounts for the absence of symptoms for a
long time in many cases, as sound waves reach the
drum not only through the plug itself, but outside of
it, between it and the wall of the canal. This plug,
seen through the speculum in siiii, presents a light yel-
lowish, yellowish-brown, or black oval surface, corre-
sponding to the circumference of the canal; it is usu-
ally concave, owing to the evaporation of its watery
constituents, and about one-half inch from the external
meatus. If it is recent, the probe lightly applied will
sink into it, but if it has been in process of forma-
tion for years, as is often the case, it may be of con-
siderable hardness, the probe in touching it sometimes
producing a perceptible sound.
When such an old ceruminous plug is removed en
masse, as is often the case, it is at times found en-
closed in a perfect epithelial cast, the lining of the
external auditory canal, its inner end presenting an
impression of the drum with its prominences and de-
pressions well marked. The plug consists of fat glob-
ules, hairs, epithelial cells, detritus, and water. It
may have for its nucleus some foreign body intro-
duced years previously, which was the original cause
of setting up the irritation which resulted in the
hypersecretion, such as a piece of cotton, a pea, a
small button, or a dead insect. The size of the plug
varies; it may be 3 cm. in length, or there may be
only a thin layer of dried waxy scales lying upon the
drum, and so lustrous as to escape the observation of
the specialist.
The second variety is the epithelial plug; it is
formed principally of epithelial scales, and is due to a
chronic desquamative dermatitis of the external audi-
tory canal; the concentric layers of epithelial scales
thrown off by the recurring attacks of inflammation
finally form an occlusive plug, which may be dry,
crumbly, and without shape, or the scales may be
rolled up into round balls, or if there be an accom-
panying hypersecretion of the ceruminous glands per-
meating the epithelial lamella, a more or less cohesive
homogeneous mass is formed. This is seen through
the speculum to be of a grayish or pearly hue, usually
not so smooth as the ceruminous plug, and removable
with considerable difficulty.
The third variety is cholesteatoma of the external
auditory canal, showing through the speculum as a
pearly-gray mass. It originates most frequently in
the mastoid cells, and by bone absorption works its
way toward the external auditory meatus, or it may
originate in the external canal and eat its way by
erosion toward the mastoid. Cholesteatoma may com-
plicate the epithelial plug, and vice versa. Absorp-
tion of the osseous portion of the auditory canal may
proceed to such an extent that its enlarged lumen
may permit the finger to be pushed down to the drum.
Strange to say, the drum membrane is rarely injured
by cholesteatomatous tumors, but bone readily yields
to them; a fissure or foramen is formed, the growth
finds its way through this into the mastoid, and, unless
thoroughly removed by operation, the case may end
fatally, through mastoid involvement and its conse-
quences.
The fourth variety is associated with chronic suppu-
ration of the middle ear and perforation of the drum.
Appropriate treatment may have caused the disease to
become quiescent for a time; the patient ceases to
attend to his ear trouble. A slight perforation re-
mains, however; a very scanty secretion, which the
patient scarcely notices, starts up in time; before it
reaches the external ear its watery elements have
evaporated. Or it may also be that a ceruminous
plug interferes with the outflow of the secretion, and a
desquamative otitis externa may cause the scales to be
June 23, 1900]
MEDICAL RECORD.
1079
intermixed; all of these constituents combine to form
a hard, grayish, ill-smelling plug, which closes up the
perforation in the drum, and which requires much
care, judgment, and skill in its dislodging. It forms
an admirable nest for the bacteria of putrefaction. In
the case of the epithelial plug or the one just described,
associated with suppuration of the middle ear, the ce-
ruminous secretion may so predominate as to mask its
real character; great care must, therefore, be exercised
in the making of diagnosis and prognosis, as the re-
moval of the mass may, if improperly performed, lead
to an acute exacerbation of the inflammation of the
middle ear with its unfortunate train of sequela:-.
Causes and Dangers. — It has been claimed by
Roosa that every case of impacted secretion in the
external ear is due to an existing or to a pre-existing
inrtammation of some part of the auditory apparatus.
VVhile this view is admitted to be true in the majority
of cases by most otologists, it is deemed too sweeping
in attributing every case of impacted cerumen to in-
flammation. As has been pointed out in the classifi-
cation, external desquamative otitis is the cause of the
epithelial plug; or a chronic suppurative otitis with
scant secretion may be the causative factor primarily.
It has been claimed that chronic pharyngitis with
its accompanying derangement of the glandular secre-
tion of the mucous membrane may, by extension, lead
to catarrhal otitis media, which in turn may cause
hyper-activity of the ceruminous glands resulting in
the accumulation of cerumen in the external auditory
canal. It has even been said that diseases of the
labyrinth may cause hyper-activity of the ceruminous
glands, nerve anastomoses being the supposed etiologi-
cal factor.
That, as a rule, after the removal of the ceruminous
plug tiiere is not that complete restoration of hearing
which the general practitioner and the patient confi-
dently expect, is the experience of every otologist.
As long ago as Toynbee's time the observation was
made that in sixty per cent, of the cases of impacted
cerumen there was more or less impairment of hear-
ing after the complete removal of the plug. This cor-
responds with the experience of specialists to-day;
whether the impairment is due to a chronic otitis
media sicca, or to the long-continued pressure of the
plug upon the drum, with the consequent interference
with the motility of the ossicles, must be determined
by the further observation of the individual case. In
some cases it is impossible to decide positively which
is the causative factor.
Dangers. — From what has been said, it is evident
that the simple ceruminous plug, being nothing but
the result of hypersecretion, is harmless to the patient;
still it is well not to be too positive in venturing a
prognosis; for, as stated, an old ceruminous plug may
have caused a chronic dry otitis with intractable deaf-
ness. Dench observed an effusion of serum, complete-
ly filling the tympanum, in a case of impacted cerumen
of twenty years' standing. The drum may be depressed
to such an extent as to become adherent to the prom-
ontory, whi«h condition naturally causes radical
impairment of hearing. Epithelial plugs, either sim-
ple or associated w^ith cholesteatoma, may cause per-
foration of the drum, although this is rare; these ac-
cumulations cause absorption of the osseous canal
more readily; they may, through admixture with
cholesteatoma, eat into the mastoid, and produce con-
ditions requiring immediate operative interference; if
not promptly and thoroughly treated they may lead to
sinus thrombosis, cerebral or cerebellar abscess, or
meningitis. These plugs are often associated with
slow suppuration of the middle ear.
Symptoms A fulness in the ear may have been
noticed by the patient for some time; but since the
plug is often dry and shrunken, hearing is not suffi-
ciently impaired to attract the patient's attention, sound
waves still reaching the drum through the air space;
as a result of a bath, either in the tub or surf, the
plug absorbs water, swells up, and completely occludes
the canal; the patient notices the sudden onset of
deafness in one or both ears, and hurries to the physi-
cian witii the idea that the sea bath has produced the
hardness of hearing because of water being left in the
ear, as he supposes. Other symptoms that have been
noted are dizziness, due to pressure on the labyrinth
through the ossicles; at times, pain due to the de-
squamative inflammation of the external canal, or to
the middle-ear catarrh; tinnitus is oftentimes a symp-
tom. Both auditory canals may contain plugs for years
without causing any symptoms to attract the patient's
attention, when a sudden jar of the body, as in jump-
ing aboard a car, a fall, or a mis-step, may cause such
a shifting of the plug as to occlude the entire canal,
producing deafness which arouses the patient's anx-
iety. A patient may never have noticed any trouble
whatever with his ears, until, after a sea bath, as I
have frequently had occasion to note, he becomes
suddenly deaf. Other symptoms which have been
noted in rare cases are facial paralysis, melancholia,
reflex cough, bronchitis. In isolated cases audition
may be improved by the presence of the hard plug.
In a case recorded by Roosa the brain symptoms were
so marked that a diagnosis of sunstroke was made by
the attending phy.sician, who tortured the patient with
blisters, etc., until the true nature of the disease was
discovered. A case of convulsions and coma lias been
recorded by Rischawy as due to impaction.
Objective Symptoms. — The writer would here lay
emphasis on the dictum that no physician should at-
tempt to do anything locally for any case of ear dis-
ease, who is not versed in the use of the ear speculum
and forehead mirror; and he would add, as a corollary,
that every practising physician should familiarize him-
self with the use of these instruments. The practice
of ordering laudanum, glycerin, sweet oil, or camphor-
ated oil for patients who complain of ear trouble, with-
out a careful local examination with the speculum, is
so vicious and so fruitful of evil consequences as to
merit the severest condemnation. By means of the
speculum and head mirror, the ceruminous plug is
easily recognized as a black or brownish-yellow mass
completely filling the external auditory canal. The
epithelial plug presents a grayish appearance consist-
ing either of a number of detached scales or small
round masses; if admixed with thin pus, the fetor is
intolerable; if with cholesteatoma, it presents a lus-
trous, pearly-gray color. The tuning-fork applied to
the forehead or teetii is heard with exaggerated loud-
ness in the ear containing the impaction. After the
removal of the plug, which frequently brings with it
the epithelial lining of the canal, this and the drum
are often seen to be deeply red from congestion;
sometimes there are erosions from which there is
slight bleeding, which at times may be considerable
from granulations from old fetid, purulent inflamma-
tions of the tympanum with perforation. The older
the plug, the more apt is the epithelial lining to be
macerated and to come away with it.
Diagnosis. — This is the division of my subject upon
which I desire to lay most stress for the benefit of the
general practitioner. I want to make an urgent plea
for a better knowledge of ear diseases, for a greater
familiarity with the proper modes of examination, and
familiarity with the simple methods of treatment
which are, after all, most efficient. It seems almost
supererogatory to say that the ear speculum and the
forehead mirror are absolutely necessary to make a
diagnosis; but we are only too familiar with the laxity
prevailing among many practitioners when brought in
contact with ear diseases; without a proper examina-
io8o
MEDICAL RECORD.
[June
1900
tion they hazard treatment which, not being based on
even a partial knowledge of the cause or nature of the
affection, results in making matters worse; and fre-
quently the specialist is called upon to repair the mis-
chief, in addition to the getting rid of the original
disease.
A patient who complains of deafness coming on
suddenly, fulness in the ear, dizziness, perhaps of
autophony, who hears the tuning-fork applied to the
middle of the forehead more markedly on the deaf
side than on the normal, has in all probability an oc-
cluding plug in the external auditory meatus; the
speculum will reveal it. In some cases the plug is so
near the external meatus that it is visible without the
aid of the speculum.
Prognosis. — From what has been said, it is evident
that the prognosis as to audition should be guarded.
The general practitioner, having made the correct
diagnosis, is prone to tell his patient that the func-
tion of hearing will be completely restored with the
removal of the plug. As stated, this is true of only a
small percentage of cases, from thirty to forty per cent.
Even in cases of simple ceruminous accumulation of
long standing, hearing will be found markedly less-
ened on account of the prolonged pressure of the plug
upon the drum and ossicles, and through these upon
the delicate labyrinthine structures.
In an epithelial or cholesteatomatous plug, seeming-
ly harmless, it should be borne in jnind that an old
purulent otitis media or a cholesteatoma of the mas-
toid may lurk behind it, markedly lowering the func-
tion of audition if not abolishing it entirely; not only
this, but the forcible or improper removal of the plug
may light up a train of grave symptoms, which hitherto
had been kept quiescent by the plug in situ, through
its acting as a bar to fresh infection. With the im-
proper removal of the accumulation, the perforative
otitis is laid bare, and an infection may occur which
will result in serious consequences.
Treatment. — Even among autliorities opinions dif-
fer as to the proper method of removal of these accu-
mulations. The consensus of opinion is that gentle
and careful syringing with warm water, all things
considered, is the best method. Peroxide of hydro-
gen, more or less diluted, and neutralized with sodium
bicarbonate, or pure, is used by many physicians; to
the writer, pure sterilized water is preferable, for
the reasons, first, that whatever matter may have oc-
cluded the canal emerges unchanged with the water,
thus aiding the diagnosis materially; and second, that
the delicate and sensitive epithelial structures of the
auditory apparatus are unduly irritated by the perox-
ide.
Buck prefers the small curette, forceps, and probe,
in the hands of the otologist throughly conversant with
the auditory apparatus, and cognizant of the danger of
wounding or injuring the delicate structure of the ear
with steel instruments. This method of removal
through the speculum and under ocular inspection is
safe in skilful hands, though damage may be done by
instruments in the most practised hands by involun-
tary starts or movements of the patient's head, the in-
tegument being lacerated and a new source of infection
opened up.
For syringing the ear, the first requisite is absolute
cleanliness. A glass and metal syringe, if possible,
which can be thoroughly disinfected and which holds
two or three ounces, having three rings, one for the
thumb and one each for the second and third fingers,
should be used. The water should be of a tempera-
ture easily borne by the back of the hand, say about
80° F. About a pint of water unmixed with anything
else should be used, although corrosive sublimate
I : 5,000, physiological salt solution, and bicarbonate of
sodium one per cent., have been recommended; I give
the preference to lukewarm water which has been
boiled. A sterilizable syringe is to be preferred;
this can be purchased of any instrument maker. The
latest in this line, from Germany, is Professor Jacob-
son's "aseptische Ballon-Ohrenspritze," consisting of
a rubber ball with ivory or bone nozzle encased in a
removable glass tube; the entire syringe is to be
boiled for from five to ten minutes before use.
The second requisite is gentleness of manipulation.
Any undue force must not be used in expelling the
water from the syringe into the ear. The reason for
these warnings is manifest from what has been said.
If an old syringe which has been lying about, exposed
to dust, is used, and the case be one of otitis media
with small perforation, masked by the plug, a new in-
fection may be introduced by the syringe which will
set up a violent inflammation; or, if too much force
be applied, the stream may force its way into the mid-
dle ear through the perforation, and drive the chole-
steatomatous particles or inflammatory products into
the mastoid cells or antrum, setting up mastoid dis-
ease. Too much force in using the syringe also may
cause, by sudden pressure upon the drum, transmitted
through the ossicles, circulatory changes in the semi-
circular canals, producing extreme dizziness and syn-
cope; even the cerebral centres may be temporarily
affected in this way.
After removal of the occlusion, continued syringing
should be done with caution, as the danger of causing
labyrinthine dizziness is increased. Too forceful a
jet of water communicated through the plug to the
drum, and thence through the ossicular chain to the
membrana tympani secundaria, causes increased intra-
labyrinthine pressure, whence such dizziness may en-
sue as to compel a cessation of the syringing process.
It is frequently the case in old, dry masses that four,
five, even six syringefuls of water make scarcely
any impression; in such a case the hard mass must be
softened, in order to be more readily removable; for
this purpose a saturated solution of bicarbonate of
sodium, or a two-per-cent. solution of carbonate of po-
tassium in equal parts of glycerin and water, may be
dropped into the ear three or four times a day. The
drops should be warm. From five to ten drops should
be instilled into the ear, and these should be allowed to
remain /// situ for about three minutes, when they may
be allowed to flow out. Two days' treatment of this
character will so soften the plug that its removal by
gentle syringing with warm water is a matter of the
greatest ease, the first syringeful frequently dislodging
the whole plug, especially if it be entirely ceruminous.
Epithelial plugs, as already stated, even after soften-
ing need care, time, and patience for their removal.
They frequently require several sittings for their
thorough removal and the complete cleansing of the
external canal of all scales and detritus. The amount
of force in using the syringe must be graduated ac-
cording to the needs of each case. Skill in the use
of the ear syringe is acquired only by long practice.
The rule is to commence the ear syringing by gently
forcing the piston home so as to send the' jet of water
into the ear under the minimum of pressure. The
next may be a trifle more forcible, gradually increas-
ing the force but never sending a powerful stream of
water against the delicate mechanism of the auditory
apparatus, with its intimate relationships to the brain.
Another rule worth remembering is that these cases
should be, if possible, attended to at once when they
present themselves for treatment. A patient should
not be sent home with instructions to syringe the ear
himself, or use certain drops. As soon as the diag-
nosis is made, the physician himself should attempt
to remove the plug either by syringing or other-
wise (Uench). If the syringing seems insufficient
after a few syringefuls have been injected, it will
June 23, 1900]
MEDICAL RECORD.
108 1
be wise to follow the advice of Blake and remove por-
tions of the periphery of the plug by means of a small
curette; the water can then pass through the opening
thus created to the space between the drum and plug,
and force the latter outward.
Roosa relates a case in which the plug was so hard
that he was forced to have recourse to fuming nitric
acid to soften it. In such old, hard masses, Blake
advises the use of liquor potassa: for the purpose of
softening. It should be mentioned that some authori-
ties are opposed to syringing altogether, and advocate
the use of the curette and probe.' In the case of epi-
thelial plugs, it is well to use a bichloride of mercury
solution I 15,000 for syringing. The rules of asepsis
should be observed in every case as thoroughly as
possible. The use of olive oil in the ear should be
absolutely discountenanced, as it favors the growth of
the aspergillus fungus in the accumulation.
After the contents of the canal have been removed,
it is well to inflate the tympanum with a Politzer bag
because of the possible depression of the drum from
the plug. A small, loose wad of cotton should be
placed in the canal, to protect the sensitive and often-
times denuded integument of the canal from the cold
air and dust.
The tendency to recurrence is one of the character-
istics of ceruminous accumulation; it is attributable
to the hyperactivity of the secretory glands, which has
not been in the least affected by the removal of the
impaction. The same patient frequently returns after
several months for the purpose of having his ears
syringed. To prevent this, it is advisable to instruct
the patient to wash out his ears thoroughly with a
mild alkaline solution ( 3 i. of aqua ammonias to the
quart of warm water, and castile soap) once every
week. The ordinary tub bath, which the patient con-
siders efficacious, has, in my experience, no effect what-
ever in removing the accumulation of wax in the ear.
In closing this paper the writer again would urge
upon the general practitioner the necessity and desira-
bility of some knowledge of otology, the more the bet-
ter for him. So many cases of incipient ear disease
are, of necessity, first seen by the family physician im-
mediately after measles, scarlatina, and diphtheria,
etc., and the consequences of even the simplest ear
disease, if improperly treated, are so lamentable, that
a better knowledge of this branch of medicine in the
profession must save many lives. The organ of hear-
ing, besides being of incalculable importance to the
individual, stands in intimate relation witii the brain
and nerve centres; improper, injudicious, or careless
treatment at the outset of affections of this organ may,
as has been shown, result in fatal disease of the si-
nuses and brain. It seems almost incomprehensible to
the writer why this important organ is accorded such
scant attention by the general profession, and if he
has succeeded, in this paper, in awakening a new in-
terest in diseases of the ear, his object will have been
accomplished.
Women as Surgeons ^An interesting speech was
made at the annual meeting of the new Hospital for
Women, London — of which all the physicians, sur-
geons, and students are women — by the eminer.t sur-
geon .Sir Henry Smith. He stated that he had lately
been present at a number of most serious operations
performed by the lady surgeons, and had come to the
conclusion that the small hands and delicate touch of
women were particularly suitable for surgical work.
The same tactile skill that makes a good needlewoman,
he intimated, is of the highest use in modern " conser-
vative" surgery; and he added that the results gained
in that hospital would compare favorably with those
recorded anywhere else. — London News.
' Buck : " Treatise on Diseases of the Ear," 1S9S.
DAMPNESS OF THE SOIL AS A FACTOR IN
THE PRODUCTION OF HUMAN TUBERCU-
LOSIS.'
Bv RICH.\KD COLE NEWTON, M.D.,
MONTCLAIR, N. J.
If an apology be needed for taking up the time of the
association with the histories of a few cases of tuber-
culosis and an imperfect and crude discussion of the
points which the cases seem to emphasize, I think that
the importance of the subject chosen will provide the
excuse. I will first recite a few family histories which
have come under my observation.
The D family, Germans of vigorous stock. No
cases of phthisis have been known to occur among the
ancestors of this family for generations. The father,
a farmer, died of some noti-tuberculous trouble at a
good old age. The mother is living, over seventy,
and in good health. They had twelve children. The
first-born, a son, is now living and in good health.
When he was one year old, the family moved into a
small stone house, now standing, which was exceed-
ingly damp. Eleven children were born in this house,
in the eleven years during which the family lived
there. Then they moved into another house, which
they had built on the same premises. It was built of
wood, was inuch less damp than the first one, but had
too many shade-trees around it. The second child, a
female, died of consumption, "following grippe," at
thirty-nine. The third child, male, died at thirty-
seven of apoplexy. The fourth child, male, died at
forty of consumption '' following grippe." The fifth
child, female, had consumption, for which she went
into Sullivan County, New York State. This change
of residence, she says, saved her life. She has lost
a child from tuberculosis and is herself still suffering
from chronic bronchitis. The sixth child, female,
died at twenty-six of pneumonia. The seventh child,
female, died at twenty-seven of consumption " follow-
ing grippe." The eighth child, a male, is living and
in good health at thirty-six. The ninth child, a male,
is living and in good health at thirty-four. The tenth
child, a male, is living and in good health at thirty-
two. The eleventh child, a female, died in childbed.
She had a diarrhoea for four weeks after the baby
came, and had had a cough. She is not known to
have had lung trouble. The twelfth child, male, died
at eighteen of dropsy. He had no cough. He was
said to have fallen and "bruised his liver.'"
C family, Irish laborers and carpenters, lived
in a damp house. Their kitchen was in the basement
and there the family lived a great part of the time.
The children were frequently seen lying in their
cradles in the basement. There was no phthisis so
far as known among ancestors. The father and his
sister and mother's sister are now living. The mother
died of heart disease. They had twelve children, all
of whom except two died of consumption.
H family, Irish laborers. The father is liv-
ing; the mother died of some disease not tuberculous.
Their house was built for them thirty years ago.
They had three children living when they moved into
it. The place was very damp. The fourth child was
born there. In about twenty years the oldest daughter
died of phthisis at the age of twenty-two. Seven years
ago the son, a printer, died of phthisis at the age of
thirty-one. In the year 1900 the youngest daughter
died of phthisis at the age of twenty-seven. One
daughter, now living, has a sensitive throat and ab-
normally red cheeks.
B family, American. They explicitly deny all
traces of phthisis among their known ancestors.
' Read before the American Climatological Association at the
fifth triennial session of the Congress of American Physicians
and Surgeons, held at Washington, D. C, May i. 2, and 3, 1900.
io82
MEDICAL RECORD.
[June
1900
The eldest daughter complained of cough, indiges-
tion, nervousness, etc. She got well after going into
central New York to live. The second daughter, a
teacher, has advanced tuberculosis, and is now in
Colorado Springs under the care of Dr. Hart. The
eldest son is anaimic and very "nervous." The
younger son is delicate, slender, and pale. The house
has been very damp. Now the surroundings have
been improved by drainage.
These are all cases that have fallen under my per-
sonal observation. I dare say that by taking t!ie ex-
perience of others the list might be indefinitely ex-
tended.
However, there have been enough cases cited to
serve as a text for what I wish to say. I have long
ielt, as no doubt many other observers have, that some-
thing besides direct contagion by the reception of the
tubercle bacilli into the body is necessary to establish
the morbid process which we know as phthisis pul-
monalis.
Jaccoud says:' "The tubercle bacillus belongs to a
class of pathogenic microbes called ' etiological dual-
isms,' because they exist in healthy organisms indefi-
nitely without injury to the latter and become noxious
only in consequence of changes in the organism itself
from other causes." If this be so, the bacillus of
Koch acts as we know that the Klebs-Loeffler bacillus,
the pneumococcus, and the streptococcus act. That is
to say, it may be present in the human body and pro-
duce no overt symptoms. And it is reasonable to sup-
pose that we are exposed over and over again to this
infection. Perhaps our bodies never are free from the
presence of the tubercle bacilli, and yet only ten or
twelve percent, of the inhabitants of the Atlantic sea-
board die of consumption. Why does not the entire
race perish from this disease? It may be said that
the contagion is rather feeble and takes a long time
to develop, and that the organism must be in a fit
state to receive and nourish the germs, else they will
not grow.
It is so easy to glide oflf into glittering generalities
and to hide our ignorance under some half-statement,
or the plausible conjecture of some w-riter. It is a
fortunate thing that we have at last adopted more exact
methods of studying disease. Still, with all the care
that has been bestowed upon the study of tuberculosis
there is still very much that requires elucidation.
Squire" and Kanthack ' assert that some other influ-
ence or influences must be acting in conjunction with
the bacillus before the latter can produce consump-
tion in human beings. This being so, the latter
argues: "It is likely in practice to be far easier to
remove the conditions causing this predisposition than
to eradicate the bacillus so long as fitting conditions
for its development are left. Tlie problem then is no
longer a matter of isolation and antiseptics, but of
improved surroundings and better conditions of life."
He mentions in this connection the divergent condi-
tions regarding the behavior of certain animals to
anthrax infection ; as, for example, " pigeons, which are
usually resistant to anthrax, are rendered susceptible
by starvation, and dogs, horses, pigeons, and frogs are
made susceptible liy being deprived of water. So a
predisposition may be established in some animals by
continued over-exertion, fatigue, loss of blood, and by
unsuitable diet. Guinea-pigs and white mice, which
are ordinarily resistant to avian tuberculosis, can easily
be infected after being kept for a time in a warm
chamber at 33°-3S° C." Precisely what changes are
produced in the animals by these disturbances of their
' Semaine Medicale, January, iSijy.
' Review of book by I. Edward Squire, in British Medical
Journal, July 14 '894, p. 72
■^ Medical magazine quoted in British Medical Journal. October
14. 1S93, p. 857.
ordinary mode of life we do not know; we only know
that whereas before we interfered the animal was in-
susceptible to the action of these various pathogenetic
germs, afterward it was easily infected. The war
against tuberculosis then becomes a matter of sanita-
tion rather than of disinfection and isolation, against
the surroundings of the people rather than against a
microbe, which can grow only when a predisposition
is set up.
On the other hand, we have long known that under
certain conditions the bacillus of Koch does little
harm to the animal into which it may be injected.
You will all remember Dr. Trudeau's rabbits. All of
those which had been injected with the tubercle ba-
cilli and' allowed to run at large got well, while all of
those which were closely confined after inoculation
died of tuberculosis. Perhaps one of the most con-
clusive experiments recently tried is reported from the
Storrs Agricultural College in Connecticut.' Four
cows were subjected to the tuberculin test in March,
1896 and did not respond. In October, 1896, they were
again tested and all responded. They were then placed
in a light, airy stable, where it is estimated that each
animal had fifteen hundred cubic feet of air space.
In January, 1897, another test was made and all re-
sponded, but in April, 1897, after a test, only two
responded, and in July of that year none of them
responded. For two years their milk was fed to eight
healthy calves, only one of which contracted the dis-
ease, and that calf showed evidence of tuberculosis
only six months after it had ceased drinking the ex-
perimental milk, so that the tuberculous infection was
probably due to some other cause.
Admitting, then, that the infection is wellnigh uni-
versal, and that it cannot become effective except un-
der certain conditions, is it not our obvious duty to
pay more attention to these conditions?
The whole trend of present scientific opinion is to
minimize, if not to deny, the danger of tuberculous
infection from cow's milk. The discovery of the tim-
othy-hay bacillus and its resemblance to the tubercle
bacillus has cleared up some of the threatened danger
from the alleged discovery of the latter bacilli in
milk, butter, etc., the bacilli so discovered really being
the timothy-hay bacilli. Baldwin," Guthrie," Carr and
Northrup,' Bouviard, Still," Moore,' and others are dis-
posed to deny that the mode of infection by the bacillus
is through cow's milk or other food. On the other hand,
Law," Smith,' Park, Robison, r.nd others believe that
while there may be danger from infected milk it is
small compared to the danger from human infection.
And human infection itself is doubtless, as a general
thing, comparatively weak. I will quote a few exam-
ples. Knopf ' shows that the villages of Goerbersdorf
and Falkenstein have had fewer deaths from consump-
tion since the sanatoria were established there than
before. \V. S. Searle" says that twent3-two hundred
and eighty-six patients have been treated in the
Brooklyn Home for Consumptives during fifteen years.
The number of employees besides the staff is at pres-
ent twenty-one. Of these three nurses have been em-
ployed over three years. In not one of these em-
ployees has consumption developed. Solly" says that
in spite of every neglect of hygiene and cleanliness
in the poorer lodging-houses at Colorado Springs not
over one case a year of tuberculosis originates there.
' Mf-Dic.ai. Record. February 3. 1900. p. 195.
'' /ill/., March 25. 1899. p 431.
'//•I,/. ,'\pril 8, 1899, p. 499
■• //'/./.. March II. 1 899.
' Clinical Journal, London, September 27, 1899.
'Journal of the American lUedical Association, January 27,
1900, p 197.
' Mf.dic.\l Record October 3, 1896.
■*■//'/(/., May I, 1897 p (■)44.
'//'/i/. . February 6, 1697. p. 215.
June 23, 1900]
MEDICAL RECORD.
1083
Da Costa' had traced the histories of the doctors and
nurses in the Pennsylvania Hospital for a period of
seventy years without finding a case of phthisis trans-
mitted by contagion. In a discussion before the
Glasgow Medico-Chirurgical Society Dr. Alexander
Robertson and Mr. H. L. Clark," one from his long
experience in the town hospital and the other from
his experience of surgical tuberculosis in the wards
of the Royal Infirmary, stated that no case of infection
among patients or attendants had come under their
observation.
I think that we must agree with Professor N. S.
Davis,' who says that if the bacillus of tuberculosis
had been as infectious as that of variola and rubeola
the human race would long ago have become extinct.
If, then, we have a feeble contagious element, which
is apparently inoperative except under certain condi-
tions, are we not neglecting our duty if we do not
more fully investigate the entire surroundings, includ-
ing the conditions of the soil in those localities in
which the disease is rife.'
As has been from time to time pointed out, the dis-
ease flourishes in some quarters of a town or settle-
ment, and will not flourisii in others. Flick' showed
that for twenty-five years (1863-87) all the deaths
from tuberculosis in the fifth ward of Philadelphia
occurred in less than one-third of tiie houses. The
famous communication of Dr. Bowditch to the Massa-
chusetts Medical Society in 1862 proved beyond ques-
tion the influence of the soil in the propagation of
phthisis. The varying prevalence of the disease in
certain localities he attributed chiefly to the dampness
or dryness of the soil, and modern criticism has not
been able to refute this conclusion. So, also, the fear-
ful mortality from consumption in the German prisons
has been shown by Baer and Cornet '' to be due in
part, at least, to the damp and unsanitary buildings.
And Buchanan's" observations in England scarcely
need comment, in which, for example, he showed that
the general death rate for Salisbury had been reduced
nine per cent, by drainage, while that from phthisis
had been reduced forty-nine per cent., and in other
localities the reduction of the death rate from tuber-
culosis was nearly as startling. Professor Welch '
says :" Although the nature of the relationship be-
tween the conditions of the soil and the presence of
tuberculosis is not well understood, practical experi-
ence has shown that many localities have secured by
good drainage great reduction from the mortality from
this most deadly scourge of the human race, a reduc-
tion amounting in some places to nearly fifty per cent,
of the former death rate."
I may have taken up too much time in endeavoring
to prove what few will attempt to confute. But the
great importance of the subject and the extreme de-
sirability of drawing the attention of the profession
and of the laity away from the contemplation of direct
contaf^ion by the bacilli and of the contagiousness of
milk and meat as the only dangers to be guarded
against, must be my excuse. BuUer," Unterberger,"
and Revillod '" point out that tuberculosis originates
in certain areas in much the same fashion as other
infectious diseases. It has, however, this difference:
one class of people in a community will suffer from it
and another will not. And people will contract the
disease by a change in their habits or occupation, as,
' Kritish Medical Journal, May 26, 1894, p. 270.
' //'/(/., January 2. i8q2. p. 34.
' Journal of the American Medical Association, March 24, igoo.
* IbiJ., May 5. 1S94.
^ Journal of the American Medical Association.
' Buck ; " Hygiene and Public Health," vol. ii., p. 577.
' Baltimore Health Magazine. January, 1S9S.
* MEniCAi. Record, Februarys, 1900, p. 195.
' St. Petersburg, med. Wochenschrift.
'" " La Tuberculose " January 30, iSgJ.
for example, " the percentage of Indian boys and girls
that develop tuberculosis after giving up their out-of-
door lives for the school-room is enormous. . . . Tu-
berculosis in all of its manifestations has increased
among the Mexicans in the same ratio as among the
Indians." '
So also at present the American negro, at one time
considered immune, suffers severely from this disease.
Dr. J. H. Girdner informs us" that in tuberculosis
it is change rather than a particular climate that does
good. He had spent the first twenty years of his life
near Asheville, N. C, and could assert positively that
the percentage of tuberculosis among the inhabitants
of that region was fully as great as on Manhattan
Island. His father, who had practised medicine in
that region, was accustomed to send his tuberculous
patients away from home to the seaside. Cases of
tuberculosis in the Adirondacks are by no means rare
among the natives, where poor food and unhygienic
surroundings counteract the beneficial influence of the
fine climate.
As Dr. Samuel West has wisely observed,' it should
be remembered that no climate is proof against the
emanations of a filthy soil either in city or country.
And Dr. Robert Barnes, who as long ago as 1855 was
a health official for a part of London, wrote graphic-
ally of the dangerous properties of the superficial soil
of cities, " the investigation of which," he asserted,
" would solve some of the mysteries of high civic mor-
talities. After solving the problems of the water sup-
ply, the problems of the soil will become urgent, and
as they, too, are solved, life-saving will begin in good
earnest." After speaking of the so-called " pest stra-
tum," that is, surface soil made up mainly of refuse,
organic matter, excreta, etc., he says: "If this 'pest
stratum ' could be kept dry, laden as it is with putres-
cent matter, it would be comparatively harmless.
Moisture is a necessary element for the evolution of
its pestiferous properties."
That disease is not engendered by a residence on
the water itself is rendered very probable by the fol-
lowing facts (I still quote Dr. Barnes): "The popu-
lation actually living on the Thames, whose every
breath is a distillation from its water, is not especially
liable to fever, not so much so indeed as the popula-
tion whose dwellings skirt the banks." Solly says:'
"Apparently humidity of the air apart from other fac-
tors does not in itself produce phthisis. The com-
parative immunity from consumption among the men
of the British navy contrasted with those of the army,
and the rarity of the disease in many islands, such
as the Faroe, the Hebrides, the Shetlands, and Iceland,
show this."
Referring back to the history of the D family,
with which this paper began, we see that the second,
fourth, seventh, and probably the eleventh and twelfth
children died of tuberculosis. The fifth contracted
the disease and probably still has it. All of those
who escaped were males, and were, of course, less in
the house than their sisters. The oldest one was not
born in the infected house, and the younger ones lived
in it a very short time. They were all exposed to the
same contagion and all lived under the same condi-
tions. It seems to me that it is more reasonable to
impute the high mortality of this family to the unsani-
tary condition of their residence than to any other
cause. In other words, I think that the damp and
polluted soil over which they dwelt supplied the nec-
essary factors to make the inroads of the tubercle ba-
' Journal of the American Medical Association, September 3,
1898, p. 494.
■^ Medical Record, May 14, i8g8, p. 709.
'Journal of the American Medical Association, January 1,
1899, p. 19.
■•Therapeutic Gazette, vol. xiii. , p. 588.
1084
MEDICAL RECORD.
[June 23, 1900
cilli upon their bodies efficient. In the case of the
B family I think it more reasonable to impute
the consumption that attacked Miss M to her
place of residence than to any other cause, and espe-
cially will this seem to be true if, after the improved
drainage of the house, the other children shall escape
tuberculosis, particularly as they have been more or
less exposed to infection from their sister.
Not to take up more time, I feel thoroughly con-
vinced that I have proved my case, and that we had
better, instead of expecting to annihilate the tubercle
bacillus, turn our attention to altering the surround-
ings of our patients and correcting their vicious meth-
ods of life. We must agree with the editor of the
Medical Record,' who says: "The causes of the
health-giving properties of a change of air are ob-
scure; at any rate up to the present time they have
not been explained." No doubt frequently all that is
needed to arrest phthisis is that the vicious combina-
tion of a damp and polluted soil, and want of sunlight
and ventilation, together with poor food and perhaps
an unwholesome occupation should be broken up by
the withdrawal of one or more factors. The results
of sanatorium treatment have so far been practically
identical, so that while a life in Colorado is desir-
able, it is not necessary to save at least a third of our
incipient cases of phthisis. And while sunlight and
life in the open air, and pure milk and a wholesome
occupation are necessary and essential, a dry, prop-
erly constructed cellar to one's dwelling, which should
be built over a pure, well-drained, sandy subsoil, is
just as essential to the alteration of the predisposition
so that the bacillus of Koch cannot gain a foothold
in the human organism, as any of the means named.
And it is our duty to insist upon this point over and
over again, until our patients shall cease to worry
about milk and meat, and while not neglecting to
burn tuberculous sputa, they shall insist in living over
properly constructed cellars and away from swamps,
cesspools, sluggish streams, and all stagnant and un-
wholesome bodies of water.
Colonel VVingate's remarks on this head are to my
mind quite applicable, and I don't know that I can
close this paper more fitly than by quoting them. He
says:'-' "I am inclined to think that the health of the
community is more affected by the sanitary state of
the soil than by all other influences. If Manhattan
Island could be thoroughly drained, consumption
would undoubtedly diminish."
A Large Dermoid Cyst of the Ovary in a Child
of Seven Years James Herbert McKee reports a
case from the history of which he draws the following
conclusions: (i) In attempting to make a diagnosis
of an abdominal tumor in a female infant or child, one
should bear in mind that ovarian tumors must be con-
sidered as possibilities. (2) As aids to diagnosis,
rectal examination under anesthesia, as recommended
by Carpenter or Kelly, should be performed as a rou-
tine measure; and whenever possible, the services of
the A-ray should be enlisted. (3) An exploratory
incision is not only a justifiable procedure, but it is to
be advised whenever a large tumor of the abdomen is
found in a child. — L'ni-etsify Mciiical Magazine,
April, 1900.
The Relation of Eye-Strain to Epilepsy, Insanity,
and Allied Conditions. — T. K. Satterthwaite relates
a series of cases bearing on this subject, and makes
an earnest plea for the addition of an eye specialist
to the staffs of institutions devoted to the care of ner-
vous patients. Eye-strain is a frequent cause of va-
' October 23, 1897.
^Medical Recokd, May i, 1S97, p. b^i, ct seq.
rious neuroses, and its relief will often afford a cure
when medication, rest cure, travel, and other means
have utterly failed. Whenever an excess of nervous
expenditure is made by one organ over the normal
amount which should be furnished, this excess must
be at the expense of other organs, which in conse-
quence must suffer sooner or later. — Medical Age, April
25, 1900.
Indigestion. — T. Lauder Brunton lays down the
following rules for the treatment of chronic functional
dyspepsia: The first rule is to eat slowly, masticate
thoroughly, and insalivate completely, three things
which are by no means always the same. The next
rule is to take solids and liquids separately, the latter
in the shape of hot water on rising in the morning,
between eleven and twelve in the forenoon, about four
or five in the afternoon, and at night before going to
bed. When these rules do not suffice to remove the
dyspepsia, the patient must take his farinaceous and
proteid foods at different meals alternately, a farina-
ceous meal at breakfast time and again at five o'clock,
and meat or fish meals at midday and at eight o'clock.
In some cases it will be found advantageous to sup-
plement the gastric juice w^ith a little acid and pepsin.
A little alkali with calumba may be given before
meals, or if there is gastric catarrh some substance
containing tannin, such as infusion of gentian, may be
preferable. In cases with flabby tongue, perchloride
of iron with quassia will probably be of more service.
When there is gastric dilatation which will not yield
to the measures above mentioned, it may be necessary
to wash out the stomach in the morning or at night. —
The Clinical Journal, April 25, igoo.
The AUeghanies for Our Tuberculous.— Under
this title Charles F. Spangler enters a plea for a trial
of the Alleghany Mountains in the climatic treatment
of tuberculosis. All that portion of the AUeghanies
extending through the middle west and northern sec-
tion of Pennsylvania is suitable, but the section that
offers the most natural advantages for the tuberculous
is the summit region comprising the vast plateau ex-
tending northward through McKean County into the
State of New York, with an average elevation of two
thousand feet. Kane, in the southern end of the
county, is the gateway to this region, which has been
appropriately termed the health belt of the State, and
has been frequented for many years by asthmatic and
hay-fever subjects, an occasional consumptive, conva-
lescents, and many others suffering from general de-
bility. The soil, for the most part, is sandy and por-
ous; the surface is undulating and moderately well
covered with timber. — Pennsylvania, Medical Journal,
April, 1900.
On Heredity in Disease. — J. Hamilton gives the
following conclusions to his article: (i) There is no
evidence proving that diseased conditions of body,
excited by external agencies, using the term in its
broadest sense, can be transmitted hereditarily through
generations; (2) that the various hereditary tenden-
cies or predispositions to disease of the hereditary type
have arisen as variations in the germ-plasm; (3) that
these predispositions to disease probably extend far
back into the history of the human race, and break
out only occasionally, in accordance with the laws of
atavism ; (4) that external agencies are merely the
means of bringing them to light; (5) that there is
little if any reliance to be placed in the evidence
bearing upon the influence of maternal impressions;
(6) that there is 10 reason to believe that telegony
may not prevail in the case of hereditary predisposi-
tion to disease, as it evidently does in regard to other
characteristics. — The Scottish Medical and Surgical
Jout'hTl, April, 1900.
June 23, 1900]
MEDICAL RECORD.
1085
Medical Record:
A Weekly Jourttal of Medicine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
m. WOOD &. CO., 51 Fifth Avenue.
New York, June 23, 1900.
MANILA FROM A HEALTH STANDPOINT.
Widely conflicting views are held in this country as
to the healthfulness or otherwise of Manila and of the
Philippines generally. By many, perhaps by the ma-
jority of Americans, the belief is current that the island
of Luzon is a hotbed of malignant fevers, and that it
is indeed a veritable death-trap for white men. This
is undoubtedly a pessimistic manner of regarding the
situation, which is not borne out by facts. The dis-
eases that flourish in Manila and in the Philippines
are either those which are almost entirely confined to
the natives or prevail owing to the lack of prophy-
lactic and sanitary precautions. It is undeniable
that Manila is under the existing conditions an un-
healthy town, but not more so than any other town in
the tropics over which the Spanish had held sway for
generations. For instance, both Havana and Santiago
were atthetimeof the outbreak of the Spanish-American
war in quite as bad a sanitary state as Manila is at the
present time. Mr. George Becker, writing in the June
number of Scribiier' s Magazine concerning the Philip-
pines and speaking of the climate of Manila, says:
" It is almost identical with that of San Juan de
Puerto Rico, and is comparable with that of the Gulf
States during the warmer portion of the year. The
climate, too, is equable. The mean temperature of
the year is 79° F. The coolest month is February;
the mean temperature is 76° F. The hot season at
Manila includes March, April, and May, the last being
the hottest month. May has an average temperature of
between 85° and 86° F. The sun is far less trying than
in British India. The rainy season lasts from June to
November. The total rainfall at Manila during the
drier months is about ten inches, and during the wet sea-
son sixty-seven inches. Although a swampy country,
there is comparatively little malaria. The census of
Manila has recently been taken, and discloses the fact
that its population has been greatly overestimated.
Former censuses and estimates have given the city a
population of 300,000. The new census, which has
been carefully conducted, gives a population of 190,-
714, of whom 30,000 are Chinamen. This numbering
does not include several villages within the city limits
nor the Americans and Europeans and priests in the
monasteries, which will add about 50,000 more to the
previous total. The death rate is calculated at over
forty per cent. Some of the causes of death were :
Beri-beri, 570; tuberculosis, 385; bronchitis, 314;
dysentery, 229; fevers, 287. Three diseases are now
epidemic in Manila, bubonic plague, beri-beri, and
smallpox. The latter and leprosy are always present
to a greater or less extent. So far as beri-beri is con-
cerned, being a malady resulting entirely from diet, it
is in no wise feared by members of the white race.
The prevalence of smallpox among the natives is due
to lack of efficient vaccination ; and lastly the bubonic
plague, which has invaded Manila on a somewhat ex-
tended scale, is doubtless chiefly owing to the filthy
habits of the native and Chinese population. There
have, it is true, been several cases of smallpox, some
of which have resulted fatally among the American
troops, but there has been nothing resembling a wide-
spread epidemic, which, considering the risk of infec-
tion to which the soldiers have been necessarily e.x-
posed, speaks volumes for vaccination as a safeguard
against the disease. With regard to the bubonic
plague, as in India and throughout the far East, the
authorities in their endeavors to stamp out the pest
have not only to contend with the unsanitary condition
of the districts inhabited by the natives and Chinese,
but also with superstition and misguided religious
sentiments. Every person dying of plague should be
cremated, but it is found impossible to carry out this
measure, as any attempt at compulsion would result in
concealment of cases and possibly in serious riots.
The rainy season, it is hoped, will wash away the
plague, and even if it does not have that effect the
surgeons in Manila have no fear that they will be un-
able to control its ravages, considering that it is an
easier disease to deal with than is yellow fever. The
statement may then be made that for a tropical coun-
try Luzon is not peculiarly unhealthy, and that Manila
is not so bad in this respect as it has been painted.
The truth should not be lost sight of, that as yet com-
paratively little has been done toward improving
Manila from a hygienic point of view, partly because
the requisite funds have not been forthcoming and
partly because the military authorities have been com-
pelled to concentrate their energies upon crushing the
rebellion. The city has no sewers; a few houses
drain into the waterways, but as a rule cesspools under
the courtyards or streets are loaded with the accumu-
lated filth of years. When the war is ended sanitary
engineers will be able to devote their attention to ren-
dering Manila a clean city, and there would seem to
be no reason to doubt that methods tending to this
end will be as successful as in the case of Havana
and Santiago."
TRAINING NATIVES IN MEDICINE.
The policy of expansion to which this country has
now committed itself will, as a matter of course, bring
in its wake many responsibilities. The acquisition
of territory situated in the tropics will necessitate the
teaching in our medical schools of all that is known
concerning the diseases common to those climes and
of the best manner in which to treat their victims. It
is also to be hoped that, following the example of
Great Britain, the government of the United States
io86
MEDICAL RECORD.
[June 23, 1900
may see fit to recognize the advisability of establish-
ing schools of tropical medicine, by means of which in-
vestigations may be conducted with the object of dis-
covering the origin and cause of several of the maladies
peculiar to dwellers in the torrid zone, in regard to
which our knowledge is lamentably defective and
vague. Much missionary work, too, will be under-
taken in our new possessions, and the missionary of
to-day is required to possess a competent acquaintance
with the healing-art, so as to be able to administer to
the body as well as to the soul diseased. Unfortu-
nately the supply of medical missionaries is not equal
to the demand, and as representatives of this praise-
worthy class of men are to be found in every part of
the world, native help must be relied on in order to
enable them to perform their arduous labors efficiently.
Consequently the training of natives in medicine is
one of the most important duties of the medical mis-
sionary.
The proposal has lately been made, both here and
in Great Britain, that a larger number of natives than
will be needed for the medical work of the mission
should be educated with the view that they should
practise independently among people of their own
race. Dr. Albert P Peck, dean of the medical de-
partment of North China College, recently read a
paper in New York on the above subject, and refer-
ring to this question said: "The peculiar conditions
of the various countries where our interests lie will
determine largely our attitude. But broadly speaking,
if we recognize and admit the value of the medical
profession as a social factor in our own civilization,
we shall be ready to see the importance of such an
element in the infusion of a new life into the effete
civilization of the East. When the medical mission-
ary, as a pioneer of a new civilization, can come in
touch with the old order so as to give to the adult
generation of practitioners even a little empirical in-
struction, it will be time and labor well spent." Dr.
Peck is, however, of the opinion that it is upon the
members of the younger generation that the hopes of
the future rest, and therefore advises that the native
youth should be educated in medicine after a sound
preliminary general education, and concludes as fol-
lows: "The average intelligence of such communities
as, for instance, we have in China is not very high.
They cannot follow very advanced hygienic teaching,
nor appreciate the most scientific practice. A plain,
practical and somewhat empirical education is the best
for an undeveloped state of society, teaching the best
uses of the imperfect equipment, the rude surround-
ings which they must have." Dr. Peck's recommen-
dation is rather for what we would now call an old-
fashioned education for our native medical students.
The points to be discussed, before passing an opin-
ion, is as to whether the idea, if capable of realization,
is a rational one; whether it would be for the benefit
of the natives themselves to have doctors of their race
who have received a thorough medical training on
modern lines, and again whether it would be to the
advantage of the dominant race. Health, an English
journal, thinks that the plan is both desirable and
feasible, and argues thus:
" If the natives by their own sons are made ac-
quainted with the ravages of diseases peculiar to their
own race or special district, if they are further taught
that many of them are curable and others are prevent-
able, we are sure that common sense, which some of
these people possess to a large extent, will induce
them to use the precautions which study of medicine
has discovered to be useful and which can be best
taught by those who have passed a medical curric-
ulum."
With all due deference to the views of the writer
in Health, and while freely admitting that it is
possible, nay, in a high degree probable, if such a
plan could be carried out, the natives would greatly
benefit by it, yet at the same time we are rather
inclined to agree with Dr. Peck, and to imagine that
the time is scarcely ripe for so radical an innovation.
Of one thing, however, there can be no doubt — that
much more attention should be paid to the study ot
tropical diseases in this country than is at present the
case. In fact, it may be asserted without much fear
of contradiction that the knowledge of some certain
tropical diseases possessed by the average medical
graduate from American schools would not warrant
him in posing as an instructor in these matters. At
present it may be said that the training given to na-
tives in medical missionary colleges is sufficient for the
purpose.
^aus of tTxe 'imceli.
International Medical Conferences at Paris. —
There has been organized at the International Hospi-
tal, 95 Boulevard Arago, Paris, a system whereby all
French and foreign physicians may hold clinics, lec-
tures, and scientific demonstrations without cost to
themselves. The idea which has led to the establisl.-
ment of this service of conferences is that, owing to the
great number of international congresses to be held in
Paris, the attendance of medical men will be very
large. Many of these will have demonstrations to
make for which there will be little or no time in the
section meetings, and it is for the accommodation of
such that the extra service has been organized. Those
desiring to avail themselves of this are requested to
communicate with the organizer of the conferences,
Dr. S. Bernheim, No. 9 Rue Rougemont, Paris.
The Association of American Medical Colleges. —
At the annual meeting of this association, held at
Atlantic City, June 4th and sth, fifty-six colleges were
represented. Amendments to the constitution exclud-
ing "sun-down " medical colleges were adopted, to take
effect in July, 1901. Officers were elected as follows:
President, Dr. Albert R. Baker, of Cleveland; First
Vice-President, Dr. Thomas H. Hawkins, of Denvei ;
Second Vice-President, Dr. W. H. Earles, of Milwau-
kee. Drs. Parks Ritchie, W. W. Keen, and J. M.
Dodson were added to the judicial council. The
Cooper Medical College of San Francisco, the Medi-
cal Department of the University of Kansas, and the
American Medical Missionary College of Chicago
were elected to membership. A committee was ap-
June 23, 1900]
MEDICAL RECORD.
1087
pointed at the request of the federation of State exam-
ining-boards to co-operate with a similar committee
appointed by them, to consider common interests.
This committee consisted of Drs. W. J. Holland,
Dudley S. Reynolds, W. E. Quine, W. J. Means,
and Parks Ritchie. The papers and proceedings of
the Association are published in the Bulktin oj the
Aiiierican Academy of Medicine.
The New York County Medical Association
At a meeting of this association on Monday of this
week, the following officers were elected: President,
Dr. Parker Syms; First Vice-President, Dr. J. Riddle
Goffe; Second Vice-President, Dr. Emil Mayer; Pc-
cording Secretary, Dr. Ogden C. Ludlow; Correspond-
ing Secretary, Dr. J. W. Draper Maury ; Treasurer, Dr.
Charles E. Denison.
The Harlem Medical Association. — At a meeting
of this society, held June nth, the following officers
were elected : President, Dr. Montrose R. Richard ;
Vice-President, Dr. Joseph E. Lumbard ; Secretary, Dr.
VVilliam H. Luckett; Treasurer, Dr. William F. Far-
rell; Trustees, Drs. Henry W. Mooney, David Frank-
lin, and M. C. O'Brien.
A Tale without a Moral. — There exists in Chi-
cago an e.xcellent organization among schoolboys,
known as the Cook County Anti-Cigarette League, the
laudable aim of which is expressed in the name of
the association. According to a story in the New York
Times, \.\\& league had a field day on June 15th, and one
of the events was a fifty-yard dash. Just before the
start a newsboy with a cigarette stump in his mouth
came along and requested permission to enter for the
race. The superintendent of the games, who thought
this was a good chance for a telling object-lesson,
readily gave permission, and the " fiend " lined up with
the other boys — and won the race.
Deaths from Lightning In a report on thunder-
storms recently issued by the United States Weather
Bureau, it is stated that the number of deaths from
lightning in the country, reported to the bureau dur-
ing the year 1899, was 562. The total number of
those struck was 1,382, 820 of whom survived the
stroke. It is believed that this record is fairly com-
plete, though doubtless some cases occurred of which
the bureau had no cognizance.
A Woman Medical Graduate in Sweden. — Miss
Anna Stecksen has recently received the degree cf
M.D. from the University of Stockholm. It is said
that this is the first time this degree was ever given to
a woman in Sweden.
The Alumni Association of St. Vincent's Hospi-
tal, of this city, was organized at a meeting held on
Monday evening. Tlie following officers were elected :
President, Dr. Charles H. Lewis; Vice-President, Dr.
Charles L. Weeks; Secretary, Dr. Joseph A. Dillon;
Committee on By-Laws, Drs. Charles Benedict, Francis
Murray, and John Curtin. Meetings of the associa-
tion will be held every three months.
The American Institute of Homoeopathy held its
fifty-sixth annual meeting in Washington this week, in
union with several societies of homoeopathic special-
ists. Of the latter the Ophthalmological, Otological,
and Laryngological Society elected officers for the
ensuing year as follows: President, Dr. Thomas L.
Shearer, of Baltimore; Vice-Presidents, Drs. Thomas
M. Stewart, of Cincinnati, and F. D. W. Bates, of
Hamilton, Ont. ; Secretary, Vlx. Herbert D. Schenck,
of Brooklyn; Treasurer, Dr. C. Gurnee Fellows, of
Chicago. The Surgical and Gynaecological Society
adopted a constitution and by-laws and elected the
following officers: President, Dr. James C. Wood, of
Cleveland; Vice-Presidents, Drs. W. Louis Hartman,
of Syracuse, and Horace Packard, of Boston; Secre-
tary, Dr. J. Wylis Hassler, of Philadelphia; Treasurer,
Dr. G. C. Jefferey, of Brooklyn.
Yellow Fever is reported to be prevalent in all
parts of the isthmus of Tehuantepec in Mexico. Sev-
eral hundred Americans, principally from Ohio, In-
diana, and Illinois, have settled on the isthmus dur-
ing the past few years, engaging in the cultivation of
coffee, and a number of these, as well as many of the
railway employees, have been attacked and have died.
The disease has also made its appearance in Vera
Cruz, and fears are entertained by the health authori-
ties that it will spread to all the Gulf ports of Mexico.
From Cuba it is reported that yellow fever has broken
out at Quemados, eight miles from Havana, where
United States troops are stationed. Thus far there
have been fourteen cases, three of which proved fatal.
At present six are under treatment, and all are ex-
pected to recover. This is the first time in several
years that there have been any cases of yellow fever
at Quemados. Havana city is exceptionally clear,
only three cases being under treatment, less than dur-
ing any month of the winter.
The Methodist Episcopal Hospital in Brooklyn.
— The new pavilion for surgical operations in this
hospital was opened for inspection on the afternoons
of June i2th, 13th, and 14th. There was a large at-
tendance each day of medical men and of friends of
the hospital.
A New St. John's Guild Hospital. — The corner-
stone of a new hospital building to be erected on the
Seaside Hospital grounds of St. John's Guild at New
Dorp, Staten Island, was laid on June 12th. The
building is the gift of Mrs. Frederick Elliott Lewis,
in memory of her son. The building will be known
as the Cottage Hospital. It is to be a frame structure
one hundred and three feet long and about thirty-one
feet wide. It is expected that the building will be
ready for this summer's use.
A Gift to the Presbyterian Hospital.— An anony-
mous benefactor has offered to erect a new building
for the Presbyterian Hospital in this city. It will be
for the accommodation of the nurses and house staff,
who now have quarters in the main building. It will
stand on the northwest corner of Park Avenue and
Seventy-first Street, directly opposite the hospital, on
property already owned by the trustees. Room for no
less than one hundred additional beds will be secured
by the change, increasing the capacity of the hospital
MEDICAL RECORD.
[June 23, 1900
one-third. Work on the new building will begin
soon, and it is expected that it will be ready for occu-
pancy in the spring or early summer of next year.
The style of architecture will be the same as that of
the other hospital buildings.
The State Orthopedic Hospital At a recent
meeting of the board of managers of the New York
State Hospital for the Care of Crippled and Deformed
Children, the committee on site reported that it had
leased the residence of Dr. Angell, Paulding Avenue,
on the Hudson River, in Tarrytown. The changes
necessary to equip the building for hospital use will
be made at once, and the work will be formally inau-
gurated early in the autumn. The following were
elected members of the consulting medical board :
Drs. Francis Delafield, Robert F. Weir, W. Oilman
Thompson, Joseph D. Bryant, Lewis A. Slimson, A.
Alexander Smith, and Reginald H. Sayre, of New
York; Roswell Park, of Buffalo, and L. A. Weigel, of
Rochester.
Medical Examination of School Teachers. — It has
been decided by the board of education of Chicago
that all applicants for appointments as teachers in
the public schools must submit to a medical examina-
tion before coming up for their technical examination.
A corps of woman physicians has been appointed to
examine all applicants for admission to the normal
school.
Women's Medical Institute in Moscow — A soci-
ety has been formed in Moscow to collect funds for
the establishment of a medical institute for women in
that city. The annual subscription is 5 rubles; life
members pay 100 rubles, and the donor of 5,000 ru-
bles becomes an honorary member. In addition to
the income from these dues, money will be raised by
means of lectures, concerts, benefit performances at
the principal theatres, balls and fairs. It is hoped
that a sufficient sum will be secured to permit of the
inception of the work within a short time.
Smallpox on the Hudson — An epidemic of small-
pox has prevailed for some time among negro brick-
yard laborers at Stockport. The State board of health
ordered all negroes vaccinated, and the local board
carried out the order as far as they could, but about
fifty of the negroes refused to submit. Quarantine
was ordered on all suspected cases, including the men
who had defied the vaccination order, and a company
of the State militia has been ordered to Stockport to
enforce the quarantine rules.
The Late Dr. Landon Carter Gray At a meet-
ing of the Medical Association of the Greater City of
New York, held at the New York Academy of Medi-
cine on June 11, igoo, the following minute was pre-
sented and adopted:
" Dr. Landon Carter Gray, a charter member of the
Medical Association of the Greater City of New York,
died on May 8, 1900. Dr. day was well known to
the profession in Manhattan and also in Brooklyn, the
latter being the scene of his earlier activities. He
had attained a high reputation by his varied work in
the special branch of medicine to which he had de-
voted himself. Dr. Gray was essentially genial in his
temperament, and especially cordial in his relations
with the younger members of the profession. He had
held many positions of honor in the various societies
with which he was affiliated, and his removal from a
busy career in the prime of life will be a loss to the
profession.
" IV/u-rcas, It has pleased an all-wise Providence to
remove our colleague from our midst; be it
"Resolved, That while. we submit to the decree, wt,
as an association, desire to express our sorrow in our
loss, and direct that this resolution be spread on the
minutes of the association, and that a copy thereof
be forwarded to the family.
" Edward D. Fisher, chairman, Frederick Peter-
son, W. H. Katzenbach, committee."
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended June 16,
1900 :
Smallpox— United States,
Cases. Deaths.
California, Oakland May 12th to June 2d 5
Colorado, Arapahoe Co May 28th to June 4th i
Archulita Co May 28th to June 4th i
El Paso Co May 28th to June 4th 2
Logan Co May 28th to June 4th i
Mesa Co May 28th to June 4th i
Delaware, Wilmington June 2d to 9th 1
District of Columbia, Wash-
ington June 2d to 9th 4
Illinois, Cairo May 26th to June 2d 4
Chicaijo June 2d to Qth 4
Indiana, Evansville June 2d to 9th I
Kansas, Wichita June2dtog[h 5 ,
Kentucky, Covington June 2d to 9th aS
Louisiana, New Orleans Juneadtogth ,. 41
Maine, Portland June 2d to 9th 4
Massachusetts, Fall River . .June 2d to gth q
Lowell June 2d to 9th i
Michigan, Grand Rapids. .. .June 2d to gth i
Jackson June 2d to oth i
N.Hampshire, Manchester. June 2d to gth 2
New York, New York June 2d to gth 4
North Carolina. Newbern. , .June 6th Several.
Ohio, Cleveland,... June 2d to gth 22
Tennessee, Memphis May 2olh to June 2d 13
titah. Salt Lake City June 2d to gth 2
Smallpox— Foreign.
Austria, Prauue ... May igth to 26th 5
Belgium, Ghent May 19th to 26th
Egypt, Cairo May 12th to 20th
England, Liverpool May 19th to 26th i
London May igth to 26th 5
France, Paris May igth to 26th
Mexico. Chihuahua. ....... May 26th to June 2d
Philippines, Manila April 21st to 28th 3
Vera Cruz May 26th to June 2d
Russia, Moscow May 12th to igth 11
Odessa May 19th to 26th 7
St. Petersburg May i2th to igth 33
Straits Settlements, Singa-
pore April 21st to 28th
Colombia. Panama. .
Cuba, Havana May 26th t
Mexico, Vera Cruz May 26th to J une 2d . , .
Siam, Bangkok April 19th ,
China, Hong Kong April 28th to May 5th 34 32
Egypt, .\le.\andria Vay 12th to igth 3 i
Port Said April 20th to May 28th 41 21
Philippines, Malabon April 20th 2
Manila April 7th to 2Sth 41 30
San Pedro Macote., April 2oth Reported.
The Pan-American Medical Congress. — The Aca-
deniia dc Cicncias of Havana has appointed the follow-
ing committee on organization of the third Pan-Ameri-
can Medical Congress: President, Yi. Santos Fernan-
dez; Viee-Presideiit, Dr. Gustavo Ldpez; Seeretary,
Dr. Coronado; Treasurer, Dr. Acosta. The secretary
of state of Cuba has been requested to issue official
invitations to all the governments of the republics and
colonies in America,
June 23, 1900]
MEDICAL RECORD.
1089
Navy Department, Bureau of Medicine and Sur-
gery, Wasliington, D. C. — Changes in the medical
corps of the United States navy for the week ending
June 16, 1900. Appointment: Charles N. Fiske to
be an assistant surgeon from May 15, igoo. June 8th.
— Surgeon T. A. Merryhill ordered to the naval lab-
oratory and department of instruction, Brooklyn, N. Y.,
June 14th. Passed Assistant Surgeon F. C. Cook or-
dered to temporary duty at naval hospital, Norfolk,
Va. June nth. — Medical Inspector G. E. H. Harmon
detached from the Oregon upon reporting of relief,
and ordered to the naval hospital, Yokohama, Japan,
as the relief of Surgeon F. Anderson. Surgeon Frank
Anderson detached from the naval hospital, Yoko-
hama, Japan, upon reporting of his relief, and ordered
home to wait orders. Surgeon P. Leach detached
from the Yosemite upon reporting of relief, and ordered
to the Oregon. Surgeon F. A. Hesler detached from
the naval hospital, Chelsea, Mass., upon reporting of
relief, and ordered to the Yosemiie as the relief of
Surgeon P. Leach, sailing from San Francisco, via
Doric, June 30th. Passed Assistant Surgeon C. D.
Brownell detached from the naval training-station,
Newport, R. L, upon reporting of his relief, and or-
dered to naval hospital, Chelsea, Mass. Assistant
Surgeon C. H. DeLancy detached from the naval
hospital, Washington, D. C, and ordered to the naval
training-station, Newport, R. I. June 12th. — Passed
Assistant Surgeon J. F. Leys ordered to temporary
duty on the Franklin. Surgeon G. M. Pickrell de-
tached from the naval station, Cavite, P. I., and or-
dered to the naval hospital, Yokohama, Japan.
Passed Assistant Surgeon Horace B. Scott, retired,
died May 20, 1900.
Obituary Notes. — Dr. S. Burke Pillsburv died
at his home in Middletown, N. Y., on June 17th, from
the results of an operation. He was a graduate of the
Harvard Medical School in 1876.
Dr. George M. Beabes died at his home in Bloom-
ingburg, N. Y., on June 15th, at the age of sixty-
eight years. He was a graduate of the Albany Medi-
cal College in the class of 1856. During the Civil
War he served as surgeon in the Fifty-Sixth New York
Volunteer Infantry. He served two terms in the leg-
islature of this State in 1890 and 1891.
Dr. William Pierson, of Orange, N. J., died at
his home there on June 12th. He was born in Orange
on November 30, 1830, and was graduated in medi-
cine from the New York University in 1852. He had
been secretary of the New Jersey State Medical So-
ciety for over thirty years, and was elected president,
although then ill, at the recent annual meeting of the
society. He was the first president of the board of
education in Orange, and held that position for twelve
consecutive years. Dr. Pierson was descended from a
long line of medical ancestors, the first one of the
name having begun practice in Orange in 1764.
Thermo-Cautery should not be used on the carti-
laginous septum on account of liability to perforation.
In cauterizing turbinates, the septum should be pro-
tected by tinfoil. — H. H. Curtis.
^trogrcBS of l^aciUcia .Science.
The A'eis.1 York Medieal Journal, June 16, /goo.
A Contribution to the Technique of Modern Uranoplasty. —
J. F. McKernon advocates the perfoi'mance of a prelimi-
nary tracheotomy, packs the cavity of the mcjuth for a week
or more, treating it as any other wounded surface, and
feeds by the rectum. He has never had any difficulty with
nourishing his patients. If no vomiting has taken place,
the packing should be removed at the end of forty-eight
hours, the wound gently cleansed, and the packing re-
placed. This should then be done daily, and the stitches
carefully inspected. If any are found drawing, they should
be severed at once, but not removed until the next day.
The tracheotomy tube should be retained until the twelfth
day, by which time the patient is able to take food by the
mouth. The introduction into' the bowel of a warm saline
solution diminishes thirst, adds to the general comfort of
the patient, and seems to be an adjuvant to nutrition.
The advantages claimed for the method are as follows :
The restoration of speech function, complete or partial. It
allows the patient to eat without regurgitation of food, giv-
ing little or no trouble thereafter, so far as deglutition is
concerned. It allows the patient to mingle on a par with
his fellow-beings. It does away to a very great extent, if
not entirely, with the facial contortion while trying to
speak. It lessens the catarrhal inflammation of nose and
throat, and improves the deafness, when existing, as well
as relieving the distressing subjective sounds so frequently
complained of b}' these patients. There will be a decided
increase in weight, and when persistent headaches have
been present and can be attributed to no other cause, and
have received treatment without avail previous to the oper-
ation, they will often clear up completely when the cleft is
closed, allowing a normal nasopharyngeal function to take
place.
Juvenile Hysteria and Neurasthenia. — C. L. De Merritt be-
lieves that much of the neurasthenia of adult life has had its
foundation laid in childhood. He condemns the introspec-
tive methods of the educational system of the present day,
claiming that children are overworked in school and are
not given proper exercise. Other causes are poor food,
anaemia, and infectious fevers. Treatment should begin
with the parents. If they are neurotic, we must get them
into some sort of trim before we can secure a proper regi-
men for the child. Tonics such as hsemic reconstructives
are generally indicated. Bathing is a useful adjuvant,
followed by small doses of hyoscyamus. Attention should
be paid to exercise, and if the child's school has a gymna-
sium, it is often better to have the child continue at school,
for the resultant effect is better than that from no school
and no gymnasium.
Hernia Abdominalis. — H. A. Duemling submits the fol-
lowing propositions : (i) A hernia is the escape of a viscus
from the abdominal cavity covered with the structures pe-
culiar to its point of exit. (2) The folds and depressions
of the peritoneum, occasioned by the passage of various
structures under it, create weak points in the belly wall.
(3) The success of a radical cure depends on the restora-
tion of the muscular and fibrous tissues to their pristine
relationship and elasticity. (4) The production of scar
tissue, artificial or accidental, lessens materially the possi-
bility of a permanent cure. (5) Destruction of the in-
guinal canal and suture of the external abdominal ring do
not prevent recurrence. (6) Destruction of the inguinal
canal and of the internal abdominal ring (or its fortifica-
tion) offers the largest percentage of cures.
A Case of Tetanus Treated with Antitetanic Serum. — By
J. F. Clarke.
Typhoid Infection of the Uterus.— By A. J. Lartigau.
Perimetric Diagnosis. — By J. W. Sherer.
Pkiladelpliia Medical [oiirnal, June ib, igoo.
An Experimental Study of the Origin of the Epidemic of
Tetanus following July 4, 1899 ; Report of Case with Re-
covery.— H. Gideon Wells calls attention to the large num-
ber of wounds made by blank cartridges which were fol-
lowed by tetanus. He records an instance of recovery ; the
only one in five occurring at the same time which did not
prove fatal. The patient was a laborer, forty years old,
who was shot above the knee. Stifl'ness of the jaw began
to come on ten days after receipt of the injury. Two paste-
board wads were found at the bottom of the wound, and
from them as well as from the pus was isolated the tetanus
bacillus according to the Kitasato method. Tetanus anti-
toxin 10 c.c. was injected and repeated twice at intervals
of twenty-four hours. Chloral and bromides were given
regularly, and perfect quiet was secured. Morphine was
also given hypodermically to a point of maintaining
drowsiness. Bacteriological investigations with various
logo
MEDICAL RECORD.
[June
1900
makes of blank cartridges failed to show that the origin of
the infection was attributable to the blank cartridges, while
this origin was not absolutely excluded.
A Case of Hereditary Ataxia with Generalized, Bilateral,
Choreiform, and Athetoid Movements. — Bernard Oettinger
relates the history of a girl aged six years, who was the
only one in the family to be affected so far as known. De-
velopmental defect was believed to underlie the condition.
The pathology, symptomatology, prognosis, and treatment
a:e all considered. Under the continued administration of
small doses of bromides the involuntary movements dimin-
ished noticeably.
The Necessity for State Aid in the Treatment of the Con-
sumptive Poor. — By Howard S. Anders.
Mijtter Lectures of the College of Physicians of Philadel-
phia.— By John B. Roberts.
A Contribution to the Study of Exophthalmic Goitre.— By
Alfred Gordon. '
Angina Pectoris.— By Clifford AUbutt.
The Boston Miuiical and Siirgiial Journal, June 14, igoo.
The Mechanics of Lateral Curvature of the Spine. — Rob-
ert \V. Lovett sums up thus a study of the subject : Tor-
sion and side flexion of the spine are parts of one com-
pound movement, and neither exists t j an)- extent alone.
Lateral deviation of any part of ; ne spinal column is there-
fore necessarily associated with torsion (rotation) at the
seat of the deviation. In flexed positions bending is asso-
ciated with torsion in one direction, in extended positions
by torsion in the opposite direction. From the kind of tor-
sion observed in scoliosis it is obvious that the deformity
originates in the flexed position of the spine. The correc-
tion of the rotation would therefore seem to be logically
made by throwing the spine into extended positions, and
in taking side bendings from extended positions. The im-
mediate cause of lateral deviation is, as a rule, to be found
in some asymmetry of development or posture which leads
to an oblique direction of superincumbent weight, causing
the spine to deviate from the middle line.
Malaria and Mosquitos. — Irving G. Rosse opposes the
modern theory that mosquitos transmit the malarial organ-
ism to man. and thus cause malaria, basing his belief on
the fact that Arctic voyagers do not suffer from the disease
after encountering the insect in so great abundance that
they actually interfered with the use of instruments in
taking ob.servations. On the Chesapeake peninsula, which
has a notorious reputation for malaria and mosquitos, a
healthy New England crew escaped malaria, although dis-
tracted by the annoyance of the mo.squitos. On the other
hand, he is told that malarial fevers are common in the
foothills of Virginia, as at Charlottesville, where mosquitos
are such a negligible quantity as to be almost unknown.
Closing Statement for the Remonstrants to the Massachu-
setts House Bill No. 917, Entitled "An Act for the Further
Prevention of Cruelty to Animals," before the Joint Commit-
tee on Probate and Insolvency, March 15, 1900. — Bv Harold
C. Krnst.
Realism in Medicine. — By A. J. Cabot.
Journal of till American Medieal Ass' n. /une 16, igoo.
Medicine and Disease in the Philippines. — D. J. Doherty
gives in condensed form the data gathered from various
authorities. There are two seasons : that in which the
northeast monsoon blows (October to February) , and that
in \yhich the southwest monsoon prevails (June to October) .
with an interval of calm. The second is the wet period.
The climate is the most healthful of any in the tropics.
Among diseases fevers occupy the first place, malarias
predominating ; next in order come dysentery, phthisis,
and other pulmonary affections, skin diseases, leprosy,
smallpox. Endemic diseases due to telluric, paludal, mi-
crobic infections, as well as rheumatism and dyscrasias,
are studied. Hemorrhagic smallpox is the most frequent
form seen. Barcones is quoted in loud condemnation of
the vices incident to the introduction of opium and the
abuse of tobacco and alcohol. The curanderos are akin to
the barber surgeons of Europe. They use native plants.
The Spaniards are given much credit for regulation of sani-
tary matters, vaccination, and medical education. Rules
for Americans .going to the islands are laid down.
Neurasthenia, Some Points in its Pathology and Treatment.
— G. \V. McCaskey points out the probable antiquity of
nerve prostration. He tinds that it is often most difficult
to determine whether the neurasthenia or gastro-intestinaf
disease was the primary condition. If it is true that pri-
mary gastro-intestinal disease can cause neurasthenia, it
follows, as a necessary corollary, that gastro-intestinal dis-
ease, even when secondary to the neurasthenia, will act as
an auxiliary etiological factor. For this very reason the se-
quence of events in the evolution of any given case is a
matter of subordinate importance from a clinical point of
view, although always of the highest scientific interest.
The real practical question is whether or not the gastro-in-
testinal disease is capable of e.xerting a prejudicial effect
on the progress of the case. The stomach tube is advo-
cated for a large number of cases. There is often much
reflex irritation from the colon, which must be cleared out
by local treatment.
Report of Case of Splenectomy, with Attempted Surgical
Cure of Ascites due to Cirrhosis of the Liver. — T. N. Raf-
ferty reports a case, with death on the fourteenth day, due
to embolism. The patient, a widow, thirt\"-one years old,
measured fifty inches at the umbilicus. No tumor could be
made out with certainty. Three gallons of fluid were with-
drawn. Twenty days after an exploratory incision the
spleen was removed.
Dental and Oral Surgery : its Relation to the General Field
of Medicine and Surgery, and the True Professional Status or
Rank of the Properly Educated Practitioner of Dental and Oral
Surgery. — By N. S. Davis.
Encouragement of Higher Education and Original Research.
— By William Ernest Walker.
Laryngeal Papillomata Requiring a Special Instrument. —
—By Seth Scott Bishop.
Technical vs. Theoretic Training. — By John S. Marshall.
Address on Stomatology. — By M. H. Fletcher.
Gastric Hemorrhage. — By William L. Rodman.
Report on Massage. — By Douglas Graham.
Course of Study. — By W. A. Evans.
Medical A'e'ws, June 16. igoo.
Periods in Gynsecology. — Henry J. Garrigues reviews the
changes in gynaecological practice which have taken place
in the last quarter of a century. In describing the opera-
tion for abdominal h)-sterectoray as he performs it at the
present day, he says that he can the more freely recom-
mend the method described, as he does not claim any part
of it as his invention. Paul Segond has adopted it, and
calls it the "American method." As American gynaecolo-
gists, it behooves us to give due credit to Henry O. Marcy
for the use of the buried continuous animal suture (18S1) ;
to J. A. Emmet for the retroperitoneal treatment of the
stump (1SS4) ; to Lewis A. Stimson for the substitution of
the direct ligation of arteries for the unsafe mass ligature
(1889) ; to William R. Pryor for having shown the advan-
tage of coming from below upward on the second side
(1S94) ; and to Howard A. Kelly for having combined most
of these ideas in a clear, precise form (iSg6).
Causation and Relative Frequency of Typhlitis, Perityph-
litis, and Appendicitis in Infancy and Childhood. — By Jo-
seph Henry Byrne.
The Prophylaxis and Control of Leprosy in this Cotxntry.
— By Prince A. Morrow.
T/ie Lancet. June g, igoo.
On Suprapubic Lithotomy in Old Men with Enlarged Pros-
tate.— W. T. Tliomas believes that calculi are frequently
lodged in the poucli behind the middle lobe of an enlaigetl
prostate, and that they may lie there for months even be-
fore their presence is suspected. The special steps for the
removal of these small calculi are thus described : After the
bladder is reached and opened the finger is passed in to
locate the calculus and ascertain its size. If small, the
stone can be readily extracted by Tait's gall-stone forceps,
which takes up less room than the unnecessarily clumsy
lithotomy forceps; if large, the wound in the bladder is
extended, the mucous membrane being divided to a lesser
extent than the muscular coat; blunt hooks are inserted
above and below to keep the opening on the stretch, and
a pair of lithotomy forceps is used to seize the calculus.
The bladder wound is sutured, continuous chromic gut for
the mucous membrane and continuous silk a la Lembert
for the muscular coat being employed. The bladder su-
ture is now tested by air distention, and if secure a few
ounces of lotion are used to wash out any small blood clot
that may be in the bladder. A small incision is made
through the skin to one side of the middle line to accommo-
date a small glass drainage tube passed down to the neigh-
borhood of the sutures in the bladder wall. The original
skin incision is closed by sutures and a gauze dressing
under a double spica bandage is applied. The catheter is
left in the bladder, tied in position, and by means of a rub-
ber tube attached to it, it conducts urine into a vessel con-
taining lotion for a few days.
On the Relative Value of Symptoms of Acute Peritonitis. —
Collating symptoms given by various authors, E. S. Bishop
makes the following list : Sudden and continuous pain ;
tenderness: hot, dry skin; temperature elevated, normal,
or depressed ; hard, "wiry " pulse ; quickened respiration ;
tympanites ; clear note on percussion, unless effusion has
occurred, when there is dulness in the tlanks; distended
abdomen ; altered facial expression ; flexed thighs and
June 23, 1900]
MEDICAL RECORD.
109 1
characteristic position of the body; and, later, vomiting.
None of these is absolutely pathognomonic, but he pins his
faith on the existence or non-existence of rigidity of the
abdominal muscles. With acute peritonitis there is always
rigidity of the abdominal muscles. This rigidity is tempo-
rary, lasting only three or four days ; it is therefore useless
as a sign of chronic peritonitis. True rigidity must be
carefully distinguished from mere stiffening of the abdomi-
nal muscles. In making the examination the surgeon
must find time to sit down. His hand must be warm,
warmer, if possible, than the patient's skin. The tips of
the fingers are not to be used. The entire hand should
come in contact with the abdomen like a feather, so that it
is almost impossible for the patient to say when actual con-
tact is made. It should then lie without any weight, almost
entirely supported by the surgeon's own muscles for a few
moments motionless, then gradually and gently move w-ith
an imperceptible sliding action over the surface. Thus,
and tlius only, will he be qualified to say whether or not
there is actual muscular rigidity.
Monogamy in its Relation to Longevity and the Diseases
of Late Life. — H. Campbell believes that all non-accidental
deaths occurring before the end of reproductive life are ra-
cially considered deaths of the unfit, such deaths acting
beneficially on the race by limiting the production of unfit
offspring. The majority of men among the civilized have
children by one wife only, and she is generally about the
same age as the husband. The effect of this is to reduce
the age-limit of reproduction in the man to that of the
woman. A man, therefore, marrying a woman about his
own age and possessing the power of propagation into ad-
vanced life leaves no more children to inherit his superior
death-resisting powers than the inferior man who dies at
the age of forty five. Monogamy in such a case reduces
the superior man to the reproductive level of the inferior
one, and robs the race of a number of individuals whose
birth would diminish the racial tendency to disease in the
later years and increase the racial span of life. The effect
of monogamy in fact is to increase the racial tendency to
disease after middle life, and to shorten the vital span.
Addison's Disease following Enteric Fever. — A case of this
rare pathological sequence is reported by H. \V. Evans,
his patient being a girl aged seventeen years, who after
an illness of six weeks presented symptoms suggestive of
a typhoid relapse, though no fever was present. The pulse
rate markedly increased, and spots were found on the ab-
domen, around the nipples, and in the axillae. The further
course was one of steady decline, and she died in about
three months from the time of the initial typhoid symp-
toms.
Use of Massage in Recent Fractures and Other Common
Injuries. — Clinical lecture by W. H. Bennett.
The Influence of the Buxton Thermal Water on the Excre-
tion of Uric Acid. — By W. Armstrong.
Note on a Case of Failure of Respiration under Anaesthe-
sia.—By F. E. Marshall.
Primary Syphilitic Chancres. — Clinical lecture by Jona-
than Hutchinson.
The Primary Disorders of Growth. — By H. Gilford.
Brilish Medical Journal, June 9, igoo.
Personal Experiences of Gout Terminating in Acute Myo-
sitis of Entire Left Lower Extremity. —A. S. Myrtle records
his own case. Following an injury in which the knee was
crushed, gouty symptoms supervened. In November,
18-59, fis awoke one morning at four o'clock with a sharp
pain in the left adductor longus. The entire left extremity
from the hip to the ankle was swollen, hard, and painful.
Pressure over muscles alone was painful. After taking
colchicum, lysidin, and potassium citrate regularly for
three days the acute pain disappeared. Eczema super-
vened. Six hay-flower baths at gS' F. gave relief. Loss
of power in muscles of leg and soreness continued. After
ten constant-current electric baths the oedema disappeared
and a mile walk could be taken. The doctor believes that
gout had been silently at work for months and broke out
thus violently, invading cellular and muscular tissues,
avoiding joints, tendons, and vessels.
Treatment of Chronic Gout. — William Bane, basing his
notes on experimentation and clinical investigation, finds
that uric acid at least plays an important incidental part
in the pathology of gout. There is little evidence in favor
of the theory of uric-acid formation by the kidneys. In
treating chronic gout our aim should be to prevent the
formation of abnormal proteid decomposition substances,
and the accumulation of these and other waste products
in the system, and to promote their elimination. The
question of diet and exercise is considered and the relative
values of various drugs are discussed. Gouty subjects
should take a relatively large amount of water between
meals.
A Case of Persistent Adenoids in a Middle-Aged Woman.
— E. F. Potter records an instance of typical chronic mouth
breathing with impaired hearing. The post-nasal space
was occupied by a considerable mass which obscured the
upper half of the septum, extending across the vault from
tube to tube. The mass resembled somewhat a sarcoma, but
microscopical examination, after removal under anaesthesia,
showed it to be adenoid which had undergone inflammatory
changes. The age (forty-sevenj is considerably below that
of Solis-Cohen's case (seventy), still it is of sufficiently
rare occurrence at this time of life to warrant comment.
A Note on Gout. — James Edmunds says he has discarded
sodium salicylate for the potassium salicylate, "cardiac de-
pression " not being observed. As long as the urine be-
comes turbid on cooling from deposition of urates he uses
potassium bitartrate. None of the remedies impudently
advertised for uric acid can compete with some very simple
and inexpensive ones. As an aperien the gives : IJ Pulv.
guaiaci, potass, bitart., sulphur, prsecip., aa 3 i. ; pulv. trag.
CO., 3 ii. M. S. Ateaspoonful at bedtime in a wineglassful
of gruel.
An Address on the Hill Stations of India as Health Resorts.
— By Sir Joseph Fayrer.
Case of Cerebellar Abscess : Operation ; Recovery. — By T.
H. Haydon.
Magnesium Sulphate in Dysentery. — By J. L. Dickie.
Clinical Lectures on Pneumonia. — By James Barr.
Certain Uses of Collodion.— By D. W. Samways.
Berliner klinische W'ochenschrift, May 2S, igoo.
Congenital Lack of Nerve-Structure. — O. Heubner de-
scribes a case of the variety to which Moebius has given
the name of "infantiler Kernschwund." It is that of a
child aged eighteen months, who was backward in respect
to power of standing, walking, and speaking. In addition
there were a lack of control over both abducentes of the eye-
ball, complete paralysis of the left facial nerve, diminished
activity of those muscles supplied by the left motor oculi, a
complete paralysis with considerable atrophy of the left
half of the tongue, and a complete lack of tear secretion.
There was also complete lack of response of the affected
structures to both faradism and galvanism. The condition
is referable to congenital structural defects in that part of
the cerebro-spinal a.xis from which the nerves going to the
affected areas arise.
Experiences in and Reflections upon the Treatment of Gon-
orrhoea.— L. Casper gives a general review of the treatment
of gonorrhoea, stating that up to the present time nothing
has been discovered which can be regarded as a therapeu-
tic specific in this affection. A simple, uncomplicated case
is not to be looked upon as a dangerous malady. The con-
dition is quite otherwise as soon as complications develop.
Many of the latter are induced by a purposeless and care-
less therapy. The abortive treatment is a myth so far as
practical success is concerned. All mstrumentation is con-
traindicated in the florid stage. The author has had good
results with injections of thallinum sulphate, which seems
to have, in his judgment, a distinct specific antigonorrhoeic
effect. Of the antiseptic salts those of silver are the best
and the oldest ; the nitrate is the best of all.
The Criminal Insane. — E. Siemerling gives a general re-
view of the literature of this subject, calling attention to
the various eras which have been characterized by the in-
troduction of new syniptomatological terms and the changes
of medical opinion relative to the care of this class of unfor-
tunates. He calls attention to the efforts which have been
made to study this class of persons on the basis of anthro-
pology and biology as inaugurated by Lombroso in 1SS7-
90. He does not regard the latter's views as entirely
correct, for he thinks that Lombroso has gone further than
facts warrant in making his classification so definitely on
the basis of various physical stigmata of degeneration.
Influenza and Chronic Cardiac Disease. — Concluding arti-
cle by Dr. Schott (Bad Nauheim).
Experimental Irritation of the Spinal Marrow of Decapi-
tated Persons. — By A. Hoche.
Deutsche medicinische Woclienschrijt, May 31, igoo.
A Case of Carcinoma of the CEsophagus Treated with Per-
manent Cannula. — C. A. Ewald describes with illustration
a case in which a man, aged sixty-four years, was admitted
to the Augusta Hospital in Berlin for difficulty in swallow-
ing. There was almost complete stenosis of the oesopha-
us opposite the bifurcation of the trachea. A cannula was
introduced and considerable relief was experienced. Silk
threads attached to the instrument were brought out
through either nostril and tied beneath the septum. He
gained in weight for some time. Rectal alimentation was
finally resorted to. A month and a half later the patient
died. At the autopsy the tube was found well engaged in
the centre of the growth, and the view was taken that the
1092
MEDICAL RECORD.
[June 23, 1900
cancer had grown downward beyond it so that its function
was interfered with. Curschmann has had good results
from permanent tubes in fourteen cases. The writer demon-
strates the technique in the clinic twice a year, and finds
that the introduction presents no difficulties; his results,
tiowever, do not equal those of Curschmann.
Observations on Diseases of the Pancreas. — J. Israel relates
an instance of e.xtirpatiun of a movablecyst of the pancreas.
The interesting feature was the abnormal mobility of the
tumor without a long pedicle being present, or descent of
the spleen, and without the slightest trace of enteroptosis.
It depended upon abnormal mobility of the whole pancreas.
The history is given in full. Three other instances of pan-
creatic disease are given. In one case there was perma-
nent and decided benefit from entire emptying of the sac
by means of puncture. Four years later the cyst was found
never to have filled again. At intervals there had been at-
tacks of vomiting and pain which made it seem probable
that pancreatic calculi were in process of formation. The
history is also given of necrosis of the pancreas with peri-
pancreatic abscess formation, and of a case of cyst in which
double-sided incision resulted in cure.
On the Symptomatology of Hysterical Deafness. — Ernst
Barth relates an instance of sudden deafness after fright in
a girl aged eleven years. This was suddenly recovered
from, and again, after an interval, came on after a second
fright and persisted, but the appreciation of musical tones
was found, by tests, to be still present, as though regulated
from an acoustic centre disconnected with or as a subdivi-
sion of the sense of hearing.
New Observations upon the Changes in the Pyramidal
Giant Cells in the Course of Paraplegias. — By G. Marinesco.
French Joiirnah.
The Treatment of Dysenterifonn Entero-Colitis of Infants
by Guarana Powder. — R. St. Philippe says infantile diar-
rhtieas vary in form, aspect, cause, and pathogenesis, and
no single treatment can be laid down for all. They should
be carefully distinguished from one another, and the ap-
pearance of the stools them.selves will lead to the proper
treatment. The glairy dysenteriform entero-colitis is a
variety apart, characterized by special etiology, symptoms,
and therapeutic indications. This variety of enteritis is
favorably modified by fresh guarana powder, which should
be used after cold maceration and should be prepared some
time in advance. The dose varies with the patient's age,
from 50 cgm. to 2 gm. in the twenty-four hours. The phy-
siological action is evidently complex, but it appears to act
in a substitutive and tonic manner. The remedy should
be ranked with other anti-dysenteric drugs, — I.e Bulletin
A/t'ilical, June 6, igoo.
Ovarian Cyst with Twisted Pedicle in a Young Subject. —
L. Monnier successfully removed a cyst from a girl aged
si.\teen years, the pedicle being found twisted. He con-
cludes that moderate-sized cysts in young women have a
natural tendency to become twisted. This complication is
to be diagnosticated by finding a fluctuating tumor which
has been the seat of sudden, violent pain, extending over
the entire belly, but more severe in one groin, accompanied
by vomiting, the peritoneal facies, and also at times by a
scarlatiniform or rubeoliform eruption. Such a rash was
present in another of the author's cases in a girl aged
fourteen years, as well as in the present instance. Imme-
diate operation is proper if the symptoms are severe, with
aggravation of the peritoneal signs, agitation, insomnia,
etc. Otherwise the acute symptoms may be allowed to
subside before operation.— y(;«?-«a/ de Medecine de Paris.
June 3. igoo.
Sterilization of the Hands. — Pierre Delbet, after a series
of experiments, finds that it is possible to render the hands
aseptic even after contact with most septic substances.
He washes in very hot water, not flowing, but in a basin
so as to get a good soap .solution. This is kept up for five
minutes, changing the water once. He then brushes with
ninety-per-cent. alcohol until a bichloride solution stays
evenly upon the whole surface, showing complete removal
of fatty matter. He ends by immersion in corrosive-subli-
mate solution for one minute. He concludes that surgery
can be done as aseptically without as with rubber gloves.
— (/' (7 -£•//(? Ilcbdo>iuidaire de AUdecine et de C/iirurgie,
June 7, igoo.
Trichorrhexis Nodosa. — Paul Paymond presented a man
with small nodosities along the hairs of the mustache.
This is a rare localization for the infection in his experi-
ence. The node formation and subsequent breaking of the
hair so as to form a brush-like end is due to a diplococcus
constantly found by the author. Antiseptic treatment has
not given important results. It is better to shave the parts
for a few weeks, practising rigorous antisepsis of the skin
surface. The toilet articles must be carefully looked after,
since nodosities have been observed upon hair-brushes. —
Journal de Medecine de J'aris, June 3, 1900.
Arc/lives of Pediairics, Ju7ie, igoo.
Remarks upon the Treatment of Whooping-Cough. — Fran-
cis Huber finds that in some cases, when intubation is not
practicable, one of the following methods gives good re-
sults; Sending the children much in the open air, or out
upon the water ; giving more food as soon as vomiting is
over ; pushing forward the jaw, as in aneesthesia, in many
cases has relieved the paro.xysm and prevented the vomit-
ing. A third method is the use of codeine in small and re-
peated doses to the verge of slight narcosis, sufficient to
overcome the spasm of the glottis. A few cases treated in
this way have been carried safely over the danger point.
As a rule it is not necessary to employ the remedy for more
than a few days or a week, at the end of which period the
severity of the attack is relieved, food is retained, and the
usual routine treatment may be continued.
A Cretin Successfully Treated with Thyroid Extract. — H.
Oliphant Nicholson reports the case of a little girl two
years and eight months old, who, up to the age of eight
months, had seemed to be normal. At that time a change
occurred, and when seen by the author she presented the
evident signs of cretinism. Thyroid treatment consisting
of about z)^ grains of thyroid powder daily, was instituted,
and in about three months' time very few traces of cretin-
ism remained. Two photographs illustrate the condition
before treatment and that after four months' taking of the
remedy, the diff^erence being very striking. Unfortunately
the child contracted measles of a malignant type and died.
Acute Glandular Fever. — W. F. Boggess describes the
course of this disease, the high, irregular fever, chills, pain
in the back, and involvement of lymph nodes. Rest in
bed and careful nursing, with local applications to the neck
of belladonna and ichthyol, he found useful, combined with
calomel to unload the bowels, followed by intestinal anti-
septics, salol, naphthalin, dermatol, and the use of tonics
and reconstructives.
Clinical Observations upon the Operative Treatment of Tu-
berculous Peritonitis. — By Augustus Caille.
Pancreatic Digestion of Casein. — By B. K. Rachford.
Bulletin of t/ic Johns Hopkins Hospital, May, igoo.
Urinary Anomalies. — T. R. Brown describes a simulative
nephritis after nephrotomies and nephropexies. The char-
acteristic feature is the presence of an enormous number of
casts, the urine quickly clearing up in the course of a few
days. The condition is referable to the handling of the
kidney, taking sutures through the renal substance, ether
irritation of the renal tissue, and diminution in elimination
of fluids almost invariably seen after ether anaesthesia.
Brown further describes post-operative glycosuria, which
he divides into toxic, those associated with diseases and
injuries of various kinds, and puerperal. He also alludes
to "malingering mellituiia," narrating the history of a
young girl who placed in the vessel containing her urine
lurups of sugar taken from food brought to her on a tray,
and who for a long time eluded detection.
Acute Leukaemia in Childhood, with Report of a Case. — T.
McCrae reports the case of a boy aged three years. A full
description of the patient's various symptoms is given, the
acute stage running a short course. Thirteen other cases
in children are reported and briefly analyzed. Eleven of
the thirteen cases were males. A bibliography of the liter-
ature bearing on the subject is given.
Personal Experience in Operations for Stone in the Blad-
der.—By A. T. Cabot.
The Practitioner, June, igoo.
Acute Phagedena of the Nose, Eye, and Face in a Syph-
ilitic Subject. — A. Phillips relates a rare case in a soldier,
aged twenty-six years, who contracted syphilis in India
two years ago. There was at first a small ulcer in the roof
of the mouth which spread rapidly. Fourteen days after
first seen the nasal cavities were filled with fetid sloughs,
and the cartilaginous septum had necrosed. A sloughing
ulcer occupied one ala of the nose, and gangrene attacked
the opposite side. The entire external nose was necrotic
within three weeks of the first observation. Succeeding
patches of skin became red and oedematous and melted
awaj'. Death occurred by septic infection one month from
the on.set. Treatment was without effect, but scraping and
cauterization arrested the oral ulcer.
Tabes Dorsalis.— James Taylor gives in the form of a
clinical lecture the history of cases of tabes, illustrating
the various phases and stages. Two were in women — one
only twenty-three years of age. She did not show the
Argyll-Robertson pupil reaction. There is little doubt of
the relation of syphilis in the large majority of cases. The
argument that one cannot cure tabes by antisyphilitic treat-
ment has no force. The most common symptom is the
pain : the next most common the girdle sensation. A
large proportion of subjects have difficulty in walking. A
common affection is that of the sphincters, especially of the
June 23, 1900]
MEDICAL RECORD.
1093
bladder. The three large divisions are: (i) those with
marked ataxy : {2) other symptoms presenting without
ataxy ; (3) optic atrophy and usually no ataxy.
On Some Points Connected with the Bdanagement of Stric-
ture of the Urethra. — \V. H. Bennett takes an unusual case
as a text for a clinical lecture, and goes through the various
steps of iirethral exploration and treatment. After inter-
nal urethrotomy the proper-sized sound should be freely
movable in the canal. The meatus should always be slit
in withdrawing the urethrotome. If it is not cut, urethral
spasm will occur and cause the sound to be grasped. Or-
ganic stricture is not curable in the strict sense of the term
by any means at present at our disposal. Avoid a too
slavish devotion to traditional routine methods : approach
each case with an open mind, common sen.se, and gentle-
ness.
The Static Method in X-Ray Work.— By A. U. Griffiths.
Cream and Fat in Infant Feeding. — By G. F. Still.
7 reatineiil, May, igoo.
Healed Phthisis. — H. W. Syers says that the evidences of
healed phthisis will be constantly found in the post-mortem
room when systematically looked for. He believes that
there is no remedy, no panacea for the cure of phthisis. He
pretests against the use of creosote. He has seen improve-
ment follow the use of counter-irritation, using equal parts
of the tincture and the liniment of iodine painted on over
the affected apex sufficiently often to roughen the skin, but
not to make it sore. Six-per-cent. iodine vasogen acts
equally well. Host cases will and must be benefited from
judicious feeding, judicious clothing, and from access to
pure air.
Infection through the Tonsils. — Frederick A. Packard calls
attention to the secondary lesions following angina ; among
these are endocarditis, pleurisy, albuminuria, skin lesions,
such as erythema nodosum, purpuric, multiform, morbilli-
form, scarlatiniform, urticarial, herpetic, and indeterminate,
chorea, phlebitis, acute yellow atrophy of the liver, perito-
nitis, acute hydrocele, strabismus, palsy, in some rare cases
pyaemia, and very frequently acute articular rheumatism.
In the few fatal cases of rheumatism in which the tonsils
were examined after death, streptococci and staphylococci
have been found.
Dublin /oiirnal of llie Medical Sciences, June, igoo.
The Dublin Method of Effecting the Delivery of the
Placenta. — H. Jellett contributes a polemic article main-
taining the following propositions: (i) That the method
of effecting the delivery of the placenta by external manip-
ulations, as opposed to its manual removal or its delivery
by traction on the funis, was originated in Dublin ; (2)
that Crede's method, when originated <le no''o\n Germany,
was identical in principle with the Dublin method, and
that it rapidly came to assimilate itself to the Dublin
method in its most important details ; (3) that, conse-
quently, there is no difference between the Dublin method
and Crede's method, and that inasmuch as the method
originated in Dublin many years before the time that Crede
discovered it for himself, its name is and ought to be "the
Dublin method."
Toxins and Antitoxins. — A. C. O'SuIlivan reviews our
knowledge of the source of antitoxins and the nature of
their action. He states his general conclusions as follows :
(i) The toxin enters into chemical, or molecular, combina-
tion with the cell protoplasm, and when in this combina-
tion is neutralized — /.<•., is innocuous for other cells. (2)
The to.xin enters into chemical combination with the anti-
toxin, and when in this combination is neutralized. (3)
The antitoxin is produced by the cell, and is thrown off by
the cell into the blood. (4) The cells which produce the
antitoxin are the same cells as those which combine with
the toxin.
On Commercial Pepsin. — By C. A. Cameron.
T/te Journal of Tropical Medicine, May, /goo.
Ankylostomiasis in the Leeward Islands. — H. A. Alford
Nicholls says that the facts concerning the life history of
the parasite of this di.sea.se show : (i) that the worms in
their larval stages are intimately' connected with the soil ;
(2) that the adult worms develop from larvae after the lat-
ter are introduced into the digestive canal of man ; (3) that
the worms act as minute leeches, e.xtracting blood and
causing little bleeding points by their bites ; (4) that, owing
to their minuteness, a multitude of the worms are neces-
■ sary to produce any serious deterioration of the vital or-
gans ; (5) that the worms cannot multiply within the body,
and that, therefore, in most instances, fresh infections are
necessary to prolong disease ; (6) that as the larvae are de-
veloped in the soil from eggs deposited thereon in human
dejecta, certain obvious and simple sanitary measures are
all that are necessary to arrest the propagation of the par-
asite, and therefore to rid any district of ankylostomiasis.
A Note on Mosquito Nets and Malaria.— R. W. Felkin re-
calls the fact that Gordon Pasha gave him the advice never
to sleep in Central Africa except under a mosquito net, as
he was convinced that it acted as a filler against malarial
poison, as well as against the mosquitos and other insects
which he thought might cause the fever. The author de-
scribes the portable mosquito netting which he made and
constantly used. For one week in Fatiko, where he thought
there were no mosquitos, he failed to use the net, and a
short time afterward had a bad attack of fever. This might
have been a mere coincidence, but he slept under the net
thereafter. A few insects are usually to be found inside
the net. By holding a light at one corner and outside the
net, they usually fly to it and can then easily be killed. Uri-
nals with covers should be used inside the net.
What Becomes of the Mosquito during the Dry Season? —
St. George Gray, from experimentation with mud from a
dried pool and with grass picked from its sides, found that
mosquito larvae developed from the grass. He thinks there
is no doubt that the eggs of Anopheles remain fertile for a
long time after drying, and would suggest as a prophylac-
tic, wherever possible, burning the grass where Anopheles'
breeding-places are known to exist, so as to destroy the
eggs before they mature, and thus prevent the pools be-
coming a source of danger to man.
Upon the Part Played by Mosquitos in the Propagation of
Malaria.— By George H. F. Nuttall.
The Endemic Centres of Plague. — By Frank G. Clemow.
T/ie luiinhurgli Medical Journal, June, igoo.
Has Antitoxin Reduced the Death Rate from Diphtheria
in Our Large Towns? — Louis Cobbett, from statistics col-
lected in London, Edinburgh, Glasgow, several other large
British towns, Paris, and Berlin, concludes that antitoxin
can have but a slight and indirect influence upon the prev-
alence of diphtheria. The proph)dactic use of the sub-
stance, in the case of children known to be exposed to in-
fection, might be employed with benefit more largely than it
is. The really eft'ective weapon that modern discovery has
given us is the bacterial test. It should be brought home
to the minds of people that diphtheria is not spread by bad
drains and insanitary surroundings, but by direct trans-
ference of the bacillus from mouth to mouth. AH persons
with suspicious sore throats should be examined by the
bacterial test, and if the bacillus is found they should be
isolated. All persons recovering from diphtheria, however
mild the attack has been, should be isolated until the spe-
cific micro-organism has disappeared from their throats.
A competent bacteriologist should be appointed in every
large town to make the necessary examinations.
Cross Infection, So-called, in Fever Hospitals. — Claude B.
Ker holds that most of the "cross infection " does not come
from other parts of the hospitals, but from outside, being
introduced in various ways. First, it may be due to a
wrong diagnosis made outside, difficult cases of scarlet
fever and diphtheria, or scarlet fever and measles, being
often confused. Secondly, it may be due to a patient being
admitted with two diseases, only one of which has been
diagnosed. Thirdly, it is due to the admission of patients
who are suffering from one disease and incubating an-
other. The second infection, in the great majority of cases
either measles or varicella, is developed some days after
admission. This is by far the most common of the causes
of so-called cross infection, and it is quite impossible to
avoid.
The Theory and Practice of the Treatment of Ringworm
of the Scalp. — W. Allan Jamiesou says that the entire
scalp must be kept bare of hair, by razor or curved surgi-
cal scissors, until the cure is complete. The scalp must be
kept rigorously clean, by being washed twice daily with a
fluid superfatted potash soap and warm water, the soap
being poured on a piece of wet flannel and moderate fric-
tion employed. The application then to be made consists
of : precipitated sulphur, 3 i. ; salicylic acid, beta naphthol,
and ammoniated mercury, aa grs. x. ; lanolin, | i. The
ointment must be rubbed in carefully and slowly for ten
minutes twice a day.
Points of Practical Interest in Surgical Gynsecology : II.
Some Pitfalls in Gynsecological Diagnosis.— By H. Mac-
Naughton Jones.
On Some Medical Superstitions. By J. L. Bunch.
Annals of Surgery. June, igoo.
Permanent (Congenital) Dislocation of the Patella. — J. S.
McLaren analyzes previously recorded cases and gives
notes of one seen in his own practice. His patient was a
girl aged nineteen years, whose left knee had always been
weak. She presented evidences of having had rachitis in
childhood. The condition of the left leg is thus described :
Marked genu valgum on the left side ; the leg is rotated
outward. When the knee is extended, the patella lies
somewhat to the outside of the normal position ; when the
1094
MEDICAL RECORD.
[June 23, 1900
joint is flexed, it passes farther and farther nut till it lies
on the outer side of the external condyle of the femur, its
anterior surface directed outward and forward. It may
with force be held in or near the middle line while the knee
is being flexed to a certain extent, but on being released
it flies out and back. The fossa patella? of the trochlear
surface of the femur can be felt to be partially filled up, as
it were, on its outer side, as if the external condyle pro-
jected into it, while the outer edge of that condyle, on the
other hand, seems to fail altogether and leave a gap under
the outer edge of the patella. The .v-rays show the posi-
tion of the patella to be higher up the femur than normal,
and give a faint indication of the altered shape of the ex-
ternal condyle.
The Leucocyte Count in Surgery. — Theodore Dunham
states that large hemorrhages are usually followed by a
marked leucocytosis. After ether operation of any magni-
tude, the count is as a rule much increased. He is inclined
to think that a similar result follows the absorption of iodo-
form. The increase has also been noticed in carcinoma
and sarcoma. The best service, however, which the leuco-
cyte count renders the surgeon is in the diagnosis of acute
inflammatory conditions. The leucocytes may help us to
infer the presence of a suppurative process not only by
their greater abundance but also by qualitative changes
which thev exhibit. In cases in which a progressive suppu-
rative process is present, a larger or smaller proportion of
the polymorphonuclear neutrophiles stains with iodine.
This reaction is not found in normal blood and is said not
to occur in any disease which could well be confounded
with acute abscess.
Splenectomy for Congestive Hypertrophy.— J. W. Bovee
reports his third ca-e. His patient was a woman aged
thirty-nine years, who had noted the presence of an abdom-
inal tumor two years before, with a small ulcer on the
inner side of the anterior surface of the left leg. Diagno-
sis of enlarged spleen was made, and in due time the latter
organ was removed. After a somewhat prolonged conva-
lescence she was allowed to leave the hospital, and her
subsequent history was uneventful. Examination of the
spleen showed a simple congestive hypertrophy. The limi-
tations and dangers of the operation are discussed by the
writer, who takes a conservative view of the general ques-
tion.
Thyroid Medication in the Treatment of Delayed Union of
Fractures. — After a brief review of cases reported by others,
F. W. Murray gives his personal experience with one case
— that of a man who was struck by a locomotive and sus-
tained two simple fractures of the left femur. Non-union
followed, and the man had had several operations before
he came under the writer's care. He was again operated
upon, but also without result. The administration of thy-
roid was begun and for a time seemed to offer promising
results. The later history of the case, however, was dis-
appointing, and the writer confesses that the result of thy-
roid treatment in this particular instance was a distinct
failure.
Report of a Case of Exstrophy of the Bladder, with Re-
marks upon the Operative Treatment of that Condition. — By
Bransford Lewis.
Operation for Cure of Large Incarcerated Hernia of Long
Standing. — By J. C. Weidman.
Interscapulo-Thoracic Amputation for Osteo-Myelitis of the
Humerus. — By G. R. Fowler.
Radical Treatment for Curvature of the Penis. — By Eugene
Fuller.
Zcilsch./. Tiibcrk. ti. HeilstCitt., \'oI. i., Xos. i and 3, /goo.
Some of the Problems Involved in the Tuberculosis Ques-
tion.— Cornet says that one of the points of the disea.se de-
serving attenti<m is that concerning mortality statistics.
The figures published heretofore have dealt only with iso-
lated countries, or districts of countries, and have appeared
sporadically at uncertain intervals. What is needed is a
systematic and searching numerical investigation of deaths
from tuberculosis, which shall be an international affair,
shall be conducted regularly, and shall embrace not only
pulmonary phthisis, but also tuberculosis of every other part
of the body. The mortality coefficient to be attributed to
the tubercle bacillus is furthermore to be estimated not by
comparison with death rates, but rather from the living
population, and to this end census taking at five-yearly
intervals becomes a necessity, and statistics should also be
available concerning the number of inhabitants affected
by the disease. A defect that is manifest in much of the
work that has been done on tuberculosis, as well as in oth-
er branches of medical science, is the habit of hasty gener-
alization from a limited number of case histories or animal
experiments. Questions that require further investigation
are those dealing with the biology of the bacillus, its life
history in the body, the conditions that determine its rate
of proliferation, virulence, etc. The significance of the
lymph glands in influencing the establishment of tubercu-
lous foci, as well as the possibility of the tonsils as affording
portals of entry for infection, and the changes produced in
the course of the disease by mixed infections, are not yet
well determined. Of the aids to diagnosis the diazo reac-
tion of Ehrlich and the Roentgen rays have both yet to es-
tablish definite claims for recognition. The question of
therapy is still very unsettled, especially the treatment of
haemoptysis and hemorrhage, which has not advanced be-
yond the purest empiricism.
The Conditions of Infection by Tubercle. — Arthur Ran-
some says that the conditions necessary for infection by
the tubercle bacillus to take place are : (i) A virulent state
of the microbe ; it is often overlooked how easily the bacil-
lus loses its power of infection. (2) The bacillus needs a
certain kind of organic impurity upon which alone it can
sustain its virulence. Tuberculosis is essentiall}- a "filth
disease, " and seldom spreads unless organic impurity is
presentin houses, workshops, or placesof publ'c assembly,
and this is generally to be discovered in the aqueous vapor
of the air of these places. (3) The third condition of infec-
tion is that it must have a su.sceptible body to attack ; race,
age, and hereditary tendency all influence this factor. (4)
The danger of infection from food is the last and least im-
portant factor, inasmuch as perfect sterilization by heat is
possible ; although the bacillus stands freezing, desiccation,
and putrefaction, and resists nearly all the aerial disinfec-
tants, it is easily de.stroyed by a moderately high tempera-
ture. In deducing from these conditions the factors neces-
sary to prevent infection he concludes: (i) All tubercu-
lous matter, sputum, etc., must be destroyed or rendered
innocuous by disinfection. (2) Houses inhabited by con-
sumptives should be subjected to a thorough cleansing and
disinfection, preferably by Delepine's method of washing
all surfaces with a one-per-cent. solution of chloride of
lime. (3) Local sanitary authorities should use all the
means in their power to render the districts under their con-
trol healthilj habitable; the same obligation rests on owners
of property. (4) Legislation should enforce ventilation of
workshops, theatres, etc., and forbid expectoration in pub-
lic places. (5) The State should insist on the use of the
tuberculin test for cattle ; meat and milk should be steril-
ized by thorough heating before use.
The Choice of Tuberculous Cases Suitable for Sanatorium
Treatment. — Moeller deprecates strongly the tendency com-
mon among both the profession and the laity to consider
the sanatorium as the forlorn hope of the consumptive.
The always beneficial and often absolutely curative effects
of sojourn in pure air, suitable diet, and strictly regulated
habits, coupled with avoidance of psychical excitement and
bodily exertion, have been too incontrovertibly demonstrat-
ed to permit of any difference of opinion as to the value of
sanatorium treatment, and the difficulty is mainly one of,
firstly, recognizing the disease at a sufficiently early stage,
and, secondly, of persuading the patient that his condition
is serious enough to demand such radical measures. Cases
in which the prognosis is most favorable are those in which
the lesion is unilateral and involves the apex ; when there
is no febrile movement, the digestive organs are not
affected, the urine is free from albumin and does not give
the diazo reaction, and the general condition has not great
ly depreciated. Very unfavorable, on the other hand, is
the prospect in those patients the victims of typical "con-
sumption," commonly hereditary in young individuals of
markedly phthisical habit; in those who have tuberculous
lesions in other parts of the body in addition to the pulmo-
nary involvement, also in those stages of the disease in
which cavity formation has taken place, or both apices or
a lower lobe are affected.
" Drop-Infection " of Tuberculosis and its Prevention.— B.
Frankel advocates the use of masks of gauze covering
mouth and nostrils as almost a necessity in preventing dis-
semination of the bacilli by patients in the acts of cough-
ing, sneezing, etc. The use of the handkerchief in place
of a mask is uncleanly and not a sufficient protection, for
the suddenness of onset of a paroxysm of coughing nearly
always means infection of the air before the handkerchief
can be applied. Inoculation of guinea-pigs with portions
of material cut from the masks after twenty-four hours'
use by patients in whose sputum the tubercle bacillus was
demonstrable, gave a positive result in every instance.
This was so even though care was taken to use for the
experiments only those portions of the gauze which were
quite spotless macroscopically, demonstrating the danger
to be apprehended from "drop-infection." Recognizing
the many difficulties attempts to introduce the universal
employment of masks will encounter, the author has sought
to devise some less objectionable substitute, but unsuc-
cessfully, and advises the use of the masks in all cases in
which the patient is forced to live in the same room with
the healthy without their being separated by a distance of
more than three feet.
June 23, 1900]
MEDICAL RECORD.
1095
The Inheritance of the Locus Minoris Resistentiae in Pul-
monary Tuberculosis. — Turban says that the extreme rarity
of direct hereditary transmission of tuberculous infection
is universally recognized, as also the fact that a tuberculous
family history does not necessarily increase the gravity of
the prognosis when the disease is contracted. The ques-
tion of hereditary predisposition, however, is still a moot-
ed one, though the statistics collected by the author would
seem to give pretty positive evidence in favor of the the-
ory. Out of tifty-five families, in eighty per cent, children
or brothers or sisters were found who were suffering from
tuberculosis as well as heads of the families, and a signifi-
cant fact is that in most of these the lesion was situated
in corresponding points of the lungs. The evidence is ap-
parently greatly in favor of an inherited point of lessened
resistance, and according to the investigations of Birch-
Hirschfeld this would seem likely to be due to a failure in
development, which he has found most frequentlv U> in-
volve the region supplied by the posterior aiiical bronchus.
Respiratory Exercises in the Treatment of Pulmonary Tuber-
culosis.— Schultzen says that the value of voluntary respi-
ratory gymnastics (as opposed to inhalations of compressed
air, tire pneumatic cabinet, etc.) in the treatment of pulmo-
nary tuberculosis is still contested by many eminent au-
thorities. He advises it in from si.xty-five to seventy-five
per cent, of the usual class of cases, and finds that both the
general condition of the patient and the diseased focus are
favorably affected. The most suitable and satisfactory
method consists in carefully graduated and regulated moun-
tain climbing, but this is often not feasible owing to the
patient's debilitated condition, and may advantageously
be replaced by full, deep, slow inspiration immediately
followed by somewhat forcible expiration. This is to be
kept up all day long, at first every half-hour two to si.x
times in succession, later at intervals of fifteen minutes.
The Agglutination of Koch's Bacillus ; its Application to the
Serum Diagnosis of Tuberculosis. — Arloing and Courmont.
after a careful series of observations and experiments with
different methods of technique, conclude as follows ; (i) It
is possible to obtain pure cultures of Koch's bacillus from
glycerin bouillon and to grow successive generations by
careful technique. (2) Using these, it is possible to get a
definite serum reaction ; in the healthy the blood serum
occasionally agglutinates at a proportion of 1:5; in the
tuberculous usually at a strength of i : 5 to i : 20. (3) This
reaction may serve to diagnosticate ordinary cases and
detect latent cases in those apparently healthy. (4) In
spite of the technical difficulties to be overcome, the reac-
tion by reason of its harmlessnessand its rapidity deserves
extended application.
The Curability of Tuberculosis. — Schrotter, without in any
way discrediting the value of prolonged sojourn in warmer
regions, such as the Riviera, in the treatment of phthisis,
warmly recommends that each country should make the
most of its own climatic and other advantages, and affirms
that by carefully conducted sanatoria erected in well-se-
lected regions it is possible to give the poor at home the
same chance for restoration to health that the rich are able
to procure by travelling. That even when taken in the lat-
er stages the disease may be arrested in cases that seem
hopeless, is evidenced by a history quoted in full, but ordi-
narily the sanatorium cases should be those still in a less
advanced state.
The Value of Meat in the Preventive and Curative Treat-
ment of Pulmonary Tuberculosis. — F. Parkes Weber directs
attention to the infrequency with which tuberculosis and
gouty diseases are found in the same individual, and sug-
gests that there may be some substance circulating in the
blood of gouty subjects, in minute quantities, yet sufficient
to have an antagonistic action toward the growth of tuber-
cle, and that this is likewise the case in persons taking an
unusual amount of food. In accordance with this view he
advocates the use of a preponderatingly proteid rather than
carbohydrate diet in tuberculous individuals, laying stress
on the necessity for seconding the treatment by abundant
out-of-door exercise.
The Significance of Tuberculosis as a Cause of Premature
Death among the Adult Population of Germany. — Rahts pre-
sents a review of statistics showing that of those dying of
known causes in Germany between the ages of fifteen and
-sixty years in 1893, thirty-three per cent, succumbed to
tuberculosis; in 1S96, 33.4 per cent. ; and in 1897, 33.5 per
cent., evidence that the proportion of deaths due to this
cause is by no means on the decrease.
Zeitsch.fiirklui. Medicin, Bd. 40, Hft. i. and it. , rgoo.
The Relation of Charcot - Leyden Crystals to the Eosino-
phile Cells. — Benno Lewy states that the Charcot-Leyden
crystals are found in leukaemia (all structures) , in the ex-
pectoration of numerous thoracic diseases, in nasal polypi,
in various tumors, in the fccces (helminthiasis) , and in
normal bone marrow. It is shown that as soon as the
eosinophils cells appear in very few numbers no Charcot-
Leyden crystals are excreted, but when eosinophile cells
appear in abundance, the crystals can always be found.
Wherever crystals occur eosinophile cells are in abun-
dance ; where no crystals exist the eosinophile cells are
few or altogether wanting.
A Case of Pernicious Ansemia with Yellow Bone Marrow
in the Epiphyses.— C. S. Engel describes the above case and
considers it an instance of the aplastic form of pernicious
anamia. Contrary to the usual forms of jjernicious an-
aemia, no red bone marrow was found in the diaphyses,
but yellow marrow in these, as well as in the epiphyses.
The ribs contained a dirty gray, watery fluid which, mi-
cro.scopically, was utterly devoid of cells. The fluid con-
sisted of numerous immobile bacilli which were easily
stained with Loeffler's methylene blue ; in addition to these
detritus and fat particles could be demonstrated.
The Pathological Changes in the Digestive Tract in Per-
nicious Anamia and the So-Called Intestinal Atrophy.—
Knud Faber and C. E. Bloch state that it may be generally
accepted that in pernicious anemia, idiopathic as well as
that due to bothriocephalus latus, atrophic inflammatory
processes are found in the stomach and intestinal tract.
Histories of several cases, microphotographs, and an ex-
tensive literature accompany the article.
Diplogonoporus Grandis (R. Blanchard) .— Tomei Kurimoto
describes a particular kind of bothriocephalus, found for
the first time in the human intestinal tract.
A Simple Method for the Direct Estimation of the Color
of the Blood.— By T. W. Tallquist.
The Mobility of the Heart upon Change of Position (Car-
dioptosis) .—By H. Determann.
Clinical-Chemical Studies.— By C. V. Stejskal and F.
Erben.
Observations upon the Mechanism of Circulation.— By O.
Rosenbach.
A Case of European Chyluria.— By \V. E. Predtetschensky.
CHorrespontleuce.
OUR LONDON LETTER.
(From our Special Correspondent.)
MEDICAL COUNCIL— CLINICAL SOCIETY — GASTRO-ENTEROSTOMY
FOLLOWED BY PVLORECTOMY — ANTISTREPTOCOCCUS IN
SEPTICEMIA — graves' DISEASE— THE ANTIS ON MR. PAGET's
BOOK — THE INTERNATIONAL MEDICAL CONGRESS.
London, June i, 1500.
The General Medical Council continued its sittings up to
last night. On Friday penal cases were resumed, and they
occupied Saturday also. Several names were ordered to
be erased from the register. The council is not a body well
adapted for judicial inquiries, but it manages to get through
this duty with fairness, though its processes are very slow.
Entering its second week of work, the first subject on Mon-
day was the prevention of personation. This is an offence
which has been actually committed, and one would there-
fore imagine obvious precautions should be enforced. But
these learned councillors seemed to have doubts. Some of
them thought it would be a serious departure from routine
to require applicants for registration to fill up and sign a
form in their own handwriting. The registrar of the Scotch
branch has always done this, but the English registrar
thinks it would impose a heavy responsibility on him. It
is hard to see why the registrar should have been asked
for his opinion. He said the difficulty was there being
three offices. But a common-sense precaution which has
always been taken in Scotland as a matter of course could
impose hardships on no one. So if "the man in the street "
picked up a lost diploma he might go into the office and
register himself in the name it bore — and if it bore the sig-
nature of the man to whom it was granted, as many diplo-
mas do, he w-ould not be asked to sign his name to the ap-
plication, and the registrar might object to the trouble of
comparing them. Could you imagine a clearer exemplifica-
tion of "how not to do it "?
Another important question related to reciprocity' of prac-
tice between this country and Italy. The council has
shilly-shallied so much ove'r this that the Privy Council has
intimated its intention to act in the matter. There was
much talk on this communication, and at last it was agreed
to represent to the Privy Council that the Italian project did
not make reciprocity equal between the two countries.
Medical aid associations were also talked over, and a depu-
tation was received. There was a report, too, of the com-
mittee, but the matter is to come up at a future session.
As much may be said for some other reports and questions.
1096
MEDICAL RECORD.
[June 23, 1900
Thanks were voted to the pharmacopoeia committee, and
other usual votes passed.
On Friday Mr. Barker read at the Clinical Society notes
of a case of gastro-enterostomy followed by pylorectomy.
The patient was a woman aged fifty-five years, with a tu-
mor to the left of the left rectus under the border of the
ribs, and partial intestinal obstruction. It was thought to
be a growth of the splenic flexure of the colon, and the ab-
domen was opened. Then it was found to be a carcinoma of
the pylorus. Consequently retro-colic gastro-enterostomy
was at once done. Recovery was rapid, and five weeks
later the whole of the pyloric end of the stomach was re-
moved. The resulting openings in it and the duodenum
were closed. The patient recovered, gained flesh, and was
soon eating ordinary food ; but recurrence took place, and
she died a year later. The first operation was done under
local eucain analgesia, the second under chloroform.
Murphy's button was employed and came away on the
twelfth day. Mr. Barker thought the operation was facili-
tated by doing it in two stages, but it should never be done
except for malignant disease.
Mr. Bidwell said he had operated in the same manner
and approved of doing it in two stages. In one case done
in one stage the patient died in ten days from adhesions of
the jejunum resulting in a kink, to prevent which he sug-
gested that the loop attached to the stomach sb mid not be
too close to the duodenum. If it were, regurgitation of bile
into the stomach miglit occur. He liked Halsted's method
of suturing, and thought about eighteen days between the
two stages a suitable interval.
Dr. Victor Bonny read a paper on a case of septicaemia
treated by anti-streptococcus serum and later by nuclein.
Of the former, forty-two injections, amounting to 420 c.c,
were given in seventeen days. Of the latter, 30 c.c. of a
one-per-cent. solution was injected in the course of eight
days, during which the temperature fell and convalescence
began. There was a suspicion of a gonococcus in one of
the examinations of the blood, but confirmation was pre-
vented by an accident. So, though Dr. Bonny thought it
improbable, the case proves nothing, for cases of gonor-
rhoeal pyaemia may go on to an extreme degree and yet re-
covery take place in a remarkable way.
Dr. Pasteur communicated the sequel to a case of Graves'
disease shown in April, 1S9S. A widow, aged sixty-seven
years, had the disease for twenty years with tachycardia.
The thyroid dwindled, and gradually bradycardia super-
vened. Whether this last was due to degenerative lesions
of the heart or to myxoedema coming on was a question.
The latter was the general opinion. A degree of thyroid
atrophy in the wake of Graves' disease is interesting.
The heart lesions found at the post-mortem did not seem
to account for the course of the disease, and the nervous
system had not been investigated.
Mr. Stephen Paget's book on "Experimentation on Ani-
mals" having been published on your side of the Atlantic
as well as this, your readers can easily satisfy themselves
as to the moderation of his statements. The anti-vivisec-
tiouists here are terribly disconcerted and have put up Mr.
Stephen Coleridge as their advocate. He is a counsel and,
perhaps naturally, adopts the professional methods of the
special pleader without realizing how inappropriate they
are to discussions of scientific matters. He would be wiser
if he were to cultivate the judicial frame of mind, and cer-
tainly more worthy of his distinguished father. But, as I
said, he is advocate for the anti-vivisectionists. I do not
know whether they pay him for his efforts, but lawyers are
not much given to gratuitous work. He has been working
the press as well as he could. On Monday I received from
the editor of The Morning Post a copy containing a letter
of his to Mr. Paget complaining of an inaccurate quotation
of one of the official certificates, and Mr. Paget's reply that
he had quoted the early form instead of the revised one
and thanking him for pointing it out. This courteous reply
strikingly contrasts with some of Mr. Coleridge's effusions.
He seems to take the counsel's liberty of almsing the oppo-
site side to an extent that betrays the emptiness of his case.
The journals have treated his one-sided statements as if
they were serious arguments, and so we have had long-
drawn-out letters leading to nothing. One of your con-
temporaries has admitted letter after letter of his contro-
verting its review of Mr. Paget's book ; but even now Mr.
Coleridge is not satisfied. How can a man be who takes
up the advocacy of such a craze, and is not qualified by
education to discuss medical matters ? He has been treated
too kindly by the press, perhaps out of respect to the mem-
ory of his father, but he ought to know better than to take
advantage of this leniency. In one of his letters he whines
about Lord Lister not replying to his several challenges to
discussion. For my part I think Lord Lister is quite right
in maintaining a dignified silence toward a professional
advocate whose equipment for scientific debate is so feeble.
On the morning on which the correspondence in 7 he
Post appeared the newspapers gave information as to some
of the barbarous practices of dishonest horse dealers. But
these and other cruelties do not seem to attract much atten-
tion from anti-vivisectionists and their advocates. Truly
the anomalies of human brains seem innumerable.
The International Medical Congress, which will be held
in Paris from the 2d to the gth of August inclusive, has not
at present attracted much attention here, but is beginning
to be spoken of. Four gentlemen have been appointed to
represent the British government officially, viz.. two In-
dian medical officers, one naval, and a local board commis-
sioner (Ireland). Members are asked to send in the titles
of their papers before the loth inst. ; if later, they will not
appear in the prospectus. Members can join up to July
15th. The fee is 25 francs, and the ticket entitles the
holder to a reduction on French railway fares and free en-
trance to the exhibition. Paris will be full and expenses
high.
OUR PARIS LETTER.
(From our Special Correspondent.)
IMPORTANCE OF SANITARY CONDITION I.N PARIS DURING THE
EXHIBITION — STATISTICS PUBLISHED — CASE OF SMALLPOX
BUBONIC PLAGUE AT PORT SAID— ARTICLES BY LOCHELONGUE
AND NETTER — ACCIDENTS AT THE EXHIBITION — AMBULANCE
SYSTEM— NECESSITY OK AN AMERICAN HOSPITAL IN PARIS —
EXHIBITION OF THE CirV OF PARIS.
P..RIS, June ,, looo.
Now that the exhibition is in full swing, crowds of for-
eigners and of provincials are flocking to Paris to see the
sights, and the health of the city as affected by this rapid
influ.x of visitors is one that merits attention. Any serious
outbreak of typhoid fever or smallpox, any hint at the ex-
istence of plague in some part of France would be fraught
with disastrous consequences. When we consider how
many different nations are represented in Paris at this
time, and how primitive are the sanitary conditions that ob-
tain among them, it is perhaps to be wondered at that no
serious outbreak has as yet occurred. The necessity of
vaccination has indeed been insisted on, and to give an
example in a humoristic line, Caran d' Ache, the celebrated
cartoonist, published recently in the I'igaro one of his ex-
ceedingly clever series of drawings, in which he showed, as
a." clou" oi the exhibition, a procession of medical men,
physicians of the hospitals, internes, and aids, all dressed
in the garb of the time of Moliere. and all prepared to vac-
cinate the dusky tribes who will furnish amusement at the
exhibition. The statistics published so far by the city of
Paris aie very encouraging, no cases of smallpox being
noted in the last weekly report. I must add, however,
that last Saturday, on going into one of my former wards
at the Beaujon Hospital, I came across a patient just re-
ceived, who had an eruption resembling that of smallpox.
On questioning him, the general history of the case seemed
to be that of this infection, with the exception of the pain in
the back. The man had just arrived from Lyons, where
smallpox would seem to be prevalent. On inquiry I found
that the diagnosis of smallpox had already been thought
of, and that the man was to be sent to Aubervilliers. a lo-
cality close to Paris, where there is a special. hospital for
such cases.
What is more to be feared than smallpox is the possibil-
ity of an epidemic of bubonic plague. The newspapers are
daily reporting cases in Port Said, where forty-eight cases
have already been declared, with a total of twenty-two
deaths. This epidemic was denied at first, and a certain
foreign element tried to prevent the health officers from
getting to their patients and carrying out the work of dis-
infection. These obstructionists, as they were called by
the newspa]]ers, were, however, overpowered, and it was
shown that the French physician who had reported the first
case was in the right. A case was reported yesterday at
Alexandria, another has been discovered at Smyrna, and
a sensation of uneasiness cannot but be felt. Stringent
measures have been carried out, however, and it is to be
hoped that the disease will not spread.
It may be mentioned in relation with this question that
a good article was written recently in the Prcsse iUdicale
by Dr. Lochelongue, sanitary officer in Egypt, on the bu-
bonic plague and the convention of Venice in 1897. This
article showed how the recent knowledge acquired as to the
origin and means of propagation of the plague necessitated
a change in the regulations concerning quarantine, the old
system being quite faulty. Moreover, new lines of traffic,
due to the constructing of railways through Asia Minor and
Arabia, would naturally completely remove whatever use-
fulness the Suez Canal may have offered as a sort of filter
by which any suspicious cargoes or ships could be arrested.
A map accompanied this article, showing the different
routes to be followed. A railway, starting from the Indian
frontier, has been constructed in Afghanistan as far as
Chaman. The Russians are already at Kouchk. The
English, the Germans, and the Russians have already
June 23, 1900]
MEDICAL RECORD.
1097
mapped out various lines through Asia Minor and Arabia,
and these will most likely be constructed in a few years.
The classification of merchandise into two distinct catego-
ries—on the one hand such articles as rags, old clothes,
hair, and leather, on the other anything not comprised in
the previous enumeration — is insufficient. Such articles as
rice, grain, and breadstuffs can be contaminated by rats,
and yet they cannot be prohibited or disinfected. The
only way out of this dilemma is to establish, as Dr. Loche-
longue said, a species of intermediary quarantine between
the ships on one side and the warehouses on the other.
Such is the plan that can be carried out in Egypt by the
use of "chalands," or large cargo-boats, used to receive
cargoes. Dr. Lochelongue demonstrated also in his article
that the present regulations concerning ships in quaran-
tine were inadequate. It is not sufficient, for instance,
that no death should have happened on board during the
voyage, as the hold may be already infected and an out-
break among the passengers may be on the point of show-
ing itself. Then, too, a port is considered safe when ten
days have elapsed without a death, and yet the mice and
rats may still be suffering from the plague. Dr. Loche-
longue ended his article by saying that quarantine, as
practised at present, was quite inadequate, and he cited
as a proof of this the fact that, railway quarantine being
abolished at present, pas.sengers could go direct by rail
from Alexandria, which was plague-stricken, to Suez,
whereas if they went by sea they had to undergo a quar-
antine of eight days.
Since the opening of the exhibition two very serious ac-
cidents have occurred, due to the haste with which the
buildings were put up. A bridge in the Avenue de Suffren,
built of wood and what is called "cement arme," gave way
and crushed a comparatively large number of per.sons who
were passing below. The bridge had not yet been opened
to the use of the public, but the shoring had been removed
too soon, it seems. Some scaffolding in the large central
hall in the Champ de Mars also gave way, and four men
who were working at a great height were killed. Two cen-
tral ambulance offices have been established inside the
exhibition, and there are at all times medical men in at-
tendance ready to render any assistance in case of need.
There is getting to be less and less room in the Paris hos-
pitals, on account of the increase in the population, and
with the present influ.x of visitors all the hospitals will be
full to overflowing. The result will be that needy foreign-
ers will have some difficulty in finding accommodation
when taken seriously ill. The English population of Paris
has, of course, its own admirably constructed hospital, the
funds for which were given by Sir Richard Wallace, but
there does not exist anything of the sort for Americans,
and it is more than likely that the need of such an institu-
tion will be felt very much during the exhibition. It hap-
pens now and then that an American is taken to one of the
French hospitals, where, not knowing French, and being
surrounded by patients who are not always well disposed
toward foreigners, he is certainly not placed in the best
conditions for making a rapid recovery. Of all the hospi-
tals in Paris, the one best suited for sending Americans to
is that of Boucicaut. as it comes up in its general style and
arrangements to what Americans are accustomed to.
I visited this morning a part of the e.xhibition which is
calculated to excite the curiosity of physicians. It is the
exhibit made by the Assistance Publique in the pavilion
of the City of Paris. If one enters by the Champs-Elysees
gate, which is certainly the finest by far and the most
impressive, he should go down the right bank of the Seine
till he comes to the Pont des Invalides, cross over the tem-
porary wooden bridge, and enter the building which is at
the right of the Invalides bridge. The building is in the
form of a large hall, with a gallery running around it. In
the centre is a reservoir, which is to be filled with water
from four different sources: the Seine, the Ourcq, the
Vanne, and the Aure. The first two are used only for wash-
ing purposes, according to the sign that is put up on each
tank. In a room near-by are exhibited cultures of the dif-
erent microbes to be found in Paris water. Near the door
there are some charts showing the mortality from conta-
gious diseases in some of the large towns in France.
Special notice should be paid to a chart showing the preva-
lence of typhoid and scarlet fever in Paris during the last
year. In one month there were seven hundred and twenty
cases of typhoid fever and in another month seven hundred
and eighty cases of scarlet fever. Diphtheria is decreas-
ing, but the mortality during the last three years is about
the same. Still further one comes to the veterinary sec-
tion, where are shown maps indicating how Paris and its
environs are divided into a certain number of districts for
the inspection of horses and cattle, specimens in wax of
curious lesions such as glanders or actinomycosis, and
some large intestinal calculi of the horse. Then there are
some good drawings in color of different varieties of mush-
rooms. The exhiliit of the Assistance Publique conies
ne.xt, and is certainly not very extensive. The most curi-
ous thing is an old four-poster bedstead, dating from the
last century, and coming from the "Hotel Dieu, confession
80," so reads the sign. This bed is covered with red tape.s-
try and a green baize cloth, and four wax manikins have
been figured, three in the bed and a fourth warming him-
self beside a brazier. This bed was only exceptionally
used for four patients. Different pots and pans are also
exposed, so as to give one .some idea of the way in which
people were taken care of in the hospitals at the end of the
last century. A drawing is hung on one of the posts, and
it represents the Duke of Chartres bleeding a patient,
while his tutor is standing by. On the opposite side of the
room is a modern bed, such as is used at the Boucicaut
hospital. It is constructed wholly in iron, and is flanked
by a night table in iron and porcelain. Plans of different
hospitals are hung up on the walls, and surgical instru-
ments, such as they were at the time of Dupuytren and as
they are nowadays, are also exposed. Further on one can
see a model destined to show how the beds are arranged
with glass compartments at the isolation pavilions at the
Enfants-Malades Hospital. It consists of a high glass case
which reaches to the roof of the ward. An extremely curi-
ous object is the "tour des enfants assistes," destined to
receive foundlings. It is a soit of crib in a large cupboard
placed in the wall of the establishment, and which can re-
volve on itself. When a child was abandoned, it was placed
in this crib, the bell was rung, and the guardian inside the
hospital turned the cupboard so as to be able to take the
child out. In this way the person who left the child could
not be recognized by the doorkeeper. This "tour" was
used up to 1S60, when it was replaced by an open office,
where the children were inscribed. In former years most
of these poor children died. Dr. Sevestre and, later on.
Dr. Hutinel have done much to ameliorate the hygienic
conditions of this Hopital des Enfants Assistes. Interest-
ing statistics as to the mortality of patients in the hospitals
are also shown, and there is a chart indicating the number
of foreigners of different nationalities who are taken care
of in the different hospitals. In iSSS there were 135,000
patients admitted, and 7,7S2 were foreigners : in iSgg there
were 195,000, of which 9, 530 were foreigners. Of this num-
ber the greater part were Germans, about 3,200, Italians,
Swiss, and Belgians coming next, the English numbering
only about 180, and the Americans 85 to 90.
SOMETHING ELSE TO DO FOR SEA-
SICKNESS.
Sir: Great minds think alike. I have read with deep in-
terest Dr. Herman Partsch's article on what to do for sea-
sickness, in the issue of June gth. To every word he has
written I can say "That's right ! " I have been there and
know it is all true, for experience is a very good instructor.
I can truly claim, I believe, the rather dubious honor of
being the champion seasick man of the universe. I always
go to sea with a bottle of beef tea at one of the head corners
of the berth and a bottle of strong tea at the other : and
take a dose after each paroxysm. This prevents the desire
for being cast overboard. But Dr. Partsch has forgotten
the greatest of all alleviations, viz., ice at the nape of the
neck and base of the brain. I was informed as to this
remedy by a stewardess on the old Guion Line many )-ears
ago. I never knew her name and I don't remember how
she looked ; but I love her still. On this particular trip I
was taking my bride abroad on a wedding-trip (as a rule
this is not a recommendable thing to do) , and I was so sick
that I did not care whether I vomited on my bride from
my upper berth or not. After observing me profoundly for
two days this good stewardess spoke to me as follows :
"You are the sickest man I ever see." Then she went
and got the ice, and I lay on it with perfect comfort for
the rest of the voyage. I would recommend all those in-
clined to this terrible evil of the sea to provide themselves
with a small rubber bag for an ice-water pillow for the
week. Those who have never had this agony may laugh ;
but not those who have been so stricken.
J. M. W. Kitchener, M.D.
East Orange, N, J.
Poisoning by Hydrogen Arsenide. — An aeronaut
was recently poisoned by hydrogen arsenide which
escaped from the balloon. This shows the necessity
of purifying the hydrogen arsenide used for balloon
purposes. The balloon was filled in the ordinary way
and nothing peculiar in the odor of the gas was no-
ticed. A few hours afterward persons who had as-
sisted in the operation were taken seriously ill. —
Scientific American. '
1098
MEDICAL RECORD.
[June 23, 1900
J>ocietij ^Icpouts.
AMERICAN MEDICAL ASSOCIATION.
Fijty-First Annual Meeting, Held in Atleiniic City,
N. /., on June j, 6, 7, atid 8, igoo.
{Concluded /rom page lobg.)
SECTION ON OBSTETRICS AND DISEASES OF
WOMEN.
Fourtli Day — Friday. June 8.
Post-Operative Treatment of Abdominal Section
in Women. — Dr. Walter B. Chase, of Brooklyn,
read this paper. He said that, other things being
equal, the best after-results in these cases followed
proper preparation of the patient and good hygiene.
In closing the abdominal incision he recommended
the use of chromicized catgut for layer suturing, and
silkworm gut when the through-and-through method
was followed, the suture not being tied too tightly.
He condemned buried unabsorbable sutures, since
they remained as foreign bodies liable to cause pain
and ulceration. Removal of the through-and-through
sutures was recommended after from eight to twenty
days, the alternate sutures being removed and the
others allowed to remain a few days more. He recom-
mended greater latitude of position after laparotomy
than had usually been permitted. In the treatment of
shock he advised before the close of the operation the
administration of a high rectal enema of a pint of hot
salt solution and an ounce of whiskey, together with
proper cardiac stimulation. Hemorrhage could be
immediately arrested by compression or ligation of
bleeding vessels; when practicable the operation
should be performed with the patient in bed. Flatu-
lence, nausea, and vomiting, if due to ether narcosis,
would subside spontaneously. In nausea he advo-
cated hot water in drachm doses frequently repeated;
if vomiting persisted, he gave high rectal enemas of
water containing two or three drachms of a saturated
solution of sulphate of magnesium at intervals of about
two hours until the bowels were opened. If nausea
was not present twelve hours after the operation, tea-
spoonful quantities of hot water or chicken broth at
intervals of an hour were given. The quantity might
be increased if it was well borne, and it might be fol-
lowed by beefsteak, lime-water, and milk. The quan-
tity and quality of the urinary secretion should be
watched. Evidence of injury to the urinary tract and
diminished or suppressed renal secretion, partial or
entire, called for prompt and energetic measures, such
as saline laxatives, pure water by the mouth, and salt
sdlution by rectal enemas, diaphoresis, and if the arte-
rial pressure was diminished digitalis and persistent
dry cupping.
Dr. I. S. Stone, of Washington, agreed with Dr.
Chase that morphine was rarely necessary, but there
were cases in which patients were apparently saved
by morphine. He cited a case in which a patient with
symptoms of impending death was remarkably revived
by gr. 1 of morphine with gr. -j,', f, of atropine. He
had for a number of years used the layer suture in
closing the abdomen, but had now discarded it. He
emphasized the importance of not using too much
medication, finding that better results followed the op-
posite treatment.
Dr. Reed, of West Virginia, recommended the use
of a running stitch of silkworm gut in bringing the
fascia together in closure of the abdomen, anchoring
the suture at either end. The fascia was thus per-
fectly apposed, and at the end of ten days or two
weeks, by cutting away one end of the shot the strand
of silkworm gut came away with ease.
Dr. W. E. B. Webb, of Birmingham, demonstrated
the use of a silver wire in the closure of the abdominal
incision. The method took the place of the through-
and-through suture and did away with the objection to
the buried suture.
Dr. Goelet thought that the after-treatment of lap-
arotomy began before the operation, in putting the
patient in the best possible general condition. He
secured a thorough regulation of the liver and of the
excretory organs. When a patient was suffering from
shock it was the physician's duty to give morphine;
and he had never found any objection to giving it
combined with atropine. In closing the abdominal
wound he objected to the layer suture because there
were apt to be knots in the suture. With deep sutures
he tried to avoid the pain by putting on several layers
of gauze and tying the sutures over them. In cases of
pain and intestinal distention he had seen good results
follow the use of asafcetida.
Dr. Ricketts said that anaesthetics had made too
many slow operators. He thought digitalis was an
over-estimated remedy and that nitroglycerin was over-
lauded. The best remedy he considered to be the old-
fashioned strychnine.
Dr. F. F. Lawrenxe, of Ohio, stated that good re-
sults in abdominal section were secured by short in-
cisions, little manipulations, and short anaesthesias.
He thought the effects of the suturing depended more
upon the mode of tying than upon the material. If
morphine was depended on, it should be given before
the patient recovered from the anesthesia.
Dr. Bonikield said that the thirst after abdominal
section was very much increased if the preparatory
purgation had been done with salts. This should be
accomplished with compound glycyrrhiza. He also
urged patients to drink freely of water two or three
times before the operation. For the relief of pain he
injected phosphite of codeine and chloral into the rec-
tum. The codeine relieved pain and the chloral was
given for its quieting effect on the nervous system.
The combination acted better than the drugs alone.
He thought a patient did not necessarily need stimu-
lants after operation. The treatment should be on the
same principle as that of the general practitioners: if
the patient required it, a stimulant should be given;
if not, it should be withheld, because, if given before
it w'as required, when it was needed there was nothing
to depend on. Regarding sutures he thought it a
strange statement that there was catgut to be depended
upon; and he believed rather that the trouble came
from not using enough sutures and there being some
capillary hemorrhage.
Dr. Harris said that lest there might be suppura-
tion he rarely allowed the first dressing to remain on
more than six or seven days without examination of
the wound; also he made it a practice to examine
every second day after the sixth or seventh.
Dr. C. C. Thayer, of Clifton Springs, suggested the
danger of ileus from handling of the intestines.
Dr. J. C. BiDDLE thought digitalis, nitroglycerin,
and strychnine each had its field. The peritoneum
in all cases of laparotomy should be brought closely
together; how it should be done was, in his opinion,
a matter for each particular operator to decide for
himself.
Dr. Engelmann called attention to a suture with
which he had no practical experience, but which was
advocated by a brilliant young surgeon of Europe— a
metallic tier suture which helped tahold the wall in
position.
Dr. Chase said, in closing, that he thought our in-
dividual experience had much bearing on the rule by
which we should work. If doubtful about his own
mind, a physician was not in a safe position to work
for patients; he must be guided by his convictions.
June 23, 1900]
MEDICAL RECORD.
1099
and in so doing he would retain all that was best in
his own methods and be able to adopt the good meth-
ods of others.
Ovulation and Menstruation Not Independent
Functions. — Dr. C. C. Thayer, of Clifton Springs,
said that if it was true that ovulation and menstrua-
tion were not interdependent, we might regard concep-
tion without menstruation as possible. The author
quoted instances on record of pregnancy after the cli-
macteric; cases were also quoted of pregnancy occur-
ring before the establishment of the menses, this being
a frequent occurrence among the Hindoos. It would
seem, then, from literature that menstruation was not
an unfailing attendant of ovulation.
Contribution to the Study of Dysmenorrhoea. — Dr.
George Tucker Harrison, of New York, drew atten-
tion to the importance of this subject to the general
practitioner, as well as to the gynaecologist. He showed
that light had been thrown on symptoms by recent in-
vestigations regarding the innervation of the uterus
and ovaries.
The Treatment of Menorrhagia (Dysmenorrhoea)
of Pelvic Origin by Electricity. — Dr. G. Betton
Massey read a paper with this title. Menstrual pain,
he said, was not due to obstruction, but to the attempt
of nature to perform a cyclic function with organs that
were underdeveloped or diseased. The obstruction
theory had been disproven by Schultz, by the speaker,
and others, who found no accumulation, and a canal
amply capable of drainage. In the obstinate cases,
that had been proved to be rebellious to medicinal
treatment of the neurotic elements, he found catarrhal
endometritis usually present, and obtained cures by
the use of the galvanic pole, preferably mercurialized,
within the uterine cavity. Dilatation was condemned
as unnecessary and at times harmful. The treatment
should not be intrauterine unless a persistent dis-
charge was present.
The papers of Drs. Thayer, Harrison, and Massey
were discussed jointly.
Dr. Zinke said that he had ceased to use e'ectricity
for at least eight years in the treatment of any gynae-
cological cases. In all cases amenable to treatment
he believed a cure could be obtained without the use
of electricity. He thought the most difficult cases
were those occurring in young girls, since it was often
impossible to make a positive diagnosis without exam-
ination.
Dr. Herzog, of Chicago, called attention to two
types of dysmenorrhoea — one dependent upon infiam-
niatory changes of the uterine mucosa, the other due
to inflammatory changes in the ovary. He also named
syphilis as a cause of dysmenorrhoea. He observed
that the mucous membrane was not thrown off at the
time of the menstrual flow.
Dr. Engelmann said he was much interested in the
subject, and had studied the menstrual conditions in
sciiool-girls. He believed a great number of" irregu-
larities were due to nervous conditions. He had gone
over nearly five thousand cases, not of hospital pa-
tients, but the so-called well women in educational
institutions and in business. Of these seventy per
cent, suffered more or less pain at the time of men-
struation; thirty per cent, suffered severe pain, which
increased with the amount of study, diminishing and
ceasing during vacation times. He thought the pos-
sible nervous cause should impress upon the profes-
sion the importance of general management of the case
in young girls without examination in order to see
what could be attained. He knew that a great many
able men said in regard to electricity exactly what
Dr. Zinke had said; but his own experience was dis-
tinctly at variance with that. He liked the effect of
electricity, but he would be unwilling to rely upon it.
He would say that, as one of the means of treatment,
in its proper place it was as potent and reliable as
any remedy we had. It must be used at the proper
time, precisely as a drug was given under certain in-
dications. This was also true in regard to inoperable
tumors. He v\-as sorry to hear a man whose word was
so authoritative as Dr. Zinke's expressing himself as
he had.
Dr. Bonifield was surprised at the statement that
a large accumulation of fluid in the uterus at the time
of menstrual flow caused no pain. It had been his
experience that such patients suffered the most pain.
Dr. Herzog's observation that the mucous membrane
was not thrown off largely at the time of the menstrual
epoch, he stated was the very latest observation on
that subject. He granted that Dr. Massey might get
the results he claimed, but believed that other men
claimed just as good results in other ways less ob-
jectionable and less troublesome. His method was
to pack the uterus with a gauze tampon and produce
a miniature labor.
Dr. Laurence said that painful menstruation was
not a disease but a symptom; and he believed dys-
menorrhcea should be eliminated as a disease from
gynaecological nomenclature. He thought the fact
should be borne in mind that there were pelvic and
uterine and tubo-uterine affections which belonged to
the constitutional disorders as did chlorosis and anae-
mia.
Dr. Zinke did not wish to convey the impression
that he had absolutely a distaste for electricity; but
there was no case on record in which the use of elec-
tricity produced a cure of any diseased condition of
the internal genitalia. It might give relief, but per-
sonally he had seen no cases in which this was so.
Dr. Thayer was greatly in favor of electricity in
dysmenorrhoea. He had used it for twenty years, and
was more in favor of it to-day than ever before. Aside
from the anatomical malformations, he would say that
the more important cause of dysmenorrhoea was a neu-
rotic one. Electricity entered along the line of hy-
gienic and constitutional treatment.
Dr. Massey said, in closing, that he did not want
to be behind Dr. Harrison in his homage to Marion
Sims, but the thought occurred to him recently that the
day of authority in medicine had passed away some-
time after he had graduated; that more harm had been
done by the blind following of authority in medicine
than could be computed. Facts, and not the person-
ality of the man bringing them forward, were wanted.
Sometimes great personality led to great error. He
referred to the incurable kind of cases and the kind
supposed to come to the surgeon. He could not too
strongly corroborate the remarks of others, that need-
less examinations should not be made.
SECTION ON PEDIATRICS.
Third Day — Thursday, June yth.
Diabetes Mellitus in Children. — Dr. Leopold F.
Haas, of New York City, presented this paper, which
was read by the secretary. The etiology was said to-
be still very obscure. Dr. Heinrich Stern, of New
York, had collected the histories of one hundred and
seventeen cases. These cases were published a few
years ago. Phthisis and gout predisposed to this dis-
ease. In most of the speaker's cases a family history of
one or the other of these diseases was present. The
clinical histories of two cases of diabetes were given,
in which both patients had what was known as " adenoid
habitus." The first case was that of a girl nine years
of age, who gave a rheumatic history. She was taken
with some fever, pains in the joints, and palpitation of
the heart. A rash appeared around the joints affected,
with a burning sensation. It was noted that the rash
MEDICAL RECORD.
[June 23, 1900
was not itching in character. The child had enlarged
tonsils and frequently wet the bed. The usual drugs,
such as codeine, etc., were tried with slight improve-
ment. The second case occurred in a boy as the re-
sult of being run over by a bicycle. The urine was
1.044 specific gravity, and contained ten per cent, of
sugar. He was placed upon restricted diet. Three
months later the patient had an attack of measles, and
the sugar in the urine was reduced to four per cent.
Dr. Haas concluded that diabetes in children was
much more common than was generally supposed. He
thought that a family history of tuberculosis predis-
posed to diabetes, and drew attention to the possible
connection of this disease with peliosis rheumatica.
Dr. Heinrich Stern, of New York, said that dia-
betes in children occurred most frequently between
the fifth and ninth years, and that he thought this dis-
ease was one of development, with some nervous dis-
turbance, probably located in the medulla. He did
not think it was due to any physiologico-chemical
substance.
Dr. Louis J. Lautenbach, of Philadelphia, spoke
of adenoids in this disease. He said that they ex-
pressed some deep-seated condition that as yet was
not absolutely determined. It was the rule, however,
to remove them.
Dr. Louis Fischer, of New York, said that, judg-
ing from his German clinic, he thought that cases with
a tuberculous family history represented the type of
this disease. In one case that he had, there was none
of the cardinal symptoms, but there was one per cent,
of sugar in the urine. He said that it was his rule to
examine the throats of all children coming under ob-
servation.
Purpura Haemorrhagica, or Scorbutus. — Dr.
Henry E. Tuley, of Louisville, presented this paper.
He spoke of the great difficulty met with in isolated
cases, in differentiating between scorbutus and purpura
hemorrhagica. He thought that purpura was an acute
infection having its origin in the gastro-intestinal
tract. He also gave the classical symptoms of scor-
butus, and added cachexia. He said that it was
caused by error in diet associated with unhygienic
surroundings. He then reviewed the history of a
case, that of a young child fed on corn. Symptoms of
diarrhoea developed with bloody stools. Spots ap-
peared on the knees, and the lips and teeth were cov-
ered with dried blood. Tlie gums bled easily.
Dr. J. P. Crozer Griffith, of Philadelphia, said
that there were many diseases in which purpura oc-
curred, and that the eruptions shaded into one an-
other. He said that the purpura in rachitis was
around the swollen joints, while that in urticaria was
not so marked. In angio-neurotic cedema there were
certain eruptions. The name "purpura," like "jaun-
dice," had several meanings.
Dr. Cotton, of Chicago, said that spongy gums did
not necssarily mean that the case was one of scorbu-
tus. He thought that it was an accidental condition
in a good many cases. It was also found in purpura
as well.
Dr. Burnes, of Arkansas, said that scorbutus was
common where he lived. He mentioned two cases,
one following a fall, the other a case of malaria with
severe chills. The patient refused to remain in bed.
Purpura developed. It was of a bluish cast. Dr.
Burnes thought that malaria might be a factor in
causing the purpura, as it was a great blood de-
stroyer.
Dr. Tuley closed the discussion. He said that the
term " purpura haemorrhagica "' should not be used and
that the disease should be classified as scorbutus.
The Value of Blood Examinations for Diagnos-
tic Purposes — Dr. J. Brandeis, of New York, read
this paper. He dwelt on the importance of blood
examinations, and spoke of accurate diagnosis in chlo-
rosis, pernicious anamia, leukaemia, malaria, filaria
sanguinis hominis, and relapsing fever. He then
spoke of the importance of such an examination in
aiding one to make a differential diagnosis, i.e., chlo-
rosis from pernicious anaemia, typhoid from malaria,
malignant disease of the liver from other liver dis-
eases. In this way certain doubtful cases were cleared
up. He mentioned several clinical cases and gave
their histories.
Differential Diagnosis between Abdominal Ty-
phoid and Appendicitis, by Means of the Iodine
Reaction. — Dr. S. Weiss, of Vienna, contributed this
paper. It was read by the secretary. If a drop of
blood taken from the ear or finger, under antiseptic
precautions, was treated with iodine, the red corpuscle
in healthy persons became yellow, and the white cells
were unaffected. In disease, however, the multinuclear
cells were stained, and it was of interest to note that
the eosinophiles were never affected. This iodine
reaction always shov^-ed the presence of pus. Cases
of appendicitis and perityphlitis could, by this reac-
tion, be differentiated from typhoid fever.
Dr. J. L. Morse, of Boston, said that a few years
ago we did not expect anything from the examination
of the blood. Now we expected too much. Blood
examinations in children differed markedly from those
in adults. He thought the so-called pernicious anaj-
mias in children were not such, but were secondary
anaemias. The blood of children reverted to the fcetal
type. The presence of leucocytosis was very impor-
tant. In his own experience he had found no leuco-
cytosis in serous pleurisy.
Hydrencephalocele. — Dr. Carl Beck, of New York,
read this paper. He reported several cases, one
of which gave a history of a fall of the mother during
the first month of pregnancy, at which time she broke
three ribs. The cases were illustrated by .r-ray and
other photographs. Several cases were operated upon,
and brain substance with cerebro-spinal fluid were
found to be contained in the tumors. One patient
was alive and doing well after operation.
Symmetrical Development ; or, Does Our Pres-
ent School System Develop the Highest Powers of
the Child? — Dr. Stuver, of Fort Collins, Colo., pre-
sented this paper. What was the best kind of educa-
tion, was a very important question. It was neces-
sary to develop all the powers of the child, physically,
intellectually, morally, and symmetrically. He said
that the predominance of physical development over
that of the mind was shown in the modern prize-
fighter. Children were born with instincts, not with
knowledge, and the child passed through all the stages
of intellectual evolution. Teachers should have a
clear conception of the phylogenetic development of
the child. As an aid in this, they should understand
the physiology of the brain as well as general hygiene.
In speaking of some of the evils of our school system,
Dr. Stuver said that the children in the kindergarten
were given too much work to do, thus having a ten-
dency to eye-strain. He thought that too little atten-
tion was given to the general health of school-chil-
dren. They needed open-air exercises. The school
sessions, together with the recitations, were generally
too long. More time should be given to the so-called
manual training. The custom known as "cramming"
for examinations was a vicious one. The calls of na-
ture were not properly attended to.
School Break-Downs. — Dr. J. Henry Bartlett, of
Philadelphia, presented this paper. He mentioned an
article that appeared in the Ladies' Home Journal
which referred to sixteen hundred children between
the ages of eight and fourteen years, who were total
physical wrecks. The speaker refused to make any
statement for fear of hurting some friend's feelings.
June 23, 1900]
MEDICAL RECORD.
He said that break-downs were rarely caused by over-
study, but that such cases usually occurred during
periods of development, such as teething and puberty.
This condition was more common in girls than in boys,
in the proportion of forty-three to seven. He spol<e
of the important part that the gastro-intestinal tract
played in this condition. Eating in haste had become
a national habit.
The Care of the Ear in School-Children.— Ur. Louis
J. Lautenbach, of Philadelphia, read this paper.
He said that the word " deaf " was too often synony-
mous with " dumb." The frequency of ear disease
among school-children was shown by the statement
that seven per cent, were deaf in both cars, and twelve
per cent, to twenty-five per cent, were deaf in one ear.
He quoted Dr. Knapp as saying that one-half of all
ear diseases occurred in children before the tenth
year. It was necessary, he thought, to submit the
children to regular periodical examinations. The
relation of nose and throat trouble to middle-ear dis-
ease was very important, for the Eustachian tube in
children was always open. When a nasal douche was
given, some of the fluid would irrigate the Eustachian
tube.
Antecedents of Valvular Heart Disease in Chil-
dren.— Dr. Frederick A. Packard, of Philadelphia,
read this paper. In analyzing a number of cases in
children who had suffered from previous illness, he
thought that endocarditis was secondary to some form
of kidney disease. In adults this affection was due
to an infection. Angina resulted from endocarditis.
Dr. Packard had collected seventy-five cases from his
hospital records, and found that rheumatism was a
most important factor in cardiac disease, as was also
scarlet fever. Measles, chicken-pox, pertussis, and
diphtheria had little effect upon the heart.
Dr. Wahrer said that the examination of chil-
dren's eyes and ears in the rural districts was impos-
sible. In regard to overwork of children, he said
that he did not favor the kindergarten system. We
sent our children to school too early, and we gave
them too much work to do. The child should be ex-
amined by the family physician before it was allowed
to go to school.
Dr. E. E. Graham spoke of the changes that took
place during development, and how they might be
modified by overwork. The system of competitive ex-
aminations for higher standing in our public schools
was a bad one. He spoke of the " played-out " physi-
cal condition of medical students, who were adults,
and then asked what it must be with children after
examinations. The school hours were too long. At
the present season all of our medical colleges were
closed, but the children must work until the first of
July.
Dr. Sutherland, of Nebraska, said that our public-
school system, as it stood, was very faulty. In the
first place, he thought that the restrictions placed
upon the teachers were greater than they should be.
The teachers should have more latitude in giving in-
struction. Secondly, there was too much politics in
the school board. Much of the work done was use-
less. It was quality of work that was wanted, not
quantity. The children should study about the birds,
rocks, etc.
Dr. Hyatt, of Pittsburg, said that there was no
question so important as this one of the schools. He
thought that the children should be classified accord-
ing to their play as well as their studies. Excesses
must be avoided. Physiological exercise of the mind
and body was necessary. Dr. Hyatt said that the
teachers were overworked.
Dr. Frank Allport, of Chicago, said that he was
very much interested in the study of the eyes and ears
of school-children. Teachers said that they could not
tell what was the matter with the children. It was not
desired that they should make a diagnosis, but by using
a simple letter chart they could tell whether a child
had one weak eye or not. He had arranged a series
of ten questions relating to headaches, cross-eyes, and
whether the child failed to read any or all of the let-
ters of the chart, etc. These questions were not ob-
jectionable, and would not cause the child any dis-
comfort. Dr. Allport said that thirty-three per cent.
of the children had some eye or ear disease, and
twenty per cent, had some nose trouble.
Therapeutic Value of Liquid Air, with a Prac-
tical Demonstration. — Dr. A. Campbell White, of
New York, read this paper. He said that he had re-
ceived letters from all parts of the United States and
Mexico, asking him for sample packages, and whether
it was given hypodermatically or for abscess of the
liver. Among experiments shown by him, Dr. White
froze a rubber ball, which became brittle; also a
peach, a strawberry, a tomato, mercury, and alcohol.
To illustrate the force of liquid air, he worked an
engine and a pop-gun with it. The composition of
liquid air was the same as that of the atmosphere. The
nitrogen was the first gas to evaporate, and thus pure
oxygen was left. In medicine, liquid air was used in
the form of a spray for local aneesthetic effect and as
a cautery. Bacteria were not killed by it, but their
activity was suspended for some time. The pain and
bad odor of carcinoma were destroyed by it. The
most promising effect of liquid air in medicine was
upon na-vi.
Just before closing the following resolution was
adopted :
" Jicsoh'eJ, That for the benefit of the physical con-
dition and the mental development of American school-
children, the American Medical Association recom-
mends the annual and systematic examination of the
sight and hearing of all school-children."
Fourth Day — Friday, June 8th.
Athrepsia Infantum : its Diagnosis and Treat-
ment. — Dr. Louis Fischer, of New York, read
this paper. He said that if an infant a few weeks
old suffered from vomiting and diarrhcea, and this
condition was allowed to become chronic, colic and
flatus supervened, and a chronic gastro-intestinal ca-
tarrh resulted. The neglect of this condition meant
a development of the condition known as "athrepsia."
Parrot was the first one to describe this disease, and
he divided it into three stages. In the first stage the
stools were liquid, curdy, and green, and contained an
excess of mucus. The abdomen was distended with
gas, the tongue was coated; stomatitis was present,
and wasting began. In the second stage all these
symptoms were intensified. Wasting became marked,
and undigested food appeared in the stools. The
stools occasionally appeared dark brown, the color
being due probably to the presence of altered bile
pigment. The child did not sleep, and the mouth be-
came the site of a parasitic stomatitis. The skin was
harsh and dry. Small boils or a rash might appear.
The temperature was subnormal. In the third stage
the child became moribund. Muscular twitchings
were present; little or no nourishment was taken, and
finally death occurred, preceded by marked convul-
sions. The greatest number of cases occurred in bot-
tle-fed children, although some were breast-fed. These
latter cases were probably caused by the mother's
milk being lacking in some chemical constituent.
The percentage of proteid was the one most frequently
deficient. The treatment, he said, was to remove the
cause if possible, with good hygiene and diet. The
so-called "cream mixture" was often of service.
This consisted of cream 3 i., barley water 3 iii., and
MEDICAL RECORD.
[June 23, 1900
sugar 3 i. He then spoke of the different methods
of modifying cow's milk. In France, the law forbade
the giving of solid food of any kind to a child under
one year of age, without the authority of the family
physician. Dr. Fischer said that no matter how bene-
ficial boiling or sterilization or pasteurization of milk
might be, one could not transform cow's milk into
woman's milk; and further, it was a great mistake to
believe that modified cow's milk was a full substitute
for woman's milk. In closing, he mentioned the proc-
ess of hydration of milk with hydrochloric acid, and
referred briefly to the small percentage of proteid in
condensed milk.
Intubation in Private Practice, and its Perfec-
tion This paper, by Dr. Joseph Trumpp, of Munich,
was read by the secretary. There was a tendency in
Europe not to use intubation in private practice. One
should not attempt to do it without first having prac-
tised on the cadaver of animals. In regard to the
serum treatment of diphtheria there were seventy-seven
per cent, of recoveries. After describing the tech-
nique of the operation, the paper gave a critical dis-
cussion of the value of rubber tubes in intubation.
The author had not seen any ill effects from their
use, and stated further that obstruction, excoriation,
etc., occurred less often with rubber than with metal
tubes.
The Injuries Resulting from Extubation. — The
paper, by Dr. Janos Bokav, of Budapest, was read
by the secretary. The author referred to certain inju-
ries which were most likely to occur, such as ulcera-
tion of the trachea, etc., and considered the best
means of their prevention and treatment.
Dr. William M. Welch, of Philadelphia, said that
he felt that there was greater danger connected with
intubation in private practice than in the hospital.
He related a hospital case that ended fatally before
the house physician could reach the patient. If this
was liable to occur in a hospital, it was evident that
the danger would be even greater in private practice.
The safest place for such cases was the hospital. In
regard to the size of the tube, Dr. Welch said that one
selected according to the age of the patient was often
too small. He had had one patient who coughed up
the tube half a dozen times in one night. The kind
■of tube chosen was important. He favored the use of
rubber tubes, for they were cleaner than metal ones.
In a hospital it made no difference. He said that it
would naturally be thought that the rubber tube, being
lighter, would be coughed up more easily, but in fact
the weight of the tube made little if any difference.
He mentioned a case in which the exudate was so ex-
tensive that the cast of tiie trachea and bronchi had
been thrown off. Making a false passage was only
possible in the hands of an inexperienced operator.
The tube occasionally fell down into the trachea. Dr.
Welch had had one case of tiiis kind in which he did
a tracheotomy. In another case on which he was
about to operate the patient coughed it up. Ulcera-
tion generally occurred about the bulge of the tube
and its lower extremity. He thought that the use of
antitoxin in intubation cases had been somewhat dis-
appointing. He said that the comparison of cases of
intubation before the days of antitoxin with the cases
of the present time was unfair.
Dr. Rigo, of Pittsburg, said that he agreed with Dr.
VVelch as to the hospital care of intubation cases.
His own experience had not been so satisfactory as
that some other physicians had reported. In regard to
antitoxin, he said that its early use was most important.
In many cases it was given too late.
Dr. a. Campbell White, of New York, said that be-
fore the days of antitoxin fifty per cent, of the cases of
croup were saved and only a small percentage were
intubated. In the hospital, intubation had been ad-
vised only as a last resort. Now that antitoxin was
in use, intubation was performed at once, and in such
cases the results had been most successful. Dr. White
mentioned a case occurring before the time of anti-
toxin, the patient being brought to the hospital in a
moribund condition. Intubation was done imme-
diately, with artificial respiration, and in a few min-
utes the child was sitting up. It died, however, in a
day or two. In such cases now life might be saved
by the use of antitoxin. Those cases in which the
membrane extended downward were benefited by in-
tubation, though they generally resulted fatally. He
mentioned a case in which the tube fell below the
vocal cords.
Dr. Louis Fischer, of New York, in speaking of
antitoxin, said that it was his rule to give 3,000 units
for an initial dose, and, if no abatement of the symp-
toms took place in twenty-four hours, to repeat it. He
said that antitoxin was the best remedy, combined
with calomel and rhubarb. He condemned the forc-
ible extraction of the tube after intubation, and said
that it resulted only in injury to the parts. He often
gave apomorphine in emetic doses to bring off the
pseudo-membrane.
Dr. Rosenthal, of Philadelphia, said that unques-
tionably intubation was oftener done by the general
practitioner than ever before. Every case in which
he used the rubber tubes had ended fatally, and he
thought that Dr. O'Dwyer was right in using the metal
tubes. When a tube was expelled, the one next in
the scale should be used. He said that it was not
diphtheria that killed, but a septic pneumonia. He
mentioned cases of heart failure that occurred six
weeks after the disease.
Dr. Welch closed the discussion by saying that
croup complicated with measles was invariably fatal.
He said that the stenosis was due to the intense con-
gestion of the mucous membrane.
Surgical Circumcision ; its Technique ; Preven-
tion of Infection; its Legal Control.— This paper
was read by Dr. Ferd. C. Valentine, of New York.
After referring to the flattering compliment paid to
him by being allowed to read a surgical paper before
the section on pediatrics. Dr. Valentine recited the
local indications for circumcision, and the general
conditions in which the operation was required even
in the absence of local disturbance. He described
the technique of a very simple circumcision, and illus-
trated it b)' means of pictures taken from his book on
" The Irrigation Treatment of Gonorrhcea; its Local
Complications and Sequelae." Insisting that circum-
cision was a surgical operation, he averred that it
should be performed only by medical men and in a
surgical manner. He mentioned the fact that tuber-
culosis, syphilis, and other diseases were frequently
communicated to infants by ritual circumcisers. The
infants so infected became menaces to public health.
If physicians were guilty of such acts, they would cer-
tainly become defendants in courts of law. Dr. Val-
entine advocated the legal prohibition of circumcision
unless it was performed by physicians, and urged that
devout Jews, who wished to follow the religious rite,
could very well avail themselves of Jewish physicians
appointed as ritual circumcisers in order to satisfy the
requirements of their religion. These physicians
could perform the religious ceremonies without vio-
lating asepsis and correct surgical technique. The
speaker mentioned that those persons circumcised in
youth seemed to be less liable to acquire syphilis than
others.
Dr. Louis Fischer asked what was the after-treat-
ment, especially in secondary hemorrhage.
Dr. V^\LENTINE said that he thought he would be
inclined to use suprarenal extract. It was an histori-
cal fact that haniophilia was more common among the
June -23, 1900]
MEDICAL RECORD.
1 103
Jews than in any other race. He said that there was
only one accident that could occur during this simple
operation, and that was a hasmatoma following the
cutting of a vein. This would often give rise to sys-
temic disturbances.
Dr. Rosenthal asked what Dr. Valentine would do
in the case of a child only a few days old with an im-
pervious foreskin ?
Dr. Valentine replied that there was only one
thing to do, namely, to slit the foreskin.
The following papers were read by title: "Tuber-
culosis of the Knee and Hip Joints in Children;
its Diagnosis and Treatment," by Edward A. Tracy,
of South Boston, Mass; "Floating Kidney in Chil-
dren," by Isaac A. Abt, of Chicago; "The Symptoma-
. tology of Appendicular Inflammation in Children,"
by Thomas H. Manley, of New Vork.
SECTION ON MATERIA MEDICA AND THERA-
PEUTICS.
Third Day — Thursday, June jth.
Election of Officers.— Dr. N. S. Davis, Jr., of Chi-
cago, was elected chairman and Dr. J. N. Upshur, of
Richmond, Va., secretary for the ensuing year.
Therapeutics of Croupous Pneumonia This paper
was read by Dr. I. M. Allen, of Liberty, Mo. The
various forms of treatment of this disease during the
past century were outlined. He divided the thera-
peutic cycles into three periods. During the first
epoch blood-letting and emetics were the remedies
employed; in the second epoch blistering and expec-
torants were relied on; in the third or last period a
tonic treatment had come into vogue. To Dr. John-
son, of Kansas City, belonged the honor of first class-
ifying pneumonia as an acute infectious disease. It
was the practice of the speaker to administer a purga-
tive at the inception of the disease. Digitalis and
strychnine were given early in small doses and in-
creased gradually. Alcohol was entirely prohibited.
In the later stage of the disease nitroglycerin was
given. For specific medication he employed sodium
salicylate in doses of gr. xv. every four hours. This
was best administered in milk of magnesia. He con-
tinued this agent for five or six days. Its value was
due to its antiseptic effect on the pneumococcus. The
number of pneumococci in the blood and sputa was
markedly diminished during its administration. Binz
ttiought that the salicylate was converted into salicy-
lic acid and thus acted as an antiseptic. The anti-
pyretic influence of the drug was also very marked.
After the sixth day iodide of potassium and tr. ferri
chloridi were to be employed. Oxygen was very valu-
able. He had obtained positive results in cases of
mixed infection from the use of anti-streptococcus
serum. He did not restrict the diet unless jaundice
was present.
Dr. Boise, of Philadelphia, pointed out the resem-
blance that existed between the products of the diph-
theria bacillus and the pneumococcus of Frankel. He
employed local applications of heat or cold for their
effect on pain. Injections of decinormal saline solu-
tion were of signal service in many cases. A hospital
mortality of twenty-five per cent, corresponded to a
mortality of ten per cent, in private practice. Serum
therapy offered the best hope for the future.
Dr. Mitchell, of Cincinnati, believed that pneu-
monia was not an inflammation, but a true toxaemia.
He employed hot plunge baths with cold to the head
and spine, especially when dyspnoea was marked.
This was very valuable in the pneumonias of children.
Digitalin and strychnine were given in all cises.
Dr. Hill, of Milwaukee, called attention to the
modifying influence of the influenza bacillus on pneu-
monia. Death resulted (i) from heart failure; (j)
from pulmonary obstruction. In all cases he used
digitalis during the first two stages and strychnine in
the last stage. He believed in external applications
for their dilating efTect on the capillaries of the surface.
Dr. Melvin, of Saguache, Col., said that the coun-
try physicians throughout the West believed that
prompt administration of veratrum viride caused the
crisis to appear earlier than usual. It certainly mod-
ified the course of the disease. Aconite in his prac-
tice had been most useful. His cases seldom had a
crisis later than the fifth day. Later on digitalis
should be employed. The mortality was very much
lower than with other plans of treatment.
Therapeutics of Vertigo.— Dr. J. Leonard CoR^f-
iNi;, of New Vork, read this paper. He said that ver-
tigo could not be regarded as a derangement induced
by morbid forces acting upon the semicircular canals.
Considering the multifarious origin of this affection,
an action of this kind was physiologically unthink-
able. By investigating the condition of the mind
during vertigo, and by determining the modification of
the reaction time, the writer was able to demonstrate
an impairment of the higher mental faculties. To
carry out these researches he invented and employed
a very ingenious apparatus consisting of a revolving
chair of unique construction and a recording appa-
ratus with appropriate electrical connections. From
these researches he concluded that vertigo, however
produced, must be regarded as a cortical difficulty.
Also it was found that the reaction time was very
much lengthened by the use of narcotic and sedative
drugs, notably the bromides and ether. In this man-
ner he proved what had long been observed, namely,
that these drugs inhibited vertigo. His conclusions
were that — (1) this derangement of the cortical centres
was always accompanied by some impairment of con-
sciousness. (2) This impairment was disclosed by
the greater length of the reaction time, and by (3) in-
trospection. (4) Vertigo might, however, be engen-
dered by direct impairment of the functional efficiency
of the centres of perception without the interference
of the afferent nerves. The vertigo associated with
auto-intoxication and that due to intracranial disease
was to be thus accounted for. (5) However origi-
nated, all forms of vertigo had this in common, that
they interfered directly or indirectly with normal cor-
tical action. (6) Rotary vertigo of the milder sort
might be inhibited by intense sensory impressions,
particularly by those of sound. (7) The impairment
of consciousness was in direct ratio to the intensity of
the vertigo.
The paper was discussed by Drs. Benedict, of Buf-
falo, and Hill, of Milwaukee.
Increasing the Value of Cod-Liver Oil bjr the
Addition of Free Iodine and Free Phosphorus. —
This paper was read by Dr. Louis J. Lautenbach, of
Philadelphia. He described the different methods of
preparation of cod-liver oil. He said that the ready
absorption and good effects were due principally to
the free iodine and phosphorus contained therein.
The old method of preparing the oil by a process of
expression preserved these principles and many other
putrefactive alkaloids. The new method consisted in
securing the oil by passing superheated steam through
the livers. This oil was far more agreeable to the
palate and stomach, but was less valuable. He be-
lieved that this defect could be remedied by the addi-
tion of free iodine and phosphorus to the ordinary
cod-liver oil of commerce. Gr. yi^ of pure phospho-
rus and gr. J of free iodine in a tablespoonful, to be
taken at bedtime, was the usual dose employed.
Protest against the Use of Proprietary Remedies.
— Dr. Daniel Brower, of Chicago, read this paper.
He said that the profession was being overwhelmed
by proprietary remedies. The manufacturers who pro-
II04
MEDICAL RECORD.
[June 23, 1900
jected them copyrighted the name, and patented the
process and the resulting product, so thiit these remedies
remained a monopoly for all time. More than twenty-
five hundred such new remedies had been introduced
within the past few years. An examination of one
thousand prescriptions of three leading Chicago drug-
gists revealed that from twenty-one to twenty-six per
cent, of those prescriptions contained these remedies.
These drugs cost from three to four times as much as
they did in other countries. The Code of Ethics ex-
pressly said that it was equally derogatory to profes-
sional character for" a physician to hold a patent for
any surgical instrument or medicine, or to dispense a
secret nostrum, whether it was the composition or ex-
clusive property of himself or others. It was also
reprehensible for physicians to give certificates attest-
ing the efficacy of patent or secret medicines or in any
way to promote the use of them. By the use of these
drugs the profession became perpetually at the mercy
of monopolists who could fix the price, vary the com-
position or purity as fancy might dictate. There was
no objection to a manufacturing chemist patenting a
process. There should, however, not be a monopoly
on any product. To those who wished to use combi-
nations the "National Formulary" furnished all of
the formulas of the best combinations that were in
general use, at one-third of the price of the corre-
sponding proprietary preparation.
Dr. N. S. Davis, of Chicago, said that we must di-
vide these drugs into two classes: (i) those whose
contents or process of manufacture was secret; (2 ) ele-
gant preparations of well-known drugs in fixed propor-
tion.
Dr. Allen protested against the physician dispens-
ing his own drugs. No one should use any fixed rou-
tine combination of remedies for any disease.
Dr. Tompkins, of West Virginia, said that relig-
ious newspapers and clergymen were responsible for
much of the circulation of these proprietary remedies.
Dr. Lochboehler pointed out the danger of these
remedies, in that they put dangerous unknown drugs
in the hands of the laity, and he cited several in-
stances in which death resulted from this indiscrimi-
nate use of these synthetic drugs by the layman.
Dr. Brower, in closing, stated that there had been
a very marked increase in the number of cases of im-
potence in late years clue to the general use by the
public of these unknown synthetics. The physicians
were responsible because they praised and prescribed
the articles, and the public came to know of it through
the advertising agents.
Irrigation of the Colon as a Therapeutic Meas-
ure.— Dr. George J. Lochboehler, of Washington,
D. C, read this paper. He said that for this purpose
from two to four quarts of decinormal salt solution
should be employed. The tube should have the open-
ing on the end and not on the side. The tube devised
by Dr. F. Turck was preferable, in order to prevent
the coiling so common with a soft tube. Such large
quantities of fluid acted mechanically and were of
especial value in strangulated hernia. Irrigation had
been used very successfully in a large number of cases
of gastro-duodenitis. The speaker reported one des-
perate case of typhoid fever and two cases of appen-
dicitis, in which a cure was effected by this means.
The only contraindication to its use in typhoid fever
was during the stage of necrosis, when it should not
be employed.
Dr. Brower pointed out the beneficial effect that
these irrigations had on the kidneys, and urged their
more frequent employment.
Dr. Osborn, of New Haven, spoke of the value of
such injections following surgical operations. Many
of the disagreeable sequelae such as thirst, anuria,
etc., were thus prevented.
Dr. Culbertson, of Cincinnati, said that as a
means of reducing temperature in acute infectious dis-
eases a quart of ice-water thrown into the lower bowel
was one of the best. It reduced the temperature at
once from a degree to a degree and a half.
Dr. Bernheim stated that as a result of his physio-
logical investigations he found that the reverse peri-
stalsis that was set up in the bowel following such in-
jections carried the salt solution as far as the stomach.
Treatment of Addison's Disease, with Case. —
Dr. John V. Shoemaker, of Philadelphia, read this
paper. This was a case of Addison's disease in a
young man. The administration of suprarenal extract
had no effect on the disease. The patient died in a
short time of general tuberculosis. The suprarenal
glands were markedly involved. A general review of
the literature was appended.
The Therapeutic Application of the Organic Ex-
tracts.— This paper was read by Dr. O. T. Osborn,
of New Haven. He outlined the history of thyroid
experimentation. Among other things it was noticed
by Kocher that symptoms of myxoedema did not ap-
pear when the thyroid was removed in old age. The
adult thyroid contained 4 mgni. of iodine, and this
was the only tissue of the body that contained that
element. It produced diuresis when taken internally.
It seemed that the thyroid was necessaiy for the prop-
er equilibrium of the central nervous system ; to reg-
ulate the proper quantity of mucin that should appear
in the tissues; to regulate the proper amount of con-
nective tissue, especially of the skin; to the proper
organization of phosphoric acid for assimilation into
bone salts; and, by its vasodilator power, to regulate
properly the peripheral circulation, thus regulating
the heat loss at least and the normal insensible-perspi-
ration, which if disturbed showed on the one hand in
the drying of the skin in my.\u;denia, and on the other
in the increased sweating in Graves' thyroid disease.
It also seemed to have some power in regulating the
rapidity of the cardiac contractions. When large
doses of this gland were given to a healthy adult, nau-
sea, vertigo, and other alarming symptoms resulted.
Exophthalmic goitre was due to hypersecretion, and
therefore the use of the thyroid extract was contra-
indicated during the continuance of active symptoms.
All of these were increased if it was administered. If
the gland underwent atrophic changes, as it very often
did, later on the reverse condition might occur, viz.,
the first stage of myxcedema, then it could be given.
It was probable that every case of overweight, espe-
cially after forty years of age, could be reduced by
larger or smaller doses of thyroid extract daily, pro-
vided there were no ill effects from its use. After the
first two weeks the patient would lose from two to five
pounds per week. At the beginning gr. ill. should be
given twice a day. This was gradually increased.
The disagreeable symptoms were the same as the early
symptoms of exophthalmic goitre. The diet needed
no modification. Thyroid extract was of value in the
treatment of certain skin diseases, such as dry, scaly
eczema and psoriasis. It had not been successful in
the past because too large doses had been given. The
speaker had found it of especial value in dull, heavy-
featured children of a strumous diathesis. Enlarged
glands in the neck had become normal under its use.
Melancholia was occasionally benefited by it. Eighty
per cent, of all cases of exophthalmic goitre occurred
in women, and it was reasonable to suppose that it
bore a close relation to the menstrual function. Thy-
roid had been successfully employed in some w^omen
at the nirnopause.
Thymus. — He said that intravenous injections of
this substance lowered the blood pressure. It had
been demonstrated that it did not contain any iodine.
It contained a large amount of nuclein and phospho-
June 23, 1900]
MEDICAL RECORD.
1 105
rus. In some cases of exophthalmic goitre it was of
service. Its use as yet was entirely empirical.
Pituitary Body. — This gland was divided into two
parts; the anterior was glandular and resembled thy-
roid tissue; the posterior was largely made up of ner-
vous elements. An extract of this latter part, when in-
jected into a vein, raised the blood pressure. When this
gland was removed in animals, they died of symptoms
like those in human beings from whom the thyroid had
been removed. This gland was always diseased in
acromegaly. Giantism was due to an increase in the
secretion of this body. Acromegaly was due to a per-
verted secretion. If disease of this gland existed, the
thyroid was enlarged, and the reverse also held true.
Two successful cases of feeding of the pituitary body
in acromegaly were reported.
Suprarenal Extract. — The active principles of this
drug did not produce their constitutional effects when
administered by the stomach. There was one prin-
ciple present in the drug which, when administered
intravenously, raised the blood pressure more than
any other known agent. Degeneration of the adrenals
was only one of the many causes of Addison's disease.
The general consensus of opinion as to its value in
eye and nose diseases was that it was invaluable.
For local use ten grains to the ounce was the usual
strength. The speaker had had much success in abort-
ing follicular tonsillitis by cleansing the tonsils with a
saline solution, swabbing with hydrogen peroxide, and
then spraying with suprarenal extract. This was to
be repeated in twelve hours. The congestive stage of
urethritis was also benefited by injections of this
agent. It should be employed locally in all forms of
capillary hemorrhage. If used in a cavity of the
body, it should be washed out, because it underwent
putrefactive changes after a few hours.
Psychic Therapeutics. — Dr. J. C. Culbertson, of
Cincinnati, read this paper. He believed that the
principal requisites for success were: (i) ability to
diagnose; (2) a strong personal influence. Other
therapeutic agents were only valuable adjuncts. He
would dispense this personal influence just as he
would dispense a nervine or an anodyne. Confidence
was a potent remedial agent. There was a psychic
element present in all disease. This often over-
shadowed the pathological state. This was especially
marked in educated people. A discriminating course
of positive injunctions or orders, with placebos, were
often of greater value than drugs. One should never
be vacillating, but positive at all times. Fear or joy
might cause either a cure or a disturbance of the organ-
ism, and the personal influence of the physician might
save life.
The paper was discussed by Drs. Reamy, Wheatly,
and Bernheim.
Dr. Culbertson, in closing, said that a diagnosis
should always be made on the first visit, and, no mat-
ter whether right or not, the name of the disease
should be the same to the patient throughout the whole
sickness. Positive men were the successful men.
Fourth Day — Friday, /iiiie Htli.
Pharmacological Assay of Drugs and its Impor-
tance in Therapeutics. — Dr. E. M. Houghton, of
Detroit, who read this paper, said that many of the
most important drugs could not be standardized by
chemical assay. For this reason animal experimenta-
tion was essential. The best theory that had been
offered to explain the reactions between the elements
of the animal body and drugs was that of chemical
affinity. The normal function of a given organ was
altered in degree by the union occurring between the
protoplasm of its cells and the given drug. This
action was quantitative. Other conditions being
equal, animals of the same size and weight would re-
spond equally when the same dose of a given drug
was administered. In the speaker's experiments, when
the conditions were similar, there was not more than
two per cent, variance between the results of two ob-
servers. He stated the following to illustrate the un-
certainty of the present system : He purchased three
specimens of tincture of strophanthus. As far as could
be determined they were alike, yet upgn injecting them
into animals the results differed as much as five hun-
dred per cent. The strength of the suprarenal extract
might likewise be determined only in this way.
Dr. Lyons, of Detroit, said that in the chemical
assay of drugs there was very often a variance of from
ten to twenty per cent, between different observers.
The paper was further discussed by Drs. Allen and
McClintock.
The United States Pharmacopoeia for 1900.— Dr.
Joseph REAriNCTON, of Philadelphia, presented this
paper. He said that the United States Pharmacopoeia
occupied a unique position among the pharmacopceias
of the world. Its authority was established through-
out the country mainly through the voluntary assent
of doctors and pharmacists of the United States. In
other countries the governmental authority was behind
it. Among the most important changes to be made in
the new pharmacopoeia would be the introduction of
any product of nature of known origin ; also any syn-
thetized product of definite composition which was in
common use by the medical profession, the identity,
purity, or strength of which could be determined. No
compound or mixture would be introduced if the com-
position or mode of manufacture thereof was kept
secret or if it was controlled by unlimited proprietary
or patent rights. The average approximate dose of
each drug would be inserted. The book would appear
about 1903. No restriction would be placed upon the
text of the book.
A resolution was adopted condemning the admission
of unethical preparations to the exhibition hall of the
association in the future. An unethical paper that
was presented to the section was returned to its author.
AMERICAN ORTHOPEDIC ASSOCIATION.
Fourteenth Aniutal Meeting, Held in Washingtoii,
D. C, Alay i, 2, and j, igoo.
Harry M. Sherman, M.D., of San Francisco,
President.
{Concluded from pa^e 1072.)
Second Day — Wednesday, May 2d.
Forcible Correction of Spinal Curvature followed
by Paralysis. — Dr. H. Augustus Wilson reported
a case in which the kyphosis had been noted only a
few weeks before he had seen it. There was a family
history of tuberculosis. In addition to the statements
of the parents, who were careful observers, there was
other evidence of the recent development of the de-
formity. Under profound anaesthesia the patient had
been subjected to full extension in the horizontal pos-
ture while he had made forcible correction with the
hands from above downward. A very decided and
audible snap had occurred, such as is present in osteo-
clasis, but there had been little improvement in the
deformity. A second attempt had yielded the same
result. A plaster-of-Paris jacket had been applied,
the jacket being fenestrated at the kyphosis. The
patient was placed in bed with counter-extension.
The temperature rose to 101.4° F. on the second day,
and remained at this point for about twelve days. It
1 1 06
MEDICAL RECORD.
[June 23, 1900
then declined for a short time, but rose again slightly,
and remained above the normal for about eight weeks.
In a short time sloughing of the soft parts occurred
above at the head, and subsequently also over the site
of the kyphosis. The latter was so marked that the
spinous processes were exposed. There had been no
pressure over these points. When discharged at the
end of nine weeks the patient was able to move around
feebly, but there was no distinct paralysis. In forty
days he had been readmitted with a spastic paraple-
gia, which was almost complete. Apparently the
membranes of the cord had become involved in a
tuberculous process. Under treatment directed tow-
ard immobilization of the spine and improved nutri-
tion, the patient had improved slowly.
Dr. a. M. Phelps was inclined to believe that the
forcible correction of the spine had had nothing to
do with the subsequent paralysis. The case seemed
to him a typical one of pressure myelitis resulting
from the invasion of the cord and thickening of the
membranes of the canal.
Dr. Ridlon took the same view of this case. "
Dr. Lovett said that Dr. Dane's brace was inter-
esting because its aim was to produce torsion. His
own studies in lateral curvature had impressed upon
him the importance of throwing the weight of the
spine backward on the articular processes, not neces-
sarily producing lordosis of the lumbar region, how-
ever. The weight should be thrown upon the articular
processes a little before the erect position was as-
sumed.
Dr. Phelps asserted that it was only when the spine
had been bent backward considerably that any press-
ure was made on the articular processes.
Dr. Lovett replied that this statement w-as not in
accord with the results of experiment, which showed
that these processes came in contact at a point about
15° in front of the erect position.
A Case of Scorbutic Spine. — Dr. John Ridlon
reported a case of tliis kind occurring in an infant of
twelve months, and coming on so suddenly that it was
difficult to resist the inference that the symptoms were
the result of some traumatism to the knee. The child
was large and fat, and it had a rough and muddy skin.
The legs were held slightly flexed at the knee, and the
hands were moved carefully. The range of motion
at the ankles, knees, and hips was normal. The spine
was arched forward, and held rigidly. The gums were
dusky. He ordered the child fed on unsterilized
milk, raw meat, and orange juice, and in two weeks
the bow was well. In making the diagnosis it should
be remembered that acute articular rheumatism was
rare in infants, and was accompanied by fever, and
that infantile paralysis and rickets must also be ex-
cluded. In rickets the onset was gradual, and there
were other evidences of the disease besides the spine.
Dr. R. H. Sayre said that his plan of treating such
cases had been to put the child on a pillow, made
rigid by inserting a short board inside of it, and then
changing the diet. Most of his cases had occurred
in children who had been fed on sterilized milk or on
patent infant foods. One child had had an extremely
tender spine and also complete paralysis of the lower
extremities.
Dr. Phil. Hoff.mann reported one case, occurring
in an infant of four months, who had been referred to
him as a case of Pott"s disease. The kyphosis was
sharper than usual in the rachitic spine. The child
had made a good recovery.
Dr. Henry Ling Taylor said that he had reported
to this association one of the earliest cases of this
kind published in this country. In the cases that he
had seen there had not been a true pa'-alysis, only
a disinclination to use the limbs because of the ex-
treme pain caused by motion. He had not found it
necessary to resort to any special mechanical treat-
ment.
Dr. Stewart L. McCurdy, of Pittsburg, said that
he had reported two or three cases several years ago.
These cases presented a gradual posterior curve rather
than a true kyphosis. In some cases there was an al-
most complete pseudo-paralysis. In none of his cases
had there been bleeding from the gums. The absence
of pain, fever, and fretfulness enabled one to differen-
tiate between scorbutus and rachitis.
Knee-joint Surgery for Other than Tuberculous
Processes. —Dr. Joel E. Goldthwait, of Boston, pre-
sented a paper on this subject. The ages of his pa-
tients had varied from four years to sixty-five. He
personally believed there was no more danger of open-
ing the knee joint than the peritoneum. If there was
any legitimate doubt as to the diagnosis there should
be no hesitation in opening the joint and determining
the true condition by actual exploration. The impor-
tance of doing so was evident when one considered
how much more could be accomplished by making an
early diagnosis of tuberculosis. The difficulty of mak-
ing the diagnosis was increased in adults, in whom
non-tuberculous lesions of the joints were in the ma-
jority. After opening the joint experience had shown
that the surgeon must rely less upon the gross appear-
ance than upon the results of microscopical examina-
tions. The present paper was based on a study of
twenty-seven patients and thirty-three operations. In
five cases both knees had been operated upon. Of the
thirty-three operations one was for the removal of loose
pieces of cartilage in a woman aged sixty-five years.
Three pieces as large as hickory nuts had been .re-
moved. In one case the exploratory incision showed
a beginning osteo-sarcoma. In eight of the cases the
operation had been demanded because of the presence
of loose cartilages. The patients were all young men,
and in quite a number of them there was a relaxed
condition of the joint which had favored the crushing
or tearing of the inner edge of the cartilage. The
point of contusion seemed to be usually the inner thin
edge. Sutures of any kind, because of the structure
of the cartilage, cut out almost immediately; hence,
the best treatment was removal of the cartilage. Un-
der the latter treatment the joint could be removed in
one week, and the after-treatment ended in three
weeks. After the first week the dressings should be
removed one a day and the joint flexed so as to pre-
vent the formation of adhesions. A Hannel bandage
was used for the third week. He felt that there was
danger of over-treatment in these cases. Apparently
the patient suffered no inconvenience from the absence
of the cartilage. Of course the mild cases could be
relieved by massage and bathing. When there were
marked fringes, these should be removed by operation.
In the majority of cases the fringes acted as foreign
bodies and became locked under the patella during
motion just as in the case of the loose cartilage, al-
though the results were not so severe. The frequent
resulting attacks of synovitis were followed by coagu-
lation of the synovia, thus forming large coagula in
the joint.
Discussion : The Treatment of Vertebral Tuber-
culosis with Reference to the Forcible Correction
of the Deformity. — Dr. John Ridlon opened the
discussion. He said that in the past three years he
had operated upon eight lateral curvatures under ether
and thirty-five cases of Pott's disease. In the worse
cases he had gained at first one and one-quarter inches
in height, and at the second attempt three-fourths of
an inch, but in almost all the cases of lateral curvature
this gain had been subsequently lost. He did not
think it was worth while now to straighten a lateral
curvature case under ether. He had operated on both
old and recent cases of Pott's disease. There had
June 23, 1900]
MEDICAL RECORD.
1 107
been two fatal cases. The first one was really due to
the prior existence of tuberculosis, the operation hav-
ing been done without having kept the patient suffi-
ciently long under observation. In the other fatal
case, everything liad gone along well for six months
or more, and then several abscesses had developed,
and the prolonged suppuration had finally resulted in
death from exhaustion. In many of the cases he had
used almost no pressure with his hands; in others he
had used very considerable force. There was almost
always some crunching of tiie bones. None of his pa-
tients had subsequently developed paralysis, but he
had operated on several cases when paraplegia existed
at the time. In the longest case the patient had been
in bed about one year, and in the shortest for four
weeks, but he had aimed to keep them from six to
eight months in bed, allowing them to lie on the face,
back, or side. He had had a few cases in which there
had been no return of the deformity, and about half a
dozen in which the patients had gone for a year with-
out any support or any return of the deformit}-, al-
though the straightening had been as much as one-
half to three-fourths of an inch. In the majority of
cases he had succeeded in keeping the deformity re-
duced to about half of what it had been before the
operation.
Dr. Goldthwait said that at the Children's Hospi-
tal the usual treatment during the past two or three
years had been the application of apparatus in the
hyperextended position. He exhibited a series of
tracings taken during tliis period. They showed that
the deformity had not increased, or only very sligiitly.
From a consideration of these and the general results
obtained, he would hesitate to correct forcibly any
spinal deformity resulting from tuberculosis of the
spine unless it was associated with an obstinate para-
plegia. He was not aware that the method of forcible
correction had materially increased the mortality.
Dr. VV. R. Townsend said that the method had
never appealed to him, and he predicted that the de-
formity would recur in the large majority of cases.
Dr. De Forrest Willard, of Philadelphia, said
that he had looked upon the method as illogical and
unsurgical, and accordingly he had employed it only
in one desperate case of total paralysis. Here, con-
trary to his expectations, the operation had been bene-
ficial, and it was only in this class that he would think
of resorting to it.
Dr. R. H. Sayre said he believed many cases of
severe lateral curvature could be greatly benefited by
the application of great force under anasthesia. The
amount of force applied usually to the scoliotic spine
was altogether insufficient. By longitudinal traction
and torsion, under anaesthesia, he believed much could
be accomplished.
Dr. T. Halsted Myers, of New York, said that in
all of the four cases in which he had tried forcible
correction the result had been unfortunate.
Dr. Galloway said that he had never performed
this operation, having always regarded it as unscien-
tific, but he was ready to try it in the first case of
Pott's paraplegia presenting itself that was incurable
by other methods. So far, he had not met with such
a case.
Dr. Weigel thought the reports presented forced
one to conclude that the mechanical support used after
forcible correction had been inefficient.
Dr. R. Tunstall Taylor, of Baltimore, thought the
older mechanical methods were safer and more accu-
rate, and did not introduce the errors incident to the
use of a method that involved manipulations by sev-
eral individuals. This last point seemed to him a
matter of considerable importance.
Dr. Phil. Hoffmann expressed some surprise that
so much stress had been laid upon the use of forcible
correction in cases of paralysis, for he had never seen
a case of Pott's paralysis that had not resulted in re-
covery.
Dr. John L. Porter, of Chicago, said that from his
observations of a large number of Dr. Ridlon's cases
he felt sure that more than fifty per cent, of these pa-
tients were straighter now than when operated upon
under anaesthesia.
Dr. Ridlon said he would not attempt to break up
a spine that seemed to him to have been entirely
cured. In very recent cases in which the weakness,
pain, and disability were considerable, he would be
disposed to choose Goldthwait's method without anaes-
thesia. It was the middle class of cases, those with
a slowly increasing deformity, that were especially
suitable for forcible straightening under an anaes-
thetic. Dr. Goldthwait's disappointing results, and
the discussion just closing, had impressed him more
than ever before with the great value of using an
anaesthetic.
Dr. Goldthwait said that he had purposely re-
frained from bringing tracings of cases that he had
treated under anaesthesia, because they were no better
than those already exhibited by him. He had not ob-
served much difference in cases which had relapsed
whether they had been kept in bed or had been al-
lowed up in a short time. Hubbard had shown that,
as a rule. Pott's paraplegia was recovered from in
from six to nine months, the time depending upon the
location of the disease, and provided the patient was
kept recumbent. Forcible correction greatly reduced
this period of recumbency, and certainly this was a
great gain. He would not^attempt forcible correction
unless paraplegia was present, and he would never
use traction or much force to bring about the correc-
tion.
Third Day— Thursday, May 3d.
Brace for Lateral Curvature of the Spine. — Dr.
GwilyiM Davis, of Philadelphia, presented a brace
that he had devised for lateral curvature. This brace
had a hip band and both an anterior and a posterior
upright. A shoulder-piece encircled the high shoul-
der. From the posterior upright a band passed over
the lump and underneath the arm of the affected side.
The two points of support were on the arm above and
the hip below.
Dr. R. H. Sayre said that if pressure was made
on the large side, as it would be with this brace, the
peak of this arch would become more and more arched.
The force should be directed so as to transfer the lev-
erage in such a way as to turn the vertebra; around
on their a.\es. All forms of apparatus which made
pressure on the bulging part simply served to increase
this bulging.
Dr. Weigel thought the apparatus exhibited did
not afford the necessary fixed point of support. Sim-
ply keeping the high shoulder down could not have
any special corrective influence on the deformity.
Dr. Davis replied that, in his opinion, the brace
did not exert merely a direct pressure, but a twisting
force. The question of support was merely a matter
of adjustment.
Retardation of Growth as a Cause of Shortening
after Coxitis Dr. Henry Ling Taylor, of New
York, read a paper with this title. He said that his
attention had been strongly directed to this subject
by a case in which he had had the mortification to
find an increase of shortening of four and a half
inches in a period of about four years. Further in-
vestigation had shown that it was quite common for
a shortening of half an inch to take place in the tibia,
and an equal amount, or even more, in the femur. In
twenty-one cases the shaft of the femur on the affected
iio8
MEDICAL RECORD.
[June
1900
side had been from one-fourth of an inch to two and
a half inches shorter, with an average difference of
five-eighths of an inch. In thirty cases, the average
shortening on the affected side had been three-fourths
of an inch. The patella of the affected side was
nearly always smaller and narrower. In twenty-six
cases there was a difference of from one-eighth to half
an inch in the transverse diameter. In only one
measured case had there been no difference, and this
patient had never worn a brace. The foot was shorter
in a number of cases. The shortening of the various
bones was found to be proportionate to the duration.
Those cases which had received the least treatment
seemed to have less than the aver-ge amount of short-
ening, but there was apt to be more displacement. A
comparison of ten cases of old unilateral poliomye-
litis, with a similar group of hip cases, showed about
the same amount of bone shortening. Further obser-
vation seemed to show that the absence of locomotion
apparently favored the occurrence of such shortening.
Retardation of growth was found in those affections
of childhood which disabled one limb, and somewhat
in proportion to the amount and duration of the dis-
ability and restraint imposed.
Developmental Shortening in Tuberculous Bone
Disease. — Dr. Stewart L. McCurpv, of Pittsburg,
presented in this paper several illustrative cases cor-
roborating some of the statements made by Dr. Taylor
in the foregoing paper.
Dr. R. H. Savre said that the records of college
gymnasiums showed that the average increase of height
after the age of nineteen or twenty years was quite
surprising. He had noticed in cases in which appara-
tus had been discarded from one limb a considerable
time before the other, when both were affected, an in-
crease in the limb first liberated. All of the small
bones of the foot, as well as those more directly con-
nected with the diseased area, were affected in this
way.
Dr. Goldthwait said that in a series of cases of
hip disease that he had measured some years ago, in
practically all a shortening had taken place below the
knee. Skiagraphs from these cases showed a per-
fectly regular atrophy or lack of development of the
upper end of the tibia or of the femur, and the epi-
physis, instead of being square in front, was wedge-
shaped. There was also a marked depression of the
epiphyseal line. It was possible that the strap about
the calf might have been a factor in producing the
atrophy as a result of pressure.
Dr. Weigel said that there was no doubt in his
mind that weight-bearing was a very important factor.
Dr. Gibney said that it seemed to him that there
should be an elongation of tbe femur in hip disease
as well as in disease of the knee. Most of the inves-
tigations that had been made showed that in tubercu-
lous disease of the knee the limb actually lengthened.
According to his experience, in some of those dry
cases which went on so well at first, an alarming
degree of shortening often showed itself after a few
years.
Dr. H. Augustus Wilson referred to the recent ob-
servations of Dr. Hurd in China regarding the changes
taking place in the feet of Chinese women. She ob-
• served that after the use of the muscles had been par-
tially restored there was evidence of increase in the
diameter and length of the bones. If these observa-
tions were accurate, it would appear that very much
of the shortening observed in cases of joint inflamma-
tion was due to the bandaging and consequent inter-
ference with the circulation rather than to the joint
inflammation.
Dr. a. M. Phelps said that he had come to the
conclusion that the shrinkage of the muscles was
laro;elv the result of a neurotic influence — a true de-
generation of the muscles due to the reflexes. The
circulation in the bone was carried on by the pressure
of the muscles, which forced the blood into the bone;
hence, if the limb wrs placed at rest the circulation
would be impaired, and the bone would undergo
atrophy.
Dr. Galloway observed that one reason for the
lengthening of the limb in knee-joint disease was that
two epiphyses were subjected to stimulation — the lower
end of the femur and the upper end of the tibia.
Dr. Shaffer said he had found that in the cases in
which the nervous phenomena had been most marked
— especially in the dry cases — the shortening had been
proportionately larger than in -those even in which
suppuration had been present. This fact had often
guided him in making a prognosis.
Dr. Ridlon cited a case to illustrate the fact that
muscular shrinkage was not always associated with
intense reflex spasm.
Dr. H. L. Taylor said that careful measurements
from the anterior spine to the knee joint would prob-
ably show lengthening in certain of the early cases.
The principal thought in the paper was, that the short-
ening in all of the bones of the lower extremity fol-
lowing hip disease of many years' standing was al-
most exactly the same as the shortening which followed
infantile paralysis of the same duration. This to him
was a very striking and surprising fact. He fully
agreed with those who attributed this retardation of
growth and lack of development to circulatory disturb-
ances. These came in part through nervous influences,
and in part from mechanical compression.
Report of Some Studies upon the Articulations
of the Foot. — Dr. John Dane, of Boston, presented
this paper, which was based on one hundred and sev-
enty-six dissections. He found that adventitious bones
were most common at the joint made by the scaphoid
and cuboid in front of the os calcis and the head of
the astragalus. This bone might coalesce with the
cuboid, changing its normal square shape. This and
other anomalies of the articulations were pointed out
and exhibited, and attention was called to their im-
portant influence on the statics of the foot.
Observations on Certain Painful Affections of the
Feet. — Dr. L. A. Weigel, of Rochester, made some
remarks on this subject, illustrating them freely with
skiagraphs from many cases.
Investigations as to the Treatment of Flat Foot.
— Dr. E. H. Bradford, of Boston, sent a communi-
cation on this subject, which comprised a study of the
mechanics of the foot, particularly as regards the vari-
ous arches of which the foot was composed, and the
effect upon these arches of changes of position and of
weight-bearing. He stated that when pressure was
made behind the scaphoid there was no difficulty in
pronating the foot, and the conclusion was reached thai
there was a point on the foot at which if pressure was
applied the pronation could be checked, and at this
point it was easy to do this. The foot-plate should,
therefore, be constructed with the " lift " at this point.
A Case of Congenital Dislocation of the Wrist.
— Dr. Phil. Hoffmann, of St. Louis, reported a case
of this kind, and Dr. Gibney followed with another
case, in the person of one of the physicians present at
the meeting.
A Case of Congenital Dislocation of the Shoul-
der.— Dr. John L. Porter, of Chicago, present by
invitation, reported this case. He said that out of
ninety-eight cases of congenital dislocations of vari-
ous kinds collected by one author, only five were con-
genital dislocations of the shoulder. Tiie large ma-
jority of these dislocations were subspinous. A
photograph was exhibited, which he believed to be
the only one extant, showing the condition present.
In his case delivery had been effected with the aid of
June 23, 1900]
MEDICAL RECORD.
1 109
forceps, although the labor had not been attended by
any special difticulty. When seen by him two months
later, the right arm had been abducted slightly and
Hexed and pronated. The humerus moved voluntarily
very little, though the hand had apparently as strong
a grasp as the other. Supination was impossible ex-
cept to a very slight degree. The humerus could be
abducted, but not carried across the chest. Examina-
tion by a neurologist subsequently showed no evidence
of paralysis. He had been able to find twenty-eight
cases of this dislocation on record. His conclusions
were: (i) It was of the greatest importance to distin-
guish between traumatic and developmental cases;
(2) a successful method of treatment had not yet been
established; (3) in cases determined to be develop-
mental by the history and measurements, an early op-
eration before the humeral head had formed a new
articular facet, and had itself become deformed, offered
the best chances of success.
Dr. a. M. Phelps said that he had had eight cases
of congenital dislocation of the shoulder, and had oper-
ated on four of them. In all the operative cases he
had found fracture of the posterior border of the gle-
noid cavity. He believed the dislocation was always
traumatic — never congenital.
Dr. Gienev said that he had reason to believe many
of these cases were treated at neurological clinics as
examples of Erb's paralysis, the true condition not
being recognized.
Dr. Porter contended that if the condition was al-
ways the result of traumatism inflicted at birth, then
measurements made within a few months after birth
should not give, as they did in some instances, such
differences in the development of the extremities.
Rapid Osteoclasis for the Correction of Rachitic
Deformities of the Legs. — Dr. Wallace Blanchard,
of Chicago, read this paper. By rapid osteoclasis he
meant osteoclasis performed in a period not exceeding
eight seconds. When operating so rapidly, the circu-
lation of the part was not impaired, and certain un-
pleasant consequences were tliereby averted. By osteo-
clasis the length of the limb would be slightly increased,
whereas by a Macewen supracondyloid osteotomy the
limb would be shortened. After osteoclasis it was his
custom to make exaggerated correction of the curve.
The same plan was adopted for bow-legs. Bending in-
stead of breaking the femur was often sufficient. After
eight years' use of the Grattan osteoclast he felt that
it had not received its just due. The lighter modifi-
cations of this instrument were decidedly inferior to
the original instrument. By rapid osteoclasis no in-
jury was inflicted on the soft parts; the instrument
did not slip nor did it cause any splintering. Speedy
union was the rule, so that all retentive appliances
might often be dispensed with after four or five weeks.
Dr. R. H. Davls expressed surprise at Dr. Blan-
chard's being willing to leave off such appliances so
soon, as certainly at this time the callus was not suffi-
ciently hard to admit of this being done without invit-
ing relapse.
Dr. T. Halsted Myers said that he used osteo-
clasis freely in his service at the New York Found-
ling Hospital. If the pressure bar was applied on
the inner side, the bone could be fractured much more
readily than when applied on the outer side.
An Operation for Ununited Intracapsular Frac-
ture of the Hip. — Dr. Gwilvm G. Davis, of Phila-
delphia, read this paper. In two cases treated by him
the incision had been made anteriorly, and by blunt
dissection the capsule had been exposed and opened.
The edges of the fracture had then been freshened and
a second incision made on the outer surface of the
greater trochanter, and the compact tissue in this part
having been perforated two ivory pegs were inserted
to hold the fragments together. In the first case steel
pegs had been used, and had been allowed to project
externally, but they had excited suppuration. For
this reason he had discarded the plan of bringing
these pins to the surface. Both patients had been
between thirty-five and forty years of age.
Officers Elected. — The following officers were elected
for the ensuing year: President, Dr. Arthur J. Gillette,
of St. Paul; First Vice-fresidriit, Dr. B. McKenzie, of
Toronto; Seeond Vice-President, Dr. Henry Ling Tay-
lor, of New York ; Treasurer, Dr. E. G. Brackett, of
Boston; Secretary, Dr. John Ridlon, of Chicago.
The next meeting will be at Niagara Falls in May,
igot.
NEW YORK ACADEMY OF MEDICINE.
SECTION ON MEDICINE.
Stated Meeting, Tuesday, Alay i§, igoo.
John H. Huddleston, M.D., Chairman.
Pernicious Anaemia. — Dr. Charles E. Nammack
presented a patient forty-eight years of age, who was
born in Ireland and who had spent thirty years of his
life as a stoker and fireman on board a tropical
steamer. For these thirty years he had been in ab-
solutely good health, not sick in bed a single day.
His first symptoms consisted of gradually increasing
weakness followed by severe vomiting in which there
were some blood flecks. He then had his attention
called to tiie fact that his skin was becoming yellow.
When he came to the hospital his pulse was 98, his
temperature 100° F., and his respirations 22 to 24.
He was not very emaciated, but the subcutaneous
layer of tat, which is often so well preserved in per-
nicious anaemia, was not present. He denied all
venereal history, though he admits that he has in-
curred the risk of infection a great number of times.
He drank some, but usually not to excess. He had
never been what might be called a steady drinker.
His teeth were examined very carefully after his ad-
mission to the hospital. Some time ago, in the Lon-
don Lancet Hunter described a series of cases of
pernicious anremia in which carious teeth were found.
Hunter attributed the blood disorder to the swallow-
ing of septic material from the mouth and its sub-
sequent absorption in the stomach. None of this
patient's teeth, however, was carious. The gums
were somewhat retracted, but the twenty-three teeth
present were in a reasonably good condition. His
heart was found to be normal, his liver slightly en-
larged, his spleen little if at all enlarged, and his
lungs were perfectly normal. There was a scar in his
right iliac region, not due to operation for appen-
dicitis, but to the opening of an old abscess. PJxami-
nation of his stomach contents showed the presence
of hydrochloric acid in about the normal quantity.
Lactic acid was also present, but only in small
amount. The blood count showed 500,000 red blood
cells to the cubic millimetre and about the normal
amount of white blood cells. There was no leuco-
cytosis, though blood examinations were repeatedly
made to ascertain this point. There was twenty per
cent, of haemoglobin, i.e., each of the red cells con-
tained about twice the normal amount of haemoglobin.
The red cells were very varied in character and size
and form, i.e., there was marked poikilocytosis. A
large number of megaloblasts were present. The
diagnosis, pernicious anaemia, seemed clear. It was
necessary only to exclude gastric carcinoma. The
examination of the stomach contents seemed to assure
the absence of cancer in the stomach. Besides, there
was no leucocytosis. This would almost surely occur
if gastric carcinoma had existed long enough to cause
1 I lO
MEDICAL RECORD.
[June 23, 1900
such symptoms as were present in the case. The pa-
tient's color was the characteristic lemon jellow of
pernicious ancemia, not the muddy yellow of cancerous
cachexia.
Frequency of Pernicious Anaemia. — There was no
doubt that this disease occurred much more frequently
than had been imagined. In this country particularly
the old school of practitioners had been inclined to
think it very rare. A few years ago Dr. Cabot, of
Boston, reported sixty-six cases of the disease before
the Association of American Physicians at Washing-
ton. At the recent session of that body he increased
the number of cases in his report to one hundred and
ten. It seemed clear then that those who looked for the
disease carefully would find it much oftener than
might be expected from the tone of the text-books and
the usual authorities on the subject.
Treatment. — The prognosis of the disease still re-
mained as before, absolutely fatal. A ray of hope
had recently been thrown on the therapeutics of the
disease by Hunter's studies in England. On the
theory that the disease was due to the absorption of
toxins from the gastro-intestinal tract, these occurring
because of the presence of foci of suppuration in
carious teeth in the mouth, Hunter advised thorough
antisepsis of the gastro-intestinal tract and the use of
some serum injected subcutaneously to neutralize as
far as possible the septic material which had already
found its way into the circulation. An English
physician had reported one case successfully treated
by this method. The patient used mild antiseptic
mouth washes, bismuth and salol and beta-naphthol
internally, and was given injections of anti-streptococ-
cus serum. Improvement began at once and was
almost marvellous in its rapidity. In forty-five days
the blood was perfectly normal. It remained, of
course, doubtful as yet whether this rapid recovery
was due to the treatment or to one of the well-known
remissions of the disease which occurred so frequent-
ly. Such remissions seldom produced so rapid an
improvement as was reported in this case, and practi-
cally never caused a complete return to normal
health. The method of treatment was, at least, en-
couraging.
Scurvy. — Dr. Nammack presented a patient aged
forty years, an Austrian by birth, suffering from scor-
butic symptoms. He had contracted the disease from
the use of unsuitable food in New York. The patient
confessed that he drank beer rather freely, used tobac-
co to excess, and took four cups of coffee a day.
During the fifteen years he had been in this country
he had never been ill before. He was a carpenter by
occupation, worked hard, and lived with extreme fru-
gality. His meals had consisted of coffee and bread,
with some sausage, canned and preserved meats of
various kinds, with smoked and salt fish and other
articles that he could obtain very cheaply. He did
not mind the quality of his food, provided he could
get it cheaply. He had evidently been living on half-
spoiled victuals most of the time. His first symptom
was tingling and prickling, with pain in the legs. He
tiien noticed that his gums were tender and bled easily
when touched, or when he chewed rough food. Black
spots, some of them as large- as a silver dollar, oc-
curred on his legs. When he came to the hospital he
was found to be poorly nourished, of a dusky yellow
color, in marked contrast to the light lemon yellow of
the patient suffering from pernicious antemia, and
with large areas of subcutaneous hemorrhage, espe-
cially on the backs of his thighs and calves. His
mucous membranes were intensely pale and the con-
junctivae especially lacked color. His gums were
purple and oedematous. They hung down over the
teeth in fungoid masses and bled at the slightest
touch. There were petechias on his body, but not
many on the arms. There were no hemorrhages into
the retina. Blood examination gave 2,200,000 red
blood cells to the cubic millimetre, and 7,000 leuco-
cytes. The haemoglobin value was sixty per cent.
No megaloblasts were present, and the poikilocytosis
was not marked. There was no leucocytosis at any
time duiing the affection. The man was evidently
suffering from secondary anaemia due to his scorbutic
condition.
Etiology of Scurvy — This case would seem to be
a striking confirmation of the explanation of the origin
of scurvy which had been advanced very recently at
Ann Arbor. It was not considered to be due to an
exclusive diet of any kind, especially not to exclusive
animal food, but rather to the absorption of ptomains
from decomposing or badly preserved food. It was
well known that scurvy did not occur among the Es-
quimaux, though their diet consisted for most of the
year of nothing else than animal food. It did not oc-
cur among the negroes in Central Africa, though they
lived almost wholly on the plantain. It was infre-
quent in India and -in China, though a great many of
the people ate nothing else than rice. Cases of scurvy
that had occurred aboard ship from the use of salt
meat could be very well explained on the theory of
poor preservation of the meat, allowing the produc-
tion of toxic ptomains in it. It seemed interesting to
note. Dr. Nammack said, that none of the soldiers of
the late war returned from Cuba or the camps, who
came under his observation, showed any signs of
scurvy. A great deal of notoriety was given by the
newspapers to the embalmed-beef scandal, yet none of
the soldiers seemed to have suffered severely from
anything like ptomain poisoning as the result of poor-
ly preserved meat. Numbers of them had severe sec-
ondary anasmia, as the result of malaria, typhoid fever,
and dysentery, but no scurvy was reported.
Bradycardia ; Pulse of Thirty-Six. — Dr. James J.
Walsh presented a patient, a woman aged thirty-one
years, whose pulse was normally about 36 and under
excitement went up to 40. There was nothing in her
family history that threw much light on the condition.
Her mother and five brothers and sisters were living
and well. As a child this patient suffered from most
of the ordinary diseases of childhood, and there was
a tradition in the family that if there was any disease
about she would catch it. She played, ran, and skipped
rope quite as other children did. Though seen a num-
ber of times by doctors they never called attention to
the fact that her pulse was slower than normal. About
ten years ago she had the grippe, and while convalesc-
ing from that her physician called her attention to the
fact that her pulse did not rise above 40. Since then
she had been apparently in perfect health. For a
while she was a dancer on the stage and in private
drawing-rooms. She did not notice that she seemed
more exhausted than others after severe exertion. Of
late she had been suffering somewhat from digestive
symptoms, and it was for these that she had come
under treatment. Her gastric symptoms had practi-
cally disappeared under simple tonic treatment, and
now she considered herself in good health once more.
The question arose whether the bradycardia was con-
genital or acquired. It seemed to exist in no other
members of the family, and the fact that physicians
did not call attention to it when she was young seemed
to indicate that her bradycardia was a sequela of in-
fluenza.
Cicatricial Stenosis of the Pylorus.— Dr. Free-
man Ward presented a patient forty years of age, a
man who had been suffering from gastric symptoms
for some eight years. He first noticed severe vomit-
ing, in which streaks of blood occurred with pain
shortly after eating. This continued for some time
and then disappeared, and for years he had very few
June 23, 1900]
MEDICAL RECORD.
gastric symptoms. Two years ago he began to have a
dull pain in the epigastrium. After a while this be-
came severe, and would wake him up between 2 and 3
o'clock in the morning and compel him to get up and
w'alk about for a while. Frequently spells of vomiting
came on during the pain, and then marked relief fol-
lowed. He noticed that the vomited material often
contained particles of food that he had eaten some
time before, sometimes as long as twenty-four or forty-
eight hours. He was given a Boas test meal, and his
stomach contents were removed for examination. Al-
together nearly 1,400 c.c. was withdrawn. The total
acidity of this was much higher than normal, and
hydrochloric acid especially was in e.xcess. All the
digestive ferments were present, and starch digestion
was particularly good. The patient's stomach was
washed out every evening for some days with marked
relief. The pain did not recur during the night. He
was then put on regular evening lavage. If this la-
vage was omitted duringt he first two weeks the pain
always recurred. Gradually, however, it became pos-
sible to lengthen the interval between the lavages. He
now could go for thirty-six and sometimes forty-eight
hours without inconvenience. His appetite was much
better, and he had no discomfort in the epigastrium.
He had gained three pounds in weight. Before the
regular washing out of his stomach was begun a cer-
tain amount of gastric dilatation could be demon-
strated. The fundus of the stomach was three fingers'
breadth below the umbilicus. It was now in its
normal position above the umbilicus. The diagnosis
of the case was post-ulcerative stenosis of the pyloric
region. The contracted scar tissue of the healed ulcer
had materially lessened the lumen of the pylorus and
so prevented exit of food. It seemed doubtful whether
the present treatment would continue to relieve his
symptoms.
Pyloric Stenosis and Loss of Weight. — Dr. Ward
also presented a patient aged twenty years who, in
twelve months had lost seventy-two pounds in weight.
His first symptom some three years ago was vomiting,
in which there was some blood and a feeling of dis-
comfort amounting almost to pain after the taking of
food. There was a distinct area of tenderness in the
pyloric region, but no thickening could be felt. The
test meal showed the stomach contents and secretions
to be perfectly normal. Inflation of the stomach with
carbonic acid gas showed that it was not dilated.
The state of malnutrition that had developed was so
serious that as no medical means seemed of any avail
surgical intervention was advised. The operation
was done by Dr. Farquhar Curtis, who found the
pylorus closed. It had been thought that perhaps a
hypertrophic stenosis of the pylorus existed, but the
condition was found to be stenosis from the scar of an
old ulcer. The patient weighted one hundred and six
pounds at the time of the operation. He novii weighed
one hundred and eighty-two pounds.
Stomach Distention and Diagnosis. — Dr. U'ard
called attention to the fact that in this case every
possible means had been taken to diagnose the pres-
ence or absence of dilatation of the stomach. Among
other means the introduction of water into the stomach
in order to find how much it would hold was tried.
At the General Memorial Hospital a resident physi-
cian succeeded in introducing ninety-eight ounces of
water. At the operation, however, no dilatation of
the stomach was found. The amount of water, then,
which could be introduced served to show not the
actual presence of dilatation of the stomach, but the
distensibility of the stomach walls.
Specific Tumor of the Stomach. — Dr. Ward'a third
patient was a man aged thirty-eight years, who began
to suffer with gastric symptoms some eight years ago.
His first symptoms were pain shortly after eating, and
frequent vomiting in which there was some blood.
The pain was increased by acid or irritating foods.
The patient went to Carlsbad and was treated by a
distinguished stomach specialist, whose diagnosis was
gastric ulcer. His symptoms, however, were not
allayed by the usual treatment for ulcer of the stom-
ach. The giving of liquid food alone did not cause
improvement, and while rectal feeding did away with
gastric pains for the two weeks during which it was
kept up, just as soon as feeding by the mouth was re-
sumed the pain recurred. Even an absolute milk diet
did not prevent the recurrence of pain. Occasionally
in the vomited material there were streaks of fresh
blood. Once or twice the hemorrhage was rather
severe. At times the vomited material contained a
substance of dark coffee-grounds appearance. No
tumor could be felt anywhere in the gastric region,
and there were no special areas of tenderness. As
the abdominal muscles were very tense an anaesthetic
was given in order to make a more complete palpation
for the tumor. No tumor was found. The patient
had become very emaciated, and weighed less than
one hundred pounds, and it became evident that un-
less something was done a fatal termination from
inanition could be looked for. An operation was
performed, when it was found that the pylorus was
completely closed by a tumor the size of a tangerine
orange. The patient's condition was so poor that it
was clear that an operation for the removal of the
tumor at this time would almost surely result fatally.
A gastro-enterostomy was done in the hope of bringing
about an improvement in his condition, and with the
idea of doing a secondary operation for the removal
of the tumor as soon as the patient's condition justi-
fied it. The tumor was considered to be an adenoma
of the stomach wall. Without any hope really of do-
ing the patient good, potassium iodide was given in
order to be assured that the tumor was not specific.
In a few weeks the man gained rapidly in weight. In
about six weeks the abdomen was opened a second
time, when it was found that the tumor had completely
disappeared. The patient had had no trouble since,
and now weighed one hundred and forty pounds, hav-
ing gained over forty pounds in six months.
Specific Treatment for Tumors. — In the discussion
of the last case. Dr. James J. Walsh said that it em-
phasized the necessity for the administration of spe-
cific treatment whenever internal tumors existed, even
though there might be no specific history. Within the
last few months, he had seen a case in which a large
tumor of the splenic flexure of the colon led a promi-
nent surgeon to diagnose a rapidly growing sarcoma.
The patient was told to prepare for operation, and was
told very frankly that the tumor was so large that there
was very little hope that the operation would be radi-
cally successful. The patient came to New York with
the idea of taking the mixed toxin treatment for sar-
coma. The man had been a most careful liver, and
there seemed no reason at all to doubt his story of the
absence of venereal infection. He was put on mixed
treatment, however, and in two weeks marked im-
provement set in. At the end of two months the
tumor had practically disappeared.
Dr. Alfred Meyer said that specific tumors might
simulate not only any form of neoplasm, but also
aneurisms. Within the last few weeks he had seen a
case presented before the German Medical Society in
which what seemed to be a pulsating tumor occurred
at the sterno-clavicular junction. With the idea
rather of relieving the pain than of effecting any im-
provement in what was presumed to be an aneurism,
the man was put on rather large doses of potassium
iodide. Improvement occurred not only as regards
the symptoms, but the tumor became greatly lessened in
size. After a few months it completely disappeared.
1112
MEDICAL RECORD.
[June 23, 1900
Relation of Gastric and Urinary Acidity. — Dr.
Alfred Meyer called attention to the fact that there
seemed to be an inverse ratio between the acidity of
the urine and the acidity of the stomach. When the
gastric contents were strongly acid the urine was re-
duced in acidity. This seemed to account for the for-
mation of certain calculi. Dr. Meyer had had under
his care two patients in whom there was an excess of
gastric acidity and a corresponding deficiency of urin-
ary acidity. In both calculi developed. In one of
the patients a phosphatic calculus of the pelvis of the
kidney led to a pyelitis which necessitated the re-
moval of the kidney. In the other a simple phos-
phatic calculus was passed to the bladder. The pos-
sible connection of excessive gastric acidity and the
formation of urinary calculi was well worth studying.
The etiology of calculi was a vexed question.
Prophylaxis was now the order of the day in all affec-
tions, and if we could ward off the formation of cal-
culi in predisposed individuals it would certainly be a
great triumph.
Dr. Nammack said that the lessening in size of
tumors and the disappearance of symptoms from them
under the administration of specific treatment did not
entirely justify the conclusion that the tumors were
syphilitic. Sarcomata particularly were often influ-
enced by the administration of potassium iodide.
Brain sarcomata and even other brain tumors were
often greatly improved by a course of the iodides.
It seemed unfortunate that more attention had not
been directed generally to the possible good that
might be accomplished by the absorptive power of the
iodides in these embryonic tumors and in granulation
tissue generally.
Absent Knee Jerk with Ankle Clonus. — Dr.
Leszvnskv said that when Dr. Mills, of Philadel-
phia, presented some years ago a patient with absent
knee jerks yet marked ankle clonus, the condition was
considered a rare one. He had seen several such
cases, and had one to present this evening. The pa-
tient, a man twenty years of age, suffered from Pott's
disease when one year old. Later he had a tuber-
culous osteitis of the knee joint. His right leg was
considerably smaller than the left, and his right foot
dropped a little in walking. In neither knee could
there now be demonstrated any knee jerk even with
most careful reinforcement. VVell-marked ankle clo-
nus existed on both sides. There were other in-
teresting symptoms. There were some numbness and
insensibility of tiie outer part of the right leg, and
some anesthetic patches in the left ankle. There
was also some disturbance of the temperature sense.
It was probable then that there was a syringomyelia
and that the cavity in the cord occurred only in the
lumbar region in the third and fourth segments of the
lumbar cord. The centre for the knee jerk was situ-
ated here, and it was obliterated by the pathological
process of the syringomyelia. It was only when there
existed an actual lesion of the lumbar cord as well as
some other pathological condition above it, yet with
the centre for ankle reflexes left untouched, that there
was ankle clonus without exaggerated knee jerks.
Lateral Sclerosis. — Dr. Leszynsky presented a pa-
tient who was sent to him some time ago for diag-
nosis. Two years ago she lost more or less the use of
her limbs. Afterward there seemed to have been
some improvement, but never a return to the normal.
Now she had completely lost the use of both legs.
They continued to be well nourished, and no trophic
conditions had developed anywhere. It was sus-
pected at first that the case was one of hysterical para-
plegia. Against this, however, were the slow and
gradual onset, the total absence of pain, the failure
to find any symptoms of hysteria in the previous his-
tory, and the absence of any cause like emotion, or
family or monetary trouble, to bring on the hysterical
palsy. Besides, none of the stigmata of major hys-
teria existed. There were no patches of anaisthesia
and no hyperajsthesia. There was a good pharyngeal
reflex and the visual fields were not narrowed. There
were exaggerated knee jerks and ankle clonus. These
last two symptoms, it was formerly thought, assuredly
stamped an affection in which they were present as
not functional. This was known now not to be true,
for both exaggerated knee jerks and ankle clonus had
been noted in purely hysterical cases. The long per-
sistence of both these exaggerated reflexes and the
amount of exaggeration, however, spoke strongly
against hysteria. It seemed probable, then, that the
case was one of chronic myelitis of the pyramidal
tracts — the so-called lateral sclerosis.
Babinsky Great-Toe Reflex. — There was present
in the case the symptom pointed out some time ago
by Babinsky in Paris, which had been thought to be
of differential diagnostic significance between func-
tional and organic spinal disease. Ordinarily when
the sole of the foot was tickled or touched, dorsal flex-
ion took place. If there was disease of the spinal
cord itself, especially of the pyramidal tracts, this
flexion was limited to the great toe, which immediate-
ly after the irritation of the sole was strongly raised
toward the dorsum of the foot. This could be seen
very readily in this case. Some doubt remained as to
the diagnosis of lateral sclerosis, because of the ab-
sence of the scissors gait, and the fact that the bowels
were not much affected and the bladder was not at all.
In women, however, we did not see the development
of the scissors gait until late in the disease. Me-
chanical factors in the muscles of the female leg and
the farther separation of the heads of the femora ac-
counted for this. There was some incontinence of
fa;ces, i.e., when the call to go to stool came it must
be obeyed at once, or the sphincter was not able to con-
trol the intestinal contents. In women incontinence
of urine in these cases was not nearly so common as
in men. Of late the affection seemed to have made
more rapid progress than before. It was probable
that if the woman could be kept under observation for
some time, it would be possible to decide with cer-
tainty that lateral sclerosis was present.
Significance of Babinsky 's Reflex. — The presence
of the Babinsky contraction of the big toe seemed
always to indicate the presence of a pathological con
dition of the spinal cord. It was not pathognomonic
of degeneration of the pyramidal tracts, but it at least
indicated some interference with their function. Sil-
ler had recently observed it in two cases of cerebral
hemorrhage in which the knee jerks were absent. He
was inclined to attribute to it an ominous significance
in these cases, because both of his patients died.
In the discussion Dr. Nam mack said that the pres-
ence of the exaggerated reflexes so persistently seemed
to him to stamp the affection as organic, not functional.
As Patrick, of Chicago, once said, a single objective
symptom meant more against the diagnosis of hysteria
than any number of theoretical considerations.
Angina Pectoris. — In the attack, rest and fresh air
are of use, with morphine hypodermically. Nitrite
of amyl up to twenty drops on a handkerchief should
be inhaled. Between the attacks, iodide of potassium,
gr. v.-xv., should be given daily for months or years.
During fifteen days of each month nitroglycerin aids
in nutrition of the heart. Ignipuncture or tincture of
iodine over the heart region may be of service. Mod-
eration at table should be observed, with suppression
of alcohol and tobacco, avoidance of emotion and fa-
tigue.— Paris Correspondent in Medical Fress, January
i7lh.
Medical Record
A IFeekly yoiinial of Medicine and Snygery
Vol. 57, No. 26.
Whole No. 1547.
New York, June 30, 1900.
$5.00 Per Annum.
Single Copies, loc.
©rirjinaX |irtictes.
CONCERNING THE PERITONEUM AND
THE TREATMENT OF EXUDATIVE PERI-
TONITIS.*
By albert a. BERG, M.D.,
The rapid and extensive progress made in surgery
during the last two decades of the nineteenth century
has left few unexplored regions, and but little fertile
soil to cultivate. It has been said that the new era
in surgery will devote itself to the perfection of our
present diagnostic knowledge, to the more sharp
definition of the indications for or against operative
attack, and to the attempt to establish on a rational
and sound basis the present therapeutic procedures,
thus eradicating all that is useless and cumbersome.
In accordance with this view I have prepared this pa-
per; not because I have any new method of treatment
to propose for diffuse exudative peritonitis, but rather
because I would wish with your aid in discussion to
bring some order out of the chaos in which the thera-
peusis of this disease is involved, and because I would
seek to establish a rational basis on which to rest our
operative measures. It seems most important at the
very outset of these remarks to consider the two cardi-
nal points which underlie the entire subject-matter of
peritonitis. These are: {a) Is the presence of bac-
teria alone sufficient to produce an exudative perito-
nitis, and if not, what else must be added to aid the
bacteria in their work? (/') What protects the peri-
toneum from becoming the seat of such an inflamma-
tion in the presence of bacteria?
It has been well enough established, both experi-
mentally and clinically, that bacteria alone are not
capable of producing an exudative peritonitis. With-
out entering too deeply into the experiments of Weg-
ner,' Grawitz,- Waterhouse,' and Orth,' I may be
permitted to quote the conclusions which the above
investigators have unanimously arrived at:
1. That the introduction of bacteria, even of the
pyogenic types, into the normal peritoneal cavity pro-
duces no evil results, provided they are not mixed
with caustic or irritating substances.
2. The introduction of non-pyogenic organisms into
the normal peritoneal cavity produces different results,
depending on whether the organisms injected cause
decomposition of albumin, or not. In the latter case
even considerable amounts of bacteria and fluid are
absorbed, without evil consequences, while in the
former general sepsis, but not purulent peritonitis,
results.
Opposed to the conclusions I have just mentioned
.ar« the results of the investigations of Pawlowsky,*
Alexander Frankel,' and others, who found that in-
jections of even very small doses of the staphylo-
coccus aureus, or of the streptococcus, produce an
exudative peritonitis. We must infer, and even Paw-
lowsky has conceded this, that there were other fac-
* Read in abstract before the Surgical Section of the New York
Academy of Medicine, May 14, 1900.
tors associated with the bacteria in their experiments,
which resulted in the production of the peritonitis
established by their injections. Clinically we are
very often confronted with evidences that the pres-
ence of bacteria alone in the healthy peritoneum is
not sufficient to establish an exudative peritonitis. It
has fallen to the lot of every one of us to soil the peri-
toneum with the pus of some very infectious abscesses,
and yet in very many cases no peritonitis has devel-
oped. The patients have recovered, and exhibited at
no time any signs leading us to suppose the coexist-
ence of an exudative peritonitis. In this connection
the observations of Bonnecken" on the bacteria of in-
carcerated hernial sacs may be briefly mentioned.
He found: (i) In the fluid of incarcerated hernial
sacs there are already in an early stage of the incar-
ceration, long before necrosis of the bowels has oc-
curred, micro-organisms. (2) These are both cocci
and bacilli, and wander out from the bowel into the
hernial sac. (3) Death is due in these cases to peri-
toneal sepsis, usually without purulent peritonitis.
Again, Tavel and Lanz" say concerning this point,
that the presence of bacteria which have wandered out
into the peritoneum is not sufficient to produce a peri-
tonitis, as long as the other parts of the serosa are
normal, and retro-absorption can take place. This is
shown by the rarity of peritonitis through wandering
of bacteria into the peritoneum. Instances of bacte-
rial peritonitis following such out-wandering of bac-
teria, in which only this factor is present, have been
shown neither experimentally nor clinically.
To what is this protection from the deleterious ac-
tion of the bacteria due? Several theories have been
advanced to account for it. First, the peritoneal
serum was supposed to exert a bactericidal action on
the organisms which had been introduced (Schnitzler
and Ewald'). Then again it was advanced that the
leucocytes which had wandered out into the perito-
neal cavity had overcome and destroyed the bacteria.
The peritoneal cells were also said to have bacteri-
cidal power. Of all the explanations, the most ra-
tional is that which ascribes the protective attribute
of the healthy peritoneum against bacterial infection
to its rapid absorptive power. The experiments of
Grawitz'" bear out this view; for he found that when
the peritoneum is injured by caustics, or when a
wound of the peritoneum favors the sedimentation of
the bacteria, so that a phlegmon results, then bacterial
peritonitis ensues.
This brings us to the consideration of absorption in
the healthy and diseased peritoneal cavity — a question
that has bothered the ablest physiologists, and one
which is even to-day not certainly decided. As an
absorbing organ we may consider the peritoneum as
being made up of endothelial cells and stroma, the
latter supporting a rich supply of vascular and lym-
phatic vessels. It must be remembered that the peri-
toneum has an enormous surface exposed for absorp-
tion, almost as extensive as the area of the skin. In
viewing the question of absorption from this surface,
we must consider by what routes, and by what method,
absorption takes place.
As to the channels by which absorption takes place,
it has been fairly conclusively 'shown through the
1 1 14
MEDICAL RECORD.
[June 30, 1900
labors of Hamburger," Orlow,'" Adier, and Meltzer,'*
that the chief route is by way of the blood-vessels; the
lymphatics, if they enter at all, play but a subsidiary
role in the path by which absorption occurs in the
healthy peritoneum. This helps us to understand the
gravity of an absorption of pathogenic organisms by
the peritoneum, provided the tissues are not able to
cope with them after absorption. For it must be re-
membered that every absorption of bacteria into the
blood is not necessarily followed by a proliferation of
these organisms, and furthermore, even when the bac-
terial resorption is very considerable, bacteria;mia is
very rare, at least in human beings. Were the lym-
phatics more concerned in the absorption from the
peritoneal surface, there would be an additional pro-
tection in the lymphatic glands against an entrance
of the pathogenic organisms into the blood, and the
picture of peritoneal septicaemia would probably be a
less frequent one.
The method of absorption from the peritoneal cavity
is still not positively decided. The one school, which
includes such able investigators as Hamburger,"
Cohnstein.'^and others, argue that they have distinctly
proven that resorption from the peritoneal or pleural
surfaces follows the physical laws of osmosis and fil-
tration; whereas another school, including equally
competent investigators, such as Orlow,"' Starling, and
Tubby," urge that absorption is a distinctly active
process, the peritoneal cells being the active factor in
the absorption.
Hamburger, the leading exponent of what I may term
the physical method of absorption, believes resorption
to be due to these factors : (d) Imbibition, both molecu-
lar and capillary; (/') osmosis; (i) hydrostatic press-
ure. He urges, in support of the first of these factors,
that all tissues, living as well as dead, can imbibe fluids,
and, owing to this property of imbibition, that fluids
will pass from the peritoneum to the blood-vessels.
But in reference to this the following objection is to
be noted: Why should the property of imbibition
carry fluids from the peritoneal cavit)' into the blood
and lymphatic vessels? Is this imbibing of fluids
and yielding them up to the blood and lymphatic sys-
tem in itself not a manifestation of cellular activity?
Thus when the latter is suspended, as for e.xample
after death, imbibition takes place until the tissues
have become saturated, and then resorption ceases.
This imbibition accounts for the absorption that has
been noticed in experiments undertaken after the
death of animals. Hut in the normal living tissues,
the cells yield up their imbibed fluids to the blood
and lymphatic vessels, and so resorption goes on in-
definitely. Hamburger, who attempted to disprove
the cellular activity in causing absorption, laid stress
upon the results of those of his experiments which
showed that even after severe injury to the perito-
neum by chemical (NaFl) or thermal means, absorp-
tion and the equalization of the osmotic coeflicient
took place, and that these also occurred in animals
dead from a few minutes to twenty-four hours. He
apparently overlooked the fact that his chemicals or
thermics did not destroy the property of imbibition,
owing to which a certain amount of fluid disappeared
from the peritoneal cavity, and which he attributed to
resorption; and also overlooked the fact that osmosis,
a purely physical phenomenon, will occur through any
animal membrane living or dead. As regards imbibi-
tion, therefore, I might say that it is owing to this prop-
erty of imbibing fluids that the peritoneal tissues are
enabled to accommodate the fluids they have absorbed
from the peritoneal cavity, while they are transporting
them to the blood and lymphatic vessels. For were
they not able to imbibe, it is very evident that no ab-
sorption by means of a membrane unprovided with
openings could take place.
In reference to his second law of absorption, viz.,
osmosis, we must remember that when fluids contain-
ing diffusible substances in solution are separated
by an animal membrane, these diffusible substances
will pass through this membrane from the side on
which the osmotic tension of that particular diffusible
substance is greater, to that on which it is less: thus
if hypotonic NaCl solutions are put into the perito-
neal cavity, NaCl will osmose from the blood-vessels
until the osmotic tension of NaCl is equalized on
both sides of the peritoneum ; and vice versa, if hyper-
tonic NaCl is placed into the peritoneal cavity, the
NaCl will osmose from the peritoneal cavity into the
vessels until the osmotic tension is again equal-
ized. The laws of osmosis will explain the passage
of diffusible materials through the peritoneal mem-
brane, but as regards the absorption of fluids from the
peritoneal cavity, in accordance with the physical
laws of osmosis, the proof is not convincing; for were
resorption due entirely to osmosis we would expect it
to be as rapid after death as during life, and we would
not expect the markedly retarded absorption that has
been observed by Orlow, while animals were kept under
continuous chloroform anaesthesia ; so that while osmo-
sis may account for some of the absorption, it must be
conceded, as Orlow has expressed it, that the peritoneum
is an active membrane in that it modifies the physical
laws of osmosis, just as does the intestinal mucosa.
As regards now the third factor, which was de-
scribed by Hamburger as being concerned in absorp-
tion, viz., hydrostatic pressure, I can only remark
that this can at the best play but a subsidiary role in
the mechanism of resorption, inasmuch as the intra-
abdominal pressure is never a constant one, but fluc-
tuates with inspiration and exspiration, with the de-
gree of intestinal distention, and with the contraction
of the abdominal muscles. The three factors con-
cerned in peritoneal resorption, as formulated by
Hamburger, do not sufficiently explain the mechanism
of absorption from the peritoneum. Imbibition, both
molecular and capillary, enables the cells to carry
the fluids only from the absorbing surface to their
place of delivery; osmosis will account for the passage
of dift'usible substances through the animal membrane,
and such diffusion takes place from the blood-vessels
into the peritoneum, as well as from the peritoneum
into the vessels; whereas hydrostatic pressure, being a
variable factor, cannot account for the steady, contin-
uous absorption which takes place from serous mem-
branes. This brings me to the consideration of the
other theory as to the mechanism of peritoneal resorp)-
tion, viz., that this is an active cellular process. If
resorption is such an active process, then if we can in
any way interfere with this cellular activity resorption
should be diminished. We know that when chloro-
form is administered there ensues a temporary paraly-
sis of the cerebral cells, and also of the leucocytes
(as shown by Massart), which lose their irritability
and their chemotactic function. It would be wrong to
suppose that this action of the chloroform is limited
only to the cerebral cells and the leucocytes; much
more rational is it to suppose that the cells of the en-
tire organism are temporarily paralyzed, and their
function consequently impaired. If this W'ere so, we
would expect a retardation of absorption while an
animal was under the influence of chloroform. This
does actually occur, and is beautifully illustrated by
the experiments of Orlow-." He found that if fhe
serum is taken from an animal and injected into
the peritoneal cavity of another animal of the same
species it is absorbed, but in less amount in the same
period of time when the animal is kept under con-
tinuous chloroform anaesthesia than would be the case
were the animal not kept under this anaisthetic. Fur-
thermore, we find that bacteria alone (Grawitz and
June 30, 1900]
MEDICAL RECORD.
1H5
others), when injected into the healthy peritoneum in
amounts not too excessive to be absorbed, do not pro-
duce peritonitis, but if the peritoneal cells are poisoned
at the same time as the injection is made, as for ex-
ample by the chemical toxins resulting from bacterial
life, thus paralyzing their resorptive power, then peri-
tonitis results; or if these cells are destroyed by the ac-
tion of caustics, then peritonitis results. Now were re-
sorption a purely physical process it would not be re-
tarded by a local disturbance of the peritoneum, such as
is produced by caustics or toxins, and the bacteria being
at once absorbed, peritonitis would not result. Inas-
much, however, as resorption is an active process, if
this activity is in any way interfered with or sus-
pended, then the bacteria can grow and multiply, and
produce their deleterious results. I maybe permitted
in this connection to cite the opinions of some of the
investigators on the mechanism of absorption from
serous membranes. Thus Starling and Tubby say :
"The cells between the blood and the pleural fluid
seem to exert a pull on the latter; in fact there is an
active absorption going on. The cells must perform
a considerable amount of work in this absorption;
so that we must look upon them as being actively
concerned in the absorption of fluids, such as one-per-
cent, saline solution." Quoting again from the same
authors: "There is evidence to show that with certain
solutions an active absorption from the cavity may
take place, whether by the blood-vessels or pleural
endothelium we are at present unable to determine."
Says Orlow : "These experiments go to prove posi-
tively that the peritoneum is not merely a passive mem-
brane, through which fluids simply diffuse, as through
animal membranes outside of the body, but that it is
an active membrane, in that it modifies the physical
laws of absorption, just like the intestinal mucosa."
The arguments thus far advanced, I think, show
conclusively that resorption from serous membranes
is an active process; and I would beg that this be
kept strongly in mind when I come to discuss the
treatment of exudative peritonitis, and have to con-
sider the best method of dealing with the exudate.
So far I have considered only the absorption from the
healthy peritoneal surface. Let me now take up the
question of resorption from the peritoneum when it
has become diseased. If the question of absorption
in the healthy state is a difficult one to decide, how
much more so is it when we consider absorption from
the diseased membrane. For here we have to consider
not only the changes which have occurred in the peri-
toneal cells, but also the changes in the blood-vessels,
in the blood current, and in the nerve supply. The
first question that comes up for discussion is: Is there
any absorption from the diseased peritoneum? This
can be answered positively in the affirmative. The
next point to consider is: What is the rate of absorp-
tion as compared with the healthy peritoneum? Here
again we have positive evidences in the results of the
experimental investigations of Schnitzler and Ewald,''
who have shown that in rabbits in which a purulent
peritonitis exists, the rate of absorption is somewhat
slower. In this connection it might be well to state
that these investigators have also demonstrated that
an increase of peristalsis hastens the rapidity of ab-
sorption up to a certain point, beyond which no
further increase in the rate of absorption is possible;
and vice versa, a slowing of the peristalsis lessens the
rapidity of absorption. The final question. By what
channels does absorption take place in the diseased
condition of the peritoneum? is difficult to determine;
it certainly is partly by the lymphatics, for the lymph-
atic glands are found enlarged in inflammatory con-
ditions of the serous membranes; it probably also
occurs by the blood-vascular system, although no ex-
periments have as yet been reported in this connec-
tion.* I beg of you to bear in mind, then, that there
is quite a rapid absorption from the peritoneal sur-
face, even when it is the seat of a severe purulent in-
flammation; for I will have cause again to refer to
this when I consider the question of drainage of the
peritoneal cavity when it is the seat of an exudative
inflammation.
I have gone thus into the details of the routes and
mechanism of peritoneal resorption, because it is ow-
ing to its very rapid absorbing-power that the perito-
neum owes its protection against the action of bacteria.
This brings me to the final question I proposed at
the beginning of this paper, viz.. If bacteria alone are
not sufficient to produce an exudative peritonitis, what
else must be present to aid the bacteria in their work?
Briefly stated it may be said that any agent which in-
terferes with the peritoneal protective attribute, viz.,
the rapid resorptive power, is sufficient to enable the
bacteria to produce their deleterious effects. The
earliest investigations of Grawitz proved this; for
he found that when the peritoneum was injured, e.g.,
by caustics, or when it was completely destroyed at a
local area, the bacteria would sediment at that partic-
ular site of injury or destruction, and establish a peri-
tonitis. This protective attribute may be lessened or
abolished by {a) chemical agents, which cause either
a death of the cells, or injury more or less marked, or
a disturbance in their physiological function, so that
the latter is either temporarily or permanently sus-
pended; (/') by mechanical agents, such as gauze,
tubes, etc., which act in the same way as the above.
This helps us to understand the apparently conflicting
results of the experiments instituted by Pawlowsky,'"
on the ability of the healthy peritoneum to withstand
the presence of bacteria; for he injected not only bac-
teria but also their chemical toxins, which latter par-
alyzed the absorptive power of the peritoneal cells,
and so favored the local sedimentation and further
action of the bacteria.
To quote from Tavel and Lanz,"' page 143: "In
order that bacteria should develop on the peritoneum,
and produce a bacterial peritonitis, there must be al-
ready a mechanical or chemical peritonitis. A pri-
mary bacterial peritonitis is not a possibility, because
the normal serosa, by its resorptive property, absorbs
the implanted bacteria, or else it does not respond by
inflammation to these bacteria."
To recapitulate from the data I have furnished thus
far, it is evident:
1. That bacteria alone, except when in very large
quantity, are not sufficient to produce an exudative
peritonitis.
2. That this immunity on the part of the healthy
peritoneum to the deleterious action of bacteria is due
to its very rapid resorptive power.
3. That this resorption under normal conditions is
mainly by way of the blood-vessels.
4. That peritoneal resorption is an active cellular
process, and not a passive one. This cellular activity
is manifested in the diseased as well as in the healthy
condition, but to a somewhat lessened degree. The
more marked the disease the greater is the interference-
with this activity, it being least when the peritoneal
endothelium has been considerably altered, and ceas-
ing altogether with the destruction of these cells,
resorption by much modified peritoneum being
similar to resorption by other types of cellular tissue.
This conclusion is of the utmost importance in con-
nection with the question of drainage of the peritoneal
cavity, and will be referred to again in the latter part
of this paper.
* The writer has commenced a series of experiments with the-
object of determining the channels by which absorption takes place
in the diseased peritoneum and will report the results at a subse--
quent time.
1 1 16
MEDICAL RECORD.
[June 30, 1900
5. In virtue of its rapid resorptive power primary
bacterial peritonitis is not a possibility, unless the
bacteria are present in such large numbers as to par-
alyze the peritoneal cells, and so hinder their rapid
resorption. There must primarily be a factor which
by interfering with the cellular activity of the perito-
neal cells favors a sedimentation of the bacteria, with
their consequent further growth and development.
Such factors may be either mechanical, e.g., gauze
packings, drainage tubes, etc., or chemical, either or-
ganic or inorganic in character.
These facts should govern our methods of procedure
with the local conditions found in exudative perito-
nitis, and reference will be made to them again. Be-
fore proceeding to the subject of the treatment of such
inflammations of the peritoneum, I would wish to di-
rect attention to the rather common fallacy of asso-
ciating the term " septic "' with the purulent types of
peritonitis, and to the error of estimating the viru-
lence of the inflammation by the character of the exu-
date. I have shown in my previous remarks that peri-
tonitis is primarily either a mechanical or chemical
process, to which may be added the further element of
bacterial life and development, with the toxin produc-
tion that necessarily accompanies them.
A mechanical or chemical peri'onitis may be either
dry, i.e., adhesive, resulting in the formation of adhe-
sions between the viscera, or e-xudative, i.e., with the
presence of an exudate in the peritoneal cavity. The
character of this exudate varies, it being hem6rrhagic,
or serous, or sero-purulent, or purulent. Such a me-
chanical or chemical peritonitis is usually of a benign
character; the patients exhibit the classical signs of
an inflammation of the peritoneum, but in the vast
majority of cases the disease goes on to a spontaneous
cure, the exudate being absorbed, or the adhesions
becoming organized. If bacteria are added to such a
mechanical or chemical peritonitis, the inflammatory
process is not altered in character, although it may be
in degree; in that the exudate becomes more distinctly
purulent, or even fetid, from the products of bacterial
life. But there is superadded the element of poison-
ing from the absorption into the system of the toxins
produced by the bacteria. The severity of the case
depends on the degree of this intoxication. Some of
the worst cases of poisoning from peritoneal absorp-
tion of toxins and bacteria occur in patients whose
peritonea show absolutely no signs either micro- or
macroscopically of a peritonitis. We have designated
such pathological conditions as peritoneal septicEcmia.
Vice versa, many of the purulent types of exudative
peritonitis are not at all septic. The bacterial ele-
ment of a peritonitis then does not modify the in-
flammation in character, but merely adds another
factor in the resorption of either toxins or bacteria, or
both, to the local manifestations. How irrational, then,
to base our estimate of a peritonitis on the character of
the exudate! Thus Fawlowsky" has shown that the
purulent and fibrino-purulent peritonitides belong to
the less intense and virulent forms, whereas the liem-
orrhagic types, and those in which no macroscopical
changes of the peritoneum are evident, are the most
virulent and fatal. This toxic factor is the one that
determines the prognosis in every individual case,
and it bears no relation to the character or amount of
the exudate.
The toxffimia and bacteriaemia which are found in
septic cases of peritonitis are due, however, not only
to resorption from the peritoneal membrane, but in
very many cases they are equall)'due to the resorption
by the intestinal mucosa of the toxins and bacteria
which are present in the intestinal canal. As we
know, the intestine is the habitat of numerous varie-
ties of cocci and bacilli, and these, owing to the stasis
of the intestinal contents from the paresis of the mus-
cularis, a result of the peritonitis, take on increased
virulence and elaborate products of much higher toxic
coefficients. This intestinal resorption must not be
considered as playing a secondary role in importance
to the peritoneal resorption, for often it is the chief
factor in causing the toxaemia and bacteriaemia. Fur-
thermore it must be distinctly remembered that pa-
tients can die from this intestinal intoxication alone.
How then are we to treat rationally this to.xamia
and bacteriaemia? As regards the former the ideal
remedies would be antitoxins to neutralize the dele-
terious influences of the toxins. Such antitoxins v.e
do not possess, hence we must rely on such therapeu-
tic measures as will, in the first place, aid the patients
to eliminate the toxic elements from the circulation
and tissues, and which will support the patients until
they have rid themselves of these toxic substances.
The chief excretory channels are the kidneys. It
should be our earnest endeavor to promote free diure-
sis. This is accomplished best by frequent infusions
of saline materials into the circulatory system. I
am accustomed to infuse either subcutaneously or in-
travenously, or per rectum, small quantities of hot
normal salt solution, about 100 gm. every hour.
These infusions both stimulate the circulation and by
increasing arterial pressure promote free and copious
diuresis. It is very important to make these infusions
frequently, and not to inject too much at any one time;
for such large infusions merely overload the right heart,
thus retarding its action and upsetting the circulation,
and so producing congestion of the kidneys and internal
viscera with consequent depression of their especial
functions. In addition to such frequent infusions I
give the patients a nourishing diet, and stimulation
as required. When the toxamia is intestinal in ori-
gin, we find these viscera paretic, distended, and con-
gested, for it is this pathological condition of the bowel
that has caused the intestinal bacteria to take on in-
creased virulence, and their products consequently to
have an increased toxic value. When this condition
of the intestine is present it is met most satisfactorily
by drawing a distended coil of intestine into the
wound, and, after due protection with hot pads, to
open it on its convexity, allow the contents to escape,
and then insert a long rectal tube into the lumen of
the intestine, washing the latter out thoroughly, both
distally and proximally to the opening. When the in-
testinal irrigation is finished, the opening in the bowel
is closed bv a few Lembert sutures. If the muscu-
lar coat of the bowel has become absolutely paralyzed,
as is evident by absence of all peristaltic move-
ment and the lack of tone of the fibres, I do not sew
up this opening in the bowel at all, but leave a large-
sized rectal tube in the proximal end of the intestine,
and irrigate the bowel through this with saline solution
several times a day, thus favoring free intestinal drain-
age and elimination of toxic materials.
If bacteria:;mia as well as toxamia exists, I am sorry
to say that our present therapeutic procedures will
avail us but little. It would appear rational to
employ the bactericidal sera in these cases; but
after an extended use of these remedies I cannot say
very much in their favor. I have attributed the failure
of the sera to produce an effect in these cases to the
fact that when bacteria have invaded the general cir-
culation, and have not been overcome by the normal
resisting-power of the human tissues, by the time clini-
cal symptoms of their invasion of the general system
are manifested they have gained so much headway
that these therapeutic measures no longer exert any
marked influence upon their development and life his-
tory.
This brings us to the consideration of the treatment
of the exudative peritonitis /cr jc. As we practically
recognize to-day no idiopathic type of exudative peri-
June 30, 1 900]
MEDICAL RECORD.
1 1 17
tonitis, the first thing to consider in this connection
is the removal of the cause of the inflammation. This
cause may be either a local or a general one — local,
in th'i form of an inriammatory process of some viscus
situated within the peritoneal cavity, or contiguous to
it; or general, the peritonitis in the latter case being
merely a manifestation of a systemic disease, e.g., a
bacteriasmia or general toxtemia. VVhen the perito-
nitis is merely such a concomitant inHammation, the
treatment is not to be directed to it, but to the general
systemic disease of which it is a manifestation, and
such a peritonitis regularly tends to spontaneous cure
when the general systemic disturbance is relieved.
When, however, the peritonitis is the direct result of a
local disease process of a viscus situated within the
cavity of the peritoneum or contiguous to it, this act-
ing cause must be removed before we can consider the
diseased peritoneum at all. Thus an inflamed appen-
di.x must be taken out, a ruptured or perforated intes-
tine must be repaired, an abscess cavity must be
drained by proper incisions, etc. Besides removing
the cause of the existing peritonitis, we can do but lit-
tle for the inflamed serous membrane. But in treating
exudative inflammations surgically, we must consider
two other points, viz., How are we best to remove the
products of exudation, and how are we to prevent their
re-accumulation.' As to the best method of removing
the exudate surgeons are at variance. Some prefer to
mop out the products of exudation with sponges or
compresses of gauze, whereas others consider it best
to sluice the peritoneal cavity with large quantities of
normal saline solution until the fluid returns from the
cavity clear of all exudate, and still others prefer to
eviscerate and wash out the peritoneal cavity. There
does not seem to be any better reason for the use of
the one or the other of these methods beyond the per-
sonal predilection of the particular surgeon, and yet
it seems that there are special indications calling for
the employment of the one or the other of these pro-
cedures.
Our chief aim in dealing with any inflamed organ
is to injure its structure and nervous mechanism as
little as possible by our manipulations. On this basis
evisceration, with the traumatism to the nervous ap-
paratus of the intestine and peritoneum that neces-
sarily accompanies this procedure, can hardly be con-
sidered a proper and rational mode of cleansing
the peritoneal cavity, even though it is the most
thorough. Its baneful effects much more than coun-
terbalance its good qualities. As regards simple irri-
gation w'ithout evisceration, Riedel and Kiimmel "■' have
shown, by experiments on animals, that irrigation of
the peritoneal cavity in cases of purulent peritonitis
worked unfavorably and harmfully; moreover, that
even healthy animals subjected to irrigation of their
peritoneal cavity became asphyxiated during the pro-
cedure, and that the peritoneum of such animals
after death showed ecchymoses and like irritative
phenomena on the intestine. No such like effects can
be attributed to the introduction of soft mops into the
peritoneal cavity for the purpose of removing the exu-
date, and this is consequently the best method to be
pursued. There are, however, cases in which wasliing
of the peritoneal cavity with saline solutions is pref-
erable to drying it out with mops. These are as fol-
lows: {a) when large masses of fibrin are present in
the cavity, these may be dislodged and carried away
with the current; (^) when the exudate is of a thick,
creamy consistency and is spread out among the intes-
tinal coils in all directions. In such cases the exudate
can be more rapidly removed and with less traumatism
to the peritoneum than by the method of mopping. It
is my custom in removing the exudate to take very soft
sea-sponges, attach them to long sponge-holders, and
carefully pass these into all the fossae and spaces of
the peritoneal cavity. This procedure takes but a
very few minutes, and I have several times convinced
myself that the peritoneal cavity can in this way be
made entirely dry.
As regards the second point in the consideration of
the exudate — viz.. How are we to prevent the re-accumu-
lation of the products of inflammation.' — this neces-
sarily implies the question, Are we to drain the peri-
toneal cavity, or not? Before entering into this
consideration, let me repeat a few of the facts I have
brought out in the first portion of this paper; these
are, that the peritoneum is an actively absorbing or-
gan; it absorbs almost as rapidly in the diseased as in
the healthy state; but wherever it has been modified
or destroyed, or removed, there active resorption does
not occur, and stagnation with the deleterious action
of the bacteria, if they are present, results. As long,
therefore, as the peritoneal surface maintains its in-
tegrity, drainage of its cavity is superfluous, for it can
easily and readily take care of the products of exuda-
tion that result from its inflammation. There are,
moreover, besides its superfluity several objections to
drainage of this serous membrane. These are : {a)
The danger of secondary infection through the me-
dium of drains. (/') All drains are foreign materials
to the peritoneum, whose presence is resented by it,
and if they are introduced an additional burden is
put upon the reactive power of the peritoneal cells, in
order to make such materials extraperitoneal, {c)
The-presence of such foreign materials, be they gauze
or tubes, by retarding the absorption favors the local
sedimentation of bacteria around them, and an aug-
mentation of the existing inflammation. This can
easily be shown by injecting organisms into the
healthy peritoneal cavity, and into a similar perito-
neal cavity into which a piece of gauze or tubing has
been placed. In the former case no peritonitis results ;
in the latter a purulent peritonitis is set up. {li) Danger
of secondary intestinal obstruction from the adhesions
resulting from the use of drains, [e) That drainage
of the general cavity is not possible for more than a
few hours at the utmost, for at the end of this time all
such foreign materials have been walled off from the
general cavity.
It follows that, as long as the peritoneum is perito-
neum, so to speak, drainage is superfluous and objec-
tionable. When, however, a region has been denuded
of its peritoneal covering, this area must be drained,
for these parts no longer possess their rapid absorbing
power, and hence their protective attribute; or when
the peritoneum, though intact, has lost its identity as
peritoneum, either on account of inflammation or trau-
matism, then all such affected parts must be drained,
even though it necessitates the employment of a com-
plicated system of drainage.
One further point demands our attention in the
consideration of the treatment of peritonitis, viz., When
is catharsis to be established? The results which are
achieved by early free evacuation of the bowels are:
(rt) the prevention of stasis of the intestinal contents,
and the increased virulence of the bacteria that goes
with such stagnation, and consequently the less ab-
sorption into the vascular system of the products of
fermentation and bacterial life; (/') the increased
rapidity of absorption from the peritoneum, on account
of the increased peristalsis (Schnitzler and Ewald).
As baneful effects resulting from early catharsis may
be especially mentioned the goading on to work of an
infiltrated and inflamed muscularis, which can certain-
ly result only in increasing the loss of tone, or even
in causing paralysis of the muscular tunic of the
bowel. When the pros and cons for early catharsis
are weighed, it is easily seen that there is more im-
mediate danger from the intestinal absorption of the
toxins due to stagnation than from the loss of tone or
iii8
MEDICAL RECORD.
[June 30, 1900
paralysis which may result from early catharsis. So
that when indications of intestinal distention are
manifested, free catharsis should be established as
soon as possible. When, however, no distention is
present, there is certainly no indication for early
evacuation of the bowel ; in fact, such a procedure is
entirely contraindicated. It has been my custom to
be guided entirely by this sign as to when to move the
bowels : if no distention is manifested, I never hesitate
to wait three or four days before resorting to catharsis.
Let me rapidly rehearse, then, the method of treat-
ment of exudative peritonitis that has yielded the best
results in my hands: Cceliotomy, the site of the inci-
sion depending on the cause of the peritonitis ; removal
of the acting cause; if the intestine is very much dis-
tended, incision of one of the most distended coils and
evacuation of its contents; suture of the bowel if its
muscular wall is not paralyzed, otherwise drainage of
the proximal end of the bowel ; removal of the exudate
from the free peritoneal cavity by moist sponges; pro-
tection of all raw spaces or moditied peritoneal sur-
faces by gauze; closure of the rest of the abdominal
wound; in addition the general systemic treatment for
the toxaemia and bacteriasmia, as I have outlined in the
paper.
I have taken from the records of the Mount Sinai
Hospital all the cases of diffuse exudative peritonitis,
following upon appendicitis, which have been oper-
ated upon during the past three years of 1897, 1898,
and 1899. In all there were seventy-three cases, of
which nineteen resulted in recovery, or twenty-six per
cent. In considering these statistics it should be
taken into account that many of these cases were in a
most desperate condition on their admission to the
hospital, and operation would have been declined by
many surgeons. Inasmuch, however, as some of these
most desperate cases have resulted in recovery, we
have in the hospital adopted the same rule as applies
in strangulated hernia, i.e., never to decline to operate
unless the patient is actually moribund.
The first table is a very important one, as showing
the relation that exists between the mortality and the
duration of the peritonitis. Thus:
of the Disease.
One day . .
Two days
Three "
Four ' '
Five
.Six
Seven "
Eight "
Mine* "
Ten "
* In one case the duration of the peritonitis was not ascertained.
Thus it is seen that the percentage of recoveries di-
minishes considerably as the duration of the disease
increases. Two apparent exceptions occur in the above
table, in that two patients recovered in whom the dis-
ease had lasted five days, and one in whom it had been
of seven days' duration. This can be explained either
on the basis that the history as given by the patient
was faulty, or that the peritonitis was not of a very
septic type ; but as a rule it can be said that the prog-
nosis becomes proportionally bad as the duration of
the disease increases.
It is considered by many that children recover more
frequently from peritonitis than do adults. But if we
compare the percentage of cures in children with that
in adults, taking into consideration also the duration
of the peritonitis, it will be seen that there is not
much difference in the various ages as regards the
percentage of recoveries. It is not the age of the pa-
tient, but rather the duration of the peritonitis before
it has been subjected to treatment, that influences the
subsequent course of the disease. (See Table II.)
In the third table which I have prepared I have ar-
ranged the cases according to the treatment they have
received ; in each class I have considered whether the
appendix when it was found was perforated or not, for
the coexistence of a perforation with the peritonitis
materially alters the prognosis for the worse, thus:
Appendix was —
Found perforated in 45 cases, of which 1 1 recovered = 24 per
cent.
Found non-perforated in 5 cases, of which 2 recovered = 40 per
cent.
Not found at all in 23 cases, of which 6 recovered = 26 per cent.
As regards the treatment four different methods
were followed: (<?) Simple packing of the outer
wound, and extensive drainage of the peritoneum with
no attempt to remove the exudate; (/') mopping out
the exudate with soft sponges, combined with more or
less extensive drainage; (1) irrigation of the perito-
neal cavity until all the exudate was removed, com-
bined with drainage; {t{) evisceration with irrigation,
with more or less extensive drainage.
Combined with either one of the procedures enter-
otomy or enterostomy was performed whenever the
intestinal distention was marked enough to demand
it. I have not compiled the statistics of the cases in
which this procedure was carried out, but we have al-
ways found it to benefit materially the septic condition
of the patient, and, by relieving the intestinal disten-
tion, to favor better and more easy respiration and cir-
culation, and to help to restore the tone of the muscu-
lar tunic of the bowel. (See Table III. )
From the above tables it will be seen that the
percentage of recoveries was highest in those cases in
which evisceration combined with irrigation was prac-
tised. It is hardly fair, however, to compare this group
of only three patients with the other groups which com-
prised many more. Comparing the other groups, we
see that the percentage of recoveries was highest when
the exudate was simply sponged away, being thirty per
cent, in these cases, as against twenty-five per cent,
when irrigation of the peritoneum was employed, and
DURATION.
I Day.
2 Days.
3 Days.
4 Days.
5 Days.
6 Days.
7 Days.
8 Days.
9 Days.
10 Days.
c3
0
0
0
I
0
i
u
5
I
3
I
3"
d
0
0
0
0
I
3
I
1
0
0
I
I
1
I
I
0
i
u
0
0
0
2
2
I
I
i
U
I
0
0
0
0
I
i
0
A
u
S
u
3
I
I
i
3
I
I
3
I
2
0
I
2
0
2
9
I
I
I
I
3
I
0
0
6
5
6
3
I
2
I
I
June 30, 1900]
MEDICAL RECORD.
1 1 19
as against fifteen per cent, when the exudate was not
removed, the peritoneal cavity being simply drained.
Furthermore it w;ll be seen that the duration of the
disease had been comparatively twice as long in those
cases of recovery in which sponging was employed as in
those cases in which the other procedures were carried
out; and we have noticed above that this duration of
the process was a most important factor in determin-
ing the prognosis. Leaving out, then, the cases in
which evisceration and irrigation were performed —
and the number is entirely too small to draw any con-
clusions— it would appear that by remoying the exji-
date by sponging the highest number of cures would
be obtained. With the removal of the exudate in this
manner, as with all the other procedures, some drain-
age was also provided. But latterly I have not at-
tempted in any way to drain the general peritoneal cav-
ity. If there were any raw spaces I have protected these
with gauze wicks, and closed the rest of the abdominal
wound. This I consider by far the best procedure. I
have followed it thus far in three cases with entirely
satisfactory results, all these cases terminating in re-
covery. The duration of the disease had been two
days on an average ; the exudate was sero-purulent in
character, was diffusely spread over the peritoneal
cavity, and the appendix was perforated in all three.
After removal of the appendix, the exudate was rapid-
ly sponged out by soft sponges on holders, and the raw-
surface of the appendix protected by a narrow wick of
gauze, which was led out of one angle of the abdomi-
nal wound, the latter being closed throughout the rest
of its extent. The gauze was removed after twenty-
four hours. It was extremely gratifying to compare
the convalescence of these patients with that in whom
irrigation or packing and drainage had been practised.
In the former the pulse and temperature had approached
the normal within thirty-six hours, and there was after
this comparatively little disturbance; whereas in the
latter the temperature and pulse remained high for
from four to seven days, and during this period the
patients suffered from the traumatism which had been
inflicted, or from a local peritonitis, which was taking
place around the packings or tubes. From either of
these the patients often seemed to succumb, even after
the primary inflammation had shown indications of
regression.
Table III.
Method of Tn
C. Exudate removed by irriga-
tion ; drainage.
Appendix r
Totals.
Appendix not found...
Appendix perforated . . .
.Appendix non-perforated
Appendix not found
Appendix perforated ...
Appendix non-perforated
Appendix not found
Appendix perforated
Appendix non perforated
* Of these 3 cases, the du
+ Of these 7 cases, the duratic
• days respectively.
J Of these 7 cases, the duratic
! davs respectively.
§ Of these 2 cases, the duratic
of the peritonitis had been 3 days in i
of the peritonitis had been 5, 2, 2, 3
of the peritonitis had been i,
I of the peritonitis had been
too active handling of this most sensitive tissue. The
pendulum of our activity is gradually swinging the
other way, and we are commencing to recognize that
gauze packings, irrigation, evisceration not only in-
' jure the delicate nervous mechanism of the perito-
neum, but also favor, by interfering with the activity of
the cellular process, the local sedimentation of bacte-
ria with their consequent local development and delete-
rious effects. The peritoneum has been endowed with
its own protective attribute, which is not heightened
by manipulation or the introduction of foreign mate-
rial. If we supplement the internist's treatment of
peritonitis, as formulated by that great master Alonzo
Clark, by a removal of the cause of the inflammation,
and cease to abuse and injure this delicate membrane,
we will meet with more gratifying results.
BIBLIOGRAPHY.
1. Wegner. G.: Chir. Bemerkungen uber die Peritonealhohle,
etc. Langenbeck's Archiv fllr klin. Chirurgie, Bd. xx., 1870.
2. Grawitz : Statistischer u. experimenteller pathol. Beitrag
zur Kenntniss der Peritonitis. Charitc-Annalen, xi., 1S86.
3. Waterhouse : Experimentelle Untersuchungen uber Peri-
tonitis. Vircliow's Archiv, cxix.
4. Ortli: Experimentelles iiber Peritonitis. Internat. klin.
Rundschau. i8go. No. 41.
5. Pavvlowsky: Beitrag zur Etiologie u. Entstehungsweise der
acuten Peritonitis. Centralblatt fur Chirurgie, 1SS7, Xo. 48.
6. Fraenkel, Alex. : Ueber Peritonitis. Wiener klinische
Wochenschrift, l8gi. Nos. 13. 14, 15.
7. Bonnecken : Ueber Bacterien des Bruchwassers einge-
klemmter Hernien, und deren Beziehung zur peritonealen Sepsis.
Virchow's Archiv, Bd. cxx.
8. Tavel und I.anz: Ueber die Etiologie der Peritonitis. Mit-
theilungen aus Kliniken u. Instituten der Schweiz, Basel, 1893,
p. 138.
9. Schnitzler und Ewald : Zur Kenntniss der peritonealen
Resorption. Deutsche Zeitschr. fiir Chirurgie, Bd. xli.
10. Loc. fit.
11. Hamburger; Ueber die Regelung der osinotischen Spann-
kraft von Bauch- und von Pericardialhuhle. Du Bois-Reymond's
Archiv fiir Physiologic, 1895.
12. Orlow : Pfiiiger's Archiv fiir Physiologic, Bd. lix.
13. Adler and Meltzer ; Experimental Contribution to the
Study of the Paths by which Fluids are Carried from the Peri-
toneal Cavity into the Circulation. Journal of Experimental
Medicine, vol. i. , No. 3, 1S96.
14. Loc. tit.
15. Cohnstein: Ueber Resorption aus der Peritonealhohle.
Centralblatt fiir Physiol., Bd. ix., No. 13-
16. Lot. cit.
17. Starling and Tubby : Journal of Physiology, vol. xvi.
18. Loc. cit. Pfiiiger's Archiv, Bd. 59, p. 176.
Loc. cit.
Loc. cit.
21. Loc. cit.
22. Pawlowsky : Zur Lehre von der Etiologie der Enstehungs-
weise und der Formen der acuten Peritonitis. Virchow's Archiv,
Bd. c.xvii.
23. Riedel und Kiimmel : Beitrag zur Etiologie und chi-
rurgische Therapie der septischen Peritonitis. Deutsche Zeitschr.
fiir Chirurgie, Bd. xxx .
19.
I cannot close these remarks on the peritoneum
without again pronouncing against what has been our
Vitiligo in a Baby Three Days Old. — Yukovski
says that vitiligo in children is very rare. Most of
the cases observed have been among negroes. The
child observed by the author was the offspring of white
parents presenting no specific history. The child had
exophthalmos, myxcedematous skin on the neck and
face, a guttural voice, and icterus. The vitiligo was
noticed only on the third day. The question arises,
whether or not those spots were present at birth. The
author accepts the theory of the neurotic origin of the
disease. Under the influence of some neurotic influ-
ence we have either a local dilatation of the blood-
vessels, decomposition of red blood corpuscles, and
emigration of melanocites, followed by deep local
pigmentation, or local spasm of the blood-vessels, ob-
literation of the arteries, and secondary pigment atro-
phy.— Meditsinskoe Ol'ozrente, April, 1900.
1 1 20
MEDICAL RECORD.
[June 30, 1900
THE TREATMENT OF TYPHOID FEVER.
r.v U. i:. ENGLISH, M.l'.,
In the treatment of typhoid fe\-er we should ever bear
in mind the nature and probable cause of the disease,
for treatment directed to the relief of the symptoms
only is not so uniformly successful as a combined
symptomatic and specific treatment.
We are told by investigators that the disease known
as typhoid fever is due to the presence in the intestine
of a microbe, the bacillus typhosus, which may be
helped in its work by one or more other microbes;
that these minute forms of life give rise to certain
poisonous matters in the intestine, which, besides act-
ing as local irritants, find their way into the blood
and are diffused throughout the body. Thus we have
a local inflammation and ulceration of the intestine;
a direct poisoning of the great nervous centres, and
an infiltration and enlargement of the lymphatic sys-
tem of vessels and glands due to a specific poison ; as
well as the prostration, emaciation, and parenchyma-
tous degeneration of various organs due to long-con-
tinued high fever. From this the indication for treat-
ment would seem to be as follows:
I. To empty the gut of all infected matters as soon
as possible.
II. To render the gut as nearly as possible uninhab-
itable by the microbes.
III. To prevent so far as possible the further ab-
sorption of the poison.
IV. To neutralize or expel the poison already ab-
sorbed.
V. To keep the temperature within safe bounds.
\'I. To prevent so far as possible overaction of or-
gans already damaged, i.e., to promote physiological
rest, and avert rupture of the intestine.
VII. To support the strength of the patient, and
guard against sudden collapse.
I. When a case of typhoid fever is seen early, it is
rarely possible to make a positive diagnosis at the
first visit. The disease for which it is most often
mistaken is malarial fever. In case of doubt it is
best to order quinine sulphate gr. iii. every three
hours. If, after thirty-six hours, the temperature has
continued on a curve typical of typhoid fever, simple
malarial fever may be excluded. This initial course
of quinine need not prevent the fulfilling of the first
indication as outlined above. My favorite purge for
this contingency is calomel, because calomel empties
the gall bladder, and the bile is nature's own intestinal
antiseptic. From ten to thirty grains may be given,
according to circumstances. If there has not been free
catharsis within six hours, it is well to give magnesium
sulphate 3 i. in a glass of boiled water, every hour
until the intestines seem to be well cleaned out.
II. To render the gut uninhabitable by the patho-
genic microbes it is necessary to keep it as nearly,
empty as possible, and as nearly aseptic as possible.
How can we keep the intestine empty and at the same
time give it physiological rest? M'hile intestinal rest
is highly desirable, experience seems to teach that the
bowels may be moved once, or even twice, each twenty-
four hours without unduly straining them, even in ty-
phoid fever. To accomplisii this a small dose of po-
dophyllin, perhaps assisted by a little aloin, may be
given morning and night: podophyllin gr. -J- to {, aloin
gr. J to |. Podophyllin is a valuable drug in these
cases because it increases the secretion of bile and so
promotes intestinal asepsis. While a large dose of
calomel will empty the gall bladder, it is probably true
that small continued doses do not increase the secre-
tion of bile, and as the local antiseptic properties of
calomel in the intestines are feeble, it is not wise to rely
on it as an intestinal antiseptic after the initial dose.
III. It is probably not possible to keep the intes-
tine aseptic, although scores of preparations are offered
to the profession for that purpose, their promoters
claiming unequalled advantages for each. My favor-
ite intestinal antiseptic is carbolated camphor.' This
preparation I have used in many conditions which
seemed to depend on putref::ctive changes in the con-
tents of the stomach or bowels, as well as in typhoid
fever. It relieves flatulence, renders the frt'ces nearly
odorless, and lowers the temperature decidedly with-
out any apparent weakening of the heart. The cam-
plior, besides being an antiseptic of considerable power,
has a good effect on the general nervous system, and
acts as a direct tonic and stimulant to the great sym-
pathetic nerve centres in the abdomen. Although this
preparation is said not to be a chemical combination,
and therefore one would expect to get the individual
effects of both of the ingredients, still much larger
doses of carbolic acid can be given in this way than
when it is administered alone. Ten to twelve drops,
representing gtt. iii. to iv. of the acid, may be given
every two hours for forty-eight hours before there will
be any change in the color or odor of the urine.
When this occurs, the dose should be decreased some-
what, or the interval between doses lengthened, but
the remedy should not be entirely discontinued until
the patient is well advanced in convalescence. The
carbolated camphor need not be stopped for slight
albuminuria; the albuminuria is caused by the dis-
ease, not by the medicine, and I have seen it disap-
pear while the patient was still taking good-sized
doses of this remedy. If one ounce of carbolic acid
crystals and three ounces of camphor gum are put to-
gether in a glass vessel and allowed to stand a short
time, the result will be a smooth, transparent, oily
liquid, almost colorless when first made, changing
with age to a light pink as carbolic acid does; having
the odor of camphor, a burning taste when put upon
the tongue, and a specific gravity of about 0.990.
If kept in an air-tight glass vessel, it remains un-
changed for an indefinite time, but when exposed to
the air the camphor evaporates faster than the car-
bolic acid, and the preparation becomes stronger with
the acid. To guard against this it is best to keep
an excess of camphor in the vessel at all times. An
elegant w-ay in which to accomplish this is to fuse
about one drachm of camphor in the bottom of an
ounce vial, and when it has solidified fill the vial with
carbolated camphor. If the acid is not entirely satu-
rated with the camphor the preparation is irritating,
or even caustic, to the mucous membranes; but when
fully saturated it can be taken pure on the tongue
without harm. This preparation mixes freely with
fixed oils, vaseline, alcohol, collodion, and ichthyol,
and dissolves iodoform in the proportion of one to
twelve, completely disguising the odor of the iodo-
form. It will not mix with water or glycerin. It is
best given by dropping the dose into a No. 2 capsule
just isefore it is administered. It will dissolve the
capsule if allowed to remain in it long. This prepa-
ration will probably keep the intestine as nearly asep-
tic as it is possible to do with any drug given by the
mouth. To empty the intestine and to keep it as
nearly as possible empty and aseptic will prevent fur-
ther absorption of the specific poison, and so fulfil
indication Xo. III.
IV. The best agent for neutralizing' the absorbed
poison and for expelling it from the body is water.
Large and frequent draughts of sterile water will act
as a diluent, a diuretic, and a diaphoretic; will relieve
in this way, or in these ways, the congestion and irri-
tation of the kidneys and the albuminuria, and will
carry the poison out of the system.
' '■ Camphorated Carbolic Acid." Meuic.^l RECORn, .Septem-
ber 30, lSg3, vol. xliv.. No. 14, p. 426.
June 30, 1900]
MEDICAL RECORD.
V. After the second day of treatment by carbolated
■camphor the temperature of typhoid fever rarely goes
above 103"' F., and more often keeps below 102" F.
■On the third day of treatment there is generally a de-
cided fall, and the temperature does not becc me high
again except by accident, such as constipation, error
in diet, or too sudden stopping of the specific treat-
ment. The prostration, typical tongue, iliac gurgling,
and perhaps some tympanites, may continue with a
nearly normal temperature, but the patient is evidently
much better, and finds it difiicult to restrain his appe-
tite, and irksome to keep his bed.
In the occasional cases in which I have used means
to reduce the temperature, the following tablet, given
every one to two hours for five or six doses, has an-
swered the purpose satisfactorily:
I^ Acetanilid gr. iij.
Camphors monobrom.,
CaffeinLU citrat aa gr. ss.
M.
VI. The two organs most liable to damage from
overaction in typhoid fever are the intestine and the
heart. It is best to have the
bowels move once or twice a
day; if the patient is taking
much milk, four or even five
movements a day seem to do
no harm. So that about the
only way in which we can pro-
mote intestinal rest is to keep
the patient quiet, not to over-
feed him, and to guard against
tympanites. The carbolated
camphor generally prevents
tympanites, but a little turpen-
tine or compound tincture of
cardamom will do no harm if
another remedy seems indi-
cated. Or a turpentine stupe
may be used on tlie abdomen ;
but it should not be forgotten
that turpentine is a renal irri-
tant and may cause albuminu-
ria, strangury, or nephritis, if
used too long or in too large a
dose. When it becomes neces-
sary to check the bowels, which
is seldom the case, I use small
doses, gr. iiss. of Dover's pow-
der, and give as few of them
as possible. To prevent car-
diac fatigue the most important measure is to keep the
patient absolutely quiet. He should lie on the back
with the head rather low; the lower extremities should
be kept warm, and everything should be done to pro-
mote easy circulation of the blood. When the pulse is
rapid and soft, small doses of tincture of digitalis
(about TTl V.) in whiskey (about Z i-) may be given ten-
tatively about every four hours. The whiskey will
tend to prevent the contraction of the arterioles by
the digitalis. But these two remedies must be used
with care in the early stages, and with the object of
resting, not stimulating, the heart. , The patient
should use a bed-pan and urinal, and should be cau-
tioned against moving a muscle unnecessarily.
VII. To support the strength of the patient ade-
quately without overloading the stomach or fatiguing
the intestine demands careful judgment. For the first
week no food should be given that will pass through
the stomach or leave any debris. For the first two
weeks I rely entirely on dissolved beef made after
Weir Mitchell's formula, as follows:
^ .\cidi hydrochlor. c. p 3 i.
Aq. destillat ad 3 i.
JI. .S. One teaspoonful to a pint of water for making beef tea.
I'ut one pint of boiled water, a good pinch of salt,
and a teaspoonful of the above prescription in a one-
quart glass fruit jar, and shake well. Then add one
pound of finely chopped beef, and shake again. Close
the jar air-tight and set it in a cool place like the
cellar fioor, but not on ice, for twelve hours. Then
put the jar into water and keep it warm, about 110°
F. to 120° F., for four or five hours. Be careful not
to let it get too hot. The contents of the jar should
be strained through a cloth, and all the liquid squeezed
out; the residue will be about the size of a hen's egg
and nearly white. This essence may be seasoned with
pepper and salt and given warm in ounce doses every
hour for the first week, and in two to three ounce
doses every hour or two hours during the second week.
If the essence is properly made, the residue will be
found to consist almost entirely of white fibrous mat-
ter, the red muscular fibres having dissolved out.
During the third week one pint of milk may be
given every twenty-four hours, but it should be given
in divided doses, and largely diluted with sterile wa-
ter, and with the addition of as much salt as will be
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palatable. This is better given at about the tempera-
ture of the stomach if the patient can take it so. Also
in the third week the white of one egg in water, and
one entire egg beaten with the juice of one lemon,
may be given each twenty-four hours. In making
"egg-lemon" the juice of one lemon should first be
rubbed with a little sugar, the well-beaten yolk then
stirred in, and last the white beaten to a froth spread
over the surface. This makes a delicious and bene-
ficial food for the third and fourth weeks. Whether
or not the diet should be changed during the fourth
week depends largely on the condition of the patient,
and must be left to the judgment of the physician in
charge, but even in the later stages of typhoid fever
it is much safer to give too little food than too much.
In cases seen early and treated in this way there
will be very few, if any, embarrassing complications
or sequela;. While the duration of the disease is not
greatly shortened the patients get well without exces-
sive prostration or emaciation, and the period of con-
valescence is shorter than under expectant or simply
symptomatic treatment. I have not lost any cases
treated in this way, nor have I seen any hemorrhage
or perforation. Carbolated camphor may be given in
MEDICAL RECORD.
[June 30, 1900
TT], vi. doses, four times a day, indefinitely, without
harm, and it is wisest to continue giving it until the
patient is entirely well. The accompanying tempera-
ture chart shows about the usual curve under this
treatment. This patient travelled over fifty miles
from a boarding-school to her home on January i,
1898, and I first saw her that evening. She contin-
ued taking ni vi. of carbolated camphor four times
a day for a week longer than the chart shows, and the
albuminuria disappeared while she was still taking
the remedy. She also took podophyllin gr. J and
aloin gr. i once or twice a day nearly every day
throughout her sickness. Once or twice in her case,
as in a number of others, when the lieart seemed to
need a stimulant I gave a few doses of the following :
I? Tr. nucis vomica;,
Tr. digitalis aa 3 ii.
Spts. vini gal ad J iij.
M. S. A teaspoonful, in water, every one to three hours
when needed.
Success in the treatment of this disease depends
largely on careful watching of the patient, and giving
nature a little aid at just the right moment; and on
strict sanitation of the bed and room of the patient.
This, combined with the specific treatment spoken of
above, will save nearly every case of typhoid fever.
THE USELESSNESS OF THE PITUITARY
BODY AS A THERAPEUTIC AGENT."
the symptoms were not ameliorated by its use. In
both of these patients bitemporal hemianopsia was
present as the result of pressure upon the optic chiasm
by the enlarged prehypophysis. In one, the remain-
ing half-fields diminished. In the other, one eye has
become blind from optic atrophy. This progressive
loss of vision would indicate that the hypophysis had
continued to enlarge, thus destroying the remaining
fasciculus of the nerve.
If we accept the theory recently enunciated by Dr.
Harlow Brooks, " that the increased secretion of the
prehypophysis in acromegaly acts as a direct stimulus
to the connective-tissue cells, and by its persistent
action slowly augments their growth," the use of the
pituitary-gland preparations would be contraindicated.
On the other hand, although extirpation of the gland
in dogs has been successfully performed, acromegaly
has not followed. It is also a well-established fact,
that in man the hypophysis cerebri has been the seat
of a destructive process, such as sarcoma, without the
presence of any of the pathognomonic symptoms of
acromegaly. \\'e must, therefore, conclude that acro-
megaly is not due to obliteration of the glandular
structure of the hypophysis.
It will thus be seen that this alleged remedy for
acromegaly has been used only empirically; that it
has prov>ed absolutely inefficacious; and that there are
neither rational nor logical grounds for its therapeutic
administration in the disease for which it has been
recommended.
By WILLIAM M. LESZVNSKV, M.D.
CONSULTING
In 1886 Marie in his original description of acro-
megaly suggested that the pituitary gland (hypophysis
cerebri) played an essential role in this disease, and
many subsequent observers are still inclined to accept
this theory. Pituitary substance has therefore been
suggested as a remedy for acromegaly, this being the
only pathological condition in which it has been ad-
ministered for therapeutic purposes. Pituitary tablets
are on the market, each three-grain tablet containing
one grain of the desiccated pituitary body of the sheep,
equivalent to eight grains of fresh gland substance.
The reports thus far published regarding the physi-
ological effects of the injection of the extract of the
pituitary body are so contradictory that they are of no
scientific value. Andriezen has demonstrated that in
the lowermost vertebrates the secretion from the an-
terior lobe of the gland (prehypophysis) is carried
through the central nervous system, and he believes
that this secretion possesses either a trophic infiuence
on the nervous tissues, or is in some way concerned
in the metabolism of nerve tissue. There is no evi-
dence, however, which would lead us to assume that
these studies in comparative anatomy and physiology
are applicable to man. While some of the published
reports as to the efficacy of the preparations of tlie
sheep's gland have seemed quite encouraging, in so
far as the relief of headache and of paresthesia of the
hands is concerned, it is the general consensus of
opinion that it in no way influences the progress of
this disease, which at best is rarely recognized until
well advanced in its course. In all of these cases,
other therapeutic measures have been employed at the
same time, to which much of the symptomatic im-
provement may be attributed.
In two patients with acromegaly recently under the
writer's observation, the daily administration of the
pituitary tablets was continued for several months, but
' Read before the New York County Medical Association, May
■-1, Igoo, in connection with a discussion on organo-therapy.
A PRELIMINARY NOTE ON A SIMPLE AND
NEW METHOD OF REPEATEDLY STERIL-
IZING SPONGES BY BOILING.
Bv CHARLES A. EL.SBERG, M.D.,
ATTENDING SCRGEON MOUNT SINAI HOSPITAL DISPKNSARV.
It is generally acknowledged that for the rapid and
thorough removal of blood, pus, or other fluids during
operations sponges are often indispensable. Their
softness, elasticity, and porosity, the ease with which
they absorb fluids, and the readiness with which they
yield them on pressure, have given to sponges a
unique and valuable place in our surgical armamen-
tarium.
Sterilization by boiling — the simplest and most
thorough method of disinfection — has been hitherto
impossible, because boiling in water, soda solution, or
other antiseptic solutions causes a loss of elasticity
and a shrinkage of the sponges.
As the result of a series of investigations into the
physical and chemical properties of this material, and
based on chemical principles identical with those
made use of in the sterilization of catgut by the am-
monium-sulphate method,' I have devised the follow-
ing method by which sponges can be repeatedly steril-
ized by boiling. The steps of the procedure are the
following:
1. The sponges are freed from calcareous matter by
immersion for twenty-four hours in eight-per-cent.
muriatic-acid solution, and are then thoroughly
washed in wrfter.
2. They are then boiled for fifteen minutes or longer
in the following solution: Potassium hydrate, i part;
tannic acid, 3 parts; water, 100 parts.
3. They are washed in water, carbolic acid, or sub-
limate solution until all of the potassium hydrate-
tannic-acid mixture (which is of a dark-brown color)
is removed.
4. The sponges are preserved in fi\e-per-cent. car-
bolic-acid solution.
Sponges that have been used can be resterilized by
' Elsberg : " .\ New and Simple Method of Sterilizing Catgut
by Boiling." Medical Ri-cokD, May 5, 1900.
June 30, 1900]
MEDICAL RECORD.
1123
washing them in water, and then boiling them once
more in the solution, etc. The solution can be used
any number of times, as it does not deteriorate by
boiling or by age.
Sponges prepared in this manner are absolutely
sterile, and the)' will be found to have retained all their
physical qualities — size, softness, elasticity, power of
absorption, etc. The procedure will be described in
further detail in a future publication.
105 East Fifty-se\ enth Street.
A REMINDER FOR THE CARE OF CHIL-
DREN DURING THE SUMMER.
By S. henry DESSAU, M.D.,
Lest we forget, let us remember that the greatest
number of infants and children under three years of
age die annually from gastro-intestinal diseases.
Lest we forget, let us remember that, with rare ex-
ceptions, the gastro-intestinal diseases of which these
children die are of the acute type and occur as diar-
rhoea.
Lest we forget, let us remember that by far the
larger majority of these diarrhceas occur during the
summer months. So true is this that they have de-
served the general name of summer diarrhceas of infants
and children.
Lest we forget, let us remember that, the combined
observations and conclusions of eminent men in the
profession in all ages until the present time have at-
tributed the underlying cause of these fatal diarrhceas
to the excessive heat of the summer months.
Lest we forget, let us remember that, although the
advanced knowledge of collateral sciences has demon-
strated the important part played by the deleterious
action of germs upon infant foods and their immense
reproduction under favorable conditions of filth and
bad air, without the all-controlling influence of the
summer heat no such extensive contamination of the
infant's food could occur.
Lest we forget, let us remember that the heat of the
summer months is now upon us, and that in our en-
deavors to protect infants and children against evil
attacks of diarrhoeas during the season by providing
them- a suitable and agreeable food, when deprived of
nature's own, we should. also bear uppermost in our
minds and daily thoughts the prime necessity of warn-
ing parents to combat the depressing influences of
prolonged heat and a humid atmosphere by every con-
ceivable means in their power.
Lest we forget, let us remember that the weak infant
has weak physiological functional powers, and for this
reason the heat-regulating function is weak and much
more easily overcome than in adults. In this way in-
fants and young children manifest a different clinical
picture of the bad effects of heat from that of adults,
which is recognized as heat-stroke or sunstroke.
Lest we forget, let us remember that one of the first
of the evil effects of heat upon the infant is to weaken
the digestive function, which is first manifested by a
loss of the appetite, and, therefore, above everything
else the infant should not be forced or induced to take
large quantities of ood, nor even the same amounts as
usual.
Lest we forget, let us remember that with a combi-
nation of germ-impaired food and weakened digestive
powers of the stomach under the influence of an exces-
sively heated atmosphere, the very best conditions are
presented for an attack of diarrhaa.
Lest we forget, let us remember that under the influ-
ence of a greatly lowered vitality of the infant, due
directly to the excessive and prolonged heat of the
summer months, certain germs, which are always
found in the intestinal canal, even during a period of
the best of health, are permitted under such altered
conditions to exert a poisonous action, and hence even
breast-fed "babies may and do become the victims of a
summer diarrhoea.
Lest we forget, let us therefore remember that,
while it is beyond question most imperative to have
only the purest food given to babies and young chil-
dren during the summer season, at the same time it is.
equally as imperative to impress upon the understand-
ing of mothers and nurses the great importance of
keeping the child in as cool a condition in summer as
circumstances will permit.
For this purpose the cool country air is best for
those whose means can afford it, while for the masses-
including the poor of large cities other devices must
be thought of — such as a liberal use of ice for sucking
or eating, bathing in cold water several times in the
day if need be, seeking the early morning air, a free
ventilation of the sleeping-apartments especially dur-
ing the night, doing as little cooking in small apart-
ments as possible, using the lightest kind of clothing,,
in fact letting children imitate little Hottentots; taking
short trips on the water to the sea-shore or crossing
and recrossing the ferries, visiting the shady parts of
the public parks during the heat of the day. All of
these need not by any manner of means preclude ai
strict observance of domestic cleanliness, which pro-
duces at least a mental effect of apparent coolness and
comfort, nor the general cleanliness of city streets and
a free use of flushing, which not only in fact cools
the air of the streets, but in addition insures a purer
breathing-air freed from decomposing matter.
Seeking the shade of trees is undoubtedly one of the
best plans for obtaining cool air in summer. Dr.
Chapin has recently called attention to the fact that
the foliage of trees has the property of reducing and
regulating atmospheric temperature in their immediate
vicinity.
Nothing here has been said regarding the infant's
food, as the purpose of this simple rubric is to direct
attention to the general care of the child.
Bacteriological Study of Meningitis Cerebro-Spi-
nalis Epidemica. — After a very exhaustive study of
the literature of this subject, and based upon his own
observation of an epidemic of cerebro-spinal menin-
gitis, Khtegloff comes to the following conclusions;
(i) The disease is caused by Weichselbaum's intra-
cellular meningococcus; (2) that the meningococcus-
is a coccus siii generis, not to be confounded with
other diplococci; (3) that its vitality in agar cultures
is especially characteristic; (4) its presence in the
nasal secretion of a patient suffering with meningitis-
is of diagnostic value. — Meditsinskoe Obozretiie, April,.
1900.
The Relationship of Diabetes Mellitus to Epi-
lepsy.— W. Ebstein says that diabetes or even glyco-
suria is a very rare complication of epilepsy. There-
are three possible relationships between diabetes mel-
litus and epilepsy; the glycosuria may be either the
cause or the effect of the epilepsy, or both conditions
may arise independently of each other, though due to
a common cause. So far as the author can find from
the literature on the subject, no proof has yet been
furnished of epileps)' determining diabetes or evert
serving as a predisposing cause. Epilepsy frequently
alternates with diabetes and mental disorders in neu-
ropathic families. Also, in a subject free from any
neuropathic taint, there may be many predisposing
causes determining simultaneously diabetes and epi-
lepsy. The author describes an illustrative case. —
Medical Press and Circular, May 16, 1900.
1 124
MEDICAL RECORD.
[June 30, 1900
Medical Record:
A Weekly Journal of jMedieine and Surgery.
GEORGE F. SHRADY, A.M., M.D., Editor.
Publishers
WM. WOOD & CO.. 51 Fifth Avenue,
New York, June 30, 1900.
DERANGEMENT OF THE WATER-SECRET-
ING POWER OF DISEASED KIDNEYS.
It is well known that disease of the kidneys may exist
in the absence of usual symptoms, including albumi-
nuria and tube casts; but even when these are present
it is desirable to know the extent of the disease, and
especially the degree of interference with function.
Studies that have recently been made in regard to
variations in the freezing-point of the urine seem to
promise helpful results in this direction. It has been
found that in cases of diffuse disease of the kidneys,
the determination of the reduction in the freezing-
point of the urine is capable of disclosing quite char-
acteristic changes in renal activity. If the disease
attains a degree and extent rendering impossible com-
pensation through increased activity on the part of
healthy portions of the kidney, it may be determined
from the freezing-point and the amount of the urine
that the absolute number of molecules eliminated with
the urine in twenty-four hours is abnormally small —
molecular oliguria. In healthy persons the osmotic
pressure of the urine corresponding to the reduction
in the freezing-point is generally greater than that of
the blood. The increased osmotic pressure of the
urine is related to increased functional activity on
the part of the kidneys. The latter is impaired in
the presence of diffuse disease of the kidneys, and
the reduction in the freezing-point of the urine is in
general less than that of the urine in health.
Although healthy kidneys generally secrete concen-
trated urine, they are also capable of secreting urine
whose molecular concentration is considerably less
than that of the blood. If greatly diluted urine is
eliminated, the water-secreting power of the kidneys
exceeds their absorptive power. After the drinking
of excessive amounts of water the molecular concen-
tration of the urine may fall to a freezing-point of
— 0.10° C. It has been shown that kidneys, the seat
of diffuse disease, lost not only their water-absorbing
but also their water-secreting power in greater or lesser
degree. While the freezing-point of the urine in
health varies between —3° and —0.10' C, tlie lim-
its gradually approximate in the presence of diffuse
disease of the kidneys in accordance with the charac-
ter and the severity of the case. Hyposthenuria is
therefore but a one-sided symptom of the lessened
accommodative power of the kidneys to the needs of
the organism in regulating the excretion of water.
Kovesi and Roth-Schulz {Berliner kUiiische Woeh-
enschr/Jt, 1900, No. 15) undertook a series of in-
vestigations to determine the changes that occur in
the power of the kidneys to secrete a greatly diluted
urine in the presence of diffuse disease of the kidneys
of various kinds. The method of procedure was as
follows : The urine was collected for twenty-four hours,
at intervals of four hours, in separate receptacles, and
the freezing-point of each specimen was determined.
On the following day 1.8 litres of water were admin-
istered in the course of an hour, the urine was voided
at intervals of half an hour, and the amount and the
freezing-point were determined. In healthy persons
the kidneys exhibited a great power of accommoda-
tion to the variations in the amount of water ingested.
The reduction in the freezing-point of the urine rap-
idly declined as much as 0.10° C. or more after co-
pious drinking. The secretion of greatly diluted
urine generally ceased within two or three hours, and
was gradually replaced by the evacuation of urine of
moderate concentration.
In cases of parenchymatous nephritis it was found
that the power of the kidneys to secret dilute urine
was greatly reduced, and apparently in proportion to
the severity of the renal disease. In cases of inter-
stitial nephritis, on the other hand, the power of the
kidneys to secrete dilute urine was, in comparison
with the kidneys in health, little if at all diminished.
Finally, it was found that the water-secreting power
of the kidneys, as well as their power of concentrating
the urine, was not impaired in cases of compensated
valvular diseases of the heart. In the presence of
compensatory derangement, however, the diluting-
power of the kidneys was diminished, as in the tran-
sition from parenchymatous to interstitial nephritis.
From these investigations it appears that the func-
tion of the kidneys is altered in a materially different
manner in the presence of contracted kidney and of
parenchymatous nephritis respectively, the difference
residing in the varying limits of accommodation of
the kidneys with relation to the amount of fluid in the
organism. These limits are quite considerable in
cases of interstitial nephritis, but are diminished in
cases of parenchymatous nephritis in accordance with
the severity of the disease. It has also been thought
that the diminution in the concentration of the urine
is more marked in cases of parenchymatous nephritis.
The results of the present investigation indicate, how-
ever, that the characteristic distinction between paren-
chymatous and interstitial nephritis resides not in the
varying amount of the reduction in the freezing-point
of the urine, but in its variability'.
The reduction in the freezing-point of the urine in
cases of disease of the kidneys depends upon (i) the
localization and the degree of the morbid process,
which together determine the extreme limits of varia-
bility of the concentration of the urine; (2) the
amount of water ingested; (3) the degree of preser-
vation of the permeability of the kidneys to solid
molecules.
In every case of nephritis a certain amount of water
will, in accordance with the permeability of the kid-
neys to solid molecules, yield urine that is isotonic
June 30, 1900]
MEDICAL RECORD.
1125
with the blood. If so much is drunk that this amount
of water is sent to the kidneys, the variety of renal
disease will have no influence upon the freezing-point
of the urine; if less be drunk, the reduction in the
freezing-point will be marked in cases of interstitial
nephritis, and inconsiderable in cases of parenchyma-
tous nephritis. If, however, more water be drunk
than is necessary for the secretion of isotonic urine,
the results will be the reverse, and more dilute urine
will be secreted in cases of interstitial nephritis than
in cases of parenchymatous nephritis. If, in cases of
renal disease, the permeability of the kidneys to solid
molecules is diminished, and if this diminution is but
imperfectly or not at all compensated for, the molecu-
lar concentration of the blood is increased and the
reduction of the freezing-point exceeds 0.56' C. This
result may not appear, or it may be modified if so
much water is retained that the increase in the molec-
ular concentration of the blood is prevented, in spite
of an increase in the absolute number of solid mole-
cules, or if the proteid metabolism falls so low that
the reduced permeability of the kidneys suffices for
the elimination of the resulting solid molecules, or if,
finally, healthy portions of the kidneys assume vicari-
ously the functions of the diseased portions.
It has been shown that increased osmotic pressure
of the blood cannot be considered as the cause of urre-
mia, as the osmotic pressure may be increased without
the occurrence of uramia, and it may be nofmal in the
presence of uraemia. The studies that have been made
in regard to the functional activity of the kidneys by
the methods under consideration show that the amount
of molecular diuresis can be determined, and in
marked cases molecular oliguria can be recognized
from a determination of the reduction in the freezing-
point and the amount of the urine passed in twenty-
four hours. The determination of the freezing-point
of the blood is capable of showing whether molecular
diuresis is adequate for the elimination of metabolic
urinary molecules. If molecular diuresis, as com-
pared with metabolism, in accordance with diminu-
tion in the permeability of the diseased kidneys to
solid substance, is insufficient, then the reduction in
the freezing-point of the blood increases.
Hyposthenuria indicates a reduction in the water-
absorbing power, and the more or less marked nega-
tive results of the dilution test indicate a reduction
in the water-secreting power of the kidneys. If the
last two alterations occur in the presence of disease
of the kidneys, the usual independence of the elimi-
nation of water and that of the solid, constituents of
the urine is impaired or lost. In the latter event the
amount of water eliminated by the kidneys is closely
dependent upon the elimination of the solid mole-
cules, so that it is determined .by the permeability of
the kidneys to solid substances.
The Plague has reappeared in Oporto, a case hav-
ing been reported on June 23d. This is the first that
is known to have occurred in that city since the epi-
demic was officially declared at an end on February
7th last.
BILLS FOR IMPROVING THE STATUS OF
THE CONTRACT SURGEON IN THE UNITED
STATES ARMY.
In the Medical Record of March 17th ult., some
remarks were made upon the injustice from which the
contract surgeons who served in the Spanish-Ameri-
can war undoubtedly suffered, and to which those now
in the Philippines and elsewhere are compelled to
submit; and the suggestion was thrown out that these
disabilities be so far as possible removed and the
standing of this necessary branch of the service be
established once and for all. This course would seem
to be for the best interests of the army and the country
at large. It has at last been clearly shown- — and the
surgeon-general himself has become an unwilling con-
vert to these views — that there is now no hope what-
ever of obtaining from Congress any increase in the
number of the medical corps of the regular army.
This on the face of it may not appear to be a far-
sighted policy, and probably will not commend itself
as such to the judgment of the "man in the street,"
who will not unnaturally be disposed to think that an
increase in the army should carry in its train a cor-
responding enlargement of the army medical corps,
and that at least the army medical corps should be
numerically strong enough to attend to the needs of
the regular army. However, the opinion of Congress
has been otherwise, and it has decided that in the
future it will rely upon the medical profession in civil
life to supply the additions to the medical staff that
may be required with an army in the field. Conse-
quently the question which now confronts the military
authorities is how to adjust in the most satisfactory
manner the grievances of the acting assistant surgeons
and to establish the conditions of their successors
upon a firmer and more equitable basis.
The surgeon-general with this end in view has in-
troduced two bills for which he has secured the ap-
proval of the Secretary of War. Of the aforesaid bills
one provides that acting assistant surgeons of the
army should have the same rights and privileges as
regards leaves of absence as commissioned officers of
the army — this clause applies to the future only; and
further, that acting assistant surgeons appointed since
May I, 1898, shall be paid for absence on sick-leave.
The other grants commissions as assistant surgeons
of volunteers with the rank of first lieutenant to acting
assistant surgeons who have served one year, and the
rank of captain to those who have served as such lieu-
tenants two years.
These bills, although an earnest of the wish of the
surgeon-general to do justice to the men who so pa-
triotically answered their country's call during the
Spanish war, and so far as they go quite satisfactory,
yet are, in the opinion of the men themselves, too
limited in scope. It is held that the bills in ques-
tion do not deal in a generous way, and in a man-
ner befitting this great and rich republic, with those
contract surgeons who were dismissed from the army
on account of disease incurred while in discharge of
their duty, or who returned to their homes broken in
health and unable any longer to follow their profes-
I I 26
MEDICAL RECORD.
[June 30, 1900
•sion. The Association of Acting Assistant Surgeons,
therefore, has caused to be drafted a bill which is
now before Congress embodying both the bills intro-
duced by the surgeon-general — with slight amplifica-
tions— and its own. This bill provides for back
pay, rank, etc., for acting assistant surgeons who served
during the Spanish war, and who were dropped for ill-
ness or disability, and also enacts that those who have
served for one year or more shall be commissioned as-
sistant surgeons of volunteers with the rank of first
lieutenant mounted, subject to honorable discharge
whenever their services are no longer needed.
The government would have acted more wisely had
it increased to a very considerable extent the strength
of the army medical corps, for the fact must be borne
in mind that an army medical officer, in order to be
competent to fulfil his duties efficiently, needs special
training. But as the "powers that be" have deter-
mined to place reliance mainly upon members of the
medical profession drawn from civil life, it would be
unjust, as well as an extreme act of folly, not to treat
these men equitably and liberally; for it stands to
reason that, if such a course be not followed, the in-
evitable result will be that in case of war surgeons
will be lacking. Therefore, aside from the legality
smd justice of the question, which are evident enough,
the bill of the Association of Acting Assistant Sur-
geons now before Congress should become law, if
only as a matter of expediency.
CHOREA AS A PYOGENIC DISEASE.
A TENDENCY has arisen of late to consider chorea as
an infectious disease, although such evidence as ex-
ists in favor of this view is circumstantial, rather than
direct, and the chain is yet incomplete. A point to
which some significance can be attached is the proba-
bility that acute rheumatism, with which chorea ex-
hibits certain relations, is also of infectious, though
perhaps of multiple, origin. In support of the infec-
tious origin of chorea is the report by Westphal, VVas-
sermann, and Malkoff (Beiiiiu-r kliiiische Woclienschrijt,
1899, No. 29) of a case of acute articular rheumatism,
followed by chorea, and complicated by endocarditis
and nephritis, in which they succeeded in isolating
from the blood, the brain, and the endocardial vege-
tation a streptococcus capable of ir.ducing polyarthri-
tis in lower animals. The pyogenic nature of both
polyarticular rheumatism and chorea had previously
been suggested by other observers, one of whom, Mir-
coli {Berliner klinische Wochenschrrft, 1900, No. 14. p.
303) now reviews his earlier investigations on this
subject. Among seventeen cases of rheumatic chorea,
pyogenic cocci were found in the joints in fourteen,
staphylococci preponderating, while in three the di-
plococcus lanceolatus was present as the etiological
agent. From a number of considerations, acute rheu-
matism is looked upon as a variety of pyemia, but
without suppuration ; and chorea as a manifestation
of the cerebral localization of the pathogenic agency.
The Annual Tetanus Epidemic is due next week.
Yellow Fever has appeared this summer in many
places in Cuba where no cases have occurred in sev-
eral years. The United States troops have escaped
hitherto, except in Quemados and Santa Clara. Up to
the last week in June there were but three cases of the
disease in Havana. The rains this season have been
more than usually heavy in the island.
Philadelnhia Pediatric Society. — At a stated meet-
ing lield June 12th, Dr. Joseph Sailer exhibited a
child presenting a fluctuating swelling in the occipital
region, with thrill on palpation, and a murmur on aus-
cultation, which was thought to be due to a form of ven-
ous aneurism. Dr. Alfred Hand presented a commu-
nication entitled "Acute Adenitis (Glandular Fever)
in Children, with Remarks on Terminology and Treat-
ment." Dr. J. P. Crozer Griffith presented a report
on three cases of influenza simulating glandular fever.
Dr. H. D. Marcus read a report of a case of gravel.
Dr. W. R. Nicholson reported a case of infection with
the bacillus pyocyaneus. Dr. Charles A. E. Codman
reported a case of leucocythamia.
New York State Conference of Charities and Cor-
rection.— Invitations were recently issued by the Hon.
William R. Stewart, president of the New York State
board of charities, to fifty persons interested in chari-
ties and charitable work, to meet in the United Chari-
ties Building, at 105 East Twenty-second Street, New
York, to organize a " State Conference of Charities
and Correction." At this meeting the following offi-
cers were elected: President, Hon. William P. Letch-
worth, of Portage; Vice-Presidents, Mr. Robert W. De
Forest, of New York, Hon. William J. Morgan, of Al-
bany, and Rev. Thomas A. Hendrick, D.D., of Roches-
ter; &(V£7r?ri', Mr. Homer Folks, of New York; Assist-
ant Secretaries, Mr. Frederic Almy, of Buffalo, Dr. John
F. FitzGerald, of Rome, and Mr. Clarence V. Lodge, of
Rochester; Treasurer, Mr. Frank Tucker, of New York.
It is proposed that the first meeting of this conference
shall be held in Albany in November next. In the
main the work of the New York State Conference of
Charities and Correction will be almost identical with
that of the national conference of the same name, except
that its scope of labors will not extend beyond the limits
of New York State.
Pathological Society of Philadelphia. — .\t a stated
meeting held June 14th, Dr. D. J. McCarthy demon-
strated the histological changes in the cells of the sym-
pathetic ganglia from animals suffering from rabies.
Dr. M. P. Ravenel presented a communication in which
he reported several instances in which bovine tuber-
culosis was transmitted to human beings. Dr. J. Hen-
drie Lloyd presented a large cystic kidney from a pa-
tient who exhibited aphasia due to urasmia. Dr. Lloyd
and Dr. A. M. Seabrooke exhibited the heart and
spleen from a patient who had passed through an at-
tack of typhoid fever, and developed symptoms of ma-
lignant endocarditis, for the relief of which anti-
streptococcic serum was unsuccessfully employed. The
June 30, 1900]
MEDICAL RECORD.
1127
heart presented vegetations on the mitral leaflets, and
the spleen was greatly enlarged and infarcted. Dr.
A. O. J. Kelly prese.ited the breasts removed surgi-
cally from a woman on account of malignant disease.
One of the growths was apparently a carcinoma, while
the other was complicated by an enormous chronic
hematoma. Dr. H. L. Williams exhibited the heart
and aorta from a patient in whom gold wire and elec-
trolysis had been employed for the cure of an aneurism
of the aorta.
Dr. James F. McKernon has recently been elected
professor of otology in the New York Post-Graduate
Medical School and Hospital.
College of Physicians of Philadelphia — At a spe-
cial meeting held June i8th, the president, Dr. VV. W.
Keen, announced the completion of the $50,000 library
endowment fund.
Dentistry at the International Medical Congress.
— It has been decided by the executive committee of
the Paris congress to admit as members of the congress
all dentists who are duly qualified in France or abroad,
even though they are not qualified in medicine or sur-
gery. Members of the dental profession who wish to
join the congress will be attached to the section of
stomatology.
The Institute of Homoeopathy. — At the fifty-sixth
annual meeting of this society in Washington last
week the following officers were elected: President,
Dr. W. W. Van Baum, of Philadelphia ; / 'ice- Presidents,
Drs. A. B. Norton, of New Vork, George Royal, of
Des Moines, and Flora N. Ward, of San Francisco;
General Secretary, Dr. Eugene H. Porter, of New
York; Recording Secretary, Dr. Wilson A. Smith, of
Chicago; Treasurer, Dr. T. Franklin Smith, of New
York; Registrar, Dr. Henry C. Aldrich, of Minne-
apolis.
The National Eclectic Medical Association held
its thirtieth annual meeting last week in Atlantic City.
The following officers were elected: President, Dr. E.
Lee Stanley, of St. Louis; First Vice-President, Dr.
J. D. McCann, of Monticello, Ind. ; Second Vice-Presi-
dent, Dr. A. B. Young, of Memphis, Tenn. ; Third
Vice-President, Dr. J. R. Duvall, of Atlanta, Ga. ; Re-
cording Secretary, Dr. Pitts Edwin Howes, of Boston ;
Corresponding Secretary, Dr. N. A. Graves, of Chi-
cago; Treasurer, Dr. W. T. Gemmill, of Forest, O.
The next meeting will be held in Chattanooga, Tenn.
A Would-Be Disseminator of Smallpox.- — A man
in an Illinois town was angered by the health authori-
ties, who insisted upon the vaccination of his daugh-
ter, and devised a novel plan for revenge. There were
some cases of smallpox in the town pesthouse, and the
fool deliberately made his way into the place in order
to infect himself and his clothing with the germs of
the disease and so spread it through the town. But he
was so pleased with his trick that he couldn't help tell-
ing of it, and now the health people have caught him
and bathed him, and will keep him in quarantin.; for
some weeks.
The Study of Tropical Diseases by an Army
Medical Board. — It is stated in the Boston Medical
and Surgical Journal that a board of medical officers
has been appointed to meet at Camp Columbia, Que-
mados, Cuba, for the purpose of pursuing scientific
investigations with reference to the infectious dis-
eases prevalent on the island of Cuba. The board
will act under instructions from the surgeon-general
of the army. The detail for the board consists of
Major Walter Reid, Surgeon U.S.A., and Acting As-
sistant Surgeons James Carroll, Aristides Agramonte,
and Jesse W. Lazear. It is understood that the board
will devote attention chiefly to the investigation of
yellow fever. Dr. Agramonte has been studying this
disease in Havana for the past eighteen months, while
Major Reid and Dr. Carroll, at the Army Medical
Museum in Washington, have been engaged in an
exhaustive study of Sanarelli's bacillus and serum,
the results of which have already been made public.
The work of the board will be done in the army lab-
oratory at Quemados.
Pharmacists in the Public Services.— At a meet-
ing of the Executive Committee of the Louisiana State
Pharmaceutical Association, held at New Orleans,
June 6, I goo, resolutions were adopted indorsing the
action of the American Pharmaceutical Association in
its efforts to obtain recognition of the profession in
the army, navy, and Marine-Hospital service of the
United States, and a fair compensation for the duties
performed by the pharmacists in these services. Reso-
lutions were also adopted indorsing the movement to
obtain for the hospital stewards of the Marine-Hospi-
tal service the change in title from that of '' hospital
steward" to "senior," "junior," and "assistant phar-
macist," with the respective pay of $1,200, $900, and
S720 per annum, with the present perquisites, and the
concessions now granted junior medical officers.
Reciprocity in Medical Licensure At the Wash-
ington meeting of the American Institute of Homoeo-
pathy the committee on legislation made a report ad-
vocating uniformity in medical license laws of the
various States which will permit an exchange of licenses
between States. The co-operation of the American
Medical Association and of the National Eclectic As-
sociation and other organizations interested in medical
licensure is to be requested. The draft of the bill
submitted, which will be introduced in Congress,
authorized the appointment of a commission of three
physicians, representing respectively the American
Medical Association, the American Institute of
Homoeopathy, and the National Eclectic Medical
Association, to examine existing laws of the various
States, and to recommend such additional legislation
as may be found necessary to secure a uniform and
efficient standard of qualification.
Complaints against British Army Hospitals in
South Africa. — A despatch to The Sun from Cape
Town states that The Times of that city has published
an interview with a colonial volunteer, who complains
bitterly of the hospital arrangements. He declares
that the accommodations, clothing, and food are insuffi-
II28
MEDICAL RECORD.
[June 30, 1900
cient, and that there are extortion and robbery by the
orderlies, who are largely left 'without supervision
owing to the paucity of medical officers. He speaks
in terms of the highest praise of the nurses from Net-
ley.
The " Goutte de Lait" Society is an organization
established recently at Rouen, France, with the object
of furthering a rational infant feeding. Every effort is
made to induce mothers to nurse their own infants, but
when this is impossible, the society furnishes a spe-
cially prepared and sterilized milk in suitable quantity
for one or two sous a day.
The Centenary of the Royal College of Surgeons.
— It is proposed to celebrate the centenary of the foun-
dation of the Royal College of Surgeons of England
on July 2Sth and 26th next. On Wednesday, the 25th,
there will be a conversazione at the college in the
evening. The following day a meeting will be held
in the theatre of the University of London in the after-
noon, and this will be followed by a festival dinner in
the hall of Lincoln's Inn.
A Children's Hospital at Athens. — It is stated in
the British Mcdiial Jonnia! that, on the initiative of
Princess Sophia of Greece, a hospital for children has
recently been built in Athens. It is appropriately
named " Saint Sophia." The hospital consists of
twelve separate buildings, each destined for the ac-
commodation of patients suffering from one form of
disease. Four of these are set apart for contagious
cases. The new hospital was lately formally opened
in the presence of the whole royal family of Greece,
the high officers of state, and the municipal authorities
of Athens.
Missionaries Lose a Hospital. — Three woman med-
ical missionaries, Drs. A. H. Kelsey, Kaku Sudo, and
Hana Abe, the two latter being Japanese, some time
ago established the Negishi Hospital, near Yokohama,
and ran it in conjunction with their missionary work.
Recently, however, the Buddhists gained control of
the hospital, and decreed that, while the ladies might
continue in medical charge, there should be no more
Christian doctrine taught there. The three physicians
have, therefore, left the institution, and have opened a
dispensary in the neighborhood, where they may re-
sume their medical missionary labors.
Unveiling of the Hahnemann Statue. — The statue
of Samuel Hahnemann, which has been erected on the
east side of Scott Circle, Washington, was formally
dedicated on the afternoon of June 21st. The statue
was formally presented to Dr. C. H. Walton, president
of the American Institute of Homoeopathy, by Dr. J. H.
McLelland, of the memorial committee. Dr. Walton
then presented it to the government, and it was accepted
by Colonel Bingham, superintendent of the public
buildings and grounds of Washington. Attorney-Gen-
eral Griggs delivered a brief address. As the draperies
were removed from the statue, an odf to Hahnemann
was read by Dr. William Todd Helmuth, of New York.
The statue, which is of bronze, is the work of the
sculptor Niehaus, and its artistic merits were certified
to by the National Sculpture Society before permission
was given for its erection in Washington.
Navy Department, Bureau of Medicine and Surgery,
Washington, D. C. — Changes in the medical corps of
the United States navy for the week ending June 23,
1900. June i8th. — Passed Assistant Surgeon A. R.
Alfred detached from the Texas and ordered to the
Asiatic station via the Nippon Mane, sailing from San
Francisco, July 10. The following are commissioned
assistant surgeons, to take rank from June 7, 1900, in
the order named : J. J. Snyder, H. A. Dunn, A. Stuart,
E. M. Blackwell, W. H. Ulsh, M. V. Stone, C. R. Burr,
G. F. Freeman, R. O. Marcour, J. K. Payne, Jr., J.
Stepp, C. H. DeLancy, F. M. Bogan, R. K. McClana-
han, \\'. E. G. High. June 20th. — Passed Assistant
Surgeon G. A. Lung, order of May 25th modified;
ordered to the Cavite naval station. June 21st. — As-
sistant Surgeon J. C. Thompson detached from the
naval hospital, Yokohama, Japan, and ordered to the
Newark.
Obituary Notes — Dr. Julius Althaus died in
London on June nth, at the age of sixty-seven years.
He was a graduate of the University of Berlin in 1855,
and soon thereafter settled in London. He was well
known for his writings on diseases of the nervous sys-
tem, and especially on the therapeutic applications of
electricity. He was one of the founders in 1866 of the
Hospital for Epilepsy and Paralysis.
Dr. Benjamin Douglas Howard died at Elberon,
N. J., on June 21st, at the age of sixty years. He was
born in England, but was graduated in medicine from
the College of Physicians and Surgeons in this city in
the class of 1858. He served during the Civil War as
surgeon in the regular army, and at the close of the
war, after a period of study abroad, was appointed
professor of operative surgery in the medical depart-
ment of the New York University. Subsequently he
held chairs in several other medical schools, and in
1873, his health failing, gave up practice and went
abroad. He finally settled in London, and took out
in 1877 the qualifications of M.R.C.S. Eng. and
F.R.C.S. Edin. He was on a visit to this country
at the time of his death.
Dr. Tommaso Crudeli, of Rome, well known for
his writings on hygiene, died recently. He was for-
merly professor of anatomy and later of hygiene at the
University of Rome, and was an Italian senator.
Dr. B. W. MacNichol died at his home in West-
chester, this city, on June 22d, of pneumonia, at the
age of forty-two years. He was born in Rondout, and
was graduated from the Jefferson Medical College in
1884. He was for several years health officer of the
town of Westchester before its incorporation into New
York City.
Dr. Llovd Morris Horwitz died at Helena, Mont.,
on June 22d, at the age of thirty-eight years. He was
graduated from the college department of the Uni-
versity of Pennsylvania in 1882, and from Jefferson
Medical College in 1884, serving subsequently as resi-
dent physician in the Philadelphia Hospital. He was
a son of Dr. Phineas J. Horwitz, U.S.N., of Phila-
delphia.
June 30, 1900]
MEDICAL RECORD.
1129
progress of Ipcdical Jicierrce.
Xc-iL' ]'iir/c Mcdual fournal, Jidie 2^. iqoo.
Inflammation of Meckel's Diverticulum with Resulting
Gangrene of the Intestine, Simulating Appendicitis. — W. P.
Nicholson reports the case of a young man aged twenty
years, who was seized with abdominal pain simulating
colic and referred to the left of the umbilicus. Gradually
the sj'mptoms of intestinal obstruction developed while
the pain shifted to the region of the right iliac fossa. La-
ter the condition became such that a diagnosis of appen-
dicitis with general peritonitis was made, and the abdo-
men was opened. A coil of distended intestine, jet-black
in color, was found crossing the wound at a right angle.
The surrounding coils were bound together by lymph. In
separating the coils of intestine, the gangrenous portion
presented the appearance of bifurcating into two unequal
parts, and these were separated. The smaller, about the
size of the thumb, was followed in a direction upward, in-
ward, and backward toward the mesentery, to which its
bulbous tip seemed attached by strong adhesions. When
this was separated, the gangrenous portion of the intestine
was easily withdrawn from the cavity, and it was now
seen to be the small intestine, entirely gangrenous for
about seventeen inches, with a blind tube about five inches
long springing from the conve.K border. Another coil of
intestine that had been in contact with the gangrene pre-
sented a gangrenous spot about the size of the thumb-nail,
and the omentum that covered it was totally gangrenous.
The intestine was resected and joined with a Murphy but-
ton, the omentum was tied off, and after thorough wash-
ing of the abdomen the gangrenous spot was brought up
to the wound and well packed about with iodoform gauze,
and much of the wound left open. The patient was put to
bed in as good condition as when the operation was begun.
The vomiting cea.sed after this, and there was apparently
.some improvement ; but later in the day evidence of in-
creasing failure developed, and he died eighteen hours
after the operation. The specimen proved to be a Meckel's
diverticulum, inflamed and gangrenous, thougli there was
no evidence of any band constriction, and no obstruction
in this sense.
The Value of the Tuberculin Test in the Diagnosis of Pul-
monary Tuberculosis. — J. M. Anders collates the experience
of various observers, and gives his own in three cases in
which the tuberculin test gave a positive reaction which
was verified by the subsequent course of the cases. An-
ders has a fixed belief that tuberculin will tend to occupy
its true sphere of usefulness just in proportion as the pro-
fession will in future keep in mind two rules as a guide — ■
to wit, moderate dosage and the limitation of its usage to
suspicious (incipient) cases and those that are unrecogniz-
able by other means. He entertains no doubt that if these
principles were enforced the re-use of tuberculin as a diag-
nostic agent would rapidly become general, and the results
prove highly satisfactory. Finally, if the use of tuberculin
as a therapeutic measure in tuberculosis was abandoned
(since this rests upon a misconception of the nature of the
agent) , much of the opposition to an invaluable aid in the
diagnosis of latent and incipient cases would be removed.
A valuable bibliography is appended.
The Advantages of the Pneumatic Cabinet or Differentiator
in the Treatment of Pulmonary Tuberculosis. — J. C. De
Vries explains the theory of action of the pneumatic cabi-
net, the main effect of wliich is the reduction of pulmonary
congestion. It is a most powerful measure for the arrest
of hemoptysis, but when a profuse bleeding points to acute
local necrosis as its cause, the cabinet must be used with
great caution and in such a way as to diminish vascular
tension without tissue distention until the bleeding vessel
has closed. In general the cabinet is an in.sferument by
means of which the following results are sought : (i) The
strengthening and developing of weak and poorly ex-
panded lungs; (2) the arrest of pulmonary disease in its
earlier stages ; (3) the prolongation of life with compara-
tive comfort in those cases of pulmonary disease in its
laterstages in which a cure is impossible.
Clinical and Pathological Observations on Some Early
Forms of Epithelioma of the Skin.— By J. A. Fordyce.
Rampancy . The Fervor of the Forehead. A Study of the
Anterior Metopic Lobule. — By W. Wood.
Iodine-Bearing Drugs in the Treatment of Chronic Puru-
lent Otorrhcea.— By C. L. Felt.
Perimetric Diagnosis. — By J. \V. Sherer.
Boston Midica! and Surgical Journal, June 21, igoo.
The Law of Dying Declarations. — M. J. Sughrue sum-
marizes the laws bearing on this point. Among the facts
stated we note that it is not necessary that the declarant
should be actually breathing his last ; even though he
lived some time, the declaration is competent if made un-
der a sense of impending death. The form of the declara-
tion is immaterial. It may be made orally, in writing, or
may be communicated by signs. In passing upon the
weight to be given to dying declarations the jury have
a right to consider all the circumstances under which it
was made, and all the conditions by which the dying per-
son was surrounded, and the state of mind of declarant,
as shown by all that was said and done. Conduct, deport-
ment, condition, all should be noted by the person who is
to be a \vitness. Declarant's conduct in saying farewell to
his relatives, in making such provision as is made by per-
sons about to die ; if the declarant is a Catholic, if he re-
ceives extreme unction, this is of importance as indicating
the state of -mind. It will be found a most useful practical
rule in these cases first to ascertain the state of mind of the
dying person, and after that an expression by him that he
has no hope of recovery, then to listen to a recital of the
story of the crime. It is becau.se of a failure to proceed in
this way that physicians frequently obtain an account of
a crime which cannot be used in evidence, and it is more
often because of inadvertence than want of knowledge;
but the result is equally disastrous so far as a successful
prosecution is concerned. Particularly is this true in abor-
tion cases, in many of which, apart from the evidence ob-
tained at the autopsy, there is no testimony save the dying
statement of the person operated upon, which by reason of
the carelessness or ignorance of the person hearing the
statement is worthless as evidence.
A Case of Extra-Uterine Pregnancy. — F. Holyoke gives
notes of an autopsy made on a woman nine and a quarter
hours after death. She complamed of terrible abdominal
pains, went into collapse, refusing to see a physician, and
died. The autopsy showed that large, black, tarry clots
covered the omentum, and the abdominal cavity was filled
with clots and serum. Beneath the omentum there was
found what looked, at first sight, lik . a large, rupture ova-
rian cyst with a very vascular wall to which the omentum
and intestines were extensively and firmly adherent. This
cyst lay between the folds of the right broad ligament.
It reached as high as the umbilicus. The cyst wall was
ruptured in the upper anterior part. The uterus was
pressed high up out of the pelvic cavity to the left, which
accounts for the inability to find the os by vaginal exami-
nation before the autopsy. This abnormal position of the
uterus was produced by the combined pressure of extrav-
asated blood in the posterior cul-de-sac and the forcible
bulging of the tumor anteriorly. The uterus was six
inches long, the cervix softened and filled with mucus.
The body of the uterus was soft and thickened proportion-
ately to its size, though the enlargement was more in the
long axis. The lining of the uterus was softened and very
pale. The tumor was ruptured at the site of the placenta.
In breaking up adhesions the sac \yall tore readily, show-
ing, beneath, the amnion, unbroken and adherent through-
out to its covering, which was composed of the anterior
and po.sterior layers of the broad ligament ; the pregnancy
being tubal in origin, and primary rupture having occurred
in the early months. The amnion contained a six-months
foetus, lying transversely with its breech toward the right
ilium.
The Marks Produced by Pistol Shots.— G. De N. Hough
has made experiments with various pistols and bullets of
different calibre. The marks consist of the bullet-hole,
burn, smut, and tattoo. The articles deals too largely
with figures and comparisons to be abstracted, but it is
a valuable contribution to the literature of pistol-shot
wounds.
Closing Statement for the Remonstrants to the Massachu-
setts House Bill No. 917, entitled "An Act for the Further
Prevention of Cruelty to Animals." Before the Joint Commit-
tee on Probate and Insolvency, March 15, 1900. — By H. C
Ernst.
Realism in Medicine. — By A. T. Cabot.
Pliiladelphia Medical Journal, June 2s, igoo.
A Contribution to the Study of Exophthalmic Goitre. — Al-
fred Gordon cites cases in which goitre followed genital
affections, floating kidney, nasal affections, etc. He finds
that clinical observation, experiments in laboratories, and
facts of autopsies, all compel us to look at the disease as
having a nervous origin. Scientists generally admit that
all the phenomena are the result of a permanent irritation
of the vasodilator nerves. Three tables are given, one
showing the results of medical treatment, one of operations
on the thyroid gland, and one of operations on the cervical
portion of the sympathetic nerve. In conclusion the au-
thor says that if the sympathetic nerve is the immediate
cause of exophthalmic goitre the treatment must be di-
rected to that nerve. If the syndrome of the disease is the
result of a mechanical pressure on the sympathetic nerve
the pressure must be removed, and if the symptoms per-
II30
MEDICAL RECORD.
[June 30, 1900
sist the sympathetic must be operated upon. If the syn-
drome of the disease is the lesult of reflex influence from
some remote affection, as fibroid uterine tumors, nasal
polyps, etc., these must, be removed ; and if the symptoms
persist the sympathetic nerve must be operated upon. If
the syndrome of the disease occurs during the course of
any spinal or other organic nervous disease operation
should be abstained from. If there is no apparent cause
the sympathetic nerve may be operated upon. We should
never operate upon the hypertrophied thyroid gland.
Medical treafment can be used if the patient refuses an
oi)eration, but under it we can never expect any perma-
nent cure or entire removal of the symptoms.
Scarlatina : Some Further Experiments. — William J.
Class, believing that tlie diplococcus described by him as
the specific causative factor in scarlatina has bad its spe-
cificity demonstrated beyond reasonable doubt, has under-
taken a search for an antitoxin. A toxin fatal to mice was
obtained from pure cultures. Female swine were used for
testing susceptibility. A serum has been prepared, and
the author purposes to test its effects in the first suitable
case of scarlatina that presents itself. He feels confident
that investigation will prove the germ he has described to
be the true cause of the disease.
Annual Address on General Medicine before the American
Medical Association.— By J. A. Witherspoon.
Mutter Lectures of the College of Physicians of Philadel-
phia.— By John B. Roberts.
Angina Pectoris.— By Clifford Allbutt.
Journal of t lie American Medical Ass' n. June 23, iqoo.
Pathology of Acquired Heart Disease in Children. — J. Dut-
ton Steele first considers the nutrition of the heart in child-
hood, and finds that the tissues respond more quickly and
more readily to stimulation and grow more vigorously in
early life than after puberty. The tissues of the child are
more yielding and more likely to give way under a sudden
distending force than the more closely knitted tissues of
older people. The local nutrition of the heart is apt to be
better than in the adult because the nutrition of the organ-
ism as a whole is better. The effect of acute rheumatism
on the heart is studied, and it is found that heart lesions
are commoner than after rheumatism in the adult, and
rheumatic diseases in children appear very virulent. Puer-
peral infection in the new-born, acute infectious diseases,
diphthe'ria, measles, rachitis, and scarlatina are all consid-
ered in their influence upon the heart. Peri- and endo-
carditis are not so common as inflammations of the myo-
cardium. In pancarditis any of the three tissues may be
the seat of the greatest involvements. Measles has little
or no efiiect on the heart. Lesions of the cardiac tissues
are lastly discussed.
Diagnosis of Heart Disease in Children.— J. P. Crozer
Griffith says the first thing is to determine whether heart
disease present is congenital or post-natal. The principal
diagnostic symptoms of the first are cyanosis, clubbing of
the fingers, thrill, characteristic murmurs, and the absence
of any great enlargement. In general it may be said that
in diagnosis of post-natal cardiac afltections in childhood we
should observe the following points : avoid making a diag-
nosis from the presence or nature of murmurs alone ; re-
member the altered position of the right side of the heart
and of the apex-beat in childhood ; remember that the
presence of an accentuated pulmonary second sound is nor-
mal, not pathological ; remember that compensation is ac-
quired very easily in childhood, and that the absence of
symptoms does not prove the absence of cardiac disease ;
remember that the most suggestive symptom is dyspnoea,
and that oedema must be studied most carefully before it
becomes of value as a diagnostic symptom.
Symptomatology of Valvular Heart Disease in Children. —
F. A. Packard says heart disease, especially in childhood,
has no symptomatology or no group of symptoms pointing
to the heart. The child is in some respects more of a free
agent than is the adult ; becoming uncomfortable from
effort, it remains quiet ; made dyspnoeic by exercise, it
ceases its play, while the adult must continue at his work.
Fifty-six cases are analyzed. Twenty-nine patients had
shortness of breath, ten had palpitation, nine oedema of
the legs, seven precordial pain, six epistaxis, five head-
ache, five had been auEEmic, four had abdominal pain, four
cyanosis, and four blood-spitting. The existence of any
abnormality makes careful examination imperative as to the
functional activity and physical condition of the heart.
Prognosis in the Heart Diseases of Children.- A. V. Meigs
savs the prognosis should be more hopeful in children, as a
general thing, than in adults. This is because the tissues
in the latter are stiffer and, it may be said, almost brittle.
Prob.ably the most important difference between prognosis
in children and adults is that the former have the better
chance of recovery owing to the opportunity they have of
outgrowing the disease.
The Pathology of Congenital Heart Disease. — Alfred Hand
says many classiHcations have been suggested, but none is
thoroughly satisfactory, and some are too broadly compre-
hensive. Faults of development are divided into tho.se that
occur early (cor biloculare or triloculare), anomalies aris-
ing between the sixth and twelfth weeks, and defects occur-
ring about the twelfth week resulting in anomalies of the
valves, persistence of fcetal opening, etc. Other changes
are usually the result of foetal endocarditis.
A Protest against Some of the Evils in the Profession of
Medicine. — Oration in medicine delivered at the tifty-first
annual meeting of the American Medical As.sociation, lield
at Atlantic C'ity, N. J., June 5-8. igoo, by J. A. Wither-
spoon.
The Ideal Physician. — Commencement address. Rush
^Medical College, Chicago June 21, 1900, by W. W. Keen.
Some Thoughts on Teaching Materia Medica and Thera-
peutics, Emphasizing Object-Teaching.— By A. H. Peck.
Should the Medical Undergraduate be Instructed in the
Principles of Dentistry? — By M. L. Rhein.
Is a Medical Education a Necessary Qualification for Den-
tal Practice ?— By Alice M. .Steeves.
The Handwriting on the Wall : What Does it Portray ? —
By A. E. Baldwin.
Report of Case of Primary Carcinoma of the Liver. — By
R. C. Harris.
Limitations in Dental Education. — By Eugene S. Talbot.
7 he Medical ye-ius, /line jj, /ijoo.
Some Points in the Management of Obstetric Cases in
Private Practice. — Joseph Brown Cooke compares a preg-
nant woman to a ship at sea. The probability is that no
accident will occur, yet the greatest watchfulness is neces-
sary to reduce still further the chance of anything going
wrong. In the first place, an accurate history of every
case should be kept from the time the patient is first seen
to the end of the puerperium. The urine'should be exam-
ined within a week ot the patient's first visit, then monthly
until the end of the seventh month, and after that weekly.
Another point of importance is the maintenance of absolute
asepsis from the beginning to the end of labor. Three
weeks before labor is expected, the author sends to the
patient's house a wooden box containing four half-gallon
bottles of distilled water : one pint of boric-acid solution for
the infant's eyes and mouth immediately after birth ; one
pint of standard sterile salt solution for infusion ; three
agate basins or trays, one for sponges, one for towels, and
one for receiving the placenta with the gush of blood that
follows it, and a tv.'o-weeks' temperature chart for the
nurse's use. The author has discarded every form of so-
called aseptic bag, and makes no attempt to carry anything
sterile to his cases except operating-gown in a muslin case,
gauze, cotton, cord dressings, and sutures of silk and cat-
gut. Instruments and silkworm gut, if it is needed, are
boiled in a long, narrow copper tray of such size and shape
that it will hold any obstetrical forceps together with cord,
scissors, catheter, douche-tube, and any other instruments
that may be required in special instances, covered with the
minimum amount of water, to secure rapid boil-ng.
Some of the Physiological Methods and Means Employed
by the Animal Organism in its Continual Struggle against
Bacteria for Maintenance of Life and Health. — By .S. J. Melt-
zer.
A Protest against Some of the Evils in the Profession of
Medicine. — By J. A. Witherspoon.
British Medical Journal. June 16, iqoo.
A Case Bearing on the Parasitic Nature of Mammary Can-
cer.— A. Marnuuluke Sheild reports the case of a woman,
thirty-six years old, who came to him in June, iSgS, suffer-
ing from Paget's disease of the left nipple. The case was
watched until the diagnosis was definitely established.
The so-called psorosperms were found in scrapings of the
patch, but there was no perceptible deep induration or signs
of cancer present. Nevertheless, in order to make sure of
the prevention of cancer, the entire breast was removed.
Examination of the skin revealed the usual appearances of
malignant dermatitis, but there was no evidence of cancer
in the breast beneath. All went well until April, igoo.
when a lump appeared in the skin near the sternal end of
the scar. This swelling, which was hard, about the size
of a large pea, and red in color, was excised and found to
be a spheroidal-celled carcinoma, with much fibrous tissue.
There was also extreme vacuolation of the epithelial cells
— so-called psorosperms. The author regards this case as
one showing that the infective nature of .so-called malig-
nant derma"titis of the nipple is very extensive and insidi-
ous, and takes place far more early t'lan is generally be-
lieved. We can hardly doubt, he says, that in this
instance there was a connection between the two affec-
tions. There was certainly no cancerous change in the
June 30, 1900]
MEDICAL RECORD.
ii^i
mamma to be detected, and he will not admit that "cell
proliferation " could have existed or spread so far.
An Easy Method of Mounting and Preserving Mosquitos. —
D. C. Rees descril:)es the following simple method which is
employed in the laboratory of the London School of Trop-
ical Medicine : " Kill the mosquito by placing it in an or-
dinary killing bottle, or if this is not available a little chlo-
roform or tobacco smoke will do as well ; when dead turn
it over on its back, separate the legs if they are together,
place a large drop of thick xjdol Canada balsam on a slide,
mvert this gently on to the mosquito, and in this way it is
picked up without any chance of injury ; then with a fine
needle spread out and arrange the wings and legs, and if
necessary press down the thorax very carefully. Next
pour on some thin xylol Canada balsam ; as this runs out it
straightens the proljo.scis and antennse, and they do not,
as a rule, require to be touched. Put the specimen on one
side to harden, then chip off the excess of Canada balsam,
place glass ring on, and fill up the chamber that is thus
formed with Canada balsam. The upper surface of the
Canada balsam should be convex, so that when the cover-
glass is applied no air bubbles are included. Allow the
specimen to harden before sending by post. If the glass
rings are not at hand the specimen will keep quite well in
the Canada balsam alone, and the last part of the mount-
ing may be completed after the specimen has been .sent
home. If the mosquito is intended for photographing
great care must be taken in mounting it so that it lies as
far as possible in one plane."
The Treatment of Pneumonia. — Referring to a previous
report of a case of pneumonia treated with Dover's pow-
der, A. de Winter Baker relates the case of a boy thirteen
years old, who was suffering from pneumonia of the left
lower lobe complicated with otitis media. Two days after
the lad came under treatment, tubular breathing was heard
in patches at the base of the left lung behind and also
slightly at the left apex. The patient was sleepless and
delirious. The author ordered Dover's powder gr. v. every
four hours, and says the result was magical. The delirium
was quieted, the skin. acted freely, and the general aspect
improved immensely. The dose was subsequently reducd
to gr. iiss. , and the remedy was continued for about two
days. The boy had no alcohol during the acute stage, and
only after the temperature fell a little port wine was given
to stimulate the appetite. After the Dover's powder was
commenced the temperature never rose above 103' F.,
whereas it was 104° F. the previous day. There was never
any necessity for the administration of oxygen or strych-
nine. The author attributed the good results obtained in
this case almost entirely to the Dover's powder.
A Neglected Point in the Treatment of Strangulated Her-
nia.— C. Hamilton Whiteford says that in a case of this
nature the surgeon usually concerns himself chiefly with
the condition of the strangulated bowel, which, if gangre-
nous, is either drained or resected, and it viable is pushed
back into the abdomen. In the latter case the patient
probably remains absolutely constipated, continues vomit-
ing, and dies within forty-eight hours. He is suiferin,g
from an accumulation, above the obstruction, of liquid filth
which is rapidly poisoning him. The point which is so
frequently overlooked is that his chance lies in the direct
evacuation of these intestinal contents. This can be done
only by draining the distended bowel through a large tube
for several days. A few cases of advanced strangulated
hernia end in recovery after reduction of the strangulated
bowel, by discharging enormous quantities of liquid fcEces
per anum, but the majority die with unemptied intestines.
This drainage of distended bowel, the author says, is sim-
ply the application to strangulated hernia of the principles
involved in the treatment of obstructions taking place
within the abdomen.
A Recent Observation on Filaria Nocturna in Culex : Prob-
able Mode of Infection of Man. — By George C. Low.
Notes on Gastro-Enteritis, Dysentery, and Enteric Fever. —
By J. W. Washbourn.
Remarks on Mauser-Bullet Wounds and Amputation. — By
Sir William Stokes.
Two Lectures on Antenatal Diagnosis. — By J. W. Ballan-
tyne.
Clinical Lectures on Pneumonia. — By James Ban-.
Tlic Lancet, June lO, igoo.
The Management of the AnsEsthetic in Cases in which
Respiratory Impediment Exists. — By Dudley W. Buxton.
The writer remarks upon certain cases in which interfer-
ence with respiration occurs in the course of anjesthesia.
First, obstructions arising in the upper air passages may
be due to enlarged tonsils with a partially occmded naso-
pharynx, or to pharyngeal abscess, enlarged tongue, or old
adhesions between the posterior wall of the pharynx and
the tissues about the faucial arches. Two instances in
children are quoted. There may also be mechanical inter-
ference intensified by the anaesthetic. Cases are cited.
Posture is another difficulty, especially when the patient
must be placed more or less ujjon the face and in semi-
prone postures. When chloroform is u.sed, the hampered
chest movements may produce cyanosis. The following
propositions are thought worth tabulation ; (i) The indi-
vidual patient possesses a certain respiratory power. In-
dividuals differ enormously in this respect, and it is the
business of the anaesthetist to make himself acquainted
with what the author terms the " personal respiratory equa-
tion of the patient." (2) This individual power of respira-
tion is interfered with by every form of anfesthetic, more by
some than by others, but under any anaesthetic the power of
inspiration and expiration is lessened, and in some cases
to a very marked degree. (3) This lessened respiratory
power may be of little or no consequence under normal
conditions, but it becomes a factor of grave danger should
any intercurrent cause of respiratory obstructiini occur.
Surgical Aspects of Constipation.— S. L. Woolmer records
two cases to demonstrate a rare sequel to the most common
morbid condition known. Aneurismal dilatation of the
colon as the result of chronic constipation exists, but works
on surgery do not mention it. In both instances cited the
condition of the patient was reduced to one of great grav-
ity. Nothing short of operation could give relief. The
histories are <given with illustrations. In both cases, the
site of the tumor was the last portion of the sigmoid flexure.
An Address on the Value of Tuberculin in Diagnosis and
Treatment. — Delivered at the Medical Graduates' College
and Polyclinic on February 9, 1900, by T. McCall Anderson.
Fractures of the Inferior Maxillae Treated by a Modified
Method of Wire Suture Aided by the Electro-Motor.— By T.
S. Carter.
Contribution to Our Knowledge of Uric-Acid Salts.— By F.
W. Tunniclift'e and Otto Rosenheim.
Pyo-pneumothorax due to Empyema Perforating the Lung ;
Recovery.— By F. Percy Elliott.
Bilateral Dislocation of the Hip, Presumably Congenital.—
By Thomas Philip Cowen.
A Few Cases of Brain Injury Clinically Examined. — By
Edmund E. Dyer.
Three Cases of Puerperal Eclampsia. — By Frederick Spurr.
Differentiation in Diabetes. — By F. W. Pavy.
Berliner klinisclte Woe/iense/iri//, June 4, igoo.
The Employment of Alcohol as z Means of Disinfection
and the Theory of its Action. — Salzwedel and Eisner have
performed a series of experiments by dipping threads in
various bacterial cultures and then dipping; the threads in
an alcoholic solution. They find that for the sterilization
of threads infected in this way with staphylococci pus, the
bactericidal effect is most certain when the solution has
about five per cent, alcoholic strength. In general it ap-
pears that the effect is heightened by a slight w^arming of
the alcohol, but the temperature should not exceed 30° C.
They further believe that the disinfecting effect of alcohol
is due to its dehydrating properties, whereby an environ-
ment is established inimical to bacterial development.
Influenza and Chronic Heart Disease. — Dr. Schott (Bad
Nauheim) presents several statistical tables showing the
distribution of influenza during receirt epidemics and the
relative proportions between the total number of deaths in
some of the European armies and deaths due to cardiac
disease. He claims that his figures show that influenza
leaves many cardiac evils in its train.
Conception of the Word " Gastric Dilatation " in German
Literature since 1875. — By A. Hesse.
The Measure of the Strength of the Heart Sounds, a Diag-
nostic Aid.— By H. Bock.
Abdominal Typhus. — By Dr. Rumpf.
Deulselie inediciniselie WoeJienseliriJt, Jitne 14, igoo.
The Importance of the Palatine Tonsil in Young Children
as a Port of Entry for Tuberculous Infection. — F. F. Fried-
niaun, believing that the tonsils are the seat of the first
manifestations of a number of infectious processes, has car-
ried out a number of histologico-bacteriological examina-
tions to determine whether in children they may not serve as
the entrance point in tuberculous disease. Ninety-one au-
topsy cases [and fifty-four living subjects were examined.
The processes are described. From the work done it is
thought that tonsillar tuberculosis exists under two condi-
tions— a primary infection from food and a secondary in-
fection from sputum containing bacilli. In spite of Koch's
doubting that a single instance of human tuberculosis can
be positively and without objections attributed to eating
the flesh or drinking the milk of a tuberculous animal, the
11.^2
MEDICAL RECORD.
[June 30, 190c
author can see no other explanation for a number of his
cases. Primary infection from food is much more frequent
in children than the secondary from infectious sputum.
The Dangers of Lumbar Puncture. — F. Gumprecht relates
an instance of sudden death after lumbar puncture, making
the sixteenth in the literature. The preceding fifteen are
briefly i-eferred to. He adds two other instances in which
death was not sudden, but occurred a few hours after punc-
ture.
Does there Exist an Amblyopia due to Lack of Use ? — By
P. Silex.
Contribution to the Question of Hsmophilia. — By Th. Klein.
Isolated Deltoid Paralysis. — By A. Steinhausen.
French Journals.
Treatment of Tuberculosis of the Kidney. — Tuffier says
the diagnosis includes, besides a recognition of the afltec-
tion, a knowledge of the condition of the opposite kidney.
When we say that every renal tuberculosis diagnosticated
should lead to extirpation, it is equivalent to stating that
lesions alreadj' severe and extensive are to be treated sur-
gically, since positive manifestations are often to be made
out only when the condition is already somewhat ad-
vanced. Catheterization of the ureter does not always
give the key to diagnosis ; it is attended with some dan-
gers, and it is a procedure which is justified only by spe-
cial clinical circumstances, which are, after all. quite rare.
A study of the total quantity of urine without catheteriza-
tion of the ureters usually permits of serious presumptive
evidence as to the state of the renal filter, and in his own
experience never deceives. Purulent urine suddenly be-
comes clear and thus gives testimony as to the functional
activity of a single kidney. As often this bacillary lo-
calization has an injurious effect upon the general health
of the patient, surgical intervention is called for whenever
it is possible. Lumbar nephrectomy is the method of
choice. The operation when entirely justifiable gives bril-
liant and lasting results, and is a step in advance in the
therapy of this affection. — Journal des Praticiens, June 9,
1900.
Secondary Cancer of the Chyliferous Passages ; Chyliform
Ascites. — Nattan-Larrier concludes that primary cancer of
very small volume can give rise to an enormous secondary-
cancer ; just as the secondary cancer can spread by way of
the veins and produce cancer of the liver. In the same
manner it may become generalized by way of the lym-
phatics and produce cancer of the lymphatic passages.
Secondary cancer of the mesentery, of the thoracic duct,
and chyle ducts piay evolute in a latent manner and
give other signs of a cachexia of rapid course and a mod-
erate chyliform ascites. Obliteration of the thoracic duct
and invasion oftthe mesentery are not sufficient to produce
chylous ascites or chyliform ascites if there is not added
a .solution of continuity or an obliteration of the chyle ducts
susceptible of impeding the course of the chyle. Cancer-
ous invasion of the peritoneum when associated with can-
cer of the thoracic duct can also give rise to chyliform as-
cites.— Lc Rullt-tin Mt'dica/, June 9, 1900.
Treatment of Pertussis by Deep Injections of Oil of Go-
menol. — Leroux and Pasteau, led by the favorable action
of the remedy in bronchitis and phthisis, have tried 'first
inhalations and then deep injections of oil charged with
gomenol. Gomenol is a pure natural essence obtained by
distillation from a variety of Melaleuca viridiflora cultivated
in New Caledonia. Forty patients were experimented
upon. From 5 to 10 c.c. of a five-per-cent. oil were injected
in the gluteal regions. A series of charts are given with
detailed observations in eighteen cases. The results were
generally favorable, there being diminution in the number
of attacks and shortening of the disease, the average
being twelve to fifteen days. Treatment .should be per-
sisted in four or five days after the last seizure. The
technique of injection is given. — Lc Bulletin Mi'dical,
June 13, 1900.
Renal Tuberculosis. — Albarran says that Tuffier recog-
nizes the value oi ureteral catheterization whenever doubt
e.xists about the supposedly healthy kidney. In point of
fact these doubts always exist. Tuffier is in error in sup-
posing that the catheter must remain in situ for twenty-
four hours ; from a few minutes to one or two hours is often
sufficient. The author says he has practised catheteriza-
tion of the ureters over one thousand times without acci-
dent. He has seen brilliant results from nephrectomy in
tuberculous pyonephroses in very cachectic patients with
high temperature. Catheterizing the ureters permits us in
almost all cases to diagnosticate the state of both kidneys,
and presents no dangers when properly done. — Gazette tics
Hcpitau.x, June 7, 1900.
Gummata of the Palatine Vault. — Fournier showed a case
of atresia of the fauces consecutive to gummous infiltra-
tion, and described two forms of lesion, one circumscribed
or nodular, and one due to diffuse infiltration causing tu-
mefaction rather than tumor. Five characteristics serve
to facilitate diagnosis from the very beginning. They are •.
deformity of the velum, redness, thickening, hardness or
firmness, and immobility or quasi-immobility^ When per-
foration occurs there may be a single or multiple opening
of varying diameter, or there may be marginal loss of tis-
sue, or adhesion of the centre with the sides drawn back
like curtains at a window, or almost the entire velum may
be destroyed. Regurgitation of liquids from the nose in
swallow-ing is one of the most striking symptoms. Another
is nasal voice. Ninety-five per cent, of all cases are of the
diffuse variety. — Journal des Praticiens, June 9, 1900.
Pediatrics, June /j, /goo.
Dangerous Communicable Diseases, How Spread, together
with Some Suggestions as to their Restriction. — M. K. Al-
len says the so-called contagious diseases are usually
spread through the medium of atmospheric dust. People
should be made to know that dust from handkerchiefs con-
taining dried secretions is laden with germs, and hence is
a source of danger. Each soiled handkerchief "should be
placed in a paper bag, the top twisted shut, and there re-
main until it can be boiled." He thinks it not improbable
that typhoid is sometimes spread by means of dust con-
taining the germs of the disease. One-third of all children
who die under ten years of age die of tuberculosis, and
nine millions of the present inhabitants of this country
will, at the present rate, die of this disease unless some-
thing is done to prevent it. Pneumonia, influenza, diph-
theria, typhoid, smallpo.x, and other contagious diseases
are considered in relation to quarantine, disinfection, the
responsibility of notification, and the duties of the health
board.
A Case of Pneumonia in a Baby Six Weeks Old. — Abra-
ham Goltman relates an instance in which the tempera-
ture was 105 F. , and the respirations 80. There was vis-
ible rapid pulsation in both subclavians and carotids.
Stress is laid upon the value of stimulating the benumbed
respiratory centre by cold and hot water douches and
fairly large do.ses of drugs considering the age. Strych-
nine gr. y^j was administered every six hours. Alternat-
ing hot and cold plunges for five minutes at a time aj)-
peared to work marvellous results.
Some Remarks on Three Symptoms of Rickets. — W. N.
Berkeley finds that in many reported cases of paraplegia,
ansemia. pseudoleukemia, hypertrophic cirrhosis, etc..
one is strongly tempted to affirm that the real underlying
condition was simply rickets. He discusses the three
symptoms : rosary, those referable to the head, and those
referable to the liver and spleen. In one case related the
diagnosis of sarcoma of the spleen had been made.
Foreign Body in the Air Passages. — By J. M. Ray.
Rc'c'ue de Mt'decine, May, tgoo.
Functions of the Thyroid Gland. — G. Gauthier says that
there is no room to doubt that there is a relation of cause
and effect between normal functioning powers of the thy-
roid gland and of the nervous sj^stem. The action of the
gland is not simply reflex or sympathetic, but direct and
intimate upon the development and the nutrition of the
nerve cells. Certain cardio- vascular troubles depend upon
thyroidism ; thyroidin has been proved experimentally to
be a heart poison, and like digitalis to have cumulative
properties. An injection of thyroid juice lowers blood
pressure and dilates the peripheral arteries. In conclusion,
all pathological conditions dependent upon a lowering of
nutrition may be traced to deficiency of thyroid substance
and will often be benefited by thyroid treatment.
Desquamation in Typhoid Fever of the Adult. — Paul
Remlinger reports si.x cases in which desquamation of the
skin was observed, which began just at the time when the
temperature began to fall. It was scaly in nature, inter-
mediate between that of measles and scarlet fever, and
began and was most marked on the lateral portions of the
thorax and abdomen. It was limited to the trunk, but iu
three cases coexisted with alopecia. The author holds that
this desquamation is the result of trophic cutaneous dis-
turbance, like falling of the hair. As a prognostic sign it
is favorable, indicating the approach of convalescence.
Clinical Study of Some Infectious Diseases. — By H. Roger.
Infantile Gastro-Enteritis. — After a purge and
washing out the bowel, a teaspoonful of dry beer yeast
or a dessertspoonful of fresh yeast dissolved in 50 or
60 gm. of tepid boiled water should be introduced.
The catiieter should be withdrawn and the child be
kept quiet. Renew two or three times a day. Liquid
diet should be given till the fever falls.
June 30, 1900]
MEDICAL RECORD.
1133
PRIORITY IN THE PUBLIC-BATH QUES-
TION.
Sir : How you manage to be so well informed on all mat-
ters medical and hygienic is a marvel. This is illustrated
by your editorial of May 12, igoo, in which you were good
enough to defend my claims to priority in having intro-
duced public baths in this country, which, as will be shown
by an exhibit at the Paris Exposition, is in advance of all
others in furnishing the poor with perennial cleansing
baths free of all cost.
As a matter of fairness I would ask you to point out the
untenability of Mr. Brown's reply to j-our editorial of May,
igoo. You wrote : " F'ailing to overcome the opposition of
Mayors Grant and Gilroy, the doctor ' found ' an earnest
and able coadjutor in Mr. Goodwin Brown, who in iSgs
brought about the passage of a mandatory act, . . . while
Mr. Brown deserves credit for aiding Dr. Baruch in this
important enterprise, etc."
Any reasonable reader would understand that "this im-
portant enterprise " referred to the establishment of free
public baths, for which I had been working since iSSg, and
in which you have taken such great interest for many
years. But Mr. Brown chooses to twist your language into
meaning he was ray coadjutor in the passage of the man-
datory act. My connection with the latter is expressed in
a letter from i\Ir. Brown dated April 18, i8g5, as follows:
"It affords nie pleasure to say that the matter which you
gave me enabled me to lay before the committee unanswer-
able arguments, and to you I largely ascribe the credit of
the most important measure of the session."
Simon B.a.ruch, M.D.
New York, June 9, 1900.
reasonable to believe that it may be the carrier of leprous
spores of a bacillary disease from man to man? And be-
cause European immigrants to that leprous country may
rarely contract leprosy, as rarely as they eat the living
carp, is that reason to conclude that mosquitos there may
not be a means of leprous contagion?
Albert S. Ashmead, M.D.
MOSQUITOS AS A MEANS OF CONT.AGION
IN LEPROSY.
To THE Editor of the Medical Record.
Sir : Replying to Jonathan Hutchinson's statement which
you quote in The Medical Record, April 7th, page 616:
"The suggestion that mosquitos are a means of contagion
m leprosy, has had its advocates. It is, however, I think,
conclusively negatived by the fact that of the European
immigrants into leprosy districts, scarcely any contract
the disease " {Archives of Surgery) . Let me say that that
fact proves nothing. In Japan it is the most notoriously
.malarial districts, therefore those most infected by mos-
quitos, Kumagato, Myasaki, Awamori, etc., that are the
most leprous. How would Jonathan Hutchinson harmo-
nize that fact with his fish-alimentation theory?
Because in leprous districts it is not the European doc-
tor, nor the immigrant Sister of Mercy who becomes con-
taminated with leprosy, nor the immigrant negro in
malarial districts who contracts malarial fever, is it rea-
sonable to conclude that leprosy is not contagious (inocu-
lable) , and that malarial fever is not transmissible by
mosquitos? Would any one, because of this last circum-
stance, dare to say that it is conclusively negatived that
mosquitos are a means of contagion in malarial fever?
■ In the case of the conveyance of plague to man by means
of fleas, Dr. Munro, in Montenegro's work, "Bubonic
Plague," published in America by William Wood & Com-
pany, cites Bandi and Stagnatti, who, observing how few
medical men and nurses were attacked by plague, could
not believe that the fleas play so important a role, since
the very greatest care did not prevent fleas passing from
the sick to the doctors or their assistants. Yet Siraonds'
ingenious experiments showed that the plague is trans-
mitted from the rat to man by means of fleas. The healthy
rat has very few fleas on him, because he is careful of his
toilet. But a sick rat becomes absolutely covered by these
insects, because he is neglectful of himself. Simonds put
two rats in a cage, one ill of plague, having fleas on it ; the
other healthy, having none. The healthy one became af-
fected after the death of the sick rat. He then put two
rats in a cage separated by a wire netting, one sick of
plague, the other healthy, but both without fleas. The sick
one died, but the other remained healthy. Thus not until
the second intermediary-host factor was at work did con-
tagion take place. Intermediar)--host function of fish and
mosquitos, in vay opinion, is a frequent source of conta-
gion in leprous Japan. There the carp, which feeds mainly
on the larvae of mosquitos, is eaten raw. It is the feast
dish, the turkey of Japan, and when served is cut up alive
and eaten while the flesh still quivers. If this carp has fed
on mosquitos which have sucked a leper's blood, is it un-
THE MODERN HOSPITAL AND ITS RESI-
DENT STAFF.
Sir: In your issue of June 9th appears a report of the
meeting of the Medical .Society of the County of New York
on the evening of May 28th. Among the papers read before
that body is one by me entitled "The Governor and His
Staff, Being a Glance at the Personnel of a Modern Hospital
and a Plea for a Permanent Resident Staff. " Your reporter
disposes of my paper in three lines, and in those three
lines he makes three points: that I dwelt on the incompe-
tence of hospital internes ; that I ridiculed the hospital
governors, and finally that I failed to offer a remedy for
the alleged abuses.
I simply said that the visiting surgeons took no cogni-
zance of a case except their attention was called to it by the
house staflf ; that this hou.se staff' .sometimes meant a stu-
dent graduated about five or six months ; that by the pres-
ent hospital system this raw young man was made the
judge, the sole judge of what must be done, and done
quickly, in a given case ; that it requires more judgment
and a riper experience to decide offhand and quickly the
thing to be done in an emergency, in which an error of
judgment may mean death to the sick man, than those
young gentlemen — members of the house staff — from the
nature of things can possess ; for remember, they are green
and inexperienced as yet. and not over the furor of enthu-
siasm that the importance of their high place has inspired.
I said further that if the science of surgery was so rap-
idly and easily mastered by those young juniors, we have
had a wrong conception of the ob.stacles to be overcome
and the great difficulties to be surmounted in acquiring a
knowledge of that art.
The man sent from the hospital as its official representa-
tive to diagnose the case of a sick woman, whose friends
made application for her admission, reported that she was
suffering with a contagious disease, and rejected her on
that account, though her family physician, who was pres-
ent, and is the writer, could not agree with him in such diag-
nosis and was afterward sustained by an expert from the
department of health. The physician sent out on this
memorable occasion was a very young junior who gradu-
ated the previous j-ear, and who had not the slightest com-
punction to measure swords professionally with a practi-
tioner of twenty years' experience. Another case was
cited by me from personal experience in which the ambu-
lance surgeon who was summoned declared a man was
suffering from alcoholism, and handed him over to a po-
liceman, who prompt!)', under protest from the writer,
placed him in a cell where he died four hours later. The au-
topsy revealed fracture of the skull as the cause of death ;
further examination of the brain and tis,sues made it plain
that the man could not have been addicted to the use of
intoxicants — in short, that he was a temperance man.
The errors of judgment, professional and otherwise,
committed by these young hospital juniors led me to con-
clude that their incompetency was clearly proven.
Now, about my ridicule of the hospital governors. This
is what I said: that when they put a young man in uni-
form and gave him charge of an ambulance it was theii*
duty to see that the young so-called surgeon had sufficient
knowledge of his business to enable him to make a diagno-
sis in ordinary cases ; that if sometimes diagnosis was diffi-
cult, the patient should get the benefit of the doubt, which
he did not get ; that the governor did not act for the best
interests of the hospital, nor with due appreciation of the
rights of the community — not to speak of the grievous
wrong done to the patient when he sent a young and alto-
gether inexperienced physician to the bedside of one who
was desirous of availing himself of the benefits of the ho.s-
pital. In that case the young doctor, overconfident and
bumptious, made a wrong diagnosis, one that reflected on
the family phj'sician, put the life of the patient in jeop-
ai-dy, and put another hospital to unnecessary trouble. I
al.so said that when the governor appointed a man on the
house staff, it was for the distinct rea.son that he knew less
thaij the man he was called on to succeed, and that for the
governor's conduct in this matter there was to be found no
precedent in the other learned professions, in which merit
and known ability are the prime factors in every case
where success or promotion is the thing to be attained.
If this is ridiculing the governors, then your correspond-
II34
MEDICAL RECORD.
[June 30, 1900
ent is right. Thirdly, and in conclusion, your reporter
says I failed to offer a' remedy for the alleged abuses. The
correspondent of another paper who was present at the
meeting does not agree with your reporter on this point,
for he savs: "Dr. A. Jacobi spoke briefly in discussion of
Dr. Hillis' paper. AVith much of it he agreed, but he did
not see how a better condition of aft'airs in some respects
criticised by Dr. Hillis was practicable. One reform,
which he thought might be productive of good results,
would be to have the city pay the staff doctors in the'insti^
tutions which it controls, thereby making it worth their
while to stay in the service after they had attained some
experience. In conclusion. Dr. Hillis suggested that the
house staffs of hospitals should be made up of older and
more experienced men, and that they should not be turned
away to make room for new applicants just as they have
acquired the experience that makes them valuable. Ju-
niors should not be left in charge of a hospital. A six
months' graduate of a law school would not be called to
argue a case before the supreme court, and Dr. Hillis
could not see why a six months' graduate of a medical
school should be called on to operate in a case of life or
death. Old doctors who have outgrown the manual skill
to operate should be employed in the hospitals as an appel-
late division of the hospital court, where their knowledge
and experience could be of use in advising the younger
men, 'The worst of all hospitals,' said Dr. Hillis, 'are
those where the power of appointing the staff is in the
hands of clergymen or of a religious order, regardless of
creed or denomination. '" Thom.\s J. Hillis.
STATISTICS OF THE WOMAN'S HOSPITAL
FOR 1898 AND 1899.
To THE Editor '
Medical Record
Sir : Will you kindly give space in the columns of the
Medic.-vl Record for the publication of the following stat-
istics, which show the total number of capital operations
performed in the Woman's Hospital from January i, iSgS,
to January i, 1900, the character of the cases, and the
death rate :
Service of
Ill
lll.i
0§M2
<< 0
I
E 8
^J2
I
T. A. Emmet.
I
14
i6
15
6.25
H. D. Nicoll..
7
5
29
92
133
127
6
4.51
C. Cleveland ..
32
39
29
75
175
162
13
7.42
B. Emmet
2
4
5
6S
7b
72
4
5.26
H. T. Hanks.
8
50
6
10
113
137
125
12
8.75
Totals
54
74
359
537
501
36
6.70
These figures are made up from the " Record-books of
Cases " on file in the hospital, and the medical board
pledges itself for the carefulness, fairness, and accuracy of
the representations in the facts here given. The records
are accessible to any one, properly accredited, who may
desire to inspect them. Dr. Bache Emmet was absent in
Europe for eight mopths in 1S9S, during which time his
service was discontinued.
He.nry D. Nicoll, Secretary oj the Medical Board.
OPERATION IN CANCER OF THE UTERUS.
Editor
Medical Reco
Sir : I beg to request the correction of a slight, but to me
important, error in the report of my remarks on the subject
of uterine cancer at page 1067 of the Medic.\l Record. I
am reported as saying that, in my opinion, " there is no case
of malignant disease with adeno-carcinomataof the fundus
for which hysterectomy was justifiable, according to the
records." What I did say, and have maintained for over
twenty years, is, that there is no case of malignant disease
of the uterus except cancer originating in and limited to
the fundus, for which hysterectomy was justifiable. In
proof of this declaration I referred to the melancholy, and
not very creditable, records of total ablation for cancer of
the cervix, while an absolutely safe and better method of
treatment had been amply demonstrated for over a quarter
of a century. John Byrne, M.D.
314 Clinton Street, Hkook'I.vn.
NEW YORK ACADEMY OF MEDICINE.
Stated Meetirn;, June 7, igoo.
William H. Thomson, M.D., President, in the
Chair.
Memorial Address on the Life of Dr. Fessenden
Nott Otis. — -Dr. T. Gaillard Thomas read a short
address, in which he reviewed, in a fitting manner, the
work of the late Dr. Fessenden N. Otis (see page
1073). He was followed by Drs. L. Bolton Bangs and
Edward L. Keyes, after which the following resolu-
tions were presented by Dr. Richard H. Derby, and
unanimously adopted by the Academy:
" Whereas, The New York Academy of Medicine
has heard of the death of Dr. Fessenden Nott Otis at
New Orleans on the 24th of May, 1900, in the seventy-
sixth year of his age;
" Resolved, That the following minute be spread
upon the records of the Academy :
" Dr. Otis was born in Ballston, N. Y., and was
graduated from the New York Medical College in
1852. He was connected for many years with the
College of Physicians and Surgeons of this city as
clinical teacher, professor and emeritus professor of
genito-urinary diseases. He held positions in many
of the hospitals in the city. Upon the special subjects
which he taught, he was a widely recognized author-
ity. His contributions to the medical press were nu-
merous. Strong in his convictions, he had the cour-
age of them, and while his theories may have been not
infrequently challenged, his frank and genial tempera-
ment, his freedom from personal littleness or profes-
sional jealousy will always be cherished by those
whose privilege it was to know the man.
" As an author in other fields than that of medicine,
and as an artist of reputation, the world has sustained
no slight loss.
"The New York Academy of Medicine hereby re-
cords its appreciation of this well-spent life, this
loyal devotion to the best interests of science, and
this example of a high character."
Pathology of Insolation. — Dr. Ira Van Gieson
read a paper on this subject. He stated that the
problem of the pathology of insolation, which was still
unsolved, was important not only in itself, but also
in its relation to other sets of phenomena, such, for
instance, as the similarity of certain manifestations of
insolation to those in poisoning by snake venom, the
losses of consciousness, comatose, convulsive, and
tetanoid conditions in general, and to the coma of
diabetes and ura-mia in particular. The problem was
mainly one for the physiological chemist, and the
pathological anatomist must follow in his wake. Al-
though, since the great epidemic of sunstroke in i8g6,
opinions regarding this condition had become unified
as regards treatment, we knew next to nothing about
Its pathology. We could only surmise. Among the
various theories which had been advanced, the follow-
ing were worthy of consideration:
Bacterial origin of sunstroke: Recently the bac-
terial origin of the disease had been suggested, and
perhaps w^e should not dismiss the theory too pe-
remptorily. Briefly, the theory was that the increase
of body heat or the exposure to the conditions under
which sunstroke was liable to occur permitted certain
bacteria to become infective. The absence of prodro-
mata and sudden onset of the disease argued against
this theory.
The caloric theory: The theory that the symptoms
of heat-stroke were due to the direct action of the
June 30, 1900]
MEDICAL RECORD.
1135
lieat was the oldest theory, and had recently been
brought into prominence again by the experiments of
Goldscheider, Flatau, Ewing, and others, who had
found certain changes in the neurons of animals after
exposing them to very high temperatures. The ani-
mals were placed in heated ovens and then resusci-
tated, and it was found that their exposure to the heat
was followed by lesions in the nerve cells. This
theory. Dr. Van Gieson said, failed to explain the
origin of the hyperpyrexia in the human subject, and
in the animals experimented upon the changes in the
cells might have resulted from some concomitant con-
dition, and were not, perhaps, directly due to the heat,
although this was the exciting cause. There might
have been accompanying changes in the blood. It
was known that high temperatures in other diseases
were not always accompanied by neuron changes.
The autotoxic theory: The speaker said that his
investigations and experiments at the Pathological
Institute of the New York State hospitals, during the
epidemic of sunstroke in 1896, convinced him that the
manifestations of the disease were the result of some
poison. It seemed to be a good example of an acute
poison originating in the body, and acting most vio-
lently on the nervous system, particularly on the gan-
glion cells which governed the heart and controlled
the vasomotor apparatus. The delirium, convulsions,
opisthotonos, the mental derangement, etc., could be
at least partly interpreted by the changes in the gan-
glion cells produced by a poison of autogenous origin.
In cases which resulted in recovery within a few hours,
there was probably very little degeneration of the gan-
glion cells. Between this grade and those in which
the cells were permanently managed, there were prob-
ably mai»y intermediate conditions. The source of
the poison, as well as its relation to the cessation of
perspiration prior and during the attack, were un-
known. The sudden onset of the disease in the great
majority of cases favored the autotoxic theory. Ani-
mal experimentation by Dr. Levene and the speaker
had shown that the virulence of the autogenous poison
was fully as great as that of snake poison, and in some
respects resembled its action. The urine of convales-
cent patients, when injected into the blood circulation
of rabbits, was found to be decidedly hypertoxic, and
injections of blood serum taken from two patients gave
prompt and decisive results.
Cessation of perspiration: The two classes of ani-
mals which perspired most, namely, human beings
and horses, were the ones which showed the most
classical types of sunstroke, and from this it might be
inferred that the occurrence of sunstroke was more or
less intimately connected with the cessation of this
function. On the other hand, the cessation of the
perspiration might be the secondary manifestation of
toxic involvement of this secretory function of the
sympathetic. It is said that swine showed symptoms
of heat-stroke, but it was quite a different disease from
that observed in human beings. In swine, when over-
heated, it was said that the fat which enveloped the
animal actually became liquefied, and it was claimed
that the melted fat had been extruded both from the
gut and mouth. Probably the succession of some of
the initial manifestations, expressed in general terms,
was as follows: The exciting cause in the form of
high external temperature induced a change in the
blood: The nature of this change was not known. It
might be a change in density, in chemical constitu-
tion, or in the addition of a hypothetical toxic agent
derived from autogenous sources. The latter factor
seemed less probable than either or perhaps both of
the first two conditions. As a result of this the angio-
paresis took place. We should naturally surmise that
the angioparesis was a sequence of the paralysis of the
vaso-constrictor nerves due to the toxic action of the
altered constitution of the blood, if its direct action on
the walls of the smaller vessels could be eliminated.
The cessation of perspiration and accumulation of
carbonic oxide were concomitant with the angioparesis.
With the angioparesis and stasis began the hyper-
pyrexia, for this interfered with the heat loss to the
extent of some ninety per cent. The loss of con-
sciousness also was to be attributed to the change in
the blood which induced retraction of the higher neu-
ron aggregates. The best working-hypothesis of sun-
stroke was the theory of auto-intoxication. In fact,
sunstroke seemed one of the most outspoken examples
of the autotoxic diseases, and should be a most inter-
esting field of investigation. There might be no ac-
tual poison derived from the body which gained en-
trance to the blood, but if the blood was changed in
its density or chemical composition, under the condi-
tions imposed by the external caloric agency, this was
nevertheless a form of auto-intoxication. Whatever
this change in the blood was, it certainly seemed to
take place quite suddenly. It would be interesting
to compare the blood as affected by snake venom with
the condition in sunstroke. In both affections the
clotting property of the blood post mortem seemed
impaired.
Dr. p. a. Levene briefly referred to the existing
theories of the mechanism of sunstroke. These were :
(i) The direct action of the temperature on the heart
and diaphragm, resulting in asphyxia; (2) direct local
active irritation of the skin, resulting in angioparesis,
which in its turn retarded the circulation; hence, ac-
cumulation of carbonic oxide and asphyxia; (3) high
perspiration, causing fall of the blood-pressure; (4)
paralysis of the heart produced by heat affected the
kidneys, and the disturbance of the function of the
kidneys was responsible for the symptoms of sun-
stroke; (s) the autotoxic theory. Nearly all the theo-
ries were speculative. The speaker referred to the
fact that in sunstroke there was a marked diminution
in the amount of urine secreted and a decrease in the
quantity of urea and other ingredients, the specific
gravity of the urine being lowered. This fact could
not be explained by an organic change in the kidneys
(as parenchymatous nephritis), as no albumin or casts
could be detected in the majority of urines analyzed.
There must be another cause for these changes in the
character of the urine secretion. Pfaff, of Harvard,
had recently demonstrated that defibrinated blood in-
fluenced the function of the kidneys in a similar man-
ner to that produced by sunstroke. This would sug-
gest that extreme heat produced changes in the blood
(as a result of the abnormal function of the skin or
other organs), similar to those produced by defibri-
nation, or probably even rendered the blood less coag-
ufeble than normally. The latter fact was observed
by some pathologists in cases of sunstroke. This
would be a corroboration of the autotoxic theory. An-
other explanation for some of the symptoms of sun-
stroke might be found in the concentration of the
blood. Under the old theory which attributed the
symptoms of sunstroke to concentration of the blood,
it was supposed that the blood became concentrated
to such a degree that the heart was unable to piopel
it. It was more probable that when the blood became
concentrated the proportion of salts was increased,
and there were a corresponding increase in the osmotic
pressure and a depression of the cells of the surround-
ing tissues. A condition similar to retraction of the
cells probably took place under these circumstances.
Dr. George M. Parker, who was a hospital interne
at the time of the epidemic of sunstroke in 1896, said
that the mortality of the cases under his observation
at that time was about sixty-six per cent., the deaths
occurring from twelve to thirty- six hours after the on-
set of the attack. The symptoms were those of an
1 136
MEDICAL RECORD.
[June 30, 1900
acute general poison. The temperature range was
a very wide one, in some cases going as high as 110°
and 112° F. Comparatively few cases of sunstroke
occurred until after the hot weather had lasted for
several days. In one case coming under his observa-
tion the attack was followed by motor aphasia, with
paresis of the lower extremity, which at the end of
three months had not entirely disappeared. He said
that the value of early treatment of sunstroke by means
of applications of ice or ice-water could not be over-
estimated. Those patients who received early atten-
tion usually recovered rapidly, whereas in those who
were neglected for a considerable length of time the
reduction of temperature was very slow. The treat-
ment consisted of applications of ice or ice-water, with
vigorous rubbing, and considerable stimulation.
Dr. Charles A. Whiting gave his experience with
sunstroke cases during the epidemic of i8g6. He
emphasized the statement made by Dr. Parker that the
cases were rare during the first two or three days of
the hot spell, and then began to multiply rapidly.
The patients usually became delirious when the tem-
perature rose above 106" F. As a stimulant, camphor,
given subcutaneously, seemed to be very efficacious.
SECTION ON SURGERY.
Stated Meeting, May 14, igoo.
■ Charles N. Dowd, M.D., Chairman.
Choledochotomy. — Dr. Howard Lilienthal pre-
sented a patient, about thirty-five years old, who w^as
admitted to the Mt. Sinai Hospital December 14,
1899. She first had jaundice six years ago after
childbirth. She was then well until three months
ago, when there developed epigastric pain, shooting
into the back, but not in the right side. There was
no colic, but severe intermittent pain. There was no
vomiting or distress after eating. The pain recurred
every five or six days. Constipation v^as present; the
stools were never clay-colored. About one month ago
jaundice occurred after an attack of pain. On admis-
sion the pulse was 92, respirations 24, and the tem-
perature 100.4° F- The urine was acid in reaction;
specific gravity, 1.024 ; otherwise negative. The liver
extended from the fifth interspace to a finger's breadth
below the border of the ribs in the mammary line; its
border was about horizontal. There was firm resist-
ance in the epigastrium, most noted under the upper
part of the right rectus. The patient was decidedly
jaundiced. On December 15th the temperature was
101.2° F. She had not much pain. On December
18th the urine contained bile, albumin, pus, and epi-
thelial, hyaline, and granular casts. The patient's
general condition seemed to be improving. On De-
cember i8th choledochotomy was done. The gall blad-
der was not tense. No stones were felt. The cystic
duct was apparently free. The common duct con-
tained a mass which, on incision, was found to consist
of eight or nine small faceted stones about the size of
hickory nuts. Before incision a purse-string suture
was made around the point of intended incision.
Twelve other stones were obtained from the common
duct by milking. A probe passed through into the
duodenum. The purse-string suture was then tight-
ened and was reinforced by a few' silk sutures. In
the upper part a short drain of gauze surrounded
by rubber tissue was carried straight down. After
the operation there were some vomiting and a mild
nephritis which subsided under appropriate treatment.
On December 24th the first dressing was changed.
The packing was taken out; there was no leakage.
The sinus was filled with iodoform i zed gauze through
an endoscope. On January 17th she was discharged,
and she has been practically well ever since.
Sarcoma of Dislocated Testicle. — Dr. James Pe-
DERSEN presented R. M , aged twenty-seven years.
When he was thirteen years old his left testicle was
driven through the inguinal ring to the internal ab-
dominal ring, if not entirely into the abdomen, by a
severe blow from a flying base-ball. The only imme-
diate effect was local pain on exertion, .\pparently
neither this nor the failure of the testicle to descend
again into the scrotum received any attention. He
did not even report the matter to his parents. Gradu-
ally a tumor formed in the left inguinal region, and
with its growth the local pain on exertion increased.
Then frequency of micturition developed. He al-
lowed the condition to take its course throughout the
intervening fourteen years until last January, when the
pain on exertion had become so great that he could
scarcely stand up. The patient's general condition
was now very poor; his anEcmia and his emaciation
combined with his dwarfish stature, presented a sorry
spectacle. Local examination showed an apparently
normal right testicle; the left half of the scrotum w-as
empty, the corresponding inguinal canal occluded; no
evidence of hernia was present. Occupying the left
inguinal region was a prominent, rounded tumor, which
sloped away toward the median line, but which filled
the hypogastrium also and encroached upon the right
inguinal region. The tumor could be felt per rectum.
on reaching high up. The diagnosis was sarcoma.
Operation was advised and accepted. After the pa-
tient had had a preliminary week of rest in bed, and
liberal diet and stimulation, the tumor was removed
February 3d, through the ordinary median incision.
The omentum was found adherent over a considerable
area of the upper surface of the growth; numerous ad-
hesions bound it to the surrounding structuras, and it
was tightly wedged in the pelvis between the bladder
and the rectum, to both of which it was adherent.
When the tumor had been shelled out of the pelvis
the pedicle was found springing from the region of
the left internal abdominal ring, and a secondary
growth was discovered, which from about the middle
of the primary extended upward behind the perito-
neum to, if not involving, the left kidney. The pa-
tient's condition making expedition necessary, the
pedicle had to be ligated 01 masse and the retroperi-
toneal growth, at its junction with the primary, was
ligated in two portions and cut. There was consider-
able hemorrhage from this point. After ascertaining
that the bladder had not been wounded, gauze drains
were inserted and the abdominal incision was closed.
The patient was in extreme shock at this stage, but
under active hypodermatic stimulation and the syste-
matic use of high enemata of hot saline solution with
coffee he recovered rapidly. Four hours after the
operation his pulse was good and his general condi-
tion surprisingly so. During the first four days the
rectal temperature ranged from 102.8° to 101° F., and
the pulse from 112 to 84. On the fifth day the tem-
perature began to rise. On the sixth day the dress-
ings were much soiled with a brownish fluid of fecal
odor. Two small drainage tubes were therefore sub-
stituted for the gauze wicks, and irrigations of the
sinus were instituted. After three or four days the
discharge became purulent and the fecal odor disap-
peared. On the seventh day the patient complained
of pain in the left inguinal region. Fxamination
showed a small tumor presenting in the region of the
internal abdominal ring. It had the physical charac-
ters of intestinal hernia, and as it was reducible with
a gurgling sound it was so regarded. It continued
to recur, however, in spite of well-directed attempts
to keep it back. Apparently as the result of the re-
peated manipulations, the tumor became inflamed, and
by evening of the following day it had increased con-
siderably in size and become irreducible. It was
June 30, 1900]
MEDICAL RECORD.
1137
boggy and no longer tympanitic; it now formed an
elongated mass, its lower extremity dipping into the
upper limit of the scrotal sac. There were no subjec-
tive symptoms of strangulation. An ice-bag was kept
applied. The following morning the patient com-
plained of increasing pain in the tumor region. The
irregular temperature had risen somewhat during the
night and there had been considerable sweating. An
abscess was, therfefore, suspected. Dr. De Garmo,
who kindly saw the patient in consultation, excluded
incarcerated intestinal hernia and made out a cyst
containing fluid (possibly pus). Acting upon his ad-
vice an exploratory puncture was made. The needle
entered a thick-walled sac and drew off about three
drachms of straw-colored serum. In the course of the
next twenty-four hours the cyst refilled and the site of
the suspected abscess became manifest by a slight
prominence of the inguinal region on the same side.
Under ether an incision was now made over the scro-
tal tumor and carried upward across Poupart's liga-
ment. From the former site an egg-shaped cyst, ap-
parently the remains of the former tunica vaginalis,
was easily enucleated. From the abscess cavity a
large quantity of very foul pus was evacuated. A
drainage tube was inserted and the wound closed.
From this point on the patient did perfectly well.
He was allowed to sit up three weeks after the first
operation. The sutured portions of both wounds
healed by primary union. Both sinuses were closed
by the end of the seventh week. Dr. F. C. Wood, to
whom the tumor was submitted for examination, re-
ported it to be a large round-celled sarcoma, devoid
of any remnant of testicle tissue. Dr. W. B. Coley,
who now kindly saw the patient for me with the view
of determining whether injections of the mixed toxins
of erysipelas and the bacillus prodigiosus should be
resorted to, found that the secondary growth was too
widely generalized. Equally, and for the same rea-
son, removal by operation of this growth was impos-
sible. As to the patient's condition at present, instead
of being scarcely able to stand up, he now goes about
with comparative comfort, and he has gained a little
in weight. Micturition is normal.
Abscess of Gall Bladder and Liver ; Gall Stone
in Common Bile Duct ; Kinking of Stomach from
Adhesions ; Gastric Ulcer ; Recovery by Choledec-
tomy and Gastro-Enterostomy. — Dr. Robert F.
Weir exhibited a woman aged thirty-five years, on
whom he had, in December last, for a distended and
pninful gall bladder, with temperature elevation and
chills, and paroxysmal vomiting, incised the abdomi-
nal wall and opened the gall bladder, which contained
some two or three ounces of pus, and which had ul-
cerated through on its posterior wall and had thus
invaded the liver tissue, in which there was found a
communicating abscess holding over an ounce of pus.
Nothing in the way of concretion was found in the
gall passages, nor were there jaundice or clay-colored
stools present. Many adhesions outside the gall-blad-
der were encountered. The gall-bladder was drained
by a retained tube through which bile flowed moder-
ately for a short time. Her attacks of vomiting soon
recurred and were associated with pain in the gastric
?nd hepatic regions. The stools were not clay-colored
nor was jaundice present. She re-entered the New
York Hospital April 2d, having lately had chills and
fever added to her symptoms. There was marked ten-
derness over the gall-bladder region, and it was thought
that this was distended. The incision was along the
outer edge of the rectus, which muscle was drawn to
the median line after section transversely of its ante-
rior sheath, and then later its posterior sheath was
secondarily divided. This gave a large exposure to
the parts. The adhesions of the omentum were slowly
released, and the gall bladder was found in good condi-
tion. As the parts were cleansed it was recognized that
a movable calculus was in the upper part of the common
duct. This was removed by incision and the wound
sewed up. Then a marked kinking of the stomach
near the pylorus by adhesions was found which was
unloosened, when palpation of the pylorus revealed
a sharply thickened mass the size and shape of half
an almond on its posterior wall running into the stom-
ach and clearly marking the site of an ulcer. This
was treated through the same wound (showing thus its
scope) by a posterior gastro-enterostomy combined
with entero-anastomosis by the Gallet method. The
patient made a rapid recovery. The buttons were
discharged on the ninth and thirteenth day respec-
tively. The gall stone was about the size of a bean.
Dr. Howard Lilienthal said that this subject was
very rapidly growing in interest, and that operations
were becoming more and more frequent. He wished
to rel^e an experience that he had this year with a
near relative of his, which showed how differently one
will act when such a condition is brought home to
you. An old lady about sixty years of age had a very
marked attack of cholecystitis which was evidently
complicated by gall stones. The fever was moderate
but the pain was extremely severe. The gall bladder
was palpable and the jaundice was quite deep, disap-
pearirig soon after the attack. He believed that tak-
ing into consideration the age of the patient and the
fact that, after all, a great many individuals have had
attacks of that sort and have gotten over them, con-
servatism was the right thing. This old lady recov-
ered. She might never have another attack. Until
he was convinced that there was what might be called
" clinical sepsis " which bade fair to become alarming,
he would be slow to urge operation upon the gall
bladder in old people. In patient^ of that age the
old-fashioned cholecystotomy with removal of the gall
stones, even perhaps leaving a fistula, he thought
would more surely conserve their lives than anything
else he knew of.
Dr. Charles A. Powers, of Denver, was in accord
with the remarks of Dr. Lilienthal relative to conser-
vatism, especially in older people. The differential
diagnosis between diseases of the gall bladder and
bile ducts had been a matter in which, on a number
of occasions, he had been absolutely unable to give a
positive opinion before operating. No less than three
times during the past year had he been in doubt as to
whether there was an acute inflammation of the gall
bladder or of the appendix. In each instance he made
a short incision midway between the two, and with the
finger swept the interior; in each instance the gall
bladder, and not the appendix, was aj: fault.
Sarcoma of Mesentery ; its Extirpation, with
Eight and One-Quarter Feet of Small Intestine ;
Peritonitis; Death.— Dr. Robert F. Weir showed
a specimen of a large sarcoma originally involving
the mesentery and subsequently invading the small
intestines, which had existed in a man forty years of
age, and had been recognized by him for about two
months. Prior to that time he had had frequent at
tacks of indigestion. From February 4th to the date
of his entrance to the New York Hospital, March 2d,
he had had continued pain in the lower abdomen,
in which a mass centrally situated was felt through the
abdominal walls, slightly movable but sensitive to
touch. It was larger than a cocoanut. A laparotomy
done on March 5th showed that it was, as previously
diagnosticated from the absence of intestinal obstruc-
tion or hemorrhage, of mesenteric origin, and that its
nature was, as expected, sarcomatous. It was dis-
lodged with but little effort from the pelvis, which it
well filled, being attached to the left side of the brim.
In raising up the tumor at the front the smnll intes-
tine, which was here largely involved, gave way and
II38
MEDICAL RECORD.
[June 30, 1900
allowed one or two tablespoonfuls of yellow mucus to
escape; though the opening was immediately plugged
and the peritoneum adjacent forthwith cleaned and
irrigated, Ihis infection had a large influence on the
subsequent progress of the case. The tumor being
raised above the skin level it was seen that a large
resection of the intestine would be necessary to remove
the mass. This was decided upon, as the patient's
condition was good. It was accordingly done, the
mesenteric vessels, when recognized, being duly
ciamped and ligated prior to division. When ablated
it was found that some seven feet and six inches had
been removed, but as some eight inches more of the
intestine demanded removal by reason of defective cir-
culation, a total of eight feet and two inches was taken
away. Instead of an end-to-end anastomosis a lateral
union by Murphy's button was resorted to, as it had
been shown in several cases that gangrene of the free
ends occurred. These ends were simply twisted and
duly seared. The patient succumbed to peritonitis at
the end of thirty-six hours, due, most probably, to the
infection incurred at the operation. It had been
shown that a greater length than this, in which the
lower end was about one foot from the ileo-caecal
valve, had been successfully removed. The longest
piece of bowel taken away was twelve feet, but this
patient did not survive. One other resection of eleven
feet was survived, and one year later the patient v^-as
in perfect health. It was believed that no more than
one-half the small intestine could be removed without
affecting nutrition. One should always leave as much
as one took away.
Differential Diagnosis in Diseases of the Biliary
Passages. — Dr. George E. Brewer read this paper
which will appear in a future issue.
Concerning the Peritoneum and the Treatment
of Diffuse Exudative Peritonitis. — Dr. A. A. Berg
read this paper (see page 1 113).
l^ctUcal Jtcttts.
Contagious Diseases — Weekly Statement — Report
of cases and deaths from contagious diseases reported
to the Sanitary Bureau, Health Department, for the
week ending June 23, 1900:
Tuberculosis
Typhoid fever
Scarlet fever
Measles
Diphtheria
Laryngeal diphtheria (croup)
Cerebro-spinal meningitis. . . .
Chicken-pox
Smallpox
18
107
9
S
304
14
257
S
0
30
3
6
19
0
4
I
Diagnosis of Incipient Forms of Pulmonary Tu-
berculosis.—Senator, of Berlin, says the best criteria
for an early diagnosis are as follows: "Analysis of
the sputum; inoculation of it into animals; reaction
to serum and to tuberculin; leucocytosis when it is
possible to eliminate all other causes capable of pro-
ducing it; auscultation and percussion when they re-
veal changes limited to the apex of the lung; different
degrees of expansion of the apices; the artificial ca-
tarrh induced by the use of potassium iodide; tuber-
culous lesions of other organs; previous pleurisies;
the habitus phthisicus; cough and sweating."- — British
Medical Jourual.
Women's Brains. — Mr. Alexander Sutherland
writes in Nineteenth Century for May upon " Woman's
Brains." Mr. Sutherland points out that as the re-
sult of recent investigations it is proved that the aver-
age man has from ten to twelve per cent, more brain
weight than the average woman, but in proportion to
the weight of her body woman has six per cent, more
brain than man has. Her average runs about fifty
ounces of brain for every pound of weight in her
body, while man in proportion to his body has only
forty-seven ounces. But, on the whole, he says that
"however or wherever we make the^inquiry,'' it is al-
ways seen that when men and women are of equal
height and weight the men have something like ten
per cent, more brain than women. The average brain
of a man of genius in only 9.3 per cent, more than that
of the ordinary individual. The average woman is to
the average man as the average man is to the man of
genius, if the weight of brains were to settle it. Lest
the average male should be inclined to vaunt himself
over his sisters, Mr. Sutherland tells him that even if
it were demonstrated that the average woman, because
she had ten per cent, less brain weight, had therefore
ten per cent, less intellectual capacity than the aver-
age man, it would have to be remembered that even
then ninety per cent, of the women are the equals of
ninety per cent, of the men, and this would seem to
imply that the average man has to recognize about
forty per cent, of the women as his superiors in intel-
lect.
Health Reports. — The following cases of smallpox,
yellow fever, cholera, and plague have been reported
to the surgeon-general of the United States Marine-
Hospital service during the week ended June 23,
1900 :
LPOX— Un
States.
Cases. Deaths.
District of Columbia, Wash-
ington June 9th to i6th 8
Illinois, Cairo 'lune 2d to 9th i'
Indiana. Evansville June 8th to i6th 1
Iowa, Ottumwa April 28th to May 5th i
Kentucky, Covington June 8th to 16th 9
Louisiana, New Orleans ....June Sth to i6th 35
Shreveport, ... June2dtOQth 5
Massachusetts, Fall River . .June Sth to 16th 3
Lowell lune 8th to i6th 3
Michigan, Grand Rapids... lune 8th to i6th 2
Minnesota, Minneapolis May 26th to June oth 26
N.Hampshire, Manchester. June Sth to i6th o
Ohio, Cleveland June Sth to i6th 28
Voungstown lune Sth to i6th i
Pennsylvania. Pittsburg "June Sth to i6th 2
Porto Rico, Ponce May 2;th to June 4th i
South Carolina, Clreenville. June Sth to 16th 2
Utah, Ogden May 1st to 31st 3
Salt Lake City June Sth to i6th 5
Washington, Spokane June Sth to i6th i
West Virginia, Charlestown. June 12th : 10
Smallpox— Foreign.
Austria, Prague May 28th to June 2d it
Belgium, Antwerp Mav iglh to 26th 1
Brazil, Rio de Janeiro April 13th to May nth
Canada, Province of Mon-
treal June 4th .
England, Liverpool May 26th to June 2d
) June 2d
30
^ , __ tolune2d
London May 26th t
e, Nice May 2sth to June 6th 3
Paris Vay 26th to June 2d
Germany, Stettin May 19th to 26th i
Gibraltar May 20th to 2Qth 4
Greece. Athens May 10th to 26th 4
India, Hombay May Sth to 15th
Kurrachee May 6th to 13th 11
Madras May sth to nth
Mexico, Chihuahua... lune 2d to 9th
Vera Cruz June 2d to 9th.
Philippines, Manila April 28th to May 5th 2
Russia, Moscow May 19th to 26th 9
Odessa May 26th to June 2d 11
St. Petersburg May igth to 26th 33
Warsaw May 12th to 19th
Spain, Corunna May 26th to June 2d
Madrid May 5th to 19th
Straits Settlements, Singa-
pore April 28th to May sth
Uruguay. Montevideo April 21st to May sth 3
Yellow Fever.
Brazil, Rio de Janeiro April 13th to May nth
Colombia, Barranquilla May 26th to June 2d 5
Cuba, Havana lune 2d to 9th
Mexico, Laguna June i6th Present.
VeraCruz June 2d to 9th 17
India, Bombay May Sth to 15th
Kurrachee May 6th to 13th 2
Madras May 5th to nth
Plague.
India, Bombay May Sth to 15th
Kurrachee May 6th to 13th 178
Japan, Osaka May 1 3th to 2Sth 6
Shidzuoka Mav 14th to 17th 3
Philippines. Manila April 28th to May sth 9
INDEX.
Abbe, Robert, spinal fracture in paraplegia,
353-
Abdomen, adhesions in the, 6oi ; diagnos-
tic signiHcance of acute exudations in
the, 158; distention of the, as an in-
dication for exploratory laparotomy in
intestinal obstruction. Si 7: foreign
bodies in the, after operation, 552 ;
general examination of the, when
opened during operation, 375 ; grave
lesions of, defying diagnosis, 2S5 ;
pistol wound of the, 112 ; sonorous-
ness of the, 121 ; technique of closure
of wounds of the, 461 ; treatment of
circumscribed abscess of the, 333 ;
treatment of viscera of the, through
the colon, 815,
Abdominal disorders in women, neuroses
depending upon, 1049; incisions,
methods of closing, S47 ; section, best
posture in bed after, S23 ; section,
post-operative treatment of, in women,
logS ; wounds, closure of, by means
of buried silver-wire net (healing in of
filigree pads) , 676.
Abrams, Albert, progressive pernicious an-
aemia and malignant disease of the
stomach, 71S.
Abscess, migratory, becoming autonomic,
888 ; perigastric and periduodenal,
694 ; subphrenic, 221.
Acetanilid, poisoning by, 552.
Acid intoxication, study of, 772.
Acidity, 113 ; relation of gastric and urin-
ary, I II 2.
Acne, treatment of, 731 ; vulgaris, etiology
and treatment of. 123
Aconite, poisoning with, 33.
Acromegaly, 33 ; a case of. 213, 214; with
symptoms of Raynaud's disease, 6g.
Acting assistant surgeons in the army, 561.
Actinomycosis, 645 ; a case of, lOoS ; in
man, 31, 763 ; in man in America, 336 ;
the organism and lesion of, S29.
Adams, William, death of, 327, 392.
Addison's disease, a family with, Sif) ; fol-
lowing typhoid fever, 1091 ; influence
of suprarenal preparations in, 160;
treatment of, 1104.
Adenoids, persistent, in a middle-aged
woman, logi.
Adiposis dolorosa, 856.
Adler, I., muscular rheumatism, 529.
Adnexa, danger of coitus in inflammation
of the, 70.
Adrenals, diagnosis of growths of the. 52S ;
lesions of the. i 53.
Advertising, medical, in religious journals.
190.
Agglutination in infectious diseases, 145 ;
in tuberculosis, logs ; mechanism of,
771-
Agglutins, influence of. in the infected or-
ganism, 25.
Ainhum, a case of, 647.
.Air, liquid, therapeutic value of. not.
.\ir passa^'es, catarrhal affections of the
upper, indications for constitutional
treatment of, 667; foreign bodies in
the. 198 ; peanut in the, 360.
.\ix-les-Bains, 163.
Albumin, formation of sugar from. 28 ; un-
importance of the presence of a trace
of, in otherwise healthy urine, 114.
Albuminuria, 2S5, 596; febrile, 119; in-
fluence of high altitude on, 886 ; path-
ogenesis of cyclic, 543.
Alcohol, case of unusual tolerance of the
organism for, 163 ; effect of, on the
brain, 887, 963 ; food value of, 596;
local application of, in gynaecology,
600; physiological effects of, 170; re-
lation of, to hard work, 8go ; thera-
peutic employment of. 157; therapeu-
tic employment of. in Europe, 66 ; use
of, in health and disease, 595; use of.
in relation to life insurance, 32 ; disin-
fection by, 1 131.
Alcoholism, digitalis in the treatment of
acute, 998 ; historical notes on the
sanatorium treatment of, 410; in the
United States army, 748.
Alexander, I.. S.. one result of attempted
abortion in the early weeks of gesta-
tion, 360.
Alexins, 511.
AUbutt. Thomas Clifford, notice of book
edited by, 930.
Allen, Charles W'arrenne, the inoculation
wound of lues, 445,
Allen, Horace P., death of, 32S.
AUyn, Alvin B., death of, 72(..
Alopecia areata, new treatment for, 1019.
Alpine Ambulance Association, 131.
Alter, Francis \V., a new nasal splint,
570.
Althaus. Julius, death of, 1128.
Altitudes, high, contraindications to, 3S0.
Altoona (Pa.) Academy of Medicine and
Surgery, officers of the, 62.
Aluminum acetate, disinfecting power of,
470.
Alveolar catarrh in children, 162.
Ambulance system in New York, needed
reforms in, 15, 130, iSg, 563 ; service
in Great Britain. 106.
Amenorrhcea, manganese citrate in, 27 ;
pathological, from other than consti-
tutional causes, 694.
American Academy of Medicine, 1014.
American Association of Genito-Urinary
Surgeons, 7S2, 870.
American Climatological Association, 827,
S75. 972.
American Dermatological Association, offi-
cers of the, 812.
American Gyn.-ecological Society, 775, 849.
American Institute of Homoeopathy, annu-
al meeting of the, 1087, 1127.
American l.aryngological Association, 781,
S67.
American Medical Association, 9S9, 1048,
logS ; general sessions, gSg, ggg,
1056; officers of the, 1000; president's
address, 9S9 ; section on materia med-
ica and therapeutics, 997, 1053, 1103 ;
section on obstetrics and diseases of
women, 994, 1048, 1065, xog8 ; sec-
tion on pediatrics, gg7, 105 1, logg;
section on practice of medicine, ggo,
1002, 1056 ; section on surgery and
anatomy, g92, 1003, 1060 ; the Medi-
cal Rkcoru report of the, 1037.
American Neurological Association, 77g,
S56.
American Orthopedic Association, io6g,
1105.
American Pediatric Society, 777. 858.
American Surgical Association, 774, S44.
American Therapeutic Society, organiza-
tion of the, S13.
Ammonia, excretion of, in the urine, 8S7.
Ammonio-formaldehyde, effects of. 872.
Amnesia, a case of, loig.
Amputation in childhood, conical stump
after, 6g3 ; osteoplasty in, 466 ; splint
for use after, 286.
Amyloid, colloid, and mucoid substances,
the chemical relationship of, 188, 304 ;
sections stained with iodine, mounting,
332.
Ansmia. dietetics of, 156; leucopenic,
769; pernicious, 830, nog; perni-
cious, a chronic infectious disease, 332,
677 ; pernicious, and malignant dis-
ease of the stomach", 71 S ; pernicious,
antistreptococcic serum in, 817; per-
nicious, condition of the blood in, 643 ;
pernicious, etiology, 65 ; pernicious,
red corpuscles not stained by methy-
lene blue in, 424 ; pernicious, with
yellow bone marrow in the epiphyses,
1095 ; secondary, simulating perni-
cious annemia, 25; splenic, 71, 764:
tropical, 248.
Anesthesia, amputation without, 72S ; by
a mixture of chloroform and ether.
204 ; by injection into the spinal ca-
nal, 246; chloroform and ether, 120;
elevation of the glottis during, gg3 ;
ether, from a medical standpoint, 1045 ;
ethylic- bromide, 765 ; ethyl chloride
preliminary to ether, g64 ; general. 32,
435 ; in cases in which a respiratory
impediment exists, H31; local, in ma-
jor Operations, 203 ; local, in the radi-
cal treatment of hernia, 161 ; nitrous
oxide and ether, 31, 627 ; nitrous ox-
ide and oxygen, an unprecedented case
of prolonged, 364 ; pathological find-
ings in a case of general and cutane-
ous. 732 ; Schleich's method of local,
55; ; study in, 5g6.
Ancesthetics, administration of, to children,
916; new apparatus for administering,
435. 524-
Anakbre, 248.
Anatomical specimens, how to send, by
mail, 823.
Aneurism, aortic, electrolysis for, 151 ; aor-
tic, tracheal diastolic shock in, 71 ; aor-
tic, treatment of, 126 ; electrolysis in
the treatment of aortic, 248 ; gelatin
injections in the treatment of, 197,
426, S32 ; innominate, 32; iodide treat-
ment of, 832; ligation of the right sub-
clavian for, 888; of the aorta, 655 ; of
the descending aorta, 554 ; of the in-
nominate artery, 380 ; of the renal ar-
tery, extirpation of the, 848 ; of the
subclavian artery, 241 ; syphilis of the
aorta as a cause of, 28 ; thoracic, 736 ;
thoracic, presenting through the ster-
num, 646 ; wire for introduction into
the sac of an, 31.
Aneurismal varix and injury to the median
nerve at the elbow, 732.
Angina, I.udwig's, 70 ; pectoris, at the
menopause, 512; pectoris, cases of,
331 : pectoris, erythrol tetranitrate in,
124 ; pectoris, self-help of the organ-
ism in, 3S0 ; pectoris, treatment of,
1 1 12 ; pectoris with endocarditis, 512 ;
rare varieties of phlegmonous, in in-
fants, 6S1 ; ulcero-membranous, 1044.
Angiotribe, e.xperience with the, 211, 687.
Angiotripsy, 515, 994.
Aniline colors, antitoxic nature of the, 695.
Ankle, dislocation at the, 361.
Ankylostomiasis in Puerto Rico, 686 ; in
the Leeward Islands, 1093.
Anosmia, complete, 203 ; congenital bilat-
eral, 69.
Anshutz, E. P., notice of book by, 1020.
Antenatal injuries, damages claimed for,
371-
Anthrax, 791 ; bacteriological investigation
of a case of, 68 ; human and bovine.
211 ; of the thigh, operation for, 643 ;
serum treatment of, 340 ; treatment of,
931-
Antifebrin, poisoning by, 552.
Antipyresis, 644.
Antisepsis, studies on internal, 374.
Antitoxic sera, elimination of deleterious
substances from, 843.
Antitoxins, genesis of, 923 ; sale of, by the
New York health board, 23g.
Antivenene, g6g.
Antivivisection, accusation by an advocate
of, 194 ; bill, 1036.
Antrum of Highmore, cancer of the, 302 ;
catarrh and suppuration of the, 463.
Anuria, transfusion of sahne fluid in. 114.
Anus, closure of rents implicating the
sphincter. 25 ; fissure of the, 599 ;
formation of an artificial. 661, 701 ,
imperforate, 200 ; treatment of chan-
croids of the, 959,
Aorta, atheroma of the, 33 ; radioscopic
appearance of the normal, Sgg.
Aortitis, 254; gonorrhoeal, 1044.
Aphakia, congenital, 764.
Aphasia, sensory, 145 ; will-making in.
643-
Apomorphine as a hypnotic, 508.
Apoplexy, uterine, 245.
Apostoli, Georges, death of, 895.
1 140
INDEX.
[June 30, 1900
Appendectomy, reprobation of normal,
592.
Appendicitis, 203. 844 ; association of
chironic, with disease of the right ad-
nexa, 948 ; cases of, 60S ; colitis as an
etiological factor of, 1004 ; complicated
with miscarriage, 638 ; early operation
in, 694, 727 ; floating kidney mistaken
for, 363 ; hjematemesis in, 2S9 ; hock-
ey-stick incision in, 329, 390 ; im-
proved operation for, 32S; in a hernial
sac, 66 ; in children, 1051 ; indications
for operation in, 600 ; in the course of
muco-membranous colitis, 424 ; leg
crossing an alleged cause of S7 ; liga-
tion of the stump in, 131 ; medical as-
pects of, 66 ; new method of entering
the abdominal cavity in operating for,
417 ; nomenclature of, 130: operation
for, 156; operation for, in 1S67, 430 ;
operation for, at two sittings. 44 ;
operations for, in young women and
girls, 1069 ; pathology and treatment
of, 243, 251 ; prognosis in, 332 ; results
of the so-called conservative treatment
of, 226, 259 ; some conditions simulat-
ing, 897, 934 ; statistics of the treatment
of, 89; treatment of, 33, 168, 2S6, 346,
37S, 383, 432, 463, 518 ; unusual condi-
tion of the skin and kidneys following
operation for, 1035 ; when shall we
operate for? S37; with gangrene and
rupture of appendix and cxcum. 66.
Appendicular colic. 376.
Appendix, abscess of the, rupturing into
the sac of a reducible inguinal her-
nia, 727 ; a tuberculous, 1009 ; foreign
body in the, simulating gall stone, 303 ;
inversion of the unc»t, 91.
Archives of Neurology from the Patholog-
ical Laboratory of the London County
Council, 166.
Arm, interscapulo-thoracic amputation of
the, 336, 374.
Armstrong, Lewis, death of, 22.
Army, acting assistant surgeons of the.
1125 ; bill to define the statu-; of act-
ing assistant surgeons of tl. ■, 194 ;
conscription in the British, 2?".
Arrow poison, 287.
Arrowsmith. Joseph E., death of, 64.
Arsenic, antidote to, 75 ; in the organs,
376 ; in the treatment of cancer, 744,
937 ; normal existence of, in animals,
29.
Arterial tensions in childhood, 277.
Arteries, changes in the, in the young, 72 ;
in the arms, rare anomalies of the,
246.
Arteriosclerosis, 462 ; a pronounced case
of, loio.
Arthritis, acute suppurative, in children,
240 ; etiology and treatment of ure-
thral, 117; deformans 1057 ; deformans
and polyarthritis chronica villosa,
422 ; deformans, electrical treatment
of, 597 ; deformans in childhood,
233, 470; gonorrhoeal, 693; mechani-
cal and traumatic, 925 ; treatment of,
165.
Ascites, chyliform, 244, 544, 730 ; chyli-
form, due to cancer, 11 32; chyliform,
in syphilitic cirrhosis of the liver, 29 ;
hemorrhagic. 113; milky, with leuco-
cytes of lymphatic origin, 466 ; opera-
tions for, 931; surgical treatment of
cirrhotic, 12S.
Ashmead, Albert S. , succus cinerarias mari-
time in cataract, 349.
Association of American Medical Colleges,
10S6.
Association of American Physicians, 772,
829, 843.
.Association of Military Surgeons of the
United States, 1015.
Asthenopia, causes of failure to relieve, 65.
Asthma. 1016; atropine for, 3S3 ; pathol-
ogy of bronchial, 887 ; suprarenal ex-
tract in, 4S2.
Astragalus, tuberculosis of the, 1071.
Ataxia, hereditary, 1090 ; permanent non-
progressive, 1044.
Athens, a children's hospital at, 1128.
Athetosis and kindred affections, 198.
Athletics in the public schools, 285.
Athrepsia infantum, lioi.
Atlee, Washington L., death of, III.
Atrophy, primary neurotic, 192.
Auditory canal, ceruminous and epithelial
impactions in the external, 107S.
Aural surger)', present state of, 332.
Auto-intoxication, 464 ; as a factor in ner-
vous diseases, 694.
.•Autopsies, earliest recorded, in America,
330.
B
Bacillus aerogenes capsulatus, infection by
the, 1042 ; encapsulated, in the nasal
mucosa, 160 ; pyocyaneus and its pig-
ments, 72; the plague, 174.
Backache as a symptom of rectal disorder,
766.
Bacteria, absorption of, by the lymphatic
ganglia, 695 ; adaptation of pathogenic,
to different species of animals, 770 ;
effect of liquid-air temperature upon,
766 ; influence of temperature on, 599 ;
peculiar property possessed by some
pathogenic, 842 ; struggle of the ani-
mal organism against, 815.
Bactericide, a new, 556.
Bacteriology, application of. to public
health. 242 ; relation of, to clinical
medicine, 771.
Bacteriuria. 426 ; associated with congeni-
tal dilatation of a ureter, S74.
Bahamas, climate of the, 472.
Bailey, Pearce, traumatic hemorrhages into
the spinal cord, 573.
Baginsky, Adolph, notice of book by, 122.
Baldwin, J. F., inversion of the uncut ap-
pendix, 91.
Balleray, G. H., early operations for can-
cer, 602.
Bandage, a new T-, 232.
Banti's disease complicated by splenic an.-e-
mia, 24.
Barbershop, hygiene of the, in Boston, 813 ;
menace of the, 190.
Barometric pressure, effects of increased.
igS.
Barry, William F. , gunshot wound of the
kidney, 500.
Bartholow, Roberts, notice of book by, 3S2.
Bartleson, S. P., death of, 154.
Barton, Amy S., death of, 551.
Basedow's disease, see Exophlhalmic goitre.
Basiotripsy, objections to, 645.
Bassini's operation for hernia, 240.
Bassler, Anthony, placenta prcevia and
twins, 965.
Batalpashinski, bitter lakes of, 376.
Bathing, hygienic effects of, 163; in typhoid
fever, 419.
Baths and exercises, treatment of cardiac
disease by, 255 ; public, 810, 928,
1133-
Beabes, George M., death of, 1089.
Beck, Carl, ligation of the stump in appen-
dicitis, 131.
Bedbugs as germ carriers. 747.
Beebe, Clarence Edwin, death of, 416.
Beef-worm in the orbit, 331.
Belcher, W. J., death of, 218.
Bell, George Huston, an operation for the
relief of an incarcerated iris, 321.
Belladonna, poisoning by, 554 ; poisoning
by the external use of, 68.
Benedict, A. L., the nomenclature of ap-
pendicitis, 130.
Bennett's fracture, 887.
Bennett, Thomas L. , new anaesthetic ap-
paratus, 524.
Benzoic acid, effectf of, upon the urine, 374.
Berg, .-K. A. , concerning the peritoneum
and the treatment of exudation peri-
tonitis, 1 113; hospital surgical service
conducted by a single chief, 746 ; re-
marks on subphrenic abscess, with a
report of three cases, 221.
Beriberi, clinical features of, 291 ; disap-
pearance of, from the Japanese navy,
891 ; in infants, 720 ; in the Australian
pearling fleet, 648.
Berks County ( Pa. ) Medical Society, oflfi-
cers of the, log.
Bernhard, Father, a predecessor of Kneipp,
288.
Beth Israel Hospital, laying the corner-
stone of the, 1014.
' ' Bibliographia Medica," a successor to the
Index Mcdicus, 459.
Bierhoff, Frederic, a new modified ure-
throtome, 659.
Bigelow, L S. , death of , 551.
Bile, abdominal extravasation of. 365 ; ac-
tion of salicylate of sodium on the se-
cretion of, 730.
Bile duct, surger)- of the, 25, 338 ; surgery
of the common, 461 ; traumatic rup-
ture of the, 336 ; tumors of the, 691.
Bilharzia hsematobia, 329, 733.
Biliousness induced by sea air, 204.
Biological examinations, a system of per-
sonal, 990.
Bird, John Stirling, death of, 686.
Birth, injuries about the shoulder at, 506.
Blackwater fever, histology and prevention
of, 113.
Bladder, exstrophy of the, 1062 ; exstrophy
of the, from ulcerative destruction of
the scar of a suprapubic cystotomy.
544 ; extra-peritoneal rupture of the,
523 ; injuries of the, occurring in the
course of gynaecological operations,
961 ; mensuration and capacity of the
female, 204 ; operative relief of ecto-
pic, 31 ; stone in the, relative merits
of operations for the extraction of,
357 ; surgical asepsis of the, 1062 ;
traumatic intra-peritoneal rupture of
the, 160 ; treatment of exstrophy of
the, 923 ; tumors of the, 732 ; washing
the, 1076.
Blind, tactile sensibility of the, 557.
Blindness in Finland, 41 ; mirror test for
simu4ated, 475 ; transient, in hysteria,
692.
Blister, painless, 165.
Blood, alkalinity of the, in certain patho-
logical conditions, 470 ; basophilic
granules in the red corpuscles of the,
423 ; changes in, at high altitudes,
973; changes in the, in disease, 791,
1021 ; diseases of the, in children, 378 ;
diseases of the, in relation to surgery,
1016 ; granular degeneration of the
red cells, 512 ; pathology of the, 1019 ;
value of examinations of the, 991.
Blood cells, counting, 433.
Blood-letting vs. leeches, 747.
Blood poisoning, an unusual case of, 27
Blood pressure in health, 769 ; in neuro-
pathic children, 1018.
Blood-vessels and lymphatics, relations be-
tween, 722.
Blue-blindness in contracted kidney, 201.
Board of charities of the State of New
York, 413.
Boards of health, fifteenth annual confer-
ence of State and provincial, 956.
Boer war, medical matters in the, 59, 62,
106, 147, 149, 166, 195, 216, 236, 250,
295. 326, 344.349. 391. 394, 414.415,
419, 427, 458, 459- 471, 504. 516. 560,
602, 649, 697, 747, 7S9, 810, 820, 919,
926, 927, 693, 1023, 1045, 1047, 1127.
Bogardus, H. J., a simple and efficient
rubber splint-shoe, 571.
Bogert, S. S., food poisoning, 195.
Bolton, Percival K., round ulcer of the
duodenum, 494, 522.
Bones, endothelioma of, 202.
Bonynge. Francis C>. , death of, 22.
Book Notices :
Accouchements obstetriques, la pratique
des, par H. Variner, 824.
An.i;mia and some of the diseases of the
blood-forming organs and ductless
glands, by B. Bramwell, 566.
Anaesthesia, general and local, bv A. P:
Heineck, 734.
Anatomic clinique des centres nerveux,
par Dr. Grasset, 1021.
Appendicite, formes et traitement, par
A. Broca, 734.
Bacteria as related to the economy of
nature, etc., by G. Newman, 382.
Bacteriology in medicine and surgery, by
W. H. Park, 653.
June 30, 1900]
INDEX.
1 141
Book Notices :
Bee-hive therapia and repertory, by S.
Jones, 381.
Brain, anatomy of tlie, by R. W. Wliite-
iiead, 102 1,
liraithwaite's Retrospect, vol. iiy, 3S1 ;
vol. 120, 735.
Cliemistry, essentials of medical, by L.
Wolff, 824.
Cfiildren, acid and alkaline, by T. C.
Duncan, 653.
Children, diseases of, by G. M. Tuttle,
381.
Christian science, bv \\ . H. Purrington,
653.
Clinical Society's Transactions, vol.
xx.xii., 3S2.
Consumption and chronic disease, a hy-
gienic cure at the patient's home,
by E. Densmore, 566.
Deaver's surgical anatomy. 122.
Dermatohistologische Technik, von M.
Joseph und G. Loevvenbach, 520.
Diabete et son traitement, par R. Lepine,
520.
Diabetes meilitus, iiber Gangriin bei, von
F. Grossmann, 929.
Diagnosis, practical treatise on medical,
by J. H. Musser, 566.
Dispensatory of the United States, i8th
edition, 565.
Embryology of invertebrates, text-book
of the, by E. Karschelt, 929.
Embryology, text-book of. by J. C. Ileis-
ler, 929.
Exercise, healthy, by K. II. Greene, 930.
Experiments on animals, bv Stephen
Paget, S2S.
Eye, compend of diseases of the, by G.
M. Gould and \V. L. I'yle, G53.
Eye, manual of the diagnosis and treat-
ment of diseases of the, by E. Jack-
son, 824.
Eye, system of diseases of the, edited by
W. F. Norris and C. A. Oliver, 734.
Figures, logic of, by T. I,. ISradford, 3S1.
Foie, chirurgie du, et des voies biliaires,
par J. Pantaloni, 566.
Gases, liquefaction of, by W. L. Hardin,
929.
Gastric methods, manual of modern, by
A. L. Gillespie, 520.
Grossesse, les autointoxications de la,
par G. B. de Saint Blaise, 520.
Gynecologie operatoire, etudes de, par
Dr. I'hocas. 520.
Helen Keller souvenir, 1020.
Helmholtz, life of, by J. G. McKen-
drick, 653.
Hygiene, manuel pratique d', par le Dr.
Guiraud, 734.
Imperative surgery, by II. I.ilienthal,
734-
Indigestion, by J. H. Clarke, 1020.
International clinics, edited by J. Da-
land, 566.
Kinderkrankheiten, Lehrbuch der, von
A. Baginsky, 122.
Letter-, word-, and mind-blindness, by
J. Hinshehvood, 930.
Living, cost of, as modified by sanitary
science, by E. M. Richards, 566.
Loveliness, by E. S. Phelps. 929.
Lute and lays, by C. S. Weller, 735.
Massachusetts, report of the Volunteer
Aid Association of, 520.
Massachusetts, thirtieth annual report
of the State board of health of, 381.
Materia medica and therapeutics, by G.
Mitchell Bruce, 653.
Materia medica and therapeutics, practi-
cal treatise on, by R. Bartholow, 382.
Materia medica, therapeutics, and
pharmacology, a text-book of, bv
G. F. Butler, 38 1.
Medical News visiting list, 3S2.
Medicine, a system of, edited by T. C.
Allbutt, 930.
Medicine, manual of the practice of, bv
A. A. Stevens, 735.
Mentally deficient children, by G. E.
Shuttleworth, S24.
Midwifery, practical text-book of, by R.
Jardine, 92S.
Book Notices :
Mt. Sinai Hospital reports, 3S1. 1020.
Nervous system of the child, by F.
Warner, 653.
Nervous system, treatment of diseases
of the. by J. Collins, 5(15.
Neurasthenia, clinical lectures on, by
T. D. SaviU. 382.
Nordrach at home, by J. J. S. Lucas,
Nurses, handbook for, by J. K. ^^'atson,
I02U.
Obsessions, contribution a I'etude des,
par G. Carrier, 566.
Obstipation, by T. C. Martin, 382.
Operations-Vademecum fiir den prak-
tischen Arzt. von E. Leser. 736.
Opium, use of, inChina, by W. II. Park,
520.
Optics, handbook of, by W. N. Suter,
520.
Orthopedic surgery, treatise on, by E.
II. Bradford and R. W. Lovett, 567.
Pathological Society of Philadelphia, pro-
ceedings of the, 1020.
Plea for a simpler life, and fads of an old
physician, by G. I. Keith, 1020.
Practice of medicine, by G. E. Malsbary,
3S1.
Progressive medicine, vol. iv. , edited by
H. A. Hare, 736.
Prostate, enlargement of the, by C. M.
MouUin, 520.
Rebel surgeon, recollections of a, by F.
E. Daniel, 566.
Rectum, chirurgie du, par E. (Jucnu et
H. Hartmann. 566.
Refraction and how to refract, by J.
Thorington, 823.
Remedies and diseases, synoptical index
toi 735 I new, old, and forgotten,
1020.
.Sexual organs of men. treatise on, by B.
(_;. Carleton, 735.
Skin-cancer, treatment of, by W. S. Gott-
heil, 122.
Skin diseases, by M. E. Douglass, 1020.
Skin, practical treatise on diseases of the,
by J. N. Hyde and F. II. Mont-
gomery, 735.
Stomach, diseases of the, by J. C. Hem-
meter, 1020.
Surgery, a treatise on, by American au-
thors, edited by Roswell I'ark, 824.
Surgery, international text-book of, ed-
ited by J. C. Warren and A. P.
Gould, 735, 1020.
.Surgery, lectures on the principles of, by
C. B, Nancrede, 122.
.Surgery, manual of, by C. Stonham, 735.
Surgery, operative, by J. D. Bryant,
736.
Surgical treatment, manual of, by W.
Watson Cheyne and I'". F. Burg-
hard, 92S.
Syphilis, cure prompte et radicale de la,
par J. F. Larrien, 520.
Therapeutics, digest of external, by E.
G. Rankin, 1020.
Thorax, essentials of physical diagnosis
of the, by A. M. Corwin, 929.
Trained nurses' directory, by M. Louise
Longeway, 653.
Transactions of the American Gynceco-
logical Society, vol. xxiv., 122.
Transactions of the American Laryngo-
logical Association, X02o.
Transactions of the Association of Amer-
ican Physicians, vol. xiv., 122.
Transactions of the British Orthopedic
Society, S23.
Transactions of the Medical .Society of
the State of California, 381.
Transactions of the Medical Society of
the State of Missouri. 520.
Transactions of the Medical Society of
the State of North Carolina, 3S1.
Transactions of the Medical .Society of
the .State of West Virginia, 3S1.
Transactions of the Vermont State Medi-
cal Society, 381.
Treatment, principles of, and their ap-
plication in practical medicine, by
J. Mitchell Bruce. 930.
Book Notices :
Tuberculose est curable, par P.. kibard,
520.
Tumors, lectures on, by J. B. Hamilton.
122.
Typhoid fever, leaders in, by E. B.
Nash. 930.
Urine, and clinical chemistry of the gas-
tric contents, the common poisons,
and milk, by J. W. Holland, 929.
Vagina and perineum, and how to mend
them, by B. Robinson, 735.
Warner's pocket medical dictionary of
today, 3S2.
Women, diseases of, by E. C. Dudley.
930-
Women, diseases of, by C. B. Penrose,
823.
Wounds, modern treatment of, by J. E.
Summers, Jr. , 734.
Booth, M. A., death of, 196.
Boric acid in preserved foods, alleged dan-
ger from, 114 ; poisoning by, 3S3.
Botryomycosis, 466, 516.
Boughner, A. L., death of, 154.
Bovine tuberculosis, significance of, 322.
Bowen, F. J., a case of Raynaud's disease,
824.
Brachial plexus, secondary suture of the.
887.
Bradford, Edward H., notice of book by.
567.
Bradford, Frank Standish, death of, 2S3.
Bradford, Thomas Lindsley, notice of book
by, 381.
Bradshaw lecture, 166.
Bradycardia, 2S5, 739: a case of, iiio;
with intermittent albuminuria, 597.
Brain, bullet Wound of the, 933 ; concus-
sion of the, 164 ; cyst of the, 727; diag-
nosis of a case of tumor of the, 241 ;
echinococcus of the, complicated by
hemiatrophy of the face, 695; effect of
alcohol on the, 963; fibrosarcoma of
the, 72; gunshot wound of the, 307;.
intestinal bacterial poison in the, 515 ;
post-otitic abscess of the, 861 ; surgery
of the, 270 ; topical diagnosis of dis-
ease of the, 599 ; topographical rela-
tions of the, to the skull, 421 ; tumor
of the, 39, 460; tumor of the, recovery
from, 197 ; tumor of the, simulating
niyxccdema, 200; tumor of the supe-
rior parietal lobule, 780 ; tumor of the,
with psycho-paralytic symptoms, 516.
Braithwaite, James, notice of book edited
by, 381.
Bramwell, Byrom, notice of book by, 566.
Brass, poisoning by, 1043.
Breach of trust, a peculiar case of, log.
Breakspear, Almira L. Fowler, death of, 23.
Breast, cancer of the, 510, 567, 598, 640,
931 ; cysts of the, 817, 926 ; epitheli-
oma of both, 770 ; osteocarcinoma of
the, looS; tumor of the areola, 733.
Bright's disease, skin affections in. 604.
Brinton professorship of American archae-
ology and ethnology, 635.
Broad ligament, fibrosarcoma of the, 205.
Broca, A. , notice of book by, 734.
Brodhurst, Bernard, death of, 350.
Bromide, sleepi produced by, 420.
Bromoform syrup, 165.
Bronchi, primary epithelioma of the, 335.
Bronchitis, pathology of chronic fibrinous,
962; senile, 76S; treatment of, 75, 165.
Bronchocele, symptoms and operative treat-
ment of, in relation to Graves' disease.
Broncho-pneumonia, acute tuberculous,
3S8 ; treatment of, in children, 75.
Bronchoscopy in pulmonary carcinoma,
1018.
Bronchus, foreign body in the, for ten
weeks,- 643.
Bronson, Charles IL, death of, 7S9.
Brothers, Abram, gynjecology and gynce-
cologists in Europe, gS.
Brown, Goodwin, priority in the public-
bath question, 92S.
Brown, Thomas R., cystitis due to the ty-
phoid bacillus introduced on a catheter
in a patient not having typhoid fever,
405.
II42
INDEX.
[June 30, 1900
Bruce. J. Mitchell, notice of book by, 653,
930.
Brushes, sterilization of, 512.
Bryant, Joseph D., notice of book by, 736.
Buboes, painless opening of, 321.
Buckley, Daniel J., death of, 551.
Bull, Charles Stedman, the significance of
intraocular hemorrhage as to prognosis
of life. 177, 215.
Bullard, W. Duff, acquired non-malignant
stricture of the rectum ; causes, symp-
toms, and treatment, 47, 81.
Bullard, William E., the climate of Nassau,
N. P., 472.
Bullets in modern warfare, 14 ; in the pop-
liteal space, .r-ray diagnosis of, 67 ;
split in half by the humerus. 277.
Bullitt, James B., cystic tumors of the
testis and epididymis, 943.
Bullous eruption, fatal cases of congenital,
in an infant. S42 ; of undetermined
nature, 103.
Buntine, R. -\. , bravery of. in battle, 306.
Burgess, O. O. , hypodermoclysis in ty-
phoid fever. 362.
Burghard, F. F.. notice of book by, 92S.
Burial alive, 633 ; premature, rectification
of, 7S, 149.
Burlington County (N. J.) Medical So-
ciety, officers of, 1 54.
Burns, application to, 128 ; causes of
death by, 334.
Burt, .Stephen Smith, thoracic aneurism :
two cases involving the descending
arch of the aorta; with an autopsy,
736.
Butler, George Frank, notice of book by,
3S1.
Cacodylic acid in tuberculosis, 466.
Crecum, adenocarcinoma of the, 245 ; and
small intestine, successful double re-
section of the, 125 ; excision of the.
610; treatment of sliding hernia of
the. 309, 343.
Ccesarean section, 69, 464, 532 ; indications
for, 292 ; indications for, compared
with symphyseotomy, craniotomy, and
premature artificial delivery, 70 ; in the
moribund, 543.
Cajeput oil, inhalation of, 331.
Calculi, diagnosis of renal, ureteral, and
vesical by the .v-rays, 1062; renal, 507;
renal, glycerin in, 203 : salivary-, 417,
46;; ureteral, 41S ; ureteral and renal,
positive and negative diagnosis of, by
the Roentgen rays, 336 ; urethral, 119 :
urinary, 201 ; vesical, high operation
for. 513 : vesical, in Sierra Leone. 332;
vesical, relative merits of operations for
the extraction of, 357.
Callison, Adolph, death of, 506.
Calomel, capillary emboli following injec-
tions of, 116.
Camac, William, death of, 63S.
Camden (N. J.) District Medical .Society,
officers of the. 20, 8g6.
Camphor as a mouth wash, 69S.
Cancer, arsenic in, 744, 937 ; circumscribed
gastric, 464 ; criticism of the mechan-
ical theory of the origin of, 200 ; cure
of, 420 ; development of, in the lym-
phatic glands, 695 ; early operations
for, 604; etiology of, 212,341; experi-
mental production of, 306; gastric, 479,
774; gastric, diagnosis of, S45; gastric,
gastrectomy for, 467 ; gastric, in the
young, 728; gastric, lymphatic involve-
ment in, 928 ; gastric, study of the
blood in, 924 ; incidence of, 564 ; in-
crease of, in Great Britain, 307 ; in-
creasing prevalence of. in America, 337;
in early life, 960; intestinal, 4S0 ; lar-
yngeal. 47S, S67; meat-eating as a cause
of. SS; nectrianin in, 676; occurring in
acid parts of the body, 765 ; of both
breasts, 770; of the breast, 567. 59S.
O40, 6S9, 931 ; of the breast, results of
operation in, 765 ; of the large intes-
tine, 376. 463 ; of the lip, spontaneous
disappearance of, S4S; of the cesopha-
gus, treatment of the, 277; of the pan-
creas, history of, 1 1 5 ; of the prostate.
S73; of the skin, S64 ; operation for.
521; operations for, in the aged, 1042 ;
parasitology of, 426; pathological anat-
omy of gastric, 770; prevention of,
564 ; radical cure of, by arsenic, 937 ;
rapidly recurring, 700 ; study of, 236 ;
study of, at Harvard. 61 ; treatment of,
535 ; treatment of, by cataphoric ster-
ilization, 5S7 ; treatment of inoperable,
480 ; treatment of, without operation,
426 ; uterine, 56S. 1065; uterine, early
diagnosis of, 115 ; uterine, operation in,
1 1 34; vaginal, 775 ; parasitic nature of,
1130.
Cantrell, William A., death of, iii.
Cantwell, F. V^. , six nephrectomies, 451.
Cape May (N. J. ) Medical .Society, 1015.
Carbolic acid, poisoning by, 96; vinegar
as an antidote to, 370.
Carbon dioxide, simple method of applying,
334.
Carbonic-acid baths, contraindications to,
383 ; elimination of, after repeated
cold baths, 2S8 ; gas, therapeutic
application of, 113.
Carbonic oxide in tobacco smoke, 162;
chronic poisoning by, 641.
Carleton, Bukk G., notice of book by,
735-
Carotid artery, ligation of, for varix of
the orbit. 46S ; traumatic aneurism of
the, caused by a sewing-needle, 703.
Carpenter, Charles Raymond, splenic ex-
tract and the splenic function, 273.
Carpenter. Henr)' B. , death of, 551.
Carrier. tJeorges, notice of book by, 566.
Carter, H. W., nitrous oxide and ether
anaesthesia, 627.
Casein, absorption of . 159 ; ferments, path-
ogenic action of the, 69 ; pancreatic
digestion of, 77S.
Cassidy. Patrick, report of a severe .v-ray
injury, iSo.
Castor-oil seeds, poisoning by, 332.
Casts, urinary, 201.
Cataract, cineraria maritima in, 165, 349 ;
origin of so-called acute, 466 ; pathol-
ogy and treatment of lamellar, 511 ;
secondary or membranous, 161 ; spon-
taneous disappearance of senile, 50S.
Catarrh of the upper air passages, indica-
tions for constitutional treatment of,
667.
Catelectrolysis in the treatment of skin
diseases, 112.
Catgut, new method of sterilizing, 701, 760;
the question of, 767.
Catheterism. aseptic, 65.
Catheters, saponic lubricant for. 474.
Cauda equina, tumor pressing upon, 7, 40.
Cavalry, wounded, removal and transport
of, 243.
Cellular specificity and its bearings on neo-
plasms, 910.
Celluloid thread, surgical use of, 463.
Cerebellum, tumor of the, with drainage of
fluid through the nose. 597.
Cerebral hemorrhage, strychnine as a factor
in the causation of, 817.
Cerebrospinal fluid, escape of, from the
ear after injury, 87.
Cerebrospinal meningitis, bacteriological
study ot, 1 1 23; etiology of, 15S.
Cervix uteri, metallic dilatation of the, 120.
Chalicosis pulmonum, H2.
Chambers, G. R., death of, 1041.
Chancre, extragenital, 103 ; of the lip in a
child seven months old, 417.
Chancroids of the anus, treatment of, 959.
Chapin, Henry D., how the milk supply of
New York may be improved, 230, 255 ;
the effect of summer heat upon public
health. 984, 1007.
Cheloid of the lobe of the ear, 653.
Chest, bullet wound of the, 420 ; control
of hemorrhage in wounds of the, 6S7.
Cheyne-Stokes respiration, ocular phe-
nomena associated with. 421.
Cheyne, W. Watson, notice of book, by 928.
Chicago, drainage canal of, 198.
Chickenpox and smallpox, 150; nephritis
in, 1034.
Children, examination of sick, 29, 68.
Chiropodists, contesting, 325.
Chisel in the naso-pharyn.x, .r-ray diagnosis
of. 67.
Chloral, poisoning by, 412.
Chloretone, hypnotic effects of, 248 ; surgi-
cal uses of, 37S.
Chloroform, administration of. 435 ; dan-
ger of administering, in the presence
of a gas-flame, 160; deaths under,
243 ; dosage of, in producing anaes-
thesia, 6S8.
Chlorosis, retinal complications in, 290 ;
treatment of, 75
Cholecystectomy for gallstones, 977 ; re-
moval of the raucous membrane of the
gall bladder as a substitute for, 993.
Cholecystitis, jaundice, and gall stones, re-
lationship between, 692.
Cholecystotomy, cases of, 240 ; with water-
proof drainage of the gall bladder, 28.
Choledochotomy. I136.
Cholelithiasis, see Gall Stones.
Cholera in India, 7S7, S95, 920.
Chorea and poiyclonia, 30 ; and taenia,
343; arsenic in the treatment of, 331,
375 ; as a pyogenic disease, 1126; eti-
ology of 374 ; influence of fever on,
115; lumbar puncture in, 792; psychi-
cal disturbances in degenerative, 557:
relation of, to rheumatism. 1057 ; rheu-
niatica, pyogenic origin of, 729; study
of 112 cases of, 556.
Chorion epithelium and decidua in tubal
gestation, 446.
Choroid, ossification of the, 544.
Christian science and psychiatry. 779; ra-
tional therapeutics versus, 213.
Chyluria, a case of, 741; nostras, 293.
Cigarettes, composition of, 17; effect of,
146.
Cinematograph in teaching surgery, 115.
Circumcision, 605, 1102.
Cirrhosis of the liver, 643, 644, 689, 728,
926; alcoholic, in a baby, 35; multi-
lobular, 15S; preascitic stage of , 163.
Clarke. John H.. notice of book by, 1020.
Clavicles, fracture of both, 157, 243, 421;
treatment of fractures of the. 426.
Clear}', John Clark, death of, iii.
Climacteric hemorrhages, causes of, 730.
Club-foot, astragalectomy for, 28S ; double,
from neuritis, 73 ; tendon-transplanta-
tion for, 1071 ; treatment of calcaneus,
1069.
Cocaine, epileptiform convulsions following
the intranasal application of. 499; poi-
soning by, 600.
Codeine for cough, 3S3.
Code of ethics, value of the, 240.
Cod-liver oil, addition of iodine and phos-
phorus to, 1 103.
Coeliotomy, angiotribe in vaginal, 994.
Cold, effect of extreme, on injuries, 33 ; ef-
fect of, on microbes, 238 ; hardening
to the action of, 287.
Colds, cause, prevention, and treatment,
462, 923.
Colectomy, two cases of, 286.
Colic, appendicular, 376; hepatic, treat-
ment of, 384.
Colitis, anni;bic, 434 ; chronic, 434 ; mem-
branous, 433 ; muco-membranous, 424;
mucous. 433 ; scorbutic membranous,
73'
College of Physicians of Philadelphia, 61,
150, 281,458, 503,636, 683, 725, 813,
920 ; section on general medicine, i S
368.
Colles' fracture, malpractice suit following,
290 ; the cardinal pathognomonic sign
of, 540-
Collins, Charles S. , death of. 922.
Collins, Joseph, notice of book by, 565.
Collodion, styptic, 75.
Colloid, mucoid, and amyloid substances,
the chemical relationship of, 188, 304.
Collum, Robert, death of, 252.
Colon, cancer of the ascending, 157; dila-
tation of the, 557 ; fatty tumor of the,
loiS ; hypertrophy and dilatation of,
in an infant. 720 ; irrigation of Lht
1 104 \ sarcoma of the, 1064.
Colored light , effect of, on the nervous sys.
tem, 263.
June 30, 1900J
INDEX.
1 143
Colostomy, iliac, by double ligature, 426 ;
for permanent fecal fistula, 1003.
C'olotomy. a modified inguinal. 4ig.
Columbia University, endowment of the
chair of psychology at, 62.
Coma, diabetic, 560 ; diabetic, preventive
treatment of, 3S3 ; diabetic, treatment
of. ggS.
Common sense in practical medicine, 246.
Compensatory processes in disease, 278.
Congress of American Physicians and Sur-
geons, 770, 826.
Conjunctivitis, bath epidemic of. i5g;diplo-
bacillary, of Morax, 145; membranous,
diphtheria antitcxin in, 68 ; treatment
of, 14.
Conklin, George H., death of, 686.
Constantinople, letter from, 743.
Constipation, beef-gall enemata in post-
operative, 289 ; surgical aspects of,
113; treatment of, in childhood, 287 ;
treatment of obstinate, based upon
new points in the anatomy and histol-
ogy of the rectum and colon. 1004.
Consumption, contagiousness of pulmo-
nary, 808 ; open-air treatment of, at
home, igg.
Consumptives, care of poor, 955 ; city hos-
pital for, 78S ; isolation of, Sgi ; sana-
toria for, 116, 7g2 ; sanatoria for, in
New Vork State, 194 ; small cottage
sanatoria for, S75 ; State care of, 34,
82, 208 ; State hospital for, 6S2, 683 ;
systematic treatment of poor, 814.
Contagious diseases in New York, weekly
statement, 175, 440, 1138.
Convalescence, dietetics of, gg5.
Convulsions in childhood, 244.
Cook, J. Elmer, death of, iii.
Cooper, John, death of, 594.
Cornea, affections of the. 118 ; corpuscular
activity in the, 329 ; electrocautery in
affections of the. 373 ; influence of new
antiseptics on infected wounds of the,
334-
Corns, treatment of. 3S4.
Corpus luteum, an enormous, 60S.
Corrosive sublimate, poisoning by, 157.
Corwin, Arthur .M. , notice of book by, 929.
Cory, Robert, death of, 604.
Coryza, treatment of, 572.
Cotton-seed oil as food, 305.
Cotton, W. G., odor records, 394.
Coues, Elliott, death of, 22.
Cough, codeine for. 383; treatment of, 384.
Cowperitis, traumatic bilateral, 1043.
Cow's milk, inaccuracies of home modifica-
tion of, 597.
Cox. Edwin Marion, comparative statistics
in the treatment of appendicitis, 8g.
Coxa vara, 765.
Craig Colony for epileptics, 680 ; board of
consulting physicians and surgeons,
no.
Crane, John Joseph, death of, 726.
Creamer, Joseph M,. death of, 373.
Creighton, Sarah Robinson, the relative in-
tensity of the second sounds at the base
of the heart ; a study of one thousand
cases, 45, 77.
Cremation in the United States, 1024.
Creolin, poisoning by, 156.
Creosotal, 384.
Cresoline, poisoning by. 863.
Cretinism, 646 ; and mongolism, differen-
tial diagnosis of, in infancy, 114 ; thy-
roid extract in, log2.
Criie, George \V., observations on the sur-
gery of the brain, based on clinical and
experimental evidence, 270.
Criticism in medicine, 1041.
Croup, membranous, and diphtheria, non-
identity of, 345.
Crudeli. Tommaso, death of, 112S.
Cuba, crowded professions in, 456 ; profes-
sional men in, 149 ; public health in,
955. 957; scientific preferment in, 367.
Cuban Medical Congress, executive com-
mittee of the second, no.
Cubebs oil, inhalation of, 331,
Cumberland County (Pa.) Medical Asso-
ciation, officers of the, log.
Cummisky, James, death of, 595.
Cunnion, Robert F,, death of, 686.
Curette, a new. 571.
Cycloplegia, value of, in optometric exam-
ination, 2S4.
Cystinuria in relation to diaminuria, 71.
Cystitis, 924 ; caused by the bacillus pyo-
cyaneus, gSS ; due to the introduction
of typhoid bacilli on a catheter, 405 ;
etiology, diagnosis, and treatment of,
36; etiology of infectious, 121 ; papil-
lomatosa, 960 ; treatment of, 14, 128.
Cystoscope, ureter, 87 1.
Cystotomy, technique of suprapubic, 5 15.
D
Dairy farm, a model. 394.
Daland, Judson, notice of work edited by,
566.
Daniel. F. E., notice of book by, 566.
Davis, Charles E., health conditions in the
Hawaiian Islands, 946.
Davis-Colley, Mr., death of, 963.
Davis, Edward P.. post-partum hemor-
rhage, its prevention and treatment,
with the report of an unusual case, 53.
Day-terrors. 2S6.
Dayton, Hughes, treatment of rheumatism
at the New York Hospital, 5S5, 605.
Deaf-mutism and consanguineous mar-
riage, 332.
Deafness, hysterical, iog2 ; influence of
heredity on, 337 ; in leukfemia. 67S ;
physical determination of unilateral,
245 ; psychical, 729 ; thyroid treat-
ment of, 377.
Death certificates, twenty-four years of, in
genc-al practice, 926; sudden, from
heart failure. 741.
Deaver, John B., notice of book by, 122.
Decubitus, clinical significance of, 1035.
Delatour. H. Beeckman, gastrectomy for
adeno-carcinoma, reco\'ery, 1 79.
Delaware County (Pa.) Medical Society,
957; officers of the. 107.
Delivery of a living child from a dead
mother by forceps. 719.
Densmore, Emmet, notice of book by, 566.
Dental Society of the State of New York,
ofiicers of the, S95.
Dentists, army, 813.
Dentition, precocious, 440.
Denver, tuberculosis in, 369.
Depilation by the -v-rays, 243.
Deppen, Joseph F., death of, 239.
Dermatitis, blastomycetic, 290, 867 , blas-
toniycetic, engrafted on syphilitic ul-
ceration, 117; bullosa in children, 863;
exfoliativa, interstitial nephritis fol-
lowing, 162; herpetiformis, eosino-
philia in, 329 ; herpetiformis, symp-
toms of, 115; polymorphous, 767.
Dermatobia noxialis in the orbit, 331.
Dermatolysis, a case of, 74.
1 lermatomyositis, acute, 767.
Dermoid cysts, origin of. 422.
Dessau, S. Henry, a reminder for the care
of children during the summer, 11 23.
Development, symmetrical, iloo.
Diabetes, bronzed, pathogenesis of, 43 ; in-
sipidus in an infant of two months, gb2 ;
phosphatic, 599; renal, 158, 159.
Diabetes mellitus, albuminuria in. 424 ;
carbohydrate variations of febrile and
alcoholic patients, 470 ; causation of
coma in, 560 ; copaiba in, 58 ; dietetic
treatment of, 159, 998 ; discussion on,
1053. 1057; double bromide of gold
and arsenic in the treatment of, 597 ;
etiology and treatment of, 1035 ; in a
child with an unusual family history,
740; in children. logg ; in vagrants,
81S : metabolism in, 769; notes on,
773 ; of apparently bacterial origin,
329 ; potatoes as a diet in, 247 ; pre-
ventive treatment of impending coma
in, 383; relation of, to epilepsy, 1123;
sugar-free milk in. 132 ; treatment of,
14. 807.
Diaminuria in relation to cystinuria, 71.
Diaphragm, influenzal spasm of the, 243.
Diarrhoea, 155 : cinnamon in the treatment
of tropical, 332 ; in children, clinical
significance of the stools in, 1053 ; in-
fantile, salol and petroleum in, 731 ;
strongylus intestinalis in a case of,
830 ; summer, ambulatory and hospi-
tal management of, 819; summer,
treatment of, 777 ; treatment of, in
children, 75 ; tropical, 340.
Diazo reaction, 46S.
Dickson, E. D., death of, 744.
Diet as a method of diagnosis, 198 ; in the
treatment of disease, 32 ; in typhoid
fever, 23.
Digestive disturbances in nursing infants,
treatment of, 572.
Digestion, process of, after resection of
about six feet of the small intestine,
243.
Digitalis, good and bad effects of, 833.
Dionin, 6g, 137.
Diphtheria, 158, 881 ; and membranous
croup, non-identity of, 345 ; antiseptic
treatment of, 1060; antitoxin of, 611 ;
antitoxin treatment of, 92, 194, igS,
646, iog3 ; complications of, 73 ; con-
tinuity of the to.xic process in fatal
cases of, 243 ; diagnosis and treat-
ment, 23 ; essential toxic symptoms
of, 68; house epidemic of, 426; im-
munity against, after the use of anti-
toxin, 1044 ; influence of the toxin of,
on metabolism, 340; in mother dur-
ing parturition and in newborn infant,
509; intubation in laryngeal, 277;
mechanism of the action of the anti-
toxin of, 719 ; mediastinal emphysema
in a case of laryngeal, 68 ; nasophar-
yngeal, 81S; orrhotherapy of , in Cuba,
73 : plea for a more extended use of
antitoxin for immunizing purposes,
32g ; relation of membranous inflam-
mation of the nose to, 118; toxic
symptoms in, 648; treatment of, 68;
varieties of the bacillus of, 843.
Diplegia, infantile cerebral, 192.
Diploma mill, raid on a Chicago, 1014.
Diplopia, monocular, in typhoid fever, 419.
Diseases, spread of dangerous communica-
ble, in children, 1132.
Disinfecting steamer, 546.
Dislocations, after-treatment of, 508 ; of
the shoulder, involuntary reduction of,
26 ; of the shoulder and hip, an easy
method of reducing. 356 ; of the radio-
carpal joint. 114 ; operative treatment
of unreduced and irreducible, 1063.
Dispensary, attack on a, 1014.
Dog malady in England, 370.
Dormiol, 730.
Double Cross, Order of the, 151.
Douche-massage. 175.
Douglas, Charles J. historical notes on the
sanitarium treatment of alcoholism,
410.
Douglass. M. E.. notice of book by, 1020.
Drink question in Great Britain, 558.
Drop infection in tuberculosis, 1094.
Dropsy, renal, diuretics in, 155 ; treat-
ment of cardiac, 741.
Drug clerks bill, 684.
Drug plants of the United States, investiga-
tion of the, 193.
Drugs, deadly, manufacture of, 704 ; phar-
macological assay of, 1 105.
Drunkenness, anti-alcoholic serum in, 289.
Dry Tortugas quarantine station, 724.
Dublin, high death rate in. 297.
Dudley, E. C notice of book by, 930.
Dudley, Gardner, death of, 218.
Duel between hospital internes in France,
no.
Duncan, Thomas C, notice of book by,
653.
Dunckel, \Yalter A. , some remarks on
whooping-cough as seen in dispensary
practice, 449.
Duodenum, congenital atresia of the. 302 ;
non-malignant ulcers of the, 485 ; per-
forating ulcer of the, 303, 749, S84 ;
round ulcer of the, 494, 522 ; ulcer of
the, treatment of, 563.
Duotal in phthisis, 244.
Dural infusion, clinical and e.xperimental
studies of, 333.
Dwarfed growth, peculiar form of, 1035.
Dying declarations, law of, Ii2g.
1 144
INDEX.
[June 30, 1900
Dysentery, 991 ; amcebic, 642 ; bacteri-
ology of, 772; pernicious, ii)43: in
Fiji, 1 19; permanganate of potassium
in, J65 ; saline treatment of, 332 ; ter-
minal, 648.
Dysmenorrhoea, 792,1099; intermenstrual,
726 ; relationship of, to appendicitis,
S55.
Dyspepsia, nervous, 203.
Dysphrenia, 40.
Dystocia caused by Bandl's ring, 425, 471 ;
due to foetal and pelvic disproportion,
prevention of, 970 ; unlooked for, in
multiparce, 25.
Ear, care of, in school children, i loi ; es-
cape of cerebro-spinal tiuid from the,
after injury, S7 ; extension massage of
the ossicles, 156; loss of cerebral Huid
from the, 245 ; maggots in the, 362 ;
normal tympanum germ-free, 4S4 ;
prevention of intracranial and intra-
venous complications in suppurative
diseases of the, 877 ; production of local
anaesthesia in the, 766 ; removal of a
foreign body from the, 1042 ; suppura-
tion of the middle, treatment of, 557 ;
suprarenal extract in diseases of the,
4S3 ; treatment of eczema of the, 572 ;
uncommon pyogenic infection of the
middle, 2S4.
Earache, significance of, in children, 207.
Eastern Medical Society of the City of New
York, officers of the, 19.
Eastman, Charles C, death of. 686.
Echinacea angustifolia, aphrodisiac proper-
ties of, 113.
Echinococcus cyst of the nose, 240.
Eclampsia, indications for premature deliv-
ery with special reference to. 970 ;
• pathogenesis of, 76S : puerperal, 74,
246 ; puerperal, treatment of, by di-
uretic infusions, 1042 ; urinary secre-
tion in, 645.
Eclectic Medical Association, 112 7.
Ecthyma, contagion of. 426.
Eczema in young children, 293 ; treatment
of, in children, 729 ; treatment of se-
borrhceal. 165.
Education, medical, in the United States.
454; overpressure, the bane of mod-
ern, 278 ; the physician as a factor in,
320.
Eggert, William E., death of, 789.
Einhorn, Max, the occurrence of mould in
the stomach and its probable signifi-
cance, 1025.
Elbow, complications following injuries
about the, 286 ; dislocation of the, 599;
external dislocation of the, 888 : false
joint after old fracture and dislocation
of the, 38S.
Elder, George, death of, 218.
Electricity, burns from, 290 ; in diseases of
the nose, throat, and ear, 240; new
applications of the undulating current
in gynecology, 2S9 ; static induced
current, 294, 396.
Electrification, is static, a specific for or-
ganic and structural nervous disorders ?
43-
Electrostatic wave current, application of
the, 359.
Elephantiasis of both ears, 301.
Ellis. George Viner, death of, 927.
Elniira State Reformatory, report of the.
918.
Elsberg. Charles A., a preliminary note on
a simple and new method of repeatedly
sterilizing sponges by boiling. 11 22;
a preliminary report on a new and
. simple method of sterilizing catgut,
760.
Emaciation, hysterical, 289.
Embolism in the fundus oculi, 114.
Embryotomy with the Karl Braun key-
hook, 652.
Emphysema, interstitial, a case of. 75; me-
diastinal, in a case of laryngeal diph-
theria, 68.
I'mpyema, unusual ending of. 553 ; valvu-
lar drainage tubes in. 157.
Encephalitis, acute non-purulent, 555.
Encephalocele, successful removal of a
large, from a child, Si.
Endocarditis, a case of. 973 ; bacteriology
of. 146; caused by micrococcus zy-
mogenes. 72 ; gonorrhceal. 1044 ; oc-
curring in the course of tonsillitis. 71 ;
streptococcal. 696 ; ulcerative, 68.
Endometritis, acute senile, 1068 ; steam in
the treatment of, 506.
Enemata, beef-gall, in the treatment of post-
operative and intestinal obstructions,
117.
English, D. E., the treatment of typhoid
fever, 1120.
Enteric fever, not typhoid, 58S.
Enteritis, dysenteriform, 161 ; treatment of
acute, 75.
Enterocolitis of infants, guarana in, 1092 ;
mucomembranous, 600.
Enteroptosis, notes on recent cases of, 199.
Enuresis, nocturnal, mullein oil in, 258 ;
operative treatment of congenital. 556.
Enzymes and immunity. 792.
Eosinophile cells, relation of Charcot-Ley-
den crystals to. 1095.
Eosolate of calcium in diabetes and phthi-
sis. 373.
Epidermolysis bullosa, 201, S20 ; heredi-
taria. Si 8.
Epididymis, tuberculosis of the, 218 : tu-
berculosis of the, castration in, 292.
Epididymitis, guaiacol in. 339.
Epigastrium, collapse or death from blows
on the. 598.
Epiglottis, tuberculous ulcer at the base of
the, 301.
Epilepsy, 240 : accidents due to attacks of,
202 ; amnesia following, 32S ; curabil-
ity of, 290 : cured by operation, 200 ;
eosinate of sodium in the treatment of,
160 ; etiology and pathology of, 552 ;
examination of the urine in, 24 ; Flech-
sig method of treatment, 719 ; in mal-
aria, 121 ; relation of diabetes mel-
litus to, II 23; relation of migraine to,
71 : relation of uric-acid secretion to,
773 ; santonin in, 378 ; strontium bro-
mide in, 29 ; treatment of, 128 ; treat-
ment of incipient, ion.
Epileptic status, 367.
Epileptics, care and treatment of, 414 :
tolerance of the bromides by aged.
205.
Epileptiform convulsions following applica-
tion of cocaine to the nares. 4q(j ; fol-
lowing injury to the head, relieved by
operation, 373.
Epiphyses, surgery of the. 461.
Epiploitis following operation, 210.
Episcleritis periodica fugax, 465.
Epistaxis, 66 ; from the ethmoidal veins.
421 ; relief of, 75; through the lacry-
mal duct after plugging of the nose,
286 ; treatment of, 474.
Epithelioma, arsenical treatment of cutane-
ous, 513 ; multiple, developing upon
lupus erythematosus, 162 ; multiple
sebaceous. 160.
Eruptions, differentiation between the bul-
lous, vesicular, and pustular, of early
life, 639 ; winter and summer recur-
rent, 340.
Erysipelas, antistreptococcus serum in,
420 : creolin in. 47 ; diplococci in,
113; treatment of, with bactericidal
remedies. 380.
Erythema, premorbilliform, 70 ; septic mac-
ulo-papular, in follicular angina. 763.
Erythrodermie pityriasique en plaques dis-
seminees. 863.
Erythromelalgia, 352.
Ether, bronchial disease not invariably a
contraindication to anaesthesia by.
854 ; death under, 158 ; inhalant, the
Gallant-AUis, I94 ; narcosis from,
436 ; practical points in anesthesia by,
814 ; spasmodic closure of the larynx
during the administration of, 200.
Ethics, code of, in relation to proprietary
medicines. 24 ; medical, breach of,
672.
Ethmoidal cells, anatomy of the, 164.
Ethyl chloride, anaesthesia by. 437.
Eucaine B, local anesthesia produced by,
199.
Eucalyptus, poisoning by the oil of, 243.
Eustachian catheterization, 923.
Exercise, effect of, upon the heart and
blood-vessels in relation to the expec-
tancy of life, 31.
Exophthalmic goitre. 121, 764, 1060, 1129 ;
significance of migraine in, 76 ; symp-
toms and operative treatment of bron-
chocele in relation to, 72.
Expert testimony, 259, 370.
Exposition, medical matters at the Paris,
1096.
Extremities, treatment of crush injuries of
the, 507.
Extubation, injuries from, 1102.
Eye. accommodation of the, to misfit glass-
es, 418; affections of the, in typhoid
fever, 335 ; books injurious to the, 6S7 :
congenital lesions of the, in a child
born of a woman recently recovered
from typhoid fever, 293 ; diagnosis of
some diseases of the, by the genera'
practitioner, 379 ; differentiation and
treatment of affections of the, com-
monly met with in family practice.
206 ; ectopia lentis, 156 ; embolism in
the fundus, 114; enucleation of the,
'55 ; gonorrhoea in its relation to dis-
eases of the, 693 ; gumma of the iris
and ciliary body, 646 ; largin in dis-
eases of the, 554 ; malignant tumors of
the, 32 ; oculomotor paresis following
indirect violence, 470 ; pin transfixing
the, 762 ; retlexes in relation to re-
cruits. 70 ; relation of the anterior cor-
pora quadrigemina to movements of
the, 159 ; removal of the cervical sym-
pathetic in certain diseases of the,
loi 7 ; retinal complications in chlorosis,
292 ; significance of hemorrhage with-
in the, as to prognosis of life, 177,
215; splinter of wood in the, 555;
symptoms on the part of the, associated
with Cheyne- Stokes respiration, 421 ;
value of symptoms relating to the, in
the diagnosis of general diseases, 286.
Eyeball, abortive treatment of suppuration
of the. 642 : eviscero-neurotomy. 329.
Eyelids, electrocautery in affections of the,
373-
Eye-strain, relation of, to epilepsy, insanity,
and allied conditions, 1084.
Face presentations, management of, S55.
Facial neuralgia, treatment. 165 ; paralysis,
916 ; paralysis complicating acute otitis
media, 925 : spasm, relation of, to er-
rors of refraction, 71.
Falkland Islands, health conditions in the,
964.
Fallopian tubes, bacteriological researches
in normal and diseased, 380.
I'amily diseases. 284.
Famine in India. 22, 192, 325, 895.
Fanoni, Antonio, antipneumonic serum,
431 ; the treatment of pneumonia, 169.
Fasting cure. S74.
Fatigue, the cure of, 203.
Fatty food in the prevention of tubercu-
losis, 973.
Fecundity, an instance of, 2S2.
F"eeble-minded. points regarding the, 997.
Feet, deforming action of shoes and stock-
ings on the. 67 ; tender, treatment of,
3S4.
Fegley. Orlando, death of, 506.
Femur, depression of the neck of the, in
early life, 336.
P'est. Francis T. B., medical practice in
Honduras, 194.
Fever, anomalous case of continued, with
abscesses of the liver, 421 ; apyretic,
160 ; colloid silver in, 207 ; prolonged,
of obscure origin, 1056.
Fever hospitals, cross infection in, 1093.
Fibroma molluscum, 246 ; case of, 74.
Fielder, Frank .S. . a criticism upon a new
method of preparing the skin for vac-
cination by denudation with caustic
potash, 143. 174.
June 30, I goo]
INDEX.
^145
Filaria sanguinis hominis, 885 ; metamor-
pliosis of, in the body of culex ciliaris,
248.
Filters, failure of, in South Africa, 1072.
Finger, rare injury to the distal phalanx of
the, 244.
Finland, venereal disease in, 470.
First-aid packages, 474.
Fish,* poisonous, 645.
Fisher, Irwin, death of, 23.
Fistula, appendiceal, 1004 ; colostomy for
fecal, 1003; fecal, 776, 849, gig ; ure-
tero-vaginal, 499 ; vesico-urethro-vagi-
nal, 162; vesico-vaginal, 289; vesico-
vaginal, withatresiaof the urethra, 205.
Fitzsimmons, T. Dana, death of. 283.
Flat-foot, treatment of, 1107.
Fluhrer, William F. , a new plan for wash-
ing the bladder, with a description of
apparatus, 1076.
Foeticide, so-called therapeutic, 293.
Fuetus, expression of the, by the abdominal
. method. 202 ; intra-uterine strangula-
tion of the, by the umbilical cord. 73 ;
movements of the five-months, 544.
Folie a deux, 687.
Folliculitis, suppurative, of the scalp, 982.
Food, adulteration of, 413 ; influence on
the health of chemical preservatives in,
351; inspection, sixteen years' experi-
ence in, 198.
Foods and drugs, pure, 563 ; legislation
for, 455. 501, 593.
Foot, articulations of the, 1108.
Football, prohibition of, 238.
Foreign bodies in the trachea, effect of, 374.
Forestier, H., chronic vertebral rheumatism
(rheumatic spondylitis) and its pseudo-
neuralgic form, 175, 630.
Forests, wholesale destruction of, 147,
Formaldehyde, disinfection of rooms with,
2S, 112, 117.
Forman, Samuel R., death of, 328.
Fortoim advantages of, 719.
Fowler, George R., diffuse septic perito-
nitis, with special reference to a new
method of treatment, namely, the ele-
vated head and trunk posture to facili-
tate drainage into the pelvis, with a
report of nine consecutive cases of
recovery, (117 ; a report of three addi-
tional consecutive cases of recovery,
1038.
Fractures, after-treatment of, 508 ; am-
bulatory treatment of, 762 ; delayed
union, thyroid extract in, 1094 ; infected
extra-capsular, of the neck of the femur,
1 14 ; in children, 379 ; influence of the
nervous system on the cure of, 513 ;
injuries of the nerves due to, 647;
massage and movement in the treat-
ment of, 65 ; of long bones without
deformity, 596 ; of the leg, use of fixa-
tion plates in. 692 ; of the neck of the
radius, mechanism of. 31 ; open or
operative treatment of fresh, 596;
pathognomonic sign of Colles', 540;
prognosis in, 1016 ; treatment of com-
pound and ununited, 461 ; .vrays in,
202.
Fraenkel, Joseph, diseases of the thoracic
division of the sympathetic chain, 103 1.
Franklin. Thomas H., death of , 154.
Fridenberg. Percy, a mirror test for simu-
lated blindness, 475.
Friedreich's ataxia, 512, 960 ; fatal case of,
150.
Frisch bacilli in nasal and oral mucous
membranes. 747.
Frontal sinus and mastoid, associated dis-
ease of the, 808.
Frothingham. George E., death of. 7S9.
Friih, Carl D. S. , a complication of mis-
carriage with appendicitis, due to trau-
matism, 638.
Fulner, George, death of. 814.
Furunculosis, treatment of, 1016.
Gallant, A. Ernest, the Gallant-Allis ether
inhaler, 194.
Gall bladder, abscess of the, 1137; water-
proof drainage of the, 464
Galloway, C. M., an abdominal varix, 825.
Gall stones, 155, 432; cases of, 1021 ;
cholecystectomy for. 977; crepitus and
friction in the diagnosis of, 71 ; diag-
nosis and treatment of, 993 ; impor-
tance of early operations for, 993 ;
nervous symptoms of, 1050; nuclei of,
derived from the intestine, 515 ; path-
ological and clinical phases of, 733 ;
seat of pain in colic form, 728 ; symp-
toms of, in movable kidney, 113; un-
common manifestation of, 720.
Gangrene complicated by glycosuria, 26 ;
multiple, in malaria. 467 ; white,
-v-ray injuries causing, 67.
Garcia, Manuel, the inventor of the laryn-
goscope, 811.
Gas, chronic poisoning by, 641 ; water-,
danger of, 322.
Gastrectomy for adenocarcinoma, 179.
Gastric electrode, a modified Einhorn, 526;
juice, method to determine the diges-
tive power of the, 461 ; neurasthenia,
203.
Gastritis, fatal hemorrhage in chronic, 145;
thrush fungus as a cause of. 553.
Gastro-enteric hemorrhage in the new-
born, 1053 ; tract, endothelial neo-
plasms of the, 555 ; tract in nervous
diseases. 461.
Gastro-enteritis, beer yeast in the treatment
of, 30; complicating congenital syph-
ilis, 289 ; in infants. 290 •, treatment of
infantile, 1132.
Gastro-enterostomy in diseases of the stom-
ach. 242.
Gastroplication, 241, 242.
Gastroptosis, 845.
Gastrostomy by Marwedel's method, 249;
for cancer. 285 ; technique of. 288.
Gastro-succorrhcea, 242.
Gau, H. F., a new curette, 571.
(jauze, iodoform, and iodol, 75.
Gehring, Henry F., death of, 22.
Gelle and Rinne tests. 925.
Genitals, development of the female, 241 ;
sensory capacity of the female, from a
forensic point of view, 22u.
Genito-urinary diseases, suppression of, by
the State, 417.
Genius, home of, in Great Britain, 976.
Gestation, ectopic, see Pregnancy, exlra-
uterinc ; protracted, 157.
Gibier, Paul, death of, 1040.
Gibney, Homer, the life of a plaster-of-
Paris jacket, 965.
Gibson. C. L., cholecystectomy for gall
stone. 977.
Gillespie, A. I.ockhart, notice of book by,
520.
Girvin, Robert M., death of, 551.
Glanders, a case of. 1019.
Glandular fever, 1092.
Glass-blower's mouth, 599.
Glatzmayer, William, death of, 460.
Glaucoma following a single instillation of
homatropine, 391; operative treatment
of chronic, 329.
Glossodynia, 163.
Glycosuria, alimentary, 55; ; gangrene
complicated by, 26 ; non-diabetic, 728 ;
psoriasis associated with. 200 ; signifi-
cance of glycuronic acid in the phenyl-
hydrazin test for, 1 59 ; surgical opera-
tions during, 692 ; tests for, l6l.
Goat vaccine among the Kabyles, S20.
Goitre, congenital, 731 ; etiology and symp-
tomatology of, 1 19; frequency of, at
different ages, 922 ; in Montreal, 72 ;
syphilitic, 375 ; treatment of, 14, 165,
377-
Goldan, S. Ormond, an unprecedented case
of prolonged anesthesia with nitrous
oxide and oxygen, 364.
Gonococci in living leucocytes, staining of,
with neutral red, 233 ; rapid staining
of the, Sig ; therapeutic uses of, 370.
Gonorrhoea, acute, and its complications,
693 ; chronic. 693 ; dangers of, to so-
ciety, 155; history of, 693; in the
p'-egnant woman, 693 ; in women,
646 ; in women, importance of the
early recognition and treatment of,
379 ; in women, recent literature on.
' 71 ; marriage in relation to. 426 ;
methylene blue in the treatment of.
498 ; relation of. to the male adnexa,
184: serious complications from faulty
injections in, 600 ; treatment of, 888,
1091.
Gonorrjueal rheumatism, treatment of , 247;
vulvo-vaginitis in children, indirect
contagion in, 507.
Goodhue, E. S., a case of fracture and
medical ethics, 672 ; leprosy in Ha-
waii, 133 ; leprosy legislation, 652.
Gordon, Frederick T., how to send moist
anatomical specimens by mail, 696.
Gorham, John, death of, 252.
Gottheil, W. S., notice of book by. 122;
suppurative folliculitis of the scalp,
982.
Gould, A. Pearce, notice of book edited
by. 735. 1020.
Gould, George M., notice of book by, 653.
Goundon, 248.
Gout, action of various drugs and diets on
the excretion of nitrogen in, 689,743 ;
artificial production of, 159 ; balneo-
therapy in, 374 ; dietetic treatment of,
552 ; electrical treatment of, 4S4 ; hot-
air treatment of, 462 • metabolism in,
114; piperazin in, 68; rheumatic,
41S ; terminating in acute myositis,
1091 ; the gelatinous form of sodium
biurate in its bearing on the treatment
of, 688, 742 ; treatment of chronic,
1091.
Goutte de Lait Society, 1128. '
Gouty deposits, treatment of, 641.
Grant, Edward Frank, death of, 726.
(irasset. Dr., notice of book by, 1021.
Grave robbery, an alleged, 21.
Graves, Schuyler Colfax, the relative mer-
its of operations for the extraction of
vesical stone in the male ; with obser-
vations on the suprapubic and left lat-
eral perineal methods, 357.
Graves' disease, see Exophthalmic goitre.
Graves' disease without exophthalmic goi-
tre, 843.
Gray, Landon Carter, obituary of, 814 ■
resolutions on death of, 1040, 1088.
Greanelle, W. J., a new gynaecological
pad, 65S.
Great Britain, medical census of, 371, 787.
Green, DeWitt C. , death of, 32S.
Green. W. C, a new T-bandage, 232.
Greene. Robert H.. notice of book by,
930.
Grigg, \V. C, death of, 604.
Grossmann, Fritz, notice of book by, 929.
Gruber, Frank, death of, 22.
Gruber, Josef, death of, 724.
Guaiac, reaction of the leucocytes to, 423.
Guaiacol. a new preparation of, 201.
Guam, sanitary progress in, 153.
Guiraud, Dr., notice of book by, 734.
Guiteras. Ramon, a recto-genital irrigating-
tube. 350.
Gumma of the palatine vault. 1132.
Gunning. R. H., death of, 743.
Gunshot wounds, 419, 420 • by small-cali-
bre weapons, 338,961 ; in the Santiago
campaign, 156; of the kidnev, 500; of
the thoracic and abdominal cavities,
333; surgical aspects of modern, 162.
Gynaecological pad, a new, 658.
Gynecology and gynecologists in Europe,
9& ; aseptic minor, 1065 ; improved
technique in operative. 995 ; parturi-
tion as a factor in. 1048 ; periods in.
logo: prophylaxis in, 208, 240; sta-
tus of, in 1S76 and 1900, g24.
H
Habirshaw, John, death of, 726.
Habitation of the poor, 59.
Hematemesis, qgg; gastric ulcer, operative
treatment of, 72; treatment of, 127.
H.Tjmatocolpos and hsematometra resulting
from congenital atresia of the vagina,
644.
Haematometra, a case of, 2gl ; in a rudi-
mentary horn of the uterus. 516.
Hematuria due to renal carcinoma, 959 ;
malarial, 284.
1 146
INDEX.
[June 30, 1900
Hjemochromatosis, etiology of, 65 ; patho-
genesis of general. 43.
HKmocjtometer, clinical value of Oliver's,
330.
Hsemoglobinuria, paroxysmal, 293, 297 ;
pathogenesis of periodic. T045.
Hasmolysin and antih.-emolysin. 244.
Haemophilia in the negro, 46S.
Hajmopneutnothorax. 42S.
Hjeraoplj-sis, parasitic. 119 ; terpinol in,
293.
Hahnemann monument in Washington,
416; unveiling of the. 1128.
Hair, anomalies of the. 8S6 ; care of the,
212; loss of. 907; management of.
during and after fevers, S14 ; peculiar
condition of the, "68.
Hair-ball in the intestine, 6S7 ; in the
stomach, 703, 726.
Hairy mole, an extensive, 739.
Hallux valgus and hallux varus, 463.
Hamilton, Allan McLane, the work done
by the Marine- Hospital corps in Ha-
vana, 473.
Hamilton, Edward, death of. 42.
Hamilton. John B., notice of book by,
122.
Hammer toe, 693.
Hammond, William Alexander, death of,
64; resolutions on the death of, 154,
327.
Hamstrings, lengthening of the, for con-
traction after a burn, 766.
Hanan, James Taylor, disinfection of the
umbilicus in abdominal operations,
323.
Hands, rare syphilitic lesion of the, 164 ;
disinfection of the. 69,
Hanging, a study of, loS.
Hardin, Willett L., notice of book by, 929.
Hare, Hobart Amory, notice of book edited
by, 73&'
Haring. Isaac C, death of, 686.
Harlem Hospital, a new, 371.
Harlem Medical Association, officers of
the, 1087.
Hartmann, H. , notice of book by, 566.
Hastings. William H., death of, 327.
Hatchette, Frances C. , death of, 686.
Havana, board of health in, 325 ; health
of, 195 ; medical course at the Uni-
versity of, 894 ; vital statistics of, 415 ;
work of the Marine- Hospital corps in,
473-
Hawaii, health conditions in, 946 ; leprosy
in. 133 ; medical practice in, 156 ; neu-
rological observations in, 553.
Hayes, Samuel, death of, 506.
Hay fever, suprarenal extract in, 4S2.
Hazel, Franklin B. , death of, 595.
Hazzard. J. S. R., death of. 959.
Head, bullet wounds of the, 65, 114 ; nod-
ding and head rotation. 862.
Headache, atropine in the diagnosis of, 6SS;
treatment of neurasthenic, 7S4.
Health reports of the Marine- Hospital ser-
vice, 88, 132, 176, 220, 308, 352, 372,
440, 484, 528, 572, 616, 660, 704, 74S,
792, Sgi, 936, 1024. 1072, 10S8, 113S.
Hearing in the insane, 29.
Heart, accentuation of the second pulmo-
nary sound, definition and significance
of. 151 ; active dilatation of the, 510 ;
affections of the, following typhoid fe-
ver, 202 ; aneurism of the, 974; aneur-
ism of the, in childhood. 291 ; ante-
cedents of valvular disease of the.
in children, iioi ; arrhythmia of the,
complicating fibroma uteri, 996 ; arti-
ficial Nauheim baths in the treatment
of chronic disease of the, 914 ; a sup-
porting apparatus in affections of the,
333: cause of pain about the, 4S4; clin-
ical study of the causes of the first
sound of the. 1017 ; congenital mal-
formation of the, S60 ; coupling and
redoubling of the second sound in mi-
tral stenosis, 720 ; diagnostic signifi-
cance of the second pulmonary sound,
730; digitalis in diseases of the,
1044: disease of the, without rheu-
matism, 161 ; disease of the, with
unusual features, 933; diseases of
the, causes of failure in compensa-
tion in, 254 ; diseases of the, in
infancy and childhood. 284, 1130; ex-
ercises suitable for children with dis-
ease of the, 974; forced, 246; hyper-
trophy of the, in kidney diseases, S18;
influence of mechanical irritation of the
liver on the. 159 ; influenzal affections
of the. 467 ; in relation to life insur-
ance, 720 ; minor forms of dilatation
of the, S43 ; mitral obstruction. 153 ;
mitral regurgitation and pulmonary
obstruction, 646 ; mobility of the, in
change of position of the body, SiS:
multiple lesions of the, 73 ; murmurs
of the. in infancy and childhood, S27 :
neurosis of the, 241 ; post-influenzal
affections of the, 58 ; reflex, .v-ray
study of the, 67 ; relative importance
of valvular and muscular lesions of the,
105S ; relative intensity of the second
sounds at the base of the heart, 45, 77;
repose and exercise in diseases of the,
1043 ; rest in bed in the treatment of
affections of the, in children, 73 ; rheu-
matic diseases of the, 642, 694, 1057;
rupture of the, 26 ; solitary tubercle of
the, SS5 ; spontaneous rupture of the.
728 ; study of the wall of the, in diph-
theria, rheumatic fever, and chorea,
962; sutureof the, 245 ; tonics for the,
1055; treatment of diseases of the, 441 ;
treatment of fatty, 490 ; treatment of
wounds of the, by suture, 72 ; tricuspid
and mitral stenosis with adherent peri-
cardium. 468 ; valvular disease of the,
240; venous thrombosis as a complica-
tion of diseases of the, S43 ; widely
conducted murmurs of the. 1044.
Heat, intense, in the Southern hemisphere,
239, 325 ; moist, therapeutic employ-
ment of, 333.
Hecker, Frederick William, death of. 460.
Hedges, E. W^, mumps versus rheuma-
tism, 738.
Heidelberg, woman admitted to the uni-
versity of, 313.
Heineck, Aime Paul, notice of book by, 734.
Heisler, John Clement, notice of book by,
929.
Helminthiasis, meningism from, 916 ;
hemiplegia and aphasia in intestinal,
288.
Hemichorea, organic, 516; preparalytic,
163.
Hemiplegia and various associated symp-
toms. 69I; claw-like hand in, 192 ; in-
fantile, associated with aphasia, 26 ;
infantile, following convulsions, 247.
Hemmeter, John C, notice of book by,
1020.
Hemorrhage, free drinking of water in,
103; gelatin in, 464; in pregnancy,
treatment of, 164 ; post-partum, cured
by simple drainage, 924 ; post-partum.
prevention and treatment of, 53 ; saline
infusion in, 362.
Hemorrhoidal nodes in earliest childhood.
600.
Hemorrhoids, application to excoriations
on, 564 ; examination necessary before
prescribing for, 65 ; treatment of, 75,
165.
Henpuye in the Gold Coast Colony, 1 13.
Hepatism and neuropathy, 988.
Heredity in disease. 10S4; influence of, on
disease, 599 ; in psychology, 418.
Herman, J. Edward, a consideration of the
failure of antitoxin in operative cases
of diphtheritic croup. 92, 194.
Hermaphrodite, 246 ; spurious. 643.
Hernia abdominalis, 1089; a neglected
point in the treatment of strangu-
lated, IT31; Bassini's operation for,
240; cure of inguinal, in men, loOi;
diagnosis and treatment of strangu-
lated, 299 ; diaphragmatic, 848 ; douDle
inguinal, on the same side, 764; en-
terectomy for gangrenous, 157; epi-
gastric, 689 ; in children, operation
for, 743 ; in pregnancy. 198 ; local
anesthesia in the radical treatment of,
161; mortality after operations for
large incarcerated. 162 ; new method
of suture in operations fcr, 466 ; of
the umbilical cord, 363 ; omental, 298 ;
perityphlitis in the sac of a, 334 ; post-
operative. 1019 ; properitoneal. 123;
properitoneal and interstitial inguinal,
31 ; radical cure of, 463 ; relative bear-
ing of the conjoined tendon and the
internal oblique muscles upon the
radical cure of hernia, 700 ; relative
frequency of, in the sexes, and the
various types in the female, 71 ; sub-
pubic, 84S ; treatment of femoral, 378 ;
treatment of, in children, 1060; treat-
ment of inguinal, 259 ; treatment of
sliding, of the c^cum or of the sigmoid
flexure, 309, 343 ; truss management
of, 300; umbilical, 19S ; umbilical, rad-
ical cure of a large, 426; ventral, 1061.
Herniotomy, sequela; to, 521.
Heroin, effect of, on respiration, 115; in
phthisis, 244 ; in respiratory diseases,
24; therapeutics of, 155, 3S0.
Herpes, neuralgic genital, 24b ; progeni-
talis, 961.
Hetol, treatment of tuberculosis with, 1043.
Hicks, Henn,-, death of, 42.
HiUis, John b. . death of, 32S.
Hiue, Robert H., death of, 64.
Hinshelwood. J., notice of book by, 930.
Hip, amputation of the, 1017 ; anterior in-
cision in resection of the, 770 ; dislo-
cations of the. S46 ; early exploratory
operations in tuberculosis of the, 338 ,
easy method of reducing dislocations
of the, 356; hysterical disease of the,
923; operation for ununited intracap-
sular fracture of the, 11 09; treatment
of congenital dislocations of the, 289,
1071 ; tuberculosis of the, 654.
Hip-disease, retardation of growth as a
cause of shortening after, 1107; treat-
ment of, 474.
Hip-splint, rubber shoe for the, 571.
Hirsch, William, puerperal insanity, 10.
Histology, employment of silver compounds
in, 729.
Hockey-stick incision, 390.
Hodgskin, Frank, death of, 239.
Hoffmann, Hans R., death of, 506 ; reso-
lutions on the death of, 551.
Holidays, public, 1012.
Holland, J. W., notice of book by, 929.
Holmes. Edward Lorenzo, death of. 328.
Holmquist. A. J., the auditory canal as an
incubator, 362.
Honduras, medical practice in, 194.
Hood, Thomas B., death of, 506.
Hopkins. Gerald C, death of, 1015.
Hopkins, Woolsey. death of. 327.
Horner, J. S.. the appendicitis question,
346, 519-
Horses, electrified oats reveal a possible
danger to, 352.
Horwitz, Lloyd Morris, death of, 112S.
Hospital, a new, in Boston, 151; clinical
laboratory, 991 ; for Crippled and De-
formed Children in New York State.
1088; fund in London. 128; inspec-
tion of public, in New York. 1013 ;
room in each dwelling, 120 ; Saturday
and Sunday collection. 685 ; senMce
conducted by a single chief, 746 ; ships
in Japan, 17; the modern, and its resi-
dent staff, 1 1 33 ; the woman's, statis-
tics of, 1134.
Hossie, Thomas R., death of. 686.
Hough, John Stockton, death of, 814.
House, William S., death of, I96.
Houses, relative humidity of, in winter,
41S.
Howard, Benjamin Douglas, death of,il28.
Hubbard, Oliver Payson. death of, 460.
Humerus, fracture of the neck of the, 466 ;
inward displacement of the lower epi-
physis of the. 422.
Humidity of houses in winter, 418.
Hydatid cyst of the pleura. 335.
Hyde. James Nevins, notice of book by,
735-
Hyde, Samuel, death of, 429.
Hydrencephalocele, iioo.
Hydroa. generalized, in its relations to
polymorphous erythema. 695.
Hydrocele. Hitter's operation for, 513; in-
tra-abdominal bilocular, 60; loose for-
June 30, 1900]
INDEX.
1147
eign body in the sac of a, 553 : of the
cord following an operation for stran-
gulated inguinal hernia, 73.
Hydrocephalus, acquired interna! idio-
pathic, 351 ; chronic, spinal puncture
in, 512 ; treatment of, by craniectomy,
85S.
Hydrogen arsenide, 1097 ; peroxide as a
local anaesthetic, g28 ; peroxide in the
treatment of infected wounds, 962.
Hydronephrosis, 7S3.
Hydrophobia, a death from, in St. Vincent's
Hospital, 686.
Hydropneumothorax, diagnosis, symptoms,
and treatment of, 249.
Hydrorrhoea, nasal, 204.
Hydrotherapy in infancy, 160.
Hygiene and State medicine in the United
States, 633.
Hymen, imperforate. So.
Hyoid bone, fracture of the, 33.
Hyperchlorhydria, 967.
Ilyperidrosis, facial, of nervous origin, 916.
Hyperkeratosic interdigital eczema, 292.
Hyperthermia, nervous, in women, 690.
Hypnotism, 640 ; alleged, in the courts,
504 ; fortune making by, 87.
Hypodermoclysisin shock, 418: in typhoid
fever, 362 ; observations and sugges-
tions concerning, 623.
Hypoglossal nerve, idiopathic partial in-
flammation of, 69.
Hypothermia, 157.
Hyssop, 1 58.
Hysterectomy, abdominal. 121 : by the
clamp method, 304 ; total abdominal,
in suppuration of the adnexa, 202 ;
without preventive hsmostasis, 35.
Hysteria, disorder of respiration in, 116;
extreme emaciation in, 2S9 ; juvenile,
1089 ; transient real blindness in, 692 ;
two practically important cases of, 729.
Hysteromyomectomy, supravaginal, 259.
I
Ichthyosis, 247 ; foetal, 1053.
Icterus, acute infectious, 207.
Ideas, imperative, in the sane, 779.
Idelson, Valerius, death of, 1041.
Idiocy and imbecility, etiology of, 997 ;
early diagnosis of, 762 ; infantile am-
aurotic, 1006.
Idiots, speech and sense perception in, 15S.
Ilium, fracture of the anterior superior
spine of the, by muscular action, 145. •
Imbecility, diagnosis of, in early childhood,
245 ; Mongolian, in infants, 118.
Immunity. 610.
Impetigo, 426.
Impotence in man, 120.
Incubators, care of premature babies in,
819.
Indicanuria. relation of hydrochloric-acid
secretion to. 765.
Indigestion, 1084; puerile, 74; relation of
intestinal, to pulmonar)' disease, 240.
Inebriates, a State hospital for, 369.
Infancy, hydrotherapy in, 160; infrequency
of the acute transmissible diseases in,
773-
Infant feeding, 1052 ; mortality, cause, and
prevention of, 468.
Infants, nutrition and diseases of, 888.
Infection, latent, 65 ; nature's method of
protecting the organism against, 512.
Infectious diseases, classification of, 208 ;
eradication of, 924 ; excretion in the
treatment of, 113.
Influenza, acute hemorrhagic poliencepha-
litis in, 246; attenuated forms of,
513 ; aural complications of, 377 : car-
diac affections due to, 467 ; heart trou-
ble following, 58, 1131; in infancy,
cerebrospinal symptoms in, iiS; in va-
rious places, loS, 16S, 196, 217, 251,
282, 296, 326, 350, 392, 428, 429, 634,
685 ; maniacal excitement during, 509 ;
nephritis of, in children, 859 ; nervous
depression as a sequel of, 462 ; skin
eruption in, 201 ; treatment of, 197.
Infusion of salt solution. 245.
Infusoria, influence of fluorescent material
on, 201.
Inguinal region, neural anatomy of the,
732.
Inhibition, a study of, 197.
Insane, care of the, 454 ; colony system of
caring for the, 33S ; criminal, 1091 ;
general paralysis of the, 599 ; hearing
in the. 29 ; treatment of the, 200.
Insanity and crime in women, relation of
the sexual function to, 251 ; changes
in circular, 69 ; incipient, 103 ; infan-
tile, 688 ; in the army, 636 ; malarial.
116, 696; puerperal, 10; relation of,
to pelvic and other lesions, 290 ; the
nails in, 1072 ; Turkish baths in, 462 ;
uterine disease in the causation of , 1049.
Insects as carriers of contagion, 616.
Insolation, pathology of, 1134.
Insomnia, 243, 547.
Instruction, medical, some advances in,
1016.
Insufficiency, cardiac, 246.
Insufilation, intralaryngeal, 1041.
Internal secretions, physiology of, S31.
International Medical Congress, prepara-
tions for the, 963.
Intestinal fever, 641; movements, mechan-
ism of the, S89 ; neuroses, 469 ; ob-
struction due to intussusception, 336.
Intestine, acute obstruction of the, 3S9 ;
anastomosis of, in a case of tubercu-
lous fistula, 462 ; anastomosis of the,
with the Murphy button, 1003 ; anti-
sepsis of the, in children, 572 ; a sut-
ure of the, 197; cancer of the, 480;
cancer of the large, 376, 463; endo-
enteric suture, 72 ; excision of the, for
malignant disease, 88 ; extensive re-
section of the, 159 ; hypertrophic tuber-
culosis of the, 1009 ;. ileocolic invagina-
tion of the, 333 ; multiple spurious di-
verticula of the. 1009; multiple stenosis
of the, of tuberculous origin, 28S ;
obstruction of the, due to persistent
Meckel's diverticulum, 421, 77S, 1042 ;
obstruction of the, due to gall stones.
962 ; obstruction of, due to peritoneal
bands. 1044 ; perforation of, by a
splinter of bone, 440 ; perforation of
the, ether inflation of the rectum in the
diagnosis of, 25 ; primary resection of
gangrenous. 26 ; repair after resection
of the. 1004 ; resection of six feet of
the, digestion after. 243 ; resection of
the, 332, 349 ; sarcoma of the small,
loii ; triple stricture of the, 70 ; tuber-
culous stricture of the small, 466.
Intubation, contraindications to, 521 ; diffi-
culties of, 881 ; feeding in cases of,
1022 ; in diphtheria. 923 ; in private
practice, 1102.
Intussusception mistaken for ectopic gesta-
tion, 80 ; mortality and treatment of
acute, 339 ; two cases of. 655.
Iodine, intravenous injections of, 962.
Iodoform, poisoning by, in an infant, 63S.
Irido-choroiditis due to intestinal auto-in-
fection, 164.
Iris, operation for the relief of an incar-
cerated. 321.
Iritis, diagnosis of, 71; treatment of, 374.
Iron, action of, in chlorosis, 720.
Ischoemic paralysis, 591.
Ischio-rectal fossa, incised wound in the,
from breaking of a chamber vessel,
362.
Italv, regulation of medical practice in, 550.
J
Jackson, Edward, notice of book by, 824.
lackson, (jeorge Thomas, loss of hair — a
clinical study founded on three hundred
private cases, 907.
Jackson. H. C, death of, 743.
Jacobi, A., seventieth birthday of, 7S7, 8li,
920.
Janeway, E. G. , remarks on some of the
conditions simulating appendicitis and
peri-appendicular inflammation, 897,
93-4 ■
Janiceps, a case of, 291.
japan, age of medical graduates in, 976;
guarding against the plague in, 345 ;
navy medical service of, 19.
Japanese, premature maturity of the. 307.
Jardine. Robert, notice of book by, 928.
Jaundice, exploratory operation in a case of
persistent, 816.
Jaw, fracture of the, 361; niultilocular cys-
tic epithelial tumor of the, 114; sar-
coma of the, 339.
Jesty, Benjamin, a pre-Jennerian vaccina-
tor. 468.
Johnson, F. \V., uretero-vaginal fistula,
operation, cure, 499.
Johnson, William Crawford, the salicylates
in pneumonia, 792.
Jones, .Alfred E., death of, 594.
Jones, Charles E., resolutions on the death
of. III.
Jones, Stacy, notice of book by, 381.
Joseph, Max, notice of book by, 520.
Josephson. J. C. , a case of iodoform poi-
soning in an infant two weeks old, 638.
Justus blood test for syphilis, 174.
K
Karschelt, E., notice of book by, 929.
Keeley, Leslie E., author of the "gold-
cure" treatment, death of, 372.
Keith, George I., notice of book by, 1020.
Keller, Frank B., death of, 595.
Kemp. Robert Coleman, observations and
suggestions concerning hypodermocly-
sis. 623.
Kendall, H. E., peroxide of hydrogen as
a local anaesthetic, 928.
Kennedy, Charles B., death of, 328.
Kennedy, R. A., death of, 32S.
Keratitis profunda, treatment of, 720.
Kernig's sign in meningitis, 2S6, 731.
Kessel, George, congenital hernia of the
umbilical cord, 363.
Ketch. Samuel, resolutions on the death of,
283.
Kidney, action upon the function of the,
of hypnotics associated with diuretics,
340 ; affections of the, in relation to
pregnancy, 726 ; calculus of the, 507 ;
cancer of the, 959 ; cancer of the, in
children, 293 ; clinical significance of
a displaced, 201; congenital malposi-
tion of the, with anomalous arterial
supply, 385 ; contracted, blue-blind-
ness in, 201 ; cystic, 477, 883 ; de-
rangement of the water-secreting pow-
er of diseased, 11 24; disease of
the, simulating other diseases, 33 ;
disturbances in the filtration power
of diffusely inflamed, 817 ; floating,
mistaken for appendicitis and ovarian
tumor. 363 ; function of the, in chronic
nephritis, 424 ; gonorrhceal, 7S3; gun-
shot wound of the, 500 ; hemorrhages
from the, 2S5 ; inadequacy of the,
from a neuropathic standpoint, 688 •
injuries of the, 65 ; movable, 113,
509, 553. 887, 1060 ; neoplasms of
the, 507 ; removal of a, excretion of
urine and urea increased after, 365 ;
role of the physician in diseases of the,
243 ; rupture of the pelvis of the, 157 ;
splitting of the, 511 ; structure and
function of the, 634 ; subjective symp-
tomatology of disease of the, 873 ;
surgery of the, 874 ; surgical treat-
ment of tuberculosis of the, 464, 554 ;
treatment of renal retention, 691 ; tu-
berculosis of the, 510, 727, 1132; tu-
berculosis of the, extraperitoneal ne-
phro-ureterectomy for, 25.
Kimball, Frank ])., death of, 686.
Kings County Medical Society, library
building of the, 951.
Kitchener. J. M. W., something else to
do for seasickness, 1097.
Knee, acute traumatic arthritis of the, 376 ;
deformity following excision of the,
103 ; internal derangement of the, 113 ;
loose body in the, 422 ; rupture of the
internal lateral ligament of the, 361 ;
surgery of the, iio6; treatment of
tuberculous, 1063 ; white swelling of
the, 24, 69.
Knee-jerk absent with ankle clonus, 1 112.
Knopf, S. A., sanatorium treatment at
1148
home for patients suffering from tuber-
culosis, 138.
Kohii, Samuel, ceruminous and epithelial
impactions in the external auditory
canal, 1078 ; epileptiform convulsions
following the intranasal application of
cocaine, 499.
Kola in seasickness, 34S.
Korea, hospital and dispensary work in. 219.
Kraurosis vulvae, 1019.
Krauf, Frederic, Jr., the modern treat-
ment of diabetes mellitus, 807.
Krise, Columbus W., death of, 155.
Kroo fly, 24S.
Labor, artificial premature, 291 ; compli-
cated by utero-abdominal fixation, 411 ;
treatment of the third stage of, 32.
Lacrymal tumor, congenital, 335.
Lactation in a male infant, 26.
Lamb, D. S. , how to send anatomical
specimens by mail, 823.
Lamb, William W., death of, 32S.
Landry's paralysis, 465, 692.
Laparotomy, accounting for gauze pads in,
408 ; exploration of the abdomen in,
601 ; limitation of, in favor of vaginal
cojliotomy, 334 ; vs. vaginal ccelioto-
my. 339-
Larrien, J. F., notice of book by, 520.
Laryngeal ictus and asthma, 719 ; paraly-
sis, a case of partial, 476.
Laryngectomy for cancer, 523 ; for sarco-
ma, and the employment of an exter-
nal artificial larynx, 719 ; statistics of.
Laryngitis, suprarenal extract m, 483;
treatment of acute, 75 ; treatment of
chronic, 1 28.
Laryngo-hyoidectomy for carcinoma, 470.
Laryngoscopic image, the, 365.
I^aryngotomy, observation on, 595.
Larynx, atresia of the, due to faulty intu-
bation, S62 ; cancer of the, 47S, S67 ;
cancer of the, endolaryngeal treatment
of. I Id; chorea of the, 544; cysts
within the, 121, S69 : direct examina-
tion of, in children, 462 ; early recog-
nition and treatment of malignant
growths of the, 557; fibroma of the.
S6g ; fracture of the cartilages of the,
33 ; intubation for syphilitic stenosis
of the, 32 ; pin in the, for two years,
S6g ; papilloma of the, 301 ; post-diph-
theritic stenosis of the, 888; spasmodic
closure of the, during the administra-
tion of ether, 206 ; suffocating papil-
loma of the, 739 ; typhoid affections of
the, 203.
Lateral curvature of the spine, 1069 ; con-
genital, "162; mechanics of, 1090;
treatment of, 1107.
Lathrop, 1. 1".., death of, 373.
Lawall, I.. 11. , death of, 196.
Lead oxide, French regulations against the
use of, 88 ; paralvsis, 200 ; poisoning
with, 27.
Leake, Henry K., the appendicitis ques-
tion, 168; what is the best posture for
tlie patient in bed after abdominal sec-
tion, particularly in pus cases? 823.
Leaming, Coleman F., death of, 922.
Leeches as germ-carriers, 747.
Leg, treatment of ulcer of the, 300.
Legislation, medical, in New York State,
917.
Lehigh Valley (Pa. ) Medical Association,
officers of, 194.
Leichtenstern, Otto, death of, 506.
Lepers in the far East, work among, 591.
Lepine, R., notice of book by, 520.
Lepride, macular, of the scalp, 117.
Leprohon, John L., death of, 959.
Leprosy, antivenene in the treatment of,
528 ; Calmette's serum in, 204; chaul-
moogra oil subcutaneously in, 248;
contagion in, 197; cultivation of the
bacillus of, 763; curability of, 212;
diagnosis of anfesthetic, 197; fever of,
527 ; in Crete, 281 ; in England, 264;
in Hawaii, 133; legislation regarding,
652; mosquitos bearing contagion of,
INDEX.
1 133; ophthalmoscopic findings in,
511; prophylaxis of, 864.
Leser, Edmund, notice of book by, 736.
Lessey, Justus, death of, 506.
Leszynsky. William M., the uselessness of
the pituitary body as a therapeutic
agent, 1122.
Lethargy, hysterical, 461.
Letters from Constantinople, 743 ; from
London, 41. 12S, 166, 217, 251, 296,
349, 391, 427. 517. 558, 603, 650,
742, 791, S21, 889, 926, 963, 1021,
1047, 1095; from Naples, 86; from
New Zealand, 392. 1046 ; from Paris.
963, 1096; from Syria, 393; from the
Falkland Islands, 964 ; from Vienna,
431.
Leucocytes, estimation of, as an aid in the
diagnosis of diseases of children, 247 ;
estimation of, in surgery, 1094 ; reac-
tion of, to tincture of guaiac, 423.
Leucocytosis, 597; origin of, 159.
Leucorrhaa. vaginal irrigation for, 165.
Leukremia. acute, in childhood, 1092 ; aural
manifestations of, 678 ; changes in the
central nervous system in. 291 ; hrema-
mceba of Lowit in, 730; lymphatic,
643; prevalence and diagnosis of, 597;
some unusual cases of, 3S5 ; splenic
myelogenous, with pulmonary tubercu-
losis, 877; spleno-myelogenous. 643.
Levene, P. A. , the chemical relationship of
colloid, mucoid, and amyloid sub-
stances, 1 88, 304.
Levin, I. , mucina;mia and its role in experi-
mental thyroprivia, 184, 304.
Lewis, Benjamin S. , death of, 506.
Libman, E. , i, on a peculiar variety of
pathogenic streptococci ; 2, on a pe-
culiar property possessed by (at least
some of) the pathogenic bacteria; pre-
liminary communication, S42.
Licensing, reciprocity in medical. 235, 545.
Life insurance, responsibilities of the med-
ical examiners for, 211 ; study of the
head and face in examinations for, 31 ;
sypliilis in relation to, 205 ; jr-ray ex-
amination for, 25.
Ligament, broad, fibrosarcoma of the, 425.
Lightning, deaths from, 10S7; injury by,
248.
Lilienthal, Howard, notice of book by, 734.
Limping, intermittent, 465.
Lip, chancre of the, in a child seven months
old, 4:7; persistent exfoliation of the,
864.
Lipoma, calcified, in a hernial sac, 158';
genesis of, 3S0; intestinal, 512; of the
neck, a gigantic, 164.
Lithotomy, suprapubic, in old men, 1090;
suture of the bladder in suprapubic,
554-
Lithotrily, painless, 564.
Liver, abscess of the, 335. 507. II3^: acute
yellow atrophy of the, 516; alcoholic
cirrhosis of the, in a baby, 35, 46S ;
alterations of the, in scarlatina, 690 ;
cancer of the, secondary to small mam-
mary cancer, 303 ; cirrhosis of the,
643, 644, 689, 72S, 926 ; cirrhosis of
the, fatal gastro-enteric hemorrhage
in, 468 ; cirrhosis of the, in the pre-
ascitic stage, 163 ; cirrhotic, hemor-
rhagic and necrobiotic infarcts in the,
340 ; congestion of the, from mer-
cury poisoning, 690 ; cysts of the,
477- S83 ; direct communication be-
tween the portal veins and the supra-
hepatic veins of the, 205 ; dysenteric
abscess of the, 600 ; engorgement of
the, predisposing to pulmonary tuber-
culosis, 767 ; enlarged, in rickets, 162;
hypertrophic alcoholic cirrhosis of the,
with diabetes, 1043 ; lesions of the,
in young children, 338 ; mucoid
cysts of the, 421 ; multilobular cir-
rhosis of the, 158; nature of new
tissue in cirrhosis of the. S43 ; path-
ology of acute yellow atrophy of the,
1043 ; pericardiac pseudo- cirrhosis of
the, 644 ; ptosis of the, 962 ; rupture
of the. 32S, 961 ; suppurations of the,
of typhlo-appendicular origin, 769 ;
surgery of malignant neoplasms of
[June 30, 1900
the, 502 ; syphilis of the, 1043 ; treat-
ment of alcoholic cirrhosis of the, 572.
Lloyd, Samuel, the results of the so-
called conservative treatment of ap-
pendicitis, 226, 259.
I^ocke, Robert, death of, 1041.
Lockwood, George Roe. a modified Ein-
horn gastric electrode, 526.
Loewenbach, Georg, notice of book by, 520.
London, letters from, 41, 12S, 166, 217,
251, 296, 349, 391,427, 517, 558, 603,
650, 742, 791, 821, 889, 926, 963,
1021, 1047. 1095.
Longevity, monogamy in relation to, 1091.
Longeway, M. Louise, notice of book by,
6;3-'
Long Island State Hospital, managers of
the, 370.
Louisiana Leper Home, 325.
Love, John J. H., memorial to the late,
592.
Loveland, B. C, locomotor ataxia, 541.
Loveland. E. IC, a case of tetanus in
which the mouth was the probable
source of infection, 363.
Lovett, Robert W., notice of book by, 567.
Lubrichondrin. 521.
Lucas, Joseph J. S., notice of book by, 929.
Ludwig's angina, a case of. 70.
Lumbar puncture in pediatric practice, 544;
dangers of , 1132; technique of, 886.
Lung, bone in the, for four years, 511 ;
changes in the, due to dust inhalation,
S18 ; disease and repair of the, 507 ;
drainage of an abscess of the, 420 ;
drainage of cavities in the, 1061 ; em-
bolism of the. in phlebitis, 424 ; gan-
grene of the, after gastro-entero-anas-
tomosis, 888 ; hypeftrophy, ectasy,
swelling, and emphysema of the, 69;
necrobiotic ischremic infarction of the,
246 ; pneumothorax in secondary sar-
coma of the. 163 ; primary neoplasm
of the, 342 ; radiograph and fluoro-
scope in diseases of the, 67 ; reflex,
113 ; relation of intestinal indigestion
to disease of the, 240 ; surgery of the,
Lupus, endothelioma developing in the scar
tissue of, 866 ; erythematosus, multi-
ple epitheliomata developing upon,
162 ; steam treatment of, 768 ; j--rays
in the treatment of. 67, Sig, 8S7.
Lustgarten, S. , the question of legal con-
trol of prostitution in America. 57.
Lymphjcmia without swelling of the lym-
phatic glands. 470.
Lymphangioma, inguino-scrotal, 121.
Lymphangitis, septic, along the ureters,
successfully treated with antistrepto-
coccus serum, 286.
Lymphatic glands in scarlet fever, 74 ; ves-
sels and blood-vessels, relations be-
tween, 722 ; vessels, relation of the
blood to, 463.
Lyon, Irving Phillips, the inoculation of
malaria by the mosquito, 266.
Lyons, William H., death of. III.
M
McBurney, Charles, resignation of, from
Roosevelt Hospital, 635.
MacCormac, Sir William, sketch of, 263.
MacDonald, John, death of, 959.
McFetridge, \\ illiam Cromwell, death of,
64.
Maclvor, Abbie Hamlin, death of, 2S3.
McKendrick, John Gray, notice of book
by, 653.
Maclagan, Sir Douglas, death of, 791.
McMurrav, Gerald J. M., death of, 328.
MacNichol, B. W., death of, 1128.
Maddox rod z's. phorometer, 329.
Mahe, Gustave, death of, ill.
Malaria and mosquitos, 119, 157, 266,284,
326, 332, 3S0, 422, 425. 550. 809.
812, 815, 916, 958, 1003, 1056, 1090,
1093 ; epilepsy in, 121 ; asstivo-au-
tumnal, 425 ; etiology of, 772 ; follow-
ing wound infection, 654; insanity in,
116; multiple gangrene in, 467; per-
nicious cerebral, in England, 331 ; pro-
posed renaming of, 791 ; study of, in
June 30, igooj
li\ L>»I1A..
1 149
Rome, 294 ; symptoms of multiple
sclerosis in, S57 ; treatment of chills
of, 12S.
Malignancy, 640.
Malignant growths, infectivy of, 119.
Malpractice, outline of the principles of,
i?6.
Malsbary, George E. , notice of book by,
3S1.
Malta fever, 465 ; serum diagnosis of, 331.
Mammary gland, eighty tumors of the, 596,
Managers and physicians, 366.
Manges, Morris, the diet in typhoid fever, r.
Mania a sero, 45S ; bromide sleep in the
treatment of, 200 ; ephemeral, 72 ; in-
fluenzal, 509.
Manila, health conditions in, 1085.
Marcet, William, death of, 559.
Marching flexion or bent-knee, 197.
Marine- Hospital corps, work of the, in
Havana. 473.
Marine-Hospital service, report of the,
279.
Marquis, D. S., death of, 239.
Marriage, consanguineous, and deaf-mut-
ism, 332 ; medical control of, 238, 417.
Martin, Thomas C. , notice of book by,
3S2.
Mason, Charles F. , smallpox in the Philip-
pines, 297.
Mason. Dr., death of, 560.
Mason. Samuel R., death of, 252.
Mastitis, suppurative, in the newborn, 27.
Mastoid and frontal sinus, associated dis-
ease of the, SoS ; disease following in-
fluenza, 377; disease in an epileptic
as a result of injury, 962 ; indication
for operation on the, Sig ; operations,
349. 430.
Mastoiditis, early surgical treatment of, 23.
Materia medica, work of the American
Pharmaceutical Association in relation
to, 24.
Maternal impressions, 1045.
Mathematical talent, 201.
Ma.xilla, dentigerous cysts of the superior,
891.
May, Charles H., a new simple ophthal-
moscope, 527.
Mayer. Abraham, note on the treatment of
chronic heart disease by the artificial
Nauheim baths, 914.
Mayo, W. J., lymphatic involvement in
cancer of the stomach, 92S.
Measles complicated with meningitis and
myelitis, 421; disinfection in, 513;
erythemas preceding, 70 ; German,
1053 ; vagus in relation to malignant
forms and complications of, 556.
Meat, deterioration of frozen, 976.
Meckel's diverticulum, a case of patent, 162 ;
inflammation of the, 1129.
Median nerve, complete section of the, 160.
Mediastinum, emphysema of the, in a case
of laryngeal diphtheria. 6S ; Oliver-
Cardarelli symptom in tumor of the,
464.
Medical and Chirurgical Faculty of Mary-
land, officers of the, S94.
Medical Association of the Greater City of
New York, 123,, 701, 8S1.
Medical courts of honor, 504 ; examina-
tions, Pennsylvania State. 416; li-
censure, reciprocity in, 235, 1127;
missions. Si 2 ; press, international
congress of the. 957; school of the
future. S15 ; societies in this country
founded prior to 1787. 199.
Medical Society of London, one hundred
and twenty-seventh anniversary of the,
560.
Medical Society of the County of New York,
81, 255, 4S1, 613, 835, 1006.
Medical Society of the State of New York,
205, 258; bureau of materia medica,
-23.
Medicine as a business proposition, 960 ;
common sense in, 246 ; lesson of the
history of, 120; training of natives in,
1085.
Medicines, classification of, 1055.
Medico-Legal Society, oflScers of the, 17.
Medico-Legal Society of Philadelphia, offi-
cers of, 237.
Mel-tna in duodenal ulcer, operative treat-
ment of, 72,
Melancholia, treatment of, 203.
Meltzer. S. ].. the pathogenesis of general
hjemachromatosis (diabetebronzej. 43.
Menges. Theodore, death of. 1015.
Meningism from helminthiasis, 916; lumbar
puncture in, 792.
Meningitis, cerebrospinal, due to the coli
bacillus, 453; etiology of cerebrospinal,
158; experimental tuberculous, 376;
Kernig's sign in, 2S6, 59S.
Menopause, angina pectoris at the, 512 ;
neuroses of the, caused by intestinal
fermentation, 73.
Menstruation and ovulation not indepen-
dent functions. 1099 ; vicarious, from
the stomach, 999.
Mental disease, blood pressure in, 644; dis-
order, thyroid extract in, 242; fatigue,
551 ; pathology at the end of the nine-
teenth century, 289.
Meralgia, paresthetic, 192. 336.
Mercury, idiosyncrasy against, 1054; in the
urine, estimation of, 157.
Messemer, Edward ]., dinner in honor of,
73s.
Mesenteric arteries, embolism of the, 730.
Mesentery, extirpation of a large cyst of
the. 116; operation for fibroma of the,
159; sarcoma of the, 1137.
Metabolism, influence of sugar upon, in
pregnancy, 120 ; influence of the diph-
theria and typhoid toxins on, 340 ; in-
fluence of the toxins of tetanus and
diphtheria on, 293.
Metatarsal bone, fracture of the fourth, 362.
Metatarsalgia, 426.
Metcalfe, Ernest G. , death of, 239.
Metritis, suppurative. 655.
Metropolitan Hospital, dismissal of the
house staff of the. 109.
Meyer, Willy, Bottini's operation for the
cure of prostatic hypertrophy, 705, 793.
Microbes, nature of. 1016.
Midwifery, a board of examiners in, 682 ;
regulation of the practice of, 366;
regulation of the practice of. in Great
Britain, 429. 559. 590, 651, S21.
Migraine. 513; mode of living for suffer-
ers from. 24S ; pathology of. 76; pre-
ventive treatment of, 1055; relation of,
to epilepsy, 71.
Military sanitary instruction. 1056: sur-
gery, use of Ji-rays in, 67.
Milk, discussion on, 255; famine in Syra-
cuse, 787 ; improvement in the supply
of, 548 ; infection carried in, 32, 156 ;
inspection of. by the New York board
of health, 460; laboratory, in in-
fant feeding, 117; products, bacterial
contents of, 287 ; sterilization of, and
intestinal putrefaction, 695 ■, sugar-
free, in diabetes, 132 ; supply at the
Kaiserin Friedrich Hospital, 105 1 ;
supply of New Y'ork, how it may be
improved, 230, 255.
Miller, H. T. , floating kidney mistaken
for an app>endicitis and ovarian tumor —
operation and recovery, 363.
Miller, Truman W., death of, 1015.
Miller. William, death of, 350.
Minchin. Humphry, death of. 252.
Mingle, L Leo, death of, in
Miscarriage complicated with appendicitis,
63S.
Missions, consolidation of medical, 151 ;
medical. Si 3.
Mitral stenosis, diagnosis of the degree of,
500.
Mivart, St. George, death of, 594, 743.
Mock. E. v.. vaccinella, 361.
Mole, uterine, loio.
Molluscs, poisoning by, 513.
Molluscum contagiosum, sodium ethylate
in, 114 ; fibrosum, unusual case of, 330.
Mongolism and cretinism, differential diag-
nosis of. in infancy, 114.
Mongolian imbecility in infants. iiS.
Montgomery County (Pa.) Medical Society,
officers of, 154.
Montgomery, Frank Hugh, notice of book
by, 735-
Moore. Henry B., death of, 373.
Moore. John William, knighthood con-
ferred upon, 103S.
Morphine poisoning. 27.
Morphinism among physicians, S96.
Morris. Robert T., the appendicitis ques-
tion, 16S, 432.
Morton. William J., is static electrifica-
tion a specific for organic and structu-
ral nervous disorders? 43, 294, 520,
674, 746.
Mosquitos and malaria, 119, 157, 266,
2S4, 326, 332, 380, 422, 42s, 550, 809.
812, 815, 916. 958, 1003, 1056, logo,
1093 ; bearing contagion in leprosy,
1133; metamorphosis of filaria in the
bod)' of, 24S ; mounting and preserv-
ing, 1 131.
Mould in the stomach, 1025.
Moullin, C. Mansell, notice of book by, 520.
Mt. Sinai Hospital, gift to. 725.
Mucincemia, role of, in experimental thy-
roprivia, 1S4, 304.
Mucocele in the newborn, 329.
Mucoid, colloid, and amyloid substances,
the chemical relationship of, 188, 304.
Mulhall. I. C, death of, iii ; resolutions
on the death of, 196.
Mulheron. Edward, death of, 686.
Mummy, anterior poliomyelitis in a, 844.
Mumps, orchitis of, 114 ; possibly antitox-
ic to rheumatism, 738.
Murphy's button, position of, in modern
medicine. 514. IC03.
Musser, John H., notice of book by, 566.
Miitter Lectureship of the College of Ph) -
sicians of Philadelphia, competition
for the next, 459.
Myalgia, treatment of, 75.
Myasthenia gravis pseudoparalytica, 50S.
Myelitis, analysis of cases of, 857; pathol-
ogy of acute, 816.
Myocarditis, 172; in infancy and child-
hood, 595.
Myomectomy per vaginam, 996.
Myo-cedema in pulmonary tuberculosis. 243.
Myositis, treatment of blenorrhagic, 571.
Myotonia congenita, 816.
Myxofibroma, excessive hemorrhage follow-
ing removal of a, from the ear, 925.
Myxcedema, 632 ; a case of, 203 ; brain
tumor simulating, 200; pathological
significance of, in mental and nervous
diseases, 293.
N
Nasvus. osteo-hypertrophic varicose- 335 ;
treatment of, 888.
Na?vus-cancer, S65.
Nagle, John T.. acting assistant surgeon
in the army, 561.
Nails in insanity, 1072 ; leucopathia of the.
377 ; of the human hand, 29.
Nancrede, C. B. , notice of book by. 122.
Naples, letter from, S6.
Narcolepsy, 337.
Narcotics, dangers from the use of. in
young persons, 998.
Nasal scissors for removal of the lower
turbinate, 1042.
Nash, E. B., notice of book by, 930.
Nassau, N. P., climate of, 472.
Nauheim, a new well at, 549 ; baths, arti-
ficial, 914.
Navy, changes in the medical corps of
the, 22, 64, III, 153, igf'. 23g, 283,
327, 372, 415, 460, 550, 5g4, 637, 68s,
7S9, S13, 894, 922, 95S, Ids, 1040,
10S9, 1 128.
Neck, gigantic lipoma of the, 164.
Necrosis of the frontal bone, treatment of,
731-
Nectrianin in cancer, 676.
Needle, migrations of a, 869.
Negro question, the, 681.
Negroes, dietary study of, 324.
Neisser, Professor, unwarranted experi-
ments by, 637.
Neoplasms, bearing of cellular specificity
on, 910.
Nephrectomy during pregnancy, 463 ; for
renal sarcoma, 286 ; primary, for rup--
ture of the kidney, 114 ; six cases of..
451.
II50
[June 30, 1900
Xephritis, acute, in typhoid fever, 243 ;
chronic interstitial in the young, 72 ;
heredity in chronic, 116 ; in chicken-
pox, 1034 ; in childhood, 733 ; influ-
enzal, in children, S59 ; mineral waters
in the treatment of, 163 ; renal func-
tion in chronic, 424 ; traumatic, 65 ;
without albuminuria in young children,
555-
Xephrolithiasis, glycerin in, 203 : ,v-ray
diagnosis of, 67.
Nephropexy, tetanus following, igg.
Nephro-ureterectomy, external, for tuber-
culosis, 25.
Nerve, sarcomatous neuroma of the popli-
teal, 766 ; section of a, restoration of
coordinated movements after, 421 ;
stretching, 376 ; suture of, with res-
toration of sensibility, 220 ; structure,
congenital lack of, logi.
Nervous diseases, age, sex, and season as
factors in, 206 ; diseases, functional,
employment-therapy of, 287 ; diseases,
gastro-intestinal tract in, 461 ; dis-
eases, importance of the early recog-
nition of certain, 329 ; manifestations
in diseases of children, 203 ; system,
action of halogens on the cells of the,
335 ; system, apparatus therapy in dis-
eases of the, 817 ; system, diagnosisof
traumatic injuries of the, 461 ; system,
effect of colored light on the, 263 ; sys-
tem, syphilis of the, use and abuse of
mercury and iodine in, 37.
Neuralgia, castor oil in the treatment of,
727 ; kryofin in, 339 ; of the face,
treatment, 165 ; of the trigeminal,
operative treatment of, 720.
Neurasthenia, logo; juvenile, io8g; na-
ture of, 469; rest cure of, 1041 ; treat-
ment of, 244.
Neuritis, hypoglossal, 6g ; peripheral, fol-
lowing chorea treated with arsenic,
33g ; sciatic, 163.
Neurology, surgical, 164.
Neuron and nerve plexus, modern concep-
tions of, 731 ; death of the, 656 ; rela-
tionship of, to disease of the nervous
system, 856 ; theory, a study of the,
72-
Neuroses and intra-abdominal diseases in
women, relation between, 1049 I intes-
tinal, 46g.
Newborn, antisepsis in the, 250 ; bathing
of the, 376 ; ophthalmia of the, 66,
201, 203 ; resuscitation of apparently
dead, by Laborde's method. 374 ; sup-
purative mastitis in the, 27 ; taking of
nourishment by the, 245.
New Jersey, vital statistics of, 306.
Newman, George, notice of book by. 382.
Newton, Richard Cole, dampness of the
soil as a factor in the production of
human tuberculosis, loSi.
New York Academy of Medicine, 34. 76,
J72.254. 341. 478, 5f'7. 656. 831, g67,
J134 ; section on medicine, 77, 174,
433. 605. 832, 1 109 ; section on obstet-
rics and gyniecology, 79, 304, 607,
970 ; section on surgery, 125, 388, 522,
69g, 1 1 36.
New York City, inquiry into the govern-
ment of, 413.
New York County Medical Association, 35,
2g8, 435, 610, 877.
New York Genito-Urinary Society, 723.
New York Medical Union, 25g.
New York Medico-Sui-gical Society. 170.
New York Neurological .Society, 3g ; offi-
cers of the, 63.
New York Pathological .Society. 301,385,
654, 883, 1008.
New York State board of charities, 413. 6S5.
New York State Conference of Charities
and Correction. 1126.
New York .State Medical Association, in-
corporation of the. 684.
New Zealand, letters from, 392, 1046.
Night sweats, treatment of, 726; terrors,
647.
Nipple, primary tumor- formation of the.
733-
Nirvanin, anesthetic properties of , 113.
Nitrous oxide, ansesthesia from, 437.
Norris. \Yilliam F., notice of book edited
by, 734.
Nose, angioma of the nasal passages, 240;
a new splint for the, 570 ; application
of the galvano-cautery to the, 959 ;
Asch operation for deviations of the
cartilaginous septum, 66 ; bullous mid-
dle turbinates, 868 : carcinoma of the
nasal passages, 240 ; correction of
deviation of the septum. S70 ; devi-
ated septum, pathological changes in
the unobstructed nostril, 640 ; disin-
fection of the, with certain essences
and essential oils, 6go ; encapsulated
bacilli in secretion from the, 160;
fractures of the, 7S1 ; hydrorrhcea
from the, 204 ; immediate and remote
effects of obstruction of the, 365 ;
maggots in the, 647 ; mucous polypi
of the septum, 544 ; obstruction of
the, in the new-born, 731 ; operations
within the, 197; perichondritis and
periostitis of the septum, of dental
origin. 334 ; red, the veil as a cause
of, 3S2 ; reflex irritability of the mu-
cosa in relation to narcosis. loiS;
relation of diseases of the, to life ex-
pectancy, 887 ; relation of membra-
nous inflammation of the, to diphtheria,
118 ; spontaneous discharge of cerebro-
spinal fluid from the, 259, 597 ; supra-
renal extract in diseases of the, 482 ;
surgery of the interior of the. 24. 213,
613 ; treatment of deflections of the
septum, 37S ; tuberculous perforation
of the septum, 55S.
Nurses, convention of trained, 813; in the
army, women as. 23S. 599.
Nutt, John- Joseph, pure foods and drugs,
563 ; reform in the ambulance system,
563; the sale of patent medicines,
1022.
O
Obesity, thyroid feeding in, 552, 727;
treatment of, 600.
Obstetric cases, management of, in private
practice, 11 30; tricyclic calendar. 25.
Obstetrics and gyn.ecology. misfortunes of
the congress of. 1039.
O'Callaghan. Thomas, death of, 22.
Odor records. 3g4.
G^^dema. angioneurotic, in infancy, 66;
malignant, 7tg; malignant, immunity
against, 131.
<lLSophagus. cancer of the, treated with
permanent cannula, 1091; diagnosis
of diverticula of the, 2SS. 644, 645;
dilatations and diverticula of the,
331. 554. 8S9 ; dilated, -v-ray diag-
nosis of, 67; epithelioma of the,
looS ; rupture of the, 742 ; rupture
of the, caused by vomiting, 1035; ski-
agram of a stricture of the, 741 ; stric-
ture of, 242 ; stricture of the, follow-
ing typhoid fever, 846 ; treatment of
cancerous stricture of the, 2g2 ; treat-
ment of cicatricial stricture of the,
467 ; varicose veins of the, 1009.
Ointments, medicinal applications of, 1054.
Old age. surgery in. 1064.
Oliver. Charles A., notice of book edited
by. 734-
Omega Upsilon Phi, a medical fraternity,
788.
Omentum, intra-abdominal torsion of the,
730 ; strangulated tumor of the. 390.
O'Neill, Joseph Alan, the prophylaxis and
treatment of gonorrhoea by methylene
blue. 49S.
Oophorin. influence on metabolism. 28.
Ophthalmia, gonorrhoeal, largin in. 819 ;
neonatorum, 66. 201. 203, 646 ; puru-
lent. 119; sympathetic. 161. 284.
Ophthalmic veins, dilatation of the. 640.
Ophthalmology, development of, in the
nineteenth century, 287 ; vasomotor
system, and importance of drugs
which act upon it. in. 24<j.
Ophthalmoplegia in tabes and Graves' dis-
ease, 296 ; tabetic, igg.
Ophthalmoscope, a new simple, 527.
Opiates, tolerance of the young child for,
365.
Opium, after-effects of the use of, in in-
fancy, 923 ; habit, bromide method of
treating, 1041 ; poisoning in an infant,
.334-
Optic chiasm, lesions of the, 514 ; neuritis
in children, 8Sg.
Orange (N. J.) Practitioners' Society, or-
ganization of the. 45g.
Orange peel, biological action of the essence
of, 500.
Orbit, traumatic varix of the, 46S.
Orchitis, acute, in an infant, 157; guaia-
col in, 33g ; of mumps, 114.
Organotherapy, S31, 1104; scientific es-
tablishment of, 27.
Organs, therapeutic problem of regenera-
tion of. 160.
Orleans Parish (La. ) Medical Society, offi-
cers of the, 19.
Orrhotherapy, discussion on, 610; notes on,
68 ; the present status of, loig.
Orthoform. antiseptic properties of, 245.
Orthopedic Hospital, the New York .State,
6S5 ; surgery, use of jr-rays in, 67.
Osborne, Joseph Davis, death of, 1015.
Osteo-arthritis, some clinical varieties of,
925. ^
Osteoclasis for correction of rachitic de-
formities, I log.
Osteomalacia, treatment of, 29.
Osteomj'elitis, acute, of the femur, 467 ;
multiple, in an infant, 73 ; of the fio-
ula with spontaneous casting off of the
entire bone, 339.
Osteopathy and the law, 347 ; in Georgia,
igi ; in Kentuckv, 104; in New York,
235.
Osteoplasty, secondary, 298.
Ostitis, typhoid, 74.
Oth.tmatoma, syphilitic, 863.
Otis, Fessenden Nott, obituary of, 959,
1073; resolutions on the death of,
1 134.
Otitis media, electrolytic dilatation of the
Eustachian tube in, 646 ; facial paraly-
sis complicating. g2 5 ; importance of
the early recognition of, by the general
practitioner, 212; in grave diseases of
infancy, 155; ossiculectomy in chron-
ic. 510; suppurativa, infectiousness of,
204 ; treatment of suppurative, in young
children, 924 ; thrombosis of the lateral
sinus and jugular vein following acute
suppurative, 508.
Otorrhcea, 15S; treatment of , 115.
Ovarian hydrorrhaa, intermittent, 511.
Ovaries, avoidance of exsection of the. in
connection with removal of diseased
tubes. 1069 ; cysts of the, 164 ; cyst
of the. impeding labor, removed by
posterior colpotomy, S18 ; cyst of the,
with twisted pedicle, in a young sub-
ject. 1092 ; cyst of the, with twisted
pedicle, mistaken for appendicitis,
305 ; dermoid cyst of the, in a child
of seven years, 10S4 ; degeneration of
the blood-vessels of the, 156; fibroma
of the, 80 : gangrenous dermoid tumor
of the. 655; ha;matoma of the. 7g;
internal secretion of the, 850 ; multi-
locular pseudomucinous cystadenoma
of the. 198; tumors of the, arising
from accessory suprarenals, 120 ; un-
usual tumor of the, 554.
Ovariotomy, double, in a girl, 766 ; for
functional nervous diseases occurring
during menstruation, 601 ; in the fifth
month if pregnancy, 30 ; in the Schauta
clinic, 291 ; per anum, 334.
Overstudy, 330.
Overton, Frank, the physician as a factor
in education. 320.
Ovulation and menstruation not indepen-
dent functions. 1099.
Oxycamphor. 515, 555.
Oxyurides, an adult infected with, 27.
Oz.-vna, etiology and operative radical treat-
ment of. 6go ; treatment of. 571.
Ozone, water sterilized by. 1023.
Paget, Sir James, death of, 167 ; obituary
of, 23.
J"'
d'-'y
"5'
Paget, Stephen, notice of book by. 928.
Pain, heart, causes of, 484 ; in the left hy-
pochondrium symptomatic of gas in
the colon, 6gi.
Pain-sense in animals and man, 263.
f^alate, motor innervation of the, gi6.
Palsy, turners', 423.
Pan-American Medical Congress, 1013;
committee on organization of the, 10S8.
Pancreas, diseases of the, 1092 ; history of
carcinoma of the, 115; primary car-
cinoma of the. loog.
Pancreatic digestion, 988.
Pancreatitis, acute, 511.
Pantaloni, J., notice of book by, 566.
Paraldehyde, association of, with chloro-
form, 719.
Paralysis, acute ascending, h^ematopor-
phyrinuria i\ 773 ; agitans. changes
in the skin in, 543; autotoxic, 249;
bilateral facial, 763; cerebral spastic,
192 ; epidemic, in children, 862 ; facial,
gi6; facial, complicating acute otitis
media, 925 ; family periodic, 837,
1044; general, of the insane, 599; gen-
eral, of the insane, etiology of, 722;
infantile cerebral, 997; infantile
pseudobulbar, 244; ischa:mic, 591,
960; lead, 200; of the serratus mag-
nus, isolated. 600; periosteal trans-
plantation of tendons in, 767; Pott's,
without changes in the cord, 2S8 ;
transitory spinal, 291, 466; trauma-
tic periodic, 244; unilateral progres-
sive ascending, 692; Volkmann's is-
chiemic, 156.
Paranoia, clinical notes on a case of, 960.
Paresis and pseudo- paresis, diagnosis of,
338 ; general, relation of. to tabes, 42,
129; leucocytosis in, 338.
Paris, American nurses in, 789; cleanliness
of, 175; letters from, 963, 1096; medi-
cal students in, 976.
Park.Roswell. notice of book edited by, 824.
Park, William H. , notice of book by, 520,
653-
Parotitis caused by the action of potassium
iodide, 288.
Partsch, Herman, seasickness and what to
do with it, 9S6.
Patella, congenital dislocation of the, 1093;
fracture of the, 285, 1063; operative
treatment of fracture of the, 469 ; su-
ture of fractured, 2S6; suture of frac-
tured, through the periosteum, 507 ;
treatment of fracture of the, 67, 474,
635; tuberculous ostitis of the, 762.
Patent medicines, sale of, 1022.
Pathological Society of Philadelphia, Ig,
152, 193, 282, 458, 548, 683. 788, 8g6,
957, 1126.
Pathology, new words and new conceptions
in, 159; progress and drift in, 397, 47S.
Patriotism, practical, 131.
Payne, William Anderson, surgical odds
and ends, 361.
Peck, Aaron Edgerton, death of, 460.
Pectoralis muscle, congenital defect of the,
244.
Pectoriloquy, 87.
Pedersen, Victor Cox, a means of account-
ing for gauze laparotomy pads, 408.
Peliosis rheumatica caused by traumatism,
loig; in a lymphatic child, 73.
Pelvic asymmetry, demonstration of, S55 ;
hematoma following labor, 113; or-
gans, surgery of the female, 74.
Pelvis, fracture of the. with rupture of the
urethra, 118 ; justo-major, as a factor
in the causation of perineal injuries,
285; measuring the, in the living wom-
an, 2g2 ; relation of deformity of the,
to lateral curvature of the spine, 1070.
Pemphigus, epidemic, 112; foliaceus. ()g5 ;
vegetans, 201.
Penis, cancer of the, 157.
Penrose, Charles B. , notice of book by, S23.
Pennsylvania, Associated Health Author-
ities of, 957.
Pennsylvania Society for the Prevention of
Tuberculosis, OS3.
Pennsylvania State medical examinations,
416.
Pentose, physiological chemistry of, 470.
Pentosuria, 769.
Peptone, albumose, nutritive value of, 383.
Pericarditis, rheumatic, 151.
Pericardium, adherent, 916 ; a method of
opening the, 510 ; chronic abscess of
the, 1017.
Pericardotom.y, 77.
Perigastritis adhiesiva, 158.
I'erineorrhaphy, 686.
Perineum, application for rigid, 75, 564 ;
operation for complete laceration of the,
607 ; rupture of the, in coitus, 2g, 435,
Periostitis, rheumatic. 5g7.
Peritoneum, disposition of the introvesical
pouch in cases of distention of the
vagina and uterus, 286 ; escape of
urine into the. 380 ; pathology of the
lymphatics of the, 336; pseudomyxoma
of the, 120 ; tuberculosis of the, 161.
Peritonitis, diiTuse septic, and the elevated
head and trunk posture, io2g ; opera-
tive-treatment of tuberculous, 77g; rela-
tive value of symptoms of, logo ; treat-
ment of dilTuse septic, 617; treatment
of exudative, IH3; tuberculous, 106S.
Pertussis, see ll'/ioopiiig-cough.
Pessary, use of the, 886.
Pes valgus, treatment of. 767.
Peters, W. H., a piece of chewing-gum in
the urethra, 825.
Perityphlitis in a hernial sac, 334.
Phagediena of the nose, eye, and face in
a syphilitic subject, 1092.
I^harmacists in the public services, 1 127,
Pharmacopoeia, U. S., for 1900, 1105.
Pharyngeal tonsil, death from operation on
the, in a subject of ha;mophilia, 5S8.
Pharyngotomy, subhyoid, for malignant
growth of the larynx. 374.
Pharynx, comparative anatomy of the,
'035 ; physiology of the, 277.
Phelps, Elizabeth Stuart, notice of book
by, 92g.
Philadelphia County Medical Society. 62,
152, 153, 192, 368, 416, 503, 594, 683,
788, 957.
Philadelphia Neurological Society, 20, 192,
457. 593. 723-
Philadelphia Pediatric Society, 18, 152,
368, 504, 683, 894, 1 1 26.
Philippine Association of Acting Assistant
Surgeons U. .S. A., 1039.
Philippines, a naval encounter in the, 6g8 ;
commission to study disease in the,
467 ; contract surgeons wanted for the,
237 ; health conditions in the, 504,
logo ; medical commission to the, 338 ;
smallpox importation from the, 2g7.
Phimosis, reflex neuroses from, 552.
Phlebitis of advanced phthisis, 877 ; pul-
monary embolus in, 42 1.
Phocas, Dr., notice of book jby, 520.
Phorometer vs. Maddox rod, 32g.
Phosphaturia. 164.
Phototherapy, 555 ; instrument for use in,
886.
Phthiriasis pubis, lotion for, 384.
Phthisiotherapy in Europe, 374.
Phthisis, diazo reaction in, 6go; formic
acid and the inhalation of formalin
in. 200; healed, iog3 ; open-air treat-
ment of, at home, 242 ; relief of vom-
iting in, 165; silver-nitrate injections
in, 25. 193; some new drugs in the
treatment of, 244; surgical treatment
of, 24; treatment of cough in, 165;
treatment of the night-sweats of, 75 ;
use and abuse of drugs in, 248 ; see
also ConsuiHption and Tuberculosis.
Physical examination, new method of, 511 ;
training in school and home, gsg.
Physicians, gratuitous services expected of,
366; outrages on, 82, 86; proportion
of, to the general population in the
United States, 1024.
Picric acid, eruptions caused by, 145.
I'ierson, William, death of, io8g.
Pilcher, Louis Stephen, degree of LL.D.
conferred upon, 1038.
Pillsbury, S. Burke, death of, io8g. ■
Pistol shots, marks produced by, Ii2g.
Pituitary body, extract of the, 1105; study
of the, 5og ; uselessness of, as a thera-
peutic agent, 1122.
Placenta, Dublin method of delivery of
the, 1093 ; fibrinous polypi of the, 425 ;
pra;via, air-emboli in, 334; prrevia in
twin pregnancy, 200, 420, g65 ; prce-
via, rupture of the uterus in, 420; re-
tention of the, for nine days, 510.
Placental tumors, 733.
Plague, a menace to the combatants in
South Africa, 147; bacillus of, 174,
304; endemic centre of the, 647, 767;
epidemic of, at Kolobovka, 29, 376;
fleas of rats and mice as conveyers of
infection to man, 455; Haffkine's
prophylactic serum, 509; in ancient
and modern times, 289; incubation
period of the, 1018; in the lower ani-
mals, g6i ; in various places, 21, 63,
108, 150, igs, igg, 23g, 283, 327, 372,
416, 425, 45g, 503 , 54g, 5g2, 637, 685,
724, 7go, 812, 8g2, 8g5, 921, 958, 1015,
1043, 1046, 1 1 25; notes on. 417;
pneumonia in, 331, 425; precautions
against. 234; preventive inoculation
against, 331 ; propagation of the, 1037;
quarantine against, at Suez, 67 ; visit to
the infected districts in India, 241.
Plantaris muscle, rupture of the, 923.
Plaster-of-1'aris jacket, life of a, 965.
Pleura, friction sound of the, 330; hyda-
tid cyst of the, 335.
Pleurisy, interlobular purulent, 691.
Pneumatha-mia. 333.
Pneumatic cabinet in tuberculosis, 1129.
Pneumatic therapy from 1875 to 1900, 287.
Pneumatocele, 444.
Pneumococcus, toxins of, 251.
Pneumography, clinical, loig.
Pneumohx'mothorax, idiopathic, 5g6.
Pneumohydrothorax with displacement of
the heart, 595.
Pneumonia, 118, 119; antitoxin of, 611;
bilobar, with purulent pericarditis, 77;
chronic, 923 ; chronic interstitial, in-
duced by stone dust, 112; contusive,
513; disturbances of the sympathetic
system in, 1035 ; Dover's powder in,
1131; family epidemic of, 505; his-
tory of the treatment of, 164; in
children, 277; in a young infant,
1132; orrhotherapy of , i6g, ggi ; path-
ogenesis and prophylaxis of, 248 ;
pathogenesis and treatment of, in the
light of the newer pathology, 207 ;
pathology, etiology, and treatment of,
469. 816; plague, 331, 425; relation
of, to pulmonary tuberculosis. 337;
salicylates in the treatment of, 792;
serum treatment of, 34S, 431 ; surgical
aspects of, 337; treatment of, 16, 337,
383; treatment of acute lobar, 678;
treatment of croupous, 1103.
Pneumothorax, 76S. iiog; acute surgical,
intralaryngeal insufllation for the relief
of, 1017; complicating whooping-
cough, 1044; etiology of tuberculous,
115; in healthy persons, 740, 1021 ; in
secondary sarcoma of the lungs, 163.
Poisoning by acetanilid, 552; aconite, 33;
belladonna, 554; belladonna, from ex-
ternal application, 68 ; boric acid, 383;
brass, 1043; carbolic acid, g6; car-
bolic acid, in an infant, 647; carbon
monoxide, 641 ; castor-oil seeds, 332 ;
chloral, 412; cocaine, 600; corrosive
sublimate, 157; creolin, 156; creso-
* line, 863 ; eucalyptus, 243 ; iodoform,
in an infant, 638 ; lead, 27; morphine,
27; opium, in an infant. 334; ptomain,
ig5. igS; salicylate of sodium. 114,
243, 286; snake-venom, g6S.
Poisons, general antidote for, 165.
Poliencephalitis, acute hemorrhagic, from
influenza, 246; combined superior and
inferior, 240; in an adult, 597; su-
perior. 244.
Poliomyelitis, acute anterior, in a youth of
seventeen years, 6g2 ; acute anterior,
of adults, 112; acute anterior, of in-
fectious origin, in an adult, 817.
Polyarthritis chronica villosa and arthritis
deformans. 422.
Polyclonia and chorea. 30.
Polydactylism, 65.
Polypus, nasal and postnasal, 157.
II52
INDEX.
[June 30. 1900
Polyuria and pollakuria. hysterical, 557.
Pony, Montana, climatic advantages of, 198.
Poor, housing of the, 59.
Porro's operation, a case of, 733.
Position and presentation, definition and
application of the terms. 640.
Potatoes in the diet of diabetics, 247.
Pott's disease, anterior siipport in, 1070;
of the cervical region with brachial
paraplegia, 202 ; or fracture of the ver-
tebr,-e, 243.
Poultices, use and abuse of, 241.
Practitioner, general, requisites of the mod-
ern. 614.
Practitioners' Society of New York, 342,
476. 739. 932-
Pregnancy and labor, anatomy of, S51 ; ex-
tra-uterine, 164, 2S9, 60S, 639. 1129;
extra-uterine, chorion epithelium and
deciduain, 446; extra-uterine, diliferen-
tial diagnosis of, 76S ; extra -uterine, fol-
lowing attempted abortion in the early
weeks of gestation, 360; extra-uterine,
following cervical dilatation for the
cure of sterility, 305 ; extra-uterine,
normal pregnancy after operation for,
29 ; extra-uterine, pain as a symptom
of, 727; extra-uterine, treatment of,
29I ; extra-uterine, vaginal operations
in cases of, 733 ; extra-uterine, with un-
usual symptoms, 79 ; interstitial, 250 ;
multiple, 2S9 ; pernicious vomiting
of. 924 ; recurrent tubal, 683 ; simul-
taneous extra- and intra-uterine, 4S4,
511; stump. 1017 ; treatment of hem-
orrhage in, 164; treatment of tumors
complicating, 971 ; toxaemia of, 970.
Pregnant women, the physician's duty to,
before labor, 203.
Prendergast, Inspector-General, death of, 42.
Preservatives in food, influence upon the
health of, 351 ; use and abuse of. 243.
Priestly, Sir William Overend. death of.
686, 791.
Prince, Christopher, death of, 416.
Prior, Israel, death of, 460.
Prize for essay on tropica! army ration,
award of the, 549 ; medal, award of
the Senn, 1000; medal of the Ameri-
can Medical Association, award of the,
1000 ; Osiris, 20 ; Samuel D. Gross, of
the Philadelphia Academy of Surgery,
457-
Proben, Charles J., some remarks on the
ireatment of syphilis, 5S2.
Professions, relative earnings of the, 786.
Prostate, affections of the, in young men,
588 ; Bottini's operation for hypertro-
phy of the, 705, 793, 927 ; cancer of
the, 873; deformities of the, due to
loss of tissue, 872 ; operation for can-
cer of the, 731 ; treatment of abscess
of the, 121,378; treatment of gonor-
rhoea! affections of the, 30; treatment
of hypertrophy of the, 24, 1062 ; treat-
ment of tuberculosis of the, 648 ; vas-
ectomy in hypertrophy of the, 339.
Prostatectomy, 1029; perineal, 560, 598;
suprapubic, 1 1 7.
Prostatitis, 247.
Prostitution, the question of legal control
of, in America, 57.
Prudden, T. Mitchell, progress and drift in
pathology, 397, 478.
Pruritus, treatment of, 556.
Psoriasis, glycosuria associated with, 200 ;
oil of cade baths in, 1044 ; primary le-
sion of, 340 ; treatment of, 202, 3S4,
572-
Psorospermosis, generalized, 691.
Psychic insult, death from, 6S7 ; therapeu-
tics, 1 105.
Psychology, heredity in, 418.
Ptomain, paralysis caused by, 249 ; poison-
ing, 1 95, igS.
Ptosis, intermittent hysterical, 204.
I'ublic health, effect of summer heat upon,
9S4, 1007.
Public service against private work, 651.
Puerperal eclampsia, 74, 246; infection,
analysis of fifty-seven cases cf, 420;
infection, antistreptococcus serum in,
420; infection, management of, 2M;
infection, medical treatment of, 383;
insanity, lo; mania with albuminuria,
339: sepsis, 74; sepsis, antistrepto-
coccus serum in, 120, 641 ; tetanus,
425.
Puerperium, effect of vaginal irrigations
during labor on the, 200 ; nursing
during the, 161.
Puerto Rico, medical practice in, 417; re-
lief work in, 150.
Pulmonary artery, thrombosis and fat em-
bolism of the, 883.
Purpura hajmorrhagica, iioo; etiology and
pathological anatomy of, 293 ; visceral
affections related to, 515.
Purrington, William H., notice of book by,
653-
Pus organisms, role of, in skin diseases. 247.
Pustule, malignant, bacteriological investi-
gation of a case of, 68,
Pyelonephritis, 7S2, 783.
Pyle, Walter L., notice of book by, 653.
Pylorectomy, 376, 8S1 ; technique of, 691.
Pylorus, benign obstruction of the, S44 ;
congenital hypertrophy of the, 1 76.
600 ; gastro-enterostomy for cancer of
the, 1017.
Pylorus, stenosis of the, 305, 11 10; steno-
sis of the, following corrosion by lye,
465 ; stenosis of the, in infancy. 731.
Pyosalpinx complicating uterine myoma,
291 ; removal of, in the early puer-
perium, 339; retroperitoneal drainage
of, 298.
Pyramidon. therapeutic uses of, 1 17, 244.
Quackery, reason for the success of, 87.
Quadriceps tendon, sphere of the, 766.
Quarantine, national, 785; regulation to
insure safe scientific passenger traffic
from an infected locality to a non-
infected one, 219.
Quenu. E., notice of book by, 566.
Quinine, intramuscular injections of, 249;
manufacture of, in Bengal, 87 ; palat-
able effervescing, 165.
R
Rabies, diagnosis of, 842 ; diagnosis of, in
the dog, 888; epidemics of, 548, 550;
histological diagnosis of, 556 ; in New
York City, 832 ; inoculations against,
in Berlin, 36S ; post-mortem diagnosis
of canine, S20.
Rain baths, 1023.
Railway carriages, disinfection of, in Ger-
many, 132; hygiene, 329.
Ramsay, William R., death of, 922.
Rankin, Egbert Guernsey, notice of book
by, 1020.
Ransom, J. B., rain baths, 1023.
Ranula, bilateral intermittent, 201 ; con-
genital, 556.
Ration, candy in the army, 616; the trop-
ical army, 593.
Ray fungi, characteristics of the, 959.
Raynaud's disease, a case of, S24; diag-
nosis of, 98S; symptoms of, in a case
of acromegaly, 6g.
Reciprocity in medical licensing, 235, 1127.
Recta! prolapse, treatment of, 925.
Recto-genital irrigating tube, 350.
Rector, Joseph M., an interesting case of
labor complicated by utero-abdominal
fixation, 41 1.
Recto-vaginal hasmatoma, 27.
Recruits incapacitated by a physician, 591.
Rectum, aljsorption and metabolism in
feeding by the, 602 ; acquired non-
malignant stricture of the, 47, 81;
adenoma of the, 7 ; backache as a
symptom of disease of the, 766 ; de-
formity of the, 243 ; etiology of non-
malignant stricture of the, in women,
240; feeding by the. in children, 157 ;
imperforate, treatment of, 286 ; prac-
tical notes on disease of the, 23 ; pro-
lapse of the, in children, 467 ; resection
of the, 699, 962 ; treatment of ulcera-
tive stricture of the, 424.
Red Cross, masquerading under the insig-
nia of the, 725 ; work of the, in the
Philippines, 282.
Reeves, Josiah, death of, 64.
Reflexes, clinical study of the, 780 ; deep,
of the lower extremities, diagnostic
value of, 639; superficial and deep,
642 ; toe, 888, 11 12.
Refraction, relation of facial spasm to
errors of, 71 ; the past and present of,
716.
Relapsing fever, a case of, 1 12.
Remington, Joseph P., notice of book by,
565.
Resonance, cracked-pot, 121.
Respiratory reflex, 159; and lingual trac-
tions, 335.
Retina, concussion of the, 157; glioma of
the, 465 ; recurrent, hemorrhage of,
342.
Retropharyngeal abscess of auricular ori-
gin, 204.
Rhachischisis, 861.
Rheumatic and neuropathic states, 767 ;
gout, 418.
Rheumatism, 1057; acute inflammatory,
204, 32S; balneotherapy in chronic,
374; cerebral, 113; chronic articular
in childhood, 470 ; chronic vertebral,
175,630; dietetic treatment of, 552;
discussion on, 603, 605 ; electricity in
chronic, 674 ; hot-air treatment of, 462;
muscular, 529; treatment of, 554, 5S5,
605, 643 ; treatment of gonorrhoea!,
247.
Rheumatoid arthritis, excretion of nitro-
gen in, 889; gout and rheumatism,
the distinguishing features of, 925;
pathology and treatment, 925.
Rhinitis, acute, 544 ; atrophic, 782 ; recur-
ring membranous, due to Friedlan-
der's bacillus, 782 ; treatment of hy-
pertrophic, 380.
Rhinoplasty, Israel's method of. 513.
Rhinoscleroma, 866.
Ribard, Elisee, notice of book by, 520.
Richards, Ellen H., notice of book by, 566.
Rickabaugh, Jacob, death of, 826.
Rickets, 46S, 960; changes caused by, in
the growth of the epiphyseal cartilages,
1045; enlarged liver in, 162; three
symptoms of, 1132.
Riding-pain in the patella. 512.
Ringworm of the scalp, treatment of, 1093.
Rinne and Gelle tests, 925.
Robinson, A. R., observations on the
treatment of cancer, 535.
Robinson, Byron, notice of book by, 735.
Robinson, William V., death of, 726.
Roche, Thomas Francis, death of, 686.
Rockwell, A. D., the static induced current,
130, 396.
Rodent ulcer, formalin in, 243.
Rodgers, Lyman, death of, 154.
Rodman, William W., death of, 595.
Roentgen ray, avoidance of the harmful
effects of the, 521; burns from, 508,
647 ; diagnosis of urethral and renal
calculi by the, 336 ; depilation by, 243 ;
error in examination by, 65, 1061 ; in
pregnancy, 704 ; in the treatment of
sarcoma, 112; limitations and value
of examinations by the, 65 ; medical
employment of, 67 ; severe injury from
the, 180 ; surgical cases illustrated by,
554 ; treatment of lupus by the, 887 ,
usefulness of, 601 ; value of, in dis-
eases of the chest, igS; value of, in
fractures, 202.
Roentgen Society, foundation of a, 956.
Roentgen, Wilhelm Conrad, award of Bar-
nard medal to, 922.
Rogers, Philip F., a remarkable case of
chloral poisoning, 412; osteopathy
and the law, 347.
Rome, Anglo-American nursing home in,
456.
Rose, A., the nomenclature of appendici-
tis, 130.
Rotheln, 1053.
Royal College of Surgeons, centennial of
the, 166.
Rumination, 552, 1045.
Russia, corporal punishment in, 375; lim-
iting the output of physicians in, 369.
June 30, 1900]
INDEX.
i'53
Sachs, B., two cases of tumor pressing
upon the cauda equina, removal, re-
covery, 7, 40.
Sadtler, Samuel 1'., notice of book by, 565.
Sailors, sanatoria for, 279.
de Saint Blaise, G. Bouffe, notice of book
by, 530.
St. John's Guild, gift to the. 805.
St. John's Long Island City Hospital,
opening of the, 64.
St. Luke's Hospital, changes at, 550 ; new
superintendent of, 896.
St. Vincent's Hospital, association of the
alumni of, 1087 ; case of Ward against
the, 1013.
Salicylic acid, endermic application of, 1 27.
Salicylate of soditim, poisoning by, 1 1 4,
243, 2S6.
Saliva, influence of, on gastric digestion,
33^-
Salivary calculus, 417, 465.
Salivation, reflex, from abdominal disor-
ders, 694.
.Salophen, therapeutic value of, 244.
Salpingitis, 1068.
Sanatozon, 555.
Sanatoria for consumptives in New York
State, 194; for sailors, 279.
Sanatorium treatment of tuberculosis, 1094.
Sane, imperative ideas in the, 779.
Sangue, Ernest Brewster, death of, 372.
Sanitation, sensational, 659.
Sarcoma, mixed toxins in the treatment of.
613; of the colon, 1064; of the sphe-
noidal sinus, removed without return
after 3 J years, 699 ; of the stomach in
a child 35 years old, 131 ; of the tibia,
523 ; recurrent spindle-cell, success-
fully treated with the mixed to.xins,
T25; spontaneous disappearance of a,
694; treatment of, by cataphoric
sterilization, 587; jr-ray treatment of,
112,
Sarcomatosis, extra-visceral, 645.
Satterthwaite, Thomas E., non-malignant
gastric and duodenal ulcers, with illus-
trative cases, 4S5.
Savill, Thomas U., notice of book by, 3S2.
Scalp, suppurative folliculitis of the, 982;
unusual form of tumor of the, 866.
Scaphoid bone, fracture of the. S87.
Scapulr , removal of the shoulder girdle for
sarcoma of the, 245.
Scarlet fever, 656; experiments in, 960,
1129; lymphatic glandsin,74; micro-
organism in, 373 ; rash of, 1053; treat-
ment of, 127 ; without eruption, 114.
Scarlett-Dixon, Mary J., death of, 239.
Scattergood, Dr., death of, 559.
Schenk, S. L., deposed from the chair of
embryology at Vienna, 63.
Schminkey, L F., death of, 373.
School, breakdowns in, iioo; hygiene of
the, 241 ; alleged dereliction of the
health board in relation to the, 787;
medical inspection of, 61, 1 58, 2S4;
psychiatry in the, 334 ; visual defects
acquired in, 155.
School children, measurements of, 861.
Schott, Th., on the treatment of fatty
heart, 490.
Schroder, Ernest, death of, 11 1.
Schuylkill County (Pa.) Medical Society,
officers of the, 61.
Sciatica, 163 , mechanical treatment of,
202, 601 ; treatment of, 763.
Sciatic nerve, tensile strength of the. 241.
Science, an international association for
the advancement of, 546.
Scientific investigation, position of the
universities in regard to, 66.
Sclerosis, lateral, 11 22: multiple, 858;
multiple cerebrospinal, 338; multiple,
with symptoms of progressive muscu-
lar atrophy, 39.
.Scoliosis, 1069 ; in an infant, 558 ; nervous
affections related to, 527.
Scorbutus, IIOO, mo.
Scurvy, cause of, 926; experimental in-
quiry into, 817; infantile, 73, 112;
land, 245.
Scurvy-rickets in a boy, 26.
Sea air and sea baths, therapeutic uses of,
092 ; biliousness induced by. 204.
Seasickness, death from. 141!; treatment
of. 9S6, 1097 ; kola in, 34S.
Seminal vesicles, treatment of gonorrhceal
affections of the, 30.
Senile bronchitis, 768.
Senility, MetchnikofE's serum against, 148,
161.
Sepsis, puerperal, 74.
Septicaemia, puerperal, antistreptococcus
serum in, 1043,
Serous membrane.s, inflammation of, 465.
Serpents, poisonous, of North America,
204.
Serum treatment, discussion of, 610; notes
on. 68; of pneumonia, 34S.
Sex, determination of. 374.
Sexual function, correlation of. with in-
sanity and crime, 330, 733 ; relation of
the, to insanity and crime in women,
251.
Shakespeare, Edwin O., death of, 1015.
Shaw, Henry L. K., the tonometer, a new
instrument to determine the amount
of blood pressure, 181.
Shaw, John Cargill. death of, 155 ; resolu-
tions on the death of, j^ji.
Sherwell, S., the use of arsenic, etc., in
cancerous and other malignant neo-
plasms, 744.
Shock, hypodermoclysis in. 41S; surgical
significance of, 507.
Shoulder, congenital dislocation of the,
331, iioS; easy method of reducing
dislocations of the, 356.
Shultz, R. C, a peanut in the air passages,
360.
Shuttleworth, G. E., notice of book by, S24.
Sickness, cost of, 220.
Siegfried, Charles A., death of, 1 1 1.
Sigmoid flexure, gangrenous perforation of
the, 298; treatment of sliding hernia
of the, 309, 343.
Sigmoidoscope, pneumatic. 1 56.
Silver catgut, 373; wire as suture material,
68 1.
Singers' nodes, sequela; of. 69.
Sinus, frontal, empyema of the, 639; fron-
tal, ethmoidal, and sphenoidal, abscess
of the, 155; frontal, growth in the,
ir64; frontal, suppuration of the,
245 ; of the head, negative politzeri-
zation of the, 203.
Shell, injuries produced by a si.^-pounder
Hotchkiss, 1 14.
Skiameter, 67.
Skin, ab.^rption through the unbroken,
iot;4; cancer of the. S64 ; certain dis-
eases of the, with unusual features,
509; changes in the, in paralysis agi-
tan.'!, 543 ; diseases of the, acconipany-
iog diabetes, 1059; diseases of the,
catalectrolysis in, 112; endothelioma
of the, 819; eruption on the, in infec-
tious diseases of the digestive tract,
925; influenzal eruption on the, 201 ;
ieuka;mic lesions of the, 72; parasitic
diseases of the, necessity of limiting
the spread of, S64 ; ;jermeability of the,
in warm-blooded animals, 484 ; resist-
ance of the red corpuscles in some
diseases of the, 376: role of pus or-
ganisms in diseases of the, 247.
Skin-flaps, transplantation of, without ped-
icle, 28.
Skin grafting, suit to recover damages for,
325-
Skull, compound depressed fracture of the,
27; punctured wound of the, 598;
tuberculosis of the flat bones of the, 73.
Sleep, the bromide, 200.
Sleeping-apartments, hvgiene of children's,
647.
Sleeplessness, 547.
Sloane Maternity Hospital. Society of the
Alumni of, 813.
Smallpox and chickenpo.x, 18, 150; bichlo-
ride baths in, 764 ; diagnosis of. 721 ;
during pregnancy, 598 ; facts observed
in an outbreak of, at Essex, 280; in-
jection of gelatinized serum in hemor-
rhagic. 70; in various places, 237, 23S,
282, 297, 326, 415. 54S, 7SS, 811, 957,
1088; pseudo- or modified, 1002 ; salol
in the treatment of, 114, 391, 1035,
1042.
Smegma bacillus, 764.
Smith, -Andrew H., serotherapy in pneu-
monia, 348.
Smith, Charies CaiTolI, death of. 283.
Smith, Edwin M., death of, 595.
Smith. Stephen, form of legislation which
will enable cities, towns, and villages
in the State of New York to establish
hospitals for the treatment of tuber-
ctilosis, 252.
Smith, AVickliff, death of, 22.
Smith. William L., death of, 4S0.
.Smoking among the young, 821.
Snake-bite, antivenene in, 26; treatment
of, 1075; yellow vision after, 836.
Snake poisoning, chemistry, toxicology,
and therapy of, 204,
Snake-venom, 968 ; nature and action of,
33-- ,
Snow, William Benham, the application of
the electrostatic wave current, 359.
Society for the Prevention of Cruelty to
Children, legal status of the, 237.
Sociological status of the physician, 826.
Somberger, S. J., transposition of vital
organs, 738.
South Africa, diseases of, 599; war in,
see Boer -i'ar.
Spasmus nutans, 240.
Species, improvement of the, 2S4.
Specimens, moist anatomical, mailing of,
696.
Spermatozoa, a specific immunizing serum
against, 333.
Sperminum, 3S4.
Sphenoid, fatal suppuration of the, 557.
.Sphygmograph, clinical uses of the, 34,313.
.Sphygmomanometer, tests of the, 769.
Spinal cord, bullet wound of the, 780;
concussion of the, 164; lesions of the
lower end of the, 1060; pathology of
the lower part of the, 249; syphilis of
the. 153; traumatic hemorrhages into
the, 573 ; tumor of the, 858.
Spinal curvature, forcible correction of,
1 105.
Spinal perimeningitis, 1044.
Spinal roots, section of the posterior. 857.
Spine, congenital lateral curvature of the,
162: distortion of the, 639; fracture-
dislocation of the, 88 7 ; fracture of the,
26, 353 ; movements of the normal,
1069; progressive ankylotic rigidity of
the, 336 ; rheumatism of the, 175; scle-
rosis of the, 117; surgery of the. 651 ;
scorbutic, 11 06; tuberculosis of the,
1 106; typhoid, 596.
Spitting nuisance in Brooklyn, 685 ; regu-
lations to abate the, 893.
Spleen, double, 302; excision of the, 243;
hypertrophy of the, difficult of expla-
nation, 932; shape and relations of
the, 259.
Splenectomy. 24, 1090, 1094.
Splenic anaemia complicated by diabetes
mellitus, 24; extract and the splenic
function, 273; pseudoleukasmia, 764.
Splints, expanded metal for, 543.
Spondylitis deformans. 161 ; rheumatic,
630; rhizomelic, 192. 424, 640.
Sponges, sterilizing, by boiling, '122.
Sporothrix, a new pathogenic fungus, S29.
Sprains, 9S8.
Sprue, treatment of, 339.
Squire, C. L., the Morton-Rockwell discus
sion, 562.
Stacke's operation.eighty consecutive cases
of, 33^-
Staining-forceps, a new, 198.
Staphylitis, 197.
Stark, Dr.. death of, 42.
Static induced current, 1 30, 562, 746.
Slatus epilepticus, 367.
Stave of thumb. 887.
Steam, gynaecological application of. 425. ■
haemostatic action of, 474 ; .sterilizing
properties of unconfined superheated,
286.
Stercor.x-mia following delivery, 1 16.
Sterilization of the hands, 1092.
Stevens, A. A., notice of book by, 735.
II54
INDEX.
[June 30, 1900
Stewart, Sir Thomas Grainger, death of,
236, 392.
Stickler Memorial Library, 336, S95,
Stimson, Lewis A., an easy method of re-
ducing dislocations of the shoulder and
hip, 356.
Stoeckel, Gustav Mozart, death of, 327.
Stomach, absorption and fat-splitting in
the, 423 ; acute dilatation of the, 242 ;
auto insufflation of the, 242; cancer
of the, 479, 774; cancer of the, in-
creased hydrochloric acid in, 206 ; can-
cer of the, in the young, 72S; cancer
of the, invasion of the lymphatic sys-
tem in, 335; cancer of the, involve-
ment of the anterior abdominal wall
in, 28 ; cancer of the, lymphatic in-
volvement in, 92S ; cancer of the, study
of the blood in, 924; case simulating
perforating ulcer of the, 836 ; circum-
scribed cancer of the, 464; condition
of the, in early tuberculosis, S76; con-
genital hypertrophy of the pylorus.
176; diagnostic significance of the di-
gestion of carbohydrates in hyperacid-
ity, 1018; dilatation of the, 336, 845;
early diagnosis of cancer of the, 242,
889; electrization of the, 242 ; excre-
tion of pepsin in disease of the, 291 ;
exploratory operation for dilatation of
the, 420; extirpation of the, 241, 242;
fatal parenchymatous hemorrhage of
the, 1019; gastrectomy for adenocar-
cinoma, 179; gastrectomy for cancer,
467; gastro-jejunostomy for ulcer of
the, 509; hour-glass, gastro-duodenos-
tomy for, 375 ; indications for surgical
interference on the, 242 ; intermitting
hypersecretion in the, 553 ; latent can-
cer of the, 241 ; lavage of, preceding
gastro enterostomy, 600 ; method to
determine the absorptive power of the,
461; motivity of the, 242; mould in
the, IC25; neurosal conditions involv-
ing excessive secretion of the gastric
juice, 71 ; nitrate of silver in hyper-
chlorhydria, 66 ; non-malignant ulcers
of the, 4S5 ; operative treatment of
dilatation of the, 246; pathological
anatomy of cancer of the, 770 ; perfo-
rating ulcer of tlie, 68, 112, 199, 509;
perforation of the, by a toothpick,
loio; perigastritis adhssiva, 158;
physical examination of the, 24; re-
moval of a hairpin from the, 26 ; re-
section of the, 645 ; sarcoma of the, in
a child three and one-half years old,
13! ; secretion of hydrochloric acid in
the, with various food-stuffs, 163 ; sur-
gery of the, 213, 510, 553, 598, 821,
844, S46, 992 ; surgery of ulcer of the,
693 ; surgical aspects of dilatation of
the, 285; surgical treatment of cancer
of the, 333; symptoms in disorders of
the, 924; syphilis of the, 241, mi;
treatment of hemorrhage from the,
999; treatment of perforating ulcer of
the, 129; treatment of ulcer of the, si 4;
ulcer of the, 241, 242, 379, 774; ulcer
of the, case simulating, 766; ulcer of
the, in pregnancy, 598; vertical, 242.
Stomach-tube, observations with the, in
infants, 292 ; uses of the, 467.
Stomatitis and pseudomembranous angina
in pneumonia, 121 ; gangrenous, anti-
streptococcus serum in, 330 ; treat-
ment of mercurial, 165.
Stonham, Charles, notice of book by,
735-
Stools of nurslings, bacilli in the, 334 ;
washing dysenteric, 694.
Storrs, Melanchthon, death of, 1040.
Strabismus, non-operative treatment of,
206.
Streptococcus, a peculiar, 842, ion; se-
rum, 612.
Streptomycosis, orrhotherapy of, 695.
Stricture, urethral, 379; urethral, massage
for, 564 ; urethral, the urethroscope in.
117.
.Strong, Albert B., death of, 506.
.Stuart, William Henry, death of. 686.
.Stuttering, principles of treatment of. 378.
Subclavian artery, ligature of the, for
aneurism, 688; vein, ligation of the,
for an arteriovenous fistula. 699.
Subphrenic abscess, 221.
Sugar, fermentation of slowly fermenting,
163 ; formation of, from albumin, 28 ;
influence of, on metabolism in preg-
nancy, 120.
Sulphonal, large dose of, 200.
.Summer, care of children during the, 1 1 23 ;
heat, effect of, upon the public health,
9S4, 1007.
Summers, John E., Jr., notice of book by,
734-
.Sunstroke, pathology of, 1 1 34.
Superfostation, a case of, 212.
.Suprapubic fistula following lithotomy in a
prostatic subject, cured by Bottini's
operation, 699.
Suprarenal body, hematoma of the right,
1008; extract, 1 105; extract, hemor-
rhage following the use of, 868 ; ex-
tract, physiological properties of, 481 ;
gland substance in asthma, 886; gland
substance in hay fever, 886.
Surgeons, acting assistant army, com-
plaints of, 456.
Surger}', relation of the clinical laboratory
to, 212; review of, for the past cen-
tury, 615.
Surgical operations, details in the care of
patients during, 1041.
Suter, William Norwood, notice of book
by, 520.
Suture, silver wire as a material for, 681.
Swimming, hygienic effects of, 163.
Sympathectomy in glaucoma and optic-
nerve atrophy, 1017.
Sympathetic, diseases of the thoracic. 1031 ;
ganglion, surgery of the superior cer-
vical, 374.
Symphysectomy, a successful, 374.
Symphysis pubi.s, rupture of the, 1 1 5.
Synovitis, treatment of acute serous, per-
mitting of joint motion, 198.
Syphilis, 966; acquired, in a child, 114;
congenital, the offspring of the sub-
jects of, 103: curability of. 695 : from
dental instruments, 197; hypodermic
injection in, 157, 165, 572; in early
life, 117; inhalation treatment of, 200;
inoculation wound of, 445; interest-
ing case of, 765 ; Justus blood test
for, 174, 641 ; of the brain and spinal
cord. 28; of the heart and liver, 26;
of the nervous system, use and abuse
of mercury and iodine in, 37; of the
spinal cord, 153 ; oth.-ematoma due to,
S63 ; peculiar features in cases of, 729 ;
prophylactic treatment of, 29; rela-
tion of, to life insurance, 205 ; treat-
ment of, 75, 582 ; wheal type of lesions
of, 866.
Syphiloderma, hemorrhagic. 720. .
Syria, letter from, 393.
Syringomyelia, hereditary, 516; trauma of
the cervical region of the spinal cord
simulating, 336.
Tabb, Sherrard R., death of, 922.
Tabes dorsalis, 541, 1092; and general
paresis, 129; a rare complication of.
544; eye symptoms in, 509; instruc-
tion in co-ordination in, 506 ; organo-
therapy in, 961 ; ophthalmoplegia in,
199; recovery of a supposed case of,
285 ; relation of, to general paralysis,
42 ; sensory crises in, 769 ; spinal
stretching in, 112; Thomsen's disease
with, 1 17 ; with bulbar symptoms, 509.
Taenia and chorea, 343 ; black, 645.
Talmey, B. S., chorion epithelium and de-
cidua in tubal gestation. 446.
Tannopin as an intestinal astringent. 730.
Taxation of medical practitioners in Tur-
key, 724.
Taylor, David N., death of, 594.
Teeth, anomalies of the, 976.
Telephone, partial paraly.sis of the vocal
cords from overuse of the, 869.
Temperance congress in London, 1039.
Temperature in psychopathic states, diag-
nostic importance of the, 340; the
border line of normal, 163.
Temporal bone, suppurative disease of the,
925.
Temporo-maxillary ankylosis, u8.
Tendon transplantation, 107 1.
Tenement House Commission, 683.
Tenements and tuberculosis, 886.
Tenosynovitis, cause of suppurative, 564.
Testicle, cystic tumors of the, 943; round-
celled sarcoma of the, 38S.
Tetanus, 888 ; antitoxin treatment of, 467,
515; carbolic add in equine, 422;
cortical changes in, 2()j ; cure of. by
antitoxin, 510; epidemic of, following
July 4, 1899, 1089; following nephro-
pexy, 199; infection of. through the
mouth, 363 ; nature and treatment of,
835; orrhotherapy of, 25. 192, 287,769,
1064; orrhotherapy of, in the French
army, 725; prognosis of, 264; puer-
peral, 425; recovery from traumatic,
240; treatment of, 162 ; valuation of
the antitoxin of, 245.
Tetany, gastric. 152.
Teubner, Charles, methyl blue and methy-
lene blue, 927.
Therapeutics, teaching of, 207.
Thermometer as a germ carrier, 5S6.
Thermometer fever. 281.
Thigh, rapid union in a case of fracture of
the, 825.
Thirst, pathological, 769.
Thomas T. Gaillard, a memorial address
upon Dr. Fessenden Nott Otis, 1073.
Thorne, Sir Richard, death of, 129.
Thomsen's disease with tabes dorsalis, 117.
Thomson, W. H., some points in the thera-
peutics of heart disease. 441.
Thoracopagus, 420.
Thorington, James, notice of book by, S23.
Thrush, treatment of creamy, 384.
Thymus extract, 1104 ; gland, functions of
the, 116.
Thyroid extract, action of, 423; gland,
cancer of the, 297 ; gland, functions of
the, 1 1 32; gland, lesions of the, in
tuberculosis, 769 ; gland, relations of
the, to the uterus, 58 ; poison, effect
and after effect of the, 720 ; therapy,
375-
Thyroglossal duct, persistent, 31.
Thyroidin, toxic psychoses due to, 31.
Tibia, sarcoma of the, 523.
Tic douloureux, hereditary, cured by elec-
tricity, 556; operation on the fifth
nerve for, 814; treatment of, 815.
Ticks, fevers caused by, 767.
Tinea tonsurans in Assam, 68.
Tinnitus aurium, 377 ; relief of, 86 ; treat-
ment of, 30.
Tobacco amblyopia, 373 ; carbonic oxide
in the smoke of, 162 ; congress against
the use of, 18.
Todd, G. R. C. death of, 789.
Tongue, hemiatrophy of the, 432; hyper-
trophied, 556 ; papilloma of the, 340;
removal of half of the. 699 ; tractions
on the, 335; traction on the, in as-
phyxia of bulbar origin, 890.
Tonometer, a new instrument to determine
the amount of blood preriure, 181.
Tonsil, hemorrhage from an abscess by
the, S70; hemorrhage following re-
moval of the, 418 ; infection through
the, 1093; papillomatous growtl) on
the, 378; spirillum occurring in falsa
membrane on the, 460 ; syphilis of the
hngual, 512; tuberculous infection
through the. 1131.
Tonsillitis, endocarditis occurring in the
course of. 71.
Toothache, mountain, 636 ; treatment of,
14, 128.
Toxins and antitoxins, 1093; from achem-
ical and pathological standpoint, 595.
Trachea, perforation of tuberculous bron-
chial lymph nodes into the, 654 ; sud-
den death from perforation of the, 859,
Trachoma, 923 . immunity of the negro
from, 329.
Transfusion of complete blood, a few ex-
periments in, 687.
Transposition of vital organs, 73S.
June 30, 1900]
INDEX.
1155
Traumatisms inflicted by animals, 692 ;
treatment of minor, 461.
Tremor, hysterical, in an old man, 192.
Trichinosis, a case of, 885 ; a family out-
break of, 71 ; diagnosis of, suggested
by examination of the blood, 478.
Trichobezoar, see Hair-hall.
Trichorrhexis nodosa, 1092.
Trional, administration of, 572.
Trochanter, tuberculous disease of the, 463.
Tropical diseases, study of, in the Philip-
pines, 238.
Tropics, the soldier in the, 641.
Trudeau, E. L., sanatoria for consump-
tives, 792.
TruneJek, C, radical cure of epithelial
cancer by arsenic, 937.
Tubal sacs, peripheral, 291.
Tubercle bacilli and other bacteria in the
sputa, diagnostic and therapeutic sig-
nificance of, 690; germs and giant
cells in human tissue, 23 ; growth of,
on Hesse's medium, 387; in milk,
butter, and margarine, 199.
Tubercle, soUtary, of the heart, 377.
Tuberculin, diagnostic value of, 2ii, 11 29;
in the early diagnosis of tuberculosis,
645; test in cattle, 193; therapeutic
and diagnostic value of old, 204.
Tuberculosis, 41 ; action of morphine upon
the development and course of, 30;
acute pneumonic form of, 768; a
Japanese serum for the treatment of,
325; among the poor, 546; arsenic
and iron in the chloro-ansmias of, 570 ;
articular and osseous, pure carbohc
acid in the treatment of, 1069; arti-
ficial immunity against, 895; bovine,
211; bovine, bill regarding, in the
New York legislature, 237 ; bovine,
communicability of, to man, 197; ca-
codylic acid in, 466 ; caseous infection
in pulmonary, 163; chronic hyper-
plastic, of the caecum, 1044; cinna-
mate of sodium in pulmonary, 202;
complicating pregnancy, 305 ; congress
in Naples, an incident of the, 1039;
contagion of, 1 61 ; dampness of the soil
in relation to, 82S, 1081; diagnosis
and therapy of pulmonary, 817; diag-
nosis of incipient, 423, 1 1 38 ; diagnosis
of pulmonary, in young children, 691 ;
diazo reaction in, 1012; discussion on.
1058; drug treatment of, 1055 ; early
diagnosis of pulmonary, 511, 815;
early sign of, 764 ; educational and
legislative control of, 82S; French in-
stitute for the study of, 456; general
miliary, 301 ; hereditary transmission
of, 762; hetol in, 1043; hydriatic
treatment of, 973; infectiousness of,
210; infectiousness of, officially pro-
claimed, 1039; international congress
on, in Naples, 788; intestinal, 1009;
intestinal, in a child, 387 ; in working-
men, 161 ; isolation in, 691 ; labora-
tory methods of diagnosis, 71 ; limita-
tion of the prevalence and fatality of,
551 ; more rapid spread of, among
cattle than in the human race, 732 ;
night-air of New England in the treat-
ment of, 453 ; intra-pleural injections
of nitrogen gas in the treatment of
pulmonary, S76 ; notification and state
supervision of, 886; of serous mem-
branes, 354 ; of the astragalus, 1071 ;
of the female genital tract in children,
819; of the hip, early exploratory
operations in, 338; of the kidney,
without distinctive symptoms, 1 56 ; of
the knee, treatment of, 1063; of the
lymph glands, 288; of the male geni-
tals, surgical treatment of, 202 ; of the
mesenteric glands, 848 ; of the nasal
duct, 115; of the nervous system, 601 ;
of the urinary apparatus, 727 ; oil of
camphor in pulmonary, 512 ; orrho-
therapy of, 148, 771; pathology of
miliary, 287; peritoneal, ifii, 1068;
postage stamps as carriers of, 70; pre-
vention of, 470, 552 ; prognosis of, 210;
prophylaxis of, in children, 203; pro-
phylaxis of pulmonary, 514; public
sanatoria for, legislation for the estab-
lishment of, 252 ; pulmonary, creosote
in, 248 ; pulmonary, hospital treat-
ment of, 893 ; pulmonary, sanatorium
treatment of, 773 ; pulmonary, trache-
al injections in the treatment of, 869;
relation of pneumonia to pulmonary,
337; renal, 510; respiratory gymnas-
tics in, 116; restriction of, 152; sana-
torium for, in Sicily, 459 ; sanatorium
treatment of, 152, 208; sanatorium
treatment of, at home, 138; sanatori-.
um treatment of incipient, 1017; sea-
service in the management of, 768;
serum diagnosis of, 729; significance
of bovine, 322 ; specific treatment of,
115; study of four hundred cases of,
32; struggle against, 924; subsequent
histories of patients apparently cured
by anti-tubercle serum, 876; surgical,
156; surgical, treatment of, 25; the
Alleghanies for sufferers from, 1084;
thyroid extract in, 27 ; thyroid gland,
lesions in, 769 ; treatment of, 247, 601 ;
treatment of pulmonary, at the Cha-
rite, 645; treatment of surgical, 67 ;
two therapeutic indications in, 418;
various papers on, 1094; vertebral,
1 106.
Tubo-ovarian adhesions, reflexes of, 1050.
Turbinated bone, treatment of hypertrophy
of the inferior, 374.
Tumbe fly, 24S.
Tumors, a study of, 350; classification of,
247 ; etiology of, 988 ; parasitism of,
424; syphilitic treatment of, nil.
Turkey, medical schools in, 743.
Turners' palsy, 423.
Turner, Charlewood, death of, 392.
Tuttle, George M., notice of book by, 3S1.
Twin pregnancy with placenta praevia, 420.
Tympanites, hysterical neurasthenia, 55G.
Tympanum, rupture of the, following a
blow on the ear, 70.
Typhoid bacillus, 598, 889; and fever, 728 ;
and typhoid fever, 642 ; cystitis due to,
405; duration of lifeof.inice, loio; in
the blood, 246 ; in the gall bladder, 343.
Typhoid fever, 193, 41S, 419; abortion
caused by, 145; acute nephritis in,
243; Addison's disease following,
1091 ; among .American soldiers, 1000;
and appendicitis, differential diagnosis
between, iioo; an epidemic of water-
borne, 109; antitoxic serum of, 611;
appendicular symptoms complicating,
844; bathing for, in childhood, 925;
cardiac complications during conva-
lescence from, 202 ; cold-bath treat-
ment of, in children, 247 ; complicated
with malaria, 284 ; complications in,
339; desquamation in, 1132; diet in,
I, 23, 157; disinfection of the urine
in, 415; epidemic of, at Northville,
N. C, 24 ; epileptiform attacks in
convalescence from, 465 ; e.xanthe-
matic forms of infantUe, 925 ; experi-
mental, 335; foetal and infantile,
1053; gangrenous dermatitis compli-
cating, 469 ; hypodermoclysis in, 362 ;
in a leper, 156; in army camps, 236;
in childhood, 860; influence of the
toxin of, on metabolism, 340; inocu-
lability of, 695; in Philadelphia, 324 ;
in South .'\frica, 88, 105,425; laryn-
geal affections in, 203 ; membranous
laryngitis complicating, 654; mild
types of, 365 ; ocular disturbances in,
335; ostitis in, 74; preventive inocu-
lations against, 199,816, 1042; prior-
ity in the serum diagnosis of, 787; prog-
nostic value of rose spots in, 648 ; pul-
monary complication of, 988; renal
form of, 262 ; rubeoliform and scarla-
tiniform erythema in, 6go; salophen in,
231; treatment of, 373, 11 20; treat-
ment of meteorism in, 292 ; unrestrict-
ed diet in, 697 ; urine as a culture
medium in the diagnosis of, 69 ; Wi-
dal's sei-um diagnosis of, 466 ; without
intestinal lesions, 886; without intes-
tinal localization, 340.
Typhoid spine, 596.
Typhus fever, bacteriology of. 33; inocu-
lation of, 1072.
U
Ulcer, duodenal, 494, 522 ; duodenal, treat-
ment, 563 : gastric, 774 ; gastric, case
simulating. 836; gastric, gastrojejunos-
tomy for, 509; gastric, in pregnancy,
598; gastric, surgery of, 693, 931;
gastric, treatment of, 5 1 4 ; massage in,
145; non-malignant, gastric and duo-
denal, 485; non-perforating gastric,
992 ; of the leg, bacteriotherapy of,
375; perforating duodenal, 749; per-
forating gastric, 509; rodent, formalin
in, 243.
Umbilical cord, hernia of the, 363.
Umbilicus, disinfection of the, in abdomi-
nal operations, S23; late spontaneous
hemorrhage from the, 249 ; tumors of
the, 163, 649.
Uremia, experimental researches on bleed-
ing in, 422 ; peculiar manifestations of,
687.
Uranoplasty, technique of, 1089.
Urate of sodium, fat, and action of acid,
in the abdominal cavity and joints of
rabbits, 762.
Ureteral calculus, 418.
Uretero-vaginal fistula, 499.
Ureters, anastomosis of the, with the in-
testines, 852 ; calculi impacted in the,
766; instrument for catheterization of
the, 201 ; obtaining urine direct from
the, for diagnostic purposes, 870; re-
section of the, 2068; rupture of the,
157; subjective symptomatology of
disease of the, 873; surgery of the,
292 ; treatment of injuries of the, 1 062.
Urethra, chewing-gum in the, 825; for-
eign body in the, 284, 421 ; obstruc-
tive diseases of the male, 71; stric-
ture of the, 379, 886; stricture of the,
with secondary cystitis and hydrone-
phrosis, 302; suprarenal extract in
diseases of the, 483 ; surgical asepsis
of the, 1062; treatment of stricture of
the, 1093; ulceration of the female,
Urethrectomy, remote results of perineal,
160.
Urethritis, electrolysis in the treatment of
chronic glandular, 543 ; picric acid in
chronic, 784 ; treatment of chronic,
.378-
Urethroscope in the treatment of stric-
tures, 117 ; the modern, 784.
Urethrostomy, perineal, remote results of,
116.
Urethrotome, a new modified, 659.
Urethrotomy, external, 553.
Uric -acid diathesis, 589 ; production of,
528: relation of leucocytes to, 119;
serious results of, when not eliminated,
640.
Urinary anomalies, 1092; infection, per-
manent sound in the treatment of,
925.
Urine, centrifugal analysis of, 284; chy-
lous, 885; differentiation of, from
each kidney, 31; disinfection of the,
in typhoid fever, 415; estimation of
mercury in the, 157, 2S7 ; forms and
significance of the proteids in the,
517; poisonous effects of normal,
287; Rosin method for determining
the reducing power of the, 464; sig-
nificance of glyceronic acid in the
phenyl-hydrazin test for sugar in the,
1 59 ; suppression of, treated by oper-
ation, 463; test for sugar in the, 161.
Urological instruments, lubricants for, 120.
Urotoxicity, relative, in children and
adults, 30.
Urticaria, treatment of. 572.
Uterus, acute inflammation of a subperi-
toneal fibroid of the, 688 ; adenocarci-
noma of the body of the, 639; back-
ward displacements of the, 421 ; bi-
cornate, with twin pregnancy, 924;
bleeding from the, from sclerosis of
the uterine arteries, 245; cancer of
the, 568; cancer of the, operation in,
1137; carcinoma psammosum of the,
292 ; chronic total inversion of the,
422 ; clinical significance of retrover-
II56
INDEX.
[June 30, 1900
sion of a movable, 120; complete in-
version and prolapse of the, 332 ; con-
servative operation for fibroids of
the, 638; dangers of coitus in inflam-
mation of the, 70 ; decidual polyp of
the, 292 ; early diagnosis of cancer of
the, 115; emphysema of the, and gas-
sepsis, 292 ; end results of operative
treatment of retroversio-flexion of,
291 ; extirpation of cancer of the,
1065; fibroids of the, 161, 421,996;
fibroids of the, complicated by preg-
nancy, 212, 515, 595; fibroids of the,
hysterectomy for, 21S; fibroids of the,
in members of the same family, 205 ;
gunshot wound of the pregnant, 842 ;
histology of adenomyomata of the,
468; hot-air douche in the treatment
of inflammatory affections of the, 245 ;
hysterectomy for fibroid of the. 341 ;
imperforate, with hsematoma of the
ovary, 79 ; importance of cervical
flexions, 289 ; importance of early
recognition of cancer of the, 71 ;
inertia and prolapse of the, 509; in-
tra-abdominal amputation of the, S53 ;
intra-abdominal method of treating
retroversion of the, 1041 ; inversion
of the, from fibroids. 117; labor com-
plicated by abdominal fixation of the,
41 1 ; Mazzoni method of treatment of
prolapse of the, 720; multiple papil-
loma of the cervix, loiS ; natural his-
tory of fibroids of the, 199; operations
for prolapse of the, 291; operative
treatment of fibroids of the, 264, 331,
733; ossification of the, 41S; post-
partum sloughing of the, 375; re-
lation of the, to the thyroid gland,
HS ; removal of a submucous fibroid
ijy section of the, 286 ; removal of
fibroids through an anterior vaginal
incision, 304 ; removal of the cancer-
ous, by the vagina, 732 ; removal of
the, for cancer, 286 ; retroversion of,
treated by " Belastungstherapie," 431 ;
risk of unoperated fibromata of the,
422 ; rudimentary, castration in a case
of, 249; rupture of the, 218; rupture
of the parturient, treatment of, 89S ;
rupture of the pregnant, 763 ; rapture
of the, with placenta pr.tvia, 420 ; scle-
rosis of the arteries of the, 648 ; serous
infiltration of the para-uterine connec-
tive tissue, 733 ; spontaneous reduc-
tion of an inverted, after three years,
66; spontaneous rupture of the, 640;
steam applications to the, 470 ; sub-
mucous fibroids, 60S ; suture of the
round ligaments to the anterior wall for
retroversions and retroflexions of the,
850; tolerance of the gravid, 601 ;
treatment of cancer of the cervix com-
plicated by pregnancy, 726 ; treatment
of complicated fibroid tumors of the.
732 ; treatment of erosions of the cer-
vix, 474 ; treatment of fibroids of the,
564, 852 ; typhoid infection of the,
655 ; ultimate results in treating can-
cer of the, 8;8.
Uvula, double, 462 ; elongated, 197.
V
Vaccination, 46S ; oedema following, 174;
preparing the skin for, by denudation
with caustic potash, 143, 174; tech-
nique of, 464.
Vaccine bodies, microscopical demonstra-
tion of, 884 ; weakened virulence of.
in hot climates.
544-
Vaccinella, 361.
Vagina, atresia of the, 259, 2S6 ; atresia of
the, with solid uterus, 285 ; cancer of
the, 775; imperforate, 200, 249; pro-
lapse of the, 648.
Vaginal coeliotorny vs. laparotomy, 334,
339-
Vaginismus, treatment of, 424.
Valk, Francis, the past and present of re-
fraction, 716.
Valvulitis, aortic, 254.
Van Santvoord, R.. the clinical uses of
the sphygmograph, 313.
Varicocele, radical operation for. 28S.
Varicose spinal veins, 50S ; . ulcer, treat-
ment of, 613.
Variner, Henri, notice of book by. .S24.
Varix, abdominal, S25.
Vas deferens, suture of the. 25.
Vasectomy in enlarged prostate and blad-
der atony, 887.
Vegetable diet, therapeutic uses of, 768.
Veil, as a cause of erythema of the nose
and cheeks, 3S2.
Veins, alterations of the coats of, in vari-
ces, 588.
Venereal diseases in Finland. 470; pre-
vention of, in Xorway. 369 ; treat-
ment of, 32.
Veitebra;, ankylosis of the, of gonorrhoeal
origin, 769 ; fracture of the. or Pott's
disease, 243.
Vertigo, aural. 161 ; therapeutics of. 1 103.
Vesico-vaginal fistula, new method of
closure of a. 696.
Vesicula; seminales, excision of. fcr -.uber-
culous disease, 199.
Vesiculitis, seminal. 247.
Vibbert, William Welsh, death of. 551.
Vibration, hypnotic and anaesthetic action
of. 373-
Vienna, letter from. 431.
Vincent. Edward E.. death of. Si 4.
Vineberg, Hiram N., the association of
chronic appendicitis with disease of
the right adnexa, 94S.
Vinton, C. C, the use of kola in seasick-
ness, 348.
Vir effeminatus. 246.
Virginity, anatomical proof of the loss of,
292.
Vitihgo in a baby three days old, 1 1 19.
Vivisection at the Harvard Medical
School, 41S.
Vocal cords, flat condyloma of the. 030 ;
partial paralysis of the, from over-use
of the telephone, S69.
Volvulus associated with hernia, 602.
Vomiting, arrest of obstinate. 75 ; of
pregnancy, pernicious, 924; periodi-
cal, in infancy, 202 ; periodic habitual,
1045 ; recurrent in children, 77^ ; sur-
gical aspects of, 59S.
Vondy, Joseph H.. death of, 595.
Vulva, hemorrhage from a varicocele of
the, 1 57 ; ulcerative lesions of the.
Si ; varicose veins of thr. 1 1^.
Walmsliy, William Edward, death of.
Ware, Martin W., the cardinal pathog-
nomonic sign of fracture of the lower
end of the radius (CoUes'). 540.
Warner, Francis, notice of book by, 653.
Warner, William R., notice of book bv,
382.
Warren, Francis G,, death of, 595.
Warren. J. Collins, notice of book edited
by, 735, 1020.
Washburn. Wickes, a model dairy farm,
394 ; needed reforms in the ambu-
lance system, 130; public service
against private work, 651 : rain baths,
1023.
Water, b.-icteria in, 72 ; internal use of. in
hemorrhage, 103; mains, disinfection
of. 743-
Water gas, dangers of, 322.
Watson, James L.. death of. 373.
Watson, J. K., notice of book bv. 1020.
Watts. .\ If red J., death of, 155.'
Weber, Leonard, an appendicitis opera-
tion in 1867, 430.
Weil's disease. 207.
Weir, Robert F., on the treatment of the
sliding hernias of the cecum and sig-
moid flexure, 309. 343 ; on the forma-
tion of an artificial anus, 661, 701 ;
perforating duodenal tilcers, 749.
Welles, Charles Stuart, notice of book
by, 735-
Well.s, Clarence A., a case of rapid union
in fracture of the thigh, 825.
Wells, J. Hunter, hospital and dispensary
work in Korea, 219; unrestricted diet
in typhoid fever, 697.
Wells, Walter A., indications for constitu-
tional treatment of catarrhal affec-
tions of the upper air passages, 667.
Wendel, A. V., a contribution to the treat-
ment of rupture of the parturient
womb — with a critical review of the
vaginal operation, 89S.
Werlhof's disease, etiology and pathologi-
cal anatomy of, 293.
West African medicine, 290.
Weston, E. Eugene, death of, 196.
Wetmore, Josephine M., a common case
and its practical suggestions, 96.
Whistler, William McNeill, death of, 505.
559-
Whitbeck, John F. W.. treatment of su-
perficial wounds without sutures, 632.
Whitehead, R. W., notice of book by, 1021.
Whittaker, James T., death of, 1040.
Whooping-cough, antitussin in, 28 ; as
seen in dispensary practice, 449; oil
of gomenol in, 1132; pneumothorax
complicating. 1044; treatment, 75, 128,
595. 73'. 1092.
Wiener, Joseph, when shall we operate
for appendicitis f 837.
Wilbur, Lloyd, death of, 239.
Winston, Gustavus S., death of, 22.
Witmer, .Abraham H., death of, 154.
Witness, the physician as an expert, 507.
Wittenieyer, Annie, death of, 239.
Wolff, Lawrence, notice of book by. S24.
Wolseley, Lord, incompetence of, as a
commander, 166.
Women admitted to the University of
Heidelberg, 313; as surgeons. 1081 ;
brains of, 1 138.
Wood, E. L., the treatment of corns. 3S4.
Wood, H. C, notice of book by, 565.
Worl-blindness, congenital, 1018.
Worms, intestinal, nervous symptoms
caused by, 511,
Worthington, S. M., identity of diphtheria
and membranous croup (?), a country
protest, 345.
Wounds, gunshot, infection and disinfec-
tion of, 121 ; gunshot, in the Santiago
campaign, 156; hermetic sealing of
aseptic, 692; in modern warfare, 16;
of the head, pistol-shot, 65; suturing
of, 564; treatment of superficial, with-
out sutures, 632.
Wright, Andrew R., death of, 373.
Wrist, congenital dislocation of the, iioS.
Wyeth, John A., a review of the history
and literature of appendicitis, 44.
X
Xanthoma tuberculatum diabeticorum,
866.
Xiphopages, 417.
X-rays, see Roentgen rays.
V
Vandell, William, death of 551.
Veast, therapeutic uses of, 916.
Vellow fever, 1002; antitoxic serum of,
612; bacteriology of. 328 ; haemogas-
trie infection in, 676; in Cuba, 326.
1 1 26: in Mexico, 108, 789, 1087; in
San Salvador, 921; orrhotherapy of,
112.
Voung, Rev. Alfred, death of, 686.
Zadig, method of. in the advancement of
medicine, 514.
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